what is dementia and why it is considered only for old age and how it goes to misdiagnose buy the health care professionals and what is infact. in nepal this issues is given low priority in both hospital and public

1. Dr. Krishna
Prasad
Pathak, CDP,
Geriatric
Memory
clinician,
• PRI Nepal
• DATE …..th ………………2019….
Venue
Dementia diagnose, management
& care
Focusing areas
by the speakers

2. Dementia Awareness
Dementia
Diagnose
Management and
Care

3.  What is dementia and its Symptoms?
 What Differences between normal aging and dementia?
 How and why health professionals do Misdiagnose?
 Dementia, and management care barriers.
 Who is the key person to diagnose?
 What are the guidelines?
 What are screening methods?
 And pharmacological and non pharmacological therapy for
the dementia.
Out Lines

5. कविता - बूढो हुँदै जाुँदा
कवि - झलक सिेदी
िाचन - महािीर विश्िकमाा
https://www.facebook.com/mahabir.bishwakarma/videos/222
244169092449/

8. Rarer and unusual types of
dementia:
Huntinton disese,
Frontotemporal disease,
Parkinsons disease
Normal pressure hydrocephalus
Wernicke-korsakoff syndrome
Pure Hippocampal Sclerosis
Human Prion disease
Niemann-Pick disease type C
Cortico-basal degeneration
Whipple’s disease.
Types of Dementia

9. Symptoms of dementia
1. Asking the same question over and over again.
2. Repeating the same story, word for word, again and again.
3. Forgetting how to cook, or how to make repairs, or how to play cards - activities that were
previously done with ease and regularity.
4. Losing one's ability to pay bills or balance one's checkbook.
5. Getting lost in familiar surroundings, or misplacing household objects.
6. Neglecting to bathe, or wearing the same clothes over and over again, while insisting that
they have taken a bath or that their clothes are still clean.
7. Relying on someone else, such as a spouse, to make decisions or answer questions they
previously would have handled themselves.

10. Symptoms of dementia

12. Differences Between Normal Aging and Dementia
Normal aging Dementia
Slightly independency in daily tasks. need dependency from others with the simply work
Memory loss problem may be appearing but can
provide considerable detail regarding incidents of
forgetfulness.
If someone complains of memory problems and asks
frequently about the recall problem is considerable notice
of memory loss.
The individual is more concerned about alleged
forgetfulness than close family members are
Close family members are much more concerned about
incidents of memory loss than the individual
Recent memory for important events, affairs, and
conversations is not impaired
Patients cannot remember even the recent memory of
events and ability to converse are both remarkable
impaired.
word-finding difficulties may appear occasionally Frequently word-finding difficulties and substitutions may
appear.
With the familiar territory, person does not get the
problem but may have to pause momentarily to
remember way.
Consequently, Person gets lost in very familiar territory
while driving, at working office, on walking and
supermarket as well as may take hours to return home too.
Individual operates common appliances even if
unwilling to learn how to operate new devices
A person cannot learn even simple and new words and
their application.
Does not seem no decline in interpersonal social skills Person may show socially inappropriate behaviors like; less
interest in social activities.
Due to the individual’s culture and education the
normal performance on mental status examinations
Mental status examinations may appear below-normal
performance even though there are not any influencing

13. Normal Aging or Dementia
https://www.youtube.com/watch?v=d4HAszywjgY
https://youtu.be/KMfvakIm-X4?t=74

14. Features Dementia Delirium Depression
Mood Unstable Fluctuates Apathetic
Course,
motion,
movement
Chronic, with deterioration over time Acute; responds to treatment Chronic to treatment.
Inception/incu
bation
1 months to years (up to 10 years) Some hours to days Weeks to months
Memory/cogni
tion
Impaired latest memory, As the phase of disease
progresses, long term memory may affected,
Other cognitive deficits like word finding,
judgement and abstract thinking
Instant memory impaired, Attention and
concentration
Impaired.
Currentent memory impaired, Long-term
memory generally entire, sporadic memory
loss, Poor consideration
Vigilance Usually normal Fluctuates-lethargic or hypervigilant Normal way
Activities of
daily living
behaviors
May be unimpaired early rising behaviors,
disability as disease progresses
May be intact or impaired Negligence basic self-care
Commenceme
nt
Usually gradual, over several years and sneaky
incharacteristics.
Acute or subacute (hours or days) Typically over days or weeksmay concur
with life changes
Activities of
daily living
As the disease progresses phase ADLs may be
intact early, impaired before.
May be intact or impaired Might be impaired early sign.
Duration It may take some months or over a years and
progressive degeneration
Many hours to days (Although it can take a month
too)
It ay takes from two weeks to several
months to years.
Self-conscious Apparently unaware of cognitive crunch. It seems slightly aware of changes in cognition and
rocky.
Likely to be concerned about memory
impairment.
Differences Delirium and Depression

