Dementia

Manifestations of Dementia Melinda Godfrey GNUR543 St. John Fisher College Mrs. Yowell is a 90-year-old woman who is a resident of a long-term care facility. She was alert and mentally quite capable until about a year ago when she began to manifest signs and symptoms of dementia. A review of her medical records failed to document a thorough analysis of her dementia, but a diagnosis of “probable Alzheimer disease” was recorded. What are the common manifestations of dementia? The definition of Dementia is “a general term for loss of memory and other mental abilities severe enough to interfere with daily life.

It is caused by physical changes in the brain. ” (Common Types of Dementia, 2012). The first manifestations of Dementia usually are: * Loss of memory – generally the patient doesn’t notice the loss of memory but a loved one will. This is generally the entree into the physician’s office leading to a diagnosis. * Trouble focusing and following conversations – the patient is unable to handle more than one task at a time and will not be able to perform a task and listen to or follow a conversation easily. * Impaired judgment and reasoning – patients become confused and are unable to cope as well when unexpected events come up.

Other symptoms could include: mood changes, personality and behavior changes. As noted, dementia is not a disease itself but a cluster of cognitive changes. The onset symptom of dementia can vary depending on the disease or syndrome that is associated (Common Types of Dementia, 2012). The major dementia diseases or syndromes are: 1. Alzheimer Disease (AD) – AD accounts for 60 – 80% of the cases of dementia (Shadlen & Larson, 2012). 2. Dementia with Lewy Bodies (DLB) – DLB starts with progressive cognitive decline and usually the patient also has hallucinations, periods of lucidity and some rigidity.

DLB has abnormal accumulations of protein structures in the patient’s brain (Dementia With Lewy Bodies Information Page, 2011). 3. Frontotemporal Dementia (FT) – FT is associated with the shrinking of the frontal and temporal anterior lobes of the brain (Frontotemporal Dementia Information Page, 2011). Generally the patient will have trouble with speech and behavior. 4. Vascular Dementia – This form of dementia results from many strokes. When a patient has a stroke, the blood flow is interrupted to the brain and the result is brain tissue damage (Types of Dementia, 2011).

These patients normally lose their cognitive ability before their memory. 5. Parkinson Disease with Dementia – Approximately 40% of patients with Parkinson’s disease will have dementia (Parkinson’s disease, 2011). The nerve cells in the brain that make dopamine are slowly destroyed leaving no way for the brain to send messages. What other potentially treatable factors might have led to Mrs. Yowell’s deteriorating mental function? There are many reasons that Mrs. Yowell may have impaired mental functioning (see Table 1). The first and easiest reason to rule out would be a urinary tract infection (UTI).

A urine sample can show if there are white blood cells (indicating infection) present in the urine. The increased levels of bacteria in an elderly person’s body can cause toxicity which leads to the altered mental status (Midthun, 2004). Most noted changes are confusion, agitation and lethargy. Table 1| | (Shadlen & Larson, 2012)| Secondly, Mrs. Yowell could have vitamin deficiencies. For example, if a patient has low levels of thiamine they can develop Wernicke’s encephalopathy. This can cause damage in the brain to the thalamus and the hypothalamus.

These patients will exhibit signs of confusion, loss of memory and hallucinations (Dugdale, 2010). If left untreated it can cause permanent damage but, it is usually corrected by injections of thiamine. Another cause of confusion/delirium in elderly patients is an adverse drug reaction or interactions with another drug. Mrs. Yowell could have been given a new medication that is directly affecting her mental status. Nearly 70% of residents in long term facilities take nine or more medications (Gillick, 2012). Elderly patients have slower clearance rates of drugs through their liver and kidney thus leading to drug accumulation (Gillick, 2012).

There should be a regular review of medications in order to anticipate and keep on top of any potential changes. Discuss in detail the organic brain/neuronal alterations that are typical of Alzheimer disease? The changes that occur in the brain with Alzheimer’s disease (AD) are threefold. The first is amyloid plaque, this is abnormal clumps of protein found outside of the nerve cells. The protein pieces are in the fatty membrane that is around the brains nerve cells. The amyloid is a protein that is snipped from a larger protein (amyloid precursor protein) during metabolism (Copstead, 2010).

These clumps form plaque and can block cell-to-cell signaling (Common Types of Dementia, 2012). In a healthy brain the fragments are broken down and eliminated before they turn into plaque. Without the ability to signal the brain may also activate the inflammatory response. At this point it is still not known whether the plaque causes or is created by AD. Secondly, inside the nerve cells there is a protein called tau. This protein is normally helps maintain the cell structure allowing proper nutrition and signaling. The tau protein in AD is changed into twisted strands, called tangles (Common Types of Dementia, 2012).

It is said that the changes are brought on by the phosphorylating enzymes which are activated by inflammatory changes, lipid abnormalities and aging (Copstead, 2010). Thirdly, the brain is losing connectivity between nerve cells and cells are dying which results in permanent brain damage. Other changes in the brain include shrinking of the hippocampus and cortex. AD also shows an increase in ventricles. The progression of the damage in the AD brain is predictable. According to the Alzheimer’s research center, the plaques and tangles spread through the cortex in a predictable fashion (Common Types of Dementia, 2012).

Summary Scientists believe that the cause of AD is multi-factorial. IT could be a combination of genetics, lifestyle and environmental factors. Specifically, it is believed that a person with diabetes, depression or heart disease is more likely to develop AD (Copstead, 2010). There is a link to a gene, APOe4 that is thought to be associated with late onset AD. However, studies have shown it is not present in some cases of AD and is present in cases with no AD (Common Types of Dementia, 2012). At this point the definitive diagnosis of AD can only be obtained after death (Common Types of Dementia, 012). This means that clinicians must ask the right questions to diagnose this disease. AD is still quite unknown as to the order of the changes that occur in the brain. As more research is conducted we will be able to identify the manifestations of the disease earlier and slow the progression of AD. References Common Types of Dementia. (2012). Retrieved March 14, 2012, from Alzheimer’s Association: http://www. alz. org Copstead, L. -E. C. (2010). Pathophysiology. St. Louis: Saunders. Dementia With Lewy Bodies Information Page. (2011, December 28).

