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Course: Mental Health Nursing

Topic: Cognitive Disorders Part II

The Nurses International Community

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Module Goals

Learners will be able to:

Describe the types of cognitive disorders.
Identify the symptoms that are reported by clients with these disorders.
Identify the clinical manifestations of these disorders.
Discuss evidence-based management of these disorders.
Identify the appropriate nursing interventions for these disorders.

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Irreversible Dementia: Classic Creutzfeldt-Jakob Disease

A rapidly progressive neurodegenerative disorder.
Caused by prions-abnormal pathogenic agents.
No known major risk factors.
Life expectancy: 6 months -1 year.
Can be transmitted with the exposure of blood and bodily fluids.
Personality changes, seizures, myoclonic movements occurs in initial stage.
Impaired vision or blindness may occur.

Birdley & Daffin, 2021

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Irreversity Dementia: AIDS Dementia Complex

Subcorticoid dementia with motor disturbance.
HIV crosses blood brain barrier; white matter changes, cerebral atrophy and macrophages infiltration in brain.
Cognitive and behavioral changes occurs in later stage.
A client rarely lives more than one year.
Mania is often the first clinical sign.
Other behavior changes include: Forgetfulness, ataxia, difficulty speaking, problem concentrating.

Birdley & Daffin, 2021

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What Would a Nurse Do?

A client has just been diagnosed with Creutzfeldt-Jakob Disease.

What should be the nurse’s focus for family care?

Provide the family with education about the disease.
Assist the family in finding an adequate care facility for their family member
Anticipate that the family will need grief support
Help the family to manage the many medications that the client will require

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Dementia Associated with Alcoholism

The criteria are met for major or mild neurocognitive disorder.
The neurocognitive impairments do not occur exclusively during the course of a delirium and persist beyond the usual duration of intoxication and acute withdrawal.
Neurocognitive impairment depend on type, duration and extent of substance use.
The temporal course of the neurocognitive deficits is consistent with the timing of substance or medication use and abstinence (e.g., the deficits remain stable or improve after a period of abstinence).

Birdley & Daffin, 2021

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Huntington’s Disease

The criteria are met for major or mild neurocognitive disorder.
There is insidious onset and gradual progression.
There is clinically established Huntington’s disease, or risk for Huntington’s disease.
Based on family history or genetic testing.
The neurocognitive disorder is not attributable to another medical condition and is not better explained by another mental disorder.
Personality changes are the initial signs.

Birdley & Daffin, 2021

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Other Conditions That May Cause Dementia

Outcome of other diseases
Metabolic imbalances
Head injury
Toxic doses or effect of medications, heavy metals, or carbon monoxide poisoning.

Keltner et al., 2003

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Differentiation Between Delirium and Dementia

Delirium

Occurs quickly, obvious, acute and can last hours to 6 months.
Cause by illness, surgery, toxins, infection.
Short term memory is impaired.
Slurred speech,altered thought process.

Dementia

Occurs slowly, noticeably and chronic with progressive deterioration.
Cause may be primary or caused by other conditions like AIDS.
Initial short term memory impairment then long term
Normal speech, logical at first and then abstraction is lost.

Keltner et al., 2003

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Differentiation Between Delirium and Dementia (Continued)

Delirium

Hallucinations and delusions may occur.
Anxious and fearful.
Requires immediate treatment to reverse delirium.
*Differentiate from Dementia in the elderly.
Appears bewilder, frightened.

Dementia

Progressive states of episodes of confusion.
Misidentification, hallucination, delusions may occur.
Wide range of feelings.
Appearance matches feelings.

Keltner et al., 2003

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Broad Treatment Options for Cognitive Disorders

Medication management

Antipsychotics
Anticonvulsants
Antidepressants
Antianxiety agents

Psychological therapies

Computer-based cognitive stimulation programs, reading books, and following the news.

Milieu Management

Stress management, fatigue, change of environment, having routine or caregivers, removing physical stressors, considering safety.

Keltner et al., 2003

Birdley & Daffin, 2021

Contact info: info@nursesinternational.org

Psychological: Among the most effective psychological treatment options for individuals with neurocognitive disorders are the use of cognitive and behavioral strategies. More specifically, engaging in various cognitive activities such as computer-based cognitive stimulation programs, reading books, and following the news, have been identified as effective strategies in preventing or delaying the onset of Alzheimer’s disease.

Engaging in social skills and self-care training are additional behavioral strategies used to help improve functioning in individuals with neurocognitive deficits. For example, by breaking down complex tasks into smaller, more attainable goals, as well as simplifying the environment (i.e., labeling location of items, removing clutter), individuals can successfully engage in more independent living activities.

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Critical Thinking Question

As a rule, clients with cognitive disorders do not require medication treatment.

