Sources and references for this study guide for delirium: Reorientation can be extremely stressful and damaging to patients with dementia, not to mention the caregiver. The nurse should ensure to always reorient the patient to reality. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). 3. Medications available to help manage symptoms in people with Alzheimers disease include cholinesterase inhibitors and NMDA antagonists. Suggest regular physical activity, a healthy diet, social activity, hobbies, and intellectual stimulation, all of which may help slow cognitive decline. Patients can benefit from written reminders to help them recall certain behaviors. The brains of these patients are oftentimes compromised and would have problems about: Patients with cognitive impairment almost always have long-term consequences due to the organ involved, which will depend on the degree or severity of the damage. Completing routine chores, such as following a recipe, takes longer. Use memory aids. Refer the person and caregiver to national and community resources, including support groups. Medical-surgical nursing: Concepts for interprofessional collaborative care. Anyone who believes their memory loss is the result of something else should see a doctor. The patients will demonstrate a reduced anxiety level. This can also be obtained from family members. Can help keep the patients mental talents for a longer time. Medications may be available to treat certain behavioral and mood symptoms associated with various forms of dementia, including delusions and depression. Discuss the diagnosis and treatment plans. Determining the specific cause and deficit will help the nurse to formulate interventions. Learn more about treatments for Parkinsons disease dementia and Lewy body dementia and frontotemporal disorders. Examine for anxiety, sadness, and rage. St. Louis, MO: Elsevier. Newer atypical antipsychotics may be safer but should still be used at the lowest dose possible for the shortest amount of time needed to control symptoms. The patient will be able to perform tasks and activities of daily living within the patients level of ability. Answer: D. Disturbance in recalling recent events related to cerebral hypoxia. Further testing may include blood and urine tests, nerve tests, and brain imaging tests such as computerized axial tomography (CAT) scans or magnetic resonance imaging, depending on the results (MRI). Manage Settings Advise the patients family to provide non-slip footwear without laces when possible. Local nonprofit and community organizations. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). 2020;2020, 1-11. doi:10.1155/2020/3620534, Yang, Q.; Tian, C.; Tseng, B.; Zhang, B.; Huang, S.; Jin, S.; et al. Disturbed Sleep Pattern Nursing Diagnosis, Agitation Nursing Diagnosis and Nursing Care Plan, Glaucoma Nursing Diagnosis and Nursing Care Plan. Responses to interventions, teaching, and actions performed. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. 2020;35(2), 220-249. doi:10.1037/pag0000442, Brandt, .; Jensen, M. P.; Sberg, M. S.; Andersen, S. D.; Sund, T. Information and communication technology-based assistive technology to compensate for impaired cognition in everyday life: A systematic review. Review the patient's prescription and over-the-counter medications and supplements. Nursing Care Plan for Dementia 1 Nursing Diagnosis: Disturbed Thought Process related to cognitive impairment secondary to dementia as evidenced by problems with coordination and motor functions, difficulty handling complex tasks, confusion and disorientation, inability to do activities of daily living (ADLs) as normal There are possible side effects to new disease-modifying immunotherapies, including amyloid-related imaging abnormalities (ARIA), which can lead to fluid buildup or bleeding in the brain. Dementia can result in: An appointment with the doctor is needed if there are instances of becoming increasingly forgetful or if memory problems are interfering with ones everyday life to establish the reason and best treatment. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). D. Suggesting new activities for the client and family to do together. The patient will report that the thoughts are less severe and less frequent with the help of drugs and nursing interventions. Introduction. Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Also, use this opportunity to ask the care partner how they are doing, and what assistance and resources are needed to deliver care and manage stress. We'll guide you in making your NANDA Chronic Turmoil Care Plan in such nursing diagnosis guide. Orientation of the patient to reality will promote patient familiarity and resumption of activities of daily living. Caregivers were spouses or children, and most lived with the patient. It is important to identify and address safety concerns related to cognitive dysfunction, such as medication adherence, decision-making capacity, safety with functional mobility tasks and wandering. The patient remains content and he or she will be safe from harm. To view the purposes they believe they have legitimate interest for, or to object to this data processing use the vendor list link below. 