dementa
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dementaTRANSCRIPT
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DEMENTELE
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EPIDEMIOLOGIE
• 5% dintre persoanele peste 65 ani - forma severa; 15% - forma usoara
• 50-60% dementa tip Alzheimer– debut: dupa 60 ani– factori de risc: sex feminin, AHC, TCC in
antecedente, sindrom Down
• dementa vasculara: 15-30% din cei cu dementa– factori de risc: HTA, sex masculin
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TULBURARI CARE PRODUC DEMENTA
• D. Alzheimer
• D. Vasculara (multi-infarct)
• Boala Pick (atrofie fronto-temporala)
• Boala Huntington asociata cu dementa
• Boala Creutzfeldt-Jacobs
• Boala Parkinson
• Dementa din HIV
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ETIOLOGIE
• Alzheimer – Genetica: AHC, monizigotii - 43%, proteina
precursoare a amiloidului– Anatomopatologic: atrofie difuza, amiloid– Neurotransmitatori: hipoactivitate Ach, NE
• Vasculara:– HTA, afectiuni c-v, AVC minore multiple
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DIAGNOSTIC - ALZHEIMER
Deficite cognitive multiple:• tulburari ale memoriei (fixare, evocare)• afazie (limbaj)• apraxie (activitati motorii)• agnosie (nu mai recunoaste)• dificultati in executarea sarcinilor (planificare,
organizare)
Disfunctie sociala/ocupationala, declin fata de nivelul anterior
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• Cu debut timpuriu: sub 65 ani
• Cu debut tardiv: peste 65 ani
• Asociat cu:– delirium– depresie– idei delirante
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DIAGNOSTIC - D. VASCULARA
• Deficite cognitive multiple – tulburari ale memoriei (fixare, evocare)– afazie (limbaj)– apraxie (activitati motorii)– agnosie (nu mai recunoaste)– dificultati in executarea sarcinilor (planificare,
organizare)
• disfunctie sociala/ocupationala, declin
• Semne neurologice de focar
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• Elemente de laborator care indica o boala cerebrovasculara: infarcte multiple in cortex si substanta alba - rol etiologic
• Asociat cu: – delirium, – depresie, – idei delirante
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CLINICA
• Initial: fatigabilitate, dificultate in sustinerea eforturilor cognitive, dificultate in adaptare la nou
• Progresiv sunt afectate: orientarea, memoria, perceptia, functiile intelectuale, judecata
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• Memoria: recenta - nr de telefon, nume, evenimentele zilei apoi progresiv date mai vechi, date personale importante (varsta, date de nastere, adresa); pierd: chei, acte; uita sa inchida apa, gazul
• Limbaj (afazia): vag, stereotip, circumstantial, anomie, mutism, ecolalie, palilalie
• Activitatea (apraxie): duce la dificultati in sarcinile cele mai simple: imbracat, gatit, desenat (teste)
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• Agnozia: nu mai recunoaste obiecte, persoane - chiat membrii ai familiei sau propria reflectie in oglinda
• Gandire: dificultate in abstractizare, in planificare, in adaptarea la sarcini noi
• Orientarea: temporala, spatiala - se ratacesc in afara casei, apoi chiar si in casa
• Modificari ale personalitatii: accentuarea trasaturilor, iritabilitate, ostilitate, uneori heteroagresivitate, comportament dezinhibat
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• Risc de suicid - stadiul timpuriu
• Halucinatii (vizuale) si idei delirante (persecutie) - in 30% din cazuri
• Depresie - mai ales la debut
• Anxietate - frecvent
• Semene neurologice in special in D. vasculara
• Delirium - se poate suprapune (datorat: boli somatice, medicamente)
• NB: vulnerabili la stresul fizic sau psihosocial
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DIAGNOSTIC DIFERENTIAL
• D. Alzheimer - declin treptat
• D. Vasculara - in trepte, semne neurologice
• Forme mixte: vasculara - Alzheimer
• Delirium: debut brusc, evolutie scurta, fluctuanta
• Depresia: pseudodementa
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Pseudodementa Dementa
• Debut mai precis• solicita ajutor repede• progresie rapida• APP psihiatrice• se plang de tulb cognitive
