introduction on dementia essay

A cultural approach to dementia prevention

• An Introduction to Alzheimer’s Disease: What is it?

By: Adrianna Fusco

Introduction: Alzheimer’s disease, something we hear about online, in commercials, on news stations, and in many other parts of life. However, we are never told much about Alzheimer’s disease other than the devastating impacts it has. What is Alzheimer’s disease? What are the symptoms or signs to look out for? How does it progress? What causes it? How can it be prevented?

What is it? Alzheimer’s disease is a form of dementia, which is just an umbrella term used to describe loss of memory, language, problem solving, and other thinking abilities. More specifically, Alzheimer’s diseaseis a progressive, neurodegenerative disease that is categorized by a loss of memory, along with basic life skills like eating, bathing, talking, etc.

Symptoms: Common symptoms include: memory loss, paranoia, depression, anger, aggression, anxiety, apathy, loneliness, and psychosis. These symptoms vary from person to person.

Progress: As mentioned above, Alzheimer’s disease is a progressive disease. This means that it develops and gets worse over time. In the first stages of Alzheimer’s disease, there is usually very mild memory loss or problems with thinking abilities. The person may have a hard time remembering where they placed something or have a hard time recalling the right word to say. However, they still are independent, meaning they can still take care of themselves and do things like driving.

During the middle stages of Alzheimer’s disease, the cognitive processes get worse. Now the person may not be able to remember their personal history, like their address or phone number. They also may have a hard time recalling memories or remembering something from their past. The person is no longer able to take care of themselves because in this stage, they tend to forget where they are and often have a hard time using the bathroom or getting dressed appropriately for the day. An example of this is the person wearing shorts in the winter. Along with the cognitive changes, the person may begin to feel sad, lonely, anxious, and paranoid. The symptoms vary from person to person.

When the person hits stage 2, they will need a caregiver to assist them with their tasks and the caregiving will increase as the disease progresses. However, it’s important to help them without trying to do everything for them. They are still adults and they want to be treated as such, so it’s important to still let them have at least some control over their life. Whether that’s letting them do simply chores, like folding clothes, or doing activities, like arts and crafts. This will help provide a sense of normalcy.

The final stage of Alzheimer’s disease is when people begin to lose sense and control of the environment around them. By this point, the cognitive abilities of the individual have tremendously decreased. They can no longer speak in long formulated sentences, instead they speak in short fragments or words. They have trouble completing everyday tasks like walking, sitting, eating, and drinking. This means that they require around the clock assistance to make sure that they are remembering to eat and to help them eat. In general, the assistance is meant to make sure the person is safe and is living to their best ability. At this point, the individuals are very susceptible to infections. When the symptoms and daily conditions get really bad, usually, families turn to hospice care, so that the patient is comfortable at the end of their life. Hospice care also provides emotional support to loved ones, which is vital. Losing a loved one can cause serious emotional and mental strain, so that support is important.

The cause of Alzheimer’s disease is still being researched, but researchers have identified what they believe to be the main culprits of the disease: plaques and tangles. 

Plaques are deposits of amyloid beta that forms between nerve cells that blocks the signals and stops the right materials from being sent to the nerve for survival. In a healthy brain, amyloid beta is used to help support neural repair and growth. However, in Alzheimer’s disease, there is an overproduction of this amyloid beta protein that disturbs these cells and eventually causes the death of the cells. The death of the old cells causes the loss of old memories and information. The blocking of nerve cells can stop the production of new connections, which means short term memories are not being accurately encoded in the brain to become long term memories. 

Tangles are made up of twisted tau that builds up between cells. In a healthy brain, tau is used to help support neural strength and is important in keeping stability in the cells. However, a build up leads to the cells not being able to receive signals and the supplies it needs to function (i.e. energy). These lead to death of the cells, leading to loss of information and life skills.

There is also a biomarker known as APOE-4, that is thought to predispose people to Alzheimer’s disease. This gene along with some environmental stressors could affect whether someone gets the disease and the progression of it. However, a lot of research is still being conducted on this topic and we are constantly rerouting what we know, as new information is found.

Alzheimer’s disease is a terrible disease that claims the lives of a lot of people every year. It’s important to know the signs and to check up with your doctor when anything seems unusual. Alzheimer’s disease and dementia are not a normal part of aging, so see your doctor if you notice any issues with your memory. The earlier the disease is detected, the better it can be treated.

Stay tuned for more blog posts about Alzheimer’s disease, including a look into the mental health of caregivers, prevention, treatment, and more! We also will be writing posts about interviews with doctors, as well as posts about brain health!

Thank you for reading!

References: 

“Alzheimer’s Caregivers: 8 Tips for People Caring for a Loved One With Alzheimer’s Disease or Dementia: Caregivers.” 30Seconds Health , 

30seconds.com/health/tip/14389/Alzheimers-Caregivers-8-Tips-for-People-Caring-for-a-Loved-One-With -Alzheimers-Disease-or-Dementia. 

Mayeux, Richard, et al. “Treatment of Alzheimer’s Disease: NEJM.” Edited by Alastair J.J. Wood, New England Journal of Medicine , 16 Mar. 2000, www.nejm.org/doi/pdf/10.1056/NEJM199911253412207. 

NHS Choices, NHS, 10 May 2018, 

www.nhs.uk/conditions/alzheimers-disease/causes/#:~:text=Alzheimer’s%20disease%20is%20thought%2 0to,form%20tangles%20within%20brain%20cells. 

Porsteinsson, Anton P., et al. “Neuropsychiatric Symptoms in Dementia: A Cause or Consequence?” American Journal of Psychiatry , American Psychiatric Association Publishing, 30 Apr. 2015, ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2015.15030277#:~:text=The%20term%20neuropsychiatric %20symptoms%20describes%20heterogeneous%20behavioral%20or,agitation%2C%20anxiety%2C%20 apathy%2C%20depression%2C%20psychosis%2C%20and%20sleep%20disturbance. 

“Stages of Alzheimer’s.” Alzheimer’s Disease and Dementia , www.alz.org/alzheimers-dementia/stages. 

“What Is Alzheimer’s?” Alzheimer’s Disease and Dementia , 

www.alz.org/alzheimers-dementia/what-is-alzheimers.

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Dementia: A Very Short Introduction

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Dementia: A Very Short Introduction explains how dementia is diagnosed, its different types and symptoms, and its effects on sufferers and their families. Why is dementia resistant to treatment? Why has the most successful scientific hypothesis not led to a cure? Are there variations between different countries, and given the rise in the ageing population, are there more or fewer cases than we think? This VSI looks at the history of dementia research and examines the genetic, physiological, and environmental risk factors and how individuals might reduce them. It also investigates developments in diagnosis and symptom management, and the economic and political context of dementia care.

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An Introduction to Dementia

An introduction to dementia

We all know that the population is aging and that more and more older people now live with dementia.  If you work in health care there is a good chance you already know a fair amount about dementia.  However, if you are a loved one of someone recently diagnosed with dementia you may be looking for an introduction to dementia.

More and more people now offer support and care for a loved one living with dementia. There is also a growing number of people who interact or meet people living with the condition and want to know a bit more about it. There is a lot of information in the press and online, in fact so much that it can be confusing but here is a basic introduction to dementia.

What is dementia?

Whilst this is a fairly short definition it is quite technical and may still leave some people confused, so let’s unpick it a bit.

There are over 100 different types of dementia that we know about. There is a tendency to group them together when offering support and help. One of the reasons the NHS consider it to be a syndrome rather than separating out to the 100 individual diseases is that there is no accurate way of diagnosing which particular one any given individual may be living with.

Symptoms of dementia

The most widely discussed symptom of dementia is of course memory loss but there are many others. Some people find it harder to communicate, they may experience language problems and it is not uncommon for there to be some changes in personality.

Again, as listed by the NHS, here are the main symptoms of dementia:

• Memory loss
• Difficulty concentrating
• Finding it hard to carry out familiar daily tasks, such as getting confused over the correct change when shopping
• Struggling to follow a conversation or find the right word
• Confusion about time and place
• Mood changes

Initially these symptoms are often quite mild and as such family and friends may not take it that seriously or even notice. But, in most cases this will get worse and have an ever greater impact on the individual and those around them.

Sometimes a doctor will diagnose someone with ‘mild cognitive impairment’ (MCI) rather dementia at an early stage of dementia.

Dementia is a progressive condition

There is no cure for dementia but there are a number of treatments that can slow the progress and therefore slow its impact. These treatments include:

• Drugs and medicines including Acetylcholinesterase inhibitors and Memantine
• Cognitive stimulation therapy (CST) including group activities and exercises designed to improve memory, problem-solving skills and language ability
• Cognitive rehabilitation
• Reminiscence and life story work

What dementia is not

Dementia is not a normal part of ageing.

Dementia is not the occasional lapse in memory or a bit of forgetfulness; it is more severe than that.

Dementia is not just a condition that affects older people, although it is more common in older people. It also affects some younger people, although it is quite rare. When someone under 65 is diagnosed with a form of dementia, it is called ‘early onset dementia’.

Many people think Alzheimer’s disease and dementia are the same thing – they are not. Alzheimer’s is a type of dementia and the most common one. However, it is not the only one. Dementia is not a mental illness. Dementia is caused by damage to the brain from a disease. It is a physical condition not a mental one.

