Neurocognitive Disorders Chapter 23 Neurocognitive Disorders Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Clinical Picture of Delirium Alteration in level of consciousness Disorientation Anxiety Agitation Poor memory Delusional thinking Hallucinations Delirium is a medical emergency Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Application of the Nursing Process Overall assessment Four cardinal features of delirium 1. Acute onset and fluctuating course 2. Reduced ability to direct, focus, shift, and sustain attention 3. Disorganized thinking 4. Disturbance of consciousness Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Process (Cont.) Cognitive and perceptual disturbances Illusions Hallucinations Physical needs Moods and physical behaviors Self assessment Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Process (Cont.) Diagnosis (Table 23-2) Risk for injury Acute confusion Risk for deficient fluid volume Outcomes identification (Table 23-3) Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Process (Cont.) 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. Evaluation Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Dementia Progressive deterioration of cognitive functioning and global impairment of intellect No change in consciousness Difficulty with memory, problem solving, and complex attention Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Clinical Picture Mild neurocognitive disorders Major neurocognitive disorders Due to: Alzheimer’s disease Frontotemporal Lewy bodies Vascular Traumatic brain injury Substances HIV infection Prior disease Parkinson’s disease Huntington’s disease Medical condition Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Etiology of Alzheimer’s Disease Biological factors Neuronal degeneration Risk factors Cardiovascular disease Social engagement and diet Head injury and traumatic brain injury Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Application of the Nursing Process Assessment General assessment Defense mechanisms Denial Confabulation Perseveration Avoidance of questions Self assessment Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Symptoms of Alzheimer’s Disease Memory impairment Disturbances in executive functioning Aphasia Apraxia Agnosia Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Stages of Alzheimer’s Disease Preclinical AD Mild cognitive impairment (MCI) Dementia due to AD Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Case Study A neighbor is concerned about her 85-year-old mother, who has dementia. She asks you to help her decide what to do about her mother. What are some important things to assess? 1. Evaluate the person's current level of cognitive and daily functioning. 2. Identify any threats to the person's safety and security and arrange their reduction. 3. Evaluate the safety of the person's home environment (e.g., with regard to wandering, eating inedible objects, falling, engaging in provocative behaviors toward others). 4. Review the medications (including herbs, complementary agents) the patient is currently taking. 5. Interview family members to gain a complete picture of the person's background and personality. 6. Explore how well the family is prepared for and informed about the progress of the person's dementia, depending on cause (if known). 7. Discuss with family members how they are coping with the patient and their main issues at this time. 8. Review the resources available to the family. Ask family members to describe the help they receive from other family members, friends, and community resources. Determine whether caregivers are aware of community support groups and resources. 9. Identify the needs of the family for teaching and guidance (e.g., how to manage catastrophic reactions, lability of mood, aggressive behaviors, and nocturnal delirium and increased confusion and agitation at night [sundowning]). Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Process (Cont.) Diagnosis (Table 23-2) Outcomes identification (Table 23-3) Implementation Person-centered care approach Health teaching and health promotion Pharmacological interventions Integrative therapy Evaluation Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Case Study (Cont.) What are some appropriate community resources you could suggest to your neighbor to help with her mother? Transportation services Supervision and care when the primary caregiver is out of the home Referrals to day care centers Information on support groups in the community Meals on Wheels Information on respite and residential services Telephone numbers for help lines Home health services Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Audience Response Questions Acute onset of disordered thinking is most associated with delirium. dementia. depression. ANS: A   Acute onset and fluctuating levels of awareness are key findings in delirium. REF: 6, 11 Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Audience Response Questions A patient with dementia attempts to brush his teeth with a spoon. Which problem is evident? Aphasia Apraxia Agnosia Perseveration ANS: B   Apraxia is the loss of purposeful movement in the absence of motor or sensory impairment. REF: 22 Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.