COGNITIVE IMPAIRMENT/DISORDER

•DEFINITION
•CLASSIFICATION
DELIRIUM
DEMENTIA
•OTHERS
SUBSTANCE ABUSE DISORDERS
INTELLECTUAL DISABILITY
EPILEPSY

1
CAUSES
Cognitive psychotic conditions have a
variety of causes or etiologies. The
following “MEND A MIND” mnemonic
aid helps you to recall the various
possible causes of cognitive
impairment disorders:

2
M - Metabolic disorder
E - Electrical disorder
N - Neoplastic disease
D - Degeneration
A - Arterial disease
M - Mechanical disorder
I - Infectious disease
N - Nutritional disease
D - Drug toxicity
3
 DELIRIUM

• Is an acute organic mental

syndrome characterized by
clouding of consciousness,
accompanied by disorientation,
memory impairment, and
decreased concentration which is
reversible.
4
Delirium is a common condition, with
up to 15% of patients over 65 being
delirious on admission to hospital.
Known risk factors include increasing
age, underlying dementia and physical
illness. Full recovery is the usual
outcome of delirium, but there is a
significant morbidity and mortality
associated with this condition.
5
Onset - Is sudden and tends to resolve
rapidly when the cause is detected and
the appropriate treatment given. The
condition is therefore said to be
reversible. It is common in children
and the aged of 60 years and above.

6
Types of Delirium
1. Delirium due to general medical
condition
2. Substance induced delirium
– Substance intoxication delirium
– Substance withdrawal delirium
3. Delirium due to multiple etiologies
4. Delirium not otherwise specified

7
Causes of Delirium
1) Infections:
- Systemic – e.g., malaria, typhoid fever,
pneumonia, etc.
- Intracranial, e.g., meningitis,
encephalitis, cerebral malaria.
2) Drug Intoxication/Withdrawal
- Alcohol, anxiolytics, opioids, CNS
Stimulation; cocaine, crack,
amphetamines, marijuana, etc.
8
3) Neurological disorders
- Seizures
- Head trauma
- Hypertensive encephalopathy
4) Postoperative state
5) Pueperium (Post Partum)

9
6) Drugs
- Antibiotics
- Antiparkinsonian
- Anticholinergics
- Antituberculosis
- Anticonvulsants
- Analgesics
- Anti-inflammatory
- Cardiac
- Sedatives
– Hypnotics
10
7) Metals and Gases
- Mercury
- Lead
- Arsenic
- Carbon Monoxide

11
CLINICAL FEATURES
• Altered state of alertness, awareness,
and consciousness (hyper alert or
obtunded; patient’s level of
consciousness may vary from time to
time.
• Onset may be dramatic/sudden but may
be subtle and evolve over days or weeks
• Disorientation and confusion
• Decreased attention, concentration and
memory 12
• Psychotic symptoms – paranoia, hallucinations
(often visual), delirious.
• Behavioural disinhibition; emotional liability,
irritability.
• Psychomotor retardation or agitation –in a 24-
hour period. may vary

13
• Fragmented sleep/work cycle; increases agitation
at night.
• Usually reversible with correction of underlying
etiology.
• Apraxia (inability to perform a particular purpose)
• Dysgraphia (difficulty with spelling)
• Dysnomia (difficulty in recalling words)
• traumas,
• abnormal reflexes (nyoclomus)

14
DIAGNOSIS/INVESTIGATIONS

The aim should be to perform

minimum of investigations that will
allow accurate diagnosis and
treatment.

15
Common Investigations Are:
• Blood HB, ESR, Blood Urea, Electrolytes and
V.D.R.L.
• Urinary sugar and protein
• Bender Gestalt Test
• Test for Memory
• Fundus Examination
• X- ray of skull
• Electroencephalography
• C.S.F. Routine
• Brain Scan
• Brain Biopsy 16
DISCUSS MANAGEMENT AND NURSING
CARE OF DELIRIUM

17
 DEMENTIA
Dementia is characterized by (usually) insidious
(but sometimes acute) development of
generalized brain dysfunction with multiple
cognitive deficits. It is essential that the
patients’ cognitive deficits result in impairment
in their social and/or occupational functioning
and a decline from their previous level of
functioning.

18
The patients’ level of awareness and
mental alertness is intact and stable in the
early phases of a dementia – in contrast to
the unstable alternating level of
consciousness seen in delirium. These
cognitive deficits are often (but not always)
predominantly manifested by memory
impairment – both the ability to learn new
information and to recall previously
learned information.
19
 TYPES OF DEMENTIA
• Dementia of the Alzheimer’s type
• Vascular Dementia
• Dementia due to HIV
• Dementia due to head trauma
• Dementia due to Parkinson’s Disease
• Dementia due to Huntington’s Disease
• Dementia due to Pick’s disease
• Dementia due to Ceutzfeldt – JaKob’s Disease
• Dementia due to other General Medical Conditions
• Substance – induced Persisting Dementia
• Dementia due to multiple etiology
• Dementia not otherwise specified
20
CAUSES OF DEMENTIA (Partial Listing)
• Alcohol – related Dementia
• Alzheimer’s disease
• Amyotrophic lateral sclerosis
• Bromide poisoning
• Chronic granulomatous meningitis
(tuberculosis, fungal)
• Folic acid deficiency
• Head trauma
• Human immunodeficiency virus (HIV)
• Huntington’s chorea
21
• Hypothyroidism
• Multi-infarct Dementia
• Multiple Sclerosis
• Neoplasms
• Normal – pressure hydrocephalus
• Parkinson’s disease
• Postanoxic state eg coma
• Progressive supranuclear palsy (difficulty walking,
balance and eye movement)
• Transmissible virus Dementia (Jacob – Creutzfeldt
disease)
• Vitamin B12 deficiency 22
CLINICAL FEATURES
• Impairment of intellectual functions
– Loss of memory of recent events
(anterograde Amnesia) followed by loss of
memory of past events (retrograde
amnesia)
– Lack of concentration to time, place and
person
– Episodes of confusion
– Poor judgment – the person begins to make
foolish and inappropriate decisions, quit out
of keeping with his previous records 23
• Lability of mood
– Depression is more common than anxiety
– Apathy or childish euphoria
– Deterioration in habits
– Poor personal hygiene
– Difficulty in controlling the sphincters; bladder –
bowel by night then at day as well.
– Inappropriate sexual behaviour, e.g., exposure of
the genital, at times assault children sexually.
– Epileptic fits
– Paranoid and hypochondriac delusions
– Hallucinations
24
 OTHER COGNITIVE IMPAIRMENT
DISORDERS
All of the following mental disorders have
an organic etiology, which can be
discovered in the client’s history, physical
exam or laboratory tests, but they do not
meet the specific criteria of delirium and
dementia.

