hello this is Amanda weberg and this is cognition for spring of 2025 all right so to start these are our student learning outcomes these are directly copied and pasted from your slos um and the biggest thing on here that I want you to know is how to differentiate between dementia and delirium um all of these are things you need to know the clinical manifestations and everything else but the biggest things that we're going to focus on are dementia and delirium and their differences but please review them in your slos that you already have copies of okay so to start what is cognition so cognition refers to the mental processes involved in acquiring knowledge and understanding as well as in making decisions solving problems and processing information it encompasses a wide range of mental activities including perception attention memory reasoning and decision making language problem solving and learning cognition is also a key component of human intelligence and it plays a central role in how individuals interact with the world and make sense of their experiences it can be influenced by factors such as age education um health and emotional states cognitive function can also be affected by neurological conditions mental disorders or even injuries all right so the nursing process of um cognition so we know that the nursing process is AD Pi so we're going to go through that um so assessment so the assessment has a lot of things so to start would be subjective information this would be the patient self-report um family and caregiver input so you could ask the patient about their own perception of their cognitive abilities so questions may include do you find yourself forgetting things more often um have you noticed any changes in your ability to focus or concentrate do you ever get confused about time or places and then you could also ask the family or caregiver um they can usually provide additional insight into the patient's cognitive State especially when the patient is unable to express um the concerns themselves so you could ask questions like has the patient's memory or behavior changed recently have you observed difficulty in their ability to complete daily tasks Okay so objective information um this would be like direct observation and screening tools so General observations um nurses should observe the patient's overall Behavior appearance and level of responsiveness so level of alertness so is the patient alert are they drowsy are they confused orientation can they identify their name location date time so are they alert and oriented times four are they alert and oriented times one or two that's a big deal we need to know um attention are they able to maintain attention or are they easily distracted um speech and language observe whether the patient is speaking coherently and if they understand and can follow simple instructions behavior and mood we also want to watch for signs of agitation aggression withdrawal or depression which may indicate cognitive impairment so some screening tools you can use um would be one of them is the mini mental state exam um you'll be using this in level two but just to kind of give you a little a little blurb now um so it's a widely used tool to assess cognitive function including orientation attention memory language and visual spatial skills typically scored out of 30 points with lower scores suggesting greater cognitive impairment um I know this one A friend of mine just had to have her dad do this one and it's called a clock drawing test it's a simple test used to assess a person's ability to organize thought and understand spatial relationships the patient is asked to draw a clock Bas um with numbers and hands pointing to a specific time then you have the blastoma scale which is really important um it's primarily used to assess Consciousness and neurological status after a trauma or injury this scale measures eye verbal and motor responses to stimuli and then you have the confusion assessment method which is a tool specifically designed to assess delirium um this evaluates the presence of acute onset of confusion inattention disorganized thinking and altered level of Consciousness so some key cognitive domains to assess um nurses should evaluate the following cognitive domains and gather a comprehensive assessment of the patient's cognitive function so again we want to talk about orientation can you tell me today's date where are you right now um attention and concentration can they stay focus so you can ask a patient to repeat a series of numbers forwards and backwards or you know tell me your ABCs or you know things like that simple things but with the numbers you could be like okay tell me some numbers 7439 and then repeat it back to me um memory we'd want to be we'd want to test their short-term and long-term memory an example of shortterm would be ask the patient to recall three words you've just said after a short delay um and then the a long term would be can you tell me the name of the hospital that you were born in or what town did you grow up in or where you know things like that um so we want to test something from a way from a long long time ago um and then language um we want to assess the patient's ability to name objects understand language um and communicate effectively so can you name these objects so you could show them like a pen an apple or you know like whatever's around you can you follow this command please close your eyes can you give me a high five can you raise your hands above your head can you lift your eyebrows that kind of stuff um executive functioning this includes the ability to plan organize problem solve and make decisions so you could give them a scenario of if you found a wallet