DementiaA Dementia (lat. dementia "Craziness") is a deficit in cognitive, emotional, and social skills that results in impaired social and occupational functioning and is almost always, but not exclusively, associated with a diagnosable brain disorder. It mainly affects short-term memory, thinking, speech and motor functions, and only in some forms also the personality structure. Decisive is the loss of already acquired abilities as opposed to congenital deficiency (oligophrenia). Today, various but not all causes of dementia have been clarified, and some forms can be treated to a certain extent, d.h. the symptoms can be delayed in the early stages of dementia. The most common form of dementia, but by no means the only one, is Alzheimer's disease. Dementia can be based on very different causes, for the therapy the clarification of these distinctive features is very important.
Table of Contents
Definition
Diagnostic criteria for dementia include combinations of deficits in cognitive, emotional, and social skills that result in impaired social and occupational functioning. The leading symptom is memory impairment. At the beginning of the disease there are disturbances of the short-term memory and the retentiveness, in its further course also already memorized contents of the long-term memory disappear, so that the persons concerned increasingly lose the abilities and skills acquired during their life.
Definition of dementia according to ICD 10
Dementia (ICD-10 code F00-F03) is a syndrome resulting from a usually chronic or progressive disease of the brain with disturbance of many higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning ability, language, speech, and judgment in the sense of the ability to make decisions. Consciousness is not clouded. For a diagnosis of dementia, symptoms must have persisted for at least 6 months according to ICD. The senses (sensory organs, perception) function within the usual range for the person. Usually, changes in emotional control, social behavior, or motivation accompany cognitive impairment; occasionally, these syndromes occur sooner. They occur in Alzheimer's disease, vascular diseases of the brain, and other conditions that primarily or secondarily affect the brain and neurons.
Definition of dementia in DSM-IV
The cognitive deficits cause a significant impairment of social and occupational functions and represent a marked deterioration compared to an earlier level of performance. They do not occur in the context of rapid-onset clouding of consciousness or delirium. Memory impairment must be accompanied by at least one of the following disorders:
– Disorder of executive functions, d.h. Planning, organizing, following a sequence of events
Frequency
According to the Berlin Study of Aging (1996), the number of people with dementia increases by age group as follows:
Age group Percentage of dementia patients 65- to 69-year-olds 1.2 % 70- to 74-year-olds 2.8 % 75- to 79-year-olds 6.0 % 80- to 84-year-olds 13.3 % 85- to 89-year-olds 23.9 % over 90-year-olds 34.6 %
It can be amed that, to date, more than half of all seniors (older than 65 years) in the general medical patient population with existing dementia have never been diagnosed with such a condition. [1]
Risk factors
The main risk factor for dementia is age. The preponderance of females is probably mainly due to the fact that women live a few years longer. Depression is considered a risk factor for the development of dementia. They occur more frequently in the early stages of dementia. Can also precede dementia.
Causes
The most common cause of dementia is Alzheimer's disease. The second most common cause is vascular dementia, accounting for about 20 percent of all cases. But also in the case of numerous other diseases of the brain, which occur mainly in old age, a so-called dementia can gradually develop. secondary dementia occur, for example, in Lewy body disease (= Lewy body dementia) or lobar atrophy (= frontotemporal dementia, see also Pick's disease), also in Parkinson's syndrome (which is probably a form of Lewy body dementia); in Parkinson's patients, however, dementia also occurs as a result of years of Parkinson's medication.
It is known from neuropathological studies that the first dementia-typical changes in brain tie occur already in young adulthood and increase steadily with increasing age. Dementia only occurs when a large proportion of the brain cells have been destroyed.
Rare causes of dementia are infectious diseases such as HIV or syphilis, Creutzfeldt-Jakob disease, normal prere hydrocephalus, metabolic disorders such as vitamin B12 deficiency, hypothyroidism or Wilson's disease, or rarer neurodegenerative diseases such as Huntington's disease.
