CHAPTER 31 Cognitive Disorders Anita Amelia Thompson Heisterman key terms learning objectives agnosia On completion of this chapter, you should be able to accomplish aphasia the following: apraxia 1. Define the term cognitive mental disorder. cognitive mental disorders confabulation 2. Discuss the incidence and significance of cognitive disorders. delirium 3. Identify clinical features or behaviors associated with cognitive dementia disorders. sundowning 4. Compare possible etiologies of various cognitive disorders, especially Alzheimer’s disease. 5. Explain the continuum of care and interdisciplinary treatment/ management for clients and families dealing with cognitive disorders. 6. Discuss common interventions for cognitive disorders. 7. Apply the steps of the nursing process to care for clients with cognitive disorders. UNIT 652 six Psychiatric Disorders ognitive mental disorders are characterized by a in a few days to weeks. In contrast, dementia results from C disruption of or deficit in cognitive function, which primary brain pathology that usually is irreversible, chronic, encompasses orientation, attention, memory, vocabulary, cal- and progressive. Prognosis with dementia depends on whether culation ability, and abstract thinking (see Chap. 10). Specific a cause can be identified and reversed. For example, prompt categories delineated by the American Psychiatric Associa- oxygen treatment for dementia stemming from hypoxia can tion (APA, 2000) include the following: prevent further damage. A comparison of the characteristics of delirium versus dementia is shown in TABLE 31.1. 1. Delirium, dementia, and amnestic and other cognitive With most cognitive disorders, the brain is temporarily disorders or permanently compromised. Usual consequences include 2. Mental disorders resulting from a general medical disturbed perceptions, delusions, paranoia, and aggressive condition (see Chap. 39) and disruptive behaviors. Clients may sense that their think- 3. Substance-related disorders (see Chap. 30) ing is impaired and become frustrated, anxious, frightened, This chapter focuses on delirium and dementia. Amnestic dis- and distraught. High emotion may compound an already orders are covered briefly, in line with their classification in disordered state. the Diagnostic and Statistical Manual of Mental Disorders, Most cognitive disturbances belong to one of the follow- 4th ed., text revision (DSM-IV-TR). ing categories: • Primary brain disease • Response of the brain to systemic (eg, metabolic, cardio- ETIOLOGIC AND DIAGNOSTIC vascular) disturbance CHALLENGES OF COGNITIVE • Unique reaction of brain tissue to an exogenous substance DISORDERS • Residual effects of or withdrawal from an exogenous sub- stance (APA, 2000) Delirium usually results from an acute disruption in the homeostasis of the brain. Once the cause of disruption is elim- Many illnesses and medications can impair cognition. inated or subsides, related cognitive deficits generally resolve Any physical illness may present initially with neurologic table 31.1 Delirium Versus Dementia Characteristic Delirium Dementia Onset Rapid development Gradual and insidious development Duration Brief duration of 1 month or less, depend- Long, with progressive deterioration ing on cause Course Diurnal alterations, more nocturnal Stable progression of symptomatology exacerbations Thinking and short-term Disorganized and impaired Short-term and long-term memory memory impairments, with eventual complete loss Orientation Markedly decreased, especially to environ- Progressively decreases mental cues Language Rambling, pressured, irrelevant Difficulty recalling the correct word; later may lose language Perceptual disturbance Environment unclear, progressing to illusions, Often absent but can progress to para- hallucinations, and delusions noia, delusions, hallucinations, and illusions Level of consciousness Cloudiness that fluctuates; inattentiveness Not affected to hyperalert with distractibility Sleep Day–night reversal, insomnia, vivid dreams May develop day-night reverse in later and nightmares stages Psychomotor actions Sluggish to hyperactive; change of range Not affected initially, late in illness, rest- unpredictable lessness with pacing Emotional status Anxious with changes in sleep; fearful if Depression/anxiety when insight into experiencing hallucinations; weeping; condition is present; late in pathology, yelling anger with outbursts CHAPTER 31 Cognitive Disorders 653 symptoms, behavioral manifestations, or both. Thus, cognitive Older adults are at significant risk for delirium, particu- disorders may be difficult to diagnose and involve multiple larly those with pre-existing cognitive impairment and post- visits to several practitioners, extensive laboratory and diag- operative