Rajiv Gandhi University of Health Sciences s186

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

NAME OF THE Ms. VANDANA SAINI 1 CANDIDATE AND NO:5, NOOR BUILDING, RMV 2ND STAGE, ADDRESS BHOOPASANDRA MAIN ROAD, BANGALORE – 94.

2 NAME OF THE NOOR COLLEGE OF NURSING, INSTITUTION NO.5, BHOOPASANDRA MAIN ROAD,

RMV II STAGE, BANGALORE-94.

COURSE OF THE STUDY M.SC. NURSING, 1ST YEAR, 3 AND SUBJECT MENTAL HEALTH NURSING

4 DATE OF ADMISSION 01.10.2011

“ A STUDY TO ASSESS THE KNOWLEDGE REGARDING CARE OF TITLE OF THE TOPIC 5 DEMENTIA AMONG CARE GIVERS OF DEMENTIA PATIENTS WHO ATTEND MIND PSYCHIATRIC HOSPITALS AT BANGALORE.” WITH A VIEW TO DEVELOP INFORMATION BOOKLET.

1 6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“You have to begin to lose your memory if only in bits and pieces to realize that memory is what makes our lives. Life with memory is our coherence, our reason, our feeling, our action, without it we are nothing.”

- LUIS BUNEUL

Increases in life expectancy during the twenty first century have produced an aged population of an unprecedented size and longevity. Ageing leads to several biological changes that take place over time and results in progressive loss of functional capacity. The aged have to cope up with many physical and mental health problems with advancing age requiring constant attention. Depressions, Hypertension, Arthritis, Dementia, and Alzheimer’s are highly prevalent among the aged.1

The theme hopes to not only promote awareness about the disease, but also help people seek early help so they can manage the disease successfully.1

Alzheimer’s disease is a form of dementia. Dementia is derived from the Latin word de — “apart, away” and “mens” — mind. Dementia is a progressive brain dysfunction which result in a restriction of daily activities and in most cases leads in the long term to need for care. Literal meaning of dementia is Madness and insanity

Dementia (meaning "deprived of mind") is a serious cognitive disorder. It may be static, the result of a unique global brain injury or progressive, resulting in long- term decline in cognitive function due to damage or disease in the body beyond what might be expected from normal aging. Although dementia is far more common in the geriatric population, it may occur in any stage of adulthood. This age cutoff is defining, as similar sets of symptoms due to organic brain syndrome or dysfunction, are given different names in populations younger than adult. Up to the end of the nineteenth century, dementia was a much broader clinical concept. Dementia is a non- specific illness syndrome (set of signs and symptoms) in which affected areas of cognition may be memory, attention, language, and problem solving. It is normally required to be present for at least 6 months to be diagnosed.2

2 Memory loss is a common symptom of dementia. However, a memory loss life does not mean you have dementia. People with dementia have serious problems with two or more brain functions, such as memory and language.3

Dementing illness are the most common disorders among elderly and thought to be the fourth leading cause of death among adults in many developed nations following heart disease, cancer and stroke. Dementia robs the quality of life not only the elderly, but also the family members who are forced to devote their lives caring for their impaired loved ones.4

Dementia is the most feared and divesting disorder of late life. Current estimates reveals that there are about 18 million cases of dementia in the world and by 2025, there will be about 34 million suffering from dementia. The overall prevalence of dementia ranges from 5 percent to 7 percent. Alzheimer’s disease is the most common dementing disorder accounting for 80 percent of all cases of dementia.5

It is clear that the main risk factor for dementia is age. About 3% of men and women between the ages of 65 and 74 suffer from dementia, but after age 65, the percentage of people with dementia approximately doubles with every decade of life. The proportion of people aged 85 and older with dementia is between 25 and 35%. However, it is important to understand that dementia is a disease which is seen more in older people, and is not a normal part of ageing. It is also clear that, as the population of older people grows throughout the world, the number of people with dementia will rise. If current population trends continue, the number of people with dementia could double every 20 years. Currently the causes of dementia are not known for certain, and there is no known cure.6

