care of the patient with a cognitive disorder

• highest level of brain activity
• cognition is the act or process of thinking, perceiving, learning
• cognition function effected by delirium or dementia include:
• - decision making
• - problem solving
• - reasoning
• - judgment
• - memory, spatial orientation- knowing r hand from L hand. this becomes a problem. also being able to transition from one activity to another. pt w/cognitive disorder..this becomes a problem.
• - thinking, reasoning
• - verbal communication- language
• how do we think how do process information. how does brain transfer information thru neurons.

• sometimes loses things, familiar items
• briefly forget a friend's name
• sometimes needs to search for words
• occasionally forgets to complete task
• forgets the distant (remote) past
• momentarily gets lost
• jokes about memory loss

• biologic illnesses with two defining characteristics:
• 1. decrease in cognitive function
• 2. Organic etiology (physical underlying problem. organic (physical) problem)
• Cognitive impairment:
• - brain chemistry and function changes (neurotransmitters serotonin if they are wack then the brain activity can slow or speed up)
• - structure, neurons lost and brain unable to compensate for the losses- brain cells begin to die  (dementia)
• - not normal part of aging
• - > 50% not identified
• dementia- there are physical structure changes
•  it be caused by
• - polypharmacy- med interaction could cause confusion
• - toxins, chemicals
• - structural changes can cause confusion

• 3 D's cognitive impairment are:
• - delirium
• - dementia
• - depression
• - all have similarities and differences. can occur any age (addiction to hallucinagenics drugs it could cause brain changes that are irreversible)
• frequently affect older adults.
• frequently affect older adults
• pathological progression require urgent
• assessment and intervention
• - any changes in mental status
• can come on suddenly or slowly
• urgency to catch this

• direct physiological consequence of medical condition: syndrome not disease
• - transient cognitive impairment- fluctuates comes and goes
• rapid/abrupt onset- suddenly
• - acute or sub acute (Potentially reversible to accurate diagnosis is needed if u take the underlying problem she can return back to normal)
• - improve if person doesn't die
• underlying med/physical issue
• contents of thought is dyfunctional
• transition (environment to environment) can cause confusion
• anesthesia can cause confusion
• assessment is key- catch early and deal with it so it doesn't cause more damage
• UTI- confused

• polypharmacy- esp polypharmacy of high dose psychotrophic drugs, high doses of hypnotics, drug toxicity
• hospitalization or post surgery
• multiple co morbid condition- severe infections, CV disease, COPD
• poor nutritional status
• hepatic failure
• chronic renal failure

• CNS: head trauma, epilepsy, brain tumor
• Vascular: stroke, hypertensive encephalopathy
• metabolic: renal/hepatic disease, fluid/electrolyte imbalance, hypoxia
• cardiopulmonary: congestive heart failure, shock arrhythmias
• systemic: septicemia, UTI, pnemonia, neoplasms

• sensory deprivation: postoperative state, visual/hearing impairment
• substance induced: intoxication or withdrawal
• medications: antichol, antihistamine, antiarhythmics, sedatives, narcotics analgesics, histamine 2- receptor blocker, anticonvulsants, beta blockers, antihypertensives, corticosteriods, antibiotics
• toxins- chemicals etc

• Delirium is prevelant disorder and can include:
• - children who swallow poisons/have high fever
• - adolescents and adults who abuse drugs
• - elders hospitalized for surgeries or who have dementia
• - elders hospitalized for acute physical illnesses and then develop delirium range from 14-80%
• - patients with delirium while hospitalized have longer hospital stays, high rates of nursing home admissions, experience greater decline in function
• cost of caring for patients with delirium is increased because of the demanding need for continous intervention from staff caregivers

• occurs over a short period of time, LOC fluctuates, no set patterns
• ability to focus is greatly impaired, easily distracted
• impaired memory- recent memory (why they are in the hosp what did they have for breakfast)
• disorientation and confusion
• misinterpretation, illusions (misinterpretation of stimulus..like looking a cord on the floor and thinking it was a snake), hallunicinations (abnormal response to anything that can effect the senses: visual, hearing, smell, touch)

• behavioral disturbances: continual aimless activity- pulling the blanket up and then pulling it down
• labile (rapidly changing) mood- rapid, unpredictable changes- mood can turn on a dime. u could be helping them and then all of sudden they start pushing you away
• sleep pattern disturbances-