25
Amnestic Syndrome: Is a cognitive
impairment disorder in which the level
of consciousness is not affected as it is
in other organic brain disorders. Short
term and long term memory are
impaired, and the client is in an
amnestic state. It is a rare condition.

26
• Organic delusional syndrome: Is a mental
disorder in which the main symptom is a
predominant delusion that occurs with no
change in level of consciousness, no
significant loss of intellectual abilities and
no hallucinations.
• Organic Hallucinations: Is a mental
disorder in which the client experiences
hallucinations. There are no changes in
level of consciousness, intellectual abilities
or mood; nor are there delusions
accompanying the hallucinations. 27
• Organic mood syndrome: Is a change in
mental status marked by two of the
symptoms listed under manic or major
depressive episode. There are no changes
in level of consciousness or in intellectual
abilities. There are no hallucinations or
delusions.
• Organic anxiety syndrome: Is a mental
disorder characterized by active, recurrent
panic attacks or generalized anxiety.
28
• Organic Personality syndrome: Is a major
change in a person’s personality style,
including at least one of the following:
– Emotional swings (lability) or sudden flaring
of emotions such as crying, angry outbursts.
– Decrease in impulse control, for example,
shoplifting, poor social or sexual judgment
– Suspiciousness or paranoid ideation
– Apathy and decreased interest in normal
pursuits of life.
29
PRE – SENILE DEMENTIA
This is a chronic organic mental
condition in which there is a state of
intellectual and emotional impairment
as a result of organic cerebral changes
occurring before the age 65 years.

30
The following are some examples of early Dementia;
• Huntington’s chorea: - Severe cerebral generation,
entirely genetic onset of 30 – 50 years. Patient
becomes severely demented, bed ridden and
entirely dependent.
• Pick’s disease: - Atrophy of The Frontal Lobe of
Cerebrum
• Alzheimer’s disease: - Premature degeneration of
C.N.S.
• Creutzfeldt – Jakob’s Disease: - Degenerative
Dementia affects cerebral cortex through cell
destruction.
31
CLINICAL FEATURES
• Progressive and profound dementia, with speech
disorders (Aphasia) and difficulty in carrying out manual
activities (Apraxia)
• There are personality changes; memory impairment;
loss of interest in the surroundings and the patient
becomes easily irritable.
• Gradually, the patient shows signs of dullness.
• Patient becomes apathetic and easily tired
• Delusion of persecution may be noted
• There is disorientation and regression to childishness
• There may be euphoria
• In the end the patient becomes severely demented,
emaciated, bed ridden and helpless. 32
DISCUSS MANAGEMENT AND NURSING
CARE OF PRESENILE DEMENTIA

33
SENILE DEMENTIA
It is a chronic organic mental condition
which is due to degenerative changes
in the brain as a result of old age or
often the age 65 years. It is
characterized by permanent
impairment symptoms and
behavioural change.

34
CLINICAL FEATURES
Psychological Features:
• They feel they are rejected
• Regression – behaving like a child
• Loss of memory/Amnesia – first they do not recollect recent
events – Anterograde amnesia and later affects past events –
retrograde.
• Overtalkative
• Repetition of words (verbigeration)
• Confabulations
• Disorientation to time, place and person
• Mood swings
• Restlessness and wanders aimlessly
• Hallucinations and delusions
• Blurred – incoherent speech 35
Physical Features
• Incontinence of urine and faeces
• General bodily weakness
• Loss of appetite
• Shuffling gait
• Weight loss
• Blurred vision
• Deafness
• Wrinkled and inelastic skin
• Loss of teeth
• Fragile bones
• Neglect of personal hygiene
• Epileptic fits 36
DISCUSS MANAGEMENT AND NURSING
CARE OF SENILE DEMENTIA

37
 DIFFERENCES BETWEEN DELIRIUM AND
DEMENTIA
FEATURE DELIRIUM DEMENTIA
Onset Acute, often at night Insidious
Course Fluctuating, with lucid intervals during day: Stable over course of day.
worse at night.
Duration Hours to weeks Months or years
Awareness Reduced Clear/Normal
Alertness Abnormally low or high Usually normal
Attention Lacks direction and sensitivity, Relatively unaffected
distractibility, fluctuates over course of day
Orientation Disorientated Usually not affected until late
in course
Memory Partial or full loss of recent memory; remote Partial loss of both recent and
memory intact remote memory

38
DIFFERENCES Cont’d.
FEATURE DELIRIUM DEMENTIA
Thinking Disorganized Impoverished
Perception Illusions and hallucinations usually Often absent
visual are common
Speech Incoherent, hesitant, slow or rapid Difficulty in finding words
Sleep wake cycle Always disrupted Fragmented sleep
Appearance and May be semicomatose; agitated Usually slow responses
behaviour
Mood Labile; anxiety or panic common Constricted affect or
depression
Prognosis Reversible in most cases Usually irreversible
Treatment Identify and remove underlying Symptomatic treatment
cause; symptomatic treatment

39
 GENERAL PARALYSIS OF THE INSANE (G.P.I.)

Syphilis is a veneral disease which if not

treated becomes chronic and affects the
central nervous system. Syphilis is caused by
Treponema Pallidum which is in the group
of organisms called spirochaetes.

