Cognitive Disorders Kimberly Gregg MS, APRN,BC N483

Objectives Define cognitive disorders. Discuss differences between reversible and irreversible cognitive disorders. Discuss the non-dementia cognitive disorders. Discuss difference between delirium and dementia. Discuss the various dementias and their symptoms. Discuss treatment for the various cognitive disorders.

Cognitive Disorders Involve “assaults” on the human brain Cognition is associated with memory and learning. The loss of memory and learning is the common thread in all cognitive disorders Some cognitive disorders are temporary or “reversible” and some are permanent or “irreversible”.

Non-dementia Cognitive Disorders 3 Types: MCI, Delirium, and Pseudodementia Mild Cognitive Impairment (MCI): ◦ Subtle onset ◦ NOT the result of normal aging ◦ Sometimes referred to as the zone between normal aging and Alzheimer's Disease. ◦ Forgetfulness is the hallmark symptom! ◦ It is not a DSM-IV-TR diagnosis

Non-dementia Cognitive Disorders Delirium ◦ Acute Onset!! ◦ Characterized by a disturbance of consciousness and a change in cognition, such as impaired attention span, disorientation, and confusion that develops over a short period of time and fluctuates throughout the day. ◦ Other symptoms: Slurred speech, nonsensical thoughts, day- night sleep reversal, visual hallucinations, tactile hallucinations (bugs under skin common in alcohol withdrawal delirium), and emotional. ◦ Examples: “ICU psychosis”, “DT’s” ◦ Most common complication of the hospitalized older adult patient. ◦ May be the sign of an underlying medical condition, such as infection, myocardial infarction, toxic response to medication, electrolyte imbalance, etc…

Non-dementia Cognitive Disorders Pseudodementia: ◦ Type of cognitive disorder that is most often linked to an underlying functional psychiatric illness, such as depression. (Depressed to the extent that they seem demented.) ◦ Typically withdrawn and apathetic—but can be anxious and agitated. ◦ Commonly responds to questions by saying “I don’t know” in contrast to the patient with dementia who would usually try and answer the question.

Dementia Dementia develops more slowly than delirium and is characterized by multiple cognitive deficits, including memory impairment. Dementias are usually primary, progressive, and irreversible—even the reversible ones after a certain extent. Alzheimer’s disease accounts for 60% to 80% of all dementias in the US.

Reversible Dementias Can be treated and symptoms may resolve or at least improve if caught early enough. 2 types: Normal Pressure Hydrocephalus & Vitamin B12 Deficiency

Reversible Dementias Normal Pressure Hydrocephalus (NPH) ◦ Usually presents with the classic triad of symptoms: urinary incontinence, apraxic gait, and dementia. ◦ Patients have enlarged ventricles seen on CT or MRI. ◦ The cause of NPH is impaired return of cerebral spinal fluid to the spinal column form the brain. ◦ Also seen: Impairment in daily activities and dulling of personality with lack of motivation. ◦ Treatment: Neurosurgery in which a ventricular shunt is placed in one of the lateral ventricles in the brain, which then leads to the peritoneum (VP shunt).

Reversible Dementias Vitamin B12 Deficiency: ◦ Pernicious anemia is the most prevalent cause of this deficiency. ◦ Dementia related to vitamin b12 deficiency is rare. ◦ When the deficiency proceeds to this level, demyelinization occurs, leading to axon loss in the brain and in the spinal cord. ◦ Paresthesias start in the lower extremities, followed by upper extremity involvement. ◦ Behavioral and mood changes occur. ◦ On an MRI of the brain, lesions may be found in the optic nerve and cerebral white matter. ◦ Treatment: Vitamin B12 replacement should be started immediately and should be continued throughout the patient's lifetime.

Irreversible Dementias No Cure—Cognitive Decline is Inevitable. Treatment focuses on symptom relief, slowing progression, and support/assistance as needed. 9 irreversible dementias: Alzheimer’s Disease, Vascular Dementia, Frontotemporal Lobe Dementia, Parkinson’s Dementia, Diffuse Lewy Body Disease, Creutzfeldt-Jakob Disease, AID’s Dementia, Wernicke’s/ Korsakoff’s Syndrome, & Huntington’s Disease.

Irreversible Dementias Alzheimer’s Disease: ◦ Most prevalent dementia ◦ Diagnosed after all other disorders have been ruled out. ◦ Age is most significant risk factor. ◦ History of head injury, lower educational level, being female are also risk factors. ◦ 4 stages: Mild, Moderate, Severe, and Late. ◦ Cholinergic Hypothesis: level of acetylcholine is reduced in the brain. ◦ Genetics plays a role as well: genes on chromosomes 1, 14, 19, and 21 have been linked to this disease. ◦ Brain Atrophy: the Alzheimer’s brain is also shrinking, weighing about two thirds the weight of the normal brain.

