1 COGNITIVE DISORDERS Comprise a variety of assaults on the human brain. Cognition revolves around learning and memory.

y. Changes in cognition include: 1. disorientation 2. decreased concentration 3. loss of abstract thinking 4. language disturbance Person might not be able to do ADL in spite of intact motor skills. The primary categories of cognitive disorders are delirium, dementia, and amnestic disorders. Delirium is a syndrome that involves a disturbance of consciousness accompanied by a change in cognition. usually develops over a short period, sometimes a matter of hour, and fluctuates or changes throughout the course of the day. difficulty paying attention, are easily distracted and disoriented May have sensory disturbances such as illusions (electrical cord on the floor may appear to them to be a snake), misinterpretation (banging of a laundry cart in the hallway for a gunshot, and hallucinations (may see angels hovering above when nothing is there). they also experience: 1. disturbances in the sleepwake cycle 2. changes in psychomotor activity 3. emotional problems such as anxiety, fear, irritability, euphoria, or apathy. Risk factors for delirium include: 1. increased severity of physical illness 2. older age 3. baseline cognitive impairment. SYMPTOMS OF DELIRIUM Difficulty with attention Easily distractible Disoriented May have sensory disturbances such as illusions, misinterpretations, or hallucinations Can have sleepwake cycle disturbances Changes in psychomotor activity May experience anxiety, fear, irritability, euphoria, or apathy MOST COMMON CAUSES OF DELIRIUM 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 - exposure to gasoline, paint solvents, insecticides, and related substances Infection Systemic: sepsis, UTI, pneumonia Cerebral: meningitis, encephalitis, HIV, syphilis o Drug-related : Intoxication: anticholinergics, lithium, alcohol, sedatives, and hypnotics Withdrawal: alcohol, sedatives, and hypnotics Reactions to anesthesia, prescription medication or illicit (street) drugs

2 DRUGS CAUSING DELIRIUM Anticonvulsants Anticholinergics Antidepressants Antihistamines Antipsychotics Aspirin Barbiturates Benzodiazepines Cardiac glycosides Cimetidine (Tagamet) Hypoglycemic agents Insulin Narcotics Propranolol (Inderal) Reserpine Thiazide diuretics The primary nursing diagnoses for clients with delirium are as follows: Risk for Injury Acute Confusion Additional diagnoses that are commonly selected based on client assessment include the following: Disturbed Sensory Perception Disturbed Thought Processes Disturbed Sleep Pattern Risk for Deficient Fluid Volume Risk for Imbalanced Nutrition: Less Than Body Requirements OUTCOME IDENTIFICATION Treatment outcomes for the client with delirium may include the following: 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. Intervention Promoting safety priority focus 1. Medications should be used judiciously. 2. Teach client to request assistance for activities. 3. Have family member stay with the cient. Managing clients confusion 1. Approach calmly and speak in a clear, low voice. 2. Give realistic assurance such as I know things are upsetting and confusing right now, but your confusion should clear as you get better (validating/giving information). 3. Facing clients while speaking helps to capture their attention. 4. provides explanations that clients can comprehend, avoiding lengthy or too detailed discussions. 5. permits clients to make decisions as they are able and takes care not to overwhelm or frustrate them. 6. Provide orienting verbal cues when talking with client. 7. Use supportive touch if appropriate. Controlling environment to reduce sensory overload 1. Keep environmental noise to minimum (television, radio). 2. Monitor clients response to visitors; explain to family and friends that client may need to visit quietly one on one. 3. Validate clients anxiety and fears, but do not reinforce misperceptions.

