Quality Life For Older People: Dementia

attribute Life For Older People derangementThere is no psychogenic disorder that is inevit commensurate in obsolescentish senesce. Older pack describe their all overall well- macrocosm as good. Hence there is such(prenominal) a thing as figure ageing in terms of mental (as well as somatic) health. Nevertheless, as in all age groups, mental disorder is non uncommon in former(a) hoi polloi and there argon nigh disorders that fabricate to a great extent prevalent as age increases. rational disorder in old age can be divided into two broad categories radical disordersThese be characterized by admiration, which may be subtile (i.e. delirium) or chronic (i.e. insanity) soundal disorderssuch(prenominal) as depression, anxiety and panic but alike psychotic disorders, such as late- attack schizophrenia (formerly known as late paraphrenia)In addition, drug and alcohol misuse and dependence can (like many disorders) continue into old age, or emerge for the scratc h time when the person is previous(a). Similarly, it should non be forgotten that personality difficulties do not necessarily disappear with ageing. (Wolstenholme et al, 2002)EpidemiologyThe prevalence of mental disorder in elderly people depends on exactly which age group is examined and where they atomic number 18 live. In community surveys of all people aged over 65 years, approximately 5% be bring to remove severe organic fertiliser judgement disorders (mainly dementedness) and a further 5% to rescue cushy symptoms of forgetfulness. 2.5-5% will have depression severe enough to physiognomy discourse with a further 10% complaining of minor depressive/anxiety symptoms. Late onset schizophrenic unsoundnesses are much less common, perhaps 0.5-1.0%. (Landau et al, 2008)If single looks at the very elderly (greater than 80 years) the place of organic disorders, mainly dementia, are much increased, (e.g. 20%) whereas separate diagnoses may sink less much in differe nt words organic disorder is (as one might expect) a disorder associated with change magnitude age.In re emplacementnts in local authority homes, hospitals or other institutional care, the rates for both(prenominal) organic and functional disorder ( evently depression) are much increased about 30% for each type. It is probable that mental disorder will have contributed to the person entering the institution, e.g. dementia making them unable to survive goloshly in their own home but the combination of losing ones home and familiar surroundings can likewise aggravate existing confusion and/or depression. (Landau et al, 2008)Ethics and LawThe main ethical concern in erstwhile(a) people relates to the issue of capacity. In some jurisdictions (e.g. Scotland) there are now laws around incapacity. energy legislation will appear shortly in England and Wales. Irrespective of the legislation, however, the need to maintain the older persons ability to make autonomous decisions is cl e arliest of ethical importance. Autonomy can be undermined by both professionals and families for both benign and malignant reasons (Colin, 2008). The presumption should always be that the person has the capacity to make a extra decision. Judgements about capacity should always be made with respect to a specific ability a person may not be able to drive, but may still be able to run his or her own finances. Having a particular capacity (or competence) means that the person can generate and understand the relevant instruction and that the person supplys shew of weighing up the information as he or she makes a decision (which need not be the decision that the person assessing capacity would have reached). (Colin, 2008)If the person lacks capacity, those pick outd must act in the persons best interests. These have to be understood broadly. The criteria for assessing a persons best interests should accept taking account of what the person has said or stipulated (e.g. on an advance directional or living will) in the past taking account of what the person now says when enabled to participate in the decision taking account of the views of all those other people involved in the persons welfare, insofar as this is practicable, oddly as regards what they think the persons wishes would have been under the benefaction circumstances if the person had been able to communicate his or her wishes making sure that the least restrictive course of action is taken.There are particular procedures to be fol subalterned if the person lacks accepted capacities. For instance, there is a variety of steps to be taken (involving the courtyard of Protection) when the person cannot manage his or her finances and if the person lacks the capacity to drive, the requirements of confidentiality may be put by in the interests of public safety. Having said this, however, the bear ons duty is to be on the side of the patient and it is an affront to the persons stand up as an autonomo us individual if his or her abilities are undermined without due cause. The General Medical Council offers advice on such issues. (Van, 1996)The Aging PopulationThe table (based on 1991 projections) shows the age structure of the UK universe of discourse for the years 2001 to 2041. The increase in the proportion