Module 23 PDF

Normal Cognition Cognition is the complex set of mental processes by which individuals acquire, store, retrieve, and use information. Cognition primarily involves activities that are controlled by the cerebral hemispheres, including perception, attention, memory, communication, decision making, and...

Normal Cognition Cognition is the complex set of mental processes by which individuals acquire, store, retrieve, and use information. Cognition primarily involves activities that are controlled by the cerebral hemispheres, including perception, attention, memory, communication, decision making, and problem solving. A definition of normal cognition depends on social and cultural norms and the environment in which the individual operates. In general, the desired and most basic consequences of normal cognition are to obtain a level of survival and adaptation, to function effectively as a social being, and to engage in meaningful and purposeful activity. Key Components and Categories Perception Perception refers to an interpretation of stimuli or inputs that takes place in the brain. External stimuli or inputs include touch, taste, vision, hearing, and smell. Internal stimuli include proprioceptive sensations that contribute to motor function and spatial awareness. Orientation is a component of normal perception that includes four basic elements: person, place, time, and situation. Orientation to person is the ability to correctly identify one’s own name. Orientation to place is the ability to identify one’s location. Orientation to time is the ability to correctly identify the time of day, the date, and the season. Orientation to situation is the ability to describe the global circumstances surrounding a particular event. Attention Attention refers to the brain’s ability to remain alert and aware while selectively prioritizing concentration on a stimulus (such as something that is seen or heard) or mental event (thinking and problem solving). The reticular activating system (RAS), thalamus, and frontal cortex are the structures that are primarily involved in arousal and attention. The neurotransmitters dopamine and norepinephrine both play a major role in regulating attention. Variations in attention span are typical among healthy individuals and may be impacted by development, genetics, biological rhythms, culture, and other environmental factors. A change in any individual’s level of awareness and attention span often signifies an underlying change or alteration in biophysical or psychosocial status. Individual safety depends on the ability to attend and focus. Memory Memory refers to the process by which individuals retain, store, and retrieve information gained from previous experiences. The ability to remember meaningful information provides the foundation for learning and adaptation from birth to death. Most models of memory classify subtypes according to their sequence and duration. These include sensory, short-term, and long- term memory. An information-processing model of memory. Many stimuli register in sensory memory. Those that are noticed are briefly stored in short-term memory, and those that are encoded are transferred to long-term memory. As shown, forgetting may be caused by failures of attention, encoding, or retrieval. Sensory memory refers to the earliest stage of memory, in which visual input and auditory information are retained for less than a few seconds. Sensory information that receives attention from an individual passes into short-term memory. Short-term memory refers to the active processing and manipulation of information in conscious awareness. Short-term memory only lasts several seconds, but it can be rehearsed or repeated and transferred into long-term memory. The total amount of information that can be managed in short-term memory is also finite, a sequence of numbers exceeding five to nine digits, cannot be retained. An important aspect of short-term memory is working memory. Working memory is defined as the capacity to manipulate information stored in short- term memory. Examples include following a sequence of directions and performing mental mathematical calculations. Long-term memory is used to describe the final sequence or destination of information that can be stored indefinitely. Long-term memory is further broken down into declarative and nondeclarative memories. Declarative memories are those that are explicit and can be consciously accessed; they are distinguished as semantic (storing facts and verbal information) and episodic (composed of personal experiences). Nondeclarative memories are characterized by information that is outside of our conscious awareness. Procedural memories are a type of implicit memories that enable individuals to perform learned skills and tasks. Examples include such activities as walking, riding a bike, and driving a car. Communication and Social Cognition Memory plays a significant role in communication and speech. Social cognition is the ability to process and apply social information accurately and effectively. It depends on the integrated function of the areas responsible for visual motor processing, language, and executive function. Individuals are normally able to apply an understanding of the needs of others and to interpret both verbal and nonverbal information or social cues with some degree of proficiency. Researchers have demonstrated that social cognition is essential for adaptive functioning across the lifespan. Motor Coordination Motor coordination refers to the planning, organizing, and execution of complex motor tasks. Cognitive function and motor coordination are carried out by shared neuronal pathways in the brain. Normally the ability to plan and coordinate motor functions progresses through the expected stages of development, with adults exercising praxis, the ability to control movement in a deliberate, smooth, and coordinated fashion. Individuals with intact cognition exhibit normal variations in motor function and coordination. Impaired motor function is characteristic of many of the alterations discussed in this module. Executive Function Executive function is an umbrella term that is used to describe the mental skills involved in planning and executing complex tasks. It incorporates coordination of the previously mentioned attributes of normal cognition, enabling individuals to selectively focus, control emotions, problem-solve, and organize speech and motor activity. Examples include following multistep directions and prioritizing to manage time on a project. Intellectual Function Intelligence is a general term used to describe the mental capacity of an individual in relation to learning, reasoning, and problem solving. It is generally measured through the administration of one or more psychometric tests. The most commonly administered tests are the Stanford-Binet Intelligence Scales and Wechsler Intelligence Scales. Subtest scores for both are used to compare performance in areas such as general knowledge, quantitative and verbal reasoning, visuospatial processing, and working memory. The average of the scores is used to calculate an overall or full-scale intelligence quotient (IQ). Subtest scores are also used to provide insight into individual strengths and weaknesses. Adaptive Behavior Adaptive behavior refers to a set of practical skills people need to function in their everyday lives. The three categories of adaptive behavior are conceptual skills (use of language, reading, or telling time), social skills (ability to follow rules and interact appropriately with others), and practical skills (ability to engage in work and perform activities of daily living [ADLs]). Physiology Review Cognition largely depends on brain and nervous system functioning. The structural integrity of and complex physiologic processes that occur within the cerebral cortex are responsible for most aspects of the individual’s ability to process sensory information. However, the limbic system, RAS, and cerebellum also play a role in arousal, motivation, emotional regulation, and balance. The physiologic processes that occur in the brain have particular significance in the maintenance and regulation of cognitive processes. Neurons are the specialized cells of the nervous system that have the capacity to carry messages through electrical and chemical signals. Microglia are the resident immune cells of the brain. They play an important role in regulating response to inflammation. Neurotransmitters are specialized chemicals that carry nerve impulses across the synaptic gaps between neurons. Research has demonstrated that abnormalities in cellular and neurotransmitter function are associated with many cognitive disorders. Normal Genetic Variations Research demonstrates that genetic makeup accounts for as much as 80% of the variations in cognition found in the general population. Different genes can be linked to particular components of cognitive function, such as attention in working memory in healthy adults. Alterations to Cognition Although the etiology, presentation, and course of diseases impacting cognitive function vary, the key clinical manifestations of alterations in mental processing all relate to dysregulation of one or more of the key components or categories of normal cognition. The Alterations and Therapies table gives an overview of alterations common across a range of disorders that can impair cognitive function. General Manifestations of Altered Cognitive Function Alterations in different aspects of cognition occur to varying degrees and are found in a number of conditions associated