NEUROCOGNITIVE DISORDERS
This module aligns with key elements of APNA’s “Growth & Development” and “Clinical Decision Making” (American Psychiatric Nurses Association Education Council, Undergraduate Branch, 2022).
Module Outline
- Assessment of Neurocognitive Disorders
- Problems Associated with Neurocognitive Disorders
- Treatment of Neurocognitive Disorders
Module Learning Outcomes
- Describe the signs and symptoms of Neurocognitive Disorders
- Identify the common nursing problems associated with Neurocognitive Disorders
- Summarize the treatment of Neurocognitive Disorders
Concepts
- Cognition
- Coping
- Safety
Overview
In this module, we will cover matters related to neurocognitive disorders including their clinical presentation, assessment, and treatment options. Our discussion will include Dementia and Delirium. The treatment for dementia will focus on Alzheimer’s disease as this is the most common subtype of dementia (Rhoads, 2021).
Dementia
Within the DSM-V-TR dementia is referred to as Major Neurocognitive Disorder (Buser and Cruz, 2022; Emmady et al., 2022). It is important to understand dementia is not synonymous with Alzheimer’s disease. Rather, dementia is the broader term referring to “significant cognitive decline in one or more areas (learning and memory, language, executive functioning, complex attention, perceptual-motor, or social cognition) (Buser and Cruz, 2022). Subtypes of a Major Neurocognitive Disorder include Alzheimer’s, Vascular, Substance-Induced, Traumatic Brain Injury, HIV, Parkinson’s Disease, Lewy Bodies, Prion Disease, Huntington’s Disease, and Frontotemporal Degeneration (Buser and Cruz, 2022). The diagnosis can be further characterized as mild, moderate, or severe (Buser and Cruz, 2022; Videbeck, 2020).
Alzheimer’s Disease
Alzheimer’s disease is the most prevalent neurodegenerative disorder. The primary symptom of Alzheimer’s disease is the gradual progression of impairment in cognition but does not present with a change in level of consciousness (Videbeck, 2020). The risk for Alzheimer’s disease increases with age (Videbeck, 2020).
Alzheimer’s disease is defined by the onset of symptoms. Early-onset Alzheimer’s disease occurs before the age of 65. While only a small percentage of individuals experience early onset of the disease, those that do experience early disease progression appear to have a more genetically influenced condition and a higher rate of family members with the disease.
Late-onset Alzheimer’s disease occurs after the age of 65 and has less of a familial influence.
Delirium
Delirium is characterized by an acute onset with “…disturbance in attention, orientation, and cognition (memory, language, and perception) (Buser and Cruz, 2022). Disturbances in attention are often manifested as difficulty sustaining, shifting, or focusing attention. Additionally, an individual experiencing an episode of delirium will have a disruption in cognition, including confusion of the setting. Disorganized thinking, incoherent speech, and hallucinations and delusions may also be observed during periods of delirium. The onset of delirium is abrupt, occurring for several hours. Symptoms can range from mild to severe and can last from days to several months.
Below is an overview of a nurse’s consideration for the assessment, problems, and treatment of neurocognitive disorders.
See Emmady et al. (2022) [Dementia] and De Lourdes Ramirez Echeverria et al. (2022) [Delirium]to read more about this topic.
Assessment
Clinically, Dementia and Delirium can present similarly, but there are a few distinctions. Look at the chart below for a side-by-side comparison of these two diagnoses. This chart was adapted from Videbeck’s (2020) table 24.1 “Comparison of Delirium and Dementia.”
Dementia Versus Delirium
| Characteristic | Dementia | Delirium |
| Onset | Insidious | Rapid |
| Duration | Progressive | Acute |
| Level of Consciousness | Not Affected | Impaired |
| Memory | Progressive from Short-term Memory (STM) to Long-Term Memory | STM Impairment |
| Speech | Not Affected Initially, Progresses to Aphasia | Possibly Slurred, Rambles, Pressured, or Irrelevant |
| Thought Processes | Impaired, Eventually Lost Ability | Disorganized |
| Perception | Possible Paranoia, Hallucinations, Illusions | Possible Visual/Tactile Hallucinations, Delusions |
| Mood | Early (Depressed & Anxious)
Later (Labile & Angry Outbursts) |
Possibly Anxious, Fearful, Weeping, or Irritable |
Dementia
Alzheimer’s Dementia accounts for approximately 70% of the cases of dementia (Emmady et al., 2022). Individuals may have a combination of contributing causes. Emmady et al. (2022) indicate the risk factors for late-onset dementia are age, family history, and genetic susceptibility. The authors also provided several modifiable risk factors that contribute to the occurrence of dementia. These modifiable risk factors are uncontrolled diabetes, mid-life obesity, hypertension, hyperlipidemia, and smoking (Emmady et al., 2022).
RegisteredNurseRN. (2022). Alzheimer’s disease (dementia) nursing: symptoms, treatment, stages, pathophysiology NCLEX [Video]. YouTube. https://youtube.com/watch?v=lql93382Hv8&si=EnSIkaIECMiOmarE
Delirium
The etiology of delirium can be related to several factors. Essentially, delirium is an acute state of confusion (De Lourdes Ramirez Echeverria et al., 2022).
