Neurocognitive Disorders: Definition, Causes, and Diagnosis PDF

# **Neurocognitive Disorders** - Definition - Classification - Delirium - Dementia - Others - Substance Abuse Disorders - Intellectual Disability - Epilepsy - Neurocognitive disorders is the new term globally used that include the diagnosis of Delirium and Dementia (DSM-...

# **Neurocognitive Disorders** - Definition - Classification - Delirium - Dementia - Others - Substance Abuse Disorders - Intellectual Disability - Epilepsy - Neurocognitive disorders is the new term globally used that include the diagnosis of Delirium and Dementia (DSM-5, 2013). In the past it was called organic mental syndrome and disorder. - The disorders in the category which include deficit in cognitive function. ## **Causes** Cognitive psychotic conditions have a variety of causes or etiologies. The following “MEND A MIND” mnemonic aid helps you to recall the various possible causes of cognitive impairment disorders: - M - Metabolic disorder - E - Electrical disorder - N - Neoplastic disease - D - Degeneration - A- Arterial disease - M- Mechanical disease - I- Infectious disease - N- Nutritional disease - D- Drug toxicity ## **Delirium** - ❖Definition: is an acute organic mental syndrome characterized by clouding of consciousness, accompanied by disorientation, memory impairment, and decreased concentration which is reversible. - Delirium is a common condition, with up to 15% of patients over 65 being delirious on admission to hospital. Known risk factors include increasing age, underlying dementia and physical illness. - Full recovery is the usual outcome of delirium, but there is a significant morbidity and mortality associated with this condition. - Onset: Is sudden and tends to resolve rapidly when the cause is detected and the appropriate treatment given. The condition is therefore said to be reversible. It is common in children and the aged of 60 years and above. ### **Types Of Delirium** - Delirium due to general medical condition - Substance induced delirium - Substance intoxication delirium - Substance withdrawal delirium - Delirium due to multiple etiologies - Delirium not otherwise specified ### **Causes Of Delirium** - **A. Infections:** - Systematic, e.g., malaria, typhoid fever, pneumonia, etc. - Intracranial, e.g., meningitis encephalitis, cerebral malaria. - **B. Drug Intoxication/Withdrawal** - Alcohol, anxiolytics, opioids, CNS stimulants; cocaine, crack, amphetamines, marijuana, etc. - **C. Neurological disorders** - Seizures - Head trauma - Hypertensive encephalopathy - **D. Postoperative state E. Puerperium (Post Partum)** - **6) Drugs:** - Antibiotics - Antiparkinsonian - Anticholinergics - Antituberculosis - Anticonvulsants - Analgesics - Anti-inflammatory - Cardiac - Sedatives - Hypnotics - **7) Metals and Gases** - Mercury - Lead - Arsenic - Carbon Monoxide ## **Clinical Features** - Altered state of alertness, awareness, and consciousness (hyper alert or obtund; patient’s level of consciousness may vary from time to time; lucid intervals may occur). - Onset may be dramatic/sudden but may be difficult to detect and evolve over days or weeks - Disorientation and confusion - Decreased attention, concentration and memory - Psychotic symptoms – paranoia, hallucinations (often visual), delirious. - Behavioural disinhibition; emotional liability, irritability. - Psychomotor retardation or agitation – may vary in a 24-hour period. - Fragmented sleep/work cycle; increases agitation at night. - Usually reversible with correction of underlying etiology. ## **Diagnosis/Investigations** The aim should be to perform minimum investigations that will allow accurate diagnosis and treatment. ### **Common Investigations Are:** - Blood HB, Blood Urea, Electrolytes - Urinary sugar and protein - Bender Gestalt Test - Test for Memory - Fundus Examination - X-ray of skull - Electroencephalography - C.S.F. Routine - Brain Scan - Brain Biopsy - MANAGEMENT AND NURSING. DISCUSS CARE OF DELIRIUM ## **Dementia** - Dementia is characterized by (usually) insidious (but sometimes acute) development of generalized brain dysfunction with multiple cognitive deficits. It is essential that the patients’ cognitive deficits result in impairment in their social and/or occupational functioning and a decline from their previous level of functioning. - The patients’ level of awareness and mental alertness is intact and stable in the early phases of a dementia – in contrast to the unstable alternating level of consciousness seen in delirium. These cognitive deficits are often (but not always) predominantly manifested by memory impairment – both the ability to learn new information and to recall previously learned information. ### **Types Of Dementia** - Dementia of the Alzheimer’s type - Vascular Dementia - Dementia due