CHAPTER 23

Neurocognitive Disorders
 OBJECTIVES

• Compare and contrast the clinical picture of delirium with that of dementia.
• Discuss three critical needs of a person with delirium, stated in terms of nursing
diagnoses.
• Identify three outcomes for patients with delirium.
• Summarize the essential nursing interventions for a patient with delirium.
 CASE STUDY

A woman brings her mother to your clinic, concerned that her 85-year-old mother may have dementia.
“I’m Ellen,” she says when you enter. “This is my mother Veronica. She’s not much of a talker these
days, so I’ve come with her to help her express a few things we’re both a bit worried about.”
“Right now,” Ellen says, “we’re pretty sure she has either delirium or dementia, maybe. What’s the
difference between those two?”
DELIRIUM
 CLINICAL PICTURE

• Disturbance in attention
• Abrupt onset with periods of lucidity
• Disorganized thinking
• Disorientation
• Anxiety and agitation
• Poor recall
• Delusions and hallucinations (usually visual)
 EPIDEMIOLOGY AND RISK FACTORS

• Common complication of hospitalization

• 10% to 30% of general medical patients
• Up to 60% in older, frail patients
• 20% to 84% of critically ill patients
• Multifactorial physiological causes
• Cognitive impairment, immobilization, psychoactive medications, dehydration, infection, sleep deprivation and vision
or hearing impairment
 CASE STUDY

Ellen continues: “Well, it’s mostly a problem with memory that

started maybe two years ago? One and a half, maybe?”
You ask, “Did something abrupt set this off?”
“No,” Ellen says. “Mom? Do you think some event may have
triggered all this?”
Veronica shakes her head.
“Does she have abrupt moments of lucidity?” you ask.
“Not really,” Ellen shakes her head. “She’s pretty much the
same all the time.”
 AUDIENCE RESPONSE QUESTIONS

Which is an indication that Veronica does not have delirium?

A. She seems confused.

B. She gets anxious and agitated.
C. She seems disorganized in her thoughts.
D. Her problems with memory have been developing
gradually.
 APPLICATION OF THE NURSING
PROCESS

• Overall assessment
• Cognitive and perceptual disturbances
• Illusions
• Hallucinations
• Physical needs
• Moods and physical behaviors
• Self assessment
 NURSING PROCESS (CONT.)

• Assessment Guidelines
• Do not assume confusion is dementia in the older patient.
• Assess for acute onset and fluctuating levels of awareness.
• Assess the person’s ability to attend to the immediate environment.
• Establish usual level of cognition, plus past cognitive impairment.
• Identify disturbances in physiological status.
• Assess vital signs, level of consciousness, and neurological signs.
• Assess potential for injury.
• Assess for availability of immediate medical interventions to help prevent irreversible
brain damage.
• Monitor situational factors that worsen or improve symptoms.
 NURSING PROCESS (CONT.)

• Nursing diagnosis
• Risk for injury
• Altered perception
• Hallucinations
• Disorientation
• Restlessness
• Fear
• Agitation
• Acute confusion
 NURSING PROCESS (CONT.)

 Outcomes criteria
• Patient will remain safe and free from injury and falls
• During periods of clarity, patient will be oriented to time, place, and person, possibly with
aids
• Fluid balance and adequate nutrition be maintained
• Patient will be comforted by quiet, calm presence
 Planning
• Ensure necessary aids and supportive home team
• Visual cues in the environment for orientation
• Continuity of care providers
 NURSING PROCESS (CONT.)

• Implementation
• Prevent physical harm due to confusion, aggression, or fluid and electrolyte imbalance
• Minimize use of restraints (increases confusion)
• Assist with identification and treatment of cause
• Use supportive measures to relieve distress
• Evaluation
• Patient will remain safe, oriented to time, place, and person; and underlying cause will be
treated
MILD AND MAJOR NEUROCOGNITIVE
DISORDERS
 OBJECTIVES

• Recognize the clinical picture of mild and major neurocognitive disorders.

• Describe the clinical picture and progression of Alzheimer’s disease.
• Give an example of the following symptoms assessed during the progression of
major neurocognitive disorders: (a) apraxia, (b) agnosia, and (c) aphasia.
 MAJOR AND MINOR NEUROCOGNITIVE
DISORDERS

• Progressive deterioration of cognitive functioning and global impairment of intellect (dementia)

• No change in consciousness
• Difficulty with memory, problem solving, and complex attention
• Mild: Does not interfere with ADLs; does not necessarily progress
• Major: Interferes with daily functioning and independence
 DSM-5 CRITERIA FOR MILD
NEUROCOGNITIVE DISORDER

• Evidence of modest cognitive decline from previous level of performance in one or more cognitive
domains
• Cognitive deficits do not interfere with independence in everyday activities
• Cognitive deficits do not occur exclusively in the context of delirium
• Cognitive deficits are not better explained by another mental disorder
 CASE STUDY

Ellen describes Veronica’s problem further.

