Cognitive

Disorder

is the brains ability to process, retain, and use information. Cognitive abilities include reasoning, judgment, perception, attention, comprehension, and memory.

A cognitive disorder is a disruption or impairment in these higher-level functions of the brain.

Delirium Dementia Amnestic disorders

Is a syndrome that involves a disturbance of consciousness accompanied by a change in cognition. It develops over a short period, sometimes a matter of hours, and fluctuates or changes throughout the course of the day.

Risk factors for delirium include increased severity of physical illness, older age, and baseline cognitive impairment. Children may be more susceptible to delirium especially related to a febrile illness or certain medications such as anticholinergics.

Difficulty with wake cycle attention disturbances Easily distractible Changes in psychomotor Disoriented activity May have sensory disturbances such May experience anxiety, fear, as illusions, misinterpretations, irritability, euphoria, or or hallucinations Can have sleep apathy

Delirium almost always results from an identifiable physiologic, metabolic, or cerebral disturbance or disease or from drug intoxication or withdrawal.

Physiologic or metabolic

Hypoxemia, electrolyte disturbances, renal or hepatic failure, hypo- or hyperglycemia, dehydration, sleep deprivation, thyroid or glucocorticoid disturbances, thiamine or vitamin B12 deficiency, vitamin C, niacin, or protein deficiency, cardiovascular shock, brain tumor, head injury, and exposure to gasoline, paint solvents, insecticides, and related substances Systemic: sepsis, urinary tract infection, pneumonia Cerebral: meningitis, encephalitis, HIV, syphilis Intoxication: anticholinergics, lithium, alcohol, sedatives, and hypnotics Withdrawal: alcohol, sedatives, and hypnotics Reactions to anesthesia, prescription medication or illicit (street) drugs

Infection

Drug-related

Sedation to prevent inadvertent self-injury may be indicated. An antipsychotic medication such as haloperidol (Haldol) may be used in doses of 0.5 to 1 mg to decrease agitation. Sedatives and benzodiazepines are avoided because they may worsen delirium.
Clients with impaired liver or kidney function

could have difficulty metabolizing or excreting sedatives. withdrawal, which usually is treated with benzodiazepines.

The exception is delirium induced by alcohol

Adequate, nutritious food and fluid intake will speed recovery. Intravenous fluids or even total parenteral nutrition may be necessary if a clients physical condition has deteriorated and he or she cannot eat and drink. If a client becomes agitated and threatens to dislodge intravenous tubing or catheters, physical restraints may be necessary so that needed medical treatments can continue.

HISTORY
Because the causes of delirium are often

related to a medical illness, alcohol, or other drugs, the nurse obtains a thorough history of these areas. The nurse may need to obtain information from family members if a clients ability to provide accurate data is impaired. Information about drugs should include prescribed medications, alcohol, illicit drugs, and over -the-counter medications.

GENERAL APPEARANCE AND MOTOR BEHAVIOR

They may be restless and hyperactive,

frequently picking at bedclothes or making sudden, uncoordinated attempts to get out of bed. Conversely clients may have slowed motor behavior, appearing sluggish and lethargic with little movement.

 Speech also may be affected,

becoming less coherent and more difficult to understand as delirium worsens. Clients may perseverate on a single topic or detail, may be rambling and difficult to follow, or may have pressured speech that is rapid, forced, and usually louder than normal. At times clients may call out or scream especially at night.

MOOD AND AFFECT

A wide range of emotional responses is

possible such as anxiety, fear, irritability, anger, euphoria, and apathy. These mood shifts and emotions usually have nothing to do with the clients environment. When clients are particularly fearful and feel threatened, they may become combative to defend themselves from perceived harm.

THOUGHT PROCESS AND CONTENT

Marked inability to sustain attention

makes it difficult to assess thought process and content.

often is unrelated to the situation, or speech is illogical and difficult to understand. how clients are

Thought content in delirium

The nurse may ask

feeling, and they will mumble about the weather.

 Thought

processes

often

are

disorganized and make no sense.

Thoughts

also may be fragmented (disjointed and incomplete). Clients may exhibit delusions, believing that their altered sensory perceptions are real.

SENSORIUM PROCESSES

AND

INTELLECTUAL

Clients usually are oriented to person but

frequently disoriented to time and place. They demonstrate decreased awareness of the environment or situation and instead may focus on irrelevant stimuli such as the color of the bedspread or the room. Clients cannot focus, sustain, or shift attention effectively, and there is impaired recent and immediate memory.

 Clients frequently experience

misinterpretations, illusions, and hallucinations. Both misperceptions and illusions are based on some actual stimuli in the environment.

