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DEMENTIA

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History

The word dementia derives from the Latin word dementatus, meaning out of one's mind

Celsus probably first used the term dementia in the 1st century AD In 4th century AD Oribasius wrote of a disease of cerebral atrophy that

caused loss of intellectual capacity and weakness of movement Term “dementia” was first introduced in 1789 by Phillipe Pinel In 1907, Alois Alzheimer was the first to identify specific histopathological

changes associated with progressive degenerative dementia characterized by neurofibrillary tangles and milar foci (plaques) that distinguished it from dementia associated with cerebral arteriosclerosis

Dement:

A person with an absence or reduction of in tellectual faculties in consequence of known organic brain disease.

DEFINITION:Dementia is an acquired progressive deterioration of previously ac quired intellectual abilities, behavior and personality as a consequence of diffuse disease of cerebral hemispheres (maximally affecting the cerebrum and hippocampus), marked by severe impairment in memory, abstract thinking, judgment, orientation and other cognitions impairing individual's socio-occupational functioning & capacity to meet the ordinary demands of living.

Dementia

Dementia is defined by a loss of previous levels of cognitive, executive, and memory function in a state of full alertness.

Epidemiology

The prevalence of dementia is rapidly increasing More than 25 million people suffered from dementia in 2000. By 2030, that is expected to rise to 63 million, 65% of whom in less

developed countries Age is the leading risk factor for dementia

. Alzheimer's disease accounts for about 50 to 75 percent of dementia

cases, Lewy bodies at 15 to 35 percent and vascular dementia 5 to 20 percent of dementia cases.

Female gender is a risk factor for Alzheimer's disease Vascular risk factors increase risk for vascular dementia, Alzheimer's

disease and dementia in general in particular hypertension is a major risk factor

Elevated body mass index (BMI) in midlife also confers greater risk for dementia in later life

cardiovascular disease, diabetes and hyperlipidemia are also associated with increased risk.

Etiology

Dementia Control

ICD 10

Decline in memory- registration, storage and retrieval of new information

Impairment of thinking, reasoning capacity and reduction in flow of ideas

Impair personal activities of daily living

Evident for at least 6 months

CLASSIFICATIONDSM-IV DEMENTIA-6 broad categories: ICD-10 DEMENTIA-4 broad categories:

Dementia of the Alzheimer's type

Vascular dementia

Dementia due to other general medical conditions

Substance-induced persisting dementia

Dementia due to multiple etiologies

Dementia not otherwise specified.

Dementia of the Alzheimer's type

Vascular dementia

Dementia due to other diseases

Unspecified Dementia. 

ICD 10

F02 Dementia in other diseases classified elsewhere

F02.0 Dementia in Pick’s disease

F02.1 Dementia in Creutzfeldt-Jacob disease

F02.2 Dementia in Huntington’s disease

F02.3 Dementia in Parkinson’s disease

F02.4 Dementia in HIV disease

F02.8 Dementia in other diseases classified elsewhere

F03 Unspecified dementia

Types

Primary Secondary Mild, moderate, severe and profound.

Primary dementia

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 dementia

Caused by or related to another disease condition such as HIV or cerebral trauma(nutritional deficiency, metabolic).

Symptoms

Impairment in abstract thinking, judgment, and impulse control.

Uninhibited and inappropriate behavior. Personal appearance and hygiene are neglected. Language may or may not be affected. (naming objects /

aphasia / vague)

Symptoms contd…

Personality changes (paranoia / difficulty to trust / extreme fear / opposite personality)

Apraxia (inability to carry out motor activities despite intact motor function)

Irritable / moody / sudden outbursts / Inability to care for personal needs Falls / wandering away – risk for accidents

Types

Alzheimer's disease

Stages of dementia

The progressive nature of symptoms associated with AD has been described according to the stages.

stage characteristics

1 –Normal adult No functional decline.

2- Normal older adult Personal awareness of some functional decline

3- early Noticeable deficits in demanding job situations.

4-mild alzheimer’s Requires assistance in complicated tasks such as handling finances, planning parties, etc.

