Dementia
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Dementia is one of the common mental illnesses among the elderly.
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Dementia
- 2. CONTENT • Definition of terms • Prevalence of dementia • Predisposing factors • Clinical features • Types of dementia • Management
- 3. INTRODUCTION • Dementia is a collective term used to describe various symptoms of cognitive decline, such as forgetfulness. • It is a symptom of several underlying diseases and brain disorders. • Dementia is not a single disease in itself, but a general term to describe symptoms of impairment in memory, communication, and thinking.
- 4. INTRODUCTION CONT’D • Alzheimer disease is the most common form of dementia and may contribute to 60–70% of cases. • Dementia is one of the major causes of disability and dependency among older people worldwide. • Dementia has a physical, psychological, social, and economic impact, not only on people with dementia, but also on their carers, families and society at large.
- 5. PREVELENCE • Worldwide, around 50 million people • 60% living in low- and middle-income countries. • 10 million new cases/year. • Age 60 and over with dementia at a given time is between 5-8%/general population • The total number of people with dementia is projected to reach 82 million in 2030 and 152 in 2050. Much of this increase is attributable to the rising numbers of people with dementia living in low- and middle- income countries
- 6. DEFINITION •Dementia is defined as global or total intellectual decline of sufficient severity to impair social and/or occupational functioning that occurs in normal consciousness.
- 7. PREDISPOSING FACTORS/CAUSES • Neurological disorders • Vascular disorders • Inherited disorders • Infections • Age • Family history • Down’s syndrome (trisomy 21)
- 8. PREDISPOSING FACTORS/CAUSES • Head Trauma (esp. late in life) • Female gender (mixed results: age bias and possible higher ‘clinical’ expression in women) • Late-onset depression (after age 65)
- 9. CLINICAL FEATURES • Aphasia • Apraxia • Agnosia • Disturbance in executive functioning • Impairment in social and/or occupational fn • All the above are referred to as cognitive disturbances
- 10. CLINICAL FEATURES • Personality changes • Depression • Anxiety • Inappropriate behaviour • Paranoia • Agitation • Hallucinations All above are called Psychological changes
- 11. STAGES OF DEMENTIA • Early stage •Middle stage •Late stage
- 12. SAMPLE QUESTION 1. Which one of the following is an early sign of dementia? A. Becoming lost in familiar places. B. Becoming forgetful of recent events and people's names C. Becoming unaware of the time and place D. Becoming lost at home
- 13. SAMPLE QUESTION • The following clinical feature is a cognitive disturbance of dementia A. Paranoia B. Agitation C. Hallucinations D. Abstract thinking ddisturbance
- 14. TYPES OF DEMENTIA Dementia is categorized according to its etiology: 1. Alzheimer’s dementia 60% 2. Vascular dementia 10% 3. Frontal-Temporal Lobe 15% 4. Dementia with Lewy bodies 15% 5. Other 10%
- 15. DIFFERENTIAL DIAGNOSIS • Common precipitating factors for delirium include infection, medication interactions and surgery • Differentiating between Dementia, Delirium and Depression (three Ds) requires skilled assessment. • The differences and similarities are outlined in the table on the next slides;
- 16. The three Ds Dementia Delirium Depression Thoughts • Repetitiveness of thought • Reduced interests • Difficulty making logical connections • Slow processing of thoughts • Bizarre and vivid thoughts • Frightening thoughts and ideas • Often paranoid thoughts • Often slowed thought processes • May be preoccupied by sadness and hopelessness • Negative thoughts about self • Reduced interest Sleep • Often a disturbed 24 hour clock mechanism (later in the disease process) • Confusion disturbs sleep (may have a reverse sleep-wake cycle) • Nocturnal confusion • Vivid and disturbing nightmares • Early morning waking or intermittent sleeping patterns (in atypical cases, too much sleep) Orientation • Increasingly impaired sense of time and place • Fluctuating impairment of sense of time, place and person • Usually normal
- 17. The three Ds Dementia Delirium Depression Orientation • Increasingly impaired sense of time and place • Fluctuating impairment of sense of time, place and person • Usually normal Onset • Usually gradual, over several years • Insidious in nature • Acute or sub acute (hours or days) • Usually over days or weeks • May coincide with life changes Memory and cognition • Impaired recent memory • As disease progresses, long term memory also affected • Other cognitive deficits such as in word finding, judgement and abstract thinking • Immediate memory impaired • Attention and concentration Impaired • Recent memory sometimes impaired • Long-term memory generally intact • Patchy memory loss • Poor attention
- 18. The three Ds Dementia Delirium Depression Duration • Months or years and progressive degeneration • Usually brief — hours to days (but can last months in some cases) • At least two weeks (but can be several months to years Course throughout the Day • May be variable depending on type of dementia • Fluctuates — usually worse at night in the dark • May have lucid periods • Commonly worse in the morning with improvement as the day continues. Alertness • Usually normal • Fluctuates — lethargic or hypervigilant • Normal Other • May be able to conceal or compensate for deficits (early) • May occur as a consequence of a drug interaction or reaction, physical disease, psychological issue or environmental changes • Often masked • May or may not have past history.
