Cognitive DisordersCognitive DisordersKimberly Gregg MS, APRN,BC

N483

ObjectivesObjectivesDefine cognitive disorders.Discuss differences between

reversible and irreversible cognitive disorders.

Discuss the non-dementia cognitive disorders.

Discuss difference between delirium and dementia.

Discuss the various dementias and their symptoms.

Discuss treatment for the various cognitive disorders.

Cognitive DisordersCognitive DisordersInvolve “assaults” on the human

brainCognition is associated with memory

and learning.The loss of memory and learning is

the common thread in all cognitive disorders

Some cognitive disorders are temporary or “reversible” and some are permanent or “irreversible”.

Non-dementia Cognitive Non-dementia Cognitive DisordersDisorders

3 Types: MCI, Delirium, and Pseudodementia

Mild Cognitive Impairment (MCI): ◦Subtle onset◦NOT the result of normal aging◦Sometimes referred to as the zone

between normal aging and Alzheimer's Disease.

◦Forgetfulness is the hallmark symptom!

◦It is not a DSM-IV-TR diagnosis

Non-dementia Cognitive Non-dementia Cognitive DisordersDisorders

Delirium◦ Acute Onset!!◦ Characterized by a disturbance of consciousness and

a change in cognition, such as impaired attention span, disorientation, and confusion that develops over a short period of time and fluctuates throughout the day.

◦ Other symptoms: Slurred speech, nonsensical thoughts, day-night sleep reversal, visual hallucinations, tactile hallucinations (bugs under skin common in alcohol withdrawal delirium), and emotional.

◦ Examples: “ICU psychosis”, “DT’s”◦ Most common complication of the hospitalized older

adult patient.◦ May be the sign of an underlying medical condition,

such as infection, myocardial infarction, toxic response to medication, electrolyte imbalance, etc…

Non-dementia Cognitive Non-dementia Cognitive DisordersDisorders

Pseudodementia:◦Type of cognitive disorder that is most

often linked to an underlying functional psychiatric illness, such as depression. (Depressed to the extent that they seem demented.)

◦Typically withdrawn and apathetic—but can be anxious and agitated.

◦Commonly responds to questions by saying “I don’t know” in contrast to the patient with dementia who would usually try and answer the question.

DementiaDementiaDementia develops more slowly

than delirium and is characterized by multiple cognitive deficits, including memory impairment.

Dementias are usually primary, progressive, and irreversible—even the reversible ones after a certain extent.

Alzheimer’s disease accounts for 60% to 80% of all dementias in the US.

Reversible DementiasReversible DementiasCan be treated and symptoms

may resolve or at least improve if caught early enough.

2 types: Normal Pressure Hydrocephalus & Vitamin B12 Deficiency

Reversible DementiasReversible DementiasNormal Pressure Hydrocephalus (NPH)

◦ Usually presents with the classic triad of symptoms: urinary incontinence, apraxic gait, and dementia.

◦ Patients have enlarged ventricles seen on CT or MRI.

◦ The cause of NPH is impaired return of cerebral spinal fluid to the spinal column form the brain.

◦ Also seen: Impairment in daily activities and dulling of personality with lack of motivation.

◦ Treatment: Neurosurgery in which a ventricular shunt is placed in one of the lateral ventricles in the brain, which then leads to the peritoneum (VP shunt).

Reversible DementiasReversible DementiasVitamin B12 Deficiency:

◦ Pernicious anemia is the most prevalent cause of this deficiency.

◦ Dementia related to vitamin b12 deficiency is rare.

◦ When the deficiency proceeds to this level, demyelinization occurs, leading to axon loss in the brain and in the spinal cord.

◦ Paresthesias start in the lower extremities, followed by upper extremity involvement.

◦ Behavioral and mood changes occur.◦ On an MRI of the brain, lesions may be found in

the optic nerve and cerebral white matter.◦ Treatment: Vitamin B12 replacement should

be started immediately and should be continued throughout the patient's lifetime.

Irreversible DementiasIrreversible DementiasNo Cure—Cognitive Decline is Inevitable. Treatment focuses on symptom relief,

slowing progression, and support/assistance as needed.

9 irreversible dementias: Alzheimer’s Disease, Vascular Dementia, Frontotemporal Lobe Dementia, Parkinson’s Dementia, Diffuse Lewy Body Disease, Creutzfeldt-Jakob Disease, AID’s Dementia, Wernicke’s/ Korsakoff’s Syndrome, & Huntington’s Disease.

Irreversible DementiasIrreversible Dementias Alzheimer’s Disease:

◦ Most prevalent dementia◦ Diagnosed after all other disorders have been ruled

out.◦ Age is most significant risk factor.◦ History of head injury, lower educational level,

being female are also risk factors.◦ 4 stages: Mild, Moderate, Severe, and Late.◦ Cholinergic Hypothesis: level of acetylcholine is

reduced in the brain.◦ Genetics plays a role as well: genes on

chromosomes 1, 14, 19, and 21 have been linked to this disease.

◦ Brain Atrophy: the Alzheimer’s brain is also shrinking, weighing about two thirds the weight of the normal brain.

Irreversible DementiasIrreversible Dementias Alzheimer’s Disease Continued:

◦ The 4 “A’s”: Agnosia: impaired ability to recognize or identify familiar

objects and people in the absence of a visual or hearing impairment.

