Dementia is a chronic, global, usually irreversible deterioration of cognition. The diagnosis is made clinically; Laboratory tests and imaging techniques are commonly used to identify treatable causes. Treatment is supportive. Cholinesterase inhibitors can sometimes temporarily improve cognitive function.
A dementia can occur at any age, but it applies more frequently elderly patients. It causes more than half of nursing home admissions.
Dementia is a chronic, global, usually irreversible deterioration of cognition. The diagnosis is made clinically; Laboratory tests and imaging techniques are commonly used to identify treatable causes. Treatment is supportive. Cholinesterase inhibitors can sometimes temporarily improve cognitive function. A dementia can occur at any age, but it applies more frequently elderly patients. It causes more than half of nursing home admissions. Dementia can be classified in different ways: Alzheimer’s or non-Alzheimer’s type cortical or subcortical Irreversible or potentially reversible frequently or infrequently dementia should not be confused with delirium although the perception is impaired in both. The following helps to distinguish these: Dementia mainly affects memory, is usually caused by anatomical changes in the brain shows a slow start and is usually irreversible. A Dellir mainly concerns the attention is usually caused by an acute illness or drug or drug toxicity (sometimes fatal) and is often reversible. Other characteristics also help to distinguish the two disorders (see Table: Differences Between Delirium and Dementia *). Etiology dementias can arise from primary disorders of the brain or other disorders (see Table: Classification of dementias). The most common forms of dementia are Alzheimer’s disease Vascular dementia dementia with Lewy bodies Frontotemporal Dementia HIV-associated dementia. Dementia also occurs in patients with Parkinson’s disease, Huntington’s disease, progressive supranuclear palsy, Creutzfeldt-Jakob disease, Gerstmann-Straussler Scheinker syndrome, other prion diseases and neurosyphilis. The patients may experience more than one type at a time dementia suffer (mixed dementia). Some structural brain changes (eg. As normal pressure hydrocephalus, subdural hematoma), metabolic disorders (eg. As hypothyroidism, vitamin B12 deficiency) and toxins (eg. As lead) cause a slow deterioration of cognition, the reversible under treatment can be. This disorder is sometimes called “reversible dementia,” but some experts limit the term “dementia” in an irreversible cognitive decline. Depression can mimic dementia (and was formerly known as “pseudo-dementia” means); the two disorders often coexist. However, a depression may be the first manifestation of dementia. The term age-associated memory impairment related to changes in cognition that occur with aging; in these changes it is not to dementia. The elderly have a relative deficit in memory retrieval, v. a. in the retrieval speed compared with the demand during their youth. However, this change does not affect the everyday functions. Mild cognitive impairment results in a larger memory loss as age-related memory disorders; Memory and other cognitive functions sometimes are worse in patients with this disorder than in age-matched controls, but the everyday functions are not usually affected. In contrast, dementia affects everyday activities. Up to 50% of patients with mild cognitive impairment develop dementia within 3 years. Many diseases can exacerbate cognitive deficits in dementia patients. Delirium is common in patients with dementia. Medicines, v. a. Benzodiazepines and anticholinergics (eg. As some tricyclic antidepressants, antihistamines, antipsychotics, Benzotropine), can cause temporary symptoms of dementia or worsen, including alcohol, even in moderate amounts. An emerging or progredientes kidney or liver failure can reduce the drug clearance and even years after taking a consistent dose of medicament drug toxicity cause (eg., Propranolol). Prions as mechanisms seem to be involved in all neurodegenerative diseases most or which manifest themselves first in the elderly. A normal cellular protein is sporadic (or an inherited mutation) misfolded in a pathogenic form or prions. The prion acts as a template, after which other proteins are similar to misfolded. This process takes place over years and in many parts of the CNS. Many of these prions are insoluble and can, like, not be removed easily from the cell amyloid. There is evidence of prion or similar mechanisms in Alzheimer’s disease (strong) as well as Parkinson’s disease, Huntington’s disease, frontotemporal dementia and amyotrophic lateral sclerosis. These prions are not as infectious as Creutzfeld-Jacob disease, but they can be transferred. Classification of dementias classification Examples beta-amyloid deposits and neurofibrillary tangles Alzheimer’s disease tau pathology Chronic traumatic encephalopathy degeneration corticobasal ganglionic frontotemporal dementia (incl. M. Pick) Progressive supranuclear palsy alpha synuclein abnormalities dementia with Lewy bodies dementia in M . Parkinson Huntingtin gene mutation Huntington’s disease Cerebrovascular