Valin, Gerielle M.

CASE ANALYSIS : DEMENTIA

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.

Clinical Manifestations:
Dementia
DSM IV DIAGNOSIS
Dementia of the Alzheimers type
Vascular dementia
Dementia due to a general medical condition
Dementia due to multiple etiologies
DEFINING CHARACTERISTICS
Slow, insidious onset

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Impaired long and short term memory

Deterioration of cognitive abilities judgement, abstract thinking
Often irreversible if untreated
Personality changes
No or slow EEG changes
Diagnostic Evaluation:
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:
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 Treatment
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

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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
Complications:
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.
Nursing Interventions:
Improving communication
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 patients view.
If patient becomes aggressive, shift the topic for a safer, more familiar one.
Promoting Independence in Self-care
Assess and monitor patients 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.

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Sit with the patient during meals and assist by cueing.

Ensuring Safety
Discuss restriction of driving when recommended.
Assess patients home for safety; remove throw rugs, label rooms, and keep
the house well lit.
Assess community for safety.
Alert neighbors about the patients 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.