CASE STUDY IN DEMENTIA

   

INTRODUCTION:-

My client name of the client / patient Age/Gender, was admitted in on date of admission with the complain of weak memory.

 DEMOGRAPHIOC DATA: -

Client’s Name          : 

 Father’s Name         :

Age                          : 69yrs

Sex                          :Male

Date of Admission   :

Address                    :

 Marital Status          : Married

Religion                   : Hindu

Informant                   :NAME OF THE INFORMANT(RELATION )

Information                : Adequate

2. CHEIF COMPLAINTS:  -

ACCORDING TO CLIENT :-

 Client reported that he is having some mental illness.

ACCORDING TO INFORMANT: -

his son  reported that client is having

difficulty in judging .

difficulty in thinking

partial memory loss                                                 last 1 year

wondering                                                

disturbed sleep,

LOSS OF APPETITE,

/

 3. PRESENT PSYCHIATRIC HISTORY: -

1.      ONSET: - Gradual

2.      DURATION:-1 year

3.      COURSE: - Continuous

4.      INTENSITY:-Increasing

5.      PRECIPITATING FACTOR: - According to Son,Client is in govt job,so because of work load his memory become weak.

6.      HISTORY OF CURRENT EPISODE:-Client was asymptomatic before 1 year suddenly he feel Difficulty in judging ,Difficulty in thinking,& forgetfulness.

4.  PAST PSYCHIATRIC HISTORY: There is no history suggestive of any psychiatric illness.

5. MEDICAL HISTORY: There is no history suggestive of any medical illness.

6.    FAMILY HISTORY :-

 

                                             59 years

                                                          

 

                        30 years                                              35 year                         26 year  

 

                                              5 year                                 3 year

        :- Not alive

       :-Female

      :- Client

                                           

       :- Male       

                

7. PERSONAL HISTORY: -

1. PRE-NATAL HISTORY:- Pre-natal history was not found.
2.  NATAL HISTORY: - Client was full term normal delivered baby at hospital and birth cry was present.
3. BEHAVIOUR DURING CHILDHOOD: - Client is not having any behavior disorder like temper tantrum & other.
4. ILLNESS DURING CHILDHOOD: - No illness during childhood was present.
5. SCHOOLING: - Client has started going to school at the age of 6 year. He was an average student in his studies & he has educated up to graduation.
6. OCCUPATIONAL HISTORY: - Client started orking from the age of 23, he works as government supervisor.
7. SEXUAL HISTORY: - He gets puberty at the age of 13 years.

8. PRE MORBID PERSONALITY:-

1.      ATTITUDE TO OTHERS IN SOCIAL, FAMILY & SEXUAL RELATIONSHIP: -

Client’s relationship with his family members were found to be strained due to his illness, but before the onset of illness client was cheerful & maintained a good peer relationship with sibling and respectful towards other family members.

                                                               

2.      ATTITUDE TO SELF: - Client had good confidence and self-consciousness. He was not a selfish person.

3.      MORAL & RELIGIOUS ATTITUDES & STANDARD: -His attitude towards religion was diligent and respectful.

4.      Mood: -Client is not having any mood swing or any mood disorder.

5.      LEISURE ACTIVITY & HOBBIES: - At leisure time client likes to watching T.V & gardening.

6.      Fantasy life: -Client is not having fantasy life & not having habit of day dreaming.

7.      REACTION PATTERN TO STREES: -Client is having ability to face his problems, generally he never get frustrated with  his problems.

8.      HABITS: - His diet consists of both vegetarian & non-veg food. His usual sleep pattern was 7-8 hrs.

Mental Status Examination

A.     GENERAL APPEARANCE & BEHAVIOR

Facial expression:- Blunted

Posture: Normal

Mannerisms: Normal

Eye to eye contact: Maintained

Rapport: Built easily

Level of consciousness: Conscious

Behavior: Preoccupied

Level of grooming: appropriate

Physical features : looks older than his age.

B.     PSYCHOMOTOR FEATURES:-

Psychomotor activity: Decreased psychomotor activity.

C.      SPEECH:-

Coherence: Speech is coherent

Relevance: Irrelevant

Volume: Increased

Tone: Normal pitch

Manner: Excessive formal

Reaction time : Decreased

D.     THOUGHT

Form: Tangentiallity

Stream: Thought retardation

Content:

o   Delusions: delusion of  persecutory

o   Obsession / Compulsive phenomena:  obsession  or  compulsive phenomena not present

o   Phobias: not present

o   Any preoccupations: not present

E.     MOOD AND AFFECT

Subjective: worried.