Retrieved March 8, 2012, from National Institute of Neurological Disorders and Stroke: http://www. ninds. nih. gov Dugdale, I. M. (2010, February 6). Wernicke-Korsakoff Syndrome. Retrieved March 10, 2012, from Medline Plus: http://www. nlm. nih. gov/medlineplus Frontotemporal Dementia Information Page. (2011, December 28). Retrieved March 8, 2012, from National Institute of Neurological Disorders and Stroke: http://www. ninds. nih. gov Gillick, M. M. (2012, February 22). Medical Care of the Nursing Home Patient in the United States. Retrieved March 10, 2012, from UpToDate: http://www. uptodate. com Lexicomp. 2012). Retrieved February 5, 2012, from Lexicomp: https://online-lexi. com Midthun, M. R. (2004). Criteria for Urinary Tract Infections. Retrieved March 4, 2012, from Medscape: http://www. medscape. com Parkinson’s disease. (2011, September 26). Retrieved March 5, 2012, from PubMed Health: http://www. ncbi. nlm. nih. gov Shadlen, M. -F. M. , ; Larson, E. B. (2012, February 10). Evaluation of Cognitive Impairment and Dementia. Retrieved March 5, 2012, from UpToDate: http://www. uptodate. com Types of Dementia. (2011, June 23). Retrieved March 14, 2012, from Cleveland Clinic: http://my. clevelandclinic. org

Dementia according to Stephen Tilley is a “progressive global impairment of cognitive function.” It means that dementia is a disorder in the mental domain and dementing illness has to do with abnormalities of ones behavior which manifested by an act of madness, craziness, or derangement.

But dementia according to Mary Kaplan does not only refer to one particular disease alone. It includes variety of disorders “that can be triggered by several un related situations.” (p5) Kaplan noted that some of this “disorder maybe reversible if diagnosed early and treated.” (p5) Thus management and treatment of person suffering from dementing illness is very important for the patient’s possibility of recovery.

Brian Draper clarified that the term dementia is a term “used medically to describe a syndrome that is caused by many different diseases.” (p1) It means that dementia has many other type including Alzheimer’s disease and other types of the disease though by definition the term was commonly identified as decline in memory and thinking due to brain disease.

Kaplan noted that recent public and professional awareness that “dementia is the result of a disease and not a normal part of aging has led to an increase in research in to the causes of dementing illnesses, as well as development of specific diagnostic criteria and tests.” (p6)

Dementia patients figured out by Nawab Qizilbash as commonly less educated adult. She says “dementia patients maybe older, less educated, and have more co- morbid medical condition and take more concomitant medication than the typical patient evaluated in clinical trial for dementia.” (p365)

Qizilbash cited some studies indicating that most of the patients suffering dementia illness were in their seventies, eighties and nineties but did not give clear idea whether the disease is age related. Here is Qizilbash statement regarding these studies:

“One is the case of the very elderly who will increasingly represent a larger portion of those with dementia, and for whom we really don’t know if there are important age related-differences in either the biology of their dementias or their response to therapies.

Although those who are older than eighty years represent at least half of those with dementias in most population, the averaged patient in clinical dementia trials is in their seventies with few nonagenarians exposed to treatment.”(p366)

I am a health care assistant (HCA) on an elderly care surgical ward and we nurse many different patients who have had elective surgery and corrective surgery after a trauma. I have a lot of contact with patients who suffer with dementia, ongoing confusion due to urinary tract infections and can often display challenging and aggressive behavior.

I have found on a daily basis that patients become can frustrated when they cannot communicate what they want, and I was sure that with my strong accent I would come across as harsh. This left me feeling worried and sometimes inadequate because it is in my job and personal nature to want to help those in my care. As part of my Personal Assessment Document (PAD) my mentor and I decided that I would I would push myself to speak with patients more and see how they reacted to me. I would read the patient’s purple “This is me” folder to try and engage them on a more personal level.

With this reflective account I will be discussing an experience that I had on my ward and how through reflection I have managed to gain more confidence in my ability to talk to my patients and convey my compassion in the way I communicate with the patients in my care.

I will use the reflective framework devised by Atkin and Murphy (1994) to construct this account. It is the right model of reflection for me to look back and learn from my experiences.

Personally, being a good student and health carer does not just come with reflection in the mind but also reflective practice which, according to the nursing standard “enables a student to develop their skills, increase their knowledge and deal with emotionally challenging situations” (RCN 2012). Reflection is something that should be engaged with on an everyday basis and from very early on in your health care career. It enables you to carry on caring about the patients you treat and how to improve yourself personally and professionally.

I enjoy both the personal rewards and the challenges that go hand in hand with working with patients with dementia. I find that on the drive home I
tend re-evaluate everything in my life and be grateful for the now. A patient whom will go by the pseudonym of “Polly” to maintain her confidentiality (The NMC Code of professional Conduct, 2004) was admitted to the ward with a fracture to the neck of her femur.

I was advised that the patient was very confused, and would spit at staff and be both physically and verbally aggressive when approached but would constantly cry out that she needed help. She was in the early to middle stages of Alzheimer’s disease and had come from a care home for those suffering with dementia. Alzheimer’s disease is characterised “by the loss of short term memory, deterioration in both behaviour and intellectual performance and slowness of thought” (Dictionary of Nursing 1998).

In handover that morning I found that I would be working with her that day, and as she was post operative I would need to wash her and try to mobilise her to sit out in her chair so that the physiotherapists could help her to walk again and get her on the pathway to being discharged back to her care home. I found that I was nervous in approaching this patient as I did not want to upset her or get hurt. Personally I would always wake patients like Polly who require the attention of more than one member of staff last as it is better to leave the patient to sleep so that they are well rested. That, and from handover I had learned that Polly had experienced a rather active night.

Before waking Polly I had read her personal “This is me” purple file to find out if she had any preferred names, and how she liked to be spoken too. This is me was devised by the Alzheimer’s society and “is intended to provide professionals with information about the person with dementia as an individual. This will enhance the care and support given while the person is in an unfamiliar environment“(Alzheimer‘s society 2011). With this information I could help maintain a similar routine for Polly and I would not confuse her by overloading her with too many questions and instructions.

I woke Polly up gently, and sat myself down in the chair by her bed so that I was not standing over her. I spent almost thirty minutes with Polly getting her up and ready, the patient did not get upset or frustrated with me, and she was able to do most of the washing and dressing herself with help from me. Once this was completed I handed over to physiotherapists that they too should take this approach with Polly.

I spent twelve days in total with Polly. In this time she was aggressive with me, and she would spit at me when I approached her. Yet, once I used her preferred name and tailored my approach to what she needed from me, I found that Polly was a pleasant and wonderful lady, who could be the complete opposite to the patient that was first handed over to me that first morning.

Morris and Morris state that the symptoms of dementia are experienced by each person in “their own unique way” (2010) and this is reinforced by the publication of the “this is me” leaflet. It enables staff to really look at each individual patient and assess what their needs are. In reflection, if I had not read this leaflet and just gone ahead and woke Polly up as I do each patient, the events of the day could have taken a very different path. I found that by talking to Polly as requested in her leaflet that she reacted in a calmer manner and did not get as anxious or frustrated as quickly as my colleagues had prepared me to think.