True
False

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Strategies to Cope with Dementias

Be informed, share your concerns
Try to solve most difficult, frustrating problems one at a time
Get enough rest
Use common sense and imagination
Maintain a sense of humor
Establish an environment that promotes maximum amount of freedom
Always have identification card when dealing with confused clients
Help the impaired client to remain active
Focus on the present when talking with the client

Keltner et al., 2003

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Strategies to Cope with Alzheimer’s and Dementia

Nursing strategies for client communication

Gently gain the client’s attention
Position self at or below client eye level
Minimize distractions
Consider client vision or hearing limitations
Use short, clear and direct sentences

Keltner et al., 2003

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Strategies to Cope with Alzheimer’s and Dementia (Continued)

Nursing strategies for client communication

Maintain a clear voice and volume
Assess and adjust to the client’s verbal and non verbal cues
Allow enough time for client to process information
Listen respectfully, do not judge the client
Assist with word finding
Respond to the content and feelings conveyed

Keltner et al., 2003

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Parkinson’s Disease

Not a type of cognitive disorder but may lead to cognitive disorders.
Second-most common neurodegenerative disorder.
Affecting approximately 630,000 individuals in USA in 2013.

Birdley & Daffin, 2021

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Psychiatric Symptoms of Parkinson’s Disease

Parkinson’s disease (PD) is brain disorder that leads to loss of movement control

Shaking
Stiffness
Difficulty with walking, talking, balance, coordination

Caused by death of nerve cells in basal ganglia
Psychiatric symptoms are:

Anxiety Disorders
Depression
Psychosis
Apathy and Anhedonia
Impulse control disorder (ICD)
Dementia
Suicide

National Institute on Aging, 2017

Grover et al., 2015

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Management of Psychiatric Symptoms of PD

Depression: Supportive psychotherapy or cognitive behavior therapy (CBT) for mild depression; Tricyclic antidepressants (TCAs) with least sedative properties and little anticholinergic effects recommended; Electroconvulsive therapy for severe depression.

Anxiety disorders: SSRIs as first line of treatment; TCAs and benzodiazepines used at minimum dose for minimum duration, psychoeducation, relaxation practices, sleep hygiene, CBT, and social measures may be tried.

Grover et al., 2015

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Management of Psychiatric Symptoms of PD

Psychosis: Stop or adjustment of anti-parkinson drugs that could cause psychosis; antipsychotics like clozapine if symptoms persists.
Apathy and Anhedonia: Dopamine agonist like rivastigmine; anticholinergic, antidepressants; Cognitive training exercise.
ICD: Dose reduction or discontinuation of dopamine agonist.
Dementia: Rivastigmine.
Suicide: Management of underlying suicide-related psychiatric symptoms, such as depression or anxiety; Preoperative assessment on potential suicidal risks before deep-brain stimulation at subthalamic nucleus.

Grover et al., 2015

Han et al., 2018

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Red Flags

It is essential to differentiate delirium from increasing dementia in clients who already have dementia.

Delirium has a physiological cause that must be addressed and reversed immediately.

Ex. A client may have a systemic urinary infection without symptoms that may cause delirium.

A postpartum mother may show signs of distancing from her newborn. This could be the beginning of a mild or major depressive episode.

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Cultural Considerations

Detection of an cognitive disorder may be more difficult in cultural and socioeconomic settings where memory loss is considered normal in old age.

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Critical Thinking Question

Do some research on how various cultures perceive the elderly and how they deal with elders who have dementia.

How would the nurse’s role differ with regard to these cultural differences?

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References:

American Psychiatric Association. (2013). Diagnostic And Statistical Manual Of Mental Disorders (5th Eds.). Arlington, VA.

Birdley, A., Daffin, L. (2021). Abnormal Psychology (2nd ed.). Washington State University. https://opentext.wsu.edu/abnormal-psych/

Dhakal A, Bobrin BD. Cognitive Deficits. [Updated 2021 July 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559052/

Grover, S., Somaiya, M., Kumar, S., & Avasthi, A. (2015). Psychiatric aspects of Parkinson's disease. Journal of neurosciences in rural practice, 6(1), 65–76. https://doi.org/10.4103/0976-3147.143197

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References:

Han, J. W., Ahn, Y. D., Kim, W. S., Shin, C. M., Jeong, S. J., Song, Y. S., Bae, Y. J., & Kim, J. M. (2018). Psychiatric Manifestation in Patients with Parkinson's Disease. Journal of Korean medical science, 33(47), e300. https://doi.org/10.3346/jkms.2018.33.e300

Keltner, N.L., Schweeke, L. H., Bostrom, C.E. (2003). Psychiatric Nursing (4th ed.). Mosby.

National Institute of Aging. (2017, May 16). Parkinson’s Disease. U.S. Department of Health and Human Services, National Institute of health. https://www.nia.nih.gov/health/parkinsons-disease#:~:text=Parkinson's%20disease%20is%20a%20brain,have%20difficulty%20walking%20and%20talking

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