Dementia
Download
1 / 46

Dementia - PowerPoint PPT Presentation


  • 260 Views
  • Updated On :

Dementia. Medical Aspects of Disability October 17, 2006. DEMENTIA. DEFINITION: Group of symptoms that can be caused by over 60-70 disorders.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Dementia' - maalik


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Dementia l.jpg

Dementia

Medical Aspects of Disability

October 17, 2006


Dementia2 l.jpg
DEMENTIA

  • DEFINITION:

    • Group of symptoms that can be caused by over 60-70 disorders.

    • Syndrome which refers to progressive decline in intellectual functioning severe enough to interfere with person’s normal daily activities and social relationships. (National Institute on Aging-1995 No. 95-3782)


Dementia3 l.jpg
Dementia

  • Marked by progressive declines in

    • memory.

    • visual-spatial relationships

    • performance of routine tasks

    • language and communication skills

    • abstract thinking

    • ability to learn and carry out mathematical calculations.


Dementia4 l.jpg
Dementia

  • Two Types:

    • Reversible

    • Irreversible

  • Individuals must have intensive medical physical to rule out reversible types of dementia.


Delirium vs dementia l.jpg
Delirium vs. Dementia

  • Delirium defined--- characterized by a disturbance of consciousness and a change in cognition that develop over a short period of time

  • About 10-15% of surgical patients experience delirium, and 15-25% of medicine inpatients will experience delirium

  • 30% Surgical Intensive Care Unit patients develop delirium, and up to 30% of AIDS patients while inpatient, will develop delirium


Delirium vs dementia6 l.jpg
Delirium vs. Dementia

  • A major risk factor is advanced age

    • Other factors include very young people (children), organic brain damage including stroke, MVA, etc, substance use, previous delirium, malnutrition, sensory deprivation (hearing or visual loss), diabetes, cancer

  • Having an episode of delirium is more than just inconvenience

    • 3 month mortality following an episode of delirium is 25-30%. 1 year mortality after an episode of delirium may be as high as 50%.


Delirium vs dementia7 l.jpg
Deliriumvs. Dementia

  • Many causes of delirium:

    • Some examples… epilepsy, CNS trauma, CNS infection, CNS neoplasm, endocrine dysfunction (pituitary, thyroid, adrenal, parathyroid, pancreas), liver failure, UTI, cardiac dysrhythmias, hypotension, vitamin deficiency, sepsis, electrolyte imbalance, iatrogenic- any medication, substance withdrawal


Delirium vs dementia8 l.jpg
Delirium vs. Dementia

  • Could be psychiatric disorder, i.e. major depression or generalized anxiety disorder, in which case need to initiate treatment for this disorder, i.e. get a psych consult

  • Or is the cause a delirium from other meds or an infection, in which case should look at labs and med list.

  • Or is cause alcohol withdrawal, in which case need to treat w/d with benzodiazepines

  • If patient is having chronic trouble sleeping, a good choice to help them is Ambien/zolpidem or Sonata/zaleplon


Delirium vs dementia9 l.jpg
Delirium vs. Dementia

  • Watch for alcohol withdrawal as cause of delirium. If elevated pulse and blood pressure, see elevated MCV, and patient begins to act bizarre, talk to family if at all possible, about substance use. If patient enters delirium tremens (DT’s), untreated has a mortality rate of 20%.


Delirium vs dementia10 l.jpg
Delirium vs. Dementia

  • How is delirium treated?

    • First line treatment for delirium is to treat underlying cause. Often will need many labs- Complete Metabolic Panel, Complete Blood Count, TFT, EEG if indicated, CT/MRI of head, sometimes LP, etc.

    • A psychiatric or psychological consult might be needed for agitation.

    • Meds- Haldol 2.5-5 mg (less for geriatric) or now, Geodon 10-20 mg IM or Ativan IM


Delirium vs dementia11 l.jpg
Delirium vs. Dementia

  • A common problem in the US

    • 5% of those over 65 have severe dementia, 15% have mild dementia

    • 20% those over 80 have severe dementia

    • One of first distinctions you must make is reversible from nonreversible.

    • Only about 10-15% are reversible


Delirium vs dementia12 l.jpg
Delirium vs. Dementia

  • Nonreversible does not mean non treatable!

  • Non reversible dementias-

    • Alzheimer’s is most common by far, accounting for about 70% of dementias.

    • See a tempero-parietal wasting at first, leading you to see the memory loss and speech problems first. The “lost keys”sign.

    • Then will progress to global atrophy of brain.

