NURSING MANAGEMENT OF DEMENTIA

An study module of dementia

Sreeja V, RN, DPN*

*Central Institute of Psychiatry, Ranchi, India

Last updated on 10-11-08

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Dementia is the most common psychiatric disorder on the later age. It is an irreversible disorder a general description of dementia is to indicate the minimum requirement for diagnosis of dementia is followed by the criteria that govern the diagnosis of more specific years. The word dementia has been in use for at least 200 years, in 1874, Maudesley used the term “Dementia” in relation to memory impairment.

Dementia is a chronic organic mental disorder and it is a syndrome due to disease of brain, chronic or progressive nature. Dementia is characterized by generalized Psychological dysfunction of higher cortical functions, with out impairment of consciousness. In fully developed dementia the higher cortical, functions affected include memory thinking, orientation, and comprehension, calculation, learning capacity, language and judgment.

The critical clinical points of dementia are the identification of the syndrome and the clinical workup of the cause.  The disorder may be progressive or static permanent or reversible. An underlying cause is always assumed, although in rare cases it is impossible to determine a specific cause. The potential reversibility of dementia is related to the underlying pathological condition and availability and application of effective treatment. Approximately 15 percent of people with dementia have reversible illness, if treatment is initiated before irreversible damage takes place.

In assessing the presence or absence of dementia special care should be taken to avoid false, positive, identification motivational or emotional factors.

Dementia produces an appreciable decline in intellectual functioning, interference with personnel activities of daily living such as washing, dressing, eating, personal hygiene, excretory and toilet activities changes in role performance occur such as lowered ability to keep or find job should not be used as criteria of dementia because of the large cross cultural difference exist in appropriate because frequent, externally imposed changes in the availability or work.

The term dementia has been used in a variety of way. It was introduced in to American Neuropsychiatric Terminology by Benjamin Rush in 1812. He borrowed the term from Pinel , the great French Psychiatrist who has used it to refer to patients with intellectual deterioration and idiocy . Since its introduction the term has been defined and redefined each new meaning reflecting the progressive evolution of knowledge concerning the types of disorders that produce intellectual deterioration as well as changing conceptions about criteria for identifying and diagnosing dementia.

Currently dementia is often used synonymously with organic brain syndrome. The later is too broad to be used meaningfully since it includes focal syndromes such as aphasia and amnesia as well as the Dementias

According to ICD – 10

1). ICD- 10 defines dementia as a syndrome due to disease of the brain usually of chronic or progressive in nature. In which, there is disturbances of multiple higher cortical functions including memory, thinking, orientation, comprehension, calculating, learning, capacity, language and judgment, and consciousness in not clouded. Occasionally deterioration in emotional control social behaviour or motivation also seen.

2). Dementia is characterized by multiple cognitive defects that include impairment in memory without impairment in consciousness. The cognitive functions that can be affected in dementia include general intelligence, learning and memory, language, problem solving, orientation, perception, attention and concentration, judgment and social abilities.

3). Dementia can be considered as a global impairment of intelligence, memory and personality in clear consciousness . It can occur a any age but become more frequent with age, with a prevalence of 5% - 10% in the over 65s and 20% in the over 80s. It is seen more frequently in women, due to their increased longevity.

II. ETIOLOGY OF DEMENTIA                                                                   Back to Top

Dementia has many causes, but Dementia of the Alzheimer’s type and vascular dementia together represent as many as 75 percent of all cases. Other causes of dementia are Pick’s disease. Creutzfeldt Jakob disease. Huntington’s disease, Parkinson’s disease, Human Immunodeficiency Virus (HIV) and Head trauma.

CAUSES OF DEMENTIA

A. Degenerative diseases of the central Nervous System.

C. Vascular causes –

1. Severe single head injury

2. Repeated head injuries  in boxers and others.

G. Infections and related conditions: -

1. Encephalitis of any cause

2. Neurosyphilic

3. c)  Chronic Meningitis

4. Cerebral Sarcoidosis

5. Cysticercosis

6. AIDS and AIDS related complex.

H. Toxic Causes :-

1. Alcohol

2. Poisoning with heavy metals – lead, arsenic, thallium, mercury, carbon monoxide.

3. Drug and alcohol withdrawal of anxiolytic sedative drugs, amphetamine.

1. Anemia

2. Post – anesthesia

3. Cardiac arrest

4. Chronic respiratory failure

SENILE DEMENTIA

It occurs usually after the age of 65 years due to degenerative brain changes as accompanied by a clinical picture of mental deterioration.

