DEMENTIA Format of practice teaching

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Specific objectives Content

TeachingLearningActivity

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After studying the topic, the student will be able to,

Introduction:Cognition is that operation of the mind process by which we become aware of objects of thought and perception, including all aspects of perceiving, thinking & remembering. Organic brain syndrome is general term referring to many physical disorders that cause impaired mental function.

Announcement of the topic: so, today we will discuss phobic anxiety disorder. Student teacher enlist the classification of mental disorders with the help of a ppt

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Enlist the classification of organic mental disorders

After studying the topic, the student will be able to,

Classification of organic brain disorders: (F00-f09) organic, including symptomatic, mental disorders(F00) Dementia in Alzheimer’s disease(F01) Vascular dementia(F02) Dementia in other diseases classified elsewhere(F03) unspecified dementia(F04) organic amnestic syndrome, not induced by alcohol and other psychoactive substances(F05) delirium not induced by alcohol and other psychoactive substances(F06) Other mental disorders due to brain damage and dysfunction and to physical disease(F07) personality and behavioural disorders due to brain disease, damage and dysfunction(F09) unspecified organic or symptomatic mental disorder.

History of dementia:Dementia was first described in a book about mental illness in 183. In 1894, dr. alois Alzheimer, a German neuropathologist who has a particular interest in “nervous disorders” described changes in the brain caused by vascular disease (now known as vascular dementia). In 1910, he treated a middle aged women who had exhibited clinical symptoms of memory loss. Disorientation,”pecular behaviour” anxiety and hallucinations.The clinical symptoms of dementia were attributed to the aging process until the 1970s when researchers determined that dementia was caused by several factors such as organic change

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2min

3min

Define the term dementia

List down the etiology of dementia

Disease process or neurochemical defiency within the brain. The discovery enabled researchers to develop a classification of various types of dementia now included in the DSM-IV-TR

Dementia: “Dementia is an acquired global impairement of intellect, memory and personality but without impairement of consciousness”

Incidence:Dementia occurs more commonly in the elderly than in the middle-aged. It increases with age from 0.1 percent in those below 60 years of age to 15 to 20 percent in those who are 80 years of age.

Etiology: Significant loss of neurons and volume in brain

regions devoted to memory and higher mental functioning

Neurofibrillary tangles (twisted nerve cell fibers that are the damaged remains of microtubules- support structures that permit nutrients to flow through neurons)

Build amyloid

Student teacher defines the term dementia with the help

of PPT

Student teacher list out the etiology of dementia with the

help of PPT

What is the definition of

dementia

What is the etiology of dementia

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Evaluation

Accumulation of beta amyloid, an insoluble protein, which form sticky patches (neuritic plaques) surrounded by debris of dying neurons.

Environmental factors: infection, metals and toxins. Excessive amount of metal ions, such as zinc and copper,

in brain Other possible factors being researched are: Defiencies of vitamin B6,B12 And Folate Possible Risk

Factor Due To Increased Levels Of Hemocysteine (amino acid that may interfere with nerve cell repair)

Early depression: common genetic factors seen in those with early depression and Alzheimer’s disease

Untreatable and irreversible cause of dementia Degenerating disorders of CNS Alzheimer’s disease (this is the most common of all

dementing illnesses) Pick’s disease Huntington’s chorea Parkinson’s disease

Treatable and reversible causes of dementia Vascular-multi-infarct dementia Intracranial space occupying lesions Metabolic disorders-hepatic failure, renal failure Endocrine disorders- myxedema, Addison’s disease Infections- AIDS, meningitis, encephalitis Intoxication- Alcohol, heavy metals (lead, arsenic), Anoxia- Anemia, post-anesthesia, chronic respiratory

failure

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5min Explain the types of dementia

Types of dementia:Dementia disorders can be classified as many different ways. the classifications include.

1. Cortical dementia : dementia where the brain damage primarily affects the brain’s cortex, or outer layer. Cortical dementias tend to cause problems with memory, language, thinking, and social behaviour.

