1. DEMENTIADEMENTIA

2. OVERVIEWOVERVIEW
Introduction.Introduction.
Dementia.Dementia.
Alzheimer’ Disease.Alzheimer’ Disease.
Delirium.Delirium.
Caregiver Burden.Caregiver Burden.
Conclusions.Conclusions.

3. I- INTRODUCTIONI- INTRODUCTION

4. Problems of Old AgeProblems of Old Age
I- Lifespan vs. Healthspan.I- Lifespan vs. Healthspan.
II- Physical Burden.II- Physical Burden.
III- Poly-Pharmacy.III- Poly-Pharmacy.
IV- Psychosocial Burden.IV- Psychosocial Burden.
V- Common Psychiatric Disorders.V- Common Psychiatric Disorders.

5. I- Lifespan vs. HealthspanI- Lifespan vs. Healthspan
Lifespan:Lifespan: Length of life increased.Length of life increased.
Healthspan:Healthspan: Length of healthy life beforeLength of healthy life before
disability.disability.
Factors affecting lifespan and healthspan:Factors affecting lifespan and healthspan:
– Exercise:Exercise: Improves mood and cognitionImproves mood and cognition..
– Sleep pattern.Sleep pattern.
– Eating pattern.Eating pattern.
– Social networks:Social networks: Protective againstProtective against
Psychosocial stressors and PsychiatricPsychosocial stressors and Psychiatric
disordersdisorders..

6. II- Physical BurdenII- Physical Burden
Diminished Effectiveness of ManyDiminished Effectiveness of Many
Systems:Systems:
- Nervous system.- Nervous system.
- Sensations.- Sensations.
- Immune system.- Immune system.
- Cardiovascular system.- Cardiovascular system.
- Respiratory system.- Respiratory system.
- Urinary system.- Urinary system.
- GIT.- GIT.
- Motor System.- Motor System.

7. III- Poly-PharmacyIII- Poly-Pharmacy
Multiple pathology.Multiple pathology.
- Cardiac disease: HPT, IHD.- Cardiac disease: HPT, IHD.
- Diabetes.- Diabetes.
- Asthma/ COPD.- Asthma/ COPD.
- Osteoporosis.- Osteoporosis.
- Neurological diseases.- Neurological diseases.
- Psychiatric disorders.- Psychiatric disorders.
Multiple medications.Multiple medications.
Multiple adverse effects.Multiple adverse effects.
Drug-Drug interactions.Drug-Drug interactions.

8. Bereavement.Bereavement.
Retirement.Retirement.
Relocated from their home.Relocated from their home.
Stresses of elderly peopleStresses of elderly people
leads to psychiatricleads to psychiatric
disorders.disorders. So, We have toSo, We have to
deal with stress.deal with stress.
IV- Psycho-Social Stressors

9. V- Psychiatric DisordersV- Psychiatric Disorders
& Old Age& Old Age
Psychiatric disorders of elderly persons may bePsychiatric disorders of elderly persons may be
divided into two groups:divided into two groups:
–Disorders of all ages:Disorders of all ages:
Depressive disorders, Anxiety disorders, Psychosis,Depressive disorders, Anxiety disorders, Psychosis,
Substance-related disorders & Sleep disorders.Substance-related disorders & Sleep disorders.
–Disorders related to old age:Disorders related to old age:
Cognitive disorders:Cognitive disorders: Delirium, Dementia &Delirium, Dementia &
Amnesia (MCI).Amnesia (MCI).
– Only about 20% receive mental health services.Only about 20% receive mental health services.