JUDGMENT AND INSIGHT

Judgment is impaired. Clients often

cannot perceive potentially harmful situations or act in their own best interests. Insight depends on the severity of the delirium. Clients with mild delirium may recognize that they are confused, receiving treatment, and will likely improve. Those with severe delirium may have no insight into the situation.

ROLES AND RELATIONSHIPS

Clients are unlikely to fulfill their roles

during the course of delirium. Most regain their previous level of functioning, however, and have no longstanding problems with roles or relationships.

SELF-CONCEPT
Clients often are frightened or feel

threatened. Those with some awareness of the situation may feel helpless or powerless to do anything to change it. If delirium has resulted from alcohol, illicit drug use, or overuse of prescribed medications, clients may feel guilt, shame, and humiliation or think, Im a bad person; I did this to myself.

PHYSIOLOGIC AND SELF-CARE CONSIDERATIONS

Clients with delirium most often

experience disturbed sleepwake cycles that may include difficulty falling asleep, daytime sleepiness, nighttime agitation, or even a complete reversal of the usual daytime waking/nighttime sleeping pattern. At times, clients also ignore or fail to perceive internal body cues such as hunger, thirst or the urge to urinate or defecate.

PROMOTING THE CLIENTS SAFETY

Teach client to request assistance for

activities (getting out of bed, going to bathroom). Provide close supervision to ensure safety during these activities. Promptly respond to clients call for assistance.

 MANAGING

CONFUSION

THE CLIENTS

Speak to client in a calm manner in a

clear low voice; use simple sentences. Allow adequate time for client to comprehend and respond. Allow client to make decisions as much as able. Provide orienting verbal cues when talking with client. Use supportive touch if appropriate.

 CONTROLLING

ENVIRONMENT TO REDUCE SENSORY OVERLOAD

Keep environmental noise to minimum (television, radio).
Monitor clients response to visitors;

explain to family and friends that client may need to visit quietly one on one. Validate clients anxiety and fears, but do not reinforce misperceptions.

PROMOTING SLEEP AND PROPER NUTRITION

Monitor sleep and elimination patterns. Monitor food and fluid intake; provide

prompts or assistance to eat and drink adequate amounts of flood and fluids. Provide periodic assistance to bathroom if client does not make requests. Discourage daytime napping to help sleep at night. Encourage some exercise during day like sitting in a chair, walking in hall, or other activities client can manage.

 Monitor chronic health conditions carefully. Visit physician regularly. Tell all physicians and health care providers

what medications are taken including over-thecounter medications, dietary supplements, and herbal preparations Check with physician before taking any nonprescription medication. Avoid alcohol and recreational drugs. Maintain a nutritious diet. Get adequate sleep. Use safety precautions when working with paint solvents, insecticides, and similar products.

is a mental disorder that involves multiple cognitive deficits, primarily memory impairment and at least one of the following cognitive disturbances

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

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 them. during 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. 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.

 The person may remain in the community if

adequate caregiver support is available, but some people move to a supervised living situation.

Severe: Personality changes occur.

and

emotional

The person may be delusional, wander at

night, forget the names of his or her spouse and children, and require assistance in activities of daily living (ADLs). Most people live in a nursing facility when they reach this stage unless extraordinary community support is available.

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.

has symptoms similar to those of Alzheimers, 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 (CT) scan or magnetic resonance imaging (MRI) usually shows multiple vascular lesions of the cerebral cortex and subcortical structures resulting from the decreased blood supply to the brain.

 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.

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.

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 deficits to severe muscle dysfunction.

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.

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 30s or early 40s and may last 10 to 20 years or more before death.

Dementia can be a direct pathophysiologic consequence of head trauma. The degree and type of cognitive impairment and behavioral 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.

Whenever possible, the underlying cause of dementia is identified so that treatment can be instituted. The prognosis for the progressive types of dementia may vary as described above but all prognoses involve progressive deterioration of physical and mental abilities until death. 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 replenishment therapy with acetylcholine precursors, cholinergic agonists, and cholinesterase inhibitors. Tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl) are cholinesterase inhibitors and have shown modest therapeutic effects and temporarily slow the progress of dementia.

They have no effect, however, on the overall course of the disease. Tacrine elevates liver enzymes in about 50% of clients using it; therefore, liver function is assessed every 1 to 2 weeks. Clients with 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 delusions, hallucinations, or paranoia. Lithium carbonate, carbamazepine (Tegretol), and valproic acid (Depakote) help to stabilize affective lability and to diminish aggressive outbursts. Benzodiazepines are used cautiously because they may cause delirium and can worsen already compromised cognitive abilities.

Assessment
The assessment process may seem confusing

and complicated to clients with dementia. They may not know or may forget the purpose of the interview. Clients may become confused or tire easily, so frequent breaks in the interview may be needed. It helps to ask simple rather than compound questions and to allow clients ample time to answer.

