Cognitive Disorders

Cognition of the brain

- Ability to process, retain, and use information
- Cognitive abilities include reasoning, judgement,
perception, attention, comprehension, and
memory

Cognitive Disorder
- Is a disruption or impairment in these higher-
level functions of the brain
DELIRIUM
• a syndrome involves a disturbance in consciousness
accompanied by a change in cognition
• 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 and hallucinations.
• Etiology
• Always results from an identifiable physiologic, metabolic, or
cerebral disturbance or disease or from drug intoxication or
withdrawal.
• Symptoms of Delirium
✓ difficulty with attention
✓ easily distractable
✓ Disoriented
✓ sensory disturbances
✓ sleep-wake cycle disturbances
✓ changes in psychomotor activity
✓ may experience anxiety, fear, irritability, euphoria, or apathy
• Treatment and Prognosis
✓ Antipsychotics
✓ Haloperidol (Haldol) may be used in doses of 0.5 to 1 mg to decrease
agitation
✓ Sedatives and benzodiazepines are avoided because they may cause
delirium
✓ Supportive physical measures
✓ Adequate nutritious food and fluid intake
✓ Restraints
• Nursing Intervention
• do not allow the client to assume responsibility for decisions or
actions if he/she is unsafe.
• involve the client in making plans or decisions as much as he/she
is able to participate
• assess level of functioning
• assist client to establish a daily routine
• Assessment
• General appearance and Motor Behavior
• restless and hyperactive
• frequently picking at bedclothes or making sudden,
uncoordinated attempts to get out of bed
• slowed motor behavior
• appearing sluggish and lethargic with little movement
• Mood and Affect
• have rapid and unpredictable mood shifts
• anxiety
• fear
• irritability
• anger
• euphoria
• Apathy
• Thought process and Content
• thought content is often unrelated to the situation
• speech is illogical and difficult to understand
• thought process are disorganized and make no sense
• thought may also be fragmented
• may exhibit delusions, believing that their altered sensory perceptions are
real
• Sensorium and Intellectual Process
• altered LOC
• disoriented to time and place
• demonstrate decreased awareness of the environment or
situation and instead
• may focus on irrelevant stimuli
• noises , people, or sensory misperceptions easily distract
them
• Judgement and Insight
• Impaired
• cannot perceive potential harmful situation or act in their own
best interests.
• patients with delirium may have no insight into the situation
• Roles and Relationships
• clients are unlikely to fulfill their roles during the course
of delirium
• Self-concept
• clients are often frightened or feel threatened
• those with some awareness of the situation may feel
helpless or powerless to do anything to change it.
• clients may feel guilt, shame, or humiliation.
• Physiologic and Self-Care Considerations
• disturbed sleep-wake cycles that may include difficulty
falling asleep, daytime sleepiness, nighttime agitation, or
even the complete reversal of the usual day time
waking/nighttime cycles
• Nursing Intervention
• promoting the client’s safety
• managing the client’s confusion
• promoting sleep and proper nutrition
DEMENTIA
•amental disorder that involves multiple cognitive
deficits, primarily memory impairment, and at least
one of the following cognitive disturbances:
 Aphasia-the deterioration of language function
 Apraxia-impaired ability to execute motor functions despite
motor abilities
 Agnosia-inability to recognize or name objects despite intact
sensory abilities
 Disturbance in executing functioning, which is the ability to
think abstractly and to plan, initiate, sequence, monitor,
monitor, and stop complex behavior
SYMPTOMS OF DEMENTIA
• 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 abilities
ONSET AND CLINICAL COURSE
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
loses
• occupational and social setting are less enjoyable, and
the person may avoid them
• Moderate
• confusion is apparent, along with progressive memory loss
• the person no longer performs complex tasks but remains oriented to
time and place
• he or she still recognizes familiar people
• toward 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
• Severe
• personality and emotional changes occur
• the person may be delusional, wander at night, forget the names of his
or her spouse and children, and requires assistance in activities of daily
living (ADLs)
Most common types of dementia and their known or hypothesized causes:
• Alzheimer’s Disease
✓ 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.
• Vascular Dementia
✓ has symptoms similar to those of Alzheimer’s disease, but onset is
typically abrupt, followed by rapid changes in functioning; a plateau or
leveling-off period; more abrupt changes; another leveling-off period;
and so on.
✓ computed tomography or MRI usually shows multiple vascular lesions
of the cerebral cortex and subcortical structures resulting from the
decreased blood supply to the brain.
• Pick’s Disease
✓ a degenerative brain disease that particularly affects the frontal and temporal
lobes and results in a clinical picture similar to that of Alzheimer’s disease.
✓ 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
• Creutztfeldt-Jakob Disease
✓ is a central nervous system disorder that typically develops in adults 40-60
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 encelopathy 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 problems
• this may result directly from invasion of nervous tissue by HIV or from
other acquired immunodeficiency syndrome-related illnesses such as
toxoplasmosis and cytomegalovirus.
• this type of dementia can result in a wide variety of symptoms and
ranging from mild sensory impairment to gross memory and cognitive
deficits to severe muscle dysfunction
• Parkinson’s Disease
• is a slowly progressive neurologic condition characterized by tremor,
rigidity, bradykinesia, and postural instability
• dementia has been reported in approximately 20%-60% of people with
Parkinson’ disease and is characterized by cognitive and motor slowing,
impaired memory, and impaired executive functioning
• Huntington’s Disease
• is an inherited, dominant gene disease that primarily involves cerebral
atrophy, demyelination, an enlargement of the brain ventricles
• initially there are choreiform movements that are continuous during
walking hours and involves facial contortions, twisting, turning, and
tongue movements
• personality changes are the initial psychosocial manifestations,
followed by memory loss, decreased intellectual functioning and
other signs od dementia
• begins in the late 30s or early 40s and may last 10-20 years or more
before death.
Treatment and Prognosis
• the prognosis involves rapid deterioration of physical and mental
abilities until death
Drugs used to treat Dementia
NAME DOSAGE RANGE AND NURSING CONSIDERATIONS
ROUTE
Donepezil 5-10 mg orally per day Monitor for nausea, diarrhea, and
(Aricept) insomia.
Test stools periodically for GI bleeding .
Rivastigmine 3-12 mg orally per day divided Monitor for nausea, diarrhea, vomiting,
(Exelon) into two doses abdominal pain, and loss of appetite

