MENTAL HEALTH; CHAPTER 24: COGNITIVE DISORDERS:

Cognitive Disorder: Dementia: Intervention: Promoting Interaction & Involvement: Reminiscence Therapy:

- (thinking about or relating personally significant past experiences) is an effective intervention for clients with dementia. - Rather than lamenting that the client is "living in the past," this therapy encourages family and caregivers to also reminisce with the client. - Reminiscing, also called nostalgia, uses the client's remote memory, which is not affected as severely or quickly as recent or immediate memory. - Photo albums may be useful in stimulating remote memory, and they provide a focus on the client's past. - Sometimes clients like to reminisce about local or national events and talk about their roles or what they were doing at the time. - In addition to keeping clients involved in the business of living, reminiscence can also build self-esteem as clients discuss accomplishments. - Engaging in active listening, asking questions, and providing cues to continue promote successful use of this technique. - Reminiscence therapy can also be effective with small groups of clients as they collectively remember their early life activities - Clients have increasing problems interacting with others as dementia progresses. Initially, clients retain verbal language skills, but other people may find them difficult to understand as words are lost or content becomes vague. - The nurse must listen carefully to the client and try to determine the meaning behind what is being said. The nurse might say, "Are you trying to say you wantto use the bathroom?" or "Did I get that right, you are hungry?" (seeking clarification) - It is also important not to interrupt clients or to finish their thoughts. - If a client becomes frustrated when the nurse cannot understand his or her meaning, the nurse might say, Can you show me what you mean or where you want to go? (assisting to take action) - When verbal language becomes less coherent, the nurse should remain alert to the client's nonverbal behavior. - When nurses or caregivers consistently work with a particular client, they develop the ability to determine the client's meaning through nonverbal behavior. - For example, if the client becomes restless, it may indicate that he or she is hungry if it is close to mealtime or tired if it is late in the evening. - Sometimes it is impossible to determine exactly what the client is trying to convey, but the nurse can still be responsive. - For example, a client is pacing and looks upset but cannot indicate what is bothering her. - The nurse says, You look worried. I don't know what's wrong, but let's go for a walk. (making an observation/offering self) - Interacting with clients with dementia often means dealing with thoughts and feelings that are not based in reality but arise from the clients' suspicion or chronic confusion. - Rather than attempting to explain reality or allay suspicion or anger, it is often helpful to use the techniques of distraction, time away, or going along to reassure the client.

Drugs Used to Treat Dementia: Memantine (Namenda):

- 10-20 mg/day divided into two doses - Monitor for hypertension, pain, headache, vomiting, constipation, and fatigue.

Drugs Used to Treat Dementia: Galantamine (Reminyl, Razadyne, Nivalin):

- 16-32 mg orally per day divided into two doses - Monitor for nausea, vomiting, loss of appetite, dizziness, and syncope.

Drugs Used to Treat Dementia: Rivastigmine (Exelon):

- 3-12 mg orally per day divided into two doses - Monitor for nausea, vomiting, abdominal pain, and loss of appetite.

Drugs Used to Treat Dementia: Donepezil (Aricept):

- 5-10 mg orally per day - Monitor for nausea, diarrhea, and insomnia. - Test stools periodically for gastrointestinal bleeding.

Cognitive Disorder: Dementia: Intervention: Structuring The Environment & Routine:

- A structured environment and established routines can reassure clients with dementia. - Familiar surroundings and routines help eliminate some confusion and frustration from memory loss. - Providing routines and structure, however, does not mean forcing clients to conform to the structure of the setting or routines that other people determine. - Rather than imposing new structure, the nurse encourages clients to follow their usual routines and habits of bathing and dressing. - For example, it is important to know whether a client prefers a tub bath or shower and washes at night or in the morning and include those preferences in the client's care. - Research has shown that attempting to change the dressing behavior of clients may result in physical aggression as clients make ineffective attempts to resist unwanted changes. - Monitoring response to daily routines and making needed adjustments are important aspects of care. - The nurse needs to monitor and manage the client's tolerance of stimulation. - Generally, clients can tolerate less stimulation when they are fatigued, hungry, or stressed. - Also, with the progression of dementia, tolerance for environmental stimuli decreases. - As this tolerance diminishes, clients need a quieter environment with fewer people and less noise or distraction.

Role Of Caregiver:

- About 34% of caregivers for those with dementia are ages 65 or older. - Two-thirds of those caring for family members with dementia are women, and over one-third are adult daughters - The trend toward caring for family members with dementia at home is largely the result of the high costs of institutional care, dissatisfaction with institutional care, and difficulty locating suitable placements for clients with behaviors that are sometimes disruptive and difficult to manage. - Family members identify many other reasons for becoming primary caregivers, including the desire to reciprocate for past assistance, to provide love and affection, to uphold family values or loyalty, to meet duty or obligation, and to avoid feelings of guilt. - Caregivers need to know about dementia and the required client care as well as how client care will change as the disease progresses. - Caregivers may also be dealing with other family members who may or may not be supportive or who may have differing expectations. - Many caregivers have other demands on their time, such as their own families, careers, and personal lives. - Caregivers must continually deal with their feelings of loss and grief as the health of their loved ones continually declines - Caring for clients with dementia can be emotionally and physically exhausting and stressful. - Caregivers may need to drastically change their own lives, such as quitting a job, to provide care. Caregivers may have young children as well. - They often feel exhausted and as if they are "on duty" 24 hours a day. - Caregivers caring for parents may have difficulty "being in charge" of their mothers or fathers (role reversal). - They may feel uncomfortable or depressed about having to bathe, feed, or change diapers for parents. - Role strain is identified when the demands of providing care threaten to overwhelm a caregiver. - Indications of role strain include constant fatigue that is unrelieved by rest, increased use of alcohol or other drugs, social isolation, inattention to personal needs, and inability or unwillingness to accept help from others. - Caregivers may feel unappreciated by other family members, as indicated by statements such as "No one ever asks how I am!" In some situations, role strain can contribute to the neglect or abuse of clients with dementia - Supporting the caregiver is an important component of providing care at home to clients with dementia. - Caregivers must have an ongoing relationship with a knowledgeable health professional; the client's physician can make referrals to other health care providers. - Depending on the situation, that person may be a nurse, care manager, or social worker. - He or she can provide information, support, and assistance during the time that home care is provided. - Caregivers need education about dementia and the type of care clients need. - Caregivers should use the interventions previously discussed to promote the client's well-being, deal with deficits and limitations, and maximize the quality of the client's life. - Because the care that clients need changes as the dementia progresses, this education by the nurse, care manager, or social worker is ongoing. - Caregivers need outlets for dealing with their own feelings. - Support groups can help them express frustration, sadness, anger, guilt, or ambivalence; all these feelings are common. - Attending a support group regularly also means that caregivers have time with people who understand the many demands of caring for a family member with dementia. - The client's physician can provide information about support groups, and the local chapter of the National Alzheimer Disease Association is listed in the phone book. - Area hospitals and public health agencies also can help caregivers to locate community resources. - Caregivers should be able to seek and accept assistance from other people or agencies. - Often, caregivers believe that others may not be able to provide care as well as they do, or they say they will seek help when they "really need it." - Caregivers must maintain their own well-being and not wait until they are exhausted before seeking relief. - Sometimes family members disagree about care for the client. - The primary caregiver may believe other family members should volunteer to help without being asked, but other family members may believe that the primary caregiver chose to take on the responsibility and do not feel obligated to help out regularly. Whatever the feelings are among family members, it is important for them all to express their feelings and ideas and to participate in caregiving according to their own expectations. Many families need assistance to reach this type of compromise. - Finally, caregivers need support to maintain personal lives. - They need to continue to socialize with friends and engage in leisure activities or hobbies rather than focusing solely on the client's care. - Caregivers who are rested, happy, and have met their own needs are better prepared to manage the rigorous demands of the caregiver role. - Most caregivers need to be reminded to take care of themselves; this act is not selfish but is in the client's best long-term interests.

