Cognitive Disorder
NCM 117/ PSYCHIATRIC NURSING/ LECTURE
Cognition
• It is the brain’s ability to process, retain,
and use information.
• Cognitive abilities include: reasoning,
judgment, perception, attention,
comprehension, and memory.
Cognitive Disorder
• It is a disruption or impairment in these
higher – level functions of the brain.
• It can cause people to forget the names
of immediate family members, be unable
to perform daily household tasks, and
neglect personal hygiene.
Neurocognitive Disorders (DSM 5)
• Delirium
• Major Neuro Cognitive Disorder
• Mild Neuro Cognitive Disorder and their
subtypes by etiology.
1. Delirium
• It is a syndrome that involves a
disturbance of consciousness
accompanied by a change in cognition.
• It usually develops over a short period,
sometimes a matter of hours, and
fluctuates, or changes throughout the
course of the day
• Clients with delirium have difficulty
paying attention, are easily distracted
and disoriented, and may have sensory
disturbances such as:
✓ Illusions
✓ Misinterpretations, or
✓ Hallucinations
• Elderly patients are the group most
frequently diagnosed with delirium
• Between 14% and 24% of people
admitted to the hospital for general
medical conditions are delirious, which
may worsen in the hospital.
Risk Factors:
• Increased severity of physical illness
• Older age
• Hearing impairment
• Decreased food and fluid intake,
medications, and
• Baseline cognitive impairment
Most Common Causes of Delirium
Physiological Hypoxemia, electrolyte
or Metabolic disturbances; renal or hepatic
failure; hypoglycemia or
hyperglycemia; dehydration;
sleep deprivation; thyroid or
glucocorticoid disturbances
Infection Systemic: sepsis, UTI,
pneumonia
Cerebral: Meningitis,
encephalitis, HIV, syphilis
Drug Related Intoxication: anticholinergics,
lithium, alcohol, sedatives, and
hypnotics
Withdrawal: alcohol, sedatives,
and hypnotics
Reactions to anesthesia,
prescription medication, or illicit
(street) drugs
Treatment and Prognosis
• Primary treatment is to identify and treat
any causal or contributing medical
conditions.
• It is almost always a transient condition
that clears with successful treatment of
the underlying cause
• People who have had delirium are at
higher risk for future episodes.
Psychopharmacology
• Clients with quiet, hypoactive delirium
need no specific pharmacologic
treatment aside from that indicated for
the causative condition.
• Antipsychotic medication [haloperidol
(Haldol)], may be used in doses of 0.5 to
1mg to decrease agitation and psychotic
symptoms as well as to facilitate sleep.
Other Medical Treatment
• Adequate nutritious food and fluid intake
• IV fluids or even TPN (if a client’s
physical condition has deteriorated)
Application of the Nursing Process: Delirium
Assessment
• History
• General appearance and motor behavior
• Mood and affect
• Thought process and content
• Sensorium and intellectual processes
• Judgment and insight
• Roles and relationships
• Self-concept
Data Analysis: Primary Nursing Diagnosis
• Risk for Injury
• Acute Confusion
• Disturbed Sensory Perception
• Risk for Deficient Fluid Volume
• Risk for Imbalance Nutrition: Less than
Body Requirements
Outcome Identification
• The client will be free from 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 return to his or her
optimal level of functioning.
Intervention
• Promoting client’s safety
• Managing client’s confusion
• Controlling environment to reduce
sensory overload
• Promoting sleep and proper nutrition
Cognitive Disorder
NCM 117/ PSYCHIATRIC NURSING/ LECTURE
Evaluation
• Usually, successful treatment of the
underlying causes of delirium returns
clients to their previous levels of
functioning.
2. Dementia
• It refers to a disease process marked by
progressive cognitive impairment with no
change in the level of consciousness
• It involves multiple cognitive deficits,
initially, memory impairment, and later
cognitive disturbances
Cognitive Disturbances
3. Mild Neuro Cognitive Disorder
• It refers to a mild cognitive decline, and a
modest impairment of performance that
doesn’t prevent independent living but
may require some accommodation or
assistance
4. Major Neuro Cognitive Disorder
• It refers to a significant cognitive decline
and a substantial impairment in
performance that interferes with activities
of daily independent living.
Dementia
• 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, forgetting where certain objects
where placed or that food is cooking on
the stove.
• In later stages, dementia affects remote
memory; clients forget the names of adult
children, their lifelong occupations, and
even their names.
Onset and Clinical Course
1. Mild Dementia
• Forgetfulness is the hallmark of
beginning, mild dementia.
