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COGNITIVE

DISORDERS

SITE MAP
OVERVIEW
DELIRIUM
DEMENTIA
PARKINSONS

DISEASE
AMNESTIC DISORDERS
COMMUNITY BASED CARE

OVERVIEW

The term cognition refers to the broad range of mental


abilities that enable us to know about the world around
us. These abilities include memory, language, attention,
perception, and reasoning.
Cognition is the ability of your brain to think, to process
and store information, to solve problems. Cognition is a
high level of behaviour unique to humans. This
behaviour is disrupted by an illness.
Gerontology is the scientific discipline that deals with
aging, and neurogerontology more specifically deals with
the aging nervous system.
Cognitive disorders are necessarily brain disorders, and
these are increasingly common after middle age.
Perhaps the most important of these illnesses is
Alzheimer's disease, one cause of severe cognitive loss
(dementia) in old age.
Physicians and scientists in the Division of Cognitive
Disorders and Neurogerontology are particularly
interested in memory loss and dementia.

DELIRIUM

DELIRIUM

Delirium is a sudden, fluctuating, and usually


reversible cognitive disorder characterized by
disorientation, the inability to pay attention, the
inability to think clearly, and a change in the level of
consciousness.
Delirium is an abnormal mental state, not a disease.
Although the term has a specific medical definition, it
is often used to describe any type of confusion.
Because delirium is a temporary condition,
determining how many people have it is difficult.
Delirium, which is usually a sign of a newly
developed disorder, affects about one third of
hospitalized people aged 70 or older.

Etiology

Development or worsening of almost any disorder


Extreme illness
Drugs that affect brain function.
Less severe conditions in older people
Disorders that cause nerve degeneration. (stroke,
dementia)
Relatively minor illness, such as retention of urine or
feces
Sensory deprivation, such as that due to being
socially isolated or not wearing glasses or hearing
aids; or prolonged sleep deprivation.
The sensory and sleep deprivation that occurs in
intensive care units (ICUs) may contribute to delirium.
This disorder is sometimes called ICU psychosis.
Delirium is also very common after surgery
Most common reversible cause of delirium is drugs.

Etiology (contd)

In younger people, ingestion of poisons (such as


rubbing alcohol or antifreeze), use of illicit drugs, or
acute intoxication with alcohol
Abnormal blood levels of electrolytes, such as
calcium, sodium, or magnesium, can interfere with
the metabolic activity of nerve
Abnormal electrolyte levels may result from use of a
diuretic, dehydration, or disorders such as kidney
failure and widespread cancer.
An underactive thyroid gland (hypothyroidism)
causes delirium with lethargy; an overactive thyroid
gland (hyperthyroidism) causes delirium with
hyperactivity.
In younger people, the cause of delirium is usually a
condition that directly affects the brainfor
example a brain infection, such as meningitis or

Symptoms

The hallmark is the inability to pay attention.


Lacks concentration.
Sudden confusion about time and, at least partially,
about place. Thinking is confused, and people with
delirium ramble, sometimes becoming incoherent.
If delirium is severe, people may not know who they
are. Thinking is confused, and people with delirium
ramble, sometimes becoming incoherent.
The level of consciousness may fluctuate between
increased wakefulness and drowsiness.
Sundowning phenomenon. Symptoms often change
within minutes and tend to worsen late in the day

Symptoms (contd)

Often sleep restlessly or reverse their sleep-wake cycle


Frightened by bizarre visual hallucinations
Paranoia or have delusions
Personality and mood may change.
If the cause of delirium is not quickly identified and
treated, the person may become increasingly drowsy
and unresponsive, requiring vigorous stimulation to be
aroused (a condition called stupor).
Stupor may lead to coma or death.

Delirium is often the first sign of another, sometimes


serious disorder, especially in older people.

Drugs Causing Delirium


Anticonvulsants
Anticholinergics
Antidepressants
Antihistamines
Antipsychotics
Aspirin
Barbiturates
Benzodiazepines

Hypoglycemic

agents
Insulin
Cardiac glycosides
Narcotics
Propranolol
Reserpine
Thiazide diuretics

Medical Management
Hypoactive

delirium - No specific
pharmacologic treatment
Sedatives to prevent inadvertent selfinjury but sedatives and benzodiazepines
are avoided this may worsen delirium
Exemption to this is delirium induced by
alcohol withdrawal.
Haloperidol

0.5-1 mg to decrease

agitation
Supportive medical measures

Assessment
History

of use of psychotropic Drugs


History of substance or alcohol abuse
Disturbed psychomotor behavior
Often have rapid and unpredictable mood
shifts
Thought processes are often disorganized and
make no sense.
Altered level of consciousness
Judgment is impaired
Disturbed sleep-wake cycles.