40
 GENERAL PARALYSIS OF THE INSANE (G.P.I.)

Syphilis, if not treated at initial stages,

progresses through Primary to Secondary to
Tertiary stages in a period of 5-75 years
resulting in a mental disorder in which there
is severe infection of the brain by
Treponema Pallidum leading to G.P.I.

41
CLINICAL FEATURES

There are neurological as well as

psychological symptoms. These
symptoms may appear slow or with
great excitement.

42
Psychological Symptoms
• Loss of memory or forgetfulness
• Impairment of judgment
• Disorientation
• Lack of initiative and concentration
• Grandiose delusions, there may be nihilistic delusions.
• Mood swings
• Patient becomes credulous( ready to believe with little evidence)
• Patient becomes talkative
• There is increase in sexual drive
• Patient becomes easily irritable and violent
• Neglect of personal hygiene
• Lack of insight

43
Neurological Symptoms
• As the illness progresses the neurological/physical
symptoms of the disease become evident.
• The pupils become small, unequal and irregular in
outline and do not react to light (Argyll
Robertson’s Pupils)
• There is tremor of the lips, the tongue and the
facial muscles so that speech becomes slurred
and indistinct and words are omitted (Dysarthria)
• There is tremor of the hands and incoordination
of all movements
• Epileptic attacks may occur
44
As the disease continues, serious and
irreversible changes occur in the brain
which leads the patient slowly into a
complete dementia coupled with physical
deterioration. There is a tendency in
increase in weight due to increase in
appetite.

45
Diagnosis of G.P.I.
• Clinical feature, both psychological and
neurological
• Lab investigations, e.g., Kahn Test or
Wasserman Test
• Lumber puncture test
• Wound swabs may also reveal the organism
under microscope.

46
DISCUSS MANAGEMENT OF G.P.I

47
 PARKINSON’S DISEASE (PARALYSIS AGITANS)

This is a common disease affecting 1 in

1000 of the population and I percent of the
population over 70 years of age. Peak
incidence is in the sixth decade of life.
Parkinsonism is the clinical syndrome of
tremor, rigidity and bradykinesia (slowing
of movements).

48
• This syndrome is seen in those on
neurolptic drugs, in Wilson’s disease
(accumulation of copper), following
cerebral anoxia or associated with other
neurological conditions, e.g., Shy-Drager
syndrome (disorder of the nervous system)
• Parkinson’s disease refers to the clinical
syndrome of idiopathic Parkinsonism
caused by degeneration of dopaminergic
striatonigral neurons.
49
Clinical Features
• Akinesia (lack of voluntary movement of muscles)
• Rigidity
• Pill-rolling tremor (tremor of the fingers/thumb)
• Postural abnormality
• Shuffling gait (dragging feet while walking)
• Difficulty in handwriting or walking – prodromal signs
• Depression
• Anxiety
• Bradyphrenia (delayed/slowed thinking)
• Slurred speech
• Mask like face (loss of facial expression)
50
DISCUSS MANAGEMENT AND NURSING
CARE OF PARKINSON’S DISEASE

51
 EPILEPSY
• It is a disorder of the brain characterized
by a recurring excessive neuronal
discharge, manifested by transient
episodes of motor, sensory or psychic
dysfunction, with or without
unconsciousness or convulsive
movements. The seizure is associated
with marked changes in recorded
electrical brain activity.
52
CAUSES
• There are many causes of epilepsy but
much remain unknown, particularly the
idiopathic group, where there is no
known disease process in evidence. The
causes may be placed under 2 broad
headings:
• Constitutional
• Predisposing Factors

53
Constitutional Factors
• They are also known as “idiopathic
factors” because the condition has no
known origin in disease of the structure
of the brain. The causes may include:-
• Genetic Predisposition
• Endocrine disorders
• Age
• Body build (Athletic) – an old theory

54
Predisposing Factors
• Intracranial infections
• Degenerative diseases
• Brain tumors
• Head injuries
• Metabolic disorders (uraemia, hypoglycaemia,
eclampsia)
• Emotional stress
• Unknown causes

55
Precipitants
• Drugs
• Boredom
• Sensory stimulus
• Fatigue
• Crowd of people
• Sexual activity
• Excitement
• Strong emotions
• Fevers
56
TYPES/CLASSIFICATION

• Seizures can be classified in several

different ways:-
• There are 2 main varieties and are
described under 2 broad headings.
• Generalized Epilepsy
• Focal/Partial Epilepsy

57
GENERALIZED EPILEPSY
• This occurs with loss of consciousness. It
is generalized in the same that the
abnormal electrical discharges spread
throughout the structure of the brain to
produce generalized seizures. There are
2 common varieties of generalized
seizures. These are:
• Grand-mal or major epilepsy
• Petit-mal or minor epilepsy
58
Grand-mal Epilepsy
• This is characterized by fits and has 4
distinctive phases.
• Aura or warning phase (Peculiar warning
sound of individuals)
• Tonic phase (A prolonged contraction of one
or more muscles)
• Clonic Phase (Clonus – Muscle rigidity and
relaxation occurring spasmodically)
• Coma Phase (complete unconsciousness with
all reflex absent)
59
 WARNING OR AURA PHASE
• A few moments before the seizure begins, many
patients experience a sign which takes the same
form on each occasion. There is a twitching is
one or more muscles, a feeling of numbers or
tingling in some particular region of the body.
There are flashes of light, sudden contraction of
the muscles of respiration which forces air
through the larynx, producing a typical loud
shout known as “Epileptic Cry”. Patient then
falls unconscious and falls to the ground.

