92 17.4 Cognition: Major Neurocognitive Disorder and Neurodegenerative Diseases
Learning Outcomes
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations for MNDs (dementia), Alzheimer disease, and delirium.
- Describe the diagnostics and laboratory values in MNDs and Alzheimer disease
- Apply nursing concepts and plan associated nursing care for the patient with MND and Alzheimer disease
- Evaluate the efficacy of nursing care for the patient with MND and Alzheimer disease
- Describe the medical therapies that apply to the care of MND and Alzheimer disease
The concept to be explored in this chapter is neurocognition. Two exemplars or diagnoses will be presented on Dementia and Alzheimer Disease. The nursing plan of care will be presented using both exemplars to better understand the nursing care of neurocognition. The decline in cognitive abilities, such as memory and reasoning, in a manner that disrupts patients’ daily lives is known as major neurocognitive disorder (MND). MND refers to a group of disorders characterized by neurological changes that make it more challenging for patients to continue routine activities.
Link to Learning
It is important to note that in DSM-5 criteria, the definition of dementia has been updated. The term major neurocognitive disorder is now the correct terminology for dementia.
MND varies in severity and may worsen over time. For some patients, MND is mild enough that they can still function reasonably well, whereas other patients experience MND so severely that they are unable to care for themselves. MND is a general term that refers to several neurological disorders. The most common form of MND is Alzheimer disease, which is also a neurodegenerative disease, a chronic condition that damages the brain and central nervous system, causing problems with cognitive abilities as well as physical movement. In addition to Alzheimer disease, amyotrophic lateral sclerosis (ALS) and Parkinson disease are other neurodegenerative diseases. Neurodegenerative diseases are incurable, but they can be treated and managed. This section will provide an overview of MND, Alzheimer disease, ALS, and Parkinson disease, including symptoms and how nurses can assess, plan, and care for patients with these diseases.
Exemplar: MND Pathophysiology
MND occurs when the brain’s neurons, or nerve cells, die after they become inactive and lose their connections to other brain cells. This is a normal process that every person experiences, particularly as individuals age. But for patients who develop MND, this process is more active, and they lose a larger number of neurons. Although MND is associated with aging, not everyone develops MND as they get older. The National Institute on Aging estimates that about one-third of people over age 85 may have some type of MND (Figure 17.8). In addition to Alzheimer disease, other common forms of MND include the following (National Institute on Aging [NIA], 2022b):
Abnormal deposits of protein in the brain lead to Lewy body dementia. The condition progresses slowly and changes patients’ ability to think and concentrate.
Damage to the brain’s frontal and temporal lobe neurons leads to a frontotemporal disorder. The condition progressively gets worse and causes personality and behavior changes.
Insufficient blood and oxygen to the brain leading to damage to the brain’s blood vessels causes vascular dementia. The condition may affect all aspects of a patient’s cognitive abilities, including behavior, memory, and reasoning.
Clinical Manifestations
The symptoms of MND include cognitive problems such as memory loss, disorientation, and confusion; difficulty reasoning and using abstract thinking, logic, and judgment to think and solve problems; decreased ability to organize and plan; communication difficulties, including forgetting simple words; spatial awareness issues, which may include getting lost; and needing more time than usual to complete routine tasks. Patients may lose things or put them in the wrong place for safekeeping. MND symptoms may also include psychological issues, such as changes in personality, which may include losing interest in favorite activities and/or no longer caring about others; feelings of paranoia; being irrational and/or impulsive; hallucinations; anxiety; and depression.
Assessment and Diagnostics
Health-care professionals assess and diagnose MND with a physical examination that includes a review of the patient’s symptoms, as well as diagnostic tests. Patients should be asked about their medical background and history, including whether their family has a history of MND and whether they are taking any medications, such as anticholinergic drugs and opioids, which can cause symptoms of MND. The patient’s general health needs to be assessed, because patients with MND may have other health problems, such as traumatic brain injury, cardiovascular disease, Parkinson disease, and immune disorders. Patients with MND may also lead unhealthy lifestyles, which may include poor nutrition and lack of exercise, particularly if they are forgetful and don’t remember to eat or get exercise.
