MH 23: Neurocognitive Disorders

2. Which statement made by a family member tends to support a diagnosis of delirium rather than dementia? a. "She was fine last night but this morning she was confused." b. "Dad doesn't seem to recognize us anymore." c. "She's convinced that snakes come into her room at night." d. "He can't remember when to take his pills or whether he's bathed."

A

5. What is the rationale for providing a patient diagnosed with dementia easily accessible finger foods thorough the day? a. It increases input throughout the day b. The person may be anorexic c. It helps with the monitoring of food intake d. It helps to prevent constipation

A

10. Nurses caring for patients who have neurocognitive disorders are exposed to stress on many levels. Specialized skills training and continuing education are helpful to diffuse stress, as well as which of the following? Select all that apply. a. Expressing emotions by journaling b. Describing stressful events on Facebook c. Engaging in exercise and relaxation activities d. Having realistic patient expectations e. Participating in a happy hour after work to blow off steam

A, c, d

4. What side effects should the nurse monitor for while caring for a patient taking donepezil (Aricept)? Select all that apply. a. Insomnia b. Constipation c. Bradycardia d. Signs of dizziness e. Reports of headache

A, c, d, e

mild neurocognitive disorder

A. Evidence of modest cognitive decline from the previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor skills, or social cognition) based on concerns expressed by the person or a knowledgeable informant or clinician, and impairment in cognitive performance that is documented by standardized testing or quantifiable clinical assessment. B. The cognitive deficits do not interfere with independence in everyday activities (i.e., at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications), but these may require greater effort and compensatory strategies. C. The cognitive deficits do not occur exclusively in the context of delirium. D. The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).

major neurocognitive disorder

A. Evidence of significant cognitive decline from previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor skills, or social cognition) based on concerns expressed by the person, or a knowledgeable informant or clinician, and impairment in cognitive performance that is documented by standardized testing or quantifiable clinical assessment. B. The cognitive deficits are sufficient to interfere with independence in everyday activities (i.e., at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications). C. The cognitive deficits do not occur exclusively in the context of delirium. D. The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).

agraphia

Agraphia occurs early in AD. It is the diminished ability and eventual inability to read or write.

Common Types of Dementia

Alzheimer's disease ([AD] 60%-80% of dementias) Early: Difficulty remembering recent conversations, names or events, apathy, and depression. Middle: Impaired communication, disorientation, confusion, poor judgment, and behavioral changes. Late: Difficulty speaking, swallowing, and walking. Cerebrovascular disease (5%-10% of dementias) One or more documented cerebrovascular events. Impaired judgment, poor decision making, planning and organizing, slow gait and poor balance. Frontotemporal lobar degeneration (<10% of dementias) Onset is usually between 45 and 60 years old (early onset). Marked changes in personality, disinhibition, difficulty with communication. Lewy body disease (5%-10% of dementias) Same as Alzheimer's disease but includes sleep disturbance, visual hallucinations, movement and visuospatial impairment. Parkinson's disease (progression) Problems with movement: slowness, rigidity, tremor, changes in gait. Mixed pathologies More than one cause, and more common than previously thought.

aphasia

Aphasia is the loss of language ability. Initially, the person has difficulty finding the correct word, then is reduced to a few words, and finally is reduced to babbling or mutism

apraxia

Apraxia is the loss of purposeful movement in the absence of motor or sensory impairment. This results in the inability to perform familiar and purposeful tasks. For example, in apraxia of dressing, the person is unable to put clothes on properly (e.g., putting arms in trousers).

3. In terms of the pathophysiology responsible for both delirium and dementia, which intervention would be appropriate for delirium specifically? a. Assisting with needs related to nutrition, elimination, hydration, and personal hygiene b. Monitoring neurological status on an ongoing basis c. Placing an identification bracelet on patient d. Giving one simple direction at a time in a respectful tone of voice

B

1. Which statement made by the primary caregiver of a person with dementia demonstrates an accurate understanding of providing the person with a safe environment? a. "The local police know that he has wandered off before." b. "I keep the noise level low in the house." c. "We've installed locks on all the outside doors." d. "Our telephone number is always attached to the inside of his shirt pocket."

C

7. After talking with her 85-year-old mother, Nancy became concerned enough to drive to her home and check on her. Her mother's appearance was disheveled, her words were nonsensical, she smelled strongly of urine, and there was a stain on her dressing gown. Because she is a nurse, Nancy recognizes that her mother's condition is likely due to a. Early-onset dementia b. A mild cognitive disorder c. A urinary tract infection d. Having skipped breakfast

C

8. Lucia, 70 years old, recently underwent a major orthopedic surgical procedure. On postoperative day 3, she responds to the nurse who has been caring for her with affection. At other times, however, she tells the nurse to leave because she does not recognize her and asks to have another nurse care for her, specifically naming the nurse as the "nice one." The most likely reason for Lucia's behavior is that she is a. Attention-seeking and manipulative b. Showing signs of early dementia c. Experiencing an acute delirium d. Playing one staff member off against another

C

confabulation

Confabulation is the creation of stories or answers in place of actual memories to maintain self-esteem. For example, here the nurse addresses a patient who has remained in a hospital bed all weekend: Nurse: Good morning, Ms. Jones. How was your weekend? Patient: Wonderful. On Sunday I went to lunch with my family.

