University of Baghdad

College of Nursing
Psychiatric Mental Health Nursing Department

Cognitive
Disorders

Dr. Qahtan

INTRODUCTION
• 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.
 INTRODUCTION
• 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.
• DSM-5 → neurocognitive disorders (NCDs).

DELIRIUM
• 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.
 Symptoms of delirium
• difficulty paying attention
• easily distracted and disoriented
• may have sensory disturbances such as
illusions, misinterpretations, or hallucinations.
• disturbances in the sleep–wake cycle
• changes in psychomotor activity
• emotional problems such as anxiety, fear,
irritability, euphoria, or apathy.

Epidemiology of delirium
• Elderly patients
• Between 14% and 24% of people admitted to
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
 Risk factors for delirium
• Increased severity of physical illness
• Older age, hearing impairment,
• Decreased food and fluid intake
• Medications
• Children may be more susceptible to delirium,
especially that related to a febrile illness or
certain medications such as anticholinergics.

Etiology of delirium
 Treatment and Prognosis
• 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.
• Haloperidol, may be used in doses of 0.5 to 1 mg to
decrease agitation and psychotic symptoms
• Adequate nutritious food and fluid intake speed
recovery.
• 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.

APPLICATION OF THE NURSING

PROCESS: DELIRIUM
Assessment: History
• the nurse obtains a thorough history of
medical illness, alcohol, or other drugs
• 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.
 Drugs Causing Delirium
• Anesthesia • Cardiac glycosides
• Anticonvulsants • Cimetidine (Tagamet)
• Anticholinergics
• Hypoglycemic agents
• Antidepressants
• Antihistamines • Insulin
• Antihypertensives • Narcotics
• Antineoplastics • Propranolol (Inderal)
• Antipsychotics • Reserpine
• Aspirin
• Steroids
• Barbiturates
• Benzodiazepines • Thiazide diuretics

General Appearance and Motor Behavior

• restless and hyperactive
• uncoordinated attempts
• slowed motor behavior
• sluggish and lethargic with little movement.
• less coherent speech.
• Clients may perseverate on a single topic
• rambling and pressured speech
Mood and Affect
• A wide range of emotional responses is possible,
such as anxiety, fear, irritability, anger, euphoria,
and apathy.
Thought Process and Content
• Thought content in delirium is often unrelated
to the situation.
• 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.

Sensorium and Intellectual

Processes
• Altered level of consciousness
• Oriented to people but frequently disoriented
to time and place.
• They demonstrate decreased awareness of
the environment or situation
• Clients cannot focus, sustain, or shift attention
effectively
• misinterpretations, illusions, and
hallucinations
 Judgment and Insight
• Judgment is impaired.
• Insight depends on the severity of the
delirium. Clients with mild delirium may
recognize that they are confused. Those with
severe delirium may have no insight into the
situation.
Roles and Relationships
• Clients are unlikely to fulfill their roles during
the course of delirium.

Self-Concept
• Although delirium has no direct effect on self-
concept
• may feel helpless or powerless to do anything to
change it

Physiological and Self-Care Considerations

• disturbed sleep–wake cycles that may include
difficulty falling asleep, daytime sleepiness,
nighttime agitation
• At times, clients also ignore or fail to perceive
internal body cues such as hunger, thirst, or the
urge to urinate or defecate.
 Data Analysis
• 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

NURSING INTERVENTIONS
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.

CLIENT AND FAMILY EDUCATION

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.
 DEMENTIA
• 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:

• Aphasia, which is deterioration of language

function
• Apraxia, which is impaired ability to execute
motor functions despite intact motor abilities
• Agnosia, which is inability to recognize or
name objects despite intact sensory abilities
• Disturbance in executive functioning, which is
the ability to think abstractly and to plan,
initiate, sequence, monitor, and stop complex
behavior
 Comparison of Delirium and Dementia

Onset and Clinical Course

Mild:
• 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.
Moderate:
• 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.

Severe:
• 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.
 Etiology
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.
• 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

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.
• 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.

Related Disorders
• Substance- or medication-induced mild or
major NCD is characterized by neurocognitive
impairment that persists beyond intoxication
or withdrawal.
• 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
 Drugs Used to Treat Dementia

APPLICATION OF THE NURSING

PROCESS: 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.
General Appearance and Motor Behavior
• aphasia
• perseverate on one idea.
• Slurred speech, followed by a total loss of
language function.
• apraxia
• In the severe stage, clients may experience a gait
disturbance
• show uninhibited behavior, including making
inappropriate jokes, neglecting personal hygiene,
showing undue familiarity with strangers, or
disregarding social conventions for acceptable
behavior.

Mood and Affect

• anxiety and fear over the beginning losses of memory
and cognitive functions.
• Mood becomes more labile over time and may shift
rapidly and drastically for no apparent reason.
• Emotional outbursts are common and usually pass
quickly.
• 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.
Thought Process and Content
• the ability to think abstractly is impaired
• The client loses the ability to solve problems
• The client cannot recognize similarities or
differences in situations.
• 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

Sensorium and Intellectual Processes

• Memory deficits
• In mild and moderate dementia, clients may
make up answers to fill in memory gaps
(confabulation).
• Agnosia
• Attention span and ability to concentrate are
increasingly impaired until clients lose the
ability to do either.
• Clients are chronically confused about the
environment,
• Visual hallucinations are most common
Judgment and Insight
• Clients with dementia have poor judgment
• Insight is limited.

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.
Roles and Relationships
• Roles as spouse, partner, or parent deteriorate
• 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.

Physiological and Self-Care Considerations

• Clients with dementia often experience
disturbed sleep–wake cycles
• 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.
 Data Analysis
• 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

NURSING INTERVENTIONS
Dementia
Promoting client’s safety and protecting from
injury
• Offer unobtrusive assistance with or
supervision of cooking, bathing, or self-care
activities.
• Identify environmental triggers to help the
client avoid them.
Promoting adequate sleep, proper nutrition and
hygiene, and activity
• Prepare desirable foods and foods the client can
self-feed; sit with the client while eating.
• Monitor bowel elimination patterns; intervene
with fluids and fiber or prompts.
• Remind the client to urinate; provide pads or
diapers as needed, checking and changing them
frequently to avoid infection, skin irritation, and
unpleasant odors.
• Encourage mild physical activity such as walking.

Structuring environment and routine

• Encourage the client to follow regular routine
and habits of bathing and dressing rather than
imposing new ones.
• Monitor amount of environmental stimulation
and adjust when needed.
Providing emotional support
• Be kind, respectful, calm, and reassuring; pay
attention to the client.
• Use supportive touch when appropriate.
Promoting interaction and involvement
• Plan activities geared to the client’s interests
and abilities.
• Reminisce with the client about the past.
• If the client is nonverbal, remain alert to
nonverbal behavior.
• Employ techniques of distraction, time away,
going along, or reframing to calm clients who
are agitated, suspicious, or confused.

Evaluation
• 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.
Finished