6.2 Basic Concepts

Before learning about cognitive impairment, it is important to understand the physiological processes of normal growth and development. Growth includes physical changes that occur during the development of an individual beginning at the time of conception. Development encompasses these biological changes, as well as social and cognitive changes that occur continuously throughout our lives. Cognition starts at birth and continues throughout the life span. See Figure 6.1^[1] for an image of the human life cycle.

There are multiple factors that affect human cognitive development. While there are expected milestones along the way, cognitive development encompasses several different skills that develop at different rates. Cognition takes the form of many paths leading to unique developmental ends. Each human has their own individual experience that influences development of intelligence and reasoning as they interact with one another. With these unique experiences, everyone has a memory of feelings and events that is exclusive to them.^[2]

Developmental Stages

As newborns, we learn behavior and communication to help us to interact with the world around us and to fulfill our needs. For example, crying provides communication to cue parents or caregivers about a newborn’s needs. The human brain undergoes tremendous development throughout the first year of life. As infants receive and experience input from the environment, they begin to interact with the individuals around them as they learn and grow.

Erikson’s Psychosocial Stages of Development

Erikson’s psychosocial development theory emphasizes the social nature of our development rather than its sexual nature. It describes eight sequential stages of individual human development influenced by biological, psychological, and social factors throughout the life span that contribute to an individual’s personality. Erikson’s stages of development are trust versus mistrust, autonomy versus shame, initiative versus guilt, industry versus inferiority, identity versus identity confusion, intimacy versus isolation, generativity versus stagnation, and integrity versus despair.^[3],[4]

• Trust vs. Mistrust: The first stage that develops is trust (or mistrust) that basic needs, such as nourishment and affection, will be met. Trust is the basis of our development during infancy (birth to 12 months). Infants are dependent upon their caregivers for their needs. Caregivers who are responsive and sensitive to their infant’s needs help their baby to develop a sense of trust, and the infant will perceive the world as a safe, predictable place. Unresponsive caregivers who do not meet their baby’s needs can engender feelings of anxiety, fear, and mistrust, and the infant will perceive the world as unpredictable.^[5]

• Autonomy vs. Shame: Toddlers begin to explore their world and learn that they can control their actions and act on the environment to get results. They begin to show clear preferences for certain elements of the environment, such as food, toys, and clothing. A toddler’s main task is to resolve the issue of autonomy versus shame and doubt by working to establish independence. For example, we might observe a budding sense of autonomy in a two-year-old child who wishes to choose their own clothes and dress themselves. Although the outfits might not be appropriate for the situation, the input in basic decisions has an effect on the toddler’s sense of independence. If denied the opportunity to act on their environment, they may begin to doubt their abilities, which could lead to low self-esteem and feelings of shame.^[6]

• Initiative vs. Guilt: After children reach the preschool stage (ages 3–6 years), they are capable of initiating activities and asserting control over their world through social interactions and play. By learning to plan and achieve goals while interacting with others, preschool children can master a feeling of initiative and develop self-confidence and a sense of purpose. Those who are unsuccessful at this stage may develop feelings of guilt.^[7]

• Industry vs. Inferiority: During the elementary school stage (ages 7–11), children begin to compare themselves to their peers to see how they measure up. They either develop a sense of pride and accomplishment in their schoolwork, sports, social activities, and family life, or they may feel inferior and inadequate if they feel they don’t measure up to their peers.^[8]

• Identity vs. Identity Confusion: In adolescence (ages 12–18), children develop a sense of self. Adolescents struggle with questions such as, “Who am I?” and “What do I want to do with my life?” Along the way, adolescents try on many different selves to see which ones fit. Adolescents who are successful at this stage have a strong sense of identity and are able to remain true to their beliefs and values in the face of problems and other people’s perspectives. Teens who do not make a conscious search for identity, or those who are pressured to conform to their parents’ ideas for the future, may have a weak sense of self and experience role confusion as they are unsure of their identity and confused about the future.^[9]

• Intimacy vs. Isolation: People in early adulthood (i.e., 20s through early 40s) are ready to share their lives and become intimate with others after they have developed a sense of self. Adults who do not develop a positive self-concept in adolescence may experience feelings of loneliness and emotional isolation.^[10]

• Generativity vs. Stagnation: When people reach their 40s, they enter a time period known as middle adulthood that extends to the mid-60s. The developmental task of middle adulthood is generativity versus stagnation. Generativity involves finding your life’s work and contributing to the development of others through activities such as volunteering, mentoring, and raising children. Adults who do not master this developmental task may experience stagnation with little connection to others and little interest in productivity and self-improvement.^[11]

