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Monday, December 1, 2014

Symptoms and Treatment of Dementia

What is dementia?

Dementia is a degenerative disease of the brain that is associated with deficits in cognitive, emotional and social skills and leads to impaired social and occupational functions. Above all, short-term memory, also the mind, language and motor skills, also affected the structure of personality in some forms. Decisive is the loss of acquired skills of thinking, in contrast to innate intellectual deficit. Today, various causes of dementia have been resolved; some forms can be treated to some extent, that is, the symptoms can be delayed at the initial stage of dementia. The most common form of dementia is Alzheimer's disease. Alzheimer's disease usually occurs on only beyond the age of 60. It is among the geriatric psychiatry disorders - rarer forms of dementia can also occur in younger patients.

Forms of dementia

There are numerous forms of dementia, the most common and best known is Alzheimer's disease. The main dementia disorders differ in cause, course and age at onset:

Alzheimer's disease
vascular dementia
Lewy Body Dementia
Korsakoff's syndrome
Parkinson dementia

Dementia definition

The diagnostic criteria for dementia include combinations of deficits in cognitive, emotional and social skills that lead to an impairment of social and professional functions. As a symptom applies the memory disorder. At the beginning of the disease are disturbances of short-term memory and the memory disappear in their further course already impressed contents of long-term memory, so that the persons concerned are losing acquired during their life skills and abilities.

Definition of dementia according to ICD-10
Dementia (ICD-10 code F00-F03) is a syndrome as a result usually of a chronic or progressive disease of the brain disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning, speech, language and judgment in the sense of the ability for decision. Consciousness is not clouded. For the diagnosis of dementia symptoms must have passed at least six months after ICD. The senses (sensory, cognitive) function in the manner customary for the person frame. Usually accompany changes in emotional control, emotional state, social behavior or motivation cognitive impairments; Occasionally these syndromes occur even sooner. They are found in Alzheimer's disease, vascular disease of the brain and other state images, the primarily or secondarily affecting the brain and the neurons.

Definition of dementia in the DSM-IV
The cognitive deficits cause significant impairment in social and occupational functions and represent a clear deterioration from a previous level of performance. They do not occur as part of a rapid onset of consciousness or delirium. For memory impairment at least one of the following disorders has yet to be added:

-Aphasia: language disorder
-Apraxia: impaired ability to carry out motor activities
-Agnosia: inability to identify and recognize objects
-Dysexekutives syndrome: disorder of executive functions, ie, planning, organizing, maintaining a sequence

Risk Factors and Prevention

The main risk factor for dementia is advanced age. The predominance of the female sex among those involved is probably primarily due to the higher a few years life expectancy of women. Depression is considered a risk factor for developing dementia. They occur mainly in the early stages of dementia on frequently and can also precede dementia. Conversely, if insufficient clarification often old people mistakenly assigned the diagnosis of dementia with mental illness, which may show that the Mini-mental state examination again greatly improved.

Other risk factors are beyond cardiovascular factors, such as hypertension, high homocysteine levels, kidney failure, obesity, and diabetes mellitus. A role is played by defects of the vascular system, the impaired insulin metabolism and signaling and glucose transport defect in the mechanism in the brain.

The current medical treatments can influence the course of dementia positive only in a very modest extent. Therefore, the prevention of dementia is of particular importance, whose cornerstone is the limitation of the risk factors. Here now regarded as the most promising strategies primarily the control of cardiovascular risk factors, physical activity (sports), social commitment, control of body weight (diet) and early treatment of depression. Since tobacco smoking is a possible risk factor for dementia, the setting of cigarette smoking also contributes to the prevention of dementia. A recent study confirmed that especially sports and a healthy lifestyle (and therefore also the prevention of cardiac risk factors) can prevent dementia. A healthy lifestyle in addition to regular physical activity are also nicotine abstinence, daily consumption of fruits and vegetables and excessive alcohol consumption. A normal body weight not prevent the waste of cognitive functions according to this study.

A study published in 2012, long-term study suggests a link between dental health and the risk of dementia. Accordingly, the risk of developing dementia, around the 1.85-fold higher when 13 or more teeth are missing and the gaps are not supplied with fixed restorations. Object of research were 4425 Japanese residents who were about 65 years old and were followed over 4 years. 220 of them suffering from dementia.


Important notes on differential diagnosis and selection of imaging examination method provides the medical history, especially with the details of the caregivers are taken into account. The people themselves often do not fall on his memory disorders and / or you can temporarily for appointments in high shape (known phenomenon for doctor visits). On the other hand, it is also possible that he overestimated his memory disorders in a depressive mood. Technical studies such as magnetic resonance imaging or computed tomography of the head or electroencephalography are also used to differentiate between different brain diseases sense.

