Cognitive Disorders

COGNITIVE DISORDERS

SITE MAP ► OVERVIEW ► DELIRIUM ► DEMENTIA ► PARKINSON’S

DISEASE ► AMNESTIC DISORDERS ► COMMUNITY BASED CARE

OVERVIEW ►

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The term cognition refers to the broad range of mental abilities that enable us to know about the world around us. These abilities include memory, language, attention, perception, and reasoning. Cognition is the ability of your brain to think, to process and store information, to solve problems. Cognition is a high level of behaviour unique to humans. This behaviour is disrupted by an illness. Gerontology is the scientific discipline that deals with aging, and neurogerontology more specifically deals with the aging nervous system. Cognitive disorders are necessarily brain disorders, and these are increasingly common after middle age. Perhaps the most important of these illnesses is Alzheimer's disease, one cause of severe cognitive loss (dementia) in old age. Physicians and scientists in the Division of Cognitive Disorders and Neurogerontology are particularly interested in memory loss and dementia.

DELIRIUM

DELIRIUM ►

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Delirium is a sudden, fluctuating, and usually reversible cognitive disorder characterized by disorientation, the inability to pay attention, the inability to think clearly, and a change in the level of consciousness. Delirium is an abnormal mental state, not a disease. Although the term has a specific medical definition, it is often used to describe any type of confusion. Because delirium is a temporary condition, determining how many people have it is difficult. Delirium, which is usually a sign of a newly developed disorder, affects about one third of hospitalized people aged 70 or older.

Etiology ► ► ► ► ► ► ►

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Development or worsening of almost any disorder Extreme illness Drugs that affect brain function. Less severe conditions in older people Disorders that cause nerve degeneration. (stroke, dementia) Relatively minor illness, such as retention of urine or feces Sensory deprivation, such as that due to being socially isolated or not wearing glasses or hearing aids; or prolonged sleep deprivation. The sensory and sleep deprivation that occurs in intensive care units (ICUs) may contribute to delirium. This disorder is sometimes called ICU psychosis. Delirium is also very common after surgery Most common reversible cause of delirium is drugs.

Etiology (cont’d) ►

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In younger people, ingestion of poisons (such as rubbing alcohol or antifreeze), use of illicit drugs, or acute intoxication with alcohol Abnormal blood levels of electrolytes, such as calcium, sodium, or magnesium, can interfere with the metabolic activity of nerve Abnormal electrolyte levels may result from use of a diuretic, dehydration, or disorders such as kidney failure and widespread cancer. An underactive thyroid gland (hypothyroidism) causes delirium with lethargy; an overactive thyroid gland (hyperthyroidism) causes delirium with hyperactivity. In younger people, the cause of delirium is usually a condition that directly affects the brain—for example a brain infection, such as meningitis or

Symptoms ► ► ►

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The hallmark is the inability to pay attention. Lacks concentration. Sudden confusion about time and, at least partially, about place. Thinking is confused, and people with delirium ramble, sometimes becoming incoherent. If delirium is severe, people may not know who they are. Thinking is confused, and people with delirium ramble, sometimes becoming incoherent. The level of consciousness may fluctuate between increased wakefulness and drowsiness. Sundowning phenomenon. Symptoms often change within minutes and tend to worsen late in the day

Symptoms (cont’d) ► ► ► ► ►

Often sleep restlessly or reverse their sleep-wake cycle Frightened by bizarre visual hallucinations Paranoia or have delusions Personality and mood may change. If the cause of delirium is not quickly identified and treated, the person may become increasingly drowsy and unresponsive, requiring vigorous stimulation to be aroused (a condition called stupor).  Stupor may lead to coma or death.

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Delirium is often the first sign of another, sometimes serious disorder, especially in older people.

Drugs Causing Delirium ► Anticonvulsants ► Anticholinergics ► Antidepressants ► Antihistamines ► Antipsychotics ► Aspirin ► Barbiturates ► Benzodiazepines

► Hypoglycemic

agents ► Insulin ► Cardiac glycosides ► Narcotics ► Propranolol ► Reserpine ► Thiazide diuretics

Medical Management ► Hypoactive

delirium - No specific pharmacologic treatment ► Sedatives to prevent inadvertent selfinjury but sedatives and benzodiazepines are avoided – this may worsen delirium  Exemption to this is delirium induced by alcohol withdrawal. ► Haloperidol

0.5-1 mg to decrease

agitation ► Supportive medical measures

Assessment ► History

of use of psychotropic Drugs ► History of substance or alcohol abuse ► Disturbed psychomotor behavior ► Often have rapid and unpredictable mood shifts ► Thought processes are often disorganized and make no sense. ► Altered level of consciousness ► Judgment is impaired ► Disturbed sleep-wake cycles.