with this concept. The pathophysiology of these conditions is generally related to conditions causing abnormalities in the structure and function of the brain. An understanding of the general manifestations of cognitive dysfunction is essential for providing nursing care to individuals presenting with cognitive problems, regardless of the patient’s specific medical diagnosis or condition. Alterations in Perception Altered perception and thinking are hallmarks of many of the conditions that impact cognition across the lifespan. Perceptual disturbances may be a function of structural and physiologic brain abnormalities in several areas of the cerebral cortex. They may be related to a primary cognitive disorder, such as dementia or schizophrenia or to an underlying medical condition. Illogical thinking may be the result of frontal lobe dysfunction and dopamine imbalance. Distortions in perceptual processing are often the result of abnormalities in the lobes responsible for that aspect of sensory processing. Terms related to thinking and perception include the following: Interventions Alteration Description Manifestations and Therapies Alterations in Identify and ability to treat interpret underlying environmental cause Hallucinations stimuli, think Reduce Delusions Perceptual clearly and environmental Disordered thinking disturbances/psychosis logically, and stimulation Disorientation/confusion maintain Reality orientation to orientation and person, place, validation time, and therapy situation Identify and Easily distracted treat Difficulty Avoids situations underlying Impaired attention sustaining or requiring sustained focus cause directing focus Difficulty learning Reduce distractions Identify and treat Getting lost underlying Difficulty with word cause finding and recognition Impairment in Cognitive Difficulty remembering Memory problems ability to recall remediation recent events information Provide Difficulty remembering compensatory remote events strategies and memory aids Confusion is a general term used to describe increased difficulty in thinking clearly, making judgments, and focusing attention. Disorientation is an element of confusion in which the individual is unable to correctly identify one or more of the following: person, place, time, and situation.  Psychosis is a general term used to describe an abnormal mental state that alters an individual’s thought processes and content in a manner that impacts the individual’s perception of reality. Indicators of altered thought processes and content are most often observed through the patient’s speech and behaviors. Indicator Description Pattern of speech in which a person’s ideas slip off track onto another Loose associations unrelated or obliquely related topic; also known as derailment. Occurs when a person digresses from the topic at hand and goes off Tangentiality on a tangent, starting an entirely new train of thought. Incoherence/word Speaking in meaningless phrases with words that are seemingly salad/neologisms randomly chosen, often made up, and not connected. Refers to speech in which there is an absence of reason and Illogicality rationality. Occurs when a person goes into excessive detail about an event and Circumstantiality has difficulty getting to the point of the conversation. Can be identified when a patient is speaking rapidly and there is an Pressured/distractible extreme sense of urgency or even frenzy as well as tangentiality, speech making it is nearly impossible to interrupt the person. The opposite of pressured speech; identified by the absence of Poverty of speech spontaneous speech in an ordinary conversation. The person cannot engage in small talk and gives brief or empty responses. Delusions are rigid, false beliefs—for example, believing that members of a healthcare team are actually government spies assigned to gather information that will be used to harm the patient or others. Common types of delusions include delusions of persecution, in which an individual believes that others are hostile or trying to harm him; delusions of reference, in which an individual falsely believes that public events or people are directly related to her; and delusions of grandeur, in which an individual has an inflated sense of self-worth and abilities. Hallucinations are sensory experiences that do not represent reality, such as hearing, seeing, feeling, or smelling things that are not actually present. Sometimes the type of hallucinations experienced by an individual provides clues to the underlying cause. Types of hallucinations include auditory, in which an individual hears voices or sounds that are not there; visual, in which an individual sees things that are not there or sees distortions of things that are there; or tactile (also known as somatic or haptic), in which an individual feels things that are not present. Alterations in Attention Individuals with attention difficulties demonstrate deficits in the ability to focus, shift, and sustain attention consistently. Attention deficits are characteristic of many of the cognitive disorders discussed in this module and may also occur as a distinct disorder classified as attention-deficit disorder (ADD) or attention-deficit/hyperactivity disorder (ADHD). Short-term difficulties with attention can also occur under conditions such as acute stress and anxiety and during periods of acute illness. Problems with attention can be related to any conditions that impact the structure and function of the brain. Such problems are manifested by alterations in one or more aspects of attention. For example, deficits in mental energy manifest in the ability to sustain effort required to complete certain tasks. Individuals with altered attention have difficulty determining what information is salient and connecting new information to what they already know. Issues in processing arise from the inability to control output—meaning that an individual may lack the ability to preview and inhibit an inappropriate or unsafe response or action. Alterations in Memory Memory impairment may be an initial manifestation of a cognitive disorder, with one or more memory functions impacted at any given time. Imbalances of acetylcholine, dopamine, gamma- aminobutyric acid (GABA), and glutamate have been implicated in memory problems. Memory impairments may be temporary or chronic and may range from mild to severe. They may also be related to an underlying illness or trauma or be caused by a medical treatment or medication. Amnesia is a general term that is used to refer to the loss of recent or remote memory. Patients experiencing memory loss may unconsciously attempt to compensate for memory gaps by filling them in with fabricated events through a process known as confabulation. Memory loss may manifest as problems related to short-term or long-term memory. Individuals with short-term memory loss may retain the ability to remember events that occurred 15 years ago but have difficulty recalling something that happened several minutes ago. Issues with working memory include difficulty following multistep directions, remembering the sequencing of numbers, or performing simple calculations. Individuals with long-term memory problems have difficulty recalling events and learning that occurred in the distant past. Examples include forgetting work skills that were learned 10 years ago or the inability to remember important life events, such as a wedding or the death of a loved one. Deficits in semantic memory can be manifested as agnosia, the inability to recognize objects through the use of one or more senses. Alterations in Communication and Social Cognition The ability to communicate with others is contingent on adequate perception, attention, and memory. In addition, any injury or insult to the areas of the brain responsible for the use of gestures and written and spoken words can impair communication and social cognition. Alterations in communication are common findings in many neurocognitive disorders. Common related terms include the following: Aphasia is the inability to use or understand language. Aphasia may be classified as expressive aphasia, receptive aphasia, or mixed (global) aphasia. Anomia is a type of aphasia where the individual is not able to recall the names of everyday objects. It is often related to the progressive degeneration and loss of semantic memory that occurs with dementia.  