Copyright © 2014. F.A. Davis Company Neurocognitive Disorders Chapter 22

Copyright © 2014. F.A. Davis Company

Neurocognitive DisordersNeurocognitive DisordersChapter 22Chapter 22


IntroductionIntroduction

• Neurocognitive disorders are disorders in which a clinically significant deficit in cognition or memory exists representing a significant change from a previous level of functioning.


• The number of people with neurocognitive disorder is growing because more people now survive into the high-risk period for the disorder, which is age 65 and beyond.

Introduction Introduction (cont.)(cont.)


DeliriumDelirium

• Delirium is characterized by a disturbance in level of awareness and a change in cognition that develops rapidly over a short period.


• Symptoms

– Difficulty sustaining and shifting attention– Extreme distractibility– Disorganized thinking– Speech that is rambling, irrelevant, pressured, and

incoherent– Impaired reasoning ability and goal-directed

behavior– Disorientation to time and place

Delirium Delirium (cont.)(cont.)


• Symptoms (cont.)– Impairment of recent memory– Misperceptions about the environment, including

illusions and hallucinations– Disturbance in level of consciousness, with

interruption of the sleep-wake cycle– Psychomotor activity that fluctuates between

agitation and restlessness and a vegetative state– Emotional instability



• Symptoms include autonomic manifestations such as:– Tachycardia– Sweating– Flushed face– Dilated pupils – Elevated blood pressure



• Usually begins abruptly• Can have a slower onset if underlying etiology

is systemic illness or metabolic imbalance• Duration is usually brief

and subsides completely on recovery from underlying determinant



Predisposing FactorsPredisposing Factors

• Delirium Due to a General Medical Condition– Examples • Infections, febrile illness, metabolic disorders, head

trauma, seizures, migraine headaches, brain abscess, stroke, electrolyte imbalance, others


• Substance-Induced Delirium– May be caused by intoxication or withdrawal from

certain substances such as:• Anticholinergics, antihypertensives, corticosteroids,

anticonvulsants, analgesics, and others• Alcohol, amphetamines, cannabis, cocaine,

hallucinogens, inhalants, and others• Toxins, including organic solvents and fuels, lead,

mercury, arsenic, carbon monoxide, and others

Predisposing Factors Predisposing Factors (cont.)(cont.)


Neurocognitive Disorder Neurocognitive Disorder

• Impairment in the cognitive functions of thinking, reasoning, memory, learning, and speaking


• Neurocognitive disorder (NCD) may be classified as mild or major, depending on severity of symptoms.

• Mild NCD has also been called mild cognitive impairment.

• Major NCD constitutes what was previously described in the DSM as dementia.

Neurocognitive Disorder Neurocognitive Disorder (cont.)(cont.)


• Primary NCDs are those in which the disorder itself is the major sign of some organic brain disease not directly related to any other organic illness (e.g., Alzheimer’s disease)

• Secondary NCDs are caused by or related to another disease or condition (e.g., HIV disease or cerebral trauma)



• Symptoms – Impairment exists in abstract thinking,

judgment, and impulse control.– Conventional rules of social conduct are

disregarded.– Personal appearance and hygiene are

neglected.



• Symptoms (cont.)– Language may or may not be affected.– Personality change is common.



• Reversible NCD may be more appropriately termed temporary.

• It can occur as a result of: – Stroke– Depression– Side effects of medications– Nutritional deficiencies– Metabolic disorders



• As the disease progresses, symptoms may include:– Aphasia – Apraxia– Irritability and moodiness, with sudden outbursts

over trivial issues– Inability to care for personal needs independently– Wandering away from the home – Incontinence



• Alzheimer’s disease (AD) accounts for 50 to 60 percent of all cases of NCD.– AD can be described in stages:• Stage 1. No apparent symptoms• Stage 2. Forgetfulness• Stage 3. Mild cognitive decline



– Stages of Alzheimer’s disease (cont.):• Stage 4. Mild-to-moderate cognitive decline• Stage 5. Moderate cognitive decline• Stage 6. Moderate-to-severe cognitive decline• Stage 7. Severe cognitive decline



1. Hospitalized and diagnosed in the fourth stage of NCD due to Alzheimer’s disease, a client, when asked about the previous evening, describes a wonderful evening spent on a cruise. Which symptom is the client exhibiting?

A. AphasiaB. ConfabulationC. DeliriumD. Apraxia



• Correct answer: B– Confabulation is a behavioral reaction to memory

loss in which the client fills in memory gaps with information about events that have not occurred. During the fourth stage of Alzheimer’s dementia, a client will use confabulation in an effort to maintain self-esteem.



Predisposing FactorsPredisposing Factors

• NCD Due to Alzheimer’s Disease– Onset is slow and insidious.– Course of the disorder is generally progressive

and deteriorating.


• NCD Due to Alzheimer’s Disease (cont.)– Etiologies may include:• Acetylcholine alterations• Plaques and Tangles• Head trauma• Genetic factors



2. A client is newly diagnosed with second stage NCD due to Alzheimer’s disease. Which cognitive change would a nurse observe?

