NURSING MANAGEMENT OF DEMENTIA
An study module of dementia
Sreeja V, RN,
DPN*
*Central Institute of Psychiatry, Ranchi, India
Last updated on
21-02-09
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Outline
Problems
of the carer
Conclusion
Pre and
Post Test
Bibliography
Glossary
I. INTRODU CTION
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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
DEFINITION
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
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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.
-
Senile dementia
-
Alzheimer’s disease
-
Pick’s disease
-
Huntington’s chorea
-
Parkinson’s disease
-
Creutzfeldt Jakob disease
-
Normal pressure hydrocephalus
-
Multiple sclerosis
-
Lewy
body disease
B. Intra Cranial Causes
C.
Vascular causes –
-
Multi-infarct dementia.
-
Occlusion of the carotid artery
-
Stroke
-
Hypertension
-
Cranial arthritis
D. Metabolic and endocrine disorders :-
-
Endocrinopathies
– Addison’s disease, Cushing’s syndrome, Hyperinsulinism, Hypothyroidsm,
Hyporupituitatism, Hypoparathyrodism, Hyperparathyrodism.
-
Hepatic
failure
-
Renal
failure
-
Renal
dialysis
-
Respiratory
failure
-
Hypoxia
-
Chronic
uraemia.
-
Chronic electrolyte imbalance.
-
Hypocalcaemia
-
Hypercalcaemia
-
Hypokalaemia
-
Hyponatraemia
-
Hyper natraemia
-
Remote
effect of Carcinoma or Lymphoma.
E. Nutritional Causes :-
1. Sustained lack of B12 pernicious
anemia
b) Niacin – Pellagra
c) Thiamine – Wernicke –
Korsakoffs syndrome
2.
Vitamin intoxication – vitamin A ,
Vitamin D – Paget’s disease
F. Traumatic Causes :-
1.
Severe single head injury
2. Repeated head injuries in boxers and
others.
G. Infections and related
conditions: -
-
Encephalitis of any cause
-
Neurosyphilic
-
c)
Chronic
Meningitis
-
Cerebral
Sarcoidosis
-
Cysticercosis
-
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.
I.
Anoxia:-
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 7th
and 8th 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 :-
Reseprine, Methylopa and phenocetin cause
chronic brain syndromes and chronic use of cannabis can produce mental and
physical sluggishness, disturbance of recent memory and volition
associated with chronic head ache and reversal of sleep rhythm. Drug use
and use of cannabis associated cerebral atrophy.
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III. EPIDEMIOLOGY
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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
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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: -
a) Memory:-
Memory
impairment is typically an early and prominent feature in dementia,
especially in dementias involving the cortex, such as dementia of the
Alzheimer’s type. Early in the course of dementia, memory impairment is
mild and is usually most marked for recent events; people forget telephone
numbers, conversations and events of the day. As the course of dementia
progresses, memory impairment becomes severe and only the earliest learned
information is retained.
b) Orientation:-
In as
much as memory is important for orientation to person, place and time,
orientation can be progressively affected during the course of a dementing
illness. For example, patients with dementia may forget how to get back to
their rooms after going to the bathroom. No matter how severe the
disorientation seems, how every, patients show no impairment in their
level of consciousness.
c) Language:-
Dementing
processes that affect the cortex, primarily dementia of the Alzheimer’s
type and vascular dementia, can affect patient’s language abilities.
Aphasia is one of the diagnostic criteria of dementia . The language
difficulty may be characterized by a vague, stereotyped, imprecise or
circumstantial locution, and patients may also have difficulty in naming
objects.
d) Thinking & Judgment:-
Thinking becomes slower with reduced flow of ideas and impaired
concentration; Judgment is impaired from early on and leads to poor
insight; Paranoid thoughts and ideas of reference are common and may
develop into delusions.
e) Comprehension of Learning
Capacity:-
The brains ability to process incoming information is
impaired.
f) Calculation:- This cognitive skill is usually impaired from early on
dementia.
g) Insight
i) Concentration
2) Emotional Changes :-
Emotions become too easily stimulated, and have
reduced control over laughter or tears.
3) Deterioration of personality:-
a)
Increasing tendency to selfishness.
b)
Lack
of consideration for other people’s feelings.
c)
Personal habits, table manners, toilet, habits and hygiene deteriorate.
d)
Sexual offences may be committed.
Changes in the personality of a person with
dementia are especially disturbing for the families of affected patients.
Pre existing personality traits may be accentuated during the development
of a dementia. Patients with dementia may also become introverted and may
seem to be less concerned than they previously were about the effects of
their behavior on others. People with dementia who have paranoid delusions
are generally hostile to family members and caretakers. Patients with
frontal and temporal involvement are likely to have marked personality
changes ad may be irritable and explosive.
4) Age – related body system changes
A) Cardio vascular system
v
Decreased
cardiac output.
v
Diminished
ability to respond to stress.
v
Slower
heart recovery rate, increased BP.
v
Leads to
fatigue with increased activity.
B)
Respiratory
System:-
v
Increase in
the residual lung volume
v
Decrease in
vital capacity
v
Decreased
gas exchange of diffusing capacity.
v
Decreased
cough efficiency
v
Leads to
fatigue and breathlessness with sustained activity, impaired healing of
tissue due to decreased oxygenation, difficulty in coughing up
secretions.
C)
Integumentary system :-
v
Decreased
protection against trauma
v
Decreased
protection against temperature extremes.
v
Diminished
secretion of natural oils and perspiration.
v
Thin and
wrinkled skin
v
Complaints
of injuries bruises and sunburns.
v
Complaints
of intolerance to heat.
v
Bone
structure is prominent Dry skin.
D)
Reproductive system:-
Female-vaginal narrowing and decreased
elasticity, decreased vaginal secretion
Male: Decreased size of penis and testes slower
sexual response.
E). Genito-Urinary System :-
Male :- Benign prostatic
hypertrophy
Female:- Relaxed perineal
muscle frequency and
incontinence of urine
F) Gastro –
intestinal system :-
Complaints
of dry mouth .
Delayed
esophageal and gastric emptying leads to complaints
Of fullness
, heartburn and indigestion .
Reduced
gastrointestinal mobility leads to constipation , flatulence and abdominal
discomfort
G). Musculoskeletal System :-
-
Loss of
bone density , muscle strength and size, degenerated
joint cartilage leads to height loss, kyphosis, fracture, complaints of
back pain, loss of strength, flexibility and endurance and joint pain.
