Dementia Unizar
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Transcript of Dementia Unizar
DEMENTIA
I Wayan Tunjung, dr.Sp.S.
Bagian NeurologiRSU Kota Mataram
DEFINISI SINDROME PENURUNAN KEMAMPUAN
INTELEKTUAL PROGRESIF YANG MENYEBABKAN DETERIORASI KOGNITIF DAN FUNGSIONAL SEHINGGA MENGAKIBATKAN GANGGUAN FUNGSI SOSIAL, PEKERJAAN DAN AKTIFITAS SEHARI-HARI.
MODALITAS FUNGSI KOGNITIF:1. ATENSI2. BAHASA3. MEMORI4. VISUOSPATIAL5. EKSEKUTIF
MODALITAS BERBAHASA:1. BERBICARA SPONTAN2. PEMAHAMAN3. PENGULANGAN4. PENAMAAN5. MEMBACA6. MENULIS
MEMORI SECARA KLINIK DIBAGI MENJADI:
1. IMMEDIATE MEMORI: RECALL DALAM HITUNGAN DETIK.
2. RECENT MEMORI: RECALL DALAM MENIT-TAHUN.
3. REMOTE MEMORI: RECALL BERTAHUN- TAHUN
Alzheimer’sDisease
•Early onset•Normal onset
Vascular (Multi-infarct)
Dementia
Lewy Body
Dementia
DEMENTIA
Other Dementias•Metabolic•Drugs/toxic•White matter disease•Mass effects•Depression•Infections•Parkinson’s
Fronto-Temporal
Lobe Dementia
s
Types of Dementia1.Cortical DementiaDisorder affecting the cerebral cortex.Exs.: Alzheimer’s and Creutzfeldt-Jakob dementia. Memory and language difficulties (Aphasia) most pronounced symptoms.Aphasia is the inability to recall words and understand common language.
2. Subcortical Dementia:Dysfunction in parts of the brain that are beneath the cortex.
Memory loss & language difficulties not present or less severe than cortical.
Exs.: Huntington’s disease and AIDS dementia complex.
Changes in their personality and attention span.
Thinking slows down.
Dementia - IncidenceSuspected that as many as 50% of people over the age of 80 develop Alzheimer’s.
5%-8% of all people over 65 have some form of dementia; number doubles every 5 years beyond that age.
Alzheimer’s causes 50%-70% of all dementia.
About 20%-30% of all dementia is believed to be caused by a vascular dysfunction (most common is multi-infarct disease).
In 2010, 57.7% of people with dementia live in low and middle income countries.
By 2050, this will rise > 70.5%.
Ferri CP et al. Lancet 2005; 366: 2112 - 2117
SO… What is Dementia? It is NOT part of normal aging! It is a disease!
It is more than just forgetfulness - which is part of normal aging
Dementia Chronic progressive disorder Deterioration in multiple aspects of cognitive function
Associated with behavioural & psychological symptoms
Severe impact on quality of life Longest duration of burden on patient, family & society
Dementia - Early StageBegins with forgetfulness - isolated incidents of memory loss do not constitute dementia.
Forgetfulness progresses to confusion and eventually disorientation.
Problem solvingJudgmentDecision makingOrienting to space and time
Personality changes - irritable, agitated, sadness (depression), manic episodes
Aging Changes in Cognition… Normal aging changes = more forgetful & slower to
learn
MCI – Mild Cognitive Impairment = 1 problem area Immediate recall, word finding & complex
problem solving problems (½ of these folks will develop dementia in 5 yrs)
Dementia = Chronic thinking problems in > 2 areas Delirium =Rapid changes in thinking & alertness
(seek medical help immediately ) Depression = chronic unless treated, poor quality , I
“don’t know”, “I just can’t” responses, no pleasurecan look like agitation & confusion
Causes of dementia Primary neurodegenerative diseases: Alzheimer’s, vascular disease, fronto-temporal dementia, Lewy body dementia
Secondary: hypothyroidism, CNS infections,vitamin B-12 deficiency, chronic subdural haematoma, tumour, etc.
