Dementia For beginners
Introduction
The term 'dementia‘: Describes symptoms that occur when the brain is affected by specific diseases and conditions These include Alzheimer's disease and stroke Symptoms of Dementia, Memory loss Mood changes, Communication problems, Reduced coping skills/practical skills, Memory loss E.g. forgetting the way home E.g. forgetting names and places.
Mood changes
 Parts of the brain that control emotion can be affected Anger/fear/sadness about their condition Communication problems, Reading, writing and talking less, Reduced skills, Problems carrying out everyday tasks and dependency on other people.
Causes of dementia
Alzheimer's disease, Vascular disease, Dementia with Lewy bodies, Fronto-temporal dementia, Rarer causes of dementia, Multiple Sclerosis, Motor Neurone Disease, Parkinson's Disease, Huntington's Chorea.
Alzheimer's Disease
Changes to the chemistry and structure of the brain changes lead to brain cell death.
Vascular disease
If the oxygen supply to the brain fails, brain cells can die causing symptoms of vascular dementia Can occur after a stroke, or a series of small strokes.
Dementia with Lewy bodies
Affects language skills, concentration and memory. Shares some characteristics with Parkinson's disease.
Fronto-Temporal Dementia
Occurs where there has been damage (usually) to the front part of the brain. Affects the ability to plan (as this is a function of the frontal lobes) Personality and behaviour can also be affected. Rarer causes of dementia Progressive Supranuclear Palsy, Korsakoff's Syndrome, Binswanger's Disease, HIV Creutzfeldt-Jakob disease (CJD), Multiple Sclerosis, Motor Neurone Disease, Parkinson's Disease, Huntington's Chorea;  People suffering from these degenerative diseases are more likely to develop Dementia.
Treatments
There is no cure for most forms of Dementia. On-going research focuses on the development of treatments and drugs Alleviation of some symptoms soon after the onset of the disease can be achieved by drug intervention (Alzheimer's Disease) Alleviation of these symptoms can continue into the middle stages of the disease
Drugs:
Aricept (Donepezil Hydrochloride), Exelon (Rivastigmine), Reminyl (Galantamine).
Side effects
Side-effects include: Diarrhoea, Nausea, Insomnia, Fatigue, Loss of appetite,
Alzheimer’s Disease
There is no cure for Alzheimer's Disease. Drug treatments stabilise symptoms for a period of time Each case is different The success of drug treatments is individual
Dementia or ageing ?
Memory loss can be an effect of ageing, stress or depression. A diagnosis by a doctor will rule out illnesses that might have similar symptoms. A diagnosis will allow for treatment of the specific illness or disease
Prevention
There is evidence that a healthy diet and lifestyle may help protect against dementia Abstinence from smoking Regular exercise Avoidance of fatty foods Sustained mental activity All may reduce the risks of developing Vascular Dementia and Alzheimer's Disease
Dementia is a label given to a range of conditions that involve loss of mental ability. All these conditions cause problems with memory, language, behaviour and emotions.
Dementia is most common in the elderly Around five per cent of people over the age of 65 are affected to some extent.
Dementia is caused by neurones not working properly or dying this often changes the amounts of the neurotransmitters, with obvious affects on brain functions.
Dementia is not a normal part of ageing it is different from the mild forgetfulness that can occur in the elderly.
Vascular (Blood Vessel) Dementia
Caused by small blood vessels in the brain becoming blocked. The blockages prevent oxygen from reaching the nearby brain cells, leading to brain cell death. It is like having lots of tiny strokes in the brain, causing a gradual decline in mental ability
Other Dementias
Lewy body dementia (often associated with Parkinson's disease)
Frontal lobe dementia
Creutzfeldt-Jakob disease
AIDS dementia
Huntington's disease
Lifestyle
Too much alcohol can result in dementia. A sexually transmitted disease called syphilis can also be the cause of Dementia. These types of dementia can be treated and in the early stages it may be possible for the dementia to be reversed IMPORTANT NOTE - most types of dementia cannot be prevented or cured.
