DEMENTIA

DEFINITION

The term dementia refers to the loss of memory reasoning,judgement,and language to such an extent that it interferes with everyday life.The changes may occur gradually or quickly and how they come about is the key to determine whether the condition causing dementia is temporary

Dementia is a syndrom e characterized by dysfunction or loss of memory,orientation,attention,language and judgementand reasoning and changes in the behaviour,ultimately these changes will result in the alteration in the individuals ability to work,social and family responsibilities and activities of daily living

CAUSES OF DEMENTIA

• Neurodegenerative disorders-Alzeimers disease,frontal lobe dementia,Frontal temperoral dementia(Eg:Pick s disease),Down syndrome,Amylotropic lateral sclerosis,Parkinson s disease,Huntingtons disease.
• Vascular diseases-Vascular multi infarct dementia,cardiac diseases producing emboli or decreased perfusion,Subarachnoid hemorrhage,chronic subdural hematoma.
• Toxic or metabolic disease-Alcoholism,Thiamine(Vitamin B1)deficiency,Cobalmin (Vitamin B12)deficiency,folate deficiency,hyperthyroidism,hypothyroidism,
• Hypoglycaemia,hypercalcemia.
• Immunological diseases or infections-Multiple sclerosis,chronic fatigue syndrome,AIDS,meningitis,encephalitis.
• Systemic diseases-Dialysis dementia,hepatic encephalopathy,
• Trauma-Head injury
• Cancer-Brain tumor,metastatic tumor
• Ventricular disorders-Hydrocephalus
• Seizure disorders-Epilepsy
• DrugsDiuretics,digoxin,anticholinergics,Narcotics,hypnotics,antihypertensives,antiparkinsonian drugs,antihistamines.
• Genetic factors are linked with Alzeimer s disease.Atleast five chromosomes(1,12,14,19,21) are involved in the familial AD including the amyloid precursor gene,the presenelin 1 gene,the presenelin 2 gene,the presenelin 1 gene and the presenelin 2 gene,apolipoprotein E gene.

Situations affecting behavior may include:

• Moving to a new residence or nursing home
• Changes in the environment or caregiver arrangements
• Misperceived threats
• Admission to a hospital
• Being asked to bathe or change clothes
• Fear and fatigue resulting from trying to make sense out of an increasingly confusing world

Potential solutions
Monitor personal comfort. Check for pain, hunger, thirst, constipation, full bladder, fatigue, infections and skin irritation. Maintain a comfortable room temperature.
Avoid being confrontational or arguing about facts; instead, respond to the feeling behind what is being expressed. For example, if a person expresses a wish to go visit a parent who died years ago, don't point out that the parent is dead. Instead, say, "Your mother is a wonderful person. I would like to see her too."
Redirect the person's attention. Try to remain flexible, patient and supportive.
Create a calm environment. Avoid noise, glare, insecure space, and too much background distraction, including television.
Simplify the environment, tasks and solutions.
Allow adequate rest between stimulating events.
Provide a security object or privacy.
Equip doors and gates with safety locks.
Remove guns.

RISK FACTORS

• Age
• Family history
• Genetics (heredity)
• Head injury
• Heart-head connection
• General healthy aging

TYPES OF DEMENTIA

• Alzeimers dementia-It is the most common dementia in people above 65 years of age and older.Dementia is intellectual deterioration severe enough to interfere with the occupation of the client as well as the social performance.It involves progressive decline of two or more areas of cognition,usually memory and language,calculation and personality.Alzeimers disease constitutes about half of all dementias.
• Multi infarct dementia-It is the second common cause of dementia.It causes irreversible dementia.Blood clots blocks small blood vessels in the brain and and destroys the brain tissue.Multi infarct dementia occurs in people over 50 years of age
• Lewy body dementia-It is similar to alzeimers disease but will progress more rapidly.Abnormal brain cells called cortical lewi bodies occurs throughout the brain and can cause manifestations
• Picks disease-It is also a form of dementia but varies from Alzeimers disease.At first both these diseases produces abnormalities in the brain,Pick sdisease is associated with the formation of Pick bodies.These are rounded bodies,microscopic structures found in the affected cells.Neurones will swell and forms balloon shape.Neither of these changes occurs in Alzeimers disease and and the pathology of Alzeimers disease is(formation of plaques and tangles )is not seen in Pick s disease.Picks disease is confined to the front part of the brain,particularly the frontal and anterior temporal lobes

Clinical manifestations are classified as mild moderate and severe

EARLY(MILD)

• Forgetfullness beyond what is seen in the normal person.
• Short term memory impairment especially for new learning.
• Difficulty in recognizing what numbers mean.
• Loss of initiative and interest.
• Decreased judgement.
• Geographic disorientation

MIDDLE(MODERATE)

• Forgetfullness beyond what is seen in the normal person.
• Short term memory impairment especially for new learning.
• Difficulty in recognizing what numbers mean.
• Loss of initiative and interest.
• Decreased judgement.
• Geographic disorientation

LATE(SEVERE)

