NLE Psychiatric Disorders — Cognitive, Organic, and Neurodevelopmental DisordersRevision Notes

Exam tips

• If the NLE item says 'sudden onset of confusion' — think DELIRIUM first; if 'gradual over months' — think DEMENTIA.
• The word 'fluctuating' in a question stem almost always points to delirium.
• If the question asks 'What is the PRIORITY nursing action for a delirious patient?' — the answer is FIND AND TREAT THE UNDERLYING CAUSE (assess vital signs, oxygen saturation, blood glucose, review medications, check for infection).
• Delirium = Medical Emergency = ABC priorities first.
• Reorientation strategies (clock, calendar, familiar objects, consistent lighting) are hallmark nursing interventions for delirium.

Key points

• Delirium is a MEDICAL EMERGENCY — always identify and treat the underlying cause first.
• Onset is SUDDEN, occurring over hours to days — this is the single most important distinguishing feature from dementia.
• Course is FLUCTUATING — symptoms are worse at night (sundowning) and vary hour to hour.
• Level of consciousness is ALTERED or CLOUDED — the patient may be hyperalert, stuporous, or shifting between the two.
• The HALLMARK of delirium is markedly impaired ATTENTION — the patient cannot sustain focus or follow simple commands consistently.
• Delirium is generally REVERSIBLE once the underlying cause is identified and treated.
• Common causes in Filipino clinical settings (remember the mnemonic I-WATCH-DEATH or common Philippine patterns): UTI and pneumonia in elderly, electrolyte imbalances, hypoglycemia, hypoxia, dehydration, polypharmacy, drug or alcohol withdrawal, post-operative/anesthesia states, and pain.
• Any sudden acute change in a patient with known dementia must be treated as SUPERIMPOSED DELIRIUM until proven otherwise.
• Priority nursing diagnosis: Risk for Injury related to altered level of consciousness and impaired attention.
• Maslow priority: Safety and Physiological needs come first — correct the physiology, ensure environmental safety.

Definitions

Common mistakes

• Assuming that confusion in an elderly patient is 'just their dementia' without checking for an acute medical cause — always look for SUDDEN CHANGE as a red flag.
• Administering sedatives liberally to a delirious patient — sedatives can worsen confusion; they are only used for dangerous agitation.
• Forgetting that UTI and pneumonia in elderly Filipinos often present as confusion BEFORE classic symptoms (fever, dysuria) appear.
• Missing that attention impairment (not just memory loss) is the HALLMARK of delirium.
• Confusing sundowning as exclusive to dementia — it occurs in delirium too.

Exam tips

• The key comparison: Delirium = Sudden + Fluctuating + Altered Consciousness. Dementia = Gradual + Stable Day-to-Day + Clear Consciousness.
• If an NLE item describes a patient with dementia who suddenly becomes MORE confused — always choose the option that investigates for a medical cause (superimposed delirium).
• Reversible dementias are a favorite NLE distractor — know B12 deficiency and hypothyroidism as the classic reversible causes.
• Recent memory lost FIRST is a consistent NLE answer for dementia.

Key points

• Dementia is a CHRONIC, PROGRESSIVE, and generally IRREVERSIBLE decline in multiple cognitive domains.
• Onset is GRADUAL — over months to years; there is no acute event triggering onset.
• Course is SLOWLY PROGRESSIVE and STABLE within a single day — it does NOT fluctuate hour to hour like delirium.
• Level of consciousness remains CLEAR and NORMAL until very late stages of the disease.
• RECENT (short-term) memory is impaired FIRST — the patient forgets recent events but can still recall distant past memories.
• A small number of dementia causes are reversible and must be excluded: vitamin B12 deficiency, hypothyroidism, normal-pressure hydrocephalus, neurosyphilis.
• Most common cause of dementia worldwide and in the Philippines: Alzheimer's disease.
• Nursing diagnosis priorities: Chronic Confusion, Risk for Injury, Self-Care Deficit, Caregiver Role Strain.
• Priority care: Safety (wandering, falls, burns), structured consistent routine, simple communication.

Definitions

Common mistakes

• Thinking consciousness is impaired in early-to-moderate dementia — consciousness stays CLEAR; impaired consciousness suggests delirium.
• Assuming all dementias are irreversible — always rule out reversible causes (B12 deficiency, hypothyroidism).
• Arguing or repeatedly correcting a confused dementia patient — this increases agitation and distress without benefit.
• Confusing which memory is lost first: RECENT memory goes first; remote memory is preserved longer.