Nursing Diagnosis
Risk

for injury
Acute confusion
Disturbed sensory perception
Disturbed thought processes
Disturbed sleep pattern
Risk for deficient fluid volume
Risk for imbalanced nutrition: less than
body requirement

Objectives
The

client will be free of injury


The client will demonstrate increased
orientation and reality contact
The client will maintain an adequate
balance of activity and rest
The client will maintain adequate
nutrition and fluid balance
The client will return to his or her
optimal level of functioning

Nursing Interventions
Ensure

clients safety

administer medications judiciously as ordered


Teach client to request assistance for activities
Close supervision must be rendered

Managing

clients confusion

Speak in a calm manner in a clear low voice


Allow adequate time for client to comprehend and
respond
Allow client to make decisions
Provide orienting verbal cues
Use supportive touch if appropriate

Nursing Interventions
(contd)
Controlling

overload

Provide a quiet environment


Monitor clients response to visitors
Validate clients anxiety and fears, but do not
reinforce misperceptions

Promoting

environment to reduce sensory

sleep and proper nutrition

Monitor sleep and elimination patterns


Monitor food and fluid intake
Discourage daytime napping
Encourage exercise during day

Evaluation
The

client experienced no injury


The client demonstrated increased
orientation and reality contact
The client returned to his or her
optimal level of functioning
The client abstained from use of drugs
or alcohol.

DEMENTIA

Dementia
Dementia

is a label for a cluster of


symptoms involving deterioration in
behaviours such as memory, language, and
reasoning. The deterioration results from a
disease process in the brain. The disease
progresses from mild through severe stages
and interferes with the ability to function
independently in everyday life. Dementias
are fatal medical diseases that have major
psychosocial consequences.

What conditions result in


dementia?

Many different conditions can result in dementia


in later life. The most common is Alzheimer's Disease,
accounting for about 50% of all cases. The next most
common is vascular dementia.
Alzheimer's Disease involves a gradual change in
the neurons, or nerve cells in the brain. There are
tangles inside the nerve cell and degenerating nerve
endings. Other deficiencies also occur in the
neurotransmitters, the chemical messengers that
allow brain cells to send signals to each other.
Vascular dementia involves repeated damage to
areas of the brain caused by blockages in the blood
vessels (small strokes). Vascular dementia is what
used to be referred to as hardening of the arteries.

Classifications of Dementia
Dementia

is classified as cortical or
subcortical depending on the area of brain
affected.

Cortical Dementia
Subcortical Dementia

Cortical dementia causes problems in


memory, thinking, and language. Alzheimer's
Disease is a disorder that causes cortical
dementia. The cognitive problems, depending
on their nature, are called aphasia, apraxia,
amnesia, and agnosia. These problems may
include difficulty finding words, difficulty
comprehending written or spoken material,
and even mutism. Speech, which is the
machinery for sound, is usually normal;
however, it is the language component that
breaks down. The memory problem is often an
inability to learn new information.

Insight into the condition is usually absent


and a person's mood is unconcerned or
uninhibited. The motor system is normal, at
least in the early stages.

Subcortical

dementia affects parts of the


brain below the cortex and is characterized
by slowing, difficulty in retrieving information
from memory, and altered mood. Parkinson's
disease and multiple sclerosis are examples
of a condition that can result in a subcortical
dementia. Language ability is usually normal,
although speech is dysfunctional and the
motor system may result in stooped or
extended posture, increased muscle tone,
and tremors. Memory problems are due to a
difficulty in retrieving information that is in
fact learned. The person's mood may be
either apathetic or depressed, and insight
into the condition is usually present.

Types of Dementia
Alzheimers

Disease

is

an irreversible, progressive disorder in which


brain cells (neurons) deteriorate, resulting in
the loss of cognitive functions, primarily
memory, judgment and reasoning, movement
coordination, and pattern recognition. In
advanced stages of the disease, all memory
and mental functioning may be lost

Vascular

Dementia

is a degenerative cerebrovascular disease that


leads to a progressive decline in memory and
cognitive functioning. It occurs when the blood
supply carrying oxygen and nutrients to the
brain is interrupted by a blocked or diseased

Types of Dementia (contd)


Picks

Disease

Pick's

Disease is the result of a build-up of protein in the


affected areas of the brain. The accumulation of abnormal
brain cells, known as Pick's bodies, eventually leads to
changes in character, socially inappropriate behavior, and
poor decision making, progressing to a severe impairment in
intellect, memory and speech. Pick's Disease is a rare disorder
that causes the frontal and temporal lobes of the brain, which
control speech and personality, to slowly atrophy.

