COGNITIVE DISORDER ,DEMENTIA� �NURSING DIAGNOSES, NURSING PROCESS FOR COGNITIVE DISORDERS ASSOCIATED WITH COGNITIVE DISORDERS�

COGNITIVE DISORDER, DELIRIUM, DEMENTIA�AMNESTIC DISORDERS, NURSING PROCESS FOR COGNITIVE DISORDERS, CLIENT AND FAMILY EDUCATION, MEDICATION MANAGEMENT OF COGNITIVE DISORDERS, �CLINICAL FEATURES (FOR ALZHEIMER'S TYPE)��TREATABLE AND REVERSIBLE CAUSES�

1. SEMINAR ON COGNITIVE DISORDER Presented by Selvaraj.p Ph.D Scholar Oct-2019 Batch Guide Dr.Sasi.Vaithilingan Professor Cum Vice-Principal VMCON Pondicherry .

2. OBJECTIVES 5/29/2020 VMRF (DU) NSG 19 OCT 07

3. COGNITION Cognition is a term referring to the mental processes involved in gaining knowledge and comprehension. Thinking Knowing Remembering Problem solving Judging Include: Reasoning, Judgment, Perception, Attention, Comprehension, and Memory. 5/29/2020 VMRF (DU) NSG 19 OCT 07

4. COGNITIVE DISORDERS Cognitive disorders (formerly called organic mental syndromes) involve problems in memory, orientation, level of consciousness, and other cognitive functions. These difficulties are due to abnormalities in neural chemistry, structure, or physiology originating in the brain, or secondary to systemic illness. Patients with cognitive disorders may show psychiatric symptoms secondary to the cognitive problems 5/29/2020 VMRF (DU) NSG 19 OCT 07

5. CLASSIFICATION OF COGNITIVE DISORDERS All processes of consciousness by which knowledge is accumulated some common cognitive disorders include Dementia Delirium Amnestic disorder 5/29/2020 VMRF (DU) NSG 19 OCT 07

6. DELIRIUM  A syndrome that involves a disturbance of consciousness accompanied by a change in cognition. Usually develops over a short period, sometimes a matter of hours, and fluctuates, or changes, throughout the course of the day. Clients have difficulty paying attention, are easily distracted and disoriented, and may have sensory disturbances such as illusions, misinterpretations, or hallucinations. 5/29/2020 VMRF (DU) NSG 19 OCT 07

7. Con’t 10%- 15% people in the hospital with general medical conditions are delirious at any given time. 30%- 50% of acutely ill older adult clients at some time during their hospital stay. 5/29/2020 VMRF (DU) NSG 19 OCT 07

8. DEFINITION A mental state characterized by a disturbance of cognition, which is manifested by confusion, excitement, disorientation, and a clouding of consciousness. Hallucinations and illusions are common 5/29/2020 VMRF (DU) NSG 19 OCT 07

9. ETIOLOGICAL IMPLICATIONS DELIRIUM DUE TO A GENERAL MEDICAL CONDITION SUBSTANCE-INDUCED DELIRIUM SUBSTANCE-INTOXICATION DELIRIUM SUBSTANCE-WITHDRAWAL DELIRIUM DELIRIUM DUE TO MULTIPLE ETIOLOGIES 5/29/2020 VMRF (DU) NSG 19 OCT 07

10. Others Some are due to hormonal imbalances in the womb, others to genetic predisposition and still others to environmental factors. Common environmental causes of cognitive disorders include a lack of proper nutrients and interaction during vulnerable stages of cognitive development, particularly during infancy. 5/29/2020 VMRF (DU) NSG 19 OCT 07

11. CLINICAL SYMPTOMS Difficulty with attention Easily distractable Disoriented May have sensory disturbances such as illusions, misinterpretations, or hallucinations Can have sleep- wake cycle disturbances Changes in psychomotor activity May experience anxiety, fear, irritability, euphoria, or apathy 5/29/2020 VMRF (DU) NSG 19 OCT 07

12. Con’t various emotions may be evidenced by crying, calls for help, cursing, muttering, moaning, acts of self-destruction, fearful attempts to flee, or attacks on others who are falsely viewed as threatening. Autonomic manifestations, such as tachycardia, sweating, flushed face, dilated pupils, and elevated blood pressure, are common 5/29/2020 VMRF (DU) NSG 19 OCT 07

13. DIAGNOSTIC CRITERIA (DSM-IV-TR) Difficulty with attention Easily distractible Disoriented May have sensory disturbances such as illusions, misinterpretations, or hallucinations Can have sleep-wake cycle disturbances Changes in psychomotor activity May experience anxiety, fear, irritability, euphoria, or apathy 5/29/2020 VMRF (DU) NSG 19 OCT 07

