Neurocognitive Disorders

BY HIWOT G.(BSC, MSC)

• Symptoms
• Diagnosis
• Frequency of Delirium and Dementia
• Causes
• Treatment and Management
• By the end of this course,
participants will be able to:
–Define “dementia”, Delirium and
Amnestic disorder

–Formulate and implement treatment

plan for patients with various types of
dementia, delirium, and amnestic
disorder
• Language
• Slower getting words from brain (late in life).
• Intelligence-
• Little slower solving problems
• Memory- decline in processing
of information
 Advances in molecular biology diagnostic techniques
and medication management have significantly
improved the ability to recognize and treat cognitive
disorders.
 Cognition includes memory, language, orientation,
judgment, conducting interpersonal relationships,
performing actions and problem solving.
 Cognitive disorders reflect disruption in one or more
of these domains and are frequently complicated by
behavioral symptoms.
 This century-old distinction between organic and
functional disorders is outdated and has been
deleted from the nomenclature.
 Every psychiatric disorder has an organic (i.e.,
biological or chemical) component.
 Because of this reassessment, the concept of
functional disorders has been determined to be
misleading, and the term functional and its
historical opposite, organic, are no longer used in
the current DSM nomenclature.
Delirium
 Delirium is marked by short-term confusion and

changes in cognition.
 There are four subcategories based on several
causes: (1) general medical condition (e.g.,
infection), (2) substance induced (e.g., cocaine,
opioids, (3) multiple causes (e.g., head trauma
and kidney disease), and (4) other or multiple
etiologies (e.g., sleep deprivation).
 Dementia, also referred to as major neurocognitive
disorder in the fifth edition of DSM (DSM-5), is marked
by severe impairment in memory, judgment,
orientation, and cognition.
 The subcategories are (1) dementia of the Alzheimer’s
type, which usually occurs in persons older than 65
years of age and is manifested by progressive
intellectual disorientation and dementia, delusions, or
depression;

 (2) vascular dementia, caused by vessel
thrombosis or hemorrhage;
 (3) human immunodeficiency virus (HIV)
disease; (4) head trauma;
 (5) Pick’s disease or front temporal lobar
degeneration;
 (6) Prion disease such as Creutzfeldt-Jakob
disease, which is caused by a slow-growing
transmittable virus);

 (7) substance induced, caused by toxin or
medication (e.g., gasoline fumes, atropine);
 (8) multiple etiologies;
 and (9) not specified (if cause is unknown).
 Amnestic disorders are classified in DSM-5 as major
neurocognitive disorders caused by other medical
conditions.
 They are marked primarily by memory impairment in
addition to other cognitive symptoms.
 They may be caused by (1) medical conditions
(hypoxia),
 (2) toxins or medications (e.g., marijuana, diazepam),
and (3) unknown causes.
Delirium
 The primary symptom of delirium is clouding
of consciousness in association with a reduced
ability to maintain and shift attention.
 The person’s thinking appears disorganized,
and he or she may speak in a rambling,
incoherent fashion.
 Short perceptual disturbances, including
 The symptoms of delirium follow a rapid
onset—from a few hours to several days—and
typically fluctuate throughout the day.
 The person may alternate between extreme
confusion and periods in which he or she is
more rational and clearheaded.
 Symptoms are usually worse at night.
 See the prevalence of Delirium from
your DSM-5
It is a rapidly developing, fluctuating state of
reduced awareness in which the following are
true:
 Delirium often starts with reduced clarity
or awareness of the environment; i.e., with
reduced ability to focus, sustain, or shift
 The client has at least one deficit of
memory, orientation, language, or
perception, and
 The disturbance develops over a short
period of time (usually hours to days)
and tends to fluctuate during the course
of the day.
 Disturbance in attention or cognition
 Acute onset
 Change from baseline
 Fluctuating severity
 Level of impairment does not occur in the
context of coma
1.Acute Onset and Fluctuating Course
2.unable to focus or pay attention
3.Disorganized thinking
4.Altered Level of consciousness
To diagnose delirium by CAM you need 1
and 2 with either 3 or 4.
Delirium is a symptom. That means you must
recognize it and decide what is causing it ;
NOT just treat it
 If the condition is allowed to progress, the
person’s senses may become dulled, and he
or she may eventually lapse into a coma.
 It isn’t always easy to recognize the difference
between dementia and delirium, especially
when they appear simultaneously in the same
patient.
1. Delirium Due to the General Medical Condition]