Table: Most frequent causes of dementia
Alzheimer's disease ca. 50-60 % Vascular dementia ca. 15% Mixed form of both o.g. ca. 15 %
(figures current August 2005)
Secondary dementias (data, numbers not currently verified! The established imaging method for diagnosis. Differential diagnosis of dementia is PET (positron emission tomography) with F18DG. Thus, even in early stages, sites in the brain with reduced glucose metabolism can be detected. Thus, demonstrating dementia of the Alzheimer's type or frontotemporal dementia (Pick's disease). Dementias due to depression show a normal activity pattern in PET. Scintigraphy with J123 beta-CIT or DAT scan, J123-IBZM scintigraphy, and PET with L-dopa are used to diagnose dementias associated with extrapyramidal motor disturbances. This can be used to differentiate Parkinson's disease, multisystem atrophy, progressive supranuclear gaze palsy, and essential tremor. The patient's medical history provides important clues for differential diagnosis and for the selection of imaging examination procedures, and the information provided by the patient's caregivers should be particularly taken into account. The affected person himself often does not notice his memory disorders and/or he can be in top form at appointments for a short time (a well-known phenomenon at doctor's appointments). On the other hand, it is also possible that he overestimates his memory disorders in the context of a depressive mood. Technical examinations such as magnetic resonance tomography or computer tomography of the head or electroencephalography are particularly useful for differentiating from other brain diseases. In order not to overlook any treatable cause, the following blood tests should at least be available: Blood count, vitamin B12 levels, blood sugar, liver values, kidney values, electrolytes, thyroid hormones, CRP.
In addition to the medical history, simple psychometric tests such as the MMSE = Mini-Mental State Examination, the Clock Test or the DemTect are helpful in establishing the diagnosis and also in checking the progression of dementia. Such simple and quick tests can then also be used for follow-up examinations, for example to check the response to medication or therapy procedures.
Differential diagnostics
Some mental and neurological disorders can be easily confused with dementia, z. B. the following:
– Simple "age forgetfulness" – denial and avoidance behavior – deprivation symptoms or. Hospitalism with regression (z. B. Deficiency of vitamins. Minerals (z. B. (e.g. vitamin B12, pernicious anemia) – strokes – brain tumors – metabolic disorders (e.g. hypoglycemia in diabetics, renal metabolism disorders, etc.). Psychosis. Delusions (z. B. Schizophrenia, mania, and psychotic depression) – Severe autism (Kanner syndrome) with mutism – Simple mutism – Simple aphasia – Fluid deficiency
Symptoms
In the run-up to dementia, psychological disturbances can often be observed that can hardly be distinguished from those of depression, such as loss of interests and initiative, irritability, feeling of being overwhelmed, loss of affective vibrancy, depressive moods.
The leading symptom of all dementia diseases is memory impairment, especially short-term memory impairment. Forgetfulness is something normal at first. Often, at least in the early stages, the outer facade of the person is well preserved, so that the memory disorders can be very well masked in superficial contact. This is particularly successful in people who have had many social contacts throughout their lives – the obligatory tone of voice replaces the content of the message (communication) to some extent.
Later, memory contents from the past are lost. As the dementia progresses, other brain dysfunctions are added, such as word-finding problems, arithmetic problems, and spatial perception disorders, so that those affected often get lost, especially when there are structural changes in the environment they have been familiar with for decades.
Dementia patients lose their initiative. They neglect their former hobbies, personal hygiene and cleaning up their home. Eventually, they are no longer able to feed themselves adequately. They have no impulse to eat, lose the feeling of hunger and eventually forget to chew and swallow food. They become emaciated and susceptible to internal illnesses such as pneumonia. Motor disturbances are also usually part of the picture of advanced dementia, if it is not a dementia disease that begins with motor disturbances, such as Parkinson's syndrome. The patients become increasingly stiff all over the body. Their gait becomes small-stepped, shuffling and wide-legged. They are at risk of falling, also because there is a disturbance of the retaining reflexes.