15. Thoughts Repetitiveness of thought decreased
interests, difficulty for logic or formal
argument. Slow brain and lazy actions, delay
response.
Weird and vivid thinking scary
thoughts and ideas, Paranoid
schizophrenia symptoms.
Often slowed thought
processesmay be
preoccupied by sadness and
hopelessness, negative
thoughts about self-reduced
interest.
Sleep or rest Often a disturbed 24 hour clock mechanism
(later in the disease process).
Confusion disturbs sleep(reverse
sleep-wake cycle), Night confusion,
Vivid and disturbing nightmares
Early morning waking
orintermittent sleeping
patterns (in atypical cases,
too much sleep)
Course May be variable depending on type of
dementia.
Fluctuates- usually worse at night in
the dark, Coherent periods.
Commonly worse in the
morning with improvement
as the day continues.
Orientations Increasingly impaired sense of time and
place.
Flicker impairment of sense of
place, person, date, time and
seasons.
Usually normal.
Spontaneous May be able to conceal or compensate for
deficits (early), frustration, helplessness,
impatience, negative, hostile, impulsive,
anger, instructions, break down tasks step-
by-step and answer repetitive questions.
May occur as a consequence of a
drug interaction or reaction,
physical disease, psychological issue
or environmental changes.
Often disguised and may
have past history with the
patients.

17. Prevalence and Cost of dementia worldwide
1. Doubling every 20 years
2. will reach 135.46 million by 20504.
3. 62% in developing countries, and by 2050 this will rise to 71%.
Source: Alzheimer’s Disease
International, (2013)
dementia affects 5-8 percent of individuals over age 65,
 15-25 percent of individuals over age 75 percent
 and 15-50 percent of individuals over age 85.
It is important to note that it is not a normal part of aging.

18. What is the situation of Nepal?
 No awareness (public, professionals and policy makers)
Estimated 135,000 some kind of dementia
No prevalence data
No national survey
Nepalese health professionals’ lack of knowledge towards the
diagnose, minimize the obstacles on caring process in hospital
General practitioners are failed to diagnose due to the over pressure of
patients in clinical room, longer treatment process, patients less alertness
to follow up, misunderstanding to dementia, access of health care services
and caregiver’s less support etc. Sourse: Pathak KP1, Montgomery A. Aging Ment Health. 2015

19. Dealing with dementia - The Himalayan Times
Dementia in Nepal and its problems - SciTechnol
Around 80,000 people live with dementia in ... - The Rising Nepal
Remembering dementia | Nation | Nepali Times
Alzheimer's disease in Nepal - Ageing Nepal
Alzheimer Emerges A Major Health Problems In Nepal | New ...
Nepal - Let's talk about Dementia: End the stigma Seminar
...

20. People with dementia don’t know what they want or can’t
communicate what they want
Dementia is a natural part of aging
Once you have dementia there is nothing you can do
Only the elderly get dementia
People with dementia can’t understand what’s going on
I should correct what a dementia sufferer says when
they are wrong
There is nothing I can do to lower my risk of dementia
Alzheimer’s disease and dementia are the same
There is a cure for dementia
Myths of Dementia

21. Common
Misconcepti
ons about
Dementia
As a
caregiver,
you are
helpless
There are no
available
treatment
options for
Dementia is
a normal part
of getting
older.
All people with
dementia have
Alzheimer’s
Dementia is
a normal part
of getting
older
Anyone
diagnosed
with
dementia is
unable to
make
decisions

23. Why
misdiagnose and
mismanagement
?
Tremor, stiffness and shakiness need not be
Parkinson,
Vitamin B12 deficiency
under-diagnosed.
Dementia may be a drug
interaction, Undiagnosed
stroke may have to aphasia,
ADHD under-diagnosed
in adults,
Eating disorders under-
diagnosed in men,
Manic-depressive or Bipolar
disorder conditions,

24. Why misdiagnose and
mismanagement
Normal brain pressure or hydrocephalus condition
with as dementia,
Undiagnosed Parkinson's disease
and related disorder,
Undiagnosed depression in
teenagers,
Undiagnosed anxiety and depression,
Normal brain pressure or
hydrocephalus condition
with as dementia,
Children and migraine often
misdiagnosed with children,

25. GP factors
Caregivers
factors
Patients
factors
Diagnosis,
Management and
Care Barriers

26.  Communicating the diagnosis,
 Negative views of dementia,
 Difficulty diagnosing early-stage dementia,
 Acceptability of specialists,
 Responsibility for extra issues,
 Knowledge of dementia and aging,
 Less awareness of declining abilities,
 Diminished resources to handle care,
 Lack of specific guidelines,
 Poor awareness of epidemiology.

27. Dementia Treatment Gap
In high-income countries, only 20-50% of dementia cases
are recognized and documented in primary care (Alzheimer disease international,
2013).
 India revealed 90% remain unidentified (Dias & Patel 2009; Nair, 2009).
 28 million people with dementia have not received a diagnosis.
 In UK, up to 90,000 patients are living without diagnosed dementia (Alzheimer Society UK, 2013).

28.  General practitioners:
 Neurologist:
 Geriatrician:
 Psychiatrist of Older Age or Later Life:
 Support of Mobility professionals:
Who is the key person for dementia diagnose?