to HIV - Dementia due to head trauma - Dementia due to Parkinson’s Disease - Dementia due to Huntington’s Disease - Dementia due to Rick’s disease - Dementia due to Creutzfeldt-Jacob’s Disease - Dementia due to other General Medical Conditions - Substance-Induced Persisting Dementia - Dementia due to multiple etiology - Dementia not otherwise specified ### **Causes Of Dementia** - Alcohol-related Dementia - Alzheimer’s disease - Amyotrophic lateral sclerosis - Bromide poisoning - Chronic granulomatous meningitis (tuberculosis, fungal) - Folic acid deficiency - Head trauma - Human immunodeficiency virus (HIV) - Huntington’s chorea - Hypothyroidism - Multi-infarct Dementia - Multiple sclerosis - Neoplasms - Normal – pressure hydrocephalus - Parkinson’s disease - Postanoxic state - Progressive Supranuclear Palsy - Transmissible virus Dementia (Jacob – Creutzfeldt disease) - Vitamin B12 deficiency ## **Clinical Features** - Impairment of intellectual functions - Loss of memory of recent events (anterograde Amnesia) followed by loss of memory of past events (retrograde amnesia) - Lack of concentration to time, place and person - Episodes of confusion - Poor judgment – the person begins to make foolish and inappropriate decisions, quit out of keeping with his previous records - Lability of mood - Depression is more common than anxiety - Apathy or childish euphoria - Deterioration in habits - Poor personal hygiene - Difficulty in controlling the sphincters; bladder – bowel by night then at day as well. - Inappropriate sexual behaviour, e.g., exposure of the genital, at times assault children sexually. - Epileptic fits - Paranoid and hypochondriac delusions - Hallucinations ## **Other Cognitive Impairment Disorders** All of the following mental disorders have an organic etiology, which can be discovered in the client’s history, physical exam or laboratory tests, but they do not meet the specific criteria of delirium and dementia. - **Amnestic Syndrome:** - Is a cognitive impairment disorder in which the level of consciousness is not affected as it is in other organic brain disorders. Short term and long term memory are impaired, and the client is in an amnestic state. It is a rare condition. - **Organic Delusional Syndrome:** Is a mental disorder in which the main symptom is a predominant delusion that occurs with no change in level of consciousness, no significant loss of intellectual abilities and no hallucinations. - **Organic Hallucinations:** Is a mental disorder in which the client experiences hallucinations. There are no changes in level of consciousness, intellectual abilities or mood; nor are there delusions accompanying the hallucinations. - **Organic Mood Syndrome:** Is a change in mental status marked by two of the symptoms listed under manic or major depressive episode. There are no changes in level of consciousness or in intellectual abilities. There are no hallucinations or delusions. - **Organic Anxiety Syndrome:** Is a mental disorder characterized by active, recurrent panic attacks or generalized anxiety. - **Organic Personality Syndrome:** Is a major change in a person’s personality style, including at least one of the following: - Emotional swings (lability) or sudden flaring of emotions such as crying, angry outbursts. - Decrease in impulse control, for example, shoplifting, poor social or sexual judgment - Suspiciousness or paranoid ideation - Apathy and decreased interest in normal pursuits of life. ## **Pre-Senile Dementia** This is a chronic organic mental condition in which there is a state of intellectual and emotional impairment as a result of organic cerebral changes occurring before the age 65 years. - Huntington’s chorea: - Severe cerebral generation, entirely genetic onset of 30 – 50 years. Patient becomes severely demented, bed ridden and entirely dependent. - Pick’s disease: - Atrophy Of The Frontal Lobe Of Cerebrum - Alzheimer’s disease: - Premature degeneration of C.N.S. - Creutzfeldt – Jacob’s Disease: - Degenerative Dementia affects cerebral cortex through cell destruction. ## **Clinical Features** - Progressive and profound dementia, with speech disorders (Aphasia) and difficulty in carrying out manual activities (Apraxia) - There are personality changes; memory impairment; loss of interest in the surroundings and the patient becomes easily irritable. - Gradually, the patient shows signs of dullness. - Patient becomes apathetic and easily tired - Delusion of persecution may be noted - There is disorientation and regression to childishness - There may be euphoria - In the end the patient becomes severely demented, emaciated, bed ridden and helpless. - ASSIGNMENT MANAGEMENT AND NURSING CARE OF PRESENILE DEMENTIA CLASS ## **Senile Dementia** It is a chronic organic mental condition which is due to degenerative