6.1 Cognitive and Mental Health Conditions
Key Takeaways
- Alzheimer's disease accounts for 60-80% of all dementia cases and is characterized by amyloid plaques and neurofibrillary tangles in the brain (Alzheimer's Association, 2024).
- Delirium is acute, fluctuating, and often reversible; the most common trigger in older adults is a urinary tract infection (UTI).
- Any direct or indirect suicidal statement must be reported to the nurse immediately and the resident must not be left alone.
- Lewy body dementia presents with vivid visual hallucinations and Parkinsonian motor features; vascular dementia worsens in a stepwise pattern after strokes.
- Depression in older adults often presents as anhedonia, sleep disturbance, appetite change, and statements of worthlessness rather than open sadness.
Mental and cognitive conditions account for roughly 8% of the NNAAP written exam (Emotional and Mental Health category) and underlie a much larger share of the day-to-day care decisions tested across the rest of the test. North Carolina facilities, especially the dementia-care special-care units licensed under 10A NCAC 13F, serve a population where cognitive impairment is the rule, not the exception.
Dementia vs. Delirium vs. Depression (The Three D's)
The NNAAP loves to test whether you can tell these apart, because each one demands a different response. A CNA who treats delirium as "just dementia getting worse" can miss a life-threatening infection.
| Feature | Delirium | Dementia | Depression |
|---|---|---|---|
| Onset | Hours to days (acute) | Months to years (gradual) | Weeks to months |
| Course | Fluctuates hour to hour | Slowly progressive | Persistent, worse in morning |
| Reversibility | Usually reversible | Generally not reversible | Treatable with therapy/meds |
| Attention | Markedly impaired | Relatively preserved early | Mildly impaired |
| Common trigger | UTI, dehydration, new medication, pain | Underlying brain disease | Loss, isolation, illness |
| CNA action | Report changes to nurse the same shift | Care plan approach, redirection | Report mood changes; never dismiss |
Any sudden change in mental status — a normally pleasant resident becoming agitated, a quiet resident becoming combative, new confusion — is treated as delirium until proven otherwise and reported promptly. UTIs in the elderly often present without burning or fever; new confusion may be the only sign.
Types of Dementia
Dementia is an umbrella term for chronic, progressive cognitive decline severe enough to interfere with daily life. The four most common types tested on the NNAAP:
- Alzheimer's disease (AD) — 60-80% of cases. Pathology shows beta-amyloid plaques outside neurons and tau neurofibrillary tangles inside neurons. Decline is gradual and global, with short-term memory loss as the first noticeable symptom.
- Vascular dementia — Caused by multiple small strokes or chronic poor brain perfusion. Decline is stepwise: a stable plateau, then a sudden drop after another stroke, then a new plateau.
- Lewy body dementia (LBD) — Hallmark is vivid, well-formed visual hallucinations (often of people or animals) and Parkinsonian features (tremor, rigidity, shuffling gait). Cognition fluctuates day to day.
- Frontotemporal dementia (FTD) — Affects the frontal and temporal lobes. Memory may be preserved early, but personality, behavior, and judgment change dramatically: disinhibition, apathy, socially inappropriate comments, loss of empathy.
Stages of Alzheimer's Disease
| Stage | Typical findings | CNA priorities |
|---|---|---|
| Early / Mild | Forgets recent events, misplaces items, word-finding trouble, can still live alone with reminders | Cueing, written reminders, encourage independence |
| Middle / Moderate | Needs help with ADLs, may not recognize friends, wandering, sundowning, sleep disturbance | Structured routine, supervised ADLs, safety from wandering |
| Late / Severe | Limited speech, incontinence, immobility, dysphagia, total ADL dependence | Total care, skin and contracture prevention, comfort, family support |
Major Mental Illnesses You Will See
NC long-term care facilities admit residents with chronic psychiatric diagnoses; the CNA does not diagnose or treat, but must observe, report, and respond therapeutically.
- Major Depressive Disorder — Anhedonia (loss of pleasure), sleep changes, appetite changes, fatigue, hopelessness, statements like "I am worthless" or "I just want to be done." Common in new admissions and after a loss.
- Generalized Anxiety / Panic Disorder — Excessive worry, rapid breathing, sweating, racing heart, sense of doom. Stay, speak slowly, coach slow breathing, do not leave alone.
- Schizophrenia — Hallucinations (most often auditory), delusions, disorganized speech, flat affect. Do not argue with the content of a hallucination; do not pretend you hear it either. Acknowledge the feeling and redirect.
- Bipolar disorder — Cycles between mania (decreased need for sleep, rapid speech, grandiosity, risky behavior) and depression. Report sleep changes.
- PTSD — Flashbacks, hypervigilance, exaggerated startle response. Especially common in veterans in NC State Veterans Homes. Warn before touching, minimize sudden noise, identify yourself.
Suicide Risk: A Mandatory-Report Topic
Suicide rates are highest in adults over age 75. Every NC nursing facility CNA must know the warning signs and the rule: any suicidal statement, gesture, or plan is reported to the nurse immediately, and the resident is not left alone.
Warning signs
- Direct statements: "I want to kill myself," "I should just end it."
- Indirect statements: "You won't have to worry about me much longer," "Everyone would be better off without me."
- Giving away prized possessions to family or other residents.
- Sudden calm or improved mood after a long depression — this can mean the person has decided on a plan and feels relief.
- Increased alcohol or drug use, withdrawing from activities, settling affairs, refusing food and fluids.
The NNAAP correct answer is always to stay with the resident, listen, and notify the nurse. Never promise to keep a suicide statement secret, and never respond with "You don't really mean that."
A resident with Alzheimer's disease who has been pleasant and oriented for months suddenly becomes agitated, confused, and disoriented during one shift. The CNA's BEST first action is to:
A resident tells the CNA, "I've been getting my affairs in order and I gave my watch to my son yesterday. You all won't have to worry about me much longer." The CNA should: