Management of patient with - Dementia (Chronic organic Brain syndrome)

1. ORGANIC BRAIN DISORDERS
PREPARED BY
MRS. DIVYA PANCHOLI
ASSISTANT PROFESSOR, SSRCN, VAPI

2. INTRODUCTION
• Organic mental disorders are behavioral or psychological
disorders associated with transient or permanent brain
dysfunction.

3. CLASSIFICATION OF ORGANIC MENTAL
DISORDERS
F00-F09 ORGANIC, INCLUDING SYMPTOMATIC, MENTAL
DISORDERS
• F00 Dementia in Alzheimer’s disease
• F01 Vascular dementia
• F04 Organic amnestic syndrome
• F05 Delirium
• F06 Other mental disorders due to brain damage and
dysfunction and physical disease
• F07 Personality and behavioural disorders due to brain disease,
damage and dysfunction

4. DEFINITION OF DEMENTIA
(CHRONIC ORGANIC BRAIN SYNDROME)
“Dementia is an acquired global impairment of
intellect memory and personality, but without
impairment of consciousness”
Alzheimer’s type dementia is an irreversible
disease marked by global, progressive
impairment of cognitive functioning, memory
and personality.

5. INCIDENCE
• Dementia occurs more commonly in the elderly than
the middle age.
• Equal in male and female.
• It increase with age from 0.1% in those below 60
years.
• 15 to 20 % in those who are 80 years of age.

6. ETIOLOGY
UNTREATEABLE AND
IRREVERSIBLE CAUSES:
 Alzheimer’s disease
 Pick’s disease (progressive
dementia involving localized
atrophy of brain)
 Huntington’s chorea
 Parkinson’s disease
TREATABLE AND REVERSIBLE
CAUSES:
 Intracranial space occupying
lesions
 Metabolic disorders-hepatic
failure, renal failure
 Endocrine disorders
 Infection-AIDS, meningitis,
encephalitis
 Intoxication
 Vitamin deficiency
 Anemia

7. Head injury

8. VASCULAR
CEREBRAL ARTERIOSCLEROSIS

9. INFECTION

10. NEOPLASTIC

11. INTOXICATION

12. TRAUMATIC

13. VITAMIN DEFICIENCY

14. ENDOCRINE AND METABOLIC

15. METALS
• Heavy metals(lead, manganese, mercury), carbon monoxide, & toxins

16. ANOXIA

17. CLASSIFICATION
•Primary dementias are those, such as AD, in
which the dementia itself is the major sign of
some organic brain disease not directly related
to any other organic illness.
•Secondary dementias are caused by or related
to another disease or condition, such as human
immunodeficiency virus (HIV) disease or a
cerebral trauma.

18. STAGES OF DEMENTIA
STAGE I : EARLY STAGE
(2 TO 4 YEARS)
STAGE II : MIDDLE STAGE
( 2 TO 12 YRS)
STAGE III : FINAL STAGE
(UPTO A YEAR)

19. STAGE-I EARLY STAGE(2 to 4 years)
Forgetfulness
Declining interest in environment
Poor performance at work
Hesitancy in initiating actions

20. STAGE-II MIDDLE STAGE (2 to12 years)
Progressive memory loss
Hesitates in response to questions
Has difficulty in following simple instructions
Irritable, anxious
Neglects personal hygiene
Social isolation
wandering

21. STAGE-III FINAL STAGE(up to a year)
Marked weight loss
Unable to communicate
Does not recognize family
Incontinence of urine & feces
Loses the ability to stand & walk
Death is usually caused by aspiration pneumonia.

