Chapter 23: Neurocognitive Disorders – Dementia & Care

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Welcome back to the Deep Dive.

Say we're tackling something really fundamental, neurocognitive disorders.

Cognition isn't just thinking, is it?

It's more like the core feature that lets us reflect on our life's journey, giving it meaning.

That's a great way to put it.

It distinguishes living from just existing.

And when brain pathology causes actual physiological changes, you get these neurocognitive disorders, NCDs.

And these NCDs can really cloud that journey, right?

Or even destroy its meaning.

Exactly.

So today we're taking a deep dive, a shortcut really, into understanding the big ones.

Delirium, mild NCD, and major NCD, which, you know, people commonly call dementia.

Right.

Our goal here is to pull out the key psychiatric, biological, and especially the nursing concepts from the source material, sort of clarify these diagnoses that can be, well, pretty confusing.

Yeah.

And maybe frame it around the central idea, the difference between an acute crisis,

something often reversible like delirium, and that more chronic progressive decline you see with dementia.

Okay.

Good plan.

So where do we start?

Maybe with how cognition itself is structured.

Good idea.

Think of cognitive processes in two main buckets, sort of.

You've got the lower level functions, the basics, like paying attention, knowing where you are, recognizing things you've seen before.

Simple attention, orientation, recognition.

Got it.

Then there are the higher level domains.

This is the more complex stuff.

Sustained attention, what we call executive function planning, decision making, learning new things, memory, and social cognition, understanding social cues.

Okay.

That makes sense.

Lower and higher levels.

So let's jump into the first condition, then.

Right.

Delirium.

If major NCD is like that slow, steady decline, you describe delirium as more like a system crash, an urgent one.

Exactly.

It's an acute cognitive disturbance.

It's a true medical emergency and frighteningly common, particularly in hospital settings.

How common are we talking?

Well, especially in frail, older patients, the prevalence can be as high as 60%.

60%.

Wow.

Okay.

So what does it look like?

What are the key signs?

The speed is the big thing.

It comes on abruptly, usually over just hours or maybe days, and the classic feature is fluctuation.

Fluctuation.

Meaning, their level of consciousness and awareness waxes and wanes.

They might seem perfectly lucid one moment, maybe during morning rounds, and then completely confused and disoriented an hour later.

That fluctuation is key.

I can imagine that's really disorienting for everyone involved, not just the patient.

Absolutely.

The core symptom is really this inability to direct, focus, sustain, or even shift attention.

That combined with disorganized thinking.

You mentioned perceptual disturbances, too.

Yes.

Illusions are quite common.

That's where they misinterpret a real stimulus,

like seeing a fold in the blanket and thinking it's a rat or a snake.

Okay.

Misinterpreting something real.

What about hallucinations?

Visual hallucinations are also pretty common in delirium, seeing things that aren't there.

But, it's important to note, auditory hallucinations hearing things are actually uncommon in delirium.

That can be a distinguishing point sometimes.

Interesting.

What else might we see?

You often see significant disorientation, usually to time and place, rarely to person though.

Lots of anxiety, agitation, and sometimes this state called hypervigilance.

Hypervigilance.

What's that like?

It's like they're extraordinarily alert, but in a fearful way.

Constantly scanning the room, maybe reacting to every little sound, it's like their threat detection system is on overdrive.

Or they could be the opposite, lethargic.

Okay.

And you said this is always secondary.

Always.

That's critical.

Delirium affects those lower level functions we talked about, and it's always caused by some underlying physiological issue.

Could be substance intoxication, withdrawal, an infection, dehydration, a metabolic imbalance.

So finding and treating that cause is paramount.

Absolutely.

Because if you don't treat the underlying cause, delirium can potentially lead to irreversible brain damage.

Are there specific things nurses should be looking out for?

Risk factors.

Definitely.

And many are modifiable, which is key for nursing.

Things like uncontrolled pain, infection, dehydration is a big one, sleep deprivation, being immobilized, and medications.

Especially psychoactive medications.

Polypharmacy again?

Often, yes.

It's frequently a combination of these factors hitting a vulnerable patient.

It sounds like with the fluctuating symptoms,

maybe looking like tiredness sometimes, it could be easy to miss.