disease M. Binswanger Lacunar disease Multi-infarct dementia strategic single infarct dementia intake of drugs or toxins Alcohol Associated Dementia Dementia by exposure to heavy metals infections mushrooms: dementia by cryptococcosis spirochetes: dementia from syphilis or Lyme disease Viral: HIV-associated dementia, Postencephalitic syndrome prion diseases Alzheimer’s disease (Editor’s note: Alzheimer’s disease, amyotrophic lateral sclerosis, frontotemporal dementia, Huntington’s disease and Parkinson’s disease are not included in the nomenclature of the current German guidelines and current German textbooks to the prion diseases.) Amyotrophic Lateral Sclerosis Creutzfeldt-Jakob disease frontotemporal dementia Huntington’s disease Parkinson’s disease variant Creutzfeldt-Jakob disease and structural disorders of the brain brain tumors Chronic subdural hematoma NPH Other potentially reversible causes depression hypothyroidism vitamin B12 deficiency Symptoms and complaints Dementia impairs cognition globally. The onset is gradual, although family members can suddenly find deficits (eg. As if the function is impaired). Often the loss of short term memory is the first indication. First, early symptoms may not be one of those age-related memory impairment or mild cognitive impairment distinguishable. If the dementia symptoms exist in a continuum, they can be divided into Early symptoms: Medium-term symptoms Late Phase personality changes and behavioral disorders may develop early or late. Motor and other focal neurological deficits occur at different stages, depending on the type of dementia; they occur late in vascular dementia early in Alzheimer’s dementia. The incidence of seizures is increased slightly at all stages. A psychosis hallucinations, delusions or paranoia occurs in about 10% of patients with dementia, although a higher proportion experiencing these symptoms at least temporarily. Early dementia symptoms Short-term memory is impaired; Learning and retention of new information is difficult. Language problems are developing (especially word finding), mood swings and personality changes. Patients may increasingly difficult for independent activities of daily living have (z. B. accounts, find the usual ways of remembering where things were put down). Abstract thinking, or judgment of inspection may be impaired. Patients can react to the loss of their independence with irritability, hostility and restlessness. The functionality can be further restricted by: agnosia: Limited ability to objects despite intact sensory function identify Apraxia: Impaired ability to previously learned motor activities despite intact motor run aphasia: Limited ability to understand language or to use Although the onset of dementia, the ability to does not have to seriously disrupt social interaction, family members can strange behavior, accompanied by emotional lability, berichten.Intermediäre dementia symptoms patients lose the ability to learn new information and reproduce. The memory for other less recent events is reduced, but not completely lost. The patient may be in need of help (eg. As washing, eating, dressing, toileting) with the basic activities of daily living. Personality changes may progress. Patients may be tempted to be fearful, self-centered, inflexible or faster annoying, or it can be passive, flat affect, depression and indecision, lack of spontaneity or general retreat of socially demanding situations. Behavioral disorders may develop: Patients may wander or suddenly and inappropriately agitated, become hostile, uncooperative or physically aggressive. At this stage, patients have lost all sense of time and place because they can not effectively use normal environmental stimuli and social cues. Patients often get lost; they may be unable to find their own room or the bathroom. They remain able to walk, but to overthrow the risk or suffer accidents as a result of confusion. The altered sensation or perception may culminate in a psychosis with hallucinations and paranoid delusions of persecution. The sleep patterns are often zerstört.Späte (severe) dementia symptoms the patient can not walk, feed herself or do anything other activity of daily living; they can be incontinent. New and Altgedächtnis are completely lost. Patients will swallow incompetent. You have a high risk of malnutrition, pneumonia (v. A. By aspiration) and pressure ulcers. Because they are totally dependent on the care of others, a placement in a long-term care is often necessary. Finally, patients are mute. Because these patients can report to the physician any symptoms and because older patients often have no fever or no leucocytes in infections, the doctor has to rely on his experience and react whenever the patient appears ill. The final stage of dementia is a coma and death, usually due to infection. Diagnostic differentiation of delirium and dementia by history and neurological examination (incl. Mental status) identify treatable causes according to clinical criteria, as well as laboratory and neuroradiological imaging Sometimes formal neuropsychological testing recommendations for the diagnosis of dementia are available from the American Academy of Neurology. (Editor’s note: In Germany’s “Guidelines for diagnosis and therapy in neurology” of the German Society of Neurology, here specifically Chapter 15 “Diagnosis and treatment of dementia.”