1. Delirium, Dementia, and Amnestic Disorders
Chapter 12
Delirium, Dementia, and Amnestic Disorders

2. Introduction
Disorders in which a clinically significant deficit in cognition or memory exists

3. Introduction (cont.)
The number of people with these disorders is growing because more people now survive into the high-risk period for dementia, which is middle age and beyond

4. Delirium
Characterized by a disturbance of consciousness and a change in cognition that develop rapidly over a short period

5. Delirium (cont.) Symptoms Difficulty sustaining and shifting attention
Extreme distractibility
Disorganized thinking
Speech that is rambling irrelevant, pressured, and incoherent

6. Delirium (cont.) Symptoms (cont.)
Impaired reasoning ability and goal-directed behavior
Disorientation to time and place
Impairment of recent memory
Misperceptions about the environment, including illusions and hallucinations

7. Delirium (cont.) Symptoms (cont.)
Psychomotor activity that fluctuates between agitation, purposeless movements, and a vegetative state
Emotional instability

8. Delirium (cont.) Symptoms include autonomic manifestations such as
Tachycardia
Sweating
Flushed face
Dilated pupils
Elevated blood pressure

9. Delirium (cont.) Usually begins abruptly
Can have a slower onset if underlying etiology is systemic illness or metabolic imbalance
Duration is usually brief and delirium subsides completely on recovery from underlying determinant

10. Etiological Implications
Delirium due to a general medical condition
Substance-induced delirium
Substance-intoxication delirium
Substance-withdrawal delirium
Delirium due to multiple etiologies

11. Dementia
Defined as the loss of previous levels of cognitive, executive, and memory function in a state of full alertness

12. Dementia (cont.)
Primary dementias are those in which the dementia itself is the major sign of some organic brain disease not directly related to any other organic illness (e.g., Alzheimer’s disease)
Secondary dementias are caused by or related to another disease or condition (e.g., HIV disease or cerebral trauma)

13. Dementia (cont.) Symptoms
Impairment exists in abstract thinking, judgment, and impulse control
Conventional rules of social conduct are disregarded
Personal appearance and hygiene are neglected

14. Dementia (cont.) Symptoms (cont.) Language may or may not be affected
Personality change is common

15. Dementia (cont.)
Reversible dementia is a function of the underlying pathological condition and of the availability and timely application of effective treatment
In most individuals, dementia runs a progressive, irreversible course

16. Dementia (cont.) As the disease progresses, signs include Apraxia
Irritability and moodiness, with sudden outbursts over trivial issues
Inability to care for personal needs independently
Wandering away from the home or care setting
Aphasia
Incontinence

17. Dementia (cont.)
Alzheimer’s disease (AD) accounts for 50% to 60% of all cases of dementia
Stages of Alzheimer’s disease
Stage 1: no apparent symptoms
Stage 2: forgetfulness
Stage 3: mild cognitive decline

18. Dementia (cont.) Stages of Alzheimer’s disease (cont.)
Stage 4: mild-to-moderate cognitive decline; confusion
Stage 5: moderate cognitive decline; early dementia
Stage 6: moderate-to-severe cognitive decline; middle dementia
Stage 7: severe cognitive decline; late dementia

19. Etiological Implications
Dementia of the Alzheimer’s type
Onset is slow and insidious, and the course of the disorder is generally progressive and deteriorating
Early onset (first symptoms at age or before)
Late onset (first symptoms after age 65)

20. Etiological Implications (cont.)
Dementia of the Alzheimer’s type (cont.)
Etiologies may include
Acetylcholine alterations
Plaques and tangles
Head trauma
Genetic factors

21. Etiological Implications (cont.)
Vascular dementia
The dementia is due to significant cerebrovascular disease
There is a more abrupt onset than is seen in association with Alzheimer’s disease, and the course is more variable

22. Etiological Implications (cont.)
Vascular dementia (cont.)
Etiologies may include
Arterial hypertension
Cerebral emboli
Cerebral thrombosis

23. Etiological Implications (cont.)
Dementia due to HIV disease
Results from brain infections caused by opportunistic organisms or the HIV-1 virus directly
Symptoms may range from barely perceptible changes to acute delirium to profound dementia

24. Etiological Implications (cont.)
Dementia due to head trauma
Serious head trauma can result in symptoms associated with the syndrome of dementia
Amnesia is the most common symptom
Repeated head trauma can result in dementia pugilistica with symptoms of
Dysarthria
Ataxia
Emotional lability
Impulsivity