Irreversible Dementias Alzheimer’s Disease Continued: ◦ The 4 “A’s”:  Agnosia: impaired ability to recognize or identify familiar objects and people in the absence of a visual or hearing impairment.  Aphasia: language disturbances are exhibited in both expressing and understanding spoken words.  Amnesia: inability to learn new information or to recall previously learned information.  Apraxia: inability to carry out motor activities despite intact motor function. ◦ Misinterpreting the environment through visual hallucinations, delusions, and misidentification. ◦ Sundowning: phrase that describes the period, usually in the afternoon and early evening, during which a patient becomes more agitated and less redirectable. ◦ Loss of ability to care for oneself is particular difficult for all parties.

Irreversible Dementias Vascular Dementia: ◦ Second most prevalent dementia ◦ Also know as multiinfarct dementia ◦ The brain has multiple vascular lesions in the cortex and subcortical areas—sometimes called “small strokes”. ◦ Memory loss is the most common presenting complaint. ◦ Patients usually maintain ability to speak without work searching. ◦ The cognitive changes that occur are directly related to the location of the lesions.

Irreversible Dementias Frontotemporal Lobe Dementia (FLD): ◦ Type of dementia caused by atrophy of the frontal and anterior temporal lobes of the brain. ◦ Pick’s Disease is a subtype of FDL: linked to chromosomes 3 & 17. ◦ Pick’s cells are “swollen, ballooned neurons”. ◦ The area of the brain affected is responsible for executive functioning. ◦ Behaviors include disturbances in judgment, decision making, impulse control, and social norms. ◦ Behavioral changes may be first sign that something is wrong—such as disrobing in public, extreme impatience, or openly masturbating.

Irreversible Dementias Parkinson’s Dementia (PD): ◦ Parkinson’s is a complex neurologic disorder that affects the extrapyramidal system. ◦ Usually diagnosed when clients in their 50’s or 60’s. ◦ The substania nigra has approximately a 50% reduction in neurons. ◦ Fifteen years is the usual course of PD— making the decline more gradual than most other dementias.

Irreversible Dementias Diffuse Lewy Body Disease (DLBD): ◦ The form of dementia that has both cognitive impairment with extrapyramidal signs. ◦ In addition to lewy bodies, these patients also have senile plaques—both of which cause neuronal dysfunction or death. ◦ 80% of patients with DLBD have severe visual hallucination, a tendency to fall, and fluctuation in alertness early in the disease. ◦ The downward course is much more precipitous than Alzheimer’s disease; usually 5 to 8 years. ◦ The extrapyramidal signs separate it from Alzheimer’s disease.

Irreversible Dementias Creutzfeldt-Jakob Disease (CJD): ◦ This disease is known as the human form of “mad cow” disease. ◦ The patients contract this after ingesting meat infected with bovine spongiform encephalopathy. ◦ Dementia is inevitable and occurs early in the disease. ◦ Personality changes, seizures, and myoclonic movements occur and blindness is not uncommon. ◦ Most patients die within 6 months to a year. Only 10% live past one year. ◦ Contrary to popular belief—Not the main reason that Kim is a vegetarian.

Irreversible Dementias AID’s Dementia: ◦ HIV crosses the blood-brain barrier. ◦ Occurs in approximately 20% to 30% of patients with AIDS. ◦ Initially motor disturbance occurs. ◦ Cognitive and behavioral changes follow. ◦ Development of the dementia takes years, however, once it occurs, the patient usually does not live past a year.

Irreversible Dementias Wernicke’s/ Korsakoff’s Syndrome: ◦ Dementia usually occurs decades after the person starts drinking alcohol. ◦ Personality changes typically precede memory disturbance. ◦ The decline is similar to the course of Alzheimer’s disease. ◦ Thiamine deficiency is the main cause of alcohol related changes, so thiamine replacement is typically part of detox protocol. ◦ Wernicke’s encephalopathy results in motor problems related to alcohol abuse—such as ataxia and nystagmus. ◦ Patient’s with Korsakoff’s syndrome confabulate as they attempt to answer questions in an attempt to cover their severe short-term memory loss.

Irreversible Dementias Huntington’s Disease (HD): ◦ Transmitted only through the autosomal dominant gene that either parent may provide. ◦ It does NOT skip generations. ◦ Not usually diagnosed until patients are in their 30’s and 40’s, and they may have children and even grandchildren by then. ◦ The child has a 50% chance of inheriting the gene and thus the disease. ◦ Personality changes are usually the fist signs to appear. ◦ Mood swings and usually behaviors, i.e. drinking alcohol can occur. ◦ Movement symptoms, i.e. facial twitches, involuntary limb movements occur. ◦ Chromosome 4 is the point at which the gene associated with HD is located. ◦ The course is unpredictable because the illness may occur over a short period, or it may last decades.

Cognitive Disorder Treatment SAFETY! Daily cares as needed Management of symptoms NPR/NCR Psychopharmacology: Namenda (affects NMDA receptors), Aricept (inhibits acetylcholine breakdown), Cognex (cholinesterase inhibitor), Exelon (a brain- selective acetylcholinesterase inhibitor), Reminyl (reversible cholinesterase inhibitor) Orientating to person, place, and time Redirection, i.e. towel folding Sensitivity to Family as well!!