Dementia Behaviour in Real Life - Case Study Example

Introduction Dementia can be defined as a deterioration in cognitive abilities that impairs activities of daily living. It results from disorders of cerebral neuronal circuits due to neuronal loss. The most common causes of dementia are Alzheimer’s disease and vascular dementia. Less common causes are vitamin deficiencies, head trauma, endocrine and other organ failure, chronic infections like HIV, and brain neoplasm’s. Background of the patient The patient is a 70-year-old male. He was brought to the clinic in a confused and agitated state. Following admission, he became restless and frequently argued with the staff and showed violent behaviour. The patient’s family members gave a past history of depression, weight loss and insomnia. He often refused his meals and required assistance to perform his daily activities. A complete physical examination was done, which was normal. A Mini-Mental State Examination (MMSE) was performed and the patient scored 14 out of 30. He was noted to be easily distracted and distressed during the examination. Differential diagnosis: 1. Delirium. 2. Dementia. 3. Mood disorder such as depression or irritable mania. Diagnosis: Behavioural and psychological symptoms associated with dementia (BPSD) Management: Investigations- routine 1. Complete blood count 2. Electrolytes. 3. VDRL. 4. Thyroid function tests. 5. Vitamin B12, and folate estimation. 6. Urine. 7. CT/ MRI of the brain Optional focussed tests: 1. HIV 2. Chest X-ray. 3. Lumbar puncture. 4. Liver and renal function. 5. Psychometric testing. 6. EEG- This may help distinguish delirium from dementia Treatment: Because of his aggression and violent behaviour, treatment with haloperidol, 0.5 mg twice daily, was initiated immediately. After three days of treatment with haloperidol, the patient was noticed to be less aggressive, but still appeared to be depressed. Therefore, sertraline 25 mg daily was combined with haloperidol. Regular exercise and music therapy was initiated. After four weeks, the patient appeared more friendlier, less aggressive and was eating and sleeping better. Sertraline treatment was withdrawn after twelve months. Case Study: In this patients case, a past history of depression along with food refusal, weight loss and insomnia could point towards dementia as the diagnosis. The patients restlessness, depression, weight loss and insomnia might be intrinsic to dementia. Aggression may be due to persecutory delusions. Aggression is suggested by his vocal outbursts and violent behaviour. The fact that he needed help even for his routine activities indicates cognitive impairment characteristic of dementia. Critical evaluation of the case Behavioural and psychological symptoms associated with dementia (BPSD) consist of many symptoms and an attempt should be made to identify specific syndromes with careful mental status examination.  The diagnosis of dementia and delirium was facilitated by the use of the Mini-Mental Status Examination test (MMSE).  A score of 24 or less indicates cognitive impairment.  A rapid decline within days or weeks is associated with delirium.  “The other features of delirium include impaired concentration, a fluctuating course, hallucinations, and an identifiable medical cause.  Dementia is characterised by an insidious onset and gradual progression of cognitive impairment.” (Frans JH, Juan PS et al, 2004.) Distinguishing depression from dementia can be difficult. In depression, it is often the patient who complains about his or her state of mind, whereas in Alzheimers disease, it is the family who usually brings the cognitive impairment to the physicians attention. The Yesavage Geriatric Depression Scale can be helpful to differentiate this.(Julie PF). The specific syndromes include psychosis, aggression, irritability and lability, apathy, anxiety, depression and night time disturbances.” (Frans JH et al. 2004.) “Dementia can result from a variety of degenerative, vascular, traumatic, neoplastic, infectious, and metabolic disorders. The three most common types are Alzheimers disease, vascular dementia (previously referred to as multi-infarct dementia), and Lewy body dementia.” (Julie PF). Alzheimers disease is the most common cause of dementia. The typical course is that of progressive decline. “Early in the disease, patients often worry about their cognition and try to cover for their deficits. Depression is common. Those with prominent frontal lobe involvement may also show poor judgment. They develop subtle changes in personality.” As the disease progresses, recent and remote memory worsen and patients have increasing difficulty in performing their routine activities. With further progression, patients become disoriented to place and time, develop apraxias and are at risk for getting lost due to wandering. When confronted or put in new environments they can become very irritable or hostile. 