The dementia ([ demɛnʦ ] Latin dementia , insanity ' , folly') is a pattern of symptoms of various diseases whose main feature is a deterioration of a plurality of intellectual (cognitive) capabilities compared to the previous state. It can arise from various degenerative and non- degenerative diseases of the brain . The term is derived from the Latin demens ' unreasonable ' (without mens , that is,' without 'understanding', 'thinking power' or 'being prudent') and can be translated as' decreasing intellectual power '.
The symptom picture of dementia includes losses of cognitive , emotional and social skills that lead to an impairment of social and professional functions. Short-term memory , thinking , language and motor skills are particularly affected ; in some forms there are also changes in the personality structure . Characteristic of dementia is the loss of thinking skills that have already been acquired in the course of life (in contrast to, for example, congenital inadequate giftedness ).
Today the causes of some dementias have been clarified, but there are still no clear, undisputed findings on the origin of many forms. A few forms of dementia are reversible; for some other forms, therapeutic interventions are possible to a limited extent, but these can only delay the onset of certain symptoms. The most common form of dementia is Alzheimer's disease .
Definition of dementia
In the scientific discussion, dementia is described using diagnostic criteria. Accordingly, dementia is a combination of symptoms of the increasing decline in cognitive, emotional and social skills, which in the course of the disease lead to an impairment of professional and later general social functions.
The memory disorder is considered to be the leading symptom . At the beginning of the disease there are disorders of the short-term memory and the ability to remember , later disorders in the orientation ability follow . In the further course of dementia, the affected person can fall back less and less on the contents of long-term memory that have already been memorized , so that he loses the knowledge, abilities and skills acquired during his life.
In the ICD-10
Dementia ( ICD-10 code F00-F03) is a syndrome resulting from a mostly chronic or progressive disease of the brain with disruption of many higher cortical functions (including memory , thinking , orientation , perception , arithmetic , learning , language , speaking ) and the Judgment (in the sense of the ability to make decisions ). However, awareness is not clouded. For the diagnosis of dementia, the ICD symptoms must have persisted for at least six months. Senses and perception function within the normal framework for the person. Usually the cognitive impairments are accompanied by abnormalities in emotional control and mood , social behavior or motivation ; occasionally these changes are more likely to occur. They occur in Alzheimer's disease, vascular diseases of the brain and other conditions that primarily or secondarily affect the brain and neurons .
In the DSM-5
The 2013 published edition DSM-5 of the American Diagnostic and Statistical Manual of Mental Disorders uses the term dementia is not more, but speaks of neurocognitive disorders ( neurocognitive disorders , NCD) and includes substantially all of the acquired one brain disorders, cognitive excluding impairments in Psychoses or schizophrenia and cognitive disorders in brain development disorders. The previously reflected in the DSM Mild cognitive impairment ( mild cognitive impairment , MCI) on the other hand considered as well as the delirium , the latter as a separate category. The DSM-5 differentiates with regard to dementias, which are now called neurocognitive disorders as a generic term , the following diseases that are considered to be certain, the full formulation being “neurocognitive disorder due to [...]” and the word “dementia” from the DSM terminology completely disappeared.
Neurocognitive disorders due to
- Alzheimer's disease
- with Lewy bodies
- traumatic brain injury
- substance / drug induced
- due to HIV infection
- due to prion disease
- due to Parkinson's disease
- due to Huntington's disease
- due to other medical factor
- due to multiple etiology
The previous diagnostic categories
- Aphasia : language disorder
- Apraxia : impaired ability to perform motor activities
- Agnosia : inability to identify or recognize objects
- Dysexecutive syndrome : disruption of executive functions, i.e. H. Plan , organize, stick to a sequence
were revised and expanded to include the diagnostic criteria of complex attention, executive functions, learning and memory, language, perceptual motor skills and social cognitions.
Forms of dementia
Numerous forms of dementia are distinguished. Alzheimer's dementia is the most common form, which probably accounts for over 60% of cases. As a rule, it does not appear until after the age of 60 and, like most other forms of dementia, is one of the gerontopsychiatric disorders - rarer forms of dementia can also occur in younger patients. The main dementias, which differ in cause, course and age of onset, are:
- Alzheimer's disease
- Vascular dementia (also outdated: multi-infarct dementia (MID), less often subcortical arteriosclerotic encephalopathy )
- Lewy body dementia
- Frontotemporal dementia or Pick's disease
Other, rarer forms are
- Dementia as a result of Creutzfeldt-Jakob disease
- Korsakoff syndrome caused by alcohol abuse
- Dementia related to Parkinson's disease
In addition, dementias can be caused by so-called extensive events in the brain, e.g. B. by tumors , hematomas or in connection with a hydrocephalus . These are reversible under certain conditions, i. That is, the dementia changes can regress when the underlying cause is removed.