Exam tips

• NLE pharmacology question: donepezil, rivastigmine, galantamine = cholinesterase inhibitors = Alzheimer's + watch for BRADYCARDIA and GI upset.
• Memantine = NMDA antagonist = moderate-to-severe Alzheimer's.
• If the NLE asks 'Which is the PRIORITY nursing action for a patient with Alzheimer's?' — SAFETY (wandering/fall prevention) is almost always the answer.
• The 4 A's (Aphasia, Apraxia, Agnosia, Amnesia) are classic NLE content — memorize and be able to identify each from a clinical description.
• Validation therapy for advanced dementia; reorientation for early stages — know WHEN to apply each.

Key points

• Alzheimer's disease is the MOST COMMON cause of dementia; pathology involves beta-amyloid plaques and neurofibrillary tangles.
• The 4 A's of Alzheimer's: APHASIA (language loss), APRAXIA (inability to perform learned motor tasks), AGNOSIA (inability to recognize familiar objects/people), AMNESIA (memory loss).
• Additional behavioral features: confabulation, perseveration, sundowning, wandering, personality changes.
• SAFETY is the PRIORITY nursing intervention — prevention of wandering (secured and alarmed doors, ID bracelet), fall prevention, burn prevention.
• Maintain a CONSISTENT, STRUCTURED ROUTINE and familiar, uncluttered environment — reduces anxiety and agitation.
• Communication approach: short, simple sentences; one instruction at a time; face the patient; speak calmly; allow adequate response time.
• Use REORIENTATION early in the disease; transition to VALIDATION THERAPY as disease advances (acknowledge feelings rather than arguing over facts).
• Manage sundowning: increase daytime light and activity, reduce evening stimulation, provide a soothing bedtime environment.
• Support CAREGIVER AND FAMILY — caregiver strain/burnout is a significant nursing concern; provide education, respite referrals, and community resources.
• Cholinesterase inhibitors SLOW progression but DO NOT CURE OR REVERSE the disease.
• Memantine is used in moderate-to-severe disease and can be combined with a cholinesterase inhibitor.

Definitions

Common mistakes

• Choosing reorientation for an advanced Alzheimer's patient — validation therapy is MORE appropriate as the disease progresses.
• Forgetting that cholinesterase inhibitors cause CHOLINERGIC side effects: bradycardia, nausea, vomiting, diarrhea, increased secretions.
• Overlooking caregiver burnout as a nursing diagnosis — Caregiver Role Strain (NANDA) is a priority concern in Alzheimer's care.
• Assuming memantine is first-line for mild disease — it is used in MODERATE TO SEVERE stages.
• Forgetting to include wandering prevention as the top safety priority for Alzheimer's patients.

Exam tips

• NLE tip: 'ADHD medication given in the morning to prevent insomnia' is a classic correct answer.
• Monitor 3 things for methylphenidate: APPETITE/WEIGHT, SLEEP/INSOMNIA, and CARDIOVASCULAR (HR and BP).
• Structured environment + clear rules + positive reinforcement = the behavioral nursing approach to ADHD.
• If the item asks about a NON-STIMULANT option for ADHD, the answer is ATOMOXETINE.
• Symptoms in BOTH home and school settings = diagnostic criterion — this appears in NLE scenario questions.

Key points

• ADHD is a NEURODEVELOPMENTAL disorder beginning in CHILDHOOD (symptoms present before age 12) and frequently persisting into adulthood.
• Core features: INATTENTION (easily distracted, careless mistakes, difficulty sustaining focus, losing things) and/or HYPERACTIVITY-IMPULSIVITY (fidgeting, unable to remain seated, always 'on the go,' interrupting, difficulty waiting turns).
• Symptoms must appear in MORE THAN ONE SETTING (e.g., both home and school) to meet diagnostic criteria.
• STIMULANTS are the first-line pharmacological treatment: methylphenidate (Ritalin) and amphetamine-based preparations (e.g., Adderall).
• Stimulants PARADOXICALLY improve focus and reduce hyperactivity in children with ADHD.
• Give stimulants IN THE MORNING (or early afternoon at the latest) — giving them late in the day causes INSOMNIA.
• Monitor for APPETITE SUPPRESSION — give medication AFTER meals; monitor height and weight regularly for growth effects.
• Monitor cardiovascular effects: increased HEART RATE and BLOOD PRESSURE.
• ATOMOXETINE is a non-stimulant alternative — useful when stimulant abuse risk is a concern.
• Non-pharmacological management: structured consistent environment, clear rules and routines, reduced distractions, tasks broken into small steps, simple clear directions, consistent POSITIVE REINFORCEMENT and FIRM LIMIT-SETTING.
• Protect SELF-ESTEEM of the child — ADHD is not a moral failing; these children are not 'bad' or 'lazy.'