22. SYMPTOMS OF ALZHEIMER’S DEMENTIA
• Stage 1. No apparent symptoms
• Stage 2. Forgetfulness
• Stage 3. Mild cognitive decline
• Stage 4. Mild-to-moderate cognitive decline; confusion
• Stage 5. Moderate cognitive decline; early dementia
• Stage 6. Moderate-to-severe cognitive decline; middle
dementia
• Stage 7. Severe cognitive decline; late dementia

23. Stage 1. No apparent symptoms
•There is no apparent decline in
memory.

24. Stage 2. 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 often are not observed by others.

25. Stage 3. Mild cognitive decline
• In this stage, 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 be interrupted.
•There is difficulty recalling names or words, which
becomes noticeable to family and close associates.
•A decline occurs in the ability to plan or organize.

26. Stage 4. 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.

27. Stage 5. Moderate cognitive decline; early dementia
• In the early stages of dementia, the individual loses the ability to
perform some activities of daily living (ADLs) independently, such
as hygiene, dressing, and grooming, and requires some assistance
to manage these on an ongoing basis.
• They may forget addresses, phone numbers, and names of close
relatives.
• They may become disoriented about place and time, but they
maintain knowledge about themselves.
• Frustration, withdrawal, and self-absorption are common.

28. Stage 6. Moderate-to-severe cognitive decline;
middle dementia
• At this stage, the individual may be unable to recall recent
major life events or even the name of his or her spouse.
•Disorientation to surroundings is common, and the person
may be unable to recall the day, season, or year.
•The person is unable to manage ADLs without assistance.
Urinary and fecal incontinence are common.
•Sleeping becomes a problem. Psychomotor symptoms
include wandering, obsessiveness, agitation, and
aggression.

29. CONTI…
• Symptoms seem to worsen in the late afternoon and evening—a
phenomenon termed sundowning.
•Sundowner syndrome: It is characterised by drowsiness,
confusion, ataxia; accidental falls may occur at night when
external stimuli, such as light and interpersonal orienting cues are
diminished.
• Communication becomes more difficult, with increasing loss of
language skills.
• Institutional care is usually required at this stage.

30. Stage 7. Severe cognitive decline; late dementia
•In the end stages, the individual is unable to
recognize family members.
•He or she most commonly is bedfast and
aphasic.
•Problems of immobility, such as decubitious and
contractures, may occur.

31. Clinical features
( For Alzheimer’s type)
Personality changes
Memory impairment
Cognitive impairment
Affective impairment
Behavioral impairment
Neurological impairment
Catastrophic reaction
Sundowner syndrome

32. Clinical features
( For Alzheimer’s type)
Personality changes:
•Lack of interest in day to day activities
•Easy mental fatigablity
•Self-centered
•Withdrawn
•Decreased self-care

33. Conti…
Memory
impairment
• Recent memory affected.
Cognitive
impairment
• Disorientation
• Poor judgement
• Difficulty in abstraction
• Decreased attention span

34. Conti…
Affective
impairment
• Labile mood
• Irritableness
• Depression
Behavioral
impairment
•Stereotyped behavior
•Alteration in sexual drives
and activities
•Neurotic/psychotic
behavior

35. Conti…
Neurological
impairment
• Aphasia
• Apraxia
• Agnosia
• Seizures
• Headache
Catastrophic
reaction
•Agitation
•Attempt to compensate
for defects by using
strategies to avoid
demonstrating failures in
intellectual performances

36. Conti…
Sundowner
syndrome
• Drowsiness
• Confusion
• Ataxia
• Accidental falls may occur at
night when external stimuli
such as light and interpersonal
orienting cues are diminished.

37. COURSE AND PROGNOSIS
•Insidious onset but slow progressive
deterioration occurs

38. DIAGNOSIS
• History
• Mental status examination
• Cognitive assessment evaluation- MMSE- shows cognitive
impairment
• Functional dementia scale (to indicate degree of dementia)
• Blood investigation
• MRI-Brain shows structural and neurologic changes
• Spinal fluid analysis shows increased beta amyloid deposits