H). Nervous system :-
-
Reduced
speed in nerve conduction, increased
confusion with physical illness and loss of environmental cues , reduced
cerebral circulation causes slower to respond and react , learning takes
longer , becomes confused, complaints of forgetfulness and frequent falls.
5). Special Senses :-
Vision:
Diminished
ability to focus on close objects , inability to tolerate glare,
difficulty in adjusting changes of light intensity , decreased ability to
distinguish colors. As a result holds objects for away from
face, complaints of glare , complaints of poor night vision and confusion
co lour.
Hearing:
Decreased ability to hear high frequency sounds Results in inappropriate
responses, asks people to repeat words .Strains forward to hear .
Taste and
smell:
Decreased ability to taste and smell, results in excessive use of
sugar and salt.
6). Hallucinations and Delusions:-
As estimated 20 to 30 percent of patients with
dementia , primarily patients with dementia of the Alzheimer’s type , have
hallucinations and 30 to 40 percent have delusions , primarily of a
paranoid or persecutory and unsystematized nature, although complex,
sustained and well systematized delusions are also reported by these
patients. Physical aggression and other forms of violence are common in
demented patients who also have psychotic symptoms.
7). Other Sign and Symptoms:-
Psychiatric:
40 to 50
percent of patients with dementia are having anxiety and depression , in
addition to psychosis and personality changes patients with dementia may
also exhibit pathological laughter or crying , extremes of emotions – with
no apparent provocation .
Neurological:
In addition
to the aphasias in patients with dementia, apraxias and agnosias are
common other neurological signs that can be associated with dementia are
seizures, seen in approximately 10 percent of patients with dementia of
Alzheimer’s type and in 20 percent of patients with vascular dementia ,and
atypical neurological presentations , such as non-dominant parietal lobe
syndromes, primitive reflex – such as the grasp , snout , suck , tonic – may be present on neurological examination
and myoclonic jerks are present in 5 to 10% of patients..
Headaches, dizziness, faintness, weakness,
focal, neurological signs and sleep disturbance are some of the additional
neurological symptoms in-patient with vascular dementia. Cerebrovascular
disease pseudobulbar palsy, dysarthria and dysphagia are also more common
in vascular dementia than in other dementing conditions.
Catastrophic reaction:
Patients with dementia also exhibit reduced ability in abstract
attitude patients have difficulty in generalizing from a single instance ,
in forming concepts and in grasping similarities and differences among
concepts. Catastrophic reaction marked by agitation
secondary to the subjective awareness of intellectual deficits under
stressful circumstances.
Sundown
syndrome:
This is characterized by drowsiness, confusion ataxia and
accidental falls. It occurs in older people who are overly sedated and in
patients with dementia who reach adversely to even a small dose of a
psychoactive drug. The syndrome also occurs in demented patients when
external stimuli, such as light and interpersonal orienting cues are
diminished. It most commonly occurs as a result of benzodiazepines.
V. TYPES OF DEMENTIA :- Back
to Top
1).
Cortical and sub cortical dementia
Dementia may be associated with multiple sub cortical or cortical infarcts
and clinical features vary according to that .
Distinguishing features of sub cortical and cortical Dementia :
Non-Alzheimer’s dementia basically means sub-cortical dementia. Some
distinguishing features of sub cortical and cortical dementia are as
follows:
|
|
Sub cortical dementia |
Cortical dementia |
|
1. Language |
No aphasia |
Aphasia early |
|
2.. Memory |
Impaired recall>recognition |
Recall and recognition impaired equally |
|
3. Attention and immediate recall & visuospatial skills |
Impaired |
Impaired |
|
4. Calculation |
Preserved until late |
Involved early |
|
5. Frontal system abilities (executive function) |
Disproportionately affected |
Degree of impairment consistent with other involvement |
|
6. Speed of cognitive processing |
Slowed early |
Normal until late in disease |
|
7. Personality |
Apathetic inert |
Unconcerned |
|
8. Mood |
Depressed |
Euthymic |
|
9. Speech |
Dysarthric |
Articulate until late |
|
10. Posture |
Bowed or extended |
Upright |
|
11. Co-ordination |
Impaired |
Normal until later |
|
12. Motor speed and control |
Slowed |
Normal |
|
13. Adventitiois movements |
Chorea, tremor, tics, dystonia |
Absent (Alzheimer’s dementia: some myoclonus). |
2).
Reversible Dementia and Non reversible 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.
3). Pre senile dementia and senile dementia:
Pre–Senile dementia
– It resembles that of senile dementia except that disorders occurs in
younger age group . the onset of disease occurs in people of 40s and 50s
and people with this disease live an average 11 years after the onset of
disease.
Senile
dementia : It occurs usually after the age of 65 yrs. Due to degenerative bring
changes as accompanied by a clinical picture of mental deterioration. The
types of senile dementia are already mentioned previously.
I. Types
of dementia according to underlying etiology.
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.
a). Dementia in Alzheimer’s disease
with early onset.
-
Dementia in
Alzheimer’s disease beginning before the age of 65 years
-
Evidence of
relatively rapid onset and progression.
-
In addition
to memory impairment, there must be rapid deterioration, disorders of the
higher cortical functions, Aphasia, Agraphia, alexia and aparaxia occur
relatively early onset of dementia.
b). Dementia in Alzheimer’s disease
with late onset
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.
Four A’s of Alzheimer’s Disease
|
|
1. Amnesia: inability to learn new information or to
recall previously learned information.
2. Agnosia: failure to recognize or identify objects
despite intact sensory function. |
3. Aphasia: language disturbances that can manifest in
both understanding and expressing the spoken word.
4. Apraxia: inability to carry out motor activities
despite intact motor function (e.g. ability to grab a doorknob but not
knowing what to do with it.) |
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:
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.
-----------------------------------------------------------
VI. ASSESSMENT AND MANAGEMENT
Back to Top
We have discussed a wide variety of problem
that relate to dementia wide because the brain is very complicated organ,
and wide because the people and families are many different types,
reacting in different ways to a dreadful illness. How are we to collect
together all the facts about a particular patient, and her/his situation
in a way that is both concise and comprehensive?
In the assessment of dementia it is important
to look for the treatable causes although they are rare. The assessment
should also include a thorough search for treatable, often minor, medical
conditions that are associated rather primary causes. Treatment of these
conditions can reduce distress and disability.
TREATMENT
Some cases of dementia are regarded as
treatable because the dysfunctional brain tissue may retain the capacity
for recovery if treatment is timely. A complete medical history. Physical
examination , and laboratory tests, including appropriate brain imaging,
should be undertaken as soon as the diagnosis is suspected . If a patient
is suffering from a treatable cause of dementia, therapy is directed
toward treating the underlying disorder.
