Published on November 20, 2013
DEMENTIA CENTRAL AMERICA HEALTH SCIENCE UNIVERSITY, BELIZE 18TH NOV 2013 INSTRUCTOR : DR. SURYA SUDARSHAN PRESENTER : MAHESH SUNDARAM : SYED ABDUL SAMIE : GIA K.SHARMA
WHAT IS IT : Dementia Latin word De "without" + ment, means “mind” Definition: It is a loss of brain function that effects memory, thinking, language, judgement, and behaviour. It is a degenerative (non-reversible) condition. This means that the damage done to the brain cannot be treated or stopped.
GOALS IN DEMENTIA Evaluation and Diagnosis Current Therapy for Dementia Complications Resources for the Caregivers
Early Symptoms and Warning Signs As we get older, many of us become more forgetful – for example we might misplace our keys occasionally or find it difficult to find the right word to describe something. This is normal and isn’t a cause for concern. It is important to be able to differentiate between these changes and the early warning signs of a more serious condition. These early signs can start to develop as much as twenty years before a diagnosis is made. Research carried out at Stanford University in the USA suggests that a newly developed blood test can identify people most at risk from developing DEMENTIA disease up to six years before the symptoms become apparent. The test measures the levels of a number of proteins in the blood associated with Alzheimer’s.
Diagnosis Based on memory loss (both short and long-term), plus one or more of the following: Aphasia – language problems Apraxia – organisational problems Agnosia – unable to recognise objects or tell their purpose Disturbed executive function – personality and inhibition
Is it JUST “Old Age?” Signs of Dementia Typical Age Related Changes Poor judgment and decision making Inability to manage a budget Making a bad decision once in a while Losing track of the date or the season Missing a monthly payment Forgetting which day it is and remembering later Sometimes forgetting which word to use Losing things from time to time. Difficulty having a conversation Misplacing things and being unable to retrace steps to find them
Types of Dementia Alzheimer’s – Most common , Memory, Language, Visuospatial, Indifferent to Loss Lewy Body – second most common (vivid hallucinations), Visual hallucinations, delusions, flucutating mental status Fronto-temporal – shrinking frontal and temporal lobes, Memory, Marked Personality changes, Preserved visuospatial
TYPES OF DEMENTIA cont… Vascular Dementia– aka multi-infarct dementia,1530% develop dementia Progressive Supranuclear Palsy The Rare Birds : Late onset Metabolic Disease Other causes: Alcoholism, AIDS, Pick’s disease, etc… Disease
EVALUATION HISTORY HPI, Medical, Medications, Psychiatric, Functional, Caregiver EXAM Physical, Neurologic, Psychiatric, Cognitive Testing
EVALUATION LABORATORY Blood Work CBC, TSH, Chem 7, Ca 2+, B12, Folate RPR Imaging CT or MRI Other Studies LP, neuropsychiatric testing, EEG, SPECT, PET
DIFFERENTIAL DIAGNOSIS DEPRESSION Pseudodementia CNS: Neoplasm, NPH, stroke Vascular: subdural, vasculitis, Endocrine: Thyroid, Calcium, Nutritional: B12, Thiamine,ETOH Infections: HIV, Cryptococcus
CURRENT THERAPY CHOLINESTERASE INHIBITORS For mild to moderate disease, slow progression, stabilize ADL and MMSE 1st Generation Tacrine hepatotoxic, last choice 2nd Generation Donepezil 5-10 mg qd $113/mp Rivastigmine 3-6 mg bid $153/mo Galantamine 16-32 $298/mo
CURRENT THERAPY cont… VITAMIN E GINKGO BILOBA Antioxident, anti-inflammatory ESTROGENS Antioxident, inexpensive neuroprotective? NSAIDS Epidemiologic suggestions
COMPLICATIONS Depression Suspicion Disinhibition Agitation Verbal, Vocal, Anxiety Aggression Withdrawal Vegetative Psychosis Hallucinations Delusions sleep Motor appetite Wandering Apathy
APPROACHES TO BEHAVIOUR PROBLEMS 1. 2. 3. 4. 5. 6. 7. 8. 9. Define target symptoms Revisit medical diagnoses Establish neuropsychiatric diagnoses Assess and remove provoking factors: environmental, psychosocial, other Adapt environment and treatments to specific cognitive deficits Educate caregivers Employ behavior management principles Treat specific psychiatric disease specifically For remaining behavior problems consider symptomatic pharmacotherapy
PHARMACOTHERAPY DEPRESSION TCADS Nortriptyline SSRI’S Paroxetine, Sertraline, Others ECT if life threatening ANXIETY Buspirone,Lorazepam, Propanolol PSYCHOSIS Rispiridone, Olanzepine, Haloperidol
PHARMACOTHERAPY Aggression Trazedone, Buspirone, Olanzepine, Others Agitation Haloperidol, Insomnia Melatonin, Lorazepam, Trazedone, Carbamazepine Benzodiazepines, Trazedone Sundowning Trazedone, Haloperidol, Risperidone, Olanzepine
PROGRESSION Forgetfulness complains of memory deficits, misplace objects, trouble word finding, functional Confusional getting lost, job trouble, language problems, lost objects denial, anxiety, lost current events, can’t handle finance other executive functions, withdrawal Early Dementia Need assistance, can’t use phone reliably, disorientation to time, place, know family, can feed and toilet with reminders
PROGRESSION Middle Dementia Late Dementia Unaware of surroundings, forget spouse’s name, loss of recent events of life, personality and behavior changes, needs help with most ADL Loss of all verbal abilities, complete incontinence, no thirst or hunger responses TIME COURSE
DAY TO DAY CARE Be Firm, Don’t Rush or Argue Now it time to….., don’t rush or argue Minimize Distractions Decrease Keep It Simple, Keep It Safe Cannot follow multi-step commands Lower Your Standards Expect noise, remove visual clutter less from the patient Establish Routines Reassuring, reduce agitation
CARE FOR CAREGIVERS Information about progression Facilitate Day-to-Day Care Stress Reduction Skills Support Risk for depression, illness, fatigue, elder abuse How to know when you can no longer provide care at home
Economics of Dementia 2-5 million affected With current demographics 10 million by 2030 Expenses TOTAL $100 Billion Ranks Per third (Heart disease and Cancer) Capita Direct $10-25K home, $40-50k NH Indirect Unpaid Paid $60k Care $10-50k Out of Pocket 65%
Consider Hospice/Palliative Care Dementia is a terminal disease. Consider palliative care referrals and/or referrals to support agencies early on. Once patient has progressed and is in the late stages of the disease, consider a hospice referral to help keep the patient comfortable and provide ongoing support for the family.
Research In 2013, multiple AD biomarkers are receiving research attention, including structural and metabolic brain alterations as well as amyloid and tau protein levels in both the brain and cerebrospinal fluid (CSF). Lilly’s experimental Alzheimer’s drug (Solanezumab): Created to attach to protein fragments in the brain before those fragments clump together to become plaques. DIAN studies – Alzheimer’s Association has funded 4.2 million for this study. DIAN is a network of investigators recruiting families with dominantly inherited AD. These families have rare, inherited gene mutations that cause young onset, familiar AD.
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