In the specialist literature, however, other forms of dementia are classified and designated differently depending on the system. While the above overview should be sufficient for the layperson, the specialist staff in the gerontopsychiatric field must distinguish the detailed diagnoses with the associated classification.
Classifications of the forms of dementia
In the German-speaking area, the specialist societies orient themselves towards the cause, here either the classification of the German Society for Neurology or the International Classification of Diseases (ICD-10) of the World Health Organization apply . In US research, the classification is based on the location of the damage in the brain.
Classification of the German Society for Neurology
According to the German Society for Neurology and the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology, the forms of dementia are divided into vascular , (neuro-) degenerative forms of dementia and mixed forms according to their pathogenesis .
Vascular dementia (VAD)
- Multi-infarct syndrome: defect syndrome after major, single or multiple, ischemic or hemorrhagic strokes (insults) with loss of a critical mass of neuronal tissue (probably approx. 100 ml)
- Strategic insults: pronounced cognitive deficits with a small lesion volume at crucial points ( thalamus , posterior capsular knee , frontal medullary bed )
- multilacunar syndrome
- confluent changes in the medullary bed ( subcortical arteriosclerotic encephalopathy , SAE)
- Microvascular changes
- Capillary loss
- Blood-brain barrier disorders
- underlying genetic diseases
Classification according to ICD-10
According to ICD-10 , dementias are divided into
- Dementia in Alzheimer's Disease
- vascular dementia (VAD)
- VAD with an acute onset (after several minor strokes, a single massive infarction as a result of cerebrovascular thrombosis, embolism, or bleeding)
- Multi-infarct dementia (predominantly cortical dementia, onset gradually, after an accumulation of infarcts in the brain tissue)
- subcortical vascular dementia ( arterial hypertension , ischemic foci in the medullary bed of the hemispheres, clinical picture reminiscent of Alzheimer's disease)
- mixed cortical and subcortical vascular dementia
- other vascular dementia
- vascular dementia, unspecified
- Dementia in Diseases Classified Elsewhere
- Pick disease
- Creutzfeldt-Jakob disease
- Chorea huntington
- primary Parkinson's syndrome
- Dementia in diseases classified elsewhere
- hepatolenticular degeneration ( Wilson's disease )
- Hypothyroidism , acquired
- Lewy Body Disease
- multiple sclerosis
- Niacin deficiency ( pellagra )
- Panarteritis nodosa
- systemic lupus erythematosus
- Vitamin B 12 deficiency
- cerebral lipid metabolism disorder
- unspecified dementia
In the US-American literature, a division into cortical and subcortical dementias is used. These differ not only according to the location of the cerebral damage ( cortex versus basal ganglia ), but also according to their clinical appearance. A classic example of cortical dementia is Alzheimer's disease . Subcortical dementias are subcortical arteriosclerotic encephalopathy , dementia in Parkinson's syndrome , normal pressure hydrocephalus , Wilson's disease or Huntington 's disease .
There appears to be a link between dementia changes and chronic kidney failure .
Frequency of forms of dementia
The most common form of dementia worldwide (as of 2020) is Alzheimer's disease with a share of around 60%. The second most common, with figures between 10 and 20%, is vascular dementia ( vascular dementia ). A diagnosis is often only made on the basis of the symptoms, in rarer cases by an autopsy after the death of the person concerned.
It is known from neuropathological studies that the first dementia-typical changes in brain tissue can already occur in young adulthood and increase steadily with increasing age. Dementia only occurs when a large part of the brain cells are destroyed. The connection between the final cognitive decline and a neurodegenerative disease has so far only been clearly established in one third of the cases.
|Alzheimer's disease||approx. 50% to 60%|
|Vascular dementia||approx. 20%|
|Mixed form of both of the above||approx. 15%|
|Lewy body disease and Parkinson's syndrome||approx. 10% to 20%|
|Frontotemporal dementia||approx. 5% to 10%|
The data are estimates, as the assignment in individual cases was difficult or impossible and mixed forms are common. The numbers are from the 1990s.
As early as 1997 it was established in the USA that the risk of dementia increases with age. In 2003 it was estimated that more than half of all people with dementia had not been diagnosed by a doctor.
According to the World Alzheimer's Report in 2015, a person worldwide gets dementia every 3.2 seconds. Approximately 46.8 million people are currently living with dementia, and 74.1 million are expected by 2030. The Alzheimer Disease International (ADI) report was largely written by researchers from King's College London .
