copyright © 2014. f.a. davis company neurocognitive disorders chapter 22
TRANSCRIPT
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Neurocognitive DisordersNeurocognitive DisordersChapter 22Chapter 22
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IntroductionIntroduction
• Neurocognitive disorders are disorders in which a clinically significant deficit in cognition or memory exists representing a significant change from a previous level of functioning.
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• The number of people with neurocognitive disorder is growing because more people now survive into the high-risk period for the disorder, which is age 65 and beyond.
Introduction Introduction (cont.)(cont.)
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DeliriumDelirium
• Delirium is characterized by a disturbance in level of awareness and a change in cognition that develops rapidly over a short period.
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• Symptoms
– Difficulty sustaining and shifting attention– Extreme distractibility– Disorganized thinking– Speech that is rambling, irrelevant, pressured, and
incoherent– Impaired reasoning ability and goal-directed
behavior– Disorientation to time and place
Delirium Delirium (cont.)(cont.)
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• Symptoms (cont.)– Impairment of recent memory– Misperceptions about the environment, including
illusions and hallucinations– Disturbance in level of consciousness, with
interruption of the sleep-wake cycle– Psychomotor activity that fluctuates between
agitation and restlessness and a vegetative state– Emotional instability
Delirium Delirium (cont.)(cont.)
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• Symptoms include autonomic manifestations such as:– Tachycardia– Sweating– Flushed face– Dilated pupils – Elevated blood pressure
Delirium Delirium (cont.)(cont.)
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• Usually begins abruptly• Can have a slower onset if underlying etiology
is systemic illness or metabolic imbalance• Duration is usually brief
and subsides completely on recovery from underlying determinant
Delirium Delirium (cont.)(cont.)
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Predisposing FactorsPredisposing Factors
• Delirium Due to a General Medical Condition– Examples • Infections, febrile illness, metabolic disorders, head
trauma, seizures, migraine headaches, brain abscess, stroke, electrolyte imbalance, others
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• Substance-Induced Delirium– May be caused by intoxication or withdrawal from
certain substances such as:• Anticholinergics, antihypertensives, corticosteroids,
anticonvulsants, analgesics, and others• Alcohol, amphetamines, cannabis, cocaine,
hallucinogens, inhalants, and others• Toxins, including organic solvents and fuels, lead,
mercury, arsenic, carbon monoxide, and others
Predisposing Factors Predisposing Factors (cont.)(cont.)
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Neurocognitive Disorder Neurocognitive Disorder
• Impairment in the cognitive functions of thinking, reasoning, memory, learning, and speaking
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• Neurocognitive disorder (NCD) may be classified as mild or major, depending on severity of symptoms.
• Mild NCD has also been called mild cognitive impairment.
• Major NCD constitutes what was previously described in the DSM as dementia.
Neurocognitive Disorder Neurocognitive Disorder (cont.)(cont.)
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• Primary NCDs are those in which the disorder itself is the major sign of some organic brain disease not directly related to any other organic illness (e.g., Alzheimer’s disease)
• Secondary NCDs are caused by or related to another disease or condition (e.g., HIV disease or cerebral trauma)
Neurocognitive Disorder Neurocognitive Disorder (cont.)(cont.)
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• Symptoms – Impairment exists in abstract thinking,
judgment, and impulse control.– Conventional rules of social conduct are
disregarded.– Personal appearance and hygiene are
neglected.
Neurocognitive Disorder Neurocognitive Disorder (cont.)(cont.)
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• Symptoms (cont.)– Language may or may not be affected.– Personality change is common.
Neurocognitive Disorder Neurocognitive Disorder (cont.)(cont.)
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• Reversible NCD may be more appropriately termed temporary.
• It can occur as a result of: – Stroke– Depression– Side effects of medications– Nutritional deficiencies– Metabolic disorders
Neurocognitive Disorder Neurocognitive Disorder (cont.)(cont.)
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• As the disease progresses, symptoms may include:– Aphasia – Apraxia– Irritability and moodiness, with sudden outbursts
over trivial issues– Inability to care for personal needs independently– Wandering away from the home – Incontinence
Neurocognitive Disorder Neurocognitive Disorder (cont.)(cont.)