Cognitive Disorder: Delirium: Thought Process & Content:

- Although clients with delirium have changes in cognition, it is difficult for the nurse to assess these changes accurately and thoroughly. - Marked inability to sustain attention makes it difficult to assess thought process and content. - Thought content in delirium is often unrelated to the situation, or speech is illogical and difficult to understand. - The nurse may ask how clients are feeling, and they will mumble about the weather. - Thought processes are often disorganized and make no sense. Thoughts also may be fragmented (disjointed and incomplete). - Clients may exhibit delusions, believing that their altered sensory perceptions are real.

Cognitive Disorder: Delirium: Self-Concept:

- Although delirium has no direct effect on self-concept, clients often are frightened or feel threatened. - Those with some awareness of the situation may feel helpless or powerless to do anything to change it. - If delirium has resulted from alcohol, illicit drug use, or overuse of prescribed medications, clients may feel guilt, shame, and humiliation, or think, "I'm a bad person; I did this to myself." - This would indicate possible long-term problems with self-concept.

Drugs Causing Delirium:

- Anesthesia - Anticonvulsants - Anticholinergics - Antidepressants - Antihistamines - Antihypertensives - Antineoplastics - Antipsychotics - Aspirin - Barbiturates - Benzodiazepines - Cardiac glycosides - Cimetidine (Tagamet) - Hypoglycemic agents - Insulin - Narcotics - Propranolol (Inderal) - Reserpine - Steroids - Thiazide diuretics

Cognitive Disorder: Dementia: Treatment & Prognosis: Symptomatic Treatment For Behaviors:

- Antidepressants are effective for significant depressive symptoms; however, they can cause delirium. - Selective serotonin reuptake inhibitor antidepressants are used because they have fewer side effects. - Antipsychotics, such as haloperidol (Haldol), olanzapine (Zyprexa), risperidone (Risperdal), and quetiapine (Seroquel), may be used to manage psychotic symptoms of delusions, hallucinations, or paranoia, and other behaviors, such as agitation or aggression. - The potential benefit of antipsychotics must be weighed with the risks, such as an increased mortality rate, primarily from cardiovascular complications. - Owing to this increased risk, the U.S. Food and Drug Administration (FDA) has not approved antipsychotics for dementia treatment, and there is a black box warning issued. Lithium carbonate, carbamazepine (Tegretol), and valproic acid (Depakote) help stabilize affective lability and diminish aggressive outbursts. - Benzodiazepines are used cautiously because they may cause delirium and can worsen already compromised cognitive abilities. - Pimavanserin (Nuplazid) has been specifically FDA approved to treat delusions and hallucinations that some experience with Parkinson disease - One 34-mg capsule per day is the recommended dose. It is known to prolong the Q-T interval. - Both conventional and atypical antipsychotics are associated with an increased risk of mortality in elderly patients treated for dementia-related psychosis.

Cognitive Disorder: Dementia: Types Of Dementia: Prion Diseases:

- Are caused by a prion (a type of protein) that can trigger normal proteins in the brain to fold abnormally. - They are rare, and only 300 cases per year occur in the United States. - Creutzfeldt-Jakob disease is the most common prion disease affecting humans - It is a CNS disorder that typically develops in adults aged 40 to 60 years. - It involves altered vision, loss of coordination or abnormal movements, and dementia that usually progresses rapidly (a few months). - The cause of the encephalopathy is an infectious particle resistant to boiling, some disinfectants (e.g., formalin, alcohol), and ultraviolet radiation. - Pressured autoclaving or bleach can inactivate the particle - Mad cow disease and kuru (seen largely in New Guinea from eating infected brain tissue) are other prion diseases.

Cognitive Disorder: Dementia: Community-Based Care:

- At least half of all nursing home residents have Alzheimer disease or some other illness that causes dementia. - In addition, for every person with dementia in a nursing home, two or three with similar impairments are receiving care in the community by some combination of family members, friends, and paid caregivers. - Programs and services for clients with dementia and their families have increased with the growing awareness of Alzheimer disease, the increasing numbers of older adults in the United States, and the fundraising efforts for education by noted figures (e.g., the family of former President Ronald Reagan). - Home care is available through home health agencies, public health agencies, and visiting nurses. - These services offer assistance with bathing, food preparation, and transportation as well as with other support. - Periodic nursing assessment ensures that the level of care provided is appropriate to the client's current needs. - Adult day care centers provide supervision, meals, support, and recreational activities in group settings. Clients may attend the center a few hours a week or full-time on weekdays if needed. - Respite care offers in-home supervision for clients so that family members or caregivers can run errands or have social time of their own. - Residential facilities are available for clients who do not have in-home caregivers or whose needs have progressed beyond the care that could be provided at home. - These clients usually require assistance with ADLs, such as eating and taking medications. - Clients in residential facilities are often referred for skilled nursing home placement as dementia progresses. - The physician, nurse, or family can initiate referrals for community-based services. - Families can contact the local public health department or the department of human or social services listed in the phone book. - If the client has been admitted to the hospital, social services can also assist in making an appropriate referral.

Cognitive Disorder: Delirium: Assessment: History:

- Because the causes of delirium are often related to medical illness, alcohol, or other drugs, the nurse obtains a thorough history of these areas. - The nurse may need to obtain information from family members if a client's ability to provide accurate data is impaired. - Information about drugs should include prescribed medications, alcohol, illicit drugs, and over-the-counter (OTC) medications. - Although many people perceive prescribed and OTC medications as relatively safe, combinations or standard doses of medications can produce delirium, especially in older adults. - Combinations of these drugs significantly increase risk.

Cognitive Disorder: Dementia: Types Of Dementia: Traumatic Brain Injury:

- Can cause dementia as a direct pathophysiological consequence of head trauma. - The degree and type of cognitive impairment and behavioral disturbance depend on the location and extent of the brain injury. - When it occurs as a single injury, the dementia is usually stable rather than progressive. - Repeated head injury (e.g., from boxing or football) may lead to progressive dementia.

Cognitive Disorder: Dementia: Types Of Dementia: HIV Infection:

- Can lead to dementia and other neurologic problems; these may result directly from invasion of nervous tissue by HIV or from other acquired immunodeficiency syndrome-related illnesses such as toxoplasmosis and cytomegalovirus. - This type of dementia can result in a wide variety of symptoms ranging from mild sensory impairment to gross memory and cognitive deficits to severe muscle dysfunction.

Cognitive Disorder: Dementia: Etiology:

- Causes vary, though the clinical picture is similar for most dementias. - Sometimes no definitive diagnosis can be made until completion of a postmortem examination. - Metabolic activity is decreased in the brains of clients with dementia; it is not known whether dementia causes decreased metabolic activity or if decreased metabolic activity results in dementia. - A genetic component has been identified for some dementias, such as Huntington disease. - An abnormal APOE gene is known to be linked with Alzheimer disease. - Other causes of dementia are related to infections such as human immunodeficiency virus (HIV) infection or Creutzfeldt-Jakob disease.

Cognitive Disorder: Delirium: Roles & Relationships:

- Clients are unlikely to fulfill their roles during the course of delirium. - Most regain their previous level of functioning, however, and have no long-standing problems with roles or relationships.

Cognitive Disorders: Dementia: Sensorium & Intellectual Processes:

- Clients lose intellectual function, which eventually involves the complete loss of their abilities. - Memory deficits are the initial and essential feature of dementia. - Dementia first affects recent and immediate memory and then eventually impairs the ability to recognize close family members and even oneself. - In mild and moderate dementia, clients may make up answers to fill in memory gaps (confabulation). - Agnosia is another hallmark of dementia. - Clients lose visual spatial relations, which is often evidenced by deterioration of the ability to write or draw simple objects. - Attention span and ability to concentrate are increasingly impaired until clients lose the ability to do either. - Clients are chronically confused about the environment, other people, and, eventually, themselves. Initially, they are disoriented to time in mild dementia, time and place in moderate dementia, and, finally, to self in the severe stage. - Hallucinations are a frequent problem. - Visual hallucinations are most common and generally unpleasant. - Clients are likely to believe the hallucination is reality.