60
TONIC PHASE
• This includes the contraction of the
entire muscles. The whole body
becomes stiff and remains in spasms for
some 15-30 seconds. Respiration is
arrested by spasms of the muscles of
respiration and cynosis may occur. The
mouth is tightly closed and the eyes
staring. The individual lies rigid, legs
extended and the arms flexed.
61
CLONIC PHASE
• This stage lasts for about 30-60 seconds.
There is violent jerking of the entire
muscles, and the jerking of the facial
muscles may cause the tongue or lips to be
bitten. The saliva becomes blood stained
and often appears on the lips. Occasionally,
urine and faeces may be passed
involuntarily. There is opisthotonos (arched
back), increased pharyngeal secretions,
tachycardia, hypertension.
62
COMA PHASE
• Following the seizure the patient may
pass into a deep heavy sleep lasting
hours, breathing nosily. Many of the
patients complain of headache, sore
muscles, pains in the body, exhaustion
and confusion.

63
POST EPILEPTIC AUTOMATISM
• In some patients the stage of coma is
followed or replaced by a state of
automatism in which there is only partial
consciousness and patient is confused.
Three varieties of post epileptic
automatism can be observed.

64
• Epileptic Fugue: This is a brief confusional state whereby the
patient wanders about in his environment or tries to undress
himself and if opposed, he may respond with violence.
There is completely amnesiac and disorientation from the
scene of the attack. This may last for hours or days.
• Epileptic Furor: In some cases this may happen after each fit
particularly if the patient is psychotic. This is a state of
extreme violence and destructive behaviour with sudden
wild activities in certain cases crimes may be committed –
homicide.
• Epileptic Twilight State: This is a dreamlike state. In this a
brief period of confusion is replaced by a long and more
serious confusional episode. This may last for hours or days.
The patient becomes disorientated, extremely restless and at
times violent.
65
FREQUENCY OF FITS
• Two varieties of frequency have been
described;
• Status Epilepticus
• Serial Epilepsy

66
 STATUS EPILEPTICUS
• This term refers to series of epileptic seizures of
either grand-mal or focal types, following one
another in quick succession without the patient
regaining consciousness between fits. It
happens when the patient suddenly stops his
medication. Patients on barbiturates are also
predisposed. Infection can also be a cause in
some instances. The continuous seizures are
accompanied by high temperature, congestion
in lungs, exhaustion and death.

67
Petit-mal Epilepsy
• In this form, patient suffers a very brief loss of
disturbance of consciousness lasting about five
to twenty seconds. The patient appears to be
lost and confused. He all of a sudden stops
whatever he is doing, seems to stare, blanking
and may show some slight twitching of the facial
muscles. The fit is over in a few seconds and the
patient resumes his previous activities as if there
was no interruption. It is more common than
major fits and it can also occur in somebody
already having major fits. It is more common in
children. 68
Similar conditions include:-
• Pyknolepsy: Slight and frequent fits in
children which ceases as child grows.
• Akinesis: Impairment of motor function
for a brief period.
• Myoclonus: Spasmodis contractions of
muscles without warning causing flexion
of the floor limbs in which the patient
falls to the ground.

69
PARTIAL OR FOCAL EPILEPSY
• In this type, consciousness may be
retained. The discharge is from a localized
area of the brain. The impulses may or
may not spread there after. There are
other names given to this group of
seizure.
• Psychomotor seizures
• Epileptic Equivalent
• Psychic Epilepsy
• Psychic Equivalent 70
Psychomotor seizures are of disturbances,
not losses of consciousness. The usually
occur without any distractable convulsive
phenomenon. They are usually associated
with Automatic Motor acts. The clouding of
consciousness may last for seconds, minutes,
hours or even days. Two common varieties
of psychomotor seizures have been
described:-
• Temporal lobe Epilepsy
• Jacksonian Epilepsy 71
TEMPORAL LOBE EPILEPSY
• This is a typical form of focal epilepsy. In
this seizure, the epileptic fit begins in the
arterial portion of the temporal lobe of
the brain.

72
Clinical Features
• There are hallucinations of taste, smell, hearing and
sight and the patient will respond accordingly.
• There is feeling of “Déjà vu” phenomenon (already
seen). Patient has a strong feeling of familiarity of
persons, places or events which in actual fact may
never have experienced. Patient will witness a new
sense or experience a situation and may feel as if he
has lived through or witnessed it before. This type of
seizure often takes the form of Post Epileptic
Automatism. Occasionally, the patient wanders away
from his environment during the seizure in a disturbed
state of consciousness. In extreme cases the patient
may show destructive behaviour. 73
JACKSONIAN EPILEPSY
• This is another type of focal seizure. Here
the focus is on the motor cortex of the
brain. This fit consists of muscular
contractions. It begins in a localized area of
the body, e.g., in one hand or one side of
the face. It then spreads in an orderly
manner to involve other group of muscles.
Consciousness may or may not be lost.