2. Subcortical dementia : dementia that affects parts of the brain below the cortex. Sub-cortical dementia tends to cause changes in emotions and emotions and movement in addition to problems with memory.

3. Progressive dementia : dementia that gets worse over time, gradually interfering with more and more cognitive abilities.

4. Primary dementia : dementia such as AD that does not result from any other disease.

5. Secondary dementia : dementia that occurs as a result of a physical disease or injury.

Student teacher explains the types of dementia with the

help of PPT

What are all the types of dementia



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Evaluation

10min Describe the stages of dementia

Vitamin deficiency, especially deficiency of thiamine and nicotine

Physiologic: Normal pressure hydrocephalus

Metabolic: Endocrinopathies (e.g. hypothyroidism)

Tumor: Primary or metastatic (e.g. meningioma or metastatic

breast or lung cancer)

Traumatic: Subdural hematoma

Stages of dementia:Stage I: Early stage (2 to 4 years):

Forgetfulness Declining interest in environment Hesitancy in initiating actions Poor performance at work

Stage II: Middle stage (2 to 12 years): Progressive memory loss Hesitates in response to questions Has difficulty in following simple instructions Irritable, anxious Wandering

Student teacher describe the stages of dementia with the help of PPT

What are all the stages of dementia

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5min Enlist the warning signs of

dementia

Neglects personal hygiene Social isolation

Stage III: Final stage (up to a year): Marked loss of weight because of inadequate intake of

food Unable to communicate Does not recognize family Incontinence of urine and faces Loses the ability to stand and walk Death is caused by aspiration pneumonia

Warning signs of Alzheimer’s dementia:1. Memory loss2. Difficulty performing familier tasks3. Problems with language4. Disorientation to time and place5. Poor or decreased judgement6. Problems with abstract thinking7. Misplacing things8. Changes in mood or behaviour9. Changes in personality10. Loss of initiative

Student teacher enlist the warning signs of dementia with the help of FLASH

CARDS

What are all the warning signs of

dementia

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TeachingLearning Evaluation

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5min Clinical features (For Alzheimer’s type)

Personality changes : lack of interest in day-to-day activities, easy mental fatigability, self-centred, withdrawn, decreased self-care.

Memory impairment : recent memory is prominently affected.

Cognitive impairment : disorientation poor judgement, difficulty in abstraction, decreased attention span.

Affective impairment : labile mood, irritableness, depression

Behavioural impairment : stereotyped behaviour, alteration in sexual drives and activities, psychotic behaviour.

Neurological impairment : stereotyped behaviour, alteration in sexual drives and activities, neurotic/psychotic behaviour.

Catastrophic reaction: agitation, attempt to compensate for defects by using strategies to avoid demonstrating failures in intellectual performances, such as changing the subject, cracking jokes or otherwise diverting the interviewer.

Sundowner syndrome : it is characterized by drowsiness, confusion, and ataxia: accidental falls may occur at night when external stimuli, such as light and interpersonal orienting cues are diminished.

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5min Discuss the diagnosis of

dementia

Diagnosis: Following test are used for diagnosis:

Cognitive assessment evaluation- mini mental status examination (MMSE) – shows cognitive impairment

Functional dementia scale (to indicate the degree of dementia)

Magnetic resonance imaging (MRI): of the brain shows structural and neurologic changes.

Spinal fluid analysis shows increased beta amyloid deposits

Treatment modalities:Medications used in the treatment of Alzheimer’s disease are:

Tacrine hydrochloride (cognex) Donepezil hydrochloride (Aricept) – both

drug inhibit the enzyme acetyl cholinesterase in the CNS, increasing the level of acetylcholine. The drugs may temporarily improve cognitive function in patients with Alzheimer’s disease. Most common side effects are headache, blurred vision, insomnia, nausea, diarrhoea

NMDA ANTAGONISTS.Memantine

ANTIPSYCHOTIC AGENTSRisperidone, quetiapine, and olanzapine

Student teacher discuss the diagnosis of dementia with

the help of PPT

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ANTIDEPRESSANT AGENTS AND MOOD STABILIZERSLow doses of the selective serotonin reuptake inhibitors and other newer antidepressive agents should be considered.