Cognitive Disorder: Dementia: Intervention: Promoting Adequate Sleep & Proper Nutrition, Hygiene, Activity:

- Clients require assistance to meet basic physiological needs. - The nurse monitors food and fluid intake to ensure adequacy. - Clients may eat poorly because of limited appetite or distraction at mealtimes. - The nurse addresses this problem by providing foods clients like, sitting with clients at meals to provide cues to continue eating, having nutritious snacks available whenever clients are hungry, and minimizing noise and undue distraction at mealtimes. - Clients who have difficulty manipulating utensils may be unable to cut meat or other foods into bite-sized pieces. - The food should be cut up when it is prepared, not in front of clients, to deflect attention from their inability to do so. - Food that can be eaten without utensils, or finger foods such as sandwiches and fresh fruit, may be best. In contrast, clients may eat too much, even ingesting inedible items. - Providing low-calorie snacks such as carrot and celery sticks can satisfy the desire to chew and eat without unnecessary weight gain. - Enteral nutrition often becomes necessary when dementia is most severe, though not all families choose to use tube feedings. - Adequate intake of fluids and food is also necessary for proper elimination. - Clients may fail to respond to cues indicating constipation, so the nurse or caregiver monitors the client's bowel elimination patterns and intervenes with increased fluids and fiber or prompts as needed. - Urinary elimination can become a problem if clients do not respond to the urge to void or are incontinent. - Reminders to urinate may be helpful when clients are still continent but not initiating use of the bathroom. - Sanitary pads can address dribbling or stress incontinence; adult diapers, rather than indwelling catheters, are indicated for incontinence. - The nurse checks disposable pads and diapers frequently and changes soiled items promptly to avoid infection, skin irritation, and unpleasant odors. - It is also important to provide good hygiene to minimize these risks. - Balance between rest and activity is an essential component of the daily routine. - Mild physical activity such as walking promotes physical health but is not a cognitive challenge. - Daily physical activity also helps clients sleep at night. - The nurse provides rest periods so clients can conserve and regain energy, but extensive daytime napping may interfere with nighttime sleep. - The nurse encourages clients to engage in physical activity because they may not initiate such activities independently; many clients tend to become sedentary as cognitive abilities diminish. - Clients often are quite willing to participate in physical activities but cannot initiate, plan, or carry out those activities without assistance.

Cognitive Disorder: Delirium: Physiological & Self-Care Considerations:

- Clients with delirium most often experience disturbed sleep-wake cycles that may include difficulty falling asleep, daytime sleepiness, nighttime agitation, or even a complete reversal of the usual daytime waking/nighttime sleeping pattern. - At times, clients also ignore or fail to perceive internal body cues such as hunger, thirst, or the urge to urinate or defecate.

Cognitive Disorder: Delirium: General Appearance & Motor Behavior:

- Clients with delirium often have a disturbance of psychomotor behavior. - They may be restless and hyperactive, frequently picking at bed clothes or making sudden, uncoordinated attempts to get out of bed. - Conversely, clients may have slowed motor behavior, appearing sluggish and lethargic with little movement. - Speech may also be affected, becoming less coherent and more difficult to understand as delirium worsens. - Clients may perseverate on a single topic or detail, may be rambling and difficult to follow, or may have pressured speech that is rapid, forced, and usually louder than normal. - At times, clients may call out or scream, especially at night.

Cognitive Disorder: Delirium: Mood & Affect:

- Clients with delirium often have rapid and unpredictable mood shifts. - A wide range of emotional responses is possible, such as anxiety, fear, irritability, anger, euphoria, and apathy. - These mood shifts and emotions usually have nothing to do with the client's environment. - When clients are particularly fearful and feel threatened, they may become combative to defend themselves from perceived harm.

Cognitive Disorders: Dementia: Judgement & Insight:

- Clients with dementia have poor judgment in light of the cognitive impairment. - They underestimate risks and unrealistically appraise their abilities, which result in a high risk for injury. - Clients cannot evaluate situations for risks or danger. - For example, they may wander outside in the winter wearing only thin nightclothes and not consider this to be a risk. - Insight is limited. Initially, the client may be aware of problems with memory and cognition and may worry that he or she is "losing my mind." - Quite quickly, these concerns about the ability to function diminish, and clients have little or no awareness of the more serious deficits that have developed. - In this context, clients may accuse others of stealing possessions that the clients themselves have actually lost or forgotten.

Cognitive Disorders: Dementia: Physiological & Self-Care Considerations:

- Clients with dementia often experience disturbed sleep-wake cycles; they nap during the day and wander at night. - Some clients ignore internal cues such as hunger or thirst; others have little difficulty with eating and drinking until dementia is severe. - Clients may experience bladder and even bowel incontinence or have difficulty cleaning themselves after elimination. - They frequently neglect bathing and grooming. - Eventually, clients are likely to require complete care from someone else to meet these basic physiological needs.

Cognitive Disorders: Delirium: Treatment: Psychopharmacology:

- Clients with quiet, hypoactive delirium need no specific pharmacologic treatment aside from that indicated for the causative condition. - Many clients with delirium, however, show persistent or intermittent psychomotor agitation, psychosis, and/or insomnia that can interfere with effective treatment or pose a risk to safety. - Sedation to prevent inadvertent self-injury may be indicated. - An antipsychotic medication, such as haloperidol (Haldol), may be used in doses of 0.5 to 1 mg to decrease agitation and psychotic symptoms, as well as to facilitate sleep. - Haloperidol is useful in a variety of situations because it can be administered orally, intramuscularly (IM), or intravenously (IV). - Historically, short- or intermediate-acting benzodiazepines, such as lorazepam (Ativan), have been used, but benzodiazepines may worsen delirium, especially in the elderly. - Their use should be reserved for treatment of sedative-hypnotic withdrawal - Clients with impaired liver or kidney function could have difficulty metabolizing or excreting sedatives. - The exception is delirium induced by alcohol withdrawal, which is usually treated with benzodiazepines

Cognition:

- Cognition is the brain's ability to process, retain, and use information. - Cognitive abilities include reasoning, judgment, perception, attention, comprehension, and memory. - These cognitive abilities are essential for many important tasks, including making decisions, solving problems, interpreting the environment, and learning new information. - A cognitive disorder is a disruption or impairment in these higher level functions of the brain. - Cognitive disorders can have devastating effects on the ability to function in daily life. - They can cause people to forget the names of immediate family members, be unable to perform daily household tasks, and neglect personal hygiene.

Cognitive Disorder: Dementia: Moderate Dementia:

- Confusion is apparent, along with progressive memory loss. - The person no longer can perform complex tasks but remains oriented to person and place. - He or she still recognizes familiar people. - Toward the end of this stage, the person loses the ability to live independently and requires assistance because of disorientation to time and loss of information, such as address and telephone number. - The person may remain in the community if adequate caregiver support is available, but some people move to supervised living situations.

Cognitive Disorders: Dementia: Assessment: History:

- Considering the impairment of recent memory, clients may be unable to provide an accurate and thorough history of the onset of problems. - Interviews with family, friends, or caregivers may be necessary to obtain data.

Cognitive Disorders: Delirium: Etiology:

- Delirium almost always results from an identifiable physiological, metabolic, or cerebral disturbance or disease or from drug intoxication or withdrawal. - Often, delirium results from multiple causes and requires a careful and thorough physical examination and laboratory tests for identification.

Delirium Vs. Dementia: Mood:

- Delirium: Anxious, fearful if hallucinating; weeping, irritable - Dementia: Depressed and anxious in early stage, labile mood, restless pacing, angry outbursts in later stages

Delirium Vs. Dementia: Duration:

- Delirium: Brief (hours to days) - Dementia: Progressive deterioration

Delirium Vs. Dementia: Level Of Consciousness:

- Delirium: Impaired, fluctuates - Dementia: Not affected

Delirium Vs. Dementia:Speech:

- Delirium: May be slurred, rambling, pressured, irrelevant - Dementia: Normal in early stage, progressive aphasia in later stage

Delirium Vs. Dementia: Onset:

- Delirium: Rapid - Dementia: Gradual and insidious

Delirium Vs. Dementia: Memory:

- Delirium: Short-term memory impaired - Dementia: Short- and then long-term memory impaired, eventually destroyed

Delirium Vs. Dementia: Thought Processes:

- Delirium: Temporarily disorganized - Dementia: Impaired thinking, eventual loss of thinking abilities

Delirium Vs. Dementia: Perception:

- Delirium: Visual or tactile hallucinations, delusions - Dementia: Often absent, but can have paranoia, hallucinations, illusions

Dementia Vs. Delirium:

- Dementia must be distinguished from delirium; if the two diagnoses coexist, the symptoms of dementia remain even when the delirium has cleared. -

Cognitive Disorders: Dementia: Roles & Relationships:

- Dementia profoundly affects the client's roles and relationships. - If the client is still employed, work performance suffers, even in the mild stage of dementia, to the point that work is no longer possible given the memory and cognitive deficits. - Roles as spouse, partner, or parent deteriorate as clients lose the ability to perform even routine tasks or recognize familiar people. - Eventually, clients cannot meet even the most basic needs. - Inability to participate in meaningful conversation or social events severely limits relationships. - Clients quickly become confined to the house or apartment because they are unable to venture outside unassisted. - Close family members often begin to assume caregiver roles; this can change previously established relationships. - Grown children of clients with dementia experience role reversal; that is, they care for parents who once cared for them. - Spouses or partners may feel as if they have lost the previous relationship and now are in the role of custodian.

