Outline

• Introduction
• Etiology
• Epidemiology
• Sign & Symptoms
• Types of Dementia
• Assessment & Management
• Nursing Management
• Nursing care plan
• Problems of the carer
• Pre and Post Test
• Bibliography
• Glossary

VI. ASSESSMENT AND MANAGEMENT

• It is important to look for the treatable causes.
• The assessment should also include serch for treatable, often minor, medical conditions that are associated rather primary causes. Treatment of these conditions can reduce distress and disability.

TREATMENT

• Some cases of dementia are regarded as treatable because the dysfunctional brain tissue may retain the capacity for recovery if treatment is timely.
• A complete medical history. Physical examination , and laboratory tests, including appropriate brain imaging, should be undertaken as soon as the diagnosis is suspected .
• If a patient is suffering from a treatable cause of dementia, therapy is directed toward treating the underlying disorder.

The general treatment approach to patients with dementia is to provide:

• supportive medical care,
• emotional support for the patients and their families and
• pharmacological treatment for specific symptoms, including disruptive behaviour.

Symptomatic treatment also includes

• the maintenance of a nutritious diet,
• proper exercise,
• recreational and activity therapies,
• attention to visual and auditory problems,
• teratment of infections such as urinary tract infections, decuibtus ulcers, and cardiopulmonary dysfunctions.

When the diagnosis of vascular dementia is made, risk factors contributing to cerebrovascular disease should be identified and therapeutically addressed. The factors include:

• hypertension
• hyperlipidemia
• obesity
• cardiac disease and
• diabetes and alcohol dependence.

Patients who smoke should be encouraged to stop smoking cessation is associated with improved cerebral perfusion and cognitive functioning.

1). Hospitalization

Clear indication for hospitalization are:

• a history of rapidly detereorating symptoms
• diagnostic uncertainity
• failure of usual support system
• unmanageable at home
• advances towards other people
• associated medical illness.

2). History taking
History of both patients and families are very important.

a). The patient’s history

• More important memories may be maintained in dementia because they have been rehearsed often over the years that they are very fixed. Patient returns to these memories when the present and recent past are fading. In the earliest stages she will be able to given quite a full account of her life up to recent times, this information must be checked for memories become incomplete and time sequences muddled. These more or less muddled memories are important in understanding how the patient reacts to her/his illness.

b). The Relative’s History

• From relative’s history we can obtain more information about patients previous personality, attitudes, level of activity, interests, social functioning and self care.
• It is important to help the relatives separate recent events, from events that happened before dementia.
• This information will provide clear evidence of how much changes has occurred and also helps in understanding what new problems that family is having to cope with and so helps to explain their reactions.

3). The Physical Examination
A physical examination should be done where indicated and this is particularly important in the following circumstances.

• Where physical symptoms such as weight loss, pain are present.
• Where the patient has a history of potentially relevant physical disorder like a history of endocrine disorder

Detailed neurological assessment with particular attention to vision and hearing is essential to rule out other neurological problems.Systemic observation should be made of his behaviour provide a scheme for assessing memory for general events, past personal events and recent personal events

Physical Investigation

• Hemoglobin , TLC, DLC,
• Blood sugar – In diabetes
• Blood Urea- For renal disease
• Serum creatinine
• Thyroid function test – Hypo/Hyperthyroidism.
• Liver function test – Liver disease
• Serum calcium – Parathyroidism
• VDRL – Neurosiphillis
• Serum copper – Wilson’s disease
• HIV – AIDS
• EEG – To find out the focal sign
• ECG – To find out cardiac problems
• CT – Scan
• MRI
• Fundus examination – Evidence of atherosclerosis

4). Psychological Testing

Psychometric tests usually employed in dementia are:

a). Wechsler Adult Intelligence Scale (WAIS) : This is a well standardized test providing a profile of verbal and non-verbal abilities Analysis of sub scores, can provide useful information for diagnosis. Organic impairment is indicated by a discrepancy between performance IQ and verbal IQ.

b). Perceptual functions , especially spatial relationship: This test is exemplified by the Benton Revised visual Retention test, which requires the patient to study and reproduce ten designs.

c). New Learning as a test of memory: There are many new word learning tasks for example the Walton Black modified word learning test and the paired associated learning test, both of which give a useful quantitative estimate of memory impairment.

d). Specific test: This test are the Wisconsin card sorting test for frontal lobe damage and the token test for receptive language disturbance.

e). Dementia Rating Scale: In this test 2 types of rating scale is used, the intellectual and behavioural. This scale have been over used in diagnosis and limited value in identifying problems. They are most informative when used to measure the progression of impairments over time and to predict the future care needs of the patient.