of elderly people is in the 75-84 year group (+39%) and much particularly in those 85+ years (+55%). Meanwhile, the numbers of jr. people changing little. The vast majority of these older people live at the present time in their own homes, only 6% being in institutional care (residential homes or hospital).The over-85 group are predominantly women, the majority widowed and living alone. The very elderly group have proud consultation rates with general practitioners, with many more home visits and occupy up to 50% of all NHS beds ( medical exam, surgical and psychiatric). They are more liable(predicate) to have complex combinations of physical, psychological and sociable difficulties, which require multidisciplinary assessment and interposition. (Birk and Harvey, 2006)DementiaAbout 5% of the general population over 65 years develop from severe cognitive impairment with further 5% show mild changes, which may progress with time. Dementia refers to a global impairment of mental function which follows a chronic and progressive course. The symptoms and signs have usually been present for at least 6 months (Birk and Harvey, 2006). The impairment of mental function is commonly associated with deterioration in emotional control, social behaviour, motivation and the ability to perform activities of chance(a) living (ADLs). These non-cognitive features of dementia, which are often the most disconcerting aspects for family carers and friends, tend now to be referred to as behavioral and Psychological Symptoms in Dementia (BPSD). Dementia is related to progressive cerebral degeneration, which may be ca employ by a variety of pathological processes, such as Alzheimers illness, vascular dementia and dementia with Lewy bodies. Post mortem changes found in the mavens of people with dementia suggest the following diagnoses (approximate figures)Alzheimers affection50%vascular dementia15%Dementia with Lewy bodies15%Mixed vascular/Alzheimers disease15%Other causes5%Alzheimers diseaseAlzheimers disease is characterised by a gradual pestilent onset and progressive course, often beginning with reposition misery before other cognitive functions (e.g. language, praxis) become affected. Non-cognitive features (depression, psychosis, wandering, aggression, incontinence) are common. physiologic examination is often normal, as are telephone number blood investigations. (Farrer, 2001)Computerized tomography (CT) scans may be normal or show talk cachexia and dilatation of ventricles. CT scans also play a role in excluding other possible causes of confusion (e.g. space-occupying lesions, haemorrhages). Angled CT scans afford go against views of the medial temporal lobes, which can show marked atrophy. However, this is not specific for Alzheimers disease. Hippo-campal atrophy is also seen with magnetic resonance imaging (magnetic resonance imaging) see. Single photon emission computerized tomography (SPECT) provides information on how the brain is functioning, usually by tracing blood flow using radio-labelled technetium. In Alzheimers disease SPECT scanning can show a generalized decrease in blood flow, or biparietal and bitemporal hypo-perfusion. However, the diagnosing must always be made on the basis of the overall clinical presentation instead than solely on the appearance of scans. (Farrer, 2001)Dementia with Lewy bodiesDementia with Lewy bodies is characterised by the triad of fluctuating cognitive impairment, continual visual hallucinations and spontaneous Parkinsonism, though not all occur in every patient. As with Alzheimers disease, onset is insidious and may begin with cognitive problems, Parkinsonism, o r both. Cognitive impairment initially affects attentional and visuo-spatial function, with fund initially relatively spared. As with Alzheimers disease, non-cognitive features are common. Parkinsonism consists mainly of bradykinesia rather than tremor and, once again, routine blood investigations are normal. CT scan may be normal or show generalised atrophy and dilatation of ventricles, with less temporal lobe atrophy than in AD. Blood flow SPECT can show similar changes to those seen in Alzheimers disease, though DLB is more likely to be associated with occipital hypoperfusion than Alzheimers disease, a finding which may relate to the hallucinations and visuospatial disturbance. Parkinsonism in DLB is associated with nigrostriatal degeneration, similar to that seen in Parkinsons disease. It is possible to image nigrostriatal degeneration using SPECT scanning with a ligand for the dopamine transporter (FP-CIT or DaTSCAN imaging) which can be helpful in assisting with the diagnosi ng of Parkinsons disease. In the future it is hoped such imaging methods may be helpful in diagnosing DLB as well. (Mo Ray, 2009)Vascular dementiaIn contrast, vascular dementia usually has an abrupt onset, often in association with a recognised stroke, and is associated with a fluctuating course, a stepwise decline and often reasonable brain wave at least in the early stages of illness. An exception to this course is subcortical vascular dementia, which may cause some 20% of all vascular dementia, when abrupt onset and a stepwise course may not be seen. Patients will often have risk factors for vascular