To STUDY - Technical - New Dacian's Medicine
Memory
loss and Dementia (4)
Translation Draft
Let's finish with the memory problems!
Disturbance of consciousness through chronic use of drugs or drugs, often prescribed by doctors themselves, is an important cause of dementia. Sedatives, tranquilizers and analgesics used to treat insomnia, pain, anxiety or agitation can cause confusion, memory loss and lethargy, especially in the elderly. Discontinuation of that medication usually improves the mental state.
And, just like that, we've come to the amnesiac or demented patient's approach. The approach of the patient with dementia should always take into account two major problems: what is the most correct diagnosis and whether the disease can be treated.
Anamnesis should focus on the onset, duration and rate of memory loss. Acute or subacute confusion may be delirium and suggest intoxication, infection or metabolism disorders. An elderly person with slow-evolving memory loss for several years is likely to have BA. Initial symptoms are often difficulty handling money, driving, shopping, following instructions or finding a way into the city.
Personality changes frequently occur. A history of stroke, with a gradual, irregular development, suggests multiinfarct dementia. Stroke is commonly associated with a history of hypertension, atrial fibrillation, peripheral vascular disease and diabetes. Rapid progression with stiffness and myoclons suggests BJC. Seizures may indicate stroke or neoplasm.
Walking disorders may suggest BP or normal pressure hydrocephalus, especially the second disease when bladder incontinence is also associated. The existence of multiple sexual partners and intravenous drug use indicates CNS infection, especially with HIV. Repeated brain trauma in the past suggests chronic subdural hematoma, pugilistic dementia or hydrocephalus with normal pressure. Alcoholism indicates malnutrition and thiamine deficiency.
A previous stomach surgery, which caused loss of intrinsic factor, suggests vitamin B12 deficiency. Some occupations, such as working in a chemical or battery factory, may suggest heavy metal poisoning. Careful checking of the drugs used, especially sedatives and tranquilizers, can raise the problem of chronic drug poisoning. The existence of a case of dementia in the family suggests BH or familial BA. Recent death of a close person, insomnia or decreased appetite suggest depression.
As for physical examination, careful examination is essential to confirm dementia, look for other signs of damage to the nervous system and to find clues that suggest another systemic disease. Cognitive functions should be evaluated as orientation, recent and long-lasting memory, and computational functions.
Many of the simple common tests for cognitive functions (such as series 7, counting in an increasing and decreasing direction) are very useful when performed correctly by the patient (this makes the diagnosis of dementia unlikely). Mistakes in these simple tests are much more difficult to interpret and have less diagnostic importance. Clock drawing and tracking test are commonly used to assess immediate memory and visual-spatial abilities.
Mini Mental Status Exam (MESM) is a cognitive test with 30 points, easy to perform. It is used for the rapid diagnosis of dementia, providing estimates on the severity and progression of the disease. MESM is influenced by the degree of culture and education and is less useful in the first and last stages of dementia.
Language should be evaluated by testing the ability to read, write, understand and name objects. Rest tremor, stiffness in the toothed wheel, bradykinesis and unsafe gait indicate parkinsonian syndrome. Apraxia or gait ataxia (inability to initiate and coordinate steps in a sequential way) suggests normal pressure hydrocephalus.
Confusion, cranial nerve paresis VI and ataxia suggest thiamine deficiency. Myoclonic movements occur in the BJC, but also in BA. Hemiparesis and other focal neurological deficits can occur in multiinfarct dementia or brain tumors. Bilateral hyperactive tendinous reflexes, Babinski's present reflex and loss of vibrating and proprioceptive sensitivity suggest myelopathy, which may occur in vitamin B12 deficiency.
Loss of sensitivity in the sock glove and decreased tendon reflexes suggest peripheral neuropathy, which can occur in diabetes, vitamin deficiency or heavy metal poisoning. Dry and cold skin, hair loss and bradycardia suggest hypothyroidism. Confusion associated with repetitive stereotypical movements may indicate an ongoing epileptic state. Hearing disorders or vision loss can cause confusion and disorientation, misinterpreted as dementia. These sensory deficits are common in the elderly.
The use of multiple laboratory tests in the assessment of dementia is controversial. The doctor does not want to pass a curable cause, however none of the curable causes occur frequently. Thus, a complete examination must include different, multiple tests, each of them, individually, with little efficiency.
Therefore, the cost/benefit ratio is difficult to estimate and many of the paraclinical dementia assessment algorithms discourage multiple testing. However, a test with only 1 to 2 percent of positive results is worth performing if the alternative is the failure to discover a curable cause of dementia.
Neuroimaging studies (CT and MRI) are particularly controversial due to their cost. However, they clearly have a high value in identifying primary and secondary neoplasms, in locating heart attack areas and in suggesting normal pressure hydrocephalus or diffuse white matter damage.
