Download - Dementia causes and management
![Page 1: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/1.jpg)
Dementia
Medical Aspects of Disability
October 17, 2006
![Page 2: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/2.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)
![Page 3: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/3.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.
![Page 4: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/4.jpg)
Dementia• Two Types:
– Reversible– Irreversible
• Individuals must have intensive medical physical to rule out reversible types of dementia.
![Page 5: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/5.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
![Page 6: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/6.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%.
![Page 7: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/7.jpg)
Delirium vs. 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
![Page 8: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/8.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
![Page 9: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/9.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%.
![Page 10: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/10.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
![Page 11: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/11.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
![Page 12: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/12.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
![Page 13: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/13.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
![Page 14: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/14.jpg)
Dementia• Irreversible:
– Alzheimer’s– Lewy Body Dementia– Pick’s Disease (Frontotemperal Dementia)– Parkinson’s– Heady Injury– Huntington’s Disease– Jacob-Cruzefeldt Disease
![Page 15: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/15.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
![Page 16: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/16.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
3. Repeated unexplained falls
• Progresses to severe dementia—found at autopsy.
![Page 17: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/17.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
![Page 18: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/18.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).
![Page 19: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/19.jpg)
Changes Caused by Alzheimer's
• Diminished blood flow
• Neurofibrillary Tangles
• Neuritic Plaques
• Degeneration of hippocampus, cerebral cortex, hypothalamus, and brain stem
![Page 20: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/20.jpg)
Atrophic hippocampus in AD
![Page 21: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/21.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
![Page 22: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/22.jpg)
74 year old AD patient: reduced blood flow on SPECT in temporal areas
![Page 23: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/23.jpg)
Normal vs AD Brain
Normal brain Alzheimer’s brain
![Page 24: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/24.jpg)
AD Prognosis
• Alzheimer’s has a slowly progressive decline. These meds can slow the progression, NOT halt it.
Time
Function
![Page 25: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/25.jpg)
Pick’s disease
• 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
![Page 26: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/26.jpg)
Case history: Pick's DiseaseThis 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.
![Page 27: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/27.jpg)
Degeneration of the basal ganglia
• 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
![Page 28: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/28.jpg)
Basal ganglia
• Caudate
• Putamen
• Globus pallidus
• Subthalamic nuclei
• Substantia nigra
Striatum
![Page 29: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/29.jpg)
![Page 30: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/30.jpg)
Multi-infarct dementia (MID)
• Many small strokes
• Often mixed with Alzheimer’s dementia
![Page 31: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/31.jpg)
Viral dementia: HIV
• 20-60% of HIV patients suffers from dementia
• Cerebral atrophy may be caused by microglial nodules
![Page 32: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/32.jpg)
Vocational Rehabilitation and Dementia
• 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?
![Page 33: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/33.jpg)
End-stage Dementia
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)
![Page 34: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/34.jpg)
Complications from dementia
• 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
![Page 35: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/35.jpg)
Treatment of complications
• 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
![Page 36: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/36.jpg)
Artificial Nutrition in Dementia
• 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
![Page 37: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/37.jpg)
Complications from dementia
• 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
![Page 38: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/38.jpg)
Drug treatment in Alzheimer’s disease
• Many drugs aim to stimulate the cholinergic system
• These drugs have limited positive effects and do not reverse the causes of AD
![Page 39: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/39.jpg)
Dementia patients are very sensitive to additional disabilities• Illness
• Pain
• Medications
• Poor hearing
• Poor vision
![Page 40: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/40.jpg)
Management of depression at end of life
• 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
![Page 41: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/41.jpg)
Suicide• 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 planONE OTHER POTENTIAL EMERGENCY:• If risk high – DON’T leave client alone, immediately consult a
psychiatrist – may need in-patient care or involvement of authorities
![Page 42: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/42.jpg)
Anxiety
• 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
![Page 43: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/43.jpg)
Related anxiety conditions
• 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
![Page 44: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/44.jpg)
Other EOL care needs for dementia
• 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
![Page 45: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/45.jpg)
Summary
• 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
![Page 46: Dementia causes and management](https://reader033.vdocuments.net/reader033/viewer/2022052820/54b5d3534a79590b108b45ad/html5/thumbnails/46.jpg)
Links
• 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