74
EPILEPTIC DEMENTIA
• In later life, a number of epileptics become
psychotic. This is a state of gradual mental decline
and deterioration. It is most often found in those
patients where the epilepsy started in children or
at an early age and has been severe.
• It is mostly among those with frequent fits whose
condition has not responded to treatment. This is
an organic type of reaction and it leads to
dementia. The affected individual becomes more
self-centred and loss interest in his environment.
Speech becomes slurred and may lose its normal
reflection. 75
• Gradually, the patient develops more and more
into boasting and yet he could not maintain his
personal hygiene. He is easily irritable. There
may be delusions of persecution and auditory
hallucination. The patient becomes suspicious,
quarrelsome, hostile and jealous. These types of
patients are dangerous, violent and homicidal.
• In the last stages of epileptic dementia, the
patient lives purely a vegetative life, like a
helpless infant and has to be fed, clothed and
cleaned. He will not be able to control his
sphincters.
76
PROGNOSIS OF EPILEPSY
• This depends on the stage at which the
patient seeks treatment and the
effectiveness of the treatment. If
treatment is started early there is a
considerable hope that the fits may at least
be made very infrequent or if they do not
stop altogether. The psychotic epileptics
tend to degenerate progressively to a
severe dementia until such time that the
patient no longer resembles anything
human and lives purely a vegetative life.77
DIAGNOSIS
• Chemical features when the patient gets the fit
• Electroencephalography (EEG) to detect the normal impulses in
the brain.
• Lumber puncture is done to obtain C.S.F. for bacteriology.
• X-ray of the skull to detect a tumor or lesion in the brain
• History or clinical feature from patient, relatives, and friends.
• Brain scan
• Blood investigations for detection if infections, urea,
hypoglycaemia, Kahn or Wassermann Test
• Urine for – sugar, urea
• Blood pressure
• Electrocardiogram (ECG)
• Stool examination

78
DISCUSS MANAGEMENT OF EPILEPTIC FIT
AND STATUS EPILEPTICUS

79
 MENTAL RETARDATION
• Mental retardation is described by the presence
of a sub-average general intellectual functioning
associated with or resulting in impairment in
adaptive behaviour. When gross structural
defects in the brain occur before birth or at a
very early age, the typical result is mental
retardation, the severity depending on the
defect

80
In mental retardation, the individual fails to
develop an optimal level of the various
skills that underlie adequate and
independent coping with environmental
demands. Mental retardation is a state of
incomplete or arrested development of the
mind which is characterized by low
intelligence, learning disability and
impairment in adaptive behaviour.

81
OTHER NAMES
• Subnormality
• Oligophrenia
• Mentally Defective
• Intellectually or mentally handicapped
• Mentally challenged
• Mentally Disabled
• Amentia (Latin, i.e., lack of mind)
• Moron/mongolism
• Imbecile
• Idiot
• Feeblemindedness
82
 MENTAL RETARDATION
Other names that are politically acceptable :
• Mental retardation
• Learning disabilities
• Intellectual disabilities

83
ONSET
• The condition is manifested during the
developmental period before the age of 18
years. When similar clinical picture develops
for the fist time after the age of 18years then
the syndrome is a Dementia. It is more
common in males than females.

TYPES:
– Pathological
– Sub-cultural or Secondary
84
CAUSES
• It may be due to genetic factor or
environmental factors.
• Genetic Factors: Some abnormal genes are
responsible for a particular physical or
mental abnormality may pass directly from
parents to the offspring who will be
affected by the disorder. Genes are
responsible for a number of metabolic
disorders which not treated early may lead
to mental retardation. 85
Such disorders include:
1. Phenylketonuria: Is a metabolic disorder
transmitted by a recessive gene that
prevents the conversion of
phenylalanine, one of the amino acids
presents in many foods into tyrosine. It
can be treated with very low protein
diet.

86
2. Tay Sach’s Disease: This is also a recessive genes
metabolic disorder in which fatty substances
accumulate in the brain and other tissues to
bring about mental retardation to the
individual.

3. Galactosaemia: Is also a metabolic disorder in

which galactose cannot be converted to
glucose. When diagnosed early, it can be
treated with milk free diet.

87
Another group of disorders associated with
Mental Retardation and due to abnormal
chromosomes are:
• Turner’s syndrome: This involves of the
X-chromosome in females (Xo). It is a
rare condition. They have mild
retardation with genital organs not well
developed.

88
• Down’s syndrome (Trisomy 21): The
chromosome in Down’s syndrome is 47
instead of the normal 46. The extra
chromosome provides 3 at the 21st of the
23 pairs. The defective gene causing this
disorder may come from a woman above
40 years, or an aged male.

89
• Klinefelter’s Syndrome: They are
apparently males. They have
undeveloped testes, little facial or pubic
hair, a feminine distribution of fat and
often some breast developments. Such
people may be sterile. This condition
involves excess number of chromosomes
in males e.g., XXY, XXXY instead of XY
(Autosome 22 pairs chromosome).

90
ENVIRONMENTAL FACTORS
A. PRE-NATAL LIFE
• Infections such as Rubella contracted by the
mother during the first trimester of pregnancy
may lead to mental retardation in the child.
Also congenital syphilis, mumps and
meningitis may cause damage to N.S. of the
foetus.
• Malnutrition in the pregnant mother may lead
to foetal damage to cause mental retardation.

