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Course: Mental Health Nursing

Topic: Cognitive Disorders Part I

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Module Goals

Learners will be able to:

Define cognitive disorder.
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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What are Cognitive Disorders

Cognition: Mental action or process of acquiring knowledge and understanding through thought, experience, and the senses.

Cognitive Disorders: The impairment of domains of cognition.

Cognitive deficit is not limited to particular disease or condition but may be due to a manifestation of an underlying condition.

Dhakal & Bobrin, 2021

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Cognitive Disorders: Etiology

By Birth trauma
By environmental factors:

Brain Injury
Mental Illness
Neurological Deficit

Early Causes:

Chromosome abnormalities/genetic syndrome.
Prenatal drug exposure,malnutrition, neonatal jaundice, prematurity, hypoxia.
Lead or heavy metal poisoning.
Hypothyrodism, trauma or child abuse.

Dhakal & Bobrin, 2021

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Cognitive Disorders: Etiology

In childhood or adolescence:

Side effects of cancer therapy
Heavy metal poisoning
Malnutrition
Metabolic conditions
Autism
Immune conditions like systemic lupus erythematosus.

Dhakal & Bobrin, 2021

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Cognitive Disorders: Etiology

In adults:

Stroke
Delirium & Dementia, Depression
Schizophrenia
Chronic alcohol use or substance use
Brain tumors
Vitamin deficiencies
Hormonal imbalances
Brain pathologies
Drugs like sedatives, tranquilizers
Head injuries

Dhakal & Bobrin, 2021

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Cognitive Disorders: Pathophysiology

Caused when neurons are damaged.
Damage to grey matter and white matter.
Damage to areas responsible for certain deficits.
Damage due to neurotoxicity from metabolic disorders, heavy metals or other toxins, infections, ischemia due to head injuries/trauma.
Neurodegenerative process such as Alzheimer, Parkinson’s Disease.

Dhakal & Bobrin, 2021

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The general pathology is damage to neuronal tissue.
This includes damage to the grey matter, which comprises the cortex and the thalamus and basal ganglia, and the white matter, which comprises the coverings of the axons of the connections between grey matter areas. The damage to certain areas is responsible for certain deficits. For instance, damage to the parietal lobe can cause the inability to dress or visuospatial function.
Damage to the frontal lobe systems can cause deficits in planning, and abstract understanding and damage to the temporal lobes cause deficits in language and memory.
The causes of this damage are due to toxicity to neurons from metabolic disorders or heavy metals or other toxins such as toluene or infection or due to ischemic damage due to stroke or hemorrhage or direct injuries such as head injury or cancer or surgery.
Damage can also be caused by neurodegenerative processes such as Alzheimer, Parkinson’s, multiple sclerosis, or Huntington disease. These illnesses appear to directly damage neuronal tissue through immunologic interaction with abnormal proteins.

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Cognitive Disorders: General Physical Symptoms

Trouble remembering things
Asking the same question or repeating the same story many times
Difficulty in learning new things
Difficulty concentrating
Vision problems

Dhakal & Bobrin, 2021

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Cognitive Disorders:

General Physical Symptoms(Continued)

Trouble speaking
Difficulty recognizing people and places
Mood changes
Change in behavior or speech
Difficulty with daily tasks

Dhakal & Bobrin, 2021

Image by:Pixabay

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Major Cognitive Disorder: Delirium

Defined as the acute and sudden onset of dramatic behavioral changes.

Has fluctuating level of consciousness, slurred speech, nonsensical thoughts.
May experience visual hallucinations.
Able to follow the conversation for a short period of time followed by sudden intense confusion.
Symptoms may fluctuate during the day.

Keltner et al., 2003

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Major Cognitive Disorder: Delirium (Continued)

Short lasting and reversible if treated on time:

Outcome from the effect of surgery medications, toxins.
Medications like mood stabilizers, antidepressants may lead to delirium.

Keltner et al., 2003

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Delirium: Diagnostic Criteria

Reduced ability to focus, reduced clarity to the environment, loss of orientation and shifting of attention.
Changes in cognition.
The disturbance or condition develops over a short period of time (lasts from hours to days) and there is tendency to fluctuate during the course of the day.
The disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal.

American Psychiatric Association, 2013

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What Would a Nurse Do?

A nurse is working in a senior care facility where many of the residents have some form of dementia. One female resident who has a mild form of dementia appears depressed and withdrawn today.

What is the nurse’s best action?

Ask the resident’s family member if they have noticed any recent behavior changes in the client
Take the resident’s vital signs and report the change to the care provider.
Ask the care provider to consider ordering an anti depressant for the resident
Invite the resident to a craft session where they can be around others
Ask the aide to obtain an urine specimen from the resident

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Examples of Delirium Types

Substance intoxication delirium: Due to sedative, hypnotic or anxiolytics.
Substance withdrawal delirium.
Medication-induced delirium.
Delirium due to another medical condition.
Delirium due to multiple etiologies.
Other specified delirium.
Unspecified Delirium.

Birdley & Daffin, 2021

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Substance withdrawal delirium: This diagnosis should be made instead of substance withdrawal when the symptoms in Criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention.

Alcohol induced persisting amnestic delirium
Alcohol intoxication delirium
Alcohol withdrawal delirium
Amphetamine intoxication delirium
Delirium due to cannabis intoxication
Delirium due to cocaine intoxication
Delirium due to opioid intoxication

Delirium due to another medical condition: There is evidence from the history, physical examination, or laboratory findings that the disturbance is attributable to the physiological consequences of another medical condition.