5-moderate Requires assistance in choosing proper clothing and abnormal behaviour.

6- moderately severe Requires assistance dressing, bathing, and toileting. Experiences urinary and fecal incontinence

7-severe Speech ability declines to about a half-dozen intelligible words. Progressive loss of abilities to walk, sit up, smile, and hold head up.

Stage 1- no apparent symptoms

No apparent decline in memory

Stage 2- forgetfulness

Begins to loose things / forget names Losses short term memory Aware of intellectual decline and may feel ashamed /

anxious / depressed Not usually observed by others Compensate with lists and structured routine work etc.

Stage 3 – mild cognitive decline

Interference with work performance Noticeable to co workers Interrupted concentration Difficulty recalling names / words Ability to plan and organize declines Lost on the road

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.

unable to understand current news events. He or she may deny that a problem exists.

Covering up memory loss with confabulation Depression and social withdrawal are common.

Stage 5. Moderate cognitive decline; early dementia.

Inability to perform activities of daily living (ADLs) independently.(hygiene, dressing, and grooming)

Stage 6. Moderate-to-severe cognitive decline;middle dementia.

Psychomotor symptoms include wandering, obsessiveness, agitation, and aggression.

Symptoms seem to worsen in the late afternoon and evening—a phenomenon termed sundowning.

Disorientation to surroundings is common, and the person may be unable to recall the day, season, or year.

Institutional care is usually required at this stage.

Stage 7. Severe cognitive decline; late dementia also called late-stage dementia,

The individual is unable to recognize family members. He or she most commonly

Aphasic, chair bound or bedbound. Muscles are rigid, contractures may develop

ASSESSMENT

Assessment serves a twofold purpose:

-first to establish whether dementia is present, and

-second, if dementia is present, to determine its cause A complete assessment for dementia begins with a thorough

history from both the subject and a reliable informant. Relevant aspects of the history include the --

-onset of cognitive impairment (insidious or sudden),

-course (gradual or stepwise, progressive or episodic, or fluctuating),

-and duration of impairment

An assessment of each cognitive domain is critical. For memory, inquire about short-term, long-term, and remote memory.

For language, inquire about word-finding difficulties and remembering names of family members and friends.

For praxis, inquire about use of familiar tools or machines, maintenance of previously acquired skills, and dressing or feeding apraxias.

For agnosia, inquire about recognition of familiar objects and insight into their condition and limitations. Inquiring into executive function involves assessing ability to perform complex tasks or solve problems.

INVESTIGATIONS OF PATIENTS WITH DEMENTIA

-Complete blood count,

-serum electrolytes, renal and hepatic function, glucose, albumin and protein,

- vitamin B12 and folate,

- rapid plasma reagin (syphilis), HIV tests

- thyroid- stimulating hormone,

Imaging: Computed tomography without contrast or magnetic resonance imaging Rule out infarcts, mass lesions, tumors, and hydrocephalus

Neurological examination Correlate imaging findings with clinical examination

Neuropsychological testing, Mini-Mental State Examination

EEG,

MEDICAL TREATMENT MODALITIES

Attention must be given to fluid and electrolyte status, hypoxia, anoxia, and diabetic problems.

Chemical and/or mechanical restraint. Low dose neuroleptics & symptomatic treatments.

NURSING MANAGEMENT

NURSING DIAGNOSIS: RISK FOR TRAUMA DISTURBED THOUGHT PROCESSES SELF-CARE DEFICIT

Effect on Caregivers:

The effects of caring for an individual with dementia often results in increased stress as well as a broad variety of other problems. The caregivers often experience depression or anxiety with an increased use of psychotropic Medications. Decreased overall life satisfaction are noted in caretakers. Higher levels of abusive behavior have been reported in the relatives of individuals with dementia.

Caregiver information and support

Caregivers should: Encourage independence for the Alzheimer’s

patient without sacrificing security Assist the patient, but only if necessary (i.e.

allow the patient as much control as possible) Learn to compromise Develop ways to share activities Establish a support network; get other family

involved Educate themselves (alzheimers.org)