NURSING MANAGEMENT OF DEMENTIA

Reversible dementia – is a term used in the medical literature to describe a dementia that as a specific treatable cause. In the past, dementia has implied a progressive or irreversible course.

Potentially reversible dementia syndromes include those arising from inflammatory processes e.g. encephalopathy caused by systemic lupus erythematosus (SLE) , infections such as syphilis ; or toxic conditions (e.g. Alcohol abuse) that produce memory loss  and   abnormal frontal lobe functions (Cummings 1987). Metabolic related dementia such as hypothyroidism or hyperthyroidism and nutritional syndromes such as Vitamin B12 and rotate deficiencies may also be reversible with appropriate therapy.

It is estimated that 30% to 40% of persons with memory disturbances have a reversible and there fore treatable dementia. Although most of the patients will have physical disorders, Psychiatric disturbances such as depression are a significant challenge in the differential diagnosis. Treatment of such conditions as depression, drug – induced dementia, infections and metabolic disturbances leads to complete restoration off functioning  with prompt diagnosis and appropriate treatment the dementia can be reversed.

Non-reversible dementia: When a reversible cause of intellectual impairment can’t be identified, the clinical diagnosis is presumed to be a nonreversible dementia many diseases can produce a progressive and nonreversible dementia . Most of these are rare and can affect adults of all ages with older individuals more likely to be affected when dementia does occur in a younger person it have been associated with suicide (Margo and Finkel 1990). The most common nonreversible dementia are Alzheimer’s disease, Parkinson’s disease, Huntington’s disease, pick’s disease, Creutzfeldt– Jakob disease and multi – infarct dementia.  transient ischomic attack (TIAs)  are included in the category because they can lead to a disabling cerebral infarction.

A, Dementia in Alzheimer’s disease :-

Alzheimer’s disease was first described by Alois Alzhemer, a German neurologist in 1906. Alzheimer’s disease is a primary degenerative cerebral disease of unknown etiology, with characteristic neuropathological and neurochemical features. The onset can be in middle adult life or even earlier but the incidence is higher in later life. In cases with onset before the age of 65-70 years. There is the likelihood of a family history of dementia, a more rapid course and prominence of features of parietal and temporal lobe damage, including dysphasia or dyspraxia, general impairment of higher cortical function.

There are characteristic changes in the brain: a marked reduction in the population of neuron, particularly in the hippocampus, appearance of neurofibrillary tangles, neurotic plagues, which consist largely of amyloid. Marked reduction in the enzyme chorine acetyl transference in acetylcholline it self.

Sign and symptoms

Insidious onset with slow deterioration while the onset usually seems difficult to pinpoint in time, realization by others that the defects exist may come suddenly.

Absence of clinical evidence of findings from special investigation, to suggest that the mental state may be due to other systemic or brain disease which can induce a dementia.

Absence of a sudden, apoplectic onset, or have neurological signs of focal damage such as hemi paresis, sensory loss, visual field defects, and in coordination occurring early in the illness.

Dementia in Alzheimer’s disease with late on set where the clinically observable onset in after the age of 65 years and usually in the late 70s or there after with a slow progression and usually with memory impairment as the principal feature.

c). Dementia in Alzheimer’s disease, a typical or mixed type.

This term and code should be used for dementia that have important atypical features or that fulfill criteria for both early – and late onset types of Alzheimer’s disease.

d). Dementia in Alzheimer’s disease unspecified.

B). Vascular Dementia

Vascular dementia which includes multi-infarct dementia, is distinguished from dementia in Alzheimer’s type by history of onset. There is a history of transient ischaemic attacks with brief impairment of consciousness, fleeting pareses or visual loss. Cerebrovascular accidents cause impairment of memory and thinking becomes apparent. Onset in later life can be abrupt in ischaemic episode or gradual emergences. The dementia is result of infraction of brain due to vascular disease including hypertensive cerebrovascular disease.

Vascular dementia is the second commonest type of dementia. This disorder arises earlier between 50 – 60 years of age, but more prevalent between ages 60-70 years. It is slightly more common in male  than in females.

Clinical Features

• The patient develops multiple episodes of cerebral ischaemia which may or may not be apparent.