According to the Berlin Aging Study (1996), the number of people with dementia is increasing by age group as follows.
|Age group||Share of people with
|65 to 69 year olds||1.2%|
|70 to 74 year olds||2.8%|
|75 to 79 year olds||6.0%|
|80 to 84 year olds||13.3%|
|85 to 89 year olds||23.9%|
|over 90 year olds||34.6%|
Development in Germany
At the end of 2016, more than 1.6 million people in Germany were suffering from dementia, including over a million women; currently (as of 2018) there are around 1.7 million. The number of people suffering from dementia is expected to rise to an estimated three million in 2050. The latest estimates (as of February 2014) go well beyond this.
Among the members of BARMER GEK Krankenkasse who died in 2009 at the age of over 60, 47% of women and 29% of men were suffering from dementia, around 90% of whom were previously in need of care.
Around two thirds of the 1.7 million dementia patients in Germany are looked after and cared for by relatives in their home environment (as of 2020).
A study by the Forsa Institute on behalf of DAK-Gesundheit found that every second German is afraid of dementia. The proportion is particularly high among those over 60.
Development in Austria
In Austria there are currently 115,000 to 130,000 people living with dementia. It is estimated that this number is expected to double by 2050.
Risk Factors and Prevention
According to the prevailing scientific opinion, the main risk factor for dementia is old age . The predominance of women among those affected is probably primarily due to the fact that women have a few years longer to live. Depression is seen as a risk factor for developing dementia. They occur more frequently in the early stages of dementia and can precede dementia. Conversely, if the clarification is inadequate, elderly people with mental illness are incorrectly assigned the diagnosis dementia, which can be shown by the fact that the mini-mental status test has improved significantly again.
Other risk factors include cardiovascular factors such as hypertension , high homocysteine levels , kidney failure , obesity and diabetes mellitus . Defects in the vascular system , impaired insulin metabolism and signaling pathways and a defect in the glucose transport mechanism in the brain play a role here .
Current medical treatment options can only have a very modest positive effect on the course of dementia. That is why the prevention of dementia is of particular importance, the cornerstone of which is the limitation of risk factors. Today, the most promising strategies are primarily the control of cardiovascular risk factors, physical activity ( sport ), social commitment , control of body weight ( diet ) and the early treatment of depression . Since tobacco smoking is also a possible risk factor for dementia, stopping cigarette consumption also helps to prevent dementia. A recent study confirms that exercise and a healthy lifestyle (and thus avoiding cardiac risk factors) can prevent dementia. In addition to regular physical activity, a healthy lifestyle also includes abstinence from nicotine and daily consumption of fruit and vegetables. A normal body weight does not prevent the decline in cognitive functions according to this study.
A long-term study published in 2012 suggests a link between dental health and the risk of dementia. Accordingly, the risk of developing dementia is 1.85 times higher if 13 or more teeth are missing and the gaps are not filled with fixed dentures. The subject of research were 4,425 Japanese residents who were around 65 years old and were followed for four years. 220 of them developed dementia.
The medical history provides important information on the differential diagnosis and the selection of the imaging examination method, whereby the information provided by the caregivers must be taken into account. The affected person himself often does not notice his memory disorders or he can be in top form at appointments for a short time (known phenomenon when visiting a doctor). On the other hand, it is possible that he overestimates his memory disorders in the context of a depressive mood. Magnetic resonance imaging or computed tomography of the head or electroencephalography are also useful for differentiating from other brain diseases.
In order not to miss any treatable cause, at least the following blood tests should be available: blood count , vitamin B12 level, blood sugar , liver values , kidney values, electrolytes, thyroid hormones , CRP . Simple psychometric test procedures such as the Mini-Mental-Status-Test (MMSE), the clock-mark-test or DemTect are helpful to confirm an initial suspicion and to check the progression of dementia . Such simple and quick tests can then be used for follow-up examinations, for example to check the response to medication or therapy methods. As already mentioned, however, early detection of the first cognitive impairments is particularly important. There is a lot of research on the topic and diagnostic early detection methods such as CFD are being developed . This is a digital test set for the age group 50+, which checks the dimensions according to the DSM-5 diagnostic criteria. For this purpose, a CFD index is issued, which enables a quick and easy assessment of the already existing impairment.