Nursing Diagnosis ► Risk

for injury ► Acute confusion ► Disturbed sensory perception ► Disturbed thought processes ► Disturbed sleep pattern ► Risk for deficient fluid volume ► Risk for imbalanced nutrition: less than body requirement

Objectives ► 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

Nursing Interventions ► Ensure

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client’s safety

administer medications judiciously as ordered Teach client to request assistance for activities Close supervision must be rendered

► Managing

client’s confusion

Speak in a calm manner in a clear low voice Allow adequate time for client to comprehend and respond  Allow client to make decisions  Provide orienting verbal cues  Use supportive touch if appropriate  

Nursing Interventions (cont’d) ► Controlling

overload

environment to reduce sensory

 Provide a quiet environment  Monitor client’s response to visitors  Validate client’s anxiety and fears, but do not reinforce misperceptions ► Promoting

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sleep and proper nutrition

Monitor sleep and elimination patterns Monitor food and fluid intake Discourage daytime napping Encourage exercise during day

Evaluation ► The

client experienced no injury ► The client demonstrated increased orientation and reality contact ► The client returned to his or her optimal level of functioning ► The client abstained from use of drugs or alcohol.

DEMENTIA

Dementia  ► Dementia

is a label for a cluster of symptoms involving deterioration in behaviours such as memory, language, and reasoning. The deterioration results from a disease process in the brain. The disease progresses from mild through severe stages and interferes with the ability to function independently in everyday life. Dementias are fatal medical

What conditions result in dementia? ►

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Many different conditions can result in dementia in later life. The most common is Alzheimer's Disease, accounting for about 50% of all cases. The next most common is vascular dementia. Alzheimer's Disease involves a gradual change in the neurons, or nerve cells in the brain. There are tangles inside the nerve cell and degenerating nerve endings. Other deficiencies also occur in the neurotransmitters, the chemical messengers that allow brain cells to send signals to each other. Vascular dementia involves repeated damage to areas of the brain caused by blockages in the blood vessels (small strokes). Vascular dementia is what used to be referred to as hardening of the

Classifications of Dementia ► Dementia

is classified as cortical or subcortical depending on the area of brain affected.

Cortical Dementia Subcortical Dementia

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Cortical dementia causes problems in memory, thinking, and language. Alzheimer's Disease is a disorder that causes cortical dementia. The cognitive problems, depending on their nature, are called aphasia, apraxia, amnesia, and agnosia. These problems may include difficulty finding words, difficulty comprehending written or spoken material, and even mutism. Speech, which is the machinery for sound, is usually normal; however, it is the language component that breaks down. The memory problem is often an inability to learn new information.

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Insight into the condition is usually absent and a person's mood is unconcerned or uninhibited. The motor system is normal, at least in the early stages.

► Subcortical

dementia affects parts of the brain below the cortex and is characterized by slowing, difficulty in retrieving information from memory, and altered mood. Parkinson's disease and multiple sclerosis are examples of a condition that can result in a subcortical dementia. Language ability is usually normal, although speech is dysfunctional and the motor system may result in stooped or extended posture, increased muscle tone, and tremors. Memory problems are due to a difficulty in retrieving information that is in fact learned. The person's mood may be either apathetic or depressed, and insight into the condition is usually present.

Types of Dementia ► Alzheimer’s

Disease

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an irreversible, progressive disorder in which brain cells (neurons) deteriorate, resulting in the loss of cognitive functions, primarily memory, judgment and reasoning, movement coordination, and pattern recognition. In advanced stages of the disease, all memory and mental functioning may be lost

► Vascular

Dementia

is a degenerative cerebrovascular disease that leads to a progressive decline in memory and cognitive functioning. It occurs when the blood supply carrying oxygen and nutrients to the brain is interrupted by a blocked or diseased

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Types of Dementia (cont’d) ► Pick’s

Disease

► Pick's

Disease is the result of a build-up of protein in the affected areas of the brain. The accumulation of abnormal brain cells, known as Pick's bodies, eventually leads to changes in character, socially inappropriate behavior, and poor decision making, progressing to a severe impairment in intellect, memory and speech. Pick's Disease is a rare disorder that causes the frontal and temporal lobes of the brain, which control speech and personality, to slowly atrophy.