10. Common Psychiatric DisordersCommon Psychiatric Disorders
Disorder Community General Hospitals
Dementia* 5-20% 20-60%
Depression 5-15% 20-50%
Sleep Disorders 5-15% 20-40%
Anxiety Disorders 5-15% 3-10%
Delirium* >1% 5-50%
Psychotic Disorders ~1% ~2%
Any Disorder ~50% ~70%

11. Brain
Environment
Endocrine Glands Immune System
Physiology
and Behavior
Nerves
Hormones
Action
The Biological Basis of Psychiatric Disorders

12. The Biological Basis ofThe Biological Basis of
Psychiatric DisordersPsychiatric Disorders
MindBrain
Body
Psychoneuro-
Immunology
Medically
Unexplained
Physical Symptoms
Biopsychosocial
model

13. Diathesis-Stress ModelDiathesis-Stress Model
Diathesis
“Predisposing Causes”
(Hereditary Predisposition)
Stress
“Precipitating Causes”
(Situational Factors)
Disorder
Recovery
“Maintaining Causes”
Physical Conditions
Bio-Psycho-Social
Approach
• Emphasizes Interaction of
Biological and Social Factors

14. II- DEMENTIAII- DEMENTIA

15. DefinitionDefinition
Persistent intellectual impairment.Persistent intellectual impairment.
Impairment in:Impairment in:
– Memory.Memory.
– Abstract thinking.Abstract thinking.
– Judgment.Judgment.
– Impulse control.Impulse control.
Disregard for social rules.Disregard for social rules.
Neglect of personal appearance and hygiene.Neglect of personal appearance and hygiene.

16. Language may not be affected.Language may not be affected.
Personality change is common.Personality change is common.
No change in L.O.C.No change in L.O.C.
Slow, insidious onsetSlow, insidious onset
Long duration; progressive.Long duration; progressive.
Irreversible: reversible only in approximate 5%Irreversible: reversible only in approximate 5%
of cases (e.g., Nutritional deficiencies).of cases (e.g., Nutritional deficiencies).
In Summary:In Summary:
Recent Memory Loss on Clear ConsciousnessRecent Memory Loss on Clear Consciousness

17. Clinical PresentationClinical Presentation
Initial presentation:Initial presentation:
-- Slight forgetfulness.Slight forgetfulness.
- Attention and concentration deficits.- Attention and concentration deficits.
- Increase repetition.- Increase repetition.
- Inconsistencies in usual behavior.- Inconsistencies in usual behavior.
Later presentationLater presentation
-- Impaired judgment.Impaired judgment.
- Inability to abstract.- Inability to abstract.
- Personality change.- Personality change.
- Rigidity, perseveration, irritability & confusion.- Rigidity, perseveration, irritability & confusion.
- Affective disturbances with loss self-care.- Affective disturbances with loss self-care.

18. Non-Reversible Types ofNon-Reversible Types of
Dementia (95%)Dementia (95%)
Alzheimer’s disease.Alzheimer’s disease.
Vascular Dementia.Vascular Dementia.
Dementia with LewyDementia with Lewy
bodies.bodies.
Fronto-TemporalFronto-Temporal
Dementia.Dementia.
Others:Others:
Parkinson’s Disease.Parkinson’s Disease.
Huntington’s Disease.Huntington’s Disease.
Creutzfeldt JakobCreutzfeldt Jakob
Disease.Disease.
Progressive SupranuclearProgressive Supranuclear
Palsy.Palsy.
Korsakoff’s Syndrome.Korsakoff’s Syndrome.
Infection-RelatedInfection-Related
Dementia (HIV, Syphilis).Dementia (HIV, Syphilis).

19. Reversible Types of DementiaReversible Types of Dementia
Malnutrition.Malnutrition.
Dehydration.Dehydration.
Metabolic Dysfunction.Metabolic Dysfunction.
Vitamin B12 Deficiency.Vitamin B12 Deficiency.
Depression.Depression.
Delirium.Delirium.
(5%)

20. Risk Factors for DementiaRisk Factors for Dementia
AgingAging
MenopauseMenopause
Family HistoryFamily History
APOE GenotypeAPOE Genotype
Serious Head TraumaSerious Head Trauma
Low Educational LevelLow Educational Level
Low Occupational LevelLow Occupational Level

21. Medical Workup for DementiaMedical Workup for Dementia
TESTS RATIONALE – rule out…
Urinalysis & S. Creatinine Kidney dysfunction & toxic encephalopathy
CBC, ESR & Electrolytes Anemia & electrolyte imbalance
Liver function tests Liver dysfunction
Thyroid function Thyroid dysfunction
Serum B 12 Vitamin deficiency
Syphilis serology Syphilis
HIV test AIDS dementia
Neuroimaging studies:
(CT or MRI)
Tumor, subdural hematomas, abscess,
stroke or hydrocephalus