Since the medical-diagnostic possibilities have massively improved in the past few years, a diagnosis of Alzheimer's disease is already possible in the stage of mild cognitive impairment (LKB). The diagnostic procedures for such a diagnosis before the onset of dementia include the representation of the atrophy of the medial temporal lobe in the MRI , the measurement of τ-protein and β-amyloid in the CSF , the representation of cortical metabolic deficits in the positron emission tomography (PET) with [18F] - fluoro-2-deoxy-D-glucose (FDG) and the possibility of making amyloid in the brain visible in vivo with PET ligands. In addition, there is increasing evidence that a patient's subjective statement that they are becoming more forgetful is a reliable parameter for predicting the development of dementia at a very early stage. This gives rise to the hope of being able to prevent dementia very early on, for example with a low-calorie diet or a little more physical activity. German scientists have also developed a clinical score with which the occurrence of Alzheimer's disease in older people without dementia can be estimated with around 80 percent prediction accuracy in the doctor's office without technical aids.
PET with FDG, which is available at selected centers, is also an established method for the differential diagnosis of dementia. In this way, even in the early stages, locations in the brain with reduced glucose metabolism can be detected and thus dementia of the Alzheimer's type or frontotemporal dementia ( Pick's disease ) can be detected. Dementia caused by depression shows a different pattern of activity on PET.
For the diagnosis of dementia with extrapyramidal motor disorders associated, which is scintigraphy with iodine -123-β-CIT or Ioflupane (DaTSCAN), iodine-123 IBZM scintigraphy and PET with L -Dopa used. This allows Parkinson's disease , multiple system atrophy , progressive supranuclear palsy and essential tremor to be distinguished.
- age-associated cognitive decline, also "age forgetfulness "
- Mild cognitive impairment
- Denial and avoidance behavior
- Deprivation symptoms or hospitalism with regression , as in old people's homes .
- Psychosis and delusion (e.g., schizophrenia , mania, and psychotic depression )
- simple mutism
- simple aphasia
- Lack of fluids ( desiccosis )
A precise differential diagnosis is necessary in order to be able to determine the correct therapy, both in drug and non-drug treatment. So z. For example, a distinction can be made between cognitive disorders as a result of depression and cognitive dementia disorders, since the former can be treated curatively, but the latter can only be treated palliatively. Some non-drug therapies, such as validation, are contraindicated in depression as this can exacerbate the depressive symptoms.
In the run-up to dementia, psychological disorders can often be observed that can often hardly be distinguished from those of depression, such as loss of interests and initiative, irritability, feeling overwhelmed , loss of the ability to oscillate, depressive moods.
The main symptom of all dementia diseases is memory impairment, especially short-term memory . The forgetfulness is initially something normal. Often, at least in the initial stages, the person's outer facade is well preserved, so that the memory disorders in superficial contact can be covered very well. People who have had a lot of social contacts throughout their lives work particularly well - the binding tone replaces the content of the message ( communication ) in parts .
Later memories are lost. As the dementia progresses, other disorders of the brain function also occur, such as word finding disorders, arithmetic disorders, spatial perception disorders, so that those affected often get lost, especially when structural changes take place in the environment they have been familiar with over decades, and severe fatigue.
At the advanced stage, those affected often do not even recognize their closest relatives. They often become apathetic , bedridden and - since urinary incontinence can occur much earlier - also stool incontinence .
Dementia usually reduces life expectancy. The earlier assumption that dementia itself cannot lead to death, but that those affected die of other diseases, especially pneumonia (to which they are particularly susceptible due to the symptoms of dementia), can no longer be taken as a generalization. Due to the generally very good health care - at least in German-speaking countries - in particular the drug supply, good care (e.g. avoiding a pressure ulcer , which also weakens the organism) and the - ethically controversial - installation of gastric tubes (PEG), many live People with dementia for a long time in a largely stable physical condition, so that in the end it can be dementia, i.e. the progressive breakdown of nerve cells in the brain, which leads to death.
Motor disorders can be part of the picture of advanced dementia. This is not only the case when it is a question of dementia as a result of Parkinson's syndrome (where the motor disorders are already based on the underlying disease), but also with other forms of dementia. Patients can become increasingly immobile, which can affect the whole body. The gait can become smaller, more shuffling and more wide-legged. Often this is accompanied by an increased risk of falling because it can lead to a disruption of the holding reflexes.
According to studies, dementia can sometimes be announced by slowing down the gait.
The behavioral disorders in people with dementia are called BPSD (Behavioral and Psychological Symptoms of Dementia) . These include apathy (76.0%), aberrant motor behavior (i.e., wandering around aimlessly, 64.5%), eating disorder (eating inedible, 63.7%), irritability / lability (63.0%), agitation / aggression (62.8%), sleep disorders (53.8%), depression / dysphoria (54.3%), anxiety (50.2%), delusion (49.5%), disinhibition (29.5%), hallucinations (27.8%) and euphoria (16.6%) were counted. The brackets refer to the prevalence of the 12 BPSD in Alzheimer's patients.