25. Etiological Implications (cont.)
Dementia due to Lewy Body Disease
Similar to Alzheimer’s Disease, but progresses more rapidly
Lewy bodies (eosinophilic inclusion bodies) present in cerebral cortex and brainstem
Progressive and irreversible
May account for as many as 25% of all dementia cases

26. Etiological Implications (cont.)
Dementia due to Parkinson’s disease
Dementia is observed in as many as 60% of clients with Parkinson’s disease
Cerebral changes in dementia due to Parkinson’s disease often resemble those of Alzheimer’s disease

27. Etiological Implications (cont.)
Dementia due to Huntington’s disease
Damage from this disease occurs in the areas of the basal ganglia and the cerebral cortex
The client usually declines into a profound state of dementia and ataxia
Average duration of the disease is based on age at onset

28. Etiological Implications (cont.)
Dementia due to Pick’s disease
Etiology of Pick’s disease is unknown but a genetic factor may be involved
Clinical picture similar to that of Alzheimer’s disease
Pathology results from atrophy in the frontal and temporal lobes of the
brain

29. Etiological Implications (cont.)
Dementia due to Creutzfeldt-Jakob disease
Clinical symptoms typical of syndrome of dementia
Symptoms also include involuntary movements, muscle rigidity, and ataxia
Onset of symptoms typically occurs between ages 40 and 60 years; course is extremely rapid, with progressive deterioration and death within 1 year

30. Etiological Implications (cont.)
Dementia due to Creutzfeldt-Jakob disease (cont.)
Etiology is thought to be a transmissible agent known as a “slow virus”
There is a genetic component in 5% to 15%

31. Etiological Implications (cont.)
Dementia due to other medical conditions
Endocrine conditions
Pulmonary disease
Hepatic or renal failure
Cardiopulmonary insufficiency
Fluid and electrolyte imbalances
Nutritional deficiencies
Frontal or temporal lobe lesions
CNS or systemic infections
Uncontrolled epilepsy
Other neurological conditions (e.g., multiple sclerosis)

32. Etiological Implications (cont.)
Substance-induced persisting dementia
Dementia is related to the persisting effects of abuse of, or exposure to, substances such as
Alcohol
Inhalants
Sedatives, hypnotics, and anxiolytics
Medications (e.g., anticonvulsants, intrathecal methotrexate)
Toxins (e.g., lead, mercury, carbon monoxide, organophosphate insecticides, industrial solvents)

33. Etiological Implications (cont.)
Dementia due to Multiple Etiologies
Diagnosis is used when the symptoms of dementia are attributed to more than one cause

34. Amnestic Disorders
Amnestic disorders are characterized by an inability to
Learn new information despite normal attention
Recall previously learned information

35. Amnestic Disorders (cont.)
Other symptoms may include
Disorientation to place and time (rarely to self)
Confabulation, the creation of imaginary events to fill in memory gaps

36. Amnestic Disorders (cont.)
Other symptoms may include (cont.)
Denial that a problem exists or acknowledgment that a problem exists, but with a lack of concern
Apathy, lack of initiative, and emotional blandness

37. Amnestic Disorders (cont.)
Onset may be acute or insidious, depending on underlying pathological process
Duration and course may be variable and are correlated with extent and severity of the cause

38. Etiological Implications
Amnestic disorder due to a general medical condition
Head trauma
Cerebrovascular disease
Cerebral neoplastic disease
Cerebral anoxia
Herpes simplex encephalitis
Poorly controlled insulin-dependent diabetes
Surgical intervention to the brain

39. Etiological Implications (cont.)
Transient amnestic syndromes can occur from
Cerebrovascular disease
Cardiac arrhythmias
Migraine
Thyroid disorders
Epilepsy

40. Etiological Implications (cont.)
Substance-induced persisting amnestic disorder
Related to the persisting effects of abuse of, or exposure to, substances such as
Alcohol
Sedatives, hypnotics, and anxiolytics
Medications (e.g., anticonvulsants, intrathecal methotrexate)
Toxins (e.g., lead, mercury, carbon monoxide, organophosphate insecticides, industrial solvents)

41. Application of the Nursing Process: Assessment
The client history: areas of concern to be addressed
Type, frequency, and severity of mood swings
Personality and behavioral changes
Catastrophic emotional reactions
Cognitive changes
Language difficulties

42. Assessment (cont.) History: areas of concern to be addressed
Orientation to person, place, time, and situation
Appropriateness of social behavior
Current and past use of medications, drugs, and alcohol
Possible exposure to toxins
Client and family history of specific illnesses