Symptoms
Memory loss (predominantly recent events). Misplacing objects, Forgetting things intended to be done. Difficulties with navigation/orientation (especially in new or unfamiliar surroundings) Problems finding the correct words, Poor concentration, Problems learning new ideas or skills Psychological problems (e.g. irritability, inappropriateness, depression, paranoia ) Loss of speech Immobility, Incontinence. Symptoms usually develop slowly over a number of years. They usually start with some memory loss and then move on to mood changes and severe dementia. It can be difficult to pinpoint whether a person has dementia as it usually begins with mild forgetfulness. Progression of Dementia
The speed of progression is very individual People with Alzheimer's disease usually progress through 7 to 10 years from the first signs of memory loss to severe dementia and death. When Lewy body dementia has been diagnosed people generally live for approximately 6 years.
Risk Factors
Increasing age, Family history, If someone in the family has suffered from dementia it increases the chances of a diagnosis in future generations. Vascular Dementia Risks are increased by the same things that increase the risk of stroke and heart disease. High blood pressure, Diabetes, Smoking, Poor diet, and too much alcohol.
Initial Diagnosis
Often it is family and friends that start to notice a difference in memory. Dementia can be diagnosed by a GP or a specialist Standard memory test are used (short-term and long-term memory). These initial tests are not particularly useful for measuring activities of daily living skills.
What is Memory?
There is no simple answer to this one. Memory utilises a combination of different skills all at the same time There are different memory skills – e.g. remembering what someone has said involves a different skill to that of remembering someone's face. Memory stores information in 3 ways: Sensory stores (these register information for about five seconds), Short-term memory (this stores information for between 15 to 20 seconds), Long-term memory (this stores information on a more permanent basis). Many people gradually find it hard to memorise things as they get older but this is not an inevitable part of the aging process. Around 40 per cent of people over 65 have some kind of memory difficulty. The majority of people continue to live quite normally without any serious affects. About 10 per cent of people aged over 65 have a memory problem that is severe enough to interfere with normal daily routines. Around 15 per cent of these will then go on to develop dementia each year Mild Dementia
Somebody who has mild dementia may forget arrangements, names and telephone numbers. They may repeat the same stories over and over again, They may find it hard to remember details about a TV programme they have just finished watching or a conversation they have just had. They will have no difficulty washing, dressing and shopping, although they may have some problems managing their money.
Progression of Dementia
When dementia worsens it can affect thinking, remembering and reasoning causing confusion, lack of concentration, speech difficulties and understanding. The person will be unable to look after themselves. In advanced cases residential care may be the best option.
Communication and dementia
 Dementia refers to a collection of symptoms characterised by a progressive loss of cognitive abilities affecting: Reasoning, Communication, The ability to carry out routine activities associated with daily living.
Care Staff and Communication
“Every person with dementia should have the support of people who are confident in adapting their interaction to reduce the stress and anxiety that dementia can bring”
Dementia - Effect on Communication
Dementia can affect a person’s ability to understand and use language accurately and appropriately. As the condition progresses communication can become increasingly difficult This is likely to vary from day to day and requires staff to respond and adapt their communication on an on-going basis Communicate Sensitively to Support Meaningful Interaction, Always make time and remain patient in every situation. Make use of the client’s past experiences and life story to support communication. Take into account a person’s usual communication skills and background culture. Keep the environment calm and quiet when communicating, allowing plenty of time to have conversations. Always face the person and be reassuring in expressions, tone of voice and words, to reduce frustration.
What is communication?
Communication is much more than talking. Communication consists of: Non verbal communication such as gestures, facial expressions and touch. It is important to encourage someone with dementia to communicate in whichever way works best for them, Take into account: Hearing or visual problems and Second language difficulties.
Communicating in the best way: Images, pictures, symbols, music All enhance communication and facilitate understanding
Non Verbal Communication
Non-verbal communication is particularly important for a person with dementia who is losing their language skills. When a person with dementia behaves in ways that cause problems, they may be trying to communicate something.