changes in the brain as a result of old age or often the age 65 years. It is characterized by permanent impairment symptoms and behavioural change. ## **Clinical Features** ### **Psychological Features:** - They feel they are rejected - Regression – behaving like a child - Loss of memory/Amnesia – first they do not recollect recent events – Anterograde amnesia and later affects past events – retrograde. - Overtalkative - Repetition of words (Verbigeration) - Confabulations - Disorientation to time, place and person - Mood swings - Restlessness and wanders aimlessly - Hallucinations and delusions - Blurred-incoherent speech ### **Physical Features** - Incontinence of urine and faeces - General bodily weakness - Loss of appetite - Shuffling gait - Weight loss - Blurred vision - Deafness - Wrinkled and inelastic skin - Loss of teeth - Fragile bones - Neglect of personal hygiene - Epileptic fits - DISCUSS MANAGEMENT AND NURSING CARE OF SENILE DEMENTIA ## **Differences Between Delirium And Dementia** | FEATURE | DELIRIUM | DEMENTIA | |-------------|-------------------------------------------------------------------|------------------------------------------------------------------| | Onset | Acute, often at night | Insidious | | Course | Fluctuating, with lucid intervals during day; worse at night.Stable over course of day. | Stable over course of day. | | Duration | Hours to weeks | Months or years | | Awareness | Reduced | Clear/Normal | | Alertness | Abnormally low or high | Usually normal | | Attention | Lacks direction and sensitivity, distractibility, fluctuates over course of day | Relatively unaffected | | Orientation | Disorientated | Usually not affected until late in course | ## **Differences Between Delirium And Mental Retardation** | CATEGORY | SENILE DEMENTIA | MENTAL RETARDATION | |---------------------|--------------------------------------------------------------------|-------------------------------------------------------------------| | Age Onset | 65 years and above | Before the age of 18 years | | Essential Features | Deterioration in memory | Sub-average intelligence | | Brain Structure | Degeneration of brain cells | No degeneration of brain cells | | Appetite | Poor | Good | | Sex | More common in females than males | More common in males than females | ## **Substance (Drug And Alcohol) Abuse** - It is the one of any mind altering agents to such an extent that it interferes with the individual’s biological, physiological and socio-cultural integrity. Also taking unprescribed drugs or taking a dose other than the prescribed dose. - **DRUG:** Is any substance other than food, intended for use in the diagnosis, cure, mitigation, treatment or prevention of diseases in man or other animals. - **Drug Dependence (Addiction):** Is a state of periodic or chronic intoxication detrimental to the individual and society, produced by the repeated consumption of a drug. This drug may be in its natural or a synthetic form. ### **Examples Of Drugs Concerned In Drug Dependence** - Marijuana - Cocaine - Heroine - Mescaline - Lysergic Acid Diethylamide (LSD) - Amphetamine - Barbiturates - Morphine ### **Causes Of Drug Abuse And Dependency ** - Hereditary factors - Familiar factors - Anxiety - Peer group influence - People with psychological problems - People with chronic physical illness - Occupation, e.g., Distillers, Barkeepers, Doctors - Some mental illness; depression, psychopaths - Doctors induced phenomenon (iatrogenic) - To rebel against people in authority - Curiosity - Advertisement on the media ### **Characteristics Of Substance (Drug Abuse And Dependency** - **Dependency:** Compulsive and repeated use of psychoactive drugs despite its adverse effects - **Chemical/physical dependency-** repeated use of the drug to prevent unpleasant effect of withdrawal symptoms - **Psychological dependency –** perceiving the use of a drug as necessary to maintain an optimal state of wellbeing; interpersonal relations or skill performance. - **Craving:** Irresistible urge to obtain and use a psychoactive drug (because of specific effect on mental activity). - **Tolerance:** Repeated use of drugs so that larger doses are required to produce the same psychological and physiological effect obtains previously by a smaller dose. - **Addiction:** Physically and psychologically dependent on a drug. - **Habituation:** Frequent or repeated use of a psychoactive drug - **Withdrawal syndrome:** Is a set of signs and symptoms characteristic of the response of individual to sudden cessation of drug intake after its chronic use. These occur when the blood level of the drug drops suddenly. ### **Examples Of Withdrawal Symptoms** - **Alcohol:** Tremors of hands, nausea, vomiting, high