Reflecting over my first day with Polly, I do not remember struggling to say my words more clearly than what I normally would have done. Polly was not deaf, nor was she a child and I kept it in my mind that this patient was still a scared lady who had broken a big part of her body and was in a large amount of pain. Furthermore, she might not be able to communicate this fact as clearly as someone without dementia.

Hobson states that, the HCA will need to “learn to adapt how they attempt to understand what the person is saying to them” and that this can only be achieved by “entering the same world as the person with dementia” (2012, P337). At times Polly would pretend to cry like a child and repeat the words “Oh Mummy, mum, mum. Oh Mummy” but not be able to give an answer when questioned what was wrong and how could we help her. Taking this into consideration, Polly might not be actually asking for her Mum but actually trying to communicate a much deeper need.

My understanding of how patients with dementia communicate lead me to point to Polly’s hip and ask her if she felt pain there when she moved, to which she replied yes she did. In reflection I found this was a much better approach rather than just asking if Polly wanted any pain relief. Elkins has stated that asking the patient with dementia a direct question is almost a waste of time, as the patient does not have the information to give you. Instead it is more beneficial for the patient’s sense of self worth to ask them a question with an optional answer of “yes” or “no”. It could also be said that a statement rather than a question is better because it leaves the patient feeling more in control (2011).

From this experience, I suggested to the nurses that when doing their drug round that they should lower themselves down to Polly’s eye level and ask her if her hip hurt her, rather than standing at the end of her bed or beside her asking if she wanted any pain relief. This suggestion meant that Polly had more regular pain relief, and as a team we knew when she was in pain.

Furthermore, this information could be added to her file and become part of Polly’s future care pathway. Elkins raised the very same argument that “once an effective communication bridge had been achieved, the individual is much more like to remain calm and anxiety free” This would show that dialogue between patient and healthcare professional had been greatly improved and would continue to do so in the future (2011).

In reflection, I have found that I was so focused on the need to be understood through my use of English that at times I under-estimated the importance of non-verbal communication. Now, having taken a step back I see that I am almost in the same boat as the patient suffering with dementia, we are both just “an individual attempting to communicate” (Hobson, 2012) and as a HCA the method of employing “feelings and emotions” should become more “significant than the spoken word” (Hobson, 2012).

Although my confidence in speaking to patients is always growing, I am more appreciative of how much more effective my body language, and the tone of my voice can be when communicating with a patient with dementia. Yes, looking after these patients can be a challenge but getting past the dementia and working in ways that compliment the patient’s mindset will be of more benefit to the patient. By spending some time reading each patient’s information leaflet I am able to help maintain a patient’s well being and create a more anxiety free environment for our patients.

Alzheimer’s disease (AD) is a progressive and fatal neurodegenerative disorder that is associated with cognitive and memory deterioration, progressive impairment of activities of daily living, a variety of neuropsychiatric symptoms, and behavioral disturbances (Robinson). This disease is seen in about 2-4 million Americans and is usually occurs after the age of 65 years (Robinson).

According to Teri and Wagner (1992) there is growing agreement among physicians that Alzheimer’s disease is often accompanied by mood and behavior disturbances, especially depression. Depression and Alzheimer’s dementia are two separate disorders, one is disorder of affect other disorder of cognition (Terri, & Wagner 1992). Despite this, depression and dementia share a number of characteristics and frequently coexist.

Impact of Associated Depression with Alzheimer’s disease on Patients and Caregivers

According to Terry & Wagner (1992) depression is one of the most frequent comorbid psychiatric disorders in Alzheimer’s disease and other dementias and is associated with poor quality of life, a great degree of disability in activities of daily living, a faster cognitive decline, a high rate of nursing home placement and high mortality rate. AD patients with coexistent depression exhibit significantly more functional disability due to presence of depressive symptoms like: dysphoric mood, vegetative signs, social withdrawal, loss of interest, feelings of guilt and worthlessness, and suicidal ideation etc (Terry, & Wagner 1992).

According to Newcomer, Yordi, DuNah, Fox, & Wilkinson (1999) depression in the patient is often a major source of stress, burden, and depression for care providers Caregivers of people with dementia and depression have been shown to experience depression, anger, anxiety, guilt, and to report negative attitudes toward the patient and other family members All these problems in patients with AD and depression can lead to massively increased health care costs (Terry and Wagner, 1992). Assessment of the Problem Gathering data on depression in order to accurately assess the prevalence of depression amongst the patients suffering from AD is a very difficult problem due to many reasons as mentioned below: Lack of established procedures to ascertain depressive symptoms in AD: Absence of a standardized procedure for assessment of depression in patients with AD was probably the main factor which has contributed to the variable rates of depression (15%-86%) in different studies (Terri, & Wagner 1992). Different versions of the DSM III [1980] and DSM-III-R [1987] criteria were used in various studies which gave rise to different rates of prevalence of depression in patients with Alzheimer’s disease.

AD and depression are now often clearly defined by using well-accepted diagnostic criteria, such as the Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. , rev. (DSM-III-R); and the National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer’s Disease and Related Disorders Association (NINCDS-ADRDA), and well-established measures pning the range of self-report and interviewer assessment (Terri, & Wagner, 1992).

Other more established measures are also been used now, including the Hamilton Depression Rating Scale (HDRS) and the Geriatric Depression Scale. Using DSM-III-R criteria, Teri, and Wagner (1991) reported prevalence of depression among AD patients in their study as 29%.. Overlap of symptoms between depression and AD: Since there can be overlap of symptoms between the two, it is difficult to attribute the symptom to a particular disorder. This overlap can often confound the diagnosis of depression (Terri, & Wagner 1992).

Existent measures can identify the presence of specific symptomatology, but they cannot clarify its cause. For e. g. : a person might be experiencing “loss of interest,” Now this loss could be due to the cognitive deterioration of dementia or due to anhedonia (loss of pleasure) related to depression.. Thus it becomes very difficult to differentiate dementia from depression in some cases. The primary source from which the history of depressive symptoms is obtained:

According to a number of studies (Gilley, et al. 1996; Teri, & Wegner1991), the traditional methods of obtaining a history of depressive symptoms like a patient interview and self-reporting questionnaires might not prove accurate to assess the patient’s symptoms as the patient with Alzheimer’s disease might be suffering from significant cognitive impairment. As a result of this cognitive impairment AD patients are unable to provide accurate information about their symptoms of depression.

As an alternative to patient-report methods, the use of collateral informants (patient’s care provider) to ascertain depressive symptomatology in cognitively impaired patients has been employed nowadays. In 1991 Teri and Wegner conducted a study in AD patients to show that the reports given by the patients themselves indicated less depression than reports from either their caregivers or reports given by clinicians after clinical observation of the patient. The results of their study indicated that most of the patients suffering from AD and dementia seemed to be unaware of their depression.

