Cognitive Impairment Disorders

Dementia
These cognitive decits must be sufciently severe to impair social or occupational functioning and must represent a decline from previous functioning. Dementia must be distinguished from delirium; if the two diagnoses coexist, the symptoms of dementia remain even when the delirium has cleared. Memory impairment is the prominent early sign of dementia. Clients have difficulty learning new material and forget previously learned material. Initially recent memory is impaired, for example, for- getting where certain objects were placed or that food is cooking on the stove. In later stages, dementia affects remote memory; clients forget the names of adult children, their life-long occupations, even their names. More progressive, gradual, and permanent Involves multiple cognitive deficits Primarily memory impairment Involves at least one of the following: a. Aphasia (deterioration of language function) b. Apraxia (impaired ability to execute motor functions) c. Agnosia (inability to name or recognize objects) d. Disturbance in executive functioning (ability to think abstractly and to plan, initiate, sequence ,monitor, and stop complex behavior)

SYMPTOMS OF DEMENTIA a. b. c. Loss of memory (initial stages, recent memory loss such as forgetting food cooking on the stove; later stages, remote memory loss such as forgetting names of children, occupation) Deterioration of language function (forgetting names of common objects such as chair or table, palilalia (echoing sounds), and echoing words that are heard [echolalia]) Loss of ability to think abstractly and to plan, initiate, sequence, monitor, or stop complex behaviors (loss of executive function): the client loses the ability to perform self-care activities

EPIDEMIOLOGY The prevalence of severe dementia has been reported to be 3% in adults, with increasing prevalence in older age groups, to as high as 25% in people over 85 years old (APA, 2000). Some minor forgetfulness usually occurs in elderly clients, but this differs drastically form changes seen in dementia. Dementia is not necessarily a component of aging process, and it is erroneous to assume that because a client is elderly he or she will be confused, forgetful or demented. Course of Disorder Although dementia is generally considered to be progressive, symptoms can also stabilize for a period of time or resolve, as sometimes seen in vascular dementia. In progressive dementia, symptoms may begin as mild memory impairment with slight cognitive disturbance and progress to profoundly impaired memory and cognitive function.

Cognitive Impairment Disorders: Dementia

Clients with dementia have an impaired ability to learn new material and eventually forget previously learned material. Deterioration of language function, including loss of the ability to correctly identify familiar objects or remember their function, to comprehend written or spoken language, and disturbances of speech pattern. Wandering confusion, disorientation, and the inability to correctly use items such as eating utensils produce profound functional impairment.

Clinical course of Dementia 1. Mild Forgetfulness Difficulty finding words Frequently loses objects and experiences anxiety about these losses. Occupational and social settings are less enjoyable, and the person may avoid them. Moderate Confusion is present along with memory loss The person cannot complete complex tasks but remains oriented to person and place Still recognizes familiar people. Some assistance with care Executive functioning suffers (especially with ADLs) Severe Personality and emotional changes occur May be delusional, wander at night, forget the names of spouse and children and require assistance in ADLs. Most live in ECF.

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Classification of Dementia 1. Primary Dementia Not reversible, progressive, and is not secondary to any disorder. Alzheimers Disease (senile and presenile dementia) Multi-infarct Dementia Picks Disease Secondary Dementia Result of some other pathological process.

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Cognitive Impairment Disorders: Dementia

ETIOLOGY

Infection a. Tuberculosis b. Tertiary Neurosyphilis c. Fungal, bacterial, and viral infections of the brain (Creutzfeldt-Jacob disease) Trauma, subdural hematoma, hypoxia Toxic, and Metabolic disturbances a. Korsakoffs syndrome; Wernickes encephalopathy (thiamine deficiency) b. Pernicious Anemia ( Vit. B12 deficiency) c. Folic acid deficiency d. Thyroid. Parathyroid, or adrenal gland dysfunction e. Liver or kidney dysfunction f. Metal poisoning g. Carbon dioxide and some drugs Neoplasms Other neurological diseases a. Huntingtons chorea b. Parkinsons disease c. Multiple sclerosis d. Cerebellar degeneration Normal pressure hydrocephalus AIDS-related dementia (HIV encephalopathy)

