Abstract
Demographic ageing is a worldwide process in consequence of the successes of improved health care over the last century. The world population has a greater proportion of older people. Becaouse of ageing is the significant increase in the number of people with chronic diseases including Alzheimer’s disease and related dementias. Different chronic diseases appear to have starkly different impacts on disability and mortality. Cognitive disoders are mainly reason of disability and they created the higher cost of healthy care for communities. Therefore World Health Organization (WHO) makes dementia a global health priority. An estimated 35.6 million people worldwide will be living with dementia in 2010. This number is estimated approximately 115.4 million in 2050. The problem is not only the numbers of patients with cognitive disorders, its enormous impact on families and, becomes a bigger public health concern because of associated problems such as long disease duration, caregiver burden, cost of providing care.
İn spite of its negative consequence, cognitive disoders are underdiagnosis because stigma cause significant problems for people with dementia and their families. Whereas cognitive impairment might prevent or delay disability by Interventions including healthier life styles and management of risks factors of cognitive decline.
Cognitive decline can range from mild cognitive impairment to dementia. Dementia is characterised
by chronic, global, non-reversible impairment in cerebral function. It usually results in loss of memory, loss of executive function such as the ability to make decisions or sequence complex task and changes in personality. 10% of persons over age 65 and up to 50 % over 85 have dementia.
Dementia is a syndrome caused by a range of illnesses. Most are currently incurable, and cause progressive, irreversible brain damage. Alzheimer’s disease is the most common cause of dementia. The other types of dementia are vascular dementia, mixed dementia, dementia with Lewy-Body, frontotemporal dementia (Pick’s disease), Parkinson’s disease related dementia, Jacob- Creutzfeldt disease, Alcohol-related dementia, normal pressure hydrocephalus. There are also types of dementia that seen rarely. The combination of Alzheimer’s disease and vascular dementia or other dementing disorders is termed “mixed dementias.”
Patients with cognitive impairment often present with concerns of recent memory loss. However,
forgetfulness not always mean dementia. Forgetfulness may be result of normal aging. İt is very important accurately to assessment early symptoms of cognitive impairment. While memory function related cognitive disorders is worse than expected for age, normal expected age-related memory functions remain relatively stable with increasing age.
Mild degrees of cognitive impairment, particularly when self-reported by patients, pose a substantial
challenge to the clinician. The physician may be dealing with a patient with a mild or transient condition, a drug-induced adverse effect, or a depressive disorder; the patient may be in the early stages of a condition that will eventually lead to a dementia; or the complaint may be due to a psychological condition rather than an organic brain disorder. Because a variety of conditions may result in a complaint of cognitive impairment, an individualized workup for such conditions and a consensus on a therapeutic approach should be sought.
Mild cognitive impairment (MCI) represents a stage of cognitive impairment that exceeds the normal expected age-related changes, but functional activities are largely preserved and so MCI does not meet the criteria for dementia. Subtypes of MCI are amnestic and nonamnestic forms of MCI. The pathophysiology of mild cognitive impairment is multifactorial.
Recognition of MCI is important in the investigation of treatments aimed secondary prevention of dementiaNonamnestic MCI may be associated with cerebrovascular disease, frontotemporal dementias. Some people with amnestic MCI go on develop Alzheimer’s disease. People MCI progressed to dementia in several studies at very different rates. Average conversion rate is %10 per year. Therefore MCI patients should be evaluated regularly for progression to AD.
Family physicians play a key role in definition, management and folloving of patients with cognitive disorders. The diagnosis of dementia basically is based history and physical examination
and assesment of cognitive function. A full clinical history should be taken.This should include interviews with the patient and their family or carer conducted together and separately. Practitioners should guestion symptoms of cognitive function and family history of dementia. The diagnosis of dementia can be suggested when there is an impairment in memory and an impairment of at least one other area of higher cognitive functioning (e.g., judgment, abstract
thinking, complex task performance, agnosia, apraxia, visuospatial awareness, personality change in the context of deficits) that interferes with normal social and executive functioning in an otherwise alert person.
Early symptoms are that:
Having difficulty in learning and retaining new information and recent events•
Asking the same question repeatedly •
Forgeting simple words or names of certain objects •
Dressesing inappropriately (e.g. may wear summer clothing on a winter day) •
Repeatedly forgets where things were left; puts things in inappropriate places •
Handling complex tasks •
Having personality changes; may become suspicious, withdrawn, apathetic, fearful, or inapp•
ropriately intrusive, overly familiar or disinhibited
There is not spesific finding of physical examination about dementia. Physical examination may be helping in differantial diagnosis of the other medical conditions that cause symptoms of cognitive impairment. A complete and thorough clinical examination should be directed towards finding evidence for specific conditions which may cause dementia such as stroke, Parkinson’s disease, cerebrovascular disease, hypothyroidism and underlying chronic conditions which may cause dementia. There is often considerable comorbidity found in people with dementia, and they may benefit from a methodical examination in search of treatable conditions.
There is no serum or radiographic tests available for the diagnosis of AD, for diagnosis of dementia. However it done to rule out any curable or reversible medical condition that cause cognitive impairment. Before diagnosis of dementia it must be to rule out this conditions.
Cognitive impairment is an important part of the diagnostic criteria for dementia. The most commonly used screening instrument for cognitive impairment is the Mini-Mental State Examination
(MMSE). The MMSE has been validated in community and primary care settings, where it has been shown to increase the recognition of cognitive impairment. It is scored out of 30 and although a low score on the MMSE is suggestive of cognitive impairment, it is not diagnostic of dementia syndrome or any subtypes.
The other screening tools are the Mini-Cog, the Montreal Cognitive Assessment (MoCA), the AD 8 Dementia Screening Interview, and the 7-Minute Neurocognitive Screen.
Patients with suspected dementia should also be screened for depression, because this psychiatric
disorder can impersonate dementia, or exist concurrently. Depression occurs in 25% of dementia
patients; it is an independent risk factor for institutionalization, and should be detected and treated. Subclinical depression in older women is a risk factor for cognitive decline. Screening for depression in older patient is used both of geriatric depression scala and mini mental state test. There is not curable treatment for dementia. Aims of intervention are to improve cognitive function
(memory, orientation, attention, and concentration); to reduce behavioural and psychological symptoms (wandering, aggression, anxiety, depression, and psychosis);to improve quality of life for both the individual and carer.
Cholinesterase inhibitors are approved for treatment of mild to moderate dementia. Cognitive symptoms of dementia can be improved by donepezil, galantamine and memantine. Rivastigmine and tacrine can improve cognitive function in people with dementia but have high rates of adverse effects. Ginkgo biloba may improve cognitive function in people with Alzheimer’s disease or vascular
dementia, but preparations are inconsistent. The US Preventive Services Task Force (USPSTF) acknowledges that fair to good evidence supports a benefit from treatment of early-stage Alzheimer’s disease. However, There is not satisfying
evidence for routine screening for dementia in older adults.

