Cognitive Disorders
Cognitive Disorders
Cognitive Disorders
Dementia
Delirium
Dementia of the Alzheimer’s Type
Amnestic Disorders
Cognitive Disorders
Cognition refers to the mental processes of
comprehension, judgment, memory, and reasoning
in contrast to emotional and volitional (willfull or
free-will) processes (Edgerton & Campbell, 1994).
A cognitive disorder occurs when there is a
clinically significant deficit in cognition from a
previous level of functioning.
At least 70 known cognitive disorders are due to
intracranial or primary diseases of the central
nervous system (eg, epilepsy, brain trauma, or
infection) and extracranial diseases or diseases of
other organ systems (eg, drug intoxication,
poisons, or systemic infections).
Cognitive Function
Research has been done to determine the
effects of aging on the brain and cognitive
function. Some findings include the
following:
The normal human brain weighs approximately
1350 grams and declines approximately 7% to
8% in weight as one ages.
Ventricular size increases with age.
Cell loss is not uniform because the frontal lobes
degenerate at a faster rate than the other lobes.
Gray matter is lost at a
greater rate initially, but
white matter loss
disproportionately
increases as one ages.
Approximately 50% of
aging individuals
experience
atherosclerosis in
cerebral vessels.
Changes in
neurotransmitter
function occur, such as
alterations in
neurotransmitter
concentration, receptor
density, and functional
activity (Salloway,
1999).
Behavior Due to Central Nervous System
Pathology
Frontal lobe:
Lack of attention tenacity or persistence
Loss of emotional control, rage, violent behavior
Changes in mood and personality, uncharacteristic behavior
Expressive aphasia or dysphasia
Parietal lobe:
Neglect or inattention to left half of space, resulting in possible
self-injury or unintentional contact with others that could be
viewed as aggressive behavior
Temporal lobe:
Inability to store or retrieve information
Inability to comprehend speech due to loss of hearing or
receptive aphasia
Occipital lobe:
Visual disturbances such as agnosia or the inability to
recognize by sight
Limbic lobe:
• Inability to feed self
• Inability to learn or store information
Decrease in socialization
Lack of emotional expression or apathy
Delirium
Delirium is defined as a transient cognitive disorder, usually
acute or subacute in onset, presenting as a reversible global
dysfunction in cerebral metabolism.
usually due to disturbance of brain pathology by a medical
disorder or an ingested substance.
Delirium is considered a syndrome (eg, a group of signs and
symptoms that cluster together), not a disease, that has
many causes.
Three major causes are:
1. central nervous system diseases (eg, epilepsy, meningitis, or
encephalitis),
2. systemic illnesses (eg, heart failure or pulmonary
insufficiency), and
3. either drug intoxication or withdrawal from pharmacologic or
toxic agents.
Other causes of delirium include endocrine or
metabolic disorders (eg, hypoadrenocorticism
or hypercalcemia) and deficiency diseases (eg,
thiamine, nicotinic acid, or folic acid). In
addition, systemic infections, electrolyte
imbalance, postoperative states, and traumatic
injury to the head or body also are associated
with causing delirium
Dementia
Dementia refers to a syndrome of global or diffuse brain
dysfunction characterized by a gradual, progressive, chronic
deterioration of intellectual function.
persistent and stable nature of the impairment distinguishes it from
the altered levels of consciousness and fluctuating deficits of
delirium.
the majority of cases (up to 75%) are of two main types: dementia
of the Alzheimer's type and vascular dementia.
Etiology of Dementia of the Alzheimer's Type (DAT)
Current theories regarding the causes of dementia are cited below
and include:
The genetic theory proposing a genetic link to DAT focuses on three
genes on three separate chromosomes (1, 14, 21).
The immune system theory suggesting that DAT is the result of
immune system malfunctions.
The oxidation theory stating that the buildup of damage from
oxidative processes in neurons results in the loss of various body
functions.
The virus and bacteria theory proposing that DAT
may be due to a viral- or bacterial-induced condition
secondary to the breakdown of the immune system
(eg, herpesvirus).
The nutritional theory postulating that poor nutrition
and lack of mental stimulation during childhood may
predispose one to DAT later in life.
The metal deposit theory speculating that an
accumulation of aluminum ions replacing iron ions
may contribute to existing dementia.
The neurotransmitter theory hypothesizing that DAT
is due to a decrease in acetylcholine, dopamine,
norepinephrine, or serotonin levels, limiting neuronal
activity. A second theory postulates that excessive
stimulation of glutamate damages neurons.
The membrane phospholipid metabolism
theory proposing that DAT is due to an
abnormality in metabolism that causes
neuronal cell membranes to be less fluid or
more rigid than normal.
The beta-amyloid protein theory postulating
that symptoms of DAT are the result of
neuronal degeneration due to the neurotoxic
properties of this protein (Peskind & Raskind,
1996; Medina, 2001; Sadock & Sadock, 2003).
FIGURE 24.3 Positron emission tomography scan comparing a
control client subject and a client with dementia of the
Alzheimer's type.
Etiology of Diseases Associated With Dementia
Several diseases are often associated with dementia (APA, 2000;
Busse & Blazer, 1996; Sadock & Sadock, 2003). They include:
Familial multiple system taupathy (eg, a buildup of tau protein in
the neurons and glial cells) occurring in individuals in their forties
or fifties; thought to be carried on chromosome 17 and shares
some brain abnormalities with DAT; often referred to as presenile
dementia.
