Cognitive Responses & Cognitive Responses & Organic Mental DisordersOrganic Mental Disorders

NUR 305NUR 305

Cognitive responsesCognitive responses

• Maladaptive cognitive responses include an inability to make decisions, impaired memory and judgment, disorientation, misperceptions, decreased attention span, and difficulties with logical reasoning.

DeliriumDelirium

• Is the behavioral response to widespread disturbances in cerebral metabolism.

• Represents a sudden decline from a previous level of functioning.

• Is usually considered a medical emergency.

DeliriumDelirium

• Should be considered any time there there is an acute change in mental status.

• Can occur at any age but advanced age is the greatest risk factor.

• Results in disturbances in consciousness, attention, cognition, perceptions, & motor ability.

• Commonly found in hospitalized patients; CCU, geriatric units, the ED, alcohol treatment units, & oncology units.

• May be related to systemic illness (i.e. systemic strep infection)

Delirium cont.Delirium cont.

• The patient experiences a diminished awareness of the environment that involves sensory misperceptions and disordered thought and also experiences disturbances in psychomotor activity and the sleep-wake cycle.

Delirium cont.Delirium cont.

• These disturbances develop rapidly (over hours to days) and fluctuate over the course of the day.

• Usually worsen at night.

DementiaDementia

• A maladaptive cognitive response that features a loss of intellectual abilities and interferes with the patient’s usual social or occupational activities.

• Alzheimer’s disease (AD) is the most common type of dementia.

• AD accounts for 65% of all cases of dementia

• Affects 4.8 million people in the US

Comparison of delirium & Comparison of delirium & dementiadementia

• Delirium• Onset: rapid ( hours to days)• Course: wide fluctuations; may

continue for weeks if cause is not found

• LOC: hyper-alert to difficult to arouse

• Orientation: disoriented;confused

• Attention: always impaired• Sleep:always disturbed

• Dementia• Onset: gradual (years)• Course: slow but continuous

decline• LOC:normal• Orientation:disoriented;confus

ed• Attention: may be intact; may

focus on one thing for long periods

• Sleep: usually normal

Comparison of delirium & Comparison of delirium & dementia cont.dementia cont.

• Delirium• Behavior: agitated;restless• Memory: especially recent

memory impairment• Cognition: disordered

reasoning• Thought content: incoherent,

confused, delusional• Perception: illusions,

hallucinations• Judgment: poor• Insight: present in lucid

moments

• Dementia• Behavior: may be agitated or

apathetic;may wonder• Memory: especially recent

memory impairment• Cognition: disordered

reasoning and calculation• Perceptions: no change• Judgment: poor;socially

inappropriate• Insight: absent

Depression and ADDepression and AD

• Depression associated with AD may be among the most common mood disorders of older adults.

• Pseudo-dementia is a cognitive impairment secondary to a functional psychiatric disorder such as depression, poor concentration, etc.

Early onset ADEarly onset AD

• Early onset AD is associated with a more rapid course and genetic predisposition as compared with late-onset AD.

• An individual with one parent with early-onset AD has a 50% chance of developing it before the age of 55.

3 stages of AD3 stages of AD

• Stage 1: Mild

• Impaired memory

• Insidious loss in performing ADL’s

• Subtle personality changes

• Socially normal

Stages of AD cont.Stages of AD cont.

• Stage II: Moderate

• Memory impairment

• Overt ADL impairment

• Behavior difficulties

• Variable social skills

• Supervision needed

Stages of AD cont.Stages of AD cont.

• Stage III: Severe

• Fragmented memory

• No recognition of familiar people

• Assistance needed with basic ADL

• Fewer troublesome behaviors

• Reduced mobility

Predisposing factors related to Predisposing factors related to impaired cognitionimpaired cognition

• Aging• Neurobiological functioning (plaques and

proteins in nerve cells and disruptions in cerebral blood supply.

• Changes in brain structures (cortical atrophy & ventricle enlargement)

• Genetic factors underlying psychiatric & medical conditions

DisorientationDisorientation

• Disorientation is a common behavior related to dementia.

• Time orientation is affected first, then place, and finally person.

ConfabulationConfabulation

• Is a confused person’s tendency to make up a response to a question when he or she cannot remember the answer.

