Cognitive Disorders Rebecca Sposato MS, RN

Cognitive Disorders  A collection of pathologies resulting in the disturbance of memory recall and formation from baseline  Delirium - acute, fluctuating course with altered consciousness  Dementia – chronic linear course, characterized by other cognitive deficits  Amnesia – memory impairment in the absence of other cognitive impairments

Delirium  Reduced clarity of awareness with inability to focus, maintain or shift attention  Often accompanied by other cognitive deficits  Disorientation to place, time, and situation  Memory: Perseverating, short-term memory loss  Language: dysarthria, word-finding, aphasia  Perception: Misinterpretations, illusions, hallucinations  Sleep: insomnia, circadian rhythm changes  Emotion: heighten state, fear/anxiety, paranoia, restless, irritable  Acute and definite shift from baseline  Over half of patients return to pre-delirium status  Often precedes worsening of condition in elderly and chronically ill

Causes of Delirium  Most cases of delirium are secondary to another disease process  Decompensated dementia  Medication, anesthesia, chemical use/withdrawal  Infection (sepsis, influenza, UTI)  Electrolyte imbalances (Na+, glucose)  Sleep deprivation  Physiological stress  Hypothermia, ICU patients

Dementia  The occasional ‘senior moment’ is normal, further impairment represents a pathology  Significant memory impairment with one or more of the following cognitive deficits that prevent independent functioning  Aphasia, apraxia, agnosia, impaired executive functioning  Prevalence: increases by 10% for each decade over 65

Causes of dementia  Course progression specific to the underlying disease  Alzheimer’s Disease: neuro tangles and plaques  Vascular: damage to blood vessels and capillaries in cerebrum  Pick’s/Frontal-Temporal Lobe: organic degeneration  Parkinson’s: deterioration of dopaminergic neurons in substantia nigra  Huntington’s disease: inherited genetic neuro- degeneration  Spongiform Encephalopathy: prion infection  Korsakoff: chronic heavy alcohol use  Head trauma, AIDS, end stage of medical conditions

Assessment  Daily routine  Physical health  Interview family and caretakers  Resources/stressors  Verify information  Impact on general functioning  Short and long term changes

Stages of Dementia  Mild: delayed ability to learn new information  Pt. makes efforts to compensate for deficits  Moderate stage: memory loss confined to short term  Forgets location of objects, getting lost, or misses details of current activity  Confabulates for unknown information  Severe: long term memory loss  Recognize family, recall life history  Labile mood, inappropriate emotions  Wander in familiar settings  End Stage: Globally impaired mental abilities,  impaired bodily functions, movement,  no discernable language

Prevention  Nutrition:  Vitamin B deficiency  Bouts of hypoglycemia  Mental Activity  Provide mental stimuli with learning language, music, mental puzzles  Physical Activity  Daily exercise and hobbies  Social Activity  Family and friend interactions  Pharmacological

Pharmacological Interventions  Medications can prevent deterioration, but cannot return lost abilities  Cautious dosing  Prevent breakdown of acetylcholine  Early stages, GI and hepatic side effects, limit NSAID use  Donezepil (aricept), rivastigmine (exelon), and galantamine (razadyne)  N-Methyl-D-Aspartate antagonist, limit glutamate release to prevent neuro-corrosion from calcium ions  Moderate to severe stages, limit if renal impairment  Mematine (Namenda)

Interventions  Think fundamental and instinctual  Creature comforts  Natural bodily rhythms  Safety precautions  falls, pulling medical devices, wandering/elopement  Frequently mention time, place, person etc.  Maintain consistent routine  Remove obnoxious stimuli  Foley, noise from hall  Communication: literal word choices  one-step directions, 2 item choices, picture boards