Primary causes of dementia include a number of neurological disorders, from the well-known Alzheimer's disease to less familiar disorders, such as Pick's disease. Primary causes of dementia usually cause irreversible memory loss and impaired thought processing. Dementia-like symptoms can develop as a result of an underlying medical condition such as medication like anti-diarrhea, anti - epileptic medication, antihistamines etc, alcohol, vitamin deficiency, infection like meningitis, encephalitis, and human immunodeficiency virus etc.7

3 There is currently no cure for Dementia. Currently available medications offer relatively small symptomatic benefit for some patient but do not show disease progression. It helps a little for the memory. Right now, Dementia is diagnosed by a battery of mental and other tests and even the diagnosis rests on the judgment of the physician.7

The sun will continue to show its rays on the world. The waves of the vast ocean will continue their rush to reach the shore and the wind will continue to blow the leaves of the tree. Let us all accept the patient with Dementia and give them a better tomorrow.7

6.1 NEED FOR THE STUDY

Life expectancy has gone up from 20 years at beginning of the 20th century to 62 years today. India has large segment of older people in the population. This segment is growing fast with rapid increase of the grey population in India. And dementia is one of great problem facing during the old age period.8

Dementia is one of the world's fastest growing diseases -- won't go away and it is fast becoming "everyone's problem." A look at the facts and statistics surrounding dementia clearly show that it is a massive issue.8 Indeed, the numbers and statistics surrounding dementia are staggering. Worldwide, there are now an estimated 24 million people living with some form of dementia. Without a major medical breakthrough in the fight against dementia, this number could jump to as many as 84 million who have age-related memory loss by the year 2040 Health analysts estimate that in just five years the number of Americans with Alzheimer's will jump to 7.7 million and by 2050 the number is projected to more than double to 16 million.9

Annual Incidence of Dementia in Victoria is: 6,175. Incidence Rate of USA is approximately 1 in 738 or 0.14% or 368,320 people. Incidence extrapolations for USA for Dementia is 368,320 per year, 30,693 per month, 7,083 per week, 1,009 per day, 42 per hour, 0 per minute, 0 per second. This extrapolation calculation uses the incidence statistic. 1,461 men died from dementia and related disorders in Australia 2002. 3,024 women died from dementia and related disorders in Australia 2002.10

4 “Dementia is a terminal illness," says lead author Susan L. Mitchell, M.D., M.P.H., a senior scientist at the Institute for Aging Research. "As the end of life approaches, the pattern in which patients with advanced dementia experience distressing symptoms is similar to patients dying of more commonly recognized terminal conditions, such as cancer."11

The study underscores the need to improve the quality of palliative care in nursing homes to reduce the physical suffering of patients with advanced dementia, and to improve communication with their family members. "This will help to ensure that patients and families understand what to expect in advanced dementia, so that appropriate advance care plans can be made," says Dr. Mitchell.11

A study conducted on carer’s knowledge of dementia and their expressed concerns. The investigator wished to determine how much carers from different settings caring for patients with dementia knew about the disorder and elicit their main concerns about the disease. A survey questionnaire was administered to 136 carers. The carers came from one of three categories one was from carers with no prior contact with elderly mental health services pre assessment group; second carers who had been in contact with mental health care professionals post assessment group; third carers in contact with an dementia Society support group. A questionnaire on the subject of dementia. Carer’s worries about the disorder also recorded. The study highlights the need for elderly mental health teams to evaluate their methods of dissemination of knowledge to carers, develop educational packages for carers and evaluate their effectiveness.12

A study examines on the multi nodal strategies for caregivers of persons with dementia. The researcher divided 139 caregivers in 3 groups: 62 in educational support; 19 -Alzheimer’s Association support group and 58 did not receive any treatment. Outcome measures coping styles, burden, caregivers concerns and symptoms profile in caregivers. Results revealed that the distress increased in educational support group after intervention; high participant satisfaction with groups; support group, members reported higher distress and life impact and lower anxiety. Control group had lowest distress and lower care giving satisfaction.13

Dementia is one of the most devastating conditions that can affect us. It progressively destroys the brain cells, affecting every aspect of daily life and can last

5 for many years. Dementia does not discriminate on the grounds of gender, culture or intellect. Whilst risk factors increase with age, younger people can also be affected. Because lack of early diagnosis and support, lack of awareness in general hospital wards of the special needs of patients with dementia, lack of palliative care – either in hospital, hospice or own home, lack of awareness of the help that can be given by friends, neighbors, shops or local services etc.14