• poor performance on memory tests cause anxiety- can be worst or judgemental.. reorient them without making them feel bad
• perform assessments with hearing aids and glasses as needed
• environment needs to be free from distractions
• timing is important (do not rush) should not be completed:
• - immediately upon wakening
• - right before/after meals or procedures

• Physiologic assessment is based on the following workup
• - hx of physical examination
• - vital signs- includes and o2 stat
• - medication and substance use abuse hx
• - neurological examination- r/o stroke, cranial, nerve, tone of muscle
• - neuropsychological exam- mental status- mini cog status
• - MSE (mental status evaluation)

• Labs: crucial, CBC, eletrolytes, LFT (new med could challenge the liver, you are looking for amonia level), thyroid, BUN, creatinine, VDRL (syphyllis), urinalysis, urine culture and sensitivity, drug screens
• CT scan, MRI and ECG
• functional assessment, geriatric depression (scale to r/o depression)
• EEG

• reversible in over 80% of the cases
• onset usually rapid, course fluctuates
• may be super imposed on other disorders
• difficult to identify because of fluctuating nature
• when unrecognized, patients can suffer irreversible brain damage
• early recognition is key in the prevention and treatment

• early recognition is early
• Assessment:
• - MSE: establish baseline
• - don't assume what you see is there baseline: interview caregivers and families
• - ongoing monitoring
• Tools objective, avoid "confusion":
• - MMSE
• - CAM- confusion assessment method
• - NEECHAM confusion scale
• - CAM- ICU (bc of the noise no transition from night to day)
• acute confusional state (NANDA)
• once u realize u change the meds...dose...u can give them K
• it could be dehydration- hydrate them

• Indentify underlying cause and treat
• - d/c or decrease meds if cause
• HELP- (hospital Elder life program) focuses on managing 6 risk factors for delirium:
• - cognitive impairment
• - sleep deprivation
• - immobility
• - visual/impairments
• - dehydration- can lead to delirium- look at skin turgor

• 1. cognitive impairment:
• - reorientation
• - attention to patient concerns and fears
• - reassure family transient
• - delay medical nursing procedure until daylight
• - sedation for agitation, restlessness, risk to self (atypical antipsychotic- low dose, monitor closely, dc asap)
• Fall risk reduction- bed alarms, low bed recliners, keep routines as normal as possible
• sitters

• 2. sleep deprivation
• - herbal tea, milk v. sleep meds
• - quiet environment
• 3. immobility
• - remove catheters/other devices that interfere with movement, avoid restraints
• 4/5. visual/hearing impairments
• - glasses/hearing impairments, speak slowly make eye contact, use familiar words and repeat when necessary
• 6. dehydration
• - fluids, electrolytes, nutrition, vitamins, o2

• delirium, an acute change in cognition and attention, is common, morbid and costly
• in the inpatient setting, all new changes in mental status should be assumed to be delirium until otherwise
• elements of the hospital environment can contribbute to delirium and expose pts to safety risk
• family members and caregivers are crucial to diagnosis and management of delirium; incorporating them into the plan of care is strongly recommended

• Def: chronic loss of previously acquired mental function due to loss of brain cells
• interferes with ability to think, perceive and reason
• develops over a slow period of time
• is a progressive and degenerative central nervous system disorder

• detoriation of mental (neurologic) function- Memory
• - memory loss
• - disorientation
• - difficulty learning
• - loss of language skills (asphasia)
• - decrease judgement and planning
• - can have perceptual and psychoses
• - personality changes, emotional labile
• 1. apraxia- inability to carry out motor activity
• 2. agnosia- failure to recognize object
• 3. aphasia- language disturbance (can use the muscles that help them speak...u know the word but u can't say it)
• impairment in social or occupational functioning
• VS normal
• progressive over the yrs irreversible
• 8-10 yrs- onset to death usually dies from complications from organ

• most disabling and burdensome of chronic conditions in older adults
• estimated 5.4 million
• African American 2x more likely as whites, hispanics 1.5x more likely
• increased in the past few decades
• - incre awareness
• - more acute diagnosis
• - incre longevity creating larger population of elderly
• 3x cost medically than those without disease

• Age, eye, and ear problems
• family hx
• genetics- more likely to develop:
• - apoE4-apollpoprotein, causes cell death, memory loss and neurological dysfunction
• head trauma, tumor
• systolic hypertension
• down's syndrome
• untreated infectious/metabolic/endocrine disease
• substance abuse/mental illness
• female gender
• lesser yrs of education- don't continually using your brain cells