Alogia refers to a lack of (sometimes called impoverished) speech. Frontal-lobe and right-brain dysfunction impact spatial awareness to the extent that affected individuals have difficulty gauging physical aspects of social communication, such as how close to stand to someone else. Impaired visual processing can result in the inability to accurately read and respond to nonverbal cues. Sometimes these individuals are mistakenly believed to be deliberately demonstrating rude or annoying behaviors. The deficits in communication and social function place patients at significant risk for health problems, social isolation, victimization, depression, and anxiety. Alterations in Motor Coordination The pathways used for cognitive processing and motor coordination and function are shared. Problems with the speed, fluency, and quality of movement are associated with many cognitive disorders and can also be a side effect of medications that alter neurotransmitter function. Dyspraxia is a general term used to describe difficulty with the acquisition of motor learning and coordination through the process of growth and development. Apraxia refers to alterations in speech as a result of impaired motor function. Ataxia is a term used to describe problems with balance and coordination associated with neurologic dysfunction. Involuntary movements include those that are not completely purposeful and occur without initiation by the patient, such as tics and tremors. Tics are semi-involuntary movements that are sudden, repetitive, and nonrhythmic. They may involve muscle groups or vocalizations (motor or phonic). Suppression of a tic may be possible but results in discomfort or anxiety for the patient. Examples of simple tics (brief movements involving one muscle group) include eye blinking and head jerking (motor tics) and throat clearing and humming (phonic tics). Complex tics involComplex tics involve a cluster of movements that appear coordinated and more purposeful and thus may be more difficult to identify. Complex motor tics include pulling at clothing or touching people or objects; echopraxia, imitating the movements of others; copropraxia, performing obscene or forbidden gestures; and carphologia, lint-picking behavior that is often seen in dementia. Examples of complex phonic tics include echolalia, the meaningless repetition of phrases spoken by another, and coprolalia, obscene language. Tremors are unintentional rhythmic movements manifested in shaking of the affected part of the body. Essential tremors are those that are not associated with another condition and may be genetic in origin. Physiologic tremors occur normally as a result of physiologic exhaustion or emotional stress. Common tremors include resting tremors, a coarse, rhythmic tremor often observed in resting arms and hands that is characteristic of Parkinson disease and sometimes seen as a side effect of certain medications, and dystonic tremors, sustained involuntary muscle contractions causing twisting repetitive movements and painful or abnormal postures. Dyskinesia represents a general category of difficulty with or distortions of movement. It may be associated with acquired disorders such as Parkinson disease or as a side effect of some medications. Types of dyskinesias are:  Akathisia: An internal feeling of restlessness that may lead to rocking, pacing, or other constant movement Akinesia: Diminished movement as a result of difficulty initiating movement Bradykinesia: Dyskinesia characterized by slow movement Dystonia: An acute episode of muscle contractions (may result from a neurodegenerative disease or a reaction to medication) Rigidity: Resistance to movement; cogwheel rigidity refers to ratchet-like resistance when attempting to move the joints. Alterations in Executive Function Executive function is significantly affected by structural and physiologic abnormalities impacting the frontal cortex. Manifestations of impaired function include emotional dysregulation; poor judgment and decision making; reduced insight; forgetfulness; difficulty in planning, organizing, and concrete thinking; and personality changes. Difficulties can range from mild to severe. Avolition is decreased motivation, or the inability to initiate goal-directed activity, and may be in part related to deficits in executive dysfunction. Alterations in Intellectual Function and Learning Alterations in intellectual function and learning may be either developmental or acquired. Nurses should recognize that there are a broad range of issues impacting learning and intellectual function and that many individuals may demonstrate deficits in adaptive function without meeting diagnostic criteria of a specific delay or disorder. Learning disabilities are a group of disorders that impact an individual’s ability to process information. The cause of learning disabilities is not entirely understood, but researchers believe that subtle variations in brain structure and function may be responsible. Both genetics and environmental factors probably contribute to these variations. In general, individuals with learning disabilities have average to above-average intelligence but demonstrate a gap between their actual and potential achievement. The impact of learning disabilities goes well beyond difficulty with basic academic skills. Most individuals with specific learning difficulties also experience one or more related problems with social cognition, executive function, memory, processing speed, attention, and motor coordination. As a result, they often face significant challenges with interpersonal relationships and other aspects of adaptive function. Nurses are in a key position to assess for variations in development that may suggest an underlying learning issue. Intellectual disabilities are characterized by significant limitations in intellectual functioning and adaptive behavior that begin prior to age 18. An IQ score of 70 to 75 or below is considered indicative of limited intellectual functioning. Intellectual disability can result from prenatal errors in central nervous system (CNS) development, external factors that damage the CNS, or pre- or postnatal changes in an individual’s biological environment. Sometimes, these changes produce only mental limitations. Other times, intellectual disability is one of a constellation of symptoms linked to a particular cause. Selected Alterations in Cognition The exemplars included in this module represent only a fraction of the disorders that impair cognition. The classification of these disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) provides a context for understanding both similarities and differences in the exemplars and related conditions; however, the nursing care focuses primarily on supporting adaptive function and collaborating with healthcare professionals to provide holistic care that meets the unique needs of affected individuals regardless of medical diagnosis. Selected Learning Disabilities The DSM-5 recognizes a number of specific learning disabilities. Two more common ones are auditory processing disorder (APD) and language processing disorder (LPD), in which individuals have difficulty processing sounds and recognizing their source. For example, a student with APD may have difficulty processing and acting on verbal instructions and benefit from visual cues, pictorial schedules, and active demonstrations. For all patients with learning difficulties, nurses support them and their families in seeking appropriate services and accommodations and encourage activities that focus on strengths and build self-esteem. Selected Intellectual Disabilities Of the various conditions associated with intellectual disability, three deserve special mention because of the range of physical and cognitive alterations they involve. Down syndrome, fragile X syndrome, and fetal alcohol spectrum disorders (FASD), including fetal alcohol syndrome, are all caused by problems during prenatal development, although the first two conditions involve genetic errors while the third involves alcohol consumption during pregnancy. All three conditions are present at birth and affect individuals for the rest of their lives. Down Syndrome: Broad hands with a single traverse palmar crease, Congenital cataracts, Decreased muscle tone, Epicanthic eye folds, Flattened nose, Hearing impairment, Increased likelihood of diabetes, leukemia, and heart defects, Protruding tongue, Short, stocky neck, Small ears located low on the head, Small head, Wide space between first two toes Fragile X Syndrome: Crossed eyes, Enlarged testicles, Epicanthic eye folds, Excessively flexible joints, High palate, Increased likelihood of middle ear infections, Increased seizure risk, Large ears, Long head with protruding jaw, Scoliosis Fetal Alcohol Syndrome: Small eyes, Abnormal joints and bones, CNS abnormalities, Flattened nasal bridge, Growth deficits, Hearing impairment, Lack of coordination, Small nose that turns up at the tip, Small palpebral fissures, Smooth philtrum, Thin vermillion border Down Syndrome Down syndrome occurs when an individual’s cells contain a third full or partial copy of the 21st chromosome (National Down Syndrome Society, 2020). Usually, a full copy of the extra chromosome is present, a situation known as trisomy 21. In either case, the excess genetic material leads to intellectual disability and physical impairments that can range from mild to severe. Individuals with Down syndrome are at increased risk of several problems not normally seen in childhood. Roughly 50% are born with congenital heart defects. Children with Down syndrome are also more likely to experience hearing loss, gastrointestinal blockages, celiac disease, vision problems, thyroid disease, skeletal abnormalities, orthodontic problems, leukemia, and eventual dementia. With appropriate support, affected individuals can lead healthy lives and sometimes live and work independently. Average life expectancy for individuals with Down syndrome is about 60 years, although some individuals live 10 or even 20 years longer. Fragile X Syndrome Fragile X syndrome arises from a single recessive abnormality on the X chromosome. Specifically, a mutation in the FMR-1 gene causes a small section of DNA to be repeated 200 or more times, rather than the normal 5 to 40 times. This change renders the gene unable to make its associated protein, and absence of the protein leads to errors in brain development and function. A variety of signs and symptoms are associated with fragile X syndrome. The most notable is intellectual disability, typically accompanied by behavioral problems such as ADHD. Affected children may also exhibit autistic behaviors; speech problems; anxiety and mood problems; delays in learning to sit, walk, and talk; and enhanced sensitivity to environmental