Worried that you or someone you love may have dementia?

If someone you know is demonstrating the above symptoms then you should encourage them to see their GP. There is a much greater chance of slowing the progress of dementia if it is diagnosed earlier.

But also, sometimes people can experience memory loss for a range of other completely treatable reasons. Either way, contacting your GP is the most sensible course of action as soon as you become worried.

This article is only an introduction to dementia, there is a great deal more to learn.  If you want to learn more then feel free to contact your closest Greensleeves Care home where the manager will be happy to help.

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• Ulster Med J
• v.84(2); 2015 May

EL Cunningham

1 Centre for Public Health, Queen's University Belfast

B McGuinness

2 Belfast Health and Social Care Trust

AP Passmore

Dementia is a clinical diagnosis requiring new functional dependence on the basis of progressive cognitive decline. It is estimated that 1.3% of the entire UK population, or 7.1% of those aged 65 or over, have dementia. Applying these to 2013 population estimates gives an estimated number of 19,765 people living with dementia in Northern Ireland. The clinical syndrome of dementia can be due to a variety of underlying pathophysiological processes. The most common of these is Alzheimer's disease (50-75%) followed by vascular dementia (20%), dementia with Lewy bodies (5%) and frontotemporal lobar dementia (5%). The clinical symptoms and pathophysiological processes of these diseases overlap significantly. Biomarkers to aid diagnosis and prognosis are emerging. Acetylcholinesterase inhibitors and memantine are the only medications currently licensed for the treatment of dementia. The nature of symptoms mean people with dementia are more dependent and vulnerable, both socially and in terms of physical and mental health, presenting evolving challenges to society and to our healthcare systems.

INTRODUCTION

Dementia is a clinical diagnosis requiring new functional dependence on the basis of progressive cognitive decline and representing, as its Latin origins suggest, a departure from previous mental functioning.

The incidence of dementia rises with age making it an increasingly common phenomenon within our aging population. The nature of symptoms mean people with dementia are more dependent and vulnerable, both socially and in terms of physical and mental health, presenting evolving challenges to society and to our healthcare systems. Despite the seemingly simple premise, the clinical diagnosis of dementia can be difficult with de novo functional impairment often obscured by physical frailty, comorbid psychiatric symptoms such as depression and a subtle but steady assuming of household responsibilities by spouses and family. Clinical and pathological criteria for the main dementia-causing diseases overlap significantly. The emergence of symptoms decades into the pathophysiological process hamper targeted disease therapy. A great number of research initiatives are underway to identify potential biomarkers of disease processes earlier. The association of both overt cognitive decline and underlying pathophysiological processes with normal aging complicate the process of identifying disease processes early within the spectrum of normal aging.

Once the diagnosis is established, prognostic measures are required, and are still lacking, as disease trajectories between individuals can vary greatly. Globally, governments are recognising these challenges. Investment and research infrastructure are beginning to reflect the scale of the need. Drugs conferring symptomatic benefit are available and memory service structures exist to diagnose dementias and guide management. The personal impact of dementia on patients and families is also being increasingly recognised, with discussion in the media surrounding famous sufferers and dramatisations in literature and film. Herein we attempt to describe the current landscape of dementia.

EPIDEMIOLOGY AND SOCIO-ECONOMIC IMPLICATIONS

Dementia is often arbitrarily considered early (< 65yrs) or late-onset (> 65yrs), with the vast majority (>97%) of cases being of late-onset 1 . Table 1 shows the most recent age-related prevalence estimates for dementia in the UK, which equate to 1.3% of the entire UK population or 7.1% of those aged 65 or over 2 . Applying these to 2013 population estimates gives an estimated number of 19,765 people living with dementia in Northern Ireland 2 . This compares to the 12,811 people registered with the Quality and Outcomes Framework for Northern Ireland (NI) with a diagnosis of dementia in 2013-2014 ( http://www.dhsspsni.gov.uk/index/statistics/qof/qof-achievement/qof-lcg-13-14.htm ).

Gender specific age-related prevalence (%) of dementia in the UK (estimates from Dementia UK 2014)

The age-related incidence of dementia in the UK is falling, presumably as a result of better public health measures 3 , meaning the increasing absolute numbers of people with dementia are based on the shifting population demographic, the aging population. Global estimates of a doubling in the dementia population every 20 years giving an estimated 115 million people with dementia by 2050 were revised further upwards in 2013, to take account of the likely further increases in lower and middle income countries 4 .

Prognosis at the time of dementia diagnosis varies, with evidence that age at diagnosis, gender, comorbidities and disease severity can all affect life expectancy 5 . Whilst methodological variations limit the usefulness of the data available, median life expectancy from the time of diagnosis has been shown to range from 3.2 to 6.6 years, and from 3.3 to 11.7 years from dementia onset 5. Local research has suggested a median survival of 5.9 years from diagnosis (unpublished data).

Transition into residential care as a result of the functional impairments of dementia is a prospect that worries many patients and a reality that many families face. It was estimated last year that 69% of all those living in residential care within the UK suffer from dementia 2 .

It is perhaps no surprise then that dementia is expensive. The updated estimated cost to the UK economy of £26.3 billion per year published last year 2 took account of the role played by unpaid carers (£11.6 billion), social care costs were estimated at £10.3 billion and healthcare costs at £4.3 billion in comparison.

CLINICAL DIAGNOSIS

The clinical syndrome of dementia, characterised by new functional dependence on the basis of progressive cognitive decline, can be due to a variety of underlying pathophysiological processes. The most common of these is Alzheimer's disease (AD; 50-75%) followed by vascular dementia (VaD; 20%), dementia with Lewy bodies (DLB; 5%) and frontotemporal lobar dementia (FTLD; 5%) ( Figure 1 ). The significant clinical and pathological overlap between these processes mean their relative frequencies are estimates at best 1 , 6 . Less common causes (3%) include Huntingdon's disease, Creutzfeldt-Jakob disease, HIV/AIDS and multiple sclerosis. We will first consider the clinical and then the pathological properties of these diseases.

Pie chart showing estimated frequencies of dementiacausing disease processes

Cognitive impairments central to the diagnosis of dementia can be categorised into five main domains: memory; executive function; language; visuospatial abilities; personality and behaviour. As dementia, of any cause, progresses, cognitive impairments will broaden, involving more domains, and deepen, causing increased functional impairment. It can thus be difficult to distinguish dementias of different aetiologies in the later stages. In the early stages however the pattern of prominent symptoms can help identify the most likely underlying disease process. Clinical criteria exist for all the main dementia sub-types, the main features of which are outlined in Table 2 7 – 11 . All criteria require a diagnosis of dementia and include the caveats that there should not be a symptom pattern more in keeping with another of the dementias and that cognitive impairments should not be better explained by a psychiatric illness. Neuropsychiatric symptoms should be sought. Depression can be a cause or effect of cognitive impairments and often features such as hallucinations and delusions will not be volunteered unless specific enquiries are made.

Clinical diagnostic criteria for dementias

AD, the most common cause of dementia, typically presents with short-term memory deficits, manifesting for example as repetitive questioning. Impairment in at least one other cognitive domain is required for a diagnosis of probable dementia due to AD (ADD). Atypical presentations of ADD include behavioural or language deficits suggesting frontal variants or prominent early visuospatial problems suggesting posterior cortical atrophy. The most relevant feature of a presentation of VaD is the temporal association of cognitive deficits with stroke and evidence of cerebrovascular disease on examination and imaging. The Lewy body diseases comprise DLB and Parkinson's disease (PD). Patients with DLB may go on to develop Parkinsonism. As a rule of thumb, if the emergence of dementia and physical PD symptoms are within one year the diagnosis is PD dementia (PDD), if cognitive symptoms predate physical symptoms and signs by more than one year the diagnosis is considered to be DLB. Early language or behavioural symptoms raise the prospect of FTLD. In the younger age groups, ie less than 65, the incidence of FTLD and ADD are almost equal, in contrast to the vastly lower incidence of FTLD in older age groups. The early symptoms of behavioural variant FTLD often raise the possibility of primary functional psychiatric diagnosis, complicating diagnosis.

It is relatively common to be presented with clinical scenarios that do not wholly and exclusively fulfil a single diagnostic criteria. Reflecting the concurrent accumulation of pathophysiological processes within the brain, symptoms can represent overlapping disease processes and mixed pictures can be said to occur, this is most commonly the case with ADD and VaD.

Many people present with objective cognitive symptoms that fall short of the requirements for a diagnosis of dementia. Criteria exist then for the diagnosis of mild cognitive impairment (MCI) 12 , 13 . Creation of this diagnostic category has facilitated focused follow up demonstrating that 5-10% per year of those with MCI will progress to fulfill the diagnostic requirements of a dementia 14 . Such symptoms can also be due to psychiatric illness, drugs known to be deleterious to cognition or may be transient and regress spontaneously. As the use of biomarkers, outlined below, evolves, identification of those more likely to be in the prodromal stages of a dementia is improving, with some arguing that patients should be identified at the MCI stage as either prodromal dementia or not 15 . For now the diagnostic bracket of MCI, whilst disputed, remains.