22. Dementia Or Depression?Dementia Or Depression?
Cognitive impairment:Cognitive impairment: There may be aThere may be a
degree in both depression and dementia.degree in both depression and dementia.
Early stages of dementia:Early stages of dementia: may mimicmay mimic
depression (loss of interest, apathy anddepression (loss of interest, apathy and
weight loss).weight loss).
Pseudo-Dementia:Pseudo-Dementia: Depression may lead toDepression may lead to
a degree of cognitive impairment severea degree of cognitive impairment severe
enough to be confused with dementia.enough to be confused with dementia.
Antidepressants:Antidepressants: may lead to anmay lead to an
improvement in cognitive performance.improvement in cognitive performance.

23. Differential DiagnosisDifferential Diagnosis
Alzheimer's diseaseAlzheimer's disease 60 - 70%60 - 70%
Multi-infarct dementiaMulti-infarct dementia 10 - 20%10 - 20%
Brain tumorsBrain tumors ~ 5%~ 5%
OthersOthers 10-15%10-15%
(Including(Including [4 Ds][4 Ds]:: DDepression,epression, DDelirium,elirium,
DDrugs,rugs, DDecline in memory[ecline in memory[MCIMCI]).]).
So, AD is the most common subtype,So, AD is the most common subtype,
(80% in mild to moderate stage & 20% severe).(80% in mild to moderate stage & 20% severe).

25. III- ALZHEIMER’SIII- ALZHEIMER’S
DISEASEDISEASE

26. ALZHEIMER’S DISEASEALZHEIMER’S DISEASE
In 1906In 1906 Dr. Alois AlzheimerDr. Alois Alzheimer was firstwas first
toto describe Alzheimer's illness anddescribe Alzheimer's illness and
since then millions of people havesince then millions of people have
been diagnosed with the disease.been diagnosed with the disease.

27. What Is Alzheimer’sWhat Is Alzheimer’s
A progressive, degenerative illness thatA progressive, degenerative illness that
attacks the brain and results in impairedattacks the brain and results in impaired
memory, thinking and behavior.memory, thinking and behavior.
The disease attacks nerve cells in allThe disease attacks nerve cells in all
parts of the cortex of the brain, as wellparts of the cortex of the brain, as well
as some surrounding structures.as some surrounding structures.
In the end, an afflicted person loses allIn the end, an afflicted person loses all
memory and mental functioning.memory and mental functioning.

28. Prevalence of ADPrevalence of AD
Kurz A. Eur J Neurol 1998; 5(Suppl 4): S1-8
Wimo A et al. Int J Geriatr Psychiatry 1997; 12: 841-56
0
10
20
30
40
50
60
60-64 65-69 70-74 75-79 80-84 85+ 95+
Age (years)
Prevalence(%)
1% 2% 4%
8%
16%
30%
50%

29. What Are the Warning Signs?What Are the Warning Signs?
Memory loss that affects job skills.Memory loss that affects job skills.
Difficulty performing familiar tasks.Difficulty performing familiar tasks.
Problems with language.Problems with language.
Disorientation to time and place.Disorientation to time and place.
Poor or decreased judgment.Poor or decreased judgment.
Problems with abstract thinking.Problems with abstract thinking.
Misplacing things.Misplacing things.
Changes in mood or behavior.Changes in mood or behavior.
Changes in personality.Changes in personality.
Loss of initiative.Loss of initiative.

30. HISTORICAL POINTERSHISTORICAL POINTERS
Forgetting recent events despite prompting.Forgetting recent events despite prompting.
Failure to attend appointments.Failure to attend appointments.
Frequent repetition of statements, stories orFrequent repetition of statements, stories or
questions.questions.
Frequent lost or misplaced items.Frequent lost or misplaced items.
Losing track in conversation or word-findingLosing track in conversation or word-finding
difficulty.difficulty.
Difficulty understanding conversation orDifficulty understanding conversation or
following the story in a book or on TV.following the story in a book or on TV.
Confusion with time e.g., day, date, time of day.Confusion with time e.g., day, date, time of day.
Becoming lost or unable to find the way.Becoming lost or unable to find the way.