- 21. Medical mgt Aims: • To establish the cause and type of dementia • To rule out any other condition that can produce signs of dementia • To prevent or minimize complications by prescribing the right medications for the client
- 22. Hx taking • This will review onset of the signs and symptoms and how they are affecting the client. • Drug hx will review what drugs the client may have being using. • Medical hx will review any other chronic conditions the client may have being suffering from. • Family hx will review what other medical and psychiatric conditions the client is predisposed to.
- 23. Mental state exam • This will review clients orientation to their immediate environment and his cognitive impairment such as memory loss, attention deficit etc. Investigations • Brain scan, will review anatomical changes to the brain and other injuries that may have being the cause of dementia. • Full blood count to rule out any other conditions that may have being affecting the patient.
- 24. Medication 1. Drug name: memantine • MOA: inhibits the release of glutamate • Dosage: 5mg/day; target dose 10mg/day bid. orally • Side effects: dizziness, hallucinations, vomiting, Anemia. • Nursing consideration: • Assess patients affect, behavioral changes regullary. • Provide assistance with ambulation • Teach client to report side effects.
- 25. 2. Drug name: prochloperazine • MOA: blocks mesolimbic dopamine receptors, and alpha-adrenergic receptors in the brain. • Dosage: 5 to 10 mgs/PO 6-8hrly • SE: dizziness, depression, tachycadia, erectile dysfunction. • Nursing consideration: Asses for vital signs before and after drug administration, teach client to report side effects if disturbing.
- 26. 3.Drug name: haloperidol • Dosage: 3-5mg 8-12hrly. Not to exceed 30mg/day • MOA: antagonizes dopamine receptors in the brain. • S.E: pseudoparkinsonism, hypertension, dysuria, dyspnea • Nursing Implications: • Asses mental status before and after giving drug. • Take vital signs 4hrly during initial treatment. • Teach client about side effects of the drug.
- 27. •More drugs • Donepezil • Galantamine • Rivastigmine • Benzodiazepines • Folic acid, B12 and B6 improves memory
- 28. Nursing Mgt Aims: • To develop a relationship with the client based on empathy and trust. • To provide an environment that supports flexible but anticipated routines. • To maintain a safe environment for the person, yourself and other staff. • To promote the person’s engagement with their social and support network • To ensure effective collaboration with other relevant service providers, through development of effective working relationships and communication • To support and promote self care activities for families and carers of the person with dementia
- 29. ENVIROMENT • I will Isolate the patient if he is violent to prevent harm. • I will maintain close observation if client is suicidal to prevent any successful suicides • If the client is agitated, I will maintain a quiet environment. Check noise levels regularly and reduce them if necessary by turning off the radio and television. • I will give the client a comfortable space. Since any activity that involves invasion of personal space increases the risk of assault and aggression. • I will mingle patient with other patients to keep him busy • I will make the environment Clean and orderly with nothing to harm the patient
- 30. Establishing a therapeutic relationship o I will explain to the person who I am, what I want to do and why. o I will respond to clients concerns if any, in a language that he understands o I will smile often— the person is likely to take cues from me, and will mirror my relaxed and positive body language and tone of voice. o I will move slowly, I may have a lot to do and be in a hurry, but the person is not, if I do this I will gain clients trust. o Be empathetic, nonjudgmental and respectful o I will avoid making promises I can not fulfil to avoid client loosing trust in me.
- 31. STRESS MANAGEMENT • I will initiate relaxation measures such as music, prayers to help patient relax. • I will teach client how to relax by taking deep breathing exercises • I will help client Identify the stressors and distressing factors for easy management. • I will keep patient occupied by having frequent talks with him/her. • I will Identify client’s coping strategies to determine whether they are effective or not. • I will involve client in activities to block and stop worrisome thoughts • Encourage patient to find solution for their problems
- 32. Orientation to time • I will Frequently orient client to reality and surroundings. • I will provide orientating cues such as a clock and calendar. • I will always inform the client what time and date it is as you attend to him/her • I will provide newspapers for clients that may be able to read • I will 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.
