Many people believe that growing old means becoming forgetful. It is a myth that aging impairs the ability to think, reason, and remember. Doctors often dismiss complaints of memory loss and confusion as a normal part of aging. Current research supports that most people remain alert with active minds as they age. Any indication of a change in memory, mental ability, or personality suggests a possibility of dementia and a need for assessment. Select from the following set of readings for this module.
SECTION 1: DEMENTIA, DELIRIUM, DEPRESSION Any discussion of dementia needs to also address delirium and depression because they all have some similar causes and symptoms. The importance of a correct diagnosis has an impact on the type and effectiveness of treatment. A misdiagnosis could turn a reversible problem into a chronic irreversible one with a discernible impact on quality of life. The term dementia refers to a brain dysfunction with a slow onset that leads to a loss of intellectual abilities and interferes with social or occupational function. Most discussions of dementia appear in concert with topics covering mental dysfunction. The factor to keep in mind is that the basic cause of dementia is physiological. The essential feature of dementia is memory impairment, but also can involve judgment, abstract reasoning, higher intellectual function, and changes in behavior and personality. Even though the cause is physiological, the evidence of dementia cannot be demonstrated through laboratory and x-ray evaluations. Dementia is diagnosed by assessment tests demonstrating decline of cognitive ability compared to a history of performance. Laboratory and x-ray evaluations are useful to rule out conditions that mimic dementia. Often, in the latter situation, symptoms can be reversed with treatment. Delirium is a transient mental disorder characterized by rapid onset, brief duration, disorganized thinking, confusional behavior from perceptual disturbances, and frequently a clouding of consciousness (either drowsiness or excitability). Like dementia, delirium has a physiological cause. They include alcohol, drug toxicity, minor head trauma, and certain disease states causing a metabolic or chemical imbalance in the brain. In most cases, early diagnosis and treatment relieves the delirium. Untreated causes of delirium can result in dementia. Therefore, the delirium must be treated quickly. Depression, considered a psychological disorder, is characterized by a sudden or gradual onset of symptoms varying from feelings of sadness and unhappiness to feelings of despair and thoughts of suicide. The cause of depression can be physical in nature. Examples of physical causes include metabolic imbalances resulting from major diseases, excess medications, or altered production and availability of mood-controlling neurotransmitters in the brain. Depression also can have a social and emotional causation such as from impact of illness, or from multiple losses experienced during aging. Research is suggesting a genetic or heredity factor in the causation of depression. Persons with depression can experience symptoms similar to dementia. Example include thought impairment, disorientation, slowed movement, shortened attention span, and emotional outbursts. Therefore, accurate assessment is necessary to insure appropriate treatment. Unlike dementia, depression can be successfully treated with medications and/or psychotherapy. SECTION 2: CAUSES OF DEMENTIAMany causes of dementia exist. Basically, anything that interferes with or compromises the normal function of brain cell function by pressure, blockage, or destruction, can result in dementia. Some examples of causes include infections, toxins, degenerative diseases, fluid or oxygen imbalance, and tumors. In many instances symptoms of dementia such as memory impairment, thought impairment, and even confusion can be confused with the symptoms of delirium caused by specific nutritional deficiencies, medications, certain diseases interfering with metabolic function, and even some mental disorders. The result is disorders that simulate dementia, and without appropriate treatment become irreversible. SECTION 3: ALZHEIMER'S DISEASEAlzheimer's disease is the most common form of irreversible dementia. Unlike most other forms of dementia, a person with Alzheimer's disease will experience a progressive decline in function. The mental decline is characterized by increasing forgetfulness, confusion, inability to concentrate, personality deterioration and impaired judgment. The physical decline progresses in the later stages involving muscle weakness and wasting, urinary and fecal incontinence, with an outcome necessitating total physical care. The person with Alzheimer's disease eventually becomes totally incapable of any self-care. Death usually occurs one to fifteen years after diagnosis due to pulmonary infection or urinary infection. Diagnosis of Alzheimer's disease is made on the basis of ruling out other forms of dementia. To date, the only accurate way to diagnose is during autopsy after death whereupon characteristic changes in the brain are identified. Those changes include neurofibrillary tangles (webs), senile plaques (deposits), and atrophy of brain tissue (shrinking size of brain). The cause of Alzheimer's disease is still unknown; effective treatment is not yet available. Researchers are studying every avenue to find the cause and cure for Alzheimer's disease. It is assumed that techniques for early diagnosis will assist in the study of the cause and cure for Alzheimer's Disease. Early identification will provide more time to study the progress of the disease providing clues for solving the puzzle of treatment and cure. Recently, researchers at Brigham and Women's Hospital in Boston and at Harvard reported that an eye drop drug called tropicamide, routinely used in eye exams, causes the pupils in eyes of people with Alzheimer's disease to dilate about four times faster than in people without the disease. This study was very small, therefore the findings will have to be verified through much larger studies before this method is used for diagnosing Alzheimer's disease. The March 1995 Longevity magazine reported the results of a study by Suzanne Craft Ph.D. at Washington University in St. Louis in which 22 healthy persons with Alzheimer's disease were given intravenous insulin and 80% showed significantly improved memory. Again, this is a small study; much more work is needed to verify the results and determine the link between glucose regulation and memory function. SECTION 4: INTERVENTION FOR DEMENTIAThe first step in providing care for someone with dementia is to understand the implications of having an altered thought process. The persons' ability to express their needs clearly is impaired, thus the potential greatly increases for having unmet needs. Unfortunately, we are speaking about the person's basic physical needs such as food , water, safety, and security. Leaving these needs unmet would be dangerous to the persons' health and life if left to fend for themselves. Secondly, understanding specific behaviors that relate to whether needs are met or not (i.e. calm vs. agitated) provides indicators of their stress level or well-being. Finally, care providers can learn new ways of communicating, provide a special environment, and use those indicators to determine their success at meeting the persons' needs. Recognizing & Meeting NeedsHall and Buckwalter (1987) developed a model known as Progressively Lowered Stress Threshold (PLST) to use for planning care for persons with Alzheimer's disease and related disorders. The model provides information to help care providers recognize anxious or agitated behaviors and alleviate the stressors precipitating the discomfort. Five groups of stressors produce excess disability in someone with altered thought process:
