02.12 Cognitive Impairment Disorders

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!