- 33. OBSERVATION • Risk for violence, suicide or escaping • Level of anxiety and coping strategies • Physical conditions • Sleeping patterns • Mental state exams • Vital signs • Side effects of psychotropic medication • Interaction and attitude towards others
- 34. NUTRITION •Fluids to prevent dehydration •Daily weight checks to monitor if the patient is gaining or losing weight •Small frequent meals to promote appetite •Meals rich in carbohydrate to prevent hypoglycemia
- 35. HYGIENE • Nail care to prevent infection • Oral and hair care to prevent halitosis and promote appetite • Change patients’ clothes and beddings if dirt to provide comfort • Keep absolute clean and wash the patient if unable to
- 36. REST • Noise free to promote rest • Sedation to calm patient while to promote rest • Non-stimulating environment to promote rest • Bathing patient to promote comfort and rest • Comfortable beddings rest
- 37. PSYCHOLOGICAL CARE • Explain the disorder to patient and family • Involve patient in his care and the family • Encourage questions and give adequate responses • Get a well managed case and allow spiritual counselling if family asks for it
- 38. SELF AWARENESS • Help patient identify personal strength and weaknesses • Privacy and confidentiality • Patient to perform tasks on their own and assign tasks to them • Show respect and keep promises • Set goals for patient and reward them for completing the tasks • Call patient by name and teach them to respond respectfully
- 39. FAMILY THERAPY • Counsel family and educate them about patient’s condition • Encourage family to visit when patient is stable • Family not to be critical, discriminating and judgmental • Patient to be respectful and thankful to family efforts • Teach family how to care for the patient
- 40. SOCIAL TRANING • Simple group chores and games • Chapel meetings • Taking walks • Creating friendships • Grooming gardening, sweeping and respect towards others • Eating with others
- 41. COMMUNICATION TRAINING • Risk for violence, suicide or escaping • Level of anxiety and coping strategies • Physical conditions • Sleeping patterns • Mental state exams • Vital signs • Side effects of psychotropic medication • Interaction and attitude towards others • Attention to both verbal and nonverbal communication
- 42. COGNITIVE BEHAVIOR THERAPY • Identify negative attitude, behavior aspects and reactions • Set cognitive targets to help change the identified negatives • Set time for the targets with patient involvement. Challenges to move from smaller to larger • Ensure the patients mind is kept busy to keep in the negatives • Identify patients coping mechanisms and strategies how to get rid of them together with patient
- 43. GENERAL PHYSICAL CONDITION • Rule out general conditions and treat these present • Do exercises for patient • Ensure adequate nutrition and hydration • Enough sleep, bowel opening and functions
- 44. MEDICATION • Administer anti-psychotics in the right doses, right time • Sedation if necessary, to promote rest • Watch the side effects and prevent if dependence/addiction • Give specific drugs according to disorders • Give other prescribed drugs for other medical conditions
- 45. SAMPLE QUESTION • Mr. Banda is a 78 year old retired Anglican Priest with admitted to your ward for hypertension. But you also suspect he has dementia. A. i) Define Dementia ii) Name the types of dementia A. Mention five signs and symptoms of Dementia B. State the 3 stages of dementia C. Identify five nursing problems and write a nursing care plan.
- 46. THE END
Editor's Notes
- Dementia is an incurable illness with failing brain functioning and increasing physical disability leading to total dependence on others for all care.
- Worldwide, around 50 million people have dementia, with nearly 60% living in low- and middle-income countries. Every year, there are nearly 10 million new cases. The estimated proportion of the general population aged 60 and over with dementia at a given time is between 5-8%. The total number of people with dementia is projected to reach 82 million in 2030 and 152 in 2050. Much of this increase is attributable to the rising numbers of people with dementia living in low- and middle-income countries
- FOUR KEY ELEMENTS TO THE DEFINITION OF DEMENTIA GLOBAL IMPAIRMENT -more than just memory DECLINE- a decrease from a previous level of functioning. SEVERITY- severe and causes impairment NORMAL CONSCIOUSNESS- impairments occur in normal state of consciousness 1. Global impairment – Dementia impairments are in total. The impairments occur in more than just memory. Most dementia patients experience impairments in reasoning, using and understanding language, recognizing what one perceives through the senses, coordinating learned motor movements, planning and decision-making. 2. Decline – the impairments represent a decrease from a previous level of functioning. To recognize a reduction, it is crucial for the nurse to know the patient’s previous level of functioning unless members of the family or significant others give correlated information. 3. Severity – Impairments are severe enough to interfere with normal functioning in everyday life. Examples are a person who was living independently and begins to make poor financial decisions or forgets how to cook a meal, although the person could previously perform those tasks. Getting lost while walking from a nearby church, neighbourhood and driving can also indicate severe impairment. 4. Normal consciousness – These impairments occur in a normal state of consciousness; patients are awake and alert. This is distinguished from an abnormal state of consciousness, such as drowsiness, stupor or coma, seen in delirium.