stimuli. Most individuals with fragile X syndrome are in generally good health and have a normal lifespan. Still, approximately 15% of affected males and 6–8% of females will experience seizures and require anticonvulsant medications. Interestingly, males usually experience the effects of fragile X syndrome to a much greater degree than females. Because females have two copies of the X chromosome, one X chromosome’s FMR-1 gene is able to produce enough protein to partially compensate for the amount normally produced by the other copy. Males, however, have just one X chromosome, so no compensatory mechanism is available. Fetal Alcohol Spectrum Disorders Unlike Down syndrome and fragile X syndrome, FASDs are completely preventable conditions caused by maternal alcohol intake during pregnancy. The only way to prevent FASD is for the woman to abstain from consuming alcohol for the duration of the pregnancy. All FASDs involve some degree of physical, intellectual, behavioral, and/or learning disability, with fetal alcohol syndrome (FAS) being the most severe. FASDs result from the presence of alcohol in a woman’s bloodstream. Because alcohol crosses the placenta and the fetal liver cannot process it, the fetus has the same blood alcohol content as its mother, regardless of the type or amount of alcohol consumed. Even small amounts of alcohol can dramatically disrupt prenatal development, causing facial, skeletal, and organ abnormalities, along with a variety of other problems. However, for a diagnosis of FAS (as opposed to another fetal alcohol spectrum disorder), a child must exhibit all of the following conditions. Growth deficits Characteristic facial abnormalities, including a smooth philtrum (ridge between the nose and upper lip), thin vermillion border (line between the lips and surrounding skin), and small palpebral fissures (separations between the upper and lower eyelids) CNS abnormalities (structural, neurologic, and/or functional). These nervous system abnormalities almost always result in some degree of mental impairment, such as intellectual disability, learning disability, communication problems, poor memory, or limited attention span. Although the many effects of FAS last a lifetime, early treatment can help lessen some symptoms and improve an affected individual’s quality of life. Other Preventable Causes of Intellectual Disability Maternal drug use, smoking, malnutrition, exposure to environmental toxins, and illness during pregnancy. Prematurity and low birth weight forecast disability more reliably than any other conditions. Difficulties at delivery, such as oxygen deprivation or birth injury, may also cause problems in intellectual functioning. Head injuries, near-drowning, and diseases such as whooping cough, chickenpox, measles, and Haemophilus influenzae type B (Hib) can damage the brain in childhood. Childhood exposure to toxins (especially lead) can also cause irreparable damage to the nervous system. Malnutrition, childhood diseases, exposure to environmental health hazards, and a lack of intellectual stimulation early in life are also factors that have been linked to intellectual disability. In the United States and in other countries around the world, prevalence rates of intellectual disability have dropped thanks to public health measures that mandate newborn screening for phenylketonuria and require vaccinations for Hib, measles, encephalitis, and rubella. Comprehensive prenatal care, including testing for diseases and administering folic acid to expectant mothers, also reduces the risk of intellectual disability. Delirium Delirium is usually an acute change in mental state that is characterized by confusion; inability to focus, shift, or sustain attention; disorientation; sleep-wake cycle disturbances; disorganized thinking; perceptual abnormalities; mood changes; and both psychomotor retardation and agitation. Delirium typically results from a medical condition, trauma, or chemical/substance exposure or withdrawal and is a common complication observed during stays in acute-care settings. Delirium is presented as an exemplar in this module. Dementia Dementia is a general term used to describe the loss of one or more cortical functions or cognitive attributes as a result of degeneration of the neurologic systems of the brain. The DSM- 5 uses the term mild and major neurocognitive disorder (NCD) to replace the older term dementia (APA, 2013). Individuals with mild NCDs are those who demonstrate limited impairment and are able to maintain independent functioning with some modifications (such as medication reminders). They are often in the initial stages of disease progression. NCDs are classified as major when additional cortical functions are lost and the individual can no longer maintain independence. Dementia can be caused or exacerbated by other conditions and variables, including metabolic problems, nutritional deficiencies, infections, poisoning, medications, and any conditions that compromise oxygenation and perfusion. Subtypes of NCDs are classified by etiology and are discussed briefly below and in more detail in the exemplar on Alzheimer disease. The terms major neurocognitive disorder and dementia are both used in clinical practice and are used interchangeably in this module. Alzheimer disease is the most common form of dementia, accounting for about 80% of all cases and affecting more than 5 million adults in the United States. Vascular dementia often results from multiple small strokes or infarcts that block major blood vessels in the brain. Low blood pressure (hypoperfusion) from other conditions, such as blood clots, ruptured blood vessels, or narrowing or hardening of blood vessels that supply the brain, can also lead to vascular dementia. The symptoms vary widely, depending on severity of the blood vessel damage and the part of the brain affected. Unlike other dementias, memory loss may or may not be a significant symptom. Often, seizures will follow a stroke, caused by bleeding in the brain (hemorrhagic stroke) or a stroke in the cerebral cortex. Many times, the progression of vascular dementia follows a “sawtooth” or stair-step pattern, where a series of strokes or ministrokes cause cognitive decline followed by periods of stabilization. After each vascular event, changes in thought processes occur in noticeable steps downward from the prior level of function. Vascular dementia can occur alone or in combination with other forms of dementia and is thought to represent at least 10% of all cases of neurocognitive decline. Disorder Etiology Clinical Manifestations Onset/Course Symptoms vary in early stages. Severe cognitive At first symptoms are Infection with HIV-1 changes, particularly subtle and may be produces a dementing Dementia due confusion, changes in overlooked. The severity of illness called HIV-1- to HIV behavior, and sometimes symptoms is associated associated psychosis, are not with the extent of the brain cognitive/motor complex. uncommon in the later pathology. stages. Dementia due Amnesia is the most to traumatic common neurobehavioral A degree of permanent brain injury Any type of head trauma. symptom following head disturbance may persist. (see Module trauma. 11, Intracranial Regulation) Parkinson disease is a neurologic condition Dementia has been resulting from the death of reported in approximately neurons, including those 20–60% of people with Dementia due that produce dopamine, Parkinson disease and is Onset and course are slow to Parkinson the chemical responsible characterized by cognitive and progressive. disease for movement and and motor slowing, coordination. It is impaired memory, and characterized by tremor, impaired executive rigidity, bradykinesia, and functioning. postural instability. Huntington disease is an Cognitive symptoms inherited, dominant-gene, include memory deficits, neurodegenerative both recent and remote, as The disease begins in the Dementia due disease. The first well as significant late 30s or early 40s and to Huntington symptoms are typically problems with frontal may last 10–20 years or disease movements that involve executive function, more before death. facial contortions, personality changes, and twisting, turning, and other signs of dementia. tongue movements. Clinically, Lewy body This disorder is disease is similar to distinguished by the Irreversible and Alzheimer disease; Lewy body presence of Lewy progressive; tends to however, there is an earlier dementia bodies—eosinophilic progress more rapidly than appearance of visual inclusion bodies—seen in Alzheimer disease. hallucinations and the cortex and brainstem. parkinsonian features. Symptoms vary widely, depending on the severity of the blood vessel damage and the part of the brain Cognitive changes may Vascular dementia affected. Seizures often occur suddenly after a features strokes or infarcts accompany strokes. stroke or they may have a in the blood vessels of the Sudden poststroke changes slower onset. Progression brain. Also caused by Vascular may occur and include typically follows hypoperfusion due to dementia confusion, disorientation, a ”sawtooth” pattern of blood clots, ruptured trouble speaking or strokes/ministrokes, blood vessels, or understanding speech, followed by decline and narrowing or hardening of sudden headache, stabilization until another blood vessels. difficulty walking, poor vascular event occurs. balance, and numbness or paralysis on one side of the face or the body. Nurses and other healthcare professionals need to recognize that a variety of conditions can mimic dementia, especially in older