Although the use of collateral informants seems to be an attractive alternative approach for the assessment of depression in AD patients, it is not without important potential limitations. Caregivers may be unavailable for many patients or the care provider may not be living with the patient (Terry &Wegner 1992). If the care provider does not stay with the patient he might not get an opportunity to routinely observe the patient and will not be able to provide accurate information. The relationship between the care provider and the patient also needs to be considered.

According to many studies (Terri, & Wegner 1992; Gilley, et al. 1995) child or spouse of the patient has been identified as the most accurate informant. Inaccurate data may be obtained if other sources of collateral informants are used. Caregivers may also provide inaccurate history as they may rely more on observable behaviors than on other sources of information because they are unable to evaluate the patient’s emotional state, or conversely, caregivers may rely more on inference, using their subjective beliefs to evaluate how the patient is feeling (Teri& Wegner 1991).

In cases where the care provider is not available, it typically becomes the responsibility of the clinician to make a diagnosis of depression. However clinician’s diagnosis is based on brief periods of patient’s observation and thus might not yield accurate results (Terri & Wegner 1992).

Effect of Depression on Cognitive Deficits

Associated with AD. Pronounced episodic memory impairment is one of the cardinal manifestations of AD. Depression on its own is also related to some amount of memory loss.

Since both depression and AD have been found to result in memory deficits, it may be hypothesized that the simultaneous occurrence of both these diseases would add to the memory problems resulting from AD alone (Terry & Wagner 1992). Many neuropathological and clinical studies have attempted to determine whether the existence of one disorder predisposes an individual to the development of the other and whether the cognitive deficits seen in AD become more pronounced if the person also suffers from depression.

The results of the study performed by Fahlander, Berger & Wahlin (1999) indicated that depression does not further impair episodic memory performance in patients with AD. This result was in agreement with prior research done by Backman, Hassing, Forsell, and Viitanen (1996) who determined the comorbidity effects of AD and depression on episodic memory performance in very old persons (90-100 years of age) with and without dementia and depression. Overall, Backman, et al. found no differences between depressed patients and healthy old controls or between patients with AD and depression and those with AD alone.

Backman, et al explained this finding as follows: Symptoms of depression which are most likely to exert negative effects on memory include motivational and attention factors like lack of interest, loss of energy, concentration difficulties etc. Some amount of memory impairment is already present among AD patients as a result of similar symptoms like lack of interest, loss of energy etc associated with dementia. Therefore, a diagnosis of major depression may not cause further impairment of memory in persons suffering from AD.

Backman, et al also suggested that although depression influences memory performance in normal aging individuals, in dementia, this effect seems to be overshadowed by the neurodegenerative changes of AD itself . Backman et al reached a conclusion that since such symptoms are more likely to be part of normal aging in the ’90s compared with earlier decades, the effects of major depression on memory would be more prevalent among younger old persons(in7-8th decade of life) as compared to the oldest old(in the 9-10th decade of life).

Tests for Differentiating Alzheimer’s disease and Depression

The utility of the Fuld profile in the differentiation of AD and depression: Bornstein, Termeer, Longbrake, Heger, & North (1989) have examined the incidence of the Fuld profile in a sample of patients diagnosed to be suffering from major depression. Fuld’s profile refers to a pattern of performance on the Wechsler Adult Intelligence Scale-Revised (WAIS-R) that appears to be associated with cholinergic deficits and thus is found to be associated with Alzheimer’s disease (Bornstein, et al).

Since a large number of patients with AD have been seen to show negative profiles, a negative profile does not prove that AD is not present. Bornstein, et al. have suggested that one should not rely on the results obtained from the Fuld profile to make a diagnosis of AD. A diagnosis of AD should be made only after a thorough medical and neurological history and a complete neuropsychological examination. According to Bornstein, et al this profile was significantly less frequent in the depressed patients as compared to that reported in previous studies in Alzheimer’s disease patients.

The study by Bornstein, et al does provide some support regarding the diagnostic specificity of the Fuld profile in the diagnosis of depression. Although this study and previous data are encouraging, considerable further investigation is needed to document the specificity and diagnostic contribution of this profile for diagnosis of depression. Measurement of a potential biological marker in the CSF: Increased CSF concentrations of a phosphorylated brain protein called tau protein, has been seen in patients with Alzheimer’s disease. Phosphorylated tau protein (tau) has been suggested as a biomarker for Alzheimer’s disease.

Since the levels of this protein are not elevated in patients with depression, measurement of this biological marker in cerebrospinal fluid (CSF) can diagnose patients with AD and thus help in differentiating them from those suffering from depression. (Vernon 2003).

Treatment of Depression in Alzheimer’s Disease Patient

Treatment of Alzheimer’s disease has proved to be quite difficult. The disease is progressive and the use of drugs (like cholinesterase inhibitors) just helps in bringing about a little improvement (20-30%) in cognitive symptoms (Zepf 2005).

However, the drugs used for improving cognitive functions have no effect on depressive symptoms. Treatment of depression must form an important part of the overall treatment of this disease. This is so as treatment of depression in patients with Alzheimer’s disease can have a significant impact on the well-being of these patients as well as their caregivers [Lyketsos, et al. 2003 (as cited in Miller 2004)]. Continuing research is taking place in order to treat depression in AD patients. Many drugs have been tried to treat depression among patients with AD.

Drugs like tricyclic antidepressants often used in cases of depression without AD are usually avoided in patients with AD, owing to their anticholinergic properties (Zepf, 2005). Lyketsos et al, 2003 (as cited in Miller 2004) showed the drug sertraline (selective serotonin uptake inhibitor) to be much superior as compared to placebo in treatment of depression in patients with AD. According to USA Today (Society for the advancement of education), the drug sertraline (Zoloft) significantly improves the quality of life and prevents disruption in daily activities for patients with Alzheimer’s disease with depression.

Use of this drug has been shown to lessen the behavioral disturbances and improve the activities of daily living but has no effect on patients’ cognitive abilities, such as thinking, remembering and learning.

Conclusion

Despite the great deal of research which has recently taken place in the field of Alzheimer’s disease with depression, more research is still required in this field as the physicians are still are not clear about the pathophysiology of AD or about the exact prevalence of depression in patients of AD or it’s etiology.

The questions of whether depression and dementia are similar or different, whether one leads to the other or whether their coexistence has any etiological significance are far from resolved. The complete knowledge and understanding in this field will help the physicians in developing effective treatment strategies for the care of such patients. Once the psychologists are able to understand the risk factors for coexistent depression in dementia and find its effective cure, they would be able to significantly improve the quality of life of the patients as well as their care providers and greatly reduce the health care costs.