Keeping above fact researcher is keen to assess the knowledge of care givers regarding dementia so that knowledge gap can be filled up by educating the caregivers and public and increasing awareness about dementia and accept the individual who is suffering dementia as an important member of society.15

6.2 REVIEW OF LITERATURE

Review of literature is a systematic search of published work to gain information about a research topic. Conducting review of literature is challenging and enlightening experience. Through the literature reviews, researcher generates a picture of what is known about a particular situation and the knowledge gap that exists between the problem statement and the research subject problems and lays a foundation for the research plan.16

Review of literature provides basis for future investigation testifies the replication, throw light on feasibility of the study and constraints of data collection, relates the findings from the study to another with a hope to establish a comprehensive body of scientific knowledge in a professional discipline from which valid and pertinent theories may develop.16

Here the review of literature related to the present study has been divided under the following areas.

Part A: Literature related to the general aspects of dementia.

Part B: Literature related to knowledge of care givers on dementia. PART A: LITERATURE RELATED TO THE GENERAL ASPECTS OF DEMENTIA.

A study conducted on the prevalence of common psychiatric disorders in long term care population. The results shows a total of 74 studies examining the

6 prevalence of psychiatric disorders and psychological symptoms in LTC populations were identified including 30 studies on the prevalence of dementia, 9 studies on behavioral symptoms in dementia, and 26 studies on depression. Dementia had a median prevalence (58%) in studies while the prevalence of BPSD was 78% among individuals with dementia. The median prevalence of major depressive disorder was 10% while the median prevalence of depressive symptoms was 29% among LTC residents. The outcome measures shows Dementia, depression and anxiety disorders are the most common psychiatric disorders among older adults in LTC.17

A study conducted to ascertain the prevalence of dementia among Kashmiri Pandit aged 60years and above. Materials and Methods are used for this study is a cross-sectional survey was conducted among the elderly population of the Kashmiri living in a migrant camp. A Kashmiri version of the Mini-Mental State Examination as the test instrument, and a score below 24 was considered indicative of dementia. A functional ability questionnaire was also administered to the subjects. A neurologist carried out the examinations. Results show a sample comprising 200 subjects (95 males and 105 females) were evaluated. The prevalence of dementia is 6.5% among the Kashmiri Pandit population aged 60 years and above, which is higher than that reported from other parts of India.18

A study conducted to identify the characteristics and causes of dementia prior to age 45. They identified 235 individuals, ages 17 to 45, who previously had normal cognitive function and were evaluated for progressive cognitive decline at Mayo Clinic from 1996 to 2006. In one-third of patients, the dementia was caused by a neurodegenerative disorder such as front temporal dementia, Huntington's disease or familial prison disease. In 20 percent of patients, young-onset dementia was caused by autoimmune or inflammatory conditions such as multiple sclerosis, autoimmune encephalopathy or neuropsychiatric Lupus. The results show that this is an important finding, because many of these diseases may have specific treatments.19

A study was conducted to determine the clinical profile of patients attending a specialist cognitive disorders clinic in West Bengal. A retrospective study was carried out in the study. Almost one-fourth (94/379, 24.5%) of all the patients with dementia were of young onset. Women constituted about one-third of these cases. The most common etiologies were Alzheimer disease (33%), front temporal dementia

7 (27%), and vascular dementia (20%). In contrast to other published studies of young-onset dementia, front temporal dementia was commoner than vascular dementia. This could be due to referral bias. A positive family history was found in close to one-fifth of the patients. Close to 10% of the patients had reversible causes of dementia.20