These tests also support the diagnosis of BA, especially if there is hippocampal atrophy associated with diffuse cortical atrophy. On the other hand, the correlation between cognitive functions and the degree of atrophy and change in white matter, determined imaging, is modest. A diagnosis of BA is put primarily on eliminating other causes of dementia.
Laboratory tests (E apolipoprotein testing for BA, serum levels of vitamin B12 and thyroid stimulating hormone, complete haemoleukogram, plasma electrolytes and VDRL) can detect treatable diseases. The lumbar puncture should not be performed routinely in the assessment of dementia, but is indicated when CNS infection is suspected, e.g. in patients with delirium, fever and nucal sensitivity. Protein levels in CRL are high and those of amyloid Abeta are low in some patients with BA.
However, the usefulness of these tests is not clear. Formal psychometric testing is not required in every patient with dementia, but can be used to determine the severity of the disease, suggest psychogenic causes and to provide a semi-quantitative method of tracking dementia. THE EEG is rarely helpful, with the exception of BJC (repeated episodes of high-voltage, diffuse sharp waves) or a nonconvulsive fundamental epileptic state (epileptiform discharges). Brain biopsy (including meninges) is not commonly indicated except for the diagnosis of vasculitis, potentially curable neoplasms, unusual infections (such as sarcoidosis) or in young people whose diagnosis is unclear. Angiography is performed only when multiple infarctions or cerebral vasculitis are suspected as the cause of dementia.
From the point of view of treatment, the two major purposes of therapy are, firstly, to treat any curable cause of dementia and, secondly, to provide comfort and support to the patient and those in care.
Treatment of the basic causes involves the administration of thyroid hormones in hypothyroidism, vitamins in vitamin B12 and thiamine deficiency, antibiotics in opportunistic infections, the achievement of a ventricular shunt in normal pressure hydrocephalus and adequate surgery, irradiation and/ or chemotherapy in CNS neoplasms. It is often useful to discontinue drug treatment and the intake of sedative drugs or drugs that disturb cognitive functions.
If the patient is depressed rather than demented (pseudodementia), depression should be treated correctly. Patients with degenerative diseases, such as BA or BIH, may also be depressed, which may respond to antidepressant treatment. Antidepressants should be used carefully in dementia patients as they may induce delirium. Antidepressants with weak cognitive side effects, such as selective serotonin reabsorption inhibitors and tricyclic antidepressants with low anticholinergic action, such as desipramine and nortriptilin, are recommended.
Anticonvulsants are used to control seizures. Agitation, hallucinations, delirium and confusion are difficult to treat. These behavioural problems are major causes of the establishment of specialized home care or the institutionalization of patients. Drugs such as phenothiazides, haloperidol and benzodiazepines may relieve behavioural disorders, but have hard-to-control effects such as sedation, stiffness and dyskinesia.
Medications that can relieve agitation and insomnia without worsening dementia are haloperidol in small doses, trazodone, buspirone and propanolol. When patients do not respond to this treatment, it is usually a mistake to increase doses or to use anticholinergics or sedatives (such as barbiturates or benzodiazepines).
Non-medicinal behavioral therapy occupies an important place in the treatment of dementia. The main goal is to make the patient's life demented, uncomplicated and safe. Developing lists, schedules, calendars, and watermarks can be useful.
It is also useful to establish familiar routines and short-term tasks, short walks and simple exercise. For many patients with dementia, the memory for events is much weaker than that for routine activities, yet they can participate in remembered physical activities such as walking, bowling, dancing and golfing.
Dementia patients usually object when they lose control of familiar tasks, such as driving, cooking or money management. Attempts to help or take them over can be followed by complaints, depression or anger. The hostile reaction from the caregiver is unnecessary and sometimes harmful.
Explanations, reassurance, distraction and calm dialogue are most useful in this situation. Finally, financial responsibilities and driving must be taken over by others and the patient will adapt. Safety is an important issue involving not only driving, but also daily activities in the kitchen, bathroom or bedroom. These areas should be monitored, monitored and made as safe as possible.
Moving to a nursing home or home care and care center can initially increase confusion and agitation. Repeated calming, reorientation and careful introduction of new staff will help ease the process. Performing activities known to be enjoyable to the patient would bring a considerable benefit.
Attention should also be paid to the depression and frustration experienced by family members and caregivers. Feelings of guilt and emotional stress frequently occur in these people.
Family members are often overwhelmed and helpless, expressing frustration with the patient, each other or those who provide medical services. Caregivers of demented patients should be encouraged to use the care facilities during the day, giving themselves breaks. Education and counselling assistance in relation to dementia are important. There are also very helpful support groups.
I'm ready! We're going to move on to sleep disorders...