Other diagnostic criteria exist. In addition to the criteria set out by McKhann et al in 2011 7 an International Working Group has proposed diagnostic criteria for ADD intended for use primarily in research 15 . The older Hachinski 16 and NINDS-AIREN 17 scales are still used to define VaD. The 5 th edition of the Diagnostic and Statistical Manual of Mental Disorders published in 2013 by the American Psychiatric Association 18 has introduced the terms major and mild neurocognitive disorders, which equate to dementia and MCI. Their criteria for the various subtypes equate broadly with the pre-existing clinical criteria.

Diagnosis and differentiation of dementias requires careful history taking and examination. Both patient and collateral histories are needed to establish a new functional dependence and to explore the progressive cognitive impairments as well as neuropsychiatric symptoms. Physical examination is required to examine for focal neurological or extrapyramidal signs. Cognition will be assessed informally during the course of the consultation but formal testing is required, and facilitates longitudinal monitoring. A suggested framework for assessment of patients presenting with cognitive complaints is outlined in Table 3 .

Suggested foci of assessment of patients with cognitive symptoms

Probably the most widely recognised formal cognitive test is the Mini Mental State Examination (MMSE), first proposed in 1975 19 . Whilst assertions of copyright have impacted on its use in recent years the MMSE has become well and widely established, and provides a common language for those fluent in its use. The Montreal Cognitive Assessment, originally developed as a test for MCI, and also marked out of 30, has expanded into the space created by MMSE apprehension ( www.mocatest.org ). The Addenbrooke's Cognitive Examination-III (ACE-III) provides a more thorough assessment and marks are calculated for each domain, then tallied to give a total, out of 100 ( http://www.neura.edu.au/frontier/research/test-downloads/ ). A growing variety of scales exist, none of which is perfect. Inter and intra-rater reliability can limit use and all scales are reliant on premorbid educational abilities. The important thing is to become familiar with a scale, ensure its consistent use within a service, and use it to monitor progression.

PATHOPHYSIOLOGY/PATHOLOGICAL FEATURES

The disease processes underlying dementia are yet to be fully understood. With the (probable) exception of VaD, all involve a pathological accumulation of a native protein: in the case of AD it is the extracellular plaques of amyloid and the intracellular tangles of hyperphosphorylated tau; in DLB it is alpha-synuclein in the form of Lewy bodes; in FTLD several culprits have been identified including TDP-43 and the hallmark proteins of AD and DLB in a frontotemporal distribution. Examples of these lesions can be seen in Figures 2 – 5 . It is important to remember that evidence of these processes is also found post-mortem in people who did not exhibit cognitive impairments prior to death, and that these patterns are not mutually exclusive, existing concurrently as they often do 20 .

An immunohistochemical section taken through the cortex in a case of ADD. An antibody to Beta A4 amyloid is applied to the tissue and detects this antigen which in turn stains the antigen brown. This shows a dense deposition of amyloid throughout the cortex as dense core (DC) and diffuse (D) plaques.

A section from the hippocampal dentate fascia showing dot like deposition of ubiquitin. This is characteristic of Frontotemporal Lobar Dementia with Ubiquitinised inclusions (now called TDP).

Neuronal tangles stained with an antibody to Tau (T)

A pigmented neuron from the substantia nigra. A single Lewy Body is present. This patient also had diffuse cortical Lewy bodies characteristic of Pure Lewy Body Dementia

These pathological accumulations are associated with synapse and neuronal loss and atrophy which also demonstrate patterns in terms of distribution. Hippocampal atrophy within the medial temporal lobe for instance is associated with AD, in keeping with the early amnestic symptoms 21

Genetic studies have contributed greatly to our knowledge of these disease processes. The observation that people with Down's syndrome (trisomy 21) almost invariably develop AD, led to the discovery of the first of three autosomal dominant genes associated with early-onset ADD 22 . Study of these genes, responsible for amyloid cleavage, have been integral to the understanding of pathological amyloid production. In contrast to the aberrant production of amyloid proteins implicated in early onset ADD, late-onset ADD (LOAD) is thought to be more to do with faulty clearance of amyloid from the brain. Apolipoprotein E 23 and, more recently, TREM-2 24 , 25 alleles have been identified as risk factors for LOAD. Their pathophysiological roles remain unclear: they are implicated in amyloid processing and neuroinflammation amongst other pathways. Neither are sufficient or requisite for LOAD and are therefore not tested for in routine clinical practice. Genome wide association studies in recent years have consistently identified several genes with significant but modest associations with LOAD 26 and examination of their relevant pathways, including immune response and inflammation, cell migration and lipid transport, have enhanced the evolving understanding of the ADD disease process.

These methods are being applied across the dementia spectrum and similar pathways are implicated in DLB, FTLD and VaD 27 , 28 . FTLD in particular has myriad of increasingly recognized heritable components.

Animal models, often based on these predisposing genetic mutations, continue to provide basic science research opportunities. Improving chemistry techniques, such as proteomics and metabolomics are also being used to study the disease using human-derived samples such as blood and cerebrospinal fluids.

The search for biomarkers further informs our understanding of these disease processes and offers the opportunity to identify them prior to symptom emergence. A biomarker has been defined as a ‘characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention 29 . Research into ADD is currently the main focus and biomarkers are generally considered as representing the underlying AD process (evidence of amyloid and tau accumulation) or neurodegeneration (markers of synapse/neuronal loss or atrophy) 7 , 15 .

Low amyloid beta and high tau in cerebrospinal fluid (CSF) and high levels of intracerebral amyloid as measured by positron emission tomography (PET) scanning predict the subsequent development of ADD 30 . The downstream markers of neurodegeneration - hippocampal atrophy on MRI and decreased uptake of a radiolabelled glucose tracer (18-fluorodeoxyglucose, FDG) as measured using PET scanning (FDG-PET) have also been shown to increase diagnostic accuracy when used to supplement clinical measures 30 .

The occurrence of these pathophysiological processes in cognitively normal people, especially with increasing age, complicates the interpretation of these biomarkers. Several studies of cognitively normal patients are ongoing and a recently published cross sectional study of 985 participants showed that over the age of 85 more people had biomarker changes in keeping with ADD than did not 31 . There are significant variations in neuroimaging techniques across centres and also in the sampling, handling and analysis of CSF 21 , 32 , 33 . Worldwide research collaborations, such as the Alzheimer's Disease Neuroimaging Initiative (ADNI), are in place to try and accelerate our understanding of the pathophysiological processes underlying dementia, and hence the interpretation of biomarker findings, in both cognitively normal and impaired participants. Global standardisation initiatives are also ongoing with regard to MRI and PET imaging and CSF amyloid and tau. Biomarkers are beginning to be used in clinical practice 34 but the likelihood, and benefit, of more widespread adoption is dependent on these issues being resolved.

INVESTIGATION

Initial investigation of patients presenting with cognitive impairment centres on the exclusion of reversible causes of cognitive impairment. The National Institute of Clinical Excellence (NICE) recommends blood tests (full blood picture, urea and electrolytes, calcium, glucose, liver function tests, thyroid function tests and vitamin B12 and folate) and structural brain imaging (preferably MRI but CT will suffice) 35 . In addition to ruling out tumours, subdural haematomas, stroke and normal pressure hydrocephalus, CT, and to a greater extent MRI, can also provide information regarding chronic ischaemia, infarcts and focal atrophy. Functional imaging, such as single-photon emission computed tomography (SPECT) and FDG-PET are recommended to help differentiate between the dementia sub-types where appropriate. Figure 6 & 7 show normal compared to reduced uptake in keeping with ADD on FDG-PET. Dopamine transporter (DAT) scanning has shown high sensitivity and specificity for DLB and is the investigation of choice when trying to differentiate between DLB and other dementias 36 .

Figures 6 and ​ and7 7 show normal and reduced uptake on FDG-PET scanning respectively. The decreased uptake in the temporoparietal and precuneus (arrow) regions, typical of ADD, can be seen.

RISK FACTORS

In tandem with the laboratory science methods outlined above, observational studies have informed our understanding of the risk factors for dementia, as well as the natural history and prognosis of the diseases. Age is the main risk factor for dementia. Established modifiable risk factors for dementia include: depression, diabetes, (midlife) hypertension, (midlife) obesity, smoking, alcohol abuse, high cholesterol, coronary heart disease, renal dysfunction, low unsaturated fat intake and inflammation 37 . It has been argued that the decrease in age-related dementia incidence seen in the UK is due to better public health measures and thus amelioration of these factors 3 . There is in addition increased focus on recognised protective factors such as: cognitive activity, physical activity, healthy dietary pattern and low/moderate alcohol intake 37 .

MANAGEMENT – NON-PHARMACOLOGICAL

Management will be guided by the nature and severity of the symptoms and any safety concerns. Vascular risk factors should be addressed. Patients and relatives should be offered information and explanations. The Public Health Agency ( www.publichealth.hscni.net ) have developed a booklet ‘Communicating effectively with a person living with dementia’ available via their website. The Alzheimer's Society have local offices and provide information and support ( www.alzheimers.org.uk ). Patients and carers should be referred to a social worker if a carer's assessment is felt appropriate and to facilitate access to services such as Day Centres and social services care provision. As a result of the NI Dementia Strategy a navigation service for all those diagnosed with dementia is being established in all Trusts; this will ensure patients and carers have a consistent contact point throughout their journey. Moderate physical exercise should be encouraged where possible. No formal cognitive training services are currently being offered consistently though supportive evidence is emerging and may translate into service provision. Where appropriate patients can be referred to community mental health teams. Transition into residential care is influenced by social circumstances, dementia severity and the behavioural and psychological symptoms of dementia (BPSD) eg aggression. Non-pharmacological measures are recommended as first line therapy for BPSD but there is as yet no consensus regarding the most effective measures. All patients should be advised to inform the Driver & Vehicle Agency and their insurer of a diagnosis of dementia. If there are concerns regarding a patient's ability to drive they should be advised to stop driving. Where patients lack capacity to manage their own affairs and assets a referral to the Office of Care and Protection ( www.courtsni.govuk/en-GB/Services/OCP/ ) may be warranted. A draft Mental Capacity Bill (NI) (working title) is due to be introduced to the NI Assembly this year having already been consulted upon. It is likely this will have significant impact on how healthcare decisions are made for people who lack capacity.

