Lecture 4- Dementia - PDF

JESMAR S. ESPIRITU Associate. Professor  PRAYER Heavenly Father, Thank you for the gift of education in every form. As these students prepare for the new school year , may confidence be their foundation, may grace be their guide, and may hope be their compass toward a bight future...

JESMAR S. ESPIRITU Associate. Professor  PRAYER Heavenly Father, Thank you for the gift of education in every form. As these students prepare for the new school year , may confidence be their foundation, may grace be their guide, and may hope be their compass toward a bight future. I pray that they would have eyes to see the needs of those around them and a heart to love well. May they face each day with positivity knowing that no matter what comes their way they don’t face it alone. In Jesus name. Amen  LEARNING OUTCOMES: ❑ At the end of the module the students will be able to 1. Define DEMENTIA 2. Differentiate between delirium & dementia 3. Differentiate between depression & dementia 2. Causes of Dementia 3. Management of Dementia  COUCH POTATO You only get old when you cease building up others in Christ and turn to watching television all day. This is the sad truth for some elderly.  DEMENTIA An acquired syndrome of progressive deteriorating cognitive function, affecting memory, thinking, behavior, and everyday activities. Or decline in memory and other cognitive functions sufficient to affect daily life in an alert patient Dementia is not a single disease. term to describe a collection of symptoms that one may experience if they are living with a variety of diseases  RISK FACTORS FOR DEMENTIA Age Family history Head injury Fewer years of education  Currently more than 55 million people have dementia worldwide, over 60% of whom live in low-and middle-income countries. PHILIPPINES ✓ the estimated number of elderly (60 years and older) will more than double from 9.5 million in 2020 to 19.7 million in 2040 (5). ✓ ALZHEIMERS & DEMENTIA ✓ According to the latest WHO data published in 2020 Alzheimers & Dementia Deaths in Philippines reached 2,010 or 0.30% of total deaths. ✓ The age adjusted Death Rate is 3.10 per 100,000 of population ranks Philippines #172 in the world. Cognitive Disorders: Dementia Dementia Clinical condition/syndrome Loss of cognitive function Interferes with normal activities Interferes with social relationships Common signs 1. Impairment of memory 2. Multiple disturbances of cognition 3. Impairment of executive function. 4. Disorientation. 5. Behavioral changes.  DEMENTIA Progressive and disabling NOT an inherent aspect of aging Different from normal cognitive lapses Types of Dementia Vascular dementia Alzheimer's disease Dementia with Lewy bodies Frontotemporal dementia (Pick's disease) Dementia from Parkinson's disease Creutzfeldt-Jakob disease The Big 4  Signs and Symptoms of Dementia Recognizing the warning signs 1 Memory Loss 2 Difficulty with Daily Tasks One of the most common early Dementia can make it signs of dementia challenging to is memory loss. complete everyday Individuals may activities such as forget important cooking, dressing, and appointments, personal hygiene. names, or recent events.  Signs and Symptoms of Dementia Recognizing the warning signs 3 Language and 4 Changes in Mood Communication and Behavior Problems People with dementia may Mood swings, struggle to find words, irritability, anxiety, and follow conversations, or uncharacteristic express themselves clearly. behaviors can all be signs of dementia.  STAGES OF DEMENTIA Stage 1: No cognitive impairment. Stage 2: Very mild cognitive decline. Stage 3: Mild cognitive decline. Stage 4: Moderate cognitive decline. Stage 5: Moderately severe cognitive decline. Stage 6: Severe cognitive decline. Stage 7: Very severe cognitive decline Stage 1: Normal behavior and no noticeable changes During this stage, the patient shows little to no signs of the disease, and there is no impact on the individual's life. MRI or CT scans of the brain may show incidental findings during routine check-ups. Early diagnosis can help to reduce the rate of progression. Stage 2: ❑Mild changes Although individuals in stage two of LBD show some very mild symptoms, they can go unnoticed. The patient may continue with their daily activities without significant challenges. Symptoms Mild forgetfulness (forgetting names or having trouble