The major disorders that result in dementia including the following: A. Vascular Dementia result from a decrease blood supply to and hypoxia of the cerebral cortex. Initial symptoms are forgetfulness and a short attention and concentration span. It usually occurs between the ages of 60 and 70, is progressive, and may result in psychosis. B. Alzheimers disease is a progressive brain disorder that has a gradual onset but causes an increasing decline in functioning including loss of speech, loss of motor function, and profound personality and behavioral changes such as paranoia, delusions, hallucinations, inattention to hygiene, and belligerence. It is evidenced by atrophy of cerebral neurons, senile plaque deposits, and enlargement of the third and fourth ventricles of the brain. Risk of Alzheimers disease increases with age, and average duration from onset of symptoms to death is 8 to 10 years. Dementia of the Alzheimers type especially with late onset (after 65 years of age) may have a genetic component. Research has shown linkages to chromosomes 21, 14, and 19 (APA, 2000). C. Picks disease is a degenerative brain disease that particularly affects the frontal and temporal lobes and results in a clinical picture similar to that of Alzheimers. Early signs include personality changes, loss of social skills and inhibitions, emotional blunting, and language abnormalities. Onset is most commonly 50 to 60 years of age; death occurs in 2 to 5 years. D. Creutzfeldt-Jakob disease is a central nervous system disorder that typically develops in adults 40 to 60 years of age. It involves altered vision, loss of coordination or abnormal movements, and dementia that usually progresses rapidly (a few months). The cause of the encephalopathy is an infectious particle resistant to boiling, some disinfectants (e.g., formalin, alcohol), and ultraviolet radiation. Pressured autoclaving or bleach can inactivate the particle.

Cognitive Impairment Disorders: Dementia

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HIV disease can lead to dementia and other neurologic problems; these may result directly from invasion of nervous tissue by HIV or from other AIDS-related illnesses such as toxoplasmosis and cytomegalovirus. This type of dementia can result in a wide variety of symptoms ranging from mild sensory impairment to gross memory and cognitive decits to severe muscle dysfunction. Parkinsons disease is a slowly progressive neurologic condition characterized by tremor, rigidity, bradykinesia, and postural instability. It results from loss of neurons of the basal ganglia. Dementia has been reported in approximately 20% to 60% of people with Parkinsons disease and is characterized by cognitive and motor slowing, impaired memory, and impaired executive functioning.

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G. Huntingtons disease is an inherited, dominant gene disease that primarily involves cerebral atrophy, demyelination, and enlargement of the brain ventricles. Initially there are chorei form movements that are continuous during waking hours and involve facial contortions, twisting, turning, and tongue movements. Personality changes are the initial psychosocial manifestations followed by memory loss, decreased intellectual functioning, and other signs of dementia. The disease begins in the late 30s or early 40s and may last 10 to 20 years or more before death. H. Dementia can be a direct pathophysiologic consequence of head trauma. The degree and type of cognitive impairment and behavioural disturbance depend on the location and extent of the brain injury. When it occurs as a single injury, the dementia is usually stable rather than progressive. Repeated head injury (for example, from boxing) may lead to progressive dementia. Related Disorder Amnestic disorder may be secondary to substance abuse or another medical condition. Typically, there is no personality change or impairment in abstract thinking. Signs include: Decreased awareness on surroundings. Inability to learn new information despite normal attention. Inability to recall previously learned information. Possible disorientation to place and time. Typically there is no personality change or impairment in abstract thinking Culture Considerations Native Americans and Eastern countries hold elders in a position of authority, respect, power, and decision making for family; this does not change despite memory loss or confusion. May feel they are being disrespectful and reluctant to make decisions or plans for elders with dementia. Clients from other cultures may nd the questions used on many assessment tools for dementia difcult or impossible to answer. Examples include the names of former U.S. presidents. To avoid drawing erroneous conclusions, the nurse must be aware of differences in the persons knowledge base. The nurse also must be aware of different cul- turally influenced perspectives and beliefs about elderly family members.

