Case 4

Question 1

What is Amlodipine?

Answer 1

Calcium channel blocker used to treat hypertension.

Question 2

What problems about Mrs Wilkins got her granddaughter concerned?

Answer 2

• Hasn’t been the same since husband’s death and has been more forgetful:
  
  • Missed payments of several bills (behviour unlike her)
  • Oven left on

Question 3

What does the doctor offer in response to Mrs Wilkins’ granddaughters’ concerns? What are the strengths and limitations of this?

Answer 3

• A cognitive screening test, more specifically a 6 item cognitive impairment test like the one attached to this card.
• Limitations are that it is a relatively new screening test so there isn’t quite a strong evidence base
• However, very quick to apply
• No cultural knowledge required

Question 4

What is dementia?

Answer 4

• Chronic or progressive syndrome –
• Linked with abnormal affects to memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement.
• Consciousness is not affected.
• The impairment in cognitive function is commonly accompanied by deterioration in emotional control, social behaviour, or motivation.

Question 5

What causes dementia?

Answer 5

• Dementia results from a variety of diseases and injuries that primarily or secondarily affect the brain, such as Alzheimer’s disease or stroke.
• Dementia is one of the major causes of disability and dependency among older people worldwide.
• It can be overwhelming for the people who have it and their carers and families inlcuding physical, psychological, social and economic impact.

Question 6

What are the early signs of dementia?

Answer 6

• Characterised by gradual onset. Common symptoms include:
  
  • forgetfulness
  • losing track of the time
  • becoming lost in familiar places.

Question 7

What are the middle stage signs of dementia?

Answer 7

• Characterised by symptoms that become clearer and more restricting. These include:
  
  • becoming forgetful of recent events and people’s names
  • becoming lost at home
  • having increasing difficulty with communication
  • needing help with personal care
  • experiencing behaviour changes, including wandering and repeated questioning.

Question 8

What are the late stage signs of dementia?

Answer 8

• Characterised by near total dependence and inactivity. Associated with serious memory disturbances and clear physical signs and symptoms. Symptoms include:
  
  • becoming unaware of the time and place
  • having difficulty recognizing relatives and friends
  • having an increasing need for assisted self-care
  • having difficulty walking
  • experiencing behaviour changes that may escalate and include aggression

Question 9

What are the different types of dimentia?

Answer 9

• Alzheimer’s disease (60–70% of cases). Other major forms include
• Vascular dementia.
• Dementia with Lewy bodies (abnormal aggregates of protein that develop inside nerve cells).
• A group of diseases that contribute to frontotemporal dementia (degeneration of the frontal lobe of the brain).
• However the boundaries between different forms of dementia are indistinct and mixed forms often co-exist.

Question 10

Worldwide where is dementia most prevelant?

Answer 10

• Around 50 million people have dementia worldwide
• Nearly 60% living in low- and middle-income countries.

Question 11

What treatment options are available for dementia?

Answer 11

• There is no treatment currently available to cure dementia or to alter its progressive course.
• However, much can be offered to support and improve the lives of people with dementia and their carers and families. The principal goals for dementia care are:
  
  • early diagnosis in order to promote early and optimal management
  • optimizing physical health, cognition, activity and well-being
  • identifying and treating accompanying physical illness
  • detecting and treating challenging behavioural and psychological symptoms
  • providing information and long-term support to carers.

Question 12

What are the risk factors and preventative measures for dementia?

Answer 12

• Age is the strongest known risk factor for dementia but demenetia is not an inevitable consequence of ageing.
• Young onset of dementia (defined as the onset of symptoms before the age of 65 years) accounts for up to 9% of cases.
• People can reduce their risk of dementia by getting regular exercise, not smoking, avoiding harmful use of alcohol, controlling their weight, eating a healthy diet, and maintaining healthy blood pressure, cholesterol and blood sugar levels.
• Additional risk factors include depression, low educational attainment, social isolation, and cognitive inactivity.

Question 13

What are the social and economic impacts of dementia?