locating objects they are familiar with) Stage 3: ❑ Mild but noticeable changes ❑ At this stage, symptoms may become noticeable. There will be a mild cognitive decline, which increases the risk of falls and can hamper daily activities. Stage 3 Symptoms Mild memory loss Slight forgetfulness Mild problems with concentration Increased risk of falls Problems at the workplace The trouble with money management Stage 4: Mild dementia (the stage of diagnosis) ▪ Generally, most patients have a confirmed diagnosis by stage 4, easily detected cognitive decline. ▪ Individuals with LBD will start exhibiting moderate symptoms that can disrupt their daily lives. Symptoms Choking, difficulty swallowing, aspiration, and excessive drooling Life-disrupting forgetfulness Difficulty performing daily activities High risk of falls Tremors Increased daytime sleeping, but with fewer hallucinations. High risk of potential health problems Increased need for supervision Stage 5: Moderate to severe dementia Individuals at this point should still be able to recognize family members and friends, but they may have increased trouble recalling past events. may need help performing daily tasks ❑ Symptoms ✓ Significant memory loss and constant confusion ✓ Struggles with daily activities ✓ Fever and high risk of infections and skin diseases. ✓ Delusions and hallucinations can cause patients to become increasingly paranoid and confused more often ✓ Require assistance while eating and using the bathroom. ✓ Bladder issues ✓ Mood swings Stage 6: Severe dementia severe cognitive decline which typically lasts for about 2.5 years. patient may need a high level of care to live comfortably. Symptoms ✓Severe memory loss ✓Urinary and bowel incontinence ✓Severe cognitive impairment ✓Difficulty recognizing family members ✓Trouble speaking ✓Delusions ✓Strong personality changes/mood swings ✓Wandering and getting lost Stage 7: Final stage of the dementia patient Generally lasting about 1.5 to 2.5 years, patients with late-stage Lewy body dementia exhibit intense symptoms which require palliative care. The individual will no longer recognize loved ones, and round-the-clock care is necessary during this final stage of LBD. Stage 7 Symptoms Inability to speak, eat and swallow Loss of bladder/bowel control Assistance is required for every task No muscle control Constant disorientation Patient is bedridden  VASCULAR DEMENTIA Development of cognitive deficits manifested by both impaired memory aphasia, apraxia, agnosia, disturbed executive function Significantly impaired social, occupational function Focal neurologic symptoms & signs or evidence of cerebrovascular disease Deficits occur in absence of delirium Vascular Dementia Clinical Presentation Abrupt onset step-wise deterioration somatic complaints emotional incontinence history of hypertension history of cebrovascular accidents focal neurological symptoms focal neurological signs  Management of vascular dementia Risk assessment – Age, hypertension, smoking, diabetes, history of stroke/TIA Reduction of risk of further damage – Management of stroke and risk factors Treatment of secondary conditions1 – Depression, anxiety, agitation Treatment of dementia symptoms – Cognition, global function, activities of daily living 1Gupta A, et al. Int J Clin Pract. 2002;56:531-537. Alzheimer’s disease ❑is a brain condition that causes a progressive decline in memory, thinking, learning and organizing skills. ❑It eventually affects a person’s ability to carry out basic daily activities. ❑most common cause of dementia. Alzheimer’s Disease Progresses Through Distinct Stages Dementia/Alzheimer’s STAGE MILD MODERATE SEVERE SYMPTOMS Memory loss Behavioral, Gait, Language personality incontinence, problems Mood changes motor swings Unable to disturbances Personality learn/recall new Bedridden changes info Unable to perform Diminished Long-term ADL judgment memory affected Placement in Wandering, long-term care agitation, needed aggression, confusion Require assistance w/ADL Normal Lapses Dementia Forgetting a name Not recognizing family member Leaving kettle on Forgetting to serve meal just prepared Finding right word Substituting Forgetting date or inappropriate day words Getting lost in own neighborhood  Normal Lapses Dementia Trouble balancing Not recognizing checkbook numbers Losing keys, Putting iron in glasses freezer Getting