Dementia:
Dementia is an
acquired global impairment of intellect, memory and personality but without
impairment of consciousness.
Incidence:
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.
Etiology:
·
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.
Definition:
Alzheimer's type
dementia is an irreversible disease marked by global, progressive impairment of
cognitive functioning, memory, and personality.
Risk factors
·
Advanced age
·
Family history
·
DM, Hypertension, CVD
·
Head trauma
Etiological factors
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
II. Neuropathology
·
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).
III.
Neurotransmitters:
·
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.
Diagnosis
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
Medical management
Treatment of the
underlying cause,
Symptomatic
management-
·
Environmental manipulations
·
Treatment of medical complications
·
Care of food and hygiene
·
Supportive care for the patient
and family
·
Short term hospitalization
Drug treatment
·
Tecrin hydrochloride (cognex)
·
Donepezil hydrochloride
(aricept)
·
Antipsychotic medications such
as risperidone and haloperidole
·
Benzodiazepines for insomnia
and anxiety.
·
Antidepressants
·
Anticonvulsants
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 .
Nursing management
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.
Nursing
diagnosis:
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
Ineffective
relationship:
-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
Self-care deficit:
-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.
Rehabilitative
services
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.
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