Delirium can be caused by trauma to the brain,

infections, epilepsy, endocrine disorders, toxicity
from medications, poisons, and various other
diseases throughout the body.
2. Substance-Induced Delirium.
Alcohol and other sedative drugs of abuse, as well
as nearly every class of street drug, including
medications can cause delirium.
Types
a. Substance Intoxication Delirium
b. Substance Withdrawal Delirium
3. Delirium Due to Multiple Etiologies. This
diagnosis is used when more than one cause for
delirium is identified in the same client

4. Delirium NOS. NOS Used for a delirium that does

not meet criteria for any specific types of
described in the DSM section.
 The underlying mechanisms responsible for
the onset of delirium involve neuropathology
and neurochemistry.
 Delirium can be caused by many different
kinds of medication.
 Delirium also develops in conjunction with a
number of metabolic diseases as well as
endocrine diseases.
A medical emergency
 Triggered by
• Oxygen deprivation
• Drug use/poisons, meds
• Infections, recent surgery, or trauma
• Severe chronic illness
• Electrolyte imbalances
• Pre-morbid brain conditions, and functional status
• Preexisting cognitive impairment
• Old age/ sensory losses
There are dozens of causes of delirium!
D Drugs
 E Eyes, ears
 L Low oxygen states (hypoxia, MI, stroke)
 I Infection
 R Retention of urine or stool
 I Ictal
 U Under hydration, under nutrition
(hypoglycemia, thiamine deficiency)
 M Metabolic
 Hypoxia & Hypoglycemia
 Sepsis

• May present with fever or hypothermia

 Hypertensive Encephalopathy
• Reduce blood pressure appropriately
 Wernicke’s Encephalopathy
• Uncommon

• Alcoholic or malnutritioned patients

• Tx: empirically with Thiamine (high dose, more than)

 Drug overdose (opiates, benzos, etc.)

 Acute neurologic disorders
• Meningitis and subarachnoid hemorrhage

• Confusion, headache, or fever

 Acute or delayed CNS trauma

• Subdural hematoma

 Seizures

• Postictal state

• Some seizures may present without convulsions and

persistent confusion (status epilepticus)
 DELIRIUM

Adequate Oxygen
and
YES Blood Glucose NO

Fever or other Correct as

signs of needed
infections? Determine cause
 Fever or other
signs of
infection?
YES NO

Do history and
Search for physical exam
source suggest likely
cause of altered
behavior?
YES NO

Pursue likely Diagnosis

cause Uncertain
 Diagnosis
Uncertain

Basic Testing:
CBC, Electrolytes, UA, ECG,
CXR

Advanced testing or consulting as need:

EEG, head CT, consults
 Delirium is a medical emergency and
investigations to detect the underlying
pathology should be carried out without
delay.
 thoroughly taken history, particularly related
to medications and substance use.
 The mental status examination should focus on
the cognitive functioning of the patient.
 The clinical examination may be aided by
“mini” tests which can be administered at the
bedside.
 A neurological examination may give reliable
cues.
 Lab. tests include a full or a complete
haematogram and urine analysis, serum
electrolytes, and LFT.
 CSF, EEG, is valuable and will show changes in
rhythm and slowing.
 encourage adequate fluids
 glasses, hearing aids
 quiet rooms, well light
 re-orientation - clocks, calendars
 personal items
 encourage self-care and mobility
 avoid frequent staffing changes
 avoid catheters, iv lines
 only use when patient is distressed, or is a
danger to themselves or others
 use small amounts
 be acutely aware of side-effects - including
INCREASE in agitation
 Hospitalization, preferably in ICU is indicated
and treatment should be directed at the
underlying cause.
 Metabolic abnormalities are corrected and
hydration and nutrition cared for.
 To control agitation and restlessness,
sedatives, both major and minor tranquilizers,
are given with hypnotics as needed to ensure
proper sleep.
 For patients who are at risk of developing
seizures, anticonvulsant are necessary.
 Patient should be nursed in an environment
with optimum sensory stimuli.
 Too much or too little sensory stimulation may
be harmful.
 The room should be quiet and adequately
lighted except for those sensory deprivation.
 Frequent change of nursing personnel is
to be avoided so that the patient is
familiar with the attending staff.
 Relatives should be encouraged to visit
the patient frequently for the same
reason.
 Soft physical restrains may be needed in
case of severe restlessness and
excitement.
 Preventive strategies include
identification of risk factors (risk
stratification) and managing them.
 Four risk factors identified in one study
are:
- visual impairment
- dehydration
- severe illness
- pre-existing cognitive impairment.
 The two major symptoms of delirium that
may require pharmacological treatment
are psychosis and insomnia.
 The drug of choice for psychosis is
haloperidol (Haldol), a butyrophenone
antipsychotic drug.
 Depending on the patient’s age, weight,
and physical condition, the initial dose
may range from 2-10 mg IM, repeated in
an hour if the patient remains agitated.
 As soon as the patient is calm, oral
medication in liquid concentrate or tablet
form should begin.
 Two daily oral doses should suffice, with
two thirds of the being given at bedtime.
 To achieve the same therapeutic effect,
the oral dose should be about 1.5 times
higher than the parenteral dose.
 The effective total daily dosage of
haloperidol may range from 5-30 mg for
the majority of the delirious patients.
 Phenothiazines should be avoided in
delirious patients, because of their
anticholinergic activity.
 Insomnia is best treated with either
benzodiazepines with short half-lives.
 Benzodiazepines with long half-lives and
barbiturates should be avoided unless
thy are being used as part of the
treatment for the underlying disorder-
e.g., alcohol withdrawal.
 Haloperidol
 not much postural hypotension
 lots of extra pyramidal/ or PARKINSONIAN side
effects - rigidity, tardive dyskinesia
 DON’T give to patients with hx Parkinson’s
 Atypical anti-Psychotics
 Olanzapine, Quetiapine, Risperidone