► Creutzfeldt-Jacob ► is

Disease

known as a prion disease, which means that healthy brain tissue deteriorates into an abnormal protein that the body cannot break down. CJD is a type of transmissible spongiform encephalopathy (TSE). "Spongiform" refers to the characteristic appearance

Types of Dementia (cont’d)

► Huntington’s

Disease

► Huntington's

Disease affects someone's ability to think, talk and move by destroying cells in the basal ganglia, the part of the brain that controls these capacities. Caused by a gene mutation that leads to a toxic accumulation of protein in the brain, Huntington's is inherited from either one or both parents. The general symptoms in early stages can include poor memory; difficulty making decisions; mood changes such as increased depression, anger or irritability; a growing lack of coordination, twitching or other uncontrolled movements; difficulty walking, speaking, and/or swallowing.

► HIV

Dementia

► AIDS

dementia complex (ADC)—dementia caused by HIV infection—is a complicated syndrome made up of different nervous system and mental symptoms. It is characterized by cognitive deficits such as inattentiveness, impaired concentration and problem solving, forgetfulness, and impaired reading, motor abnormalities such as tremors, slurred speech, ataxia, and generalized hyperreflexia; and behavioral changes such as sluggishness and social withdrawal. 

4 As in dementia ► Amnesia

 memory impairment ► Aphasia

 language disturbance ► Apraxia

 unable to perform motor activities ► Agnosia

 difficulty in identifying objects

Some of the conditions that result in dementia include: ► ► ► ► ► ► ► ► ► ►

Alzheimer's disease Limbic encephalitis Vascular dementia Heavy metal exposure Lewy body disease Normal pressure hydrocephalus Parkinson's disease Post-traumatic dementia Pick's disease Multiple sclerosis

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Jakob-Creutzfeldt disease Idiopathic basal ganglia calcification Neurosyphilis Acquired immune deficiency syndrome (AIDS) Fungal infections Tuberculosis Progressive supranuclear palsy Huntington's disease

Diagnostic Exam ► ► ► ► ► ► ►

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•     Psychological Tests •     Neurological Tests –    Electroencephalograph (EEG) – measures electrical activity of brain cells –    Computerized Axial Tomography (CAT) – assessed brain damage by X-ray –    Positron Emission Tomography (PET) – glucose metabolism in brain is monitored –    Cerebral Blood Flow – patient inhales radioactive gas and blood flow is monitored –    Magnetic Resonance Imaging (MRI) – patient placed in magnetic field and radio waves used to produce picture of brain. •     Mental Status Exam •     Physical Status Exam •     Laboratory tests targeted at identifying general medical and substance-related causes

Assessment ► ► ► ► ► ►

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Level of consciousness – not affected Thought processes is impaired Mental function is lost, relatively consistently for all functions Memory is lost, especially for recent events l Use of language - sometimes has difficulty finding the right word Mood is usually depressed and anxious in early stage, labile mood, restless pacing, angry out-bursts in later stage. Self-concept is usually angry or frustrated Often experiences disturbed sleep-wake cycles. Has at least one of the 4 A’s

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

Objectives ► 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 indepently 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 ► Promote

client’s safety

 Offer unobtrussive assistance with or supervision of activities  Identify environmental triggers to help client avoid them

► Promote

adequate sleep and proper nutrition, hygiene and activity    

Sit with client while eating Monitor bowel elimination pattern Remind client to urinate Encourage mild physical activities

► Structure

the environment and routine

 Encourage client to follow regular routines and habits  Monitor environmental stumulation, and adjust when needed

Nursing Interventions (cont’d) ► Provide emotional support ►

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 Be kind, respectful, calm, and reassuring, pay attention to client  Use supportive touch when necessary Promote interaction and involvement (Milieu management)  Plan activities according to client’s interest and abilities  Allow the client to have familiar objects around him/her -> reality orientation, self-worth, dignity  Reminisce with client about the past  Be alert to nonverbal cues  Employ techniques of distraction Provide a list of community resources, support