Definitions

Common mistakes

• Giving stimulants in the afternoon or evening — this causes insomnia; always give in the MORNING.
• Forgetting to monitor weight and height — appetite suppression can impair growth in children.
• Thinking stimulants will make a child 'high' or more hyperactive — in ADHD, stimulants PARADOXICALLY reduce hyperactivity.
• Overlooking cardiovascular monitoring — methylphenidate increases heart rate and blood pressure.
• Neglecting behavioral and environmental strategies — medication alone is not sufficient; structure, routine, and positive reinforcement are essential.

Exam tips

• NLE key: ASD = social-communication deficits + restricted/repetitive behaviors + insistence on SAMENESS.
• Priority intervention for ASD = MAINTAIN ROUTINE AND CONSISTENCY.
• If the NLE scenario shows a child who becomes very distressed when the schedule changes — think ASD.
• Early behavioral intervention (NOT medication) is the primary treatment that improves outcomes in ASD.
• Poor eye contact + repetitive rocking + intense interest in a single topic = ASD clinical picture for NLE scenarios.

Key points

• ASD is a NEURODEVELOPMENTAL disorder appearing in EARLY CHILDHOOD (symptoms present in early developmental period).
• Two CORE DOMAINS define ASD — both must be present for diagnosis:
• Domain 1: PERSISTENT DEFICITS IN SOCIAL COMMUNICATION AND SOCIAL INTERACTION — poor eye contact, difficulty with social-emotional reciprocity, impaired development of relationships, limited verbal and nonverbal communication.
• Domain 2: RESTRICTED, REPETITIVE PATTERNS OF BEHAVIOR, INTERESTS, OR ACTIVITIES — stereotyped or repetitive movements (rocking, hand-flapping), insistence on SAMENESS AND ROUTINE, intense fixated interests, unusual sensory sensitivities (hypo- or hypersensitivity to stimuli).
• ASD is a SPECTRUM — severity varies widely from those needing full-time support to highly verbal and independent individuals.
• There is NO CURE for ASD; EARLY BEHAVIORAL INTERVENTION (applied behavior analysis, speech therapy, occupational therapy) significantly improves outcomes.
• Medications treat specific ASSOCIATED SYMPTOMS only (e.g., irritability, aggression, anxiety, sleep problems) — not the core disorder.
• Priority nursing intervention: MAINTAIN CONSISTENCY AND ROUTINE — sudden changes and transitions are major triggers for distress.
• Ensure SAFETY and reduce OVERWHELMING SENSORY STIMULATION in the care environment.
• Communicate using CLEAR, CONCRETE, SIMPLE LANGUAGE at the child's developmental level; use visual supports (pictures, schedules) when helpful.
• Support the FAMILY — caregiving for a child with ASD is demanding; provide education and referrals.

Definitions

Common mistakes

• Assuming ASD children lack emotion — they have difficulty expressing and processing emotion but do experience emotional states.
• Imposing sudden schedule changes without preparation — always prepare ASD children for transitions in advance.
• Thinking medication cures ASD — medications ONLY treat specific associated symptoms.
• Overstimulating the ASD child with too much noise, light, or activity — sensory sensitivity requires a calm, controlled environment.
• Confusing ASD with intellectual disability — ASD and intellectual disability are separate diagnoses, though they can co-occur.

Exam tips

• NLE tip: ID requires BOTH intellectual AND adaptive functioning deficits — knowing only one is not enough for diagnosis.
• Fetal Alcohol Syndrome = maternal alcohol intake = PREVENTABLE intellectual disability — always connects to health teaching.
• Newborn Screening Program (Philippine RA 9288) = early detection of preventable causes of ID = public health nursing role.
• Teaching approach for ID = SIMPLE, CONCRETE, REPEATED, STEP-BY-STEP — this is the consistent NLE answer for ID care.
• Goal of care = MAXIMIZE INDEPENDENCE through habilitation — not dependency or institutionalization.