De Lourdes Ramirez Echeverria et al. (2022) provide several examples of associated factors that include:
- substance intoxication or withdrawal
- medication side effects
- infection
- surgery
- metabolic derangements
- pain
- constipation or urinary retention
Osmosis from Elsevier. (2017). Delirium-causes, symptoms, diagnosis, treatment & pathology [Video]. YouTube. https://youtube.com/watch?v=qmMYsVaZ0zo&si=EnSIkaIECMiOmarE
Instruments
The Mini-Mental State Exam and the Mini-Cog are two instruments that may be used to assess for potential cognitive impairment and the need for a full evaluation (Alzheimer’s Association, 2022). The Mini-Cog may also be used to assess delirium (Rhoads, 2021). The Confusion Assessment Method (CAM) can evaluate delirium risk (De Lourdes Ramirez Echeverria et al., 2022; Rhoads, 2021).
Problems
The problems that may be associated with a neurocognitive disorder include:
- Impaired Memory
- Acute Confusion
- Chronic Confusion
- Self-Care Deficit
Treatment
Delirium
The major goal of delirium treatment is to identify the underlying cause. De Lourdes Ramirez Echeverria et al. (2022) and Rhoads (2021) provided several nursing interventions to help treat delirium. These interventions include:
- Maintain safety
- Promote daytime activity and stimulation
- Assist in sleep hygiene
- Correct sensory deficits (e.g., ensure the patient has access to personal eyeglasses and hearing aids)
- Decrease stimuli when possible
- Provide care for bladder and bowel needs
- Monitor intake and output
- Orient the patient and re-orient during interactions (e.g., in acute care settings update the communication board in the patient’s hospital room).
Dementia
As aforementioned, the explanation of treatment for dementia will focus on the treatment of Alzheimer’s disease as it is the most commonly seen form of dementia (Rhoads, 2021). Emmady et al. (2022) indicate cognitive function can be optimized by:
- Promoting adequate sleep
- Consuming an anti-inflammatory diet
- Ensuring adequate exercise
- Treating hearing or vision loss
- Minimizing stress
- Maintaining healthy blood sugar, cholesterol, and blood pressure levels.
Pharmacological
Pharmacological interventions for Alzheimer’s disease, and more specifically medications designed to target acetylcholine and glutamate, the primary neurotransmitters affected by the disease, have been the most effective treatment options in alleviating symptoms and reducing the speed of cognitive decline. Remember, there is no medication to stop or cure this disease. Specific medications such as donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne), and memantine (Namenda) are prescribed to slow the progression of Alzheimer’s disease (Rhoads, 2021). See the MODULE 4: PSYCHOPHARMACOLOGY chapter for a review of these medications.
Support for Caregivers
Supporting caregivers is an important treatment option to include as the emotional and physical toll on caring for an individual with a neurocognitive disorder is often underestimated. It is important that medical providers routinely assess caregivers’ psychosocial functioning, and encourage caregivers to participate in caregiver support groups, or individual psychotherapy to address their own emotional needs.
Additional Resources
See the Alzheimer’s Association website for more information.
Key Takeaways and Learning Activities
You should have learned the following in this section:
- The rate of occurrence of delirium and dementia increases with age.
- Delirium is a state of acute confusion.
- The main goal is to identify and treat the underlying cause.
- Major neurocognitive disorder (i.e., dementia) is characterized by a significant gradual decline in both overall cognitive functioning as well as the ability to independently meet the demands of daily living.
- The most common type of is Alzheimer’s disease.
- Pharmacological interventions for Alzheimer’s disease target the neurotransmitters acetylcholine and glutamate.
- Caregivers may benefit from support groups.
Concept Map Activity
- Create a concept map that depicts the assessment and treatment of Neurocognitive Disorders.
- If needed, see the INTRODUCTION for a concept map tutorial.
Case Study: Dementia versus Delirium
Case Scenario
Mary, an 80-year-old woman, presents with her son to her primary care nurse practitioner with confusion, altered consciousness, and difficulty focusing. Mary lives alone, and her son comes to her house before and after work to check on her. He states that he places her medication in a pill organizer for his mom. He reports a gradual decline in memory and cognitive function. Lately, he has noticed an increase in Mary’s confusion. He indicates that “this is different” and “she seems more confused than usual.”
Reflective Case Study Questions:
- Differentiate between dementia and delirium, noting the similarities and differences in the diagnoses.
- Assess and discuss the potential causes of Mary’s confusion.
- Develop a nursing care plan for managing Mary’s symptoms and providing support.
- How can the nurse involve Mary’s family in her care, considering her long-term needs?
- Discuss the importance of early recognition and intervention in cases of delirium and dementia.
Adapted from Fundamentals of Psychological Disorders 2nd Edition- Module 14 by Alexis Bridley, Ph.D. and Lee W. Daffin Jr., Ph.D. licensed under a Creative Commons Attribution 4.0 International License. Modifications: revised for clarity and flow 
.
