COGNITIVE DISORDERS

Prepared by:
Mary Ruth V. Enriquez, RN MAN
Cognitive
Is the brains ability to process, retain, and use information.
Cognitive abilities : include reasoning, judgment, perception, attention, comprehension, and
memory.
These are essential for many important tasks, including making decisions, solving problems,
interpreting the environment, and learning new information.
Cognitive disorder
Is a disruption or impairment in these higher-level functions of the brain.
Can have devastating effects on the ability to function in daily life.
They can cause people to forget the names of immediate family members, to be unable to
perform daily household tasks, and to neglect personal hygiene.
The Primary Categories of Cognitive Disorders are:
Delirium
Dementia
Amnestic disorders
AMNESTETIC DISORDER
Characterized by a disturbance in memory that results directly from the physiologic
effects of a general medical condition or from the persisting effects of a substance
such as alcohol or other drugs.
Delirium
is an acute condition; it develops quickly, often in response to prescription
medications, alcohol, exposure to some toxic environmental substance, fever, or
systemic illness.
People in a state of delirium may feel frightened, anxious, and confused, and they
may also experience hallucination.
Usually develops over a short period , sometimes a matter of hours, and fluctuates, or
changes, throughout the course of the day.
Client s w/ delirium have difficulty paying attention, are easily distracted and
disoriented, and may have sensory disturbances such as illusion, misinterpretations,
or hallucinations.
Ex. Illusion: an electrical cord on the floor may appear to them to be a snake
Misinterpretation : they may mistake the banging of a laundry cart in the hallway for
a gunshot.
Hallucination : they may see angels hovering above when nothing is there.

Delirium

Etiology:

Delirium almost always results from an identifiable physiologic, metabolic, or cerebral

disturbance or disease or from drug intoxication or withdrawal.
DSM-IV-TR DIAGNOSTIC CRITERIA
SYMPTOMS OF DELIRIUM
Difficulty with attention
Easily distractible
Disoriented
May have sensory disturbances such as illusion, misinterpretation, or hallucinations
Can have sleep-wake 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
Hypoglycemia or hyperglycemia
Dehydration
Sleep deprivation
Thyroid or glucocorticoid disturbances
Thiamine or vit. B12 deficiency, vit C, niacin or protein deficiency
Cardiovascular shock, brain tumor
Head injury, and exposure to gasoline
Pain solvents, insecticides and related substances
Infections :
Systemic sepsis
UTI
Pneumonia
Cerebral meningitis
Encephalitis
HIV

 Syphilis
Drug related:
Intoxication
Anticholinergic
Lithium
Alcohol
Sedative and hypnotics
Reactions to anesthesia
Prescription medication, or illicit (street) drugs.
Treatment and Prognosis
The primary treatment for delirium is to identify and treat any causal or contributing
medical conditions.
Some causes such as head injury or encephalitis may leave clients w/ cognitive,
behavioral, or emotional impairments even after the underlying cause resolves.
Pharmacology
Antipsychotic medication such as haloperidol (Haldol) may be used in doses of 0.5 to 1mg to
decrease agitation.
Sedative and benzodiazepines are avoided because they may worsen delirium.
The exception is delirium induced by alcohol withdrawal, w/c usually is treated w/
Benzodiazepines
Nursing Interventions for Delirium
1.Promoting clients safety

Teach client to request assistance for activities (getting out of bed, going to bathroom)

Provide close supervision to ensure safety during activities.

Promptly respond to clients call for assistance

2. Managing clients confusion

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.

3.Controlling environment to reduce sensory overload.

Keep environmental noise to minimum (TV, 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 mispercepceptions.

4.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 food 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.

DEMENTIA

Is a chronic, progressive deterioration of the brain usually characterized by

severe memory loss, disorientation, and impairments associated w/ attention,
judgment, and inability to take in and use new information.

Is a mental disorder that involves multiple cognitive deficits, primarily memory

impairment, and at least one of the following cognitive disturbances

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
Disturbances in executive functioning : which is the ability to think abstractly and to plan,
initiate, sequence, monitor, and stop complex behavior
Memory Impairment
Is the prominent early sign of dementia.
Clients have difficulty learning new material and forget previously learned material, initially,
recent memory is impaired.
Ex. Forgetting where certain objects were placed or that food is cooking on the stove.
In later stages, dementia affects remote memory; clients forget the names of adult children, their
lifelong occupations, and even their names.
Aphasia usually begins w/ the inability to name familiar objects or people and then progresses to
speech that becomes vague or empty w/ excessive use of terms such as it or thing.
Clients may exhibit echolalia (echoing what is heard) or palilalia (repeating words or sounds over
and over).
Apraxia may cause clients to lose the ability to perform routine self-care activities such as
dressing or cooking.
Agnosia is frustrating for clients: they may look at a table and chairs but are unable to name
them.

