Cognitive Disorders

1. Cognitive Disorders Kimberly Gregg MS, APRN,BC N483

2. Objectives • Define 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.

3. Cognitive Disorders • Involve “assaults” on the human brain • Cognition 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”.

4. Non-dementia Cognitive Disorders • 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

5. Non-dementia Cognitive Disorders • 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…

6. Non-dementia Cognitive Disorders • 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 • Typically withdrawn and apathetic—but can be anxious and agitated.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.

7. Dementia • Dementia 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.

8. Reversible Dementias • Can be treated and symptoms may resolve or at least improve if caught early enough. • 2 types: Normal Pressure Hydrocephalus & Vitamin B12 Deficiency

9. Reversible Dementias • Normal 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).

10. Reversible Dementias • Vitamin 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.

11. Irreversible Dementias • No 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.

12. Irreversible 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.

13. Irreversible 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.

14. Irreversible Dementias • Vascular 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.

15. Irreversible Dementias • Frontotemporal 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.

16. Irreversible Dementias • Parkinson’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.

17. Irreversible Dementias • Diffuse 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.

18. Irreversible Dementias • Creutzfeldt-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.

19. Irreversible Dementias • AID’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.

20. Irreversible 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.

21. Irreversible 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.

22. Cognitive Disorder Treatment • SAFETY! • Daily cares as needed • Management of symptoms • NPR/NCR • Psychopharmacology: 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 time • Redirection, i.e. towel folding • Sensitivity to Family as well!!