Dementia

Dementia is one of the common mental illnesses among the elderly.

1. DEMENTIA MR MULUNDANO BSC NS-UNZA

2. CONTENT Definition of terms Prevalence of dementia Predisposing factors Clinical features Types of dementia Management

3. INTRODUCTION Dementia  is a collective term used to describe various symptoms of cognitive decline, such as forgetfulness. It is a symptom of several underlying diseases and brain disorders.  Dementia  is not a single disease in itself, but a general term to describe symptoms of impairment in memory, communication, and thinking.

4. INTRODUCTION CONT’D Alzheimer disease is the most common form of dementia and may contribute to 60–70% of cases. Dementia is one of the major causes of disability and dependency among older people worldwide. Dementia has a physical, psychological, social, and economic impact, not only on people with dementia, but also on their carers , families and society at large.

5. PREVELENCE Worldwide, around 50 million people 60% living in low- and middle-income countries. 10 million new cases/year. Age 60 and over with  dementia  at a given time is between 5-8%/general population The total number of people with dementia is projected to reach 82 million in 2030 and 152 in 2050 . Much of this increase is attributable to the rising numbers of people with dementia living in low- and middle-income countries

6. DEFINITION Dementia is defined as global or total intellectual decline of sufficient severity to impair social and/or occupational functioning that occurs in normal consciousness.

7. PREDISPOSING FACTORS/CAUSES Neurological disorders Vascular disorders Inherited disorders Infections Age Family history Down’s syndrome (trisomy 21)

8. PREDISPOSING FACTORS/CAUSES Head Trauma (esp. late in life) Female gender (mixed results: age bias and possible higher ‘clinical’ expression in women) Late-onset depression (after age 65)

9. CLINICAL FEATURES Aphasia Apraxia Agnosia Disturbance in executive functioning Impairment in social and/or occupational fn All the above are referred to as cognitive disturbances

10. CLINICAL FEATURES Personality changes Depression Anxiety Inappropriate behaviour Paranoia Agitation Hallucinations All above are called Psychological changes

11. STAGES OF DEMENTIA   Early stage Middle stage Late stage

12. SAMPLE QUESTION 1. Which one of the following is an early sign of dementia? Becoming lost in familiar places. Becoming forgetful of recent events and people's names Becoming unaware of the time and place Becoming lost at home

13. SAMPLE QUESTION The following clinical feature is a cognitive disturbance of dementia Paranoia Agitation Hallucinations Abstract thinking d disturbance

14. TYPES OF DEMENTIA Dementia is categorized according to its etiology: Alzheimer’s dementia 60% Vascular dementia 10% Frontal-Temporal Lobe 15% Dementia with Lewy bodies 15% Other 10%

15. DIFFERENTIAL DIAGNOSIS Common precipitating factors for delirium include infection, medication interactions and surgery Differentiating between D ementia, D elirium and D epression ( three Ds ) requires skilled assessment. The differences and similarities are outlined in the table on the next slides;

16. The three Ds Dementia Delirium Depression Thoughts • Repetitiveness of thought • Reduced interests • Difficulty making logical connections • Slow processing of thoughts • Bizarre and vivid thoughts • Frightening thoughts and ideas • Often paranoid thoughts • Often slowed thought processes • May be preoccupied by sadness and hopelessness • Negative thoughts about self • Reduced interest Sleep • Often a disturbed 24 hour clock mechanism (later in the disease process) • Confusion disturbs sleep (may have a reverse sleep-wake cycle) • Nocturnal confusion • Vivid and disturbing nightmares • Early morning waking or intermittent sleeping patterns (in atypical cases, too much sleep) Orientation • Increasingly impaired sense of time and place • Fluctuating impairment of sense of time, place and person • Usually normal

