02.12 Cognitive Impairment Disorders

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Overview

  1. Includes Autism-spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD), Dementia, Alzheimer’s Disease
    1. ASD and ADHD discussed in Peds course

Nursing Points

General

  1. Dementia definition: a broad category of brain diseases that is gradual and long-term  that results in self-care deficits, largely affecting their ability to function.
    1. There are various types that can affect people of varying ages and it can progress at different rates.  
    2. This results in judgement impairments, and issues problem solving and behavior.
  2. Alzheimer’s Disease definition:  Alzheimer’s is a TYPE of dementia and is an irreversible form caused by nerve cell deterioration.  
    1. There is a steady, progressive decline in functional capacity.

Assessment

  1. Apraxia: difficulty performing motor tasks
  2. Aphasia: difficulty progressing to inability to speak and understand what is being said to them
  3. Agnosia: doesn’t recognize familiar people or objects
  4. Amnesia: memory loss

Therapeutic Management

  1. Always educate family as disease progresses on best ways to interact to maximize time.
  2. Caregiver stress
    1. Role strain – i.e. child caring for parent
    2. Sadness due to loved one not recognizing them
  3. SAFETY
    1. Wandering can be an issue.  Units should be locked/secured, patients should be supervised.
    2. Watch water temperature – may burn themselves
    3. Remove anything toxic or hazardous from easy access
    4. Watch for agitation
      1. Remove things that increase agitation
    5. Decrease stimuli/reassure patient
    6. Never argue
    7. Use a calm, reassuring voice with gentle touch (when appropriate)
    8. Watch for sundowning (more issues at night)
  4. Communicate
    1. Needs will change as disease progresses
    2. Maintain eye contact
    3. Stand in front of them, be calm, firm, and direct with communication and tasks
    4. Simple one-step tasks/direction
    5. Use short, simple words
    6. Always identify them and yourself
    7. Reorient as needed (this may be very frequent)
  5. Promote their current abilities
    1. Keep familiar things around them
    2. Continually reinforce what they know and can do at this point in time
    3. Promote independence, supervise to ensure ADL’s are taken care of
    4. Utilize familiar simple games and activities they enjoy
      1. Pay attention to their TV and music preferences
      2. Coloring
      3. Talk about their memories
      4. Books they enjoy
      5. Maintain routine
      6. Pay attention for fatigue, memory strain, and agitation and provide ample time for rest
      7. Keep a calendar and clock on the wall and refer to it when discussing the date/time
    5. Provide positive reinforcement

Nursing Concepts

  1. Mood Affect
  2. Cognition
  3. Safety

Patient Education

  1. Educate family on their role in promoting independence and safety
  2. Provide resources for respite care

Reference Links

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Video Transcript

Okay, we’re going to talk about Cognitive Impairment Disorders.

There are actually 4 that fall into this category – Autism Spectrum Disorder, Attention Deficit Hyperactivity Disorder, Dementia, and Alzheimer’s. ASD and ADD/ADHD are discussed in the Peds course. Here in this lesson we want to focus specifically on Dementia and Alzheimer’s Disease.

So, first, we want you to understand that there are multiple types of dementia that may all have slightly different presentations and progressions, but these are the general characteristics. Dementia is a gradual progression of cognitive decline that ultimately affects a client’s ability to function. While some types progress faster than others, it is still gradual over months to years, not days to weeks. Clients will experience self-care deficits – they will struggle to perform normal ADLs or cook for themselves. They’ll have impaired judgment and problem solving – they lose the complex problem solving at first and as it progresses, even the more simple tasks are difficult. And we may even see some behavioral changes as their cognition declines, they may even get aggressive – sometimes out of fear or anxiety and sometimes because the neural connections are just firing differently.

Now, when we talk about Alzheimer’s, it is actually a TYPE of Dementia. So…all patients with Alzheimer’s have dementia, but not all patients with dementia have Alzheimer’s. To remember it, sometimes instead of said “Alzheimer’s Disease”, I will say “Alzheimer’s Dementia” or “Alzheimer’s Type Dementia”. It is a condition of irreversible nerve-cell deterioration. So you can see in this image that there is extreme atrophy, or shrinkage, of the cerebral cortex – that’s where the majority of our thought and memory is processed. So if you don’t remember anything, remember this cerebral atrophy – and you can imagine all the struggles that would come along with that!

So, what we see is a steady, progressive decline in functional capacity – remember there is no cure and it is irreversible. The 4 hallmark signs of Alzheimer’s Type Dementia are Apraxia, Aphasia, Agnosia, Anomia, and Amnesia – the 5 A’s. Apraxia is a difficulty performing motor tasks, starting with fine motor tasks and moving to the more gross motor tasks. Aphasia is difficulty with speech and recognizing language. Agnosia is when they don’t recognize familiar people or objects. Here’s how I remember this. Have you ever been out at a store or something and someone waves at you from across the store – they recognized your face, right? Obviously, they “knows ya”. Get it? So remember that when we put an A in front of anything it means not or they don’t – so in Alzheimer’s they see your face, but they don’t “knows ya”. So that’s agnosia. Now, anomia is similar except it’s a difficulty remember the name of the object – so they may say “oh, I know who that is or what that is, but I can’t think of the name”. Even looking at an apple, something they’ve seen and known their whole lives, they’ll struggle to come up with the word ‘apple’. And finally amnesia, that’s memory loss – and typically we see the short term memory go first. They’ll remember a story from when they were 12, but can’t remember what they had for breakfast. Remember this is a gradual, steady decline, so it will be little things at first like forgetting to turn the stove off, and it will progress more and more until they can’t even remember how to walk or talk or feed themselves.