Cognitive Disorders: Dementia: General Appearance & Motor Behavior:

- Dementia progressively impairs the ability to carry on meaningful conversation. - Clients display aphasia when they cannot name familiar objects or people. - Conversation becomes repetitive because they often perseverate on one idea. - Eventually, speech may become slurred, followed by a total loss of language function. - The initial finding with regard to motor behavior is the loss of ability to perform familiar tasks (apraxia), such as dressing or combing one's hair, though actual motor abilities are intact. - Clients cannot imitate the task when others demonstrate it for them. - In the severe stage, clients may experience a gait disturbance that makes unassisted ambulation unsafe, if not impossible. - Some clients with dementia show uninhibited behavior, including making inappropriate jokes, neglecting personal hygiene, showing undue familiarity with strangers, or disregarding social conventions for acceptable behavior. - This can include the use of profanity or making disparaging remarks about others when clients have never displayed these behaviors before.

Executive Functioning:

- Disturbance in executive functioning, which is the ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior

Cognitive Disorder: Delirium: Community-Based Care:

- Even when the cause of delirium is identified and treated, clients may not regain all cognitive functions, or problems with confusion may persist. - Because delirium and dementia frequently occur together, clients may have dementia. - A thorough medical evaluation can confirm dementia, and appropriate treatment and care can be initiated (see the section "Dementia"). - When delirium has cleared and any other diagnoses have been eliminated, it may be necessary for the nurse or other health care professionals to initiate referrals to home health, visiting nurses, or a rehabilitation program if clients continue to experience cognitive problems. - Various community programs provide such care, including adult day care or residential care. - Clients who have ongoing cognitive deficits after an episode of delirium may have difficulties similar to those of clients with head injuries or mild dementia. - Clients and family members or caregivers might benefit from support groups to help them deal with the changes in personality and remaining cognitive or motor deficits.

Cognitive Disorder: Dementia: Mild Dementia:

- Forgetfulness is the hallmark of beginning, mild dementia. - It exceeds the normal, occasional forgetfulness experienced as part of the aging process. - The person has difficulty finding words, frequently loses objects, and begins to experience anxiety about these losses. - Occupational and social settings are less enjoyable, and the person may avoid them. - Most people remain in the community during this stage.

Cognitive Disorder: Dementia: Types Of Dementia: Vascular Dementia:

- Has symptoms similar to those of Alzheimer disease, but onset is typically abrupt, followed by rapid changes in functioning; a plateau, or leveling-off period; more abrupt changes; another leveling-off period; and so on. - Computed tomography or magnetic resonance imaging usually shows multiple vascular lesions of the cerebral cortex and subcortical structures resulting from the decreased blood supply to the brain.

Most Common Causes Of Delirium: Physiological Or Metabolic:

- Hypoxemia; electrolyte disturbances; renal or hepatic failure; hypoglycemia or hyperglycemia; dehydration; sleep deprivation; thyroid or glucocorticoid disturbances; thiamine or vitamin B12 deficiency; vitamin C, niacin, or protein deficiency; cardiovascular shock; brain tumor; head injury; and exposure to gasoline, paint solvents, insecticides, and related substances

Cognitive Disorder: Dementia: Intervention: Promoting Interaction & Involvement:

- In a psychosocial model of dementia care, the nurse or caregiver plans activities that reinforce the client's identity and keep him or her engaged and involved in the business of living. - The nurse or caregiver tailors these activities to the client's interests and abilities. - They should not be routine group activities that "everyone is supposed to do." - For example, a client with an interest in history may enjoy documentary programs on television; a client who likes music may enjoy singing. - Clients often need the involvement of another person to sustain attention in the activity and to enjoy it more fully. - Those who have long periods without anything to engage their interest are more likely to become restless and agitated. - Clients engaged in activities are more likely to stay calm. - A wide variety of activities have proven beneficial for clients with dementia. - Music, dancing, pet- or animal-assisted therapy, aromatherapy, and multisensory stimulation are examples of activities that can be explored to maximize the client's involvement with the environment and enhance the quality of his or her life

Cognitive Disorders: Dementia: Self-Concept:

- Initially, clients may be angry or frustrated with themselves for losing objects or forgetting important things. - Some clients express sadness at their bodies for getting old and at the loss of functioning. - Soon, though, clients lose that awareness of self, which gradually deteriorates until they can look in a mirror and fail to recognize their own reflections.

Cognitive Disorders: Dementia: Mood & Affect:

- Initially, clients with dementia experience anxiety and fear over the beginning losses of memory and cognitive functions. - Nevertheless, they may not express these feelings to anyone. - Mood becomes more labile over time and may shift rapidly and drastically for no apparent reason. - Emotional outbursts are common and usually pass quickly. - Clients may display anger and hostility, sometimes toward other people. - They begin to demonstrate catastrophic emotional reactions in response to environmental changes that clients may not perceive or understand accurately or when they cannot respond adaptively. - These catastrophic reactions may include verbal or physical aggression, wandering at night, agitation, or other behaviors that seem to indicate a loss of personal control. - Clients may display a pattern of withdrawal from the world they no longer understand. - They are lethargic, look apathetic, and pay little attention to the environment or the people in it. - They appear to lose all emotional affect and seem dazed and listless.

Cognitive Disorders: Dementia: Thought Process & Content:

- Initially, the ability to think abstractly is impaired, resulting in loss of the ability to plan, sequence, monitor, initiate, or stop complex behavior. - The client loses the ability to solve problems or to take action in new situations because he or she cannot think about what to do. - The ability to generalize knowledge from one situation to another is lost because the client cannot recognize similarities or differences in situations. - These problems with cognition make it impossible for the employed client to continue working. - The client's ability to perform tasks such as planning activities, budgeting, or planning meals is lost. - As the dementia progresses, delusions of persecution are common. - The client may accuse others of stealing objects he or she has lost or may believe he or she is being cheated or pursued.

Most Common Causes Of Delirium: Drug-Related:

- Intoxication: Anticholinergics, lithium, alcohol, sedatives, and hypnotics - Withdrawal: Alcohol, sedatives, and hypnotics - Reactions to anesthesia, prescription medication, or illicit (street) drugs

Cognitive Disorder: Dementia: Intervention: Promoting Interaction & Involvement: Time Away:

- Involves leaving clients for a short period and then returning to them to reengage in interaction. - For example, the client may get angry and yell at the nurse for no discernible reason. - The nurse can leave the client for about 5 or 10 minutes and then return without referring to the previous outburst. - The client may have little or no memory of the incident and may be pleased to see the nurse on his or her return.

Cognitive Disorder: Dementia: Intervention: Promoting Interaction & Involvement: Distraction:

- Involves shifting the client's attention and energy to a more neutral topic. - For example, the client may display a catastrophic reaction to the current situation, such as jumping up from dinner and saying, "My food tastes like poison!" - The nurse might intervene with distraction by saying, "Can you come to the kitchen with me and find something you'd like to eat?" or "You can leave that food. Can you come and help me find a good program on television?" (redirection/distraction) - Clients usually calm down when the nurse directs their attention away from the triggering situation.

