Gerontology 1 Flashcards
What is dementia
a syndrome
Deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from normal ageing.
What does dementia affect
Memory
Thinking
Orientation
Comprehension
Calculation
Learning capacity
Language
Judgement
what will people with dementia have problems with
Day-to-day memory- difficulty recalling events that happened recently
Concentrating, planning or organising - difficulties making decisions, solving problems or carrying out a sequence of tasks (eg cooking a meal)
Language - difficulties following a conversation or finding the right word for something
Visuospatial skills - problems judging distances (eg on stairs) and seeing objects in three dimensions
- Orientation - losing track of the day or date, or becoming confused about where they are.
what does dementia not affect
Consciousness
The impairment in cognitive function is commonly accompanied, and occasionally preceded, by deterioration in what?
Emotional control
Social behavior
Motivation
What are the different types of dementia
Pathology of Alzheimers
Reduction size of the Cortex, severe in hippocampus
Plaquesare deposits of a protein fragment called beta-amyloid that build up in the spaces between nerve cells.
Tanglesare twisted fibres of tau protein build up inside cells.
Distinctive Features: STML (short term memory loss), Aphasia, Communication Difficulties, Muddled over everyday activities, mood swings, withdrawn, loss of confidence
what are the 2 important features associated with Alzheimers
Plaquesare deposits of a protein fragment called beta-amyloid (toxic to neurons) that build up in the spaces between nerve cells.
Tanglesare twisted fibres of tau protein build up inside cells.
what is pathology of vascular dementia
Vascular dementia is caused by reduced blood flow to the brain, which damages and eventually kills the brain cells.
Features of vascular dementia
- narrowing and blockage ofthe small blood vessels deep inside the brain(known as small vessel disease)
- a single large stroke(where the blood supply to part of the brain is suddenly cut off)
- lots of mini-strokes that cause tiny, but widespread, damage to the brain
- In many cases, these problems are linked to underlying health conditions– such as high blood pressure and diabetes– as well as lifestyle factors, such as smoking and being overweight.
- Distinctive Features: Memory problem of sudden onset, visuospatial difficulties, symptoms of stroke, anxiety, delusions, seizures
pathology of dementia with lewy bodies
Deposits of anabnormal protein called Lewy bodies inside brain cells
These deposits, which are also found in people with Parkinson’s disease, build up in areas of the brain responsible for things such as memory and muscle movement.
Features of dementia with lewy bodies
Distinctive Features: Cognitive ability fluctuates, visuospatial difficulties, attentional difficulties, overlapping motor disorders, speech and swallowing problems, sleep disorders, delusions
Pathology of frontotemporal dementia
The frontal lobes of the brain, found behind the forehead, deal with behaviour, problem-solving, planning and the control of emotions.
Changes in personality and behaviour, and difficulties with language.
Younger age of onset
Ubiqitin associated clumps of protein
TDP-43
Distinctive features of frontotemporal dementia
Distinctive features: STML not always present, uncontrollable repetition of words, mutism, repetition of words of other people, personality change, decline in personal and social conduct
Rarer forms of dementia
HIV – related genitive impairment
Parkinson’s disease
Corticobasal degeneration
Multiple Sclerosis
Niemann-Pick disease
Creutzfeldt-Jakob disease
Behavioural aspects of dementia
Depression
Apathy / Emotional Blunting
Anxiety
Irritability/ Disinhibition
how is depression related to dementia
Affect 40% of all people with Alzheimer’s dementia
Depression may precede a diagnosis of Alzheimer’s by several years
Earliest signs of Alzheimer’s – apathy and social withdrawal
Purpose of neuropsychological testing is to ascertain if memory is disturbed or whether memory is affected as result of depression
Depression may go untreated
Maybe treated with medications generally classified as antidepressants
what is apathy/emotional blunting and how is it related to dementia
Operationally defined as someone who is content to sit in a chair all day
Emotional blunting refers to a lack of a person’s affective response –
(Mood is how one feels himself or herself. Affect is how he or she is perceived by others.)
Someone with emotional blunting may not smile or laugh at appropriate junctures or reciprocate an expression or gesture of love, such as a hug, kiss, or “I love you”.
Treatment of apathy is more challenging as response to medication is not robust.
If medication is indicated, physicians tend to use categories of medication that increase availability of norepinephrine and dopamine in the brain.
Stimulants have a higher side effect profile, so they are used judiciously.
how is anxiety related to dementia
- Anxiety can be either situational or generalized.
- Situational anxiety may be seen in patients early in disease who have heightened awareness of their deficits. May become anxious when they struggle with a task that once came relatively easy to them. Slower or less accurate.
- Increasing anxiety as the complexity of the task increases, such as completing a tax return.
- In later stages we may see patients become anxious whenever they leave their home, such as to go to a doctor’s visit.
- More generalized symptoms are typically described as a general feeling of unease.
- May ruminate on anxiety-laden topics such as their various physical problems or their fear of running out of money.
- It is not uncommon to have a more advanced patient repeatedly ask others what they should be doing.
- Anxiety and/or irritability may also respond to non-stimulating antidepressants.
- When possible prescribing sedatives is avoided for anxiety in geriatric patients due to the increased risk for somnolence, confusion, and falls with these drugs.
how is irritability/disinhibition related to dementia
- Irritability is regularly seen in Alzheimer’s disease
- Families often describe the patient as being snappy, on edge, or having a short fuse.
