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Cognitive Disorders

DELIRIUM
- A syndrome that involves a disturbance of consciousness accompanied by a
change in cognition.
- Usually develops over a short period, sometimes a matter of hours, and fluctuates,
or changes, throughout the course of the day.
- Common in older acutely ill clients.
- Prolonged disorder can lead to dementia.

Etiology
• Results from an identifiable physiologic, metabolic ,or cerebral disturbance or
disease or from drug intoxication or withdrawal

Common causes
• Physiologic or metabolic
• Infection
• Drug related
• Hypoxemia, electrolyte imbalances, renal or hepatic failure, hyper/hypogly, B12,
vit C, niacin or CHON deficiency, brain tumor, head injury, paint solvents, insecticides
and related substances,cardiovascular shock
• Systemic: sepsis, UTI, pneumonia
• Cerebral: meningitis, encephalitis, HIV, syphilis
• Intoxication: anticholinergics,lithium, OH, sedatives and hypnotics
• Withdrawal: OH, sedatives, hypnotics
• Rxn to anes, Rx meds or illicit drugs

Signs and symptoms


• Fluctuating levels of consciousness
 Sundowning: disoriented and severely confused at night and early morning hours
• Impaired ability to reason and carry out goal-directed behavior.
• Alternating patterns of hyperactivity-hypoactivity
• Impaired attention span
• Alterations in sleep-wake patterns
• Fear and high levels of anxiety
• Cognitive changes
 Memory impairment
 Disoriented
 Language disturbance: incoherent
 Perceptual disturbance: hallucinations and illusions

Hyperactive Behavior
 Hypervigilance
 Restlessness
 Incoherent, loud, or rapid speech
 Anger
 Distractibility
 Nightmares
 Persistent abnormal thoughts(delusions)

Hypoactive Behavior
 Lethargy
 Speaks or moves little or slowly
 Has spells of staring
 Reduced alertness
 Generalized loss of awareness of the environment
Pharmacologic and Non-pharmacologic Treatment
Primary tx: identify and treatany causal or contributing medical condition

DRUGS
• Sedatives: to prevent inadvertent self-injury
• Antipsychotics (Haldol): to decrease agitation
• Benzodiazepines: ONLY for delirium induced by OH withdrawal
***NOTE: Sedatives and benzodiazepines are avoided because they may worsen
delirium
Health Teachings:
• Monitor chronic health conditions carefully
• Visit physician regularly
• Tell physicians and health care providers the meds taken, inc over-the-counter
meds, dietary supplements and herbal preparations.
• Check with physician before taking any non Rx meds
• Avoid OH and recreational drugs
• Maintain a nutritious diet.
• Get adequate sleep.
• Use safety prec when working with paint solvents, insecticides and similar
products.
Nursing Interventions
• Promote client’s safety.
• Manage client’s confusion
• Control env’t toreduce sensory overload
• Promote sleep and proper nutrition.
DEMENTIA
- Marked by progressive deterioration in intellectual function, memory, and ability
to solve problems and new skills.

- Judgment and moral and ethical behaviors decline as personality is altered.

- Unlike delirium, it can be of a primary nature and is NOT reversible.

- Usually slow and insidious process progressing from months-years.

Signs and Symptoms


• Memory impairment usually short-term at first.
• Cognitive impairment:
– Aphasia: language disturbance
– Apraxia: inability to carry out motor activities despite intact motor fxns
– Agnosia: loss of sensory ability
• Significant decline in previous level of functioning; poor judgment
• Mood disturbances: anxiety, hallucinations, delusions, and impaired sleep

Common Types
• Alzheimer’s dementia
• Vascular dementia (multi-infarcts)
• HIV dse
• Head trauma
• Parkinson’s dse
• Huntington’s dse
• Pick’s dses
• Creutzfeldt-jakob dse
• General medical condition (brain tumors, subdural hematoma)
• Substance use
Alzheimer’s Dementia
• Progressive brain disorderthat has gradual onset but causes and increasing decline
in functioning: speech, loss of motor function and profound personality and behavior
changes (paranoia, delusion,hallucintation, inattention to hygiene)

