Dementia is an acquired global impairment of intellect, memory and personality but without impairment of consciousness.
Dementia occurs more commonly in the elderly than in the middle aged. It increases with age from 0.1% in those below 60 years of age to 15% to 20% in those who are 80 years of age.
· Significant loss of neurons and volume in brain regions devoted to memory and higher mental functioning.
· Neurofibrillary tangles (twisted nerve cell fibres that are the damaged remains of microtubules support structures that permit nutrients to flow through neurons).
· Accumulation of beta amyloid, an insoluble protein, which form sticky patches (neurotic plaques) surrounded by debris of dying neurons.
· Environmental factors: infection, metals, and toxins.
· Excessive amounts of metal ions such as zinc and copper in brain.
· Others are:
o Deficiencies of vitamins B6,B12 and folate:
o Possible risk factor due to increased levels of homocysteine (amino acid that may interfere with nerve cell repair).
o Early depression: common genetic factors seen in those 'with early depression and Alzheimer's disease.
o Serious head injuries: possible link between injury in early adulthood and later development of Alzheimer's disease.
o Education level: increased risk in those with less education than in those who remain because learning may stimulate increased neuron growth, resulting in greater brain reserve.
Untreatable and Irreversible causes of Dementia
· Degenerating disorders of CNS
· Alzheimer's disease
· Pick's disease
· Huntington's chorea
· Parkinson's disease
Treatable and Reversible causes of Dementia
· Vascular- Multi-infarct dementia
· Intracranial space occupying lesions
· Metabolic disorders- Hepatic failure, renal failure
· Endocrine disorders- Myxedema, Addison's disease
· Infections- AIDS, meningitis, encephalitis
· Intoxication- Alcohol, heavy metals (lead, arsenic), chronic barbiturate poisoning
· Anoxia- Anemia, post-anesthesia, chronic respiratory failure
· Vitamin deficiencies-especially deficiency of thiamine, and nicotine
· Miscellaneous-Heat stroke, epilepsy, electric injury.
Stages of Dementia:
Stage I: No apparent symptoms — there is no apparent decline in memory.
Stage II: Forgetfulness
The individual begins to lose things or forget names of people. Losses in short term memory are common. The individual is aware of the intellectual decline and may feel ashamed, becoming anxious and depressed, which in turn may worsen the symptoms. Maintaining organization with lists and a structured routine provide some compensation. These symptoms are not often observed by others.
Stage III: Mild cognitive decline
There is interference with work performance, which becomes noticeable to co-workers. The individual may get lost when driving his or her car. Concentration may interrupted. There is difficulty recalling names or words, which becomes noticeable to family and close associates. A decline occurs in the ability to plan and organize.
Stage IV: Mild to moderate cognitive decline; confusion
At this stage, the individual may forget major events in personal history, such as his or her own child's birthday; experience declining ability to perform tasks, such as shopping and managing personal finances; or be unable to understand current news events. He or she may deny that a problem exists by covering up memory loss with confabulation. (Creating imaginary events to fill in memory gaps). Depression and social withdrawal are common.
Stage V: Moderate cognitive decline; early dementia
In the early stages of dementia the individual loses the ability to perform some activities of daily living independently, such as hygiene, dressing and grooming and require some assistant to manage these on an ongoing basis. They may forget addresses, phone numbers, and names of close relatives. They may become disoriented and place and time, but they maintain knowledge about themselves. Frustration, withdrawal and self- absorption are common.
Stage VI: Moderate to severe cognitive decline; middle dementia
At this stage the individual may be unable to recall recent major life events or even the names of his/ her spouse. Disorientation to surrounding is common, and the person may unable to recall the day, season, or year. The person is unable to manage ADL's without assistance. Urinary and faecal incontinence are common. Sleeping becomes a problem. Psychomotor symptoms include wandering, obsessiveness, agitation, and aggression. Symptoms seem to worsen in the late afternoon and evening- a phenomenon termed sun downing. Communication becomes more difficult, with increasing loss of language skills. Institutional care is usually required at this stage.