• Impairment of cognitive function.

• Memory disturbances.

• Intellectual deficits

• Focal Neurological sign changes.

• There may be aphasias, disarthria, and dysphagia.

• There may be headache, dizziness, faintness , weakness, sleep disturbance and personality changes.

• Insight and judgment may be preserved.

• An abrupt onset or a step wise deterioration.

• Seizure occurs in 20 percent of cases.

a). Vascular Dementia of acute onset:

This dementia develops rapidly (i.e. usually within one month but with in no longer than 3 months) after a succession of strokes or a single large infarction.

b). Multi-infract dementia:

This is more gradual in onset than the acute form , following a number of minor ischaemic episodes which produce an accumulation of infarcts in the cerebral parencyma.

c). Subcortical vascular dementia

There may be a history of hypertension. There is evidence of foci of ischemic destruction in the deep white matter of the cerebral hemispheres.

Which can be suspected on clinical groups and demonstrated on computerized cortex is preserved and this contrasts with the clinical picture, which may closely resemble that of dementia in Alzheimer’s disease.

d). Mixed cortical and sub cortical vascular dementia.

Mixed cortical and sub cortical components of the vascular dementia may be suspected from the clinical features, the results of investigation (including autopsy) or both.

e). Other vascular dementia

f). Vascular dementia, unspecified.

3). Dementia in Other Disease

Cases of dementia due to cause other than Alzheimer’s disease or vascular disease. Onset may be at any time in life, rarely in old age.

a). Dementia in Huntington’s disease.

Huntington’s disease is an autosomal dominant disorder caused by a gene which has been localized to the most distal band of the short arm of chromosome 4. Therefore 50% of the children of one affected parent can develop this disorder. Spontaneous mutations can also give rise to sporadic cases in which there is no known family history.

Pathological features

Microscopically the brain is usually small with reduced mass and there is marked atrophy of the corpus striatum of the basal ganglia, particularly the caudate nucleus, and of the frontal lobes.

Histological change include neuronal loss in the cerebral cortex, particularly affecting the frontal lobes, and in the corpus striatum, particularly affecting GABA neurons;

Biochemical changes include reduced levels of GABA and glutamic acid decarboxylase, and dopamine hypersensitivity. Huntington disease – the coronal section shows atrophy of caudate nucleus.

Clinical features:-

• Males and females are affected equally by Huntington’s disease and the average age of onset is in the 30s.

• Insidious onset of involuntary choreiform movement disorder.

• Involuntary choreiform movements in face, hands, shoulder or in the gait.

• Slurring of speech, extra pyramidal rigidity and epilepsy.

• Psychiatric features include depression, increased risk of suicide and schizophreniform and delusional disorders.

• Insight tends to be retained until a late stage.

• Death usually occurs within 15 years of the onset of symptoms.

Although there is no known cure, phenothiazine antipsychotics in low  doses may be given to help with emotional disturbance, while depression may be treated with antidepressants. Involuntary movements may be decreased by giving tetrabenzine. This may act by causing dopamine depletion at never endings, but may cause depression to develop, thereby limiting.

b). Dementia in pick’s disease:-

It occurs in middle life usually between 50 and 60 years, characterized by slowly progressing changes of character and social at deterioration, memory impairment, impairment of intellect and language functions with apathy, euphoria and extra pyramidal phenomena. There will be atrophy of the frontal and temporal lobes, but with out the occurrence of neuritic plaques and neurofibrillary tangus in excess of that seem in normal aging.

Signs ad symptoms

• Onset is slow with steady deterioration.

• A predominance of frontal lobe involvement is evidenced by two or more of the following.

• Emotional blunting

• Coarsening of social behaviour

• Disinhibition

• Apathy or restlessness

• Aphasia

• Behavioural manifestations which precede memory impairment.

c). Dementia in Creutzfeldt – Jakob disease

Creutzfeldt– Jakob disease with extensive neurological signs due to specific neuropathological changes that are presumed to be caused by a transmissible agent, onset is middle age or later age typically in the fifth decade, but may be at any adult age. The course is sub acute, leading to death within 1-2 years.