Several questions regarding the management of depression in AD still need to be answered. The comparative efficacy of anti-depressants from various classes still needs to be explored by performing larger clinical trials. The role of non-pharmacological methods for the treatment of depression also needs to be explored. Further research and studies are required in the future to address these topics. The number of studies at present is quite small and the need for further investigation in the future persists.

References

1. Backman, L. , Massing, L. , Forsell, Y. , & Viitanen, M. (1996). Episodic Remembering in a population-based Sample of Nonagenarians: Does major depression exacerbate the memory deficits seen in Alzheimer’s disease? Psychology and Aging, 2(4),649-657. Bornstein, R. A. , Termeer, J. , Longbrake, K. , Heger, M. , & North, R. (1989). WAIS-R Cholinergic Deficit Profile in Depression. Psychological Assessment, 1(4), 342-344. Fahlander, K. , Berger, A. K. , Wahlin, A.,& Backman, L. (1999). Depression does not aggravate the episodic memory deficits associated with Alzheimer’s disease. Neuropsychology, 13 (4), 532-538. Gilley, D. W., Wilson R. S., Fleischman D. A., Harrison, D. W., Goetz, C. G., & Tanner, C. M. (1995). Impact of Alzheimer’s-Type Dementia and Information Source on the Assessment of Depression. Psychological Assessment, 7(1), 42-48. Miller, E. K. (2004). Depression in patients with Alzheimer’s disease. American Family Physician. Retrieved on 8 Nov 2006 from http://www. findarticles. com/p/articles/mi_m3225/is_3_69/ai_112915116 Newcomer, R. , Yordi, C. , DuNah, R. , Fox, P. , & Wilkinson, A. (1999).
2. Effects of the Medicare Alzheimer’s disease demonstration on caregiver burden and depression: The medicare alzheimer’s disease demonstration program. Health Services Research.
3. Retrieved on 8 Nov 2006 from http://www. findarticles. com/p/articles/mi_m4149/is_3_34/ai_55610150 Robinson, R. Alzheimer’s disease. Encyclopedia of Medicine. Retrieved on 8 Nov 2006 from http://www. findarticles. com/p/articles/mi_g2601/is_0000/ai_2601000053 Teri, L. , & Wagner, A. W. (1991). Assessment of depression in patients with Alzheimer’s Disease: Concordance among informants. Psychology and Aging, 6(2), 280-285. Teri, L. , & Wagner, A. (1992). Alzheimer’s disease and depression. Journal of Consulting and Clinical Psychology, 60(3), 379-391. USA Today. (Society for advancement of education). (2003).
4. Antidepressant slows patient decline: Alzheimer’s Disease. Retrieved on 8 Nov 2006 from http://www. findarticles. com/p/articles/mi_m1272/is_2701_132/ai_109085096 Vernon, H. (2003). Hemoxymed’s diagnostic test in development is useful in differentiating patients with Alzheimer’s disease from patients with geriatric major depression. Business wire. Retrieved on 8 Nov 2006 from http://www. highbeam. com/doc/1G1-97485997. html Zepf, B. (2005). Drug therapy for patients with Alzheimer’s disease. American family physicians Retrieved on 8 Nov 2006 from http://www. findarticles. com/p/articles/mi_m3225/is_10_71/ai_n13790924.

There are a heterogeneous group of degenerative diseases that involve destruction of the large motor neurons of the brain. Amyotrophic Lateral Sclerosis (ALS) is one. The motor effects of this disease can be devastating. The usual course is a progression to death within 3 to 4 years. In the United Kingdom, ALS is often known as motor neuron disease. ALS is a progressive neuromuscular disease that weakens and eventually destroys motor neurons that connect the brain with the skeletal muscles.

NIEHS grantee Serge Przedborski of Columbia University has pioneered the investigation of the molecular mechanisms leading to the death of neurons that occurs in ALS and Parkinson disease. ALS, the most common adult-onset paralytic disease, is most commonly diagnosed in middle age, and affects men more often than women. Patients gradually lose the ability to speak, swallow, and move voluntarily. Sensory function and intellectual ability are unaffected, and death usually results from loss of respiratory function.

The disease affects all racial, socioeconomic, and ethnic groups, and the life expectancy of ALS patients is usually three to five years after diagnosis. ALS results in progressive damage to the pyramidal motor system. There is a degeneration of both the upper and lower motor neurons leading to muscle weakness, atrophy, and losts of function. In most cases there is no loss of sensation, and intellect and sphincter control are preserved. The damage is typically bilateral, and although usually rapid in progression, the disease may on occasion proceed slowly, or stabilize after a period of progression.

The reported incidence is about 0.4 to 1. 8/100,000 (Tandan & Bradley, 1986) and prevalence estimates range from 4 to 7/100,000. The mean age of onset lies between 55 and 60 and the disease is more common in males than females (2:1; Hudson, 1981). Death is usually preceded by progressive respiratory failure. The cause of ALS is unknown. In about 5% to 10% of cases the disease is familial; in most of these cases the mode of inheritance is autosomal dominant. The disease also occurs amongst the Chamorros on the island of Guam at a much higher rate than elsewhere, suggesting an environmental toxin can cause the disease (Rowland, 1987).

However, the majority of cases arise sporadically. Cognitive Deficits Clinicians working with ALS patients generally conclude that the disease does not cause dementia. Although there are cases of ALS where dementia does present, this can be attributed to the concurrent effects of DAT (Caroscio, 1986). Testing ALS patients with intellectual scales has produced mixed results. Poloni, Capitani, Mazzini, and Ceroni (1986) found no difference on the WAIS between 21 ALS subjects and 21 comparison subjects with nondementing neurological conditions.

In two other studies (Gallassi, Montagna, Ciardulli, Lorusso, Mussuto, & Stracciari, 1985; Iwaski, Kinoshita, Ikeda, Takamiya, & Shiojima, 1990) intellectual deterioration in ALS patients was found when the test results were compared to those of healthy controls. It remains to be determined whether these cognitive changes occurred as a result of ALS, or whether the differences were due to the nonspecific effects of hospitalization and treatment. ALS is not generally regarded as a dementing disorder. Psychosocial Consequences

The individual with ALS faces major problems in communication because of dysarthria, a reduction in mobility, pain from muscle atrophy, and the knowledge that the disease will progress to incapacity and death. Motor dysfunctions occur in the absence of cognitive decline and so patients retain the capacity for awareness of their disabilities. The nature of the disorder is likely to provoke an emotional response. The onset of the disease provides an illustration of the working of psychosocial stress model outlined in the next chapter.

Although ALS patients confront the disorder with courage (B.S. Gould, 1980), the debilitation caused by the disease challenges the capacity to adjust in even the most resolute individual. Luloff (1986) describes the demands and emotional sequelae of the disease as follows: Loss of resources — physical, psychological, social, and economic — evokes grief and depression. As the patient anticipates experiences or experiences failures in mastering problems and challenges of everyday life, he develops feelings of helplessness…. Helplessness and failure, real or anticipated, lead to decrease of self-esteem, sense of worth, dignity and confidence.