14. INTERVENING IN DELIRIUM 1.Physiological needs-Nutrition and fluid balance. Sleep deprivation. 2.Hallucination-Patient room must be safe, one on one observation. 3.Communication- Clear message and instruction, Orientation, Reassuring, and matter of fact. 5/29/2020 VMRF (DU) NSG 19 OCT 07

15. PATIENT EDUCATION Disruption in functioning Stressors Reinforcement Educational materials Discharge plan 5/29/2020 VMRF (DU) NSG 19 OCT 07

16. DEMENTIA A mental disorder that involves multiple cognitive deficits, primarily memory impairment, and at least one of the following disturbances: Aphasia: Deterioration of language function. Apraxia : Inability to execute motor functions despite intact memory abilities. Agnosia : Inability to recognize or name objects despite intact sensory abilities. 5/29/2020 VMRF (DU) NSG 19 OCT 07

17. DEFINITION Dementia A loss of previous levels of cognitive, executive, and memory function in a state of full alertness (Bourgeois et al, 2008). 5/29/2020 VMRF (DU) NSG 19 OCT 07

18. ETIOLOGICAL IMPLICATIONS UNTREATABLE AND IRREVERSIBLECAUSES (DEGENERATING DISORDERS OF CNS) Alzheimer's disease (this is the most common of all dementing illnesses) Pick's disease Huntington's chorea Parkinson's disease 5/29/2020 VMRF (DU) NSG 19 OCT 07

19. TREATABLE AND REVERSIBLE CAUSES Vascular-multi-infarct dementia Intracranial space occupying lesions Metabolic disorders-hepatic failure, renal failure Endocrine disorders- myxedema , Addison's disease Infections-AIDS, meningitis, encephalitis Intoxication-alcohol, heavy metals (lead, arsenic), chronic barbiturate poisoning Anoxia- anemia , post- anesthesia , chronic respiratory failure Vitamin deficiency, especially deficiency of thiamine, and nicotine Miscellaneous-heatstroke, epilepsy, electric injury 5/29/2020 VMRF (DU) NSG 19 OCT 07

20. CLINICAL SYMPTOMS Stage 1. No apparent symptoms: In the first stage of the illness, there is no apparent decline in memory. 5/29/2020 VMRF (DU) NSG 19 OCT 07

21. Stage 2. Forgetfulness lose things or forget names of people. Losses in short-term memory. Anxious and depressed, Maintaining organization with lists and a structured routine provide some compensation. These symptoms often are not observed by others. 5/29/2020 VMRF (DU) NSG 19 OCT 07

22. Stage 3. Mild cognitive decline Interference with work performance, The individual may get lost when driving his or her car. Concentration may be interrupted. There is difficulty recalling names or words, which becomes noticeable to family and close associates. 5/29/2020 VMRF (DU) NSG 19 OCT 07

23. Stage 4. Mild-to-moderate cognitive decline; confusion Forget major events in personal history, such as his or her own child’s birthday Experience declining ability to perform tasks, such as shopping and managing personal finances; He or she may deny that a problem exists by covering up memory loss with confabulation Depression and social withdrawal are common. 5/29/2020 VMRF (DU) NSG 19 OCT 07

24. Stage 5. Moderate cognitive decline; early dementia loses the ability to perform some activities of daily living (ADLs) independently, such as hygiene, dressing, and grooming, Forget addresses, phone numbers, and names of close relatives. Disoriented about place and time, but they maintain knowledge about themselves. Frustration, withdrawal, and self-absorption are common. 5/29/2020 VMRF (DU) NSG 19 OCT 07

25. Stage 6. Moderate-to-severe cognitive decline; middle dementia Unable to recall recent major life events or even the name of his or her spouse. Disorientation to surroundings Urinary and fecal incontinence. Sleeping becomes a problem. Psychomotor symptoms include wandering, obsessiveness , agitation, and aggression. Sundowning . Communication becomes more difficult, 5/29/2020 VMRF (DU) NSG 19 OCT 07

26. Stage 7. Severe cognitive decline; late dementia In the end stages of DAT, the individual is unable to recognize family members. He or she most commonly is bedfast and aphasic. Problems of immobility, such as decubiti and contractures, may occur 5/29/2020 VMRF (DU) NSG 19 OCT 07

27. CLINICAL FEATURES (FOR ALZHEIMER'S TYPE) Personality changes: lack of interest in day to-day activities, easy mental fatigability, self-centred, withdrawn, decreased self-care Memory impairment: recent memory is prominently affected Cognitive impairment: disorientation, poor judgment, difficulty in abstraction, decreased attention span 5/29/2020 VMRF (DU) NSG 19 OCT 07