“She has trouble remembering things, like where she put the electric bill. I helped her find it, and I thought
that was that.”
“But then, the next week I picked her up for a lunch date, and she looked really nice, no problem with that; she
was already to go, but her house was freezing!!!” I said, “Mom, did you pay your electric bill?”
She just stared at me.
 MAJOR NEUROCOGNITIVE DISORDERS

• Alzheimer’s disease
• Frontotemporal lobar
degeneration
• Lewy body disease
• Parkinson’s disease
• (with progression)
• Traumatic brain injury
• Cerebrovascular disease
ALZHEIMER’S DISEASE
 CLINICAL PICTURE

• Important to distinguish normal forgetfulness and memory deficits in dementia

• In dementia: memory loss interferes with ADLs
• AD progression
• Mild
• Moderate
• Severe
 SYMPTOMS OF ALZHEIMER’S DISEASE

• Memory impairment
• Disturbances in executive functioning
• Aphasia: Loss of language ability
• Apraxia: Loss of purposeful movement
• Agnosia: Loss of sensory ability to recognize objects
 EPIDEMIOLOGY AND RISK FACTORS

• Epidemiology
• Most common: Late-onset and female
• Biological factors
• Genetics
• Cardiovascular disease
• Head injury and trauma
• Modifiable risk factors
• Exercise and sleep
• Social engagement and diet
• Education and mental stimulation
 APPLICATION OF THE NURSING
PROCESS

• Assessment
• Confabulation (creation of stories in place of missing memories to maintain self-esteem)
• Perseveration (repetition of phrases or gestures long after stimulus is gone)
• Agraphia (diminishing ability to read or write )
• Hyperorality (tendency to put everything in the mouth)
• Aphasia, apraxia, agnosia (discussed earlier)
• Sundowning / sundown syndrome (tendency for mood to drop and agitation to rise as light of day diminishes)
 APPLICATION OF THE NURSING PROCESS

• Assessment (cont.)
• Memory impairment
• Initially, for recent events
• Progresses to both recent and remote events
• Disturbances in executive functioning
• Problem-solving
• Planning & organizing
• Abstract thinking
• Diminishment of emotional expression
 NURSING PROCESS

• Assessment (cont.)
• Diagnostic tests
• Computed tomography scan (CT)
• Positron emission tomography (PET)
• Mental status questionnaires
• Mini-Mental State Examination
• Complete physical and neurological exam
• Complete medical and psychiatric history
• Review of recent symptoms, meds, and nutrition
 NURSING PROCESS

• Assessment (cont.)
• Assessment Guidelines
• Evaluate current cognition level
• Identify and address any threats to safety, including home
• Review medications
• Interview family to assess preparation & coping
• Review available resources
• Identify teaching & guidance needs regarding sundowning
 NURSING PROCESS (CONT.)

• Self-assessment
• Realistic understanding of the disease
• Stress management
• Support and educational resources
• Realistic outcomes and recognition when these are achieved
• Maintaining good self-care
 CASE STUDY

Ellen continues: “But then, the next week I picked her up for a lunch date, and she looked really nice, no
problem with that; she was already to go, but her house was freezing!!! I said, “Mom, did you pay your
electric bill?”
She just blinked at me. “I don’t know,” she said.
“’Well, okay,” I said. “Let’s see. Where’s your checkbook?”
“‘I don’t know,’ she said. ‘Just stop asking questions!’ I thought she was going to cry!”
 AUDIENCE RESPONSE QUESTIONS

Veronica tries to refer to the electric bill, but ends up saying, “you know, the invitation.
The invitation”. What is this a sign of?

A. Aphasia
B. Apraxia
C. Agnosia
D. Perseveration
 OBJECTIVES

 Formulate three nursing diagnoses suitable for a patient with a major neurocognitive disorder and define
two outcomes for each.
 Formulate a teaching plan for a caregiver of a patient with major neurocognitive disorder, including
interventions for (a) communication, (b) health maintenance, and (c) safe environment.
 NURSING PROCESS (CONT.)

•Nursing diagnoses
• Impaired sleep
• Risk for injury (& wandering)
• Self-care deficit
• Anxiety
• Confusion
• Impaired verbal communication
• Hopelessness
• Caregiver stress
• Anticipatory grief
 OBJECTIVE

• Compose a list of appropriate referrals in the community—including a

support group, hotline for information, and respite services—for individuals
with dementia and their caregivers.
• Discuss pharmacological treatments for Alzheimer’s disease.
 NURSING PROCESS

• Outcomes identification
 Direct correlation to nursing diagnoses
• Planning
• Connect caregivers to support services
• Implementation
• Person-centered care approach
• Health teaching and health promotion
• Referral to community supports
• Evaluation
 COMMUNITY SUPPORT

• Transportation services
• Supervision and care when the primary caregiver is out of the home
• Referrals to day care centers
• Information on support groups in the community
• Meals on Wheels
• Information on respite and residential services
• Telephone numbers for help lines
• Home health services
 TREATMENT MODALITIES

 Pharmacotherapy

• Medications for Cognitive Symptoms

• Cholinesterase inhibitors
• Rivastigmine transdermal system (Exelon Patch)
• N-methyl-D-aspartate (NMDA) receptor antagonist
• Medications for Behavioral Symptoms
• None approved; risk is high; antipsychotics used off-label and with extreme caution
• Last resort (risks are high)
 Integrative Therapy
• Omega-3 fatty acids
 CASE STUDY DISCUSSION

• What are some appropriate community resources you could suggest to Ellen to help with her mother?
 AUDIENCE RESPONSE QUESTIONS

Acute onset of disordered thinking is most associated with:

A. delirium.
B. Alzheimer’s disease.
C. frontotemporal dementia.
D. dementia with Lewy bodies.
 CASE STUDY DISCUSSION

Your patient, 85-year-old Veronica, is diagnosed with Alzheimer’s disease. What are
some next steps you as her nurse can help with as both patient and family adjust to this
news?
 AUDIENCE RESPONSE QUESTIONS

Veronica’s AD has progressed. One morning, she attempts to brush her teeth with a
spoon. Which problem is evident?

A. Aphasia
B. Apraxia
C. Agnosia
D. Perseveration