DementiaReversible:
D = Drugs, DeliriumE = Emotions (depression) and Endocrine Disorders
M = Metabolic DisturbancesE = Eye and Ear ImpairmentsN = Nutritional DisordersT = Tumors, Toxicity, Trauma to HeadI = Infectious DisordersA = Alcohol, Arteriosclerosis
Dementia Irreversible:
Alzheimer’s Lewy Body Dementia Pick’s Disease (Frontotemperal
Dementia) Parkinson’s Heady Injury Huntington’s Disease Jacob-Cruzefeldt Disease
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
DementiaLewy Body DementiaEpisodic confusion with intervals of lucidity with at least one of the following:1. Visual or auditory hallucinations2. Mild extrapyramidal symptoms
(muscle rigidity, slow movements).3. Repeated unexplained falls
Progresses to severe dementia—found at autopsy.
Dementia - DiagnosisImportant to establish the cause of the dementia - Alzheimer’s and dementia are not the same thing.
A differential diagnosis compares the symptoms of two or more diseases.
DD is important because some forms of dementia are “treatable”. Chronic drug abuse, Normal Pressure Hydrocephalus, Chronic subdural Hematoma, Benign Brain Tumors, Vitamin Deficiency, and Hypothyroidism.
Dementia - Diagnosis1. Medical History - Physician wants to determine the onset of symptoms and how they’ve changed over time.Determine risk factors for infection, family history of dementia or other neurological disease, alcohol and drug use, and a patient’s history of strokes.
Dementia - Diagnosis2. Neuropsychological Exam - Evaluates a person’s cognitive ability, e.g. orientation in time and space, memory, language skills, reasoning ability, attention, and social appropriateness.Tests involve asking a person to repeat sentences, name objects, etc.Someone with Alzheimer’s is usually cooperative, attentive, and appropriate but has poor memory.Someone with hydrocephalus is likely to be distracted and less cooperative.
Dementia - Diagnosis3. Brain Imaging/Lab Tests - CT or MRI, cerebrospinal fluid (all used to confirm a diagnosis or eliminate various possibilities)4. Blood tests - used to diagnosis neurosyphilis.5. Metabolic tests - determine treatable disorders such as a vitamin B12 deficiency6. EEG (electroencephalography) is used to diagnose Creutzfeldt-Jakob disease.
1. DEMENTIA ALZHEIMER
Where did we start?•Alzheimer’s first diagnosed in 1907 •OBS – organic brain syndrome - common term 60’s
•Psychiatric illness – mentally ill – 60’s-80’s•De-institutionalization - nursing homes – 70’s-80’s
•Little could be done once diagnosed – until the 90’s
•Families - ‘do the best you can’ – 60’s – 90’s.•Diagnosis of Alzheimer’s on autopsy only – till 90’s
Normal Brain Cells
Neurotransmitters (AChE)– being sent – message being
communicated to the next cell
Normal Brain Cells
Once the message is sent, then enzymes lock onto the messenger chemicals and take them out of circulation so a new message can be sent
What happens with Alzheimer’s Disease?Two processesCells are shrinking & dyingCells are producing less chemical to send messages
plaques tangles
Less neurotransmit
ter Further to go to get to the next cell
Enzymes (AChE inhibitors) – get to them BEFORE they
deliver their message
Brain Cells with Alzheimer’s
Alzheimer-type pathology
Silver stained plaques and tangles
• Thick arrow: senile (neuritic) plaque• Small arrow: diffuse plaque• Star: tangle
AD Pathology Amyloid plaques (Ab)
Amyloid Hypothesis
Secretase
Secretase
A
AggregatedA
APPs
N C
Cellproliferation
Calciumregulation
Membrane
KPI
Secretase Secretase
717670, 671APP
Reduced Ca++
NeuroprotectionNeuroplasticity
Increased Ca++
NeurotoxicityAbnormal outgrowth
Pathogenesis of amyloidosis in AD
AD: Risk Factors IEstablished•Age•Family history•Down’s syndrome•Apolipoprotein e4 allele•Autosomal dominant mutations: amyloid precursor protein gene (APP) chr 21, presenilin-1 gene chr 14, presenilin-2 gene chr 1. (<2% cases).