A. Memory disturbanceB. ConfabulationC. ApraxiaD. Inability to plan or organize



• Correct answer: A– In the second stage of the illness, losses in short-

term memory are common and the individual may begin to lose things or forget names of people. It’s at this stage that a diagnosis may be considered.



• Vascular NCD– NCD occurs as a result of significant

cerebrovascular disease.– There is a more abrupt onset than is seen in

association with Alzheimer’s disease, and the course is more variable.



• Vascular NCD (cont.)– Etiologies may include:• Hypertension• Cerebral emboli• Cerebral thrombosis



• Frontotemporal NCD– Occurs as a result of shrinking of the frontal and

temporal anterior lobes of the brain– Previously called Pick’s disease– Exact cause is unknown, but genetics appears to

be a factor



• NCD Due to Traumatic Brain Injury– Amnesia is the most common neurobehavioral

symptom following head trauma.– Repeated head trauma can result in dementia

pugilistica with symptoms of:– Emotional liability– Dysarthria– Ataxia– Impulsivity



• NCD Due to Lewy Body Disease– Similar to Alzheimer’s disease, but progresses

more rapidly– Appearance of Lewy bodies in the cerebral cortex

and brainstem– Progressive and irreversible– May account for 25 percent of all NCD cases



• NCD Due to Parkinson’s Disease– This is caused by a loss of nerve cells located in

the substantia nigra and a decrease in dopamine activity.

– Cerebral changes in NCD due to Parkinson’s disease sometimes resemble those of Alzheimer’s disease.



• NCD Due to HIV Infection– Caused by brain infections with opportunistic

organisms or by the HIV-1 virus directly.– Symptoms may range from barely perceptible

changes to acute delirium to profound cognitive impairment.



• Substance-Induced NCD– Occurs as a result of reactions to, or the overuse

or abuse of, substances such as:• Alcohol• Inhalants• Sedatives, hypnotics, and anxiolytics• Medications that cause anticholinergic site effects• Toxins, such as lead and mercury



• NCD Due to Huntington’s Disease– This disease is transmitted as a Mendelian

dominant gene.– Damage occurs in the areas of the basal ganglia

and the cerebral cortex.– The client usually declines into a profound state

of cognitive impairment and ataxia.– Average course of the disease is based on age at

onset, with juvenile-onset and late-onset having the shortest duration.



• NCD Due to Prion Disease– The disorder is attributable to prion disease (e.g.,

Creutzfeldt-Jakob disease or bovine spongiform encephalopathy).

– Onset of symptoms typically occurs between ages 40 and 60 years; course is extremely rapid with progression from diagnosis to death in less than 2 years.

– Five to 15 percent of cases have a genetic component.



• NCD Due to Another Medical Condition‒ Hypothyroidism‒ Hyperparathyroidism‒ Pituitary insufficiency‒ Uremia‒ Encephalitis‒ Brain tumor‒ Pernicious anemia‒ Thiamine deficiency‒ Multiple sclerosis

‒ Pellagra‒ Uncontrolled epilepsy‒ Cardiopulmonary

insufficiency‒ Fluid and electrolyte

imbalances‒ CNS and systemic infections‒ Systemic lupus

erythematosus



3. Which statement is true about vascular NCD?

A. Vascular NCD is reversible.B. Vascular NCD is characterized by plaques and

tangles in the brain.C. Vascular NCD involves a gradual, progressive

cognitive deterioration.D. Vascular NCD involves a variable pattern of

cognitive functioning.



• Correct answer: D– In vascular NCD, clients suffer the equivalent of small

strokes that destroy many areas of the brain. The pattern of deficits is variable, depending on which regions of the brain have been affected.



Application of the Nursing Application of the Nursing Process/AssessmentProcess/Assessment

• The Client History– Areas of concern to be addressed:• Type, frequency, and severity of mood swings • Personality and behavioral changes • Catastrophic emotional reactions• Cognitive changes • Language difficulties


• The Client History (cont.)– Areas of concern to be addressed (cont.)• Orientation to person, place, time, and situation• Appropriateness of social behavior• Current and past use of medications, drugs, and

alcohol• Possible exposure to toxins• Client and family history of specific illnesses

Application of the Nursing Application of the Nursing Process/Assessment Process/Assessment (cont.)(cont.)


• Physical Assessment– Assessment for diseases of various organ systems

that can induce confusion, loss of memory, and behavioral changes



• Physical Assessment (cont.)– Neurological examination to assess mental status,

alertness, muscle strength, reflexes, sensory perception, language skills, and coordination



• Physical Assessment (cont.)– Psychological tests to differentiate between

NCD and pseudodementia (depression)



• Diagnostic Laboratory Evaluations– Include blood and urine to test for the following:• Various infections• Hepatic and renal dysfunctions• Diabetes or hypoglycemia• Electrolyte imbalances• Metabolic and endocrine disorders• Nutritional deficiencies• Presence of toxic substances



• Other diagnostic evaluations may include:– Electroencephalogram (EEG)– Computed tomography (CT) scan– Positron emission tomography (PET)– Magnetic resonance imaging (MRI)– Lumbar puncture to examine cerebrospinal

fluid (CSF)



Nursing Diagnosis/Outcome Nursing Diagnosis/Outcome IdentificationIdentification

• Risk for trauma • Disturbed thought processes• Impaired memory• Disturbed sensory perception• Risk for other-directed violence• Impaired verbal communication• Self-care deficit• Situational low self-esteem• Grieving


Outcome CriteriaOutcome Criteria

• The Client:– Has not experienced physical injury.– Has not harmed self or others.– Has maintained reality orientation to the best

of his or her capability.– Discusses positive aspects about self and life.– Participates in activities of daily living with

assistance.