Words
An early sign of language impairment is ‘not finding the right words’ (particularly the names of objects). Substitution of an incorrect word or not finding a word at all is also common. As dementia progresses some sufferers may be hardly able to communicate in language at all. People with dementia often confuse the generations E.g. mistaking their wife for their mother, this is a natural aspect of their memory loss.
Interpretation- brain changes
Because of changes in the brain the person with dementia may be trying to interpret things that no longer makes sense to them. The brain is interpreting information incorrectly therefore attempts at communication can be misinterpreted (can be distressing)
Listening Skills
Listen carefully to what the person is saying Use plenty of encouragement If they have difficulty finding the right word or finishing a sentence, ask them to explain in a different way, Listen for clues if speech is hard to understand. Use what you know about the person to interpret what they might be trying to say, always check back with them to see if you are right. If they are feeling sad let them express their feelings without trying to cheer them up, Sometimes the best thing to do is listen and show empathy and compassion.
Before communicating
Get the client’s attention and try to hold it, make sure they can see you clearly. Make eye contact as this helps them focus on you. Eliminate or reduce any noises - e.g. radio, TV, other people’s conversation you will communicate better this way.
Body Language
A person with dementia will read your body language; agitated movements or a tense facial expression can be upsetting and make communication more difficult Stay calm and still while you communicate this shows the client that you are giving your full attention and that you have time for them. Find ways to relax so that your body language shows confidence and reassurance. If words fail the person, pick up cues from their body language Their expressions and the way they hold themselves and move can give you clear signals about how they are feeling.
Speaking clearly.
As dementia progresses the client may become less able to start a conversation. You need to start off conversations, speak clearly and calmly, avoid speaking sharply or raising your voice as this may distress the client. Speak in short simple sentences and allow time for processing the information (what you are saying to them). If you try to hurry, they may feel pressured so use simple words (no jargon) and avoid asking direct questions. The client may become frustrated if they cannot find the answer and could respond with irritation or even aggression. Ask questions one at a time and phrase them in a way that allows for a ‘yes’ or ‘no’ answer. Don’t ask the client to make complicated decisions, too many choices are confusing and frustrating. Rephrase what you are saying rather than simply repeating the same thing.
Humour
Humour can help to take away a lot of pressure It is essential that you have a caring, professional relationship with the client if you are to bring humour into conversations.
Falsehoods
If the person says something you know to be false find ways around the situation Do not respond with a flat contradiction Never put the client in a situation where they feel foolish, It is best to accept whatever is said to you and not argue.
Respect
Do not speak down to the client or treat them like a child try to include them in conversations with others, being included in social groups can help preserve a sense of identity It also helps to protect from feelings of exclusion and isolation.
Lack of response
If you are getting little response from client: Do not speak about them as if they were not there This can worsen feelings of isolation, frustration and sadness.
Repetition
Repetitive questions from people with dementia can be challenging. Try to respond as though it is the first time you have heard the question.
Aggression
People with dementia sometimes behave aggressively: Verbally, or In a threatening manner, or even physically.
Why the aggression
Aggression is a behavioural symptom of dementia: Fear, humiliation, frustration, Being unable to understand others or make themselves understood. Impaired judgment and self-control, Inhibitions and ‘how to behave’ learned in early childhood may have been forgotten
Aggression in context
It can take the form of an over-reaction Shouting, screaming, agitation following a minor setback or criticism. The aggression is not deliberate and the incident is likely to be forgotten, the emotion may persist though. Identify the trigger and Reflect on  the events that led up to the incident. Can you identify a trigger? If so you gain some insight into what the real problem is. Analysing the situation when it is over is called reflection. Where there is no trigger and it is becoming very difficult to manage, professional advice should always be sought.