• Integrity vs. Despair: The mid-60s to the end of life is a period of development known as late adulthood. People in late adulthood reflect on their lives and feel either a sense of satisfaction or a sense of failure. People who feel proud of their accomplishments feel a sense of integrity and often look back on their lives with few regrets. However, people who are not successful at this stage may feel as if their life has been wasted. They focus on what “would have,” “should have,” or “could have” been. They face the end of their lives with feelings of bitterness, depression, and despair.^[12]

Piaget’s Theory of Development

Jean Piaget, a well-known cognitive development theorist, noted that children explore the world as they attempt to make sense of their experiences. His theory explains that humans move from one stage to another as they seek cognitive equilibrium and mental balance. There are four stages in Piaget’s theory of development that occur in children from all cultures:

• Sensorimotor: The first stage is the sensorimotor period. It extends from birth to approximately two years and is a period of rapid cognitive growth. During this period, infants develop an understanding of the world by coordinating sensory experiences (seeing, hearing) with motor actions (reaching, touching). The main development during the sensorimotor stage is the understanding that objects exist, and events occur in the world independently of one’s own actions.^[13] Infants develop an understanding of what they want and what they must do to have their needs met. They begin to understand language used by those around them to make needs met.
• Pre-Operational: Infants progress from the sensorimotor period to a pre-operational period in their toddler years that continues through early school age years. This is the time frame when children learn to think in images and symbols. Play is an important part of cognitive development during this period.
• Concrete Operations: Older school age children (age 7 years to 11 years) enter a concrete operations period. They learn to think in terms of processes and can understand that there is more than one perspective when discussing a concept.^[14] This stage is considered a major turning point in the child’s cognitive development because it marks the beginning of logical or operational thought.
• Formal Operations: Adolescents transition to the formal operations stage around age 12 as they become self-conscious and egocentric. As adolescents enter this stage, they gain the ability to think in an abstract manner by manipulating ideas in their head. Moving toward adulthood, this further develops into the ability to critically reason.^[15],[16]

Cognitive Impairments in Children

Cognitive impairments in children range from mild impairment in these specific operations to profound intellectual impairments leading to minimal independent functioning. Cognitive impairment is a term used to describe impairment in mental processes that drive how an individual understands and acts in the world, affecting the acquisition of information and knowledge. The following areas are domains of cognitive functioning:

• Attention
• Decision-making
• General knowledge
• Judgment
• Language
• Memory
• Perception
• Planning
• Reasoning
• Visuospatial^[17]

Intellectual disability (formerly referred to as mental retardation) is a diagnostic term that describes intellectual and adaptive functioning deficits identified during the developmental period. In the United States, the developmental period refers to the span of time prior to the age 18. Children with intellectual disabilities may demonstrate a delay in developmental milestones (e.g., sitting, speaking, walking) or demonstrate mild cognitive impairments that may not be identified until school age. Intellectual disability is typically nonprogressive and lifelong. It is diagnosed by multidisciplinary clinical assessments and standardized testing and is treated with a multidisciplinary treatment plan that maximizes quality of life.^[18] See Figure 6.2^[19] for an image of an adolescent with an intellectual disability participating in a Special Olympics event.

Cognitive Impairments in Adults and Older Adults

There are several physical changes that occur in the brain due to aging. The structure of neurons changes, including a decreased number and length of dendrites, loss of dendritic spines, a decrease in the number of axons, an increase in axons with segmental demyelination, and a significant loss of synapses. Loss of synapse is a key marker of aging in the nervous system. These physical changes occur in older adults experiencing cognitive impairments, as well as in those who do not.^[20] See Figure 6.3^[21] of an older adult experiencing typical physical changes of aging.

It is a common myth that all individuals experience cognitive impairments as they age. Many people are afraid of growing older because they fear becoming forgetful, confused, and incapable of managing their daily life leading to incorrect perceptions and ageism. Ageism refers to stereotyping older individuals because of their age. Losing language skills, becoming unable to make decisions appropriately, and being disoriented to self or surroundings are not normal aging changes.

Dementia, Delirium, and Depression

If cognitive changes in adults occur, a complete assessment is required to determine the underlying cause of the change and if it is caused by an acute or chronic condition. For example, dementia is a chronic condition that affects cognition whereas depression and delirium can cause acute confusion with a similar clinical appearance to dementia.

Dementia

Dementia is a chronic condition of impaired cognition, caused by brain disease or injury, and marked by personality changes, memory deficits, and impaired reasoning. Dementia can be caused by a group of conditions, such as Alzheimer’s disease, vascular dementia, frontal-temporal dementia, and Lewy body disease. Clinical manifestations of dementia include forgetfulness, impaired social skills, and impaired decision-making and thinking abilities that interfere with daily living. Dementia is gradual, progressive, and irreversible.^[22] While dementia is not reversible, appropriate assessment and nursing care improve the safety and quality of life for those affected by dementia.

