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New notes

  • BPSD = behavioural and psychological symptoms of dementia
  • RACF = residential aged care facility (nursing home)
  • Management is complex and includes a bunch of social issues
  • Question family might ask is: "is dementia hereditary?". Actually that risk is very low
    • But remember that 95% of dementia is environmental
  • A bunch of sad stories
  • Fast dementias:
    • CJD = 1 year
    • FTD = 2 years
    • Slow - AD = up to 20 years
  • Australia's social care is down the tubes
    • Some people have to get divorced just so that the patient (their husband/wife) can get money for a nursing home without having to sell their house
  • Progressive disease - every day is worse, never better.
  • Carers get hypervigilant and have high high morning cortisol - get anxiety disorders etc. More anxious if patient is more sick
  • Early age dementia = harder for people to understand; harder to get in nursing home (due to lack of frailty etc)
  • There's probably some stuff about carers in the exam
  • Support carer to support the patient

Old notes

Introduction

  • There is a perception that dementia is a bit of memory loss
    • It is actually a relentless progressive neurodegenerative disorder

Dementia

  • Diagnostic and statistical manual of mental disorders criteria 1987
    • Memory impairment
    • +lossof1of:
      • abstract thinking, judgement, personality
      • higher cortical disturbance – aphasia, apraxia, agnosia
        • +impaired occupational/social functioning
      • An umbrella term for a group of neurodegenerative disorders

Causes

  • Alzheimer’s disease – 60-70% of all dementia
  • Vascular dementia
  • Lewy body dementia
  • Alcohol dementia
  • Parkinson’s dementia
  • Other extrapyramidal dementia
  • Fronto-temporal dementia

Alzheimer’s disease

  • Pathology
    • Brain atrophy
    • Aβ deposition + perivascular neuritic plaques
    • Tau protein phosphorylation and deposition resulting in neurofibrillary tangles
    • Underlying brain damage that may be particular to the disease
  • AD + other diseases may have:
    • Medial temporal lobe – hippocampus + memory
    • Temporal cortex – language deficit (aphasia)
    • Parietal cortex – visuospatial problems, complex movements coordination lost (apraxia) o Frontal cortex – judgement, planning, personality, organisation
    • Limbic cortex – mood, sleep/appetite, attention/alertness

Epidemiology

  • The problem:
    • Age is proportional to dementia cases, there is a demographic change occurring
  • The ageing population is leading to an increased number of dementia cases
    • Carers – in high demand, need health support services
  • 2005, 1% of population
    • in 2050, predicted 2.8%
  • Prevalence >50% of people over 90

Assessment

  • There are many benefits to early and accurate diagnosis
    • Reversible causes can be diagnosed and reversed
    • We can anticipate problems that may occur with acute illness o Carer support + support networks can be activated
    • Education
    • Accurate prognosis
    • Future plans
    • Early treatment

*note: + cholinergic neurotransmission problems 

Management – non-medical

  • Early communication
  • Minimisation of the sensory deficit
  • Modification of the environment for safety and convenience
  • Daily routines – create order in life
  • Social/physical stimulation
  • Care givers + support (for care givers)
  • Seek medical help when psychosocial interventions don’t help