on the street what would you do or how would you plan a trip to the store that kind of stuff visual spatial functioning um this ability to understand and interpret visual information about the environment so we could ask the patient to copy a simple geometric shape such as like drawing a square or Circle um and then we have some additional tools and tests so functional tests or functional assessments I mean these assess the patient's ability to perform ADLs such as bathing dressing grooming um what would be indicative of a cognitive decline would be things like they're unable to dress themselves they forget how to you know they haven't showered in four days that kind of stuff they don't know how to brush your teeth um then we could get some Imaging such as like CT scans and MRI to see if there's any kind of like structural changes in the brain are there lesions is there atrophy are there tumors um and then also lab tests so like your blood glucose your thyroid function and your vitamin B12 levels all of these can affect um cognition if you have some sort of deficiency or infection or underlying condition so they'd want to do pretty much a general workout to make sure you know kind of check check everything out make sure that there's like a mental decline rather than like a physical reason because if there's a physical reason we can usually fix it a little faster all right so then we go into diagnosis so these would be um like impaired memory acute confusion chronic confusion risk for injury um the impaired memory would be related to neurological changes Dementia or trauma as evidenced by difficulty recalling recent events acute confusion could be related to a metabolic imbalance or an infection um for a sudden change in mental status chronic confusion could be a progressive cognitive decline as evidenced by consistent or disorientation and then risk for injury would be related to cognitive impairment um planning developing goals and expected outcomes for the patient goals should be smart specific measurable achievable relevant and time bound so short-term goals um the patient will accurately State their name and location by the end of the shift the patient will respond to simple questions and follow basic commands during the assessment some long-term goals examples would be like the patient will demonstrate improved orientation to surroundings within one week or the patient will patient safety will be maintained through proper interventions um and some interventions so environment we'd want want to maintain a calm structured and familiar environment we want to reduce distractions and use Simple clear instructions um cognitive support use Memory aids such as calendars clocks and photos we could reent the uh reorient the patient frequently to time place in person physical needs ensure the patient is well hydrated and that they're nourished uh Monitor and address any pain hypoxia or metabolic imbalances safety use B alarms and non-restrictive safety measures um supervise activities and remove potential hazards family involvement we want to educate the family on cognitive changes and involve them in care so provide emotional support to the patient and the family members and then finally evaluation so we would just want to assess the effectiveness of all of our interventions and progress toward our goals that we made during the planning phase um so check the if the goals were met um did their orientation improved did it decrease any confusion and then honestly if it doesn't work you would just modify it as needed or based on the patient's response if they need it tweaked a little bit to be more specific to them then you would just do that and try to get those goals under control okay this is um box 154 it ISS communicating with patients who have impaired cognition um I didn't actually put all of them on the slide because some of them are kind of weird but I think I included it all on your outline so I'm just going to read them all but you can also get them from the book as well um so we want to always try to communicate make every effort to communicate even if you think the client cannot understand you um do not use in room intercom to speak with the patient so I didn't put that one on there because generally we don't have in room intercoms other than like a call light but usually we're going into the patients room anyway um so a voice sounding from the intercom on a bedside call system might frighten the patient and cause confusion delirium or other cognitive impairments and it's better to talk face to face so they would be more comfortable if we just went and spoke to them rather than talking to them on the call I um we don't want to rush the patient so please make sure that you're being patient and providing adequate time to allow the patient to communicate uh they need time to respond to your questions or commands we want to reduce environmental distractions like we already said previously um so um you know turn the lights down if there's a lot of noise we could turn the TV down shut the door um even smells can compete for attention so just kind of make sure you have everything in like a neutral like we want a quiet calm environment um and then sorry guys and then so we could approach the patient directly to avoid frightening the patient um approach the patient from the front make eye contact address the person by name smile and speak in a calm and friendly voice talk first and touch second so touching a patient before establishing basic Trust might frighten or confuse them um so please make sure that you're talking to them before you're like putting a hand on their shoulder or trying to do a blood pressure or anything just think about how you would