• Should not be viewed as lying or as an attempt to deceive but rather as a way of saving face in an embarrassing situation

AD progressionAD progression

• Aphasia- difficulty finding the right word

• Apraxia- an inability to perform familiar skilled activities

• Agnosia-difficulty in recognizing well-known objects, including people

• Amnesia- significant memory impairment in the absence of clouded consciousness or other cognitive symptoms.

DisorientationDisorientation

• Can result in fear and agitation when individuals have cognitive impairment.

• Behavior that becomes extremely agitated is called a catastrophic reaction and is a medical emergency

Predisposing Factors for ADPredisposing Factors for AD

• Biological:Genetic predisposition: runs in families; genes have been identified

Aging – risk factor for dementia associated with ADNeurobiological- neuronal plaques altered glial cells, twisted

or tangled protein fibers in neurons.Alterations in neurotransmitter systems; in particular, a

significant deficiency in acetylcholine.Disruptions in cerebral blood supply (vascular dementia)Dementia with Lewy bodies (DLB) neurofilaments assoc

w/Parkinsons. In AD, 50-75% also have Lewy bodies.

Precipitating Stressors for Precipitating Stressors for DeliriumDelirium

-drug/substance use; polypharmacy

-underlying medical conditions; CNS disorders, (head trauma; encephalitis) metabolic disorders, (hypothyroidism) poor nutrition with vitamin B deficiency, cardiopulmonary disorders, hypoxia, systemic illness & sensory deprivation or sensory overload.

Precipitating StressorsPrecipitating Stressors

Associated with dementia:-depression

-degenerative brain disorders;AD, Parkinson’s, Huntington’s disease

-cerebrovascular dementia; multi-infarct dementia

-toxic metabolic disturbances; alcoholism,poisons

CNS infections; chronic meningitis, neurosyphilis

Brain imagingBrain imaging

• Positive Emission Tomography (PET), CT, & MRI

Patients with early onset AD may show cortical atrophy, ventricular enlargement, and loss of temporal lobe volume, as well as marked loss in brain weight.

Early and late onset AD show a pattern of frontal and temporal hypometabolism.

Coping mechanismsCoping mechanisms

• Associated with delirium: due to altered awareness with delirium, coping mechanisms are not generally used.

• Associated with dementia: include intellectualization, rationalization, denial, and regression, joking, depression, & withdrawal.

Primary NANDA Nursing Primary NANDA Nursing DiagnosesDiagnoses

• Acute and chronic confusion

• Disturbed thought processes

DSM-IV-TR diagnosesDSM-IV-TR diagnoses

• Delirium

• Dementia

• Amnestic disorders (memory disorders)

OutcomeOutcome

• The patient will achieve the optimum level of cognitive functioning.

Interventions related to deliriumInterventions related to delirium

• Caring for physiological needs (nutrition and fluid balance; IV therapy)

• Responding to hallucinations (protect patient from harm,orient back to reality)

• Therapeutic communication (simple, direct statements, clear messages)

• Patient education may need reinforcement

Interventions related to Interventions related to dementiadementia

• Pharmacological approaches-cholinesterase inhibitors to increase levels of acetylcholine

• Orient the patient (clocks, calendars, newspaper)

• Therapeutic communication (empathy, respect; encourage reminiscence)

• Orient patient to surroundings (place a night light

in the patient’s room.

Interventions related to Interventions related to dementiadementia

• Reinforcement of positive coping mechanisms (staying active and socializing with others)

• Responding to wandering (observation and decrease stress in the environment

• Decreasing agitation (avoid power struggles, offer choices to patient)

• Family/community approaches address caregiver stress and respite care

Pharmacological Interventions Pharmacological Interventions related to dementiarelated to dementia

• Cholinesterase inhibitors for AD:

Aricept (Donepezil)

Galantamine (Reminyl)

Rivastigmine (Exelon)

Pharmacological approaches in Pharmacological approaches in AD cont.AD cont.

• Antipsychotics for psychotic s/s

• Antidepressant for depressive s/s

• Benzodiazepines for anxiety/agitation

• Anticonvulsants for agitation, mood swings

• Serotonergic agents for psychosis. agitation