Answer 13

• Dementia has significant social and economic implications in terms of direct medical and social care costs, and the costs of informal care.
• In 2015, the total global societal cost of dementia was estimated to be equivalent to 1.1% of global gross domestic product (GDP).
• The total cost as a proportion of GDP was 0.2% in low- and middle-income countries and 1.4% in high-income countries.

Question 14

What impacts does dementia have on families and carers?

Answer 14

• Physical, emotional and financial pressures can cause great stress to families and carers, and support is required from the health, social, financial and legal systems.

Question 15

How are human rights of people with dementia violated and what can be done to support them further?

Answer 15

• People with dementia are frequently denied the basic rights and freedoms available to others. In many countries, physical and chemical restraints are used extensively in care homes for older people and in acute-care settings, even when regulations are in place to uphold the rights of people to freedom and choice.
• An appropriate and supportive legislative environment based on internationally-accepted human rights standards is required to ensure the highest quality of care for people with dementia and their carers.

Question 16

What is mild cognitive impairment?

Answer 16

• Mild cognitive impairment (MCI) is a condition in which someone has minor problems with cognition - their mental abilities such as memory or thinking.
• In MCI these difficulties are worse than would normally be expected for a healthy person of their age. However, the symptoms are not severe enough to interfere significantly with daily life, and so are not defined as dementia.

Question 17

What is the link between dementia and MCI?

Answer 17

• MCI is not dementia but a person with MCI is more likely to go on to develop dementia.
• Many people who are diagnosed with MCI use this as an opportunity to change their lifestyle for the better.
• There is a lot that someone can do to help reduce their chances of MCI progressing to dementia.

Question 18

What are the symptoms of MCI and how can they affect a person’s life?

Answer 18

• The term MCI describes a set of symptoms, rather than a specific disease. A person with MCI has mild problems with one or more of the following:
  
  • memory - for example, forgetting recent events or repeating the same question
  • reasoning, planning or problem-solving - for example, struggling with thinking things through
  • attention - for example, being very easily distracted
  • language - for example, taking much longer than usual to find the right word for something
  • visual depth perception - for example, struggling to interpret an object in three dimensions, judge distances or navigate stairs.
• For a person with MCI, these changes may cause them to experience minor problems or need a little help with more demanding daily tasks (for example paying bills, managing medication, driving). However, MCI does not cause major problems with everyday living. If there is a significant impact on everyday activities, this may suggest dementia.
• Most healthy people experience a gradual decline in mental abilities as part of ageing. In someone with MCI, however, the decline in mental abilities is greater than in normal ageing. For example, it’s common in normal ageing to have to pause to remember directions or to forget words occasionally, but it’s not normal to become lost in familiar places or to forget the names of close family members.
• If the person with MCI has seen a doctor and taken tests of mental abilities, their problems will also be shown by a low test score or by falling test scores over time. This decline in mental abilities is often caused by an underlying illness.

Question 19

What are some preventative measures that can be taken to delay or prevent onset of dmeentia/MCI?

Answer 19

• Emergent evidence suggests that lifestyle factors contributing to cardiovascular health are also likely to benefit cognitive function in later life.
  
  • These factors include:
  • Physical activity
  • Mediterranean diet
  • Not smoking
  • Not drinking to excess
• In addition, interventions to address the ‘intermediate disease precursors’ such as raised blood pressure, raised blood cholesterol, obesity and diabetes through screening, early detection, treatment and good management of the condition are thought to help reduce risk, progression and severity of dementia.

Question 20

What preventative measures can be taken to slow the development of dementia/MCI?

Answer 20

• Post-diagnostic interventions for those with MCI or dementia can include factors particularly amenable to change:
  
  • Social isolation - consequence of others finidng it easier to avoid people with the conditions rather than social withdrawal.
    