Types of Senile dementia

a) Simple deterioration :- In this patient gradually develops loses of  contact with environment poor memory, tendency to reminiscence, intolerance of change, disorientation, restlessness, insomnia, and failure of judgment. This is the commonest psychotic reaction in about 15% of the entire group of senile dementia.

b)  Paranoid reaction :-  Gradual formation of delusion. He feels that his relatives are turned against him and are trying to rob or kill him

c) The presbyophrenic type :- Characterized by jovial mood, marked impairment of memory, restlessness and excitability.

d) Depressed and agitated type :-  Severally depressed and agitated, suffers from hypochondrical and Nihilistic delusion .expresses morbid ideas about cancer, syphilis and other diseases. Has marked poverty of ideas.

e) Delirious and contused type: - Shows severe mental clouding, which make him restless, contused, resistive and incoherent. Completely disoriented to time, place and person.

All these type of senile dementia deteriorate and the patient becomes asocial and bedridden . He is reduced to a vegetative life.

PRE- SENILE DEMENTIA

It resembles that of senile dementia except that disorders occur in younger age group.

Alzheimer’s disease: - Dementia of insidious onset and slowly progressive course due to specific lesions in the brain–stem, hippocampus, parietal and frontal cortex The first sign are usually impairment of memory for recent events and inability to process information. Individual thinking becoming limited, inability to retain new information. The pattern of interference occurs according to the area of Brain is affected, Hippocampal damage cause memory, impairment, parietal lobe of brain damage cause difficulty in use of words or knowing the name of common objects also cause dyspraxia, frontal lobe damage cause impaired ability to behave appropriately, leading to tactlessness, dis-inhibition and loss of finer feelings, speech is also affected.

Usually developing age of Alzheimer's disease is between 40 to 50 yrs. Rapid progression with severe brain and mental deterioration, accompanied by over activity, emotional distress and agitation, frequent development of aphasia death occurs between 2 and 10 yrs of sickness, usually an average of 4 years. The patient should be hospitalized treatment is symptomatic.

Genetic factors: - Although the cause of dementia of the Alzheimer’s type remains unknown, progress has been made in understanding the molecular basis of the amyloid deposits that are a hallmark of the disorder’s neuropathology, some studies have indicated that as many as 40% of patients have a family history of dementia of the Alzheimer’s type thus, genetic factors are presumed to play a part in the development of the disorder, at least in some cases. Additional support for a genetic influence is the concordance rate for monozygotic twins, which is higher than the rate for dizygotic twins. (43% Vs 8%, respectively) In several well-documented cases, the disorder has been transmitted in families through an autosomal dominant gene, although such transmission is rare.

Neuropathology: - The classic gross neuroanatomical observation of a brain from a patient with Alzheimer’s disease is diffuse atrophy with flattened cortical sulci and enlarged cerebral ventricles.

Neurotransmitters: - The neurotransmitters that are most often implicated in the pathophysiological condition of Alzheimer’s disease are acetylcholine and norepinephrine, both of which are hypothesized to be hypoactive in Alzheimer’s disease. The decrease in nor epinephrine activity in Alzheimer’s disease is suggested by the decrease in norepinephirine containing neurons in the locus ceruleus found in some pathological examinations of brains from people with Alzheimer’s disease. Two other neurotransmitters implicated in the pathophysiological condition of Alzheimer’s disease are the Neuro active peptides somatostain and corticotropin, both of which have been found to be decreased in Alzheimer’s disease.

MULTI-INFRACT CAUSE.

The primary cause of multi-infract dementia is presumed to be multiple cerebral vascular disease, resulting in a symptom pattern of dementia. It is most common in men, especially those with pre existing hypertension or other cardiovascular risk factors the disorder affects primarily small and medium size cerebral vessels , which under go infraction and produce multiple parenchyma lesions spread over wide areas of the brain . The cause of the infarctions may include occlusion of the vessels by arteriosderotic plaque or thromboemboli from distant origins. An examination of a patient may reveal carotid bruits, funduscopic abnormalities enlarged cardiac chambers.

