Nursing Management of patients with Dementia

1. Prof: Shanmuga Meenakshi.G.
MSN,RN QHCP

2. Definition:-
Dementia is a syndrome characterized by dysfunction or loss of memory,
orientation, attention, language, judgment and reasoning which result in
personality changes and agitation, delusion and hallucinations.
DEMENTIA (Progressive mental disorder)

3. Etiology:-
A- Neurodegenerative disorder.
•Alzheimer’s disease
•Lowy body dementia.
•Frontal-temporal dementia (Pick’s disease)
•Down syndrome.
•Amyotrophic lateral sclerosis.
•Parkinson’s disease.
•Huntington’s disease B- Vascular disorder.
•Vascular (Multi infarct) dementia.
•Cardiac disease (emboli / decreased perfusion)
•Binswanger’s disease.

4. •Subarachnoid haemorrhage.
•Chronic subdural hematoma. C- Toxic/metabolic diseases.
•Alcoholism.
•Thiamine (B1 vitamin) deficiency.
•Cobalamin (B2 vitamin) deficiency.
•Hyper / hypothyroidism.
•Hypoglycemia.
•Hypercalcemia.
D- Immunological diseases/ infections (bacterial infections)
•Multiple sclerosis
•Chronic fatigue syndrome.
•Infections (Creutzfeldt –Jakob disease)

5. •AIDS – Meningitis – Encephalitis.
•Neurosyphilis – Systemic Lupus Erythematosus disease (SLE). E- Systemic
diseases.
•Uremic encephalopathy.
•Dialysis dementia.
•Hepatic encephalopathy.
•Wilson’s disease.
F.Trauma - Head Injury.
G.Tumours - Brain tumours (i)
- Metastatic tumours.
H.Ventricular disorders -- hydrocephalus. I- Seizure disorders -
Epilepsy.
J- Drugs. (Potentially reversible)

6. • Diuretics
• Digoxin
• Anticholinergic
• Opioids.
• Hypnotics.
- Antihypertensive
- Anti parkinsonian drug.
- Antihistamines.
Types/classification of dementia
1.Cortical dementia- cerebral cortex is affected. Problem with memory, thinking,
social behaviours occur
2.Subcortical dementia- Areas below cortex are affected. Along with memory
problems arises in emotions and movements.
3.Progressive dementia- gradually increases and disturbs cognitive abilities
4.Primary dementia- dementia due to alzheimer’s disease
5.Secondary dementia- occurs due to any other disease or injury.

7. Pathophysiology

8. Some of the conditions also causes pathophysiological changes leads to dementia as
follows,
1.Vascular Dementia- Caused by significant cerebrovascular disease. The client suffers
the equivalent of small strokes caused by arterial hypertension or cerebral emboli or
thrombi, which destroy many areas of the brain. The onset of symptoms is more
abrupt than in AD and runs a highly variable course, progressing in steps rather than a
gradual deterioration.
2.HIV disease- The immune dysfunction associated with human
immunodeficiency virus (HIV) can lead to brain infections by other organisms. HIV also
appears to cause dementia directly.
3.Head trauma-The syndrome of symptoms associated with dementia can be brought
on by a traumatic head injury.
4.Lewy Body Disease-Clinically, Lewy Body disease is fairly similar to AD,;
however, it tends to progress more rapidly, and there is an earlier appearance of visual
hallucinations and parkinsonian features .This

9. disorder is distinctive by the presence of Lewy bodies-eosinophilic inclusion
bodies- seen in the cerebral cortex and brainstem .
5.Parkinson’s disease- Parkinson's disease is caused by a loss of nerve cells in
the substantia nigra of the basal ganglia. The symptoms of dementia associated
with Parkinson’s disease closely resemble those of AD.
6.Huntington’s disease- This disease is transmitted as a Mendelian dominant gene,
and damage occurs in the areas of the basal ganglia and the cerebral cortex.
7.Pick’s disease- Pathology occurs from atrophy in the frontal and temporal lobes
of the brain. Symptoms are strikingly similar to those of AD, and Pick’s disease is
often misdiagnosed as AD.
8.Creutzfeldt-Jakob disease-This form of dementia is caused by a
transmissible agent known as a “slow virus” or prion. The clinical presentation is
typical of the syndrome of dementia and the course is extremely rapid, with
progressive deterioration and death within one year after onset.