17. The three Ds Dementia Delirium Depression Orientation • Increasingly impaired sense of time and place • Fluctuating impairment of sense of time, place and person • Usually normal Onset • Usually gradual, over several years • Insidious in nature • Acute or sub acute (hours or days) • Usually over days or weeks • May coincide with life changes Memory and cognition • Impaired recent memory • As disease progresses, long term memory also affected • Other cognitive deficits such as in word finding, judgement and abstract thinking • Immediate memory impaired • Attention and concentration Impaired • Recent memory sometimes impaired • Long-term memory generally intact • Patchy memory loss • Poor attention

18. The three Ds Dementia Delirium Depression Duration • Months or years and progressive degeneration • Usually brief — hours to days (but can last months in some cases) • At least two weeks (but can be several months to years Course throughout the Day • May be variable depending on type of dementia • Fluctuates — usually worse at night in the dark • May have lucid periods • Commonly worse in the morning with improvement as the day continues. Alertness • Usually normal • Fluctuates — lethargic or hypervigilant • Normal Other • May be able to conceal or compensate for deficits (early) • May occur as a consequence of a drug interaction or reaction, physical disease, psychological issue or environmental changes • Often masked • May or may not have past history.

19. MANAGEMENT Medical Nusring care

20. Medical mgt Aims: To establish the cause and type of dementia To rule out any other condition that can produce signs of dementia To prevent or minimize complications by prescribing the right medications for the client

21. Hx taking This will review onset of the signs and symptoms and how they are affecting the client. Drug hx will review what drugs the client may have being using. Medical hx will review any other chronic conditions the client may have being suffering from. Family hx will review what other medical and psychiatric conditions the client is predisposed to.

22. Mental state exam This will review clients orientation to their immediate environment and his cognitive impairment such as memory loss, attention deficit etc. Investigations Brain scan, will review anatomical changes to the brain and other injuries that may have being the cause of dementia. Full blood count to rule out any other conditions that may have being affecting the patient.

23. Medication 1. Drug name: memantine MOA : inhibits the release of glutamate Dosage : 5mg/day; target dose 10mg/day bid. orally Side effects : dizziness, hallucinations, vomiting, Anemia. Nursing consideration : Assess patients affect, behavioral changes regullary . Provide assistance with ambulation Teach client to report side effects.

24. 2. Drug name : prochloperazine MOA : blocks mesolimbic dopamine receptors, and alpha-adrenergic receptors in the brain. Dosage : 5 to 10 mgs/PO 6-8hrly SE : dizziness, depression, tachycadia , erectile dysfunction. Nursing consideration : Asses for vital signs before and after drug administration, teach client to report side effects if disturbing.

25. 3. Drug name : haloperidol Dosage : 3-5mg 8-12hrly. Not to exceed 30mg/day MOA : antagonizes dopamine receptors in the brain. S.E : pseudoparkinsonism , hypertension, dysuria, dyspnea Nursing Implications : Asses mental status before and after giving drug. Take vital signs 4hrly during initial treatment. Teach client about side effects of the drug.

26. More drugs Donepezil Galantamine Rivastigmine Benzodiazepines Folic acid, B12 and B6 improves memory

27. Nursing Mgt Aims: To develop a relationship with the client based on empathy and trust. To provide an environment that supports flexible but anticipated routines. To maintain a safe environment for the person, yourself and other staff. To promote the person’s engagement with their social and support network To ensure effective collaboration with other relevant service providers, through development of effective working relationships and communication To support and promote self care activities for families and carers of the person with dementia

28. ENVIROMENT I will Isolate the patient if he is violent to prevent harm. I will maintain close observation if client is suicidal to prevent any successful suicides If the client is agitated, I will maintain a quiet environment. Check noise levels regularly and reduce them if necessary by turning off the radio and television. I will give the client a comfortable space. Since any activity that involves invasion of personal space increases the risk of assault and aggression. I will mingle patient with other patients to keep him busy I will make the environment Clean and orderly with nothing to harm the patient

29. Establishing a therapeutic relationship I will explain to the person who I am, what I want to do and why. I will respond to clients concerns if any, in a language that he understands I will smile often— the person is likely to take cues from me, and will mirror my relaxed and positive body language and tone of voice. I will move slowly, I may have a lot to do and be in a hurry, but the person is not, if I do this I will gain clients trust. Be empathetic, nonjudgmental and respectful I will avoid making promises I can not fulfil to avoid client loosing trust in me.

