What are cognitive mental disorders?

• A group of disorders characterized by a disruption or a deficit in cognitive functioning.

What are the categories according to the DSM?

1. Delirium, dementia, amnestic and others
2. Mental disorders resulting from a general medical condition
3. Substance-related disorders

What is a significant risk factor for the development of delirium in all ages?

• Surgery

In most cognitive disorders what is compromised?

• The brain

Most disturbances fall into one of the following categories?

1. Primary brain disease
2. Response of the brain to the influence of systemic disturbances
3. Unique reaction of brain tissue to an exogenous substance
4. Residual effects or withdrawal of an exogenous substance

What do these clients sense?

• That their thinking is impaired
• Frustrated, anxious, frightened and emotionally distraught

Why may these disorders be difficult to diagnose?

• Because many illnesses and medications can cause cognitive impairment

What may complicate the cognitive disorder?

• Acute intoxication from overmedication
  • Exogenous substance
  • Process that occurs during withdrawal of this substance
  • Residual effect of an exogenous substance

Sometimes a client with a chronic problem experiences an episode of further cognitive impairment resulting form an acute problem, explain this.

• A chronic problem can be vascular dementia and it can become worse with delirium cause by an underlying physical problem like infection

What are the two most common neuropsychiatric disorders causing cognitive impairment?

1. Delirium
2. Dementia

Delirium

• Caused by an acute disruption of brain homeostasis
• When the cause of disruption is eliminated the deficit usually subsides
• Rapid onset, acute reversible clouding fo consciousness (decreases awareness of environment) and reduced ability to focus and maintain attention

Dementia

• A primary brain pathologic process that usually is irreversible, chronic, progressive and less amenable to treatment
• Irreversible, impairments in memory, abstract thinking, and judgment as well as changes in personality

Persistent dementia results from

• Hypoxia

Why are older adults particularly susceptible to delirium?

• Because of their aging neurologic system is vulnerable to insults by systemic conditions
• The number of OTC and prescriptions they use

Which medications are the frequent causes of delirium?

• Those that exert their effects on the CNS

What are specific causes of delirium?

1. Primary brain disease (concussion, contusion, hemorrhage, vascular obstruction, tumors)
2. Systemic diseases
3. Withdrawal of exogenous substances
   • Alcohol
   • Barbiturates
   • Sedative hypnotics
   • Tranquilizers

What are the 3 features that usually present with delirium?

1. Disordered cognition
2. Attention deficit
3. Disturbance of consciousness

What does cognition include?

• Aspects of thinking, perception, and memory

What are the manifestations of delirium?

• Pressured
• Rambling
• Bizarre
• Incoherent
• Nearly absent
• Cannot distinguish reality form imagery and dreams
• Suspiciousness and persecutory delusions is fairly common
• Hallucinations and illusions
• Agitated and combative to elude perceived threat

What are some behavioral changes?

• Hyperkinetic delirium
  • Psychomotor hyperactivity
  • Excitability
  • Hallucinations
• Hypokinetic delirium
  • Lethargic
  • Somnolent
  • Apathetic

Delirium indicates the existence of what:

• A medical illness and should be considered a medically urgent condition

Medical interventions include:

• Treatment of underlying cause so treatment varies according to each clients physical condition

Why should the environment be structured

• To ensure safety and maximize cognitive abilities

Why is providing a private room in a hospital setting good?

• So that the staff can minimize noxious and confusing environmental stimuli and maximize the use of a sitter or supportive family members

Why can you not completely extinguish all stimuli?

• Because doing so may cause the client to withdraw and attend to more internal stimuli

What can help the client’s comfort level in the hospital?

• Familiar objects from home

How can you reorient the patient?

• Calendars
• Clocks
• Decorations commemorating holidays

Who are clients with an increased risk of delirium?

• Head injury
• Older

What should you do throughout the course of treatment?

• Mental status examinations routinely

The Delirium Observation Screening Scale focuses on what

1. Acute onset and fluctuating course of the condition
2. Inattention
3. Disorganized thinking

Which tools are specific for delirium?