feel if you were in a room and a foreign environment and someone just came in and started touching all over you like trying to take your blood pressure and everything and you don't really understand what's going on just think about how scary that might be so um don't argue with them or insist that they agree with you so the patient with altered perception or cognition might not have the capacity to understand or even accept reality so pushing them to agree with you can just create anxiety and hostility and we just don't want a hostile environment we want to use multiple communication modalities um so verbal and written discharge instructions review them several times include family members and all the teaching provide reminders so Memory aids schedules um remind reminder notices to reinforce information we want to orient the patient so verbally Orient to time person place and provide visual orientation material such as a calendar or a schedule stimulate memory if the client loses their place in conversation stimulate the memory by the repeating their last expressed thought so we were talking about your back pain tell me more about your back pain and then they be like oh yeah I've been having back pain since for 30 years blah blah blah blah blah so use short simple sentences but avoid Elder speak so use short sentences containing single thoughts like are you hungry avoid complex statements such as you look hungry would you like a sandwich or milkshake or can you hold off till dinner that would be way too much for them to understand so simply just asking them are you hungry is much easier ask yes or no questions I know generally we tell y'all to ask open-ended questions but for this situation yes or no questions are going to be a lot easier and limiting those choices is also going to be a lot easier so because if you don't um if you give them too many choices or you're asking open-ended questions and expecting an elaborate answer for them it can cause them to get frustrated um they might be more confused and kind of look at you like what are you talking about I don't even understand what's going on right now so um you want to make sure you're being concrete and specific so don't use vague comments um the patient may be unable to interpret comments such as I see instead repeat the uh patients's words back and directly sayate your response like you're cold I'll bring you a blanket we want to avoid any slang or jargon they may not understand what we're saying and they also could get agitated or anxious so so just make sure you're saying it in a way um putting things in layman's terms and not using any Slinger jargon use gestures so model desired Behavior so you might say brush your teeth now and then pantomine brushing your teeth um don't assume so bear in mind that the patient cannot behave differently and that they may be confused about reality so when the person is talking about superficial routine matters they may seem more competent than they actually are all right this is in your med surch book not your fundamentals book um but this one's really important so I would definitely make sure that you understand the differences between dementia and delirium so we'll talk about dementia first so the course of dementia is usually chronic and it's a gradual onset um usually progresses slow but it's an even progression duration could be months to years awareness they usually have clear awareness alertness generally pretty normal um orientation could be impaired kind of depends on where we're at in the um disease um memory recent and remote impairment um thinking they might have impaired judgment word finding and abstraction are difficult perception so they misperceptions can be absent psychomotor Behavior usually normal U may have a loss of some previously learn skills and then sleep weight cycle um might be fragmented they could take frequent naps but delirium is more of an acute onset it usually happens in the evening it's abrupt um progression it dur the duration is usually from hours to less than a month awareness there it's reduced um their alertness can fluctuate so they could be lethargic or they could be hypervigilant just really kind of depends on what's going on um orientation is generally impaired and also can fluctuate in severity memory um recent and immediate impairment thinking it could be disorganized or disoriented fragmented speech is incoherent you it's just really hard to kind of understand what they're saying or like kind of even though I know this is a level two thing but like kind of word salad or like flights of ideas kind of thing like it's just all over the place um perception they could be having Illusions delusions hallucinations um and just difficulty distinguishing what's real and what's not psychomotor Behavior can be variable they could be hypo kinetic which is slow or they could be hyper kinetic which is fast um and then sleep weake cycle um it's Disturbed it's usually a day night reversal all right let's do a case study so this case study is regarding delirium um a 78-year-old male Mr Johnson is admitted to the hospital after a hip fracture following a fall at home he has a history of hypertension type 2 diabetes and Mild cognitive impairment he is receiving pain management and is scheduled for surgery in two days his vital signs on a mission are stable however after 24 hours the nurse staff reports that he seems confused agitated and is unable to recognize family members his family tells the nurse that he has never exhibited these behaviors before and the nurse knows that Mr Johnson is restless frequently trying to pull out his IV and call out to people who are not present and the healthc care provider orders a delirium assessment