• Impaired ability recognize close family members or friends.
• Agitation
• Wandering
• Getting lost
• Loss of remote memory
• Confusion
• Impaired comprehension.
• Forgets how to do simple tasks
• Apraxia
• Receptive aphasia
• Expressive aphasia
• Insomnia
• Delusions,Illusions,hallucinations
• Behavioural problems

DIAGNOSTIC EVALUATIONS
WHEN THE PERSON NEEDS TREATMENT

• Consult a doctor when you have concerns about memory loss, thinking skills and behavior changes in yourself or a loved one. For people with dementia and their families, an early diagnosis has many advantages:
• Time to make choices that maximize quality of life
• Lessened anxieties about unknown problems
• A better chance of benefiting from treatment
• More time to plan for the future
• It is also important for a physician to determine the cause of memory loss or other symptoms. Some dementia-like symptoms can be reversed if they are caused by treatable conditions, such as depression, drug interaction, thyroid problems, excess use of alcohol or certain vitamin deficiencies.

DIAGNOSIS

• The diagnosis is based on the cause of the disease whether it is reversible or irreversible
• An important first step is the thorough medical ,neurological history of the patient.
• Screening for cobalmin(Vitamin B12)deficiency and hypothyroidism is performed.
• Mental status examination is done for the patient
• Cognitive testing is focussed on the evaluation of memory,ability to calculate,language etc..
• When the depression is severe poor memory ,attension and concentration impairment occurs
• If the dementia is due to vascular cause cognitive impairment will be there and presence of vascular lesions will be there in neuro imaging techniques
• CT Scan and MRI is usually done
• SPECT is done and PET to rule out the degenerative changes in the brain

MINI MENTAL STAUS EXAMINATION
TREATMENT FOR BEHAVIOURAL OR PSYCHIATRIC PROBLEMS
For many individuals, Alzheimer's disease affects the way they feel and act in addition to its impact on memory and other thought processes. As with cognitive symptoms, the chief underlying cause is progressive destruction of brain cells. In different stages of Alzheimer's, people may experience:

• Physical or verbal outbursts
• General emotional distress
• Restlessness, pacing, shredding paper or tissues and yelling
• Hallucinations (seeing, hearing or feeling things that are not really there)
• Delusions (firmly held belief in things that are not real)

Many diagnosed individuals and their families find these symptoms the most challenging and distressing effects of the disease..
There are two approaches to managing behavioral symptoms: using medications specifically to control the symptoms or non-drug strategies. Non-drug approaches should always be tried first.

Non-drug approaches
Steps to developing successful non-drug treatments include:

• Recognizing that the person is not just "acting mean or ornery," but is having further symptoms of the disease
• Understanding the cause and how the symptom may relate to the experience of the person with Alzheimer's
• Changing the person's environment to resolve challenges and obstacles to comfort, security and ease of mind

Everyone who develops behavioral symptoms should receive a thorough medical examination, especially if symptoms appear suddenly. Even though the chief cause of behavioral symptoms is the effect of Alzheimer's disease on the brain, an exam may reveal treatable conditions that are contributing to the behavior.
Treatable conditions may include:Drug side effects. Many people with Alzheimer's take prescription medications for other health problems. Drug side effects or interactions between drugs can sometimes affect behavior.

• Physical discomfort. As the disease gets worse as it progresses to Alzheimer's have more and more difficulty communicating about their experience. As a result, symptoms of common illnesses may sometimes go undetected. Pain from infections of the urinary tract, ear or sinuses may lead to restlessness or agitation. Discomfort from a full bladder, constipation, or feeling too hot or too cold may also be expressed through behavior.
• Uncorrected problems with hearing or vision. These can contribute to confusion and frustration and foster a sense of isolation.
• Factors in the environment may also trigger behaviors. Events or changes in a person's surroundings may contribute to a sense of uneasiness, or increase fear or confusion.

Medications for behavioral symptoms

• If non-drug approaches fail after they have been applied consistently, introducing medications may be appropriate when individuals have severe symptoms or have the potential to harm themselves or others. Medications can be effective in some situations, but they must be used carefully and are most effective when combined with non-drug approaches.
• Medications should target specific symptoms so their effects can be monitored. In general, it is best to start with a low dose of a single drug. Effective treatment of one core symptom may sometimes help relieve other symptoms. For example, some antidepressants may also help people sleep better. Individuals taking medications for behavioral symptoms must be closely monitored. People with dementia are susceptible to serious side effects, including stroke and an increased risk of death from antipsychotic medications. Sometimes medications can cause an increase in the symptom being treated. Without careful evaluation, some medical providers will increase rather than decrease the dose, putting the person at greater risk. Risk and potential benefits of a drug should be carefully analyzed for any individual.
• When considering use of medications, it is important to understand that no drugs are specifically approved by the U.S. Food and Drug Administration (FDA) to treat behavioral and psychiatric dementia symptoms..
• The decision to use an antipsychotic drug needs to be considered with extreme caution. A recent analysis shows that atypical antipsychotics are associated with an increased risk of stroke and death in older adults with dementia. The FDA has asked manufacturers to include a “black box” warning about the risks and a reminder that they are not approved to treat dementia symptoms. The warning states: “Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo.”
• The analysis states that while risperidone and olanzapine are useful in reducing aggression and risperidone reduces psychosis, both drugs are associated with severe side effects. Despite some efficacy, these drugs should not be used routinely with dementia patients, unless the person is in severe distress or there is a marked risk of harm.