In order not to overlook any treatable cause, should be at least the following blood tests: complete blood count, vitamin B12 levels, blood glucose, liver function tests, kidney function, electrolytes, thyroid hormones, CRP. Helpful to substantiate a first suspicion and also to check the progression of dementia in addition to the medical history first simple psychometric testing procedures such as the MMSE, the clock drawing test or DemTect. Such simple and quick tests can then be used for follow-up examinations, for example, to check the response to drugs or therapeutic procedures.

Differential diagnosis

Some mental and neurological disorders can be confused with dementia, such as the following.:

-Age-related cognitive decline, or "age forgetfulness"
-Mild cognitive disorder
-Denial and avoidance behavior
-Deprivationserscheinungen or hospitalism with regression, as in nursing homes.
-Psychosis and delusions (eg. As schizophrenia, mania and psychotic depression)
-Simple mutism
-Simple aphasia

-Lack of fluids (dehydration)

Symptoms of dementia

In advance of dementia are often observed mental disorders that often little from those of depression can be distinguished, such as loss of interest and initiative, irritability, feeling of being overwhelmed, loss of affective ability to vibrate.

Cognitive symptoms
Symptom of dementia is the disturbance of memory, especially short-term memory. Forgetfulness is initially something normal. Often the outer facade of the person is well preserved, at least in the early stages, so that the memory impairment may very well be dubbed in the superficial contact. This works particularly well the people who all their lives had many social contacts - the mandatory tone replaced in parts the content of the message (communication).

Later longer lose past memory contents. If the dementia progresses, other disorders of brain function are in addition, such as word-finding problems, computer problems, disorders of spatial perception and feeling very tired, so that those affected often run, especially if the them for decades familiar environment take place structural changes.

In the advanced stage that often leads not even recognize again their immediate families. They are completely apathetic, bedridden and incontinent.

The dementia limits the life expectancy. However, the dementia itself is not a cause of death, but the beneficiary by the dementias.

Motor symptoms
Also motor disturbances are usually used to image an advanced dementia, if it is not a dementia that starts with movement disorders such as Parkinson's disease. Patients are increasingly stiff all over. Your gear is small steps, shuffling and legs apart. They are vulnerable camber, also because there is a disorder of postural reflexes.

Behavioural disorders
The behavior disorders of dementia are BPSD (behavioural and psychological symptoms of dementia) called. Including counting the apathy (76.0%), aberrant motor behaviour (i.e., wandering around, 64.5%), eating disorder (eating of Unessbarem, 63.7%), irritability/instability (63.0%), agitation/aggression (62.8%), insomnia (53.8%), depression/dysphoria (54.3%), anxiety (50.2%), delusion (49.5%), disinhibition (29.5%), hallucinations (27.8%), and euphoria (16.6%). The brackets refers to the prevalence of 12 BPSD in Alzheimer's patients.

Psychotic symptoms may occur in all forms of dementia. Relatively typical they are for Lewy body dementia, dementia form in Parkinson's disease. It is all about visual hallucinations. Typically seen those concerned at first mainly in the twilight of dusk persons not present with which they sometimes even lead discussions. Patients can usually dissociate hallucinations at this stage of its (pseudo-); that is, they know that the people with whom they are talking about are not present. Later they see animals or mythical creatures, patterns on the walls, Staubfussel. Finally, they experience grotesque, often threatening things, such as kidnappings. This scenic hallucinations are very anxious usually colored. Patients are often aggressive when installing the approaching at best intentions relatives and carers in their delusional system. Here the transitions for delirium are fluid.

People with dementia lose their initiative. They neglect their former hobbies, their personal care and cleaning up her apartment. Finally, they are no longer able to feed themselves adequately. You have no drive to eat, hunger and lose eventually forget to chew and swallow the food. They become emaciated and become susceptible to internal diseases such as pneumonia. Shifts in the circadian rhythm can cause considerable nursing problems.

Experience of people with dementia

If you try to empathize with the feelings of people with dementia, communication is easier with them.

For people with dementia, the world looks strange and incomprehensible, because they lose the specific human perception, orientation. You can not put it into a larger context of the objects, situations and people. Due to their memory disorders to access prior knowledge (semantic memory) and experiences them (episodic mnemonic back-extinguishing) refused to navigate to redress the current situation. It lacks the knowledge and security of resources intended overcoming current situations. Often blurs the difference between dream and reality past. There are often hallucinations. In dealing with persons with dementia, it is often not possible to use this to explain the unreality of hallucinations. Ideally, the nurses detect the application behind the hallucinations mood and go on this one.

If the ill person is still able to recognize that he has not responded adequately in a situation which can cause him anxiety and resignation.

Dementia need a lot of time for all actions and reactions. In advanced stages, for example, an adequate diet naturally no longer possible, because people no longer drive because of her severe disturbance able to swallow the food. The patience and the time constraints of the nurses encounter so regularly in the late stage of their limits.

People who are suffering from dementia, often feel misunderstood bossed around or patronized, because they can not grasp the reasoning of them nurses. A surprising number of people with dementia can express their wishes. Some are still able to feel when bored fellow man or are embarrassed by their behavior. In the late stage is increasingly also the ability to emotional contact is lost, which can be very stressful for the family.