disease, for example high or low blood pressure, ischaemic heart disease or peripheral vascular disease, but also diabetes mellitus and hypercholesterolaemia. Physical examination is likely to reveal focal neurology and a CT scan would be anticipate to show rise of cerebrovascular disease. (Mo Ray, 2009)Other dementiasOther causes include rarer degenerative processes, e.g. Fronto -temporal dementia, Huntingtons disease, in addition to sousing dementia, tumours, haematoma, etc. In some cases no discernible pathology is found. (Mo Ray, 2009)Clinical assessment and managementBy awake history taking (usually from patient and informant) and examination of both physical (particularly neurological) and mental submit, it is possible to predict the likely underlying pathology in most patients with dementia. No specific diagnostic tests are yet available, but clinical diagnosis may be usefully booked by structural brain imaging methods such as CT or MRI scanning and functional imaging techniques such as SPECT (Single Photon emanation Computer Tomography) scanning. It is important to give way methods of establishing the aetiology of dementia during lifetime (Eastwood and Reisberh, 1996) To assist in predicting course of illness and determining prognosis. To inform management decisions for example specific treatments are becoming available for Alzheimers disease ( cholinesterase inhibitors) and vascular dementia and it is necessary to know which patients should receive which treatment.Patients with dementia usually present either because of failure to mete out or with disturbed behaviour occasionally with both. They often lack insight into their illness or, in the early stages, deny it. People with dementia require An assessment of the cause and severity of the dementia (cognitive impairment and behavioral abnormalities) An assessment of deficits in function and the need for care (dependency) An assessment of the persons social situation Provision of treatment and care appropriate to the identified needs Support for carers both practical and emotional Review of the to a higher place points is the treatment and care appropriate and beneficial?About 50% of cases of dementia have con up-to-the-minute physical health problems. The burden of care produced by a physically sick patient with dementia is greater than that of a fit one therefore, diseases should be sought and enured where appropriate. Dementia may also be complicated by Emotional liability clinical depression Psychotic features (i.e. delusions and hallucinations) Behavioural disturbances (i.e., wandering, aggression, incontinence)These may be helped by pharmacotherapy, counselling and explanation and support to relatives. Such patients may respond either to antidepressants for liability and depression, or major tranquillizer agent agents for psychotic features and some behavioural disturbances. Patients with dementia are often sensitive to side effects of mind-blowing drugs and so it is important to begin therapy with very low doses of medicinal drug and monitor carefully for side-effects, particularly extra-pyramidal problems. In 2004, the two drugs Risperidone and Olanzapine were recommended not to be used for the control of agitation and disturbed behaviour in dementia because of the risk of stroke. The use of antipsychotic medication to control agi tation and other difficult behaviours in top to severe dementia remains common but controversial. (Birk and Grimley, 2005)Memory ClinicsThe assessment of forgetfulness is often undertaken by memory clinics. These exist in a variety of forms (some being very clinically focused and others having a query basis). The aim is to provide thorough assessment (clinical history, with mental state, neuropsychological and physical examinations and appropriate investigations e.g. blood tests and neuro-imaging) in order to arrive at an accurate diagnosis. Some clinics then initiate and monitor the use of medication (e.g. the cholinesterase inhibitors for Alzheimers disease). Increasingly, memory clinics are seeing people with milder symptoms, many of whom will be anxious about the calamity of dementia. Some such patients will have other conditions, such as depression (i.e. pseudo-dementia) or other physical illnesses. (Seltzer et al, 2004)The diagnosis of mild cognitive impairment (MCI) is now sometimes made in people who present with forgetfulness but who do not replete the criteria for even a mild dementia (because, for instance, their perfunctory activities are not impaired). A proportion of people given the diagnosis of MCI will progress to break down dementia on followed-up. Identifying MCI may, therefore, open up the possibility of early treatment. But MCI is not uncontroversial, because some people given this label will show no such progression of symptoms and might be more properly regarded as normal. (Seltzer et al, 2004)Acute Confusion (Delirium)Elderly people seem particularly likely to develop confusion in response to a wide score of stimuli either physical insults or sudden social change. This presumably reflects the reduced ability of the aged brain to cope with such events, particularly if it is to boot damaged by a dementing process. An acute confusional episode may sometimes