Signs and symptoms

There is very rapid progression of dementia with disintegration of virtually all higher cerebral functions. One or more of the following types of neurological symptoms and signs emerge, usually after or simultaneously with the dementia.

• Pyramidal symptoms

• Extra pyramidal symptoms

• Cerebellar symptoms

• Aphasia

• Visual impairment

d). Dementia in Parkinson’s disease

Parkinson’s disease is a disorder of a nucleus of norm cell, deep in the centre of the brain , called the substantianigra. Because of the death of cells in this nucleus there is a reduction in the neurotransmitter dopamine and cause the typical symptoms. The dementia in Parkinsonism develop is thought to be due to reduction in acetylcoline and the evidence in affected of cell death in the nucleus of Meynert.

Signs and Symptoms:

• Rigidity

• Shuffling gait

• Mask like face

•  Mumbling of speech

• Hypokinesia

• Difficulty in co-ordination

e). Dementia in Human Immunodeficiency Virus (HIV) disease.

A disorder characterized by cognitive deficits meeting the clinical diagnostic criteria for dementia. HIV dementia presents with complaints of forgetfulness, slowness, poor concentration and difficulties with problem solving and reading, Apathy,  reduced spontaneity and social withdrawal are common and in significant minority of affected disorder, psychosis or seizure. Tremor, impaired rapid, repetitive movements, imbalance, ataxia, hypertonia, generalized, hyper reflexia.

Positive frontal release signs and impaired pursuit and saccadic eye movement, children also develop and HIV associated neuro developmental disorder characterized by developmental delay, hypertonia, microcephaly and basal ganglia calcification.

f). Alcoholism Dementia

Chronic alcoholics develop a specific recent memory loss called Korsakoff’s syndrome. This is progressive if the person continues to drink or as after a head injury or stroke, some recovery of function may be possible over months or even years. Since it does not affect the over all functions of the cerebrum, Korsakoff’s syndrome is not strictly speaking a dementia. There is evidence that some alcoholics develop a more generalized shrinking of the brain which shows up on CT scanning. This shrinkage is a sign of developing general dementia.

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VI. ASSESSMENT AND MANAGEMENT                                                    Back to Top

TREATMENT

1). Hospitalization

2). History taking

a). The patient’s history.

The patient’s history gives information about the past, which comes from the patient, older and more important memories may be maintained late in dementia because they have been rehearsed often over the years that they are very fixed, because patient returns to these memories when the present and recent past are fading. In the earliest stages she will be able to given quite a full account of her life up to recent times, this information must be checked for memories become incomplete and time sequences muddled. These more or less muddled memories are important in understanding how the patient reacts to her/his illness.

b). The Relative’s History

From relative’s history we can obtain more information about patients previous personality, attitudes, level of activity, interests, social functioning and self care it is important to help the relatives separate recent events, from events that happened before dementia. This information will provide clear evidence of how much changes has occurred and also helps in understanding what new problems that family is having to cope with and so helps to explain their reactions.

History taking gives the essential baseline in assessing what support the patient can expect from family and friends, what interests and activities might continue to engage in and what her living conditions are we need to know whether a good supportive relationship has existed in the pass or whether there was animosity or indifference.

3). The Physical Examination

Physical Investigation

• Hemoglobin , TLC, DLC,

• Blood sugar – In diabetes

• Blood Urea- For renal disease

• Serum creatinine

• Thyroid function test – Hypo/Hyperthyroidism.

• Liver function test – Liver disease

• Serum calcium – Parathyroidism

• VDRL – Neurosiphillis

• Serum copper – Wilson’s disease

• HIV – AIDS

• EEG – To find out the focal sign

• ECG – To find out cardiac problems

• CT – Scan

• MRI

• Fundus examination – Evidence of atherosclerosis

4). Psychological Testing

Psychometric tests depends on the patient’s co-operation but can be valuable when it is done by experienced tester. They may help in localizing lesion in certain sites. They are of more value in monitoring changes in psychological functioning over time and assessing patterns of disability as a basis for planning rehabilitation.  Some of the tests are :-

a). Wechsler Adult Intelligence Scale (WAIS)

This is a well standardized test providing a profile of verbal and non-verbal abilities Analysis of sub scores, can provide useful information for diagnosis. Organic impairment is indicated by a discrepancy between performance IQ and verbal IQ.

b). Perceptual functions , especially spatial relationship.