Delusional disorders can occur in all forms of dementia. They are relatively typical of Lewy body dementia, the form of dementia associated with Parkinson's disease. These are mainly visual hallucinations. Typically, the affected persons initially see persons who are not present, especially in the twilight, with whom they sometimes even have conversations. Patients can usually distance themselves from their hallucinations at this stage, meaning they know the people they are talking to are not present. Later they see animals or mythical creatures, patterns on the walls, dust fluff. Finally, they experience grotesque, usually threatening things, for example, abductions. These scenic hallucinations are usually very anxiety-ridden. Patients often become aggressive when they incorporate relatives and caregivers who approach them with the best of intentions into their delusional system. Here the transitions to delirium are fluid.
Shifts in day-night rhythms can cause significant caregiving problems.
In the very advanced stage, the affected person does not even recognize his or her closest relatives. They become completely apathetic, bedridden and incontinent.
Dementia limits life expectancy. However, dementia itself is not the cause of death, but rather the illnesses promoted by dementia.
Experience of people with dementia
If you try to put yourself in the emotional world of people with dementia, communication with them is easier.
For dementia patients, the world looks strange and incomprehensible because they lose the specific human ability to perceive, orientation. They are unable to place objects, situations, and people in a larger context. Due to their memory disorders, they are denied access to previous knowledge (semantic memory) and experiences (episodic memory- back-erasing) in order to find their way in the current situation with their help. They lack knowledge and certainty of resources to cope with current situations. Often the difference between dream, past and reality becomes blurred. Often there are hallucinations that are experienced as real for the affected person. In dealing with persons with dementia, it is often not possible to explain to them the unreality of the hallucinations. Ideally, caregivers capture and address the mood behind the hallucinations.
If the person with the disease is still able to recognize that he or she has not reacted appropriately in a situation, this can trigger restlessness and resignation in him or her.
Dementia patients need a lot of time for all reactions and actions. In advanced stages, for example, adequate nutrition is no longer possible by natural means, because those affected are no longer able to swallow food due to their severe drive disorder. The patience and the temporal possibilities of the carers therefore regularly reach their limits in the late stage.
People suffering from dementia often feel misunderstood, ordered around or patronized, as they are unable to grasp the reasons for decisions made by their caregivers. Surprisingly many persons suffering from dementia can express their wishes. [3] Some people are still able to sense when others are bored or embarrassed by their behavior. In the late stages, the ability to make emotional contact is increasingly lost, which can be very stressful for the relatives.
Dementia patients occasionally react with great anger when they are held responsible for things they have forgotten in the meantime. Thus they are cornered twice: once by being accused of intentionally making mistakes, and secondly because they are confronted with their weaknesses – being unable to remember.
Even people with dementia still have feelings. Depression in particular is a common problem, often even before the dementia manifests itself, often when those affected are aware of their mental decline. Since the symptoms of depression are similar to those of dementia, the two diseases can be confused in the absence of sufficient knowledge. The more the dementia progresses, the more the emotional world flattens out and, parallel to an increasing lack of interest, gives way to an affective indifference with the inability to be happy or sad or to feel sadness. to express their emotions.
Dealing with dementia patients should be adapted to their changed experience. Methods that have proven helpful in dealing with dementia patients are: Validation, biography work/memory care, basal stimulation, and self-maintenance therapy (SET) according to B. Romero.
Therapy
Drug therapy
Drugs against dementia have been available for some years (antidementia drugs). On the one hand, centrally acting cholinergics (cholinesterase inhibitors) such as donepezil, galantamine or rivastigmine, on the other hand memantine. Clinical experience shows that on the one hand some patients benefit very well from the drugs, others not at all. Therefore, very bitter discussions arose again and again, whether one should prescribe these very expensive medicines at all (daily therapy costs ca. 4 to 5 €). Dementia cannot be cured, but in many cases its course can be halted by 1 to 2 years.
Controversial in its effect are considered ginkgo, garlic, piracetam. All sedative medications given for sleep disturbances or shifts in day-night rhythm, for example, worsen cognitive performance. The same is true for neuroleptics with anticholinergic side effects, which sometimes cannot be avoided in cases of hallucinations.
Drug treatment of vascular dementia corresponds on the one hand to the treatment of chronic vascular diseases (arteriosclerosis), on the other hand antidementives have also proven effective in dementia, both acetylcholinesterase inhibitors and memantine.