Stage VII: Severe cognitive decline; late dementia
In the end stages of AD, the individual is unable to recognize family members. He or she most commonly is bedfast and aphasic. Problems of immobility, such as decubiti and contractures may occur. The person may no longer recognize any family members bowel and bladder incontinence are and caregivers need to complete most ADL's for the person. Death may be caused by infection, sepsis or aspiration.
Types of Dementia:
1. Dementia of Alzheimer's Type (DAT)
2. Dementia in HIV Disease (AIDS Dementia Complex) :
It is characterized by forgetfulness, slowness, poor concentration and difficulty in problem and reading. It progresses quickly to severe global dementia, mutism and death.
3. Multi-infract Dementia (MID) :
The multi-infract dementia is a form of vascular dementia, where the onset of dementia is gradual and often there is history of several episodes of brain ischemia of minor nature.
4. Hypothyroid Dementia :
This is one of the most important treatable and reversible causes of dementia, second only to toxic dementias
5. Lewy Body Dementia:
There will be fluctuating cognitive impairment over weeks or months with involvement of memory and higher cortical functions (language, reasoning, visuospatial ability) recurrent visual hallucination, spontaneous extrapyramidal syndromes, repeated falls, orthostatic hypotension, urinary incontinence, delusions and depressive features.
Dementia of Alzheimer's Type (DAT)
Alzheimer's disease (AD) also called Alzheimer disease, Senile Dementia of the Alzheimer Type (SDAT) or simply Alzheimer's, is the most common form of dementia. This incurable, degenerative, and terminal disease was first described by German psychiatrist and neuropathologist Alois Alzheimer in 1906 and was named after him.
It is a condition in which anterograde amnesia is the dominant symptom that is dementia in impairment in learning, reasoning, handling complex tasks, language functions etc.
Alzheimer's type dementia is an irreversible disease marked by global, progressive impairment of cognitive functioning, memory, and personality.
· Advanced age
· Family history
· DM, Hypertension, CVD
· Head trauma
I. Genetic factors
· 40% have family h/o AD
· Monozygotic twins
· Amyloid Precursor protein genes: It is present on chromosome 21 & elderly patients with Down syndrome
· Multiple E4 genes: Gene E4 is the origin of AD
· Brain atrophy with flattened cortical sulci & enlarged cerebral ventricles
· senile plaques (amyloid plaques),
· neurofibrillary tangles (in the cortex, hippocampus, locus ceruleus),
· neuronal loss (in the cortex & hippocampus) & granulovascular degeneration of the neurons).
· Acetylcholine & Norepinephrine-hypoactive
· decrease acetylcholine & acetyl transferase concentration in the brain
· Atropine(cholinergic antagonist): impair cognitive abilities & Physostigmine (cholinergic agonist) enhance cognitive abilities
· Others: Glutamate, Neuroactive peptides, somatostatin & corticotrophin
IV. Other causes:
· Aluminium toxicity
· Infection: infection with virus cause amyloid deposition
· Herpes Simplex virus
· Head injury
Clinical Features of Dementia
1. Personality changes- lack of interest in day-to-day activities, easy mental fatigability, self cantered, withdrawn, decreased self are.
2. Memory impairment- recent memory is prominently affected
3. Cognitive impairment- disorientation, poor judgment, difficulty in abstraction, decreased attention span
4. Affective impairment- labile mood, irritableness, depression.
5. Behavioral impairment- stereotyped behavior, alteration in sexual drives and activities, neurotic/psychotic behavior.
6. Neurological impairment- Aphasia, apraxia, agnosia, seizures, headache.
7. Catastrophic reaction- agitation, attempt to compensate for defects by using strategies to avoid demonstrating failures in intellectual performances, such as changing the subject, cracking jokes or otherwise diverting the interviewer.
