Cognitive Disorders: A Case Study

Cognitive Disorders
Definitions
Cognition: The act, process, or result of knowing, learning, or understanding
-represents a fundamental human feature that distinguishes living from existing
-has a distinctive personalized impact on the individual’s physical, psychological, social & spiritual conduct of life
-Direct relationship with ADL’s
Cognitive Disorders: Psychiatric disorders that are manifested in deficits in memory, perception, & problem solving. 1) Delirium 2) Dementia 3) Amnestic Disorder
Delirium
DMS Criteria
A) Disturbance of consciousness reduced clarity of awareness of environment w/ reducded ability to focus, sustain, or shift attention
B) A change in cognition (memory deficit, disorientation, language disturbance)
or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.
C) The disturbance develops over a short period of time (hours-days) and tends to fluctuate during the course of the day Caused by: 1) a general medical condition 2) substance-induced 3) Both 1&3 or unknown reasons
Delirium: Characterized by a disturbance of consciousness & change in cognition that develop over a short period of time. Always secondary to another problem
*considered a priority problem to prevent irreversible damage
*two common causes are UTI’s & Benadryl
-can get aggressive or combative
-most frequently seen in older pt.’s
Risk Factors for development
-existing cognitive impairment, low functional autonomy, polypharmacy (especially benzo’s, narcotic analgesics, & anticholinergics), clinical severity of the primary illness
Assessment
4 cardinal features: 1) Acute onset & fluctuating course sundowning 2) Inattention need to repeat questions, conversation is difficult, easily distracted by irrelevant stimuli 3) Disorganized thinking 4) Disturbance of consciousness
-pt. may appear withdrawn, agitated of psychotic
-Sundowning is common
Nursing assessment includes observations of:
1) cognitive & perceptual disturbances
2) Physical needs
3) Moods & physical behaviors
Cognitive & Perceptual disturbances
-attention deficits may be subtle or very obvious -memory impairment
-Illusions -Hallucinations -usually aware something is wrong my thoughts are all jumbled -emotional responses to perceptual disturbances are fear & anxiety (psychomotor agitation
Physical Needs
-wandering, pulling out IV or catheters, falling out of bed are common
-difficulty processing stimuli keep physical environment as simple as possible
-clocks & calanders maximize orientation
-Eyeglasses, hearing aids, & nonglaring light maximize interpretation of environment
- Interact w/pt. often short periods of social interaction help reduce anxiety & misperceptions
-Signs often present skin breakdown, poor nutrition, tachycardia, sweating, flushed face, dilated pupils, high BP, alterations in sleep/wake cycle
Moods & Behaviors
-moods & behaviors are very labile and changed rapidly
-Feelings fear, anger, anxiety, euphoria, depression, & apathy
-Behaviors (in response)striking out, crying, call for help, curse, moaning
Assessment Guidelines assess for…
1) Acute onset & fluctuating levels of consciousness
2) Person’s ability to attend to the immediate environment, including responses to nursing care
3) Establish “normal” consciousness & cognition by interviewing family, caregivers
4) Past cognitive impairment- especially existing dementia,& other risk factors
5) Identify disturbances in physiological status infection, hypoxia, pain
6) Identify any physiological abnormalities doc. In pt. record
7) Vital signs, LOC, & neurological signs
8) Potential for injury especially in relation to potential for falls/wandering
9) Maintain comfort measures pain, cold, positioning
10) Monitor situation factors that worsen/improve symptoms
11) Availability of immediate medical interventions to prevent irreversible damage
12) Remain Nonjudgmental
* know tables for Nursing Diagnosis, interventions, & outcomes
Nursing Interventions
*focused on protecting patient dignity, preserving functional status, & promoting well being

Comparison | Delirium | Dementia | Depression | Onset | Sudden: hours-days | Slowly- over months | Gradual with exacerbation during crisis or increased stress | Cause/Contributing Factors | Hypoglycemia, fever, dehydration, hypotension, infection, conditions that disrupt homeostasis; Adverse drug reaction, head injury, change in environment, pain, emotional stress | Alzheimer’s disease, vascular disease, HIV, neurological disease, chronic alcoholism, head trauma | Life long history, losses, loneliness, crises, declining health, medical conditions | Cognition | Impaired memory, judgment, calculations, attention span: Can fluctuate through the day | Impaired memory, judgment, calculations, attention span, abstract thinking, agnosia | Difficulty concentrating, inattention, forgetfulness | Level of Consciousness | Altered | Not altered | Not altered | Activity Level | Can be increased or decreased; restlessness, behaviors may worsen in evening (sundowning), sleep/wake cycle may be reversed | Not altered; Behaviors may worsen in the evening | Usually decreased; lethargy, fatigue, lack of motivation, may sleep poorly & wake up early
| Emotional State | Rapid swings; can be fearful, anxious, suspicious, aggressive, hallucinations/delusions | Flat; delusions | Extreme sadness, apathy, irritability, anxiety, paranoid ideation | Speech & Language | Rapid, inappropriate, incoherent, rambling | Slow, Incoherent, inappropriate, rambling, repetitious | Slow, flat, low | Prognosis | Reversible with proper & timely treatment | Not reversible, progressive | Reversible with proper treatment | Nursing consideration/interventions | can get aggressive or combative | | | Special Bits | | | |