Aphasia: language disturbances are exhibited in both expressing and understanding spoken words.

Amnesia: inability to learn new information or to recall previously learned information.

Apraxia: inability to carry out motor activities despite intact motor function.

◦ Misinterpreting the environment through visual hallucinations, delusions, and misidentification.

◦ Sundowning: phrase that describes the period, usually in the afternoon and early evening, during which a patient becomes more agitated and less redirectable.

◦ Loss of ability to care for oneself is particular difficult for all parties.

Irreversible DementiasIrreversible DementiasVascular Dementia:

◦Second most prevalent dementia◦Also know as multiinfarct dementia◦The brain has multiple vascular lesions

in the cortex and subcortical areas—sometimes called “small strokes”.

◦Memory loss is the most common presenting complaint.

◦Patients usually maintain ability to speak without work searching.

◦The cognitive changes that occur are directly related to the location of the lesions.

Irreversible DementiasIrreversible DementiasFrontotemporal Lobe Dementia (FLD):

◦ Type of dementia caused by atrophy of the frontal and anterior temporal lobes of the brain.

◦ Pick’s Disease is a subtype of FDL: linked to chromosomes 3 & 17.

◦ Pick’s cells are “swollen, ballooned neurons”.◦ The area of the brain affected is responsible

for executive functioning.◦ Behaviors include disturbances in judgment,

decision making, impulse control, and social norms.

◦ Behavioral changes may be first sign that something is wrong—such as disrobing in public, extreme impatience, or openly masturbating.

Irreversible DementiasIrreversible DementiasParkinson’s Dementia (PD):

◦Parkinson’s is a complex neurologic disorder that affects the extrapyramidal system.

◦Usually diagnosed when clients in their 50’s or 60’s.

◦The substania nigra has approximately a 50% reduction in neurons.

◦Fifteen years is the usual course of PD—making the decline more gradual than most other dementias.

Irreversible DementiasIrreversible DementiasDiffuse Lewy Body Disease (DLBD):

◦ The form of dementia that has both cognitive impairment with extrapyramidal signs.

◦ In addition to lewy bodies, these patients also have senile plaques—both of which cause neuronal dysfunction or death.

◦ 80% of patients with DLBD have severe visual hallucination, a tendency to fall, and fluctuation in alertness early in the disease.

◦ The downward course is much more precipitous than Alzheimer’s disease; usually 5 to 8 years.

◦ The extrapyramidal signs separate it from Alzheimer’s disease.

Irreversible DementiasIrreversible DementiasCreutzfeldt-Jakob Disease (CJD):

◦ This disease is known as the human form of “mad cow” disease.

◦ The patients contract this after ingesting meat infected with bovine spongiform encephalopathy.

◦ Dementia is inevitable and occurs early in the disease.

◦ Personality changes, seizures, and myoclonic movements occur and blindness is not uncommon.

◦ Most patients die within 6 months to a year. Only 10% live past one year.

◦ Contrary to popular belief—Not the main reason that Kim is a vegetarian.

Irreversible DementiasIrreversible DementiasAID’s Dementia:

◦HIV crosses the blood-brain barrier.◦Occurs in approximately 20% to 30%

of patients with AIDS.◦Initially motor disturbance occurs.◦Cognitive and behavioral changes

follow.◦Development of the dementia takes

years, however, once it occurs, the patient usually does not live past a year.

Irreversible DementiasIrreversible Dementias Wernicke’s/ Korsakoff’s Syndrome:

◦ Dementia usually occurs decades after the person starts drinking alcohol.

◦ Personality changes typically precede memory disturbance.

◦ The decline is similar to the course of Alzheimer’s disease.

◦ Thiamine deficiency is the main cause of alcohol related changes, so thiamine replacement is typically part of detox protocol.

◦ Wernicke’s encephalopathy results in motor problems related to alcohol abuse—such as ataxia and nystagmus.

◦ Patient’s with Korsakoff’s syndrome confabulate as they attempt to answer questions in an attempt to cover their severe short-term memory loss.

Irreversible DementiasIrreversible Dementias Huntington’s Disease (HD):

◦ Transmitted only through the autosomal dominant gene that either parent may provide.

◦ It does NOT skip generations.◦ Not usually diagnosed until patients are in their 30’s and

40’s, and they may have children and even grandchildren by then.

◦ The child has a 50% chance of inheriting the gene and thus the disease.

◦ Personality changes are usually the fist signs to appear.◦ Mood swings and usually behaviors, i.e. drinking alcohol

can occur.◦ Movement symptoms, i.e. facial twitches, involuntary

limb movements occur.◦ Chromosome 4 is the point at which the gene associated

with HD is located.◦ The course is unpredictable because the illness may

occur over a short period, or it may last decades.

Cognitive Disorder Cognitive Disorder TreatmentTreatment

SAFETY!Daily cares as neededManagement of symptomsNPR/NCRPsychopharmacology: Namenda (affects

NMDA receptors), Aricept (inhibits acetylcholine breakdown), Cognex (cholinesterase inhibitor), Exelon (a brain-selective acetylcholinesterase inhibitor), Reminyl (reversible cholinesterase inhibitor)

Orientating to person, place, and timeRedirection, i.e. towel foldingSensitivity to Family as well!!