HISTORY
Considering

the impairment of recent memory, clients may be unable to provide an accurate and thorough history of the onset of problems. Interviews with family, friends, or caregivers may be necessary to obtain data.

GENERAL APPEARANCE AND MOTOR BEHAVIOR

Dementia progressively impairs the ability to

carry on meaningful conversation. Clients display aphasia when they cannot name familiar objects or people. Conversation becomes repetitive as they often perseverate on one idea. Eventually speech may become slurred, followed by a total loss of language function.

MOOD AND AFFECT

Initially clients with dementia experience anxiety

and fear over the beginning losses of memory and cognitive functions. Mood becomes more labile over time and may shift rapidly and drastically for no apparent reason. Emotional outbursts are common and usually pass quickly. Clients may display anger and hostility, sometimes toward other people. They begin to demonstrate catastrophic emotional reactions in response to environmental changes that clients may not perceive or understand accurately or when they cannot respond adaptively.

THOUGHT PROCESS AND CONTENT

Initially the ability to think abstractly is

impaired, resulting in loss of the ability to plan, sequence, monitor, initiate, or stop complex behavior. The client loses the ability to solve problems or to take action in new situations because he or she cannot think about what to do. The ability to generalize knowledge from one situation to another is lost because the client cannot recognize similarities or differences in situations.

SENSORIUM AND INTELLECTUAL PROCESSES

Clients lose intellectual function, which

eventually involves the complete loss of their abilities. Memory deficits are the initial and essential feature of dementia. Dementia first affects recent and immediate memory, then eventually impairs the ability to recognize close family members and even oneself. In mild and moderate dementia, clients may make up answers to fill in memory gaps (confabulation).

 Agnosia is another hallmark of dementia.

Clients lose visual spatial relations, which is

often evidenced by deterioration of the ability to write or draw simple objects. Attention span and ability to concentrate are increasingly impaired until clients lose the ability to do either. Clients are chronically confused about the environment, other people, and eventually themselves.

JUDGMENT AND INSIGHT

Clients with dementia have poor judgment

in light of the cognitive impairment. They underestimate risks and unrealistically appraise their abilities, which results in a high risk for injury. Clients cannot evaluate situations for risks or danger.

SELF-CONCEPT
Initially clients may be angry or frustrated

with themselves for losing objects or forgetting important things. Some clients express sadness at their bodies for getting old and at the loss of functioning. Soon, though, clients lose that awareness of self, which gradually deteriorates until they can look in a mirror and fail to recognize their own reflections.

ROLES AND RELATIONSHIPS

Dementia profoundly affects the clients

roles and relationships. If the client is still employed, work performance suffers even in the mild stage of dementia to the point that work is no longer possible given the memory and cognitive deficits. Roles as spouse, partner, or parent deteriorate as clients lose the ability to perform even routine tasks or recognize familiar people. Eventually clients cannot meet even the most basic needs.

PHYSIOLOGIC AND SELF-CARE CONSIDERATIONS

Clients with dementia often experience

disturbed sleepwake cycles; they nap during the day and wander at night. Some clients ignore internal cues such as hunger or thirst; others have little difficulty with eating and drinking until dementia is severe. Clients may experience bladder and even bowel incontinence or have difficulty cleaning themselves after elimination. They frequently neglect bathing and grooming. Eventually clients are likely to require complete care from someone else to meet these basic physiologic needs.

Offer unobtrusive assistance with or supervision of cooking, bathing, or selfcare activities. Identify environmental triggers to help client avoid them.

Prepare desirable foods and foods client can self-feed; sit with client while eating. Monitor bowel elimination patterns; intervene with fluids and fiber or prompts. Remind client to urinate; provide pads or diapers as needed, checking and changing them frequently to avoid infection, skin irritation, unpleasant odors. Encourage mild physical activity such as walking.

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.

Be kind, respectful, calm, and reassuring; pay attention to client. Use supportive touch when appropriate.

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.

Amnestic disorders are characterized by a disturbance in memory that results directly from the physiologic effects of a general medical condition or the persisting effects of a substance such as alcohol or other drugs. Clients with amnestic disorders are similar to those with dementia in terms of memory deficits, confusion, and problems with attention. They do not, however, have the multiple cognitive deficits seen in dementia such as aphasia, apraxia, agnosia, and impaired executive functions.

The main difference between dementia and amnestic disorders is that once the underlying medical cause is treated or removed, the clients condition no longer deteriorates. Treatment of amnestic disorders focuses on eliminating the underlying cause and rehabilitating the client and includes preventing further medical problems. Some amnestic disorders improve over time when the underlying cause is stabilized.

Remember how important it is to provide dignity for the client and family as the clients 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.