Cognitive Disorder: Dementia: Types Of Dementia: Lewy Body Dementia:

- Is a disorder that involves progressive cognitive impairment and extensive neuropsychiatric symptoms as well as motor symptoms. - Delusions and visual hallucinations are common. - Functional impairments may initially be more pronounced than cognitive deficits. - Several risk genes have been identified, and it can occur in families, though that is less common than no family history

Cognitive Disorder: Dementia: Types Of Dementia: Alzheimer Disease:

- Is a progressive brain disorder that has a gradual onset but causes an increasing decline in functioning, including loss of speech, loss of motor function, and profound personality and behavioral changes such as paranoia, delusions, hallucinations, inattention to hygiene, and belligerence. It is evidenced by atrophy of cerebral neurons, senile plaque deposits, and enlargement of the third and fourth ventricles of the brain. - Risk for Alzheimer disease increases with age, and average duration from onset of symptoms to death is 8 to 10 years. - Research has identified genetic links to both early- and late-onset Alzheimer disease

Cognitive Disorder: Dementia: Types Of Dementia: Parkinson Disease:

- Is a slowly progressive neurologic condition characterized by tremor, rigidity, bradykinesia, and postural instability. - It results from loss of neurons of the basal ganglia. - Dementia has been reported in approximately 25% (mild NCD) to as many as 75% (major NCD) of people with Parkinson disease and is characterized by cognitive and motor slowing, impaired memory, and impaired executive functioning.

Cognitive Disorders: Delirium:

- Is a syndrome that involves a disturbance of consciousness accompanied by a change in cognition. - Delirium usually develops over a short period, sometimes a matter of hours, and fluctuates, or changes, throughout the course of the day. - Clients with delirium have difficulty paying attention, are easily distracted and disoriented, and may have sensory disturbances such as illusions, misinterpretations, or hallucinations. - An electrical cord on the floor may appear to them as a snake (illusion). - They may mistake the banging of a laundry cart in the hallway for a gunshot (misinterpretation). - They may see "angels" hovering above when nothing is there (hallucination). - At times, they also experience disturbances in the sleep-wake cycle, changes in psychomotor activity, and emotional problems such as anxiety, fear, irritability, euphoria, or apathy. - Elderly patients are the group most frequently diagnosed with delirium. - Between 14% and 24% of people admitted to the hospital for general medical conditions are delirious, which may worsen in the hospital. - Delirium is reported in 10% to 15% of general surgical patients, 30% of open heart surgery patients, and more than 50% of patients treated for fractured hips. - Delirium develops in 80% of terminally ill patients. - In many cases, the causes of delirium are multiple stressors, such as trauma to the central nervous system (CNS), drug toxicity or withdrawal, and metabolic disturbances related to organ failure - Risk factors for delirium include increased severity of physical illness, older age, hearing impairment, decreased food and fluid intake, medications, and baseline cognitive impairment such as that seen in dementia. - Children may be more susceptible to delirium, especially that related to a febrile illness or certain medications such as anticholinergics.

Cognitive Disorder: Dementia: Types Of Dementia: Huntington Disease:

- Is an inherited, dominant gene disease that primarily involves cerebral atrophy, demyelination, and enlargement of the brain ventricles. Initially, there are choreiform movements that are continuous during waking hours and involve facial contortions, twisting, turning, and tongue movements. - Personality changes are the initial psychosocial manifestations followed by memory loss, decreased intellectual functioning, and other signs of dementia. - The disease begins in the late 30s or early 40s and may last 10 to 20 years or more before death.

Cognitive Disorder: Dementia: Intervention: Providing Emotional Support: Supportive Touch:

- Is effective with many clients. - Touch can provide reassurance and convey caring when words may not be understood. - Holding the hand of the client who is tearful and sad and tucking the client into bed at night are examples of ways to use supportive touch. - As with any use of touch, the nurse must evaluate each client's response. - Clients who respond positively will smile or move closer toward the nurse. - Those who are threatened by physical touch will look frightened or pull away from the nurse, especially if the touch is sudden or unexpected or if the client misperceives the nurse's intent.

Cognitive Disorder: Delirium: Judgement & Insight:

- Judgment is impaired. - Clients often cannot perceive potentially harmful situations or act in their own best interests. - For example, they may try repeatedly to pull out IV tubing or urinary catheters; this causes pain and interferes with necessary treatment. - Insight depends on the severity of the delirium. - Clients with mild delirium may recognize that they are confused, are receiving treatment, and will likely improve. - Those with severe delirium may have no insight into the situation.

Cognitive Disorder: Delirium: Promoting Client Safety:

- Maintaining the client's safety is the priority focus of nursing interventions. - Medications should be used judiciously because sedatives may worsen confusion and increase the risk for falls or other injuries. - The nurse teaches clients to request assistance for activities such as getting out of bed or going to the bathroom. - If clients cannot request assistance, they require close supervision to prevent them from attempting activities they cannot perform safely alone. - The nurse responds promptly to calls from clients for assistance and checks clients at frequent intervals. - If a client is agitated or pulling at IV lines or catheters, physical restraints may be necessary. - Use of restraints, however, may increase the client's fears or feelings of being threatened, so restraints are a last resort. - The nurse first tries other strategies such as having a family member stay with the client to reassure him or her.

Cognitive Disorders: Dementia: Data Analysis:

- Many nursing diagnoses can be appropriate because the effects of dementia on clients are profound; the disease touches virtually every part of their lives. Commonly used nursing diagnoses include: •Risk for injury •Disturbed sleep pattern •Risk for deficient fluid volume •Risk for imbalanced nutrition: Less than body requirements •Chronic confusion •Impaired environmental interpretation syndrome •Impaired memory •Impaired social interaction •Impaired verbal communication •Ineffective role performance - In addition, the nursing diagnoses of disturbed thought processes and disturbed sensory perception would be appropriate for a client with psychotic symptoms. - Multiple nursing diagnoses related to physiological status may also be indicated based on the nurse's assessment, such as alterations in nutrition, hydration, elimination, physical mobility, and activity tolerance

Cognitive Disorder: Dementia: Intervention: Promoting Interaction & Involvement: Going Along:

- Means providing emotional reassurance to clients without correcting their misperception or delusion. - The nurse does not engage in delusional ideas or reinforce them, but he or she does not deny or confront their existence. - For example, a client is fretful, repeatedly saying, "I'm so worried about the children. I hope they're OK," and speaking as though his adult children were small and needed protection. - The nurse could reassure the client by saying, There's no need to worry; the children are just fine (going along), - Which is likely to calm the client. - The nurse has responded effectively to the client's worry without addressing the reality of the client's concern. - Going along is a specific intervention for clients with dementia and should not be used with those experiencing delusions whose conditions are expected to improve. - It is important to remember that different interventions are indicated for dealing with psychotic symptoms, depending on the cause. - People with dementia cannot regain their cognitive functions, so techniques like redirection or going along with the person are indicated. - However, when psychotic symptoms are due to a treatable illness, such as schizophrenia, the nurse should not say or do anything to reinforce the notion that the delusions or hallucinations are real in any way. - This would only interfere with or impede the client's progress. - The nurse can use reframing techniques to offer clients different points of view or explanations for situations or events. - Because of their perceptual difficulties and confusion, clients frequently interpret environmental stimuli as threatening. - Loud noises often frighten and agitate them - For example, one client may interpret another's yelling as a direct personal threat. - The nurse can provide an alternative explanation such as That lady has many family problems, and she yells sometimes because she's frustrated. (reframing) - Alternative explanations often reassure clients with dementia and help them become less frightened and agitated.

Cognitive Disorder: Dementia: Types Of Dementia: Frontotemporal Lobar Degeneration:

- Originally called Pick disease - Is a degenerative brain disease that particularly affects the frontal and temporal lobes and results in a clinical picture similar to that of Alzheimer disease. - Early signs include personality changes, loss of social skills and inhibitions, emotional blunting, and language abnormalities. - Onset is most commonly 50 to 60 years of age; death occurs in 2 to 5 years. - There is a strong genetic component, and it tends to run in families

Cognitive Disorder: Dementia: Severe Dementia:

- Personality and emotional changes occur. - The person may be delusional, wander at night, forget the names of his or her spouse and children, and require assistance with ADLs. - Most people live in nursing facilities when they reach this stage, unless extraordinary community support is available.

