ORGANIC BRAIN DISORDERS (DEMENTIA) By: M.Shakila M.SC(N)-II VMCON KARAIKAL INTRODUCTION Organic mental disorders: Psychological or behavioral abnormalities associated with a dysfunction of the brain. History and physical examination or laboratory tests demonstrate the presence of a specific organic factor judged to be etiologically related to the abnormal mental state and loss of previously acquired functional abilities. DEFINITION Organic mental disorders are behavioral or psychological disorders associated with transient or permanent brain dysfunction and include only those mental and behavioral disorders that are due to demonstrable cerebral disease or disorder either primary or secondary. CLASSIFICATION OF ORGANIC BRAIN DISORDERS F00-F09-ORGANIC INCLUDING SYMPTOMATIC MENTAL DISORDERS F00- DEMENTIA IN ALZHEIMERS DISEASE F01- VASCULAR DEMENTIA F04-ORGANIC AMNESTIC SYNDROME F05- DELIRIUM F06- OTHER MENTAL DISORDERS DUE TO BRAIN DAMAGE AND DYSFUNCTION AND PHYSICAL DISEASE F07- PERSONALITY AND BEHAVIOURAL DISORDERS DUE TO BRAIN DISEASE , DAMAGE AND DYSFUNCTION DEMENTIA DEMENTIA (F00): DEFINITION : Dementia is an acquired global impairment of intellect memory and personality but without impairment of consciousness Alzheimers type dementia is an irreversible disease marked by global ,progressive impairment of cognitive functioning ,memory and personality INCIDENCE OF DEMENTIA : Dementia occurs more commonly in the elderly than in the middle aged. It increases with the age from 0.1%in this below 60 years of age to 15 to 20% in those who are 80 years of age . CNTD…… Suspected that as many as 50% of people over the age of 80 develop Alzheimer’s. 5%-8% of all people over 65 have some form of dementia; number doubles every 5 years beyond that age. Alzheimer’s causes 50%-70% of all dementia. About 20%-30% of all dementia is believed to be caused by a vascular dysfunction (most common is multi-infarct disease). ETIOLOGICAL FACTORS : Significant loss of neurons and volume in brain regions devoted to memory and higher mental functioning . Neuro fibrilliary tangles (twisted nerve cell fibers that are damaged remains of microtubules – support structures that permit nutrients to flow through neurons) Build up of amyloid Accumulation of beta amyloid , an insoluble protein ,which form sticky patches CAUSES OF DEMENTIA : UNTREATABLE CAUSES : 1. Degenerating disorders of CNS 2. Alzheimers disease (a progressive disease that destroys memory and other mental functions ) 3. Picks disease (it’s a type of fronto temporal dementia , a neuro degenerative disease ) 4. Huntingtons disease (an inherited condition in which nerve cells in the brain break down over time ) 5. Parkinsons disease (a disorder of the central nervous system that affects movement , often including tremors) TREATABLE CAUSES : 1. 2. 3. 4. Vascular multi infarct disease Intracranial space occupying lesions Metabolic disorders (hepatic failure ,renal failure ) Endocrine disorders –myxedema ,addisons disease 5. Infections – AIDS ,,meningitis , encephalitis 6. Intoxication – alcohol ,heavy metals (lead arsenic ),chronic barbiturate poisoning heatstroke , epilepsy ,electric 7. Anoxia – anemia ,post anesthesia ,chronic respiratory failure 8. vitamin deficiency ,especially deficiency of thiamine , and nicotine 9. miscellaneous –injury TYPES OF DEMENTIA 1.Cortical – Disorder affecting the cortex, the outer portion or layers of the brain. Alzheimer’s and Creutzfeldt-Jakob are two forms of cortical dementia Memory and language difficulties(Aphasia) most pronounced symptoms. Aphasia is the inability to recall words and understand common language. 2.Subcortical Dysfunction in parts of the brain that are beneath the cortex. Memory loss & language difficulties not present or less severe than cortical. Huntington’s disease and AIDS dementia complex. Changes in their personality and attention span. Thinking slows down. TYPES OF DEMENTIA DUE TO PREDISPOSING FACTORS Dementia of the Alzheimer’s Type: The exact cause of Alzheimer’s disease (AD) is unknown, but several theories have been proposed, 1.such as reduction in brain acetylcholine, 2. the formation of plaques and tangles, 3. serious head trauma, and genetic factors. 