Reasons for aggression
Not being able to cope with the everyday demands of life, Frustration/pressure/humiliation, Processing information and responding to a situation takes longer in dementia. Independence and privacy are threatened by being forced to accept help E.g. washing/dressing/going to the toilet. Feeling judged or criticised, Forgetting something or making a mistake in completing a routine task, too much noise, too many people around, Change in routine, Sharp voices, Abrupt movements, Someone approaching from behind,m Feeling bewildered or frightened, Feeling anxious or threatened, Feeling discomfort E.g. pain, boredom or thirst, No longer able to recognise places or people. What can you do? Find out what may be upsetting the person, Try to reassure them, Find ways of making situations less distressing. Obtain advice from other carers or from professionals. Ensure that routines are unrushed and stress-free. When communicating: Explain things calmly and simply Allow more time for the person to respond.
Coping measures
Prevention is the best solution for aggressive behaviour - but it will not always work. Do not blame yourself or others, Concentrate instead on handling it as calmly and effectively as possible.
Coping with physical violence
Give the person space, Do not restrain them unless necessary (in my opinion, it is never necessary. No elderly person or anyone suffering from dementia should warrant any type of restraint) Only those who have received approved training can use restraint. Leave the room if necessary and Call for help. You must be familiar with any policies on handling aggressive behaviour and receive regular training updating After an incident remember You are caring for a vulnerable adult and You have safeguarding responsibilities. Do not punish the person E.g. withdrawing something they enjoy do not ignore them – this is psychological abuse. Behave normally and reassuringly. All incidents should be recorded in the care plan notes. Discuss aggressive incidents with a line manager a  Referral to the GP or other professional may be required. Drugs to treat aggressive behaviour should be avoided. If drugs are prescribed they should be reviewed regularly. Talk things over with a colleague, your line manager or a professional. Remember though the rules about confidentiality Who you can and cannot talk to about any incidents.
Psychological Treatments
These include Reality Orientation which Involves regularly reminding patients of information such as the day, date, season and where they are. Reminiscence Therapy Encourages people to talk about the past it may also help by bringing past experience into consciousness.
Reality Orientation
There is evidence that reality orientation can help with memory and thinking. Any improvement is likely to be small, Reality orientation is a way of exercising the memory. Doctors who specialise in caring for elderly people use reality orientation to help people who are confused. The aim of reality orientation is to help people understand their situation by reminding them or telling them about what is going on. This can help people cope better with everyday life, It can also improve self-esteem and help them feel less aggressive and restless. Reality Orientation can be given by anybody who has been trained in the technique E.g. psychologist, nurse or carer this is usually done at the patient's home, preferably near a window so that they can be aware of the time of day and weather. If someone with dementia is given reality orientation their memory is likely to improve, they may also behave more normally and be less aggressive and less easily upset. Reality orientation uses repetition to help the memory. You can be shown how to use reality orientation to help someone with dementia. You will need to repeat information several times each day, all the time you must treat the person with respect and do not to talk down to them. Reality orientation should include lots of encouragement E.g. if a person gets dressed without help, they should get lots of praise. There is no evidence that reality orientation can be harmful Some researchers however have suggested that the constant repetition could put some people with dementia in a bad mood and lower their self-esteem. Reminiscence Therapy
In this type of therapy people are encouraged to remember things that happened in their life. Usually they talk to someone or join special groups that meet regularly. It is thought that the effort of remembering past events may help memory, It may also help people who are restless, aggressive or easily upset as it can give them something else to think about. There is no evidence that reminiscence therapy can be harmful. There is not enough good evidence to say whether it helps or not. Psychological treatments
Dementia raises difficult feelings and thoughts, Anger, Confusion, Fear and Anxiety. Family and friends may have their own difficulties coping This can make it hard for the sufferer to discuss their feelings.
Counselling
An opportunity to talk about feelings and work out ways to live with the condition. Note - traditional counselling expects clients to have full use of their cognitive abilities. People with significant changes in their cognition (memory, speech, thought processes) still respond well to the emotional content of the counselling sessions.