Objective: Tensed

F.     PERCEPTION

o   Illusions: -Absent.

o   Hallucinations: - Absent.

G.     COGNITIVE FUNCTION :

               Attention  & concentration :-

Q. what comes before January ?

Ans. Patient answers February. Client attention is poor

Memory:

Immediate :- immediate memory absent. Client did not know where he is sitting know.

Recent  memory  :-Absent , on asking what you have taken in breakfast, he forget answer.

Remote:- Absent ,On asking his date of birth. He gets confused.

H.     ORIENTATION:

Q. where are you at this time ?

Ans. Patient answers he is  in hospital .but not known why he is brought to hospital.

Abstraction :

Q . proverb - bander kya jane adrak ka swaad ?

Ans. Client says he don’t know.

INTELEGENCE :

Q . solev 5+95 ?

Ans. Client answers 60, his intelegence is poor.

JUDEGEMENT:

Personal :-

Q what will you do after getting discharge from hospital?

Ans. Client answers ,he will continue his job.

Social:-

what will you do for your country?

Ans. Patient replies nothing.

I.        INSIGHT:  insight not present.

             Provisional Diagnosis:

            On the basis of history, physical examination and mental status examination my patient is diagnosed as DEMENTIA.

                                                                  DEMENTIA

Definition

ICD-10 defines Dementia as a syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgment. Consciousness is not clouded. Impairments of cognitive function are commonly accompanied and occasionally preceded, by deterioration in emotional control, social behavior or motivation. This syndrome occurs in Alzheimer’s disease, in cerebrovascular disease, and in other conditions primarily or secondarily affecting the brain.

Etiology:

·        Vascular – Hypertensive Encephalopathy, cerebral arteriosclerosis, intracranial hemorrhage, thrombosis, circulatory collapse.

·        Infective – Encephalitis, Meningitis, General Paresis

·        Neoplastic – Space occupying lesions, abscesses

·        Degenerative – Senile and pre senile dementias such as Alzheimer’s, picks disease, Huntington’s chorea.

·        Intoxication – Intoxication or withdrawal of sedatives, opiates, tranquillizers, anticholinergics, anticonvulsants.

·        Congenital – Congenital and post-ictal states

·        Traumatic – Subdural, epidural hematoma, contusion, post operative

·        Intra ventricular – Normal pressure hydrocephalus

·        Vitamin – Deficiency of thiamine, Niacin and B12

·        Endocrine – Metabolic – Diabetic coma, shock, uremia, myxoedema, hyperthyroidism, parathyroid dysfunction, hepatic failure acidosis, and alkalosis.

·        Metals – Heavy metals [lead, mercury, manganese] carbon monoxide, toxins.

·        Anoxia – secondary to respiratory syndrome, cardio vascular system disorders, anemia.

·        Depression – Depressive Pseudo dementia, Hysteria, Catatonia.

Psychopathology:

            There are characteristic changes in the brain: a marked reduction in the population, of neurons particularly in the hippocampus, substantia innominata, locus ceruleus, and temporoparietal and frontal cortex.

Appearance of neurofibrillary tangles made of paired helical filaments.

Neurotic plaques, which consist largely of amyloid and show a definite progression in their development; and granulovacuolar bodies

A marked reduction in the enzyme choline acetyltransferase, in acetylcholine itself, and in other neurotransmitters and neuromodulators.

Clinical Manifestation

In book

In client

Decline in memory and thinking which is sufficient to impair personal activates of daily living. The impairment of memory typically affects the registration, storage, and retrieval of now information. The impairment of thinking and reasoning capacity, and a reduction in the flow of ideas. Impaired processing of incoming information. Difficulty to attend to more than one stimulus at a time.  No clouding of consciousness. Isolation and withdrawal.  Depression. Confusion.

Present Present Present Present Present  Present Present Present Present

INVESTIGATIONS:                                                                                                      

S. No.	Parameters	Value in Client	Normal Value
1.	Hemoglobin	10.4 gm%	13-18gm/dl
2.	RBCs	4.66 millions/ mm3	4.62-6.2millions/mm3
3.	WBCs	9,400/ mm3	4000-12000/mm3
4.	DLC	N62  Eo3 Mo5	N60-70%E1%-4%M2%-6%
5.	ESR	08 mm at the end of 1st hour	<15mm/hr
6.	Sickling	negative	negative

Physical symptoms

            Neuro-Psychiatric symptoms

1.     Alzheimer’s Disease

Memory

Disorientation in time and place                                    First stage

Restlessness and anxiety  

Diagnostic evaluation

1.     Decline in both memory and thinking which is sufficient to impair activities of daily living.

2.     Reduction in the flow of ideas.

3.     Difficult to attend to more than one stimulus at a time, the above symptoms and impairments should have been evident for at least 6 month for a confident clinical diagnosis of dementia to be made.