Treatment for Dementia

Cognitive Impairment Disorders: Dementia

Underlying cause Example: Vascular dementia can be helped by diet, exercise, control of hypertension or diabetes. Psychopharmacology a. Cognex (Tacrine), Exeleon (Rivastigmine) and Aricept (Donepezil) are cholinesterase inhibitors and have shown therapeutic effects; slow the progress of dementia They do not reverse damage already done. have liver function tests done with Cognex. Flu-like symptoms, diarrhea, sleep disturbances are common. b. Tegretol and Depakote help stabilize mood and diminish aggressive outbursts. These doses are often -2/3 less lower than prescribed for seizures, therefore, does not need to be in the therapeutic level for blood work. c. Benzodiazepines (Aprazolam) may cause delirium and can worsen already compromised cognitive abilities.

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Antipsychotics agents ; Haloperidol (Haldol) and Risperidone (Risperdal)

ASSESSMENT History a. b. Remember, interview family Motor behavior and general appearance Display aphasia Conversation repetitive Apraxia (such as combing hair) Gait disturbance Uninhibited behavior ; never have displayed these behaviors before. c. Mood and Affect Grieve at first Emotional outbursts are common Pattern of withdrawal; lethargic, apathetic, look dazed and listless. d. Thought process and content Executive functioning impaired Have to stop working Client may accuse others of stealing lost objects

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Sensorium and Intellectual Processes First affects recent and immediate memory, eventually impairs the ability to recognize family members and oneself. Confabulation: clients make up answers to fill in memory gaps; often inappropriate words or fabricated ideas. Visual hallucinations are common. f. Judgment and insight Underestimate risk g. Self-concept Initially grieve, and then slowly lose sense of self. h. Roles and Relationships Physiologic and self-care considerations Altered sleep-wake cycle

Cognitive Impairment Disorders: Dementia

Some clients ignore internal cues such as hunger or thirst

Neglect bathing and grooming; become incontinent.

ALZHEIMERS DISEASE Alzheimer's disease bears the name of Dr. Alois Alzheimer, a German physician. In 1906, Dr. Alzheimer noticed changes in the brain tissue of a woman who had died of an unusual mental disorder. During the autopsy, he found abnormal clumps (now called amyloid plaques) and tangled bundles of fibers (now called neurofibrillary tangles) within the brain. Today, these plaques and tangles are considered classic signs of Alzheimer's disease. Scientists have also found other brain changes in people with Alzheimer's disease, including: The death of nerve cells in areas of the brain that are vital to memory and other mental abilities Disruptions in the connections between nerve cells Lower levels of some of the chemicals in the brain that carry messages back and forth between nerve cells. All three of these changes may contribute to the impaired thinking and memory seen with Alzheimer's disease. Common symptoms of Alzheimer's may include: Memory loss Poor judgment Confusion Deterioration of language skills Diagnosis History Chest and skull x-ray Electroencephalography Electrocardiography Urinalysis Sequential multiple analyser-12 test serum profile CBC Venereal Disease Research Laboratory (VDRL) Serum creatinine assay Serum Vit. B12 assay Serum folate assay Vision and hearing evaluation Impaired ability to understand visual information Mood swings Restlessness.

ASSESSMENT IN ALZHEIMERS DISEASE Four defensive behaviors 1. 2. 3. 4. Denial protective defense against terrifying reality of losing ones place in the world. Confabulation making-up stories or answers to maintain self-esteem when the person doesnt remember. Perseveration the repetition of phrases or behaviour. Avoidance of questions the client is able to maintain self-esteem unconsciously in the face of severe memory deficits.

Four Signs of Alzheimers Disease (Wolanin and Fraelich-Philips 1981) 1. 2. Aphasia loss of language ability Apraxia loss of purposeful movement in the absence of motor or sensory impairment.

Cognitive Impairment Disorders: Dementia

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Agnosia loss of sensory ability to recognize objects. Mnemonic disturbance memory loss.

Four Phases of Alzheimers Disease 1. Phase 1 Mild Loses energy, drive, and initiative Difficulty learning new things Personality and social behaviour remain intact, which often influences others to minimize and underestimate the loss of individuals ability.

