Delirium, Dementia, and Amnestic and Other Cognitive Disorders

These disorders include etiology associated with (1) the aging process (dementias arising in the senium or presenium, including primary degenerative dementia of the Alzheimer type and multi-infarct dementia), (2) substance-related disorders (e.g., alcohol, barbiturates, opioids, cocaine, amphetamines, PCP, hallucinogens, cannabis, nicotine, and caffeine), and (3) general medical conditions.

Concepts, principles, and subtypes:
- Course may be progressive, with steady deterioration.
- Alternative pathways and compensatory mechanisms may develop to show a clinical picture of remissions and exacerbations.
- Delirium is characterized by a disturbance of consciousness with reduced ability to focus, sustain, or shift attention; and a change in cognition (e.g., memory deficit, disorientation [time and place], language disturbance); or development of perceptual disturbance (e.g., illusions, hallucinations) that develop over a short time (hours or days) and fluctuate during the course of the day. Etiology: a direct physiological consequence of a general medical condition, substance intoxication or withdrawal, use of a medication, or toxin exposure. Diagnostic feature: cannot repeat sequential string of information (e.g., digit span).
- Dementia is characterized by persistent multiple cognitive deficits (e.g., aphasia, apraxia, agnosia, disturbance in executive functioning) accompanied by memory impairment and mood and sleep disturbances. Possible etiology: vascular dementia, HIV infection, head trauma, Parkinson’s disease, Pick’s disease, Alzheimer’s disease, Huntington’s disease, substance induced, toxin exposure, medication, infections, nutritional deficiencies (hypoglycemia), endocrine conditions (hypothyroidism) brain tumors, seizure disorders, hepatic and renal failure; cardiopulmonary insufficiencies; fluid and electrolyte imbalances. Diagnostic features: cannot learn (register) new information (e.g., a list of words), or retain, recall, or recognize information.
  1. Alzheimer’s disease: progressive; irreversible loss of cerebral function due to cortical atrophy; exists in 2-4% of people over age 65 years; may have a genetic component; may begin at ages 40-65; may lead to death within 2 years. Average duration from onset of symptoms to death: 8-10 years.
    - Progressive decline in intellectual capacity (recent and remote memory, judgment), affect and motor coordination (apraxia); loss of social sense; apathy or restlessness.
    - Problems with speech (aphasia), recognition of familiar objects (agnosia), disorientation to self (even parts of own body).
  2. Pick’s disease: unknown cause; may have genetic component. Onset: middle age; women affected more than men. Pathology: atrophy in frontal and temporal lobes of brain. Clinical picture similar to Alzheimer’s.
  3. Creutzfeldt-Jacobs disease: uncommon, extremely rapid neurodegeneration caused by transmissible “slow” virus (prion); genetic component in 5-15%. Clinical picture: typical dementia, with muscle rigidity, ataxia, involuntary movements. Occurrence: ages 40-60 years. Death within 1 year.
- Amnestic disorder is characterized by severe memory impairment without other significant impairments of cognitive functioning (i.e., without aphasia, apraxia, or agnosia). Diagnostic features: memory impairment is always manifested by impairment in the ability to learn new information and sometimes problems remembering previously learned information or past events. May result in disorientation to place and time, but rarely to self. Appears bewildered or befuddled.
  1. Etiology: due to direct physiological effects of a general medical condition (e.g., physical trauma or vitamin deficiency) or due to persisting effects of a substance (e.g., drug of abuse, a medication, or toxin exposure).
  2. Memory disturbance: sufficiently severe to cause marked impairment in social or occupational functioning and represents a significant decline from a previous level of functioning. May require supervised living situation to ensure appropriate feeding and care.
  3. Lacks insight into own memory deficit and may explicitly deny the presence of severe memory impairment despite evidence to the contrary.
  4. Altered personality function: apathy, lack of initiative, emotional blandness, shallow range of expression.