Cognitive Disorder: Dementia: Intervention: Reframing:

- Psychosocial models for care of clients with dementia are based on the approach that each client is a unique person and remains so, even as the disease's progression blocks the client's ability to demonstrate those unique characteristics. Interventions are rooted in the belief that clients with dementia have personal strengths. T - hey focus on demonstrating caring, keeping clients involved by relating to the environment and other people, and validating feelings and dignity of clients by being responsive to them, offering choices, and reframing (offering alternative points of view to explain events). - This is in contrast to medical models of care that focus on progressive loss of function and identity. - Nurses can use the following interventions in any setting for clients with dementia. - Education for family members caring for clients at home and for professional caregivers in residential or skilled facilities is an essential component of providing safe and supportive care. T

Cognitive Disorders: Dementia:

- Refers to a disease process marked by progressive cognitive impairment with no change in the level of consciousness. - It involves multiple cognitive deficits, initially, memory impairment, and later, the following cognitive disturbances may be seen - These cognitive deficits must be sufficiently severe to impair social or occupational functioning and must represent a decline from previous functioning. - In the DSM-5, mild NCD refers to a mild cognitive decline, and a modest impairment of performance that doesn't prevent independent living but may require some accommodation or assistance. - A major NCD refers to a significant cognitive decline and a substantial impairment in performance that interferes with activities of daily independent living. - As people progress from mild to major NCD, it is not always easy for the diagnostician to decide which one to u - Memory impairment is the prominent early sign of dementia. - Clients have difficulty learning new material and forget previously learned material. - Initially, recent memory is impaired—for example, forgetting where certain objects were placed or that food is cooking on the stove. - In later stages, dementia affects remote memory; clients forget the names of adult children, their lifelong occupations, and even their names. - Clients with dementia may also underestimate the risks associated with activities or overestimate their ability to function in certain situations. - For example, while driving, clients may cut in front of other drivers, sideswipe parked cars, or fail to slow down when they should.

Cognitive Disorder: Dementia: Mental Health Promotion:

- Research continues to identify risk factors for dementia. - People with elevated levels of plasma homocysteine are at increased risk for dementia. - As levels of plasma homocysteine increase, so does the risk for dementia. - Because folate, vitamin B12, and betaine are known to reduce plasma homocysteine levels, potential therapeutic strategies using these substances may modify or diminish the risk for dementia. - Clinical trials are currently in progress to see if lowering homocysteine levels actually decreases the risk for dementia and whether taking high supplemental doses of B vitamins slows the progression of Alzheimer disease. - People who regularly participate in brain-stimulating activities, such as reading books and newspapers or doing crossword puzzles, are less likely to develop Alzheimer disease than those who do not. - Engaging in leisure-time physical activity during midlife and having a large social network are associated with a decreased risk for Alzheimer disease in later life. - In addition, healthy eating habits, physical activity, and minimizing health risks help decrease or delay cognitive decline.

Cognitive Disorder: Dementia: Intervention: Promoting Client's Safety:

- Safety considerations involve protecting against injury, meeting physiological needs, and managing risks posed by the environment, including internal stimuli such as delusions and hallucinations. - Clients cannot accurately appraise the environment and their abilities; therefore, they do not exercise normal caution in daily life. - For example, the client living at home may forget food cooking on the stove, and the client living in a residential care setting may leave for a walk in cold weather without a coat and gloves. - Assistance or supervision that is as unobtrusive as possible protects clients from injury while preserving their dignity. - A family member might say, "I'll sit in the kitchen and talk to you while you make lunch" (suggesting collaboration) rather than "You can't cook by yourself because you might set the house on fire." - In this way, the nurse or caregiver supports the client's desire and ability to engage in certain tasks while providing protection from injury. - Clients with dementia may believe that their physical safety is jeopardized; they may feel threatened or suspicious and paranoid. - These feelings can lead to agitated or erratic behavior that compromises safety. - Avoiding direct confrontation of the client's fears is important. - Clients with dementia may struggle with fears and suspicion throughout their illness. - Triggers of suspicion include strangers, changes in the daily routine, or impaired memory. - The nurse must discover and address these environmental triggers rather than confront the paranoid ideas. - For example, a client reports that his belongings have been stolen. - The nurse might say, Let's go look in your room and see what's there. - and help the client to locate the misplaced or hidden items (suggesting collaboration). - If the client is in a room with other people and says, "They're here to take me away!" the nurse might say, Those people are here visiting with someone else. Let's go for a walk and let them visit. (presenting reality/distraction) - The nurse then can take the client to a quieter and less stimulating place, which moves the client away from the environmental trigger.

Cognitive Disorder: Dementia: Related Disorders: Korsakoff Syndrome:

- Substance- or medication-induced mild or major NCD is characterized by neurocognitive impairment that persists beyond intoxication or withdrawal. - The deficits may stabilize or even show some improvement after a sustained period of abstinence. - Long-term use of alcohol that results in dementia is called Korsakoff syndrome or dementia. - It was previously known as an amnestic disorder since amnesia and confabulation are common - Mild or major NCD due to another medical condition is caused by diseases such as brain tumor, brain metastasis, subdural hematoma, arteritis, renal or hepatic failure, seizures, or multiple sclerosis. - Mild or major NCD due to multiple etiologies is caused by more than one distinct cause of those discussed previously. - Unspecified NCD is characterized by neurocognitive symptoms that cause the person distress or impairment, but do not meet the criteria for any other NCD. - Neurocognitive deficits due to stroke, head injuries, carbon monoxide poisoning, or brain damage from other medical causes were previously classified as amnestic disorders. - An estimated 5 million people in the United States have moderate-to-severe dementia from various causes. - It is estimated that there are 4.6 million new cases each year worldwide. - Prevalence rises with age; estimated prevalence of moderate-to-severe dementia in people older than 65 years is about 5%, and 20% to 40% of the general population older than 85 years have dementia. - Predictions are that by 2050, there will be 18 million Americans with dementia and 114 million people with dementia worldwide - Dementia of the Alzheimer type is the most common type in North America (60% of all dementias), Scandinavia, and Europe; vascular dementia is more prevalent in Russia and Japan. - Dementia of the Alzheimer type is more common in women; vascular dementia is more common in men.

Most Common Causes Of Delirium: Infection:

- Systemic: Sepsis, urinary tract infection, pneumonia - Cerebral: Meningitis, encephalitis, HIV, syphilis

Neurocognitive Disorders (NCDs):

- The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) previously categorized adult cognitive disorders as dementia, delirium, and amnestic disorders. - Those categories have been reconceptualized in the DSM-5 as neurocognitive disorders (NCDs). - This now includes delirium, major NCD, mild NCD, and their subtypes by etiology. - The term dementia is still used, even in the DSM-5, and also in the literature and by practitioners.

Cognitive Disorders: Dementia: Assessment:

- The assessment process may seem confusing and complicated to clients with dementia. - They may not know or may forget the purpose of the interview. - The nurse provides simple explanations as often as clients need them, such as "I'm asking these questions so the staff can see how your health is." - Clients may become confused or tire easily, so frequent breaks in the interview may be needed. - It helps to ask simple rather than compound questions and to allow clients ample time to answer. - A mental status examination can provide information about the client's cognitive abilities, such as memory, concentration, and abstract information processing. - Typically, the client is asked to interpret the meaning of a proverb, perform subtraction of figures without paper and pencil, recall the names of objects, make a complete sentence, and copy two intersecting pentagons. - Although this does not replace a thorough assessment, it gives a cursory evaluation of the client's cognitive abilities. - It is important to remember that people with severe depression or psychosis may also be unable to perform some of these cognitive tasks correctly.