1. Nursing Interventions Assessing the level of impairment or confusion will help in determining the amount of reorientation and intervention the patient needs to evaluate reality accurately. C. Personality change is common in vascular dementia. Cases of dementia are increasing due to longer life expectancy of the world population. Oliva, H. N. P.; Machado, F. S. M.; Rodrigues, V. D.; Leo, L. L.; Monteiro-Jnior, R. S. The effect of dual-task training on cognition of people with different clinical conditions: An overview of systematic reviews. Medications are also emerging to treat the progression of the disease. National Institute for Health and Care Excellence (NICE). Nursing Diagnosis: Impaired Memory related to alterations in cognition, neuronal destruction or chemical imbalance in the brain secondary to dementia as evidenced by time, place, person and condition disorientation, reduced reasoning and conceptualization abilities, inability to think clearly, calculation difficulties, memory problems, attention span decreases, easy distractibility, inability to obey simple or complex instructions, personal hygiene and attractiveness have deteriorated. Loss of focus in conversations. Determine the severity of the impaired memory and if it affects the patient's ability to perform tasks, participate in conversation, and remain safe. However, unless you work in a neuro unit, you won't typically need to perform a sensory and cerebellar assessment. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Marianne leads a double life, working as a staff nurse during the day and moonlighting as a writer for Nurseslabs at night. 2018;2018, 1-14. doi:10.1155/2018/7301530, Naef, R.; Ernst, J.; Burgi, C.; Petry, H.. Quality of acute care for persons with cognitive impairment and their families: a scoping review. 2018, Jan;90(3), 126-135. doi:10.1212/WNL.000000000000482 [Quality Measures,Clinical Practice Guidelines], Reilly, J. C.: Houghton, C. The experiences and perceptions of care in acute settings for patients living with dementia: A qualitative evidence synthesis. As always, refer to an evidence-based nursing care planning resource when customizing interventions for specific patients. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. The nurse should remove all potential and obvious hazards to allow the patient to move as freely as possible. 2019;, 1-25. doi:10.1007/s00415-019-09493-9 [Metasynthesis,Meta-analysis,Systematic Review], Demurtas, J.; Schoene, D.; Torbahn, G.; Marengoni, A.; Grande, G.; Zou, L.; et al. Provide written instructions and ensure that treatment plans are understandable and feasible for both the patient and caregiver. Approach the patient with a nonjudgmental approach and attentively listen to his feelings and worries. 1. Dementia is defined by a loss of previous levels of cognitive, executive, and memory function in a state of full alertness (Bourgeois, Seaman, & Servis, 2008). Nursing care plans: Diagnoses, interventions, & outcomes. Provide conducive environment for sleep, such as uninterrupted sleep times and light therapy. Effect of computerised cognitive training on cognitive outcomes in mild cognitive impairment: A systematic review and meta-analysis. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Decrease distractions such as television and radio at a minimum when talking to the patient. Reality orienting treatments promote awareness of self and environment only in people with delirium or depression. 3. 2018;45, 1-14. doi:10.1016/j.arr.2018.04.002 [Metasynthesis,Meta-analysis,Systematic Review], Cicerone, K. D.; Goldin, Y.; Ganci, K.; Rosenbaum, A.; Wethe, J. V.; Langenbahn, D. M.; Malec, J. F.; Bergquist, T. F.; Kingsley, K.; Nagele, D.; Trexler, L.; Fraas, M.; Bogdanova, Y.; Harley, J. P. Evidence-based cognitive rehabilitation: Systematic review of the literature from 2009 through 2014. A person who is losing STM frequently asks the same questions, forgets where he just put something, and forgets recent events or anything he saw or read recently. Determine the medications the patient is currently taking. Journal of the American Medical Directors Association. Applied Nursing Research. A thorough neurologic assessment will include assessing mental status, cranial nerves, motor and sensory function, pupillary response, reflexes, the cerebellum, and vital signs. 1 For information on assessing patients with memory complaints or other symptoms of dementia, see Assessing Cognitive Impairment in Older Patients. 