Galantamine 16-32 mg orally per day Monitor for nausea, vomiting, loss of
(Reminyl) divided into two doses appetite, dizziness, and syncope

Memantine 10-20 mg per day divided into Monitor for hypertension, pain,
(Namenda) two doses headache, vomiting, constipation, and
fatigue.
COMPARISONS OF DELIRIUM AND DEMENTIA
INDICATOR DELIRIUM DEMENTIA
• Onset • Rapid • Gradual and insidious

• Duration • Brief (hours to day) • Progressive deterioration

• Level of consciousness • Impaired, flactuates • Not affected

• Memory • Short-term memory • Short- then long-term memory

impaired, eventually destroyed
• speech • Impaired, may be slurred, • Normal in early stage, progressive
rambling, pressured, irrelevant aphasia in later stage

• Temporarily disorganized • Impaired thinking, eventually loss of

• Thought processes
thinking abilities
• Visual or tactile hallucinations, • Often absent, but can have paranoia,
• Perception
delusions hallucinations, illusions

• Anxious, fearful in • Depressed and anxious in early stage,

● Mood
hallucinating, weeping, irritable labile mood, restless pacing, angry
outbursts
Neurodevelopmental
Disorders
Intellectual Disability (Intellectual
Developmental Disorder)
⮚ Intellectual disability is a “developmental disorder with onset prior to age
18 years, characterized by impairments in measured intellectual
performance and adaptive skills across multiple domains”
⮚ General intellectual functioning is measured by both clinical assessment
and an individual’s performance on intelligence quotient (IQ) tests.
⮚ Intellectual disability is the correct diagnostic term for what was once
called mental retardation, a term often used in a disparaging manner to
bully or ridicule individuals with impaired cognitive abilities.
⮚ The degree of disability is based on IQ and cognitive functioning, often
categorized as mild, moderate, severe, or profound (King, Toth, DeLacy, &
Doherty, 2017).
Predisposing Factors
⮚ The etiology of intellectual disability may be primarily biological, primarily
psychosocial, a combination of both, or, in some instances, unknown.
⮚ Black and Andreasen (2011) state that intellectual disability “is a
syndrome that represents a final common pathway produced by a variety
of factors that injure the brain and affect its normal development”
o Genetic Factors
o Disruptions in Embryonic Development
o Pregnancy and Perinatal Factors
o General Medical Conditions Acquired in Infancy or Childhood
o Sociocultural Factors and Other Mental Disorders
Note:
⮚ Nurses should assess and focus on each client’s strengths and
individual abilities. Knowledge regarding level of independence in the
performance of self-care activities is essential to the development of an
adequate plan for the provision of nursing care.
AUTISM SPECTRUM DISORDER
⮚ diagnosis that includes disorders previously categorized as different
types of a pervasive developmental disorder (PDD), characterized by
pervasive and usually severe impairment of reciprocal social
interaction skills, communication deviance, and restricted
stereotypical behavioral patterns.
⮚ ASD, formerly called autistic disorder, or just autism, is almost five
times more prevalent in boys than in girls, and it is usually identified
by 18 months and no later than 3 years of age.
⮚ Children with ASD have persistent deficits in communication and
social interaction accompanied by restricted, stereotyped patterns of
behavior and interests/activities.
⮚ The goals of treatment of children with autism are to reduce behavioral symptoms
(e.g., stereotyped motor behaviors) and to promote learning and development,
particularly the acquisition of language skills.
o Comprehensive and individualized treatment, including special education and
language therapy, as well as cognitive behavioral therapy for anxiety and
agitation, is associated with more favorable outcomes. Pharmacologic
treatment with
▪ antipsychotics, such as haloperidol (Haldol), risperidone (Risperdal),
aripiprazole (Abilify), or combinations of antipsychotic medications, may be
effective for specific target symptoms such as temper tantrums,
aggressiveness, self-injury, hyperactivity, and stereotyped behaviors
(Sharma, Gonda, & Tarazi, 2018).
▪ Other medications, such as naltrexone (ReVia), clomipramine (Anafranil),
clonidine (Catapres), and stimulants to diminish self-injury and hyperactive