be the first evidence of an underlying dementia. Elderly patients with acut e confusion are seen throughout medical practice, e.g. 20% of all acute medical ward admissions are found to be acutely confused. In elderly people apathy, under-activity and overcast of consciousness are more common presentations of delirium than the florid, overactive restless, hallucinating states usually exposit in relation to younger patients. Causes include (Birk et al, 2006) Intercurrent physical ill-healthAdverse reaction to a prescribed drug or drugsCatastrophic social situations, e.g. a move into residential careAcute confusion should be regarded as indicative of underlying disease and investigated medically. Untreated it has a 40% mortality rate.The clinical approach is to round out a full physical examination looking for evidence of infection, stoke, MI or other illness. A review of medication should focus on drugs started or stopped recently. Until the underlying cause is determined and treated, a small dose of an antipsychotic agent may reduce the severity of deliri ous episodes. (Birk et al, 2006)Functional DisordersDepressionThis is the most common psychiatric disorder found in old people (if milder cases are counted) and the entropy commonest single underlying cause for all GP consultations for people over 70. The majority of depressive syndromes are of mild to moderate severity. About one fifth of cases are severe and carry the risk of suicide especially in men, in those which fail to remit within 6 months of onset and in those who feel physically ill (hypochondriacal) especially if they have the delusional belief that they suffer from cancer. Depression in old age may be precipitated by adverse life circumstances bereavement passing play of health brat of bereavement or loss of health in a key figure. As with younger patients, those who suffer from depression may have vulnerable personalities (i.e. they may be anxious and obsessional by nature) or they may have no close confidantes (i.e. they may be socially isolated). More recently ev idence has emerged suggesting that depression occurring for the first time in later life may be associated with subtle brain abnormalities, such as an increase in white matter lesions (detected on neuroimaging), which may reflect cabalistic or undetected cerebrovascular disease. (Rands et al, 2006)Depressive illness in old people shows a wide range of clinical presentations. The typical picture of low style, anhedonia and vegetative disturbance of sleep and appetite seen in younger people may predominate. Some patients become apathetic, withdrawn and appear to lose their cognitive abilities (this is called depressive pseudo-dementia as cognitive impairment may be so marked as to mimic organic dementia). Others may present with a picture of severe agitation and restlessness, accompanied by delusions of ill health or poverty, e.g. that they are dying of a brain tumour, that their bowels have stopped working and are rotting inside them, or that they are unable to pay for their hospit al treatments.The clinical approach with mild cases of depression is unlikely to involve the Old Age Psychiatry Service, since they will be treated by the Primary Health charge Team. Support and counselling may be supplemented by the use of antidepressants. More severe or firm cases are likely to be referred for specialist assessment and treatment. The majority of cases respond as well to treatment as younger patients perhaps even better Poor outcome is often the consequence of myopic treatment. The older tricyclic antidepressants are often not well tolerated, postural hypotension, urinary and gastrointestinal side effects being prominent. (Rands et al, 2006)Dosage should be titrated to the maximum tolerated, starting doses generally being 1/3 1/2 of those for younger patients. Newer antidepressants such as SSRIs have a particular place in the treatment of the elderly. Delusional depressions require the addition of neuroleptics for unresponsive or severe depressions ECT is a s afe and telling treatment. Lithium carbonate has a valuable place in prophylaxis of recurrent episodes and is also effective in potentiating or augmenting the antidepressant actions of tricyclics.Many elderly depressed patients have previous or current physical illness. Not only must this be taken into account during treatment (e.g. tricyclic antidepressants are usually avoided in a patient with ischaemic heart disease and, in patients with a high risk of bleeding, SSRIs should be used with caution), but also physical illness must be treated in its own right to maximise the patients chances of recovering from the depression. (Rands et al, 2006)Anxiety DisordersAnxiety disorders do occur in old people, about half of it persisting from early life and half coming on for the first time in response to the stresses of ageing. A common precipitant stress is that of failing physical health, e.g. development an acute phobic state after a fall from a bus, leading to a work shift and a peri od of reduced mobility.Behavioural methods of treatment may be effective. Diffuse anxiety and loss of confidence, even if precipitated by an adverse event, may indicate an atypical form of depression. Such patients