.) It may be difficult, the type or cause of dementia to distinguish; The definitive diagnosis often requires a post-mortem histological examination of brain tissue. So clinical Diagnos ezielt the distinction of dementia from delirium and other disorders, and on identifying the brain areas affected and potentially reversible causes. Dementia must be distinguished from: Delirium: The distinction between dementia and delirium is extremely important (because with prompt treatment, the delirium is usually reversible), but it can be difficult. First, attention is being investigated. If a patient is inattentive, the diagnosis is likely to delirium, although advanced dementia also be distracting strong. Other features that rather suggest that delirium as of dementia (eg duration of cognitive impairment-see table. Differences between delirium and dementia *) will be determined by medical history, physical examination and targeted search for causes. Age-associated memory impairment: memory problems do not affect the everyday functions. If affected people will be given enough time to learn new information, their intellectual performance is good. Mild cognitive impairment: memory and / or other cognitive functions are impaired, but this impairment is not strong enough to interfere with everyday activities. Depression Associated cognitive symptoms: These cognitive disorder regresses with the treatment of depression. Depressed elderly patients may experience a decline in cognitive abilities, but unlike patients with dementia they tend to exaggerate their memory loss, and they rarely forget important current events or personal matters. The neurological examination results are normal except for the symptoms of psychomotor retardation. On examination, the patient do with depression a few efforts to respond, by contrast, patients often seek with dementia much, but she does not respond correctly. When depression and dementia coexist, does not question the treatment of depression, the cognitive abilities completely restore. Clinical criteria The latest diagnostic guidelines of the National Institute on Aging-Alzheimer’s Association stipulate that a general diagnosis of dementia requires all of the following disorders: cognitive or behavioral (neuropsychiatric) symptoms that run the ability to function at work and the usual daily activities affect. These symptoms represent a decline of previous functional levels. These symptoms can be explained not by delirium or major mental disorder. The cognitive or behavioral influence should be diagnosed on the basis of medical history from the patient and from a person who knows the patient, plus an assessment of cognitive function (test of mental status at the bedside, or when neuropsychological examination at the bedside is inconclusive, formal neuropsychological Examination ). In addition, the impairment of ? 2 of the following areas should include: impaired ability to learn new information and to remember this (. Ask, for example, repeated questions, often misplace items or forgetting appointments) impaired reasoning and dealing with complex tasks and poor judgment (for example, not be able to manage a bank account to make bad financial decisions) speech disorders (eg. as difficult to remember frequently used words, errors in speaking and / or writing) visuospatial dysfunction ( helps identify. B. inability faces or common objects) personality changes, changes in behavior or behavior. If the cognitive impairment confirmed should history and physical examination then focus on signs of treatable disorders that may cause cognitive impairment (eg, vitamin B12 deficiency, neurosyphilis, hypothyroidism, depression, see table. Causes of delirium). (Editor’s note: Clinical criteria are not executed in the German Guidelines in this form The diagnosis should be based on the definition in the ICD-10 [International Classification of Diseases] ICD-10 Definition:.. dementia [ICD-10 code : F00-F03] is a syndrome due to a usually chronic and progressive disease of the brain disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language, speech and judgment in terms of the ability for decision. consciousness is not clouded. the symptoms must have passed by ICD at least 6 months for a diagnosis of dementia. the senses (sensory organs, perception) operate in the manner customary for the person frame. Usually accompany changes in emotional control, social behavior or motivation cognitive impairment; sometimes these syndromes also occur e her on. They are found in Alzheimer’s disease, vascular disease of the brain and other state images that relate primarily or secondarily the brain and the neurons.) Assessment of cognitive function, the Mini-Mental State Examination test (test of mental status) is often used as a screening test at the bedside. If it is not a delirium, says the presence of multiple deficits, especially in patients with a moderate or higher level of education, of dementia. The best screening test for the memory