Dementia and Alzheimer's Disease - Essay Example

Dementia 'Dementia' is a term used medically to describe a syndrome (set of symptoms) that is causedby many different diseases. These include Alzheimer's disease, vascular dementia and dementia with Lewy bodies. An analogy is the term 'cancer', which is used to describe any malignant tumor but is not itself a specific disease. The answer to the frequently posed question 'What is the difference between Alzheimer's disease and dementia' is that, in a sense, there is no difference-Alzheimer's disease is one of the many different types of dementia (Brian Draper; 2004) The Dictionary of Physiological and Clinical Psychology has this to add: Finally, at least one form of senile dementia (Alzheimer's disease) is marked by the degeneration of some of the neurons which produce acetylcholine and communicate with the neocortex (Whitehouse et al. 1981). since blockage of acetylcholine interferes with memory formation in normal people, it is possible that the loss of acetylcholine-containing neurons underlies the memory deficit in Alzheimer's disease. (p. 193) 1. Burden of illness In the case of dementia, the effects have been widely noted and accepted (although the quantity of descriptors may vary from one authority to another): often cited are such symptoms as memory loss, particularly in short-term loadings, confusion, and disorientation in time and place, and personality alterations. Unfortunately, such effects may result from a variety of causes, some of which are treatable and others that are not. Depression is a good example of the former; Alzheimer's of the latter. The prevalence of dementia we see currently is merely the tip of the iceberg at that. There are now some 32 million individuals in this country age 65 and older. That figure is expected to grow to 39 million (a 19 percent increase) in less than 20 years. Though there are now an estimated 5 million victims of dementia, the number may increase to more than 17 million in the same time period. If true, within 20 years, over 40 percent of the elderly will suffer some form of dementia compared to less than 15 percent at the present time. These are staggering figures, and they are only estimates because no statistics are kept by any agency of the exact number of persons diagnosed by physicians as suffering from dementia. In fact, doctors resist any imposition of record keeping that would lead to actual numbers and realistic data. (M. Powell Lawton, Robert L. Rubinstein, 2000) Recent analyses of people with dementia have suggested that a loss of self or a process of "unbecoming" are ascribed to this illness by many clinicians. However, many studies fail to consider and assess the wide variation in levels of self-awareness across both persons and areas of functioning. That is, there may be extensive individual differences not only in overall level of self-awareness but also in the specific patterns of unawareness across functional areas as well as different types of awareness (Danner & Friesen, 1996). To the degree that those with dementia retain awareness of their deficits across a range of functions, their ability to report on their emotional reactions to their deficits might be preserved. Neglect of the patient perspective in dementia may also reflect the failure to consider premorbid expressive styles when drawing conclusions about a person's internal experience (Cotrell & Schulz, 1993). An understanding of premorbid expressive style can help to bring order and meaning to the apparently random expressions of the demented patient. What appears to be indiscriminate, meaningless emotional behavior might instead represent a distorted attempt to communicate one's feelings and needs to caregivers. The new wave in attempting to understand the subjectivity of dementing illness asserts that the person with dementia clearly has feelings but lacks the ability to express them in some of the usual ways. Informed by the knowledge that the demented person has a longstanding tendency to react strongly and negatively to particular circumstances, caregivers and researchers might be able to interpret better their signals of emotional distress. A consideration of these challenges in translating the demented person's message reveals the vital role of careful assessment in understanding their self-reported inner experience. The need to translate dementia patients' oftentimes distorted communication constitutes one of several methodological obstacles to accurate interpretation of self-report information. The ability to "read" a patient is facilitated by assessment efforts that emphasize attention to complementary sources of information, including verbal, facial, postural, vocal, and contextual cues, as well as by the establishment of rapport, which serves to allay patients' fears and mistrust, thereby minimizing emotional barriers to self-revelation (Cotrell & Schulz, 1993). Further, given the extreme fluctuations