 Benzodiazepines
 Can be for a long time!
 Identify high risk patients
 Do cognitive assessment as routine
 reduce bad drugs
 maintain adequate analgesia
 maintain Oxygenation
 try not to move patients
 use the same nurse if possible
 familiar things - pictures from home, clothes,
books
RISK FACTORS INTERVENTION
 Cognitive impairment  Routine mental status
assessment, staff education
 Dehydration/electrolyte  Non pharmacologic sleep
imbalance aids, decreased noise and
 Sensory deprivation/ sleep light at night, frequent rest
disturbances periods, daytime activities
 Staff education of
 Pharmacy medication side effects,
pharmacy liaison, start low
go slow
 Confusion with altered Concentration +
Consciousness
 Lots of Risk factors – dementia and blindness
 Look for and treat underlying causes
 Get history from family/friends
 Avoid changing rooms
 Try familiar items,
 Remember sedatives can make it worse!
 Unless adequately treated, delirium has a high
mortality and may progress to death or
permanent dementia.
 Most cases clear without any residual
symptoms.
 Dementia is a collection of
symptoms resulting from
disease or injury to the brain.
 It is
this means it typically gets
over time.
 May progress slowly or quickly
 May affect younger persons as well as elderly
 Different kinds of dementia
 Treatment generally depends on the stage/
severity of the disease
 Becoming old doesn’t mean you will develop
dementia
 Is terrifying while the client is still able to
realize that they are not thinking properly
 Nature of Dementia
• Gradual deterioration of brain functioning
• Affects judgment, memory, language, and other
cognitive processes
• Dementia has many causes and may be reversible or
irreversible
 Progression of Dementia: Initial Stages
• Memory impairment, visuospatial skills deficits
• Agnosia – inability to recognize and name objects
(most common symptom)
• Facial agnosia – inability to recognize familiar faces
• Other symptoms – delusions, depression, agitation,
aggression, and apathy
 Amnesia
 Aphasia
 Apraxia
 Agnosia
 Agitation
 Recent Memory
• Recent memory is most difficult for people with
dementia.
 Cannot store information
 Cannot retrieve stored information
 Long-Term Memory
• Store information from
months or years ago.
• These are often the only
memories individuals
with dementia can
remember.
 Cannot understand speech
• Will not be able to respond appropriately
because they do not understand what you are
saying.
 Cannot produce speech
• Difficulty finding words
• Jumble words
 Canno longer perform tasks they have
done throughout their lives.
• Cooking
• Operating appliances
• Dressing
• Bathing
• Eating
 Inability to correctly recognize images.
• People
• Animals
• Objects
 Alsolose ability to
identify scents (smells)
and touch.
• Agitation is common in
dementia & more likely if-
– Have discomfort
• Thirsty
• Need to urinate
• Too hot or cold
– Environment too
stimulating
• Noisy
• Too many people
 Progression of Dementia: Later Stages
• Cognitive functioning continues to
deteriorate
• Person requires almost total support to carry
out day-to-day activities
• Death results from inactivity combined with
onset of other illnesses
 By the final stages of dementia, intellectual
and motor functions may disappear almost
completely.
 The diagnostic hallmark of dementia is
memory loss.
 Retrograde amnesia refers to the loss of
memory for events prior to the onset of an
illness or the experience of a traumatic event.
 Anterograde amnesia refers to the
inability to learn or remember new
material after a particular point in time.
 Anterograde amnesia is usually the most
obvious problem during the beginning
stages of dementia.
 Another manifestation of cognitive
impairment in dementia is loss of the ability to
think in abstract ways.
 Related to deficits in abstract reasoning is the
failure of social judgment and problem-
solving skills.
Dementia is an impairment in memory with
associated cognitive disturbances.
• Dementia means “loss,” so there must be a decline
from a previous level of functioning – usually a
gradual decline.
• In addition to memory loss, client must show at
least one other cognitive deficit: aphasia, apraxia,
agnosia, or loss of executive functioning.
 Dementia cannot be diagnosed if the
symptoms occur only when the client is
delirious
 Dementia may be caused by a
nonpsychiatric medical condition, a
substance, or a mixture of the two
problems.
1. Dementia of the Alzheimer’s Type
a. Most common cause of senility
b. Begins gradually and usually progresses
relentlessly
c. More than 50% all dementias are Alzheimer’s type
2. Vascular Dementia
a. Due to vascular brain disease
b. A stepwise process, with relatively sudden onset
and a fluctuating course
c. About 10-20% of dementias are vascular
3. Dementia Due to … HIV disease, Head
Trauma, Parkinson’s Disease,
Huntington’s Disease, Pick’s Disease,
Creutzfeldt-Jakob disease (infection by
a slow virus), and Other GMC. Most
common toxins causing dementia are
those resulting from kidney and liver
failure.
4. Substance-Induced Persisting Dementia.
5-10% are related to prolonged use of
alcohol, inhalants, or sedatives
5. Dementia Due to Multiple Etiologies. Use
this category when client has more than one
of the
causes above
5. Dementia NOS.
Use this category when you know the client
is demented, but you don’t know why
 What is AD?

Alzheimer’s disease is an
irreversible, progressive brain
disease that slowly destroys
memory and thinking skills.

Although the risk of developing AD increases with age – in

most people with AD, symptoms first appear after age 65 –
AD is not a part of normal aging. It is caused by a fatal
disease that affects the brain.

Slide 4
What is AD?

AD Statistics….
• AD is the most common
cause of dementia among
people age 65 and older.
• Scientists estimate that
around 4.5 million people
now have AD. • By 2050, 13.2 million older
• For every 5-year age Americans are expected to have
group beyond 65, the AD if the current numbers hold
percentage of people with
AD doubles. and no preventive treatments
become available.

Slide 5
What is AD?
Where are people with AD cared for?
• home
• assisted living facilities (those in
the early stages)
• nursing homes (special care units)

• The national cost of caring for

people with AD is about $100
billion every year.