B.P., tachycardia, sweating, headache, anxiety, insomnia, hallucination, illusions, delusions, seizures, craving. - **Amphetamine:** Depression, fatigue, insomnia, disorientation. - **Cocaine:** Depression, irritability, insomnia, severe craving. - **Marijuana:** Anger, frustration, lack of concentration, decreased appetite, craving. - **Opioids:** Nausea, vomiting, muscle aches, lacrimation or rhinorrhoea ### **Diagnosis Of Substance Abuse** - History from client, friends or relatives - Characteristics or features of the individual - Blood or urine screening for drug level in the blood - The use of “breathalyzer” to detect blood alcohol level - DISCUSS MANAGEMENT OF SUBSTANCE ABUSE ## **Alcoholism** - This is excessive and prolonged intake of alcohol which may lead to physical and mental illness and interferences with socio-economic functions and interpersonal relationships of the individual. ### **Causes Of Alcoholism** - Strains and stresses - Peer group influence - Poor upbringing - Anxiety - Hereditary - People with low self-esteem - Occupation – Breweries, mortuary, bar, etc. - Curiosity ### **Effects Of Alcohol** - The end result is depression, because it depresses the CNS for that matter memory and the power of reasoning is impaired. - Alcohol in small doses creates a state of well-being - In large doses, symptoms of alcoholism tends to appear, e.g., muscular in-coordination, poor judgment, nausea, vomiting, diplopia, ataxia, amnesia, cold, clammy skin which may lead to coma and then death. ## **Alcoholic Psychoses** It is a group of organic mental illness which is due to excessive intake of alcohol. - **Pathological Intoxication :**This is a state of acute excitement with violence, confusion and loss of self control. These people drink occasionally just because some people are drinking. They become restless and destructive. These people later have no recollection of the event. This condition is seen in those who are not used to taking alcohol so they respond to quite small doses. It is usually seen in psychopaths, epileptics and those who have had head injuries. They are not habitual drinkers. ### **Management** - Induce vomiting by giving salty water to patient to drink - The individual is bathed - Give some warm sweet drinks, e.g., coffee or mashed kenkey with sugar. - Encourage him to sleep - When he wakes up, educate him not to take alcohol because it is not good for his health. ## **Dipsomania** This is a condition characterized by periodic drinking of excessive amount of alcohol for about 2-3 weeks. Whenever the individual is in this mood, he has the compulsion or crave for alcohol. This strong desire vanishes for sometime and then reappears again with renewed vigor. When the individual is in the drinking bouts, he neglects his work and personal hygiene and can take anything that contains alcohol. The victim remains perfectly sober at the periods of abstinence and may find alcohol distasteful. Observations have shown that neurotic, depressives, and psychopaths often suffer this condition. ### **Management Of Dipsomania** - The main management is psychotherapy. It is done to help the individual to understand himself and to control himself. - Counseling and advice by a psychiatrist or a clinical psychologist - Family therapy - Alcohol Anonymous (AA) - Blue cross ## **Delirium Tremens (Alcohol Withdrawal Delirium)** This is a psychiatric condition characterized by signs and symptoms, often seen in chronic alcoholics who suddenly withdraw from alcohol for about 72 hours due to hospitalization, imprisonment or for any other reasons that make it impossible to have access to alcohol. - Onset – The onset is sudden ### **Causes** - Sudden withdrawal from alcohol for 3-5 days - Reduction in alcohol consumption - An alcoholic with existing physical illness - Drugs, e.g., barbiturates - Malnutrition in alcoholism - Infection in alcoholism - Anaemia in alcoholism ### **Clinical Features** #### **Physical Signs And Symptoms** - Tremors of the limbs, facial muscles, the lips and the tongue - Nausea and vomiting - Headache - Insomnia - Profound sweating - Palpitation - Tachycardia - Gastritis - Furred tongue - High temperature - Malaise - High BP - Seizures #### **Psychological Signs And Symptoms** - Anorexia - Confusion - Disorientation - Irritability - Depression - Anxiety - Agitation - Restlessness - Illusions and hallucinations ### **Management** - Hospitalization may be necessary - Close observation and protection fro injury - Complete bed rest - Anxiolytic/sedatives prescribed - Nutrition / copious fluid/vitamins e.g., B- Complex - Personal hygiene (total self care) ## **Alcoholic Hallucinosis** - This refers to auditory hallucinations reported by clients with alcohol dependence. The hallucinations occur approximately 24 – 48 hours after heavy drinking and may be vivid and threatening to the client. The auditory