People with dementia are frequently admitted acutely to hospital, most commonly following a fall, and it is estimated that up to one quarter of in patients in UK hospitals, at any one time, have dementia 38 . This is important as caring for patients with dementia requires modification of communication, diagnostic and, at times, management approaches. Patients may have difficulties articulating symptoms. Constipation and acute urinary retention for example should be actively sought out. Disorientation and agitation may develop and both environmental (eg clear signage and clocks) and attitudinal (eg repeated reassurance, clear explanations, good lighting, involvement of families) approaches can ameliorate this. Dysphagia is a common occurrence as dementia progresses and patients may require dietary modification and assistance at meal times. Dyspraxia can hinder personal care, with considerate assistance required. Patients with dementia are more likely to develop delirium which can further complicate care needs 39 . Rehabilitation attempts can be hampered by cognitive impairments but dementia should not be a contraindication to rehabilitation as evidence for benefit exists. Discharge planning is required, often with inclusion of families. More than one third of patients with dementia admitted to hospital from their own homes will be discharged to an institutional setting 38 . A scheme has been introduced to increase the understanding, and identification, of dementia within hospital settings ( http://butterflyscheme.org.uk ).

MANAGEMENT – PHARMACOLOGICAL

Offending medications, in particular those with anticholinergic properties should be reconsidered and stopped where possible. It is important to note that even over the counter medications can affect cognition 40 . An association with benzodiazepines has been suggested by observational work and these too should be reconsidered 41 .

Acetylcholinesterase inhibitors and memantine, an NMDA receptor antagonist, ( Table 4 ) are the only medications currently licensed for the treatment of dementia. All three acetylcholinesterase inhibitors (AChEi) have a license and are recommended by NICE for the treatment of ADD with rivastigmine additionally approved for the treatment of PDD 42 , 43 . Memantine is approved for the treatment of moderate ADD where AChEi are contraindicated or not tolerated and as an adjunct to AChEi therapy in severe disease 43 . Evidence exists to suggest a moderate improvement in cognitive function with these drugs 44 , 45 . These drugs are not licensed for use in VaD. In clinical practice it can be difficult to distinguish whether there is an ADD component and these medications are often offered as a therapeutic trial. There is no evidence to support the use of AChEi or memantine in FTLD; 46 , 47 AChEi usually make symptoms of FTLD worse as the underlying pathological process is different to that of ADD.

Acetylcholinesterase inhibitors and memantine

Mild, moderate and severe disease severity categories are often used but are arbitrary by nature. As a rule of thumb NICE considers corresponding cut-offs by MMSE of 21-26, 10-20 and less than 10 35 but in practice this is only a single facet of the assessment outlined in Table 3 .

AChEi therapy exerts its benefit by raising pathologically low levels of the neurotransmitter acetylcholine. Potential adverse events include risk of bradycardia and syncope, potential worsening of obstructive airways disease and gastrointestinal disturbance. Assessment should therefore include an ECG and chest auscultation, with severe sinus bradycardia or evidence of a significant cardiac conduction defect or significant audible wheeze all contraindications to AChEi therapy. The possibility of reduction in the dose of beta-blocker or ratelimiting calcium channel blocker could be considered prior to initiation of an AChEi. An anti-emetic, usually domperidone, can be prescribed on an as required basis for the first few weeks to alleviate nausea. The British National Formulary recommends nocte administration of donepezil but it is acceptable to take it in the morning. The decision to continue or terminate drug therapy, in the setting of inevitable cognitive decline, can be difficult. The DOMINO-AD 48 study showed that continuation of donepezil therapy, even in severe disease, was associated with significant cognitive benefit.

Souvenaid is a food for special medical purposes with evidence for improved memory function in early ADD 49 . It is not available on prescription and requires a recommendation from a healthcare professional.

BPSD is an umbrella term for a variety of symptoms including apathy, agitation, disinhibition and sleep disturbance. These can be particularly distressing for carers and often precipitate admission to institutional care. Atypical antipsychotics are sometimes employed to combat BPSD but are associated with significant side effects including an increase in mortality and so should be carefully considered 50 . Only risperidone has a license for the treatment of BPSD and short-term treatment (<6 weeks) is recommended 42 . Depression is a common symptom (see the upcoming review in this Journal regarding diagnosis and treatment of depression).

Many pharmacological avenues are being explored in an effort to find new effective, safe drugs for dementia. Efforts are hampered by the as yet incomplete understanding of the pathophysiological processes being targeted. Drugs targeting amyloid production and amyloid plaque clearance have failed on safety and efficacy grounds. Anti-tau agents are currently being studied. Apart from Souvenaid the much vaunted dietary supplements have yet to be supported by consistent evidence. Safety concerns are being addressed, and emerging pathophysiological insights exploited, by attempts to reposition existing drugs within the dementia field, for example metformin 51 .

Significant advances have been made in our understanding of dementia in recent decades. Dementia presents laboratory, clinical, societal and economic challenges. Diagnosis remains clinical, supplemented by improving biomarkers. Dementia causing diseases overlap in their pathophysiology and phenotypes. The only licensed drugs to date provide symptomatic benefit. Disease-modifying drug development is reliant on early identification of disease processes prior to symptom emergence, where it is currently felt best therapeutic window exists. Both biomarker and drug development depend on better understanding of underlying pathophysiological processes. The wide-reaching benefits of improved public health measures have yielded a decrease in age-related incidence but the ongoing demographic shift means efforts on all fronts must be redoubled if we are to diagnose, treat, understand and care for those of us who develop dementia. The importance of dementia as a global priority is recognised in the declarations of the G8 Dementia Summit in 2013, committing the G8 nations to the improvement in the quality of life for people with dementia and their carers and identification of disease-modifying therapies by way of a co-ordinated and funded international research framework.

ACKNOWLEDGEMENTS

Dr William Murphy, Consultant Radiologist, provided the FDGPETCT images. Drs Shane Gallagher and Brenda Campbell, General Practitioners, reviewed the article and provided advice. Patients and relatives have donated tissue over the years to further the study and understanding of dementia.

CONFLICTS OF INTEREST

ELC has received a contribution towards conference fees from Lundbeck

BMcG has received honoraria and assistance with travel from Nutricia

BH has nothing to declare

APP has received honoraria and assistance with travel from Pfizer/Eisai, Shire, J&J, Novartis, Lundbeck and Nutricia

Introduction to Dementia

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Search the Greater Manchester Mental Health NHS FT website

Memory problems.

Memory problems are common, however, they can be an early sign of a medical condition such as dementia.

Many people notice that their memory becomes less reliable as they get older, and tiredness, stress, anxiety, depression, some physical illnesses and the side effects of medications may also be factors.

You should seek help if your memory is not as good as it used to be, especially if:

• You struggle to remember recent events, although you can easily recall things that happened in the past
• You forget the names of friends or everyday objects
• You lose the thread of what you are saying
• You feel confused even when you are in a familiar environment.

Are you starting to feel anxious or depressed about your memory loss, or are other people starting to comment on it?

If you are worried about your memory, go and see your family doctor, who will address your concerns and may arrange for further investigation.

What is dementia?

Dementia is not a single illness but a group of symptoms caused by damage to the brain. The symptoms include loss of memory, mood changes and confusion.

Dementia is caused by a number of diseases of the brain. The main types of dementia are:

Alzheimer’s disease : small clumps of protein, known as plaques, begin to develop around brain cells. This disrupts the normal workings of the brain.

Vascular dementia : problems with blood circulation result in parts of the brain not receiving enough blood and oxygen.

Dementia with Lewy bodies : abnormal structures, known as Lewy bodies, develop inside the brain.

Fronto-temporal dementia : the frontal and temporal lobes of the brain begin to shrink. Unlike other types of dementia, fronto-temporal dementia develops most often in people under the age of 65.

Some people have mixed dementia – more than one of the four types.

It is important that these conditions are identified as early as possible, yet less than half of people who have dementia have been diagnosed.

Dementia mainly affects people who are older, and the numbers of people with dementia is forecast to grow as people live longer, but younger people can sometimes have dementia - this is referred to as early onset dementia.

Who can get dementia?

Anyone can develop dementia – it is not restricted to sex, age, gender, ethnicity or background.

However, some groups are statistically more likely to develop it. For example, women are more likely to develop it than men.

People with learning disabilities may carry a higher genetic risk of developing it. Also, people from black and minority ethnic populations have higher rates of early onset dementia than other groups.

How common is dementia?

In England, 800,000 people currently live with dementia. The older the age, the more common it is.