individuals. Depression and emotional problems may cause cognitive slowing and disorientation. It may also be difficult to distinguish symptoms of delirium from those of dementia. Delirium Dementia Depression Onset Acute, sudden, rapid Slow, progressive Variable Duration Hours to days Months to years Episodic Memory, Abstract thinking, Memory and Cognitive impairment consciousness memory concentration Mood Rapid mood swings Depression, apathy Sadness, anxiety May present in later Delusions/hallucinations Both; often visual Delusions only stages Outcome Recovery possible Poor Recovery possible Schizophrenia Spectrum and Other Psychotic Disorders As mentioned previously, psychotic disorders encompass a broad range of cognitive alterations that result in altered perceptions of reality and abnormal thinking in the absence of an underlying condition. Schizophrenia represents one type of psychotic disorder identified in the DSM-5 and is discussed in detail as an exemplar for cognition. Approximately 1–4% of the population experiences some type of psychotic disorder, and up to 1% of the worldwide population meets the criteria for schizophrenia. The DSM-5 identifies a number of psychotic disorders in addition to schizophrenia spectrum disorder. Because psychosis can result from an underlying medical condition or ingestion of one or more substances, diagnostic tests should be run to rule out any underlying illness or causative agent. Risk Factors for Altered Cognitive Function Although risk factors for impaired cognition vary according to the conditions described in this section, a few general principles apply. Most developmental and acquired cognitive disorders have a nonmodifiable familial/genetic component that predisposes individuals to the development of a specific disorder, such as dementia or schizophrenia. Other categories of risk factors include population-specific factors, lifestyle behaviors, environmental exposures, and certain health conditions. Most cognitive disorders are believed to be multifactorial or the consequence of genetic factors and age, sex, lifestyle behaviors, environmental exposures, or other health conditions. Cognitive function and other systems tend to be interdependent, so determining the extent to which other concepts or systems are involved can be difficult. For example, cerebral perfusion is necessary for normal cognitive functioning but depends on the adequate intake of oxygen and osmotic pressure needed to maintain adequate blood flow. Even subtle variations in perfusion can result in acute alterations in cognitive function, such as delirium, with older adults being more sensitive to these changes because of diminished functional reserves. Cerebral perfusion and cognitive integrity depend on normal gas exchange. Chronic and subtle mechanisms involved in decreased oxygen supply to the brain (as seen in chronic obstructive pulmonary disease [COPD] and anemia) can negatively impact the neurochemical signaling and synaptic plasticity necessary for normal cognitive development and function. Genetic factors and early environmental insults can influence development in utero or in the child’s first years, affecting learning, cognition, and speech and language development. Exposure to alcohol or other toxins during pregnancy can have long-term implications for child health and cognition. Inflammation appears to play a key role in altered cognitive function. Stress, infection, surgery, and cancer all result in an inflammatory response and the release of cytokines. Inflammation can occur in the brain and CNS as a direct result of trauma, cerebral infarction, or infection. Peripheral inflammation (outside of the CNS) causes a cascade of physiologic events with implications for an array of affective, cognitive, and behavioral responses. Initially, these changes are adaptive, enabling individuals to conserve energy necessary for healing. However, chronic or persistent inflammation can lead to irreversible neuronal changes. Substances such as alcohol, illicit drugs, and some pharmaceuticals can impact cognitive function. Alterations in cognitive function have the potential to impact an individual’s competency to make healthcare decisions and consent to certain treatments and procedures. Patients with mental health disorders, intellectual disabilities, and other cognitive conditions are often unable to advocate for themselves and are considered vulnerable populations. Establishing advance directives during mild stages of cognitive dysfunction or relapse is essential. A health-promotion model for cognition views cognitive function on a continuum from optimal to impaired function, with the goal being to support independence and quality of life for all individuals at risk for or experiencing an alteration in cognitive function. The CDC (2019a), through its Healthy Brain Initiative, stresses the importance of prevention and early screening to address the public epidemic of cognitive disorders. When individuals are diagnosed with a cognitive disorder, the goal is to provide care that enables them to achieve their fullest potential, maintain their orientation to their families and communities, and live in environments that promote their inherent worth and self-efficacy. Prevention Prevention of cognitive disorders includes measures to reduce modifiable risk factors and enhance protective factors. Universal prevention of cognitive disorders targets the general population and includes interventions such as public health campaigns regarding the use of seat belts and other safety devices. Selective prevention targets subgroups of the population whose risk of developing a cognitive disorder is higher than that of the general population based on an analysis of biological, psychologic, or socioeconomic factors. Examples include early intervention programs for children from disadvantaged backgrounds and counseling following exposure to trauma. Indicated prevention is aimed at individuals who have minimal but detectable manifestations of cognitive disorder. An example would be initiating treatment for an individual who demonstrates prodromal symptoms of schizophrenia or has biomarkers for dementia. Screening and Early Detection The progression and or impact of many of the cognitive disorders described in this module can be positively impacted through early detection and intervention. A variety of screening tools are identified in the sections on assessment later in this module. Screening and detection of cognitive disorders occur in a number of settings, including but not limited to primary care settings, community health settings, and schools. Nursing Assessment A general assessment of cognitive status is an essential component of the nursing assessment of all patients. When a patient presents with the onset of any cognitive changes, the priority assessment focuses on addressing potentially life-threatening factors that may be contributing to the problem through physical assessment, history, and diagnostic procedures, such as laboratory values. SAFETY ALERT! Any changes in cognition require immediate attention. Cognitive disturbances put patients at increased risk of injury, so rapid initiation of safety measures is critical. Also, prompt assessment of a patient’s cognitive impairment may allow the healthcare team to more quickly identify and treat the underlying cause. Cognitive assessment is performed both for the purposes of initial screening for the presence or absence of cognitive problems and for monitoring changes in cognition over time. An assessment of cognitive status should be performed during an initial provider or home care visit, following any changes in medical treatment and pharmacotherapy, during any transitions in care, and prior to obtaining consent for procedures. Certain individuals are at increased risk for cognitive problems and warrant more frequent assessment of cognitive status. For example, clinical guidelines published by Ellis et al. (2017) suggest that on admission older adults who are hospitalized should receive a comprehensive geriatric assessment (CGA). The CGA is a multidimensional, multidisciplinary assessment of the medical, mental, and functional problems of older people with frailty. Use of the CGA promotes collaborative, integrated care. Observation and Patient Interview Initial observation of the patient focuses on appearance and behavioral manifestations that may be indicative of cognitive function. Appearance and dress can provide cues to the patient’s mental state and ability to maintain self-care. The nurse may also make general observations related to social skills, motor function, activity level, ability to attend and focus on the assessment, and ability to provide logical and coherent responses to questions. The best source of information comes directly from the patient. However, when assessing pediatric patients or patients with moderate to severe cognitive impairment, a family member or caregiver may be asked to provide information. During the patient interview, ask direct questions to elicit information related to biophysical and psychosocial history, development, family history, and environmental factors. Use judgment in direct questioning of individuals with established cognitive and perceptual problems, as some may not have the capacity to respond logically. In addition, cognitive problems such as perceptual problems and delusional thinking are likely to increase the patient’s anxiety and may result in an escalation of inappropriate behaviors during the patient interview and examination. Biophysical and Psychosocial History The medical