Introduction to Dementia: Complications Created in March 2005 Duration: about 15 minutes Axel Juan, MD The Geriatrics Institute axel.juan@med.va.gov 305-575-3388
Credits Principal medical contributor: Axel Juan, MD Consulting contributors: Alan Katz, MD Marcos Milanez, MD Bernard Roos, MD Michael J. Mintzer, MD Jorge Ruiz, MD Rose van Zuilen, PhD Narrator: Axel Juan, MD Instructional designer/developer: Yat-Soon Lee, MS Usability engineer: Michael W. Smith
Complications Let s discuss what happens to patients with dementia.
Introduction Functional Socio economic Complications Behavioral Psychiatric Dementia usually worsens over time. The pattern and rate depend on the underlying cause. Depending on the severity of the cognitive impairment and the type of dementia, functional, behavioral, and psychiatric sequelae may occur. Socioeconomic consequences arise for the individual, caregiver, and society.
Learning Objective Identify the sequelae (functional, behavioral, psychiatric, and socioeconomic) of dementia. At the end of this section, you will be able to identify the functional, behavioral, psychiatric, and socioeconomic sequelae of dementia when presented with a case of a patient with a dementia.
Functional Decline in Alzheimer s Function Keep appointments Telephone Prepare meals Travel alone Use home appliances Find belongings Select clothes Dress Groom Maintain hobby Dispose of litter Early Middle Clear table Late Walk Stage Stage Stage Eat 25 20 15 10 5 0 MMSE Score Loss of specific functional activities occurs at different times depending on the type of dementia. As an example, the progression of functional loss for Alzheimer's dementia, the most common type, is depicted here. Higher-level activities, such as keeping appointments, preparing meals, managing medications and finances, may be lost through the early stages of the disease (which correlate roughly to Mini-Mental Status Examination [MMSE] scores of 20 and above). Loss of these functions is not a part of normal aging and should serve as clinical clues to recognizing patients with dementia early in their illness. The largest range of functional loss occurs in the middle stages (MMSE in the 19-11 range ). Here the patient loses the ability to perform more complex activities, such as using home appliances, selecting clothes, traveling, grooming, and dressing. By the late stages, (MMSE of 10 and below), the ability to eat and swallow, toilet, and walk are lost. As a result, malnutrition from feeding problems and contractures from immobility are not uncommon in this stage. Although there is no set time period, a typical person with Alzheimer s will live 10 years after diagnosis, though the presence or absence of comorbidities (e.g., heart disease, malignancy, lung disease) may decrease or increase lifespan, respectively.
Behavioral Manifestations Personality changes Apathy Sleep disturbances Sundowning Wandering Agitation Begins in early stage; becomes more selfcentered and passive Begins in early stage; lack of motivation or behavioral initiation Common in middle stage; sleep efficiency is poor; resulting fatigue leads to irritability Increase in confusion and behavioral symptoms in late afternoons or evenings Occurs in middle to late stages; poses safety concerns to patients Physical behaviors such as hitting, spitting; Verbal behaviors such as temper outburst Behavioral manifestations become more prevalent as the underlying disease progresses. It is especially important that caregivers be aware of these problems because they can cause significant caregiver burden. These disturbances can take the form of the following: Personality changes tend to begin in the early stages. Families or caregivers may notice the person being more self-centered and passive with a decreased expression of affection. Apathy may also begin early in dementia. Apathy refers to a lackof motivation or behavioral initiation that cannot be attributable to disordered consciousness or emotional distress. It often is misunderstood as the patient s voluntary or willful refusal to cooperate. It is present in 25% of patients with dementia and may be difficult to distinguish from depression. Sleep disturbances are common in the middle stages of Alzheimer s dementia, disrupting the sleep of both the patient and the caregiver. Sleep efficiency becomes poor. In other words, patients spend more time in bed not sleeping. The fatigue associated with sleep deprivation can lead to increased irritability and confusion. Sundowning refers to a predictable increase in confusion and behavioral symptoms in the late afternoon or evening. It occurs in 25% of patients with Alzhemier s dementia, usually beginning in the middle stages. In severely demented people, sundowning can take the form of aggresssive behavior and restlessness. The sudden onset of sundowning may indicate the presence of an occult medical problem, such as an infection. Wandering usually occurs in the middle to late stages of dementia, introducing safety concerns for the patient, including getting lost, wandering into traffic, and falls. Agitation does not represent a specific symptom, rather a group of behaviors that can be either aggressive or nonaggressive. Aggressive behaviors can be physical such as hitting, biting, or spitting. They can also be verbal such as cursing and temper outbursts. Agitated behaviors that are nonaggressive include repetitive questioning, rambling, constant searching, or inappropriate disrobing. These behaviors may occur throughout the course of a dementia. Medical, environmental, and psychiatric causes should be considered, especially if there is sudden onset.
Psychiatric Manifestations Mood Disorders Depression Anxiety Psychotic Symptoms Delusions Hallucinations Persons with dementia may also display psychiatric manifestations, including mood disorders and psychotic symptoms. The most common mood disorder is depression. It may coexist with dementia in more than a third of outpatients and an even greater proportion of nursing home residents. Depression may worsen cognitive function, but often responds to treatment. Anxiety may be related to depression and is more prominent in the earlier phases of the illness. With anxiety, one may see an acute expression of overwhelming anxiety or fearfulness, known as a catastrophic reaction. These usually occur in response to or in anticipation of an adverse experience, such as traveling to a new place. Psychotic symptoms also occur commonly in dementia. Delusions affect 30 to 50% of Alzheimer s patients. They are more common in Alzheimer s than in vascular dementia. They tend to be paranoid in nature and frequently include themes of theft, infidelity, and persecution. Their prevalence increases with the severity of the dementia and delusions are closely associated with aggressive behaviors. Hallucinations occur in about 10 to 15% of demented patients. They tend to be visual in patients with dementia as opposed to auditory in patients with primary psychotic disorders (schizophrenia). Frequent themes include seeing deceased parents or siblings and unknown intruders. In contrast to delusions, hallucinations are not usually associated with aggression.
Resulting Caregiver Burden Caregiver Burden Depression Risk for Dementia Dufferer Physician visits Hospitalization Increased institutionalization Abuse The functional, behavioral, and psychiatric consequences of dementia can result in caregiver burden. Caregiver burden denotes the physical, emotional, and financial stresses in providing care, especially for patients who exhibit delusions and other disruptive behaviors. High burden is associated with increased morbidity and mortality of caregivers, including depression, physician visits, and hospitalization. In addition, burden on the caregiver places the dementia sufferer at risk for increased institutionalization and abuse.
Key Points Early functional decline should alert us to the possible presence of a dementia. Personality and mood changes and serious behavioral disorders can occur. Dementia reduces length and quality of life for patients and caregivers. Key points to remember are that: Signs of early functional decline should alert us to the possible presence of a dementia. Personality and mood changes and serious behavioral disorders can occur throughout the course of dementia. Dementia reduces length and quality of life for patients and caregivers.
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