The dysfunctional behavior may be exhibited through excess anxiety, violent behavior, pacing, or even wandering. CommunicationSomeone with altered thought process will have difficulty comprehending complex information. They are aware of their difficulty and may act out their discomfort through disruptive behavior. Simplify information provided and limit choices they have to make. Break instructions or information down into manageable parts. Provide time for a response before giving them the next piece of information. Instead of saying "here are your clothes so you can get dressed", hand them each piece and wait for them to put it on before you hand them the next piece of clothing. Avoid situations encouraging the person to make a choice, such as by asking "What would you like to wear today?", or "What would you like to eat for dinner tonight?". The person with dementia no longer needs control over such issues in their life. Also, avoid "why" questions. Prompting them to perform this type of task forces them to face their limitations which could lead to catastrophic reactions. A voice can have a profound impact on a person with dementia. A loud, stern voice can precipitate fear and panic, whereas as a soft, calm voice can not only prevent anxiety but be used as a tool to diffuse a panic reaction. Speak slowly, look at the person while talking, and avoid the use of a demanding, confronting, or criticizing tone. Safety and SecurityA person with dementia is unable to comprehend their own safety needs and the risks that would compromise their safety. Slippery floors, obstacles in the path of walking, and inadequate lighting are the most common causes of falls. Persons with dementia are at high risk for falls because of their inability to determine that a risk exists. Mishandling of or exposure to hazardous objects like razors, electrical appliances, hot food and beverage temperatures, and hot bath water temperature can cause major injuries. Impaired thought processes can lead to someone swallowing harmful objects which can result in poisoning and choking. Examples include plants, cleaning solutions, small toys, or marbles. A recent unfortunate event occurred where a person with dementia choked and died after trying to swallow modeling clay. The best solution is to become very aware of potential environmental hazards, plan for safety, and never leave a person with dementia unattended. Wandering is common for persons with dementia and should not be considered an aimless activity. Wandering can be an indication of restlessness, boredom, hunger, or pain. The social and emotional needs of persons with dementia are often overlooked; wandering can be an expression of feelings of loneliness. Therefore, this behavior should be assessed for an underlying cause and intervention initiated. A positive attribute of wandering is that of helping to maintain mobility. Allowing someone the freedom to roam within a protected environment avoids the agitated and hostile reaction to the alternative of physical restraints. Medications are commonly used as chemical restraints for managing wandering and other difficult behaviors. This solution usually increases confusion and mental deficits because most sedative medications are not tolerated well by older people. Forced immobility by physical and chemical restraints can actually cause more physical and emotional problems than it solves. Caring for CaregiversThe difficulty for a caregiver of someone with dementia such as Alzheimer's disease is dealing with the mental decline seen as increasing forgetfulness, confusion, inability to concentrate, personality deterioration and impaired judgment. Caring for a loved one at home can be exhausting and difficult. The difficulty is in dealing with the constant, and even bizarre behavior changes, seeing the personality of your loved one slowly disappear through the course of the disease. Success with being a caregiver relates to developing successful coping strategies that avoid becoming burned out. Strategies include having confidence in the ability to solve problems, keeping an open mind to alternative ways to perceive problems and solutions, giving up the need to control things out of your control, and having a strong support system. Caregiver self-confidence in dealing with the constant behavior changes and progressive mental decline increases with experience over time. Remaining open to alternative solutions to problems also increases self-confidence. Sometimes, objectivity becomes clouded from exhaustion and impedes a willingness to try new ideas. Exploring solutions to problems causing exhaustion might avert the exhaustion in the first place. The difficult aspect of control is knowing the difference between things that can be controlled and those things that cannot be controlled. You cannot control the memory of persons with Alzheimer's disease, no matter how loud you speak or how many times you ask them to try to remember. You can learn ways to lead or prompt the person with dementia to do things, instead of losing the battle with a deteriorating memory. A strong support network includes immediate family, friends, neighbors, other relatives, church members, support groups, and a health care team. People are available to help caregivers with personal needs, caregiving needs, and the needs of the person with dementia. They include socialization needs, respite, errands, health care, and emotional support. Having and using a large support network relates to successfully coping with caregiving. Hall, G.R., & Buckwalter, K.C. (1987). Progressively Lowered Stress Threshold: A Conceptual Model for Care of Adults with Alzheimer's Disease. Archives of Psychiatric Nursing, 1(6), 399-406. Alzheimer's causes unique cell death. Science News 146(13) Sept 24, 1994America's Hidden Disease. Parade Magazine Feb. 12, 1995 pg 4-5. Arresting Alzheimer's: The Insulin Factor. Longevity March 1995 Brain changes may foretell Alzheimer's. Science News Mar 25, 1995. Human, J & Wasem, C. (1991) Rural Mental Health in America. American Psychologist. Vol 46, No.3. 232-239. Thompson, J. & Scott, N. (1991). Counseling Service Features: Elders Preferences and Utilization. Clinical Gerontologist, vol 11(1) 39-45. .Wallace, J. & O'Hara, M. (1992). Increases in depressive symptomatology in the rural elderly: results from a cross-sectional and longitudinal study. Journal of Abnormal Psychology 101(3) 398-404.
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