That's a huge problem.

The evidence shows nurses often do fail to recognize delirium.

Maybe they fear labeling the patient, or they just don't pick up on the acute onset because it changes so much.

So the take -home message for a nursing student listening?

Never ever assume that acute confusion in an older person is just dementia setting in.

Always assess for that sudden onset and the fluctuating awareness.

And always consider medications as a potential culprit.

So if we suspect delirium, given the confusion, the potential agitation, the hypervigilance,

what's the number one priority?

Safety.

Without a doubt.

Safety first, safety last.

These patients are at incredibly high risk for injury.

They might wander, fall out of bed, pull out IV lines or catheters.

So keep them safe while you figure out the why.

Exactly.

Identify the cause while maintaining safety.

And a crucial point, never leave a patient in acute delirium alone.

Period.

And restraints.

Physical restraints.

Avoid them.

Strongly avoid them.

They almost always make the confusion and agitation worse.

Instead focus on simple, clear, direct communication.

Use environmental cues, clocks, calendars, maybe a window with natural light if possible.

Keep things calm and quiet.

Makes sense.

Ground them in reality as much as possible.

And the goal, if we catch it and treat the cause.

The goal is always to return the patient to their previous level of functioning, their pre -morbid state.

And keep them safe and comfortable during the process.

Okay, so that's delirium, the acute crisis.

Now let's pivot to the other end of the spectrum, that longer, slower journey of major NCD or dementia.

Right.

And the first key distinction here is between mild NCD and major NCD.

How do we tell them apart?

You said it comes down to independence.

Exactly.

With mild NCD, there's a noticeable, modest cognitive decline from a previous level.

But crucially, it does not interfere with their independence in everyday activities.

So they can still manage their bills, their meds, drive maybe?

Yes.

Though they might need to use more effort or compensatory strategies like making detailed lists or relying more on reminders.

But fundamentally, they can still manage their own affairs.

It may or may not progress to major NCD.

And major NCD.

With major NCD, the cognitive decline is significant.

And it does interfere with independence in those everyday activities.

They now need help with things like paying bills, managing complex medication schedules, maybe even basic self -care eventually.

And this is what people usually mean when they say dementia.

Correct.

Dementia is the umbrella term, and major NCD is the formal diagnostic category.

And unlike delirium, it's typically progressive and, unfortunately, irreversible.

It's probably important to also distinguish this from just normal aging, right?

Sure.

People worry about forgetting things as they get older.

That's a really important clarification.

The source material gives good examples.

Normal aging might be occasionally forgetting someone's name, but recalling it later.

Alzheimer's disease, the most common cause of major NCD, is memory loss that actually disrupts daily life, forgetting recent events or conversations entirely.

Or maybe making an occasional math error, versus… Having significant trouble planning, following steps in a familiar task, or managing a budget things they used to do easily.

That's more indicative of AD.

And AD accounts for what percentage of dementia cases?

About 60 to 80 percent.

Age is the biggest risk factor, but it's not normal aging.

So as AD progresses, we see worsening symptoms.

The sources talk about stages mild, moderate, severe, and specific behavioral things emerge.

Yes, understanding these specific terms is really helpful for nurses, because they guide how we interact and intervene.

Let's talk about some cute ones.

Okay.

How about confabulation?

That sounds like something easily misunderstood.

It really is.

Confabulation is when a person creates stories or fills in gaps in their memory with plausible but untrue information.

The absolute crucial thing to understand is this is not lying.

Not lying.

No.

It's an unconscious defense mechanism.

They're trying to maintain their self -esteem and make sense of a world that's becoming increasingly confusing due to memory loss.

Confronting them about it is counterproductive and potentially harmful to their sense of self.

Okay.

So unconscious ego defense.

Got it.

What about perseveration?

That's the persistent repetition of a specific word, phrase, or even a gesture.

Even when the context is changed, it's like they get stuck on an idea or action.

And then there are the A words, the losses.

Like agrafia.

Right.

Agrafia is the diminished ability and eventual loss of the ability to read or write.

This often happens relatively early in AD.

And aphasia.

Loss of language.

Yes.

It usually starts with difficulty finding the right word.

That tip of the tongue feeling becomes constant.