Diagnostics and Laboratory Values
The diagnostic tests that can help diagnose MND include brain scans, such as a CT or MRI, lumbar puncture, positron emission tomography (PET) scans, and cognitive and neurological tests. Brain scans may show tumors and stroke, and lumbar punctures may show a high level of protein in CSF. PET scans may show abnormal brain activity and may also reveal deposits of protein in the brain. Cognitive and neurological tests will show decline and problems in the patient’s mental abilities. Each of these problems can contribute to MND.
Link to Learning
The Alzheimer’s Association (AA) provides a guide to help patients understand the medical tests available to determine if someone has Alzheimer disease or another form of MND. AA’s website also includes a link to an interactive tour that helps patients understand what to expect when they are evaluated for cognitive issues.
Nursing Care of the Patient with MND
MND cannot be cured. Patients who have mild MND may be able to continue functioning reasonably well with minimal assistance, but as MND progresses, patients may need more in-depth and routine care. Patients with MND should be in a safe, secure environment that provides the resources they need to function as well as possible, such as health-care facilities that provide memory care or assistance with ADLs.
Recognizing Cues and Analyzing Cues
To recognize and analyze the cues of MND, nurses should review the findings of the patient’s physical examination. This includes noting whether the patient seems confused, struggles to communicate, or has paranoid tendencies. Patients with MND may do things such as repeat questions, have trouble writing, or lack interest in a conversation. To gather additional cues, nurses can talk with the patient’s family members and ask them about problems they have noticed in the patient. Other cues will come from diagnostic test results. If the results of brain scans, lumbar punctures, PET scans, and/or cognitive and neurological tests show abnormal results, these may be cues that indicate the patient has MND.
Describe the clock test
Because most patients with dementia or MND enter the hospital without the diagnosis in their chart, the nurse becomes very powerful in screening for MND. The clock test is a very simple and easy to apply at the bedside.
RN Story: Kim is a nursing instructor who was teaching the first level nursing students on a medical surgical floor on a Saturday morning. At 7am Kim and one student entered an older patient’s room. She answered all our questions seeming appropriately but there was something in her eyes that seemed like she was confused. She had a history of right sided breast cancer with mastectomy and was not supposed to have intravenous (IV) catheters inserted in her right arm. A resident entered the room and asked the patient for consent to initiate an IV in her right arm since there were no good insertion sites assessed on her left arm. The patient gave consent. Kim was concerned and wanted to be assured her hunch was correct. She immediately implemented the clock test to demonstrate to her student. Five minutes later, the test was completed with findings that could indicate MND. At that moment, the daughter who was in her 60’s entered the room with two coffees for her and her mom. I explained about the consent obtained from the resident about the IV. She immediately said, “Oh no! My mom has dementia. I have power of attorney. All consents must come through me.” Kim called the resident back to the bedside and explained the situation and the results of the clock test. Her chart was updated and we all learned a big lesson that day.
Link to the Clock Test: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://hign.org/sites/default/files/2020-06/Try_This_General_Assessment_3.pdf
Link to other assessments: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://hign.org/sites/default/files/2020-06/Try_This_General_Assessment_3.pdf
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The symptoms of patients with MND should be prioritized based on their severity. For example, if a patient’s symptoms are so severe that they do not remember others and do things such as wander from home and get lost, this is more urgent than symptoms that cause a patient to do things such as misplace their keys. Keeping patients safe is paramount, and symptoms that put patients in danger must be prioritized. Solutions should focus on ensuring patients’ safety while helping them live as independently as possible. The nursing interventions appropriate for patients with MND may include those in Table 17.12.
