Cognitive Impairment

  1. Cognitive disorders Include?
    • Delirium
    • Dementia
    • Amnestic Disorder
  2. Characterized by a disturbance of consciousness and a change in cognition such as impaired attention san and disturbances of consciousness, that develops over a short period of time.  Very common in medical practices.
  3. Develops more slowly and is characterized by multiple cognitive deficits that include impairment in memory.
  4. Characterized by loss in both short-term memory and long-term memory, sufficient to cause some impairment in the person's functioning.
    Amnestic Disorder
  5. Gradual with exacerbation during crisis or stress.
    Difficulty concentrating, forgetfulness, inattention.
    LOC not altered
    Lethargy, lack of motivation and poor sleep
    Extreme sadness, apathy, anxiety, irritabillity
    Speech is slow, flat and low
    It is reversible with proper and timely treatment.
  6. Dilirium can occur
    • MOre frequently in elderly
    • Postops
    • Drugs
    • Cardio Vascular disease
    • CHF
    • Children with fever
  7. Symptoms of delirium
    • Disturbance in consciousness
    • Thinking
    • Memory
    • Attention
    • Perception
    • Develop over a short period
    • Fluctuates during the day ( It flucuates during the day.  They may be ok during the day but then confused at night
    • Progressive disorientation to time and place 
  8. Common causes of Delirium
    • Infections: pneumonia,uti, fevers
    • Postoperative: Meds used for sugery
    • Metabolic Abnormalities:dehydration or hypoglycemic
    • Hypoxic conditions: No O2 to brain
    • Drug withdraw
    • Drug intoxications
    • Polypharmacy:  Phenobarbitol, valium, haldol. morphine, compazine, and elavil
    • Psych: pain and sleep depravasion
  9. Nursing concerns and management
    • Assisting with proper health management to eradicat the underlying cause: treat the cause.  There is usually an underlining issue.
    • Preventing physical harm due to confusion, agrression, or electrolyte and fluid imbalance
    • Use supportive measures to relieve stress. 
    • *********Acknowledge the fear, limit decision making.
    • *********Use reality orintation: reoriant the pt to reality (person, place, time, and thing)
  10. What is the KEY to Delirium
    Reality orintation
  11. Nursing Diagnosis for Dilirium
    • Risk for injury: Hallucinations
    • Fluid vol. deficit
    • Acute confusion
    • Sleep-pattern disturbance
    • Impaired verbal communication
    • Self-care deficits: unable to do adl's
    • Impaired social interaction
  12. marked by progressive deterioration in intellectural functioning, memory, and ability to solve problems and learn new skills
    Judgement, moral and ethical behaviors decline as personality is altered.
    • Dementia
    • It is important to educate the family.  It  is usually very hard for them that their mother/father is changing.
  13. Etiology of dementia
    Neurodegenerative: AD, Lewy, ALS-Lou Garics disease, parkinsons, huntings korea

    Vascular: Ischemic, hypoxic, hemoragic, brain lesions caused by cardio. disease-hemorrage and infact.
  14. Typer of Dementia
    • Alzheimers
    • Picks: rare senile dementia-middle age
    • Creutzfeldt Jakob: Virus, infectious ( not contagious-mad cow disease)
    • Multiinfact: vascular
    • Parkinson's: more likely to develop dementia
    • Dorsakoff's syndrome: vit b deff related to alcoholism
    • Huntington's disease: hereditary physical and mental deteriation leading to death.
  15. More likely to develop dementia
  16. Is not reversible, progressive, not secondary to any other disorder
    • Primary dementia
    • (They are not going to get better-Cognitive cont. to decline 70% AD)
  17. Result of some other pathological process
    • Secondary dementia
    • (other pathological process is causing the disease)
  18. Mimics dementia
    Drug tocicity
    Metabolic disorders
    Nutritional defecinences
  19. What nursing interventions to determine pseudodementia
    • Complete physical and history, exam incl. EEG, EKG, CT, CBC,B12, TSH.
    • R/O Anemia
    • Chem 8: R/O DM, Renal, Liver.
    • Don't want to label patient before testing.
  20. Dementia
    Make sure they don't have problems with:
    • D-Drugs and Alcohol (under the influence?)
    • E-Eyes and Ears (Sensory Deff)
    • M-Metabolic and Endocrine
    • E-Emotional Disorders (depression can mimmic)
    • N-Neurologic Disorders
    • T-Tumors and trauma
    • I-Infection
    • A-Arterivovascular disease
  21. Causes of Alzheimer's
    • It is unknown.  Numerous hypotheses:
    • Neurochemical changes
    • Genetic Defects-24,12, and exp.19 gene mutations
    • Abnormal proteins