AD: Risk Factors IIProbable:
•Depression•Hypertension•Head injury•Homocysteine
AD: Risk Factors IIIPossible:
•Gender (F>M)•Education / neuro-cognitive reserve•Diabetes•Smoking•Cholesterol•Herpes simplex virus-I?
Possible protective factors Anti-inflammatory drugs Estrogen Apolipoprotein e2 allele High neurocognitive reserve &
cognitively stimulating activities Cholesterol lowering drugs (statins) Alcohol
AD & vascular disease
Diagnosing ADDefinite AD - Histopathological evidence (requires autopsy)
- Course and examination characteristic of ADProbable AD - Deficits in > 2 areas of cognition
- Onset 40-90 (usually > 65); progressive course
- Other causes excluded Possible AD - Deficit in only 1 area of cognition
- Atypical course - Other dementia causes present
Unlikely AD - Sudden onset- Focal signs- Seizures or gait disturbance early in
course
AD - SymptomsLoss of MemoryAphasiaApraxia - (decreased ability to perform physical tasks such as dressing, eating, ADL’s
DelusionsEasily lost and confusedInability to learn new tasksLoss of judgment and reasonLoss of inhibitions and belligerenceSocial WithdrawalVisual hallucinations
AD Early StageCharacteristicsBegins with forgetfulness
Progresses to disorientation and confusion
Personality changes
Symptoms of depression/manic behaviors
InterventionsMedications - Aricept and Cognex (both are commercial names).
Both increase acetylcholine (Ach) in the brain by inhibiting the enzyme that breaks it down.
Therapy (deal with depression that often accompanies diagnosis
Counseling with family
AD - Early StageMusic TherapyUsed to relieve depressionCoupled with exercise and relaxation techniques
Increase or maintain social relationships (dancing, improvisation)
Maintain positive activities (church choir, Handbell choir, Senior social dances, etc.)
AD - Middle StageCharacteristicsNeed assistance with ADLs
Unable to remember names
Loss of short-term recall
May display anxious, agitated, delusional, or obsessive behavior
May be physically or verbally aggressive
Poor personal hygiene
Disturbed sleepInability to carry on a conversation
May use “word salad” (sentence fragments)
Posture may be altered
Disoriented to time and place
May ask questions repeatedly
AD - Middle StageInterventionsValidation Therapy
Structured Areas for Mobility
Positive, nurturing, loving environment
Music TherapyProvides avenue for social interaction (Instrumental Improvisation; TGS, Guided Music Listening)
Provides a medium for verbal/non-verbal expression (TGS)
Can help maintain cognitive and affective functioning
AD - Middle StageMT (cont’d)Music associated with positive memories will evoke a positive response.
Use client preferred music
Music from late teens through early 30’s
Lower keys (F3 to C5 for women ~ one octave lower for men
Only use sheet music when helpful ~ might be a distraction
Dancing allows for intimacy between spouses
Mallet in dominant hand, drum in non-dominant hand so one can play independently
*Careful - some may react to loud noises adversely
AD - Late StageCharacteristicsLoss of verbal articulation
Loss of ambulationBowel and bladder incontinence
Extended sleep patterns
Unresponsive to most stimuli
InterventionsCaring for physical needs
Maintain integrity of the skin
Medical interventions
Most activities are inaccessible
AD - Late StageMusic TherapyTape by bedsideGentle singing by therapist ~ one-sided, client will not participate
Can provide some connection between patient and family members through singing
Use a calm voiceUtilize touch: holding hands, hugging, rocking, hand on shoulder, etc.
Alzheimer’s drugs provide FAKE messenger
chemicals that distract the enzymes. They attach
to the Fake AChE & the message can get thru
What do Alzheimer’s drugs DO?