28. Con’t Affective impairment: labile mood, irritableness, depression Behavioral impairment : stereotyped behavior , alteration in sexual drives and activities, neurotic/psychotic behavior Neurological impairment: aphasia, apraxia , agnosia , seizures, headache Catastrophic reaction: agitation, attempt to compensate for defects by using strategies to avoid demonstrating failures in intellectual performances, such as changing the subject, cracking jokes or otherwise diverting the interviewer 5/29/2020 VMRF (DU) NSG 19 OCT 07

29. Con’t Sundowners syndrome: It is characterized by drowsiness, confusion, ataxia; accidental falls may occur at night when external stimuli such as light and interpersonal orienting cues are diminished   5/29/2020 VMRF (DU) NSG 19 OCT 07

30. DIAGNOSTIC CRITERIA (DSM-IV-TR) 1. Loss of memory (initial stages- recent memory loss; later stages-remote memory loss 2. Deterioration of language function (forgetting names of common objects, and echoing words that are heard [echolalia]) 3. Loss of ability to think abstractly and to plan, initiate, sequence, monitor, or stop complex behaviors 5/29/2020 VMRF (DU) NSG 19 OCT 07

31. INTERVENING IN DEMENTIA 1. Orientation- Patient room, reality orientation. 2.Communication- Unconditional positive regards, reminiscence. 3.Wandering- Use of restrains 4. Decreasing agitation- Explained simply and completely. 5/29/2020 VMRF (DU) NSG 19 OCT 07

32. AMNESTIC DISORDERS Amnesia on the other hand, is a serious mental condition affecting a person's memory. ANTEROGRADE AMNESIA: Inability to create new memories. RETROGRADE AMNESIA :Inability to recall previously made memories. The inability to retain or recall past experiences. The condition may be temporary or permanent, depending on etiology. 5/29/2020 VMRF (DU) NSG 19 OCT 07

33. ETIOLOGY Thiamine deficiency, - It is also called as " Wernicke-Korsakoff syndrome." Wernicke's encephalopathy. Head trauma Bilateral temporal lobectomy Hypoxia Brain tumours Herpes simplex encephalitis Stroke. 5/29/2020 VMRF (DU) NSG 19 OCT 07

34. CLINICAL FEATURES Recent memory impairment Anterograde and retrograde amnesia There is no impairment of immediate memory 5/29/2020 VMRF (DU) NSG 19 OCT 07

35. MEDICATION MANAGEMENT OF COGNITIVE DISORDERS 1.Cholinesterase Inhibitors ( Donepezil (Aricept))- 5-10 mg Give once daily; provide small, frequent meals if GI disturbance occurs; monitor for bradycardia , insomnia, fatigue, GI disturbances, muscle cramps, skin rash, jaundice, and changes in color of urine or stool; use with caution in clients with peptic ulcer disease. 5/29/2020 VMRF (DU) NSG 19 OCT 07

36. 2.Tacrine ( Cognex ) - 40–160mg Give q.i.d . in divided doses on an empty stomach unless severe GI disturbance occurs; arrange for regular transaminase level determination before and during therapy; monitor for symptoms of impaired hepatic function, syncope, and bleeding; give with vitamin E 1,000 IU b.i.d . if ordered. 5/29/2020 VMRF (DU) NSG 19 OCT 07

37. 3.NMDA Receptor Antagonist.- Memantine ( Namenda )-5-20mg FDA approved for use in moderate-to-severe AD. Use caution with other NMDA antagonists; may affect or be affected by renally excreted drugs; monitor for dizziness, headache, hypertension, pain, GI upset, somnolence, hallucinations, and dyspnea . 5/29/2020 VMRF (DU) NSG 19 OCT 07

38. NURSING PROCESS FOR COGNITIVE DISPRDERS ASSESSMENT TOOLS Several assessment tools are available to assess a client’s mental status or cognitive abilities ( eg , orientation, concentration, memory), instrumental functionality ( eg , ability to perform ADLs), neurologic or motor functioning ( eg , gait, reflex changes), and behavioral symptoms ( eg , agitation, mood, wandering). MMSE (Mini-Mental Status Exam)• ADAS-Cog (AD Assessment Scale-Cognitive Subscale)• Confusion Assessment Method (CAM) Instrument and • Diagnostic Algorithm 5/29/2020 VMRF (DU) NSG 19 OCT 07

39. NURSING DIAGNOSES ASSOCIATED WITH COGNITIVE DISORDERS BEHAVIORS BEHAVIORS Falls, wandering, poor coordination, confusion, misinterpretation of the environment (illusions, hallucinations), lack of understanding of environmental hazards, memory deficits Risk for trauma Disorientation, confusion, memory deficits, inaccurate interpretation of the environment, suspiciousness, paranoia Disturbed thought processes 5/29/2020 VMRF (DU) NSG 19 OCT 07