• Difficulty finding words, frequent
loses objects, and begins to
experience anxiety about these
loses.
• Occupational and social settings
are less enjoyable, and the person
may avoid them.
2. Moderate Dementia
• Confusion is apparent, along with
progressive memory loss.
•Can no longer perform complex
tasks but remains oriented to
person and place
• Still recognize familiar people
• Toward the end of this stage, the
person loses the ability to live
independently and requires
assistance because of
disorientation to time a loss of
information, such as address and
telephone number.
3. Severe Dementia
• Personality and emotional
changes occur
• May e delusional, wander at night,
forget the names of his or her
spouse and children, and require
assistance with ADLs.
• Most people live in nursing
facilities when they reach this
stage.
Etiology of Dementia
• Causes vary, through the clinical picture
is similar for most dementias.
• Metabolic activity is decreased in the
brains of clients with dementia
• Genetic component.
Common types of Dementia and their known or
hypothesized causes
1. Alzheimer’s 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 the following:
✓ Atrophy of cerebral neurons
✓ Senile plaque deposits, and
✓ Enlargement of the third and
fourth ventricles of the brain.
2. Lewy Body Dementia
• It is a disorder that involves
progressive cognitive impairment
and extensive neuropsychiatric
symptoms as well as motor
symptoms.
• Delusions and visual hallucinations
are common
• Functional impairments may initially
be more pronounced than cognitive
deficits.
3. Vascular Dementia
• Has symptoms similar to those of
Alzheimer’s Disease, but onset is
typically abrupt, followed by rapid
changes in functioning.
• There is a plateau, or leveling-off
period; and so on.
• CT scan or MRI usually shows
multiple vascular lesions of the
Cognitive Disorder
NCM 117/ PSYCHIATRIC NURSING/ LECTURE
cerebral cortex and subcortical
structures resulting from the
decreased blood supply to the
brain.
4. Frontotemporal Lobar Degeneration
(originally called Pick Disease)
• It is degenerative brain disease that
particularly affects the frontal and
temporal lobes and results in a
clinical picture similar to that of AD.
• Early signs include personality
changes, loss of social skills and
inhibitions, emotional blunting, and
language abnormalities.
• Onset is most commonly 50 – 60
years of age; death occurs in 2 – 5
years.
• There is a strong genetic
component, and it tends to run in
families.
5. Prion Disease
• These are caused by a prion (a
type of protein) that can trigger
normal proteins in the brain to fold
abnormally.
• It is a CNS disorder that typically
develops in adults aged 40 – 60
years.
• It involves altered vision, loss of
coordination or abnormal
movements, and dementia that
usually progresses rapidly (a few
months)
6. HIV infection leading to dementia and
other neurologic problems
• 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.
7. Parkinson Disease
• It 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 25% (mild NCD) to
as many as 75% (major NCD) of
people with Parkinson disease
8. Huntington Disease
• It 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 walking 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.
• Begins in the last 30s or early 40s
and may last 10 – 20 years or more
before death.
9. Traumatic brain injury
• This can cause dementia as a direct
pathophysiological consequence of
head trauma.
• The degree and type of cognitive
impairment and behavioral
disturbance depend on the location
and extent of the brain injury.
Treatment and Prognosis
• Treating the underlying cause.
• Prognosis for the progressive types of
dementia may vary as described earlier,
but all prognoses involve progressive
deterioration of physical and mental
abilities until death.
• For degenerative dementias, no direct
therapies have been found to reverse pr
retard the fundamental
pathophysiological processes.
Application of the Nursing Process: Dementia
Assessment
• History
• General appearance and motor behavior
• Mood and affect
• Thought process and content
• Sensorium and intellectual processes
• Judgment and insight
• Roles and relationship
• Physiological and self-care
considerations.
Data Analysis (commonly used 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
Cognitive Disorder
NCM 117/ PSYCHIATRIC NURSING/ LECTURE
Outcome Identification
• The client will be free from injury
• The client will maintain an adequate
balance of activity and rest, nutrition,
hydration, and elimination.
• The client will function as independently
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
Intervention
• Promoting the client’s safety
• Promoting adequate sleep and proper
nutrition, hygiene, and activity
• Structuring the environment and routine
• Providing emotional support
• Promoting interaction and involvement
Points to consider when working with clients
with dementia
• Remember how important it is to provide
dignity for the client and family as the
client’s life ends.
• Remember that death is the last stage of
life. The nurse can provide emotional
support for the client and family during
this period.
• Clients may not notice the caring,
patience, and support the nurse offers,
but these qualities will mean a great deal
to the family for a long time.