Donepezil, Rivastigmin, Galantamine (Aricept, Exelon, Reminyl (Razadyne)
2. DEMENTIA VASCULAR
Vascular DementiaNerve cells are OKBlood supply is damagedNo oxygen gets to the cellNo nutrients get to the cell
Then … the nerve cells die
Vascular DamageHealthy cell with
oxygen and nourishment
Dead nerve cell - no blood supply
No message
Training to care for people with dementia
What is Vascular Dementia?Second most common form of dementia after Alzheimer’s
disease.Occurs when the blood supply to the brain is interrupted by
a blocked or diseased vascular system.
Training to care for
people with dementia
A Little Bit of HistoryArteriosclerosis and senile dementia described as different syndromes as early as 1899.
Mayer-Gross et al in 1969 reported hypertension to be the cause in 50% of patients.
Hachinski in 1974 used the term multi-infarct dementia.
In 1985 the term vascular dementia was used by Loeb.
Training to care for
people with dementiaDifferent Types 0f Vascular Dementia
1. Mild vascular cognitive impairment2. Multi-infarct dementia3. Vascular dementia due to a strategic single infarct.4. Vascular dementia due to lacunar lesions5. Vascular dementia due to haemorrhagic lesions6. Binswanger disease7. Subcortical vascular dementia8. Mixed dementia (combination of AD and
Vascular)
Training to care for
people with dementia
Multi-infarct dementiaMost common formCaused by a series of small strokes or TIA.Damage caused to the cortex of the brainArea associated with learning, memory and language.
Can be temporary but over time with repeated incidents become permanent
Symptoms include severe depression, mood swings and epilepsy
Training to care for
people with dementiaBinswanger’s Disease
(or Subcortical vascular dementia)
Associated with stroke-related changes.Damage to tiny blood vessels of the white matter, deep within the brain.
Symptoms develop more gradually and include
Slowness, lethargy, difficulty walking, emotional ups and downs, lack of bladder control.
Signs and Symptoms of Vascular Dementia
Physical signs/symptomsMemory problems, forgetfulnessDizzinessLeg or arm weaknessLack of concentrationMoving with rapid, shuffling stepsLoss of bladder or bowel control
Training to care for
people with dementia
Behavioural signs/symptomsDepressionSlurred speechLanguage problemsAbnormal behaviourWandering/getting lostLaughing/crying inappropriatelyDifficulty following instructionsProblems handling money
Training to care for
people with dementia
Risk Factors that increase risk of developing Vascular Dementia
Training to care for
people with dementiaRisk Factors
High blood pressureSmokingDiabetesHigh CholesterolHistory of mild warning strokesEvidence of arterial disease elsewhereHeart rhythm abnormalitiesLack of physical activityFatty dietGender – Men are at a slightly higher risk.Age – Usually between 60 and 75, incidence increases with age.
Training to care for
people with dementia
GOOD NEWS
Unlike Alzheimer’s Disease, there are ways to prevent and reduce the severity of vascular dementia.
Training to care for
people with dementiaMedical management of:
High blood pressureHigh CholesterolHeart diseaseDiabetesAdministering medication to prevent clots forming eg AspirinDrugs to relieve restlessness or depressionRecent research indicates that cholinesterase inhibitor
medications which are helpful with Alzheimer’s disease may be of benefit in Vascular Dementia eg Aricept, Reminyl.
In some cases surgery such as carotid endarterectomy may be indicated.
Unlike Alzheimer’s Disease, there are ways to prevent and reduce the severity of vascular dementia.
Receiving Rehabilitative Support:
PhysiotherapyOccupational TherapySpeech Therapy To help the person regain lost functions.
A Healthier Lifestyle:
•A healthy diet•Regular Exercise•Stop smoking•Moderate intake of alcohol
Training to care for
people with dementiaProgression of Vascular Dementia
Onset gradual or dramatic
StabiliseTIA/Stroke
StabiliseTIA/Stroke
Typically Vascular Dementia progresses gradually in a stepwise fashion in which
a person’s abilities deteriorate after a stroke, then stabilise until the next stroke.
TERIMA KASIH…