What is Dementia?
Dementia is a condition in which the brain gradually becomes impaired over a period of time. This is not to be confused with delirium, which is a sudden onset of confusion that is treatable, reversible, and caused by physical or mental illness. Dementia causes short term memory loss, confusion, disorientation, difficulty learning, or retaining new information and changes in behavior. The gradual decline in brain function eventually leads to the inability to perform day-to-day tasks such as driving, doing household chores, and self-care such as bathing, eating, and getting dressed. Dementia commonly occurs in the elderly population and for a long time was considered to be part of the normal aging process. There are seven stages of dementia, ranging from no cognitive decline to severe cognitive decline where the person is unable to even communicate and needs assistance with just about every daily activity.
There are many different causes of dementia, which can be difficult to conclude, especially in the geriatric population. It can be caused by a number of diseases or infections, tumors, drugs, stroke, brain injury, or nutritional deficiencies. These causes lead to the death of cells in the cerebral cortex, which controls the brain's cognitive abilities.
Alzheimer’s disease is currently the leading cause of dementia. About 50-70% of people with dementia have the disease. One of the risk factors is age as it becomes more common in people after the age of 70, and even more common after the age of 85. Other risk factors include hypertension, heart disease, and diabetes. It is also believed that people with little education are at higher risk than those with more extensive education. The exact cause of the disease is unknown, however, it is strongly believed that the accumulation of a certain protein (beta-amyloid) leads to nerve cell death in the brain.
Dementia in EMS
Because dementia is a chronic condition, most emergency situations involving patients with dementia are due to a sudden change in their symptoms or the inability to manage their behavior. There is no treatment for dementia, but any sudden changes in their condition may be indicative of some other underlying condition. When assessing a patient with dementia, it is important to identify the patient's baseline status and find out the specific reason EMS was needed. History from the patient is usually difficult to obtain due to the patient's inability to communicate or give accurate information. For this reason, information can likely be obtained by family or caregivers.
Treatment of patients with dementia is usually supportive unless there is an additional condition to be treated. Communicate slowly and calmly as they are usually fearful of being away from their home. Remind them often of the treatments you are providing so that nothing you do frightens them. The fear and confusion of being away from home and inside an ambulance may cause them to become aggressive and combative. Medications may be used for combative patients if they are a threat to themselves or anyone else, but should only be used if means of communication are ineffective.
Don’t Just Assume it’s Dementia
When responding to a call with an elderly patient who has symptoms of confusion or altered mental status, you may assume that their symptoms are part of the normal aging process or a result of dementia. However, we can never assume that altered mental status is a patient's baseline as these symptoms could very likely be caused by some other life-threatening condition. Sepsis is a common condition in the elderly that cannot be overlooked. When an elderly patient has altered mental status, look for signs of infection, such as red or swollen surgery wounds, foul odors, or history of taking antibiotics. Other symptoms such as hypotension, hot skin, or fever can also be indicators that the patient is septic. Hyperglycemia is another condition that can lead to altered mental status in the elderly. Even if they do not have a history of diabetes, the aging process can lead to a pancreatic failure as well as insulin resistance, which may result in a patient having high glucose levels. This is another reason to do a thorough assessment of all elderly patients with altered mental status and never assume their condition is caused by aging or dementia.