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.
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
12. SAMPLE QUESTION
1. Which one of the following is an early
sign of dementia?
A. Becoming lost in familiar places.
B. Becoming forgetful of recent events and
people's names
C. Becoming unaware of the time and place
D. Becoming lost at home
13. SAMPLE QUESTION
• The following clinical feature is a
cognitive disturbance of dementia
A. Paranoia
B. Agitation
C. Hallucinations
D. Abstract thinking ddisturbance
14. TYPES OF DEMENTIA
Dementia is categorized according to
its etiology:
1. Alzheimer’s dementia 60%
2. Vascular dementia 10%
3. Frontal-Temporal Lobe 15%
4. Dementia with Lewy bodies 15%
5. Other 10%
15. DIFFERENTIAL DIAGNOSIS
• Common precipitating factors for
delirium include infection, medication
interactions and surgery
• Differentiating between Dementia,
Delirium and Depression (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.
21. 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
22. 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.
23. 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.
24. 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.
25. 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.
26. 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.
28. 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
29. 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
30. Establishing a therapeutic
relationship
o I will explain to the person who I am, what I want to do and
why.
o I will respond to clients concerns if any, in a language that
he understands
o 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.
o 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.
o Be empathetic, nonjudgmental and respectful
o I will avoid making promises I can not fulfil to avoid client
loosing trust in me.
31. 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
32. 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.
33. 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
34. 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
35. 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
36. 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
37. 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
38. 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
39. 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
40. SOCIAL TRANING
• Simple group chores and games
• Chapel meetings
• Taking walks
• Creating friendships
• Grooming gardening, sweeping and
respect towards others
• Eating with others
41. 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
42. 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
43. 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
44. 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
45. 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.
A. i) Define Dementia
ii) Name the types of dementia
A. Mention five signs and symptoms of
Dementia
B. State the 3 stages of dementia
C. Identify five nursing problems and write a
nursing care plan.
Dementia is an incurable illness with failing brain functioning and increasing physical disability leading to total dependence on others for all care.
Worldwide, around 50 million people have dementia, with nearly 60% living in low- and middle-income countries.
Every year, there are nearly 10 million new cases.
The estimated proportion of the general population aged 60 and over with dementia at a given time is between 5-8%.
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
FOUR KEY ELEMENTS TO THE DEFINITION OF DEMENTIA
GLOBAL IMPAIRMENT -more than just memory
DECLINE- a decrease from a previous level of functioning.
SEVERITY- severe and causes impairment
NORMAL CONSCIOUSNESS- impairments occur in normal state of consciousness
1. Global impairment – Dementia impairments are in total.
The impairments occur in more than just memory.
Most dementia patients experience impairments in reasoning, using and understanding language, recognizing what one perceives through the senses, coordinating learned motor movements, planning and decision-making.
2. Decline – the impairments represent a decrease from a previous level of functioning.
To recognize a reduction, it is crucial for the nurse to know the patient’s previous level of functioning unless members of the family or significant others give correlated information.
3. Severity – Impairments are severe enough to interfere with normal functioning in everyday life.
Examples are a person who was living independently and begins to make poor financial decisions or forgets how to cook a meal, although the person could previously perform those tasks.
Getting lost while walking from a nearby church, neighbourhood and driving can also indicate severe impairment.
4. Normal consciousness – These impairments occur in a normal state of consciousness; patients are awake and alert.
This is distinguished from an abnormal state of consciousness, such as drowsiness, stupor or coma, seen in delirium.
Neurological disorders such as Alzheimer’s (est. 50-70% of people with dementia have Alzheimer’s)
Vascular disorders such as multi-infarct disease (multiple strokes)
Inherited disorders such as Huntington’s
Infections such as HIV
Cerebrovascular disease (and the risk factors for CV disease – including smoking, diabetes, hyperlipidemia, hypertension) is associated with vascular dementia risk
Recurrent MDD may be associated with risk of dementia in general. (Kessing and Anderson found risk of dementia to be 6 times higher in patients with 5 or more prior episodes.)1
Subclinical Hyperthyroidism (especially when antithyroid antibodies are present.2
Drug abuse, Normal Pressure
Hydrocephalus,
Chronic subdural Hematoma,
Benign Brain Tumors,
Vitamin Deficiency, and Hypothyroidism
Aphasia, which is deterioration of language function OR language impairments
Apraxia, which is impaired ability to execute motor functions despite intact motor abilities
Agnosia, which is inability to recognize or name objects despite intact sensory abilities
Abstract thinking/Disturbance in executive functioning, which is the ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior
Early stage:
The early stage of dementia is often overlooked, because the onset is gradual. Common symptoms include:
forgetfulness
losing track of the time
becoming lost in familiar places.
Middle stage:
As dementia progresses to the middle stage, the signs and symptoms become clearer and more restricting. These include:
becoming forgetful of recent events and people's names
becoming lost at home
having increasing difficulty with communication
needing help with personal care
experiencing behaviour changes, including wandering and repeated questioning.
Late stage
The late stage of dementia is one of near total dependence and inactivity. Memory disturbances are serious and the physical signs and symptoms become more obvious. Symptoms include:
becoming unaware of the time and place
having difficulty recognizing relatives and friends
having an increasing need for assisted self-care
having difficulty walking
experiencing behaviour changes that may escalate and include aggression.
i) Alzheimer’s dementia,
a consequence of degenerative brain changes as an individual age.
Alzheimer disease (AD) is the most common cause of dementia and thus the most common type that nurses encounter in clinical practice
AD is an incurable neuro- degenerative disease
One also sees general shrinkage of the brain and a decrease in the number of functioning neurons.
Clinical picture:
Memory, visual, spatial and language decline behavioural changes
Risk factors are;
familial, Down syndrome, prior head trauma, increasing age.
Pathology reveals
Cortical atrophy, neurofibrillary tangles, amyloid plaques, granulovacuolar degeneration, loss of basal forebrain cholinergic nuclei.
ii) Vascular dementia result from small brain infarcts; small brain haemorrahges.
Clinical Picture
Aphasia, focal neural deficits, sudden onset
Risk factors are;
Cardiovascular and cerebrovascular disease.
Pathology reveals
Multiple areas of neuronal damage.
Focal findings.
Course;
Can be rapid onset or more slowly progressive. Deficits are not reversible, but progress can be halted with appropriate treatment of vascular disease
iii) Frontal temporal lobe dementia
Damage to the brain’s frontal and temporal lobes causes forms of dementia called frontotemporal disorders.
Clinical picture
Socially inappropriate
Poor executive function
Decreased motivation, apathy
Imaging
Frontotemporal atrophy
Prognosis
8-10 years
Feeding failure, aspiration, infection
Treatment
SSRI
Antipsychotics
stimulants
It is important to understand the difference between dementia, delirium and depression
Depression and delirium are treatable conditions that present similar to dementia
Remember that all three conditions can be present and that dementia increases the risk for delirium
When the person is severely agitated and as a result, distressed or representing a danger to himself, herself or others, sedation (a waking calm) is indicated (avoid oversedation)
Benzodiazepines with lower toxicity and shorter half-life (for example, temazepam, and/or oxazepam) are preferred to longer-acting agents (for example, diazepam, and/or nitrazepam).
Research shows that giving a patient suffering from dementia a cocktail of vitamins, such as Folic acid, B12 and B6 improves memory. This treatment has to be given simultaneously once daily (OD) for one month and then the patient to be observed for signs of improvement.