Memory training
Evidence of efficacy of memory training (Which differs from "brain jogging" in that it is directed at a diseased audience or is used for prevention and does not have the character of a sport or a purely recreational activity.), could be provided for the tasks performed, such as recognizing photos of faces or orienting themselves in the environment in which it was practiced. The everyday relevance of memory training in the social care of dementia patients is controversial, since there is a danger that the affected persons are confronted with their deficits and rather leads to a worsening of the overall situation if the affected persons feel like failures. Therefore, this method of social care for dementia patients is only used in the early stages of the disease and adapted to the respective disease situation.(see also Validation Therapy)
Biography work
Understanding the resident
Try to find out through biography work what meaning certain behaviors have for the person with dementia ( What does it mean when Mr. M. does not want to go to sleep at night? Does he want to signal "I still miss my nightcap"? or he means "I miss my wife when I go to bed"?). The more thoroughly the biography as well as the habits and peculiarities of a person are known, the easier it will be for you to understand him or her. Again, thorough documentation. Close cooperation of all persons involved in the care necessary.
Source: Thiemes Altenpflege (Published by Ilka Kother) (Edition of 2005)
Validation therapy
Dealing with dementia patients
The most important thing in dealing with people suffering from dementia is patience. Due to impatience on the part of the contact persons, the person affected has the feeling of having done something wrong – this is the cause of dissatisfaction, sadness and discomfort (no one likes to do things wrong).
It is also important to be aware that those affected are only capable of learning to a limited extent due to their memory disorders. Most of what is said to them is forgotten within a few minutes. Therefore, nothing can be reliably agreed with demented people. A conditioning of dementia patients is nevertheless possible; if one leads an affected person again and again to a place at a table and explains to him that this is his place, it is quite possible that he will choose this place to sit in the future himself. In response to the question: "Where is your place??" the concerning will answer nevertheless evasively. That is why it makes sense to avoid questions as much as possible.
Stella Braam, daughter of a person affected, describes some typical misunderstandings between (professional) caregivers and people suffering from Alzheimer's, such as paternalism, fixation as a pretended safety against falls, inappropriate employment offers and too large, too loud groups of people. [4]
The dementia paradox
The Hamburg scientist Jens Bruder speaks in connection with dementia of the Alzheimer type of the Dementia paradox. This refers to the increasing disease-related inability of the ill person to appropriately perceive the loss of his cognitive capacity and to deal with its consequences.
Communication
Communication should be in a simple language. On the one hand, this is given by the mostly difficult communication due to old age dustiness, on the other hand, an understanding of long sentences is not always given due to the impairment of the abstract thinking ability. Each sentence should contain only one piece of information. So not: "Get up and put on your coat" but only "please get up" and only then the next step. The language should be simple and the sentences concise and short. Mostly proverbs. Sayings better understood than abstract phrases. It is helpful to remember phrases and terms that were understood by the dementia patient in order to then refer back to them. Arguing with the person with dementia should be avoided at all costs, even if he or she is clearly in the wrong; this would increase confusion and the unhappy "feeling" that remains after an argument (although the person cannot remember the argument itself). For the person with dementia, the argument is also very threatening because he cannot fall back on the experience that the argument will also pass again, because dementia patients live almost exclusively in the present. Future has no meaning for them.
When language is hardly possible, it becomes even more important to address the other senses. Access can also be created through tasting, smelling, seeing, hearing, touching and movement. Z. B. well-known folk songs, with which the concerning can blossom truly. However, it should also be noted here that some senses may change. The sense of taste, for example, responds primarily to sweet foods. With all stimuli, care should be taken not to use too many at once. An overlapping of different sensory impressions can have a threatening effect, as the different originators can no longer be separated and assigned. An overabundance of stimuli thus leads to confusion rather than stimulation. So a balance should be found between oversupply and absolute lack of stimulation.
Ideally, the caregiver is able to empathize with the demented person's world of thoughts, z.B. through validation.