30. CLINICAL STAGES OF DEMENTIA
Normal Normal aged
forgetfulness
Mild cognitive
impairment
Mild dementia
disease
Moderate
dementia disease
Moderately severe dementia disease

31. Severe Dementia Disease
Contractures of the
elbow, wrists and
fingers
Sucking reflex Babinski or plantar extensor reflex
Physical rigidity
Arm rests to hold the
patient up in the chair

32. Dementia Awareness Short Film
https://www.youtube.com/watch?v=HnIReQqR5LQ
What is dementia
https://www.youtube.com/watch?v=t--mkzfHuIE

33. Life struggling with dementia
https://www.youtube.com/watch?v=9iXPHhfk_7E

34. : Dementia Village
https://www.youtube.com/watch?v=LwiOBlyWpko

35. What cognitive screening tools in the clinical practice we do?

36.  Geriatric situation-constipations, vision, hearing, depression, vision, falls and fall related injuries, osteoporosis, sleep disorders, continence and others activities,
chronic pain, balance, hypoxia, anaemia, postural hypotension, physical appearance, gait, Katz index of independence in activities of daily living etc.
 Social engagement/participation.
 Preventive medicine- review of Immunizations, cancer types, diabetics, HIV.
 Family interview- asking a social attitudes (positive-negative), perceptions and relationship.
 Cognitive incapacity and problem behaviours.
 Patients’ nutrition- body weight, height and good looking body figure.
 Individuals’ history of past and present (current functioning, memory status, cognitive issues, safety activities, behavioural activities).
 Medication/ medical history- head trauma and some neurological functioning, poly pharmacy.
What are the Clinical Consideration?

37.  Laboratory test- CBC, TSH, drug level-digoxin/lanoxin, toxin, Glucose, BUN/ creatinine, level of cholesterol, diabetics, cancer, liver functions,
VDRL-screening test for Syphilis), Calcium, B12,b6, haemoglobin rate, vitamins-A-B-C, iron; zinc; and other trace minerals deficient etc.
 Therapeutic test-
 Lawton instrumental daily living activities scale.
 Genetic test-ceruloplasm, huntigton’s disease, copper, wilson’s disease.
 Brain imaging- Hydrocephalos, mass lesions, infarcts, and subcortical ischemic changes,
 Lumber puncture test-(spinal cord, cerebrospinal cord, and other neurons.
 Anasthesia using, operations of tumors, kidney failure, hurt and lungs,
kidney transplantation, chronic infections,

38. Alexander disease, Autism (Infantile),
Batten disease, Metabolic diseases,
Niemann-Pick Type C,
Adrenoleukodystrophy,
Subacute-sclerosing Panencephalitis (SSPE),
Tay Sachs disease, Canavan disease,
Juvenile Huntington’s disease etc (Hempel C, 2010).
Lafora body disease
Do children suffer from dementia ?
Yes! Children can have similar symptoms as adults have like; fear, feel grief and sadness, loss, anger,
irritation, impatience, and less ‘acceptable’ emotions.
What are
these
cause?
Yes? No?

40. Preventive ways
 Free from tension, mediation, yoga, physical exercise balance
diet, Mediterranean diet, Quality of life, Positive thinking, No smoking,
no over drinking, maintaining body weight, Pain management
 Manage the Omega-3 polyunsaturated fatty acids (PUFA),
 Vitamins B6-B12- B9
 Vitamin E- 15 mg a day,
 Vitamin C-90 mg/day for men, 75 mg a day for women.
 Nutrition, Antioxidants-vitamin C,
 Vitamin E and flavonoids-,
 Consequences of dementia-related
 Undernutrition and weight loss, Education and training interventions,

41. Vitamin B6-pyridoxine,
Intake: 1.7 mg a day for men, 1.5 mg a day for women; B12- 0.0024 mg a day; B9-0.4 mg a day.
Vitamin B9-folate: it produce red blood cells, in the metabolism of amino acids and nucleic
acids
and in aiding normal cell division during pregnancy.
Sources: asparagus, broccoli, brown rice, brussels sprouts, chickpeas, liver, peas, Spinach
Vitamin B12, also known as cobalamin, is essential in the production of red blood cells
(together with folic acid) and nerve sheaths, and in the metabolism of carbohydrates, lipids
and proteins.
Sources: cheese, cod, eggs, meat, milk, salmon
Vit- E Sources: nuts and seeds, plant oils (corn, olive and soya oil, wheat germ

43. What drugs for Dementia?
Acetylcholinesterase inhibitors:
Tacrine (Cognex),
Donepezil (Aricept),
Galantamine/ Galanthamine (Reminyl),
and Rivastigmine (Exelon)
Other Therapeutic Interventions for Dementia
•Selegiline (Eldepryl):
•Estrogens:
•Antioxidants: .
•Anti-inflammatory agents:
•Statins:

44. What can we do further?
•Urgently needed to generate a better evidence
base for the update of guideline,
•Training based and clinical trial based research is
needed.
•Trained health professionals
•Early diagnosis

45. Dementia diagnose, management and Care Plan
Proposed by Dementia-Nepal
https://solvenepal.org/dementia

46. Discussion,,,,,,,,,,,,,,,,,
Questions?,,,,,,,,,,,,