Nursing Management:Nursing care for patients of Alzheimer’s disease is most important. Whether at home, in acute hospital environment, a day-care center or in long term stay in institution, care givers must be trained to promote the patient remaining intellectual abilities.

Nursing assessment:Assessment data for the patient with dementia should include a past health and medication history.

Data to be included for nursing assessment Disorientation Mood changes Fear Suspiciousness Self-care deficit Social behaviour Level of mobility, wandering behaviour Judgement ability Sleep disturbances

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10min Discuss the nursing nursing intervention of

dementia

Speech or language impairment Hallucinations, illusions or delusions Bowel and bladder incontinence Apathy Any decline in nutritional status Recognition of family members Identify primary care giver, support system and the

knowledge base of the family members.

Nursing intervention:Daily routine:Maintaining a daily routine includes drawing up a fixed timetable for the patient for waking up in the morning, toilet, exercise and meals. This gives the patient a sense of security.

Nutrition & body weight:Patient should be provided a well-balanced diet, rich in protein, high in fiber, with adequate amount of calories, allow plenty of time for meals. Tell the patient which meal it is and what is there to eat: food served should neither be too hot nor too cold. Many patients have sugar craving. Care should be taken that such patients do not gain weight

Personal hygiene:Particular care should be taken about the patient’s personal hygiene, including brushing of teeth, bathing, keeping the skin clean & dry, particularly in areas prone to perspiration, such as armpits and groin. Caustic substances such as spirit

Student teacher discuss the nursing intervention with the help of CHART

What is the nursing intervention of dementia

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ActivityA.VAids

or antiseptic solution should not be used routinely on the skin. Remember to check finger and toe nails regularly, cut them if the person cannot do it by himself. Toilet habits and incontinence:Toilet habits should be established as soon as possible and maintained as a rigid routine.i.e going to a toilet after drinking up of a tea.

Accidents:Great care should be taken to avoid accidents caused by tripping over furniture, falling down the stairs or slipping in the bathroom. The reason for falling include loose and poorly fitting footwear.

Fluid management:The patient require as much as fluid as normal people and this depend on the season, ideally sufficient fluid should be given during the day and the minimum essential amount of fluid (some water with dinner) after 6pm.

Moods and emotions:Some patient of Alzheimer’s disease have abrupt change in their moods and emotions. These change can be unpredictable. Mood changes are the best controlled by keeping a calm environment with fixed daily routine. The

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patient should not be questioned repeatedly or given too many choices.

Wandering:Patients of Alzheimer’s disease often lose their geographic orientation and can get lost even in familiar surroundings. They may be found wandering aimlessly either in the neighbourhood or far away. It is advisable to have some identification bracelet or card always in their possession.

Disturbed sleep:Sleep disturbances are extremely distressing to the family. If the patient is restless at night or wanders or talks at night, the entire family is disturbed. Sleep pattern’s must be maintained

Interpersonal relationship:Verbal Communication Should Be Clear and unhurried. Questions that require ‘yes’, or ‘no’ answers are best. Give necessary information repeatedly.

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NURSING MANAGEMENT

Biologic DomainAssessmentThe nursing assessment should include a medical history, current medication profile (prescription and OTC medications or home remedies), substance abuse history (including alcohol intake and smoking history), chronic physical or psychiatric illness, and a description of the onset, duration, range, and intensity of symptoms associated with dementia.

Physical Examination and a Review of Body SystemsA review of body systems must be conducted on each patient suspected of having dementia. Specific biologic assessment parameters for a patient with dementia include vital signs, neurologic status, nutritional status, bladder and bowel function, hygiene (including oral hygiene), skin integrity, rest and activity level, sleep patterns, and fluid and electrolyte balance.

Physical FunctionsEvaluation of the patient’s functional abilities includes bathing, dressing, toileting, feeding, nutritional status, physical mobility, sleep patterns, and pain.