blues in sad situations Rapid mood swings for no Gradual changes with aging reason Sudden, dramatic personality change The four A's of Alzheimer's disease are: amnesia, aphasia, apraxia, agnosia ❑ Amnesia, loss of memory, the most common sign of Alzheimer's disease,  Pathology of AD There are 3 consistent neuropathological hallmarks: ❑ Amyloid-rich senile plaques ❑ Neurofibrillary tangles ❑ Neuronal degeneration changes eventually lead to clinical symptoms, but begin years before the onset of symptoms  DIAGNOSIS & MANAGEMENT ❑Medical history and examination – ✓ A review of previous and current illnesses, medications, and current symptoms and tests of movement and memory give the doctor valuable information. ❑Medical tests ✓ Laboratory studies can help rule out other diseases and hormonal or vitamin deficiencies that can be associated with cognitive changes.  DIAGNOSIS & MANAGEMENT ❑Brain imaging – ✓ Computed tomography or magnetic resonance imaging can help detect brain shrinkage or structural abnormalities and help rule out other possible causes of dementia or movement symptoms. ❑Neuropsychological tests ✓ used to assess memory and other cognitive functions and can help identify affected brain region  Stages of Alzheimers Symptoms Memory loss Difficulty recalling known words Vision problems Impaired reasoning or judgment These problems may lead to behaviors such as: Wandering and getting lost Forgetting to pay bills Missing appointments Losing things Repeatedly asking the same questions  Stages of Alzheimers Stage 1: Preclinical Alzheimer's The brain may have begun to change. ✓ imaging studies may reveal changes in nerve cells and the build-up of amyloid-ß (beta), an abnormal protein that forms masses in the brain called plaques. During this stage, you may have no symptoms or symptoms that are too mild to notice. ADLs remain unimpaired. May last for many years or even decades. most often diagnosed in research studies, not in clinical practice.  Stages of Alzheimers Stage 1: Preclinical Alzheimer's The brain may have begun to change. ✓ imaging studies may reveal changes in nerve cells and the build-up of amyloid-ß (beta), an abnormal protein that forms masses in the brain called plaques. During this stage,you may have no symptoms or symptoms that are too mild to notice. ADLs remain unimpaired. May last for many years or even decades. most often diagnosed in research studies, not in clinical practice.  EARLY STAGE  Stages of Alzheimers Stage 2:Mild Cognitive Impairment More memory problems than are normal for your age Symptoms still don't have a significant impact on ADL Symptoms are usually mild and involve problems in cognition—brain-based abilities required to learn, form, and retrieve memories, problem-solve, and pay attention. first symptoms of Alzheimer’s vary from person to person. Mild Dementia In mild Alzheimer’s dementia, symptoms are severe enough to interfere with ADLs. They include: ✓ Worsening memory loss, when compared to MCI ✓ Poor judgment ✓ Making bad decisions ✓ Declines in motivation and spontaneity ✓ Taking longer than normal to perform daily tasks  MIDDLE STAGE Stage 3: Alzheimer’s Dementia stage involves problems with the brain Loss of normal neuron (brain cell) connections Death of nerve cells due to amyloid plaques and other factors classified by its severity. LATE STAGE Alzheimer's has no cure, but one treatment ❑ removing amyloid, one of the hallmarks of Alzheimer’s disease, from the brain is reasonably likely to reduce cognitive and functional decline in people living with early Alzheimer’s SUNDOWNING ▪ Lewy body dementia (LBD) is a disease associated with abnormal deposits of a protein called alpha-synuclein in the brain. ▪ Lewy bodies- affect chemicals in the brain whose changes leads to problems with thinking, movement, behavior, and mood. ▪ Lewy body dementia (LBD) is caused by abnormal protein deposits that disrupt the brain's normal functioning. The proteins found in the brain stem deplete dopamine levels, causing Parkinson’s-like symptoms. Frontotemporal Dementia  Pick’s Disease -1892 Arnold Pick Frontotemporal dementia ▪ Frontal lobar atrophy ▪ Pick’s bodies – tau protein ▪ Chr17 abnormality Signs of Pick's disease ❑ BEHAVIORAL CHANGES: ✓ Not able to keep a job. ✓ Compulsive behaviors. ✓ Impulsive or inappropriate behavior. ✓ Inability to function or interact in social or personal situations. ✓ Problems with personal hygiene. ✓ Repetitive behavior. ✓ Withdrawal from social interaction. ❑ Initial neurological symptoms ✓ difficulty walking caused by problems with balance and co-ordination. ✓ slurred speech. ✓ numbness or pins and needles in different parts of the body. ✓ dizziness. ✓ vision problems, such as double vision. ✓ hallucinations (seeing or hearing things that aren't really there)  Clinical Features Behavioral abnormalities. Inertia, loss of volition, decreased initiative. Social disinhibition, loss of insight. Impulsivity, overactivity. Emotional blunting. Stereotyped and perseverative behavior.  