history includes gathering information about both the presenting problem and the presence or development of altered health patterns across the lifespan. History of the Current Problem Initial questions focus on the patient’s perception of the problem and what brings the patient to the healthcare setting currently. Initial questions may proceed from broad questions about a typical day, including ADLs, self-care activities, and perceived level of health and wellness. When patients or family members report changes in cognitive function, ask nonthreatening questions such as: Can you describe the changes? What do you think may be contributing to the changes? When did you begin experiencing these changes? Are these changes constant and, if not, how frequently do they occur? Have you previously sought medical advice or care related to these changes? More focused questions include the following: Are you experiencing any changes in your ability to pay attention or remember things? Do you have difficulty planning and organizing things? Do you ever hear, see, or smell things that are not apparent to others? Have you been experiencing any problems that are making it difficult to learn or function in school (or work)? Have you been experiencing any problems expressing yourself or understanding others? Depending on the patient’s responses, seek additional detail about the impact on daily functioning, frequency and duration of symptoms, suspected causes or contributing factors (such as a preexisting medical or psychiatric diagnosis), and how the patient has been treating or managing the symptoms. Be sure to obtain a list of all current medications with the dose, route, and frequency and to inquire about the use of any complementary health approaches. History of Prior Biophysical and Psychosocial Alterations A thorough history of patient development, illness and injury, and health behaviors (including substance use) is necessary when working with patients with alterations in cognition. For children, it is necessary to assess for achievement of expected milestones and to note any factors that may impede normal growth and development (such as chronic illness or exposure to trauma). Ask if any family members had disorders such as dementia, schizophrenia, and/or developmental or learning problems. Because many patients may not have knowledge of the specific diagnoses in family members, use lay terms when inquiring about unusual symptoms and behaviors, such as confusion or memory loss, and treatment history. Assess for environmental factors that may be contributing to the patient’s cognitive status, including nutrition and lifestyle considerations, use of any type of medication or herbal supplement, and any accommodations or services in place to support independent function. When assessing cognition in children, consider parenting techniques and capabilities, as well as access to activities and stimulation that promote cognitive development, such as age-appropriate activities and toys. Determine the possibility of any current or past exposures to toxic substances at home or at work. Physical and Mental Status Examination Once the interview is completed and the patient’s history has been obtained, the nurse progresses to a physical assessment of the patient and a mental status examination. The physical examination incorporates an organized pattern of assessment to identify alterations that may be contributing to cognitive dysfunction. The mental status exam includes a series of procedures and tools used to detect alterations in perception and thinking. Physical Examination Because changes in cognitive function are often an early sign of decreased oxygenation or perfusion or an alteration in another biophysical process, begin by obtaining a complete set of vital signs and assessing the patient’s level of pain. Auscultation of the heart and lungs may reveal an underlying problem with gas exchange or perfusion. For example, murmurs in infants and young children may indicate congenital heart defects associated with other neurodevelopmental problems. An assessment of peripheral perfusion may indicate vascular problems that are compromising cerebral perfusion. An assessment of neurologic signs is an essential component of cognitive evaluation (detailed information can be found in Module 11, Intracranial Regulation). An evaluation of hearing, vision, touch, taste, and smell can help rule out perceptual problems related to impaired sensory function. Physical development and height, weight, and fat distribution should be within normal limits for the patient’s age. Observable physical alterations may be associated with many cognitive syndromes, including intellectual disabilities and schizophrenia. Examples include small head circumference, wide- or close-set eyes, prominent forehead, folds on the inner corners of the eyes (epicanthic eye folds), asymmetry or malformation of facial features and ears, tongue protrusion, palate and mouth abnormalities, flattened face or nose, limb abnormalities, small stature, poor muscle tone, some birthmarks, palmar folds, and altered posture. Suspicions of genetic and metabolic/biochemical disorders accompanying developmental delay can be investigated through genetic testing and serum and urine tests. An important component of the physical examination includes an assessment of motor function. Movements should be consistent with age and development. Any changes in gait or other evidence of movement disorders should be noted. Mental Status Examination The mental status exam is a broad screening tool that is used to assess current cognitive functioning of the individual. Many tools are available, and most serve to capture data related to orientation, perception and thought content (including judgment and insight), attention and concentration, memory, speech/language/communication, mood and affect, and psychomotor activity. Other assessments may be used to rule out related conditions such as depression or other mood disorders or to gather information on developmental status or level of functional impairment. The Mental Status Assessment feature presents an example of an organized formal mental status examination with a description of normal and abnormal findings and patient- centered considerations. Formal assessment often serves to validate findings gathered through observation. Ages & Stages Set of questionnaires tailored to detect alterations in development in Questionnaires young children. (ASQ), Kit for health promotion and prevention published by the American American Academy Academy of Pediatrics that includes schedules for screening and care and of Pediatrics—Bright a variety of questionnaires used to detect health problems, including Futures developmental alterations. Confusion Five-minute interview-style exam that screens specifically for signs of Assessment Method delirium. Pediatric versions are available for children 5 years and older (CAM) (pCAM/psCAM-ICU for critically ill infants and children). Cornell Assessment Validated, rapid observational tool for screening children in intensive care of Pediatric Delirium for delirium. Cornell Scale for Nineteen-question tool that involves interviews with both patients and Depression in their caregivers; assesses for signs of depression in individuals known to Dementia have dementia. Edinburgh Validated 10-item questionnaire used to screen for the presence and Depression Scale severity of symptoms of postnatal depression. Geriatric Depression Brief questionnaire (15 or 30 items) that asks patients how they’ve felt Scale (GDS) over the past 7 days; assesses for depression in older adults. Twenty-minute, 17-question examination that assesses severity of Hamilton Rating depression in adult patients. The Weinberg Depression Scale for Children Scale for Depression and Adolescents (WDSCA) and the Children’s Depression Rating Scale (HRSD) (CDRS-R) are modeled on the HRSD and adapted for children over age 5.  Thirty-question interview-style exam that assesses a patient’s memory, Mini-Mental State language skills, attention level, and ability to engage in mental tasks; also Examination known as the Folstein Mini-Mental State Examination. It may be modified (MMSE) for use in children over the age of 4. One-page test that briefly assesses a patient’s ability in a variety of cognitive domains, including problem solving and sequencing (traits, Montreal Cognitive similarities), attention (digit span, letter vigilance), memory (word list, Assessment orientation), visuospatial construction and reasoning (cube, clock), and language (naming, repetition, word generation). Nonverbal Learning Assesses deficits in the areas of motor skills, visuospatial skills, and Disabilities (NVLD) interpersonal skills. Scale Full-length 11-item tool that screens for depression and anxiety, somatic Patient Health symptoms, and related disorders; abbreviated forms (PDQ-9 and PDQ-2) Questionnaire (PHQ) are used to more selectively screen for depression. Registered nurses and other licensed healthcare providers (HCPs) can Positive and administer to detect positive, negative, and other manifestations of Negative Symptoms psychotic disorders and schizophrenia. May be useful in screening for Scale (PANSS) peripartum psychosis. Postpartum Depression Validated short inventory that can be integrated into all phases of perinatal Predictors Inventory care to predict the risk of maternal depression. (PDPI) Diagnostic Tests Nurses collaborate with other disciplines to support diagnostic assessment of individuals for cognitive disorders. When individuals present with alterations