A BRIEF HISTORY OF DEMENTIA CASE PROBLEM: "A woman in her early 50s was admitted to a hospital because of increasingly

odd behavior. Her family reported that she had been showing memory problems and strong feelings of jealousy. She also had become disoriented at home and was hiding objects. During a doctor's examination, the woman was unable to remember her husband's name, the year, or how long she had been at the hospital. She could read but did not seem to understand what she read, and she stressed the words in an unusual way. She sometimes became agitated and seemed to have hallucinations and irrational fears." This description, of a woman known as Auguste D., was the first scientific report of the disease now known as Alzheimer's disease, after Alois Alzheimer, the German doctor who wrote it. After Auguste D. died in 1906, doctors examined her brain and found that it appeared shrunken and contained several unusual features, including strange clumps of protein called plaques and tangled fibers inside the nerve cells. Memory impairments and other symptoms of dementia, which means "deprived of mind," had been described in older adults since ancient times. However, because Auguste D. began to show symptoms at a relatively early age, doctors did not think her disease could be related to what was then called "senile dementia." The word senile is derived from a Latin term that means, roughly, "old age."

DEFINITION:

Dementia is a progressive decline in memory and at least one other cognitive area in an alert person. These cognitive areas include attention, orientation, judgment, abstract thinking and personality. Dementia is rare in under 50 years of age and the incidence increases with age; 8% in >65 and 30% in >85 years of age. Dementia is a decline of reasoning, memory, and other mental abilities (the cognitive functions). This decline eventually impairs the ability to carry out everyday activities such as driving; household chores; and even personal care such as bathing, dressing, and feeding (often called activities of daily living, or ADLs).

Dementia is most common in elderly people; it used to be called senility and was considered a normal part of aging. We now know that dementia is not a normal part of aging but is caused by a number of underlying medical conditions that can occur in both elderly and younger persons. In some cases, dementia can be reversed with proper medical treatment. In others, it is permanent and usually gets worse over time.

CAUSE/ETIOLOGY: Believed to be an IDIOPHATIC (unknown Cause), but several hypothesis were introduced (MS brunner and suddarth page 342-343) Various diseases and infections, stroke, drug toxicity and nutritional deficiencies. Dysfunction in the cerebral Cortex, or brain tissues. Brain damage, alcoholism, alteration in Immune system- Antibodies are being produced in the brain which causes a reaction against self it is called autoimmune Accumulation of aluminum-Studies show that aluminum accumulates in damaged areas of the brain. Head trauma: head injuries Genetic factor: pattern of inheritance Acetylcholine Alteration: Decrease in acetylcholine reduces the amount of neurotransmitter which results in disruption of cognitive process. Irreversible causes The main irreversible causes of dementia are described here. These damage brain cells in both cortical and subcortical areas. Treatment focuses on slowing progress of the underlying condition and relieving symptoms.

Alzheimer disease: This is the most common cause of dementia, accounting for about half of all cases. Alzheimer disease is at least partly hereditary in that it tends to run in families. (Just because a relative has Alzheimer disease, however, does not mean that another family member will have the disease.) In this disease, abnormal protein deposits in the brain destroy cells in the areas of the brain that control

memory and mental functions. People with Alzheimer disease also have lower-than-normal levels of brain chemicals called neurotransmitters that control important brain functions. Alzheimer disease is not reversible, and no known cure exists. However, certain medications can slow its progress. Vascular dementia: This is the second most common cause of dementia, accounting for as many as 40% of cases. This dementia is caused by atherosclerosis, or "hardening of the arteries," in the brain. Deposits of fats, dead cells, and other debris form on the inside of arteries, partially (or completely) blocking blood flow. These blockages cause multiple strokes, or interruptions of blood flow, to the brain. Because this interruption of blood flow is also called "infarction," this type of dementia is sometimes called multi-infarct dementia. One subtype whose origin is not well understood is Binswanger disease. Vascular dementia is related to high blood pressure, high cholesterol, heart disease, diabetes, and related conditions. Treating those conditions can slow the progress of vascular dementia, but functions do not come back once they are lost. Parkinson disease: People with this disease typically have limb stiffness (which causes them to shuffle when they walk), speech problems, and tremor (shaking at rest). Dementia may develop late in the disease, but not everyone with Parkinson disease has dementia. Reasoning, memory, speech, and judgment are most likely to be affected. Lewy body dementia: This is caused by abnormal microscopic deposits of protein, called Lewy bodies, which destroy nerve cells. These deposits can cause symptoms typical of Parkinson disease, such as tremor and muscle rigidity, as well as dementia similar to that of Alzheimer disease. Lewy body dementia affects thinking, attention, and concentration more than memory and language. Like Alzheimer disease, Lewy body dementia is not reversible and has no known cure. The drugs used to treat Alzheimer disease also benefit some people with Lewy body disease. Huntington disease: This inherited disease causes wasting of certain types of brain cells that control movement as well as thinking. Dementia is common and occurs in the late stages of the disease. Personality changes are typical. Reasoning, memory, speech, and judgment may also be affected. Creutzfeldt-Jakob disease: This rare disease occurs most often in young and middle-aged adults. Infectious agents called prions invade and kill brain cells, leading to behavior changes and memory loss. The disease progresses rapidly and is fatal. Pick disease (frontotemporal dementia): This is another rare disorder that damages cells in the front part of the brain. Behavior and personality changes usually precede memory loss and language problems. Parkinson disease and Huntington disease begin in subcortical areas. They cause the subcortical type of dementia. Dementia: reversible dementia causes D-E-M-E-N-T-I-A: D-rugs/ Depression E-lderly M-ulti-infarct/ Medication E-nvironmental N-utritional T-oxins I-schemia A-lcohol Dementia: treatable causes D-E-M-E-N-T-I-A: D-rug toxicity E-motional (depression, anxiety, OCD, etc.) M-etabolic (electrolytes, liver dz, kidney dz, COPD) E-yes/ Ears (peripheral sensory restrictions) N-utrition (vitamin, iron deficiencies) T-umors/ Trauma (including chronic subdural hematoma) I-nfection (meningitis, encephalitis, pneumonia, syphilis) A-rteriosclerosis and other vascular disease

Dementia Symptoms Symptoms of dementia vary considerably by the individual and the underlying cause of the dementia. Most people affected by dementia have some (but not all) of these symptoms. The symptoms may be very obvious, or they may be very subtle and go unrecognized for some time. The first sign of dementia is usually loss of short-term memory. The person repeats what he just said or forgets where she put an object just a few minutes ago. Other symptoms and signs are as follows: Early dementia

Word-finding difficulty - May be able to compensate by using synonyms or defining the word Forgetting names, appointments, or whether or not the person has done something; losing things Difficulty performing familiar tasks - Driving, cooking a meal, household chores, managing personal finances Personality changes (for example, sociable person becomes withdrawn or a quiet person is coarse and silly) Uncharacteristic behavior Mood swings, often with brief periods of anger or rage Poor judgment Behavior disorders - Paranoia and suspiciousness Decline in level of functioning but able to follow established routines at home Confusion, disorientation in unfamiliar surroundings - May wander, trying to return to familiar surroundings

Intermediate dementia

Worsening of symptoms seen in early dementia, with less ability to compensate Unable to carry out activities of daily living (eg, bathing, dressing, grooming, feeding, using the toilet) without help Disrupted sleep (often napping in the daytime, up at night) Unable to learn new information Increasing disorientation and confusion even in familiar surroundings Greater risk of falls and accidents due to poor judgment and confusion Behavior disorders - Paranoid delusions, aggressiveness, agitation, inappropriate sexual behavior Hallucinations Confabulation (believing the person has done or experienced things that never happened) Inattention, poor concentration, loss of interest in the outside world Abnormal moods (anxiety, depression)

Severe dementia

Worsening of symptoms seen in early and intermediate dementia Complete dependence on others for activities of daily living May be unable to walk or move from place to place unassisted Impairment of other movements such as swallowing - Increases risk of malnutrition, choking, and aspiration (inhaling foods and beverages, saliva, or mucus into lungs) Complete loss of short- and long-term memory - May be unable to recognize even close relatives and friends Complications - Dehydration, malnutrition, problems with bladder control, infections, aspiration, seizures, pressure sores, injuries from accidents or falls

Early stage (Forgetfulness Stage: Mild) The first symptom of Alzheimers disease is Progressive memory loss. This is followed by disorientation, personality changes, language difficulty, and other symptoms & dementia. The patient can compensate for the memory loss but the family may notice personality changes and mood swing. Recent memory is affected including the ability to learn new information. Managing daily living activities becomes progressively more difficult. The patient may notice difficulty balancing his checkbook and

may forget where he put things. Forgetfulness: loose things; forget names, short-term memory loss, and the individual is aware of the intellectual decline. Early Confusion: Symptoms of confusion begins and concentration may be interrupted. Individual may forget major event in personal history such as birthday of his/her child: experience declining activity to perform task; individual may deny memory loss. Findings that are observed in the early stages of Alzheimers disease are inappropriate affect, disorientation to time, paranoia, memory loss, and an impaired judgment. Middle stage (Wandering Stage/Sundown syndrome) The patient is increasingly disoriented and completely unable to learn and recall new information. He may wander or become agitated or physically aggressive. He may have bladder incontinence and may require assistance with activities of daily living. Individual may be unable to recall major life events even the name of spouse. Disorientation in the surroundings is common and the person may be unable to recall the day, season, and year. Sleeping becomes a problem. Symptoms worsen in the evening known as SUNDOWNING. Late stage (Kluver Bucy like Syndrome) The patient may be unable to walk and is completely dependent on caregivers. Hes totally incontinent of bowel and bladder. He may even be unable to swallow and is at risk for aspiration. Hes unable to speak intelligibly. In the late stages of Alzheimers disease it is better to go along with the patients reality rather than confront him with logical reasoning. Asking close ended simple questions that relate to his reality is nonthreatening and calming. Note that the nurses response in a way that is congruent is the main concern. The individual may not recognize family members. There may be problems of immobility. OTHER STAGES USED BY PHYSICIAN/PSYCHIATRIST GLOBAL DETERIORATION SCALE- for assessment of primary degenerative dementia (7stages) FUNCTIONAL ASSESSMENT STAGING (fast)- Based on level of functioning and daily activities. (7stages) Clinical Dementia rating (CDR) Scale- based on cognitive (thinking) abilities and the individuals ability function. A diagnosis of dementia is based on: memory loss - both in short and long-term, plus one or more of the following: aphasia language problems apraxia organizational problems agnosia unable to recognize objects or tell their purpose disturbed executive function personality and inhibition ASSESSMENT: History, both from the patient and close observers Focused/ comprehensive physical exam Mini Mental State Exam/comprehensive mental status exam Comprehensive Neuropsychiatric Evaluation Lab work including CBC, basic metabolic profile, TSH, Vitamin B12, STS, Chest X-ray, ABGs, Blood Chemistry, If brain injury or space occupying lesion such as a tumor is in question, CT, or MRI. SCREENING TEST: ELECTROENCEPHALOGRAPHY COMPUTED TOMOGRAPHY MAGNETIC RESONANCE IMAGING CONFIRMATIVE TEST: CEREBRAL BIOPSY AFTER DEATH Referrence: ..MS BRUNNER AND SUDDARTH (Pg 160)

Treatment: Treatment is generally community focused; the goal of treatment is to maintain the quality of life as long as possible despite the progressive nature of the disease. Effective treatment is based on: Diagnosis of primary illness and concurrent psychiatric disorders. Assessment of auditory and visual impairment Measurement of the degree, nature, and progression of cognitive deficits. Assessment of functional capacity and ability for self care Family and social system assessment. Environmental strategies in order to assist in maintaining the safety and functional abilities of the patient as long as possible. Best Drug: Anticholinesterase:Increases ACH (acetylcholine) levels MS Brunner and Suddarth (pg 160) No cure or definitive treatment exists for Alzheimers disease. However, three drugs, tacrine (Cognex), rivastigmine (Exelon), and donepizel (Aricept), have been approved by the Food and Drug Administration to improve cognitive function in patients with mild to moderate Alzheimers disease.Tacrine hydrochloride (Cognex)-monitor patient for liver toxicity. Tacrine hydrochloride (Cognex)-enhances acetylcholine uptake in the brain, thus maintaining memory skills for a period of time. SUMMARIZED DRUGS USED TO TREAT DEMENTIA

NAME

DOSAGE RANGE AND ROUTE

NURSING CONSIIDERATION

Tacrine (Cognex)

40 160 mg orally per day divided into 4 doses

Monitor liver enzymes for hepatotoxic effects. Monitor for flu like symptoms.

Donepezil (Aricept)

5 10 mg orally per day Monitor for nausea, diarrhea, and insomnia. Test stools periodically for GI bleeding.

Rivastigmine (Exelon)

3 12 mg orally per day divided into 2 doses

Monitor for nausea, vomiting, abdominal pain, and loss of appetite.

Galantamine (Reminyl)

16 32 mg orally per day divided into 2 doses

Monitor for nausea, vomiting, loss of appetite, dizziness, and syncope.

BEST HERBAL DRUG FOR ALZHEIMERS: Enhancing memory with ginkgo biloba Ginkgo biloba, a plant extract, contains several ingredients that many believe can slow memory loss in people with Alzheimers disease, Research has shown that ginkgo produces arterial, venous, and capillary dilation, leading to improved tissue perfusion and blood flow. Adverse effects are uncommon but may include GI upset or using anticoagulants. OTHER DRUG: Agitation management: neuroleptic drugs Psychosis: neuroleptic drugs Depression: antidepressants, ECT Non-pharmacologic Interventions: Social activities Adequate sleep Adherence to a strict schedule Maintenance of a proper stimulation level Adequate hydration Reformatting task (occupation therapy) Support caregivers

Nursing Interventions:
Improving communication Speak slowly and use short, simple words and phrases. Consistently identify yourself, and address the person by name at each meeting. Focus on one piece of information at a time. Review what has been discussed with patient. If patient has vision or hearing disturbances, have him wear prescription eye glasses and/or hearing device. Keep environment well lit. Use clocks, calendars, and familiar personal effects in the patients view. If patient becomes aggressive, shift the topic for a safer, more familiar one. Promoting Independence in Self-care Assess and monitor patients ability to perform activities of daily living. Encourage decision making regarding activities of daily living as much as possible. Monitor food and fluid intake. Weigh patient weekly. Provide food that patient can eat while moving. Sit with the patient during meals and assist by cueing. Ensuring Safety Discuss restriction of driving when recommended. Assess patients home for safety; remove throw rugs, label rooms, and keep the house well lit. Assess community for safety. Alert neighbors about the patients wandering behavior. Alert police and have current picture taken Install safety bars in the bathroom. Encourage physical activity during day time Preventing Violence and Aggression Respond calmly and do not raise your voice.

Remove objects that might be used to harm self or others. Identify stressors that increase agitation. Distract patient when an upsetting situation develops. NURSING DIAGNOSIS: Nursing Diagnosis: Risk for trauma Nursing Intervention: 1) Milieu Therapy is needed: a CONSISTENT UNCHANGING & FAMILIAR ENVIRONMENT IS NEEDED to decrease chances of disorientation & confusion. In milieu therapy, patients plan and lead activities rather than the staff. Milieu therapy involves scientific manipulation of the environment that can influence improvement patients behavior 2) Store frequently used items within reach. 3) Keep bed in unelevated position with soft padding if client has history of seizure and keep the rails up. A confused Alzheimers patient who gets out of bed several times must be provided with a safe environment like placing a hand rails for the patient to hold. Bed of confused Alzheimers patient must always have its side rails up. 4) Assign room near nurses station. 5) Assist patient with ambulation 6) Keep dim light on at night. Decrease environmental stimulus. 7) If patient is a smoker, stay with him/her at all times. 8) Frequently orient patient to time, place and situation. 9) If patient is prone to wander, provide an area in which the client is safe to wander. 10. Family counseling about Alzheimers disease includes checking that pt is wearing ID bracelet when going out at all times 11. Soft restrain may be required if the client is disoriented and hyperactive as ordered by the physician. 12. Provision of simple, structured environment, choices. Consistency and ROUTINE in care to increase security; Brief, frequent contacts; reinforce reality-oriented comments. Ample time and patience to allow client to talk / complete tasks using associative patterns to improve recall: simplicity, focusing, repeating, summarizing. Allow REMINISCING of past life / exploits / achievements. Reminiscing helps lessen the patients loneliness. 13. Wear the Medical Alert Bracelet (name, Address, Tel #, Diagnosis, Medication) 14. Avoid afternoon naps, avoid caffeine, TV & radio remote 15. REMEMBER THE 3 Cs for Alzheimers to DECREASE DISORIENTATION: Color, Calendar, Clock

Nursing Diagnosis: Altered thought process Nursing intervention: 1) Frequently orient the patient to reality. Sensory stimulation for elders helps to increase pts arousal 2) Keep explanation simple and use face-to-face interaction. Speak slowly and do not shout. In caring for elderly w/ Alzheimers use short & simple words & face him while you are talking. 3) Discourage rumination of delusional thinking. Talk about real people and real events. 4) Monitor for medication side effects. 5) Use soft tone, simple sentences, and a slow, calm manner when speaking to a person with Alzheimers disease. If he doesnt understand you, repeat yourself using the same words. Your nonverbal communication is more important than your actual spoken message. Dont a hurried tone, which will make the patient feel stressed. Move slowly and maintain eye contact. Nursing Diagnosis: Self-care deficit Nursing Intervention: 1) Identify self-care deficit and provide assistance. Urinary incontinence in patient with Alzheimers can be controlled by decreasing fluid intake at night time.

2) Allow plenty of time for the patient to perform task. 3) Provide guidance and support for independent actions by talking the patient through the task. 4) Provide structure schedule of activities that does not change from day to day. 5) ADLs should follow home routine as closely as possible. 6) Provide clients nutritional needs, safety and security. 7. Give foods high in carbohydrates to an Alzheimers who refuses to eat his meal PREVENTIVE: There is no known way to prevent dementia. However, there are actions that you can take to reduce your risk for dementia and, in some cases, slow the progression of the disease. These factors include: exercise diet heart healthy behaviors avoiding head injury mental activities socializing

Some factors may decrease the effect of the damage by developing more connections between the remaining brain cells, rather than preventing damage. With more connections between brain cells, function can be maintained longer despite damage to the brain.

Diet- A diet that includes a lot of fruit, vegetables, and whole grains may reduce the risk of developing
dementia. These foods appear to protect brain neurons from chemicals, called free radicals, that damage cells. The protective chemicals in these foods are called anti-oxidants. Other foods that may protect against dementia include curcumin, the main ingredient in the spice tumeric, and omega-3 fatty acids, found in fish. In one study, women who ate green, leafy vegetables (spinach, for example) and cruciferous vegetables (for example, broccoli and cauliflower) had a slower rate of cognitive decline when compared with women who ate fewer vegetables (Snowdon, 2003). Research has also suggested that a Mediterranean diet, marked by high intake of olive oil and low intake of monounsaturated fat, is associated with a lower risk of developing Alzheimer's disease (Scarmeas et al, 2009).

Exercise-Exercise leads to a healthier brain, just as it leads to better health for the rest of the body. Exercise
and physical activity improve cognitive performance and reduce cognitive decline. The amount of exercise does not have to be extreme. Research has found that moderate activity levels (for example, exercising just 3 times a week) decrease the risk of developing dementia. The effect is increased with a greater variety of activities and there appears to be a benefit even if exercise is started late in life. Keep Your Heart Healthy The same factors that protect against heart disease help reduce some of the risk factors for dementia. These include, in addition to exercising and healthy eating, not smoking, maintaining a healthy weight, controlling blood pressure, relaxing and reducing stress.

Mental Exercise- Stimulation of the mind increases the number and strength of connections between the
brain cells, strengthens the brain cells you have, and even increases the number of brain cells slightly. Examples of mental exercises that are particularly effective include solving puzzles, learning something new, reading challenging material, playing board games, playing a musical instrument, and dancing.

Protect Your Head-Head injury is associated with increased risk for dementia. Protect your head with
helmets during sports, wear seat belts, and avoid sports and situations that involve repeated injury to the head.

Socialize- Older people who engage in regular social activities show less cognitive decline. One reason for
this effect is that social activities promote new connections between brain cells.