in dementia patients' levels of lucidity or self-awareness, the usefulness of self-report information might be maximized by making every effort to interview a patient at what is a "good time" for him or her (Cotrell & Schulz, 1993). Katzman (1986) reports that Alzheimer's disease is just one of more than 60 disorders that may produce dementia. Katzman also reports that positron emission tomography (PET) has made it possible to measure and image oxygen and glucose metabolism within the brain of the Alzheimer's patient. Changes first occur in the parietal lobe (which is responsible for sensory discrimination and body image). Later in the temporal lobe (hearing, olfaction, sensory speech and short term memory) and the frontal lobe (abstract thought, mature judgement, social inhibition, intellectual function, and storage of sensory information). In advance cases there may be a generalized decrease in metabolism in all cerebral hemispheres. 2. Diagnostic tests Psychological measurement of dementia patients has centered on the ability to function in the everyday world. This includes a considerable emphasis on space and time awareness and relationships, as has been shown by the most popular of the instruments used in the evaluation process. Yet there have been questions about the role and evidence of utility of such instruments since their first usage over a quarter century ago. Typical of such judgments is a literature review undertaken by Cooper and Bickel (1984) on early detection of dementing disorders. Their principal interest was in screening of the general population in order to detect dementia as early as possible. Within this view, however, they considered "what may be broadly termed 'psychological' screening instruments, where evaluation in terms of applicability and accuracy in case-finding is now assuming an increasing importance in preventive geriatrics" (p. 88). As they note, such tests were devised and applied for differential diagnosis, measurement of any changes (positive or negative) in terms of treatments, or defining more precisely a particular form of psychopathology. Today, those uses are still the most frequent, particularly the first two. Cooper and Bickel included a table that listed and described the dementia scales available at the time. These include: the Mental Status Questionnaire, the Abbreviated Mental Test Score, the Short Portable Mental Status Questionnaire, the Mini-Mental State Examination, the Cognitive Assessment Scale, and the Cognitive Capacity Screening Examination. It is worth noting that several of these scales are still the major vehicles used in the professional setting, for both diagnostic information and notations of change in performance (Allen Jack Edwards; 2002). 3. Frequency The case reported by Alzheimer was unique in certain respects. First, the patient was 51 years old, not a rare occurrence but certainly not typical of the age group most at risk. Burns et al. (1995) report that 3.2% of those in their seventies and 10.8% of those in their eighties show evidence of Alzheimer's disease, with similar ratings for dementia arising in connection with vascular disease. The prevalence for those under 70 is much smaller. In addition, those who display the symptoms leading to a diagnosis at a younger age tend to die earlier than those who are diagnosed at a later age. (There is, of course, a limit to this statement just as to other such generalizations.) The point is that Alzheimer's may run a course of several years (say, 5 as in Alzheimer's own case) or as many as 15 or 20 years for those who display behavioral effects in the years following diagnosis. Predicting a terminal point is practically impossible. The most reasonable position is to say that a patient may live for a number of years and become progressively less mentally competent. The relentless nature of the condition places increasing burden on the caregiver, so the patient, who becomes less and less aware of stressors, may outlive the caregiver. Because professionals prefer order, and families want answers, it is not surprising that there have been attempts to provide "stages" in the progression of the disease. Butler (1990, pp. 934-935) has supplied such a scheme but makes the point that " there is great variability and the progression of stages often is not as orderly as the description implies " (italics in original). Edwards (1993, p. 146) has critiqued attempts at staging in two ways: confounding of disease with outcome and an implication of a linear relationship between the course of the disease and the associated dementia. It seems more appropriate to inform patient and family that the disease is irreversible at the present and shows overall decline into senility so that dependence will become greater as the disease progresses. Of course, how one informs the affected persons is an important component. Nor is it reasonable to leave the situation at this level. There are skills that caregivers can learn, practice, use more and more proficiently, and achieve adaptability. Providing training and direction in building trust, problem solving, and assertiveness provide more assurance of positive outcomes than a list of changes to anticipate. (Allen Jack Edwards; 2002). 