• tulb de dipozitie evidente• apatie, “nu stiu”• raspunde la ttm AD
• Debut greu de precizat• ajunge tarziu la medic• progresie lenta• -• se plange putin,
disimuleaza • -• depun eforturi pt
indeplinirea sarcinilor• -
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EVOLUTIE SI PROGNOSTIC
• Deteriorare progresiva in 5-10 ani, pana la deces
• Durata medie de supravietuire in d. Alzheimer - 8 ani
• 50% dintre cei cu Alzheimer - debut intre 65-70 ani
• Debut insidios in d. Alzheimer si mai brusc in d. vasculara
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PRINCIPII TERAPEUTICE - ALZHEIMER
• Identificare + tratare boli coexistente
• control periodic saptamanal/ lunar
• evaluare risc suicidar, acte autoagresive
• evaluare posibilitate condus
• educarea familiei
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• Tratament psihosocial:– art-terapie, dans-terapie– “reminiscence therapy”– terapie cognitiva
• Tratament medicamentos: Aricept (donepezil), Exelon (rivastigmina) in stadiile usoare si medii
• vit. E
• Agitatie, delir: risperidona - doze mici
• Depresie: antidepresive
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PLAN TERAPEUTIC
Deteriorare usoara (poate indeplini sarcini usoare):
• ajutoare pt orientare: calendar, jurnal etc• restrictionare condus• grup de suport pt familie• medicatie• evaluare depresie, risc suicid• testament, procura etc
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Deteriorare medie (necesita asistenta pt sarcinile uzuale):
• risc de accidente, caderi, incendii
• sa nu conduca
• ttm specific, ttm depresiei, agitatiei
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Deteriorare severa (incapacitare totala):
• ajutor pt imbracat, spalat, alimentare
• medicatia pt dementa nu mai este utila
• atentie la boli somatice
• eventual internare in azil
• 30% din apartinatori fac depresie
• personal calificat pentru ajutorul rudelor
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DELIRIUM
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DEFINITIE
• tulburare a constiintei si a functiilor cognitive, care se dezvolta intr-o perioada scurta de timp
• este un sindrom !!!
• majoritatea cauzelor - in afara SNC
• subdiagnosticat, subtratat
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EPIDEMIOLOGIEETIOLOGIE
• 1-20% din pacientii sectiilor de chirurgie, medicala
• Cea mai mare rata: postcardiotomie
• Factor de risc major: varsta inaintata
• acetilcolina, posibil NA, serotonina
• substanta reticulata
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CAUZE
Intracranian
• Epilepsie
• TCC
• Infectii: meningita, encefalita
• Boli vasculare
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Extracraniene
• substante: anticolinergice, sedative, alcool, antihipertensive, antiparkinsoniene, antipsihotice
• disfunctii endocrine: hipofiza, suprarenale, tiroida
• boli hepatice (encefalopatie), renale, pulmonare, cardiace
• tulburari hidroelectrolitice
• infectii sistemice
• postoperator
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DIAGNOSTIC
• Tulburarea constiintei si scaderea capacitatii de concentrare, de mentinere a atentiei, de comutare a atentiei
• Tulburari cognitive:– memoria recenta, mai putin cea indepartata– dezorientare TS si la persoana
• Tulburarea somnului, a ritmului nictemeral:– insomnie, inversarea ritmului, accentuarea
vesperala a simptomelor, cosmaruri
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• Debut brusc, evolutie fluctuenta
• Dovezi clinice (istoric, examinare somatica, neurologica) care leaga simptomele de o suferinta organica
• Dispozitia: depresie, anxietate, iritabilitate, euforie
• Apatie, perplexitate, agitatie
• Iluzii, halucinatii, idei delirante fragmentare
• Dg dif cu dementa; se poate suprapune pe dementa
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EVOLUTIE, TRATAMENT
• debut brusc
• durata se suprapune pe cea a cauzei
• frecvent sub o saptamana
• dupa inlaturarea cauzei - remisiune in 2-7 zile
• amnezie partiala a episodului
• Tratamentul: al cauzei, supraveghere, evitarea accidentelor