is a test of short-term memory (for example, call of 3 concepts and queries for 5 min.); Patients with dementia fail in this test. Another test of mental status checked the ability to name terms within categories (eg. As lists of animals, plants or furniture). Patients with dementia are struggling just to name a few; Patients without dementia find it easy to specify many. Neuropsychological tests should be performed when the medical history and examination of mental status at the bedside are inconclusive. You rate your mood as well as several cognitive domains. Take 1-3 hours to complete and be performed or supervised by a neuropsychologist. Such tests are useful primarily in the differentiation of the following disorders: age-associated memory impairment, mild cognitive impairment, and dementia, especially if the cognition is only slightly affected or if the patient or family members are trying to confirm. Dementia and focal syndromes cognitive impairment (eg. As amnesia, aphasia, apraxia, visuospatial difficulties, impaired executive functions), if the distinction is not clinically manifested tests can also help to characterize certain deficits that are due to dementia, and they can detect a depression or personality disorder that beiträgt.Laboruntersuchungen to poor cognitive performance laboratory tests should include the determination of TSH and vitamin B12 levels. Routine blood and liver function tests are sometimes recommended, but their benefits are very low. (Editor’s note: The German guidelines recommend a blood test: As part of the diagnostic assessment following serum or plasma studies are recommended: blood count, electrolytes [Na, K, Ca], fasting blood glucose, TSH, sedimentation or CRP, GOT, gamma GT, creatinine, urea, vitamin B12.) If clinical results suggest a specific disorder suggest further investigations (eg. as for HIV and syphilis) are indicated. A lumbar puncture is rarely erforderllich, but should be considered if a chronic infection or neurosyphilis is suspected. (Editor’s note: The German guidelines recommend for CSF: In the initial diagnosis of dementia, the CSF should be performed to rule out an inflammatory disease of the brain, when an issue arises for evidence from the history, the physical findings or the additional diagnostics.) Further studies can be used to rule out causes of delirium. Biomarkers for Alzheimer’s disease can be useful for research purposes, in clinical practice, they are still not routine. For example, increases in the course of Alzheimer’s disease, the Liquorkonzentration of dew, while the beta-amyloid levels decrease. In addition, routine genetic testing on the apolipoprotein E4 allele (Apo ?4) are not recommended. (For support of two ?4 alleles, the risk of developing Alzheimer’s disease, at the age of 75 years 10 to 30 times higher than in people without the allele.) Neuroimaging A CT or MRI should be in the initial diagnosis of dementia or be performed after each sudden change in cognition or mental status. A neuro-radiological imaging can identify potentially reversible structural disorders (eg. B normal pressure hydrocephalus, brain tumors, subdural hematomas) and certain metabolic disorders (eg. As Hallervorden-Spatz syndrome, Wilson’s disease). Occasionally, the EEG is useful for. B. clarify an episodic loss of attention or bizarre behavior. Functional MRI or SPECT can provide information on cerebral perfusion and differential diagnosis support (z. B. in the discrimination of Alzheimer’s disease, Frontotemporal dementia and dementia with Lewy bodies). Radioactive amyloid tracer that specifically binds to beta-amyloid plaques bind (z. B. “Pittsburgh Compound B” [PiB] Florbetapir Flutemetamol, florbetaben) were used with PET to the amyloid plaques in patients with mild cognitive impairment display or dementia. This test should be used when the cause of cognitive impairment (eg. B. slight cognitive impairment or dementia) according to a comprehensive evaluation is uncertain when and Alzheimer’s disease is a diagnostic examination. From the determination of the amyloid status using PET is expected that this increases the reliability of diagnosis and treatment. Prognosis Dementia is progressive usually. However, the progression rates vary within a wide range and will depend on the cause. Dementia shortens life expectancy, but the expected remaining lifetime is different. Treatment measures to ensure the safety of the patient providing appropriate stimulation, activities and instructions for orientation discontinuation of drugs with sedative or anticholinergic activity might administration of cholinesterase inhibitors and memantine support for the nurses regulations on palliative measures recommendations for dementia treatment are available from the American Academy of Neurology , (Editor’s note:. In Germany, the “Guidelines for diagnosis and therapy in neurology,” published by the German Society of Neurology apply here specifically Chapter 15 “Diagnosis and treatment of dementia”) Basic treatment measures, as well as nursing aid should increase the safety of the patient and create an appropriate environment. Medications are available. Patient safety occupational