3 Promoting sleep and proper nutrition 1. Monitor sleep and elimination patterns. 2. Monitor food and fluid intake; provide prompts or assistance to eat and drink adequate amounts of food and fluids. 3. Provide periodic assistance to bathroom if client does not make requests. 4. Discourage daytime napping to help sleep at night. 5. Encourage some exercise during day like sitting in a chair, walking in hall, or other activities client can manage. PSYCHOPHARMACOLOGY 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 (Caine & Lyness, 2000). Clients with impaired liver or kidney function could have difficulty metabolizing or excreting sedatives. The exception is delirium induced by alcohol withdrawal, which usually is treated with benzodiazepines DEMENTIA Memory impairment is the prominent early sign of dementia. a mental disorder that involves multiple cognitive deficits, primarily memory impairment and at least one of the following cognitive disturbances (APA, 2000): Aphasia, which is deterioration of language function Apraxia, which is impaired ability to execute motor functions despite intact motor abilities Agnosia, which is inability to recognize or name objects despite intact sensory abilities Disturbance in executive functioning, which is the ability to think abstractly and to plan, initiate, sequence, 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 activities STAGES OF dEMENTIA Mild - Forgetfulness is the hallmark of beginning, mild dementia. Moderate: Confusion is apparent along with progressive memory loss. 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 require assistance in activities of daily living (ADLs). COMPARISON OF DELIRIUM AND DEMENTIA
Indicator Onset Duration LOC Memory Speech Thought Process Perception Delirium Rapid Brief (hours to days) Impaired, fluctuates Short-term memory impaired May be slurred, rambling, pressured, irrelevant Temporarily disorganized Visual or tactile hallucinations, delusions Anxious, fearful if hallucinating; weeping, irritable Dementia Gradual and insidious Progressive deterioration Not affected Short- then long-term memory impaired, eventually destroyed Normal in early stage, prog-ressive aphasia in later stage Impaired thinking, eventual loss of thinking abilities Often absent, but can have paranoia, hallucinations, illusions Depressed and anxious in early stage, labile mood, restless pacing, angry outbursts in later stages

Mood

4 Etiology no definitive diagnosis can be made until completion of a postmortem examination. Metabolic activity is decreased in the brains of clients with dementia; it is not known whether dementia causes decreased metabolic activity or if decreased metabolic activity results in dementia. genetic component has been identified for some dementias such as Huntingtons disease. Other causes of dementia are related to infections such as HIV or Creutzfeldt-Jakob disease. - 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 levelingoff 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. 3. 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. - Early signs include: a. personality changes b. loss of social skills and inhibitions emotional blunting d. language abnormalities.

The most common types of dementia

1. Alzheimers disease - is a progressive braindisorder 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: a. paranoia b. delusions c. hallucinations d. inattention to hygiene e. 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 (APA, 2000). 2. Vascular dementia

c.

- Onset is most commonly 50 to 60 years of age; death occurs in 2 to 5 years. 4. Creutzfeldt-Jakob 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.

5 5. HIV - disease 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. 6. Parkinsons disease - is a slowly progressive neurologic condition characterized by: a. tremor b. rigidity c. bradykinesia d. postural instability. -It results from loss of neurons of the basal ganglia. - Dementia has been reported approximately 20% to 60% of people with Parkinsons disease and is characterized by cognitive and motor slowing, impaired memory, and impaired executive functioning. 7. 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 30s or early 40s and may last 10 to 20 years or more before death. 8. 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. DRUGS USED TO TREAT DEMENTIA
Name Dosage Range and Route 40160 mg orally per day divided into 4 doses 510 mg orally per day 312 mg orally per day divided into 2 doses 1632 mg orally per day divided into 2 doses Nursing Considerations

Tacrine (Cognex)

Monitor liver enzymes for hepatoxic effects. Monitor for flu-like symptoms. Monitor for nausea, diarrhea, and insomnia. Test stools periodically for GI bleeding. Monitor for nausea, vomiting, abdominal pain, and loss of appetite.

Donepezil (Aricept)

Rivastigmine (Exelon)

Galantamine (Reminyl)

Monitor for nausea, vomiting, loss of appetite, dizziness, and syncope.

Other meds: 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 (Boyd, 2001).