Psychotic symptoms can occur with all forms of dementia. They are relatively typical for Lewy body dementia . These are mainly visual hallucinations. Typically, especially in the twilight of twilight, those affected initially see people who are not present, with whom they sometimes even have conversations. At this stage, patients can usually distance themselves from their (pseudo-) hallucinations; that is, they know that the people they are talking to are not there. Later they see animals or mythical creatures , patterns on the walls, lint of dust. After all, they experience grotesque, mostly threatening things, such as kidnappings. These scenic hallucinations are usually very fear-colored. It is not uncommon for patients to become aggressive when they incorporate relatives and caregivers who are approaching each other with the best of intentions into their delusional system. Here the transitions to delirium are fluid.
People with dementia lose their initiative. They neglect their previous hobbies , personal hygiene and tidying up their homes. Eventually, they are no longer able to eat adequately. They have no drive to eat, they lose hunger and eventually forget to chew and swallow the food. You lose weight and become prone to internal diseases such as pneumonia . Shifts in the day-night rhythm can cause considerable nursing problems.
Situation of people with dementia
In the public perception, people with dementia usually only appear as patients or as people in need of care. However, this is only a small excerpt if the overall situation of people with dementia is considered. The group of people with dementia as a whole affects people with dementia in all stages, i.e. with early dementia, middle-stage dementia as well as people with very advanced dementia, who are mostly completely dependent on care.
People with early stages of dementia
While people with dementia in the middle and advanced stages of dementia are already the focus of various research areas, there is still little attention paid to people with beginning or moderate middle dementia who can still actively participate in life. Those affected are increasingly taking action, i.e. people who have been diagnosed with dementia but who continue to actively participate in life themselves. You speak in public as dementia activists . The best-known dementia activist in Germany is Helga Rohra from Munich , who has lived with a Lewy body dementia diagnosis since 2009 . Helga Rohra speaks at many conferences and congresses and, among other things, as chairwoman of the European Working Group of People with Dementia, advocates the rights of people with dementia and “a change in awareness on the subject of dementia”.
Middle-stage dementia people
People in the middle stage of dementia perceive reality differently, as they normally perceive oriented, cognitively healthy people. They increasingly lose certain perceptual abilities , first and foremost the ability to orientate themselves in terms of time , later the ability to orientate themselves with regard to place, situation and finally the people. They are less and less able to place objects, situations and people in a larger context. Due to their memory disorders , they are denied access to previous knowledge ( semantic memory ) and experiences ( episodic memory - back-erasing) in order to help them find their way in the current situation. There is a lack of knowledge and the security of resources that serve to cope with current situations. The difference between dream, past and reality is often blurred. When dealing with people in the middle stage of dementia, it is usually no longer possible to explain the differences to them.
Hallucinations (especially with Lewy body dementia) or delusions are common. A correction of the delusional ideas is hardly possible. Ideally, the caregivers will grasp the mood behind the hallucinations and respond to them. If the sick person is still able to recognize that he has not reacted appropriately in a situation, this can trigger restlessness and resignation in him.
People with dementia need a lot of time for all reactions and actions. In advanced stages z. For example, adequate nutrition is an increasing challenge for the companions because those affected do not feel hungry, refuse to eat or seem no longer able to take in food. The reasons for this can be complex, in particular it must be checked whether it is a misunderstanding of the situation (failure to recognize the food), a physiologically caused swallowing disorder or a deterioration in cognitive abilities that has already progressed so far, so that between feeling food in the Mouth and triggering a swallowing reflex, no cognitive connection is possible. In the middle stage it is through sufficient sensory stimuli (appetizing and clearly identifiable food, well-spiced or sweet food), a good eating culture (eating together at the table, healthy "models" who eat with you) and continuous offering of food throughout the day and Even at night it is often possible to provide the affected person with sufficient food such as nutrients. However, there may be restrictions here because the sense of smell and taste decrease in some forms of the disease. Associated with Alzheimer's disease , several cognitive skills can be impaired, such as recognizing colors .
People suffering from dementia often feel misunderstood, commanded around or patronized because they cannot understand the reasons for the decision of the caregiver. People with dementia are usually very capable of expressing their wants and needs. Some are still able to sense when other people are bored or embarrassed by their behavior. People with dementia can become very upset when they are held responsible for things they have forgotten. They are cornered twice: on the one hand, because they are accused of deliberately making mistakes, and on the other, because they are confronted with their weaknesses - not being able to remember.