- Neurological disorders such as Alzheimer’s (est. 50-70% of people with dementia have Alzheimer’s) Vascular disorders such as multi-infarct disease (multiple strokes) Inherited disorders such as Huntington’s Infections such as HIV
- Cerebrovascular disease (and the risk factors for CV disease – including smoking, diabetes, hyperlipidemia, hypertension) is associated with vascular dementia risk Recurrent MDD may be associated with risk of dementia in general. (Kessing and Anderson found risk of dementia to be 6 times higher in patients with 5 or more prior episodes.)1 Subclinical Hyperthyroidism (especially when antithyroid antibodies are present.2 Drug abuse, Normal Pressure Hydrocephalus, Chronic subdural Hematoma, Benign Brain Tumors, Vitamin Deficiency, and Hypothyroidism
- Aphasia, which is deterioration of language function OR language impairments Apraxia, which is impaired ability to execute motor functions despite intact motor abilities Agnosia, which is inability to recognize or name objects despite intact sensory abilities Abstract thinking/Disturbance in executive functioning, which is the ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior
- Early stage: The early stage of dementia is often overlooked, because the onset is gradual. Common symptoms include: forgetfulness losing track of the time becoming lost in familiar places. Middle stage: As dementia progresses to the middle stage, the signs and symptoms become clearer and more restricting. These include: becoming forgetful of recent events and people's names becoming lost at home having increasing difficulty with communication needing help with personal care experiencing behaviour changes, including wandering and repeated questioning. Late stage The late stage of dementia is one of near total dependence and inactivity. Memory disturbances are serious and the physical signs and symptoms become more obvious. Symptoms include: becoming unaware of the time and place having difficulty recognizing relatives and friends having an increasing need for assisted self-care having difficulty walking experiencing behaviour changes that may escalate and include aggression.
- i) Alzheimer’s dementia, a consequence of degenerative brain changes as an individual age. Alzheimer disease (AD) is the most common cause of dementia and thus the most common type that nurses encounter in clinical practice AD is an incurable neuro- degenerative disease One also sees general shrinkage of the brain and a decrease in the number of functioning neurons. Clinical picture: Memory, visual, spatial and language decline behavioural changes Risk factors are; familial, Down syndrome, prior head trauma, increasing age. Pathology reveals Cortical atrophy, neurofibrillary tangles, amyloid plaques, granulovacuolar degeneration, loss of basal forebrain cholinergic nuclei. ii) Vascular dementia result from small brain infarcts; small brain haemorrahges. Clinical Picture Aphasia, focal neural deficits, sudden onset Risk factors are; Cardiovascular and cerebrovascular disease. Pathology reveals Multiple areas of neuronal damage. Focal findings. Course; Can be rapid onset or more slowly progressive. Deficits are not reversible, but progress can be halted with appropriate treatment of vascular disease iii) Frontal temporal lobe dementia Damage to the brain’s frontal and temporal lobes causes forms of dementia called frontotemporal disorders. Clinical picture Socially inappropriate Poor executive function Decreased motivation, apathy Imaging Frontotemporal atrophy Prognosis 8-10 years Feeding failure, aspiration, infection Treatment SSRI Antipsychotics stimulants
- It is important to understand the difference between dementia, delirium and depression Depression and delirium are treatable conditions that present similar to dementia Remember that all three conditions can be present and that dementia increases the risk for delirium
- When the person is severely agitated and as a result, distressed or representing a danger to himself, herself or others, sedation (a waking calm) is indicated (avoid oversedation) Benzodiazepines with lower toxicity and shorter half-life (for example, temazepam, and/or oxazepam) are preferred to longer-acting agents (for example, diazepam, and/or nitrazepam). Research shows that giving a patient suffering from dementia a cocktail of vitamins, such as Folic acid, B12 and B6 improves memory. This treatment has to be given simultaneously once daily (OD) for one month and then the patient to be observed for signs of improvement.