2017;78, 44-51. doi:10.1016/j.ijnurstu.2017.08.005 [Metasynthesis,Meta-analysis,Systematic Review], Yang, J.; Zhang, L.; Tang, Q.; Wang, F.; Li, Y.; Peng, H.; et al . Nursing Diagnosis: Impaired Memory related to chemical modifications (e.g., medications, electrolyte imbalances), support systems are insufficient, life experiences that are really stressful, possible hereditary factor, anxiety at a panic level, and expunged fears secondary to Schizophrenia as evidenced by delusions, inaccurate environmental perception, non-realistic thinking is inappropriate, memory problems/deficiency, and self-centeredness. Ageing Research Reviews. Check the patients strength to accomplish the activity of daily living efficiently and cautiously daily using proper assessment tools. Healthcare . This stage enables the caregiver and the patient to work toward goals. People who are unable to distinguish between reality and fiction or what they see on television may experience agitation and disorientation as a result of overstimulating television and radio shows. Utilize positive feedback. Establish familiarity using a structured routine congruent with home schedule, when possible, such as family presence, consistent caregiver, sleep and meal schedule, toileting schedule. 2020;52, 1-17. doi:10.1016/j.smrv.2020.101308, Erickson, K. I.; Hillman, C.; Stillman, C. M.; Ballard, R. M.; Bloodgood, B.; Conroy, D. E.; Macko, R.; Marquez, D. X.; Petruzzello, S. J.; Powell, K. E. Physical Activity, Cognition, and Brain Outcomes: A Review of the 2018 Physical Activity Guidelines. 5. Neurology. The customer will feel even more lonely and misunderstood as a result of this. Startup learning today for freely! Optimize nutrition and fluid intake; encourage and offer fluid intake frequently and assist with meal set-up and feeding if needed. St. Louis, MO: Elsevier. Vital signs should be checked every 4 hours and on demand. Requesting the patient to hurry heightens the tension and may impede the patients ability to think effectively. Early detection and treatment of CNS illness can help to prevent persistent cognitive impairment. The patient will acquire optimal functional capacity with adaptations and alterations to his/her environment to compensate for limitations. Call the patient and caregiver to follow-up on the care plan after the visit. Tai Chi is effective in delaying cognitive decline in older adults with mild cognitive impairment: Evidence from a systematic review and meta-analysis. Nursing Care Plan for Alzheimer's 1 Nursing Diagnosis: Disturbed Thought Process related to cognitive impairment secondary to Alzheimer's disease as evidenced by problems with coordination and motor functions, difficulty handling complex tasks, confusion and disorientation, inability to do activities of daily living (ADLs) as normal This overview guide for health care providers suggests treatment strategies to consider when working with patients who have been diagnosed with dementia or cognitive impairment. Those with severe enough impairments would need significant support from other people or institutions, to function and sustain life. Prevent the patient from coming up with false ideas. In the case of young-onset dementia, planning and management concerns can be even more complex; specialty clinics can address such rare conditions. Offer the patient alternative means of communication. International Journal of Nursing Studies. A systematic review and meta-analysis. If the patient can hear you but does not understand what you are saying, try rephrasing your statement. Medicine and Science in Sports and Exercise. Consider referring the patient to a geriatrician, geriatric psychiatrist, neuropsychologist, geriatric social worker, geriatric counselor, mental health counselor, or substance abuse professional for help with care management. The effects of yoga on patients with mild cognitive impairment and dementia: A scoping review. Treatments for memory loss problems may also be particular. The consent submitted will only be used for data processing originating from this website. Assessments should be done at least once every six months to uncover difficulties that will assist the person with dementia in living a complete life. Divert the patients attention when agitated or if the patient shows dangerous behaviors. Nursing Interventions. A: Nursing interventions that help address nursing diagnosis impairedmemory include patient-centered care, environmental management, education, physical assistance, intercessory prayer, cognitive stimulation, and social support. Q: What Types of nursing Outcomes Are Aimed For With Nursing Diagnosis Impaired Memory? A calm environment should be provided because any noise and stimuli can be misinterpreted by a confused patient. Psychology and Aging. Archives of Gerontology and Geriatrics. 