- The irritability can be triggered by a frustrating event or may be fairly generalized.
- Hateful words may be uttered. Some may even start cursing or making derogatory comments about another’s race, gender, or religion.
- The latter can be quite disturbing to families, particularly when viewed as out of character for their loved one.
- Increased activity for the psychiatric symptoms of dementia are recommended
- Apathy or depression does not improve when spending time alone or being idle.
- The combination of meaningful activity and being around others lifts spirits.
- Anxiety likewise thrives with inactivity.
what may be the first symptom of dementia
- Social withdrawal or mood disturbance may be the first symptom of Alzheimer’s disease.
what is significant forgetfulness caused by
a primary memory disorder
in what ways is psychosis related to dementia
- hallucinations
- delusions
what is a hallucination
A hallucination is an abnormal sensory perception of a stimulus that isn’t really there.
what are the most common types of hallucination in dementia
Visual (seeing things),
Auditory (hearing something)
Tactile (sensation of feeling something).
In dementia, visual hallucinations are the most common, but auditory hallucinations may also occur.
Tactile hallucinations suggest a different diagnosis than dementia.
In what type of dementia is hallucination a diagnositic criterion
Dementia with Lewy bodies
what is a delusion
- A delusion is a fixed false belief that is resistant to reason or confrontation with facts.
- Delusions may involve paranoia (in which a patient mistakenly believes that others are trying to in inflict harm in some way).
- Delusions are estimated to occur in approximately 22 % of people with Alzheimer’s dementia
Management of dementia
- Difficult to correct the misperception with words
- Best to avoid explanations
- Strong declarative statement in attempts to end the discussion may be beneficial.
- Stay general but assertive.
- Avoid lengthy conversations
- Paranoia is often driven by fear.
- Consider not correcting, contradicting, or otherwise confronting or arguing with a person who is having a hallucination or delusion.
- Avoid explanations or confrontation.
- If you are going to address the psychosis head on, try a more medical interpretation to allay a patient’s anxiety.
- Then find an activity to engage the mind and change the environment which may help the brain let go of the image.
- Distraction works well for psychosis and other behavioural problems.
- Change the topic of conversation, activity, or even the venue
- Distraction can also work
- Humour helps defuse potentially explosive situations.
Medications for dementia
No FDA-approved medications to treat dementia-related psychosis, but antipsychotic medications may be used “off-label” Be advised that all antipsychotics carry a FDA boxed warning regarding their use in dementia .
Summary of dementia management
- Identify and avoid behavioural triggers.
- Avoid explanations or confrontation.
- Find the right balance of stimulation.
- Maintain a daily routine of structured activities.
- Support and reassure a patient with psychosis.
- Distraction works wonders.
- Humour defuses tension.
Treatment planning in dementia (early stage)
- Should oral assessment be part of multi-disciplinary care of the person with dementia following diagnosis?
- Planning for the future as we consider the progressive nature of dementia
- Assessment
- Identify and attempt to retain “Key Teeth”
- Focus on high quality restorations
- Are complex restorative treatments able to be cared for in the long term?
- Establish a preventative regime
What are the key teeth to retain for QoL?
- Occluding pairs of teeth
- Number of teeth
- Attempt to retain anterior teeth
why should you not just jump to edentulous planning
Natural teeth have a significant impact on QoL
Chewing and Eating
Nutrition
Independence / Pride and Achievement
Social Aspects of Life
Treatment planning for dementia (mid-stage)
- Maintenance and Prevention are essential
- Ability to co-operate may deteriorate limiting the ability to provide care intervention
- Consideration must be given to medical status and its implications upon provision of care
- Access becomes increasing more challenging
Treatment planning (late-stage dementia)
- Focus on comfort
- Moist, clean and healthy mouth which is free of pain and infection
- Non-invasive
- Emergency management – limited options
aspects to think about behavioural management
- Communication
- Touch and reassurance
- Best time of the day
- Find out about the person
Is sedation appropriate for people with dementia
- **Pre-medication **- e.g. diazapam the night before they see you, can help but frailty is risk
- Oral sedation - higher risk for older people, dysphagia risk/dose risk/ ability to hold nose piece over nose for long period of time/ behavioural reassurance
-
Inhalation Sedation - not good in this group, behavioural reassurance etc
** Intravenous Sedation **- most commonly used in this group. Although cannulation can be harder/metabolism changes as we age so will require less drug/ resp depression/ aftercare difficult as won’t always have 1-1 care
Consideration for IV sedation for older people
- Pharmacodynamics
- Pharmacokinetics
- Cannulation – venous access is challenging
- Titration rate
- Total dose required
- Dose for patients over the age of 70 (2.8 mg) was 50% less than the mean dose for those under the age of 70 (5.7 mg). (Chauhan et al. (2014))
- Monitoring
- Escort and Home care situation
Considerations with GA
Best to not do with these patients if possible - avoid at all costs. Very risky. Limited physiological reserve upon application of stressors
Complications increase:
- Death
- Thromboembolic events
- Dehydration
- Insufficient nutrition intake
- Insufficient pain treatment
- Post operative delirium
- Post operative cognitive function – affects 1 in 3 of those >80
Possible causes of negative consequences of GA
Emboli
Perioperative physiological disturbances –hyponatraemia
Pre-existing cognitive impairment – increases risk
In-patient care ?
Environment is safer for mentoring but with increased length of stay risk of HAI