PICK”S DISEASE

Pick’s disease is characterized by a preponderance of atrophy in the front temporal regions.  These regions also have neuronal loss, gliosis, and the presence of neuronal pick’s bodies, which are masses of cytoskeletal elements. Pick's bodies are seen in some postmortem specimens but are not necessary for the diagnosis. It is most common in men, especially those who have a first-degree relative with the condition. Pick’s disease is difficulty to distinguish from Alzheimer’s type, although the early stages of pick’s disease are more often characterized by personality and behavioral changes, with a relative preservation of other cognitive functions. Features of Kluver – Bucy syndrome (such as hypersexuality, placidity and hyperorality) are much more common in pick’s disease than in Alzheimer’s disease.

LEWY BODY DISEASE :-

Lewy body disease is a dementia clinically similar to Alzheimer’s disease and often characterized by hallucinations, Parkinsonian features and extrapyramidal signs, and lewy bodies are found in the cerebral cortex. The exact incidence is unknown. These patients show marked adverse effects when given antipsychotic medications.

HUNTINGTON’S DISEASE :-

Huntington’s disease is classically associated with the development of dementia. The dementia seen in this disease is the sub cortical type of dementia, characterized by more motor abnormalities and fewer language abnormalities than in the cortical type of Dementia. The dementia of Huntington’s disease exhibits psychomotor slowing and difficulty with complex tasks, but memory, language and insight remain relatively intact in the early and middle stages of the illness. As the disease progress, however, the dementia becomes complete; the features distinguishing it from dementia of the Alzheimer’s type are the high incidence of depression and psychosis, in addition to the classic choreoathetoid movement disorder.

PARKINSON’S DISEASE :-

It is characterized by bradykinesis, rigidity, and hyperkinesias, evident in slowness in initiating and executing motor acts. The unblinking face is mask like, writing is cramped and the gait is slow and shuffling with difficulty in starting and turning associated movements are lacking.

Decreased motivation and spontaneity fatigability and feeling of depression are very common. There will be disturbance in other neurological condition which presenting symptom of the disorder.

NORMAL–PRESSURE HYDROCEPHALUS :-  

Hydrocephalus is an increase in the intracranial cerebrospinal fluid volume associated with dilatation of the ventricular system. In the case of primary hydrocephalus an increased volume of CSF with in the cranial cavity can result from increased formation of CSF, an obstruction to its circulation or decreased absorption. This is turn leads to raised CSF pressure.

Normal – pressure hydrocephalus is both obstructive and communicating. It is caused by an obstruction in the subarachnoid space which prevents CSF from being reabsorbed, but allows it to flow in to the subarachnoid space from the ventricular system.

HYDROCEPHALUS IS ASSOCIATED WITH DILATATION OF THE VENTRICULAR SYSTEM

In Normal pressure hydrocephalus the features of raised ICP are generally absent. The syndrome mainly occurs in the 7^th and 8^th decades of life.  Varying degrees of cognitive impairment and physical slowness occur. Other features include unsteadiness of gait, urinary incontinence and nystagmus.  When it caused pre-senile dementia particularly If physical features are absent, it may prove difficult to differentiate normal – pressure hydrocephalus from Alzheimer’s disease.

TRAUMATIC CAUSES :-

HEAD INJURY

The commonest cause of head injury is motor vehicle accidents. Acute posttraumatic psychosis and the chronic Psychological sequence of head injury cause, cognitive impairment, personality change and neurotic symptoms. A common consequence of head injury which does not reflect the extent of brain damage is called post concussional or posttraumatic syndrome. Such as head ache dizziness, emotional liability, anxiety, irritability, sensitivity to noise, impaired concentration and subjective memory loss, confusion, disorientation and mood disturbance, also cause defect in memory and calculation, damage to the frontal lobe maybe followed by personality change towards a apathy and indifference.

SUBDURAL HAEMATOMA :-

Subdural haematoma commonly caused by head injury arise in association with clotting disorder. Acute haematoma associated with disturbed consciousness up to extreme of coma and neurological signs cause dementia.

EXTRACRANIAL CAUSE OF DEMENTIA :-

Systemic conditions may affect neuronal function through the blood stream, producing a dementia or a sub acute delirious syndrome.

ENDOCRINE DYSFUNCTIONS :-

Endocrine disorders, such as hyper and hypothyroidism, Addison’s disease, Cushing’s syndrome, acromegaly hyper and hypoparathyrodism and diabetes mellitus are all potential cause of an organic brain syndrome.