6. Ophelia, a 69-year-old retired nurse, attends a reunion of her former coworkers. Ophelia is concerned because she usually knows everyone, and she cannot recognize faces today. A registered nurse colleague recognizes Ophelia's distress and "introduces" Ophelia to those attending. The nurse practitioner understands that Ophelia seems to have a deficit in her a. Lower-level cognitive domain b. Delirium threshold c. Executive function d. Social cognition ability

D

9. Since his wife's death 2 months earlier, Aaron, 90 years of age and in good health, has begun to pay less attention to his hygiene and seems less alert to his surroundings. He complains of difficulty concentrating, disrupted sleep, and lacks energy. His family has to remind and encourage him to shower, take his medications, and eat, all of which he then does. Which of the following responses would be most appropriate? a. Reorient Mr. Smith by pointing out the day and date each time you have occasion to interact with him. b. Meet with the family and support them to accept, anticipate, and prepare for the progression of his stage 2 dementia. c. Avoid touch and proximity. These are likely to be uncomfortable for Mr. Smith and may provoke aggression when he is disoriented. d. Arrange for an appointment with a mental health professional for the evaluation and treatment of suspected major depressive disorder.

D

delirium

Delirium is an acute cognitive disturbance and often reversible condition that is common in hospitalized patients, especially older patients. It is characterized as a syndrome—that is, a constellation of symptoms rather than a disorder. The cardinal symptoms of delirium are an inability to direct, focus, sustain, and shift attention; an abrupt onset with clinical features that fluctuate with periods of lucidity; and disorganized thinking. Other characteristics include disorientation (often to time and place, but rarely to person), anxiety, agitation, poor memory, and delusional thinking. When hallucinations are present, they are usually visual

dementia

Dementia is a broad term used to describe deterioration of cognitive functioning and global impairment of cognitive functioning. It is a term that does not refer to specific disease but rather to a collection of symptoms. The DSM-5 (APA, 2013) incorporates forms of dementia into the diagnostic categories of mild and major neurocognitive disorders. These disorders are a result of actual brain pathology and are characterized by cognitive impairments that signal a decline from a person's previous functioning

hallucinations

Hallucinations are false sensory stimuli (refer to Chapter 12). Visual hallucinations are common in delirium, although tactile hallucinations may also be present. For example, persons experiencing delirium may become terrified when they see giant spiders crawling over the bedclothes or feel bugs crawling on or under their bodies. Auditory hallucinations are uncommon and occur more often in other psychiatric disorders, such as schizophrenia

hyperorality

Hyperorality refers to the tendency to put everything in the mouth and to taste and chew

illusions

Illusions are errors in the perception of sensory stimuli. A confused person may mistake folds in the blanket for white rats or the cord of a window blind for a snake. The stimulus is a real object in the environment. However, the person misinterprets it, and it often becomes an object of fear. Unlike delusions or hallucinations, you can explain and clarify illusions for the individual.

hypervigilance

In hypervigilance, patients are extraordinarily alert, and their eyes constantly scan the room. They may have difficulty falling asleep or may be actively disoriented and agitated throughout the night.

perseveration

Perseveration is the persistent repetition of a word, phrase, or gesture that continues after the original stimulus has stopped. For example, a person may continue to repeat "hello" long after the initial greeting is over.

executive function

Planning, decision making, problem solving, and abstract thinking

social cognition

Processing, storing, and applying information about other people and social situations

sundowning

Sundowning, or sundown syndrome, is the tendency for an individual's mood to deteriorate and agitation increase in the later part of the day, with the fading of light, or at night. Other symptoms observed in AD include the following: • Memory impairment. Initially, the person has difficulty remembering recent events. Gradually, deterioration progresses to include both recent and remote memory. • Disturbances in executive functioning such as problem solving, planning, organizing, and abstract thinking. • Diminution of emotional expression. At the most extreme end, there seems to be a complete absence of emotion. This is manifested in a flat affect and unresponsiveness.

agnosia

The person experiences agnosia, which is the inability to identify familiar objects or people, even a spouse. Apraxia is a common symptom, where a person so affected needs repeated instructions and directions to perform the simplest tasks: "Here is the face cloth. Pick up the soap. Now, put water on the face cloth, and rub the face cloth with soap."