FTD: Clinical Features Mean age of presentation: 53 years Predominantly males Cognitive impairment mostly in areas of executive function (planning, judgment, problem-solving) and attention Memory, visuospatial and calculation might be relatively preserved at the beginning Speech might be either economically leading to mutism, or increased / pressed in disinhibited patients CREUTZFELDT-JAKOB DISEASE Creutzfeldt-Jakob disease (CJD) very rare brain disease that typically affects people starting around age 60. Symptoms of this disease progress quickly. CJD can cause dementia. dementia is a serious brain disease that affects memory, ability to make decisions, daily functioning, as well as mood and behavior. types of Creutzfeldt-Jakob disease Sporadic CJD which is the most common and happens without any known reason. Hereditary CJD which usually runs in families. It is the second most common form of this disease. Acquired CJD which is the result of being exposed to infected tissue. It is the least common. Symptoms: Changes in behavior Problems with memory Changes in personality Vision problems Muscle coordination problems treatment ❑ Currently, there is no cure for CJD. ❑ focus of treatment : managing the symptoms of the disease and supporting the patient and caregivers as the disease progresses. ❑ People with CJD usually have a very rapid decline in brain and physical function.  Parkinson’s A neurological syndrome or disease caused by a lack of dopamine within the brain. ✓incurable, ✓degenerative and ✓eventually impacts on all aspects of daily life. Dopamine is a neuro transmitter which ensures smooth movement of muscles.  Parkinson's disease is a brain disorder that causes unintended or uncontrollable movements, ✓ such as shaking, ✓ stiffness, and ✓ difficulty with balance and coordination. Symptoms usually begin gradually and worsen over time. As the disease progresses, people may have difficulty walking and talking. Parkinson’s  Signs & Symptoms SLOWNESS* (bradykinesia) STIFFNESS* (rigidity) TREMOR* POSTURAL INSTABILITY* STOOPED POSTURE SHUFFLE LACK OF ARM SWING WHEN WALKING. LACK OF FACIAL EXPRESSION DEPRESSED OR LOW IN MOOD  The early stages of Parkinson’s Diagnosis/ Early Maintenance Raise awareness and Promotion of normal self management activities. Education and Maintenance of function consider therapy input and self care. Reduce symptoms Consider therapy and distress referral Acceptance of Assess carer needs diagnosis Symptom reduction, treatment compliance  The later stages of Complex Parkinson’s Palliative ▪ Adaptations to promote self-care ▪ Relief of symptoms ▪ Optimise symptom ▪ Absence of distress/Carer control/compliance with support meds ▪ Maintenance of dignity ▪ Assess for complications ▪ Good nursing care. of medication and ▪ Analgesia, appropriate fluctuations sedation, pressure care, ▪ MDT input/Annual continence, mouth care, review/Carer support communication. ▪ Minimisation of disability  The effects of Parkinsons. MOTOR SYMPTOMS (physical capability) NON-MOTOR SYMPTOMS affect anything within the body which is governed by muscles. Symptoms will fluctuate from day to day and throughout the course of the day and night  Walking Talking, communicating in a group, social isolation and embarrassment. Non-verbal communication, lack of vocal tone. Facial expression Swallowing/saliva control. Eating in public. Bladder and bowel control Writing Buttons, zips Concentration, motivation, low mood Sleep problems Dementia, hallucinations  Supporting people with Parkinson’s and their carers. Listen to and support those closest to the person with Parkinson’s… they are often the experts. Educate home care workers Be patient. Give time….. Refer to specialists if you identify any difficulties with speech, swallow, dietary intake and obviously physio. For freezing, use techniques of queuing….marching, counting, something which creates a rhythm.  