May still continue to work Depression may occur early in the disease but usually lessens as the disease progresses. Marketing and managing financial activities noticeably impaired

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Phase 2 Moderate Deterioration evident Cannot remember his or her address or the date Memory gaps in persons history that may fluctuate form one moment to another. Affects hygiene and ability to dress appropriately May put on clothes backward Button the buttons incorrectly or not zip zippers Phase 3 Moderate to Severe Often not able to identify objects or people, even a spouse Needs repeated instructions and directions for simplest tasks Individual cannot remember where the toilet is and becomes incontinent Total care is necessary Behaviour affects the sleep of others

Coaxed to bathe Mood becomes labile May have a burst of paranoia, anger, jealousy, and apathy May suddenly speed or slow down for no apparent reason or go through stop signs. care supervision of family is full-time job denial occurs and the person begins to withdraw activities and people moments of becoming tearful and sad

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The world becomes frightening to the client Agitation Violence Paranoia Delusions Wandering behaviour

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Phase 4 Late Agraphia inability to read and write Hyperotality the need to taste chew, and put everything in ones mouth Blunting emotions Visual agnosia loss of ability to recognize familiar objects Hypermetamorphosis touching everything in sight Ability talk and walk are lost

INTERVENTION

Cognitive Impairment Disorders: Dementia

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Promoting clients safety and protecting from injury Offer unobtrusive assistance with or supervision of cooking, bathing, or self-care activities. Identify environmental triggers to help client avoid them. Promoting adequate sleep, proper nutrition and hygiene, and activity Prepare desirable foods and foods client can self-feed; sit with client while eating. Monitor bowel elimination patterns; intervene with uids and ber or prompts. Remind client to urinate; provide pads or diapers as needed, checking and changing them frequently to avoid infection, skin irritation, and unpleasant odors. Encourage mild physical activity such as walking. Structuring environment and routine Encourage client to follow regular routine and habits of bathing and dressing rather than impose new ones. Monitor amount of environmental stimulation, and adjust when needed. Providing emotional support Be kind, respectful, calm, and reassuring; pay attention to client. Use supportive touch when appropriate. Promoting interaction and involvement Plan activities geared to clients interests and abilities. Reminisce with client about the past. If client is nonverbal, remain alert to nonverbal behavior. Employ techniques of distraction, time away, going along, or reframing to calm clients who are agitated, suspicious, or confused.

PSYCHOTHERAPEUTIC INTERVENTIONS 1. 2. 3. 4. 5. 6. Do not provide more than one visual clue (object) at one time. Know that the client may lack understanding of the task assigned. Remember that relevant information is remembered longer than irrelevant information. Break tasks into very small steps. Give only one instruction at a time. Report, record and chart all data.

HEALTH TEACHING 1. 2. 3. 4. Family need to know where to get help. Help includes professional counselling and education regarding the process and progression of the disease. Family members can call the nearest Alzheimers Association. Family need to know where and how to place the ill member. Families need support, information, legal and financial guidance.

THERAPEUTIC ENVIRONMENT Safety considerations Activities that increase socialization and minimize loneliness

3 Categories of Intervention 1. 2. 3. Modifying the environment Using interpersonal strategies Using physical or chemical restraints

Cognitive Impairment Disorders: Dementia

EVALUATION Treatment outcomes change constantly as the dis- ease progresses. For example in the early stage of dementia, maintaining independence may mean that the client dresses with minimal assistance. Later the same client may keep some independence by selecting what foods to eat. In the late stage, the client may maintain independence by wearing his or her own clothing rather than an institutional nightgown or pajamas. The nurse must assess clients for changes as they occur and revise outcomes and interventions as needed. When a client is cared for at home, this includes providing ongoing education to family members and caregivers while supporting them as the clients condition worsens. See the sections below on the role of the caregiver and communitybased care.

REFERENCE: Videbeck Psychiatric Mental Health

Cognitive Impairment Disorders: Dementia

Keltner book for Pychiatric Nursing http://alzheimers.emedtv.com/alzheimer's-disease/alzheimer's-disease-p2.html

Cognitive Impairment Disorders: Dementia