Transcript Cognitive Disorders

Cognitive Disorders
Kimberly Gregg MS, APRN,BC
N483
Objectives
Define cognitive disorders.
Discuss differences between reversible and
irreversible cognitive disorders.
 Discuss the non-dementia cognitive
disorders.
 Discuss difference between delirium and
dementia.
 Discuss the various dementias and their
symptoms.
 Discuss treatment for the various cognitive
disorders.
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Cognitive Disorders
Involve “assaults” on the human brain
 Cognition is associated with memory and
learning.
 The loss of memory and learning is the
common thread in all cognitive disorders
 Some cognitive disorders are temporary
or “reversible” and some are permanent
or “irreversible”.
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Non-dementia Cognitive Disorders
3 Types: MCI, Delirium, and
Pseudodementia
 Mild Cognitive Impairment (MCI):
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◦ Subtle onset
◦ NOT the result of normal aging
◦ Sometimes referred to as the zone between
normal aging and Alzheimer's Disease.
◦ Forgetfulness is the hallmark symptom!
◦ It is not a DSM-IV-TR diagnosis
Non-dementia Cognitive Disorders
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Delirium
◦ Acute Onset!!
◦ Characterized by a disturbance of consciousness and a change in
cognition, such as impaired attention span, disorientation, and
confusion that develops over a short period of time and
fluctuates throughout the day.
◦ Other symptoms: Slurred speech, nonsensical thoughts, daynight sleep reversal, visual hallucinations, tactile hallucinations
(bugs under skin common in alcohol withdrawal delirium), and
emotional.
◦ Examples: “ICU psychosis”, “DT’s”
◦ Most common complication of the hospitalized older adult
patient.
◦ May be the sign of an underlying medical condition, such as
infection, myocardial infarction, toxic response to medication,
electrolyte imbalance, etc…
Non-dementia Cognitive Disorders
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Pseudodementia:
◦ Type of cognitive disorder that is most often
linked to an underlying functional psychiatric
illness, such as depression. (Depressed to the
extent that they seem demented.)
◦ Typically withdrawn and apathetic—but can be
anxious and agitated.
◦ Commonly responds to questions by saying “I
don’t know” in contrast to the patient with
dementia who would usually try and answer the
question.
Dementia
Dementia develops more slowly than
delirium and is characterized by multiple
cognitive deficits, including memory
impairment.
 Dementias are usually primary,
progressive, and irreversible—even the
reversible ones after a certain extent.
 Alzheimer’s disease accounts for 60% to
80% of all dementias in the US.
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Reversible Dementias
Can be treated and symptoms may
resolve or at least improve if caught early
enough.
 2 types: Normal Pressure Hydrocephalus
& Vitamin B12 Deficiency
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Reversible Dementias
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Normal Pressure Hydrocephalus (NPH)
◦ Usually presents with the classic triad of symptoms:
urinary incontinence, apraxic gait, and dementia.
◦ Patients have enlarged ventricles seen on CT or MRI.
◦ The cause of NPH is impaired return of cerebral
spinal fluid to the spinal column form the brain.
◦ Also seen: Impairment in daily activities and dulling of
personality with lack of motivation.
◦ Treatment: Neurosurgery in which a ventricular
shunt is placed in one of the lateral ventricles in the
brain, which then leads to the peritoneum (VP shunt).
Reversible Dementias
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Vitamin B12 Deficiency:
◦ Pernicious anemia is the most prevalent cause of this
deficiency.
◦ Dementia related to vitamin b12 deficiency is rare.
◦ When the deficiency proceeds to this level,
demyelinization occurs, leading to axon loss in the brain
and in the spinal cord.
◦ Paresthesias start in the lower extremities, followed by
upper extremity involvement.
◦ Behavioral and mood changes occur.
◦ On an MRI of the brain, lesions may be found in the optic
nerve and cerebral white matter.
◦ Treatment: Vitamin B12 replacement should be started
immediately and should be continued throughout the
patient's lifetime.
Irreversible Dementias
No Cure—Cognitive Decline is Inevitable.
 Treatment focuses on symptom relief, slowing
progression, and support/assistance as needed.
 9 irreversible dementias: Alzheimer’s Disease,
Vascular Dementia, Frontotemporal Lobe
Dementia, Parkinson’s Dementia, Diffuse Lewy
Body Disease, Creutzfeldt-Jakob Disease, AID’s
Dementia, Wernicke’s/ Korsakoff’s Syndrome, &
Huntington’s Disease.
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Irreversible Dementias
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Alzheimer’s Disease:
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Most prevalent dementia
Diagnosed after all other disorders have been ruled out.
Age is most significant risk factor.
History of head injury, lower educational level, being female are
also risk factors.
4 stages: Mild, Moderate, Severe, and Late.
Cholinergic Hypothesis: level of acetylcholine is reduced in the
brain.
Genetics plays a role as well: genes on chromosomes 1, 14, 19,
and 21 have been linked to this disease.
Brain Atrophy: the Alzheimer’s brain is also shrinking, weighing
about two thirds the weight of the normal brain.
Irreversible Dementias
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Alzheimer’s Disease Continued:
◦ The 4 “A’s”:
 Agnosia: impaired ability to recognize or identify familiar objects and
people in the absence of a visual or hearing impairment.