6 o 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. a. Offer unobtrusive assistance with or supervision of cooking, bathing, or self-care activities. b. Identify environmental triggers to help client avoid them. 2. Promoting adequate sleep, proper nutrition and hygiene, and activity a. Prepare desirable foods and foods clien can self-feed; sit with client while eating. b. Monitor bowel elimination pattern; intervene with fluids and fiber or prompts. c. Remind client to urinate; provide pads or diapers as needed, checking and changing them frequently to avoid infection, skin irritation, unpleasant odors. d. Encourage mild physical activity such as walking 3. Structuring environment and routine a. Encourage client to follow regular routine and habits of bathing and dressing rather than impose new ones. b. Monitor amount of environmental stimulation, and adjust when needed. 4. Providing emotional support a. Be kind, respectful, calm, and reassuring; pay attention to client. b. Use supportive touch when appropriate. 5. Promoting interaction and involvement a. Plan activities geared to clients interests and abilities. b. Reminisce with client about the past. ( Reminiscence therapy)

Data Analysis 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 Treatment outcomes 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 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. NURSING INTERVENTIONS FOR DEMENTIA 1. Promoting clients safety and protecting from injury

7 c. If client is nonverbal, remain alert to nonverbal behavior. d. Employ techniques of distraction, time away, going along, or reframing to calm clients who are agitated, suspicious, or confused. Terminology: Reminiscence therapy (thinking about or relating personally significant past experiences) is an effective intervention for clients with dementia. Distraction involves shifting the clients attention and energy to a more neutral topic. Time away involves leaving clients for a short period then returning to them to re-engage in interaction. Going along means providing emotional reassurance to clients without correcting their misperception or delusion. 3. physical symptoms( decrease BP, decrease therapy, decrease protein) 4. refusal to eat reports of Not being hungry although actual feeling of hunger do not cease until late in the disorder. 5. preoccupation with food. Prepare a lot for friends but refuses to eat. 6. extensive exercising DSM IV Criteria: 1. Refusal to maintain body weight at or above a minimum normal weight for age and height 2. Intense fear of gaining weight or becoming fat, although significantly underweight. 3. Disturbance in the way in which ones body weight or shape is experienced, over valuing of shape or weight or denial of seriousness of low weight or weight loss. 4. In women or female adolescents, the absence of at least 3 consecutive menstrual cycles. Restricting Type During an episode of anorexia nervosa, individuals do not engage in recurrent episodes of binge eating or purging. Binge-eating type or Purging type During an episode of anorexia nervosa, individuals engage in recurrent episodes of binge eating and purging.

Eating Disorders
Anorexia Nervosa Syndrome of self-starvation; cause is
emotional disturbance which causes emaciation and physical problem. negative behavior due to power struggle with family over pressure to eat. Morbid fear of obesity. Not a disturbance in appetite but distorted body image perception related to disturbance in sense of identity and autonomy. Symptoms include: 1. weight loss 25% of original weight 2. delayed sexual development (amenorrhea)

Bulimia binge and purge syndrome

Characteristics:

8 1. Rapid consumption of a large amount of food in a discrete period of time. 2. A feeling of lack of control over eating behavior. 3. Engage in self- induced vomiting, use of laxative, diuretic, strict dieting, or fasting. 4. Experience depression after each episode. Symptoms: 1. Binges are usually solitary and secret. May consume as many as 11,500 calories in one episode. 2. Binges is viewed as pleasurable but are followed by intense self-criticism. Purging type Regularly engages in self induced vomiting or the use of laxatives, diuretics or enemas. Nonpurging type Regularly uses strict diet, fasting, or vigorous exercise, but does not regularly engage in purging. Medical Complications: esophagitis esophageal rupture dilatation, rupture of stomach arrythmias dehydration dental resume fungal infestism Predisposing Factor: Ego development is retarded. Individual remains in the dependent position. Disorder in the neuroendocrines within the hypothalamus. Family dynamics. Family consist positive father, a domineering mother, and an overly dependent child. There is high value place on perfectionism in the family, and the child feels he must satisfy these standards. Nursing Care: If patient is unable to maintain adequate oral intake, feeding may be given per NGT. Behavior modification. Focus is placed on emotional issues rather than food and eating. A limit in mealtime (30 minutes) should be imposed. Observe for at least an hour following meals. Strict documentation of intake and output. Weigh daily. Do not discuss food or eating with client once protocol has been established. Initially, allows patient to maintain dependent role to decrease anxiety. Encourage independence only when trust has been established and condition has proved.