• Evidenced by atrophy of cerebral neurons, senile plaque deposits and enlargement


of the 3rd and 4th ventricles of the brain

• Risk of the dse increases with age, and average duration from noset of Sx to death
is 8-10years
Vascular dementia
• CT scan/ MRI result: multiple vascular lesions of the cerebral cortex and
subcortal structures resulting to decrease blood supply to the brain
HIV diseases
• These may result directly from the invasion of nervous tissue by HIV or other
AIDS-related illnesses such as toxoplasmosis and cytomegalovirus.

• Sx: from mild sensory impairment- gross memory and cognitive deficits-severe
muscledys function
Parkinson’s Disease
• Slowly progressive neurologic condition characterized by hand tremor, rigidity,
bradikinesia and postural instability.

• Results from loss of neurons in the basal ganglia

• Cognitive and motor slowing, impaired memory and impaired executive


functioning.
Huntington’s Disease
• An inherited dominant gene disease that primarily involves cerebral atrophy,
demyelination and enlargement of the brain ventricles.

• The dse begins late 30’s- early 40’s and may last for 10-20 years or more before
death.

• Involves facial contortions, twisting, turning and tongue mov’ts during waking
hours
Pick’s Disease
• Degenerative brain dse that particularly affects frontal and temporal lobes
resulting to Alzheimer’s dse manifestations.

• Onset: 50-60 years of age; death occurs in 2-5 years

• Early signs: personality changes, lossof social skills and inhibitions, emotional
blunting and language abnormalities.
Creutzfeldt-jakob Disease
• CNS disorder that typically develops in 40-60 years

• Encephalopathy due to infectious particle to resistant to boiling, some


disinfectants and ultraviolet radiation.

• It involves altered vision, loss of coordinationand dementia that usually


progresses rapidly
Basic Workup for Dementia
• Chest and radiograph studies
• EEG
• U/A
• Thyroid fxn test
• Folate levels
• VDRL,HIV
• Serum creatinine assay
• Electrolyte assessment
• Vitamin B12 levels
• Vision and hearing evaluation
• Neuroimaging (whendiagnostic isuues not clear)
Pharmacologic Treatment
Drug Name
 Tacrine (Cognex)

 Donepezil (Aricept)

c. Rovastigmine (Exelon)

d. Galantamine (Reminyl)

Nursing Considerations
- Monitor for hapatotoxic effect
- Monitor for flu-like Sx

- Monitor for nausea, diarrhea and insomia


- Test stools for GI bleediing

- Monitor for nausea, vomiting, abdominal pain and loss of appetite

- Monitor for nausea, vomiting, abdominal pain and loss of appetite, dizziness
andsyncope

Nursing Interventions
• Promote client’s safety andprotect from injury
• Promote adequate sleep, proper nutrition and hygiene and activity
• Structure env’t and routine
• Provideemotional support
• Promote interaction and involvement in
Delirium vs Dementia
Onset: acute impairment of orientation, memory, intellectual fxn, judgment and affect
Essential Feature: Disturbance in consciousness, fluctuating levels of consciousness and
cognitive impairment

Cause: secondary to many underlying d/o that cause temporary, diffuse disturbances of
brain fxn
Course: usually brief (hours-days) prolonged may lead to dementia
• Slow insidious dedterioration in cognitive fxning
• Progressive deterioration inmemory, orientation, calculation and judgment, Sx do
not fluctuate

• Either primary in etiology or secondary to dse state or condition


• Progresses over months-years; irreversible

Speech: maybe slurred; disorganized thinking

Memory: impaired short-term memory


Perception: visual or tactile hallucinations; illusions
Mood: fear, anxiety and irritability most prominent
EEG: pronounced diffuse slowing or fast cycle
• Gen normal in early stages, progressive aphasia
• Short-term then long-term memory destroyed
• Hallucinations not prominent

• Labile; paranoid, depressed, withdrawn, OC


• Normal or mildly low