The general treatment approach to patients with
dementia is to provide supportive medical care, emotional support for the
patients and their families and pharmacological treatment for specific
symptoms, including disruptive behaviour. The maintenance of a patient’s
physical health, a supportive environment, and symptomatic
psychopharmacological treatment are indicated in the treatment of most
type of dementia. Symptomatic treatment also includes the maintenance of a
nutritious diet, proper exercise, recreational and activity therapies,
attention to visual and auditory problems, such as urinary tract
infections, decuibtus ulcers, and cardiopulmonary dysfunctions.
When the diagnosis of vascular dementia is
made, risk factors contributing to cerebrovascular disease should be
identified and therapeutically addressed.
The factors include hypertension,
hyperlipidemia, obesity, cardiac disease, and diabetes and alcohol
dependence. Patients who smoke should be encouraged to stop smoking
cessation is associated with improved cerebral perfusion and cognitive
functioning.
1).
Hospitalization
Clear indication for hospitalization are need
for diagnostic procedure. A history of rapidly symptoms, and the rupture
of patient, usual support system also indication for hospitalization any
adverse changes in symptoms, external behaviour or attitude of support
system is sufficient to warrant hospitalization.
2). History
taking
This is the baseline from which all other
information is judged by history taking information continues to be
relevant in other ways through out the illness. History of both patients
and families are very important.
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
A physical examination should be done where
indicated and this is particularly important in the following
circumstances.
-
Where
physical symptoms such as weight loss, pain are present.
-
Where the
patient has a history of potentially relevant physical disorder like a
history of endocrine disorder.
Including
an appropriately detailed neurological assessment with particular
attention to vision and hearing.
Systemic
observation should be made of his behaviour provide a scheme for assessing
memory for general events, past personal events and recent personal events
which gives a useful indication of the severity of intellectual handicap.
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
- Management of hypertension in multi-infract
dementia.
- Thyroid replacement in hypothyroid dementia .
- Shunting in hydrocephalic dementia.
- L-Dopa in Parkinsonism.
- Removal of toxic agent in toxic dementia.
7). Symptomatic
Management
- Environmental manipulation to reduce stress in
day to day activities.
- Treatment of medical complications
- Care of food and hygiene and supportive care for
the patient and family.
- Anxiety can be treated with short acting
benzodiazepines in low doses.
- Depression can be treated with Trazodone or
Miamserin as these agents have low anticholinergic,
activity and low cardiac toxicity. Agents with
anticholinergic activity can cause confusion or
frank delirium.
8). Currently
Available Treatments
Clinicians may prescribe benzodiazepines for
insomnia and anxiety, antidepressants for depression, and antipsychotic
drugs for X delusions and hallucinations, but they should be aware of
possible idiosyncratic drug effects in older people (such as paradoxical
excitement, confusion and increased sedation). In general drugs with high
anticholenergic activity should be avoided, although some data indicate
that thioridazine (Melleril), which does have high anticholenergic
activity, may be an especially effective drug in controlling behaviour in
demented patients when give in low dosages. Short acting benzodiazepines
in small dosage are the preferred anxiolytic and sedative medication for
dementia patients. In addition, Zolpiden (Ambien) may also be used for
sedative purposes.
Tacrine has been approved by the food and Drug
Administration as a treatment for Alzheimer’s disease. The Drug is a
moderately long acting inhibitor of cholinesterase activity, and
well-controlled trials have shows a clinically significant improvement in
20 to 25 percent of patients who take it. Because of the cholinomimetic
activity of the drug. Some patients are not able to tolerate the side
effects. Others must discontinue the drug because of elevations in liver
enzymes. A new drug, donepezil (Aricept), also improves cognition as has
fewer adverse effects. Neither drug, how ever prevents progressive
neuronal degeneration.
|
Noortropics: Piracetam, Oxiracetam, Aniracetam derivatives of GABA are
postulated to have neuroprotective effect on CNS against hypoxia
|
|
Ergoloidmesylate: Hydergine is currently used for the non-specific
cognitive impairment. |
|
Aspirin and NSA ID: Data suggests that it protect against the development
of disease due to its anti-inflammatory properties |
|
Estrogen Therapy: Oestrogen therapy in postmenopausal women might help in
the delaying the development of dementia. |
|
Sabeluzole: This substance shown to protect neuronal cells against gutamate
induced and hypoxia induced injury and may potentiate the tropic
effect of nerve growth factor. It may improve long term memory of
elderly patient. |
|
Rivastigmine: Rivastigmine in the dose of 6 to 12 mg/Day was given to two
groups. One group of patient was Alzheimer’s disease with vascular
risk factor as hypertension and other group was without risk factor.
After 26 weeks of trial vascular risk factor group showed significant
improvement. Rivastigmine in diffuse Lewy body dementia had shown
improvement in cognition particularly attention and in psychiatric
symptoms. |
|
Nitrendipine: Elderly people who were suffering from systolic hypertension
when treated with nitrendipine, a calcium channel blocker occurrence of
dementia was less in this group. |
|
Gingko Biloba, Ginseng: It is also helpful in demented patient. |
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.
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.
10). Physiotherapy
It will help to organic and structure their
daily activities such as muscle and joint exercises, breathing exercises,
speech therapy to improve blood circulation etc.
Physiotherapy is helpful for chronic
encephalitis, meningitis and general paresis of insane. It is also helpful
to remove contracture of limbs, deformities of extremities or embolities.;
It improves physical health. Appetite, digestion elimination, circulation,
muscle tone and body temperature.
11). Social Relationship
Dementia patient become isolated from
community. So community member should be in a sympathetic manner. Talking
to them and asking ordinary questions also help the patient. More
deterioration will take place when there is nothing to talk, to think or
to work. The social approach plays a great role in psychiatric illness.
The patient must learn or relearn how to assume responsibility for the
welfare of himself and others for social relationship.
12). Day centres
Day
centres are run by the social work department. These have been developed
partly because larger day centres are usually not organized to cope with
dementia. The core of the large day centre’s work concerns older people
who wish to meet other people and engage in activities. It is assumed that
they will be able to select their friends and select their activities,
will take an active part in what goes and in most cases, make their own
way to and from centre.
The need for day centres to cater for dementia
suffers. Day care is needed who are the Physically and the mentally
impaired attending together and involving a mice of services.