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• Alzheimer’s disease (AD) accounts for 50 to 60 percent of all cases of NCD.– AD can be described in stages:• Stage 1. No apparent symptoms• Stage 2. Forgetfulness• Stage 3. Mild cognitive decline
Neurocognitive Disorder Neurocognitive Disorder (cont.)(cont.)
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– Stages of Alzheimer’s disease (cont.):• Stage 4. Mild-to-moderate cognitive decline• Stage 5. Moderate cognitive decline• Stage 6. Moderate-to-severe cognitive decline• Stage 7. Severe cognitive decline
Neurocognitive Disorder Neurocognitive Disorder (cont.)(cont.)
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1. Hospitalized and diagnosed in the fourth stage of NCD due to Alzheimer’s disease, a client, when asked about the previous evening, describes a wonderful evening spent on a cruise. Which symptom is the client exhibiting?
A. AphasiaB. ConfabulationC. DeliriumD. Apraxia
Neurocognitive Disorder Neurocognitive Disorder (cont.)(cont.)
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• Correct answer: B– Confabulation is a behavioral reaction to memory
loss in which the client fills in memory gaps with information about events that have not occurred. During the fourth stage of Alzheimer’s dementia, a client will use confabulation in an effort to maintain self-esteem.
Neurocognitive Disorder Neurocognitive Disorder (cont.)(cont.)
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Predisposing FactorsPredisposing Factors
• NCD Due to Alzheimer’s Disease– Onset is slow and insidious.– Course of the disorder is generally progressive
and deteriorating.
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• NCD Due to Alzheimer’s Disease (cont.)– Etiologies may include:• Acetylcholine alterations• Plaques and Tangles• Head trauma• Genetic factors
Predisposing Factors Predisposing Factors (cont.)(cont.)
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2. A client is newly diagnosed with second stage NCD due to Alzheimer’s disease. Which cognitive change would a nurse observe?
A. Memory disturbanceB. ConfabulationC. ApraxiaD. Inability to plan or organize
Predisposing Factors Predisposing Factors (cont.)(cont.)
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• Correct answer: A– In the second stage of the illness, losses in short-
term memory are common and the individual may begin to lose things or forget names of people. It’s at this stage that a diagnosis may be considered.
Predisposing Factors Predisposing Factors (cont.)(cont.)
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• Vascular NCD– NCD occurs as a result of significant
cerebrovascular disease.– There is a more abrupt onset than is seen in
association with Alzheimer’s disease, and the course is more variable.
Predisposing Factors Predisposing Factors (cont.)(cont.)
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• Vascular NCD (cont.)– Etiologies may include:• Hypertension• Cerebral emboli• Cerebral thrombosis
Predisposing Factors Predisposing Factors (cont.)(cont.)
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• Frontotemporal NCD– Occurs as a result of shrinking of the frontal and
temporal anterior lobes of the brain– Previously called Pick’s disease– Exact cause is unknown, but genetics appears to
be a factor
Predisposing Factors Predisposing Factors (cont.)(cont.)
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• NCD Due to Traumatic Brain Injury– Amnesia is the most common neurobehavioral
symptom following head trauma.– Repeated head trauma can result in dementia
pugilistica with symptoms of:– Emotional liability– Dysarthria– Ataxia– Impulsivity
Predisposing Factors Predisposing Factors (cont.)(cont.)
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• NCD Due to Lewy Body Disease– Similar to Alzheimer’s disease, but progresses
more rapidly– Appearance of Lewy bodies in the cerebral cortex
and brainstem– Progressive and irreversible– May account for 25 percent of all NCD cases
Predisposing Factors Predisposing Factors (cont.)(cont.)
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• NCD Due to Parkinson’s Disease– This is caused by a loss of nerve cells located in
the substantia nigra and a decrease in dopamine activity.
– Cerebral changes in NCD due to Parkinson’s disease sometimes resemble those of Alzheimer’s disease.
Predisposing Factors Predisposing Factors (cont.)(cont.)
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• NCD Due to HIV Infection– Caused by brain infections with opportunistic
organisms or by the HIV-1 virus directly.– Symptoms may range from barely perceptible
changes to acute delirium to profound cognitive impairment.
Predisposing Factors Predisposing Factors (cont.)(cont.)
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• Substance-Induced NCD– Occurs as a result of reactions to, or the overuse
or abuse of, substances such as:• Alcohol• Inhalants• Sedatives, hypnotics, and anxiolytics• Medications that cause anticholinergic site effects• Toxins, such as lead and mercury
Predisposing Factors Predisposing Factors (cont.)(cont.)