respond better to antidepressant, rather than anxiolytic, drugs. (Rands et al, 2006)Paranoid StatesIt appears to be a normal feature of ageing that individuals become rather more inflexible in their attitudes and fearful of adverse influence by the outside world. Elderly people are often not only physically and financially disadvantaged, but they enjoy relatively low social status and are often the victims of attack or deception. It is, therefore, perhaps not surprising that persecutory ideas (which we tend to clustering together as paranoid symptoms) often emerge. The main conditions in which paranoid persecutory symptoms occur are as follows (Corey-Bloom, 2000)Late onset schizophrenia/delusional disorderThis was formerly known as paraphrenia. The typical consequence i s an elderly spinster, with sensory impairments (deafness or visual impairment), living alone and isolated. Her self-care skills are good and she is apparently normal apart from the possession of a complex delusional system in which she believes she is the victim of a faction (usually to defraud her). She hears third person auditory hallucinations, may smell odours, which she interprets as poison gas manage into her room and misinterprets chance occurrences as having special significance. This psychotic illness, similar to schizophrenia in younger life, responds to antipsychotic drugs if the patient can be persuaded to take them. The delusions, however, seldom completely disappear but instead become encapsulated the patient is no longer bothered by them although he or she never gains full insight into their delusional nature. A depot injection given by a Community Psychiatric foster is often a useful vehicle which improves compliance with medication and provides regular contact w ith the patient. (Corey-Bloom, 2000)Acute confusional state/deliriumParanoid symptoms are common during delirium, the patient misinterpreting events because of his/her altered direct of consciousness. The management of these symptoms has already been described neuroleptic medication may help to reduce agitation and behavioural disturbances.Paranoid Reactions to ForgetfulnessThese usually occur in independent old people who explain their experience of forgetting where things have been placed by incriminate others of stealing them. Objects stolen are usually everyday ones, e.g. cups, teapots, pension book, money or glasses. Stolen objects often are returned or reappear in the usual place. The most likely cause of forgetfulness and paranoid misinterpretation is, of course, a dementing process. major tranquilliser medication is seldom of benefit in these circumstances. (Corey-Bloom, 2000)Assessment ProceduresClinical diagnosis of dementia includes identifying the cause of the cognit ive impairment, which may be a treatable non-dementing process, delirium, or depression (Rockwood et al., 2007). When an illness that is associated with dementia is identified, the severity and character of cognitive impairment is commonly assessed in conjunction with the degree of illness and the potential for other psychiatric disorders such as depression (APA, 2000). Diagnostic assessments include a review of the patients medical history, a physical exam, and paygrade of depression, delirium, and cognitive status (Beck, Cody, Souder, Zhang, Small, 2000). Physical assessment results may identify treatable physiological imbalances that affect cognition (Freter, Bergman, Gold, Chertkow, Clarfield, 1998).Referral to neurology, neuropsychiatry, or a geriatric specialist in dementia has been stated as an important element in diagnostic assessment (Beck et al., 2000). Other elements in the assessment process commonly include neuro-imaging that can support the findings of assessments, and over time, the progression of the disease (Van Der Flier et al., 2005). Studies have also indicated that research using electroencephalography (EEG) might be an inexpensive tool that could contribute to the differentiation of dementias.Another important set of tools for assessment of cognitive deficits is neuropsychological testing (Sano, 2007). Neuropsychological assessments include testing for deficits in cognitive abilities such as current gifted functioning, orientation, attention, verbal and non-verbal memory, verbal fluency, naming of items, and executive functioning (Petersen Lantz, 2002). Neuropsychological testing has been suggested as providing a character to clinical data in diagnostic assessment for dementia, differentiating between different types of dementias, early detection of cognitive loss, and identifying potential interventions (Sano, 2007 Savla Palmer, 2005). The diagnosis of dementia, even with the use of diagnostic tools, remains primarily based on o bservational data and judgment of the combined clinical data.The process involved in dementia assessment and diagnosis can be overwhelming and has been report as one reason for delaying diagnosis (Sternberg, Wolfson, Baumgarten, 2000). There is also evidence that suggests that differentiating between MCI that can precede AD, and memory loss that does not have emerging pathology, poses trouble and hesitation in requests for formal assessment (Shah, Tangalos, Petersen, 2000). The literature also suggests