Key words: Aged, Delirium, Dementia, Amnestic, Cognitive Disorders

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Birincil Bakımda Bilişsel Sorunların Yönetimi

Özet
Dünyanın demografik yapısı değişmekte, yaşlı kişilerin nüfus içindeki sayıları hızla artmaktadır. Tıp alanındaki gelişmeler ve nüfusun yaşlanması birincil sağlık bakımının hasta yelpazesini de değiştirmektedir. Nüfusun yaşlanması ve pek çok akut hastalıkta sağaltım sağlanabilmesi kronik hastalıkları toplumların sağlık öncelikleri konumuna yükseltmektedir. Kronik hastalıklar içinde bilişsel
sorunlar hem hastayı hem de aile ve toplumu etkileyen yönleri ile özel önem taşımaktadır. Demans prevelansı yaşla artan ve her 5 yılda bir ikiye katlanan bir sendromdur. Yapılan prevelans çalışmaları coğrafi, kültürel, ırksal faktörlere göre değişmekle birlikte 65 yaş ve üzerindekilerin %3-11’inde, 85 yaş ve üzerindekilerin %25-47’’sinde bilişsel bozulmaya bağlı hastalıklar için ortak
bir ad olarak kullanılan demansın bir formunun bulunduğunu göstermektedir. 2009 Dünya Alzheimer Raporu’na göre tüm dünyada 2050 yılında demanslı kişi sayısı 115.4 milyon olacaktır. Ancak bu hastaların büyük çoğunluğu hastalığın erken evrelerinde tanı alamamakta ve tedavi edilememektedir. Birincil bakım bu hastaların ilk temas noktasıdır. Aile hekimleri bu hastaları tanıma
ve uygun tedavi almalarını sağlamada önemli konumda bulunur ve bakımın koordinasyonunu sağlayabilir.
Demans birdenbire gelişen bir hastalık değildir. Yıllar içinde giderek artan biliş bozulması ile seyreden kronik bir hastalıktır ve günümüzde demans için tam sağaltım sağlayan bir tedavi yoktur. Bu nedenle koruma özel önem taşımaktadır. Genel sağlığın korunması ve sağlıklı yaşam önlenebilir ya da geciktirilebilir. Birincil bakım hekiminin demans yönetimindeki rolü multidisipliner bir yaklaşım içinde hastaların erken saptanmasını ve uygun tedavi almalarını sağlama, hastalığın seyri sırasında ortaya çıkabilen sorunları yönetme, aileye ve bakım verenlere rehberlik etmedir. Bu amaçla demans tanı ve yönetiminde birincil bakım için hazırlanan yönetim rehberleri kullanılabilir.
biçimlerinin benimsenip uygulanması yanında risk etmenlerine yönelik girişimlerle hastalık

Anahtar Kelimeler: Yaşlı, Deliryum, Demans, Amnestik, Bilişsel Bozukluk