hallucinations are usually voices of unformed sounds such as Hissing or Buzzing. Onset is about age 40 and the individual drinking heavily for 10 years or more. ## **Korsakof’s Psychosis** - This is a psychiatric disorder found in alcoholism. It is sometimes referred to Alcohol Amnesic Disorder. It is associated with lack of nutritious food and vitamins particularly vitamin B1 (Thiamine), leading to Wernicke’s Encephalopathy. It was first described by a Russian Neurologist and Psychiatrist called Sergei Korsakov in 1877. Onset is gradual. ### **Causes** - Alcoholism - Malabsorption syndrome - Severe anorexia - Upper – gastro intestinal obstruction - Prolonged intravenous feeding - Thyrotoxicosis - Thiamine deficiency - Hemodialysis The disease is characterized by 2 sets of symptoms. Mental and Physical symptoms. ### **Mental Symptoms** - Poor memory of recent events (Anterograde Amnesia) - Mistaking of identity, e.g., patient cannot identify members of his own family - Episodes of confusion and disorientation - Confabulation - Emotional liability (mood swings) - Illusions are common - Patient has no insight into his condition ### **Physical Symptoms** - Malnutrition - Damage to the peripheral nerves particularly in the legs which may lead to pain and tenderness in the calfs weakness of the muscles of the feet. - Sensory loss of the hands and feet, and absence of tendon reflexes. - There may be ocular palsies and nystagmus ### **Management** - Hospitalization may not be necessary - Vitamin B complex and Ascorbic acid may be prescribed by doctor, and good nutritious diet is given - General Nursing Care ## **Chronic Alcoholism** - This is a condition found in those who have been habitual drinkers for many years. They gradually deteriorate mentally and physically. ### **Clinical Manifestations** - Patient neglects his work and personal hygiene - Memory defects, i.e., forgetfulness - Failure in judgment - Irritability, childishness and easy to be suggested to - May become violent - At times shed “Crocodile” tears - He accuses his friend, employers and relatives for letting him down. - Lack of sexual drive, impotency. - Pathological jealousy - Confabulation - Neglect personal hygiene - Negligence of responsibilities- that lends to loss of job, divorce, broken homes, etc. - Suicidal tendencies - Liver cirrhosis - Tremors ### **General Management Of Chronic Alcoholism** - Hospitalization is necessary - Prevention of delirium tremens in the first problem to tackle. - Some tranquilizers may prescribed - Nutrition and hydration(vitamin B complex) - Observation for suicidal tendencies - Attention to other physical needs and personal hygiene - Aversion therapy (Antabuse or apomorphine) - Psychotherapy-counseling, Alcohol Anonymous meeting - Recreational therapy - Occupation therapy - Rehabilitation for patient to obtain a suitable job ### **Effects** - **Social** - Poverty - Divorce - Loss of social status - Loss of job - **Physical** - Cirrhosis of the liver - Peripheral Menritis - Kidney disease - Arteriosclerosis - Heart diseases - Gastritis - Tuberculosis - Pneumonia - Brain damage - **Psychological** - Delirium - Dementia - Alcoholic - Psychosis ## **Prevention Of Drug/Alcohol Dependence** - There is the need to educate the general public particularly the youth on the effects of abuse of drugs. Places for these educational programs can as follow; churches, mosques, schools, lorry parks, social gathering, and the general public. - **Means of education** - Health talks - Film shows - Distribution of leaflets - On the media, e.g., TV, Radio, newspapers - **Means of legal action** - Banning of the sale of heard drugs - Drugs must be prescribed only by qualified physicians - Drugs must be sold by qualified pharmacists - Those who sell of found to possession of these drugs illegally be prosecuted - **D. D.A.(Dangerous Drug Act) Regulations must always be applied in giving these drugs** - Drugs must be under lock - Drugs collected and served must be witnessed and both nurses and senior nurses sign for. - People who cultivate some of these drugs illegally must be arrested and prosecuted - Children under age must not be allowed to buy alcohol or sell it. - There must be proper checking at ports and border. - Only some specified companies must be allowed to produce these drugs. - There should be proper distribution of these drugs so that it does not go into wrong hands. - **In the community** - There should be recreational facilities for the youth - Job avenues for the general public - Vocational institutions for the youth - Parents must serve as a good models to their children - Parents create harmonious atmosphere at homes for their children’s proper development - Teachers must identify students with drug problems so that they can be counseled. - **THANK YOU**