Dementia occasionally react very angry if you do them accountable for things they have since forgotten. So that they are equal to twice driven into a corner: once by the fact that they are accused of deliberately making mistakes, and secondly, because they and their weaknesses - not being able to remember - be confronted.

Even people with dementia have feelings. Particularly depression is a common problem, often even before the onset of dementia, often when the person concerned perceive their mental decline. Because the symptoms of depression which of dementia are similar, both diseases can be confused with insufficient knowledge. But the further progresses dementia, the more flattened the world of feeling and gives way to be sad or express emotions in parallel with an increasing loss of interest of an affective indifference with the inability to be happy or not.

Dementia treatment

Drug Therapy
For several years, medications are available against dementia (dementia treatments). First, it is centrally active Cholinergica (cholinesterase inhibitors) such as donepezil, galantamine, rivastigmine or, on the other hand memantine. This preparation was 2009, and 2010, the Institute for Quality and Efficiency in Health Care, however, to conclude that there was no proof of benefit of memantine treatment for Alzheimer's disease. This clinical experience shows that very well benefit some patients on the medication on the one hand, others not at all. Incurable dementia is not currently, but reside in many cases in their course by 1 to 2 years, if it is detected and treated early.

Later shows that treatment with the drugs known brings no improvement. For some time, there is also a therapy with a medicated plaster available. Through constant drug levels, fewer side effects, so that a higher dosage is possible. At the same time the care provided by nurses is facilitated because the application of the patch is often easier than administration of tablets or solutions. The aim is to improve the cognitive abilities and the everyday skills of affected patients.

As controversial apply in their effect garlic and piracetam. Is controversially discussed the efficacy of Ginkgo biloba. The Institute for Quality and Efficiency in Health Care (IQWiG) in 2008 came to the conclusion that patients with Alzheimer's disease by treatment with the standardized extract EGb 761 then benefit when it is taken regularly at a daily dose of 240 milligrams. A US study (GEM study, "Ginkgo Evaluation of Memory") and its sub-analysis showed, however, that the extract compared to placebo during the mean follow-up of six years neither prevent the occurrence of Alzheimer's dementia nor the acceptance of mental could counteract services. However, the authors themselves pointed to some methodological weaknesses of their study.

The "Cochrane Collaboration" in 2008 came nevertheless concluded that ginkgo biloba extracts had no reliable effect against dementia. All sedative drugs that are given, for example, in sleep or shifts of the circadian rhythm, worse cognitive performance. The same applies to antipsychotic drug with anticholinergic side effects that are sometimes unavoidable in hallucinations. Drug treatment of vascular dementia corresponds both to the treatment of chronic vascular disease (atherosclerosis), on the other hand have also in dementia dementia treatments proven to be effective, both acetylcholinesterase inhibitors and memantine.

Non-pharmacological treatment
To a favorable effect on symptoms, to improve the well-being of individuals and / or receive capabilities (resources) as long as possible, various forms of non-pharmacological interventions have been developed:

Memory Training
Memory training differs from Brain that it turns to a diseased audience or is used for prevention, it does not have the character of a sport or a mere pastime. An efficacy could not be demonstrated for the tasks that were practiced, such as the recognition of faces in photos or orientation in the area. The everyday relevance of memory training in the social care of people with dementia is controversial, as there is a risk that those affected are confronted with their deficits and more likely to lead to a deterioration of the overall situation, if you feel the person concerned a failure. Therefore, this method of social care for people with dementia is applied only in the early stages of the disease and adapted to the disease situation.

Biographical work
By Biografiearbeit can learn it, the significance of certain behaviors for the demented patients (What does it mean when Mr M. never in the evening will go to sleep he wants to indicate: "I still miss my nightcap." Or he said: "I miss the bedtime my wife "?). The more thorough the biography as well as the habits and peculiarities of a person are known, the easier it is to understand him. Again, a thorough documentation and close cooperation between all those involved in the care is necessary again. The I-Pass, developed by Sigrid Hofmaier can facilitate the biographical work in everyday life: With classic questions, as we know from friends albums, for example by the Food, taste in music or hobbies can I pass owners hold his likes and dislikes. This can be very helpful when, for example, in the case of dementia can not articulate themselves and rely on outside help. The information from the I-Pass, for example, the nursing staff without contact with relatives quickly get good access to the person concerned.

Existence-thematic accompaniment
Based on the dynamic theory of personality development of psychologists Hans Thomae was investigated by Andreas Kruse in a study of people with dementia extent possible through open and trusting relationships with the expression of personal, developed in the course of life or topics is encouraged.

Specifically refers existence-thematic accompaniment to topics talents and characteristic patterns that have shaped a person in the course of life and remain to the end, even if the specific memories fade on their own biography. Examples of life issues are a semester abroad, foreign language skills and forms of expression.

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