Depression, in particular, is a common problem, often before the onset of dementia, often when the person affected perceives their mental decline. Since the symptoms of depression are similar to those of dementia, the two diseases can be confused with insufficient knowledge. The further the dementia progresses, the more the emotional world flattens out and, in parallel to an increasing lack of interest, gives way to affective indifference with the inability to be happy or sad or to express emotions.
Dealing with people with dementia should be adapted to their changed experience. The following have proven to be helpful methods in dealing with people with dementia: validation , biography work / memory maintenance , basal stimulation and self- maintenance therapy (SET) according to Barbara Romero .
In Germany, people with dementia can receive support benefits from long-term care insurance .
For some years now, drugs against dementia have been available ( antidementia drugs ). On the one hand there are centrally effective cholinergics ( cholinesterase inhibitors ) such as donepezil , galantamine or rivastigmine , on the other hand memantine . In 2009 and 2010, however, the Institute for Quality and Efficiency in Health Care came to the conclusion that there was no evidence of any benefit from memantine therapy in Alzheimer's disease. There is currently no cure for dementia, but in many cases it can be delayed for one to two years if it is recognized and treated early.
In the later course it turns out that treatment with the previously known drugs does not bring any improvement. Therapy with an active substance-containing plaster has been available for some time. Due to the constant active level, there are fewer side effects, so that a higher dosage is possible. At the same time, care by nurses is made easier, as the application of the patch is often easier than the administration of tablets or solutions. The aim is to improve the cognitive skills and everyday skills of the affected patients.
Garlic and piracetam are controversial in their effect . The effectiveness of ginkgo biloba is controversial . In 2008 the Institute for Quality and Efficiency in Health Care (IQWiG) came to the conclusion that patients with Alzheimer's disease benefit from therapy with the standardized extract EGb 761 if it is taken regularly at a daily dose of 240 milligrams. A US study (GEM study, Ginkgo Evaluation of Memory ) and its subanalysis showed, however, that the extract neither prevented the occurrence of Alzheimer's dementia nor counteracted the decline in mental performance compared to placebo during the mean observation period of six years could. In 2008, however, the Cochrane Collaboration came to the conclusion that Ginkgo biloba extracts have no proven effect against dementia.
All calming medications that are given, for example, in the event of sleep disorders or shifts in the day-night rhythm , impair cognitive performance. The same applies to neuroleptics with anticholinergic side effects, which sometimes cannot be avoided in hallucinations . The drug treatment of vascular dementia corresponds on the one hand to the treatment of chronic vascular diseases ( atherosclerosis ), on the other hand, antidementia drugs have proven to be effective in vascular dementia, both acetylcholinesterase inhibitors and memantine.
In order to favorably influence signs of illness, to improve the well-being of those affected and / or to maintain skills (resources) for as long as possible, various forms of non-drug interventions have been developed.
These interventions can be carried out in occupational therapy , for example . Dancing can also activate cognitive, physical, emotional and social skills, contribute to the well-being of dementia sufferers and strengthen their self-esteem.
Memory training differs from brain jogging in that it is aimed at a sick audience or is used for prevention; it does not have the character of a sport or a pure leisure activity. Proof of effectiveness could be provided for the tasks that were practiced, such as recognizing faces in photos or orientation in the environment. The everyday relevance of memory training in social care for people with dementia is controversial, as there is a risk that those affected will be confronted with their deficits and it tends to lead to a worsening of the overall situation if those affected feel like failures. This is why this method of social care for people with dementia is only used in the initial stages of the disease and adapted to the respective disease situation.
Through biography work, it is possible to experience the importance of certain behaviors for a person with dementia. (What does it mean if Mr M. does not want to go to sleep in the evening? Does he want to signal: “I still miss my sleeping draft” or does he mean: “I miss my wife when I go to bed”?). The more thoroughly a person's biography as well as their habits and idiosyncrasies are known, the easier it is for a companion to empathize with a person with dementia and understand their current drives and needs - a technique that is the basis of validation . Thorough documentation and close cooperation between all those involved in the care is necessary again. The Ich-Pass can facilitate the biography work in everyday life: The Ich-Pass holder can record his likes and dislikes with classic questions as they are known from friend albums, for example about their favorite food, musical taste or hobbies. This can be very helpful if, for example, in the event of a dementia change, he can no longer articulate himself verbally and is dependent on outside help. With the information from the I-Passport, for example, the nursing staff can quickly get good access to the person concerned without contact to relatives.
Based on the dynamic personality theory of developmental psychologist Hans Thomae , Andreas Kruse conducted a study with people with dementia to determine to what extent open, trusting relationships enable or promote the expression of personal issues that have developed in the course of life.