A Study conducted on behavioral and psychological symptoms of dementia in Taiwan. Studies showed that between 30% and 63% of Taiwan's AD patients experienced delusion. Hallucination occurred less frequently, which ranged from 21% to 26%. Anxiety occurred in 35-76% of patients and depression 22-50%, sleep abnormalities 26-61% and 39-46%. The differences in the prevalence of BPSD might result from the different clinical settings and evaluation instruments. The prevalence and clinical manifestations of BPSD in Taiwan are similar to Western reports. Based on differing cultural backgrounds, the interpretation of agitation and apathy might differ, so, the development of cross-cultural applicable criteria and rating scales for the assessment and treatment of BPSD are important for future studies.21 A study conducted of around 7,000 people over 65 identified significant differences in the risk factors for men and women. The main risk for men is a variation in a gene linked with the most common form of Alzheimer's disease, according to the French study. The main risk for women was difficulty with routine daily tasks that would allow them to live without assistance, such as preparing meals, managing money, food shopping, doing housework and using a telephone. Women who struggled with such tasks were around 3.5 times more likely to develop dementia, whereas for men it more than doubled the risk. None of the 6,892 people in the study had dementia when it began but 2,882 were classed as having mild cognitive impairment, meaning they were starting to show signs of mental decline and did not perform highly on memory tests. The study noted that Women are more vulnerable to getting Alzheimer's disease than men and this study shows how risk factors, such as stroke and depression, affect men and women differently.22

A study to identify the 15 point index to identify patients at risk of developing dementia before symptoms develops. A total of 3375 persons were included in the longitudinal study. The participants' average age was 76, and the length of the study was six years. None of the patients showed signs of dementia at the onset of the study.

8 The 15-point Index was compiled retrospectively by the researchers, who looked back over the data to discover signs and symptoms that would help to identify patients at risk for Alzheimer's. A total of nine items were identified as risks, and each item was given a point value that brought the highest possible risk to 15. Result shows that the participants, 480 persons developed Alzheimer's. Of these, 56% scored an 8 or higher on the 15-point index, 23% had moderate scores, and 4% had low scores. This indicates that the index could provide a useful assessment tool to medical practitioners when assessing older patients for Alzheimer's disease risks.23

A study conducted on protocol of a cluster randomized trial on dementia management in a general practice setting. Methods/Design is used for this study the IDA project a three armed cluster-randomized trial where dementia patients and their informal caregivers are recruited by general practitioners. In the control group patients receive regular treatment, whereas in the two intervention groups general practitioners participate in a training course in evidence based dementia treatment. The study recruitment and follow-up took place from July 2005 to January 2009. 303 general practitioners were randomized of which 129 recruited a total of 390 patients.. Discussion says that from a public health perspective, the IDA trial is expected to lead to evidence based results on the community effectiveness of non-pharmaceutical support measures for dementia patients and their caregivers in the primary care sector.24

A study conducted on Health Professionals perspectives of providing care to people with dementia in the acute setting. Open-ended interviews were conducted with 25 medical, nursing, and other health care professionals drawn from 3 metropolitan teaching hospitals in Australia. Results showed acute care hospitals are not the best place for people with dementia and can negatively influence health outcomes such as functional independence and quality of life. Participants reported attempts to provide best practice but experienced major constraints stemming largely from environmental, socio cultural and economic issues. Recommendations include the delivery of acute services in tandem with dementia services and a whole organization shift in thinking away from what conveniently suits the institution to thinking that is person-centered and dementia-friendly.25

9 A study conducted on acute care management of older people with dementia. A descriptive qualitative Design used for data collection using semi-structured approach. Method used was audio-taped interviews with a cross section of thirteen staff that worked in acute medical or surgical wards in Queensland, Australia Hospital. The result shows sub themes with the overarching theme being paradoxical care, in that an inconsistent approaches to care emphasized safety at the expense of well-being and dignity. In conclusion dementia as a risk management strategy does not encourage an evidence-based approach. Staff education and environmental resources may improve the current situation so that people with dementia receive care that takes into account their individual needs and human dignity.26 PART B: LITERATURE RELATED TO KNOWLEDGE AND PRACTICE OF CARE GIVERS ON DEMENTIA. A study conducted on mindfulness meditation and education for dementia caregivers. Design used for this study was a pilot randomized trial. In this study two comparison groups were there. Caregivers serving as an active control group and a respite-only group serving as a pragmatic control. This study was conducted at the Oregon Health & Science University, Portland. The subjects were community- dwelling caregivers aged 45-85 years of close relatives with dementia. Results shows there were 31 caregivers randomized and 28 completers. There was a significant effect on RMBPC by group co varying for baseline RMBPC, with both active interventions showing improvement compared with the respite-only group. In conclusions both mindfulness and education interventions decreased the self-rated caregiver stress compared to the respite-only control.27

