COGNITIVE

DISORDERS
 SITE MAP
► OVERVIEW
► DELIRIUM
► DEMENTIA
► PARKINSON’S DISEASE
► AMNESTIC DISORDERS
► COMMUNITY BASED CARE
 OVERVIEW
► 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
► 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
► 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)
► 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
► 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.
► Delirium is often the first sign of another,
sometimes serious disorder, especially in older
people.
 Drugs Causing Delirium
► Anticonvulsants ► Hypoglycemic
► Anticholinergics agents
► Antidepressants ► Insulin

► Antihistamines ► Cardiac glycosides

► Antipsychotics ► Narcotics

► Aspirin ► Propranolol

► Barbiturates ► Reserpine

► Benzodiazepines ► Thiazide diuretics

 Medical Management
► Hypoactive delirium - No specific
pharmacologic treatment
► Sedatives to prevent inadvertent self-
injury 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 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 environment to reduce sensory
overload
 Provide a quiet environment
 Monitor client’s response to visitors
 Validate client’s anxiety and fears, but do not
reinforce misperceptions
► Promoting 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?
► 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
► 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.

► 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
►isan 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
 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 Disease
► is 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 ► Jakob-Creutzfeldt

► Limbic encephalitis disease
► Vascular dementia ► Idiopathic basal ganglia
► Heavy metal exposure calcification
► Lewy body disease
► Neurosyphilis
► Normal pressure
► Acquired immune
hydrocephalus deficiency syndrome
(AIDS)
► Parkinson's disease ► Fungal infections
► Post-traumatic ► Tuberculosis
dementia
► Pick's disease
► Progressive
supranuclear palsy
► Multiple sclerosis ► Huntington's disease
 Diagnostic Exam
► •     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
► Level of consciousness – not affected
► Thought processes is impaired
► Mental function is lost, relatively consistently for all
functions
► Memory is lost,
l especially for recent events
► 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
 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 Almost always present; may Possibly none
physical problems be a severe illness, drug use
or withdrawal, or a problem
with metabolism

Variation at night Almost always worse Often worse

Attention Greatly impaired
Level of consciousness Fluctuates from lethargy to
agitation
Orientation to surroundings Varies
Use of language Slow, often incoherent, and
inappropriate
Memory Jumbled and confused
Mental function Lost, variably and
unpredictably
Cause Usually an acute illness or
drugs; in older people, usually
infection, dehydration, or
drugs
Need for treatment Emergency medical attention
Maintained until late stages
Normal until late stages
Impaired
Sometimes difficulty finding
the right word
Lost, especially for recent
events
Lost, relatively consistently
for all functions
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 and cognitive:
 Depression
 Anxiety
 Psychosis
 Dementia
 Apathy
 Fatigue
 Sleep disturbance
 Mild Cognitive Impairment
MCI
► Cognitiveimpairment 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

► 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