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Vicki Notes

• Cognitive disorders may be defined as a group of disorders characterized by the disruption of or deficit in cognitive functioning. Also referred to as organic metal disorders.
• Includes:
• Delirium, dementia, amnestic & others.
• Mental disorders r/t a medical condition.
• And Substance – related disorders.
• Cause is considered to be primarily biological.
• The brain in these disorders is not a healthy intact organ.
• Incidence of these disorders continue to increase in the geriatric population, chronic disease survivor population & acute care facilities.
• 5% (million) Americans > 65 y/o are affected by dementia enough to deter independent living.
• Cognitive disorders can result from:
• A primary brain disease (tumors, head injury)
• The brains response to influences of systemic disturbances.
• The brains reaction to an exogenous substance.
• Residual effects or withdrawal from such substances.
• The cause may determine whether or not the cognitive problem can be reversed.

• Is a group of cognitive disorders.
• Its Hallmark – is a rapid onset of cognitive dysfunction & disruption in consciousness.
• The elderly are especially susceptible r/t aged neurological systems that are often accompanied by physical illness.
• Causes include – conditions affecting metabolic balance i.e. postop conditions, metabolic disorders, alcohol or other substance withdrawal.
• Clinical features – there are three main features of delirium:
• Disordered thinking (cognition)
• Attention deficit
• And decreased LOC
• The main disorders of cognition are thinking, perception & memory. Let’s explain further.
• The thinking aspect here is disorganized and is evidenced by – a person who appears to be in a confused state, with little or no problem solving ability, they can’t comprehend the situation, their speech is pressured, rambling, bizarre, even incoherent, can’t tell reality from imaginary & dreams, persecutory delusions are not uncommon.
• The perceptual aspect is disturbed as evidenced by hallucinations & illusions that can be auditory, tactile or visual.
• The memory aspect is impaired, especially short term with antegrade (can’t remember events occurring AFTER a precipitating event or medication) or retrograde (can’t remember events occurring BEFORE the precipitating event).
• Attention deficit – presents itself as an inability to focus or shift attention readily, being frequently distracted, with the symptoms being more pronounced at night, and disorientation to time, if not place & person.

• Is a group of disorders with progressive (gradual onset), cognitive deficiencies – largely MEMORY LOSS & a deficit in thought process functioning & presence of the following:
• Memory impairment – showing an inability to learn new material (short-term memory) & inability to recall previously learned material (long term memory).
• Agnosia – which is not being able to recognize or identify familiar objects i.e. parts of a telephone.
• Aphasia – which is not be able to use the forgotten words i.e. referring to Thanksgiving Day as the time of turkey or pumpkin.
• Apraxia – which is not being able to carry out motor tasks i.e. brushing teeth & combing hair despite intact motor function.

• Is the most prevalent of the dementia’s.
• An estimated 4 million Americans are its victim.
• Occurs more often in women.
• Correlates with increased age.
• Cause is unknown – however here are possible theories:
• Degenerative changes in cholinergic neurons & biochemical changes r/t enzyme for acetylcholine.
• Aluminum deposits – found in the brains of these patients, may be a cause or result of the disease.
• An immunological defect – abnormally high antibody titers have been seen.
• Defect in chromosome 21 (could link to Down’s syndrome) or other chromosome.

• Is the second most common form of dementia & is r/t cerebrovascular disorders.
• Most common in those > 85 y/o.
• Risk factors for this include – stroke, hypertension, smoking, hyperlipidemia, atrial fib & diabetes that can lead to hemorrhage or ischemia in the brain.
• Verified by CT & MRI.
• In this patient you will see problems with impaired memory – and other symptoms will depend on the area & extent of the brain affected.

• Is a neurodegenerative illness that progresses slowly with no known cure.
• It affects 1 million Americans.
• The end result of the pathology here is a depletion of the neurotransmitter dopamine.
• S/S seen with this patient include – immobility, cognitive decline (which varies), involuntary muscle movements at rest with overall slowness & rigidity.
• Does not ravage the language as other dementia’s do.

• Is a familial disease passed on by an autosomal dominant trait & may be the result of biochemical changes within brain cells.
• There is a 50% chance of inheriting the trait-carrying gene.
• The disease will inevitably manifest between 35 – 45 years of age.
• From its onset to death is approximately 15 years.
• Dx is by clinical history – while autopsy usually reveals frontal cerebral atrophy.
• S/S seen with this patient include – jerking movements, memory deficits, slowed thinking, decreased attention span & judgement.
• Emotional component is apparent by 20 or 30 years of age – the person is labile, impulsive, easily frustrated, irritable, hostile & aggressive

• Resembles Alzheimer’s disease but occurs less frequently.
• Usually occurs in the mid-50s & genetics is suspected as the cause.

• Is a rare disease that targets the CNS.
• It is thought to be caused by a virus.
• Seen in middle-age to elderly.
• S/S – start with dementia (rapidly progressing) à then progresses to jerking à then to generalized myoclonus & extrapyramidal signs (disruption of many of the senses, seizures) à final phase is marked by coma with infection & respiratory problems.

• Are conditions in which short-term memory loss is a hallmark.
• This patient is seriously deterred from learning new information.

• An amnestic disorder that is substance-induced (a.k.a. Korsakoff’s syndrome) and featured by compulsive ingestion of alcohol & usually found in 40 – 70 year old alcoholics.

In time the patients develop a B1 (thiamine) deficiency that interfers with the brains main nutrient, glucose.

• The most significant behavioral problems are due to emotional reactions occurring when the patient becomes aware of the cognitive deficits resulting from his or her condition.
• When the organic integrity of the brain is interrupted or interfered with, maladaptive behavior will often follow.
• Deficits in the sensorium stem from the patient’s inability to use the information collected by the five senses to discern the environment.
• Disorientation occurs when a patient is hampered from successfully receiving & centrally using the information from their internal & external environment.
• Memory disturbances are the most common deficits in cognitive disorders.
• Inability to register, retain & retrieve accumulated information is a hallmark clinical manifestation of cognitive disorders.
• Many of the behaviors seen r/t memory impairment tend to worsen at after sunset – this is termed the sundown effect.

• Focuses on the patient’s behavior & the family is key to insight of when the behavior started & about its progression.
• Here the nurse gathers data & behavioral reports.
• A classic assessment tool for intellectual or cognitive deficits is the MSE (mental status exam).
• Assess LOC, sensorium, stimulus response, orientation to person, environment, time & date and of course memory – have them recall events of the previous week or day.
• Assess attention span by – asking patient to repeat 6 or 7 digits forward or cross out all the a’s in a paragraph – inability to do this indicates difficulty concentrating.
• Assess perceptual disorders by observation & asking about any strange or unusual feeling or sensory experiences.
• Ask family if patient experiences the sundown effect.
• Assess interactions between patient & family members – may reveal social assets & deficits.

• Many apply here – please consult page 501 or any Nursing Diagnosis book.

• Should involve family, spouse or adult children – as members may have to assume responsibility for the patient’s care.

• To eliminate the organic etiology, if possible (or reduced symptoms)
• To prevent (or minimize) the acceleration of symptomatology.
• To preserve the patients dignity.

• Maintain peak physical health – and minimize sensory problems with glasses & hearing aids.
• Promote a structured environment – and increase or decrease sensory input as needed, a level in which the patient can cope, rest or sleep. Use clocks, calendars & seasonal pictures to orient to time & place, and encourage familiar people & objects in the environment.
• Promote socialization
• Promote independent functioning
• Preserve the family unit – families with responsibility of caring for this patient will need respite care.

• Success may be measured in terms of slowing down the process rather than stopping or curing the problem.

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