30. STRESS MANAGEMENT I will initiate relaxation measures such as music, prayers to help patient relax. I will teach client how to relax by taking deep breathing exercises I will help client Identify the stressors and distressing factors for easy management. I will keep patient occupied by having frequent talks with him/her. I will Identify client’s coping strategies to determine whether they are effective or not. I will involve client in activities to block and stop worrisome thoughts Encourage patient to find solution for their problems

31. Orientation to time I will Frequently orient client to reality and surroundings. I will provide orientating cues such as a clock and calendar. I will always inform the client what time and date it is as you attend to him/her I will provide newspapers for clients that may be able to read I will allow client to have familiar objects around him or her; use other items, such as a clock, a calendar, and daily schedules, to assist in maintaining reality orientation.

32. OBSERVATION Risk for violence, suicide or escaping Level of anxiety and coping strategies Physical conditions Sleeping patterns Mental state exams Vital signs Side effects of psychotropic medication Interaction and attitude towards others

33. NUTRITION Fluids to prevent dehydration Daily weight checks to monitor if the patient is gaining or losing weight Small frequent meals to promote appetite Meals rich in carbohydrate to prevent hypoglycemia

34. HYGIENE Nail care to prevent infection Oral and hair care to prevent halitosis and promote appetite Change patients’ clothes and beddings if dirt to provide comfort Keep absolute clean and wash the patient if unable to

35. REST Noise free to promote rest Sedation to calm patient while to promote rest Non-stimulating environment to promote rest Bathing patient to promote comfort and rest Comfortable beddings rest

36. PSYCHOLOGICAL CARE Explain the disorder to patient and family Involve patient in his care and the family Encourage questions and give adequate responses Get a well managed case and allow spiritual counselling if family asks for it      

37. SELF AWARENESS Help patient identify personal strength and weaknesses Privacy and confidentiality Patient to perform tasks on their own and assign tasks to them Show respect and keep promises Set goals for patient and reward them for completing the tasks Call patient by name and teach them to respond respectfully

38. FAMILY THERAPY Counsel family and educate them about patient’s condition Encourage family to visit when patient is stable Family not to be critical, discriminating and judgmental Patient to be respectful and thankful to family efforts Teach family how to care for the patient

39. SOCIAL TRANING Simple group chores and games Chapel meetings Taking walks Creating friendships Grooming gardening, sweeping and respect towards others Eating with others

40. COMMUNICATION TRAINING Risk for violence, suicide or escaping Level of anxiety and coping strategies Physical conditions Sleeping patterns Mental state exams Vital signs Side effects of psychotropic medication Interaction and attitude towards others Attention to both verbal and nonverbal communication

41. COGNITIVE BEHAVIOR THERAPY Identify negative attitude, behavior aspects and reactions Set cognitive targets to help change the identified negatives Set time for the targets with patient involvement. Challenges to move from smaller to larger Ensure the patients mind is kept busy to keep in the negatives Identify patients coping mechanisms and strategies how to get rid of them together with patient

42. GENERAL PHYSICAL CONDITION Rule out general conditions and treat these present Do exercises for patient Ensure adequate nutrition and hydration Enough sleep, bowel opening and functions

43. MEDICATION Administer anti-psychotics in the right doses, right time Sedation if necessary, to promote rest Watch the side effects and prevent if dependence/addiction Give specific drugs according to disorders Give other prescribed drugs for other medical conditions

44. SAMPLE QUESTION Mr. Banda is a 78 year old retired Anglican Priest with admitted to your ward for hypertension. But you also suspect he has dementia. i ) Define Dementia ii) Name the types of dementia Mention five signs and symptoms of Dementia State the 3 stages of dementia Identify five nursing problems and write a nursing care plan.

45. THE END