91
• Exposure of pregnancy to frequent radiation,
e.g., X-ray may damage the foetus leading to
congenital abnormalities and mental
retardation.
• Certain chemicals taken during pregnancy,
e.g., drugs such as Thalidomide, large doses of
insulin or alcohol.
• Threatened abortion
• Rhesus incompatibility – Rhesus negative
married to a Rhesus positive
• Mother taking poisons like lead.
92
B. DURING BIRTH
• Improper forceps delivery
• Difficult or prolonged labour may cause brain
damage directly or deprivation of oxygen to
the brain or haemorrhage into the brain
tissue.
• Placenta praevia or premature separation of
the placenta
• Pre-maturity has also been associated with
mental retardation

93
C.DURING CHILDHOOD OR INFANCY
• Childhood malnutrition
• Tumor or haematoma in the brain
• Injuries to the brain
• Ingestion of lead poison
• Defective development of thyroid gland
causing cretinism
• Infections of the GNS depending on the
severity, e.g., meningitis, encephalitis,
congenital syphilis, brain abscess

94
LEVELS OF RETARDATION
Mental retardation is classified by the Intelligent
Quotient (IQ) scores and deficits in adaptation
1.MILD RETARDATION (IQ 55 -70%)
• This group is quite large about 85% of those
with the disorder. They benefit from modified
education and may need special training and
supervision in vocational training. They may
need guidance and assistance when under
unusual social or economic stress.

95
2. MODERATE RETARDATION (IQ 35 -55%)
• This group consists of 10% of the entire
population of people with mental
retardation. They may benefit from
modified education. They can perform
unskilled or semi-skilled work under close
supervision.

96
3.SEVERE RETARDATION (IQ 20 – 35%)
• This group constitutes 3% - 4% of the
population of people with mental
retardation. They can respond to a very
little extent of training programmes.
They do not benefit from modified
education. They can achieve elementary
degree of socialization and minimum
standard of personal care.

97
PROFOUND RETARDATION (IQ less than 20%)
• This group constitutes 1% - 2% of people with
mental retardation. They are totally
dependent, unable to protect themselves;
from ordinary physical dangers and require
constant care and supervision.

98
CLINICAL FEATURES
• Apart from the low intelligence, the
patient may show one or more of the
physical stigmata of mental deficiency.
The outstanding physical clinical features
may include the following:
• A. DEVELOPMENTAL STAGES
• There is delay in the way the child
develops, e.g., delay in sitting; standing,
walking; talking; etc.
99
B. PHYSICAL ABNORMALITIES
• There are a number of physical abnormalities which
often accompany mental subnormality. They are
malformation of the body which are linked to the
maldevelopment of the mind. These malformations are
called “STIGMATA”. The following physical deformities
are often observed.
• I. The Cranium
• Excessively large head (Hydrocephalus or
Macrocephalus)
• Excessively small head (Microcephalus or Tower head)
• Delayed closure of the fontanelles

100
II.The Mouth
• With shaping jaw and teeth
• High arched palate
• Cracked and large tongue too big for the
mouth and difficulty in producing sensible
words or speech
III. The Ear
• Too large or too small
• There are also some irregularities in the shape
of ears
• Abnormality adherent lobules
101
IV. The Nose
• Depressed bridge of the nose due to
congenital syphilis
• Cross irregularities in shape
V. The Eyes
• The eyes are slanted with extra folds of skin at
each inner angle with a description
(mongolism)
• Corneal opacity
• Nystagmus :- Involuntary rapid movement of
the eye
102
VI. The Trunk
• Long trunk
• Supplementary nipples
• Bulgy (pot) belly
VII. Hand and Feet
• Shorter little fingers and toes
• Too many digits (finger and toes)
• Webbed fingers and toes
• Absence of patterns in palm and boles
• They are also clumsy in walking and muscular
incoordination
103
DIAGNOSTIC CRITERIA
• The physical outlook of the child or patient
• Mental development, school and occupational
performance
• Formal intellectual testing based on IQ.
The formula for IQ = mental Age (MA) X 100%
Chronological Age (CA)

104
 DISCUSS MANAGEMENT AND
PREVENTION OF MENTAL RETARDATION

105
 DIFFERENCES BETWEEN DMENTIA AND
MENTAL RETARDATION
CATEGORY SMILE DEMENTIA MENTAL RETARDATION

1. Age of Onset 65 years and above Before the age of 18 years

2.Essential features Deterioration in memory Subaverage intelligence

3. Brain structure Degeneration of brain cells No degeneration of brain cells

4. Appetite Poor Good

Sex More common in females More common in males than

than males females

106
 SUBSTANCE (DRUG AND ALCOHOL) ABUSE

It is use of any mind altering agents to such

an extent that it interferes with the
individual’s biological, physiological and
socio-cultural integrity. Also taking
unprescribed drugs or taking a dose other
than the prescribed dose.
107
DRUG: Is any substance other than food,
intended for use in the diagnosis, cure,
mitigation, treatment or prevention of
diseases in man or other animals.

Drug Dependence (Addiction): Is a state of

periodic or chronic intoxication detrimental to
the individual and society, produced by the
repeated consumption of a drug. This drug
may be in its natural or a synthetic form.
108
Examples of Drugs Concerned in Drug Dependence
• Marijuana
• Cocaine
• Heroine
• Mescaline
• Lysergic Acid Diethylamide (LSD)
• Amphetamine
• Barbiturates
• Morphine

109
Causes of Drug Abuse and Dependency
• Hereditary factors
• Familiar factors
• Anxiety
• Peer group influence
• People with psychological problems
• People with chronic physical illness
• Occupation, e.g., Distillers, Barkeepers, Doctors
• Some mental illness; depression, psychopaths
• Doctors induced phenomenon (iatrogenic)
• To rebel against people in authority
• Curiosity
• Advertisement on the media
110
Characteristics of Substance Drug Abuse and
Dependency
• Dependency: Compulsive and repeated use of
psychoactive drugs despite its adverse effects
– Chemical/physical dependency- repeated use of the
drug to prevent unpleasant effect of withdrawal
symptoms

– Psychological dependency – perceiving the use of a

drug as necessary to maintain an optimal state of
well-being; interpersonal relations or skill
performance.
111
• Craving: Irresistible urge to obtain and use
a psychoactive drug (because of specific
effect on mental activity).
• Tolerance: Repeated use of drugs so that
larger doses are required to produce the
same psychological and physiological
effect obtains previously by a smaller dose.
112
 Characteristics of Substance Drug Abuse and
Dependency cont.