Treatment Modalities

i.       Validation Therapy: in validation therapy, nursing staff attempt to enter the clients world rather than force him or her to an external world be or she can no longer comprehend. When a client has an irreversible, degenerative cognitive impairment, quality of life issues are important validation strategies increase the clients sense of being understood by others and reduce the incidence of agitation and catastrophic reaction, there by enhancing quality of life.

ii.     Remotivation Therapy: In emphasis is placed on experiencing the world and deriving pleasure and sensory stimulation from a structured group welcoming each other and assisting him o her to feel safe and comfortable. The purpose of remotivation therapy is to interrupt self-absorption and isolation, to create a bridge to external reality and to provide pleasure and sensory stimulation.

DRUG THERAPY:

Benzodiazepine

Alprazolam chloradiazepoxide Clonazepam Diazepam Lorazepam

Xanax Librivin Klonopin Valium Activan

75-4mg 15-100mg 15-20mg 15-20mg 4-40mg

MECHANISM OF ACTION:

                        Anxiolytics depress sub cortical level of CNs, particularly the limbic system and reticular formation. They may penetrate the effects of powerful inhibitory neurotransmitter gamma amino butyric acid (GABA) on the brain.

                                                Increased effects of anxiolytics can occur when taken concomitantly with alcohol, barbiturates, narcotics, antipsychotics, antidepressant antihistamines etc. decrease effects can be noted with cigarette smoking & caffeine consumption.

CONTRAINDICATIONS:

Ø Known hypersensitivity

Ø Acute narrow – angle glaucoma

Ø Untreated open angle glaucoma

Ø Depressed or psychotic clients in the absence of anxiety.

Ø First trimester of pregnancy.

Ø Shock of coma.

SIDE EFFECTS:

CNS    : Sedation, Vertigo, Weakness, ataxia, confusion.

Ocular: Double or blurred vision.

Skin    : Urticaria, rash, photosensitivity.

GI        : Change in weight, dry mouth, constipation.

CNS    : When used in combination with other CNS depressant, may lead to death.

CVS     : Tachycardia or cardiovascular collapse.

NURSING ACTIONS FOR SIDE EFFECTS OF ANXIOLYTE

Sr.No	Side Effects	Nursing Intervention
i.	Drowsiness, confusion & lethargy	Ø Instruct the client not to drive or operate dangerous machinery while taking the medicine.
ii.	Tolerance, physical & psychological dependence	Ø Instruct the client on long-term therapy not to quit taking the drug abruptly. Ø Abrupt withdrawal can be life threatening.
iii.	Ability to penetrate the effects other CNS DEPRESSANTS	Ø Instruct the client not to drink alcohol or other medications that depress the CNS while taking medication.
iv.	Orthostatic HTN.	Ø Monitor lying & standing B.P. & pulse every shift.

Pharmacotherapy:

Phenothiazines:

(a)  Chloropromazine               (Throazine)                                      40 - 300mg

(b)  Fluphnozine                        (Prolixion)                                        1 - 40mg

(c)   Mesordezine                      (Serntile)                                           30 – 400mg

(d)  Prochlorperazine              (Compazine)                                                15 – 150mg

(e)   Thioridazine                        (Mallaril)                                           150 – 800mg

1.     Thioxanthew                       Thiothixine                                       6 – 30mg

                                               (Navan)                                             

2.     Benzisaxazole                      Rsperidone                                       4 – 8 mg

                                               (Rispidal)                                           

3.     Butyrophenone                  Haloperidol                                      1 – 100mg

(Haldul)

4.     Dihydroindolone                Malindone                                        15 – 225mg

(Moban)                                                      

5.     Dibenzodiazepine              Clozapine                                          300 – 900mg

6.     Dibenzothiazepine             Quetiapine                                       150 – 750mg

MECHANISM OF ACTION:

                        The exact mechanism of action is not known. These drugs are thought to work by blocking postsynaptic dopamine receptors in the basal ganglia, hypothalamus, kimbic system, brain stem and medulla. Antipsychotic effect may also be related to inhibition of dopamine medicated transmission of neural impulses of synapses.