Slide 6
 People with Amnestic disorders experience
memory impairments that are more limited than
those seen in dementia or delirium.
 The person loses the ability to learn new
information or becomes unable to recall
previously learned information, but other higher
level cognitive abilities—including the use of
language—are unaffected.
 Because of the close link between cognitive
disorders and brain disease, patients with these
problems are often diagnosed and treated by
neurologists, physicians who deal primarily with
diseases of the brain and the nervous system.
 Multidisciplinary clinical teams study and
provide care for people with dementia and
Amnestic disorders.
 Direct care to patients and their families is
usually provided by nurses and social workers.
NORMAL BRAIN PLAQUES & TANGLES
 Dr. Aloysius "Alois" Alzheimer (14 June
1864 – 19 December 1915)was a German
psychiatrist and neuropathologist and a
colleague of Emil Kraepelin. Alzheimer is
credited with identifying the first published
case of "presenile dementia", which
Kraepelin would later identify as Alzheimer's
disease
 Alzheimer's disease, named after the doctor
who first described it (Alois Alzheimer), is a
physical disease that affects the brain.
 There are more than 520,000 people in the UK
with Alzheimer's disease.
 During the course of the disease, proteins
build up in the brain to form structures called
'plaques' and 'tangles'.
 This leads to the loss of connections between
nerve cells, and eventually to the death of
nerve cells and loss of brain tissue.
 Increasing forgetfulness about recent
activities or events
 Forget to take medications
 Forget what was eaten for breakfast
 Forget where things were placed
 Forget information you were just given
• Changes in how people act and behave.
• Can’t follow a conversation
• Respond inappropriately or in a way that is
very different from their past behavior
patterns
• Decreased ability to perform tasks
requiring reasoning and higher level
mental skills.
• Forget how to count correct change
• Forget how to drive to familiar places
• Have increasingly greater difficulty with
memory.
• Eventually will not know their loved ones or
themselves
• Will not remember simple directions
• Become unable to perform daily tasks.
• Bathing
• Dressing
• Eating
• Become unable to communicate through
language.
• Display more behavior changes.
• Agitation
• Wandering
• Continuously repeat verbal and/or physical
behaviors
• Eventually be unable to walk or care for
self in any way.
 Range of Cognitive Deficits
• Aphasia – difficulty with language
• Apraxia – impaired motor functioning
• Agnosia – failure to recognize objects
• Difficulties with planning, organizing,
sequencing, or abstracting information
• Impairments have a marked negative impact
on social and occupational functioning
Nature and Progression of the Disease
• Deterioration is slow during the early
and later stages, but rapid during
middle stages
• Average survival time is about 8 years
• Onset usually occurs in the 60s or 70s,
but may occur earlier
 Vascular Dementia
• Acquired mental changes from damage due to
disease of the vessels in the brain.
• Stroke is the most common cause of
damage.
• Damage may happen in a step by step
progression over time.
• Changes caused by many small strokes over
time.
 Nature of Vascular Dementia
• Progressive brain disorder caused by
blockage or damage to blood vessels
• Second leading cause of dementia next to
Alzheimer’s
• Onset is often sudden (e.g., stroke)
• Patterns of impairment are variable, and
most require formal care in later stages
 Substance-Induced Persisting Dementia
• Results from drug use in combination with
poor diet
• Examples include alcohol, inhalants,
sedative, hypnotic drugs
• Resulting brain damage may be permanent
• Dementia is similar to that of Alzheimer’s
• Deficits may include aphasia, apraxia or
agnosia
 To diagnose a dementia, multiple cognitive
deficits must be present
 With dementia, impairment in the ability to
focus or shift attention is not prominent
 The cause of dementia is usually found within
the central nervous system; the cause of
delirium is often found elsewhere in the body
 Dementia is relatively fixed (unchanging), as
compared to delirium.
 Although a client occasionally recovers from
dementia, this is not usual.
 One important consideration involves the
period of time over which the symptoms
appear.
 Delirium has a rapid onset, whereas dementia
develops in a slow, progressive manner.
 In dementia, the person usually remains alert
and responsive to the environment.
 Speech is most often coherent in demented
patients, at least until the end stages of the
disorder, but it is typically confused in
delirious patients.
 Finally, delirium can be resolved, whereas
dementia cannot.
 DELIRIUM
 Acute
 Reversible
 Consciousness: fluctuating
 Decreased awareness of self
 Perceptions: illusions,
hallucinations common
 Speech: slow, incoherent
 Disorientation: time, others
 Cognitive dysfunction
 Illness, med. toxicity: often
 Diurnal disruptions
 Outcome: excellent if
corrected early
DEMENTIA
 Gradual
 Irreversible
 Consciousness: rarely alters
 Decreased awareness of self
 Perceptions: Hallucinations not
common
 Speech: repetitive difficulty
finding words
 Disorientation: time, person,
place
 Memory impairment
 Illness, med. toxicity: rarely
 Diurnal disruptions
 Outcome: poor
 When a person clearly suffers from a primary
type of dementia, such as dementia of the
Alzheimer’s type, a return to previous levels of
functioning is extremely unlikely.
 No form of treatment is presently capable of
producing sustained and clinically significant
improvement in cognitive functioning for
patients with Alzheimer’s disease.
 Realistic goals include helping the person to
maintain his or her level of functioning for as long
as possible in spite of cognitive impairment and
minimizing the level of distress experienced by
the person and the person’s family.
 Some drugs are designed to relieve cognitive
symptoms of dementia by boosting the action of
acetylcholine (ACh), a neurotransmitter that is
involved in memory and whose level is reduced
 New drug treatments are being pursued that
are aimed more directly at the processes by
which neurons are destroyed.
 Although the cognitive deficits associated with
primary dementia cannot be completely
reversed with medication, neuroleptic
medication can be used to treat some patients
who develop psychotic symptoms.
 Foragitation, aggression, hallucinations, thought
disturbances, and wandering
• Risperidone (Risperdal)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Ziprasidone (Geodon)
• Haloperidol (Haldol)
 For depression
• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Citalopram (Celexa)
• Paroxetine (Paxil)
 For
anxiety (should not be used routinely for
prolonged periods)
• Chlordiazepoxide (Librium)
• Alprazolam (Xanax)
• Lorazepam (Ativan)
• Oxazepam (Serax)
• Diazepam (Valium)
 For sleep disturbances (for short-term therapy only)
• Flurazepam (Dalmane)
• Temazepam (Restoril)
• Triazolam (Halcion)
• Zolpidem (Ambien)
• Aleplon (Sonata)
• Trazodone (Desyrel)
 Patients with dementia experience fewer
emotional problems and are less likely to
become agitated if they follow a structured
and predictable daily schedule.
 Severely impaired patients often reside in
nursing homes and hospitals.
 The most effective residential treatment
programs combine the use of medication and
behavioral interventions with an environment
that is specifically designed to maximize the
level of functioning and minimize the
emotional distress of patients who are
cognitively impaired.
 One important issue related to patient
 It is useful to help the person remain active
and interested in everyday events.
 Patients who are physically active are less
likely to have problems with agitation, and
they may sleep better.
 Social interactions are often troublesome for
patients with dementia due to distorted views
 Is often what relationships are built on