• Addiction: Physically and psychologically

dependent on a drug.
• Habituation: Frequent or repeated use of a
psychoactive drug
• Withdrawal syndrome: Is a set of signs and
symptoms characteristic of the response of
individual to sudden cessation of drug intake
after its chronic use. These occur when the blood
level of the drug drops suddenly.
113
Examples of Withdrawal Symptoms
• Alcohol: Tremors of hands, nausea,
vomiting, high B.P., tachycardia, sweating,
headache, anxiety, insomnia, hallucination,
illusions, delusions, seizures, craving.
• Amphetamine: Depression, fatigue,
insomnia, disorientation.
114
Examples of Withdrawal Symptoms cont.

• Cocaine: Depression, irritability, insomnia,

severe craving.
• Marijuana: Anger, frustration, lack of
concentration, decreased appetite, craving.
• Opioids: Nausea, vomiting, muscle aches,
lacrimation or rhinorrhoea
115
Diagnosis of Substance Abuse
• History from client, friends or relatives

• Characteristics or features of the individual

• Blood or urine screening for drug level in

the blood
• The use of “breathalyzer” to detect blood
alcohol level
116
DISCUSS MANAGEMENT OF
SUBSTANCE ABUSE

117
 ALCOHOLISM

This is excessive and prolonged intake of

alcohol which may lead to physical and
mental illness and interferences with socio-
economic functions and interpersonal
relationships of the individual.

118
CAUSES OF ALCOHOLISM
• Strains and stresses
• Peer group influence
• Poor upbringing
• Anxiety
• Hereditary
• People with low self-esteem
• Occupation – Breweries, mortuary, bar, etc.
• Curiosity

119
EFECTS OF ALCOHOL
• The end result is depression, because it
depresses the CNS for that matter memory and
the power of reasoning is impaired.
• Alcohol in small doses creates a state of well-
being
• In large doses, symptoms of alcoholism tends
to appear, e.g., muscular in-coordination, poor
judgment, nausea, vomiting, diplopia, ataxia,
amnesia, cold, clammy skin which may lead to
coma and then death.
120
 ALCOHOLIC PSYCHOSES
It is a group of organic mental illness which is
due to excessive intake of alcohol.
• Pathological Intoxication (Mania a Potu)
This is a state of acute excitement with
violence, confusion and loss of self control.
These people drink occasionally just
because some people are drinking. They
become restless and destructive.

121
• These people later have no recollection of
the event. This condition is seen in those
who are not used to taking alcohol so they
respond to quite small doses. It is usually
seen in psychopaths, epileptics and those
who have had head injuries. They are not
habitual drinkers.
122
Management of Mania A Potu
• Induce vomiting by giving salty water to
patient to drink
• The individual is bathed
• Give some warm sweet drinks, e.g., coffee
or mashed kenkey with sugar.
• Encourage him to sleep
• When he wakes up, educate him not to take
alcohol because it is not good for his health.
123
 DIPSOMANIA

This is a condition characterized by periodic

drinking of excessive amount of alcohol for
about 2-3 weeks. Whenever the individual is
in this mood, he has the compulsion or crave
for alcohol. This strong desire vanishes for
sometime and then reappears again with
renewed vigor. 124
• When the individual is in the drinking bouts, he
neglects his work and personal hygiene and can
take anything that contains alcohol. The victim
remains perfectly sober at the periods of
abstinence and may find alcohol distasteful.
Observations have shown that neurotic,
depressives, and psychopaths often suffer this
condition.
125
 MANAGEMENT OF DIPSOMANIA
• The main management is psychotherapy. It is
done to help the individual to understand
himself and to control himself.
• Counseling and advice by a psychiatrist or a
clinical psychologist
• Family therapy
• Alcoholic Anonymous (AA)
• Blue cross
126
 DELIRIUM TREMENS (ALCOHOL
WITHDRAWAL DELIRIUM)
This is a psychiatric condition characterized
by signs and symptoms, often seen in chronic
alcoholics who suddenly withdraw from
alcohol for about 72 hours due to
hospitalization, imprisonment or for any
other reasons that make it impossible to have
access to alcohol.
• Onset – The onset is sudden
127
CAUSES
• Sudden withdrawal from alcohol for 3-5
days
• Reduction in alcohol consumption
• An alcoholic with existing physical illness
• Drugs, e.g., barbiturates
• Malnutrition in alcoholism
• Infection in alcoholism
• Anaemia in alcoholism
128
CLINICAL FEATURES
Physical Signs and Symptoms
• Tremors of the limbs, facial muscles, the lips and
the tongue
• Nausea and vomiting
• Headache
• Insomnia
• Profound sweating
• Palpitation
• Tachycardia
129
 Physical Signs and Symptoms
• Gastritis

• Furred tongue

• High temperature

• Malaise

• High BP

• Seizures

• Anorexia
130
Psychological Signs and Symptoms
• Confusion
• Disorientation
• Irritability
• Depression
• Anxiety
• Agitation
• Restlessness
• Illusions and hallucinations
131
MANAGEMENT
• Hospitalization may be necessary
• Close observation and protection from
injury
• Complete bed rest
• Anxiolytic /sedatives prescribed
• Nutrition / copious fluid/vitamins e.g.,B-
Complex
• Personal hygiene (total self care)

132
ALCOHOLIC HALLUCINOSIS
• This refers to auditory hallucinations reported by
clients with alcohol dependence. The
hallucinations occur approximately 24 – 48 hours
after heavy drinking and may be vivid and
threatening to the client.
• The auditory hallucinations are usually voices of
unformed sounds such as Hissing or Buzzing.
Onset is about age 40 and the individual drinking
heavily for 10 years or more.