50% of patients have delusions. Paranoid delusions are the most common type. In late-stage disease, patients begin to lose motor skills, including swallowing and control of bowel and bladder. Cognition becomes severely impaired and they gradually lose the ability to recognize family members or themselves. Patients often become bedridden and mute. The cause of death is usually an intercurrent infection. (Julie PF). The physical examination should focus on cognitive, emotional, and neurological findings but must also look for signs of hypothyroidism, congestive heart failure, and diabetes. The most commonly used cognitive tests in clinical practice is the MMSE i.e., Folstein Mini-Mental Status Examination (Folstein MF, Folstein SE et al.1975). The MMSE tests for memory, orientation, attention, and language skills. “Other useful screening tools are the Clock Test, where the patient is asked to draw a clock (this test is sensitive in identifying early dementia), the Yesavage Geriatric Depression Scale, and the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) rating scores.” (Julie PF) There is a controversy whether extensive laboratory testing and imaging studies is required. Even a test with only a 1-2% positive rate is worth undertaking if it can detect a treatable cause of dementia (Thomas DB, 1998, p.149). It is generally considered that “simple laboratory tests (e.g., complete blood count, thyroid stimulating hormone, vitamin B12, serum electrolytes (including calcium), kidney function, blood glucose, and selected drug and alcohol levels if indicated) are useful. Erythrocyte sedimentation rate should be measured if the patient is suspected of having vasculitis as a potential cause of dementia, and testing for syphilis or HIV infection is indicated given the appropriate clinical setting and risk factors.” Imaging studies is indicated for those with “atypical presentation, rapid decline, or focal neurological findings.” (Julie PF). CT and MRI can detect primary and secondary neoplasms, identify areas of infarction or suggest normal-pressure hydrocephalus or diffuse white matter disease. “They also support the diagnosis of Alzheimer’s disease, especially if there is hippocampal atrophy in addition to diffuse cortical atrophy.” (Thomas DB, 1998, p.149) Agitation, hallucination, delusion, and confusion are difficult to treat. These behavioural problems are the major reasons for nursing home placement and institutionalisation. Drugs like phenothiazines, haloperidol, and benzodiazepenes may reduce the behaviour problems but can have side effects like sedation, rigidity, and dyskinesia. (Thomas DB, 1998, p.149). The following is the commonly used treatment methods: Antipsychotics “Medications that may calm agitation and insomnia without worsening dementia includes low-dose haloperidol (0.5-2mg). When patients do not respond, it is a mistake to progress to higher doses or use anticholinergics or sedatives like barbiturates or bezodiazepenes.” (Thomas DB, 1998, p.149) Risperidone and olanzapine are newer antipsychotics and have a lower incidence of extrapyramidal side effects compared with other drugs of this class. Therefore, despite their higher cost, they are the drugs of choice. (Julie PF). “The best evidence is for low-dose risperidone, which has been approved for the management of behavioural disturbance in dementia. The usual starting dose of risperidone in older people with dementia is 0.25-0.5 mg daily, with the final dose generally 1-2 mg per day.” (Gerard JB, 2005.) “Recently, however, risperidone and olanzepine have been shown to increase the incidence of stroke in older patients with dementia. This risk is highest in those with cardiovascular disease or with risk factors such as, hypertension, diabetes, atrial fibrillation, and in those who smoke.” (The Committee on Safety of Medicines.) It is important to have a stopping rule when starting an antipsychotic drug in older people with dementia. Treatment should not be prescribed for longer than 3-6 months. The dose should then be tapered before a trial of stopping the medication. Regular review of patients is essential because their behavioural problems may decrease as their dementia progresses. (Gerard JB, 2005.) Cholinesterase inhibitors Patients with Alzheimer’s disease (AD) often have cholinergic deficits in association with the disease. The cholinesterase inhibitors donepezil hydrochloride, galantamine hydrobromide, and rivastigmine tartrate are the preferred treatment for patients with AD. Although none of the cholinesterase inhibitors has been approved for treatment of patients in advanced stages of AD, patients with less severe forms of the disease have had beneficial cognitive effects with all three agents. “When administered with caution, galantamine, rivastigmine, and donepezil are generally well-tolerated pharmacologic treatment options.”(Jay ME, 2005, p.145-158). However, cholinesterase inhibitor treatment is sometimes associated with deterioration in behaviour. (Gerard JB, 2005.) Benzodiazepines Benzodiazepines should be avoided in older people with dementia. It impairs cognition, gait and may worsen constipation. “If a benzodiazepine is prescribed for severe anxiety, it should not be continued for more than two weeks. Benzodiazepines should not be used to treat insomnia in people with dementia.” (Gerard JB, 2005.) Antidepressants Depression and anxiety symptoms are common in patients with dementia. Sometimes these symptoms are short-lived and do not require any specific treatment. However, if a clinically significant depressive or anxiety disorder occurs in a person with dementia, they should be treated. Modern antidepressant medication is effective against both depressive and anxiety disorders. “The adverse effect profiles of sertraline, citalopram, escitalopram and moclobemide make them suitable for use in older people, including those with dementia. The best evidence exists for sertraline. The usual starting dose is 25 mg daily. If the treatment is effective, it should continue for about 12 months, or longer if there is a history of recurrent depression. With sertaline there is less depression, behaviour disturbance and improved activities of daily living, but not improved cognition.”