31. HISTORICAL POINTERSHISTORICAL POINTERS
Difficulty handling money or paying bills.Difficulty handling money or paying bills.
Difficulty working gadgets, planning orDifficulty working gadgets, planning or
preparing meals or performing handyman tasks.preparing meals or performing handyman tasks.
Neglect of personal care, home maintenance orNeglect of personal care, home maintenance or
nutrition.nutrition.
Withdrawal from previous community and socialWithdrawal from previous community and social
activities (poor work performance if employed).activities (poor work performance if employed).
Difficulty coping with new events or change toDifficulty coping with new events or change to
routine.routine.
Personality and behavior change.Personality and behavior change.

32. Cognition
Activitiesofdailyliving
Behaviour
ABC: The Key SymptomABC: The Key Symptom
Domains Affected In ADDomains Affected In AD

34. Natural History of ADNatural History of AD
1 2 3 4 5 6 7 8 9
0
5
10
15
20
25
30
Time (years)
Symptoms
Diagnosis
Loss of functional independence
Behavioural problems
Nursing home placement
Death
Mini-MentalStateExamination(MMSE)
Early Diagnosis Mild-to-Moderate Severe
Feldman and Gracon. The Natural History of Alzheimer’s Disease. London: Martin Dunitz, 1996

35. Risk Factors For ADRisk Factors For AD
1- General risk factors of Dementia.1- General risk factors of Dementia.
2- Age.2- Age.
Number of cases of Alzheimer's diseaseNumber of cases of Alzheimer's disease
doubles every five years in people over 65.doubles every five years in people over 65.
3- Family History.3- Family History.
Evidence is not clear:Evidence is not clear: Cases where severalCases where several
members of a single family are rare.members of a single family are rare.
People with a FH of AD are at higher thanPeople with a FH of AD are at higher than
average risk for AD due toaverage risk for AD due to GeneticsGenetics (ApoE-4 &(ApoE-4 &
Down’s syndrome).Down’s syndrome).
4- Gender.4- Gender.
A number of studies suggest that F M while˃A number of studies suggest that F M while˃
one reported that M F.˃one reported that M F.˃

36. Protective Factors?Protective Factors?
Genetic (ApoE-2).Genetic (ApoE-2).
NSAID’s (Anti-inflammatories).NSAID’s (Anti-inflammatories).
Statins (Cholesterol lowering).Statins (Cholesterol lowering).
Prevent alcohol consumption.Prevent alcohol consumption.
Higher education.Higher education.
Ongoing intellectual stimulation.Ongoing intellectual stimulation.
Physical and leisure / social activities.Physical and leisure / social activities.
Diet (fruit and vegetables, low in saturated fat).Diet (fruit and vegetables, low in saturated fat).
Long-term use of estrogens (in women).Long-term use of estrogens (in women).

37. What Causes Alzheimer's?What Causes Alzheimer's?
Scientists are still not certain.Scientists are still not certain.
A slow actingA slow acting virusvirus..
Toxic substancesToxic substances (e.g., aluminum in non-(e.g., aluminum in non-
natural sources).natural sources).
HomocysteineHomocysteine (an amino acid that is harmful to(an amino acid that is harmful to
nerve cells). It is a known risk factor in heartnerve cells). It is a known risk factor in heart
disease and hypertension.disease and hypertension.
Tau-proteinTau-protein abnormalities.abnormalities.
Genetics: (CHGenetics: (CH 14, 19, 2114, 19, 21).).
AcetylcholineAcetylcholine alterations (ACh).alterations (ACh).
Alterations inAlterations in immune systemimmune system..