 When communication
becomes faulty our
relationships crumble

 Our communication
strategies can help an
older adult with advancing
dementia feel safe, less
anxious, and less likely to
become upset or aggressive
• Gain the persons attention
• Turn off extraneous noise
• Stand in front of the person and
maintain eye contact
• Go slow, direct and redirect their
attention
• Do not shout!

• Do not speak in a condescending tone

• Speak slowly
• Use adult language

• Concrete simple language, short phrases

• Be positive and reassuring

• Don’t talk about the person as if they weren’t

there
• Use 2 choice questions like do you
want juice or soda?
• Are you hungry?
• Are you tired?
• Can I read to you?
 This is a difficult strategy but is helpful to
maintain conversation and helps fill in the
missing information the person with dementia
may omit
 Repeating-helps fill in speech Ex: I want a cup of…. If
you repeat this the elder may add the word coffee,
water or juice
 Rephrasing- helps the person hear the
corrected response if they say juice you might
point to a juice container and say I want a
glass of juice
 Repairing-uses both tactics to fix or fill in
missing information for example a person
points at a pantry cabinet and says, “look
there.”, you might say, “your Hungry?”
 You won’t win

 The person with dementia is not trying to be

disagreeable they are usually unaware that they

are making mistakes
 If the person is in immediate danger then
correcting the thought or behavior might be
appropriate. If not
 DON”T ARGUE you will only cause
 In the United States, spouses and other family
members provide primary care for more than 80
percent of people who have dementia of the
Alzheimer’s type.
 Their burdens are often overwhelming, both
physically and emotionally.
 In addition to the profound loneliness and
sadness that caregivers endure, they must also
learn to cope with more tangible stressors, such
 Some treatment programs provide support
groups, as well as informal counseling and ad
hoc consultation services, for spouses caring
for patients with Alzheimer’s disease.
 Some treatment programs arrange for direct
assistance in addition to social support.
 Respite programs provide caregivers with
No health with
out mental
health!