Disturbances in executive functioning are evident as clients lose the ability to learn new material,
solve problems, or carry out daily activities such as meal planning or budgeting.
Onset and Clinical Course
When an underlying, treatable cause is not present, the course of dementia is usually
progressive. Dementia often is described in stages:
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 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.
Towards 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 supervised living situations.
Severe : personality and emotional changes occur. The person may be delusional,
wander at night, forget the names of his or her spouse and children, requires
assistance in activities of daily living (ADLs).
Most people live in nursing facilities when they reach this stage unless extraordinary
community support is available.
The most common types of dementia
Alzheimers disease
Vascular dementia
Picks disease
Creutzfeldt-Jacob disease
HIV infection
Parkinsons disease
Huntingtons disease
Alzheimers disease
Is a progressive brain disorder that 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.
Alzheimers disease

Alzheimers disease
Risk for Alzheimer's disease increases w/ 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.
Vascular dementia
Has symptoms similar to those of Alzheimers disease, but onset is typically abrupt,
followed by rapid changes in functioning; a plateau, or leaving off period; more abrupt
changes; another leveling-off period; and so on.
Computed tomography or magnetic resonance imaging usually shows multiple
vascular lesions of the cerebral cortex and subcortical structures resulting from the
decreased blood supply to the brain.
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 disease.
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.
Creutzfeldt-Jacob 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.
HIV INFECTION
Can lead to dementia and other neurologic problem; these may result directly from
invasion of nervous tissue by HIV or from other acquired immunodeficiency syndromerelated 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.
Parkinsons disease
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 Parkinson's
disease and is characterized by cognitive and motor slowing, impaired memory, and
impaired executive functioning.

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 thirties or early forties and may last 10 to 20 years or
more before death.
Treatment and Prognosis
The underlying cause of dementia is identified so that treatment can be instituted.
For example, the progress of vascular dementia, second most common type, may be
halted w/ appropriate treatment of the underlying vascular condition (e.g. Changes in
diet, exercise, control of hypertension or diabetes). Improvement of cerebral blood flow
may arrest the progress of vascular dementia in some people.
The prognosis for the progressive types of dementia may vary, but all prognoses involve
progressive deterioration of physical and mental abilities until death. Typically , in the
later stages, client s have minimal cognitive and motor function, are totally dependent on
caregivers, and are unaware of their surroundings or people in the environment. They may be
totally uncommunicative or make unintelligible sounds or attempts to verbalize.
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 replishment therapy with acetylcholine precursors,
cholinergic agonists, and cholinesterase inhibitors.
Medications
Cholinesterase inhibitors : have shown modest therapeutic effects and temporarily slow the
progress of dementia.
Tacrine (Cognex)
Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Reminyl)
Clients w/ 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 delusion, hallucinations, or paranoia.
Lithium carbonate , Carbamazepine (Tegretol), and Valproic acid (Depakote)

 Help stabilize affective lability and diminish aggressive outbursts.

Benzodiazepines : used cautiously because they may cause delirium and can worsen already
compromised cognitive abilities.
Nursing Interventions for Dementia
1. Promoting clients safety and protecting from injury offer unobtrusive
assistance w/ supervision of cooking, bathing, or self-care activities.

environmental triggers to help client avoid them.

2. Promoting adequate sleep, proper nutrition and hygiene, and activity

Prepare desirable foods and foods client can self-feed; sit w/ client while eating

Monitor bowel elimination patterns, intervene w/ 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.

3. Structuring environment and routine

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

4. Providing emotional support

Be kind, respectful, calm, and reassuring, pay attention to client.

Use supportive touch when appropriate

5. Promoting interaction and involvement

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.

Comparison of Delirium and Dementia

INDICATOR

DELIRIUM

DEMENTIA

ONSET

RAPID

GRADUAL AND INSIDUOUS

(slowly and harmful)

DURATION

BRIEF (HOURS TO DAYS)

PROGRESSIVE
DETERIORATION

LEVEL OF
CONSCIOUSNES

IMPAIRED, FLUCTUATES

NOT AFFECTED

S
MEMORY

SHORT-TERM MEMORY IMPAIRED

SHORT-TERM MEMORY
IMPAIRED, EVENTUALLY
DESTROYED

INDICATOR

DELIRIUM

DEMENTIA

SPEECH

MAY BE SLURRED, RAMBLING,

PRESSURED, IRRELEVANT

NORMAL IN EARLY STAGE,

PROGRESSIVE APHASIA IN
LATER STAGE.

THOUGH
PROCESSES

TEMPORARILY DISORGANIZED

IMPAIRED THINKING,
EVENTUAL LOSS OF
THINKING ABILITIES

PERCEPTION

VISUAL OR TACTILE
HALLUCINATIONS, DELUSION

OFTEN ABSENT, BUT CAN

HAVE PARANOIA,
HALLUCINATIONS, ILLUSIONS

MOOD

ANXIOUS, FEARFUL IF
HALLUCINATING; WEEPING,
IRRITABLE

DEPRESSED AND ANXIUOS

IN EARLY STAGE, LABILE
MOOD, RESTLESS PACING,
ANGRY OUTBURSTS IN LATER
STAGE