in cognition, nurses can anticipate that a number of laboratory values and diagnostic tests will be ordered to rule out an underlying medical condition. Priority diagnostic assessment focuses on life-threatening conditions that may manifest in cognitive alterations. Analysis of blood and cerebrospinal fluid (CSF) can identify biomarkers associated with Alzheimer disease and schizophrenia, although this is not typically used for diagnosis. Relevant laboratory tests include the following: Toxicology screens to rule out alcohol or substances as a causative factor for changes in mental status Drug levels to rule out mental status changes related to toxic levels of therapeutic agents Liver function tests (LFTs), complete blood count (CBC), thyroid function,B1(thiamine), sedimentation rate, urinalysis, HIV titer, and fluorescent treponemal antibody absorption (FTA-abs) to rule out metabolic, inflammatory, and infectious conditions that may contribute to alterations in mental status Blood tests to identify biomarkers for schizophrenia  CSF and blood markers to identify biomarkers for certain conditions Genetic testing to identify risk factors or underlying causes of a variety of cognitive disorders Metabolic screening, which are newborn screens for 26 to 40 metabolic disorders that can cause learning and intellectual disabilities Diagnostic imaging to detect conditions requiring emergency management, such as cerebral edema, cerebral vascular accidents, tumors, and traumatic injuries MRIs and CT to detect abnormalities that are suggestive of some neurocognitive, neurodevelopmental, and psychotic disorders. Step 1: Prepare the Patient Tell the A number patient of you will assessment be tools are performin available, g a series with some of tests. tailored to Describe specific what Patient conditions equipmen pays and/or t you’ll attention population use. and asks s. Patient displays high levels of Explain questions Direct confusion, anxiety, or agitation. that the as questionin Patient shows signs of delusions or exam appropriate. g may not hallucinations. should be Patient may be Patient pays no attention to the comfortab be nervous, appropriat information you provide. le and ask but this e for Patient is partially or fully the should not patients uncommunicative. patient to interfere who are inform with the experienci you assessment ng should process. hallucinati difficultie ons, s arise. delusions, Provide or extreme an anxiety. overview Questions of the for assessme children or nt individuals activities with and the intellectual order in disabilities which should be they will modified. occur. Step 2: Observe the Patient Take note of the patient’s Patient general follows appearanc directions. e, Patient’s including hygiene hygiene, Poor hygiene may be and overall Poor hygiene and/or posture, related to economic appearance inappropriate expressions body circumstances. Patient are and body language might language, expressions and body acceptable. be reflective of and language may be Patient’s depression, schizophrenia, expressio congruent with cultural expressions dementia, or another n. norms that are different and body cognitive disorder. from the provider’s. language Observe are the appropriate patient’s to the ability to situation. follow your instructio ns. Step 3: Assess the Patient’s Language Abilities Patient’s tone, Problems Consider whether rate, with the patient’s hearing pronunciation, language may be impaired, and volume could be a especially when Note the tone, rate, are result of working with older pronunciation, and appropriate. anxiety, adults. volume of the patient’s Patient speaks dementia, Don’t assume all speech throughout the easily and depressio patients are native course of the exam. naturally, n, or an English speakers. Consider the patient’s without expressiv Some patients may vocabulary and whether searching for e or communicate more what you are saying is words. receptive effectively in understood. Patient language another language understands disorder and require what you are related to assistance from an saying and brain interpreter.  indicates this injury/illn Consider the child’s through verbal ess. stage of and physical development. reactions. Social and language milestones have been met. Step 4: Assess the Patient’s Level of Orientation Noticeable decreases in consciousnes s during the exam may Patient is fully Assess Reduced or varying necessitate conscious and orientation consciousness may be due to immediate alert, oriented to person, hypoglycemia, stroke, seizure, medical to self, place, time, delirium, or organic brain attention. location, time, and disease. Modify and situation. situation. questions for children according to development al level. Step 5: Assess the Patient’s Memory In Alzheimer disease, loss Inability of short- to recall term See whether the events memory patient knows name, from Patient can recall basic typically birth date, and one’s past personal information and precedes address. Ask the may be provide an accurate loss of long- patient for a brief suggestiv biography appropriate to age term summary of places e of and developmental level. memory. lived and jobs held. dementia, Alterations Attempt to verify all especially in memory responses. Alzheime in children r disease. may suggest a problem with learning or  intellectual function. Step 6: Assess the Patient’s Computational Ability Patient can comput e the Patient’s correct responses may Have the patient values. be negatively answer several Depend affected by arithmetic problems. ing on Inability to perform language Start with basic facts age and simple calculations may barriers, and work toward more cognitiv be suggestive of brain cognitive complicated questions. e stage, disease or learning development, The age and the patient problems. anxiety, and/or developmental status may be limited of the patient should able to experience or be considered. identify education in numeric mathematics. symbol s and count. Step 7: Assess the Patient’s Emotions and Mood Mismatch Note the between the patient’s affect. patient’s Ask how the affect and patient is feeling speech may and whether this Patient’s affect reflect is typical. If not, Culture, corresponds with the neurologic or ask about events temperament, and tone and content of psychologic that may have development speech. problems. prompted the impact emotional Patient’s emotions Absent, change. expression. Certain and mood are excessively developmental appropriate given past subdued, or Modify stages are events and current excessively questions for associated with situation and animated children. increased lability. developmental status. expressions Children may be and responses asked to draw may be pictures of how indicative of they are feeling psychologic or to select from disorders. a visual scale. Step 8: Assess the Patient’s Perceptions and Thinking Abilities Note whether the patient’s statements are Patient is aware of complete, Patient’s reality. rational, and responses may Patient’s pertinent, and Patients who are be negatively statements are whether the unaware of reality affected by logical and patient seems may be experiencing language complete. aware of neurologic barriers, Patient correctly reality. disturbances or a education level, compares two mental disorder. and/or objects and/or Ask the Illogical, incomplete intellectual explains the patient to statements suggest disability or meaning of a compare two problems with level of phrase. different concrete thought and cognitive Patient denies things or may be indicative of a development. hallucinations of explain the mental disorder. Perceptual any kind, or meaning of a Absent or strange differences in perceptual common comparisons and young children differences may be phrase. explanations are may be related explained by level frequent symptoms of to magical of cognitive Ask if the psychologic disorders. thinking and development or patient can animism. sociocultural see, hear, Children may h factors. smell, or feel things that are not apparent to others. Step 9: Assess the Patient’s Decision-Making Ability Consider whether the patient’s Ask the patient Patient considers options and about a personal possible, Patient considers decisions make situation that probable, and impossible, sense—not requires good appropriate improbable, or whether they judgment. options. inappropriate reflect the choice Determine Patient’s thinking options. you would make. whether the and decision- Patient’s decision Decision-making patient’s making reflects absent or capacity depends responses reflect capabilities are inadequate on the stage of consideration of appropriate for consideration of cognitive viable options and age and stage of available options. development; logical decision development. refer to normal making. characteristics of thinking  associated with each stage. Psychometric tests include a variety of standardized tests that are usually administered by a psychologist or neuropsychologist to measure cognitive function in a variety of areas. Comprehensive neuropsychologic testing may include the use of a number of tests administered over a period of several days. Nurses, teachers, parents, and patients may be asked to complete one or more rating scales to contribute to an overall understanding of the presentation of the problem across a variety of domains. Independent Interventions Given the importance of health promotion with respect to cognitive disorders, nurses should be prepared to carry out a variety of interventions across settings. Nursing interventions include