Then it progresses to using incorrect words, nonsensical phrases, and eventually potentially mutism in the very late stages.

That must be incredibly frustrating for them.

Immensely.

And then you have the functional losses that create significant safety concerns.

Apraxia and agnosia.

Okay.

Break those down for us.

Apraxia.

Apraxia is the loss of purposeful movement, despite intact motor function.

They can physically move their limbs, but they can't organize the sequence of movements to complete a task, like getting dressed or using utensils correctly.

So they can't figure out how to put on a shirt, even though their arms work fine.

Exactly.

So nursing interventions focus on breaking tasks down into single steps, providing cues not on retraining the motor skill itself.

And agnosia.

Agnosia is the loss of the ability to recognize familiar objects or people, despite intact sensory function.

They can see the phone, but don't recognize it as a phone.

Visual agnosia.

Or they hear it ring, but don't recognize the sound.

Auditory agnosia.

Where they can't identify a familiar object like a toothbrush just by holding it.

Tactile agnosia.

Wow.

That really impacts safety and basic interaction with the world.

Absolutely.

Imagine not recognizing food, or a hot stove, or even a family member.

And we have to mention sundowning.

Yes, sundowning.

That tendency for mood to deteriorate and agitation or confusion to increase, typically in the late afternoon or early evening.

It's a common and very challenging behavior for patients and caregivers alike.

Okay, so with all these potential losses and behavioral changes in major NCD, what are the key things nurses need to assess?

You really need a comprehensive assessment.

Evaluate their current level of functioning across all domains.

Identify all potential threats to safety wandering as a big one, but also risk of falls, burns from cooking,

ingesting non -food items due to hyperororality later on.

Hyperororality.

Putting non -food things in the mouth.

Yes, that can happen in later stages.

You also need to meticulously review every single medication they're taking, prescription, over -the -counter supplements, and, crucially, talk to the family.

Why are family observations so important?

Because they provide the baseline.

They know what the person used to be like, which helps gauge the extent and progression of the decline.

Their insights are invaluable.

And from that assessment, the priority nursing diagnoses often emerge as… Risk for injury is almost always at the top.

Right alongside it, risk for caregiver stress or burden.

We absolutely have to assess and support the family caregivers, their well -being is critical to the patient's care.

That's so important.

Let's talk interventions, focusing on safety.

What about wandering?

It's a major concern.

Interventions include things like medical alert bracelets or pendants, maybe GPS trackers.

Alerting local police and neighbors with a photo can be helpful.

Ensuring the person gets enough physical activity during the day can sometimes reduce nighttime restlessness and wandering.

And securing the home environment.

I remember reading about locks.

Yes, installing secure locks, sometimes complex ones, placed high up on the doors.

Why high up?

It's a fascinating detail.

As the disease progresses, people often lose the cognitive and physical inclination to look up and reach high.

So a high lock can be a simple but effective deterrent they might not even notice or try to figure out.

Also removing things like throw rugs to prevent falls, ensuring good lighting.

Basic home safety stuff but amplified.

What about ADLs, like dressing and bathing?

The key is maximizing independence while ensuring safety and dignity.

Use clothing that's easy to manage elastic waistbands, Velcro instead of buttons or complex clasps.

And breaking down the task.

Absolutely.

Give simple, one -step instructions at a time.

Pick up your shirt, pause.

Put your right arm in, pause.

Now your left arm.

Keep it calm, patient, and don't rush.

This all seems to tie into the idea of person -centered care.

It's the cornerstone, really.

We have to strive to see the person behind the disease, focusing on their remaining strength and their experience, not just their deficits.

It means prioritizing the relationship, understanding that distressing behaviors like agitation or calling out are often a form of communication.

Communication of what?

Usually an unmet need.

Are they in pain, hungry, thirsty, scared, bored,

constipated?

Our job is to be detectives, trying to figure out the trigger for the behavior rather than just trying to suppress it.

That's a powerful shift in perspective.

Let's talk about medications for AD.

What's the realistic outlook here?

It's really important to manage expectations.

The medications currently available for Alzheimer's disease offer, at best, a clinically marginal improvement in cognitive symptoms for some people.

Marginal.

So not a cure, not even close.

No.