VIII. NURSING MANAGEMENT OF
PATIENTS WITH DEMENTIA
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The Nursing care should be given according to
its cause, onset of illness and severity. The main aim of nursing care is
to make the patients life easier and pleasant. There is no effective
treatment of cerebral pathology but we can help the patient in adjustment
to life and coping with stress.
1). Maintenance
of optimal cognitive functions.
a). Reduce environmental confusion
- Approach patient in a pleasant, calm way.
- Introduce yourself to the patient and greet
him/her
- Keep the environment simple and pleasing, remove
all unwanted utensils from the room.
- Maintain a regular daily living schedule, so
that the patient will get touch with the daily
living activities.
- Provide memory device like, lists of activities,
reminding notes, labels on items; pictures, diagrams
etc. will assist the patient to remember..
b). Increased environmental cues.
- (It will enhance orientation to time place and
person by filling memory gaps and serving as
reminders)
- Identify yourself when interacting with the
patient
- Address patient by name facilitate orientation
to self.
- Offer environmental cues for orientation to
time, place and person.
- Bring the patient near the window and shows him
the surroundings.
- Interpret environmental stimulation as part of
the conversation.
- E.g. : Prior to switch on the light late in the
evening, tell the patient that the day is going to
be over and we need light, hence switch on the light
2). Maintenance
of Physical Safety
a). Control of environment
- Approach patient in a pleasant, calm way.
- Introduce yourself to the patient and greet
him/her
- Keep the environment simple and pleasing,
remove all unwanted utensils from the room.
- Maintain a regular daily living schedule, so
that the patient will get touch with the daily
living activities.
- Provide memory device like, lists of
activities, reminding notes, labels on items;
pictures, diagrams etc. will assist the patient to
remember..
b). Monitor medication regimen
- Administer drug at appropriate time and dose, should not leave the
medicine by the patient.
c). Monitor the temperature of food.
- Patient is
protected from burning his mouth with warm food.
d). Permit maximum independence and
freedom.
-
Allow freedom to move
around in the safe environment will give a sense of
autonomy and relaxation
-
Avoid use of restraints
(restraints may increase agitation)
-
Keep identification tag
on patient will facilitate a safe return to the
ward.
3).
Maintenance
of an optimal level of psychological functioning.
a). Reduce
anxiety provoking situations in daily routine.
-
Keep reality orientation,
non-threatening but acceptable to the patient –
repeat the answer if the patient asks again and
again.
-
Be patience with
forgetfulness.
-
Maintain a daily, regular
routine so that the client is able to recall the
daily activities.
-
Simple structured stimuli
are easiest to interpret, for example call the
patient by name just before lunch, tell him the
exact time and about the lunch.
-
Be with the patient and
listen to him what he/she actually wish to
communicate with you.
-
Avoid situation that have
upset patient in the past.
-
Do not try to reason with
the patient (Patient is unable to conduct abstract
thinking)
b). Enhance the
quality of life.
-
Offer multiple
opportunities for fulfillment like light music ,
walks , exercises, old hobbies watching TV etc. if
the patient is able to perform such activities.
c). Encourage
positive feeling of self.
-
Treat the person as an
individual with feelings (acceptance is the great
inner support)
-
Should not under estimate
the patient.
-
Openly discuss his
feelings of anxiety and encourage him for further
emotional ventilation when ever he needs and teach
him relaxation methods , to reduce anxiety.
-
Praise appropriately for
expected behaviour.
-
When skills are lost do
not try to restrain deterioration of the cognitive
process makes loss of skills inevitable.
4). Attainment
of an optimal exchange of ideas between the patient and others.
a). Implement
strategies to promote the patient’s interpretation of messages.
-
Be calm , pleasant , and
unhurried.
-
Keep verbal message short
and simple.
-
Use non-verbal messages
along with words .
-
Be consistent in
conversation.
-
Simple message are
easiest to interpret .
-
Write down simple
instructions and lists.
-
Observe patient’s
expression for signs that he understands.
-
Talk to the patient even
if he givens little or no response.
b). Develop
strategies to improve the patient’s ability to express messages.
-
Supply forgotten words
when possible. This will allow to express his needs
and feelings.
-
Guess the message and
confirm with the patient (Active listening will
minimize frustration)
-
Ignore mistakes
-
Allow adequate time for
conversation
-
Encourage short, simple
sentences.
-
Ask “Yes/No” questions
unhurried attitude will enhance communication.
-
Provide alternative
methods for communication pointing, describing with
pictures etc.
-
Acknowledge frustration
in conversation that the patient is experiencing. It
facilitate confidence.
5).
Maintenance
of maximum independence in activities of daily living.
a). Develop
plan to facilitate daily performance of activities.
-
Maintain a regular daily
schedule at a time convening with the patient.
-
Provide adaptive devices
like lengthy brush for bath. Keep the instruction
simple and divide the tasks in to small parts and do
it first then ask the patient to do if further as
much as he can. Stay with the patient till the task
is over. Remind him if he stops in between because
of confusion or short attention span.
-
Monitor functions of body
system supervision will promote optimal function and
help to detect early problems.
b). Provide
specific safe guards of safety in bathing.
-
Monitor bath water
temperature
-
Help the patient to take
his bath completely and safely.
-
If we leave the patient
alone for bath he may pour few mugs of water and
come off, some times he may loose connection with
what is being done ? why he is in the bath room ?
-
Encourage use of safety
measures in the bathroom like hand rails , rubber
mats to prevent bath room falls
c). Provide specific measures to remember places.
-
Provide accessibility to
bath room. Indicate bathroom with colored pictures ,
visual stimuli reinforces recognition.
-
Remind the patient about
toilet, where it is , it is in the north/south?
Confused or disoriented patient may pass motion in
an odd place thinking that is toilet.
-
Use clothing that open
easily .
-
Maintain toileting
schedule every two hourly (This help to maintain
normal elimination)
-
Encourage adequate fluid
and fiber rich food and activity for regular bowel
movement.
-
Restrict fluid in evening
hours . (This may interfere with sleep)
6). Maintenance of optimal level of
nutrition
a). Monitor food intake and observe food
habits.
-
Note weight loss or gain
-
Provide regular mealtime
schedule.
-
Encourage adequate fluid
intake.
-
Provide balanced diet. If
the client is unable to feed himself, feed the
patient; during feeding narrate short stories which
stimulate appetite as well as concentration.
-
Maintain a calm and
pleasant atmosphere.
-
Offer a menu choice if
possible.
-
Offer familiar food.
