You can’t see that our brain is diseased,

so that we are having difficulties

functioning

DEMENTIA
by

Dr Mariam Ashraf
Roll # 17
October 2009
HSA-Islamabad
 Dementia
A progressive and largely irreversible
syndrome , 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.
WHO, ICD 10 version
 At a personal level . . .

• One man describes dementia as

“the feeling of having been betrayed by his

brain, ‘which somehow short-circuited on
him’.”

(Zgola, 1987, pg 1)
AETIOLOGY contd..

VD

AD 50-70%

Others
 RISK FACTORS

• Gender Male/female •High cholesterol

•Smoking
• Age 60-70 years •Race
• Prior stroke •Family history
• Hypertension
CADASIL-cerebral
• Cardiovascular disease
autosomal dominant
• Diabetes
arteriopathy with sub
cortical infarcts and
leukoencephalopathy
 Ten early symptoms of dementia
1. Memory loss
2. Difficulty performing familiar tasks
3. Problems with language
4. Disorientation in time and place
5. Poor or decreased judgement
6. Problems with keeping track of things
7. Misplacing things
8. Changes in mood or behaviour
9. Change in personality
10. Loss of initiative
 Burden of disease (BoD)
• Burden of disease = loss of wellbeing, measured in
disability adjusted life years (DALYs)
• Dementia is among the most disabling of all chronic
diseases. World Health Organization (WHO) data
shows in Asia Pacific:
– Neuropsychiatric conditions are second only in disability
burden to infectious and parasitic diseases.
– Disease burden of dementia exceeds that of malaria,
tetanus, breast cancer, drug abuse or war.
– Disease burden from dementia is projected to increase by
over 76% over the next 25 years.
 Dementia
Why a Public Health Problem?
• Currently 30 million people
with dementia in the world
• 4.6 million new cases annually
• One new case every 7 second
• The number of older people in
developing countries will have
increased by 200 % as
compared to 68% in developed
countries in 30 years up to 2020

Alzheimer’s disease International, December 2008, The Prevalence of

Dementia world wide.
PREVALANCE OF DEMENTIA ACCORDING TO
AGE
18 16.4
16
14
12
10 8.7
percent

8
6 4.9
4 2.8
1.6
2 0.9
0
60-64 65-69 70-74 75-79 80-84 85 +
Age in ye a rs
Global burden of disease 2000
Global burden of disease 2000
The growth of numbers of people with dementia
in high income countries and low and middle
income countries

Alzheimer’s disease International, December 2008, The Prevalence of Dementia world wide.
 In South East Asia

• Pakistan 330.1 cases per year

• India 3248.5 cases/ year
• Sri lanka 89 cases/ year
• China 5541.2 cases / year

A study to estimate prevalence of dementia in Asia, access

economics September 2006
 ALZHEIMER’S DISEASE
INTERNATIONAL
is the umbrella organization of national
Alzheimer's association worldwide
 A few facts about ADI

• Founded in 1984 in the US

• Secretariat in London
• Currently 66 national members
• One member per country
• Officially affiliated to WHO
 PAKISTAN

• Is a low income group country

• One of the major health problems of
this country is mental illness
 Mental health resources
• National mental health programme 1986
• Mental health policy 1997
• Mental health legislation 2001
• Mental health financing 0.4 % of total health
budget on mental health
• No. of psychiatrists/ 100,000 population =0.2
• No. of neurologists /100,000 population = 0.14
• No. of psychologists / 100,000 population = 0.2

Mental health Atlas, 2005, WHO

• Information gathering system- none for
mental health reporting system – has been
initiated in NHMIS
• Alzheimer's Pakistan is the National
Organization of Alzheimer's and
related dementias. The main objective
of this Non Government organization
is to work towards the welfare of
people suffering from dementia and
their care givers
 WHY DEMENTIA IS
IMPORTANT FOR PAKISTAN ?
Pakistan population pyramid for the year 2010
Predicted age and sex distribution
Pakistan population pyramid for the year 2050
Predicted age and sex distribution
 Challenges - summary
• Limited awareness of dementia a cultural context
that denies its existence or attaches stigma to the
condition.
• An assumption that dementia is a natural part of
ageing and not a result of disease.
• Inadequate human and financial resources to meet
care needs and limited policy on dementia care.
• High rates of institutionalisation in cities and lack
of facilities in other regions.
• Inadequate training for professional care givers
and a lack of support for family care givers.
 PROGNOSIS
• Poor at present:
– Most patients suffer progression of the disease
manifested first by increased dependence on
caregivers, and latter by loss of capacity to
perform basic activities of daily living.
– Patients with advanced dementia will suffer
incontinence, motor abnormalities and finally
death.
 Let’s stop denying and do
something about it!

• Then what do we do
about it?
– Doctors, governments,
professionals, families
all need to change
– but how?
 WHAT CAN BE DONE ?

