Chapter 21 Cognitive Impairment Cognitive Impairment Describes disturbances in cognitive function.

. Disturbances in memory, orientation, and concentration Other disturbances of cognition affect intelligence, judgment, learning abilities, perception, problem solving, psychomotor abilities, reaction time, and social intactness. *Withdraw from social events a lot of times Three Ds of Cognitive Impairment The Ds of cognitive impairment are: Dementia Delirium Depression All frequently affect older adults. Although not normal consequences of aging, these impairments increase with age. Pathological progression of the three Ds requires urgent assessment and intervention. Comprehensive Evaluation Complete assessment (rule out possible causes- neuro- physical examination is very important) Laboratory workup Need to rule out possible causes for cognitive impairments Neuropsychological examination Interview with family and client Observation Functional assessment Computed tomography (CT), magnetic resonance imaging (MRI), and electrocardiography (ECG) Considerations in Cognitive Assessment Poor performance on tests of memory cause anxiety. Assessments need to be performed with hearing aids and glasses, if needed. Environment should be free of distractions when assessment is performed. Assessment is best completed immediately upon wakening.

Always know baseline of pt to be able to distinguish something out of the ordinary

Difficulties with tests of memory can cause them to have anxiety Be sure theyre wearing their glasses/ hearing aids Environment free of distractions as much as possible

Delirium Onset may be acute or subacute. Symptoms develop over a short time (hours to days). Symptoms fluctuate over the course of the day and are worse in the evening. Symptoms include disturbances in consciousness and attention, memory deficits, and perpetual disturbances accompanied by delusional (paranoid) thoughts and behaviors.

Causes of Delirium Delirium results from interaction of predisposing factors: Cognitive impairment Severe illness Sensory impairment Medications Procedures Restraints Iatrogenic events A highly vulnerable older individual requires fewer precipitating factors to develop delirium. Is reversible; consequently, an accurate diagnosis is needed. *Always look at what the medications are of the pt FIRST b/c it could be causing their delirium if caused by medication, and let physician know theyre on a new medicationtheir cognition can reverse itself if theyre taken off the med

Consequences of Delirium Is a high priority nursing challenge for all nurses who care for older adults. Is a stressor for nurses and family. Is associated with lasting cognitive impairment and psychiatric problems that may persist after discharge.

Lack of Recognition of Delirium Inadequate education about delirium Lack of formal assessment methods View that delirium is not essential to the clients well being Failure to recognize Failure to initiate timely interventions- makes delirium worse

Implications for Gerontological Nursing and Healthy Aging Instruments used for assessment include: **Minimental state examination, 2nd edition (MMSE-2) Confusion assessment method Neelon and Champagne (NEECHAM) Confusion Scale Determine the clients mental status. Intervention begins with prevention. Sedatives or analgesics may reduce the incidence or duration of delirium. **Whats their orientation to person, place, time? Has their cognition deteriorated or improved? Are they are analgesics or sedatives?

Dementia Onset is gradual and slow. Pattern of decline is steady without alterations in consciousness. Is irreversible, and its progression causes memory impairment and a loss of intellectual abilities severe enough to interfere with daily life. Some degenerative dementia conditions are: Alzheimers, dementia with Lewy bodies Parkinson disease dementia, frontotemporal lobe dementia, and other less common dementias Alzheimers disease: Sometimes not fully diagnosed until an autopsy is performed

Incidence and Prevalence of Dementia Is the most disabling and burdensome (upon the adult & the family) of chronic conditions in older adults.

 Frightening implications face the client and family. Societal costs are related to the disease. Were previously living independently now need a caregiver or need to move int o a living facility, etc.

Alzheimer Disease Is the most common form of dementia. Is the third most expensive medical condition. Types include early onset and late onset; late onset is the most common, developing after 60 years of age. Potential risks include vascular risk factors, midlife obesity, dyslipidemia, hypertension, cigarette smoking, obstructive sleep apnea, diabetes, and cerebrovascular lesions. Early onset OR Late onset- most common, developing after 60 years of age

Protective Roles of Psychosocial Factors Behaviors that possibly cause protective abilities include: Higher education Regular exercise Healthy diet Intellectually challenging leisure activities Active socially integrated lifestyle *These are factors to HELP a person

Diagnosis of Alzheimer Disease Three stages of Alzheimer disease are: Preclinical Mild cognitive impairment Dementia as a result of Alzheimer pathologic characteristics Goal is to provide standards for research and practice that further advance the field for early detection and treatment. (more research needed)

Treatment Ongoing monitoring of disease progression, regular health maintenance, and health promotion Assessment 6 months after diagnosis and anytime a change in behavior occurs Administration of cholinesterase inhibitors Residency in an Alzheimer care unit Common Care Concerns Communication Behavior concerns Activities of daily living (ADLs) care- continue to decline Wandering= most dangerous, cant find their way back

Progressively Lowered Stress Threshold Model Progressively lowered stress threshold (PLST) is the first model used to plan and care for those with dementia. Care decreases the stressors and provides a safe, predictable environment. **What is the PLAN that can be done to keep this patient with dementia safe This care can decrease the stress and the stress of the caregiver, family member, and provides safe environment

Need-Driven, Dementia-Compromised Behavior Model Need-driven, dementia-compromised behavior (NDB) model provides the framework for studying and understanding behavioral symptoms of dementia. Interventions are performed to minimize behaviors or actions. **When assessing a pt, the nurse needs to be able to differentiate between delirium and depression in an older adult The way to distinguish is a persons orientation (If the orientation decreases then the person is suffering from some type of delirium) Very important to approach their hygienic care very carefully- explain each step as you go along and be certain to keep them covered as much as possible to respect their privacy (They will fight you, because they dont understand whats going on) Milieu: environment, setting needs to be CALM- for a person experiencing delirium

21-1 table pg 310 delirium, depression, and dementia differentiation (Precipitating factors 21-1 box) #1 thing that can cause dementia- what is the total number of medications If more than 6 meds, they could be affecting one another and causing the delirium Most important thing about delirium is to KNOW the pts baseline- whats their mental status baseline , whats their functional abilities, whats their living conditions, medication use, and alcohol use?? Pg 317 box 21-2 dementia types As a nurse, will most frequently come across: Alzheimers disease dementia, vascular dementia, Parkinsons disease dementia, dementia with lewy bodies 21-3 table- risk factors for A.D. Whats their age, family history, depression level, mental activity, diet, medications Pg 323 box 21-7 Useful strategies for communicating box 21-7 always introduce self and explain WHY your there, what it is that youre going to be doing When a person happens to have cognitive impartment simplification strategies are important: Give 1 step directions (1 step at a time, speak slowly), interact with person individually, give time to respond, reduce distractions

Implications for Gerontological Nursing and Healthy Aging Client assessment is conducted. Behavioral changes occur with distressing conditions such as constipation and urinary tract infections. Behavioral symptoms include fear, discomfort, unfamiliar sounds and people, illness, fatigue, depression, and need for autonomy and control. Comprehensive assessment and the use of medications are treatments of choice. Bathing can be perceived as an attack by the client. *explain step by step to the patient Caregivers Stress of the caregiver is caused by: Fewer health-promoting behaviors Higher depression and anxiety rates Higher morbidity and mortality rates Sleep problems

 Higher number of illness-related symptoms Caregiver plays the roles of magician, detective, carpenter, and jester. Sleep problems can be caused by fear of the pt wandering Caregiver fatigue can lead to unintentional abuse