Dementia Case Study
Dementia is an acquired syndrome that causes progressive loss of intellectual abilities, such as memory, as well as aphasia, apraxia, and loss of executive function. Dementing disorders are characterized by gradual onset plus continuing cognitive decline that is not due to other brain disease. Screening tests can identify persons who should be referred for a complete diagnostic workup.
Early diagnosis of dementia is the goal of a diagnostic workup, which is done to exclude potentially reversible causes and initiate therapy as early as possible. Short term memory impairment is usually the first symptom of dementia. Clinical diagnosis of dementia requires (1) loss of an intellectual ability with impairment severe enough to interfere with social or occupational functioning and (2) ruling out delirium. Delirium must be ruled out because cognitive impairment caused by delirium may be reversible.
Mild cognitive impairment is another risk factor for dementia. Persons with mild cognitive impairment have complaints and objective evidence of memory problems, but do not have deficits in activities of daily living or in other cognitive functions and do not meet the diagnostic criteria for dementia. Mild cognitive impairment refers to a transitional state between normal aging and dementia; it is associated with an increased risk of death, greater decline in cognitive abilities, and incident, with annual conversion rate of 8.3% to Alzheimer disease. Elder persons with mild cognitive impairment who are depressed are at greater risk of converting to Alzheimer disease. Dementia may be caused by more than one mechanism, even in the same individual. An autopsy examination is necessary to confirm the diagnosis.
DSM –IV DIAGNOSIS
- Dementia of the Alzheimer’s type
- Vascular dementia
- Dementia due to a general medical condition
- Dementia due to multiple etiologies
- Slow, insidious onset
- Impaired long and short term memory
- Deterioration of cognitive abilities – judgement, abstract thinking
- Often irreversible if untreated
- Personality changes
- No or slow EEG changes
Various diagnostic tests may be done to determine the cause. A comprehensive neuropsychiatric evaluation must be completed to make an accurate diagnosis.
- Basic laboratory examination, including CBC with differential, chemistry panel (including blood urea nitrogen, creatinine, and ammonia), arterial blood gas values, chest x-ray, toxicology screen (comprehensive), thyroid function tests, and serologic tests for syphilis.
- Additional test may include CT scan, MRI, additional blood chemistries (heavy metals, thiamine, folate, antinuclear antibody, and urinary porphobilinogen), lumbar puncture, PET/ single photon emission computed tomography scans.
- Complete mental status examination.
- Comprehensive physical examination.
- 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.
- Pharmacologic therapy used for the person with DAT is directed toward the use of anticholinesterase drugs to slow the progression of the disorder by increasing the relative amount of acetylcholine. Available drugs include donepezil (Aricept), galantamine (Reminyl), rivastigmine (Exelon) and tacrine (Cognex). An NMDA-receptor antagonist memantine (Namenda) may be provided in an attempt to improve recognition. Other drugs may be used for behavioral control and symptom reduction.
- Agitation management: neuroleptic drugs
- Psychosis: neuroleptic drugs
- Depression: antidepressants, ECT
- Without accurate diagnosis and treatment, secondary dementias may become permanent.
- Falls with serious orthopedic or cerebral injuries.
- Self-inflicted injuries
- Aggression or violence to self, others, or property.
- Wandering events, in which the person can get lost and potentially suffer exposure, hypothermia, injury, and even death.
- Serious depression is demonstrated in caregivers who receive inadequate support.
- Caregiver stress and burden may result in patient neglect or abuse.
- 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 patient’s view.
- If patient becomes aggressive, shift the topic for a safer, more familiar one.
Promoting Independence in Self-care
- Assess and monitor patient’s 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.
- Discuss restriction of driving when recommended.
- Assess patient’s home for safety; remove throw rugs, label rooms, and keep the house well lit.
- Assess community for safety.
- Alert neighbors about the patient’s 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.