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Nursing Care |
Rationale |
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Complete focused neurological assessments. |
The patient’s cognitive status, including confusion, memory issues, communication difficulties, and problem-solving skills may indicate MND. This includes whether the patient acts impulsively, wanders away and gets lost, seems disinterested in others, and repeats questions. |
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Monitor vital signs. |
Changes in the patient’s vital signs, such as heart rate and blood pressure, as well as balance issues may indicate health problems. |
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Administer medications. |
Patients with MND may need medications, such as cholinesterase inhibitors and memantine, to help with MND symptoms. |
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Coordinate with occupational therapist. |
Some patients with MND may benefit from occupational therapy, which can teach coping behaviors, particularly how to keep patients with MND safe from threats such as losing their balance and falling. Nurses may refer patients to occupational therapy. |
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Help with exercise. |
Patients with MND may benefit from exercise and should be encouraged to develop an exercise regimen. Although results are not definitive, research suggests that exercise such as walking and swimming may improve brain functioning. Nurses can help patients identify exercise opportunities and formulate a plan to make exercise part of their daily routine. |
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Coordinate mental health support. |
Patients with MND and their families may need consultation with a mental health professional to help them cope with the challenges of living with MND. Some patients may need prescription medications to help with issues such as anxiety and depression. |
Table 17.12 Nursing Interventions for Patients with MND
Link to Learning
Read this article to learn more about how exercise can decrease the risk for cognitive decline from the Alzheimer’s Association.
Evaluation of Nursing Care for the Patient with MND
The desired outcome for patients with MND is alleviation of symptoms if possible. If a patient’s symptoms of MND cannot be alleviated, or at least improved, the desired outcome is to help patients and their families learn how to cope with MND. Patients with MND should be kept safe and provided the support needed to enhance their quality of life as much as possible. Goals for patients with MND include helping them live at home if possible, maintaining a routine of physical activity, engaging in activities that provide mental stimulation, and avoiding hospitalization.
Real RN Stories
Nurse: Jen
Years in Practice: Five
Clinical Setting: Memory care/Alzheimer unit
Geographic Location: Las Vegas, Nevada
As part of my nursing shift, I struggled with both anger and empathy when caring for Mrs. Sutherland, an older patient experiencing advanced Alzheimer disease. My challenge lay not in an absence of commitment or medical interventions but in Alzheimer disease itself being incurable. Mrs. Sutherland’s memory loss and confusion were emotionally taxing, which highlighted medical limitations, as it left Mrs. Sutherland emotionally distraught and confused. It was profoundly humbling. Normally, people with Alzheimer disease can become mean, but she was so sweet and childlike. She seemed to have reverted to the mental capacity of a 3-year-old who was sweet and trusting. As I carefully attended to her needs by providing comfort, reassurance, and steady presence, I struggled with the inherent frustration associated with treating a condition that demands not just clinical competence but an inexhaustible reservoir of compassion. My focus remained on compassionate care rather than finding solace in small victories such as fleeting smiles or moments of clarity. I saw pictures her family brought in when she used to be a fancy nightclub singer, and now she was a wheelchair-bound older woman who took no care for her physical appearance anymore. It was such a contrast and humbling to see what life can reduce a person to. Gentle redirection was essential, creating an environment that minimized confusion and anxiety for Mrs. Sutherland. I met her where she was instead of where she was previously. I acknowledged the fragmented elements of her reality while managing the fluctuations of her emotional landscape. Disgust turned to profound admiration of human resilience, leading me to pledge my advocacy on behalf of those dealing with Alzheimer disease. By providing care that transcended medical interventions alone, I witnessed firsthand the profoundly powerful effect that compassionate nursing care could have in dealing with an incurable condition. Her family was deeply grateful for the compassionate care I showed to her, which was also rewarding.
Video Clip of Real RN Interview
6.1 Critical Thinking in Assessment
Consider a scenario where the nurse is talking to a patient with dementia. Due to their cognitive condition, the patient may give answers to the nurse’s assessment questions that don’t line up with what the nurse is observing or expecting. The patient is not lying intentionally, but they are unable to be a reliable historian/informant about their own health. A patient with dementia may state that they do not take any medications, but the nurse can see in the patient’s chart that they are prescribed several drugs to manage multiple chronic conditions, and the nurse may also know that the patient was administered a medication earlier that day. A patient with dementia may not recall any of their current health conditions and may not be able to describe their present state of health or concerns. The patient may say they feel “great,” but the nurse may question that statement if they note an elevated temperature and heart rate.