38. Pathophysiology of Alzheimer’sPathophysiology of Alzheimer’s
Amyloid Precursor Protein (APP):Amyloid Precursor Protein (APP):
Production and accumulation ofProduction and accumulation of ß amyloid (AB)ß amyloid (AB)
peptide is central to the pathogenesis of AD.peptide is central to the pathogenesis of AD.
Mutations inMutations in APPAPP gene lead to early-onset AD bygene lead to early-onset AD by
increasing production of AB which is neurotoxic inincreasing production of AB which is neurotoxic in
vitro & leads to cell death.vitro & leads to cell death.
In patients with trisomy 21 (In patients with trisomy 21 (Down’s syndrome: 3Down’s syndrome: 3
copies of the APP genecopies of the APP gene): neuro-pathological): neuro-pathological
characteristics of AD develop by midlife.characteristics of AD develop by midlife.

39. Pathophysiology of Alzheimer’sPathophysiology of Alzheimer’s
Presenilins:Presenilins: PS 1 & PS 2 are homologous 43-50PS 1 & PS 2 are homologous 43-50
kD proteins & they are neurodegenerative in AD.kD proteins & they are neurodegenerative in AD.
Plasmin:Plasmin: Lower levels of plasmin inLower levels of plasmin in
hippocampus of AD brain.hippocampus of AD brain.
Calcium:Calcium: Increased intracellular calcium elicitsIncreased intracellular calcium elicits
the characteristic lesions of AD, including thethe characteristic lesions of AD, including the
accumulation of ß amyloid, the hyper-accumulation of ß amyloid, the hyper-
phosphorylation of TAU proteins and neuronalphosphorylation of TAU proteins and neuronal
death.death.

40. Brain
Atrophy
Senile
Plaques
Neurofibrillary
Tangles
Katzman, 1986; Cummings and Khachaturian, 1996
AD: A Progressive CNS DisorderAD: A Progressive CNS Disorder
with A Characteristic Pathologywith A Characteristic Pathology

41. Cholinergic deficit
– Progressive loss of cholinergic
neurons.
– Progressive decrease in
available Ach.
– impairment in ADL, behavior
and cognition.
Hippocampus
Cortex
N. basalis Meynert
Bartus et al., 1982; Cummings and Back, 1998, Perry et al., 1978
Cholinergic Deficit Underlies ClinicalCholinergic Deficit Underlies Clinical
SymptomsSymptoms

42. What Parts of The Brain areWhat Parts of The Brain are
Affected?Affected?
TheThe hippocampushippocampus,,
which is part of thewhich is part of the
limbic system and inlimbic system and in
part functions as thepart functions as the
focal point wherefocal point where
processes leading toprocesses leading to
memory storage andmemory storage and
retrieval begin.retrieval begin.
TheThe cortexcortex,, which iswhich is
used in formingused in forming
associations betweenassociations between
ideas and memories.ideas and memories.

43. The Pathological Cascade of AD
Clinical symptoms
Neuro-degeneration
Neurofibrillary
tangles
β-amyloid
Environmental
Risk Factors
Genetic
Risk
Factors
Apo-E
Pathogenetic
Mutations
APP
PS1,2
Cholinergic dysfunction
TAU hypophosphorylation

44. 4444
Cognitive impairment
Dementia
Alzheimer's disease
Exclude other causes (e.g.
Delirium and Depression, etc)
Exclude other dementias
Differentiating AD from otherDifferentiating AD from other
DementiasDementias

45. 4545
Functional Activities Questionnaire (FAQ)
1. Dealing with financial matters, paying bills, writing checks
2. Keeping records of taxes, business affairs
3. Shopping for everyday necessities: groceries, clothes, etc
4. Hobbies or playing games
5. Making tea, turning the kettle on and off
6. Cooking a balanced meal
7. Perception of current events
8. Level of attention and understanding: books, television
9. Memory: remembering appointments and medications
10. Getting about: driving or taking public transport
Pfeffer et al 1982
Score
Maximum
3
3
3
3
3
3
3
3
3
3
Total 30
Score
Actual
Diagnosing AD In Primary CareDiagnosing AD In Primary Care
Functional AssessmentFunctional Assessment

46. 4646
Cognitive area
MMSE: Test outline and Scoring:
Orientation
*What is the (date, day, month, year, season)?
* Where are you (clinic, town, country)?
Memory
*Name three objects. Ask the patient to repeat them
Attention
*Serial sevens. Alternatively ask the patient to spell
world backwards (dlrow)
Folstein et al 1975
Score
Maximum
5
5
3
5
Score
Actual
Diagnosing AD In Primary CareDiagnosing AD In Primary Care
Cognitive Assessments, MMSECognitive Assessments, MMSE