10 A study conducted on the isolate needs. Families express both for medical and psychological care, and for educational and social support in 112 caregivers of patients affected by moderate to severe dementia. The medical needs caregivers express are mainly relative to a better knowledge of the disease (78%) and the exact diagnosis (65%); the education-related needs are mainly relative to the acquisition of communicational skills (83%) and the optimal handling of cognitive (77%) and behavioral disorders (81%); the psychological ones mainly concern the area of assistance induced emotional stress management (37%) and the elaboration of feelings such as anxiety, rage and guilt (49%). Variance analysis shows a correlation between emotional caregivers' needs and the subjective and objective burdens they carry. The results shows caregivers still express low levels of illness-consciousness and high levels of psychological discomfort.28

A study conducted on knowledge about dementia in the general public of Japan. A quota sampling method was used to select 2,500 participants, 2,115 of who were eligible for the analyses. A result shows the average number of correct responses among females was significantly greater than that among the males. A multiple comparisons test demonstrated that middle-aged women were more knowledgeable than younger and older respondents. In conclusions the gaps in knowledge on dementia among the general public, which may prevent caregivers from planning upcoming social and financial challenges? Correct information needs to be given by health professionals and care staff. Educational initiatives planned for the general public could be useful, and should target those groups, men and non-middle aged women who have lower knowledge.29

11 A study conducted on empowering older people with early dementia and family caregivers. A rural town in Japan is selected as setting. This study involved 37 community-dwelling elderly with early or mild dementia and 31 family caregivers. Three types of data were collected; observational data collected during the activities, written comments from the caregivers, the record of phone interviews and counseling’s with caregivers. The PAR lasted for 5 years and evolved over three cycles: individual, group and community. In the first cycle, the major focus of the intervention was to regain procedural skills for each PWD through a cooking programme. In the second cycle, to increase interactions with family members and with other PsWD, group activities that promoted communication among family members as well as among PsWD were implemented. In the third cycle, community participation was planned and implemented through culturally relevant sequential activities. The results shows the importance of interventions for both community dwelling elderly with early dementia and their family caregivers.30 A study conducted on factors that influence home return from health care facilities for the elderly--related to the attitude of family caregivers. Subjects were elderly who were in long-term care insurance facility in June 2004, and their caregivers. A face-to-face interview based on a questionnaire was conducted for the institutionalized elderly and by the mail for the caregivers. The caregivers of 34.6% of the elderly who hoped to return home intended to accept them home. There were differences between the plans of the elderly and caregivers. It has been suggested that more physical activities in the facility, establishment of a care-system for the demented elderly living in the community and an educational campaign by the long-term care insurance system are necessary to increase the willingness of caregivers to accept home return of institutionalized elderly.31

12 A study conducted on the structure of risk factors and outcomes for family caregivers: implications for assessment and treatment. A sample of 67 caregivers caring for a family member in the middle stages of dementia were assessed on 15 risk factors and six outcome measures. Results shows risk factors were at best only moderately correlated with one another. Outcome measures showed somewhat higher correlations with one another, but participants varied in terms of the number and type of outcomes that were elevated. Implications of study were Caregivers possess unique combinations of risk factors and outcomes that suggest the need for individualized or tailored interventions.32 A study conducted on Caregiver burden associated with behavioral and psychological symptoms of dementia in elderly people in the local community Japan. The subjects were 67 participants with dementia living with their caregivers, 51 Alzheimer's disease, 5 vascular dementia and 11 other. The Neuropsychiatric Inventory and NPI Caregiver Distress Scale were used to assess subjects' BPSD and related caregiver distress, respectively. The results shows aberrant motor behavior had the highest mean NPI score, and depression/dysphoria had the lowest. Agitation/aggression had the highest mean NPI-D score, and euphoria/elation had the lowest. Delusion, agitation/aggression, apathy/indifference, irritability/lability and aberrant motor behavior showed a correlation between the NPI and NPI-D scores. In conclusion the burden associated with BPSD is different for each symptom and does not always depend on frequency and severity of BPSD. These findings suggest that some symptoms, such as agitation/aggression and irritability/lability, may affect the caregivers significantly, although their frequency and severity are low.33 6.3 STATEMENT OF THE PROBLEM

“ A study to assess the knowledge regarding care of dementia among care givers of dementia patients who attend in Mind psychiatric hospitals at Bangalore.” with an view to develop information booklet.