Care for the caregiver ► Presenting

reality & attention to the emotional response  dementia is a primary brain pathology.  It is a long term care ► Preventing burnout of the caregiver  Be supportive – acknowledge the burden  Early detection of burnout – what the caregiver’s routine life  Respite care

Burden to the caregiver ► Physical

care – basic ► Preventing injury for the client accidental injury ► Others –  Dealing with pt’s specific behaviors ie agitation,  Do not challenge pt’s memory

Evaluation ► The

client experienced no injury ► The client maintained an adequate balance of activity and rest, nutrition, hydration, and elimination ► The client can function indepently given his or her limitations ► The client felt respected and supported ► The client interacts with others in the environment

Comparing Delirium and Dementia Feature

Delirium

Dementia

Development

Sudden

Slow

Duration

Days to weeks

Months to years

Presence of other disorders or physical problems

Almost always present; may be a severe illness, drug use or withdrawal, or a problem with metabolism

Possibly none

Variation at night

Almost always worse

Often worse

Attention

Greatly impaired

Maintained until late stages

Level of consciousness

Fluctuates from lethargy to agitation

Normal until late stages

Orientation to surroundings

Varies

Impaired

Use of language

Slow, often incoherent, and inappropriate

Sometimes difficulty finding the right word

Memory

Jumbled and confused

Mental function

Lost, variably and unpredictably

Lost, especially for recent events Lost, relatively consistently for all functions

Cause

Usually an acute illness or drugs; in older people, usually infection, dehydration, or drugs Emergency medical attention

Need for treatment

Usually Alzheimer's disease, vascular dementia, or Lewy body dementia Nonemergency medical attention

PARKINSON’S DISEASE

Parkinson’s Disease ►

Parkinson's disease (PD) is commonly viewed as an extrapyramidal motor disorder. Hence, a substantial body of research has focused on understanding the neural mechanisms underlying the most apparent symptoms (tremors, slowness, initiation of movements) and on treatment of these debilitating clinical manifestations. However, PD is more than a motor disease; it also affects thinking, reasoning, learning, processing speed, and other cognitive abilities. Consequently, Parkinson's patients exhibiting motor and cognitive symptoms present unique challenges for the assessment and treatment of psychopathology in their disease process. In such patients, both quality of life and treatment outcome are severely compromised. The cognitive changes seen in PD patients are less understood and studied than parkinsonian motor symptoms.

OBJECTIVES Identify and assess nonmotor symptoms in patients with Parkinson's disease. ► Discuss the impact of these symptoms on patients with PD. ► Offer treatment strategies to improve nonmotor symptoms. ►

NONMOTOR SYMPTOMS OF PARKINSON’S DISEASE ► Neuropsychiatric

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and cognitive:

Depression Anxiety Psychosis Dementia Apathy Fatigue Sleep disturbance

Mild Cognitive Impairment MCI ► Cognitive

impairment not severe enough to meet criteria for dementia  Affects = 50% of PD patients

► Executive

impairment common to PD

 Inability to plan and carry out complex activities  Involves frontal regions of the brain  May be prelude to dementia ► Visuospatial,

attention, and language deficits is also reported

Risk factors or correlates ► Increasing

age ► Lower level of education ► Increasing severity and longer duration of PD ► “atypical” Parkinsonism ► Psychiatric correlates or risk factors include psychosis, apathy and depression

AMNESTIC DISORDER

Amnestic Disorder ►

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Amnestic disorders present as deficits in memory, either in the inability to recall previously learned information or the inability to retain new information. The cognitive defect must be limited to memory alone; if additional cognitive defects are present, a diagnosis of dementia or delirium should be considered. In addition to defect in memory, there must be an identifiable cause for the amnestic disorder Amnestic disorders are reversible in some cases.

Memory in Amnestic Disorders  Impairment in ability to learn new information (Anterograde amnesia)  Impairment in ability to recall previously learned information (Retrograde amnesia)

COMMUNITY-BASED CARE

Community-Based Care ► Home

care through home health agencies, public health, and visiting nurses ► Adult day care centers ► Residential fascilities – skilled nursing home placement