To ensure a holistic picture of the representation of the patient, the nurse uses critical thinking skills during the comprehensive health assessment and physical examination to explore a patient’s whole person needs. A comprehensive assessment and physical examination include not only details about physical state of health, but also the emotional, social, psychological, spiritual (Ambushe et al., 2023), cultural, sexual, energetic, and environmental aspects of a person’s life (ANA, 2019). These factors impact the health and well-being of the individual and are important in planning care for current health problems and preventative care (Figure 6.2).
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Figure 6.2 Older adult patients with cognitive decline or neurological diseases, such as dementia, may not be reliable historians. (credit: Mass Communication Specialist Seaman Apprentice Joshua Adam Nuzzo/U.S. Navy, Public Domain)
Medical Therapies and Related Care
The medical therapies used for patients with MND may include medications, such as cholinesterase inhibitors, which can decrease acetylcholine breakdown, enabling nerve cells to communicate; and memantine, which can decrease neurotoxicity (damage to nerve cells) and protect nerve cells from damage. Other treatments include occupational therapy and regular exercise. Some patients may also need mental health support.
Exemplar: Alzheimer Disease
Alzheimer disease is a disorder in the brain that gradually destroys patients’ memory and thinking abilities, eventually making it challenging for patients to handle basic tasks and live independently. As noted previously, Alzheimer disease is the most common form of MND, accounting for at least 60 percent of MND cases. Generally, Alzheimer disease affects people over age 65 and gradually worsens as patients age. The disease, which has no cure, affects memory and causes patients to be disoriented and confused. Patients with Alzheimer disease struggle to remain independent and continue their daily routines (Alzheimer’s Association, 2024).
Life-Stage Context
Early-Onset Alzheimer Disease
Whereas Alzheimer disease may be regarded as a disease that primarily affects individuals over age 65, early-onset Alzheimer disease affects people in their 40s and 50s. Cases for this age group may be overlooked because providers generally do not expect younger patients to have Alzheimer disease. But occasionally, younger patients with memory problems are experiencing Alzheimer disease, particularly if they have a family history of the disease.
Pathophysiology
Medical experts have not identified the specific cause(s) of Alzheimer disease, but it appears to be linked to factors such as a family history of Alzheimer disease; poor lifestyle, such as lack of exercise and excessive alcohol consumption; head trauma; and environmental factors, such as excessive exposure to air pollution. Alzheimer disease may result when the brain’s neurons become damaged, losing their connections and eventually dying.
In addition, patients with Alzheimer disease tend to have issues with beta-amyloid and tau proteins, which provide support to the brain’s neurons. When the beta-amyloid proteins malfunction, they may clump together in amyloid plaque deposits, which disrupt cell functioning, and the tau proteins may transform into structures called neurofibrillary tangles, which occur when proteins inside neurons accumulate abnormally. These conditions contribute to Alzheimer disease by disrupting brain functioning.
Clinical Manifestations
Typically, Alzheimer disease affects memory first before spreading to affect other brain functioning. Initially, patients with Alzheimer disease may do things such as forget appointments, misplace items, and have trouble remembering the right words to describe things. As problems with memory progress, patients with Alzheimer disease may repeat themselves, sometimes over and over, and do other things such as get lost in familiar surroundings and even forget people they know well.
As the disease progresses, it affects other brain functioning, making it challenging for patients with Alzheimer disease to do things such as reason, make decisions, organize, and make plans. Patients with Alzheimer disease also typically experience personality changes, which may include disinterest in activities they once enjoyed, social withdrawal, moodiness, and aggressive behavior that may include anger. They may also have delusions, change their sleeping habits, and become depressed. As the disease progresses into late-stage Alzheimer disease, patients experience additional symptoms, including the inability to participate in a conversation and difficulty responding to their environment. Eventually, they tend to lose the ability to control their movements, and additional personality changes may occur. At this stage, patients typically need round-the-clock care, and they may become more susceptible to infections, such as pneumonia.
Assessment and Diagnostics
Alzheimer disease is diagnosed by conducting a physical examination that reviews the patient’s overall health to gather details about any recent changes in memory, personality, and daily habits. This examination should include a family member who can provide additional details about any recent changes in the patient’s behavior and thinking abilities. One goal of the physical examination is to rule out other conditions and diseases that may be causing symptoms similar to Alzheimer disease, such as brain tumors, stroke, and Parkinson disease. As part of this process, the physical examination should review the patient’s overall physical health, including eye movements, coordination, speaking patterns, and reflexes.