• mediterranean diet
• incre education
• incre mental activity- doing things like a cross word puzzles
• increa physical activity

• alzheimer's # 1
• vascular dementia #2 (3), multi infarct, post stroke
• diffuse lewy body disease #3 (2)
• parkinson's dementia
• mixed dementia
• Less commonly occuring:
• - frontotemporal/picks disease
• - creutzfeldt jakob disease
• - down syndrome dementia
• - neurosyphillis dementia
• - normal- pressure hydrocephalus
• - ALS (amyotrophic lateral sclerosis= lou gelrig's disease)

• alzheimer disease- causes 50-70% of cases of dementia. it is the most common form of dementia. it is a degenerative neurological disorder
• there is progressive deterioration of areas in the brain essential learning and memory (cortex) caused by lesion:
• - neuritic plagues and neurofibrillary tangles destroy nerve cells
• - degeneration (forebrain) diminishes
• acetylcholine (some meds now that will slow down the progression of disease), neurotransmitter that conducts impulses between neutrons

• insidious, gradual onset (months), mild severe fluctuations
• long duration of symptoms
• normal level of conscious: alert, aware, attentive, BUT altered content (disorientation)
• VS normal typically
• multiple cognitive deficits, especially memory impairment and one or more of the following: aphasia, agnosia, apraxia, impaired executive functioning

• hallmark symptom as with delirium is memory impairment- short term first, inability to learn new material/recall previously learned /both
• memory impairment progresses to other intellectual abilities: speech, reading, writing, comprehension, difficulty finding words
• aphasia- deficits in language
• apraxia- problems with motor activities
• agosia- difficulties with object identification (usually common household items)

behavior changes: sleeplessness, sundowning (incre behavioral difficulties in the evening), catastrophic reactions (overexaggerated emotional responses initiated as a result of a perceived failure at a task or change in the environment), wandering, agitation, combativeness, perserveration (excessive repetition)

• Physiologic Assessment is based on the following workup including laboratory data:
• - urinalysis
• - CBC
• - serum vitamin b12 level
• - metabolic screen: serum electrolytes with mg and LFT
• - TSH
• - VDRL
• - HIV
• - lyme titer
• - urine toxicology screen

• recent head trauma
• hx of CVA or vascular disease
• tumors
• abscesses
• subdural hematoma
• seizure disorder
• some PET scans being done, showing shrinkage of hippocampis: decre glucose metabolic activity

• look at slide
• purpose: to assess orientation, intellectual functioning, memory, reading and math skills and identify specific stages of dementia
• mental status screening

• I orientation:
• what is today
• what is the year
• what is the month
• can u tell me the season
• can u tell me the name of the hospital
• what floor are we on
• what town/city
• what county are we in
• what province are we in

• II immediate recall
• this is to test their memory
• three unrelated items ie ball, flag, tree
• have them repeat back...if they get wrong do it up to 6 times
• number all the trials

• III attention and calculation
• counting backward by 7 start with 100. check each response in the box to the right
• spelling backward test
• like world

• IV recall
• ask them to recall the three words. check the box to the right with each response

• Naming- show them an object and let them tell u what it is
• Repetition- ask them No, ifs, ands, or buts
• Three stage command- esta which hand they write with...take paper, fold it in half and put in on the floor..they should follow commands

IV reading:hold up and paper and have something written on it...ask them to read and do it ie close your eyes

writing- ask to write sentence. it should contain a subject and a verb

copying- show picture of intersecting pentagons..have them copying..ignore tremors and rotations

look at slides to get an idea

• based on six things
• bathing, dressing, toileting, transferring in and out of bed and chair
• urine and bowel incontinence
• eating
• each criteria is graded on level of indepence:
• - performs independently
• - performs with assistance
• - unable to perform
• independent- suggest a score of 0-1
• dependent- approaches 6

• indications
• assess functional capabilities of older patients
• survey
• based on 7 things
• - telephone (look up numbers dial and answer)
• - traveling via car public transportation
• - food or clothing shopping
• - meal prep
• - housework
• - management of medication
• - managing money
• graded in three parts
• independent
• assistance needed
• dependent
• two separate surveys completed
• pt
• informant- nurse, caregiver, family

• onset slow, insidious, progressive, and terminal
• usual 8-10 yr of onset of symptoms death
• some can live up to 15 yr
• it will lengthen continually
• cost- 80-100 billion annually