Troubleshooting THINGS TO CHECK…. 1. Do they have a UTI? 2. Are they constipated? 3. Have they been getting their medication? 4. Any changes to their medication lately? DEMENTIA CARE  Responding Calm & positive Reassuring manner Verbal and non-verbal Avoid arguing Meet the emotional need Know your limitations Night time care ✓ different culture & atmosphere ✓ experiences & misunderstood  Night time experiences Time when fears and worries take hold Misunderstanding cues Disorientation Time for sleep and rest  Noise Sleep requires a calm and quiet environment What noises may disturb? May cause disorientation, confusion & fear Reduce or eliminate noise  Light A good sleep/wake requires darkness at night and bright light during day Melatonin secretion assists sleep process Melatonin secretion suppressed by light  Night time lighting Light blocking curtains Minimise light spill e.g. under doors Night light only if used previously Minimise electronic Automatic light activation Dimmer switches Careful use of torches  Nutrition Hunger and hydration Dinner to breakfast may be over 12 hours  Activities Not everyone sleeps Evening activities – person with dementia may need help initiating activities Life story is also significant at night  Pain Age increases chronic pain Pain maybe expressed different ways Pain affects well-being and coping Sensory experience  SYMPTOM MANAGEMENT Psychoses (delusions, hallucinations) Sleep disturbances Aggression, agitation 111  NONPHARMACOLOGIC Cognitive enhancement Individual and group therapy Regular appointments Communication with family, caregivers Environmental modification Attention to safety 112  PHARMACOLOGIC Cholinesterase inhibitors: Inhibit cholinesterase at the synaptic cleft Offer a small improvement : cognition and activities of daily living Examples: donepezil, rivastigmine, galantamine Memantine: (Namenda): N-Methyl-D-Aspartate Antagonist: A receptor activated by glutamate: decr nmda 113  TREATING PSYCHOSIS IN DEMENTIA Antipsychotic medications (side effects): Higher potency: haloperidol (extrapyramidal symptoms) Lower potency: thioridazine (anticholinergic effects, sedation, hypotension, constipation, urine retention) Atypical antipsychotics: clozapine, risperidone, olanzapine ❖Beware new prescribing information on some of the atypical antipsychotics! 115  MANAGING SLEEP DISTURBANCES Improve sleep hygiene (e.g, consistent bedtime, comfortable setting) Provide daytime activity, prevent daytime sleeping Use bright-light therapy Treat associated depression, delusions If the above do not succeed, consider: trazodone 25-150 mg nefazodone 100-500 mg zolpidem 5-10 mg Avoid benzodiazepines or antihistamines 116  MANAGING AGITATION Behavioral interventions: distraction, supervision, routine, structure Behavior modification using rewards Pharmacologic interventions: antipsychotics, antidepressants, mood stabilizers, buspirone, -blockers Avoid physical restraints 117 The 5 R's of Dementia Care | ✓ Remain calm: Don't argue or try to reason.... ✓ Respond to feelings: Validate how your loved one seems to be feeling at the time. ✓ Reassure: Remind your loved one that s/he is safe and cared for. ✓ Remove yourself physically or distance yourself psychologically for a moment to regain your composure. ✓ Return fully to the situation when your loved one begins to calm down.. ✓ Remember, no matter how hard you try, you can never separate the emotional connection to your loved one from the irrational behaviors, but you can try your best to respond in a manner that won’t worsen the situation. Aids & Dementia  AIDS dementia complex Approximately two-thirds of persons with AIDS develop dementia, mostly due to AIDS dementia complex. In some patients HIV is found in the CNS at postmortem. In others an immune mechanism or an unidentified pathogen is blamed. Dementia is initially of a "subcortical " type. CT - atrophy; MRI - increased T2 signal from white matter. Treatment with Zidovudine (AZT) halts and partially revers es neuropsychological deficit.  References: Brunner_and_Suddarth_Textbook _of_Medical-Surgical_Nursing Chapter 17, End of life care www.sharecare.com https://www.izito.ws/ws?q=urinar y%20incontinence&asid=iz