Specifically, Dasein-themed accompaniment refers to topics, talents and characteristic patterns that have shaped a person in the course of life and that remain until the end, even if the concrete memories of one's own biography fade. Examples of issues of existence are a semester abroad, foreign language skills or forms of expression.
Dealing with people suffering from dementia
The most important thing when dealing with people with dementia is patience . Impatience on the part of the contact person gives the person concerned the feeling of having done something wrong - this is the cause of dissatisfaction, sadness and discomfort (nobody likes to do things wrong).
It is also important to be aware that those affected are only able to learn to a limited extent due to their memory disorders. Most of what they are told is forgotten within minutes. Nothing can therefore be reliably agreed with people suffering from dementia. Conditioning of dementia patients is still possible. If a person concerned is repeatedly taken to a place at a table and explained to him that this is his place, it is quite possible that he will choose this place himself to sit in the future. To the question: "Where is your place?" The person concerned will still answer evasively. That is why it makes sense to avoid asking questions if possible. Anti-runaway systems can be used to control the freedom of movement . These can avoid unwanted consequences or dangerous situations if relatives or people involved in the message chain are informed in good time.
Stella Braam, daughter of an affected person, describes some typical misunderstandings between (professional) caregivers and people suffering from Alzheimer's such as paternalism, restraint as an alleged security against falls, inappropriate job offers and groups of people that are too large and too loud.
The dementia paradox
The Hamburg scientist Jens Bruder speaks of the dementia paradox in connection with dementia of the Alzheimer's type . This refers to the increasing illness-related inability of the sick person to perceive the loss of his or her cognitive performance and to deal with the consequences.
The communication should be appropriate to the respective stage of dementia. In the mild stage of dementia, a special form of communication is often not necessary, and can even be an offense for those affected, who are usually aware of their deficits in this phase. However, it is helpful to refrain from asking too much questions and being right if a temporary memory loss is evident in the person you are talking to with dementia.
In the moderate stage of dementia, communication should be dominated by simply structured language. Short sentences without subordinate clauses, clear, clear formulations, the renouncement of why questions are simple rules for this. People with middle-stage dementia are usually no longer able to understand foreign words and long sentences with a complex sentence structure due to the cognitive changes. Each sentence should only contain one piece of information. So instead of: "Get up and put your coat on" just: "Please get up" and only then take the next step. Most of the time, proverbs and sayings are better understood than abstract expressions. It is helpful to memorize phrases and terms that were understood by the dementia patient in order to then refer to them.
A dispute with the person suffering from dementia should be avoided at all costs, even if it is clearly in the wrong; this would increase the confusion and dissatisfied "feeling" that remains after an argument (although the person concerned can no longer remember the argument). The argument is very threatening for people with dementia because they cannot fall back on the experience that the argument will pass again, because people with dementia live almost exclusively in the present. The future has no meaning for them. Ideally, the caregiver is able to empathize with the thoughts of people with dementia, e.g. B. by validation .
It should also be noted that people with dementia do not lose their ability to interpret other people's non-verbal communication . Companions should therefore consciously pay attention to their own gestures and facial expressions and other elements of body language . An unconsciously grimacing face or an unconscious defensive gesture can be mistakenly perceived as threatening by people with dementia . This is primarily related to the so-called challenging behavior to be observed: A of nurses as aggressive, so challenging perceived behavior of people with dementia often has its cause in the behavior of the nurses or the environment that the person concerned as threatening, dangerous or humiliating interpreted has been.
When communication via verbal language is hardly possible anymore, it becomes all the more important to address the other senses. Access can be created through taste, smell, sight, hearing, touch, movement, like popular folk songs, in which those affected can truly flourish. However, it should be noted that some senses can change. The sense of taste responds primarily to sweet dishes. With all stimuli, care should be taken not to use too many at once. A superimposition of different sensory impressions can have a threatening effect, as the different authors can no longer be separated and assigned. An oversupply of stimuli leads to confusion rather than stimulation. So a balance should be found between excess supply and absolute lack of stimuli.
The environment and the behavior of the helpers should be adapted to the sick person, for example when waking up in a retirement home: The patient wakes up in a strange room without familiar objects; a person (caregiver) whom he has never seen comes up to him. He begins to wash and dress him - without asking and therefore completely incomprehensible to the patient. Instead, recommended course of action: The nurse should introduce himself as possible and explain beforehand in simple sentences what he is going to do and also comment on further actions. It shows how important it is to scatter familiar objects in the immediate vicinity of the sick person in order to combat his confusion and therefore growing fear, because familiar objects, noises, etc. provide security. Good lighting is important, as shadows often lead to uncertainty as they cannot be classified. Furthermore, the spatial, three-dimensional vision decreases in people with dementia. That is why changes in the color of the floor are often interpreted as thresholds. It is therefore important to keep the patient free of fear and as oriented as possible in order to be able to work with him.