4. Etiology The disease process by which the causal factors turn a normal state into a pathological (diseased) state must also be understood. Recognition of 'risk factors' that may facilitate or are associated with the disease process, and 'protective factors' that may suppress the process or are associated with normality, is also crucial. Risk and protective factors may include genetic, medical, biological, environmental, dietary, social and cultural aspects. In the field of dementia, it has only been over the last decade that knowledge has grown sufficiently in these domains for prevention strategies to be mounted. 5. Clinical course and prognosis There is increasing evidence of a connection between high blood pressure and the occurrence of multi-infarct dementia resulting from silent strokes. Cardiac disease and hypertension (high blood pressure) are found commonly in the medical histories of persons who develop such a dementia. The relationship may not be a direct one; that is, there may be some other factor intervening between the two conditions. By contrast, there is no strong evidence of any relationship between high blood pressure and the occurrence of Alzheimer's disease. So, it seems reasonable to assume that vascular disease is involved in multiinfarct dementia. Prognosis for the patient with multi-infarct dementia is poor, suggesting even more strongly the need for us to take appropriate care of ourselves. A diet low in fat and cholesterol, proper aerobic exercise, and weight control are more than just "good" for us. They may actually prevent a later mental problem that cannot be corrected after it occurs. Multiinfarct dementia is more commonly diagnosed in men, and particularly black men, than in women. It occurs earlier in life (usually beginning in the late 50s or early 60s because of the connection with vascular disease) and has a more rapid course of decline than does Alzheimer's. Section B 6. Efficacy of preventive and therapeutic interventions Efficacy of preventive and therapeutic interventions is not yet found very helpful. Though, for many years, low dose aspirin has been prescribed to stop platelets from sticking together, which has been shown to reduce the risk of stroke. There is also evidence that aspirin can slow the progression of vascular dementia; however, no studies have examined whether it may actually prevent dementia. As aspirin is a potent cause of stomach irritation and bleeding, unless other vascular risk factors demand its use to reduce the risk of stroke, it cannot be recommended as a routine preventive measure for dementia until strong studies demonstrate its effectiveness. Though, diagnostic approach conveys a fairly extensive description of an individual patient. It obviously communicates much more than a frequently applied label, "depression with attempted suicide." It tells us, for example, that this man has a job and works regularly, that he is unable to function in the family setting, and that in the past he has been able to handle his problems in his characteristic passive-aggressive manner. It tells us that because of some change, either in him or in his environment, his life style no longer suffices for the handling of stresses and that he has developed a depression that was superimposed upon his character structure. With such information, we can make a number of educated guesses as to treatment, prognosis, and etiology. A second approach to illness is a dynamic description of the processes involved. In this situation, we can then move to a higher level of inference, where we no longer describe the behavior of the individual, but rather describe the mechanisms that are part of the motivational system resulting in the behavior. Our understanding of the dynamic mechanisms involved in certain kinds of symptom formation has been most helpful in the development of approaches to treatment. For example, consider a person who has developed his response patterns in an emotional atmosphere lacking in or inconsistent in the availability of experiences that confirmed his views of himself as a worth while person and who had to grow to maturity in a family whose communications system was fraught with unpredictable corroborations and denials of the meaningfulness of his verbalizations. We are not surprised to find later an adult who gives evidence of low self-esteem and whose thinking is unclear. This kind of understanding of the dynamics of a symptom leads to important therapeutic interventions that have been found to be helpful. Nevertheless, dynamics are inferences and therefore not entirely trustworthy. Dynamic formulations can be used in designing a treatment intervention