5). Mental Status Examination
The purpose of the mental state examination is to detect abnormal features in a patient’s behaviour and state of mind at the time of the assessment. If the abnormal features are found this information contributes to the diagnostic process. The examination consists of systemic observation of the patient during the interview and various aspects of their thinking , feelings , perceptions and cognitive functioning , impairment of memory, orientation and consumption problems.

a). General appearance and Behaviour

• Abnormalities in patient’s appearance and behaviour may point to organic impairment, in an early dementia or minor dementia or minor delinquency in a confusional state and it reflect the patient’s failing intellectual powers.
• Patient may restrict his activities to an increasingly limited area within which he is able to cope. He will often repeat things that he has done several times, apparently without any awareness of what he is doing. It is an inability to stop one thing and move on to next.

Appearance following things to be noted:-

- Neatness
- Untidy
- Appropriateness
- Cleanliness
- Apparent age etc.

b). Speech

Speech may show a variety of more or less non-specific anomalies together with restriction of content, difficulty in finding words and naming objects, reduced fluency, repetition, preservation and lastly speech is striking when it occurs again be alert to any neurological abnormalities.

c). Attitude

Observe the attitude of the patient whether it may :- 

- Co-operative
- Hostile
- Suspicious
- Fearful
- Evasive etc.

d). Mood

Organic mood change is an impoverishment of mood. The patients emotional response lack of depth and are poorly sustained. They may show more specific changes:-

• Emotional incontinence
  
• Excessive laughing or crying initiated by frivol stimuli and than continuing unchecked.
  
• Threshold effects :- No apparent response up to level of stimulation and then a sudden excessive reaction.
  
• Incongruous emotion
  
• Failure to respond to significant stimuli but excessive respond to trivial stimuli.
  
• Catastrophic reaction
  
• A sudden explosive outburst of rage and distress often prompted by the recognition of falling powers. This is the first signal of early organic impairment .

e). Cognitive function

Organic states such as toxic confusional states and dementia’s are not difficult to diagnose once they are well establishe. Cognitive impairment may indicate organic etiology, cognitions are:

- Orientation
- Memory
- Concentration and attention

Orientation

Orientation is tested in time, place and person , A patient is fully oriented if he/she known,

what time it is ? 
Where he is and
who are the people around him?

Disorientation for time is not necessarily sign of organic impairment. Distress are being in unfamiliar surroundings is enough to cause a greater or lesser degree of disorientation. Ask the patient the day of the week and the date. Find out if the patient knows qualitatively, where he is in time. A patient who is merely distressed and unfamiliar surroundings, is unlikely to have lost tract of time to point where he no longer knows even qualitatively where he is in time.
Testing orientation for place, ask the patient where he is, if patients is not able to tell then organically impaired. Testing orientation for person, if the patient knows who you and who other people around him are.

Memory
Memory is tested as recent and remote recent memory is tested with new learning, It is the ability to retain and recall new information remote memory is tested that the ability to recall.

• Recent memory: To test for recent memory ask to patients, what did you eat for lunch ? (Verify)
• Remote memory:- For testing remote memory ask him
  · Birth date
  · Stories from child hood
  · Current Indian President  
  
• Retention of memory:- For testing this ask the patient to repeat the names of 3 items that you list (immediately and in 5 minutes)

Concentration
Concentration is the capacity for sustained attention, it is tested both in its own right, and because normal concentration is condition of adequate performance in any other test. The serial seven test. In this ask the patient to take seven away from a hundred, until he/she gets down to naught – write down what patient says as he says it, marking any errors and the time is taken, with this we can fine the patients concentration other test also can applied for concentration like counting forwards or reciting the days of the week forwards.

Intelligence
In intelligence test IQ test is done. It is verbal and performance , Verbal IQ is concerned with language function and performance IQ with arithmetic and visuospatial functions.
In dementia there is a fall in full scale. This may be difficult to assess at an early stage. It has to be judged against previous academic and employment achievements. Verbal IQ is more dependent than performance IQ on long established skill and therefore relatively protected in early dementia. A performance IQ is more than 20 points below verbal IQ may be significant.

f). Thought content
The content of the patient’s thought like their behaviour and speech, reflects the decline in their intellectual functions in being impoverished may also show concrete thinking. This can be tested by asking the patient to explain the meaning of a common proverb e.g. ask to explain “Do not cry over split milk” or “Astilch in time” etc.

g). Judgment:
It can be tested by asking “what would you do with a stamped, addressed letter that you find out on the side walk “or why are criminals put in to prison".

h). Delusions
Organic delusion is characterized by their form. They are poor quality delusion, a product of combined intellectual and emotional impoverishment functional delusions are poorly sustained coming and going in a few hours or days, simple rather than elaborate, lacking in emotional intensity.

i). Hallucinations
Where organic delusions are poor quality delusions but organic hallucinations are good quality hallucinations. Organic hallucinations are visual formed being of people animals and things, coloured moving often show size distortion etc.

j). Rapport
At the end of the examination the examiner should evaluate how friendly and open the relationship with the patient was, whether the patient was frank, hostile or guarded, evasive and negative. The patient’s responses to both the examination and examiner are important factor in the overall quality of the mental status examination.

6). Identification of cause and treatment

• Management of hypertension in multi-infract dementia.
• Thyroid replacement in hypothyroid dementia .
• Shunting in hydrocephalic dementia.
• L-Dopa in Parkinsonism.
• Removal of toxic agent in toxic dementia.