Let's finish with the memory problems!
Disturbance of consciousness through chronic use of drugs or drugs, often prescribed by doctors themselves, is an important cause of dementia. Sedatives, tranquilizers and analgesics used to treat insomnia, pain, anxiety or agitation can cause confusion, memory loss and lethargy, especially in the elderly. Discontinuation of that medication usually improves the mental state.
And, just like that, we've come to the amnesiac or demented patient's approach. The approach of the patient with dementia should always take into account two major problems: what is the most correct diagnosis and whether the disease can be treated.
Anamnesis should focus on the onset, duration and rate of memory loss. Acute or subacute confusion may be delirium and suggest intoxication, infection or metabolism disorders. An elderly person with slow-evolving memory loss for several years is likely to have BA. Initial symptoms are often difficulty handling money, driving, shopping, following instructions or finding a way into the city.
Personality changes frequently occur. A history of stroke, with a gradual, irregular development, suggests multiinfarct dementia. Stroke is commonly associated with a history of hypertension, atrial fibrillation, peripheral vascular disease and diabetes. Rapid progression with stiffness and myoclons suggests BJC. Seizures may indicate stroke or neoplasm.
Walking disorders may suggest BP or normal pressure hydrocephalus, especially the second disease when bladder incontinence is also associated. The existence of multiple sexual partners and intravenous drug use indicates CNS infection, especially with HIV. Repeated brain trauma in the past suggests chronic subdural hematoma, pugilistic dementia or hydrocephalus with normal pressure. Alcoholism indicates malnutrition and thiamine deficiency.
A previous stomach surgery, which caused loss of intrinsic factor, suggests vitamin B12 deficiency. Some occupations, such as working in a chemical or battery factory, may suggest heavy metal poisoning. Careful checking of the drugs used, especially sedatives and tranquilizers, can raise the problem of chronic drug poisoning. The existence of a case of dementia in the family suggests BH or familial BA. Recent death of a close person, insomnia or decreased appetite suggest depression.
As for physical examination, careful examination is essential to confirm dementia, look for other signs of damage to the nervous system and to find clues that suggest another systemic disease. Cognitive functions should be evaluated as orientation, recent and long-lasting memory, and computational functions.
Many of the simple common tests for cognitive functions (such as series 7, counting in an increasing and decreasing direction) are very useful when performed correctly by the patient (this makes the diagnosis of dementia unlikely). Mistakes in these simple tests are much more difficult to interpret and have less diagnostic importance. Clock drawing and tracking test are commonly used to assess immediate memory and visual-spatial abilities.
Mini Mental Status Exam (MESM) is a cognitive test with 30 points, easy to perform. It is used for the rapid diagnosis of dementia, providing estimates on the severity and progression of the disease. MESM is influenced by the degree of culture and education and is less useful in the first and last stages of dementia.
Language should be evaluated by testing the ability to read, write, understand and name objects. Rest tremor, stiffness in the toothed wheel, bradykinesis and unsafe gait indicate parkinsonian syndrome. Apraxia or gait ataxia (inability to initiate and coordinate steps in a sequential way) suggests normal pressure hydrocephalus.
Confusion, cranial nerve paresis VI and ataxia suggest thiamine deficiency. Myoclonic movements occur in the BJC, but also in BA. Hemiparesis and other focal neurological deficits can occur in multiinfarct dementia or brain tumors. Bilateral hyperactive tendinous reflexes, Babinski's present reflex and loss of vibrating and proprioceptive sensitivity suggest myelopathy, which may occur in vitamin B12 deficiency.
Loss of sensitivity in the sock glove and decreased tendon reflexes suggest peripheral neuropathy, which can occur in diabetes, vitamin deficiency or heavy metal poisoning. Dry and cold skin, hair loss and bradycardia suggest hypothyroidism. Confusion associated with repetitive stereotypical movements may indicate an ongoing epileptic state. Hearing disorders or vision loss can cause confusion and disorientation, misinterpreted as dementia. These sensory deficits are common in the elderly.
The use of multiple laboratory tests in the assessment of dementia is controversial. The doctor does not want to pass a curable cause, however none of the curable causes occur frequently. Thus, a complete examination must include different, multiple tests, each of them, individually, with little efficiency.
Therefore, the cost/benefit ratio is difficult to estimate and many of the paraclinical dementia assessment algorithms discourage multiple testing. However, a test with only 1 to 2 percent of positive results is worth performing if the alternative is the failure to discover a curable cause of dementia.
Neuroimaging studies (CT and MRI) are particularly controversial due to their cost. However, they clearly have a high value in identifying primary and secondary neoplasms, in locating heart attack areas and in suggesting normal pressure hydrocephalus or diffuse white matter damage.