(Lyketsos CG, DelCampoL etal. 2003, p.737-46) Older patients taking antidepressants have a risk of developing hyponatraemia. The patients serum sodium should therefore be checked before and approximately one week after starting treatment with an antidepressant. Increasing confusion is a common symptom of hyponatraemia in older patients. “It is more common in women, patients with cerebrovascular disease, and in patients on diuretics.” (Gerard JB, 2005.) Anticonvulsants Carbamazepine and sodium valproate have been used in the management of agitated behaviour with dementia. The evidence favours carbamazepine, despite its relatively greater tendency for side effects, including drug-drug interactions. Anticonvulsants, however, should only be prescribed for a limited time. (Gerard JB, 2005) Estrogen Experiments with animal models have shown that estrogen enhances neuronal growth, diminishes the extent of neuronal damage from stroke, and improves cognitive performance. However, it has been difficult to establish the influence of estrogen on cognitive function in women. Thus, given the potential side effects of estrogen and doubtful efficacy, its use for the prevention or treatment of dementia remains controversial. (Julie PF). Vitamin E Vitamin E is an antioxidant, which limit free radical formation, oxidative stress, and lipid peroxidation, and may have disease-modifying effects in Alzheimers and other forms of dementia. One placebo-controlled trial with high-dose vitamin E (2,000 IU/day) delayed both disease progression and institutionalisation in Alzheimers patients, although there were no differences in formal cognitive testing. However, the role of vitamin E in dementia prevention and treatment remains unclear. (Julie PF). Treating Coexisting Conditions Coexisting medical conditions and infections should be diagnosed and treated early to avoid any exacerbation. This may include, thyroid replacement, vitamin replacement, antibiotics and appropriate treatment for CNS neoplasms. (Thomas DB, 1998, p.149) Management of aggression “Physical aggression is common in dementia, particularly towards caregivers. Sometimes aggression can be managed by modifying the behaviour of the caregiver or by modifying the environment in some other way. However, pharmacological intervention is often required, particularly when there is a risk of physical injury to the patient or their caretaker. In an emergency, aggressive behaviour in a patient with dementia may need to be treated with antipsychotic medication. If oral treatment is feasible, risperidone or haloperidol should be tried.” If parenteral treatment is required, the short-term use of intramuscular haloperidol (initial dose of 1-2 mg) or olanzapine (initial dose of 2.5 mg) is given. Following parenteral antipsychotic medication, the patient is monitored for an extended period. Adverse effects including excessive sedation and extrapyramidal reactions may occur. (Gerard JB, 2005) Non-pharmacological therapy: Social and environmental interventions for relieving psychological distress should always be used first before starting medication. “Music, especially classical music, has been shown to decrease aggressive outbursts, agitation, and anxiety and to foster a positive outlook.” (Julie PF). “Music invites social opportunities that can foster and reinforce meaningful interactions.” (Bright R, 1998). When music therapy is combined with dance or movement therapy, patients show improved orientation and ability for self-expression. (Julie PF). It is also useful to stress familiar routines, short-term tasks, brief walks and simple physical exercises. (Thomas DB, 1998, p.149) Wandering can become a significant problem for patients, who can get lost or injured. “Restraints will only increase the wandering patients agitation and combativeness. The best approach is to provide a safe environment in which patients can wander at will. If the patient is at home, caregivers can provide supervised exercise several times a day with engaging activities between exercise periods. All wandering patients should wear an identification bracelet or anklet and be enrolled in the Alzheimers Association Safe Return Program.” (Julie PF). National support groups like the Alzheimer’s Disease and Related Disorders Association may help. (Thomas DB, 1998, p.149) Conclusion The dementias with challenging behaviours can be devastating and debilitating. However, early diagnosis and proper treatment including non-pharmacological treatment and institutionalisation in select cases can help patients, their caregivers, and society at large. REFERENCES Bright R. (1988). Music Therapy and the Dementias: Improving the Quality of Life. St.Louis: MMB Music, Inc. Frans JH, Juan P Schrönen, et al, 2004, An algorithm for the treatment of behaviour and psychological symptoms associated with dementia. Retrieved on October 22, 2005,  http://www.gomemory.co.za/clinicians/bpsd_treatment.htm et al. Folstein MF, Folstein SE et al. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res.1975. Vol: 12. pp. 189-198) Gerard J. Byrne, Pharmacological treatment of behavioural problems in dementia. Retrieved October 23, 2005. http://www.australianprescriber.com/index.php?content=/magazines/vol28no3/67_70_dementia.htm Jay M. Ellis, JAOA . Vol 105. No 3. March 2005. pp. 145-158 Julie PF, Dementia: Causes, Evaluation, and Management). Retrieved October 23, 2005. http://www.hosppract.com/issues/2001/01/cefago.htm Lyketsos CG, DelCampoL etal. Arch Gen Psychiatry. 2003 Jul;60(7):737-46.) The Committee on Safety of Medicines. Retrieved on October 22, 2005, http://www.mca.gov.uk/aboutagency/regframework/csm/csmhome.htm) Thomas DB, Memory loss and dementia. Harrison’s principles of internal medicine, 1998, 14th edition, vol 1, p.149 Read More