Risks and potential benefits of a drug should be carefully analyzed for any individual. Examples of medications commonly used to treat behavioral and psychiatric symptoms of Alzheimer's disease, listed in alphabetical order, include the following:

Antidepressant medications for low mood and irritability:

Anxiolytics for anxiety, restlessness, verbally disruptive behavior and resistance:

Antipsychotic medications for hallucinations, delusions, aggression, agitation, hostility and uncooperativeness:

Research evidence as well as governmental warnings and guidance regarding the use of antipsychotics indicate that individuals with dementia should only use these medications when:

1) Their behavioral symptoms are due to mania or psychosis
2) The symptoms present a danger to the resident or others
3) The resident is experiencing inconsolable or persistent distress, a significant decline in function or substantial difficulty receiving needed care

Antipsychotic medications should not be used to sedate or restrain persons with dementia. The minimum dosage should be used for the minimum amount of time possible. Adverse side effects require careful monitoring.

Although antipsychotics are the most frequently used medications for agitation, some physicians may prescribe a seizure medication/mood stabilizer, such as:

NURSING MANAGEMENT OF THE CLIENT
ASSESSMENT

• A complete history has to be taken to assess for the causes.Data can be obtained from the client,family and the co-workers
• Secondary sources are usually used because the client is unaware of the thought process and usually minimizes it.
• Ask questions regarding the activities of daily living,increasing forgetfulness and changes in personality.
• Assess the past medical history for any history head injury or surgery,recent falls,head ache and family history.
• A mini mental sttus examination helps in ongoing assessment.
• As the condition progresses the client may become paranoid,uses abusive language and becomes suspicious of others
• Assess the strengths and weaknesses of the family members and the ability to provide care for the patient and financial concerns.

NURSING DIAGNOSIS
Impaired verbal communication related to neuronal degeneration

• In the initial stage the clients verbal capacities will be intact,as the time progresses the capacities of the client will deteriorate.
• The nurse must be adaptable toprepare for the communicative level of the client.
• Always speak firmly and slowly in a low pitch voice.
• The tone of the voice should be calm and reassuring.
• When the language is impaired new techniques should be adopted to communicate with the client.
• Understand the non verbal communication of the client.Clients with AD often will avert the eyes,look down,and increase motor activity ,waving their arms and shaking their fists,raising their volumeand pitch or tightening the facial muscles.Interventions can include the following:

ü Decreasing the environmental stimuli.
ü Approaching the client calmly and reassurance
ü Gently distracting the client.
ü Making sure that all verbal and nonverbal communication cues are concordant.
ü The client should be removed from the stressful environment and reassurance should be given.
ü Calm non threatening environment should be given to the client.
ü Elicit listening behaviour by reaching out and touching,holding a hand,putting an arm around the wrist,or some way maintaining physical contact with the patient.Dementia patients can perceive non verbal cues of others and can cause agitation if a negative non verbal cue is observed
ü Promote activities of interest ,exercises and oppurtunities to wander in safe environment reduces the stress and strain in the patient

• Behavioural indicators of discomfort includes noisy breathing,negative vocalization,a sad facial expression and frowning

Disturbed thought process related to neuronal degeneration

• Apply constant intervention to reduce the fear and anxiety
• Reorient the client by providing calendar or clock.
• Be aware of the past experiences of the client and share it meaningful.
• Repetition is necessary.

 
Risk for injury related to impaired judgement,forgetfulness and motor impairments

• Teach the clients family members how to eliminate the safety hazards,which includes mainlyloose rugs,hot water,inadequate lighting and unlocked doors.
• Ensure that the client will not roam unnecessarily without being unnoticed.
• The patient must wear an identification badge in case if they are lost
• Windows and the doors must be locked and secured.Dangerous items should be kept away from the client and assistance should be given on cooking..
• The clients driving ability should be evaluated at regular intervals.

 
Self care deficit related to loss of memory and motor impairments

• Ask the client to do as much as activities as possible provided that it is safer for the client to do.
• Help the client in maintaining the autonomy.
• Develop the clients self respect and confidence.
• Give the client ample time to complete a task
• Constantly encourage and guide the client

 
Urge urinary incontinence related to neuronal damage

• Schedule the voiding and defecation timings of the client in the initial stage.
• Understand the non verbal signs of the client to urinate and to defecate(restlessness,grasping the genital area,picking at the clothing etc..
• Clear signs indicating the position of the bathrooms should be there because the patiet may forget the location of the bathroom.
• Fluid after the dinner time should be avoided.
• The bowel and the bladder pattern should be maintained.
• External urinary drainage devices are given in the night
• Extra absorbabale washable underwear, and bedpads can be given to the client.

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