Case study 2

75
3 1





PHx: HT, BP 140/90 mmHg
Current Medications : Enalapril 5 mg/d
FHx:

SHx:
1


Physical examination
Afebrile, P 72/min regular, R 18/min, BP
140/90 mmHg
No carotid bruit, No LV heaving, no thrill, no
murmur
Clear chest, No hepatosplenomegaly
No pedal edema
No localizing signs


1.

Discussion
74
multiple cognitive deficits
1) Recent Memory impairment

2) Cognitive disturbances
- Agnosia
- Apraxia
- Disturbance
in executive functioning

1 2

dilirium progress 3

DSM-IV Dementia
A. The development of multiple cognitive deficits
manifested by both
1. Memory impairment
2. One (or more) of the following cognitive
disturbances
a. Aphasia
b. Apraxia
c. Agnosia
d. Disturbance in executive functioning
B. The cognitive deficits in Criteria A1 and A2
each cause significant impairment
in social or occupational functioning and represents a
significant decline from a
previous level of functioning
Derilium
acute disorder of attention and global cognition
(memory and perception)
treatable
risk factors
age, pre-existing brain disease, and
medications.
the most common
D Dementia
E Electrolyte disorders
L Lung, liver, heart, kidney, brain
I Infection
R Rx Drugs
I Injury, Pain, Stress
U Unfamiliar enviroment
M Metobolic

Prevention
avoidance of psychoactive drugs
quiet environment
daytime activity
dark and quiet at night
visual and hearing assistive devices,
orientation devices
avoidance of restraints.
Diagnosis
based on clinical observation (no diagnostic
tests ).
The essestial features of delirium include:
Acute onset (hours/days) and a fluctuating
course Inattention or distraction Disorganized
thinking or a altered level of consciousness
Onset Acute/subacute Insidious (generally)
Duration Days-weeks Months-years
Course Fluctuating Progressive
Level of Consciousness Altered & Variable Normal (unless severe)
Attention Impaired Intact (initially)
Psychomotor Slowed, agitated or mixed Often normal
Sleep Sleep-Wake cycle disrupted Less disruption
Clinical feature Derilium Dementia

2.
DDx : Type of dementia
Type Common
Diesase
Degenerative /
inherited
Alzheimers
disease
Cerbrovascular Diffuse small
vessels disease
Demyelinating Multiple Sclerosis
Neoplastic Metastatic Disease
Alzheimer's disease
Alzheimer's is the most common form of
dementia
a general term for memory loss and other
intellectual abilities serious enough to interfere
with daily life.
Alzheimer's disease accounts for 50 to 80 percent
of dementia cases.
Alzheimer's disease
Symptoms:
Difficulty remembering names and recent events

Early clinical symptom; apathy and depression are also
often early symptoms.

Later symptoms include impaired judgment,
disorientation, confusion, behavior changes and
difficulty speaking, swallowing and walking.


Vascular dementia
Previously known as multi-infarct or post-
stroke dementia, vascular dementia is the
second most common cause of dementia after
Alzheimer's disease.

Vascular dementia
Symptoms:
Impaired judgment
Impaired ability to plan steps

as opposed to the memory loss often associated
with the initial symptoms of Alzheimer's.


Vascular dementia
Occurs because of brain injuries such as
microscopic bleeding and blood vessel
blockage. The location of the brain injury
determines how the individual's thinking and
physical functioning are affected.


3.
Laboratory test
Standard tests Additional tests
-CBC
-BUN/Cr
-Electrolyte
-ALT
-TSH
-VDRL
-FPG

-Brain imaging
-Serum&CSF VDRL TPHA if
serum VDRL positibe
-Anti-HIV
-LFT, Calcium, ESR, S.B12,
-S.folic/red cell folate
-Toxicology&heavy metal
-Chest X-ray
-LP,EKG,EEG
Laboratory test

Dementia

4.
Management
The major goal of dementia management are
to treat correctable cause and to provide
comfort and support to the patient and
caregiver

Treatable DEMENTIA
D : Drug toxicity(alcohol , organic poison)
E : Emotional disorder (depression)
M : Metabolic(B12,Folate,B1,niacin def,wilson)
& endocrine disorder(thyroid,PTH,pituitary,insulinnoma)
E : Eye & ears disorders
N : Nutritional disorder & NPH
T : Tumor & trauma (SDH)
I : Infection (Syphilis,chronic meningitis)
A : Arteriosclerosis (vascular&vasculitis)

Promoting and maintaining independence
of people with dementia

consistent and stable staffing
retaining a familiar environment
minimising relocations
flexibility to accommodate fluctuating abilities
assessment and care-planning advice regarding ADLs,
and ADL skill training from an occupational therapist
assessment and care-planning advice about
independent toileting skills; if incontinence occurs all
possible causes should be assessed and relevant
treatments tried before concluding that it is permanent

environmental modifications to aid
independent functioning, including assistive
technology, with advice from an occupational
therapist and/or clinical psychologist
physical exercise, with assessment and advice
from a physiotherapist when needed
support for people to go at their own pace
and participate in activities they enjoy

Interventions for cognitive symptoms and
maintenance of function for people with dementia

Non-pharmacological interventions for cognitive symptoms
and maintaining function
People with mild-to-moderate dementia of all types should be given
the opportunity to participate in a structured group cognitive
stimulation programme.

Pharmacological interventions for the cognitive
symptoms of Alzheimer's disease
The three acetylcholinesterase (AChE) inhibitors donepezil,
galantamine and rivastigmine are recommended as options for
managing mild to moderate
Memantine is recommended as an option for managing
Alzheimer's disease for people with:
moderate Alzheimer's disease who are intolerant of or have a
contraindication to AChE inhibitors or
severe Alzheimer's disease.