Transcript Chapter 017

Cognitive Disorders
CHAPTER 17
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
1
 Delirium
Etiology
 An underlying systemic illness, including
infection, and endocrine disorder, trauma,
and drug/alcohol abuse
 Dementia
 Classified as to the cause or area of brain
damage
 Amnestic disorders
 Head trauma, hypoxia, encephalitis,
thiamine deficiency, and substance abuse
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
2
Differentiating Types of Cognitive
Disorders
 Delirium
 Acute confusional state characterized by
disruptions in thinking, perception, &
memory
 Dementia
 Chronic state characterized by declines in
multiple cognitive areas, including memory
 Amnestic disorders
 Uncommon cognitive disorder characterized
by amnesia
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
3
Delirium – Clinical Picture
• Disturbances in consciousness
• Change in cognition
• Develops over a short period of time
• Common in hospitalized patients, especially
older adults
• Always secondary to another physiological
condition
• Is a transient disorder
• If underlying condition corrected, complete
recovery should occur
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
4
Delirium Assessment
• Four cardinal features
– Acute onset and fluctuating course
– Inattention
– Disorganized thinking
– Disturbance of consciousness
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
5
Delirium Assessment
• Cognitive and perceptual disturbances
– Illusions
– Hallucinations
• Physical needs
• Mood and physical behaviors
• Attention span
• Reasoning
• Sleep and wake cycle
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
6
Delirium
Nursing Diagnoses
• Risk for injury
• Acute confusion
• Deficient fluid volume
• Insomnia, Sleep deprivation
• Impaired verbal communication
• Fear
• Self-care deficit
• Disturbed thought process
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
7
Delirium
Outcomes Identification
• Patient will return to premorbid level of
functioning.
• Patient will remain safe and free from
injury while in the hospital.
• Patient will be oriented to time, place,
and person.
• Patient will be free from falls and injury.
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
8
Delirium Implementation
• Prevent physical harm due to confusion,
aggression, or fluid and electrolyte
imbalance.
• Perform comprehensive nursing
assessment to aid in identifying cause.
• Assist with proper health management to
eradicate underlying cause.
• Use supportive measures to relieve
distress.
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
9
Interventions for Delirium
 Introduce self and call client by name at
each contact
 Maintain face-to-face contact
 Use short, concrete phrases
 Keep room well lit
 Keep environmental noise low
 Set limits on behavior
 1:1 staffing as needed
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
10
Delirium Evaluation
• Patient will remain safe.
• Patient will be oriented to time,
place, and person by discharge.
• Underlying cause will be treated and
ameliorated.
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
11
Dementia
• Progressive deterioration of cognitive
functioning and global impairment of
intellect
• No change in consciousness
• Difficulty with memory, thinking, and
comprehension
• Majority of dementias are irreversible
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
12
Dementia
Primary Versus Secondary
• Primary
– Irreversible
– Progressive
– Not secondary to any other disease
– Example: Alzheimer's disease
• Secondary
– Result of some other pathological process
– Example: AIDS-related dementia
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
13
Alzheimer’s Disease Etiology
• Biological factors
– Cerebral atrophy
– Neurofibrillary tangles
– Neuritic plaques
• Genetic
 Dementia of Alzheimer’s type
 Dementia from Huntington’s disease
 Dementia from Pick’s disease
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
14
Alzheimer’s Disease Etiology
• Environmental factor
• Dementia from Creutzfeldt–Jakob disease
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
15
Nursing Process
• Assessment
– Confabulation
– Perseveration
• Cardinal symptoms observed in AD
– Amnesia or memory impairment
– Aphasia
– Apraxia
– Agnosia
– Disturbances in executive functioning
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
16
Nursing Process
 Poor judgment
 Decline in previous abilities
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
17
Stages of
Alzheimer's Disease
• Stage 1 (Mild) – forgetfulness
• Stage 2 (Moderate) – confusion
• Stage 3 (Moderate to Severe) – unable
to identify familiar objects or people
• Stage 4 (Late) – end-stage
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
18
Alzheimer’s Disease
Nursing Diagnoses
• Risk for injury
• Impaired verbal communication
• Impaired environmental interpretation
syndrome
• Impaired memory
• Confusion
• Caregiver role strain
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
19
Alzheimer's Disease
Outcomes Identification
• Areas to target
– Injury
– Communication
– Agitation level
– Caregiver role strain
– Impaired environmental interpretation:
chronic confusion
– Self-care needs
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
20
Alzheimer's Disease
Planning
• Geared towards person’s immediate
needs
• Identify level of functioning
• Assess caregivers’ needs
• Plan and identify appropriate
community resources
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
21
Alzheimer's Disease
Implementation
• Maintain optimal nutrition
• Counseling and communication
techniques
• Health teaching and health promotion
• Referral to community supports
• Structure the environment to support
cognitive functions
• Pharmacological interventions
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
22
Pharmacological Interventions
for Alzheimer’s Disease
• Tacrine (Cognex)
• Donepezil (Aricept)
• Rivastigmine (Exelon)
• Galantamine (Razadyne)
• Memantine (Namenda)
Slows the rate of cognitive decline
Potent acetylcholinesterase inhibitors
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
23
Common Medications for Cognitive
Disorders
 Dementia with Lewy Bodies
 Escitalopram (Lexapro)
Reduce symptoms of depression when present
 Pick’s Disease
 Valproic Acid (Depakote)
Reduce problematic mood swings and agitated
behavior
 Vascular Dementia with psychosis
 Quetiapine (Seroquel)
Reduce or eliminate delusions and hallucination
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
24
Amnestic Disorder
 Characterized by short-and long-term
memory deficits
 Inability to recall previously learned
information or past events
 Inability to learn new materials
 Cofabulation, apathy, bland affect
 Amnestic disorder NOS: not enough
supporting evidence to link a cause to
the amnesia (medical or substance)
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
25
Depression
 Depression can be masked by
symptoms suggestive of dementia
 The term pseudodementia is used to
describe the reversible cognitive
impairments seen in depression
 Pseudodementia is characterized by an
abrupt onset, rapid clinical course, and
client complaints about cognitive
failures
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
26
Caregiver Difficulties
 Wandering behaviors
 Sundowning disorientation
 Activities of Daily Living
 Medication management
 Burnout and fatigue
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
27
Caregiver Resources
 Family meetings
 Alzheimer’s Disease and Related
Disorders Association (ADRDA)
 Caregiver support groups
 Identify community resources
 ID bracelet for the client
Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.
28