• 1-2 yr
• recent memory impairment: neologisms common pt complains of forgetfulness, covers up, called confabulation, blames accuses others, transitory delusions of persecution
• disorientation about time people and place usually remains in tact initially
• cognitive losses in communication- difficulty in noisy, distracting environment, judgement impaired, errors in judgemental accident
• losses in calculating, unable to balance check book
• acts confused, becomes irritable and quiet. emotionally inability common
• personal apprearance may decline needs help in selecting appropriate clothing
• sensory and muschle functions still in tact except muscle can be hypertonic/twiching
• self awareness- recognize their own confusion, covers this up, frightened. leads to depression-worsens symptoms of dementia
• begins to have problems and work family school

• several yrs. cognitive decline decre, amnesia, disoriented all three spheres, apraxia, agnosia, aphasia, misidentification syndrome (familiar people are seen as unfamiliar vice versa), perservation
• poor impulse control/outburst/tantrums emotionally labile
• behavior problems:
• - catastrophic reactions
• - wandering/pacing
• - sundowning- sleep cycle impaired
• poor jugdement
• sleep disturbance

• loss of meaningful communication- may lose all speech, perservate/echo sounds
• emotional response dwindle to nonresponsive
• total dependence on caregiver
• incontinence
• secondary illness related to immobility-motor skills seriously deteriorated, cannot walk sit smile bedridden

LOOK AT SLIDES

• absence from risk of harm to self or others
• reach and maintain the highest functional level possible
• maintain the best possible physical status
• be free from catastrophic reactions
• participate in therapeutic activity program for cognitive stimulation and socialization

• knowledge of dementia
• uses positive interaction with pt
• plans for develops resources/respite services
• appro legal and financial plans in place for self and pt
• back up in case of emergency

• reassure
• caring relationship, unconditional positive regard
• - positive therapeutic reaction- patience
• respect personal space- dont touch
• redirect: less demanding activity- modify environment stable provide as much control as possible
• observe and evaluate verbal/non verbal responses
• identify triggers and indicators of anxiety
• evaluate care routine and responses q 24 hr
• leave alone if unable to stop/decrease reaction
• - act like nothing happens...talk about something else. speak one person at a time

• give realistic positive feedback- praise success
• watch time, maybe easy fatigue, have short attention span
• encourage pt to use skills, promote indepence
• do not ask pt to participate in ADLs when agigated
• structured routines, simple choices, simple verbal msgs, 5-6 words, repeat in necessary, flexibility

look at slide

• may be r/t visuspatial impairments, anxiety, depression,poor sleep patterns, unmet needs, more socially active & outgoing premorbid lifestyle
• safety concerns
• affects sleep, eating, caregiver's ability to provide care interes with privacy of others
• stimulus may be internal and external
• can be predicted thru observation knowing patterns

• alarms bells on windows and door
• keyed locks, child door lock
• lock windows
• label all rooms
• disconnect garage door
• hats, purse, keys- items associated with leaving home
• fence in good repair/gates locked
• dont leave home alone
• hide car keys disconnect battery
• ID braceltes
• ask neighbors to call if they see them
• have photos and identifying data on hand
• provide for exercise
• safe return program thru alze assoc
• for the rest look at slide

• what was the person doing prior
• trying to understand > 1 direction at a time
• new environment/staff
• minor accident
• make judgement. multitask
• negative interaction- being scolded, arguement
• experiencing hallucination, delusions, illusions

look at slide

• neurotransmitter that aids in transferring information into meaning (memory and thinking)
• the process of this disease breaks down acychl
• the brain makes less and less use (why memory and abilty to think thru things is diminished)
• meds stop acychol from breaking down- it delays the the memory loss, delays the progression of symptoms. not a cure. just slows it down

• Aricept: donepezil, second generation
• - better tolerated longer half life
• s/s GI N/D, insomonia, musc cramps
• Exelon- rivastigmine
• -gi n/v anorexia agitation, urination incre
• - patch consistent dosing
• Reinyl- razadyne has improved ADL
• fewer side effects

• regulates the activity of glumate- which is a chemical messenger involved in information processing, storage, and retrieval
• too much glumate causes brain cell death
• Namenda- Memantine 2003
• SE dizziness, confusion, constipation, headache,skin rash (not for peeps with renal impairment)
• less common- HTN, fatigue hallucination SOB

• new drug
• slows down the formation of plaques in the brain