Planning/ImplementationPlanning/Implementation

• Care plan for the client with a cognitive disorder is aimed at:– Protection of self and others– Maintaining orientation to reality to the best of

client’s ability– Minimizing confusion– Fulfilling basic needs– Assisting and educating prospective caregivers

about appropriate care for the client


Client/Family EducationClient/Family Education

• Nature of the Illness– Possible causes– What to expect– Symptoms


• Management of the Illness– Ways to ensure client safety– How to maintain reality orientation– Provide assistance with activities of daily living– Nutritional information– Difficult behaviors– Medication administration– Matters related to hygiene and toileting

Client/Family Education Client/Family Education (cont.)(cont.)


• Support Services– Financial assistance– Legal assistance– Caregiver support groups– Respite care– Home health care

Client/Family Education Client/Family Education (cont.)(cont.)


Nursing Process: EvaluationNursing Process: Evaluation

• Based on the accomplishment of outcome criteria


Medical Treatment ModalitiesMedical Treatment Modalities

• Delirium– Determination and correction of the underlying

causes– Staff to remain with client at all times to monitor

behavior and provide reorientation and assurance


• Delirium (cont.)– Room with low stimulus level – Low-dose antipsychotic agents to relieve agitation

and aggression– Benzodiazepines commonly used when etiology is

substance withdrawal

Medical Treatment ModalitiesMedical Treatment Modalities (cont.) (cont.)


• NCD– Primary consideration is given to etiology,

with focus on identification and resolution of potentially reversible processes.



• NCD (cont.)– Pharmaceutical agents• For cognitive impairment:– Physostigmine (Antilirium)– Donepezil (Aricept)– Rivastigmine (Exelon) – Galantamine (Razadyne)– Memantine (Namenda)



– Pharmaceutical agents for NCDs (cont.)• For agitation, aggression, hallucinations, thought

disturbances, and wandering:– Risperidone (Risperdal)–Olanzapine (Zyprexa)–Quetiapine (Seroquel)– Ziprasidone (Geodon)

– These drugs cause fewer anticholinergic and EPS than older antipsychotics.

– They carry a black-box warning that all antipsychotics are associated with an increased risk of death in elderly patients with NCD.



‒ Pharmaceutical agents for NCDs (cont.)• For agitation, aggression, hallucinations, thought

disturbances, and wandering (cont.):

– Haloperidol (Haldol)• Still commonly used because of its proven

efficacy• Higher potential for anticholinergic, EPS, and

sedative effects than with the atypical antipsychotics

• Carries black-box warning that it is associated with increased risk of death in elderly patients with NCD



4. A client has recently been diagnosed with mild to moderate NCD due to Alzheimer’s disease. Which medication would the nurse expect the physician to order for this client’s cognitive impairment?

A. Nortriptyline (Pamelor)B. Zaleplon (Sonata)C. Donepezil (Aricept)D. Quetiapine (Seroquel)



• Correct answer: C– Donepezil is used to improve cognition in clients

diagnosed with mild to moderate dementia associated with Alzheimer’s disease. Its action improves cholinergic function by inhibiting acetylcholinesterase.



‒ Pharmaceutical agents for NCDs (cont.)• For depression:

– SSRIs• Often considered first line due to favorable side

effect profile– Tricyclic antidepressants• Often avoided due to anticholinergic and cardiac

side effects– Trazodone (Desyrel)• Good choice for clients with insomnia

– Dopaminergic agents• Helpful in treatment of severe apathy



‒ Pharmaceutical agents for NCDs (cont.)• For anxiety (should not be used routinely for prolonged

periods):– Chlordiazepoxide (Librium)– Alprazolam (Xanax)– Lorazepam (Ativan)– Oxazepam (Serax)– Diazepam (Valium)



‒ Pharmaceutical agents for NCDs (cont.)• For sleep disturbances (for short-term therapy only):

– Flurazepam (Dalmane)– Temazepam (Restoril)– Triazolam (Halcion)– Zolpidem (Ambien)– Zaleplon (Sonata)– Ramelteon (Rozerem)– Eszopiclone (Lunesta)– Trazodone (Desyrel)– Mirtazapine (Remeron)



‒ Pharmaceutical agents for NCDs (cont.)• Dosage adjustments with regard to physiological

changes in aging clients must be made with all medications.


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Copyright © 2014. F.A. Davis Company Neurocognitive Disorders Chapter 22