Cognitive Disorder: Delirium: Managing Client's Confusion:

- The nurse approaches these clients calmly and speaks in a clear low voice. - It is important to give realistic reassurance to clients, such as "I know things are upsetting and confusing right now, but your confusion should clear as you get better." (validating/giving information) - Facing clients while speaking helps capture their attention. - The nurse provides explanations that clients can comprehend, avoiding lengthy or too detailed discussions. - The nurse phrases questions or provides directions to clients in short, simple sentences, allowing adequate time for clients to grasp the content or respond to a question. - He or she permits clients to make decisions as they are able to and takes care not to overwhelm or frustrate them. - The nurse provides orienting cues when talking with clients, such as calling them by name and referring to the time of day or expected activity. - For example, the nurse might say, "Good morning, Mrs. Jones. I see you are awake and look ready for breakfast." (giving information) - Reminding the client of the nurse's name and role repeatedly may be necessary, such as "My name is Sheila, and I'm your nurse today. I'm here now to walk in the hall with you." (reality orientation) - Orienting objects such as a calendar and clock in the client's room are useful. - Often, the use of touch reassures clients and provides contact with reality. - It is important to evaluate each client's response to touch rather than to assume all clients welcome it. - A client who smiles or draws closer to the nurse when touched is responding positively. - The fearful client may perceive touch as threatening rather than comforting and startle or draw away. - Clients with delirium can experience sensory overload, which means more stimulation is coming into the brain than they can handle. - Reducing environmental stimulation is helpful because these clients are easily distracted and overstimulated. - Minimizing environmental noises, including television or radio, should calm them. - It is also important to monitor response to visitors. - Too many visitors or more than one person talking at once may increase the client's confusion. - The nurse can explain to visitors that the client will best tolerate quiet talking with one person at a time. - The client's room should be well lit to minimize environmental misperceptions. - When clients experience illusions or misperceptions, the nurse corrects them matter-of-factly. - It is important to validate the client's feelings of anxiety or fear generated by the misperception, but not to reinforce that misperception. - For example, a client hears a loud noise in the hall and asks the nurse, "Was that an explosion?" - The nurse might respond, "No, that was a cart banging in the hall. It was really loud, wasn't it? It startled me a little when I heard it." (presenting reality/validating feelings)

Cognitive Disorder: Delirium: Promoting Sleep & Proper Nutrition:

- The nurse monitors the client's sleep and elimination patterns and food and fluid intake. - Clients may require prompting or assistance to eat and drink adequate food and fluids. It may be helpful to sit with clients at meals or to frequently offer fluids. - Family members also may be able to help clients improve their intake. - Assisting clients to the bathroom periodically may be necessary to promote elimination if clients do not make these requests independently. - Promoting a balance of rest and sleep is important if clients are experiencing a disturbed sleep pattern. - Discouraging or limiting daytime napping may improve ability to sleep at night. - It is also important for clients to have some exercise during the day to promote nighttime sleep. - Activities could include sitting in a chair, walking in the hall, or engaging in diversional activities (as possible).

Cognitive Disorder: Delirium: Sensorium & Intellectual Processes:

- The primary and often initial sign of delirium is an altered level of consciousness that is seldom stable and usually fluctuates throughout the day. - Clients are usually oriented to people but frequently disoriented to time and place. - They demonstrate decreased awareness of the environment or situation and instead may focus on irrelevant stimuli such as the color of the bedspread or the room. - Noises, people, or sensory misperceptions easily distract them. - Clients cannot focus, sustain, or shift attention effectively, and there is impaired recent and immediate memory. - This means the nurse may have to ask questions or provide directions repeatedly. - Even then, clients may be unable to do what is requested. - Clients frequently experience misinterpretations, illusions, and hallucinations. - Both misperceptions and illusions are based on some actual stimuli in the environment; clients may hear a door slam and interpret it as a gunshot or see the nurse reach for an IV bag and believe the nurse is about to strike them. - Examples of common illusions include clients believing that IV tubing or an electrical cord is a snake and mistaking the nurse for a family member. - Hallucinations are most often visual; clients "see" things for which there is no stimulus in reality. - When more lucid, some clients are aware that they are experiencing sensory misperceptions. - Others, however, actually believe their misinterpretations are correct and cannot be convinced otherwise.

Cognitive Disorders: Delirium: Treatment:

- The primary treatment for delirium is to identify and treat any causal or contributing medical conditions. - Delirium is almost always a transient condition that clears with successful treatment of the underlying cause. - Nevertheless, some causes such as head injury or encephalitis may leave clients with cognitive, behavioral, or emotional impairments even after the underlying cause resolves. - People who have had delirium are at higher risk for future episodes.

Cognitive Disorder: Dementia: Intervention: Providing Emotional Support:

- The therapeutic relationship between client and nurse involves "empathic caring," which includes being kind, respectful, calm, and reassuring and paying attention to the client. - Nurses use these same qualities with many different clients in various settings. - In most situations, clients give positive feedback to the nurse or caregiver, but clients with dementia often seem to ignore the nurse's efforts and may even respond with negative behavior such as anger or suspicion. - This makes it more difficult for the nurse or caregiver to sustain caring behavior. - Nevertheless, nurses and caregivers must maintain all the qualities of the therapeutic relationship even when clients do not seem to respond. - Because of their disorientation and memory loss, clients with dementia often become anxious and require much patience and reassurance. - The nurse can convey reassurance by approaching the client in a calm, supportive manner, as if nurse and client are a team—a "we can do it together" approach. - The nurse reassures the client that he or she knows what is happening and can take care of things when the client is confused and cannot do so. - For example, if the client is confused about getting dressed, the nurse might say, I'll be glad to help you with that shirt. I'll hold it for you while you put your arms in the sleeves. (offering self/suggesting collaboration)

Cognitive Disorder: Dementia: Treatment & Prognosis: Medications: Cholinesterase Inhibitors:

- This has led to attempts at replenishment therapy with acetylcholine precursors, cholinergic agonists, and cholinesterase inhibitors. - Donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl, Razadyne, Nivalin) are cholinesterase inhibitors and have shown modest therapeutic effects and temporarily slow the progress of dementia - They have no effect, however, on the overall course of the disease. - Tacrine (Cognex) is also a cholinesterase inhibitor; however, it elevates liver enzymes in about 50% of clients using it. - Lab tests to assess liver function are necessary every 1 to 2 weeks; therefore, tacrine is rarely prescribed. Memantine (Namenda) is an NMDA receptor antagonist that can slow the progression of Alzheimer in the moderate or severe stages. - Namzaric (memantine and donepezil) is a newer combination of two other medications, thereby having the actions of both cholinesterase inhibition and NMDA receptor antagonist - Clients with dementia demonstrate a broad range of behaviors that can be treated symptomatically. - Doses of medications are one-half to two-thirds lower than usually prescribed.

Cognitive Disorder: Dementia: Evaluation:

- Treatment outcomes change constantly as the disease progresses. - For example, in the early stage of dementia, maintaining independence may mean that the client dresses with minimal assistance. - Later, the same client may keep some independence by selecting what foods to eat. - In the late stage, the client may maintain independence by wearing his or her own clothing rather than an institutional nightgown or pajamas. - The nurse must assess clients for changes as they occur and revise outcomes and interventions as needed. - When a client is cared for at home, this includes providing ongoing education to family members and caregivers while supporting them as the client's condition worsens. - See the sections that follow on the role of the caregiver and community-based care.

Cognitive Disorders: Dementia: Outcome Identification:

- Treatment outcomes for clients with progressive dementia do not involve regaining or maintaining abilities to function. - In fact, the nurse must reassess overall health status and revise treatment outcomes periodically as the client's condition changes. - Outcomes and nursing care that focus on the client's medical condition or deficits are common. - Current literature proposes a focus on psychosocial care that maximizes the client's strengths and abilities for as long as possible. - Psychosocial care involves maintaining the client's independence as long as possible, validating the client's feelings, keeping the client involved in the environment, and dealing with behavioral disruptions respectfully. Treatment outcomes for a client with dementia may include: •The client will be free of injury. •The client will maintain an adequate balance of activity and rest, nutrition, hydration, and elimination. •The client will function as independently as possible given his or her limitations. •The client will feel respected and supported. •The client will remain involved in his or her surroundings. •The client will interact with others in the environment.

Cognitive Disorder: Delirium: Evaluation:

- Usually, successful treatment of the underlying causes of delirium returns clients to their previous levels of functioning. - Clients and caregivers or family must understand what health care practices are necessary to avoid a recurrence. - This may involve monitoring a chronic health condition, using medications carefully, or abstaining from alcohol or other drugs.