5. Such memory impairment can interfere with daily tasks in severe cases. D. Disturbance in recalling recent events related to cerebral hypoxia. Assessing Cognitive Impairment in Older Patients. Assists in the detection of any drug usage or adverse effects that may trigger depressed symptoms. Encourage the patients family and SO to socialize by providing current news and family events. Reviews in the Neurosciences. When depression is present, treating it may be beneficial to memory. The patients environment will be kept safe with no injuries and injuries obtained. St. Louis, MO: Elsevier. 5. (2020). Address potential issues of driving, getting lost, and home safety during each visit. PloS One. 2020;21(10), 1415-1422. doi:10.1016/j.jamda.2020.08.031, Dequanter, S.; Gagnon, M. P.; Ndiaye, M. A.; Gorus, E.; Fobelets, M.; Gigure, A.; et al . Please follow your facilities guidelines, policies, and procedures. Anna Curran. Nursing diagnoses handbook: An evidence-based guide to planning care. Inform the patient and family about opportunities to participate in clinical trials and research studies. Conduct comprehensive person-centered assessments and interim assessments on a regular basis. The nurse should identify the specific problems that will help in establishing a plan of care. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. Picmonic is research proven in increase your memory retention furthermore test scores. Assess the patients needs and pay attention to the patients nonverbal cues. 1. When dementia is irreversible and the patient can no longer understand reality, it does not work. 5. Sleep Medicine Reviews. Provide environmental adaptations to support cognitive function and safety; consider sensory exposure, hearing ability and distractions. Neuropsychological testing, a battery of tests that helps pinpoint memory loss, may also be ordered. 2020;8(3), 278-322. doi:10.3390/healthcare8030278, Lai, X.; Wen, H.; Li, Y.; Lu, L.; Tang, C. The Comparative Efficacy of Multiple Interventions for Mild Cognitive Impairment in Alzheimer's Disease: A Bayesian Network Meta-Analysis. Family members will demonstrate knowledge of required care, acceptable coping skills, and use of community resources. Consider sharing these publications with your patients: NIA Alzheimers and related Dementias Education and Referral (ADEAR) Center May be related to: . ), Obvious problems with memory such as remembering names, looking up words, and recalling items from a sample list (e.g., shopping list, etc. Hurrying the patient when speaking will make it less clear and may cause impaired communication. Impaired memory; Self-care deficit; Risk for injury; Risk for other-directed violence; Actual nursing diagnosis for acute confusion #1 Acute confusion. This intervention will help in preventing the patients risk of falls and injury. These activities can aid in stress reduction. Comprehensive pain assessment. An official website of the United States government. 2. Provide the patient with a peaceful atmosphere that includes fewer stimuli, a cold room, and dark lighting. One of the first indicators of dementia is memory loss that causes a disruption in ones life. Use simple terms. Allow client to have familiar objects around him or her; use other items, such as a clock, a calendar, and daily schedules, to assist in maintaining reality orientation. Risk for other-directed violence related to suspiciousness of others. With assistance from caregiver, client is able to distinguish between reality-based and non-reality based thinking. Treating the modifiable risk factors can help prevent additional stroke. Journal of Neurology. There are four stages, and they are: The following are sample tools used in evaluating impairment: Patients with cognitive impairment can result from various issues, some of them reversible but while others are not. Assess the patients ability to receive and send effective communications. Sleep Medicine Reviews. There are four clinical dementia syndromes accounting for 90% of all cases after excluding other common reversible causes of cognitive impairment. In a first phase of the study, they tested goal setting with 32 people who had dementia and their caregivers. Archives of Physical Medicine and Rehabilitation. The patient will express their recognition if delusional beliefs persist. Buy on Amazon, Silvestri, L. A. Refer the patient to a speech therapist as indicated and as needed. Certain peoples memory may improve over time. Buy on Amazon. For instance, they may have trouble following instructions about their care. A. Mindfulness and meditation: Treating cognitive impairment and reducing stress in dementia. Patient survivors with cognitive impairment are likely to have the following characteristics: Aside from a thorough history and physical examination, the care provider would employ a variety of techniques to screen for cognitive impairments. Physical activity and exercise in mild cognitive impairment and dementia: An umbrella review of intervention and observational studies. The patients ability to reply or respond to verbal directions may vary with the degree of orientation. 