    • Genetics a risk factor (up to 35-40% patients have a family history of Alzheimer’s


Dementia13 l.jpg
Dementia

  • Reversible:

    • D= Drugs, Delirium

    • E= Emotions (such as depression) and Endocrine Disorders

    • M= Metabolic Disturbances

    • E= Eye and Ear Impairments

    • N= Nutritional Disorders

    • T= Tumors, Toxicity, Trauma to Head

    • I= Infectious Disorders

    • A= Alcohol, Arteriosclerosis


Dementia14 l.jpg
Dementia

  • Irreversible:

    • Alzheimer’s

    • Lewy Body Dementia

    • Pick’s Disease (Frontotemperal Dementia)

    • Parkinson’s

    • Heady Injury

    • Huntington’s Disease

    • Jacob-Cruzefeldt Disease


Dementia15 l.jpg
Dementia

  • Irreversible:

    • Alzheimer's most common type of irreversible dementia

    • Multi-Infarct dementia second most common type of irreversible dementia

      • Death of cerebral cells

      • Blockages of larger cerebral vessels, arteries

      • More abrupt in onset

      • Associated with previous strokes, hypertension

      • Can be traced through diagnostic procedures


Dementia16 l.jpg
Dementia

  • Lewy Body Dementia

    • Episodic confusion with intervals of lucidity with at least one of the following:

      1. Visual or auditory hallucinations

      2. Mild extrapyramidal symptoms (muscle rigidity, slow movements

      • Repeated unexplained falls

    • Progresses to severe dementia—found at autopsy.


Dementia17 l.jpg
Dementia

  • Diagnosis of Frontemporal Dementia (Pick’s Disease)

    • Pick’s bodies in cells.

    • Personality changes

    • Behavioral dis-inhibition.

    • Loss of social or personal awareness.

    • Disengagement with apathy

    • Maintain ability to draw and calculate well into later stages


Alzheimer s disease l.jpg
Alzheimer's Disease

  • Estimated that 4,000,000 people in U.S. have Alzheimer's disease.

  • Estimated that 25-35% of people over age 85 have some time of dementia.

  • After age 65 the percentage of affected people, doubles with every decade of life.

  • Caring for patient with Alzheimer's disease can cost $47,000 per year (NIH).


Changes caused by alzheimer s l.jpg
Changes Caused by Alzheimer's

  • Diminished blood flow

  • Neurofibrillary Tangles

  • Neuritic Plaques

  • Degeneration of hippocampus, cerebral cortex, hypothalamus, and brain stem



Compare central sulcus of alzheimer s patient with normal 81 year old woman l.jpg
Compare central sulcus of Alzheimer’s patient with normal 81 year old woman

From Whole Brain Atlas at http://www.med.harvard.edu/AANLIB/home.html



Normal vs ad brain l.jpg
Normal vs AD Brain temporal areas

Alzheimer’s brain

Normal brain


Ad prognosis l.jpg
AD Prognosis temporal areas

  • Alzheimer’s has a slowly progressive decline. These meds can slow the progression, NOT halt it.

Function

Time


Pick s disease l.jpg
Pick’s disease temporal areas

  • 25 times rarer than Alzheimer’s dementia

  • Frontal lobe clinical features

  • Assymetrical frontal or temporal atrophy

  • Has been connected with semantic dementia, but evidence is not conclusive yet


Slide26 l.jpg

Case history: Pick's Disease temporal areasThis 59 year old woman had a three year history of a progressive alteration in social behavior which included apathy and occasional disinhibition. Images reveal severe focal shrinkage of temporal and frontal lobes bilaterally.


Degeneration of the basal ganglia l.jpg
Degeneration of the basal ganglia temporal areas

  • Huntington’s disease

    • Rare: 5 in 100,000

    • abnormal ‘exaggerated movements

  • Parkinson's disease

    • Common: 1 in 100 over age 65

    • General slowing of voluntary movements

  • Both diseases involve the basal ganglia, but in large opposite ways


Basal ganglia l.jpg
Basal ganglia temporal areas

  • Caudate

  • Putamen

  • Globus pallidus

  • Subthalamic nuclei

  • Substantia nigra

Striatum


Multi infarct dementia mid l.jpg
Multi-infarct dementia (MID) temporal areas

  • Many small strokes

  • Often mixed with Alzheimer’s dementia


Viral dementia hiv l.jpg
Viral dementia: HIV temporal areas

  • 20-60% of HIV patients suffers from dementia

  • Cerebral atrophy may be caused by microglial nodules


Vocational rehabilitation and dementia l.jpg
Vocational Rehabilitation and Dementia temporal areas

  • Can dementia occur while an individual is employed?

  • Is dementia covered under the American’s with Disabilities Act?

  • Can jobs and tasks be modified to assist individuals with mild forms of dementia?

  • Can job discrimination occur for these individuals?

  • What types of job modifications and/or assistive technology can you think of for an individual with dementia?