These tests also support the diagnosis of BA, especially if there is hippocampal atrophy associated with diffuse cortical atrophy. On the other hand, the correlation between cognitive functions and the degree of atrophy and change in white matter, determined imaging, is modest. A diagnosis of BA is put primarily on eliminating other causes of dementia.
Laboratory tests (E apolipoprotein testing for BA, serum levels of vitamin B12 and thyroid stimulating hormone, complete haemoleukogram, plasma electrolytes and VDRL) can detect treatable diseases. The lumbar puncture should not be performed routinely in the assessment of dementia, but is indicated when CNS infection is suspected, e.g. in patients with delirium, fever and nucal sensitivity. Protein levels in CRL are high and those of amyloid Abeta are low in some patients with BA.
However, the usefulness of these tests is not clear. Formal psychometric testing is not required in every patient with dementia, but can be used to determine the severity of the disease, suggest psychogenic causes and to provide a semi-quantitative method of tracking dementia. THE EEG is rarely helpful, with the exception of BJC (repeated episodes of high-voltage, diffuse sharp waves) or a nonconvulsive fundamental epileptic state (epileptiform discharges). Brain biopsy (including meninges) is not commonly indicated except for the diagnosis of vasculitis, potentially curable neoplasms, unusual infections (such as sarcoidosis) or in young people whose diagnosis is unclear. Angiography is performed only when multiple infarctions or cerebral vasculitis are suspected as the cause of dementia.
From the point of view of treatment, the two major purposes of therapy are, firstly, to treat any curable cause of dementia and, secondly, to provide comfort and support to the patient and those in care.
Treatment of the basic causes involves the administration of thyroid hormones in hypothyroidism, vitamins in vitamin B12 and thiamine deficiency, antibiotics in opportunistic infections, the achievement of a ventricular shunt in normal pressure hydrocephalus and adequate surgery, irradiation and/ or chemotherapy in CNS neoplasms. It is often useful to discontinue drug treatment and the intake of sedative drugs or drugs that disturb cognitive functions.
If the patient is depressed rather than demented (pseudodementia), depression should be treated correctly. Patients with degenerative diseases, such as BA or BIH, may also be depressed, which may respond to antidepressant treatment. Antidepressants should be used carefully in dementia patients as they may induce delirium. Antidepressants with weak cognitive side effects, such as selective serotonin reabsorption inhibitors and tricyclic antidepressants with low anticholinergic action, such as desipramine and nortriptilin, are recommended.
Anticonvulsants are used to control seizures. Agitation, hallucinations, delirium and confusion are difficult to treat. These behavioural problems are major causes of the establishment of specialized home care or the institutionalization of patients. Drugs such as phenothiazides, haloperidol and benzodiazepines may relieve behavioural disorders, but have hard-to-control effects such as sedation, stiffness and dyskinesia.
Medications that can relieve agitation and insomnia without worsening dementia are haloperidol in small doses, trazodone, buspirone and propanolol. When patients do not respond to this treatment, it is usually a mistake to increase doses or to use anticholinergics or sedatives (such as barbiturates or benzodiazepines).
Non-medicinal behavioral therapy occupies an important place in the treatment of dementia. The main goal is to make the patient's life demented, uncomplicated and safe. Developing lists, schedules, calendars, and watermarks can be useful.
It is also useful to establish familiar routines and short-term tasks, short walks and simple exercise. For many patients with dementia, the memory for events is much weaker than that for routine activities, yet they can participate in remembered physical activities such as walking, bowling, dancing and golfing.
Dementia patients usually object when they lose control of familiar tasks, such as driving, cooking or money management. Attempts to help or take them over can be followed by complaints, depression or anger. The hostile reaction from the caregiver is unnecessary and sometimes harmful.
Explanations, reassurance, distraction and calm dialogue are most useful in this situation. Finally, financial responsibilities and driving must be taken over by others and the patient will adapt. Safety is an important issue involving not only driving, but also daily activities in the kitchen, bathroom or bedroom. These areas should be monitored, monitored and made as safe as possible.
Moving to a nursing home or home care and care center can initially increase confusion and agitation. Repeated calming, reorientation and careful introduction of new staff will help ease the process. Performing activities known to be enjoyable to the patient would bring a considerable benefit.
Attention should also be paid to the depression and frustration experienced by family members and caregivers. Feelings of guilt and emotional stress frequently occur in these people.
Family members are often overwhelmed and helpless, expressing frustration with the patient, each other or those who provide medical services. Caregivers of demented patients should be encouraged to use the care facilities during the day, giving themselves breaks. Education and counselling assistance in relation to dementia are important. There are also very helpful support groups.
I'm ready! We're going to move on to sleep disorders...
A fruitful, soothing and
preparatory Saturday for tomorrow's Flowers!
Dorin, Merticaru