CONTRAINDICATIONS:

1.     Alcohol or barbiturate withdrawal state.

2.     Bone marrow depression

3.     Pregnancy & lactation

4.     Hypersensitivity

5.     Parkinson’s depression

6.     Risk for other directed violence related to panic anxiety and distrust of others.

NURSING ACTIONS FOR SIDE EFFECTS OF ANTIPSYCHOTICS:

	Side - Effects	Nursing Measures
1.       (a)    (b)           (c)                (d)	Ant cholinergic effects: Drug mouth Blurred vision Constipation Urinary retention	-         Provide sugarless candy orgum. -         Explain that the symptoms will most likely subside after a few weeks. -         Clear small items from the pathway to prevent falls. -         Order food high in fibrer; enwurage increase in physical activity & fluid intake if not contraindicated. -         Instruct the client to report any difficulty urinating. -         Monitor intake & output.
2.	Sedation	-         Discuss the physician the possibility of administering the drug at bed time. -         Instruct the client not to drive or operate dangerous equipment while experiencing sedation.
3.	Photosensitivity	-         Ensure that client wears protective sun screens, clothing & sunglasses while spending the outdoor.
4.       (a)    (b)	Hormonal effects : Amenorrhea Weight gain	-         Instruct the client to continue contraception because amenorrhea does not indicate cessation of ovulation. -         Weight the client every other day. -         Order a caloric controlled diet.

                                            NURSING CARE PLAN

S. No.	Problems	Nursing Diagnosis	Nursing Goals	Nursing intervention	Evaluation
1.	Weakness, fatigue.	Impaired physical mobility R/T Muscle rigidity & motor weakness postural instability.	Improving mobility.	Daily exercise to increase muscle strength. Improve co-ordination & dexterity.	Client felt a sense of well being.
2.	Self care deficit.	Self care deficit R/T tremors & Motor disturbance.	Enhancing self care activities.	Barrier free environment. Use of adaptive of assertive devices.	Client learnt the devices to enhance self care.
3.	Constipation.	Constipation related to Medication & reduced activity.	Improving nutrition.	Supplementary feeding to increase caloric intake. Dietary restrictions for high protein intake are suggested as it interferes with the absorption of levodopa.	Client improved his maturation & got releasing from constipation.
4.	Slowness of speech.	Impaired communication R/T decreased speech volume, slowness of speech, inability move facial muscles.	Improving communication	offer a guess to the forgotten word instead of correcting. Ask to take a few deep breaths before speaking. Slow a creating quietude when the client is trying to speak.	His communication was slightly improved as he tried to speak by following the instructions.

Psycho education:

1.     Use memory aids – written reminders placed in strategic places such as locking the door or turning off the iron.

2.     Use memory place as a memory aid specific places to keep the items like keys, glasses and money.

3.     Use music therapy to enable communication since the client has the ability to sing familiar songs, as their memory remains infact. Music helps to preserve quality of life.

4.     Give only one task at a time since they cannot comprehend two tasks simultaneously.

5.     Speak and move slowly and quietly to gain client’s attention and confidence.

6.     Allow clients to rest after a major activity to reduce their level of stress.

7.     Place the client in a quiet, dimly lit bed room.

8.     Eliminate the factors (excessive noise, light) that contribute to disturbed sleep.

9.     Place alarms on doors and windows to alert caretakers about possible wandering.

10.                         Delusions and hallucination

·        Accept the client as he is.

·        Reassure him.

·        Do not deny or accept the delusions or hallucinations.

11.                         Encourage the client to participate in ADLs for as possible.

12.                         Provide the family and client specific information about the disease.

13.                         Identify caregivers stress and give counseling and stress management teachings.  

                                                                                                    

BIBLIOGRAPHY: -          

1.       Basvanthappa BT (2007) “Psychiatric Mental Health Nursing” 1^st edition,     published by Jaypee Brothers Medical published (P) Ltd. (PP- 982-93)

       2.  Gail Wiscars Stuart() “Principles & Practice of Psychiatric Nursing, 8^th edition,  

             published by an imprint of Elsevier, (PP- 803-809)

      3.Lilitha’s “mental & psychiatric, Health nursing, An Indian perspective”                

           Pp (557-570)

                

 NOTE:- SOME OF THE DATA RELATED TO PATIENT NOT INVOLVED IN THIS CASE STUDY DUE TO PUBLIC POST.