by

Pajanustan, Ben David B.

- Is not a specific disease
- General term for a decline in mental ability severe
enough to interfere with daily life
- Affects adults older than 65 years of age
- Characterized by uneven, downward decline in mental
function
In order for a diagnosis of Dementia to be made, at least
two domains of altered function must exist:

MEMORY CALCULATION
LANGUAGE JUDGEMENT
PERCEPTION ABSTRACTION
VISUOSPATIAL FUNCTION PROBLEM-
SOLVING



The changes characteristic of dementia fall into 3
categories:

COGNITIVE
FUNCTIONAL
BEHAVIORAL
Reversible:
-alcohol abuse
-medication use (polypharmacy)
-psychiatric disorder
-normal-pressure hydrocephalus
Non-reversible(most common):
-Alzheimers disease
-Multi-Infarct dementia
-Mixed
Multi-infarct or vascular dementia- has the following
defining characteristics:
-There must be evidence of dementia
-There must be evidence of cerebrovascular disease
-The two disorders must be reasonably related
Alzheimers disease is a progressive, irreversible,
degenerative neurologic disease that begins insidiously
and is characterized by gradual losses of cognitive
function and disturbances in behavior and affect.
Specific neuropathologic and biochemical changes are
found to patients with Alzheimers disease. It includes:
-Neurofibrillary tangle(mass of nonfunctioning
neurons)
-Senile or neuritic plaques
Neuronal damage occurs primarily in cerebral cortex that
results in decreased brain size.
Acetylcholine using cells are the ones principally affected
by the disease
Biochemically, the enzyme active in producing
acetylcholine is that is involved in memory processing is
decreased.

Early stages of Alzheimer's:
-Forgetfulness
-Subtle memory loss
-Depression
Further progression, deficits can no longer be concealed
-forgetfulness is manifested in ADLs
-looses ability to recognize familiar faces, places and objects
-conversation becomes difficult
-word finding difficulties
-ability to formulate concepts and think abstractly disappears


Personality changes are also evident, patient may
become:
-depressed -paranoid
-suspicious -hostile
-combative
Further progression intensifies symptoms:
-speaking skills deteriorate into nonsense syllables
-agitation and physical activity increase
-may wander at night
-dysphagia
-incontinence develops
Histories:
-health -medical
-family -social and cultural
-medication
Physical exam
Functional and mental health status

These are KEY in the diagnosis of Alzheimers.
CBC
VDRL test for syphilis
HIV TESTING
Chemistry profile
Vitamin B12 and thyroid hormone levels
EEG
CT scan
MRI
MMSE
Clock drawing test
Cerebral biopsy
First medication for treatment of the symptoms of
Alzheimers disease.
Tacrine Hydrochloride (Cognex)
-enhances acetylcholine uptake in the brain
*Can cause liver toxicity

Acetylcholinesterase Inhibitors:
-Donepezil (Aricept)
-Rivastigmine (Exelon)


-Physical Safety
-Reducing anxiety and agitation
-Improving communication
-Promoting independence in self care activities
-Providing patients needs for socialization, self-esteem,
and intimacy
-Maintain adequate nutrition
-Managing sleep pattern disturbances
-Support and educating family caregivers
-Supporting cognitive function
Provide a calm, predictable environment
Environmental stimuli are limited
Quiet, pleasant manner of speaking
Clear and simple explanations
Use of memory aids and cues
All obvious hazards should be removed
Nightlights are helpful
Intake of food and medication is monitored
Identification bracelet or neck chain
Environment should be familiar and noise free
Excitement and confusion are upsetting and may
precipitate combative state (Catastrophic reaction)
Listening to music
Stroking
Rocking
Distraction
Nurse must remain unhurried and reduce noises and
distractions
Use clear and easy to understand sentences to convey
messages
Lists and written instructions can serve as reminders
Tactile stimuli
Simplify daily activities by organizing them into short,
achievable steps
Encourage to make choices when appropriate

Visits, letter and phone calls are encouraged
Visits should be brief and nonstressful
Encouraged to enjoy simple activities (e.g. walking,
exercising)
Having a pet can provide a satisfying activity and outlet of
energy
Sexual counseling for the spouse may be suggested as
the disease does not eliminate need for intimacy

Mealtime should be kept simple and calm
One dish should offered at a time
Food is cut into small square pieces to prevent choking
Liquids may be easier to swallow if converted to gelatin
Use of adaptive equipment when lack of coordination id
present


If rest is interrupted or the patient is unable to sleep
music, warm milk, or a back rub may help the person to
relax
During the day patient should be given sufficient
opportunity to participate in exercise activities because it
will enhance nighttime sleep
Long periods of daytime sleep are discouraged
Refer to support groups such as Alzheimers Association
Nurse must be sensitive to the highly emotional issues
that the family is confronting
ALZHEIMERS MULTI INFARCT
Etiology Familial; Sporadic CVD, Cerebrovascular dse
Hypertension
Risk factors Advanced age; genetic
factor
Preexisting CV disease
Occurrence 50-60% of dementias 20% ofdementias
Onset Slow Often abrupt
Follows stoke or TIA
Age of
onset(yr)
Early onset: 30s-65
Late onset: 65+
Most commonly: 85+
Most commonly 65-70
Gender Males and females
equally
Predominantly males
Course Chronic, irreversible ;
progressive, regular,
downhill
Chronic, irreversible,
Fluctuating, stepwise
progression
ALZHEIMERS MULTI-INFARCT
Duration 2-20 yr Variable; years
Symptom progress Onset insidious. Early-
mild and subtle
Middle and Late-
intensified
Progression to death
(infection or malnutrition)
Depends on location of
infarct and success of tx;
death due to underlying
CV disease
Mood Early depression 30% Labile: mood swings
Speech Language Speech remains intact
until late in disease
May have deficit/aphasia
depending on location of
lesion
Physical signs Early-no motor deficits
Middle-apraxia
Late-Dysarthria
End stage- loss of all
voluntary activity
According to location of
lesion: focal neurologic
signs, seizures
Exhibits motor deficits
Orientation
Topographic disorientation
Visual and Spatial disorientation
Time, Place and Person- as dse progresses
ALZHEIMERS MULTI-INFARCT
Memory Loss is an early sign of dementia; loss of recent
memory soon followed by progressive decline in
recent and remote memory
Personality Apathy, Indifference, Irritability
Early Disease- social behavior intact; hides
cognitive deficits
Advanced Disease- disengages from activity and
relationships; suspicious; paranoid delusions
caused by memory loss; aggressive; catastrophic
reactions
Functional status (ADL) Poor judgement, decline in activity to handle money,
use telephone, function in home and workplace
Attention Span Distraction; short attention span
Psychomotor Activity Wandering, hyperactivity, pacing, restlessness,
agitation
Sleep-wake cycle Often-impaired; wandering and agitation a nighttime




END