and physical therapists can review the apartment to safety, prevent (especially falls) to treat behavioral problems and plan changes when the dementia progresses with the aim of accidents. How well patients cope in different environments (eg. As kitchen, car) should be checked under simulation conditions. If the patients have deficits and remain in the same environment protection measures (eg. As put away knives, hats power the oven, remove the car, confiscating car keys) are necessary. Some situations require the involvement of the driving license office by the doctor, because patients can no longer drive safely with dementia at some point. If patients wander or run away, monitoring systems can be installed, or patients can be registered in the “Safe Return Program.” (Editor’s note: In Germany there is no analog to the “Safe Return program,” but are used positioning systems, the transmitter, for example in a lockable watch or a key chain are located and their signal, then on a cell phone, laptop.. is received or the switching center of the location system provider.) information is available from the Alzheimer’s Association. Finally aids can (eg. As home help, home care) or an adaptation of the environment (barrier-free apartments, assisted living, nursing station) appears sein.Maßnahmen to adapt around patients with mild come to moderate dementia usually best in familiar surroundings cope. Whether at home or in a home, the environment should be designed so that a sense of self-control and personal dignity are safeguarded by the following is offered: Common reinforcing the orientation Bright, friendly, family environment A Minimimum of new stimuli Regular, low-stress activities The orientation can be strengthened by placing large calendars and clocks in the room and by regulated activities of daily living; medical personnel can carry large nameplates and imagine repeated. Changes in the environment, processes or persons should precise the patient and simply explained, omitting insignificant operations. Patients need time to adapt and become familiar with the changes. to explain the patient what is about to happen (eg. as a bath or food intake), can avoid resistance or violent reactions. Frequent visits by nurses and familiar people encourage the patient to adhere to social contacts. The room should be sufficiently lit and sensory stimuli included (z. B. Radio, television, night light) to help the patient to stay oriented and focus their attention. In a quiet, dark, closed room should be avoided. Activities can help patients to function better; a good choice are those activities, which was followed with interest before the start of dementia. Activities should be fun, provide some stimulation, but do not include too many choices or challenges. Exercises to reduce restlessness, to improve the balance and to maintain a certain cardiovascular tone should be performed daily. Exercise can also help induce sleep, and to control behavioral problems. Occupational therapy, and music therapy, help to maintain fine motor control, and include non-verbal stimulation. Group therapy, (z. B. memory therapy, group activities) can help the linguistic and interpersonal relations beizubehalten.Medikamentöse Therapy Discontinuation or reduction of drugs with central nervous system effects often improves function. Sedative and anticholinergic drugs that rather worsen dementia should be avoided. The cholinesterase inhibitors donepezil, rivastigmine and galantamine are effective to improve cognitive function in patients with Alzheimer’s disease or dementia with Lewy bodies, to some extent, and may be useful in other forms of dementia. These drugs inhibit acetylcholinesterase and thereby increase acetylcholine levels in the brain. Memantine ,, an NMDA (N-methyl-D-aspartate) antagonist, can help to slow the loss of cognitive function and act synergistically when combined administration with a cholinesterase inhibitor in patients with moderate to severe dementia. Drugs to control behavioral disorders (for example neuroleptics) were used. Patients with dementia and symptoms of depression should be treated with antidepressants nichtanticholinergen, preferably with SSRI.Pflegerische Help / carers The immediate family is largely responsible for the care of patients with dementia (family care for the elderly). Nurses and social workers can train them and other caregivers in how they can best respond to the needs of the patient (for example, how can they deal with the daily care and also with financial matters.); This training should be continuous. Other resources (eg. As support groups, training materials, web addresses) are available. Nurses can come under considerable stress. The stress may be due to concern how the patient is to be protected, and frustration, exhaustion, anger and bitterness over a so large burden of care. Die Mitarbeiter des Gesundheitswesens sollten auf frühe Symptome von Stress und Burnout bei Pflegenden achten und nötigenfalls vorschlagen, unterstützende Dienste (z. B. Sozialarbeiter, Ernährungsfachleute, Pfleger, häusliche Krankenpflege) in Anspruch zu nehmen. Wenn ein Patient mit Demenz eine ungewöhnliche Verletzung hat, sollte