(Pleasant mealtime C favorite and familiar food, the
client will eat well with enjoyment).
b). Promote regular mouth care.
7). Maintain optimum personal hygiene
a).
Promote
healthy skin
-
Keep the skin clean and
dry.
-
Massage the extremities
and back it will helps to improve muscle tone and
circulation.
-
Lubricate the skin it is
dry.
-
Assist with back, buttock
and foot, care to prevent bedsore.
Provide
clean and dry under clothing’s.
b). Promote
healthy hair and scalp.
c). Encourage
nail care.
-
Maintain clean and short
nails of both extremities.
-
Provide soap and water to
wash hands after each toiler visit.
8). Maintenance of a balance of sleep
and activity.
-
Reduce nighttime
distractions such as noise, nursing procedures or for
mid – night medications etc.
-
Take measurement to
increase safety.
-
Provide adequate
night-lights.
-
Enhance comfort if awake at
night.
-
Avoid use of restraints
-
Design a balanced schedule
of activity / sleep
-
Increase daytime
wakefulness and encourage short rests than long time
rest.
-
Encourage regular exercise
and activity programs to mobilize joints (Daily
activity and exercise reduce agitation and produce
soothening and a calming effect.
9).
Enhancement
of socialization and fulfillment of intimacy needs.
-
Encourage visits from
family and friends.
-
Use touching to maintain
contact with patient. Tactile stimulation is easiest
to interpret.
-
Introduce the family
members and friends using names which is familiar to
the patient.
-
Address the patient with
his designation e.g.: Daddy, Uncle, and Granny etc.
-
Share feelings honestly and
openly with patient simultaneously holding his/her
hands or touching on his/her shoulder. (He client
continuous to need love and affection from his own
people)
-
Limit numbers of visitors
one or two at a time, to avoid confusion and to
maintain single stimuli.
-
Accept the patient despite
negative interactions.
10. Provide
Rehabilitation
-
Support and retrain the
existing skills.
-
Provide Physiotherapy if
the client has difficulty in walking.
-
Provide hearing aids, if
the hearing is impaired.
-
Speech therapy and
cognitive retraining in the case of aphasia
(expressive aphasia)
-
Impaired vision, provide
big lettered books/schedule
-
Reading glass if necessary
-
Bladder and bowel training
if incontinence is present.
IX. NURSING CARE PLAN FOR PATIENTS
WITH DEMENTIA
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A.
|
Nursing Needs |
Goals |
Planning |
Implementation |
Evaluation |
|
Therapeutic Needs |
1. To All types of illness may be treated
symptomatically reduce any types of infection
2. To recover from any infection
3. Help him to develop sense of security.
|
All types of illness may be treated
symptomatically |
1. Give medicines as prescribed.
2. Help the patient to express his physical
complaints.
3. Give assurance that medicine will be provided
in time.
|
|
B.
|
Nursing Needs |
Goals |
Planning |
Implementation |
Evaluation |
|
Physical needs
Prevent from injuries |
1. To help to avoid repeated injuries
2. To feel confident that environment is safe. |
1. Plan safe and less congested environment
.
2. Plan to keep few activities, no injuries to
patient |
1. Provide adequate furniture in the room.
2. Check no wires, tubes etc. are spread in room.
3. Electricity connections should be covered
4. Provide the same physical setup.
5. Any change in the room should inform the
patient.
6. Provide a bell.
7. Adequate light.
8. Pleasant and quite environment. |
Moves in the room with confidence. |
|
Promote Communication |
1. To enhance self concept.
2. Develop sense of satisfaction of interacting
with others.
3. Feel accepted |
1. Spend time with patients.
2. Selective Communication |
1. Approach in a slow calm manner.
2. Observe non-verbal cues.
3. face the patient
4. Talk gently
5. Give simple clear message him to talk .
6. Listen with respect
70 Repeat instruction frequently |
Express happiness that, he is able to convey
message clearly |
|
Nursing Needs |
Goals |
Planning |
Implementation |
Evaluation |
|
Reduce disorientation |
1. To help him feel comfortable and decreased
confusion
2. To help in regular activities
3. To feel secure and decreased restless. |
1. Re-orientation
2. Clear communication |
1. Orient him to time, place of persons with help
of a clock calendar and physical setup.
2. Call him by his name.
3. Repeat the routine activity
4. Avoid argument
5. Speak slowly, clearly in simple sentence.
6. Convey warmth and concern.
7. Touch him to provide a sense of security.
8. Respond to his question
9. Encourage him to speak clearly, not to mumble
words
10. created comfortable environment without stress
or hurry |
1. He looks less confused
2. Feels comfortable in the setting
|
|
Help in personal hygiene |
1. To help patient to feel fresh
2. Develop sense of well being
3. Habit of cleanliness
4. Prevent infection
5. Feel accepted |
1. Setup a routine plan out activities for
regular bowel and bladder habits |
1. Help him to brush and take bath
2. Help him to clean his back
3. Give message at the back to prevent bed sore.
4. Change position
5. Observe skin for injuries, bruising or abrasion
6. If in continence change the dress put deodorant
to prevent odor
7. If constipation provide laxatives
8. Step by step directions to be given
9. Don’t be in hurry
10. Encourage to comb, shave etc. |
Patient brush his teeth, take bath, combs hair
trice to tries to be self sufficient.
|
|
Nursing Needs |
Goals |
Planning |
Implementation |
Evaluation |
|
Help to adjust with perceptual change |
1. To reduce anxiety
2. To adjust perceptual deprivation
3. To improve in his sensation
4. To decreased irritability |
1. Patients are very confused and had anxiety.
2. Not able to recognize places
3. Help to reduce anxiety and confusion
4. Patient will be disturbed with hallucination.
Help him to cop up |
1. Re-orient the place and allow him to touch and
feel familiarity .
2.Allow him to smell his old perfume
3. Prevent him from burns. Lack of sensitivity may
cause burn.
4. Speak very clearly to patient.
5. Help the relatives to understand that changes
is due to disease. |
Patients feel less restless. |
|
Help to adjust in alteration in memory of
attention |
1. Help the patient to increased attention span.
2. To adjust memory changes. |
1. Patients get irritated unable to recall, recent
events.
2. Feels inadequate in front of relative and
friends. |
1. Make them to understand change is due to
disease.
2. Tell the relatives not to get irritated if he
were forget to inform important messages.
3. Switch an old songs or show old photographs to
stimulated memory.