only so long as they are useful. If they turn out not to be useful, they must be discarded. Alzheimer's disease is becoming a major social problem. Mobily and Hoeft (1985) report that 1 - 1.5 million people currently suffer from dementia and that 50% or more of those cases are thought to be caused by Alzheimer's. According to Blumenthal (1981) and Rathbone-McCuan & Hashimi (1982) the current population at risk can be defined as those having the disease, an estimated 330,000 families extensively involved, and an additional two million individuals impacted in various ways; as reported by McNew (1987). Williams (1984) predicts that by the year 2050 more than 3 million patients will be diagnosed as having Alzheimer's. Section C 9. Health policy The largest numerical group of residents in mental hospital beds are older people, in particular those affected by senile dementia. The demographic aging of the population is leading to increasing demands on the services and also on informal carers in the community. Government policy is to develop services to enable such people to live as long as possible in their own homes: community psychiatric nursing, home helps, meals-on-wheels, day centers, and in some instances respite services for carers. The availability of such services is very uneven. Much depends on the priority given to mental health by both health and local authorities. In 1997 one local authority spent $22,000 in total on mental health, while another spent over $2,000,000. The government is now requiring both health authorities and social services to move to being purchasers of services rather than exclusive providers. The aim is to stimulate the growth of a larger independent sector through the contracting out of service provision to either voluntary (not-forprofit) agencies or to the private sector. Both health and social services are being subjected to major reorganizational change, the outcomes of which are yet uncertain. As, Disruptive behaviors are a major obstacle in the care of a person suffering from dementia, they bring challenges to caregivers both in the home and in the nursing home. Frequently, it is because family members are not able to cope with these disruptive behaviors at home that they are then forced to institutionalize their relative. In the nursing home, higher staff-to-resident ratios are often required in order to control agitated behaviors of residents. Disruptive or agitated behaviors have been defined as inappropriate verbal, vocal, or motoric activity that is not judged by an outside observer to result directly from the needs or confusion of the agitated individual. These comprise a variety of inappropriate behaviors, including repetitive acts, such as repeating the same word continuously; behaviors that deviate from social norms, such as opening one's blouse in public; and aggressive behaviors directed toward one or others. Although not disruptive, inappropriate behaviors that may not disturb anyone, such as repetitive mannerisms, should not be overlooked, because they may provide information about the inner state of the person who is suffering from dementia. It is the caregiver who characterizes any behavior as disruptive. Often, the labeled disruptive behavior may be caused by an older person's physical need, such as fatigue or the need to go to the bathroom, and this need not being obvious to the caregiver. Indeed, the older person suffering from dementia may not even be consciously aware of such needs and thus may not be able to report them even when their verbal skills are intact. On the other hand, behaviors that are clearly a result of a need, such as an accident on the way to the bathroom, or behaviors that obviously result directly from the cognitive impairment suffered by the individual, such as getting lost on the way to the dining room, are not included in this category of disruptive behaviors. As of the effects of dementia including a combination of perceptual problems, communication difficulties, and inability to manipulate the environment through appropriate channels, the elderly resident is unable to fulfill these needs. Disinhibition is an aggravating factor in the manifestation of these needs. The goal of treatment is to uncover the unmet need. Prior research established the connection between symptoms of agitated behavior and common causes eliciting this response. This, then, allows the clinician to expedite detection of the appropriate need and at times directs the clinician to appropriate interventions. The most common needs found are those for social and physical stimulation, both of which are lacking because of a combination of the effects of dementia, sensory deficits, and the monotony of the nursing home environment. However, other needs are often present, such as the need to avoid pain or hunger. A related theoretical framework is that which concerns the concept of person- environment congruence and that of the press-competence model. These suggest that for optimal functioning, there must be a match between the person's needs and abilities and the demands of the environment as they relate to those needs and abilities. For any level of competence, there is a range of environmental demands that is favorable. The notion that lack of sufficient and appropriate stimulation is at the heart of certain types of disruptive behaviors and that the environment must be modified to match the person's stimulation needs and capabilities fits both those theoretical perspectives (M. Powell Lawton, Robert L. Rubinstein; 2000). 