Around one-in-14 people aged 65 or over has a form of dementia, and one-in-six people aged 80 or over.

So the great majority of people with dementia are morethan 75 years old, but it does occur among younger people.

What affects the development of dementia?

Anyone can develop dementia, but some factors appear to ontribute to whether we develop the disease:

Age : you are more likely to develop dementia when you get older, especially if you have high blood pressure or have a higher risk of other genetic diseases such as heart attacks and strokes.

Genetics : genetics are known to play play some role in the development of dementia, but the specific effects vary considerably.

Medical history : having current conditions or having experienced certain conditions in the past may make us more likely to develop dementia – such as multiple sclerosis, Down’s syndrome, diabetes, HIV and metabolic syndrome.

General lifestyle : a poor diet, a lack of exercise and excessive alcohol or drug consumption can all increase the chances of developing the disease.

People with Parkinson’s disease have a higher-than-average risk of developing dementia, although most people are unaffected.

Further information

The Alzheimer’s Society national dementia helpline has trained advisers ready to discuss your concerns from 9am to 5pm from Monday to Friday and 10am to 4pm at the weekend.

T: 0800 222 11 22

The Open Dementia e-learning programme is for anyone who comes into contact with someone with dementia and provides an introduction to the disease and living with dementia.

There are Alzheimer’s Society factsheets on a wide range of topics related to information about dementia.

As a service user, relative or carer using our services, sometimes you may need to turn to someone for help, advice, and support. 

Find resources for carers and service users    Contact the Trust

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Dementia – 2000 words essay

Introduction

This essay will aim to provide a comprehensive overview of the mental health problems and needs that are characteristic of older people with dementia who live alone in the United Kingdom. Accordingly, in addition to clinical management, the social and legislative aspects of the same have been taken into account.

The mental health of the elderly living alone and uncared for became a primary concern almost a decade ago when the “Forget me not” 2000 report was published by the UK government to highlight the dire state of circumstances pointing to neglect in terms of mental health provision of older people (Burns et al, 2005). A 2002 Audit Commission update commissioned by the UK government followed this and it was duly pointed out that the provision of welfare for old mental health patients did not spell equity of access for these people in terms of mental health across the United Kingdom (Nice, 2006,2009).

It has been a general complaint particularly in welfare based economies such as that of the UK, that government provisions do not always seem to be adequate in addressing the needs of old people with mental health problems, particularly dementia, especially in more remote, less economically stable areas of the country (Burns et al, 2005). This is mainly due to inadequate training of the medical staff and the unavailability of social services and multiagency frameworks to support the caring and social needs of old people suffering from dementia (Chew et al, 2008). Even though things have since  improved in the United Kingdom based on the efforts of governmental and non governmental organisations, a number of gaps still remain with the provision of specialist mental health interdisciplinary teams for senior citizens and day care services at old homes (Nice, 2009).

Needs of the Elderly Dementia Patients in General

Basically, the experience of dealing with senior citizens living alone and coping with dementia has shown that there needs to be a better collaboration between the social and medical sectors caring for the elderly in a more multiagency context (Lindesay et al, 2002). This would mean establishment of more primary care trusts for mentally ill old people with better mechanisms for testing clinical governance and better care management procedures and integrated planning arrangements (HL Paper 156). The urgency of the matter was sensed more than ever a few years ago when it was estimated in the year 2007 when the Alzheimer’s society website [1] estimated (using extrapolation) that the by the year 2010 the number of people in United Kingdom with dementia would rise to 840,000 and by 2050 this figure would rise over 1.5 million [2] .

Dementia in the UK: Problems and symptoms

Specifically analysing the major mental health problems and needs of dementia patients living in seclusion in the UK, the author has come to the following conclusions based on the relevant literature. Dementia itself is a result of mental disorders like Alzheimer’s disease or vascular dementia where as the brain tissue will experience shrinkage and there will be an overall reduction in the brain fibres (Burns et al, 2005). The primary cause remains nonetheless Alzheimer, which is basically an ulterior alteration in the brain chemical function to cause long-term memory loss in the patient causing dementia (Hodges, 2007). Very rarely the patient will be suffering from dementia based upon Lewy Bodies (DLB) which is an incidence of protein deposits with in the brain and can badly affect the cognitive functioning of the brain by blocking oxygen and blood for the same. When this happens dementia will occur as the thinking and reasoning ability of the patient will decline (Jacoby et al, 2008).

By nature this disorder is primarily a mental illness affecting senior citizens and is characterised by a slow cerebral deterioration in the patient to the extent that they suffer memory loss and experience problems in performing day-to-day functions. The disorder can hit other vital and cognitive senses in terms of perception, judgment, calculation and attention spans of the patients.

The first thing a person facing dementia-like conditions has to realize is that this is not a reversible disorder and while avoiding alcohol abuse, stress and drugs might slow down the process, the deterioration is more likely than not to proceed. It may be the result of a stroke or even brain infection (Butler, 1998). In the UK the most common symptoms, which are noted in terms of dementia, are the occurrence of memory loss and the tendency to misplace objects. This is generally be followed by low self esteem and mood swings. This does not mean that this will begin as memory loss of a long-term nature but it will begin as a memory loss of recent events (Burns et al, 2002).

The patient, especially if living alone, might feel emotionally disturbed and disorientated when recalling places and people’s identities (Lindesay et al, 2002). Mild dementia based attacks might make the patient prefer sticking to their home base for long periods of time in order to avoid more confusion. At the same time another well-known symptom is losing track of time and having a general disregard towards the timings in a day (Ibid).

As the disease progresses, it will be possible to observe the lack of an attention span on behalf of the aging patient. This may be accelerated in people with a history of alcohol abuse and be followed by a slow disability or reluctance to engage with new gadgets or technologies. Memory loss is likely to cause irritation and the patient’s relations with their families are more likely to be a target of this slowing down (Chew et al, 2008).

The patient will clearly suffer a break down in his or her social and personal activities and display varying personality patterns at times. The most concerning aspect of the situation remains the fact that such people might not be paying attention to personal hygiene and their families and caregivers have to understand the need to help them with such issues at the earliest (Burns et al, 2005).

A person who is losing brain functions might neglect his or her daily meals or nutrition. Dementia patients often lose track of time and become prone to weight loss and unexpected accidents. In its most ulterior forms the patient might need to become dependent on full time care due to the inability to move or to speak (ibid.). Perhaps the trickiest aspect of dementia is that sometimes it may go undetected for many years and it is often recommended that if the patient has a history of mental health problems, there is a tendency for mental health practitioners to confuse the symptoms of depression with dementia; even though there is a thin red line between the two, they tend to manifest themselves in terms of long-term effects very differently (ibid.). Thyroid and brain tumour malfunctions can always display similar symptoms, but the patient’s complete Liver Function Test profile and the TSH (Thyroid functions T3 and T4) should be carried out in conjunction with MRI’s before the presence of dementia is confirmed (Burns, 2005).

In the case of Britain, studies show that such patients will also tend to suffer from mood swings and irregular patterns of sexual desire over time. Such patients are very vulnerable due to the constant impairments and deterioration they suffer emotionally and mentally as time passes (Hodges, 2007). Older patients might suffer a loss of self-esteem and dignity. Caregivers for such people suffer from ethical and legal dilemmas themselves. For example the position is still unclear whether a old person suffering from dementia should be allowed by the care giver to have sexual relations with their partner without facing prosecution under the Mental Health Act 2007. The problem with dementia in a medical sense is that its intensity varies from day to day as well as during different parts of the day. It is medically accepted that the person living alone might be facing more misery due to heightened sexual desire arising from a damaged frontal part of the brain (Hodges, 2007).

It is important that the caregivers of such people are trained in emotionally counselling them out of their miserable condition. Such people are a part of the vulnerable groups within society and are thus more likely to suffer abuse from unscrupulous relatives or people close to them. In the UK, the problem of abuse involving elders with dementia has been identified.

There is a need in line with the NICE guidelines (2006.2009) to treat this issue as a matter of social gravity as well as a serious matter of public health. The perceived embarrassment of a patient and his or her family in losing control over their daily functions as well as the cognitive and behavioural trauma the patient goes through should all be a focus of therapy and care being given to the same (Hodges, 2007).

Pertaining specifically to the condition of old people in Britain suffering from dementia, their cognitive deterioration is coupled with loss of health and energy. Such people might be losing their vitality and at its worse the old patient living alone will face ulterior memory loss as well as possibly displaying inappropriate social behaviour (The Alzheimer’s Website).

Such a condition can at times mandate a complete dependence upon a caregiver or even the relatives of the patients. The clinical facilities for the treatment of the same will need to provide for full time care. However, it can be seen that while some families in UK will be willing to provide their elders home support, many will choose to admit such patients into care facilities due to their reluctance to spend time caring for them, as well as the their lack of resources (Chew et al, 2008). In more traditional, rural societies the extended family would arguably provide the care.

Therefore, if this happens and the families cannot afford private facilities for this patient there is a chance that the patient will have to rely solely on government support for the alleviation of their condition as well as their daily care. The behaviour and deteriorating condition of a patient suffering from dementia can be a stressful experience for their families as well as spouses (Ibid). The main problem remains that the near and dear ones have to watch the patient’s condition get worse every day, as this is not a reversible disease at all. While private nurses are readily available in the UK for their care the amount of costs involved therein as well as the standard of care vary (Lindesay, 2002).

