Dementia is a progressive
irreversible clinical syndrome characterized by widespread impairment of mental
function which may include memory loss, language impairment, disorientation,
personality change, difficulties with daily living activities, self-neglect and
psychiatric syndrome 4. It is more than just forgetfulness. The most common
problems arises in a dementia patient are as follow:
Communication and language problem
Behavior problem: reasoning and judgment
Hallucination and delusion: visual perception
Causes of dementia: in most cases, dementia is not caused by a person’s behavior or actions.
It may be due to:
Cerebrovascular- damage to cerebral blood vessels, like vascular or multi
Infection related – associated with HIV/AIDS
Metabolic disorder, eg, Wernicke korsakoff syndrome
Traumatic brain injury
Managing the symptoms according to the severity: our patient Mr M 80
years old man diagnosed with dementia is agitated. This agitation might be due
to his extreme age and disease process. As he is suffering from severe
dementia, he does not have any communication with his family members or care
givers. Thus unable to express his day to day needs and sufferings. Moreover he
passes urine involuntarily and his clothes get wet frequently. This urinary
incontinence might be due to urinary tract infection or just due to severe
He also has a recent history of fall, from which we can understand that
he is quite bed bound thus chance of developing bed sores if not taken care
properly. Moreover there must be undiagnosed pain which needs to be ameliorate.
There is chance of infection as he reaches at his extreme age with
multiple comorbidities. Fever and infection commonly occur in patients with
advanced dementia, mainly respiratory tract and urinary tract infections.
Feeding issue: in advance dementia the care givers always find it very
difficult to feed the patient. Difficulty in swallowing, delayed swallowing are
the most common problems while feeding a patient. Although family members are
worried about the proper nutrition, the requirements of enteral feeding or
naso-gastric feeding has to be well explained as there are evidence that
artificial feeding has not shown significant benefit.
Advance care planning: the families or care givers should be well awared
about the consequence of the later stage of dementia and get prepared for the
critical periods as they have to take good decision making and patient-centered
care at some point of disease process.
Psycho-social issue: patient with advance dementia always find to be
depressed and isolated from his or her families and neighbors. The person may
become agitated, distressed, socially withdrawn and may show resistive
Ethical issue: especially concerned with personal care and invasive
procedures. Here the goal of care is to provide comfort and maintenance of
function rather than prolongation of life, so end of life care issues to be taken
The factors need to be reviewed:people with dementia has
complex problems thus while intervening person consider to be as a whole and
his physical, psychological, social and spiritual health must be ensured.
Physical symptoms need to be amended as much
At first try to prevent malnutrition and its consequences. We have to
review and correct the factors that cause reduce food intake. Try to provide
the desired taste and texture of the food, and also temperature of the food is
also important. Oral candidiasis, ulcers, loose or painful teeth or loosle
fitted dentures need to be corrected. Medications need to be reviewed that may
cause loss of appetite, or constipation. Frequent small amount (tea spoon size
or smaller bollus) of feeding to be ensured as they often forget to swallow the
food in their mouth.
It is obvious that patient with advance dementia like our patient has
been experiencing some level of pain which needs to be assessed and managed
efficiently. It is difficult to assess pain in people with dementia due to lack
of communication. Pain may be expressed by certain facial expression (frowning,
sad frightened face, distorted expression, rapid blinking), groaning, granting,
noisy breathing, rigid tense body posture, decreased social interaction,
restricted movement, refusing food, crying, irritability, or distress, etc.
Thus pain should be measured properly and managed accordingly.
Family members or care
givers are always worried about the patient’s condition. The carer’s burden and
stress are very important factor to focus on. There is always a conflict or
misunderstanding between the perceptions of cure and care observed in the family
members. Their stress, burden and sadness must be lessened in order to achieve
the quality of life.