4. Pathologic changes in the brain include atrophy, enlarged ventricles, and the presence of numerous neurofibrillary plaques and tangles. ALZHEIMERS CNTD …… Progressive disorder in which neurons deteriorate resulting in the loss of cognitive functions (memory), judgment and reasoning, movement coordination, and pattern recognition. Predominantly affects the cerebral cortex and hippocampus which atrophy as the disease progresses. RISK FACTORS OF ALZHEIMERS DISEASE Family History - a clear inherited pattern exists in approximately 10% of cases Down’s Syndrome - Nearly 100% of people who live into their 40’s Chronic Hypertension - Treatment reduces the risk Head Injuries - Three times more likely to develop AD Gender - inclusive data. Some studies show a greater risk for females while others show an increased risk for male SYMPTOMS OF AD …… Loss of Memory Aphasia Apraxia - (decreased ability to perform physical tasks such as dressing, eating, ADL’s Delusions Easily lost and confused Inability to learn new tasks Loss of judgment and reason Loss of inhibitions and belligerence Social Withdrawal Visual hallucinations EARLY STAGE OF AD …… Begins with forgetfulness Progresses to disorientation and confusion Personality changes Symptoms of depression/manic behaviors INTERVENTION OF EARLY STAGE AD…… Medications - Aricept and Cognex (both are commercial names). Both increase acetylcholine (Ach) in the brain by inhibiting the enzyme that breaks it down. Therapy (deal with depression that often accompanies diagnosis Counseling with family MIDDLE STAGE AD…… Need assistance with ADLs Unable to remember names Loss of short-term recall May display anxious, agitated, delusional, or obsessive behavior May be physically or verbally aggressive INTERVENTIONS OF MIDDLE STAGE AD Validation Therapy Structured Areas for Mobility Positive, nurturing, loving environment LATE STAGE AD …… Loss of verbal articulation Loss of ambulation Bowel and bladder incontinence Extended sleep patterns Unresponsive to most stimuli INTERVENTIONS Caring for physical needs Maintain integrity of the skin Medical interventions Most activities are inaccessible Music Therapy Tape by bedside Gentle singing by therapist ~ one-sided, client will not participate Can provide some connection between patient and family members through singing Use a calm voice Utilize touch: holding hands, hugging, rocking, hand on shoulder, etc Vascular Dementia: This type of dementia is caused by significant cerebrovascular disease. The client suffers the equivalent of small strokes caused by arterial hypertension or cerebral emboli or thrombi, which destroy many areas of the brain. The onset of symptoms is more abrupt than in AD and runs a highly variable course, progressing in steps rather than as a gradual deterioration. Dementia Due to HIV Disease: The immune dysfunction associated with human immunodeficiency virus (HIV) disease can lead to brain infections by other organisms. HIV also appears to cause dementia directly. Dementia Due to Head Trauma: The syndrome of symptoms associated with dementia can be brought on by a traumatic brain injury. Dementia Due to Parkinson’s Disease: Parkinson’s disease s caused by a loss of nerve cells in the substantia nigra of the basal ganglia. The symptoms of dementia associated with Parkinson’s disease closely resemble those of AD. Dementia Due to Huntington’s Disease: This disease is transmitted as a Mendelian dominant gene, and damage occurs in the areas of the basal ganglia and the cerebral cortex. The average duration of the disease is based on age at onset Dementia Due to Pick’s Disease Pathology occurs from atrophy in the frontal and temporal lobes of the brain. Symptoms are strikingly similar to those of AD, and Pick’s disease is often misdiagnosed as AD Substance-Induced Persisting Dementia: This type of dementia is related to the persisting effects of substances such as alcohol, inhalants, sedatives, hypnotics, anxiolytics, other medications, and environmental toxins. The term “persisting” is used to indicate that the dementia persists long after the effects of substance intoxication or substance withdrawal have subsided. STAGES OF DEMENTIA : STAGE I: EARLY STAGE (2 TO 4 YEARS ) Forgetfulness Declining interest in environment Hessistancy Poor in initiating actions 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 Neglects personal hygiene Social isolations STAGE III:FINAL STAGE (UPTO A YEAR ) Marked loss of weight because of inadequate intake of food Unable to communicate Does not recognize family Incontinence of urine and feces Loses the ability to stand and walk Death is usually caused by aspiration pneumonia Symptomatology : The following symptoms have been identified with the syndrome of dementia: 1. Memory impairment (impaired ability to learn new information or to recall previously learned information). 