Understand the neurology of dementia
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1.1 The causes of dementia are not yet fully understood but we do know that it is a deteriotation in mental functions which include memory, speach, judgement and orientation.The brain is a complex organ with over 100 billion cells. In dementia some of these cells stop working properly. The part of the brain this occurs in will affect how the person communicates, thinks, feels and remembers. Dementia can start in people well before the age of 65 this is called early onset dementia, but it is far more wide spread in the over 65 age group. Dementia is a major condition which affects over 820.000 people in the uk, but over 35 million people world wide have some form of dementia, with millions more ever year being diagnoses. Alzheimers disease; Alzheimers and dementia are not the same, Alzheimers is caused by nerve cells in the brain dying in certain areas and connections between affected nerve cells as the disease progresses deteriorate. The reason for this is not fully known, but research is on going. Vascular dementia; vascular dementia is caused by damage to the brain by lack of oxygen in the blood going through your veins and arteries, if this happens that organ will die the organ being your brain. Conditions which can cause vascular dementia are preventable, they include diabetes, heart problems, high blood pressure, high cholestrol. Helping people to lead a healthy and active life style can help prevent this disease.
Creutzfeldt-Jakob disease (CJD); This is a rarer form of dementia that is caused by prion diseaes they are proteins that are found in mammuls. when they cluster together in the brain, the affect is the brain cells die, when they die they leave holes in the brain called spongiosis, they appear sponge like under microscope. The damage this causes to the brain are neurological difficulties and dementia. There are four forms of CJD they are Sporadic, Familial, Iatrogenic and Variant. These conditions are very rare but life expectancy is very short, death can happen within 6-24 months from diagnosis. Biswanger’s diseas; (BD) also called subcortical vascular dementia is caused by damage to the blood vessels in the deep white matter of the brain, the damage is a result of the thickening and narrowing of the arteries commonly known as hardening of the arteries. It usually affects people over the age of 60 and is often a result of high blood pressure or long-term hypertension. Dementia with Lewy Bodies (DLB); DLB is a type of dementia that has similar symptoms to alzheimers and parkingsons disease.
Lewy bodies are tiny deposits of protine in nerve cells.These deposits alter the way the brain works. There is still not full understanding of why LB appear in the brain, or how they contribute to dementia.But there presence is linked with low levels of acetylcholine and dopamine and a loss of conections between nerve cells. Over time the nerve cells die and there is a loss of brain tissue. About four percent of the older population with dementia are affected with DLB. Fronto-temmporal dementia; This is a group of disorders caused by progressive cell degeneratio in the brains frontal lodes or its temporal lobes. Cell damage leads to tissue shrinkage and reduced function in the front of the brain which control how people understand speach, how they feel, how they speak, how they move and how they behave.
1.2 Memory is information we have stored in our brain, that we can remember and recall as and when needed.We have information in our brains that we can remember from years ago, some is harder to recall some is easier. If we are distracted or not concentrating when a memory is forming, we probably wont remember it in detail, but if it is very interesting or you enjoyed the experience a lot you will likley remember those events clearly, but the boring stuff wont be as clear. Some memorys get replaced to make room for new memorys like clearing out your filing cabinet to make room for the new events. This sort of memory loss is normal and all people have this. Memory loss is defined by the shrinking of the hippocampus which is where we store long term memorys and is usualy the first part of the brain which suffers damage and could lead to alzheimers disease. A person with amnesia may not remember facts and certain memorys from their past, but do remember their procedural skills like the ability to swim, type, or ride a bike. Dementia sufferers can remember things that happend in their youth or younger life, but cant recall what happend five minuits before. They are unable to recall due to the damage to their cells.
There are several memory loss difficulties such as not recognising peoples faces or names and repeating conversations they have just had, people with this type of memory loss can become very frustrated with them selfs. Not every one with dementia will be affected the same, there will be a variety of symptoms Also physical changes in the brain will affect the behaviour of the person with dementia. Here is a list of different symptoms, impairments can include memory loss, confusion, mood changes, difficulty with simple day to day tasks. Disorientation especially when in unfamiliar surroundings, reduced judgement, decline in language abilities, personality changes, inappropriate behaviour, lack of social awareness, declining motor functions, behavioural changes, paranoia, hallucinations, sexual actions, cognitive decline and many more depending on the type of dementia and the person.