that there is a strong need for individuals and families to bring their concerns forward to a physician for assessment as often the first indication that an older adult is experiencing cognitive problems occurs during a crisis situation (Boise, Neal, Kaye, 2004 Borson, Scanlan, Watanabe, Tu, Lessig, 2006). In AD, memory loss has been described as insidious and can include a period of concealment preceding diagnostic investigation related to a need to preserve feelings of self-wor th, identity and control (Keady Gilliard, 1997, p. 245). A diagnosis of dementia coinciding with a health crisis (e.g., stroke leading to vascular dementia) or with a progressive neurological disease (e.g., Parkinsons disease) are reported more frequently because of a higher associated incidence and known relationship with these disorders (Lindsay, Hebert, Rockwood, 1997 Wientraub, Moberg, Duda, Katz, Stern, 2004).The most common pulse for diagnostic evaluation is a realization of memory problems by the individual, or their family and social contacts, or associated with upsetting behaviour in social situations. Thomas and OBrien (2002) described behavioural changes that have been reported in dementia categorized as psychotic symptoms or possible alterations in mood or motivation.Psychotic symptoms include delusional ideas and beliefs (e.g., believing that misplaced articles have been stolen), hallucinations (e.g., seeing and speaking to people who are not physically present in a room), and misidentification of individuals (e.g., mistaking a son for a husband). Subtle changes in mood or motivation that may initially go unaddressed but increase in level of concern include apathy (e.g., lethargy), agitation (e.g., wandering, repeated dressing and undressing), aggression (e.g., verbal and/or physical, or increasing frustration with common tasks), sleep disturbances (e.g., up during the night related to distortions in sleep cycles), changes in eating habits (e.g., progressing to dependency for awareness of meal times) and personality changes (e.g., depression or unsubstantiated suspiciousness of motives of family members). Dementia and depression have been reported as the two most common medical problems in older adults (Leplaire Buntinx, 1999). However, the association between depression and dementia severity has not been confirmed, and in some instances depression has been misdiagnosed as signalling cognitive impairment (Maynard, 2003).Diagnostic ProceduresT hese are of primary importance and include both psychiatric and medical history-taking together with physical examination and mental state assessment (including cognitive examination). Investigative procedures, e.g. EEG, blood tests, CT, MRI or SPECT scans are used as necessary.There are now operational criteria or consensus statements for the diagnosis of the main types of dementia (e.g. Alzheimers, Lewy body, vascular and fronto-temporal dementias), as well as for functional disorders. Many of the investigative procedures used in old age psychiatry are aimed at excluding other conditions in order to satisfy accepted international diagnostic criteria (e.g. the International Classification of Diseases, Tenth Edition, and ICD-10).Thus, the diagnosis of Alzheimers disease requires that other systemic or brain diseases should be absent. This suggests the importance of blood tests (e.g. to exclude amongst other things vitamin B12 or folate deficiency) and brain scans (e.g. to rule out t he possibility of tumours or haematomas). On the other hand, some diagnoses can be clinched by a particular finding on investigation (e.g. the finding on CT of tenfold cerebral infarcts in a person whose history is in keeping with a diagnosis of vascular dementia). A functional scan, e.g. SPECT, might be a useful means to confirm a diagnosis of fronto-temporal dementia in someone where the anatomical scan (e.g. CT) only shows very mild frontal lobe atrophy. Such a scan might then be used to explain this bewildering and distressing condition to the family.Illnesses in old age are commonly multiple, so that patients often suffer from several disorders simultaneously. Investigations become important, therefore, in functional illnesses too, not only because certain conditions need to be excluded (e.g. hypothyroidism in depression), but also because other physical conditions might make some psychiatric symptoms worse, or might preclude the use of certain medications. For example, chroni c obstructive pulmonary disease, if not optimally treated, might exacerbate anxiety and panic or a bleeding disorder or ulcer might limit the use of SSRIs.Disorder of FunctionDiagnosis alone does not tell you how severely disabled someone is. Two people with the corresponding condition may behave very differently, e.g. dementia due to Alzheimers disease may render one person unsafe for independent living, but simply slow the other one down in the time taken to complete the daily crossword. It is important therefore to assess the functional disability that an old person suffers from and decide whether it can be relieved. Occupational Therapists and Physiotherapists play an important part here, but the doctor needs to be aware of this aspect of illness when he/she is taking a history. No