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• NCD Due to Huntington’s Disease– This disease is transmitted as a Mendelian
dominant gene.– Damage occurs in the areas of the basal ganglia
and the cerebral cortex.– The client usually declines into a profound state
of cognitive impairment and ataxia.– Average course of the disease is based on age at
onset, with juvenile-onset and late-onset having the shortest duration.
Predisposing Factors Predisposing Factors (cont.)(cont.)
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• NCD Due to Prion Disease– The disorder is attributable to prion disease (e.g.,
Creutzfeldt-Jakob disease or bovine spongiform encephalopathy).
– Onset of symptoms typically occurs between ages 40 and 60 years; course is extremely rapid with progression from diagnosis to death in less than 2 years.
– Five to 15 percent of cases have a genetic component.
Predisposing Factors Predisposing Factors (cont.)(cont.)
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• NCD Due to Another Medical Condition‒ Hypothyroidism‒ Hyperparathyroidism‒ Pituitary insufficiency‒ Uremia‒ Encephalitis‒ Brain tumor‒ Pernicious anemia‒ Thiamine deficiency‒ Multiple sclerosis
‒ Pellagra‒ Uncontrolled epilepsy‒ Cardiopulmonary
insufficiency‒ Fluid and electrolyte
imbalances‒ CNS and systemic infections‒ Systemic lupus
erythematosus
Predisposing Factors Predisposing Factors (cont.)(cont.)
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3. Which statement is true about vascular NCD?
A. Vascular NCD is reversible.B. Vascular NCD is characterized by plaques and
tangles in the brain.C. Vascular NCD involves a gradual, progressive
cognitive deterioration.D. Vascular NCD involves a variable pattern of
cognitive functioning.
Predisposing Factors Predisposing Factors (cont.)(cont.)
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• Correct answer: D– In vascular NCD, clients suffer the equivalent of small
strokes that destroy many areas of the brain. The pattern of deficits is variable, depending on which regions of the brain have been affected.
Predisposing Factors Predisposing Factors (cont.)(cont.)
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Application of the Nursing Application of the Nursing Process/AssessmentProcess/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
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• The Client History (cont.)– Areas of concern to be addressed (cont.)• 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
Application of the Nursing Application of the Nursing Process/Assessment Process/Assessment (cont.)(cont.)
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• Physical Assessment– Assessment for diseases of various organ systems
that can induce confusion, loss of memory, and behavioral changes
Application of the Nursing Application of the Nursing Process/Assessment Process/Assessment (cont.)(cont.)
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• Physical Assessment (cont.)– Neurological examination to assess mental status,
alertness, muscle strength, reflexes, sensory perception, language skills, and coordination
Application of the Nursing Application of the Nursing Process/Assessment Process/Assessment (cont.)(cont.)
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• Physical Assessment (cont.)– Psychological tests to differentiate between
NCD and pseudodementia (depression)
Application of the Nursing Application of the Nursing Process/Assessment Process/Assessment (cont.)(cont.)
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• Diagnostic Laboratory Evaluations– Include blood and urine to test for the following:• Various infections• Hepatic and renal dysfunctions• Diabetes or hypoglycemia• Electrolyte imbalances• Metabolic and endocrine disorders• Nutritional deficiencies• Presence of toxic substances
Application of the Nursing Application of the Nursing Process/Assessment Process/Assessment (cont.)(cont.)
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• 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)
Application of the Nursing Application of the Nursing Process/Assessment Process/Assessment (cont.)(cont.)
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Nursing Diagnosis/Outcome Nursing Diagnosis/Outcome IdentificationIdentification
• Risk for trauma • Disturbed thought processes• Impaired memory• Disturbed sensory perception• Risk for other-directed violence• Impaired verbal communication• Self-care deficit• Situational low self-esteem• Grieving
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Outcome CriteriaOutcome Criteria
• 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.– Participates in activities of daily living with
assistance.