is assessment findings are as follows so Vital Signs blood pressure 128 over 78 heart rate 92 respiratory rate 18 10 986 mental status is disoriented to time and place they're unable to recognize family members Behavior agitated pulling at IV physical exam no new findings no signs infection and no new neurological deficits all right so which of the following is most likely occurring uh most likely diagnosis for Mr Johnson's current condition delirium so Mr Johnson's symptoms acute confusion agitation disorientation are classic signs of delirium which is often precipitated by factors like infection medication or surgery unlike dementia which has a slow onset and his chronic delirium develops suddenly and is typically reversible once the underlying cause is identified and treated the sudden onset of confusion and inability to recognize family and agitation Point toward delirium rather than depression Dementia or psychosis what is the priority nursing intervention for Mr Johnson at this time assess for potential causes of delirium administer a sedative to calm Mr Johnson provide a structured environment and clear communication increase Mr Johnson's oral intake of fluids so we'd want to assess her potential causes of delirium so the first step in managing delirium is to identify and treat the underlying cause delirium can be triggered by factors again such as infection dehydration electrolyte imbalance medication side effects or pain so since Mr Johnson's delirium is acute a thorough assessment should be conducted rule out these possible causes while providing a calm environment and clear communication is also important identifying and addressing the root cause is the priority to resolve delirium which of the following interventions would be most appropriate to prevent further episodes of delirium in Mr Johnson restrict visitors to minimize stimuli encourage Mr Johnson to remain in bed at all times promote a regular sleep wake cycle and orientation to time and Place limit hydration to prevent fluid overload we'd want to promote regular sleep wake cycle and orientation to time and place so maintaining a regular sleep wake cycle and Orient um orienting the patient to time and place and people is the key to preventing and managing delirium so frequent reorientation providing a clock ensuring that the patient is exposed to Daylight can help reduce confusion restricting visitors or limiting hydration could actually contribute to worsening the condition encouraging mobility and Independence rather than complete bed rest is also important for reducing risk such as um deconditioning and further cognitive decline which of the following is a common risk factor for delirium in hospitalized older adults physical therapy chronic hypertension use of anticholinergic medications well-rolled blood sugar levels be the use of anti-cholinergic medications um anti-cholinergic medications commonly Ed in the elderly for conditions such as allergies or GI issues can increase the risk of delirium due to their impact on the central nervous system they impair cognitive function and can contribute to confusion while chronic hypertention and well controlled blood sugar levels are important for overall health they're not a direct risk factor for delirium in the same way as the anti-cholinergic drugs physical therapy is generally beneficial for patients and does not contribute to any delirium what is an appropriate goal for nursing care for patient what is an appropriate goal for nursing care for a patient with delirium like Mr Johnson um we want to do we want to promote return to Baseline cognitive function sedate the patient to prevent agitation provide a Qui isolated environment or do we want to eliminate all medications that contribute to confusion so our biggest goal is to promote return to Baseline cognitive function so the goal in managing delium is to identify and treat the underlying CA and then we want to promote the patient return to Baseline cognitive function this might involve adjusting medications managing pain treating any infections improving hydration and nutrition while sedation might be necessary in some cases it should not be the primary intervention unless the patient is a danger to themselves or others creating a quiet isolated environment could lead to increased confusion and agitation and then eliminating all medications is not appropriate without first identifying which medications are contributing to the delirium all right summary so delirium is a serious often reversible condition that is common in older adults especially in the hospital setting early recognition and intervention to treat the underlying causes are key to reducing morbidity and improving outcomes managing delirium includes reorienting the patient maintaining regular sleep wake cycle and assessing for possible triggers such as medications infections and metabolic imbalances all right so let's talk about dementia so Miss Davis 74 year old woman who has been living at home with her daughter for the past 5 years she was recently admitted to the hospital for a routine checkup due to increasing m problems and some difficulty performing daily activities her daughter reports that over the past year Miss Davis has been forgetting names misplacing items and having difficulty managing finances additionally Miss Davis has been getting lost in familiar places which has led to increasing concerns about her safety Miss Davis has a history of hypertension osteoarthritis and Mild depression her medication list includes Ace and hibitors or lenil um for blood pressure management acetominophen for arthritis and an anti-depressant culine for her depression she denies any recent changes in health but notes that