Management - medical

  • Treatment of agitation
    • Sedatives and tranquilisers (AE – falls etc) [eg: risperidone, haloperidol]
  • Cognitive enhancers
    • Cholinesterase inhibitors [eg: Tacrine, Galantamine]
      • AChE breaks down ACh, inhibitor prevents this
        • ACh is thought to be related to symptoms of dementia (especially to do with the ACh, DA balance)
      • ADAS-cog (AD assessment scale) is a dementia assessment scale – drugs are shown to improve score
      • PBS criteria:
        • Mild to moderate dementia, confirmation of diagnosis
  • MMSE (mini-mental state examination) - <25, or ADAS-cog low
    • Need to improve after 6 months: MMSE 2 points, ADAS, 4 o NMDA antagonists [eg: Memantine]
  • Experimental
    • Gene therapy
    • Nerve growth factor
  • Cholinesterase inhibitors
    • AChE breaks down ACh, inhibitor prevents this
      • ACh is thought to be related to symptoms of dementia (especially to do with the ACh, DA balance)
    • ADAS-cog is a dementia assessment scale – drugs are shown to improve score o PBS criteria:
      • Mild to moderate dementia, confirmation of diagnosis
      • MMSE (mini-mental state examination) - <25, or ADAS-cog low
  • Need to improve after 6 months: MMSE 2 points, ADAS (AD assessment scale), 4 • If we can delay AD by 5 years, there is a huge cost saving

Carers

  • Dementia living conditions:
    • 51% at home, 37% NH, 9% hostels (low level care), 4% other
  • Carers have a complex role
    • It is a hard role with much stress/emotional burden/social isolation
    • A change in personality can be the hardest thing, especially the apathy
  • Need continual support
    • Even after admission of patient to NH, with guilt and grief

Support for carers

  • Information/education
  • Respite care – in-home, day-centre, residential
  • Community support, services at home
  • Strategies for managing behaviours
  • Counselling + planning for the future
  • Support groups, GPs, meals on wheels
  • After moving into residence, advice on: visiting, continued caring, dealing with wanting to go home



Nursing homes

  • 24 hours care from trained nurses
  • Useful for late-stage dementia
    • In nursing homes, most patients have dementia

Hostels

  • For patients with higher levels of function
    • Have a single room and a private/shared bathroom
  • Dementia units – facilities catered specifically for people with dementia

Ethics

  • Guided by values
  • Issues
    • Telling the truth about diagnoses
      • Withholding diagnoses?
  • May prevent early treatment, education, planning
  • Initial discussion should instead be about future planning, concerns, finances, affairs
    • Driving
      • Driving is complex, need to divide and maintain attention
        • Need good judgement
        • Need to know and remember the road rules
        • Need to be able to locate your destination
        • Need to have good eyesight/hearing
      • Objections
        • Driving represents freedom
        • Driving is a ‘right’
        • “I’ve driven all my life”
        • other forms of transport are rare
      • Strategies
        • Stop driving immediately
        • Driving assessment
        • Monitoring by the family – not very reliable
          • Quality of life
      • Quality of life of the carer is often lower than that of the patient
      • Decreases with decreasing dementia (for both patient and carer)
      • Defined by many factors, complex and persona
        • Social, physical health, living arrangements, religion, culture, finances
        • Need to avoid imposing own definitions about quality of life
    • Choices – attorney/free will/autonomy, capacity and competence
      • Depends between individuals – often to do with personality
      • Conflicts between family and patient wants/needs
      • Strategies:
        • Recognise the patients abilities to make decisions and adjust as necessary
        • Open discussion
        • Advance directives
          • Death and dying, research, genetic testing, behavioural control



Restraints

  • Devices used to limit freedom/movement
    • Prescribed in hospitals to prevent injury and ensure safety
      • Often can cause harm and lessen independence and self-esteem
      • Better to try and understand the behavioural changes in AD and thus try and find alternatives
      • Dementia causes changes in the way people interact with life
  • Behaviours that are considered inappropriate may the be only way they can communicate

Acute illness

  • Dementia can predispose to many acute illnesses
    • Due to incontinence, depression, falls, confusion, immobility, aspiration
  • Prognosis is better at home than in hospital
    • Home – familiar environment, some treatments can be administered at home, don’t even need admission to hospital
    • Hospital – delirium worse, risk of iatrogenic complications
      • Safer, access to treatments and investigations, home may be inappropriate, carer respite

Important neurobiology

  • AD
    • 3 important factors
      • Cholinergic neurotransmission
      • Tau protein neuropathology
      • Aβ Amyloid neurodegeneration