Social, clinical and legal considerations

On a final note, it is also worth perusing the connected ethical and legal aspects for the care of dementia patients in Britain. In addition to the above, many other considerations come to fore in terms of the dignity and confidentiality of such patients. For example, the NMC code of 2008 lays down clear guidelines pertaining to the retention of confidentiality in terms of the patient’s private life and data. Any information retained by the nurses and caregivers at this point is governed by the safeguards inherent not only in the Data Protection Act 1998 but also, as McKenzie explains, the notion of confidentiality, “as applied to information obtained by health professionals has ethical, legal and clinical dimensions…. (With) three basic ethical principles relating to confidentiality: autonomy, duty of care and non-maleficience” (2002:1). The duties of a caregiver or a medical professional caring for a person with dementia include an express requirement under the NMC (2004) to “treat information about patients and clients as confidential, and use it only for the purposes for which it was given” (NMC, para 5.1) unless the disclosure of the same would mandate some sort of a prevention of public harm.

Another point to note in terms of patients suffering from dementia is the application of the Mental Health Act 2007 which is aimed at the protection of elderly mental health patients suffering undue influence and unfair extortion where as their weak mental conditions are taken advantage of by those close to them to fake financial transactions by gaining false consent (NMC, 2008). To counter this, in addition to legal provisions, important NICE (2006,2009) and NMC  (2004,2008) codes are in place dealing with aspects of ethics and clinical governance with regards to caring for Dementia patients. It has also been observed that the fact that, as Britain has an increasing number of potential dementia patients every year, more has to be done to secure their physical, mental and psychological welfare – though perhaps it is only the presence of large numbers of older patients with dementia that the issue is receiving more attention.

In conclusion, it is clear that dementia is a growing problem in the UK and all developed countries due to the ever-expanding population of older people. That does not, however, mean that the problems posed are insoluble; rather, this large aging population could well be seen as an opportunity to improve the care of the old and those with dementia. After all, in time perhaps most families and people in the UK with have experience of dementia via their families, relative and friends.

The Alzheimer’s Website (2007-2009)- Alzheimers.org.uk

Butler R, Pitt B (Editors) Seminars in Old Age Psychiatry (College Seminars Series) Gaskell (Royal College of Psychiatrists), 1998

Burns A, Lawlor B, Craig S. Assessment Scales in Old Age Psychiatry (2nd edition). London, Taylor and Francis 2003

Burns A, Denning T, Lawlor B. Clinical Guidelines in Old Age Psychiatry. London, Martin Dunitz 2002

Burns A, O’Brien J, Ames D. Dementia. London, Hodder Arnold 2005.

Chew-Graham CA, Baldwin R, Burns A. Integrated Management of Depression in the Elderly. Cambridge University Press 2008

Eighteenth Report of Session 2006-07, The Human Rights of Older People in Healthcare, HL Paper 156-I, HC 378-I.

Jacoby R, Oppenheimer C, Dening T, Thomas A (Editors)  Oxford Textbook of Psychiatry in the Elderly. Oxford University Press, 2008.

Mckenzie.K (2002) Complaints And Confidentiality: Practice And Research Vol 5 No 4 May 2002 Learning Disability Practice

National Institute of Clinical Excellence: Clinical Guideline 42: Dementia, 2006. Available from: www.nice.org.uk

National Institute of Clinical Excellence: Clinical Guidelines 90 and 91: Depression in adults and Depression with a chronic physical health problem, 2009. Available from: www.nice.org.uk

Hodges JR. Cognitive assessment for clinicians 2nd edition. Oxford University Press, 2007.

Lindesay J, Rockwood K, Macdonald A.  Delirium in Old Age   Oxford University Press, 2002;

The NMC Code (2004) and (2008) as available online

The NMC Guidelines on Confidentiality (2008) available at http://www.nmc-uk.org/aDisplayDocument.aspx?documentID=4289

[1] Alzheimers.org.uk

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Dementia and Alzheimer’s Disease, Essay Example

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Introduction

One of the first steps in providing a community assessment of the chosen population is to a comprehensive assessment of the chosen community. This is accomplished using the windshield survey, which is conducted by making observations visually from a driving car through the neighborhood. Windshield surveys can be used in conjunction with walking surveys that can systematically observed on foot, each can be appropriate in understanding the general community and the specific aspect or condition of it. Data collection and valuable information acquired during the windshield survey can be utilized to highlight the health-related needs of the community chosen, and examine the need for additional health services and resources for the communities. In understanding the chosen community of dementia and Alzheimer’ this paper will examine the condition, nature, and age of the community’s available facilities, infrastructures, and the absence of presence of function care faculties. In addition, the use, condition, and location of available resources, and other essential components that will be used in assessing the needs of the community. The windshield theory will be conducted using the quantitative data that will be supported by the direct qualitative observations that will help to reveal the issues within the community.

Dementia is an encompassing term in which consist of a group of the cognitive illnesses that are typically regarded for difficulty in the domains of object recognition, motor activity, language, memory impairment, and the disturbance of execution function, that includes the ability to abstract, organize, and plan. For patients that are diagnosed with dementia, they are generally older individuals, which can also be diagnosed for Alzheimer disease, a common form. For Alzheimer patients it is a progressive disease of the brain, in which people start by losing parts of their memory, then progresses to thinking ability, decision making, lack of capability to perform daily activities, and recognize love ones.  Dementia and Alzheimer’s disease are serious syndromes in which affect over 47.6 million people around the world, and annually have over 7 million new cases. (WHO, 2015) Dementia and Alzheimer is one of the major causes of dependency and disability among older people throughout the world. Dementia has serious impact on society, families, and caregivers, economically, socially, psychologically, and physically. What is critical to the community is there is often a lack of general awareness and understanding of dementia and other disorders that result in barriers and stigmatization to care and diagnosis. The underlying issues is that it is the only cause of death for United States’ top ten that cannot be slowed, cured, or prevented. Almost two-thirds of Americans that are diagnosed with Alzheimer’s disease are women, and just about one in three senior citizens die of Dementia or Alzheimer’s. (ALZ, 2015)

In the United States Alzheimer’s disease ranks as the sixth leading cause of death, but only 45 percent of people, including their caregivers are told of their diagnosis, which leaves over half not aware of their diagnosis. That leads to increase in hospital costs in which doctors have either misdiagnosed or not diagnosed them, in which Alzheimer and other dementias will cost the US over $225 billion, with costs expected to rise to $1.1 trillion by 2050. (ALZ, 2015) It is also estimated that by 2050, the US age group, 65 and over will make up 20%, in which over 11 million will be living with Alzheimer and other dementias. These issues and facts alone, bring significance to understanding the chosen population more critically by looking at the available resources, and developing an appropriate and realistic plan of care that is targeted at resolving the inherent issues in the community. This assessment will include information collected from different care facilities and community profile that will be beneficial to the community.

Windshield Survey

The windshield survey that was conducted on the Alzheimer’s and dementia facility was conducted on a population of 65 years old and older conducted using an internet search that used free online mapping tools to review the facility and the neighborhood. This was done to establish the boundaries of the windshield tour, as the facility was explored mainly through driving around, and using strategies that can collect viable information and data. The constant rise in the older population has led to awareness in the lack of tertiary care hospitals that contributes to the lack of physical activity, and unhealthy dietary habits, to which local clinics must address these growing problems. The facility is well-maintained, with the primary infrastructure made of brick, and modernized with central heat and plumbing. The transportation that the facilities uses are large vans, and the transportation used around the facility are cyclists and walkers.

There is also a public bus system that offers a fixed schedule and fare. The race and ethnicity is mainly made up of African Americans, Latinos, and Caucasians, with no overt indicators of ethnicity observed. There are many open spaces and parks available lined with trees and public trails. There is an accessible hospital, and other health facilities in walking distance. There are natural boundaries around the neighborhood, with several local meat markets and grocery stores. The most obvious health concerns are dementia and Alzheimer’s that is coupled with obvious chronic disease conditions that pose serious health hazards. There are no signs of decay, with major common area is in close proximity to downtown.

Gordon’s Functional Health Patterns

According to Gordon’s Functional Health Patterns, according to Yoost and Crawfod is used in helping nurses focus on patient strengths in relationships (Yoost, Crawford, 2015). The accurate assessment of the patterns is effective in providing patient-centered plan of care. More importantly this information will be used in developing assessment skills that appropriately aid in accurate treatment and diagnosis of their patients. Looking at the Health Perception/Health Management the patterns described the compliance with regimen for medication, the use of health-promotion activities such as annual check-ups, and regular exercise. Looking at the nutritional-metabolic patterns described in the Alzheimer’s and Dementia Facility, shows that patients are accessible to a healthy habit of food and fluid consumption patterns and the condition of teeth and skin shows good nutrition provided.