This test is exemplified by the Benton Revised visual Retention test, which requires the patient to study and reproduce ten designs.

c). New Learning as a test of memory.

There are many new word learning tasks for example the Walton Black modified word learning test and the paired associated learning test, both of which give a useful quantitative estimate of memory impairment.

d). Specific test.

This test are the Wisconsin card sorting test for frontal lobe damage and the token test for receptive language disturbance.

e). Dementia Rating Scale

In this test 2 types of rating scale is used, the intellectual and behavioural. This scale have been over used in diagnosis and limited value in identifying problems. They are most informative when used to measure the progression of impairments over time and to predict the future care needs of the patient.

5). Mental Status Examination

The purpose of the mental state examination is to detect abnormal features in a patient’s behaviour and state of mind at the time of the assessment. If the abnormal features are found this information contributes to the diagnostic process. The examination consists of systemic observation of the patient during the interview and various aspects of their thinking , feelings , perceptions and cognitive functioning , impairment of memory, orientation and consumption problems.

a). General appearance and Behaviour.

Abnormalities in patient’s appearance and behaviour may point to organic impairment , in an early dementia or minor dementia or minor delinquency in a confusional state. Rather more specific abnormalities that reflect the patient’s failing intellectual powers. In appearance and behaviour observe the pt. May restrict his activities to an increasingly limited area within which he is able to cope. He will often repeat things that he has done several times. Apparently without any awareness of what he is doing. It is an inability to stop one thing and move on to next. Appearance following things to be noted:-

- Neatness

- Untidy

- Appropriateness

- Cleanliness

- Apparent age etc.

b). Speech

Speech may show a variety of more or less non-specific anomalies together with restriction of content, difficulty in finding words and naming objects, reduced fluency, repetition, preservation and lastly speech is striking when it occurs again be alert to any neurological abnormalities.

c). Attitude

Observe the attitude of the patient whether it may :-    

- Co-operative

- Hostile

- Suspicious

- Fearful

- Evasive etc.

d). Mood

Organic mood change is an impoverishment of mood. The patients emotional response lack of depth and are poorly sustained. They may show more specific changes:-

- Emotional incontinence

-Excessive laughing or crying initiated by frivol stimuli and than continuing unchecked.

- Threshold effects :- No apparent response up to level of stimulation and then a sudden excessive reaction.

- Incongruous emotion

-Failure to respond to significant stimuli but excessive respond to trivial stimuli.

- Catastrophic reaction

- A sudden explosive outburst of rage and distress often prompted by the recognition of falling powers. This is the first signal of early organic impairment .

e). Cognitive function

Organic states such as toxic confusional states and dementia’s are not difficult to diagnose once they are well established cognitive impairment may indicate organic etiology, cognitions are

- Orientation

- Memory

- Concentration and attention

If any impairment in these cause may lead to dementia.

Orientation

Orientation is tested in time, place and person , A patient is fully oriented if he/she known,

what time it is ? 

Where he is and

who are the people around him . 

Disorientation for time is not necessarily sign of organic impairment. Distress are being in unfamiliar surroundings is enough to cause a greater or lesser degree of disorientation. Ask the patient the day of the week and the date. Find out if the patient knows qualitatively, where he is in time. A patient who is merely distressed and unfamiliar surroundings, is unlikely to have lost tract of time to point where he no longer knows even qualitatively where he is in time.

Testing orientation for place, ask the patient where he is, if patients is not able to tell then organically impaired. Testing orientation for person, if the patient knows who you and who other people around him are.

Memory

Memory is tested as recent and remote recent memory is tested with new learning, It is the ability to retain and recall new information remote memory is tested that the ability to recall.

- Recent memory: To test for recent memory ask to patients, what did you eat for lunch ? (Verify)

- Remote memory:- For testing remote memory ask him

· Birth date

· Stories from child hood

· Current Indian President  

- Retention of memory:- For testing this ask the patient to repeat the names of 3 items that you list (immediately and in 5 minutes).