and obsessive behaviors, have had varied but unremarkable results. There
are no medications approved for the treatment of ASD itself.
Behaviors Common with ASD
⮚ Not responding to own name by 1 year (e.g., appears not to hear)
⮚ Doesn’t show interest by pointing to objects or people by 14 months of
age
⮚ Doesn’t play pretend games by 18 months of age
⮚ Avoids eye contact
⮚ Prefers to be alone
⮚ Delayed speech and language skills
⮚ Obsessive interests (e.g., gets stuck on an idea)
⮚ Upset by minor changes in routine
⮚ Repeats words or phrases over and over
⮚ Flaps hands, or rocks or spins in a circle; answers are unrelated to
questions
⮚ Unusual reactions to sounds, smells, or other sensory experiences
Related Disorders
⮚ Tic Disorders
▪ A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or
vocalization. Tics can be suppressed but not indefinitely. Stress exacerbates
tics, which diminish during sleep and when the person is engaged in an
absorbing activity.
▪ Tic disorders are usually treated with risperidone (Risperdal) or olanzapine
(Zyprexa), which are atypical antipsychotics.
▪ It is important for clients with tic disorders to get plenty of rest and to manage
stress because fatigue and stress increase symptoms (Jummani & Coffey,
2017).
o Tourette disorder
▪ involves multiple motor tics and one or more vocal tics, which occur many times
a day for more than 1 year. The complexity and severity of the tics change over
time, and the person experiences almost all the possible tics described
previously during his or her lifetime.
⮚ Chronic Motor or Tic Disorder
o Chronic motor or vocal tic differs from Tourette disorder in
that either the motor or the vocal tic is seen, but not both.
⮚ Learning Disorders
o A specific learning disorder is diagnosed when a child’s
achievement in reading, mathematics, or written expression
is below that expected for age, formal education, and
intelligence.
o Learning problems interfere with academic achievement and
life activities requiring reading, math, or writing.
⮚ Motor Skills Disorder
o The essential feature of developmental coordination disorder is
impaired coordination severe enough to interfere with academic
achievement or activities of daily living.
o This diagnosis is not made if the problem with motor coordination is
part of a general medical condition, such as cerebral palsy or
muscular dystrophy. This disorder becomes evident as a child
attempts to crawl or walk or as an older child tries to dress
independently or manipulate toys such as building blocks.
o Stereotypic movement disorder is characterized by rhythmic,
repetitive behaviors, such as hand waving, rocking, head banging,
and biting, that appears to have no purpose.
⮚ Communication Disorders
o A communication disorder involves deficits in language, speech, and
communication and is diagnosed when deficits are sufficient to hinder
development, academic achievement, or activities of daily living, including
socialization.
▪ Language disorder involves deficit(s) in language production or
comprehension, causing limited vocabulary and an inability to form
sentences or have a conversation.
▪ Speech sound disorder is difficulty or inability to produce intelligible
speech, which precludes effective verbal communication.
▪ Social communication disorder involves the inability to observe social
“rules” of conversation, deficits in applying context to conversation,
inability to tell a story in an understandable manner, and inability to take
turns talking and listening with another (Koyama & Beitchman, 2017).
⮚ Elimination Disorders
o Encopresis is the repeated passage of feces into
inappropriate places such as clothing or the floor by a child
who is at least 4 years of age either chronologically or
developmentally.
o Enuresis is the repeated voiding of urine during the day or
at night into clothing or bed by a child at least 5 years of
age either chronologically or developmentally.
o Both encopresis and enuresis are more common in boys
than in girls; 1% of all 5-year-olds have encopresis and 5%
of all 5-year-olds have enuresis.
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
⮚ is characterized by inattentiveness, overactivity, and impulsiveness. ADHD is a
common disorder, especially in boys, and probably accounts for more child
mental health referrals than any other single disorder.