43. Assessment (cont.) Physical assessment
Assessment for diseases of various organ systems that can induce confusion, loss of memory, and behavioral changes

44. Assessment (cont.) Physical assessment (cont.)
Neurological examination to assess mental status, alertness, muscle strength, reflexes, sensory–perception, language skills, and coordination

45. Assessment (cont.) Physical assessment (cont.)
Psychological tests to differentiate between dementia and pseudodementia (depression)

46. Assessment (cont.) Diagnostic laboratory evaluations
Include blood and urine to test for
Various infections
Hepatic and renal dysfunctions
Diabetes or hypoglycemia
Electrolyte imbalances
Metabolic and endocrine disorders
Nutritional deficiencies
Presence of toxic substances

47. Assessment (cont.) Other diagnostic evaluations may include
Electroencephalogram (EEG)
Computed tomography (CT) scan
Positron emission tomography (PET)
Magnetic resonance imaging (MRI)
Lumbar puncture to examine cerebrospinal fluid (CSF)

48. Diagnosis/Outcome Identification
Risk for trauma
Disturbed thought processes
Disturbed sensory-perception
Risk for other-directed violence
Impaired verbal communication

49. Diagnosis/Outcome Identification (cont.)
Self-care deficit
Situational low self-esteem
Grieving

50. Outcomes The client Has not experienced physical injury
Has not harmed self or others
Has maintained reality orientation to the best of his or her capability
Discusses positive aspects
about self and life
Fulfills activities of daily living
(ADLs) with assistance
Is able to communicate with consistent caregiver

51. Planning/Implementation
Care plan for the client with a cognitive disorder is aimed at
Protection of self and others
Maintaining orientation to reality
Minimizing confusion
Fulfilling basic needs
Assisting and educating prospective caregivers about appropriate care for their loved one

52. Client/Family Education
Nature of the illness
Possible causes
What to expect
Symptoms

53. Client/Family Education (cont.)
Management of the illness
Ways to ensure client safety
How to maintain reality orientation
Provide assistance with ADLs
Nutritional information
Difficult behaviors
Medication administration
Matters related to hygiene and toileting

54. Client/Family Education (cont.)
Support services
Financial assistance
Legal assistance
Caregiver support groups
Respite care
Home health care

55. Nursing Process: Evaluation
Based on the accomplishment of outcome criteria

56. Medical Treatment Modalities
Delirium
Determination and correction of the underlying causes
Staff to remain with client at all times to monitor behavior and provide reorientation and assurance

57. Medical Treatment Modalities (cont.)
Delirium (cont.)
Room with low stimulus level
Low-dose neuroleptic agents to relieve agitation and aggression
Benzodiazepines when etiology is substance withdrawal

58. Medical Treatment Modalities (cont.)
Dementia
Primary consideration is given to etiology, with focus on identification and resolution of potentially reversible processes

59. Medical Treatment Modalities (cont.)
Dementia (cont.)
For cognitive impairment
Physostigmine (Antilirium)
Tacrine (Cognex)
Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Razadyne)
Memantine (Namenda)

60. Medical Treatment Modalities (cont.)
Other pharmaceutical agents
For agitation, aggression, hallucinations, thought disturbances, and wandering
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Ziprasidone (Geodon)
Haloperidol (Haldol)

61. Medical Treatment Modalities (cont.)
Alert
All antipsychotics carry a black-box warning stating that the drugs are associated with an increased risk of death in elderly patients with psychotic behaviors associated with dementia.

62. Medical Treatment Modalities (cont.)
Other pharmaceutical agents (cont.)
For depression
Fluoxetine (Prozac)
Sertraline (Zoloft)
Citalopram (Celexa)
Paroxetine (Paxil)
Trazodone (Desyrel)

63. Medical Treatment Modalities (cont.)
Other pharmaceutical agents (cont.)
For anxiety (should not be used routinely for prolonged periods)
Chlordiazepoxide (Librium)
Alprazolam (Xanax)
Lorazepam (Ativan)
Oxazepam (Serax)

64. Medical Treatment Modalities (cont.)
Other pharmaceutical agents (cont.)
For sleep disturbances
Flurazepam (Dalmane)
Temazepam (Restoril)
Triazolam (Halcion)
Zolpidem (Ambien)
Aleplon (Sonata)
Eszopiclone (Lunesta)
Ramelteon (Rozerem)