They don't stop or reverse the underlying brain degeneration.

They might slow the decline slightly for a period, maybe help manage some symptoms, but the benefits often diminish after about a year or two.

OK, so what are the main types?

There are cholinestery inhibitors.

Yes.

Drugs like dunpeazle, revistimine, and galantamine.

In AD, there's a deficiency of a neurotransmitter called acetylcholine, which is important for memory and thinking.

These drugs work by inhibiting the enzyme that breaks down acetylcholine, so there's more available in the brain.

Who are they typically used for?

Usually for mild to moderate stages of AD, though dunpeazle is approved for all stages.

Any key side effects or practical tips?

The main side effects tend to be gastrointestinal nausea, vomiting, diarrhea.

So taking them with food can help.

Rarely they can cause slowed heart rate bradycardia.

Oh, and the revistigmine also comes as a transdermal patch, which avoids the need to take it with food and can be easier for some patients.

And then there's another class,

mementine.

Right, mementine.

It's an NMDA receptor antagonist.

It works differently.

It targets another neurotransmitter, glutamate.

How does that help?

Well, glutamate is excitatory, and in AD, it's thought that there's excessive glutamate activity, which allows too much calcium into brain cells.

That influx of calcium is actually toxic to the cells.

Mementine helps regulate glutamate activity by partially blocking those NMDA receptors, sort of protecting the cells from that toxic overload.

And mementine is typically for?

Usually for moderate to severe stages of dementia, often added onto a cholinesterase inhibitor.

OK.

Now what about medications for the behavioral symptoms, the agitation, aggression, psychosis that can sometimes occur?

This is where we need extreme caution.

Using psychotropic medications like antipsychotics to manage behavioral symptoms in dementia is done off -label.

Off -label meaning not officially approved for that specific use.

Exactly.

And crucially, these medications are associated with significant risks in older adults with dementia, including an increased risk of stroke and death.

That's serious.

Very.

So non -pharmacological approaches should always be the first line.

If medication is absolutely necessary, the mantra is crystal clear.

Start low, go slow.

Use the lowest possible dose for the shortest possible time and monitor very closely for side effects.

Got it.

Start low, go slow, and prioritize non -drug approaches.

And finally, the care plan needs to look beyond just the patient, right?

Absolutely essential.

We need to connect families with resources.

The Alzheimer's Association is a fantastic resource.

Adult daycare programs can provide respite for caregivers and stimulation for the patient.

Support groups are vital.

And practical matters, too.

Yes.

Counseling families on legal and financial planning is part of holistic care.

Discussing things like advanced directives, durable power of attorney for health care and finances, maybe even guardianship later on, getting these things in place before a crisis hits is so important.

Hashtag outro.

OK, this has been incredibly informative.

If we were to boil it down for someone trying to keep it straight.

Delirium versus dementia.

The quick takeaway.

Delirium is acute, sudden onset.

Fluctuating consciousness.

Usually reversible if the underlying cause is fixed.

Think medical emergency.

Major NCD, dementia, is typically insidious onset, progressive decline, generally irreversible.

Think chronic condition requiring long -term management and support.

But both need immediate attention to safety and understanding the why.

Absolutely.

Safety and assessment are paramount in both.

So that brings us to a final thought.

We talked about cognition giving meaning to our life's journey.

And the source material highlights things we could actually do to potentially reduce dementia risk education, staying mentally active, physical exercise, social engagement.

Right.

These factors seem to build what's called cognitive reserve.

Cognitive reserve.

Right.

Like a buffer in the brain.

Sort of, yeah.

The brain's ability to cope with damage, to find alternative ways of working.

It raises a really interesting question for everyone listening regardless of age.

Which is - If building this reserve through lifestyle choices, learning new things, staying active, connecting with others can potentially protect against cognitive decline later,

what does that mean for how we should live our lives now, even when we're young and healthy?

Hmm.

Is continuous engagement and learning maybe the best preventative medicine we have?

Something to really think about.

Definitely food for thought.

Well, thank you so much for guiding us through this complex topic today.

My pleasure.

And thank you, our listeners, for joining us for this deep dive into neurocognitive disorders.

We hope it's provided some clarity and practical takeaways.

We'll see you next time on the deep dive.