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Assessment of physical functions includes activities of daily living, recent changes in functional abilities, use of sensory aids (glasses and hearing aids), activity level, and assessment of pain.

INTERVENTIONS FOR THE BIOLOGIC DOMAIN

Self-Care InterventionsPatients should be encouraged to maintain as much self-care as possible. Promotion of self-care supports cognitive functioning and a sense of independence. In the early stages, the nurse should maximize normal perceptual experiences byfunction, hygiene (including oral hygiene), skin integrity, rest and activity level, sleep patterns, and fluid and electrolyte balance.

Physical FunctionsEvaluation of the patient’s functional abilities includes bathing, dressing, toileting, feeding, nutritional status, physical mobility, sleep patterns, and pain.Assessment of physical functions includes activities of daily living, recent changes in functional abilities, use of sensory aids (glasses and hearing aids), activity level, and assessment of pain.



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INTERVENTIONS FOR THE BIOLOGIC DOMAIN

Self-Care InterventionsPatients should be encouraged to maintain as much self-care as possible. Promotion of self-care supports cognitive functioning and a sense of independence. In the early stages, the nurse should maximize normal perceptual experiences by

Making sure that the patient and family have appropriate eyeglasses and working hearing aids.Oral hygiene can be a problem and requires excellent basic nursing care.

Activity and Exercise InterventionsThe activity or exercise must be designed to prevent excess stress (both physical and psychological), which means that it must be individualized for each patient with dementia, based on their relative strengths and deficits

Pain and Comfort ManagementNursing care of non-communicative patients who have dementia and who also have pain can be challenging.Because of the difficulty in identifying and monitoring the pain, the patients are often undertreated. However, several measures may be used to assess the efficacy of pharmacologic interventions, such as decreased restlessness

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and agitation. Small doses of oral morphine solution appear to reduce discomfort during routine nursing procedures.

Administering and Monitoring MedicationsBecause No Medication Can Cure AD, Psychopharmacologic Interventions Have Two Goals: Restoration Or Maintenance Of Cognitive Function And treatment of related psychiatric and behavioural disturbances that cause discomfort for the individual, interfere with treatment, or worsen the individual’s cognitive status.

CHOLINESTERASE INHIBITORS.Cognex, Donepezil, rivastigmine (Exelon) and galantamine

NMDA ANTAGONISTS.Memantine

ANTIPSYCHOTIC AGENTSRisperidone, quetiapine, and olanzapine

ANTIDEPRESSANT AGENTS AND MOOD STABILIZERSLow doses of the selective serotonin reuptake inhibitors and other newer antidepressive agents should be considered.

ANTIANXIETY MEDICATIONS (SEDATIVE–HYPNOTICS).

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MEDICATION WITH ANTI-CHOLLINERGIC EFFECTCaptopril (Capoten)CodeineCimetidine (Tagamet)Digoxin (Lanoxin)Dipyridamole (Trental)Furosemide (Lasix)Isosorbide (Ismotic)Nifedipine (Procardia)PrednisoloneRanitidine (Zantac)Theophylline (Bronkodyl)Triamterene (Dyrenium) and hydrochlorothiazide (HCTZ)Warfarin (Coumadin)

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Summary: Introduction Classification History Definition Etiology Types Stages Warning signs Clinical features Diagnosis Treatment modalities Nursing management

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Conclusion:• Dementia is a serious

cognitive disorder all together dementia is a far common in the geriatric population, it may be occur in any stage of childhood

• So as a nurse we need to get aware about the preventive measures of dementia and educative the individuals about its signs and symptoms with its treatment

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Bibliography: R Sreevani, a guide to mental health and psychiatric

nursing, jaypee publishers, 3rd edition, pg.no: 310-311

Townsend c Mary, text book on “Psychiatric Mental Health Nursing.”

Jaypee publications. 5th edition, page 387-405

Lalit batra, a textbook of mental health nursingPEEPEE Publishers1st edition

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Education

DEMENTIA Format of practice teaching