Key points

• Intellectual Disability (ID) is a NEURODEVELOPMENTAL disorder with onset in the DEVELOPMENTAL PERIOD (before age 18).
• Defined by TWO core deficit areas: (1) INTELLECTUAL FUNCTIONING — significantly subaverage reasoning, problem-solving, learning, and abstract thinking; (2) ADAPTIVE FUNCTIONING — deficits in conceptual (language, literacy, math), social (interpersonal, social judgment), and practical (self-care, job, finances) skills.
• Severity is classified as MILD, MODERATE, SEVERE, or PROFOUND — based on ADAPTIVE FUNCTIONING and support needs, NOT IQ score alone.
• Common causes: genetic (Down syndrome, Fragile X syndrome), prenatal exposures (FETAL ALCOHOL SYNDROME — a preventable cause), birth injury/hypoxia, infections (congenital rubella, meningitis), and metabolic disorders (PKU — detected by newborn screening).
• Nursing care is INDIVIDUALIZED — promote the HIGHEST POSSIBLE LEVEL OF INDEPENDENCE.
• Teaching approach: SIMPLE, CONCRETE, STEP-BY-STEP instructions; use REPETITION; break tasks into small manageable steps.
• SAFETY is a priority — protect from injury and exploitation (vulnerability is increased).
• Support COMMUNICATION at the individual's developmental level.
• Emphasize HABILITATION (building functional skills) and COMMUNITY INTEGRATION.
• PREVENTION is a key public health nursing role: prenatal care, avoidance of alcohol in pregnancy, genetic counseling, newborn screening programs (e.g., the Philippine ENBS — Expanded Newborn Screening), vaccination, and injury prevention.
• Family education and involvement is essential in ALL levels of care.

Definitions

Common mistakes

• Classifying intellectual disability severity based on IQ alone — severity is now based on ADAPTIVE FUNCTIONING and support needs.
• Setting unrealistic goals — goals must be individualized and realistic based on the patient's functional level.
• Using complex, abstract, or multi-step instructions — always use SIMPLE, CONCRETE, STEP-BY-STEP approaches.
• Forgetting that intellectual disability and mental illness are different — a person with ID can also develop a mental illness (dual diagnosis).
• Overlooking exploitation risk — people with intellectual disability are vulnerable and require protective interventions.

Exam tips

• If the NLE asks the mechanism of donepezil: CHOLINESTERASE INHIBITOR = increases acetylcholine.
• If the NLE asks side effects of donepezil: BRADYCARDIA and GI UPSET (nausea, vomiting, diarrhea).
• Memantine = NMDA antagonist = moderate-to-severe Alzheimer's.
• Methylphenidate: give MORNING, monitor WEIGHT and SLEEP and HEART RATE.
• Atomoxetine = non-stimulant ADHD drug = use when abuse risk is a concern.

Key points

• Donepezil (Aricept), Rivastigmine (Exelon), Galantamine (Razadyne) — CHOLINESTERASE INHIBITORS for mild-to-moderate Alzheimer's. Mechanism: inhibit acetylcholinesterase → increase acetylcholine. Side effects: bradycardia, nausea, vomiting, diarrhea, anorexia (cholinergic effects).
• Memantine (Namenda) — NMDA RECEPTOR ANTAGONIST for moderate-to-severe Alzheimer's. Can be combined with a cholinesterase inhibitor. Side effects: dizziness, headache, confusion.
• Methylphenidate (Ritalin) and amphetamine salts (Adderall) — CNS STIMULANTS, first-line for ADHD. Administration: MORNING dosing. Side effects: anorexia/weight loss, insomnia, tachycardia, hypertension. Monitor: weight, height, HR, BP, sleep.
• Atomoxetine (Strattera) — NON-STIMULANT for ADHD. Selective norepinephrine reuptake inhibitor. Alternative when stimulant abuse is a concern.
• Antipsychotics (low-dose, e.g., haloperidol, quetiapine) — used ONLY for dangerous agitation in delirium; NOT first-line and used sparingly. For delirium: treat the CAUSE first.
• Antipsychotics (e.g., risperidone, aripiprazole) — used in ASD for ASSOCIATED symptoms (irritability, aggression) ONLY. Do NOT treat core ASD symptoms.
• Key principle: Alzheimer's drugs SLOW progression but DO NOT CURE. ADHD stimulants are effective but require careful monitoring. ASD and ID have no pharmacological cure.

Common mistakes

• Giving cholinesterase inhibitors and expecting a CURE — they only slow progression, not reverse it.
• Giving methylphenidate at bedtime — always morning dosing.
• Using antipsychotics as FIRST-LINE for delirium — they are last resort for dangerous agitation; treating the CAUSE is always first.
• Thinking antipsychotics treat CORE symptoms of ASD — they only address associated symptoms like aggression or irritability.