End stage dementia l.jpg
End-stage Dementia temporal areas

Prognosis < 6 mos:

  • Severe dementia with need for total assistance in ADLs (dressing, bathing, continence), unable to walk, only able to speak a few words

  • Comorbid conditions – aspiration pneumonia, urosepsis, decubiti, sepsis

  • *Unable to maintain caloric intake with weight loss of 10% or more in 6 months (and no feeding tubes)


Complications from dementia l.jpg
Complications from dementia temporal areas

  • Delusions in up to 50%, most with paranoia

  • Hallucinations in up to 25%

  • Depression, social isolation may also occur

  • Aggressive behavior in 20-40% (may be related to above problems, misinterpretation)

  • Dangerous behavior – driving, creating fires, getting lost, unsafe use of firearms, neglect

  • Sundowning – nocturnal episodes of confusion with agitation, restlessness


Treatment of complications l.jpg
Treatment of complications temporal areas

  • Hallucinations, delusions, agitation, sun-downing may be improved with anti-psychotics like haloperidol, risperdal, mellaril…

  • If any signs of depression, may be beneficial to treat

  • Anxiety may respond to benzodiazepines

  • Behavioral mod – reinforce good behavior, DON’T fight aggressive behavior

  • Familiarity (change in environments make things worse)

  • Safety – key locks, knobs off stoves, take away car keys/cigarettes/firearms…, lights, watch stairs

  • Avoid restraints, use human contact/music/pets/

    distraction


Artificial nutrition in dementia l.jpg
Artificial Nutrition in Dementia temporal areas

  • Many excellent reviews demonstrate no improvement in quality of life and quantity of life with G-tubes.

  • 5% morbidity and mortality with the procedure itself

  • No decrease in aspiration with them

  • Risk of infection

  • Can keep patient comfortable without it


Complications from dementia37 l.jpg
Complications from dementia temporal areas

  • Delusions in up to 50%, most with paranoia

  • Hallucinations in up to 25%

  • Depression, social isolation may also occur

  • Aggressive behavior in 20-40% (may be related to above problems, misinterpretation)

  • Dangerous behavior – driving, creating fires, getting lost, unsafe use of firearms, neglect

  • Sundowning – nocturnal episodes of confusion with agitation, restlessness


Drug treatment in alzheimer s disease l.jpg
Drug treatment in Alzheimer’s disease temporal areas

  • Many drugs aim to stimulate the cholinergic system

  • These drugs have limited positive effects and do not reverse the causes of AD


Dementia patients are very sensitive to additional disabilities l.jpg
Dementia patients are very sensitive to additional disabilities

  • Illness

  • Pain

  • Medications

  • Poor hearing

  • Poor vision


Management of depression at end of life l.jpg
Management of depression at end of life disabilities

  • Psychotherapy – behavioral, cognitive, and other supportive approaches by psychologists, licensed social workers, chaplains, even bereavement counselors may help

  • New coping strategies like meditation, relaxation, guided imagery, hypnosis may help

  • Medications


Suicide l.jpg
Suicide disabilities

  • Women attempt it twice as much, but men are 4x more likely to succeed

  • White men over 85 are at highest risk to do it

  • All patients with depressive symptoms should be assessed for it

  • Talking about it can decrease risks

  • High risk of attempt if thoughts are recurring or if have thought out the plan

    ONE OTHER POTENTIAL EMERGENCY:

  • If risk high – DON’T leave client alone, immediately consult a psychiatrist – may need in-patient care or involvement of authorities


Anxiety l.jpg
Anxiety disabilities

  • May be a normal response to the situation – fears, uncertainty, reaction to physical condition, social or spiritual needs

  • Usually with 1 or more of the following signs – agitation, restless, sweating, tachycardia, hyperventilation, insomnia, excessive worry, tension

  • Look for signs of depression, delirium, alcohol/drug abuse, caffeine abuse

  • About 5% are affected by agoraphobia


Related anxiety conditions l.jpg
Related anxiety conditions disabilities

  • Panic attacks – acute onset of palpitations, sweating, hot, shaking, chest pain, nausea, dizzy, derealization, fear, numbness; usually short lived

  • Phobias – fears with avoidance, feelings of being trapped, exposed

  • Post-traumatic Stress Syndrome – in response to severe trauma, get more intense fear, terror, dreams, feelings of helplessness, detachment that can occur later on


Other eol care needs for dementia l.jpg
Other EOL care needs for dementia disabilities

  • In bedbound, watch out for and prevent decubiti

  • Feeding instructions to prevent aspiration – head up, chin tucked, thick consistency foods like pudding/jello/ice cream…

  • Caregiver stress – difficult care, poor sleep, education to prevent aggressive behavior, early bereavement losing loved one before they are gone, need for support/respite


Summary l.jpg
Summary disabilities

  • A change in mental or emotional status of the patient is not uncommon with a life-threatening illness

  • Need to be aware of conditions that may be normal reactions or have causes that are potentially reversible, but at the end of life, may need to focus on acute management of these conditions

  • Need compassionate, supportive care for patient and caregiver, always addressing safety


Links l.jpg
Links disabilities

  • Alzheimer’s Association: http://www.alz.org/

  • National Institute of Neurological Disorders and Stroke’s page on dementia: http://www.ninds.nih.gov/disorders/dementias/dementia.htm

  • How to manage difficult behaviors from the Association for Frontotemporal Disorders:http://www.ftd-picks.org/?p=caregiver.managing


ad