The nursing researcher Erwin Böhm relies on childhood emotions in order to rehabilitate seniors with dementia. Böhm advises creating what is known as a socigram at a young age . It should be noted exactly what was fun as a child and adolescent. This information can later be used to revive childhood memories. This creates emotions that make people with dementia particularly happy and infuse them with new life energy. The disease cannot be cured in this way, but its effects can be reduced. In this sense, the dialectical training of the nursing staff can prove beneficial for dealing with the patient.
Relatives of people with dementia
When dealing with people with dementia, it is important to coordinate medical and nursing recommendations and measures with the needs of the sick person and their relatives. It is also undisputed in scientific research that caring for relatives affected by dementia is a special psychological and physical burden. In total, around two thirds of all people affected by dementia are cared for at home, usually by one or more relatives, often with at least temporary support from an outpatient care service . In the majority of cases, the wives, daughters or daughters-in-law of the affected people take care of them. The stress experience for the various groups of relatives is different. The main caregivers are most at risk, in whom studies have found an increased risk of later developing dementia themselves. But also the less involved family contacts are exposed to particular stress. Studies are available for the grandchildren of the sick and for the spouses of those affected.
For the relatives of people with dementia there are support and relief offers in almost every larger town. Almost all psychiatric clinics, university clinics and other large clinics have a geriatric psychiatric ward and / or a memory clinic , which also offer discussion groups and advice for relatives. The self-help organization German Alzheimer's Society lists the reminder consultation hours by region on its website. The local Alzheimer's societies offer - depending on their capacities, as the work is often done on a voluntary basis - advice for relatives or events, e.g. B. afternoons for family carers and their sick family members as an opportunity to exchange experiences, singing groups as well as music and dance cafés. In some cases, volunteers from the Alzheimer's Society support those affected with exercise training at home.
In addition, there are health clinics that enable family carers to take a cure where they can take their relatives suffering from dementia with them. This is then supervised by specialists during the applications within the clinic. There are also rehabilitation measures for people with dementia that relatives can travel with. The program is called "Medical rehabilitation for people with dementia and their relatives", information on this from the German Alzheimer's Society, among others.
The SGB XI provides care courses for relatives and volunteer carers ( before SGB XI), as well as offers of support in everyday life ( SGB XI) and promotion of appropriate care structures ( SGB XI). (For support in everyday life, see also: Everyday companion , senior carer .)
The term dementia was used in legal and colloquial language in the 18th century for all forms of mental disorders. In 1827, Jean-Étienne Esquirol made a distinction between congenital and acquired dementia and introduced démence as a medical term for the latter. For a long time, only the final stage of intellectual decline was referred to as dementia in German-speaking psychiatry. In 1916 Eugen Bleuler described the unspecific organic brain psychosyndrome with the characteristics cognitive disturbance, emotional change and personality change as the psychopathological consequence of chronic brain diseases. In 1951, his son Manfred Bleuler differentiated from it the local brain psychosyndrome and pointed out its similarity to the endocrine disruptions. In the course of the development of modern classification systems such as ICD-10 and DSM-IV , the definition of dementia syndrome has expanded significantly. Today this term no longer only describes the severe cases of cognitive disorders, but now an acquired complex disorder pattern of higher mental functions. The disturbances can be reversible as well as irreversible, but must affect the memory and must not be accompanied by a disturbance of consciousness. In addition, coping with everyday life must be impaired.
In the fourth report on the elderly by the German federal government from 2004, the treatment and care costs for dementia sufferers were estimated at 26 billion euros. A large part of this, namely 30% for nursing care, has not yet impacted expenditure because it was provided by relatives of the patients. In 2010, it is expected that 20% of all German citizens will be over 65 years of age and so the (still fictitious) costs will rise to 36.3 billion euros under the same conditions. Due to the changing family structures ( single households, small families ), the share of care costs will also increase.
Calculations from 2015 put the annual care costs for a person with dementia at 15,000 to 42,000 euros. In contrast, according to the federal care officer, Karl-Josef Laumann , the maximum possible reimbursement through long-term care insurance is 14,400 euros per year.
The government of the Principality of Liechtenstein had a dementia strategy drawn up in 2012. She came to the conclusion that the medical treatment costs (hospital stays, medication and costs for diagnostics) are very low in relation to the costs for care and support (only approx. 5%). However, the task of the study was not to calculate the financial outlay, but to show alternative courses of action for a sustainable improvement in the care and support of people with dementia.
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