2. Impairment in abstract thinking, judgment, and impulse control. 3. Impairment in language ability, such as difficulty naming objects. In some instances, the individual may not speak at all (aphasia). 4. Personality changes are common 5. Impaired ability to perform motor activities despite intact motor abilities (apraxia). 6. Disorientation. 7. Wandering. 8. Delusions are common (particularly delusions of persecution Personality changes: lackof interest in day-to-day activities ,easy mental fatiguability, self-centered, withdrawn, decreased self-care Memory impairment: recent memory is prominently affected Cognitive impairment: disorientation,poor judgment, difficulty in abstraction, decreased attention span Affective impairment: labile mood,irritableness, depression Behavioral impairment:stereotyped behavior, alteration in sexual drives and activities ,neurotic/psychotic behavior Neurological impairment: aphasia ,apraxia, agnosia, seizures, headache 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, ataxia; accidental fall may occur at night when external stimuli such as light and interpersonal orienting cues are diminished DIAGNOSIS According To Signs And Symptoms Laboratory Data EEG CT Scan MRI Psychological Testing Medical History - Physician wants to determine the onset of symptoms and how they’ve changed over time. Determine risk factors for infection, family history of dementia or other neurological disease, alcohol and drug use, and a patient’s history of strokes Neuropsychological Exam - Evaluates a person’s cognitive ability, e.g. orientation in time and space, memory, language skills, reasoning ability, attention, and social appropriateness. Tests involve asking a person to repeat sentences, name objects, etc. Someone with Alzheimer’s is usually cooperative, attentive, and appropriate but has poor memory. Someone with hydrocephalus is likely to be distracted and less cooperative Brain Imaging/Lab Tests - CT or MRI, cerebrospinal fluid (all used to confirm a diagnosis or eliminate various possibilities) Blood tests - used to diagnosis neurosyphilis. Metabolic tests - determine treatable disorders such as a vitamin B12 deficiency EEG (electroencephalography) is used to diagnose CreutzfeldtJakob disease Medical management Treatment Until now no specific medicine is available to treat Alzheimer's disease. A drug called 'Tacrine 'is being used in western countries. Tacrine (Tetrahydroaminoacridine) is a long-acting inhibitor of acetyl choline and also delays the progression of the illness. The following drugs may be of some use in causing symptomatic relief benzodiazepines for insomnia and anxiety antidepressants for depression antipsychotics to alleviate hallucinations and delusions anticonvulsants to control seizures THERAPIES PHARMACOTHERAPY PSYCHOTHERAPY PSYCHOSOCIAL TREATMENT IMPROVING COGNITIVE ABILITIES REHABILITATION TREATING OTHER PSYCHOLOGICAL SYMPTOMS Nursing Interventions 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. Patients often deteriorate after dark, a phenomenon known as 'sundowning'. Additional care must be taken during the evening and at night. Orient the patient to reality in order to decrease confusion; clock with large orientation to time. Use calendar with large writing and a separate page for each day. Nursing diagnosis Social Isolation related to declining cognition as evidenced by forgetting names or dates Self-Care Deficit related to weakness as evidenced by difficulties in movement Impaired Memory related to central nervous changes secondary to degenerative brain disease as evidence by reported experiences of forgetting and inability to recall recent events Impaired Verbal communication related to cognitive disturbances as evidenced by lack of speech Risk for injury related to movement difficulties THANK YOU
