Prepared by:
Mary Ruth V. Enriquez, RN MAN
Cognitive
Is the brains ability to process, retain, and use information.
Cognitive abilities : include reasoning, judgment, perception, attention, comprehension, and
memory.
These are essential for many important tasks, including making decisions, solving problems,
interpreting the environment, and learning new information.
Cognitive disorder
Is a disruption or impairment in these higher-level functions of the brain.
Can have devastating effects on the ability to function in daily life.
They can cause people to forget the names of immediate family members, to be unable to
perform daily household tasks, and to neglect personal hygiene.
The Primary Categories of Cognitive Disorders are:
Delirium
Dementia
Amnestic disorders
AMNESTETIC DISORDER
Characterized by a disturbance in memory that results directly from the physiologic
effects of a general medical condition or from the persisting effects of a substance
such as alcohol or other drugs.
Delirium
is an acute condition; it develops quickly, often in response to prescription
medications, alcohol, exposure to some toxic environmental substance, fever, or
systemic illness.
People in a state of delirium may feel frightened, anxious, and confused, and they
may also experience hallucination.
Usually develops over a short period , sometimes a matter of hours, and fluctuates, or
changes, throughout the course of the day.
Client s w/ delirium have difficulty paying attention, are easily distracted and
disoriented, and may have sensory disturbances such as illusion, misinterpretations,
or hallucinations.
Ex. Illusion: an electrical cord on the floor may appear to them to be a snake
Misinterpretation : they may mistake the banging of a laundry cart in the hallway for
a gunshot.
Hallucination : they may see angels hovering above when nothing is there.
Delirium
Etiology:
Syphilis
Drug related:
Intoxication
Anticholinergic
Lithium
Alcohol
Sedative and hypnotics
Reactions to anesthesia
Prescription medication, or illicit (street) drugs.
Treatment and Prognosis
The primary treatment for delirium is to identify and treat any causal or contributing
medical conditions.
Some causes such as head injury or encephalitis may leave clients w/ cognitive,
behavioral, or emotional impairments even after the underlying cause resolves.
Pharmacology
Antipsychotic medication such as haloperidol (Haldol) may be used in doses of 0.5 to 1mg to
decrease agitation.
Sedative and benzodiazepines are avoided because they may worsen delirium.
The exception is delirium induced by alcohol withdrawal, w/c usually is treated w/
Benzodiazepines
Nursing Interventions for Delirium
1.Promoting clients safety
Teach client to request assistance for activities (getting out of bed, going to bathroom)
Speak to client in a calm manner in a clear low voice; use simple sentences.
Monitor clients response to visitors; explain to family and friends that client may need to
visit quietly one on one.
Monitor food and fluid intake; provide prompts or assistance to eat and drink adequate
amounts of food and fluids.
Encourage some exercise during day like sitting in a chair, walking in hall, or other
activities client can manage.
DEMENTIA
Disturbances in executive functioning are evident as clients lose the ability to learn new material,
solve problems, or carry out daily activities such as meal planning or budgeting.
Onset and Clinical Course
When an underlying, treatable cause is not present, the course of dementia is usually
progressive. Dementia often is described in stages:
Mild : forgetfulness is the hallmark of beginning, mild dementia. It exceeds the
normal, occasional forgetfulness experienced as part of the aging process.
The person has difficulty finding words, frequently loses objects, and begins to
experience anxiety about these losses. Occupational and social settings are less
enjoyable , and the person may avoid this stage.
Moderate : confusion is apparent, along with progressive memory loss. The person no
longer can perform complex tasks but remains oriented to person and place.
He or she still recognizes familiar people.
Towards the end of this stage, the person loses the ability to live independently and
requires assistance because of disorientation to time and loss of information such as
address and telephone number.
The person may remain in the community if adequate caregiver support is available,
but some people move to supervised living situations.
Severe : personality and emotional changes occur. The person may be delusional,
wander at night, forget the names of his or her spouse and children, requires
assistance in activities of daily living (ADLs).
Most people live in nursing facilities when they reach this stage unless extraordinary
community support is available.