Diagnostics and Laboratory Values
Diagnostic tests of the patient’s memory and skills, such as cognitive/thinking, language, and mathematical abilities, can provide additional evidence of Alzheimer disease. Other tests that may provide helpful data include blood tests, lumbar puncture, and imaging with brain scans. For patients with Alzheimer disease, the diagnostics and laboratory values that indicate the patient has Alzheimer disease include the following:
Blood tests cannot confirm an Alzheimer disease diagnosis but can be used to rule out other causes of memory loss, such as vitamin deficiencies and thyroid disorders.
Lumbar punctures will show increased levels of beta-amyloid and tau proteins, which are indicative of Alzheimer disease and other forms of MND.
MRI imaging may show shrinkage of areas of the brain that are associated with Alzheimer disease. In addition, MRIs provide evidence to rule out other conditions and diseases that have symptoms similar to Alzheimer disease, such as brain tumors and strokes.
PET scans can show areas of the brain that have poor metabolism, which is an indicator of Alzheimer disease.
CT scans will not help diagnose Alzheimer disease, but their findings can help rule out other conditions and diseases, such as head injuries, strokes, and brain tumors.
Nursing Care of the Patient with Alzheimer Disease
Nursing care for patients with Alzheimer disease should focus on controlling symptoms, as well as helping patients and their families learn to manage and live with the disease. This includes helping patients recognize when they are no longer able to care for themselves. Nurses should educate patients and their families about Alzheimer disease and help them establish routines that can help patients live more independently. For example, caregivers should be educated to gently remind patients with Alzheimer disease when it is time for meals and other tasks, such as taking medications. Nurses should also help patients and their caregivers create a safe environment that protects patients from risks, such as wandering away from home and forgetting where they are.
Link to Learning
Visit the Alzheimer’s Association for more information and resources about MND.
Recognizing Cues and Analyzing Cues
The cues of Alzheimer disease may include memory loss, struggles to think clearly, language difficulties, personality changes, despondency, and aggression. The cues from the diagnostic tests may include increased levels of beta-amyloid and tau proteins and shrinkage of the areas of the brain that control memory and related functioning.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Care for patients with Alzheimer disease should be prioritized based on the severity of their symptoms. Symptoms that threaten patient safety should be prioritized over less severe symptoms, such as mild forgetfulness. Solutions should be generated based on recommendations from the patient’s care team to address each patient’s needs. The nursing interventions appropriate for patients with Alzheimer disease may include assisting with daily routines and providing healthy meals.
Evaluation of Nursing Care for the Patient with Alzheimer Disease
The desired outcome for patients with Alzheimer disease is control and management of their symptoms to improve their quality of life and help them live as independently as possible. This includes enabling them to cope with the challenges of Alzheimer disease and maintaining a safe environment. For example, helping them develop a daily schedule that includes healthy meals and an exercise regimen can help them establish a routine that promotes independence and safety, while also helping them learn to live with Alzheimer disease.
Medical Therapies and Related Care
The medical therapies used to treat Alzheimer disease may include medications such as antiamyloid treatments, which remove beta-amyloid proteins from the brain, preventing the formation of plaques and promoting healthy brain cells. Some patients with Alzheimer disease may benefit from taking cholinesterase inhibitors, which increase the amount of acetylcholine in the nervous system, promoting healthy nerve cells that can sustain memory and learning processes. Some patients with Alzheimer disease may need other medications, such as sedatives and pain relievers to treat additional health problems such as insomnia and pain. If necessary, patients and their families struggling to cope with the challenges of Alzheimer disease should receive mental health support.
Exemplar: Delirium
Pathophysiology
Clinical Manifestations
Assessment and Diagnostics
Diagnostics and Laboratory Values
Nursing Care of the Patient with Parkinson Disease
Recognizing Cues and Analyzing Cues
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Evaluation of Nursing Care for the Patient with Parkinson Disease
Medical Therapies and Related Care
3.3 Challenges Throughout the Lifespan
Learning Objectives
By the end of this section, you will be able to:
Discuss health challenges encountered with the older adult population
As individuals grow and develop throughout their lives, health challenges and health-promotion opportunities change. The type of health issues and methods of health promotion must take into consideration a wide range of factors, including health literacy, physical limitations, motivations, family dynamics, support systems, and access to health services. Creating health-promotion activities with these factors in mind can increase the success of the activity.