Anger becomes mixed with fear and accentuated by limitations in ability to master everyday problems, in achieving relief from tension, and in providing oneself with gratifying experiences. Anger is often directed against oneself for being damaged, helpless, and worthless, and a failure. . . . Anger is also directed against other persons, and at natural processes which appear to be increasingly harsh and threatening as the individual becomes progressively impaired and weaker. (p. 268) Although anecdotal reports of depressive and emotional reactions are common in the literature, few studies have examined emotionality in ALS systematically.

Houpt, B. S. Gould, and Norris (1977) found that the incidence of depression in ALS was comparable to that in cancer patients. About 65% of the ALS patients scored in the nil-mild range on the BDI, 32. 5% were moderately depressed, and 2. 5% were severely depressed. Other reactions to ALS have been cited in clinical reports including denial (Tandan & Bradley, 1985), guilt (Luloff, 1986), and diminished self-esteem (Ringel, 1987). Emotional lability and inappropriateness have also been reported on occasion (Gallagher, 1989). These symptoms have been attributed to damage to brainstem nuclei.

Controlled investigations of psychiatric symptoms suggest these are not a consequence of ALS (Houpt et al. , 1977; Peters, Wedell, & Mulder, 1977). Families and caregivers are likely also to feel distressed by the onset and progress of the disease. The physical deficits reduce the patient’s mobility and communication, leading to greater dependence on the family for emotional and functional support. The demands involved in caring for the ALS sufferer at home can result in the caregiver feeling alone, housebound, and unappreciated. Financial concerns and preexisting family conflict may accentuate these problems (Ringel, 1987).

For spousal caregivers there are many changes in role to be contemplated. Finally it is important to recognize that many people with ALS adapt to their illness in a creative, positive, and stoical manner. In an insightful commentary, B. S. Gould (1980) described how many ALS patients project a positive aspect to the people around them. Although this may mask a deeper and realistic concern or fear, the use of some degree of denial may represent an adaptive response to the disease. In his view, the role of the counselor may be to provide a supportive environment in which this despair may be acknowledged.

The ALS patients in our series frequently maintained a strategy of partial denial throughout their illness, but in a most healthy fashion. Reality was not denied as much as redefined; the most distressing immutable aspects of the disease were not part of ordinary conscious functioning, and hope was maintained. Under safe conditions that allowed reflection and ventilation, however, the second-order denial was easily overridden; distressing awareness was allowed to enter the consciousness in a controlled fashion, and considerable dysphoric tension was discharged.

Treatment Highlights In view of the fact that by far there is no treatment for ALS and there is no known cure. Current theraphy consists of a daily dose of an experimental drug. For this reason, it is still best to count on the available resources for the treatment of ALS. The drug myotrophin will be injected twice a day, alternating left abdomen, right abdomen, left thigh, right thigh to reduce scarring, as well as regular visits from occupational and physical therapists. Neither drug is really thought to do much, but they are all there is right now.

The physical therapy controls the rate of atrophy and minimizes edema in the extremities. It is also helpful to ingest huge amounts of vitamins. Three thousand milligrams a day of vitamin C and 800 milligrams of vitamin E, both of which are thought to be especially important in protecting the outer nerve cell sheath. Sublingual B12, antioxidants, CoQ10 and other dietary supplements are also thought to slow the disease’s progression. Ventilation is Still on Top From the patients’ perspectives, there are certain issues on the use of mechanical ventilation for the treatment of ALS.

These may include the examination of the process of and factors involved in decision making by people severely disabled by the disease by the time they face the choice of whether to use the support of mechanical ventilation. Moreover, issues that should also be addressed will include patients’ impact on family, the decision as related to level of disability, and the ventilation availability through a nasal mask. Research format will include several general questions along with a demographic information questionnaire.

These general questions will focus on obtaining information about the process of the participant in their consideration of the use of mechanical ventilation, their current decision on the use of mechanical ventilation, the influence of others, and their decision’s commitment. Interviews will also be utilized for the participants so that they will be rated according to their function in the areas of speech, swallowing, lower and upper extremities with the use of ALS Severity Scale as designed by Hillel et al.(1989).

The scale allows for rapid, ordinal measurement of the aforementioned areas. Each symptomatic area is rated from 1 to 10, with 10 indicating normal functioning and 1 reflecting the most severe disablement. A total score of 40 would denote normal functioning in all four areas. Since several participants were unaware of available ventilatory options, the physician on the research team individually met with the participants who had not already gained knowledge concerning ventilatory methods.

During these meetings, the physician imparted basic information on the following: the disease process that leads to respiratory insufficiency, simple measures such as positioning in alleviating respiratory distress, the capability to discontinue use of assisted ventilation, availability of palliative measures in end-stage ALS, care needs of people with the use of mechanical ventilation (such as suctioning of excess secretions; management of the ventilator itself, including arrangement for regular maintenance; and possible necessity of a caregiver 24 hours a day), and types of mechanical ventilation.

The two basic methods of mechanical ventilation are a nasal mask and a tracheostomy. A tracheostomy is a surgical opening into the trachea to which a ventilator hose is connected. The nasal mask method is noninvasive and involves wearing a plastic mask apparatus over the nose, held in place by a strap around the back of the head. The mask can be awkward and uncomfortable and may slip out of place at night. Limitations In view of the reason that only a limited time was allowed for completion of the work, fiscal and temporal constraints were in effect, thus limiting the size of the subject sample.

The principal author was also the clinical social worker for the participants. The principal author’s familiarity with the participants may have influenced the selection process and the responses of the participants. Patients who had no means of communication were not approached to take part in the study. Participant population was unequally distributed by gender, as there were 11 men and two women, and by race, as all were white. All participants had a comparable baseline knowledge of ventilatory methods.

Four participants were atypical of classical ALS in that they had been diagnosed as having the disease for between nine and 23 years. A significant portion of the interviews with those participants already using mechanical ventilation was retrospective and based on recall. Not all participants answered all questions, and not all questions were applicable to all participants. Results may not be replicable with a different or larger sample. Conclusions Both past and present researches have failed on their quest for the cure or treatment of ALS.

While this is apparently true, there are nevertheless several treatments that are found to be promising and responsive to patients. Individually, a specific approach may not be effective enough for treating ALS but a collaboration and combination of all known and practiced treatments is proved to be helpful. By now, this is the least that we can do for treating ALS while attempts are made in finding a cure for this certain incurable disease.