 Aphasia: language disturbances are exhibited in both expressing and
understanding spoken words.
 Amnesia: inability to learn new information or to recall previously
learned information.
 Apraxia: inability to carry out motor activities despite intact motor
function.
◦ Misinterpreting the environment through visual hallucinations,
delusions, and misidentification.
◦ Sundowning: phrase that describes the period, usually in the
afternoon and early evening, during which a patient becomes
more agitated and less redirectable.
◦ Loss of ability to care for oneself is particular difficult for all
parties.
Irreversible Dementias
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Vascular Dementia:
◦ Second most prevalent dementia
◦ Also know as multiinfarct dementia
◦ The brain has multiple vascular lesions in the
cortex and subcortical areas—sometimes called
“small strokes”.
◦ Memory loss is the most common presenting
complaint.
◦ Patients usually maintain ability to speak without
work searching.
◦ The cognitive changes that occur are directly
related to the location of the lesions.
Irreversible Dementias
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Frontotemporal Lobe Dementia (FLD):
◦ Type of dementia caused by atrophy of the frontal and
anterior temporal lobes of the brain.
◦ Pick’s Disease is a subtype of FDL: linked to
chromosomes 3 & 17.
◦ Pick’s cells are “swollen, ballooned neurons”.
◦ The area of the brain affected is responsible for
executive functioning.
◦ Behaviors include disturbances in judgment, decision
making, impulse control, and social norms.
◦ Behavioral changes may be first sign that something is
wrong—such as disrobing in public, extreme
impatience, or openly masturbating.
Irreversible Dementias
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Parkinson’s Dementia (PD):
◦ Parkinson’s is a complex neurologic disorder
that affects the extrapyramidal system.
◦ Usually diagnosed when clients in their 50’s or
60’s.
◦ The substania nigra has approximately a 50%
reduction in neurons.
◦ Fifteen years is the usual course of PD—
making the decline more gradual than most
other dementias.
Irreversible Dementias
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Diffuse Lewy Body Disease (DLBD):
◦ The form of dementia that has both cognitive
impairment with extrapyramidal signs.
◦ In addition to lewy bodies, these patients also have
senile plaques—both of which cause neuronal
dysfunction or death.
◦ 80% of patients with DLBD have severe visual
hallucination, a tendency to fall, and fluctuation in
alertness early in the disease.
◦ The downward course is much more precipitous than
Alzheimer’s disease; usually 5 to 8 years.
◦ The extrapyramidal signs separate it from Alzheimer’s
disease.
Irreversible Dementias
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Creutzfeldt-Jakob Disease (CJD):
◦ This disease is known as the human form of “mad
cow” disease.
◦ The patients contract this after ingesting meat
infected with bovine spongiform encephalopathy.
◦ Dementia is inevitable and occurs early in the disease.
◦ Personality changes, seizures, and myoclonic
movements occur and blindness is not uncommon.
◦ Most patients die within 6 months to a year. Only
10% live past one year.
◦ Contrary to popular belief—Not the main reason
that Kim is a vegetarian.
Irreversible Dementias
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AID’s Dementia:
◦ HIV crosses the blood-brain barrier.
◦ Occurs in approximately 20% to 30% of
patients with AIDS.
◦ Initially motor disturbance occurs.
◦ Cognitive and behavioral changes follow.
◦ Development of the dementia takes years,
however, once it occurs, the patient usually
does not live past a year.
Irreversible Dementias
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Wernicke’s/ Korsakoff’s Syndrome:
◦ Dementia usually occurs decades after the person starts
drinking alcohol.
◦ Personality changes typically precede memory disturbance.
◦ The decline is similar to the course of Alzheimer’s disease.
◦ Thiamine deficiency is the main cause of alcohol related changes,
so thiamine replacement is typically part of detox protocol.
◦ Wernicke’s encephalopathy results in motor problems related to
alcohol abuse—such as ataxia and nystagmus.
◦ Patient’s with Korsakoff’s syndrome confabulate as they
attempt to answer questions in an attempt to cover their
severe short-term memory loss.
Irreversible Dementias
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Huntington’s Disease (HD):
◦ Transmitted only through the autosomal dominant gene that either
parent may provide.
◦ It does NOT skip generations.
◦ Not usually diagnosed until patients are in their 30’s and 40’s, and they
may have children and even grandchildren by then.
◦ The child has a 50% chance of inheriting the gene and thus the disease.
◦ Personality changes are usually the fist signs to appear.
◦ Mood swings and usually behaviors, i.e. drinking alcohol can occur.
◦ Movement symptoms, i.e. facial twitches, involuntary limb movements
occur.
◦ Chromosome 4 is the point at which the gene associated with HD is
located.
◦ The course is unpredictable because the illness may occur over a short
period, or it may last decades.
Cognitive Disorder Treatment
SAFETY!
Daily cares as needed
Management of symptoms
NPR/NCR
Psychopharmacology: Namenda (affects NMDA
receptors), Aricept (inhibits acetylcholine breakdown),
Cognex (cholinesterase inhibitor), Exelon (a brainselective acetylcholinesterase inhibitor), Reminyl
(reversible cholinesterase inhibitor)
 Orientating to person, place, and time
 Redirection, i.e. towel folding
 Sensitivity to Family as well!!
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