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Planning/ImplementationPlanning/Implementation
• Care plan for the client with a cognitive disorder is aimed at:– Protection of self and others– Maintaining orientation to reality to the best of
client’s ability– Minimizing confusion– Fulfilling basic needs– Assisting and educating prospective caregivers
about appropriate care for the client
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Client/Family EducationClient/Family Education
• Nature of the Illness– Possible causes– What to expect– Symptoms
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• Management of the Illness– Ways to ensure client safety– How to maintain reality orientation– Provide assistance with activities of daily living– Nutritional information– Difficult behaviors– Medication administration– Matters related to hygiene and toileting
Client/Family Education Client/Family Education (cont.)(cont.)
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• Support Services– Financial assistance– Legal assistance– Caregiver support groups– Respite care– Home health care
Client/Family Education Client/Family Education (cont.)(cont.)
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Nursing Process: EvaluationNursing Process: Evaluation
• Based on the accomplishment of outcome criteria
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Medical Treatment ModalitiesMedical 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
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• Delirium (cont.)– Room with low stimulus level – Low-dose antipsychotic agents to relieve agitation
and aggression– Benzodiazepines commonly used when etiology is
substance withdrawal
Medical Treatment ModalitiesMedical Treatment Modalities (cont.) (cont.)
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• NCD– Primary consideration is given to etiology,
with focus on identification and resolution of potentially reversible processes.
Medical Treatment ModalitiesMedical Treatment Modalities (cont.) (cont.)
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• NCD (cont.)– Pharmaceutical agents• For cognitive impairment:– Physostigmine (Antilirium)– Donepezil (Aricept)– Rivastigmine (Exelon) – Galantamine (Razadyne)– Memantine (Namenda)
Medical Treatment ModalitiesMedical Treatment Modalities (cont.) (cont.)
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– Pharmaceutical agents for NCDs (cont.)• For agitation, aggression, hallucinations, thought
disturbances, and wandering:– Risperidone (Risperdal)–Olanzapine (Zyprexa)–Quetiapine (Seroquel)– Ziprasidone (Geodon)
– These drugs cause fewer anticholinergic and EPS than older antipsychotics.
– They carry a black-box warning that all antipsychotics are associated with an increased risk of death in elderly patients with NCD.
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‒ Pharmaceutical agents for NCDs (cont.)• For agitation, aggression, hallucinations, thought
disturbances, and wandering (cont.):
– Haloperidol (Haldol)• Still commonly used because of its proven
efficacy• Higher potential for anticholinergic, EPS, and
sedative effects than with the atypical antipsychotics
• Carries black-box warning that it is associated with increased risk of death in elderly patients with NCD
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4. A client has recently been diagnosed with mild to moderate NCD due to Alzheimer’s disease. Which medication would the nurse expect the physician to order for this client’s cognitive impairment?
A. Nortriptyline (Pamelor)B. Zaleplon (Sonata)C. Donepezil (Aricept)D. Quetiapine (Seroquel)
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• Correct answer: C– Donepezil is used to improve cognition in clients
diagnosed with mild to moderate dementia associated with Alzheimer’s disease. Its action improves cholinergic function by inhibiting acetylcholinesterase.
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‒ Pharmaceutical agents for NCDs (cont.)• For depression:
– SSRIs• Often considered first line due to favorable side
effect profile– Tricyclic antidepressants• Often avoided due to anticholinergic and cardiac
side effects– Trazodone (Desyrel)• Good choice for clients with insomnia
– Dopaminergic agents• Helpful in treatment of severe apathy
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‒ Pharmaceutical agents for NCDs (cont.)• For anxiety (should not be used routinely for prolonged
periods):– Chlordiazepoxide (Librium)– Alprazolam (Xanax)– Lorazepam (Ativan)– Oxazepam (Serax)– Diazepam (Valium)
Medical Treatment ModalitiesMedical Treatment Modalities (cont.) (cont.)
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‒ Pharmaceutical agents for NCDs (cont.)• For sleep disturbances (for short-term therapy only):
– Flurazepam (Dalmane)– Temazepam (Restoril)– Triazolam (Halcion)– Zolpidem (Ambien)– Zaleplon (Sonata)– Ramelteon (Rozerem)– Eszopiclone (Lunesta)– Trazodone (Desyrel)– Mirtazapine (Remeron)
Medical Treatment ModalitiesMedical Treatment Modalities (cont.) (cont.)
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‒ Pharmaceutical agents for NCDs (cont.)• Dosage adjustments with regard to physiological
changes in aging clients must be made with all medications.
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