Elimination patterns of the excretory functions shows the perception of a normal function, as one can assess a frequency of bowel movements from the amount of diapers and other waste material in trash. The activity-exercise pattern shows the amount of physical activity involved in a patient’s daily life. From the facility is seems that patients are involved in minimal exercise routine that is influential in their drug therapy, that is also tied with leisure activities such as arts and crafts. Looking at the Cognitive- Perceptual pattern of the facility shows that patients have a poor diagnosis, as there level of cognitive function continues to deteriorate from the debilitating disease. This is also an indicator of the symptoms and diagnostic criteria of dementia patients provided by Kensigner (Kensigner, 2006). The Sleep-Rest pattern also shows a poor condition as the use of sleep aids, and steady routine is needed in providing consistent quantity and quality of sleep and energy of the patient population. Examining the Self-Perception/Self Concept pattern shows that the patients have a poor pattern of attitudes of body image, feeling state, or body posture and eye contact, but the facility has a good condition of body comfort. The Role-Relationship pattern sees that the major roles and responsibility falls on the nurses and other attendants of the facility, as they satisfy the social, work, and family relationships of the patients.  The Sexuality-Reproductive Patterns shows poor diagnosis of the satisfaction of reproductive and sexuality patterns. The population is aging and this is not a priority of sexual functioning or sexual relationships. The Coping/Stress Tolerance Patterns show a poor system of handling stress, with limited support systems, and the lack of the ability to control or manage situations. The Value-Belief Patterns of the facility shows that a majority of the clients have a strong religious affiliation, which at times conflict with the special religious and health practices of the facility.

Community Diagnosis

Examining the assessment of the community population of the Alzheimer’s and Dementia facility, shows that the strengths in the level of comfort provided, as indicated in the Gordon Functional Health Patterns, shows that the conditions are fair. Additionally, it is a phenomenological community in which patients share an intra/inter personal connections as they try to cope with their chronic conditions (Harkness, DeMarco, 2012). The strength of the facility is also the patient-centered approach taken by nursing staff in order to provide quality care for patients in which they understand the different levels of dementia patients. According to Gallagher, Steffen, and Thompson (2007), “preliminary data suggesting that people with Alzheimer’s dementia present with decreased affective components of pain and have a higher pain tolerance than vascular dementia patients who tend to have increased affective components of pain and less pain tolerance.” A third strength of the facility is also the cultural concerns that give prevalence to the religious beliefs that can sometimes interfere with the members being able to be treated accurately. They have included coalitions with religious and community leaders that help to improve health status maintenance of the patients.

The weaknesses of the facility however are the lack of physical activity that is beneficial to patients suffering from Dementia/Alzheimer’s. “Exercise also favors brain health via the well-known attenuating influences on atherosclerotic cerebrovascular disease” (Ahlskog, Geda, Graff-Radford, Peterson 2011). An additional weakness of the facility is the poor attention that is paid to the emotional and social relationships that are needed in helping to increase the cognitive functions of patients. Emotional support is needed for Alzheimer’s dementia patients in providing ways in which they can cope with the disease. Lastly, a weakness that the facility needs to improve on is the Self-Perception/Self-Concept of the patients in which does not provide an adequate care paid to increasing the perceptions of their self-image as they are impacted by both the signs of aging, and the conditions of the chronic disease.

A nursing diagnosis that is accurate for the community, which is supported, includes improving cognitive impairment of patients, improve the levels of activity for patients which as addressed will be beneficial to improving their social activity, and control over the disease.  The domain of health promotion with an increase in sedentary lifestyles, ineffective self-health management, domain of self-perception, and domain of self-perception/cognition. An additional diagnosis that needs to be focused on is the improvement for self-concept and self-perception for patients that do not have normal or positive assessments of self-image.

Population-Based Intervention

For the community population, there are several population-based interventions that can be provided to patients in the facility. The first intervention is promoting independence and self-perception. This intervention will also help with patients in which functions begin to deteriorate and they begin to withdraw from social environments and complex activities. It is important for the care providers and nurses to consider the appropriate activities, the level of engagement, and the complexity of the activity that helps them maintain their social roles and active life. This includes ADL skill training that involves assessing patient’s task performance, impairments, and abilities to understand the underlying neurological, psychosocial, and physical factors. This intervention involves developing programs of activity planning, environmental modifications, adaptive aids, assistive technology, and rehabilitation programs for patients. Each of these programs is useful in providing interventions that can be combined to address the issues of social, emotional, physical concerns. According to the NICE Clinical Guidelines (2007), “Continual engagement in life’s roles and activities is a means in itself for maintaining independence; however, as dementia progresses, some aspects will inevitably become more difficult.” Other intervention possibility is centered towards the psychological development, includes cognitive rehabilitation, cognitive training, and cognitive stimulation that involves engagement and exposure with materials and activities involving a degree of cognitive processing; specific training; and individually tailored work towards personal goals for patients. (Claire, Woods, 2004) These population based intervention approaches encourage enthusiasm and creativity for not only the patients’ benefit, but for the development of the practitioners and nurses attending to patients.

Expected Outcomes

These interventions are feasible for the facility in which they will be able use case studies, and experimental designs in which help in creating individually tailored programs for rehabilitation, that target the selected goals of the patients. Based on research from numerous sources these approaches shows promises to improving the prompting of remote memories, memory triggers, and physical stimulation that includes hand massages or other programs for dementia patients. The expected outcomes for the intervention includes focus on incorporating a group-based approach, validation therapy, atmospheric music and sounds, and visual light displays that encourages communication in a facilitative and safe environment.

Healthy People 2020 objective(s)

According to the Healthy People 2020 Objectives, in relation to the population, the objectives include, health-related quality of life and well-being, dementias including Alzheimer’s disease, physical activity, and educational and community-based programs. For Dementia, the goal is to reduce the costs and morbidity in relation to enhance or maintain their quality of life. (Healthy People 2020, 2015) Educational and Community-Based Programs are used in increasing the quality of effectiveness and availability of programs that are designed to enhance and health and quality of life. The Physical Activity goals are improve the quality, fitness, and health of life through daily physical activity for all individuals. (Healthy People 2020, 2015) These objectives are used in combination to address the problems of the facility which will help in improving the overall quality of life of patients.

Overall, the community of the Alzheimer’s and Dementia facility patient provides an overall well-maintained facility based on the Windshield Survey, and the Gordon Patterns that have been explored in this assessment. Based on the collected data, and in-depth analysis the facility needs in improvement in several areas that include the cognitive functioning, physical activity, and the promotion of self-perception of patients that are negatively impacted by the debilitating disease. It is important to apply these interventions that address the numerous diagnosis, and problems that outlined by the highlighted weaknesses of the facility. In addition to the Healthy People 2020 objectives addressed in the assessment, in applying the goals of each objective it will increase the patient’s quality of life, as well as their overall well-being. By applying these interventions and addressing these problems will greatly improve the quality of life for patients, and improve patient satisfaction.

2015 Alzheimer’s Disease Facts and Figures. (2015). ALZ. Retrieved from http://www.alz.org/facts/overview.asp

Ahlskog, J. E., Geda, Y. E., Graff-Radford, N. R., & Petersen, R. C. (2011). Physical Exercise as a Preventive or Disease-Modifying Treatment of Dementia and Brain Aging. Mayo Clinic Proceedings , 86 (9), 876–884. doi:10.4065/mcp.2011.0252

Dementia. (2015). WHO . Retrieved from http://www.who.int/mediacentre/factsheets/fs362/en/

Dementia/Alzheimer’s Disease. (2015). CDC . Retrieved from http://www.cdc.gov/mentalhealth/basics/mental-illness/dementia.htm

Thompson, Dolores Gallagher, Steffen, Ann, Thompson, Larry. (2007). Handbook of Behavioral and Cognitive Therapies with Older Adults . Springer Science & Business Media.

Harkness, G. A., DeMarco, R. F. (2012). Community and public health nursing evidence for practice. Philadelphia, PA: Wolters Kluwer Health/Lippincott, Williams, and Wilkins.

Kensinger, Elizabeth. (2007). Cognition in Aging and Age-Related Disease. Department of Psychology. Boston College.

Logsdon, R. G., McCurry, S. M., & Teri, L. (2007). Evidence-Based Interventions to Improve Quality of Life for Individuals with Dementia. Alzheimer’s Care Today , 8 (4), 309–318.

National Collaborating Centre for Mental Health (UK). (2007). Dementia: A NICE-SCIE Guideline on Supporting People With Dementia and Their Carers in Health and Social Care. Leicester (UK): British Psychological Society; 2007. (NICE Clinical Guidelines, No. 42 Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK55462/

U.S. Department of Health and Human Services. (2015). Healthy people 2020. Retrieved from http://healthypeople.gov/2020/TopicsObjectives2020/pdfs/HP2020_brochure_with_LHI_508.pdf

Yoost, Barbara, Crawford, Lynne R. (2015). Fundamentals of Nursing: Active Learning for Collaborative Practice. Elsevier Health Sciences.

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Dementia College Essays Samples For Students

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Do you feel the need to examine some previously written College Essays on Dementia before you begin writing an own piece? In this free directory of Dementia College Essay examples, you are granted an exciting opportunity to explore meaningful topics, content structuring techniques, text flow, formatting styles, and other academically acclaimed writing practices. Applying them while composing your own Dementia College Essay will surely allow you to finalize the piece faster.

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The three mental complications that include dementia, delirium, and depression have similar symptoms which make it difficult to determine the exact condition the patient suffers from (Yasin, 2013). As such, it becomes very important to learn the diagnosis procedure. Such practice helps in instilling some sense of accuracy when it comes to differentiating the three conditions (Alonso, Chatterji & He, 2013). This paper seeks to analyze a typical case study whereby the patient has presented her scenario with specific details of the condition as it represents itself symptomatically.