Lewy body disease resulting from neurohistologic changes in the
brain stem and widespread throughout the cerebral cortex;
clinically similar to DAT, presenting with some features of
Parkinson's disease.
Pick's disease, progressive disorder of middle and late life
characterized by atrophy and microscopic changes of the
frontotemporal regions; difficult to differentiate from DAT.
Parkinson's disease due to the presence of neurohistologic lesions
in the basal ganglia; associated impairment of cognitive abilities;
commonly associated with dementia.
TABLE 24.1 Comparison of Dementia, Delirium, and Depression
SYMPTOMS DEMENTIA DELIRIUM DEPRESSION
Retrograde Amnesia
A type of amnesia wherein memories
that were encoded or in the process of
being encoded in long term memory are
erased.
Anterograde Amnesia
A type of amnesia wherein there is
difficulty creating recent term lost of
memories.
Dissociative Amnesia
The client cannot remember important
personal information usually of a traumatic
or stressful nature.
Korsakoff Syndrome
Alcohol-induced amnestic disorder which
results from a chronic thiamine or vitamin B
deficiency.
Clinical Symptoms and Diagnostic Characteristics of
Cognitive Disorders
Delirium
- is one of the most common and, by far, one of the most life-
threatening psychiatric illnesses.
Clinical symptoms includes:
- a rapid onset with symptoms varying sharply in a short
period.
- Disorientation to person and place usually occurs.
- Dysnomia, the inability to name objects, and
- dysgraphia, the impaired ability to write, may occur.
- Thought processes appear confused, with possible delusional
content.
- Asterixis, an abnormal movement in which the client exhibits
a peculiar flapping movement of hyperextended hands,
Delirium Due to a General Medical Condition
findings indicate that the cognitive disturbance is the direct physiologic
consequence of a general medical condition such as a urinary tract
infection (see Clinical Example 24-1), respiratory tract infection,
septicemia, or end-stage renal disease.
Certain focal lesions of the right parietal lobe and occipital lobe also
may cause delirium.
Substance-Induced Delirium
- Clinical symptoms of substance-induced delirium occur within minutes
to hours after taking relatively high doses of certain drugs. The
delirium resolves as the substance is discontinued or eliminated from
the body.
Delirium Due to Multiple Etiologies
- This diagnosis is used to alert clinicians to the common situation in
which the delirium has more than one etiology.
Delirium, Not Otherwise Specified
- This diagnosis refers to delirium that does not meet criteria for any
specific type of delirium. There is insufficient evidence to establish a
specific etiology.
Dementia
Dementia is characterized by impaired judgment, orientation,
memory, cognition, and attention, which are affected either by a
pattern of simple, gradual deterioration or by rapid, complicated
deterioration.
Clients with dementia often seem to exhibit increased confusion,
restlessness, agitation, wandering, or combative behavior in the late
afternoon and evening hours.
Clinical symptoms
Dementia of the Alzheimer's Type (DAT)
silent epidemic characterized by the development of multiple
cognitive deficits including memory impairment,
aphasia (language disturbance),
apraxia (impaired ability to carry out motor activities despite
motor function),
agnosia (failure to recognize or identify objects despite intact
sensory function), and disturbances in executive functioning (eg,
planning, organizing).
The course is characterized by gradual onset. The client is aware
of the loss of mental abilities as they occur.
diagnosis is coded or labeled based on when and what symptoms
appear.
If clinical symptoms appear before age 65 years, the diagnosis is
coded as DAT with early onset; after age 65, the coding with late
onset is used. Additional coding indicates with delirium, with
delusions, with depressed mood, or uncomplicated.
Stages of Dementia of the Alzheimer's Type
first system groups clinical symptoms into three progressive stages
described as mild, moderate, and severe in nature.
second system describes seven stages of AD according to functional
consequences
Vascular Dementia
Vascular dementia, formerly known as multi-infarct dementia, is the
second most common cause of dementia after DAT. The disorder is
more common in males than in females. The onset of vascular
dementia is usually earlier than that of DAT. Onset is generally
abrupt with fluctuating, rapid changes in memory and other
cognitive impairment.
Apathy, unsteady gait, weakness, dizziness, and sensory loss
generally occur.
Clients with vascular dementia often exhibit the same clinical
symptoms seen in DAT: aphasia, apraxia, agnosia, and
disturbances in executive functioning.
Dementia Due to Other General Medical Conditions
This classification is used to diagnose dementia due to general
medical conditions (eg, HIV, traumatic brain injury, and
Parkinson's disease); endocrine, nutritional, and infectious
conditions; structural lesions of the brain; and renal or hepatic
dysfunction.
Amnestic Disorders
Individuals with amnesia experience impairment in their ability
to recall information or past events. Clients with anterograde
amnesia are unable to recall events of long ago but have
normal recall of recent events. Retrograde amnesia refers to
the loss of memory of events occurring before a particular time
in a person's life.
The Nursing Process
Assessment
The single most important piece of information when assessing a client
with cognitive impairment is a careful history from the client's family or
another reliable observer.
Assessment focuses on the client's ability to meet basic needs,
appearance, severity and duration of cognitive impairment, and
behavioral manifestations, including any associated clinical symptoms to
determine the presence of delirium, dementia, or amnestic disorder.
Judgment, orientation, memory, affect, and cognition (JOMAC) are key
areas to assess. Also note the client's intellectual ability, both past and
present.