40. MANAGEMENT
MEDICAL (pharmacology)
 Tacrine hydrochloride (cognex)
 Donepezil hydrochloride (Aricept)
 Hydrergine
 Papaverine
 Mamantine
MOA: This drugs inhibit the enzyme
acetylcholinesterase in the CNS,
increasing the level of acetylcholine.
Drug used in causing
symptomatic relief.
 Benzodiazepines : for insomnia and
anxiety
 Antidepressants: for depression
 Antipsychotic : Risperidone,
Haloperidol to decrease verbal and
physical aggressiveness to alleviate
halluciantions and delusions
 Anticonvulsants to control seizures

41. Conti…..
Agents under
investigation:
• Estrogen, Non steroidal
anti inflammatory agents,
prophylactic nutritional
agents as vitamin E
PSYCHOLOGICAL
MANGEMENT
•Brief Psychotherapy
techniques such as reality
orientation, memory
training
•Reminiscence therapy

42. REMINISCENCE THERAPY-DEFINITION

44. NURSING DIAGNOSIS
1. Risk for trauma related to : impairment in cognitive and
psychomotor functioning.
2. Disturbed Thought process related to: cerebral,
degeneration evidence by disorientation, confusion,
memory, deficits and inaccurate interpretation of the
environment.
3. Self –care Deficit related to disorientation, confusion and
memory deficits inability to fulfill ADLS .

45. NURSING INTERVENTIONS
•Daily routine
•Nutrition
•Personal hygiene
•Accidents
•Wandering
•Sleeping and rest
•Follow up

46. 1. Daily Routine
• Maintaining a daily routine includes drawing up a fixed timetable for the patient
for waking up in the morning, toilet, exercise and meals.
• This gives the patient a sense of security.
• Patients often deteriorate after dark, a phenomenon known as 'sun downing'.
• Additional care must be taken during the evening and at night.
• Orient the patient to reality in order to decrease confusion;
• clock with large faces aid in orientation to time.
• Use calendar with large writing and a separate page for each day.
• Provide newspapers which stimulate interest in current events.
• Orientation of place, person and time should be given before approaching the
patient.

47. 2. Nutrition and Body Weight
• Patient should be provided a well-balanced diet, rich in protein, high in
fiber, with adequate amount of calories.
• Allow plenty of time for meals.
• Tell the patient which meal it is and what is there to eat; food served
should be neither too hot nor too cold.
• Many patients have sugar craving. Care should be taken that such
patients do not gain weight.
• The diet should take into account other medical illnesses which require
diet modification, such as diabetes or high blood pressure.
• Semisolid diet is the safest while liquids are the most dangerous as these
can be easily aspirated into the lungs.

48. 3. Personal Hygiene
• Particular care should be taken about the patient's personal
hygiene including brushing of teeth, bathing, keeping the skin clean
and dry, particularly in areas prone to perspiration, such as the
armpits and groin.
• Caustic substances such as spirit or antiseptic solutions should not
be used routinely on the skin.
• Remember to check finger and toe nails regularly, cut them if the
person cannot do it by himself.
• People with dementia may have problem with the lock on the
bathroom door; if this happens it is advisable to remove the lock.
• Compliment the patient when he/ she looks good.

49. 4. Toilet Habits and Incontinence
• Toilet habits should be established as soon as possible and
maintained as a rigid routine.
• This includes conditioned behavior such as going for bowel
movement immediately after a cup of tea.
• The patient should be taken to urinate at fixed interval, depending
on the season and amount of fluid intake.
• Prostate trouble common in elderly men leads to discomfort as it
causes urgency and frequency of urination particularly in winters. A
doctor should check this.

50. CONTI…
• Incontinence is very distressing to the patient and family. Once
incontinence sets in, the undergarments, pants of the patient and the
house in general start reeking of foul smell. Toilet habits, established in
healthy years must be maintained as long as possible by gently persuading
the patient to go to the toilet and use it. When the first sign of
incontinence appears doctor should check for an underlying cause if any,
such as urinary infection or urinary tract damage.
• Constipation is a frequent cause of discomfort to the patient.
• The quantity of faeces passed each morning should be checked to ensure
that the patient is not constipated. Constipation can be avoided by adding
fiber supplements and roughage to the diet on a daily basis.