The most common types of dementia
Alzheimers disease
Vascular dementia
Picks disease
Creutzfeldt-Jacob disease
HIV infection
Parkinsons disease
Huntingtons disease
Alzheimers disease
Is a progressive brain disorder that 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.
Alzheimers disease
Alzheimers disease
Risk for Alzheimer's disease increases w/ 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.
Vascular dementia
Has symptoms similar to those of Alzheimers disease, but onset is typically abrupt,
followed by rapid changes in functioning; a plateau, or leaving off period; more abrupt
changes; another leveling-off period; and so on.
Computed tomography or magnetic resonance imaging usually shows multiple
vascular lesions of the cerebral cortex and subcortical structures resulting from the
decreased blood supply to the brain.
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 disease.
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.
Creutzfeldt-Jacob 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.
HIV INFECTION
Can lead to dementia and other neurologic problem; these may result directly from
invasion of nervous tissue by HIV or from other acquired immunodeficiency syndromerelated 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 deficits 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 Parkinson's
disease and is characterized by cognitive and motor slowing, impaired memory, and
impaired executive functioning.
Huntingtons disease
Is an inherited, dominant gene disease that primarily involves cerebral atrophy,
demyelination, and enlargement of the brain ventricles, initially, there are choreiform
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 thirties or early forties and may last 10 to 20 years or
more before death.
Treatment and Prognosis
The underlying cause of dementia is identified so that treatment can be instituted.
For example, the progress of vascular dementia, second most common type, may be
halted w/ appropriate treatment of the underlying vascular condition (e.g. Changes in
diet, exercise, control of hypertension or diabetes). Improvement of cerebral blood flow
may arrest the progress of vascular dementia in some people.
The prognosis for the progressive types of dementia may vary, but all prognoses involve
progressive deterioration of physical and mental abilities until death. Typically , in the
later stages, client s have minimal cognitive and motor function, are totally dependent on
caregivers, and are unaware of their surroundings or people in the environment. They may be
totally uncommunicative or make unintelligible sounds or attempts to verbalize.
For degenerative dementias, no direct therapies have been found to reverse or retard the
fundamental pathophysiologic processes. Levels of numerous neurotransmitters such as
acetylcholine, dopamine, norepinephrine, and serotonin are decreased in dementia.
This has led to attempts at replishment therapy with acetylcholine precursors,
cholinergic agonists, and cholinesterase inhibitors.
Medications
Cholinesterase inhibitors : have shown modest therapeutic effects and temporarily slow the
progress of dementia.
Tacrine (Cognex)
Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Reminyl)
Clients w/ dementia demonstrate a broad range of behaviors that can be treated
symptomatically. Doses of medications are one half to two thirds lower than usually
prescribed.
Antidepressants are effective for significant depressive symptoms.
Antipsychotics such as haloperidol (Haldol), Olanzapine (Zyprexa), Risperidone (Risperdal),
and Quetiapine (Seroquel)
May be used to manage psychotic symptoms of delusion, hallucinations, or paranoia.
Lithium carbonate , Carbamazepine (Tegretol), and Valproic acid (Depakote)
Prepare desirable foods and foods client can self-feed; sit w/ client while eating
Encourage client to follow regular routine and habits of bathing and dressing rather than
impose new ones.
Employ techniques of distraction, time away, going along or reframing to calm clients who
are agitated, suspicious, or confused.
DELIRIUM
DEMENTIA
ONSET
RAPID
DURATION
PROGRESSIVE
DETERIORATION
LEVEL OF
CONSCIOUSNES
IMPAIRED, FLUCTUATES
NOT AFFECTED
S
MEMORY
SHORT-TERM MEMORY
IMPAIRED, EVENTUALLY
DESTROYED
INDICATOR
DELIRIUM
DEMENTIA
SPEECH
THOUGH
PROCESSES
TEMPORARILY DISORGANIZED
IMPAIRED THINKING,
EVENTUAL LOSS OF
THINKING ABILITIES
PERCEPTION
VISUAL OR TACTILE
HALLUCINATIONS, DELUSION
MOOD
ANXIOUS, FEARFUL IF
HALLUCINATING; WEEPING,
IRRITABLE