• CAM
• DOS

What about the mini mental status exam?

• Doesn’t differentiate between delirium and dementia

What does the MMSE include?

1. Orientation
2. Attention span
3. recall
4. Ability to execute simple instructions

Questions on the MMSE

• What is the year
• What is the date
• In what city are we
• Spell globe backward
• Repeat the following statement: a rolling stone gathers no moss
• Writ a sentence of your own choice (evaluate whether sentence has a subject, predicate, and object

MANAGING SYMPTOMS OF DELIRIUM

The primary medical intervention for managing delirium is to:

• Manage the underlying cause and to prevent future/further decline

Confusion and agitation can be easily worsen by?

• Pain
• Too many unsettling stimuli
• Too little routine
• Abrupt changes in routine
• Poor sleeping
• Insensitive approaches from other

The confused client will be calmer when:

• When environmental stimuli is eliminated as it invites misinterpretation, such as abstract picture on the wall or excessive background noise

What environmental cues can you provide?

• Clocks
• Recognizable pictures
• Calendars

How to manage symptoms of delirium:

1. Manage underlying cause
2. Safety, hydration
3. Manage environment
4. Consistent daily routine
5. Directed activity
6. Call by name and never approach from behind
7. Never assume client does not and will not understand explanations

How can you reinforce the predictability of the routine?

1. Tell patient or client what you are doing
2. What to expect
3. The time of day
4. And other relevant info

What medications are used to treat delirium?

• Haloperidol (Haldol) orally or IM is the mostly commonly used for symptoms
• Quetiapine (Seroquel) and Risperidone have been used for agitation related to delirium

Why is Haldol used?

• Has minimal anticholinergic effects and does not cause the serious cardiovascular and respiratory side effects with other antipsychotics

What bad side effects does it have though?

• Extrapyramidal effects

If the client has hepatic dysfunction the treatment team may choose to use?

• Lorazepam (Ativan)

What’s the dosage?

• 0.5 – 2mg IM or IV

Ativan can affect?

• Respiratory and cardiac function

How can you provide safety for your clients?

• Placing personal and familiar items close at hand
• Alert staff and family of elopement precautions so that family may make arrangements to stay
• Keeping bed low and side rails down
• Provide regular toileting so pt doesn’t attempt to go to bathroom
• Lighting bright enough so client can see accurately

DEMENTIA

What is it?

• A syndrome characterized by several cognitive deficits that result form a general medical condition, use of substance, or multiple biologic etiologies

All forms of dementia affect:

• Memory and cognition

They are all categorized by?

• Ongoing multiple cognitive deficits
• Memory impairment sever enough to impair social or occupational function
• Decline from previous level of functioning

Memory impairment in dementia encompasses?

• Ability to learn
• Ability to retain new material (short-term) or recall previously learned material (long-term

Family members first notice the decline in their loved ones because of difficulties with?

• Meal planning
• Managing checkbook
• Driving
• Using familiar equipment (like the telephone)?

Is reasoning affected?

• Yes, clients no longer can responsd with a reasonable plan to problem that occure at work or him eventually affecting abstract thinking

What about rules?

• They may begin to exhibit uncharacteristic disregard for rules of social conduct

They may have impairments with spatial abilities and ability to recognize or identify familiar objects

• Agnosia

Why do they have problems driving?

• Because of their diminished spatial ability

Clients may ride around and around for hours trying to find their way home but have little

• Insight that this is happening

What is aphasia?

• Difficulty finding words he or she wants to use in a conversation

 

Are motor tasks affected?

• Yes they may have difficulty brushing teeth, combing hair)

What is this called?

• Apraxia, inability to carry out skilled and purposeful movements

What is sun drowning?

• Disorientation that worsens at the end of the day

Confused clients may be too distracted to

• Eat, drink adequately and may be inattentive to personal hygiene

Major goals for treatment include:

1. Ability to remain safe
2. Basic needs will be me until self care ability resumes
3. Will return to baseline cognitive functioning
4. Will remain calm

What are the types of dementia?