51. 5. Accidents
• Great care should be taken to avoid accidents caused by tripping over furniture,
falling down the stairs or slipping in the bathroom.
• The reasons for falling include loose and poorly fitting footwear and wrinkled
carpets.
• Ideally, patients should be made to wear soft slip-on shoes with straps which fit
securely.
• Any floor covering must be firmly secured. Older people have been driving for
years and in modem cities many people are dependent on their personal cars for
transportation.
• Once early signs of the disease appear, patients should be gently persuaded to
stop driving as this can pose a hazard to them and others. Make sure that lights
are bright enough. Keep matches, bleach, and paints out of reach.
• Do not allow the patient to take medication alone

52. 6. Fluid Management
• The patients require as much fluid as normal people and this
depends on the season.
• Ideally, sufficient fluid should be given during the day and
only the minimum essential amount of fluid (some water with
dinner) after 6pm. The last cup of tea should be given around
5pm. After that no beverages including tea, coffee, cocoa or
any other caffeine containing drinks should be given, as all
these promote urination.
• Proper fluid management will reduce bed-wetting and also
reduce the number of times the patient will need to get up
during the night.

53. 7. Moods and Emotions
• Some patients of Alzheimer's disease have abrupt change in their moods
and emotions.
• These changes can be unpredictable.
• Mood changes are best controlled by keeping a calm environment with
fixed daily routine.
• The patients should not be questioned repeatedly or given too many
choices, such as what they want to eat or what they want to wear.
• Mood changes are also amenable to distraction, particularly if topics
related to the past are discussed or favorite pieces of music played. For
example, if music that reminds the patients of their childhood is played,
the pleasant associations put them in a nostalgic mood. If patient behavior
and emotions are distressing to the family members the doctor may
prescribe some medications to calm the patient.

54. 8. Wandering
• Patients of Alzheimer's disease often lose their geographic
orientation and can get lost even in familiar surroundings.
• They may be found wandering aimlessly either in the
neighborhood or far away. It is advisable to have some
identification bracelet or card always in their possession.
• The doors of the house should be securely locked so that the
patients cannot leave unnoticed.
• The patient should always be accompanied while going for walks
or for simple chores outside the house.

55. 9. Disturbed Sleep
• Sleep disturbances are extremely distressing to the family. If the
patient is restless at night or wanders and talks at night, the entire
family is disturbed.
• Sleep patterns must be maintained. Napping during the day
should be avoided.
• Sleeping pills are best avoided as their effect is temporary and
frequently unpredictable in patients of Alzheimer's disease.
Causes of discomfort at night, such as pain, uncomfortable
temperature or prostate trouble, should be checked.

56. 10. Interpersonal Relationship
• Verbal communication should be clear and unhurried.
• Questions that require 'yes', or 'no' answers are best.
• Reinforce socially acceptable skills. Give necessary information
repeatedly. Focus on things the person does well rather than on
mistakes or failures.
• Try to make sure that each day has some thing of interest for the
patient- it might be going for a walk, listening to music; talk about the
day's activities.
• Try to involve him with old friends for a chat, reminiscing about the past.
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.

57. CONTI…
• Early diagnosis and early intervention can be beneficial both to the
patient and the family. As the disease progresses, the family
remains the main pillar of support for the patient.
• 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.

58. MOVIES RELATED TO ALZHEIMER’S DEMENTIA

59. You can refer following link also
• https://www.youtube.com/watch?v=HobxLbPhrMc
• https://www.youtube.com/watch?v=v5gdH_Hydes
• https://www.youtube.com/watch?v=WgC3D-eG7EI
• https://www.youtube.com/watch?v=hgVMKEnkvHo
• https://www.youtube.com/watch?v=v5gdH_Hydes&t=331s
• https://www.youtube.com/watch?v=8lc0nvHU56E
• https://www.youtube.com/watch?v=GQznQMAi8E0
• https://www.youtube.com/watch?v=nLdLfmFzLSo