• We don’t need high tech, or huge

amounts of money, or a parallel system
• Instead we need integration,
integration, integration and to
implement basic steps
 WHAT CAN BE DONE ? BCC
•Education
• Dementia Prevention
•Awareness
•Mitigating risk
factors associated
Reduction of dementia with dementia
associated disability

•Do not smoke •Be financially stable

•Regular physical •Be spiritual
•Early Rehabilitation
exams •Eat less and include
detection
•Continue learning antioxidants
•Regular Exercise •Maintain family and
•Have fun and relax friendship networks
•Cardiovascular care •Do not retire from life:
have a role/purpose
 Possible interventions
Early detection Rehabilitation

•Identify potentially
reversible illnesses that Comprehensive
manifest as symptoms model for care
of dementia.
•Enable the primary
care physician to
diagnose and optimize
Montessori-based Dementia
treatment plans
programming
•Learn and monitor for
signs, symptoms, and
behavioral triggers of
dementia. Mc Master university
Canada 2008
•10 warning signs of
Dementia
 MBDP… adapted

• Focusing on strengths and abilities, what the person

can continue to DO – not the just losses that are
part of the dementia
• Promoting engagement in long life activities and
interests using retained abilities
MONTESSORI-BASED PROGRAMMING
ADAPTED FOR DEMENTIA

•This method of intervention focuses

on rehabilitation, where rehabilitation
is defined not as a return to a pre-
morbid state, but as a set of methods
and procedures that enable
individuals to circumvent existing
deficits to achieve higher levels of
functioning.

•In the Montessori-based context, the

resident is engaged in more
meaningful activity.

•Activities are matched with interests,

strengths, needs and abilities.
Excess Disability
Actual disability is the
disability associated
with the disease.
Excess disability is
not a result of the
disease. It arises from
the disuse of
remaining abilities.
 IN OTHER WORDS

• The person gets better with practice

• EVEN IF THE PERSON DOES NOT REMEMBER

HAVING LEARNED THE INFORMATION/TASK/
BEHAVIOUR
 Montessori-based Activities

• Scooping exercises
• Pouring exercises Decisions
Made based
• Squeezing activities
On:
• Fine motor activities Needs
• Care of the environment Interests
• Care of the person Strengths
• Matching activities Abilities
• Seriation activities
 Motor activities
• Montessori-based programming for
dementia could focus on physical activities,
that are aimed at maintaining (and perhaps
restoring) physical function. Consider:
• Scooping exercises, pouring exercises,
squeezing exercises and fine motor
activities
SCOOPING ACTIVITIES
MBPD: Care of the environment
 Cognitive
Animal / Plant Sort
 Group or social activities

• Montessori Reading books available

with appropriate sized print and group
discussion questions
• We can use Montessori for Dementia
programming with persons in all stages of
dementia.
Where can you use these techniques?

• Anywhere!
Day Programs

At Home

Hospitals
Who Can Use These Techniques?

• Anyone who has been trained!

Professionals Family

Volunteers
 Evaluation of Care
Monitor progress in concrete terms.

• Number of hours of sleep

• Weight
• Food intake
• Incidents (falls)
• Number of stress-related events (hitting, yelling)
• Sedative and tranquilizer use
• Family's expression of satisfaction with the care
 The ULTIMATE GOAL is
prevention of excess disability
among patients through
rehabilitation
 OUTCOME
– Problematic behavior is rarely seen
since being engaged and displaying
problematic behaviors generally are
two mutually exclusive categories of
behavior
 Why Rehabilitation

In 1906, Dr Alois Alzheimer, a famous

German pathologist, described a
patient who had died of an unusual
mental illness.
A woman, 56 years old, showed unreasonable jealousy
towards her husband as the first noticeable sign of the
disease.
Soon a rapidly increasing loss of memory could be
noticed. She could not find her way around in her own
apartment. She carried objects back and forth and hid
them. At times she would begin shrieking loudly.
Her ability to remember was severely disturbed. If one
pointed to objects…..... Sometimes, one noticed her getting
stuck.. She seemed no longer to understand the use of
some objects.
The generalized dementia progressed however. Towards
the end, the patient was completely stuporous; she lay in
bed with her legs drawn up under her, and in spite of all
precautions she acquired bedsores. After 4-1/2 years of
suffering, death occurred.
IN OUR SOCIETY THERE ARE NUMBER OF
PEOPLE WHO EXPERIENCE SAME KIND
OF DISABILITY…. BUT INSTEAD OF
HELPING THEM OUT WE SIMPLY CLOSE
OUR EYES…..LEAVING THEM TO GOD
AND THANKING THAT WE DON’T HAVE
SUCH PROBLEM…. BUT IN REALITY IF
WE DON’T DO ANYTHING ABOUT IT
NOW ….U NEVER KNOW … WE CAN
SUFFER FROM THIS IN FUTURE
 FUTURE ASPECTS
• Create a climate for change thru’ greater awareness
• Build effective constituencies and coalitions for
partnership.
• Promote development of responsive primary and
community care services.
• Provide information on lifestyles that may reduce dementia
risk.
• Make provision for special needs, including for younger
people and people with behavioural and psychological
symptoms.
• Promote investment in research for cause, prevention and
quality dementia care.