As dementia progresses and cognition continues to deteriorate, nursing care must be individualized to meet the needs of the patient and family. Providing patient safety and maintaining quality of life while meeting physical and psychosocial needs are important aspects of nursing care. Unsafe behaviors put individuals with dementia at increased risk for injury. These unsafe or inappropriate behaviors often occur due to the patient having a need or emotion without the ability to express it, such as pain, hunger, anxiety, or the need to use the bathroom. The patient’s family/caregivers require education and support to recognize that behaviors are often a symptom of dementia and/or a communication of a need and to help them to best meet the needs of their family member.^[23]

Delirium

Delirium is an acute state of cognitive impairment that typically occurs suddenly due to a physiological cause, such as infection, hypoxia, electrolyte imbalances, drug effects, or other acute brain injury. Sensory overload, excess stress, and sleep deprivation can also cause delirium. Hospitalized older adults are at increased risk for developing delirium, especially if they have been previously diagnosed with dementia. One third of patients aged 70 years or older exhibit delirium during their hospitalization. Delirium is the most common surgical complication for older adults, occurring in 15 to 25% of patients after major elective surgery and up to 50% of patients experiencing hip-fracture repair or cardiac surgery.^[24]

The symptoms of delirium usually start suddenly, over a few hours or a few days, and they often come and go. Common symptoms include the following:

• Changes in alertness (usually most alert in the morning and decreased at night)
• Changing levels of consciousness
• Confusion
• Disorganized thinking or talking in a way that does not make sense
• Disrupted sleep patterns or sleepiness
• Emotional changes: anger, agitation, depression, irritability, overexcitement
• Hallucinations and delusions
• Incontinence
• Memory problems, especially with short-term memory
• Trouble concentrating^[25]

Delirium and dementia have similar symptoms, so it can be hard to tell them apart. They can also occur together.

Nurses must closely monitor the cognitive function of all patients and promptly report any changes in mental status to the health care provider. The provider will take a medical history, perform a physical and neurological examination, perform mental status testing, and may order diagnostic tests based on the patient’s medical history. After the cause of delirium is determined, treatment is targeted to the cause to reverse the effects. See Figure 6.4^[26] for an illustration of an older adult experiencing delirium.

General interventions to prevent and treat delirium in older adults are as follows:

• Control the environment. Make sure that the room is quiet and well-lit, have clocks or calendars in view to provide time orientation, and encourage family members to visit.
• Ensure a safe environment with the call light within reach and side rails up as indicated.
• Administer prescribed medications, including those that control aggression or agitation, and pain relievers if there is pain.
• Ensure the patient has their glasses, hearing aids, or other assistive devices for communication in place. Lack of assistive sensory devices can worsen delirium.
• Avoid sedatives. Sedatives can worsen delirium.
• Assign the same staff for patient care when possible.^[28]

Depression

Depression is a brain disorder with a variety of causes, including genetic, biological, environmental, and psychological factors. It is a commonly untreated condition in older adults and can result in impaired cognition and difficulty in making decisions. It is likely to occur in response to major life events involving health and loved ones. Having other chronic health problems, such as diabetes, dementia, Parkinson’s disease, cancer, heart disease, and kidney disease, increases the likelihood for depression in older adults and can cause the loss of their ability to maintain independence.^[29] See Figure 6.5^[30] for an illustration of an older adult experiencing symptoms of depression.

Symptoms of depression include the following:

• Feeling sad or “empty”
• Loss of interest in favorite activities
• Overeating or not wanting to eat at all
• Not being able to sleep or sleeping too much
• Feeling very tired
• Feeling hopeless, irritable, anxious, or guilty
• Aches, pains, headaches, cramps, or digestive problems
• Thoughts of death or suicide^[31]

Depression is treatable with medication and psychotherapy. However, older adults have an increased risk for suicide, with the suicide rates for individuals over age 85 years the second highest rate overall. Nurses should provide appropriate screening to detect potential signs of depression as an important part of promoting health for older adults.

Comparison of Three Conditions

When an older adult presents with confusion, determining if it is caused by delirium, dementia, depression, or a combination of these conditions can pose many challenges to the health care team. It is helpful to know the patient’s baseline mental status from a family member, caregiver, or previous health care records. If a patient’s baseline mental status is not known, it is an important patient safety consideration to assume that confusion is caused by delirium with a thorough assessment for underlying causes.^[32] See Table 6.2 for a comparison of symptoms of dementia, delirium, and depression.^[33]

Table 6.2 Comparison of Dementia, Delirium, and Depression^[34]