1. Vascular dementia
2. Substance induced persisting amnestic disorder
3. Alzheimer’s
4. Medical conditions

What are the three stages of dementia?

1. Mild (1-3 years)
   1. Short term memory loss
   2. Decreased attention span
   3. Subtle personality changes
   4. Mild cognitive deficits
   5. Difficulty with depth perception
2. Moderate (2-10 years)
   1. Obvious memory loss
   2. Confusion
   3. Sundowning
   4. Irritability and agitation
   5. Impaired motor skills
   6. Impaired judgment
   7. Covers up memory loss through confabulation
   8. Symptoms intensify with stress
3. Severe (8-10 years before death occurs

The risk is higher for?

• Women

What are some priority care issues?

• Priorities will change throughout the course of the illness

What is the first thing when the client is just displaying signs?

• Delay cognitive decline

What would you do later?

• Protect pt from hurting self

In AD the client had multiple deficits manifest by:

1. Impaired memory (long and short)
2. One or more of the following
   1. Aphasia
   2. Apraxia
   3. Agnosia
   4. Disturbed executive functioning

Which is the most prevalent of the dementias

1. AD

Two kinds of AD

2. Familial onset (early) 65 years and younger
3. Late onset (over 65)

What are the hallmark pathologic features of Alzheimer’s Disorder (AD)?

• Neurofibrillary tangles and beta plaques in the brain on postmortem examination

The disease process of AD result in?

• Neuronal death and the disruption of neurotransmitters

Which neurotransmitter is extremely important to memory and cognition?

• Acetylcholine (Ach)

What genetics have been involved in AD?

• Chromosomes 1, 14, 21

What are the goals of collaborative management?

• Ensuring that all ADL and nutritional needs are met
• Medication Adherence
• Assessment and treatment for physical problems
• Ensuring safety wit no harm to self or other

The second most common form of dementia is?

• Vascular dementia

This may be the most common dementia in

• Men and those over 85

Risk factors are comparable to

• CVA risk factors

What is a cardiovascular accident?

• It results because there are multiple infarcts in the cortex and the white matter of the brain after the hemorrhage or ischemia inherent in a CVA.

What is Lewy Body Disease?

• Sometimes mistaken for AD because of the clinical similarity
• Characterized by earlier and more prominent visual hallucinations, Parkinson’s features, behavioral disturbances

What confirms diagnosis?

• Presence of inclusion bodies in the cortex

What is a distinguishing characteristic?

• Clients have significant adverse effects when given antipsychotic drugs

What is Creutzfeldt-Jakob disease (CJD)

• A rare disease that causes a cognitive disorder by targeting the CNS
• May be spread with contact of brain tissue
• May be genetic
• Occurs in 50-75 years olds
• Middle eastern or Chile descent
• Rapid onset, fatal in one year
• Spongiform appearance of the cerebral and cerebellar cortex
• Progresses in 3 stages: dementia, jerking, seizure, ataxia, dysarthria, extrapyramidal effect; and coma and dying from infections and respiratory problems

Does the MMSE assess abstract thinking?

• No but you can ask a proverb and ask to decipher it

Caregiver burnout, guilt, frustrations may be ameliorated when

• The family member understands the commonality of his or her feelings

What are the major goals for care of a client dementia?

• Physical needs will be met
• Environment will be safe
• Will have infrequent episodes of agitation
• Family members will have psychosocial support and resources for respite care

What are some interventions for dementia?

1. Assist client to identify and express feelings about the diagnosis
2. Give him time to process feelings
3. Identify danger areas in home
4. Modify environment to make is safer
   • Plug electrical items that pose hazards
   • move thermostat and hot water heater so that its low setting
   • take them off the counters
5. Establish a calm environment
   • create predictability and simplify choices
   • establish a daily routine for grooming, meals, activities
6. Provide environmental memory cues
7. Provide information
   • Describe options available for care (nursing home, assisted living etc)
8. Help client clarify his values and make important decisions while cognition is still high
   • Encourage family to provide advance directives
9. Promote family cohesion
   • Help family identify feelings about role of health change
   • Help resolve conflicts
   • Suggest attending an AD meeting