Cognitive Disorder: Dementia: Treatment & Prognosis:

- Whenever possible, the underlying cause of dementia is identified so that treatment can be instituted -. For example, the progress of vascular dementia, the second most common type, may be halted with appropriate treatment of the underlying vascular condition (e.g., changes in diet, exercise, control of hypertension, or diabetes). - Improvement of cerebral blood flow may arrest the progress of vascular dementia in some people. - The prognosis for the progressive types of dementia may vary as described earlier, but all prognoses involve progressive deterioration of physical and mental abilities until death. - Typically, in the later stages, clients have minimal cognitive and motor function, are totally dependent on caregivers, and are unaware of their surroundings or people in the environment. - They may be totally uncommunicative or make unintelligible sounds or attempts to verbalize. - For degenerative dementias, no direct therapies have been found to reverse or retard the fundamental pathophysiological processes. - Levels of numerous neurotransmitters such as acetylcholine, dopamine, norepinephrine, and serotonin are decreased in dementia.

Aphasia:

- Which is deterioration of language function - Aphasia usually begins with the inability to name familiar objects or people and then progresses to speech that becomes vague or empty with excessive use of terms such as it or thing. Clients may exhibit echolalia (echoing what is heard) or palilalia (repeating words or sounds over and over).

Apraxia:

- Which is impaired ability to execute motor functions despite intact motor abilities - Apraxia may cause clients to lose the ability to perform routine self-care activities such as dressing or cooking.

Agnosia:

- Which is inability to recognize or name objects despite intact sensory abilities - Agnosia is frustrating for clients; they may look at a table and chair but are unable to name them. - Disturbances in executive functioning are evident as clients lose the ability to learn new material, solve problems, or carry out daily activities such as meal planning or budgeting.

Cognitive Disorder: Delirium: Other Medical Treatment:

- While the underlying causes of delirium are being treated, clients may also need other supportive physical measures. - Adequate nutritious food and fluid intake speed recovery. - IV fluids or even total parenteral nutrition may be necessary if a client's physical condition has deteriorated and he or she cannot eat and drink. - If a client becomes agitated and threatens to dislodge IV tubing or catheters, physical restraints may be necessary so that needed medical treatments can continue. - Restraints are used only when necessary and stay in place no longer than warranted because they may increase the client's agitation.

Cognitive Disorders: Self-Awareness Issues:

- Working with and caring for clients with dementia can be exhausting and frustrating for both nurse and caregiver. - Teaching is a fundamental role for nurses, but teaching clients who have dementia can be especially challenging and frustrating. - These clients do not retain explanations or instructions, so the nurse must repeat the same things continually. - The nurse must be careful not to lose patience and not to give up on these clients. - The nurse may begin to feel that repeating instructions or explanations does no good because clients do not understand or remember them. - Discussing these frustrations with others can help the nurse avoid conveying negative feelings to clients and families or experiencing professional and personal burnout. - The nurse may get little or no positive response or feedback from clients with dementia. - It can be difficult to deal with feelings about caring for people who will never "get better and go home." - As dementia progresses, clients may seem not to hear or respond to anything the nurse does. - It is sad and frustrating for the nurse to see clients decline and eventually lose their abilities to manage basic self-care activities and to interact with others. - Remaining positive and supportive to clients and families can be difficult when the outcome is so bleak. - In addition, the progressive decline may last months or years, which adds to the frustration and sadness. - The nurse may need to deal with personal feelings of depression and grief as the dementia progresses; he or she can do so by discussing the situation with colleagues or even a counselor.

A client makes up answers to fill in memory gaps. The nurse identifies this as which of the following? A. Echolalia B. Palilalia C. Aphasia D. Confabulation

D. Confabulation - Rationale: Confabulation is the making up of answers to fill in gaps in the memory. o Echolalia is echoing or repeating what is heard; palilalia is repeating words or sounds over and over. Aphasia refers to a deterioration in language function.

Is the following statement true or false? A client with dementia experiences changes in his or her level of consciousness.

False - Rationale: Clients with dementia do not typically experience altered levels of consciousness but do exhibit multiple cognitive deficits along with aphasia, apraxia, agnosia, or a disturbance in executive functioning.

Cognitive Disorder: Delirium: Data Analysis:

The primary nursing diagnoses for clients with delirium are: •Risk for injury •Acute confusion Additional diagnoses that are commonly selected based on client assessment include: •Disturbed sensory perception •Disturbed thought processes •Disturbed sleep pattern •Risk for deficient fluid volume •Risk for imbalanced nutrition: Less than body requirements

Cognitive Disorder: Delirium: Outcome Identification:

Treatment outcomes for the client with delirium may include: •The client will be free of injury. •The client will demonstrate increased orientation and reality contact. •The client will maintain an adequate balance of activity and rest. •The client will maintain adequate nutrition and fluid balance. •The client will return to his or her optimal level of functioning.

Is the following statement true or false? There is usually an identifiable cause for the development of delirium.

True - Rationale: Delirium is usually caused by an identifiable physiological, metabolic, or cerebral disturbance or disease or by drug intoxication or withdrawal.

3. When teaching a client about memantine (Namenda), the nurse will include which information? a.Lab tests to monitor the client's liver function are needed. b.Namenda can cause elevated blood pressure. c.Taking Namenda will improve the client's cognitive functioning. d.The most common side effect of Namenda is gastrointestinal bleeding.

b.Namenda can cause elevated blood pressure.

1. The nurse is talking with a woman who is worried that her mother has Alzheimer disease. The nurse knows that the first sign of dementia is: a.disorientation to person, place, or time. b.memory loss that is more than ordinary forgetfulness. c.inability to perform self-care tasks without assistance. d.variable with different people.

b.memory loss that is more than ordinary forgetfulness.

4. Which statement by the caregiver of a client newly diagnosed with dementia requires further intervention by the nurse? a."I will remind Mother of things she has forgotten." b."I will keep Mother busy with favorite activities as long as she can participate." c."I will try to find new and different things to do every day." d."I will encourage Mother to talk about her friends and family."

c."I will try to find new and different things to do every day."

2. The nurse has been teaching a caregiver about donepezil (Aricept). The nurse knows that teaching has been effective when the caregiver makes which statement? a."Let's hope this medication will stop the Alzheimer disease from progressing any further." b."It is important to take this medication on an empty stomach." c."I'll be eager to see if this medication makes any improvement in concentration." d."This medication will slow the progress of Alzheimer disease temporarily."

d."This medication will slow the progress of Alzheimer disease temporarily."

Client & Family Education For Delirium:

•Monitor chronic health conditions carefully. •Visit physician regularly. •Tell all physicians and health care providers what medications are taken, including OTC medications, dietary supplements, and herbal preparations. •Check with physician before taking any nonprescription medication. •Avoid alcohol and recreational drugs. •Maintain a nutritious diet. •Get adequate sleep. •Use safety precautions when working with paint solvents, insecticides, and similar products.

Nursing Intervention For Delirium:

•Promoting client's safety •Teach the client to request assistance for activities (getting out of bed, going to bathroom). •Provide close supervision to ensure safety during these activities. •Promptly respond to the client's call for assistance. •Managing client's confusion •Speak to the client in a calm manner in a clear low voice; use simple sentences. •Allow adequate time for the client to comprehend and respond. •Allow the client to make decisions as much as he or she is able to. •Provide orienting verbal cues when talking with the client. •Use supportive touch if appropriate. •Controlling environment to reduce sensory overload •Keep environmental noise to minimum (television, radio). •Monitor the client's response to visitors; explain to family and friends that the client may need to visit quietly one-on-one. •Validate the client's anxiety and fears, but do not reinforce misperceptions. •Promoting sleep and proper nutrition •Monitor sleep and elimination patterns. •Monitor food and fluid intake; provide prompts or assistance to eat and drink adequate amounts of food and fluids. •Provide periodic assistance to bathroom if the client does not make requests. •Discourage daytime napping to help sleep at night. •Encourage some exercise during the day, such as sitting in a chair, walking in hall, or other activities the client can manage.

Points to Consider When Working with Clients with Dementia:

•Remember how important it is to provide dignity for the client and family as the client's life ends. •Remember that death is the last stage of life. The nurse can provide emotional support for the client and family during this period. •Clients may not notice the caring, patience, and support the nurse offers, but these qualities will mean a great deal to the family for a long time.