6.4 OBJECTIVES OF THE STUDY

 To assess the knowledge and practice regarding dementia among care givers of dementia patients.

13  To find out the association between knowledge and practice with selected demographic variables.  To develop information booklet for care giver regarding care of dementia. 6.5 OPERATIONAL DEFINITIONS

Assess:

It refers to the estimation of knowledge level of care givers regarding dementia. Knowledge: It refers to level of understanding regarding dementia Dementia: It refers to a condition in which there is a gradual loss of brain function; it is a decline in cognitive/intellectual functioning The main symptoms are usually loss of memory, confusion, problems with speech and understanding, changes in personality and behavior and an increased reliance on others for the activities of daily living. Information Booklet: It refers to self contained information regarding care of dementia patients for self learning prepared by investigator. Care givers: Refers to persons who are responsible for attending to the needs of old age people between the age group of 21-50 yrs 6.6 ASSUMPTIONS  Care givers may have little knowledge on Dementia  Socio demographic variables influence the knowledge

6.7 DELIMITATIONS OF THE STUDY

 Study is limited to care givers of patients with dementia  Study is limited to 6 weeks.

7.0 MATERIAL AND METHODS

7.1 Source of data:

14 Care givers of patients with dementia who attend in Mind psychiatric hospitals at Bangalore.

7.2 Research Approach:

Descriptive survey approach will used for the study

7.3 Research design:

The study will be used for this is Descriptive Research Design

7.4 Variables:

Age, sex, religion, Type of family, Family history

7.5 Population:

Care givers of patients with dementia attending mind psychiatric hospital at Bangalore.

7.6 Sample:

Sample for present study consist of 50 caregivers of patients with dementia at mind psychiatric hospital Bangalore

7.7 Sample Size:

50 caregivers of patients with dementia

7.8 Sample Technique:

Non probability convenient sampling

7.9 Criteria for sample selection

Inclusion Criteria

15  Care givers who are present at the time of data collection.  Care givers who are willing to participate in study.  Care givers who can understand English / Kannada.

Exclusion Criteria

 Those who have other chronic illness.  Those who are not willing to participate

Setting of the study

Study will be conducted in mind psychiatric hospital at Bangalore. The distance of 10 Kms from Noor College of nursing which is 200 bedded hospitals with all types of facilities with rehabilitation for the psychiatric patients. There are different specialty doctors who treat dementia patients very effectively.

8.0 DESCRIPTION OF THE TOOL

The tool was organized in to two sections

Section I

Socio-demographic data containing 9 items age, Gender, religion, type of family, Educational status, Monthly income, Family history of dementia, Sources of information.

Section II

Knowledge questionnaire regarding care of dementia.

9.0 DATA COLLECTION PROCEDURE  Prior to data collection, formal written permission will be obtained from concerned authority and from participants.  After explaining about the study, structured knowledge questionnaire will be used assess the level of knowledge and duration of data collection will be up to 6 weeks. 10.0 PLANS FOR DATA ANALYSIS Data will be analyzed by using descriptive and inferential statistics. 11.0 DESCRIPTIVE STATISTICS

16  Frequency percentage distribution will be analyzed with the demographic data of caregivers of patients with dementia.  Mean standard deviation will be used for analysis of knowledge of caregivers of patients with dementia. 12.0 INFERENTIAL STATISTICS  Chi- square test will be used to analyze the knowledge of care givers of patients with dementia with selected demographic variables.

13.0 DOES THE STUDY REQUIRE ANY INVESTIGATION OF INTERVENTION ON CLIENT OF OTHER HUMANS? IF SO, PLEASE DESCRIBE BRIEFLY No. investigation or intervention will be conducted on the subjects

14.0 ETIHICAL CONSIDERATION TOWARDS SAMPLE RELATED TO STUDY Yes, informed consent will be obtained from the concern authorities to conduct study. Privacy, Confidentiality and anonymity will be maintained will be maintained throughout the study.

15. LIST OF REFERENCES

1. Dementia. Available from: URL: http://en.wikipedia.org/wiki/Dementia.

17 2. World Alzheimer’s day September 21(2010). Available from: URL: http://www.alz.co.uk/adi/wad/2010events.