⮚ There are other disorders and situations that may look similar to ADHD, such as
bipolar disorder or behavioral acting out in response to family stress, such as
divorce, parental mental disorders, and so forth. A key feature of ADHD is the
consistency of the child’s behavior—every day, in almost all situations, and
with almost all caregivers, the child demonstrates the problematic behaviors.
Distinguishing bipolar disorder from ADHD can be difficult but is crucial to
prescribe the most effective treatment.
Onset and Clinical Course
⮚ ADHD is usually identified and diagnosed when the child begins
preschool or school, though many parents report problems from a much
younger age. As infants, children with ADHD are often fussy and
temperamental and have poor sleeping patterns.
o Toddlers may be described as “always on the go” and “into
everything,” at times dismantling toys and cribs. They dart back and
forth, jump and climb on furniture, run through the house, and cannot
tolerate sedentary activities such as listening to stories.
o By the time the child starts school, symptoms of ADHD begin to
interfere significantly with behavior and performance.
Etiology
⮚ Although much research has taken place, the definitive causes of ADHD
remain unknown.
⮚ Combined factors, such as environmental toxins, prenatal influences,
heredity, and damage to brain structure and functions, are likely
responsible.
⮚ Prenatal exposure to alcohol, tobacco, and lead and severe malnutrition
in early childhood increase the likelihood of ADHD.
⮚ Risk factors for ADHD include family history of ADHD;
o male relatives with antisocial personality disorder or alcoholism;
o female relatives with somatization disorder; lower socioeconomic
status; male gender; marital or family discord, including divorce,
neglect, abuse, or parental deprivation; low birth weight; and various
kinds of brain insult (McGough, 2017).
Treatment
⮚ No one treatment has been found to be effective for ADHD
⮚ The most effective treatment combines pharmacotherapy with
behavioral, psychosocial, and educational interventions.
⮚ Psychopharmacology
o Medications are often effective in decreasing hyperactivity and impulsiveness and
improving attention; this enables the child to participate in school and family life.
▪ The most common medications are methylphenidate (Ritalin) and an
amphetamine compound (Adderall).
● Methylphenidate is also available in a daily transdermal patch, marketed as
Daytrana. Because pemoline can cause liver damage, it is the last of these
drugs to be prescribed.
▪ Dextroamphetamine (Dexedrine) and pemoline (Cylert) are other stimulants used
to treat ADHD.
▪ Giving stimulants during daytime hours usually effectively combats insomnia.
▪ Eating a good breakfast with the morning dose and substantial nutritious snacks
late in the day and at bedtime helps the child maintain an adequate dietary
intake.
▪ When stimulant medications are not effective or their side effects are intolerable,
antidepressants are the second choice for treatment.
Strategies for Home and School
⮚ therapeutic play, play techniques are used to understand the
child’s thoughts and feelings and to promote communication.
o Dramatic play is acting out an anxiety-producing situation
such as allowing the child to be a doctor or use a
stethoscope or other equipment to take care of a patient (a
doll).
o Play techniques to release energy could include pounding
pegs, running, or working with modeling clay.
o Creative play techniques can help children to express
themselves; for example, by drawing pictures of themselves,
their family, and peers.
NURSING INTERVENTIONS
⮚ For ADHD
o Ensuring the child’s safety and that of others
o Improved role performance
o Structured daily routine
o Client/family education and support: Listen to parent’s feelings and frustrations.
▪ Include parents in planning and providing care.
▪ Refer parents to support groups.
▪ Focus on child’s strengths as well as problems.
▪ Teach accurate administration of medication and possible side effects.
▪ Inform parents that child is eligible for special school services.
▪ Assist parents in identifying behavioral approaches to be used at home.
▪ Help parents achieve a balance of praising child and correcting child’s
behavior.
▪ Emphasize the need for structure and consistency in child’s daily routine
and behavioral expectations.