she is becoming more confused especially in the evenings the family reports that Miss Davis also has had difficulty sleeping and becomes agitated when asked about her memory loss all right and her assessment findings are as follows blood pressure 130 over 80 heart rate 80 respiration 16 temp 982 mental status short-term memory deficits difficulty recalling recent events but able to recall long-term memory physical exam no sign of acute illness um no acute distress normal neurological exam lab results normal CBC and electrolytes B12 and thyroid levels are within normal range all right so based on Miss davis' symptoms which of the following is the most likely diagnosis major depressive disorder Alzheimer's disease delirium or stroke it be Alzheimer's disease um Miss Davis's symptoms are progressive memory loss difficulty of daily activities getting lost in familiar places and agitation in the evening which is also referred to a su Downing by the way um which you may hear a lot of with older patients um our characteristic of Alzheimer's disease Alzheimer's disease is a type of dementia that involves gradual cognitive decline especially in memory and can affect the ability to perform activities in daily living while depression can also cause memory problems it is less likely to cause a progressive cognitive decline seen in Alzheimer's delirium involves a sudden onset of confusion and fluctuating Consciousness which does not match Miss Davis's gradual memory Decline and a stroke typically causes sudden neurological deficits and Miss Davis does not exhibit any focal neurological signs all right so which is the following nursing interventions would be most appropriate to help Miss Davis with her cognitive impairment provide a structured daily routine and frequent reminders administer sedatives to manage agitation encourage physical exercise to prevent muscle atrophy limit visitors to reduce over stimulation we'd want to provide a structured daily routine and frequent reminders so a structured daily routine and frequent reminders are effective strategies for managing dementia consistent help patients feel more secure and they can reduce anxiety um reminding Miss Davis about daily activities and using qes such as notes or visual reminders can support her ability to function independently as much as possible because also a thing said with patients is you either use it or you lose it and with Alzheimer's patients a big thing is we want them to use it so whatever they can do independently we want them to do all right so which of the following would be a priority consideration for Miss Davis's safety at home ensure that Miss Davis has access to a telephone at all times install locks on the bedroom door to prevent wandering remove any rugs or obstacles that could cause Falls or allow Miss Davis to manage her finances independently to maintain autonomy we'd want to remove any rugs or obstacles that could cause Falls so safety is our top priority in patients with dementia especially since they may be at risk for Falls due to impaired judgment memory so removing any rugs or obstacles that could cause trips or Falls would help create a safer living environment for her and while access to a telephone is important ensuring physical safety buting Falls is way more critical installing locks on a bedroom door might be necessary if wandering becomes a concern but is not of the immediate priority and allowing Miss Davis to manage her finances independently is likely unsafe due to her cognitive decline it would need to be reassessed to protect her from Financial exploitation which also is a very common thing with older adults and um Alzheimer's with you know family members or whoever and which of the following is the common symptom of Alzheimer's disease that Miss Davis might be might exhibit in later stages rapid onset of severe confusion hallucinations or delusions inability to recognize family members um or sudden severe changes in mood so inability to recognize family members in the later stages of Alzheimer's disease patients often have difficulty recognizing familiar people including close family members this is a Hallmark symptom of advanced Alzheimer's disease um rapid onset of confusion more typical with delirium um huc inations and delusions may occur but they're more common in other types of dementia and then sudden severe mood changes might occur but they're not as characteristic of as Alzheimer's and the loss of recognition and memory and which of the following medications is commonly prescribed to manage symptoms of Alzheimer's disease diazapam Don episil alip paradol or prazone the answer would be Dil um or AOSP um this is a Chine esterase inhibitor that is commonly prescribed to manage symptoms of Alzheimer's it works by increasing levels of acetylcholine in the brain which can help improve cognition memory and daily functioning in individuals with mild to moderate Alzheimer's so some of your patients in the hospital might be on this medication and they might have di aan PRN for um you know agitation or things like that so all right dementia including Alzheimer's disease is a progressive condition characterized by memory loss difficulty performing daily activities and changes in Behavior it is important to recognize the gradual onset of symptoms and provide support uh supportive care that includes structured routine safety measures and appropriate medication by addressing both cognitive and emotional needs of the patient nurses can improve quality of life and promote safety and daily living all right so if you have any questions please post on the discussion board which will be opening after class um and if you need anything just let me know yall have a great day