3. World alzheimer’s day September 21(2011). Available from: URL: http://www.alz.co.uk/adi/wadi/2011events.

4. Dementia. Available from: URL http:/www.nlm.nih.gov/medlineplus/dementia .html.

5. Dr. K Lalitha. Nursing care of elderly with Neuro psychiatric problem. National conference on geriatric nursing. Pondicherry; 2005.

6. Dementia statistics worldwide. 2008; Available from: URL: http://www.google.com

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8. Dementia. Available from: URL:

http://www.about-dementia.com/articles/about-dementia/dementia-

9. Dementia statistics.2008 Aug 15; Available from: URL: http://www.articlesbase.com/anti-aging-articles/dementia-facts-and-statistics- present-and-future

10.Ferri CP, Prince M, Brayne C, Brodaty H, Fratiglioni L, Ganguli M et.al. Global prevalence of dementia: a Delphi consensus study. Lancet 2005 Dec 17; 366(9503): 2112-7.

11.Dementia: Available from: URL: http://www.wrongdiagnosis.com/d/dementia/stats.htm

12.Dementia.Available from: URL: http://www.physorg.com/news174761992.html

18 13.Graham C, Ballard C and Sham P. Carer’s knowledge of dementia and thus expressed concern. International journal of geriatric psychiatry 1997 Apr; 12 (4): 470-3.

14.Faran. C, Keane H. Multimodal intervention strategies for care givers of person. International journal of geriatric psychiatry 2000 Mar; 13(2): 220-4

15.Manifestation of dementia. Available from: URL: http://www.alzscot.org/pages/policy/manifesto.htm

16.Krishnamurthy OR. Methodology of research in social sciences. New Delhi: Himalaya Publishing House; 2008.

17.Riana S, Razdan S, Pandita KK and Raina S. Prevalence of dementia among Kashmiri migrants. Ann Indian Academy of Neurology 2008;(11):106-8

18.Dr. Kelly. To identify the characteristics and causes of dementia prior to age 45. Medical news today 2008; (10):41-47.

19.S.P Nandi, A Biswas, S pal and S Basu. Clinical profile of young onset Dementia. Neurology medical news today 2008; 103-108.

20.K Ritchie, L carrier, C W Ritchie and C barr. Designing prevention programmes to reduce incidence of dementia. BMJ 2010; 341- 385.

21. A study designed to generate epidemiological and clinical data on dementia. [Online] 2005; Available from: URL: http://www.neurologyindia.com/article.asp?issn=0028-3886.

22.S. Shaji, Srija Bose and Shan Kuriakose. Behavioral and psychological symptoms of dementia a study of symptomatology. Indian Journal of Psychiatry 2009; (15): 38-41.

23.Dr Susanne Sorensen. Study to identify significant differences in the risk factors for men and women. Guardian News & Media 2008; 4: 509-18.

24.Sauvaget C. Dementia as a predictor of functional disability: a four-year follow-up study. Gerontology 2002; 4: 226-233.

19 25. Tariot. A study on assess the interest and the limits of anticonvulsant mood stabilizer on dementia patients. Geriatric Psychiatry 2005;13:942-945

26.HaJY. Development of dementia care standards. Journal of Korean academy of nursing 2010; 5:631-641.

27.Devore EE, Grodstein F, Van Rooji FJ, Hoffman A, Stampfer MJ, Witteman JC, Breteler MM. Dietary antioxidants and long-term risk of dementia. Arch Neurology 2010; 7:819-825.

28.Arai Y, Arai A, and Zarit SH. A survey on knowledge about dementia in the general public of Japan. International journal of nursing studies 2009; 4:43-41.

29.Polit DF, Hungler BP. Nursing research. 6th ed. Philadelphia: JB Lippincott publication; 1999.

30.Gail W Stuart. Principles and practice of psychiatric nursing. 9th edition. philadelphia: 2009.

31.Post graduate psychiatry by ten teachers. Adit J medical publishers; 2003.

32.Dementia.[Online].Available from: URL:

http://www.dementiaomnimedicalsearch. com.

20 6. Signature of the Candidate

17. Remarks of the guide

18. 18.1 Name and Designation

of the guide (in block

letters)

18.2 Signature

18.3 Co –Guide

18.5 Head of Department

18.6 Signature

19. 19.1 Remarks of the

Chairman and Principal

19.2 Signature