Concentration

Concentration is the capacity for sustained attention, it is tested both in its own right, and because normal concentration is condition of adequate performance in any other test. The serial seven test. In this ask the patient to take seven away from a hundred, until he/she gets down to naught – write down what patient says as he says it, marking any errors and the time is taken, with this we can fine the patients concentration other test also can applied for concentration like counting forwards or reciting the days of the week forwards.

Intelligence

In intelligence test IQ test is done. It is verbal and performance , Verbal IQ is concerned with language function and performance IQ with arithmetic and visuospatial functions.

In dementia there is a fall in full scale. This may be difficult to assess at an early stage. It has to be judged against previous academic and employment achievements. Verbal IQ is more dependent than performance IQ on long established skill and therefore relatively protected in early dementia. A performance IQ is more than 20 points below verbal IQ may be significant.

f). Thought content

The content of the patient’s thought like their behaviour and speech, reflects the decline in their intellectual functions in being impoverished may also show concrete thinking. This can be tested by asking the patient to explain the meaning of a common proverb e.g. ask to explain “Do not cry over split milk” or “Astilch in time” etc.

g). Judgment:

It can be tested by asking “what would you do with a stamped, addressed letter that you find out on the side walk “or why are criminals put in to prison".

h). Delusions

Organic delusion is characterized by their form. They are poor quality delusion, a product of combined intellectual and emotional impoverishment functional delusions are poorly sustained coming and going in a few hours or days, simple rather than elaborate, lacking in emotional intensity.

i). Hallucinations

Where organic delusions are poor quality delusions but organic hallucinations are good quality hallucinations. Organic hallucinations are visual formed being of people animals and things, coloured moving often show size distortion etc.

j). Rapport

At the end of the examination the examiner should evaluate how friendly and open the relationship with the patient was, whether the patient was frank, hostile or guarded, evasive and negative. The patient’s responses to both the examination and examiner are important factor in the overall quality of the mental status examination.

6). Identification of cause and treatment

7). Symptomatic Management

8). Currently Available Treatments

 9). Psychotherapy

Psychotherapy – the specific psychotherapy treatments divided in to 4 broad of range: Behaviour oriented, Emotion oriented cognition oriented and stimulation oriented, behaviour approached can be effective in lessening or abolishing problem behaviour e.g. aggression, incontinence emotion oriented intervention include supportive psychotherapy reminiscence therapy sensory integration and stimulated presence therapy.

a. Behavior– oriented approaches: it can be effective in lessening or abolishing where it occurs, how often it occurs have to be determined.  The next step is an assessment of specific antecedents and consequences, which will often suggest specific strategies for intervention.  Precipitants should be avoided whenever possible.

Whatever intervention, it is critical to match the level of demand on the patients with his or her current capacities, to modify the environment in so far as possible to compensate for deficits and capitalize on the patient’s strengths.

b. Emotion– oriented approaches – The intervention includes supportive psychotherapy, reminiscence therapy, validation therapy, sensory integration and simulated presence therapy.

• Reminiscence therapy, which acme to stimulate memory and mood in the context of the patient’s life history is associated with modest short lived gain in mood.

• Validation therapy, aims to restore self-worth and reduce stress by validating emotional ties to the post.

• Simulated presence therapy may be helpful in diminishing problem behavior with social isolation.

• Supportive psychotherapy may be helpful in mildly impaired patients to adjust to their illness.

c. Cognition – oriented approaches: these techniques include reality orientation and skills training.  The aim of these treatments is to redress cognitive deficits, often in a classroom setting.  There is some evidence of transient benefit from cognitive redemption and from skills training but here have been report of frustration in patients and depression in caregivers associated with the type of intervention.

d. Stimulation – oriented approaches:  these treatments include activities or recreational therapies (crafts, gene, and pets) and are therapies (music, dance, art).  They provide stimulation and enrichment and thus mobilize the patient’s available cognitive resources.  There are evidences that, while they are in use, these interventions decrease behavioral problems and improved mood.

Psychotherapy can be given to family members as well as patient’s psychotherapy is not very useful for patients. It will be helpful for family members to encourage them to take care of patients family members can be taught to take care of the patients which will help to improve patient’s self esteem, and make the patient independent oriented as much as possible. Family members should not neglect the patient but should help in humanitarian way.