CEREBRAL ANOXIA:-

Cerebral anoxia arises from any hindrance to the transport of oxygen from the level of the alveoli to its place of eventual utilization with in neuron, respiratory failure cardiac failure, suffocation, severe anemia cerebral vascular disease and metabolic disturbances such hypoglycemia and cyanide, poisoning are all Important cause

VITAMIN DEFICIENCY :-

Due to vitamin deficiency associated with chronic physical and mental illness, ageing and social disadvantage vitamin B group are associated with neuropsychiatry symptoms, chronic thiamine deficiency leads to beriberi with cardiac failure neuropathy and in acute cases Wernicke’s encephalopathy.

Nicotine acid deficiency leads to pellagra with triad to gastrointestinal disorder, dementia and psychiatric disturbance like, irritability, anorexia and emotional instability and delirium, vitamin biz deficiency cause sub acute combined degeneration of the spinal cord accompanied by a macrocytic anaemia and progressive dementia.

METABOLIC DISORDER :-

Hepatic and renal disease, electrolyte and fluid disturbances and acute porphyria. Hepatic failure is associated with marked neuropsychiatric symptoms. It cause liver disease is cause consciousness in impaired during episodes of ecephalopathy concentration and memory impaired.

Electrolyte imbalance cause lassitude, apathy and confusion associated with hyponatraemia, hypocalcaemia, hypercalcaemia, alkolosis and acidosis.

Electrolyte abnormalities cause apathy, slowness and withdrawal, which may resemble dementia.

DRUG AND DEMENTIA :-

III. EPIDEMIOLOGY                                                                               Back to Top

Dementia is essentially a disease of older people. About 5 percent of every one who reaches age 65 has dementia of the Alzheimer’s type, compared with 15% to 25% of everyone age 85 or older patients with dementia of Alzheimer’s type occupy more than 50 percent of nursing home beds. Over 2 million person with dementia are cared for in these homes. The risk factors for the development of dementia of the Alzheimer’s type include being female, having a first degree relative with the disorder, and having a history of head injury. Down’s syndrome is also characteristically associated with the development of dementia of the Alzheimer'’ type.

Alzheimer’s type generally occurs in late life, most commonly in the 60s, 70s and 80s and beyond , but in rare instances the disorder appears in the 40s and 50s (known as early-onset dementia). The incidence of Alzheimer's disease also increase with age and it is estimated at:-

0.5 %  Per year from age 65 to 69

1 % Per year from age 70 to 74

2 %  per year from age 75 to 79

3 % Per year from age 80 to 84

8 % Per year from age 85 onwards.

Progression is gradual but steadily downward, with an average duration from onset of symptoms to death of 8 to 10 years. Plateaus may occur, but progression generally resume after 1 to several years.

The second most common type of dementia is vascular dementia, which is causally related to cerebrovascular diseases. Hypertension predisposes a person to the disease. Vascular dementia accounts for 15 to 30% of all dementia cases. Vascular dementia is most common in people between the ages of 60 and 70 and is more common in men than in women. Approximately 10 to 15% percent of patients have coexisting vascular dementia of the Alzheimer’s type.

Other common causes of dementia, each representing 1 to 5 percent of all cases, include head trauma, alcohol related dementias, and various movement disorder related dementia’s such as Huntington’s disease and Parkinson’s disease. Because dementia is a fairly general syndrome. It has many causes and clinicians must embark on a careful clinical workup of a patient with dementia to establish its cause.

The current annual cost of caring for patients with dementia is 15 billion, which is likely to increase. By the year 2030, an estimated 20% of the population will be older than age 65.

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IV. SIGNS AND SYMPTOMS                                                                    Back to Top

At the initial stages of dementia, patients show fatigue, difficulty in sustaining mental performance, and a tendency to fail when a task is novel or complex or requires a shift in problem – solving strategy. The inability to perform tasks becomes increasingly severe and spreads to every day tasks, such as grocery shopping as the dementia progresses. Eventually, patients with dementia may require constant supervision and help to perform even the most basic tasks of daily living. The major defects in dementia involve orientation, memory, perception, intellectual functioning and reasoning and all these functions become progressively affected as the disease process advance. Affective and behavioral changes, such as defective control of impulses and liability of mood, are frequent, as are accentuations and alterations of premorbid personality traits.

1) Intellectual deterioration with failure of: -