10. 9. Other general medical conditions-A number of other general medical
conditions can cause dementia. Some of these include endocrine conditions,
pulmonary disease, hepatic or renal failure, cardiopulmonary insufficiency, fluid
and electrolyte imbalances, nutritional deficiencies, frontal or temporal lobe
lesions, uncontrolled epilepsy, central nervous system or systemic infections,
and other neurological conditions.
Substance-induced Persisting Dementia- This type of dementia is related to the
persisting effects of substances such as alcohol, inhalants, sedatives, hypnotics,
anxiolytics, other medications, and environmental toxins.
Type of Dementia:
1- Gradual / abrupt onset. 2- Acute / Sub acute.

11. Clinical characteristics :-
a.Onset - usually insidious.
b.Course - long & Stable.
c.Progression – Slow & even.
d.Duration – Months & Years.
e.Awareness - Clear
f.Alertness - normal.
g.Orientation - progressive impairment.
h.Thinking - difficulty with abstraction thoughts impoverished
i.Impaired judgment, difficult to find words.
j.Perception - misinterpretations often delusions, illusions,
k.Hallucination.
l.Psychomotor behaviour – Apraxia.
m.Sleep-wake cycle – frequent awakenings.
n.Mental status testing - frequent “near miss” answer
o.Struggles with test great effort to find appropriate reply consistently poor
performances.

12. Clinical manifestations:
• Mild / Early.
• Moderate / Middle
• Late / Severe.
A. Mild dementia.

13. • Forgetfulness. Short term memory impairment.
• Difficulty in recognizing numbers.
• Loss of initiative & interest.
• Loss judgement.
• Geographic disorientation
B. Moderate dementia.
• Impaired ability recognizes close friends.
• Agitation. Wandering / getting lost.
• Loss of remote memory, Confusion.
• Impaired comprehension, Apraxia.
• Forgets how to do simple tasks
• Receptive aphasia. Expressive aphasia.
• Insomnia, Delusions, Illusion,Hallucination.

14. • Behavioral problems.
C. Severe dementia.
• Little memory, unable to process new information.
• Cannot understand words/ Immobility.
• Difficulty eating, swallowing / incontinence.
• Repetitious words / sounds.
• Unable to perform self-care activities.
Diagnostic Evaluations:-
• Thorough medical, neurological & psychic agitation for the presence of signs and
symptoms.
• Physical examination to identify nutritional deficiency and weakness.
• Screening for B12 deficiency – presence of decreased Vitamin B12 indicates lack
of nerve conduction due to demyelination and insulation.

15. •Screening for hypothyroidism, the variations show that the patient is at risk for
cognitive and mood disorder.
•Mental status testing to identify cognitive abilities and mood changes.
•Structural neuroimaging to identify the structural abnormalities, atrophy of organs
etc.
•Genetic screening –to identify the positive inheritance pattern (abnormal genes)
•CSF markers –presence of CSF markers indicates brain atrophy
● Vascular drain less will be identified through -CTscan, MRI, SPECT,PET
Medical management:- Aims
•To relieve pain induced by spasms.
•Slow disease progression
•Increase the patient's functional ability

16. Other management
•Weight reduction
•Physical therapy
•Biofeedback therapy
•Exercises to strengthen back muscles and
decrease pain
Medical Management of Dementia
Sl
no
Drug group Action/ indication Example Contraindication
1 Antipsychotics
(Low dose)
Neuroleptics
Reduces
aggression and
behavioral
symptoms.
Haloperidol Proper dosage must be administered carefully ,it
may cause epilepsy.
2 Antipsychotics Short term use
may reduce
agitation and
symptoms of
psychosis.
Risperidone
(Risperdal)
Olanzapine (Zyprexa)
Quetiapine
(Seroquel)
Advised only for short term use.
3 Short acting
Benzodiazepines
Makes the patient
calm by
Lorazepam(ativan) Provide adequate bed rest. Monitor vitals, cardiac
parameters closely

17. reducing anxiety.
4 Vitamin B 12,
Thiamine
Treat the vitamin
B1 and B12
deficiency and
support the
nerves.
Vitamin B1-B2-B12
protease.
Must be consumed with a full glass of water, never
must be crushed and consumed.
5 Hypnotic Agents Induces sleep. Melatonin,Ramelt
on
Contra indicated for pregnancy.
Nursing management of dementia
1.Risk of trauma related to disorientation and confusion 2 Risk for violence
related to suspicious on others
3 Self care deficit related to cognitive impairment
4.Chronic confusion related to alteration in the structure and function of brain
tissue.
5.Risk for Falls related to cognitive impairment

18. Prof: Shanmuga Meenakshi.G.
MSN,RN QHCP
Thank You