4. Provide activities of his own choice
5. Give appreciation for complete work
6. Provide opportunity to do the tasks, which he
had been doing for many years |
1. The patients shows concentration and efficiency
in his works
2. Feels comfortable with old things. |
|
Nursing Needs |
Goals |
Planning |
Implementation |
Evaluation |
|
Help to adjust with perceptual change |
1. To reduce anxiety
2. To adjust perceptual deprivation
3. To improve in his sensation
4. To decreased irritability |
1. Patients are very confused and had anxiety.
2. Not able to recognize places
3. Help to reduce anxiety and confusion
4. Patient will be disturbed with hallucination.
Help him to cop up |
1. Re-orient the place and allow him to touch and
feel familiarity .
2.Allow him to smell his old perfume
3. Prevent him from burns. Lack of sensitivity may
cause burn.
4. Speak very clearly to patient.
5. Help the relatives to understand that changes
is due to disease. |
Patients feel less restless. |
|
Help to adjust in alteration in memory of
attention |
1. Help the patient to increased attention span.
2. To adjust memory changes. |
1. Patients get irritated unable to recall, recent
events.
2. Feels inadequate in front of relative and
friends. |
1. Make them to understand change is due to
disease.
2. Tell the relatives not to get irritated if he
were forget to inform important messages.
3. Switch an old songs or show old photographs to
stimulated memory.
4. Provide activities of his own choice
5. Give appreciation for complete work
6. Provide opportunity to do the tasks, which he
had been doing for many years |
1. The patients shows concentration and efficiency
in his works
2. Feels comfortable with old things. |
|
Nursing Needs |
Goals |
Planning |
Implementation |
Evaluation |
|
Help to adjust with perceptual change |
1. To reduce anxiety
2. To adjust perceptual deprivation
3. To improve in his sensation
4. To decreased irritability |
1. Patients are very confused and had anxiety.
2. Not able to recognize places
3. Help to reduce anxiety and confusion
4. Patient will be disturbed with hallucination.
Help him to cop up |
1. Re-orient the place and allow him to touch and
feel familiarity .
2.Allow him to smell his old perfume
3. Prevent him from burns. Lack of sensitivity may
cause burn.
4. Speak very clearly to patient.
5. Help the relatives to understand that changes
is due to disease. |
Patients feel less restless. |
|
Help to adjust in alteration in memory of
attention |
1. Help the patient to increased attention span.
2. To adjust memory changes. |
1. Patients get irritated unable to recall, recent
events.
2. Feels inadequate in front of relative and
friends. |
1. Make them to understand change is due to
disease.
2. Tell the relatives not to get irritated if he
were forget to inform important messages.
3. Switch an old songs or show old photographs to
stimulated memory.
4. Provide activities of his own choice
5. Give appreciation for complete work
6. Provide opportunity to do the tasks, which he
had been doing for many years |
1. The patients shows concentration and efficiency
in his works
2. Feels comfortable with old things. |
|
Nursing Needs |
Goals |
Planning |
Implementation |
Evaluation |
|
Nutritional need |
1. To build general health
2. To make him to take regular meals.
3. Build up health |
1. May take small quantity for fear of in
continence
2.. Soft, easily digestible food.
|
1. Ask his likes and dislikes.
2. Soft and frequent meals.
3. Don’t scold him, if he has messed up
4. don’t make him to hurry up
5. Provide roughage and green leafy vegetable. |
Patient enjoys soft meals. |
|
Improve sleep |
1. To reduce loneliness and depression at height
2. To feel fresh
3. Participate in day activities.
4. Get reduce fatigued |
1. Planning sleep schedule.
2. A calm and quite environment |
1. Discourage day time sleep.
2. Keep him busy with activities
3. Encourage warm water bath at night
4. Keep the room calm.
5. Give bath massage
6. Allow him to read books in he interested
7. Provide warm milk |
Sleep for long hours at night |
C.
|
Nursing Needs |
Goals |
Planning |
Implementation |
Evaluation |
|
Psychological needs |
1. To reducing the feelings of isolation.
2. To develop sense of belongingness
3. Enhance self concept |
1. Feels alien among his own
2. Likes to participate in activities
3. Provide an attitude of concern |
1. Call him by his name.
2.Tell the relatives to visit
3. Encourage activities
4. Actively listen to his past experience
5.Listen him with respect
6.Encourage visit by children |
Feel satisfied
Talking to others |
D.
|
Nursing Needs |
Goals |
Planning |
Implementation |
Evaluation |
|
Recreational needs |
1. To decrease social isolation
2. To spend time productively
3.To enjoy life
4. Feel useful for family members |
1. Help in diverting patients mind
2. Hobbies of his own, in which some productive
outcome is possible |
1. Tell children to pay with patients, simple
games.
2. Provide knitting which she enjoys.
3. Read story for children.
4. TV. program of his choice.
5. Encourage to interact with his own group |
Patients enjoys life and feels he is useful for
family members. |
E.
|
Nursing Needs |
Goals |
Planning |
Implementation |
Evaluation |
|
Spiritual needs |
1. To help him to follow his routine
2. To reduce distress and despair. |
1. Help him to maintain their rituals
2. Help them to adjust |
1. Allow the patient to attend his regular
prayers.
2. Don’t get irritated with extra time spent by
patient.
3. Graduals help him to reduce the time.
4. Provide religious books. Videos and cassettes.
|
The patient says “ Now I am not able to pray for
long because I get tired”. |
F.
|
Nursing Needs |
Goals |
Planning |
Implementation |
Evaluation |
|
Discharge plan |
1. To help him to be self sufficient.
2. To cope with changes due to illness |
1. Depends on family support.
2. Discuss with family
3. To develop realistic goal towards patients
recovery |
1. Encourage family to talk about problems they
have to face at home.
2. discuss the plan of care at home.
3. Explain the needs to make physical and social
adjustment
4. Educate patient’s relatives for after care help
from various agencies.
5. Importance of follow-up care |
Relative of patients get prepared to adjust at
home. |
X. PROBLEMS OF THE CARER
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The carer, often a spouse is likely to also be
elderly and possibly with poor physical health. If the carer is a child
they may have family responsibilities such as dependent children,
producing divided loyalties and some times marital conflict. The carer may
live a distance away and suffer financial problems from travel expenses.
There may be embarrassment caused by the reversal of roles, especially if
caring for the personnel hygiene of a parent of the opposite sex. Lack of
insight and knowledge of the progress of dementia, which symptoms can be
modified and how to obtain help, can all be remedied by introducing the
carer to a support group such as Age concern and the Alzheimer’s Disease
society.