    Autopsy after client has passed is the only way to determine.
  22. Risk Factors for Alzheimer's
    • Advance age
    • Genetics
    • Down Syndrome
    • Head injury
    • CV factors-HTN
    • Obesity
    • Smoking
    • High lipids
    • Arthrosclerosis
  23. Pathological changes
    Neurofibrillary Tangles: proteins in the neurons in the Hippocampus-responsible for short term memory.

    Senile plaques: Degenative neuron materials.  #'s of plaques-the more they have is related to the degree of dementia.  the less memory they have.

    Granulovascular degeneration: filling of brain cells w/fluid and degeneration of granulation.
  24. The areas affected in the brain
    Hippocampus: region to be first affected.

    • Cortex:  memory and congnition
    • Neurons can not synaps
  25. Four signs of AD
    • Aphasia
    • Apraxia
    • Agnosia
    • Mnemonic Disturbance
  26. Loss of language ability
    • Aphasia
    • Finding correct word-end stages they loose the ability to communicate or talk.  Babbling.
  27. Loss of purposeful movement
    • Aproxia
    • Careing out motor activity-dressing or walking
  28. loss of sensory ability to recognize objections
    ex. sounds
    • Agnosia
    • Sounds they hear the noise but cant recognize
    • Vision-family members or visual objects.
  29. Loss of memory
    • Mnemonic Disturbance
    • they loose short term memory then long term memory
  30. 5 A's to alzheimer Diagnosis
    • Anomia: inability to remember names of things
    • Aproxia: misuse of objects because of failure to identify them
    • Agnosia: inability to recognize familiar objects, tastes,sounds, and other sensations
    • Aphasia: inability to express oneself through speech
    • Amnesia: memory loss
  31. Cognitive assessment tools
    • Mini-mental status Examination (MMSE)
    • Clock drawing test
    • Geriatric depression scale
    • Functional Assessement (Katz)
  32. Measures their global coginitive performance, orintation, attention span.  Lauguage recall and perception.
    Widely accepted-has been proven to be valid
  33. Detect degression of cog. decline over a period of time.
    Clock drawing test
  34. Detect depression can contribute or memic dementia.
    Geriatric depression scale
  35. Activites of ADL's cog. assessment tool
    Functional Assessment (KATZ)
  36. Stages of AD
    • Mild (early)
    • Moderate (middle)
    • Severe (late)
  37. Averages 2-4yrs. Recent memory loss, affecting job performance.  Forget to pay bills.  Trouble finding familuar places.  Trouble with routine chores-getting up and around-getting dressed.   Gets up earlier because it takes them a while to get up.  Cut off notices from utilities. 
    Mood and personality changes.
  38. It is the most important nurse intervention for AD patient in the mild stage?
    Let them maintain and function as much as possible.
  39. 2-10 years.  Increase memory loss, confusion, trouble reading, writing, and understanding #'s.  Hard to think logically-hard to process. Needs supervison.  Sundowning
  40. 1-3 years: instituinalized.  UI and BI.  Does not recognize family.  Cant care for themselves.  Unable to communicate.  They put things in their mouths.
  41. Nursing interventions for Moderate to Severe?
    Keep the client safe from injury