Creutzfeldt-Jacob
is

Disease

known as a prion disease, which means that healthy brain


tissue deteriorates into an abnormal protein that the body
cannot break down. CJD is a type of transmissible spongiform
encephalopathy (TSE). "Spongiform" refers to the
characteristic appearance of an infected brain, which becomes
filled with holes until it looks like a sponge under a microscope

Types of Dementia (contd)

Huntingtons

Disease

Huntington's

Disease affects someone's ability to think, talk


and move by destroying cells in the basal ganglia, the part of
the brain that controls these capacities. Caused by a gene
mutation that leads to a toxic accumulation of protein in the
brain, Huntington's is inherited from either one or both
parents. The general symptoms in early stages can include
poor memory; difficulty making decisions; mood changes
such as increased depression, anger or irritability; a growing
lack of coordination, twitching or other uncontrolled
movements; difficulty walking, speaking, and/or swallowing.

HIV

Dementia

AIDS

dementia complex (ADC)dementia caused by HIV


infectionis a complicated syndrome made up of different
nervous system and mental symptoms. It is characterized by
cognitive deficits such as inattentiveness, impaired
concentration and problem solving, forgetfulness, and
impaired reading, motor abnormalities such as tremors,
slurred speech, ataxia, and generalized hyperreflexia; and
behavioral changes such as sluggishness and social
withdrawal.

Parkinsons Disease
Dementia caused by head trauma

4 As in dementia
Amnesia

memory impairment
Aphasia

language disturbance
Apraxia

unable to perform motor activities


Agnosia

difficulty in identifying objects

Some of the conditions that result


in dementia include:

Alzheimer's disease
Limbic encephalitis
Vascular dementia
Heavy metal exposure
Lewy body disease
Normal pressure
hydrocephalus
Parkinson's disease
Post-traumatic
dementia
Pick's disease
Multiple sclerosis

Jakob-Creutzfeldt
disease
Idiopathic basal ganglia
calcification
Neurosyphilis
Acquired immune
deficiency syndrome
(AIDS)
Fungal infections
Tuberculosis
Progressive
supranuclear palsy
Huntington's disease

Diagnostic Exam

Psychological Tests
Neurological Tests
Electroencephalograph (EEG) measures
electrical activity of brain cells
Computerized Axial Tomography (CAT)
assessed brain damage by X-ray
Positron Emission Tomography (PET)
glucose metabolism in brain is monitored
Cerebral Blood Flow patient inhales
radioactive gas and blood flow is monitored
Magnetic Resonance Imaging (MRI) patient
placed in magnetic field and radio waves used
to produce picture of brain.
Mental Status Exam
Physical Status Exam
Laboratory tests targeted at identifying
general medical and substance-related causes

Assessment

Level of consciousness not affected


Thought processes is impaired
Mental function is lost, relatively consistently for all
functions
Memory is lost,
especially for recent events
l
Use of language - sometimes has difficulty finding the
right word
Mood is usually depressed and anxious in early stage,
labile mood, restless pacing, angry out-bursts in later
stage.
Self-concept is usually angry or frustrated
Often experiences disturbed sleep-wake cycles.
Has at least one of the 4 As

Nursing Diagnosis

Risk for injury


Disturbed sleep pattern
Risk for deficient fluid volume
Risk for imbalanced nutrition: less than body
requirements
Chronic confusion
Impaired environmental interpretation syndrome
Impaired memory
Impaired social interaction
Impaired verbal communication
Ineffective role performance

Objectives
The

client will be free of injury


The client will maintain an adequate balance of
activity and rest, nutrition, hydration, and
elimination
The client will function as indepently as possible
given his or her limitations
The client will feel respected and supported
The client will remain involved in his or her
surroundings
The client will interact with others in the
environment

Nursing Interventions
Promote

clients safety

Offer unobtrussive assistance with or supervision


of activities
Identify environmental triggers to help client avoid
them

Promote

adequate sleep and proper nutrition,


hygiene and activity

Sit with client while eating


Monitor bowel elimination pattern
Remind client to urinate
Encourage mild physical activities