47. 4747
Recall
*Ask for the three objects mentioned above to be
repeated
Language
*Name a pencil and watch
*Repeat, 'No ifs, ands or buts’
*A three stage command
*Read and obey - CLOSE YOUR EYES
*Write a sentence
*Copy a double pentagon
Score
Maximum
3
2
1
3
1
1
1
Total 30
Score
Actual
Folstein et al 1975
Diagnosing AD In Primary CareDiagnosing AD In Primary Care
Cognitive Assessments, MMSECognitive Assessments, MMSE

48. 4848
The Clock Draw Test
Time: 5.00
Score: 7 (normal)
Time: 'no real time'
Score: 2 (demented)
Thalmann et al 1996.
Time: .10.30
Score: 3 (demented)
Time: 1/4 past 25
Score: 3 (demented)
Diagnosing AD In Primary CareDiagnosing AD In Primary Care
Cognitive AssessmentCognitive Assessment

49. Treating Alzheimer’s Disease

50. CHOLINESTERASE INHIBITORSCHOLINESTERASE INHIBITORS
-Second Generation-Second Generation
1- Donepezil (Aricept): 8 CT, 2664 pts.1- Donepezil (Aricept): 8 CT, 2664 pts.
2- Rivastigmine (Exelon):2- Rivastigmine (Exelon): 7 CT, 3370 pts.7 CT, 3370 pts.
3- Galantamine (Reminyl):3- Galantamine (Reminyl): 6 CT, 3170 pts.6 CT, 3170 pts.
9204 patients in 21 clinical trials9204 patients in 21 clinical trials →→ modestmodest
benefit in mild-moderate AD.benefit in mild-moderate AD.

51. Post synaptic
Acetyl CoA
+
Choline
Choline
+
Acetate
AChE
ACh
ACh
ChAT
Central Cholinergic Synapse
X
Cholinesterase
Inhibitors
(-)
M2
Muscarinic 1
receptor
(+)

52. Memantine (Ebixa)Memantine (Ebixa)
NMDA receptor antagonist.NMDA receptor antagonist.
It normalize the transmission of nerveIt normalize the transmission of nerve
signals involved in memory and othersignals involved in memory and other
mental functions.mental functions.
FDA approvrd in moderate to severeFDA approvrd in moderate to severe
dementia.dementia.
Modest benefit in cognition, function andModest benefit in cognition, function and
behavior.behavior.
Available in MOH.Available in MOH.

53. Treatment of BehaviorTreatment of Behavior
ProblemsProblems
Antipsychotics should not be firstAntipsychotics should not be first
choice, unless the patient ischoice, unless the patient is
psychotic.psychotic.
Consider the likelihood ofConsider the likelihood of
depression and anxiety.depression and anxiety.
Consider using behavioral methods.Consider using behavioral methods.
Valproic acid may be of benefit.Valproic acid may be of benefit.
BZD’s may aggravate confusion.BZD’s may aggravate confusion.

54. AntipsychoticsAntipsychotics
For agitation, aggression, hallucinationsFor agitation, aggression, hallucinations
and thought disturbances:and thought disturbances:
– Risperidone (Risperidal).Risperidone (Risperidal).
– Olanzapine (Zyprexa).Olanzapine (Zyprexa).
– Quetiapine (Seroquel).Quetiapine (Seroquel).
Combination of Antipsychotics withCombination of Antipsychotics with
Ebxia is contraindicatedEbxia is contraindicated

55. IV- DELIRIUMIV- DELIRIUM

56. DefinitionDefinition
ImpairedImpaired consciousnessconsciousness..
Alterations in cognition:Alterations in cognition:
– Orientation: (Orientation: (T.P.PT.P.P))..
– Attention.Attention.
– Concentration.Concentration.
– Memory: (Memory: (I.R.RI.R.R))..
– Thinking:Thinking: DisorganizedDisorganized..
– Language:Language: Incoherent speechIncoherent speech..
– Perception:Perception: Illusions and HallucinationsIllusions and Hallucinations..
Disturbances of sleep-awake cycle.Disturbances of sleep-awake cycle.
Psychomotor changes.Psychomotor changes.
Sudden onset & Short duration with fluctuation.Sudden onset & Short duration with fluctuation.