clients. With aging, the neurologic system becomes nostic tests, and many examinations over an extended period. more vulnerable to insults caused by underlying systemic con- Such intensive care usually is necessary to establish what is ditions. Indeed, delirium often predicts or accompanies phys- causing or contributing to the cognitive decline so that health- ical illness in older adults (Cole, 2004). This population also care providers can initiate appropriate treatment or manage- is at risk because of the number of medications (over-the- ment. Failure to treat a reversible condition may cause further counter and prescription) many of them use (FIGURE 31.1). damage, functional decline, or death. Medications, particularly those that exert effects on the CNS, Another complication is that multiple factors may under- are frequent causes of delirium (Gurwitz et al., 2003). lie the clinical presentation of a cognitive disorder. For exam- Any disturbance in any organ or system can disrupt ple, the same client may have Alzheimer’s disease (dementia) overall metabolism and neurotransmission, leading to cog- and acute intoxication from overmedication (delirium). Or nitive decline. Infections and fluid and electrolyte imbal- a client with the chronic problem of vascular dementia may ances are common examples. Not surprisingly, medications experience delirium while hospitalized with pneumonia. are the primary exogenous offenders, especially in older Dementia itself is a risk factor for delirium. Thus, connecting adults. Often, an interplay of several factors leads to delir- the correct etiology and symptoms can challenge the most ium (Foreman et al., 2003). capable clinicians. As a practice standard, any change from the client’s baseline functioning is a clue to investigate causes beyond the primary diagnosis. Checkpoint Questions 1. How does delirium differ from dementia? 2. What is a frequent✔ cause of delirium in older adults? DELIRIUM Delirium is characterized by rapid onset of cognitive dys- function and disrupted consciousness. It also is referred to as intensive care unit psychosis, acute brain syndrome, acute Signs and Symptoms/Diagnostic Criteria Clinical pictures of delirium vary. Nevertheless, the three confusion, and acute toxic psychosis. salient features that comprise the main diagnostic criteria are (1) disordered cognition, (2) attention deficit, and (3) disturbed Incidence and Prevalence consciousness (DSM-IV-TR BOX 31.1). Growing rates of delirium mirror the increasing older adult In delirium, cognition becomes disorganized. Clients population and are expected to continue to rise. Delirium is the appear confused and cannot reason, handle complex tasks, most common psychiatric syndrome in general hospitals, or problem-solve. Associated speech may be pressured, ram- occurring in as many as 50% of elderly inpatients. It is associ- bling, bizarre, incoherent, or nearly absent. Impaired orienta- ated with significantly increased morbidity and mortality both tion and spatial ability may cause clients to confuse reality during and after hospitalization (Balas et al., 2007; McAvay with imagery and dreams. Suspiciousness and persecutory et al., 2006; Rigney, 2006). Approximately 30% to 40% of delusions are common (Sadock & Sadock, 2007). clients older than 65 years experience delirium while hospi- Clients may experience disturbed perceptions. Halluci- talized for a medical condition; another 10% to 15% have nations usually are graphic and can induce anxiety verging delirium on admission (Sadock & Sadock, 2007). The preva- on panic. Agitated clients can become combative to elude lence of repeated episodes of acute confusion in nursing perceived threats. Mood alterations can lead to great lability, homes for those older than 75 years is 60%; more than 80% of from irritability and dysphoria to euphoria (Sadock & Sadock, clients with terminal illnesses experience delirium-related 2007). cognitive impairment (Sadock & Sadock, 2007). Memory, particularly short-term, becomes impaired. Delirium related to surgery is common among all age Another feature is an inability to focus or shift attention. Clients groups. Estimates are that 30% of clients in surgical intensive may have trouble attending to environmental stimuli. Atten- care units, 40% to 50% of clients recovering from hip surgery, tion problems usually are more pronounced at night. Clients and more than 50% of postcardiotomy clients experience may be disoriented to time, place, and person (Sadock & delirium (Sadock & Sadock, 2007). Sadock, 2007). In severe cases, they mistake the unfamiliar for the familiar. For example, they may identify and subsequently Etiology call healthcare providers by the names of siblings, spouses, Any process, disorder, or agent that disrupts