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Dear Sir, As the director of the Alzheimer’s House, it is my mission to deliver the best kind of care to our patients with Alzheimer’s condition. Along with this mission is my vision to have a facility equipped with all types of materials that would be beneficial in conducting their therapy. In my desire to offer quality care, I researched some of the latest alternative therapies for our patients. In my research, I found some of the best equipment, games, and activities that are age-appropriate and stage-appropriate to our patients.

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Symbolic interaction theory views society as the conglomeration of all of the different ways that individual people interact with one another. The pioneers of this theory were Max Weber and George Herbert Mead, but the person to give this theory its name was Herbert Blumer, who summarized it like this: people tend to treat things according to the significance that those things have from their perspective. This significance comes through social interaction and can change over time as the interpretation of those things varies over time (Nelson). Blumer outlined three tenets of this theory:

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Dementia: Disease Analysis and Treatment Strategies Essay

Introduction, disease analysis, signs and symptoms, causes and risk factors: treatment methods, future research.

Medical professionals and psychologists apply their competencies to provide personalized services to patients with terminal conditions. Dementia is one of these conditions that require constant support and care. Individuals affected by this disease record or experience numerous challenges that make it impossible for them to pursue their aims in life. The purpose of this paper is to research this mental condition and present evidence-based ideas that different professionals can utilize to meet the changing health demands of more patients. The essay will go further to offer additional suggestions for future researchers to empower more people with this condition.

Dementia is a common medical condition recorded in all populations and regions. Fymat (2018) argues that the syndrome is associated with a prolonged deterioration in mental abilities, thinking, and completion of daily tasks. Although this disease is usually common among the elderly, younger people can also develop it (James & Bennett, 2019). Experts in the fields of psychology and medicine agree that dementia should not be studied or treated as a normal process of human aging. A study by Deckers (2017) indicated that over 50 million people across the globe had the condition. These statistics explain why different stakeholders and scientists should collaborate to learn more about it and present evidence-based measures to support every affected patient.

Past studies have managed to discover that dementia is a group of medical illnesses and conditions that affect a person’s mental capabilities. The occurrence of changes in the brain remains the leading possible cause of these diseases. Such developments result in reduced cognitive abilities and the ability to engage in a wide range of personal activities. Patients will experience significant changes in the manner in which they behave, feel, or engage in interpersonal relationships (Fymat, 2018). Some of the common types of dementia recorded in different parts of the world today include vascular dementia and Alzheimer’s disease (Gale et al., 2018). Some health problems affecting the human brain have the potential to trigger this condition, such as inadequate intake of vitamins, bleeding in the brain, and thyroid problems (James & Bennett, 2019). The nature of these illnesses explains why dementia does not need to be studied or analyzed as a form of mental decline due to aging.

People who develop any form of dementia tend to encounter various signs and symptoms that eventually disorient their goals and experiences in life. Firstly, the affected patients will have significant challenges with their short-term memories. They can also be unable to remember certain items or make wrong calculations. Secondly, most of these individuals do not keep track of their valuables, such as purses or wallets (Deckers, 2017). Thirdly, they might encounter numerous challenges when trying to settle their utility bills. Fourthly, they will forget their appointments and tasks that ought to be completed in a timely manner. Fifthly, some people might find it hard to locate their way back home due to the presence of this disease. In advanced stages, patients will have most of their social skills affected significantly. They will be unable to complete their daily tasks and even become disinterested in certain activities that might have been enjoyable before.

Medical professionals consider these signs and symptoms whenever trying to figure out the patient’s condition. Such a process is usually helpful since it informs the most appropriate treatment method that can improve the health outcomes of the targeted individual. Those who live with people who have the condition will be in a position to learn more about it. For instance, this illness progresses slowly until it becomes a serious problem (Gale et al., 2018). Relatives and friends should be keen to identify individuals who might be experiencing different forms of difficulties or memory challenges. Psychologists and other professionals should be ready to diagnose the condition and offer the right treatment.

The brain has different regions and parts that work together to influence human behavior, feelings, thoughts, and coordination. When one or two of such parts are affected, chances are high that a person’s judgment, movement, or memory will be affected. Using the case of Alzheimer’s disease, the increased levels of different types of proteins inside the brain will make it impossible for it to function optimally (Fymat, 2018). Some of the parts will be unable to communicate effectively, thereby affecting the level of judgment and coordination. These developments will eventually result in memory loss and make it impossible for the person to perform certain tasks. These changes might take place permanently and eventually trigger additional complications.

Some scholars have managed to present several variables or factors that tend to trigger this medical illness. For instance, James and Bennett (2019) indicate that depression and alcohol use are associated with the development and progression of this disease. Other risk factors for this medical condition include thyroid problems, excessive use of drugs and alcohol, and vitamin deficiencies. Due to the nature of dementia and other related illnesses, psychologists and psychiatrists focus on a person’s medical history and conduct an analysis of his or her mental abilities in order to make informed decisions. They will also consider the behaviors associated with various types of dementia before arriving at a conclusion.

Patients who have developed dementia require timely medical support and attention. According to Deckers (2017), there is no known cure or medication for stopping the development of this disease. However, physicians and psychiatrists can consider various drugs that are capable of improving the signs and symptoms of the selected type of dementia. Many professionals use medicines intended for Alzheimer’s to help more patients manage the disease. Some of the common drugs include Namenda and Exelon (Fymat, 2018). Most of these drugs are classified as cholinesterase inhibitors and have been found to be effective in treating dementia.

The use of therapy is also essential since it can make it easier for patients to record noticeable improvements within a specified period of time. Some techniques have been observed to improve the outcomes of patients, such as changing the environment and attention redirection (James & Bennett, 2019). Each person will require personalized care depending on the exhibited symptoms. Similarly, the common symptoms should inform the most appropriate therapy or drugs that will result in improved health outcomes.

The field of genetic technology is making it easier for scientists to learn more about various conditions affecting humanity. Most of the techniques are making it possible for researchers to analyze genes and even edit them. A good example is the CISPR technology that is providing additional information that can transform the fields of radiology, imaging, and medicine (Li et al., 2019). These aspects explain why future researchers should focus on new studies in order to understand the relationship between age and dementia (Duong et al., 2017). They can go further to examine whether there is a correlation between a person’s genetic constitution and the development of this condition. This knowledge can inform superior methods to help patients and ensure that they record positive health outcomes.

A report by the Alzheimer’s Association International Conference (AAIC) revealed that people could consider a number of practices to protect themselves against this condition. For instance, individuals who are at risk of this disease can consider the importance of pursuing healthy lifestyles and diets. Such a practice will improve their immunities and be able to fight some of the opportunistic diseases (Osman et al., 2016). Some other evidence-based practices that are capable of improving the health experiences of more people include avoiding smoking and exercising regularly (Osman et al., 2016). They can also stimulate their minds by reading widely and completing puzzles. The consideration of additional studies in this field will make it possible for more practitioners and psychologists to provide superior care to more citizens who are suffering from dementia.

The above discussion has identified dementia as a group of mental conditions affecting many people. The common symptoms associated with it include loss of memory and the inability to keep track of daily activities. Medical professionals can consider the nature of this disease to provide personalized care and therapy to empower more patients. Future scholars can consider the above areas and undertake additional studies in order to present new guidelines to meet the changing needs of more citizens with this mental condition.

Deckers, K. (2017). The role of lifestyle factors in primary prevention of dementia: An epidemiological perspective . NeuroPsych Publishers.

Duong, S., Patel, T., & Chang, F. (2017). Dementia: What pharmacists need to know. Canadian Pharmacists Journal, 150 (2), 118-129. doi:10.1177/1715163517690745

Fymat, A. (2018). Dementia: A review. Journal of Psychiatry & Neuroscience , 1 (3), 27-34.

Gale, S. A., Acar, D., & Daffner, K. R. (2018). Dementia. The American Journal of Medicine, 131 (10), 1161-1169. doi:10.1016/j.amjmed.2018.01.022

James, B. D., & Bennett, D. A. (2019). Causes and patterns of dementia: An update in the era of redefining Alzheimer’s disease. Annual Review of Public Health, 40, 65-84. doi:10.1146/annurev-publhealth040218-043758

Li, J., Walker, S., Nie, J., & Zhang, X. (2019). Experiments that led to the first gene-edited babies: The ethical failings and the urgent need for better governance. Journal of Zhejiang University Science B, 20 (1), 32-38. doi:10.1631/jzus.B1800624

Osman, S. E., Tischler, V., & Schneider, J. (2016). ‘Singing for the Brain’: A qualitative study exploring the health and well-being benefits of singing for people with dementia and their carers. Dementia, 15 (6), 1326-1339. doi:10.1177/1471301214556291

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IvyPanda . 2022. "Dementia: Disease Analysis and Treatment Strategies." February 14, 2022. https://ivypanda.com/essays/dementia-disease-analysis-and-treatment-strategies/.

1. IvyPanda . "Dementia: Disease Analysis and Treatment Strategies." February 14, 2022. https://ivypanda.com/essays/dementia-disease-analysis-and-treatment-strategies/.

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IvyPanda . "Dementia: Disease Analysis and Treatment Strategies." February 14, 2022. https://ivypanda.com/essays/dementia-disease-analysis-and-treatment-strategies/.

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