The environment should be adapted to the ill person. Imagine the situation that z.B. When waking up in a retirement home, the following occurs: a person wakes up in a strange room without familiar objects; a person (caregiver) comes in whom he has never seen before and, without asking and completely as a matter of course, starts to wash and dress the person. The caregiver should introduce him/herself if possible and explain beforehand in simple sentences what he/she is going to do and also comment on further actions. Here it becomes clear how important it is to scatter familiar objects in the immediate environment of the person with dementia in order to combat their confusion and therefore burgeoning anxiety. Because familiar objects, sounds, etc. provide security. Good lighting is also important, as shadows often lead to uncertainty because they cannot be classified. Furthermore, spatial, three-dimensional vision decreases in dementia patients. This is why color changes in the floor are often interpreted as thresholds. It is therefore necessary to keep the patient free of fear and as oriented as possible in order to be able to work with them.
The nursing researcher Prof. Erwin Bohm (Austria) uses childhood emotions to rehabilitate seniors with dementia. Bohm advises to draw up a so-called sozigram at a young age. In it, one should note exactly what one enjoyed as a child and adolescent. This information can be used later to revive childhood memories. This gives rise to emotions that make dementia patients in particular happy and infuse them with new vital energy. The disease cannot be cured in this way, but its effects can be reduced.
Dealing of the carers with themselves
90% of dementia patients are cared for by relatives, 80% by women. A widely underestimated problem is how relatives deal with themselves. Often they increasingly neglect their own social contacts and live only for the person with dementia with whom they cannot communicate. Often they are full of feelings of guilt because of the aggression towards the affected person that arises again and again. And finally, they themselves are very afraid of also suffering from a similar disease in the foreseeable future. All this leads in very many cases to a relevant depression of disease value or psychosomatic complaints such as chronic pain disorders. It is not uncommon for the mental illness of the relatives to appear only after the dementia patient has passed away, then, when one actually wants to enjoy life again.
The illness of their life partners or parents also seriously affects other family members. Attacks on the partner are always also attacks on the family members providing the care. If the ill partner behaves nonsensically, caring relatives also repeatedly impute malice, lack of good will.
For this reason, too, the relatives should seek help at the same time as the affected person if possible, for example in a relatives' group, with a neurologist, at a dementia counseling center or by sharing the burden on several shoulders (theoretically correct, but often difficult to implement).
Alzheimer's societies and initiatives for relatives now exist almost throughout Germany. Here you can find information for affected persons and relatives, also about concrete support offers close to home.
See also: Foreign home help, German Alzheimer's Association, gerontopsychiatric specialist, family helper for the age-addled (abbreviation: FFA)
Historical
The term dementia was coined in the 18. Used in legal and colloquial language in the nineteenth century for any form of mental disorder. End of the 18. At the beginning of the twentieth century, the term came to mean among physicians the decline of intellectual powers and the inability to think logically. For a long time, only the final stage of intellectual decline was referred to as dementia in German-speaking psychiatry. In 1916, Eugen Bleuler described the nonspecific brain-organic psychosyndrome with the characteristics of cognitive disturbance, emotional change and personality change as a psychopathological consequence of chronic brain disease. In 1951, his son Manfred Bleuler distinguished the brain-local psychosyndrome from it. Pointed out its similarity to the endocrine-induced mental disorders. In the course of the development of modern classification systems such as ICD-10. DSM-IV has significantly expanded the definition of dementia syndrome. Today, this term no longer describes only the severe cases of cognitive disorders, but now an acquired complex disorder pattern of higher mental functions. The disturbances can be reversible or irreversible, but they must affect memory and not be accompanied by a disturbance of consciousness. In addition, the management of everyday life must be impaired. In the fourth geriatric report of the German federal government from 2004, the treatment-. Care costs for dementia patients estimated at 26 billion euros. However, a large proportion of this, 30% for care, has not been spent so far because it has been provided by patients' relatives. In 2010, 20 % of all German citizens are expected to be over 65 years of age, thus increasing the (still fictitious) costs to 36.3 billion euros under the same conditions. Due to the changing family structures (single households, small families), however, the share of care costs will additionally increase.