    • Good information, advice, advocacy and emotional support services, soon after a person has received a diagnosis, can be instrumental in reducing these sorts of problems.
  • Cognitive stimulation - Participating in stimulating and social activities can reduce the risk of developing dementia. These activities can also help reduce depression and feelings of loneliness in people with dementia, increasing quality of life and self-confidence.
  • Prompt treatment of infection -
  • Prompt treatment of depression - check cognitive stimulation

Question 21

What drug treatments are available for dementia/MCI? (break these cards down further)

Answer 21

• Prolonged presymptomatic stage of dementia may mean that the disease is so far progressed by the time symptoms are apparent that it has become too late to reverse the damage to the brain.
• Drugs developed to slow the progression of dementia have mixed success and do not work for everyone.
• Some short-term gains in memory have been demonstrated in some individuals, but the effects are usually small and do not last.
• Other suggested medications include non-steroidal inflammatory inhibitors (NSAIDs), oestrogen replacement therapy, and ginko biloba.
• There is no robust evidence that any of these therapies work to reduce risk or progression of cognitive decline, and even some evidence that oestrogen could increase risk.
• Various vitamin and other supplements have also not shown to improve cognitive risk or decline.
• Drugs are, however, commonly used to manage other conditions or behaviours associated with dementia. Commonly, people with dementia exhibit what is termed Dementia and Cognitive Decline
• ‘Challenging behaviour’ (such as aggression), which can make caring for them very difficult, both for family or other non-professional carers, and care practitioners alike.
• ‘Anti-psychotic’ medication (e.g. drugs developed to treat symptoms such as delusion or paranoia) might be prescribed in these cases, however the National Institute for Clinical Excellence recommends that such drugs are used sparingly and only for a short time.
• It could well be that being diagnosed with MCI or dementia, or even prediagnostically noticing the signs, can be distressing and result in depression in some people.
• Responding appropriately to symptoms of depression is very important and anti-depressants might be helpful in some cases alongside appropriate emotional support, talking therapies, information, advice and advocacy.
• Blood pressure medication has been shown, in one study, to ameliorate cognitive decline in dementia.

Question 22

What cognitive inteventions can be made to improve the profression of symptoms in Dementia/MCI?

Answer 22

• Cognitive interventions are usually separated into three categories (although some people use them interchangeably, especially in non-academic literature): Cognitive Stimulation, Cognitive Training, and Cognitive Rehabilitation.
• Cognitive stimulation comprises involvement in group activities that are designed to increase cognitive and social functioning in a nonspecific manner.
• Cognitive training is a more specific approach, which teaches theoretically supported strategies and skills to optimize specific cognitive functions.
• Cognitive rehabilitation involves an individualised approach using tailored programs centred on specific activities of daily life. Personally relevant goals are identified, and the therapist, patient and family work together to achieve these goals (e.g., joining a social group).

Question 23

What are the impacts of physical exercise on Dementia/MCI?

Answer 23

• In all studies, the benefits of physical exercise only last for at most a few months after exercise interventions have ceased. Therefore, physical exercise in the case of cognitive function is the same as it is in the case of cardiovascular function, ie. it needs to become a lifestyle change rather than a one-off, time-limited intervention.
• For people with MCI (who have an increased risk of eventually developing dementia), several studies show improvements in cognitive function through physical activity. One study reported modest improvements in cognitive function after six months.
• Other studies have shown that physical activity benefits memory, attention, executive functions and cognition in general.
• For people with dementia, several research studies have shown physical activity to be beneficial in terms of their cognitive function. For example, people with Alzheimer’s showed significant cognitive improvements when doing cycling training and somatic and isotonic-relaxation exercises.
• Studies have shown that in people diagnosed with Alzheimer’s patients, cardiorespiratory fitness has been associated with brain volume, in terms of the overall amount of brain tissue and the volume of white matter. The parts of the brain most associated with memory are notably affected.
• As well as cognitive function, exercise can also improve strength, cardiovascular fitness and, some argue, ‘challenging behaviour’.

Question 24

Continue reading the paper from other cogniitve stimulating activities onwards.

Question 25

Facts about Mrs. Wilkins

Answer 25

• She has MCI so she will have mild impairments in memory and other mild forms of thinking
• Symptoms do not interfere her life at the moment

Question 26

What are the characteristic features of the 4 most common types of dementia?

Answer 26

Question 27

Using simple language and analogies, explain the following terms:

• amyloid plaque
• neurofibrillary tangles
• synaptic deterioration
• neuronal death