There are four main nursing priorities in clients with Alzheimer’s and Dementia – the first is safety. Many clients have a tendency to wander, so we use alarms in our facilities, or they should wear a medical alert bracelet with emergency contact information on it. Sometimes they’ll go for a walk and not remember how to get home, so this is really important. We also want to be cautious with water temperature and toxic materials in the home because judgment will be impaired. And as they get more and more apraxia, they will be a high fall risk. We also see a lot of agitation and sundowning in later stages where their symptoms and agitation are worse in the evenings. We just want to decrease stimuli, reassure and reorient, and never argue – that just makes it worse.

The third priority is communication – always be calm, firm, and direct with what you need. Use simple one- or two-step directions. Always identify yourself and tell them what you’re going to be doing and reorient them as needed – this cuts down on the overwhelming confusion. And finally we want to promote independence for them as long as possible. Encourage them to perform their own ADL’s while they can, use familiar tasks or games and a routine to help them remember what to do – and allow time for reminiscing. Like I said they’ll remember stories from their childhood for a long time – so allowing them to talk about things they DO remember gives them a sense of security and safety.

Finally I just want to point out that we need to provide a lot of caregiver support as well – there will be role strain as we see adult children taking care of their parents. Make sure we are clear with them about the progression of the disease and give them tips and tricks for effective communication with their loved ones. And there are always respite care options that will allow them a break from the 24/7 care – this is SO beneficial, make sure you let them know they need to care for themselves as well.

So, priority nursing concepts, as we already talked about – safety, cognition, and communication.

Let’s recap quickly – Dementia is an umbrella condition of gradual cognitive decline – Alzheimer’s is a type of Dementia that involves progressive, irreversible nerve-cell deterioration and cerebral atrophy. The hallmark signs are the 5 A’s of Alzheimer’s – Apraxia, Aphasia, Agnosia, Anomia, and Amnesia. Our big nursing priorities are safety, behavior, communication, and independence. And, we always want to make sure we’re supporting the caregivers as well because this can be emotionally and physically exhausting.

So that’s it for Cognitive Impairment Disorders, specifically dementia and alzheimer’s disease. Make sure you check out the care plan and patient story attached to this lesson to learn more. Now, go out and be your best self today. And, as always, happy nursing!

Read more

  • Question 1 of 10

A 70-year-old client is worried about developing dementia because his father had Alzheimer’s disease at an early age. What lifestyle interventions would the nurse recommend that would potentially reduce this patients risk of dementia? Select all that apply.

  • Question 2 of 10

A 9-year-old child has been diagnosed with ADHD and is acting impulsively with hyperactivity. Which developmental activity would most likely be difficult for this child to achieve?

  • Question 3 of 10

A client is cognitively impaired. What techniques can the nurse use to facilitate communication? Select all that apply.

  • Question 4 of 10

A client who is cognitively impaired has become agitated and upset with the nursing staff. The nurse does not want to use restraints with the client but is struggling to keep her calm. Which is an example of an appropriate intervention that would be an alternative to using restraints?

  • Question 5 of 10

A 65-year-old woman has been diagnosed with Alzheimer’s disease and is suffering from repeated bouts of memory loss. The client asks the nurse, “How am I supposed to handle this? I do not think I can cope with having this many memory problems.” Which response from the nurse is most appropriate?

  • Question 6 of 10

Which medical condition has been shown to cause dementia in some adults?

  • Question 7 of 10

A nurse is caring for a client who has dementia as a result of Alzheimer’s disease. The provider writes an order for bilateral wrist bands for restraints prn. Which action of the nurse is most appropriate regarding this order?

  • Question 8 of 10

A 14-year-old teen has been hospitalized for acute exacerbation of ADHD symptoms. The nurse tries to help the client to engage with others on the unit. Which of the following interventions would be most appropriate for supporting social interaction for this client?

  • Question 9 of 10

A client with Alzheimer’s disease has been transferred to the medical unit accompanied by the spouse. The client is cognitively impaired and confused. The nurse assigns the client a room with low lighting near the nurse’s station. Which of the following best explains the reason for this room assignment?

  • Question 10 of 10

The parents of a child with autism talk with a nurse about their feelings of being overwhelmed in caring for their child. They state that they do not get a break from their child, the child’s needs are almost more than they can handle, and they are considering divorce. Which of the following initial responses from the nurse is most appropriate?