10. Significance to dentistry Caring for the dental needs of a person with dementia requires monitoring dietary habits, ensuring the regular use of fluoride, helping with oral hygiene and denture hygiene. People with dementia can rapidly develop tooth decay with severe consequences to their comfort, appearance and health. If you are caring for someone with dementia, follow these guidelines to help secure a healthy mouth for the person you care about. Diet Always use artificial sweeteners in tea and coffee. Try to avoid constantly having sugary snacks and drinks and sucking on lollies. Encourage the person with dementia to drink water instead of sugary drinks or use diet varieties since they contain artificial sweeteners. If the person with dementia suffers from dry mouth, use artificial saliva such as 'salube' prior to eating. Fluoride Fluoride toothpaste should be used to brush natural teeth both in the morning and in the evening. If possible, fluoride mouth rinse should be used after lunchtime to protect teeth from tooth decay. If rinsing is difficult for the person, the mouth rinse can be put in an atomiser and sprayed onto the teeth. Fluoride mouth rinse or spray will also help control bad breath. Fluoride mouth rinse can be bought from any pharmacy, (e.g. Dentamint). Oral hygiene All surfaces of all teeth should be brushed using a soft toothbrush twice each day and always use fluoride toothpaste. People with dementia will need help to do a thorough job. Where no teeth are present, the gums should be brushed daily. Denture care Dentures should be rinsed after every meal. Dentures should be thoroughly brushed with a toothbrush, denture brush or a soft nailbrush once each day. People with dementia will need help to prevent oral diseases caused by poor denture hygiene. Always ensure that a face washer is placed in the sink when cleaning a denture so that it if is dropped, the denture will not be cracked. Alternatively, fill the sink with 5 cm of water. Toothpaste is too abrasive to use on clean dentures. Soap on a toothbrush is recommended. Dentures should be removed overnight and soaked in water. All dentures of people with dementia in residential care should be marked with the owner's initials. Dental visits Everybody requires regular check-ups from a dentist. This includes people who have no natural teeth left. When escorting a person with dementia to the dentist, ensure a full medical history is available for the dentist. Take a list of their medications to the dental visit. Many large dental hospitals have staff that specializes in the treatment of people with special needs. If you have any difficulties finding dental care for the person you are caring for, phone the dental hospital nearest to you for advice. http://www.mydr.com.au/default.asparticle=2825 Work Cited Brian Draper; Allen & Unwin, Dealing with Dementia: A Guide to Alzheimer's Disease and Other Dementias, 2004 Danner, D. D., & Friesen, W. V. (1996). Are severely impaired Alzheimer' patients aware of their environment and illness Journal of Clinical Geropsychology, 2, 321-335. Cotrell, V., & Schulz, R. (1993). The perspective of the patient with Alzheimer's disease. The Geroyatologist, 33, 205-211. M. Powell Lawton, Robert L. Rubinstein; Interventions in Dementia Care: Toward Improving Quality of Life Springer, 2000 Cooper, Brian, and Bickel, Horst (1984). Population screening and the early detection of dementing disorders in old age: A review. Psychological Medicine, 14, no. 1, 81-95. Allen Jack Edwards; A Psychology of Orientation: Time Awareness across Life Stages and in Dementia, Praeger, 2002 Burns, Alistair, Howard, Robert, and Pettit, William (1995). Alzheimer's disease: A medical companion. Cambridge, MA: Blackwell. Butler, Robert N. (1990). Senile dementia of the Alzheimer type (SDAT). In William B. Abrams and Robert Berkow (Eds.), The Merck manual of geriatrics. Rahway, NJ: Merck Sharp and Dohme Research Laboratories, pp. 933-998. Edwards, Allen Jack (1998). Standardization of the Edwards Scale of Temporal Orientation. Unpublished manuscript. Springfield, MO: Edwards. Edwards, Allen Jack (1994). When memory fails: Helping the Alzheimer's and dementia patient. New York: Plenum Press. Edwards, Allen Jack (1993). Dementia. New York: Plenum Press. http://www.mydr.com.au/default.asparticle=2825 http://www.accg.net/alzheimer.htm Read More