Help of Carer
Carer giving is hard work and is usually
considered a professional activity. Amateur careers are untrained so it is
not surprising they makes mistakes such as using restrain to prevent
behaviour (e.g.: locked doors or request for sedation) rather than
environmental or Psychological management Brodaty (1992) Suggests that,
training should be comprehensive, tailored to Individual needs, and
continuing through the different phases of the illness. A joint report by
the RCP (1989) suggests that for the massive issue of Dementia, the
emphasis should be on support of carer. Attention should be given to
“Those aspects which wear careers down such as restlessness, aggression,
disturbed nights and in continence “together with complicating problems
such as depression in patient of career. The report describes the role of
the community Psychiatric Nurse as monitoring and support, counseling,
helping with practical, financial and emotional difficulties and advocacy
on behalf of the patient and families. How ever one must beware the
tendency for paternalistic control. Where a patient is in capable of
consent, relatives should be consulted closely at every stage of
treatment. But when a patient is capable of making certain decisions. It
is both unnecessary and stigmatizing to wish to confirm the decision with
a relative (Murphy 1986).
1) In the Home:
- The home
help service can reduce the amount of work necessary in the house, leaving
the carer more time to spent with the patient. Some district run schemes
where paid or voluntary carers come to the house and stay with the
demented patient while the carer with the demented patient while the
career goes out, or take the patient out for some hours giving the career
since alone in the home.
2)
Outings: Many voluntary
and statutory groups are able to arrange outings, either day trips or even
holidays, for the carer and patient, to give interest and stimulation to
them both.
3) Day Care: - Social service
department and voluntary service run day care scheme in all areas. It is
usually possible for transport to collect and return the patient, although
sometimes a carer may do this, if there are major problems with physically
dependency or behaviour such as aggression day care may be provided by the
psycho geriatric day hospital, which has a higher number of staff,
including nurses to deal with such problems.
XI. CONCLUSION
Back to Top
Dementia is irreversible psychiatric disorder
characterized by the global impairment of higher cortical function
including, memory, the capacity to solve the problems of day to day
living, the performance of learned percept motor skills, the correct use
of social skill and control of emotional reactions, in the absence of
clouding of consciousness. The condition is often irreversible and
progressive.
A necessary pre-requisite for the development
of dementia is a relatively wide spread cerebral dysfunction or damage or
both. Psychological and psychosocial factors influence to a limited
extent, the degree of severity of dementia. The diagnosis of dementia
rests on clinical grounds and identification of the underlying disease
process. The clinical diagnosis of dementia is arrived at by the
information obtained from a detailed longitudinal history and a mental
status examination, supplemented by a thorough physical examination, once
the diagnosis of dementia is established the choice of investigation
should be done. Basic screening test is necessary for proper diagnosis.
After diagnosis psychosocial management,
institutionalization, treatment of concurrent psychiatric disorder and
various medical interventions purposed to improve cognitive functions
assume importance. Nursing care is also ever important for demented
patient according to its cause, onset of illness and severity. The main
aim of nursing care is to make the patients life easier and pleasant. It
also provides safe environment for the patient. Fulfill his basic needs
and emotional needs. Demented patients can be treated in community mental
health centres. The team members visit the home and teach patient and
family members and educational, recreational and social activities are
planned and provided.
Demented patient can also be placed in dementia
centres and geriatric nursing homes. In India also emphasis is being given
good care to dementia patients. There are provisions to treat these cases
in the Dementia centres in India, Example Kerala, Madras, Vellor, and
Bangalore etc.
XII. PRE AND POST TEST
Back to Top
Time – 1 hour
Total Mark – 25
|
1. |
Define Dementia |
2 |
|
2. |
Mention 4 Degenerative causes of Dementia? |
2 |
|
3. |
List down 4 metabolic causes of dementia |
2 |
|
4. |
List down 4 types of dementia |
2 |
|
5. |
Name 2 types of senile dementia |
2 |
|
6. |
Mention 6 major sign and symptoms of Parkinson’s disease |
3 |
|
7. |
What are the main signs and symptoms of Pick’s disease |
2 |
|
8. |
List down 4 sign and symptoms of Creutzeld-Jakob disease |
2 |
|
9. |
What are the common mood changes in dementia ? |
2 |
|
|
Makes Questions 10 & 11 true or false |
|
|
10. |
Antipsychotic mediations are not particularly effective
in treating symptoms of dementia. |
½ |
|
11. |
The primary goal of nursing care for patient with dementia is an
individualized approach that maintains an optimal level functioning. |
½ |
|
12. |
What are the main goals of NSG: Management of dementia patient? |
5 |
XIII
ANSWER KEY
1). ICD – 10 define 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, consciousness is not clouded, occasionally
deterioration in emotional control, social behaviour or motivation seen.
2)
a) Alzheimer’s disease
b) Pick’s disease
c) Huntington’s chorea
d) Lewy body disease
3)
a) Sustained uremia
b) Liver failure
c) Hyponatremia
d)
Hypocalcemia
4)
a) Dementia is Alzheimer’s disease
b) VAScular dementia
c)
Dementia in Parkinson's disease
d)
Alcoholism dementia
5) a) Simple deterioration
b) Paranoid reaction
6)
a) Rigidity
b)
Shuffling gait
c) Mask like face
d)
Mumbling of speech
e) Hypokinesia
f)
Difficulty in co-ordination
7)
a) emotional blunting
b)
Coarsening of social behaviour
c) Disinhibition
d) Apathy & Aphasia
8)
a) Pyramidal symptoms
b)
Extra pyramidal symptoms
c) Cerebellar symptoms
d)
Visual impairment
9)
a) Emotional in continence
b)
Threshold effect
c)
Incongruous emotion
d)
Catastrophic reaction
10. False
11. True
12)
a) Maintenance of optimal cognitive functions.
b)
Maintenance of Physical safety.
c)
Maintenance of an optimal level of psychological functioning .
d)
Attainment of an optimal exchange of ideas between the patient and others.
e)
Maintenance of maximum independence in activities of daily living.
f)
Maintenance of optimal level of nutrition .
g)
Maintenance of optimum personnel hygiene.
h)
Maintenance of a balance of sleep and activity.
i)
Enhancement of socialization and fulfillment of intimacy needs.
j)
Provide Rehabilitation.
XIV. BIBLIOGRAPHY
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Gelder M, Gath D, Mayou R, owen P. Oxford
Textbook of Psychiatry. Third Edition. Oxford
University Press. New delhi 2000.