57. SYNONYMS FOR DELIRIUMSYNONYMS FOR DELIRIUM
Acute confusion state.Acute confusion state.
Toxic-metabolic encephalopathy.Toxic-metabolic encephalopathy.
Organic brain syndrome.Organic brain syndrome.
ICU psychosis.ICU psychosis.

58. DELIRIUMDELIRIUM
Prevalence:Prevalence:
15-30% of hospitalized patients.15-30% of hospitalized patients.
Highly prevalent in last weeks of life (40-85%).Highly prevalent in last weeks of life (40-85%).
Due to:Due to:
General Medical Condition.General Medical Condition.
oror
Substance – Induced:Substance – Induced:
– Intoxication.Intoxication.
– Withdrawal.Withdrawal.
oror
Multiple Etiologies.Multiple Etiologies.

59. Causes of DeliriumCauses of Delirium
Direct:Direct:
– Primary CNS tumor.Primary CNS tumor.
– Metastatic spread.Metastatic spread.
Indirect:Indirect:
– Hypoxia.Hypoxia.
– MetabolicMetabolic
encephalopathy.encephalopathy.
– ElectrolyteElectrolyte
imbalance.imbalance.
– Withdrawal status.Withdrawal status.
• Indirect (cont):
– Infection.
– Hematologic abnormalities.
– Nutritional deficiencies.
– Paraneoplastic syndrome.
– Treatments side-effects.
• Chemotherapy.
• Steroids.
• Radiation.
• Opioids.
• Anticholinergics.
• Antiemetics.

60. Assessment of EtiologyAssessment of Etiology
Unclear, not found 50-60%.Unclear, not found 50-60%.
Etiology found 40-50%.Etiology found 40-50%.
Three or more etiologies usuallyThree or more etiologies usually
present.present.
Irreversible 30-40% of cases.Irreversible 30-40% of cases.
60-70% improve with treatment of60-70% improve with treatment of
etiology.etiology.

61. Management of DeliriumManagement of Delirium
Find the cause(s): Usually multi-factorial.Find the cause(s): Usually multi-factorial.
Look for medication toxicity.Look for medication toxicity.
Re-orient the patient.Re-orient the patient.
Quiet, non stimulating environment.Quiet, non stimulating environment.
Antipsychotic medications for agitation.Antipsychotic medications for agitation.
Benzodiazepines often makes deliriumBenzodiazepines often makes delirium
worse except in delirium tremens.worse except in delirium tremens.
One to one observation.One to one observation.
Restraints only when needed.Restraints only when needed.

62. PharmacologicalPharmacological
InterventionsInterventions
Thiamine:Thiamine: for alcoholics andfor alcoholics and
malnourished.malnourished.
Benzodiazepines:Benzodiazepines: for alcohol withdrawal.for alcohol withdrawal.
Haloperidol:Haloperidol: was the drug of choice forwas the drug of choice for
critically ill delirious patients.critically ill delirious patients.
Atypical antipsychotics:Atypical antipsychotics:
- Risperidone.- Risperidone.
- Olanzapine.- Olanzapine.

63. Distinguishing 3DsDistinguishing 3Ds
Delirium Dementia DepressionDelirium Dementia Depression
 OnsetOnset Acute Insidious GradualAcute Insidious Gradual
 Course 24HrsCourse 24Hrs Fluctuate Stable StableFluctuate Stable Stable
 CourseCourse Fluctuate Persist Slow remitFluctuate Persist Slow remit
 ConsciousnessConsciousness Redused Clear ClearRedused Clear Clear
 AttentionAttention ImpairedImpaired Intact IntactIntact Intact
 CognitionCognition ImpairedImpaired ImpairedImpaired IntactIntact
 PsychosisPsychosis VH, paranoia Occass S. casesVH, paranoia Occass S. cases
 EEGEEG Abnormal Late Abnl. NormalAbnormal Late Abnl. Normal

64. V- CAREGIVERSV- CAREGIVERS
BURDENBURDEN

65. CAREGIVERS BURDENCAREGIVERS BURDEN
Physical Burden.Physical Burden.
Financial Burden.Financial Burden.
Time Burden.Time Burden.
Role Burden.Role Burden.
Emotional Burden.Emotional Burden.
Others.Others.