Structure

the environment and routine

Encourage client to follow regular routines and


habits
Monitor environmental stumulation, and adjust
when needed

Nursing Interventions
(contd)
Provide emotional support
Be kind, respectful, calm, and reassuring, pay
attention to client
Use supportive touch when necessary
Promote interaction and involvement (Milieu
management)
Plan activities according to clients interest and
abilities
Allow the client to have familiar objects around
him/her -> reality orientation, self-worth, dignity
Reminisce with client about the past
Be alert to nonverbal cues
Employ techniques of distraction
Provide a list of community resources, support groups,

Care for the caregiver


Presenting

reality & attention to the


emotional response
dementia is a primary brain pathology.
It is a long term care
Preventing burnout of the caregiver
Be supportive acknowledge the burden
Early detection of burnout what the
caregivers routine life
Respite care

Burden to the caregiver


Physical

care basic
Preventing injury for the client accidental injury
Others
Dealing with pts specific behaviors ie
agitation,
Do not challenge pts memory

Evaluation
The

client experienced no injury


The client maintained an adequate
balance of activity and rest, nutrition,
hydration, and elimination
The client can function indepently
given his or her limitations
The client felt respected and supported
The client interacts with others in the
environment

Comparing Delirium and Dementia


Feature

Delirium

Dementia

Development

Sudden

Slow

Duration

Days to weeks

Months to years

Presence of other disorders or


physical problems

Almost always present; may


be a severe illness, drug use
or withdrawal, or a problem
with metabolism

Possibly none

Variation at night

Almost always worse

Often worse

Attention

Greatly impaired

Maintained until late stages

Level of consciousness

Fluctuates from lethargy to


agitation

Normal until late stages

Orientation to surroundings

Varies

Impaired

Use of language

Slow, often incoherent, and


inappropriate

Sometimes difficulty finding


the right word

Memory

Jumbled and confused

Lost, especially for recent


events

Mental function

Lost, variably and


unpredictably

Lost, relatively consistently


for all functions

Cause

Usually an acute illness or


drugs; in older people, usually
infection, dehydration, or
drugs

Usually Alzheimer's disease,


vascular dementia, or Lewy
body dementia

Need for treatment

Emergency medical attention

Nonemergency medical
attention

PARKINSONS DISEASE

Parkinsons Disease

Parkinson's disease (PD) is commonly viewed as an


extrapyramidal motor disorder. Hence, a substantial body
of research has focused on understanding the neural
mechanisms underlying the most apparent symptoms
(tremors, slowness, initiation of movements) and on
treatment of these debilitating clinical manifestations.
However, PD is more than a motor disease; it also affects
thinking, reasoning, learning, processing speed, and
other cognitive abilities. Consequently, Parkinson's
patients exhibiting motor and cognitive symptoms
present unique challenges for the assessment and
treatment of psychopathology in their disease process. In
such patients, both quality of life and treatment outcome
are severely compromised. The cognitive changes seen in
PD patients are less understood and studied than
parkinsonian motor symptoms.

OBJECTIVES
Identify and assess nonmotor
symptoms in patients with
Parkinson's disease.
Discuss the impact of these
symptoms on patients with PD.
Offer treatment strategies to improve
nonmotor symptoms.

NONMOTOR SYMPTOMS OF
PARKINSONS DISEASE
Neuropsychiatric

and cognitive:

Depression
Anxiety
Psychosis
Dementia
Apathy
Fatigue
Sleep disturbance

Mild Cognitive Impairment


MCI
Cognitive

impairment not severe enough to


meet criteria for dementia
Affects = 50% of PD patients

Executive

impairment common to PD

Inability to plan and carry out complex activities


Involves frontal regions of the brain
May be prelude to dementia
Visuospatial,

attention, and language


deficits is also reported

Risk factors or correlates


Increasing

age
Lower level of education
Increasing severity and longer
duration of PD
atypical Parkinsonism
Psychiatric correlates or risk factors
include psychosis, apathy and
depression

AMNESTIC DISORDER

Amnestic Disorder

Amnestic disorders present as deficits in


memory, either in the inability to recall
previously learned information or the inability
to retain new information. The cognitive defect
must be limited to memory alone; if additional
cognitive defects are present, a diagnosis of
dementia or delirium should be considered. In
addition to defect in memory, there must be an
identifiable cause for the amnestic disorder
Amnestic disorders are reversible in some
cases.

Memory in Amnestic Disorders


Impairment in ability to learn new
information (Anterograde amnesia)
Impairment in ability to recall previously
learned information (Retrograde amnesia)

COMMUNITY-BASED
CARE

Community-Based Care
Home

care through home health


agencies, public health, and visiting
nurses
Adult day care centers
Residential fascilities skilled nursing
home placement