1. Address the patient directly and use simple wording, presenting one idea at a time. Assist in the psychotherapy of the client. Exercise, guided meditation, and massage are examples of supplementary and alternative therapy. Nursing Diagnosis Risk for injury related to impaired judgment, gait instability, muscle weakness, and sensory/perceptual alteration Patient Goals 1. (2018). The nursing management of a client with dementia include the following: Assessment of a client with dementia include the following: Nursing diagnoses that you can use for developing nursing care plans for patients with dementia include: The major nursing care planning goals for dementia are: The nursing interventions for a dementia client are: The outcome criteria for a patient with dementia include: Documentation needed for a client with dementia include the following: Quiz time about the topic! 2019; doi:10.1016/j.apmr.2019.02.011 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins], Dauwan, M.; Begemann, M. J.; Slot, M. I.; Lee, E. H.; Scheltens, P.; Sommer, I. E. Physical exercise improves quality of life, depressive symptoms, and cognition across chronic brain disorders: a transdiagnostic systematic review and meta-analysis of randomized controlled trials. Archives of Physical Medicine and Rehabilitation. It is important to assess the patients choice because the patient should be eager to submit himself or herself to a treatment regimen that will support his or her individual preferences. The patient will be able to comply with the therapeutic regimen that will help with his or her condition. The NIA ADEAR Center offers information and free print publications about Alzheimers and related dementias for families, caregivers, and health professionals. Encourage client to express honest feelings in relation to loss of prior level of functioning; acknowledge pain of loss; support client through process of grieving. Explain (or re-explain) who you are and what you will be doing during the visit. Cognitive Impairment Nursing Care Plans Diagnosis and Interventions Cognitive Impairment Nursing Care Plans Diagnosis and Interventions Cognitive impairment is a medical term used to describe patients who have survived debilitating and critical illnesses but have persistent neurological deficits. Cochrane Database of Systematic Reviews. Orientation of patients to surrounding, ward staff, and day-to-day schedule at the hospital. The patient will adhere to the therapy regimen. 1. Nursing Care Planning and Goals. 2019;(3), 1-121. doi:10.1002/14651858.CD012279.pub2 [Meta-analysis,Systematic Review], He, W.: Wang, M.; Jiang, L.; Li, M.; Han, X. Cognitive interventions for mild cognitive impairment and dementia: An overview of systematic reviews. Following are major etiologic categories for the syndrome of dementia: The following symptoms have been identified with the syndrome of dementia: Laboratory tests can be performed to rule out other conditions that may cause cognitive impairment. 2019; doi:10.1186/s12888-019-2180-x [Metasynthesis,Meta-analysis,Systematic Review], Li, W.; Wang, Q.; Du, S.; Pu, Y.; Xu, G. Acupuncture for mild cognitive impairment in elderly people: Systematic review and meta-analyses. Demonstrate empathy for the clients feelings. This content is provided by the NIH National Institute on Aging (NIA). Care of the hospitalized patient experiencing impairment related to cognitive skills that include attention, memory, orientation, judgment, reasoning, problem-solving and executive functioning with reasonable potential for improvement. Learn how your comment data is processed. Hospitalization and illness stress cognitive abilities and exacerbate dysfunctional behaviors. Answer: B. Establish and maintain a dialogue with the care partner to discuss safety concerns and help monitor changes in the patient's daily routine, mood, behavior, and sleep. Correcting them when they are struggling to make sense of the world and their ability to retain new information is hampered, only serves to upset them and doesnt improve the quality of their life. This will help in avoiding or preventing accidents, injuries, ingestion, or burns. These patients would have difficulties fulfilling activities of daily living, such as school tasks and job roles. The nursing interventions for Amnestic disorders are: Encourage expression of feelings. Other early warning signs could include: The signs and symptoms of impaired memory may also depend on the type of memory loss: Some of the most common causes of memory loss are discussed below. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Reduced alertness, disorientation, withdrawal, and hypoactivity may occur, necessitating additional examination and treatment. The patient will be able to use techniques that will effectively reduce the amount and frequency of depressive episodes. The patients family will be able to identify and eliminate hazards for the patients safety. Poor decision-making skills for simple or complex tasks. Impaired Memory Interventions. The patients family will help and follow ways to ensure the patients safety. The cognitively impaired patient would have challenges in letting others know of their pain and discomfort levels. Dementia has a slow, insidious onset, and is chronic, progressive, and irreversible. 2018;33(9), 1177-1197. doi:10.1002/gps.4919 [Review Articles], Gates, N. J.; Vernooij, R. W.; Di Nisio, M.; Karim, S.; March, E.; Martinez, G.; et al. Discuss whether the patient takes medications as prescribed, uses a pill organizer, and has someone who oversees medication intake to avoid undertreatment and overdoses. D. Sensory perceptual change. The body might experience high cortisol levels as anxiety, and insomnia is quite common in clients using steroids and having high cortisol levels. 2020;101(10), 1818-1821. doi:10.1016/j.apmr.2020.05.020, Zhang, H.; Huntley, J.; Bhome, R.; Holmes, B.; Cahill, J.; Gould, R. L.; et al. For most other forms of dementia, there is relatively little information about the efficacy and safety of drug treatments. Assess the patients choice of food, personal care items, and other things. Maturitas. The patient will talk about concrete events in the environment without mentioning illusions for 5 minutes. There are also drugs to treat muscle stiffness and risk factors for vascular cognitive impairment such as high blood pressure. Nursing Diagnosis: Disturbed Thought Process related to cognitive impairment secondary to Parkinsons disease as evidenced by inaccurate interpretation of the environment, changes in lifestyle, distractibility, memory impairment, and inability to perform usual activities. Objective measurement of sleep in mild cognitive impairment: A systematic review and meta-analysis. Keep a calm and unhurried manner when communicating with the patient and provide ample time for the patient to respond. The patient will be able to establish methods that will help him or her to communicate to meet his or her needs. Physical slowness and the enormous effort that even little actions demand can cause PD patients to feel ashamed, apathetic, bored, and lonely. She has worked in Medical-Surgical, Telemetry, ICU and the ER. Offer the patient and caregiver a checklist of next steps and resources. The prevalence and incidence rates of cognitive impairment vary, but they are common worldwide. The patient will be free of delusions or have the ability to function in the absence of delusional thinking. Short-term and long-term memory work differently, and each can be affected by different factors. An example of data being processed may be a unique identifier stored in a cookie. 4. Differential effects of cognitive training modules in healthy aging and mild cognitive impairment: A comprehensive meta-analysis of randomized controlled trials. The patient will discover elements that trigger depressive reactions and employ ways to minimize the severity and frequency of these episodes. Depression may be exacerbated by the dismal effects of a major and incapacitating illness. Loss of abstract thinking related to emotional state. 2020;9, 24-31. doi:10.1016/j.ibror.2020.06.005, OCaoimh, R.; Mannion, H.; Sezgin, D.; ODonovan, M. R.; Liew, A.; Molloy, D. W. Non-pharmacological treatments for sleep disturbance in mild cognitive impairment and dementia: A systematic review and meta-analysis. Monitor for the presence of impulsive behavior or actions that may indicate altered judgment. Cushings disease causes melancholy, mood swings, and anxiety, which can be treated with psychotherapy. 4. The patient will be compliant in speech therapy or other therapy that will help him or her to have effective communication. Desired Outcome: The patient will maintain normal reality orientation and cognitive performance. Readily becomes exhausted by simple tasks and responsibilities that were previously easily done by the patient. Explain the cause of emotional instability to the client and his or her family. The memory loss could be temporary and eventually disappear (transient). Please follow your facilities guidelines, policies, and procedures. Nursing Diagnosis: Chronic Confusion related to cognitive impairment secondary to amnestic disorder as evidenced by difficulty doing tasks, poor attention span, and difficulty following a conversation.

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