66. Caregiving BurdenCaregiving Burden
Signs of Caregiver BurnoutSigns of Caregiver Burnout
1- Physical Burden:1- Physical Burden:
Weight Change:Weight Change: Gain or LossGain or Loss..
Unexplained Somatic Complaints:Unexplained Somatic Complaints:
((Chronic headaches, backaches orChronic headaches, backaches or
othersothers).).
Caregiver’s Syndrome:Caregiver’s Syndrome:
((Fatique from physical strain & sleep lackFatique from physical strain & sleep lack).).
Osteoporosis and Arthritis.Osteoporosis and Arthritis.

67. Caregiving BurdenCaregiving Burden
Signs of Caregiver BurnoutSigns of Caregiver Burnout
3- Time Burden:3- Time Burden:
Caregiving is time-consuming.Caregiving is time-consuming.
Less time for other tasks.Less time for other tasks.
Activities can be stressful.Activities can be stressful.
4- Role Burden:4- Role Burden:
Feelings of being pulled in differentFeelings of being pulled in different
directions.directions.
Family responsibilities.Family responsibilities.
Pressure and tension.Pressure and tension.

68. Caregiving BurdenCaregiving Burden
Signs of Caregiver BurnoutSigns of Caregiver Burnout
5- Emotional Burden:5- Emotional Burden:
Common feelings: Being overwhelmed, Anger,
Frustration, Guilt, Exhaustion, Loneliness and
Social withdrawal.
Cognitive disturbances: Lack of concentration
and finding it difficult to complete complex tasks.
Sleep disorders: Sleeplessness / stressful dream.
Anxiety: about facing another day and what the
future holds.
Depression: feeling sad and hopeless.
Adjustment disorders.

69. Psychiatric Disorders AmongPsychiatric Disorders Among
Caregivers of Dementia PatientsCaregivers of Dementia Patients
Depression.Depression.
Anxiety disorders.Anxiety disorders.
Unexplained Somatic Complaints.Unexplained Somatic Complaints.
Adjustment disorders.Adjustment disorders.
Sleep disorders.Sleep disorders.

70. VI- CONCLUSIONSVI- CONCLUSIONS

71. Overall Approach DementiaOverall Approach Dementia
AdoptAdopt A Bio-Psycho-SocialA Bio-Psycho-Social approachapproach..
Treat inter-currentTreat inter-current Physical ProblemsPhysical Problems..
Identify majorIdentify major Psychological IssuesPsychological Issues..
ProvideProvide SupportSupport..
Give an opportunity for the patientGive an opportunity for the patient To TalkTo Talk..
AssessAssess Social SituationSocial Situation..
Organize appropriateOrganize appropriate InterventionsInterventions..

72. NursingNursing Is of Paramount ImportanceIs of Paramount Importance
In Dementia.In Dementia.
We have to take care of theWe have to take care of the
dementeddemented patientpatient and his/ herand his/ her
caregivercaregiver..
TheThe goodgood physician will treat thephysician will treat the
disease, but thedisease, but the greatgreat physician willphysician will
treat the patient.treat the patient.
Mental health care of old age meansMental health care of old age means
enhancing physical treatment andenhancing physical treatment and
decreasingdecreasing morbidity and mortalitymorbidity and mortality..

73. ADVICE FOR OLD AGE PERSONADVICE FOR OLD AGE PERSON
Caring For YourselfCaring For Yourself
Maintain a positive outlook on life.Maintain a positive outlook on life.
Take good care of your health.Take good care of your health.
Remain active.Remain active.
Stay in close contact with family and friends.Stay in close contact with family and friends.
Eat right.Eat right.
Remain mentally active & never stop learning.Remain mentally active & never stop learning.