Chapter 27  Cognitive Disorders

1. Chapter 27Cognitive Disorders

2. In older people, the development of delirium or acute confusion…has been associated with increased lengths of hospital stay, the need for chemical and physical restraints, readmission, and increased mortality. Wakefield, 2002

3. Learning Objectives After studying this chapter, you should be able to • Discuss the changes that occur in the aging brain • Describe the four distinct, yet mutually interacting, memory systems identified by Heindel and Salloway • Explain the latest research findings related to the etiology of dementia of the Alzheimer’s type • Compare and contrast the etiology of vascular dementia and dementia with Lewy bodies • Distinguish the clinical symptoms of delirium, dementia, and amnestic disorders • Describe the onset and course of dementia from early to terminal stages

4. Learning Objectives (cont.)‏ • Explain the rationale for use of the Wong-Baker Faces Rating Scale, NEECHAM Confusion Scale, and Agitated Behavior in Dementia Scale when assessing clients with cognitive disorders • Articulate the importance of identifying a client’s cultural and educational background during the assessment process • Identify the elements of a comprehensive history and physical examination for a client who exhibits clinical symptoms of dementia of the Alzheimer’s type • Formulate nursing interventions for a client with the diagnosis of delirium who exhibits agitated and aggressive behavior • Develop an educational program to use with family members of clients with the diagnosis of dementia

5. Areas of the Brain Involved in Cognitive Function

6. Memory Systems and Their Locations

7. Etiology of Cognitive Disorders • Etiology of delirium • Etiology of dementia • Etiology of dementia of the Alzheimer’s type (DAT)‏ • Etiology of dementia with Lewy bodies (DLB)‏ • Etiology of vascular dementia • Etiology of diseases associated with dementia • Etiology of amnestic disorders

8. Clinical Symptoms and Diagnostic Characteristics of Cognitive Disorders • Delirium • Delirium due to a general medical condition • Substance-induced delirium • Delirium due to multiple etiologies • Delirium, not otherwise specified

9. Clinical Symptoms and Diagnostic Characteristics of Cognitive Disorders (cont.) • Dementia • Dementia of the Alzheimer’s type • Stages of dementia of the Alzheimer’s type  • Dementia with Lewy bodies • Vascular dementia • Dementia due to other general medical conditions

10. Clinical Symptoms and Diagnostic Characteristics of Cognitive Disorders (cont.) • Amnestic disorders • Anterograde amnesia • Retrograde amnesia • Cognitive disorder, not otherwise specified

11. The Nursing Process • Assessment • Nursing diagnoses • Outcome identification • Planning interventions • Implementation • Evaluation

12. Assessment • Ability to meet basic needs • Appearance, mood, and affect • Cognitive abilities • Behavioral manifestations • Assessment tools • Transcultural considerations

13. Nursing Diagnoses • Interrupted family processes • Ineffective role performance • Disturbed thought processes • Hopelessness • Impaired social interaction • Ineffective coping • Risk for injury • Situational low self-esteem • Social isolation

14. Outcome Identification Outcomes for clients with cognitive disorders include the following: • Elimination of organic etiology, if possible • Prevention of acceleration of symptoms • Preservation of the client’s dignity

15. Planning Interventions Interventions are planned that focus on the following: • Maintaining the client’s contact with reality • Reducing agitation • Preventing injury • Promoting adequate nutritional and fluid intake • Promoting adequate sleep and rest • Treating any underlying causes • Encouraging expression of feelings • Stimulating the memory through various activities • Decreasing socially inappropriate behavior • Encouraging satisfactory social relationships • Assisting to live in as nonrestrictive an environment as possible

16. Implementation • Establishment of a safe environment • Assistance in meeting basic needs • Stabilization of behavior • Behavioral intervention techniques and programs • Outreach programs • Medication management • Client and family education • Continuum of care

17. Future Research • The short-term and long-term efficacy of donepezil and cognitive training to improve memory in elderly adults not affected by dementia • The effects of NSAIDs in the delay of cognitive decline in older adults with age-associated memory impairment • Alzhemed, an investigational drug that appears to prevent formation of amyloid fibrils in the brain • Use of a low-flow cerebrospinal fluid shunt to increase the clearance of beta amyloid deposition from the brain to improve cognitive stability • Passive immunization by vaccine to develop antibodies that target the beta amyloid peptide in the brain to prevent DAT

18. Evaluation • Successful interventions for a client with dementia are measured in terms of quality of life. • It is achieved by slowing down the disease process.

19. Key Terms • Delirium • Dementia • Dementia with Lewy bodies • Disturbances in executive functioning • Dysgraphia • Dysnomia • Perseveration • Retrograde amnesia • Sundown syndrome • Agnosia • Amnestic disorders • Anterograde amnesia • Aphasia • Apraxia • Asterixis • Binswanger’s disease • Cognition • Cognitive disorder • Confabulation

20. ? Reflection Reflect on the chapter-opening quote, “In older people, the development of delirium or acute confusion…has been associated with increased lengths of hospital stay, the need for chemical and physical restraints, readmission, and increased mortality.” • Articulate the rationale for increased length of hospital stay, the need for chemical and physical restraints, readmission, and increased mortality in older clients who exhibit clinical symptoms of delirium or acute confusion. • What nursing interventions could you provide to older clients who exhibit clinical symptoms of delirium or acute confusion following relocation to a rehabilitation unit?