Assessment:
- Most common areas of difficulty can be grouped V under the mnemonic term JOCAM: J - judgment, O - orientation, C - confabulation, A - affect, and M - memory.
  1. Judgment: impaired, resulting in socially inappropriate behavior (such as hypersexuality toward inappropriate objects) and inability to carry out activities of daily living.
  2. Orientation: confused, disoriented; perceptual disturbances (e.g., illusions, misidentification of other persons and objects; misperception to make unfamiliar more familiar; visual, tactile, and auditory hallucinations may appear as images and voices or disorganized light and sound patterns). Paranoid delusions of persecution.
  3. Confabulation: common use of this defense mechanism to fill in memory gaps with invented stories.
  4. Affect: mood changes and unstable emotions; quarrelsome, with outbursts of morbid anger (as in cerebral arteriosclerosis); tearful; withdrawn from social contact; depression is a frequent reaction to loss of physical and social function.
  5. Memory: impaired, especially for names and recent events; may compensate by confabulating and by using circumstantiality and tangential speaking patterns.
- Other areas of difficulty:
  1. Seizures (e.g., in Alzheimer’s disease and cerebral arteriosclerosis).
  2. Intellectual capacities diminished.
    - Difficulty with abstract thought.
    - Compensatory mechanism is to stay with familiar topics; repetition.
    - Short concentration periods.
  3. Personality changes.
    - Loss of ego flexibility; adoption of more rigid attitudes.
    - Ritualism in daily activities.
    - Hoarding.
    - Somatic preoccupations (hypochondriases).
    - Restlessness, wandering away.
    - Impaired impulse control.
    - Aphasia (in severe dementia).
    - Apraxia (inability to carry out motor activities).
  4. Diagnostic tests:
    1. Neurological exam: perform maneuvers or answer questions that are aimed at eliciting information about condition of specific parts of brain or peripheral nerves.
      - Assessment of mental status and alertness.
      - Muscle strength and reflexes.
      - Sensory-perception.
      - Language skills.
      - Coordination.
    2. Laboratory tests:
      - Blood, urine to test for: infections, hepatic and renal dysfunction, diabetes, electrolyte imbalances, metabolic/endocrine disorders, nutritional deficiencies, and presence of toxic substances (e.g., drugs).
      - Electroencephalography (EEG) to check brain’s electrical activity.
      - Computed tomography (CT) scan - image of brain size and shape.
      - Positron emission tomography (PET) - reveals metabolic activity of brain (important for diagnosis of Alzheimer’s).
      - Magnetic resonance imaging (MRI) - computerized image of soft tissue, with sharply detailed picture of brain tissues.

Analysis/nursing diagnosis:
- Risk for trauma related to cognitive deficits (inability to recognize/identify danger in the environment; confusion; impaired judgment) and altered motor behavior (restlessness, hyperactivity, muscular incoordination).
- Altered thought processes/confusion (altered abstract thinking and altered knowledge processes [agnosia]) related to destruction of cerebral tissue, inability to use information to make judgments and transmit messages, and memory deficits.
- Sensory/perceptual alterations: visual, auditory, kinesthetic, gustatory, tactile, olfactory related to neurological deficit.
- Sleep pattern disturbance resulting in disorientation at night, related to confusion; increased aimless wandering (day/night reversal).
- Self-care deficit (feeding, bathing/hygiene, dressing, toileting) related to physical impairments (poor vision, uncoordination, forgetfulness), disorientation, and confusion.
- Altered nutrition, more or less than body requirements, related to confusion.
- Total incontinence related to sensory/perceptual alterations.
- Altered attention and memory related to progressive neurological losses.
- Altered conduct/impulseprocesses (irritability and aggressiveness) related to neurological impairment.
- Impaired communication related to poverty of speech and withdrawal behavior, progressive neurological losses, and cerebral impairment.
- Caregiver role strain related to long-term illness and complexity of home care needs.
- Relocation stress syndrome related to separation from support systems, physical deterioration, and changes in daily routine.

Nursing care plan/implementation:
- Long-term goal: minimize regression related to memory impairment.
- Short-term goal: provide structure and consistency to increase security.
- Make brief, frequent contacts, because attention span is short.
- Allow clients time to talk and to complete projects.
- Stimulate associative patterns to improve recall (by repeating, summarizing, and focusing).
- Allow clients to review their lives and focus on the past.
- Use concrete questions in interviewing.
- Reinforce reality-oriented comments.
- Keep environment structured the same as much as possible (e.g., same room and placement of furniture); routine is important to diminish stress.
- Recognize the importance of compensatory mechanisms (e.g., confabulation) to increase self-esteem; build psychological reserve.
- Give recognition for each accomplishment.
- Use recreational and physical therapy.
- Health teaching: give specific instructions for diet, medication (e.g., tacrine [Cognex], donepezil [Aricept] for improving cognition), and treatment; how to use many sensory approaches to learn new information; how to use existing knowledge, old learning, and habitual approaches to deal with new situations.

Evaluation/outcome criteria:
- Symptoms occur less frequently and are less severe in areas ofi emotional lability and appropriateness; false perceptions; self-care ability; disorientation, memory, and judgment; and decision making.
- Client is able to preserve optimum level of functioning and independence while allowing basic needs to be met.
- Stays relatively calm and noncombative when upset or fearful.
- Accepts own irritability and frustrations as part of illness.
- Asks for assistance with self-care activities.
- Knows and adheres to daily routine; knows own nurse, location of room, bathroom, clocks, calendars.
- Uses supportive community services.