teaching prevention, coordinating care and making appropriate referrals, implementing measures to promote individual/family safety and well-being, and advocating for the needs of individuals impacted by alterations in cognition. Prevention and Coordination of Care Nurses in community health and primary care settings play a critical role in addressing health- related behaviors and suggesting protective measures that can reduce the risk of developing cognitive disorders. They also independently carry out routine assessments for cognitive problems and refer patients for further diagnosis and treatment. Examples of independent interventions in this category include: Teaching about healthy diet and lifestyle and the importance of preventive healthcare Ensuring that patients use protective headgear during sports and activities such as bike riding Stressing the importance of developmentally appropriate activities Administering routine developmental and cognitive screenings Making referrals to other members of the interprofessional team. Promoting Safety and Well-Being Nurses in all settings often plan care for individuals that promotes safety and adaptive functioning. For example, the home health nurse may work with individuals with schizophrenia or Alzheimer disease, monitoring adherence (compliance) to treatment, providing emotional support to the patient and family, and assessing comorbid health conditions. When patients do require hospitalization for acute changes in cognition, the priority is to identify and manage underlying conditions that may be contributing to the problem. Priority interventions address immediate safety. Secondary interventions include teaching patients and families about the illness and prescribed treatments, providing emotional support, and preparing for discharge to settings where they can receive the support necessary to achieve optimal functioning and prevent future hospitalization. Examples of interventions across settings include:  Evaluating risk of injury or suicide Implementing environmental modifications to support patient safety Educating patients and families about diseases, medications, and other therapeutic interventions Identifying patient and family strengths Encouraging the use of adaptive coping skills Supporting cultural and spiritual needs Providing ongoing emotional support to both patients and families Ensuring healthcare needs are met Monitoring the effectiveness of care. Advocating for Patients Because cognitive disorders have the potential to reduce decision-making capacity, nurses have a role in ensuring that patients are not abused or exploited and are able to partner in healthcare decisions to the greatest degree possible. This includes encouraging patients in remission or in the early stages of neurocognitive dysfunction to establish advance directives and providing teaching about legal protections that may apply to them (see the Patient Teaching feature). Other interventions related to advocacy include providing teaching related to legal rights and assisting caregivers and community members to understand cognitive disorders. Nurses working in the newborn nursery and in pediatric settings should be familiar with the processes of referring families to area agencies that provide early childhood intervention services. Patient Teaching Legal Protections for Patients with Cognitive Dysfunction Nurses should teach individuals with cognitive alterations and their families about several key laws that may affect them. For example: The Americans with Disabilities Act of 1990 ensures that individuals with disabilities have equal access to government services, employment, and public accommodations. The Education for All Handicapped Children Act of 1975 requires that children with any type of disability have access to free public education. An amendment to this act in 1986 provides federal funding to states that offer early intervention services. The Developmental Disabilities and Bill of Rights Act of 2000 provides federal funding to state, public, and nonprofit agencies that provide community-based training activities and education to individuals with developmental disabilities. The law also created the U.S. Administration on Developmental Disabilities to oversee these efforts. Collaborative Therapies When working with individuals at risk for or experiencing alterations in cognitive function, nurses should anticipate collaborating with the patient, family, other members of the healthcare team, and potentially professionals from other disciplines, such as education and law. Table 37.1 in Module 37, Collaboration, provides an overview of select members of the interprofessional team and their roles. Other professionals sometimes involved with assessment, diagnosis, and treatment planning of individuals with cognitive impairments or intellectual disabilities include developmental pediatricians and developmental psychologists, neuropsychologists, and neurologists. Additional resources may be available through local chapters of organizations such as the Alzheimer’s Association, the American Psychiatric Association, the American Association of Intellectual and Developmental Disabilities, and the National Alliance on Mental Illness. Pharmacologic Therapy Nurses play a key role in medication administration, education, and adherence, and they must be familiar with the different classes of drugs prescribed to individuals with cognitive alterations. Drugs for treating neurocognitive disorders are primarily aimed at slowing further brain changes and deterioration in functioning. Medications used to treat psychosis target the presenting symptoms, in an attempt to balance brain chemistry and help the patient normalize behaviors and restore life functions. Experienced nurses will check their facility’s intranet, use an online database or a current drug reference, and consult with the pharmacist or physician if they have medication questions. Finally, nurses are responsible for educating family and caregivers about administering medications and their side effects, particularly noting adverse drug reactions that require immediate attention. More specific information on medications used in the treatment of patients with cognitive disorders can be found in the exemplars on Alzheimer disease and schizophrenia. SAFETY ALERT! Nurses must assess patients with cognitive alterations to determine their ability to self-administer medication. Many patients will require caregiver administration of medications. Missed doses may result in a return or exacerbation of symptoms and increase the patient’s risk for deterioration or injury. Long-acting drug formulations (e.g., extended-release tablets, transdermal drug patches) may enhance adherence. Assess for factors that affect adherence at each healthcare interaction. Lifespan Considerations Cognitive function is mediated by the interaction of genes and experience, both of which provide the foundation for cognitive changes that occur across the lifespan. Nurses use knowledge of these changes to modify assessment and interventions with individuals who are at risk for or are experiencing alterations in cognitive function. A major consideration is the impact of normal growth and development. Lev Vygotsky (1896–1934), a Russian psychologist, emphasized the importance of social interaction in the development of cognition: When children interact with others, they learn. Furthermore, he argued that social interactions assist in helping individuals find meaning and form memories and that these interactions can be culturally influenced. Vygotsky’s work provided the theoretical underpinnings for collaborative education and online learning. While Vygotsky viewed learning as a social process, Swiss psychologist Jean Piaget (1896– 1980) believed cognitive development is constructed by the individual. Piaget claimed that cognitive development is an orderly, sequential process in which children form adaptive cognitive structures—called schemes—in response to environmental stimuli. According to Piaget, as children learn more about the world by physically interacting with it, they actively revise their schemes to better fit with the reality they observe. Over time, as their brains mature and they are exposed to additional stimuli, children become capable of building more complex schemes—and as they do so, they move from one stage of development to the next. Stage and Age Description Developments Range Infants use motor and sensory Children develop a sense of “self” and Sensorimotor capabilities to explore the physical “other” and come to understand object environment. Learning is largely trial permanence. Behavioral schemes begin Birth to 2 years and error. to produce images or mental schemes. Young children use symbols (images Children participate in imaginative Preoperational and language) to explore their play and begin to recognize that others environment. Thought is egocentric, and don’t see the world the same way they 2–7 years children cannot adopt the perspectives of do. others. Older children acquire cognitive Children are no longer fooled by Concrete operations or mental activities that are appearances. They understand the basic operational an important part of rational thought. properties of and relations among Logical reasoning is possible but limited objects and events, and they are 7–11 years to concrete (observable) problems. proficient at inferring motives. Formal Logical thinking is no longer limited to Adolescents’ cognitive operations are operational the concrete or observable. Children organized in a way that permits them to