8. Sun downing occur at night syndrome- when external it is stimuli characterized such as light by drowsiness, and interpersonal confusion, orienting ataxia; cues accidental are diminished.
Based on ICD 10 criteria.
Tests used for diagnosis are:
· Cognitive assessment evaluation- Mini Mental Status Examination (MMSE)-shows cognitive impairment
· Functional dementia scale (to indicate degree of dementia)
· MRI often brain shows structural and neurologic changes
· Spinal fluid analysis shows increased beta amyloid deposits
Treatment of the underlying cause,
· Environmental manipulations
· Treatment of medical complications
· Care of food and hygiene
· Supportive care for the patient and family
· Short term hospitalization
· Tecrin hydrochloride (cognex)
· Donepezil hydrochloride (aricept)
· Antipsychotic medications such as risperidone and haloperidole
· Benzodiazepines for insomnia and anxiety.
Alzheimer's disease prevention, targeting individuals at nutritional agents (such as vitamin E) or cholinergic or amyloid
· Brief psychotherapy techniques, as reality orientiation and memory training .
Diagnostic Laboratory Evaluation:
Evaluation of Blood and Urine samples to test for diabetes, electrolyte imbalance, nutritional deficiency etc.
Other diagnostic tests include EEG, CT scan, PET, MRI.
Lumbar puncture is done to examine CNS infection or haemorrhage.
l . Risk for trauma related to impairments in cognitive and psychomotor functioning
2.Risk for self directed violence related to depressed mood secondary to awareness in decline of mental and / or physical capability.
3.Risk for violence directed towards others related to hallucinations
4.Self care deficit related to disorientation, confusion, memory deficit as evidenced by inability to fulfil activities of daily living.
5.Impaired environmental syndrome related to cerebral degeneration evidenced by disorientation, confusion and memory deficit
6.Self esteem disturbance related to loss of independent functioning as evidenced by expression of shame and self degradation
Planning and implementation:
Risk for Trauma:
-Arrange furniture and other items in the room to accommodate client's disabilities
-Keep bed in un elevated position
-Observe the client frequently
-Assist the client with ambulation
-Orient the client to the place, time and situation -Provide safety to the client
-Orient the client to the reality
-Give simple explanation
-Use face to face communication
-Speak slowly and do not shout
-Talk about real events and real people
-Monitor for medication side effect
-Provide assistance as required.
-Promote independent actions as far as possible
-Give plenty of time to perform the task
-Provide guidance and support for independent actions by talking to the client
-Perform ongoing assessment of the client's ability to fulfil nutritional needs, safety etc.
-Provide available community support from whom the client and their family can seek assistance when required.
Follow-up, Home care and Rehabilitation
Family members should be aware of early warning signs which may suggest that one of the older members may be on the verge of developing Alzheimer's disease. Programs and services for patients with dementia and their families have increased with the growing awareness of Alzheimer’s disease. Home care is available through home health agencies, public health agencies, and visiting nurses. These services offer assistance with bathing, medication management and transportation as well as with other support.
Role of caregiver
Caregivers need to know about dementia and the required patient care as well as how patient care will change as the disease progresses. Caregivers must deal with their feelings of loss and giefas the health of their loved ones continually declines.
Caring for patients with dementia can be emotionally and physically exhausting and stressful. Role strain is identified when the demands of providing care threaten to oven helm a caregiver. Supporting the caregivers is an important component in providing care at home to patients with dementia. Support groups can help them to express frustration, sadness, anger, guilt or ambivalence. Nurses should offer hope to the family and avoid false reassurance when possible. Teach the family/caregiver strategies that promote the patient's existing memory, for example, reminiscence activities, environmental cues, familiar songs, pictures, pets etc.
Alzheimer's associations around the world provide practical and emotional help and information to families, health care professionals and the community. Alzheimer's and Related Disorders Society of India (ARDSI) started in 1992, a national organization dedicated to dementia care, support and research.