7). Symptomatic Management

• Environmental manipulation to reduce stress in day to day activities.
• Treatment of medical complications
• Care of food and hygiene and supportive care for the patient and family.
• Anxiety can be treated with short acting benzodiazepines in low doses.
• Depression can be treated with Trazodone or Miamserin as these agents have low anticholinergic, activity and low cardiac toxicity. Agents with anticholinergic activity can cause confusion or frank delirium.

8). Currently Available Treatments

Clinicians may prescribe benzodiazepines for insomnia and anxiety, antidepressants for depression, and antipsychotic drugs for X delusions and hallucinations, but they should be aware of possible idiosyncratic drug effects in older pesople (such as paradoxical excitement, confusion and increased sedation). In general drugs with high anticholenergic activity should be avoided, although some data indicate that thioridazine (Melleril), which does have high anticholenergic activity, may be an especially effective drug in controlling behaviour in demented patients when give in low dosages. Short acting benzodiazepines in small dosage are the preferred anxiolytic and sedative medication for dementia patients. In addition,  Zolpiden (Ambien) may also be used for sedative purposes.

Tacrine has been approved by the food and Drug Administration as a treatment for Alzheimer’s disease. The Drug is a moderately long acting inhibitor of cholinesterase activity, and well-controlled trials have shows a clinically significant improvement in 20 to 25 percent of patients who take it. Because of the cholinomimetic activity of the drug. Some patients are not able to tolerate the side effects. Others must discontinue the drug because of elevations in liver enzymes. A new drug, donepezil (Aricept), also improves cognition as has fewer adverse effects. Neither drug, how ever prevents progressive neuronal degeneration.

 9). Psychotherapy

Psychotherapy – the specific psychotherapy treatments divided in to 4 broad of range: Behaviour oriented, Emotion oriented cognition oriented and stimulation oriented, behaviour approached can be effective in lessening or abolishing problem behaviour e.g. aggression, incontinence emotion oriented intervention include supportive psychotherapy reminiscence therapy sensory integration and stimulated presence therapy.

a. Behavior– oriented approaches: it can be effective in lessening or abolishing where it occurs, how often it occurs have to be determined.  The next step is an assessment of specific antecedents and consequences, which will often suggest specific strategies for intervention.  Precipitants should be avoided whenever possible. Whatever intervention, it is critical to match the level of demand on the patients with his or her current capacities, to modify the environment in so far as possible to compensate for deficits and capitalize on the patient’s strengths.

b. Emotion– oriented approaches – The intervention includes supportive psychotherapy, reminiscence therapy, validation therapy, sensory integration and simulated presence therapy.

• Reminiscence therapy, which acme to stimulate memory and mood in the context of the patient’s life history is associated with modest short lived gain in mood.
• Validation therapy, aims to restore self-worth and reduce stress by validating emotional ties to the post.
• Simulated presence therapy may be helpful in diminishing problem behavior with social isolation.
• Supportive psychotherapy may be helpful in mildly impaired patients to adjust to their illness.

c. Cognition – oriented approaches: these techniques include reality orientation and skills training.  The aim of these treatments is to redress cognitive deficits, often in a classroom setting.  There is some evidence of transient benefit from cognitive redemption and from skills training but here have been report of frustration in patients and depression in caregivers associated with the type of intervention.

d. Stimulation – oriented approaches:  these treatments include activities or recreational therapies (crafts, gene, and pets) and are therapies (music, dance, art).  They provide stimulation and enrichment and thus mobilize the patient’s available cognitive resources.  There are evidences that, while they are in use, these interventions decrease behavioral problems and improved mood.

Psychotherapy can be given to family members as well as patient’s psychotherapy is not very useful for patients. It will be helpful for family members to encourage them to take care of patients family members can be taught to take care of the patients which will help to improve patient’s self esteem, and make the patient independent oriented as much as possible. Family members should not neglect the patient but should help in humanitarian way.

10). Physiotherapy

It will help to structure their daily activities such as muscle and joint exercises, breathing exercises, speech therapy to improve blood circulation etc. Physiotherapy is helpful for chronic encephalitis, meningitis and general paresis of insane. It is also helpful to remove contracture of limbs, deformities of extremities or embolities.; It improves physical health. Appetite, digestion elimination, circulation, muscle tone and body temperature.

11). Social Relationship

Dementia patient become isolated from community. Talking to them and asking ordinary questions also help the patient. More deterioration will take place when there is nothing to talk, to think or to work. The social approach plays a great role in psychiatric illness. The patient must learn or relearn how to assume responsibility for the welfare of himself and others for social relationship.

12). Day centres

The day care centres help elder people to meet other people and engage in activities. It is assumed that they will be able to select their friends and select their activities, will take an active part in what goes and in most cases, make their own way to and from centre. The need for day centres to cater for dementia suffers. Day care is needed who are the Physically and the mentally impaired attending together and involving a mice of services.