References

1. Caroscio J. (Ed. ). (1986). Amyotraphic lateral sclerosis: A guide to patient care. New York: Thieme.
2. Gallagher J. P. (1989). Pathologic laughter and crying in amyotrophic lateral sclerosis: A search for their origin.
3. Acia Neurologica Scandinavica. 80, 114-117. Gallassi R. , Montagna P. , Ciardulli C. , Lorusso S. , Mussuto V. , & Stracciari A. (1985).
4. Cognitive impairment in motor neuron disease. Acta Neurologica Scandinavica. 71, 480-484. Gould, B. S. (1980).
5. Psychiatric aspects. In D. W. Mulder (Ed. ), The diagnosis and treatment of amyotrophic lateral sclerosis (pp. 157-168).
6. Boston, MA: Houghton Mifflin. Hillel, A. D. , Miller, R. M.
7. , Yorkston, K. , McDonald, E. , Norris, E H. , & Konikow, N. (1989).
8. Amyotrophic Lateral Sclerosis Severity Scale. Neuroepidemiology. 8, 142-150. Houpt J. L. , Gould B. S. , & Norris F. H. (1977).
9. “Psychological characteristics of patients with amyotrophic lateral sclerosis”. Psychosomatic Medicine. 39, 299-303. Hudson A. J. (1981).
10. “Amyotrophic lateral sclerosis and its association with dementia, Parkinsonism, and other neurological disorders: A review”. Brain. 104, 217-247. Iwasaki Y. , Kinoshita M. , Ikeda K. , Takamiya K. , & Shiojima Y. (1990).
11. “Cognitive impairment in amyotrophic lateral sclerosis and its relation to motor disabilities”. Acta Neurologica Scandinavica. 81, 141-143. Luloff P. B. (1986). “Reactions of patients, family, and staff in dealing with amyotrophic lateral sclerosis”.
12. In J. Caroscio (Ed. ), Amyotrophic lateral sclerosis: A guide to patient care (pp. 266-271). New York: Thieme Publishers. Peters P. K. , Wedell M. S. , & Mulder P. W. (1977). “Is there a characteristic personality profile in amyotrophic lateral sclerosis? ” Archives of Neurology. 35, 321-322. Poloni M. , Capitani E.

Currently, incidences of disruptive behavioural problems such as agitation, aggression, rest-activity pattern and sleep wake disturbance are reported to be high in people with dementia. The specific determinants of disruptive behaviour are still unclear but predisposing factors are considered to be associated with the external factors such as the negative staff attitudes and environment. Actually, disruptive behaviour is an umbrella that describes behaviours such as throwing objects, hoarding, resisting care, self abuse, wandering, repetitious verbalization, aggression and general agitation.

Prevalence of aggressive behaviour has been considered as a subset of disruptive behaviour among individuals with dementia in long-term care facilities as 86. 3% has been reported. (Ryder et al. 1991). According to studies on cognitively intact residents and residents with dementia, shows a consistently higher prevalence of behaviours. This paper presents research literature to support the role of a positive environment including attitudes and staff interaction in the aggressive individuals with dementia.

Importance of a positive environment including staff interaction and attitudes towards the aggressive individuals with dementia Environment has been increasingly recognized as a significant therapeutic element in care of individuals with dementia. In the last decade, it has been realized that environment plays a significant role in reducing the disruptive behaviour, increasing the functional ability of the individuals with dementia, as well as improving their quality of life.

Problem behaviour in dementia is associated with deficits in the executive control functions of the frontal lobe. However, complex behaviours seen in individuals with dementia are as a result of multiple, over-learned routines the environmental stimuli triggers. The executive control functions orchestrate the routines into coherent goal-directed behaviours which in turn contribute to the expression of the required habitual response while limiting the unrequited responses.

It therefore means that failure of executive control function leads to distractibility and overdependence on environmental factors or can even lead to apathy and environmental indifferences. However in any case modification of social and physical environment can reduce behaviours that are not required and can elicit the desired behaviours effectively. Moreover, environment is the major component in progressively lowered stress threshold model. (Sife, 1998).

Subject to the model, since the ability to adapt in individuals with dementia declines as the dementia progresses, the care givers should reduce the environmental demands to ensure that the level of the environmental demands is congruent with the abilities of individuals with dementia. Basically, disruptive behaviours are more often when the stress threshold of an individual is exceeded. Most of the intervention strategies given in the literature engage manipulation of physical and social environments to meet the unique needs and personalities of individuals with dementia.

Following the recognition of the important role of environment to individuals with dementia, many long-term care facilities have come up with special care units that give a total supportive milieu for them. Following the increase of such special care units design guidelines such as recommendation for both social and physical environments have been developed to ensure that the environment provided by the facilities enhanced the well-being and personhood of individuals with dementia.

(Morgan & Stewart1997). However, since there is no empirical data, the special care unit design manuals are based on extrapolations and clinical experience. Predictability and structure are the important aspects of the environment in which individuals with dementia live. The daily routines that reflect the rhythm of the society are predictable, and with a chance to rest and opportunity for activity, individuals are kept in touch, thus promoting their well being.

Patient-centred dementia care is the recommended approach in caring individuals with dementia as it focuses on independence, it is value-driven, and it is concerned with the empowerment and well being of individuals with dementia and their families. Moreover the patient-centred care makes the individuals to feel socially confident, valued and supported thus creating personhood which is described by Kitwood (1997a) as a status that is bestowed in individuals by others within the society in the context of social being and relationship.

Care for the individuals with dementia should focus on maintaining the personhood in the face of the individuals whose mental powers is failing. (Kitwood, 1996). Paying attention to personhood involves recognizing the centrality of the relationship and the uniqueness of the individuals as well as the fact of the embodiment. It therefore means that dementia care that is only involved with the dementia as the disease and its treatment has nothing to do with the patient’s personhood, damages the patient, and treats as a passive object rather than a human being.

Patient-centred dementia care is recommended as it is based on the ethic that regardless of disabilities, all human beings have absolute value and need to be respected, and on the convictions that just like all other human beings, people with dementia are capable of living a fulfilling live. (Kitwood, 1999). The principle central to patient-centred dementia care is that the life experience of the individuals, their network relationships and unique personalities should be valued and considered with constant attention by the staff giving the care.

This is based on the observation that once dementia is presentation it can never be reduced to the neuropathological damage effects, instead, it is a combination of factors such as social psychology, neurological impairment, physical health, biography and personality. Focusing on the losses or deterioration of the patients with dementia reinforces negative perceptions, progression of dementia and its treatment. Based on several studies, self-esteem is considered as a necessity for the well being of individuals with dementia. (Thorngate, 1999).