Older Adults
The older adult age group, ages 65 years and older, is the fastest-growing age group (Edleman & Kudzma, 2022). The growth and development stage associated with older adults is integrity versus despair, which suggests that older adults are focused on whether their life has provided them personal satisfaction or has been wasted (Erikson, 1995). The mindset of this age group determines how engaged they will be with health promotion. An older adult who is satisfied with their contributions to society may have more motivation to maintain optimal health than an individual who feels like their life has been a waste of time and energy. People in the older adult age group are often finished raising kids, have retired from jobs, and are adjusting to a new lifestyle. A social determinant of health that is applicable to this age group is poverty since many older adults who are not working depend on Social Security benefits as their only income. Older adults have been found to have poor health literacy, which means that they may not readily comprehend or understand health concepts (Stewart, 2020).
Life-Stage Context
Meals on Wheels
America’s Meals on Wheels Program is a network of 5,000 programs across the nation that provide older adults with healthy meals to help decrease hunger and isolation (Meals on Wheels America, 2023). This rapidly growing population is considered at risk due to their fixed incomes (the inability to make more money), compromised health, and higher risk for malnutrition. Meals on Wheels America delivers 251 million meals a year to older adults. It improves their health, makes them feel more secure, and allows them to live independently for longer.
(Meals on Wheels America, 2023).
Falls are the most common cause of injury in older adults (CDC, 2023a). Fall prevention is crucial for older adults because falls are a leading cause of injury and loss of independence among this demographic. As individuals age, changes in balance, vision, and muscle strength increase the risk of falls. Implementing fall prevention strategies are essential, such as regular exercise to improve balance and strength, home modifications to reduce hazards, and medication management to minimize side effect that could lead to falls. It is imperative to educate the care providers on fall prevention, as the patient with memory loss with fail to remember fall prevention education. By addressing fall risk factors, older adults can maintain their independence by reducing the likelihood of fall-related injuries that may result in hospitalization or long-term care placement.
Cognitive stimulation is another vital health-promotion topic for older adults. As individuals age, cognitive decline becomes more common, impacting memory, reasoning, and decision-making abilities. to continue living actively and autonomously for longer periods. Additionally, maintaining Engaging in activities that stimulate the brain, such as puzzles, reading, socializing, and learning new skills or hobbies, can help preserve cognitive function and delay the onset of cognitive decline or dementia. By promoting cognitive stimulation, older adults can maintain their independence by preserving their cognitive abilities, allowing them cognitive function enhances overall well-being and quality of life, enabling older adults to remain engaged and fulfilled in their daily activities and relationships
Health promotion for older adults should also focus on preventing new diseases and managing their chronic diseases (Table 3.6). Older adults are at increased risk for developing diseases like dementia, heart disease, type 2 diabetes, arthritis, and cancer (CDC, 2023b). Other topics to consider for health promotion in older adults include warning signs of dementia, caregiver wellness, screening and prevention of disease or disability, promotion of independence, and promotion of physical activity (CDC, 2023b).
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Category |
Education Topic |
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Nutrition |
Food insecurity Bone health |
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Elimination |
Constipation prevention Urinary continence maintenance |
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Physical activity |
Maintaining physical ability Promotion of independence Pain prevention/alleviation |
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Cognition |
Maintenance of intellectual ability Cognitive decline awareness Dementia/Alzheimer disease risk awareness |
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Sensory changes |
Identification of vision changes Eye diseases common in aging |
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Community |
Encourage active roles in the community |
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Chronic disease |
Risk reduction Prevention and management |
Table 3.6 Health-Promotion Topics for Older Adults (Edelman & Kudzma, 2022)
Link to Learning
Resources for Older Adults
The National Council on Aging presents the Center for Healthy Aging for Professionals. This resource provides evidence-based health-promotion information with the goal of helping older adults live healthier lives.
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Case Study or Further Question
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