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Ahuja,N. A short Textbook of Psychiatry. 5th
Edition Jaypee Brothers New Delhi 2002.
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Alan Jacques. Under standing dementia, Churchill Livingstone,
New York, 1988.
-
Murray and Huelskoetter – Psychiatric Mental health Nursing: Giving
Emotional care; 2nd edn, Prentice Hall, Englewood cliffs, New Jersey , 1989 PP 567 – 87.
XV. GLOSSARY
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Acetylcholine: A chemical transmitter
that is released by some nerve ending at the synapse.
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Acromegaly: A chronic condition
producing gradual enlargement of the hands feel and
bones of the head and chest Associated with over
activity of the anterior lobe of the pitutary gland in
adults.
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Addison’s disease: deficiency
disease of the suprarenal cortex, often tuberculosis.
There is wasting, brown pigmentation of the skin and
extreme debility.
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Agnosia: Difficulty in recognizing
familiar objects a symptoms of organic brain
disease.
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Agitation: Anxiety associated with
severe motor restlessness.
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Alzheimer’s disease: more currently
referred to as dementia of the Alzheimer’s type
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(DAT). DAT is the common type of
dementia.
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Amyloid:1. pertaining to starch 2. A
waxy starch that forms in certain tissues.
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Aphasia: A communication disorder due
to brain damage, characterized by complete or partial
disturbance of language, comprehension, formulation or
expression.
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Apraxia: The inability to perform
correct movements because of a brain lesion.
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Arteriosclerosis: A gradual loss of
elasticity in the walls of arteries due to thickening
and calcification
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Autopsy: Postmortem examination of a
body to determine the cause of death.
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Brady Kinesia: Slow or retarded
movement
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Chromosome: In animal cells, a
structure in the nucleus containing a linear thread of
DE OXY RIBONUCLEIC ACID (DNA) which transmits genetic
information and is associated with ribonucleic acid
and histones.
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Comprehension: The capacity to
perceive and understand.
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Cognition: The act or Process of
knowing and perceiving.
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Consciousness: State of awareness
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Confusion: Disturbed orientation, some
times accompanied by disordered consciousness.
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Corticotrophin: Advenocorticotrophic
hormone – (ACTH)
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Cushing’s disease: A condition of over
secretion by the adrenal cortex due to an adenoma of
the pituitary gland.
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Dementia: A disorder that causes
pronounced memory and cognitive disturbances.
Typically dementia are gradual in onset and
progressive in course.
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Delusion: A false idea or belief held a
person which cannot be corrected by reasoning.
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Development :the process of growth and
differentiation.
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Delirium: A disorder with alteration
in consciousness and changes in cognition, which is
usually caused by a general medical condition or is
substance induced. Typically, delirium develop over a
short period of time and are treatable. A (usually)
reversible bewildered state of clouded consciousness,
generally accompanied by restlessness, disorientation
and fear, may include periods of hallucination.
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Dopamine: A substance allied to
noradrenaline and used in the treatment of cardiogenic
shock. Also occurs naturally in the adrenal medulla
and the brain where it functions as a transmitter of
nervous impulses.
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Dysphagia: Difficulty in swallowing
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Dyspraxia: Partial loss of ability to
perform coordinated movements.
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Encephalitis: Inflammation of brain.
There are many types of encephalitis depending on the
causative agent and the structure involved.
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Hallucination: A sensory impression
(sight, touch, sound, smell or taste) that has no
basis in external stimulation
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Heredity: the transmission of both
physical and mental characteristics to the offspring
from parents.
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Hypocalcaemia: An excess of calcium in
the blood may be caused by over administration of
Vitamin D, hyper parathyrodism, thyrotoxicosis, break
down of bone by malignant disease, or impaired renal
function.
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Hyper insularism: 1- excessive
secretion of insulin, 2. Shock produced by an overdoes
of insulin .
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Hyperkalaemia: An excess of potassium
in the blood. If untreated it will lead to cardiac
attest.
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Hypochondria: A morbid pre-occupation
or anxiety about one’s health . The sufferer feels
that first one part of his body and then another part
is the seat of some serious disease.
-
Impairment: Any loss or abnormality of
psychological, physiological or anatomical structure
or function.
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Infarct: The wedge shaped area of
necrosis is an organ produced by the blocking of blood
vessel , usually due to an embolus. The area is
suddenly deprived of blood and is pale in colour.
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Insomnia: Inability to sleep.
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Insight: Mental awareness . The
capacity of an individual to estimate a situation or
his own behaviours or the connection between his
present attitudes and past experience.
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Judgment: The ability of an individual
to estimate a situation , to arrive at reasonable
conclusions and to decide on a course of action.
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Memory: The mental capacity that
enables one to retain and recall previously
experienced , sensations , impressions , information
and ideas.
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Meninges: the membranes covering the
brain and spinal cord.
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Meningitis: Inflammation of the
meninges due to miroorganisms , such as bacteria
viruses and fungi.
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Neurosyphilis: Manifestation of third
stage syphilis in which the nervous system is
involved.
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Nihilism: In psychiatry , a term used
to describe feelings of not existing and hopelessness,
that all is lost or destroyed.
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Nystagmus: An involuntary rapid
movement of the eyeball .it may be hereditary or
result from disease of the semi circular canals of the
central nervous system.
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Organic: Pertaining to the organs
disease of an organ accompanied by structural changes.
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Orientation: A sense of direction . The
ability of a person to estimate his position of a
person to estimate his position in regard to time, and
person.
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Paranoia: A mental disorder
characterized by delusion of grandeur or persecution
which may be fully systematized in logical form , with
the personality remaining fairly well preserved.
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Pathological : Pertaining to pathology
causing or arising from disease.
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Psychometrics :The measurement of
mental characteristics by means of a series of tests.
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Rapport: In psychiatry, a satisfactory
relationship between two persons , either the doctor
and patient or nurse and patient or the patient with
any other person significant to him.
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Rehabilitation: Re-education ,
particularly of one who has been ill or injured, so
that he may become capable of useful activity.
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Senile: Related to the involuntional
changes associated with old age.
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Schizophrenia: A general term
encompassing a large group of mental disorder
characterized by mental deterioration from a previous
level of functioning and characteristic disturbances
of multiple psychological processes .
-
Stroke: A popular term to describe the
sudden onset of symptoms, especially those of cerebral
origin.
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Sub arachnoids: Below the arachnoids
space between the arachnoids and piamater of brain and
spinal cord, and containing cerebrospinal fluid.
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Subdural: below the dura mater space
between the arachnoids and durra mater
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