    (Some move through stages quicker and some go through it slower.)
  42. Care of issues to be aware of?
    • Diagnostic disclosure issues
    • End of life issues
    • Advance directives
    • Treatment withdrawl and refusal
    • Hospice care-Will take care of family as well.
    • Disclose AD to advance planning
    • Living hopxy
  43. Communication Guidelines
    • Simple common words
    • One command at a time
    • Use only nouns
    • Same words on repetition
    • Speak face to face
    • Call name to get attention
    • Speak softly
    • Calm, quiet voice
    • Minimize enviromental stimuli-TV can agitate
    • Theraputic fibbing-goal is to comfort the client and avoid upsetting.
    • Don't correct them-  Its Jan but X says its July...Agree
    • Music therapy-classical
  44. Tips for nursing care
    • Introduce each time
    • Explain care simply
    • Smile and touch
    • Chest frequently
    • Consistent Schedule
    • Identify clients-photo of client when they were young
    • ***********remember they don't know who they are**
    • Decorate room with home items-help them relize that is their room
    • Take to bathroom q 2 hrs!!!!!!!!
  45. Tips for Dressing and Grooming?
    • Can increase self esteme
    • Encourage street clothes
    • Limit choices of clothes-Take out only 2 outfits and let them choose.
    • Lay out clothes in order
    • **********IMPORTANT:::  instruct step by step
    • Have short hair
    • Demonstrate tooth brushing.
  46. Tips for Incontinence
    • Take to bathroom q 2 hrs:: they forget to go
    • Limit fluids near bedtime
    • Easy on and off clothin-Elastic waste and remember soft clothing and cut off tags.
    • Label bathroom door-picture of a toilet-  they can't read.
  47. Tips for Meals
    • Strong cravings:: they can't control.  Watch out for unuall cravings to plastic, foam ect....They can't tell whats edible.
    • Forget to swallow:: they pocket food.  Give cues on how to swallow.
    • Forget how to swallow:: family will be brought in and discuss tube feeding.
    • Provide quiet area
    • Appropriate temp:  not too hot or cold
    • Limit choices
    • Remove seasonings after use:: they will eat the pepper, salt, and sugar out of the container.
    • Cut food into small bites to prevent aspiration.
    • Use finger food:: its hard for them to sit still
    • Dentures need refitting
    • Grind food prn.
  48. Tips for sleep Disturbance
    • Limit naps
    • Simplify bedtime routine-consistant sleeping routine
    • Have a daytime activity
    • Dim lights
    • Relaxing back rubs
    • Avoid restraints-agitates them
    • REMEMBER********sundowning-let them get up and move around.
  49. Tips for Restlessness
    • Remove distracting stimuli.
    • Are basic need met? ::  bathroom, pain, hungry.  What is causing them to act this way.
    • Plan exercise
    • Re-direct if repetitive
    • Reassurance of care
    • Only decaffeinated beverages
    • Distract from upsets.
    • Doll therapy******Nurses must treat as real*********
  50. Tipps for Aggression:
    • Usually during ADL's and treatments-ask family members what worked for them at home.
    • Tension escalates aggression
    • Fight perceived attack
    • Stand close to client
    • Reduce cause of fear
    • Reassure all is ok.
    • Pain manafest as a agatation and clients cant rate their pain.
  51. Tips for memory loss
    • Keep belongings in same place
    • Identify bed
    • Large calender and clock
    • Same structure and routine
    • Picture at a younger age.

    • Pictures of younger years.  Reminec-talk about their pass.
    • Work crossword puzzles in the early stage-use it or loose it.
    • Ex. program less likely to develop memory problems.
  52. Don't -Communication w/ AD patien
    • Reason
    • Argue
    • Confront
    • Remind them they forget
    • Question recent memory
    • Take it personally
  53. Do-Communication with the AD patient
    • Give short-one sentence explanations
    • Repeat instruction or sentences exactly the same way
    • Allow plenty of time for comprehension
    • Eliminate but from or vocab; say nevertheless
    • Agree with them or ditract them to a different subject or activity
    • Accept the blame
    • Leave the room if there could be a confrontation
    • Respond to the feelings rather than the words
    • Be patient and cheerful and reassuring.  Do the go with the flow
Card Set
Cognitive Impairment
Cognitive Impairment