133
KORSAKOF’S PSYCHOSIS
• This is a psychiatric disorder found in
alcoholism. It is sometimes referred to as
Dysmnesic syndrome or Alcohol Amnesic
Disorder.
• It is associated with lack of nutritious food
and vitamins particularly vitamin B1
(Thiamine), leading to Wernicke’s
Encephalopathy. It was first described by a
Russian Neurologist and Psychiatrist called
Sergei Korsakov in 1877. Onset is gradual.134
CAUSES
• Alcoholism
• Malabsorption syndrome
• Severe anorexia
• Upper – gastro intestinal obstruction
• Prolonged intravenous feeding
• Thyrotoxicosis
• Thiamine deficiency
• Hemodialysis
135
The disease is characterized by 2 sets of symptoms.
Mental and Physical symptoms.
MENTAL SYMPTOMS
• Poor memory of recent events (Anterograde
Amnesia)
• Mistaking of identity, e.g., patient cannot identify
members of his own family
• Episodes of confusion and disorientation
• Confabulation
• Emotional liability (mood swings)
• Illusions are common
• Patient has no insight into his condition
136
PHYSICAL SYMPTOMS
• Malnutrition
• Damage to the peripheral nerves
particularly in the legs which may lead to
pain and tenderness in the calfs weakness
of the muscles of the feet.
• Sensory loss of the hands and feet, and
absence of tendon reflexes.
• There may be ocular palsies and
nystagmus
137
MANAGEMENT
• Hospitalization may not be necessary

• Vitamin B complex and Ascorbic acid may

be prescribed by doctor, and good nutritious
diet is given
• General Nursing Care

138
CHRONIC ALCOHOLISM
• This is a condition found in those who have
been habitual drinkers for many years. They
gradually deteriorate mentally and
physically.

139
CLINICAL MANIFESTATIONS
• Patient neglects his work and personal hygiene
• Memory defects, i.e., forgetfulness
• Failure in judgment
• Irritability, childishness and easy to be
suggested to
• May become violent
• At times shed “Crocodile” tears
• He accuses his friend, employers and relatives
for letting him down.
• Lack of sexual drive, impotency.
140
• Pathological jealousy
• Confabulation
• Neglect personal hygiene
• Negligence or responsibilities- that lends
to won of job, divorce, broken homes, etc.
• Suicide tendencies
• Kindly problems
• Liver cirrhosis
• Tremors
141
GENERAL MANAGEMENT OF
CHRONIC ALCOHOLISM

• Hospitalization is necessary
• Prevention of delirium tremens in the in the
first problem to tackle..
• Some tranquilizers may prescribed
• Nutrition and hydration(vitamin B complex)
• Observation for suicidal tendencies
142
 GENERAL MANAGEMENT OF CHRONIC
ALCOHOLISM CONT.
• Attention to other physical needs and personal
hygiene
• Aversion therapy (Antabuse or apomorphine)
• Psychotherapy-counseling, AA, Blue Cross
• Recreational therapy
• Occupation therapy
• Rehabilitation for patient to obtain a suitable job

143
 COMPLICATIONS
Social Physical Psychological

 Poverty  Cirrhosis of the liver  Delirium

 Divorce  Peripheral Menritis  Dementia
 Loss of social status  Kidney disease  Alcoholic

 Loss of job  Arteriosclerosis  Psychosis

 Heart diseases
 Gastritis
 Tuberculosis
 Pneumonia
 Brain damage

144
PREVENTION OF DRUG/ALCOHOL
DEPENDENCE
• There is the need to educate the general public
particularly the youth on the effects of abuse of
drugs. Places for these educational programs
can as follow; churches, mosques, schools, lorry
parks, social gathering, and the general public.
145
• Means of education

– Health talks

– Film shows

– Distribution of leaflets

– On the media, e.g., TV, Radio,

newspapers
146
• Means of legal action

– Banning of the sale of heard drugs

– Drugs must be prescribed only by qualified

physicians
– Drugs must be sold by qualified pharmacists

– Those who sell of found to possession of

these drugs illegally be prosecuted
147
• FDA Regulations must always be applied
in giving these drugs
– Drugs must be under lock

– Drugs collected and served must be

witnessed and both nurses and senior
nurses sign for.

148
• People who cultivate some of these drugs
illegally must be arrested and prosecuted
• Children under age must not be allowed to buy
alcohol or sell it.
• There must be proper checking at ports and
border.
• Only some specified companies must be allowed
to produce these drugs.
• There should be proper distribution of these
drugs so that it does not go into wrong hands.

149
• In the community
– There should be recreational facilities for the
youth
– Job avenues for the general public
– Vocational institutions for the youth
– Parents must serve as a good models to their
children
– Parents create harmonious atmosphere at
homes for their children’s proper development
– Teachers must identify students with drug
problems so that they can be counseled.
150