Patient-centred dementia care is concerned with establishment and maintenance of positive and supportive social environment for individuals with dementia. In the context of this care, the personhood of the individuals is established through strengthening of the individuals positive feelings, promoting the healing of psychic wound and nurturing the individuals skills or abilities. Generation and sustenance of positive interaction used singly or together, secure and stable relations, replenishes the personhood of individuals with dementia constantly.

Some of the psychotherapeutic techniques that promote these relationships include: facilitation which involves providing the missing parts of action to enable the individuals to do what they would not have done, holding which involve providing physical and psychological space for the individuals to expose vulnerability and tension, and validation which involves the accepting reality – the fact that they have dementia- and the feeling of being connected, alive and real.

Actually, caring for individuals with dementia possess challenges to the care giver in all environments probably because the condition is characterized by progressive brain damage making creating difficulties in their communication, remembering things and to think clearly. Because dementia is associated with swing s in moods, and changes in behaviour and personality, the staff and other care providers should develop positive attitudes when dealing with the troubling behaviour such as aggressiveness and communication difficulties encountered while providing the care.

Aggressive behaviour among individuals with dementia continues to burden and challenge the caregivers in special care units and nursing homes. It therefore means that working in such facilities increases the risks of experiencing aggression. Actually, aggression is associated with older people with cognitive impairment than individuals with no cognitive behaviour. The staffs in long-term care facility and nursing home are required to set a positive mood for interaction. The body language and attitude communicates the thought and feeling of an individual better than words.

The positive mood is set by speaking to the individuals in a respectful and pleasant way. To show affection and to convey message, the staff should use tone of voice and facial expression. Studies show both positive and negative attitude of staff towards the aggressive behaviour of individuals with dementia. These two domains are consistent with the theory of planned behaviour which suggests that attitudes follow from the beliefs held by individuals about the attitude’s object just as actions and intentions follow from attitudes.

(Ajzen, 1998, p. 32). Although the personality traits and attitudes are similar in a way, attitudes are more malleable and they can change unlike the personality traits. This means that although most of the caregivers’ attitudes toward aggressive individuals with dementia are negative, they can be changed through appropriate training. Negative and positive attitudes are associated with various forms of care used to prevent the aggressive behaviour from continuing.

Acknowledging the relationship between care for individuals with dementia and attitudes, and indication of the effectiveness the positive needs-based approach in reducing aggression can prompt change in the attitudes of the staff. According to the findings of the study carried out by Nakahira et al. (2008, pp. 13 on attitudes towards dementia-related aggression among staff, staff characteristics such as level of education, years of experience, position, occupation and age are related to their attitudes. Staffs with higher position, more clinical experience and the older ones have positive attitudes towards patients’ aggression.

It is therefore believed that education factors, and clinical experience influences the attitudes of the staff towards patient’s aggression hence appropriate education can be used to influence the negative attitudes of the staff towards aggressive individuals with dementia Based on the findings of the study carried out by Middleton et al. (1999) carried out to compare the staff’s attitude towards aggressive behaviour of patients with dementia in traditional unit and in special care unit, the staffs from the special care unit have sympathetic towards aggressive individuals with dementia than the staff in traditional unit.

Although aggressive behaviour is more in special care unit than in traditional unit, the staff at the special care unit understands that the behaviours are part of the dementia disease thus they do not feel that the patients intentionally directs the aggressiveness towards them as is it believed by staffs in traditional unit. Furthermore, the staffs’ attitudes and decision-making can be influenced by organisational factors. Staffs working in dementia units of gerontological and mental hospitals within acute hospitals have negative attitudes towards aggressive patients.

By measuring the attitudes of staff towards aggressive individual s with dementia, areas requiring skill improvement or education can be identified and it can be used over time to monitors changes in attitudes. Staff education to change the negative attitudes should advocate that there are possibilities of unmet needs among individuals with dementia, and that aggressive behaviour is a form of communication used by the patient and that efforts to understand the message conveyed by the patient, and attempts to meet the possibly unmet needs lowers the aggression incidences.

Conclusion Incidences of disruptive behavioural problems such as agitation, aggression, rest-activity pattern and sleep wake disturbance are reported to be high in people with dementia. The specific determinants of disruptive behaviour are still unclear but predisposing factors are considered to be associated with the external factors such as the negative staff attitudes and environment. Environment has been increasingly recognized as a significant therapeutic element in care of individuals with dementia.

Moreover, it is the major component in progressively lowered stress threshold model which states that the ability to adapt in individuals with dementia declines as the dementia progresses, the care givers should reduce the environmental demands to ensure that the level of the environmental demands is congruent with the abilities of individuals with dementia. Basically, disruptive behaviours are more often when the stress threshold of an individual is exceeded.

Most of the intervention strategies given in the literature engage manipulation of physical and social environments to meet the unique needs and personalities of individuals with dementia. Patient-centred dementia care is recommended as it is based on the ethic that regardless of disabilities, all human beings have absolute value and need to be respected, and on the convictions that just like all other human beings, people with dementia are capable of living a fulfilling live.

The principle central to patient-centred dementia care is that the life experience of the individuals, their network relationships and unique personalities should be valued and considered with constant attention by the staff giving the care. Staff education to change the negative attitudes should advocate that there are possibilities of unmet needs among individuals with dementia, and that aggressive behaviours are forms of communication used by the patient and that efforts to understand the message conveyed by the patient, and attempts to meet the possibly unmet needs lowers the aggression incidences.

References:

Ajzen, I (1988). Attitudes, behaviour and personality. Buckingham: Open University.

Kitwood, T (1996). Building up mosaic of good practice. J DementCAre, 3, 12-13.

Kitwood, T (1999). When your heart wants to remember: person- centred dementia care in RCN Nursing update. Nursing standards, 13, 1-22.

Kitwood, T. (1997a). Dementia reconsidered: the person comes first. Buckingham: Open University, pp. 7-8, 91,

Middle ton JI, Stewart NJ & Richardson. (1999) Caregivers distress; related to disruptive behaviours on special care units versus traditional long-term care units. Journal of Gerontological Nursing 25, 11-19.

Morgan, D.G., & Stewart, N.J. (1997). The importance of the social environment in Dementia care. Western Journal of Nursing Research, 19(6), 740-761

Nakahira, Miwa, Moyle, Wedy, Creedy, Debra and Hitomi, Hiroe. (2008). Attitudes towards dementia-related aggression among staff among Japanese aged care setting. Clinical Nursing Journal, 18, 807- 816.

Ryden, M, Bossenmaier, M and McLahlan, C (1991). Aggressive behaviour in cognitively impaired home residents.  Research in Nursing and Health14, 87-95.

Sife, W (1998).  After stroke: enhancing quality of life. New York: Haworth, pp. 129-42

Thorngate W (1999).  Forget me not: some comments on    self-esteem among Alzheimer’s sufferers. Culture and Psychology, 5, 33-39.