Delirium due to phencyclidine intoxication
Delirium due to sedative, hypnotic or anxiolytic intoxication
Delirium due to sedative, hypnotic or anxiolytic withdrawal
Delirium due to medical condition
Delirium due to multiple etiologies
Delirium due to NOS (Not Otherwise Specified)

Delirium due to multiple etiologies: There is evidence from the history, physical examination, or laboratory findings that the delirium has more than one etiology (e.g., more than one etiological medical condition; another medical condition plus substance intoxication or medication side effect).

Other Specified Delirium: This category applies to presentations in which symptoms characteristic of delirium that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for delirium or any of the disorders in the neurocognitive disorders diagnostic class. The other specified delirium category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for delirium or any specific neurocognitive disorder. This is done by recording “other specified delirium” followed by the specific reason (e.g., “attenuated delirium syndrome”).

Attenuated delirium syndrome: This syndrome applies in cases of delirium in which the severity of cognitive impairment falls short of that required for the diagnosis, or in which some, but not all, diagnostic criteria for delirium are met.

Unspecified Delirium: This category applies to presentations in which symptoms characteristic of delirium that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for delirium or any of the disorders in the neurocognitive disorders diagnostic class. The unspecified delirium category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for delirium, and includes presentations for which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings).

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Cognitive Disorders: What is Dementia?

A form of illness that has a progressive deteriorating course that ultimately affects cognition, perception, language, behaviour and motor abilities.

Reversible forms of Dementia:

Normal pressure hydrocephalus.
Vitamin B12 deficiency is a reversible cause of dementia.

Keltner et al., 2003

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Dementia: Diagnostic Criteria

Impaired memory where an individual loses the ability to learn new information and to recall previously learned information.

Cognitive disturbance (one or more of the following): Aphasia, apraxia, agnosia, disturbed executive function.

Significant impairment in social and occupational functioning; significant decline from previous level of functioning.

American Psychiatric Association, 201

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Reversible Dementia:

Normal Pressure Hydrocephalus

Classic symptoms: urinary incontinence, apraxic gait and dementia.
Cause: impaired return of cerebral spinal fluid to spinal cord.
Ct or MRI report shows enlarged brain ventricles.
Cerebrospinal fluid pressure is normal or slightly elevated.
Urinary urgency, frequency & incontinence.
Dulled personality with lack of motivation, memory loss is terminal symptom.
If untreated, results in client becoming bedridden.
Treatment requires neurosurgery i.e. ventriculoperitoneal (VP) shunt.

Keltner et al., 2003

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Reversible Dementia: Vitamin B12 Deficiency

Very rare.
Result of malabsorption of vitamin B12 in the stomach.
Lack of B12 may lead to demyelination of axon-results in paresthesias of lower extremities.
Behavioral or mood changes.
MRI report shows lesions in the optic nerve or cerebral white matter.
Treatment: Immediate replacement of vitamin B12.

Keltner et al., 2003

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Irreversible Dementia: Alzheimer’s Disease

Most common type of dementia.
Slow shrinking of brain to approx ⅔ of the normal-Atrophy occurs in temporal and parietal region.
Causes: Genetic,environmental, beta amyloid plaque deposits on brain, oxidative stress.
Advanced age is significant risk factor for dementia.
History of head injury, low educational level, females have major risk factors.
Three stages: mild, moderate and severe.

Birdley & Daffin, 2021

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Dementia: Clinical Symptoms

4 “A”s:

Agnosia: Inability to recognize familiar objects.
Aphasia: Inability to understand and express spoken words, difficulty finding words.
Amnesia: Inability to learn new information or recall previously learned information, impaired concentration.
Apraxia: Inability to carry out motor activities despite intact motor functioning.

Memory loss: affects short term memory which gradually affects long term.
Trouble understanding conversation, inability to comprehend.

Keltner et al., 2003

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Critical Thinking Question

A nurse hears a 56 years old client who has been diagnosed with dementia screaming, “Get off my hands.” Which of the following assessment is the most accurate?

The client is experiencing aphasia.
The client is experiencing dysarthria.
The client is experiencing apraxia.
The client is experiencing visual hallucination.

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Irreversible Dementia: Vascular Dementia

Second most common type of dementia.
Caused by multiple vascular brain lesions (in cortex and subcortical area).
Memory loss is the most common symptom.
Usually maintains speech without word-finding difficulty.
Cognitive changes.
Risk factors: Hypertension, diabetes mellitus, previous stroke, cardiac arrhythmias, coronary artery disease, tobacco, alcohol and substance use.

Birdley & Daffin, 2021

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Irreversible Dementia: Frontotemporal Lobe Dementia

Results from atrophy of frontal and anterior temporal lobe of the brain.
Initial signs are behavioral changes: disinhibition, disrobing in public, extreme impatience, openly mastrubating.
Difficulty with abstraction, reasoning, and planning.
Speech disturbance, memory problems, gait disturbance in later life.
Risk factor: Older adults >60, may live with disease from 2 to 15 years.

Birdley & Daffin, 2021

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Irreversible Dementia: Secondary to Parkinson’s Disease

The prevalence of dementia is present in 15-20% of clients with Parkinson’s.

Clinical signs of Parkinson’s Disease

Muscular rigidity, mask like face, stooped and rigid posture.
shuffling gait, rubbing the thumb up and down across the tips of fingers, drooling.
May develop depression in later life.

Birdley & Daffin, 2021

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Irreversible Dementia: Diffuse Lewy Body Disease

Caused by senile plaques that cause neuronal dysfunction or even death.
Cognitive impairment with extrapyramidal signs.
May occur as sole dementia or can be combined with Alzheimer’s.
Many of the signs are the same as Alzheimer’s.
80% of clients may have severe visual hallucinations, tendency to fall, fluctuation in alertness.

Birdley & Daffin, 2021

Contact info: info@nursesinternational.org

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Red Flags

It is essential to differential 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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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/

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

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