40. Having hallucinations (hears voices, sees visions, feels crawling sensation on skin) Disturbed sensory perception Aggressiveness, assaultiveness (hitting, scratching, or kicking Risk for other-directed violence Inability to name objects/people, loss of memory for words, difficulty finding the right word, confabulation, incoherent, screaming and demanding verbalizations Impaired verbal communication 5/29/2020 VMRF (DU) NSG 19 OCT 07

41. Inability to perform activities of daily living (ADLs): feeding, dressing, hygiene, toileting Self-care deficit (specify) Expressions of shame and self-degradation, progressive social isolation, apathy, decreased activity, withdrawal, depressed mood Situational low self-esteem Grieving 5/29/2020 VMRF (DU) NSG 19 OCT 07

42. NURSING DIAGNOSIS-I Disturbed Thought Processes related to cerebral degeneration as evidenced by Disorientation, confusion, memory deficits, and inaccurate interpretation of the environment OUTCOME: The client will demonstrate decreased confusion and disorientation 5/29/2020 VMRF (DU) NSG 19 OCT 07

43. NURSING DIAGNOSIS-2 Self-Care Deficit Related to Disorientation, confusion, and memory deficits as evidenced by Inability to fulfil ADLs OUTCOME: The client will demonstrate an increased ability to perform ADLs. 5/29/2020 VMRF (DU) NSG 19 OCT 07

44. NURSING DIAGNOSIS-3 Risk for Injury related to disorientation and confusion OUTCOME: The client will be free of injury 5/29/2020 VMRF (DU) NSG 19 OCT 07

45.   NURSING INTERVENTIONS 1. Daily Routine 2. Nutrition and Body Weight 3. Personal Hygiene 4. Toilet Habits and Incontinence 5. Accidents 6. Fluid Management 7. Moods and Emotions 8. Wandering 9. Disturbed Sleep 10. Interpersonal Relationship 5/29/2020 VMRF (DU) NSG 19 OCT 07

46. EVALUATION In the final step of the nursing process, reassessment occurs to determine if the nursing interventions have been effective in achieving the intended goals of care. Evaluation of the client with cognitive disorders is based on a series of short-term goals rather than on long-term goals. Resolution of identified problems is unrealistic for this client. Instead, outcomes must be measured in terms of slowing down the process rather than stopping or curing the problem 5/29/2020 VMRF (DU) NSG 19 OCT 07

47. CLIENT AND FAMILY EDUCATION To ease the day-to-day demands of care giving; and plan ahead by investigating long-term care options and Determining what services are covered by health insurance Stay informed about the disease and treatment options; Take a break ( eg , use adult day care or respite care services) 5/29/2020 VMRF (DU) NSG 19 OCT 07

48. CONTINUUM OF CARE According to the findings of research comparing end-of-life care between clients with advanced dementia and clients with terminal cancer, Clients with advanced dementia are not always recognized as having a terminal condition and do not receive adequate palliative care in the final stage of the illness. Distressing signs and symptoms are not recognized or managed adequately. Lacking advance directives that limit aggressive care, Many clients with advanced dementia undergo painful, unnecessary interventions including the insertion of feeding tubes in the final weeks before death. Clients with advanced dementia are eight times less likely to have a Do Not Resuscitate order than other clients (Moon, 2004). 5/29/2020 VMRF (DU) NSG 19 OCT 07

49. SUMMARY Cognitive disorders constitute a large and growing public health concern. Cognitive disorders include delirium, dementia, and amnestic disorders. Nursing care of the client with a cognitive disorder is presented around the six steps of the nursing process. Objectives of care for the client experiencing an acute syndrome are aimed at eliminating the etiology, promoting client safety, and a return to the highest possible level of functioning. Nursing interventions are also directed toward helping the client’s family or primary caregivers learn about a chronic, progressive cognitive disorder 5/29/2020 VMRF (DU) NSG 19 OCT 07

50. REFERENCE Sheila L. Videbeck , Psychiatric Mental Health Nursing, Lippioncott Williams & Williams’s publication, 4 th edition. Mary C. Townsend, Essentials of Psychiatric Mental Health Nursing, FA Davis company publication, Philadelphia, 4 th edition. Louise Rebraca Shives , Basic Concepts of Psychiatric Mental Health Nursing, Lippincott Williams & Williams’s publication, Flordia.8 th edition https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3580783 / https://www.psychguides.com/neurological-disorders/cognitive / https://www.mayoclinic.org/diseases-conditions/amnesia/symptoms-causes/syc-20353360 5/29/2020 VMRF (DU) NSG 19 OCT 07