1.3 The brain is a very complex organ made up of over 100 billion cells, these are mostly called neurons. When they are all working properly they fire electrical impulses along the axon which then releases a chemical, which travels over the synapse, which in turn turns on another neuron. These are neurotransmitters. There are 60 identified chemicals in the brain which controle the way people behave and think, one of them is Dopamine, it controls our movements you need dopamine to move freely, it also controls the information from areas such as memory, problem solving and attention. Without enough dopamine we are unable to function properly. Serotonin is another if we don’t have enough we can become depressed as it affects our mood and can also make us feel aggressive if we don’t have enough, seratonin is known as the feel good neurotransmitter.
Acetylcholine (ACH) people with alzheimers tend to have low levels of ACH in their brain,as it controls the part of the brain concerned with, attention, learning and memory. A person with dementia has damage to the neurons and one of the chemicals called Glutamate is essential for linking the neurons that help people learn. When the neurons are damaged it means that people with alzheimers are unable to function fully. With the 100 billion cells in the brain they are split in two halves we know them as hemispheres. The right side puts information together and the left side analysis the information collected by the right, so you are able to see something then identify it. Dementia sufferers with damage to cells on the right side of the brain will have difficulty putting the information together, while people with left side cell damage will be more depressive and have problems with language and organization.
1.4 Loss or reduction of memory does not always mean the person has dementia other health conditions which can affect memory and are often refered to as reverible dementia. Brain injury caused by a blow to the head like a boxer, or stroke or aneurisum, these can cause long or short term difficulties or cause permanent difficulties. A person could have a brain tumour either benign or malignant. Diet can have an effect some foods with colouring or sugars can have an effect on memory. Delirium can occure from abrupt withdrawl from certain drugs from the group benzodiazepines, certain drugs used for other illnesses can cause dementia like symptoms, causing neorological difficulties including memory loss. Depression, hydrocephalus (water on the brain), tumors, subdural hematomas (blood clots caused by bruising), thyroid disease, alcholism, chest infection.Other factors could be a urinary tract infection, myalgic encephalomyelitis (m.e) is a chronic, disabling neurological disorder with persistant lathargy and muscle pain. Huntingtons disease is hereditary a neurodegenerative disorder of the central nervous system. People get movement problems and intellectual, emotional problems. parkingsons disease, movement problems speach, memory as written about in the previous section. lyme disease, multiple sclerosis (m.s), hydrocephalus, stress, & insomnia can all contribute to memory problems & dementia symptons.
1.5 Every one with dementia experiences it differently and there is no difinitive path that the dementia will follow.It is not fully known why people with dementia have good days & bad but we all have good & bad days so that may be part of it. When we do things we don’t like the time drags & we start to get negative then make mistakes, the same can be said about the person with dementia, when they have activities they like to do they appear confident with the routine they are familiar with but if you take them out of there familiar surroundings & routine then there confusion will grow causing them to become more agitated making there symptoms more obvious. Stress has an affect on our memory, with people who have dementia in the early stages they can be very aware that they have forgotten where they have placed things making them more agitated, it is very inportant for those of us who work with people with dementia to try & help them to calm down because the more they are agitated the greater there difficulty’s will be. It is always inportant that when the person keeps repeating a question over & over that we answer it like it is the first time they have asked it, other wise if they see there behaviour is affecting us it will upset them more making there symptoms worse.
2.1 Early diagnosis could have a profound affect on some one with dementia, once the cells are damaged they can not be repaired, but with early diagnosis which can be difficult for the doctor to make because symptoms can be so similar to other health conditions, the doctor will be able to monitor the person to keep track of any personality changes as well as memory changes & they could have a ct scan or mri scan & see a specialist. The person could have a better quality of life and be provided with treatment to help the symptoms that affect thinking and memory ( cognitive symptoms) and treatment to help with mood and how some one behaves (non cognitive). Early diagnosis is also essential to rule out other treatable conditions & access support, information & advice & also so the person & the family can plan & make arrangements for the future. They can also research there illness & better prepare them self’s for the future. Following diagnosis they may want to be as independant as they can for as long as they can so it is a good idea to have notice boards with lists of of daily tasks on them & a list with important phone numbers next to the phone so they always can call some one when they need them.
Putting lables on doors so they know what is where & on doors with keys to remind them to lock the doors. All these little things help to keep the person with dementia as independant for as long as they can be. It is also a good idea for the person to start a life history book with pictures with dates & events written on them so they can look at them & read where & when the event was. early diagnosis is also helpful to help the person start to live there life again with support they can start do do there hobbies again & persue their interests having a full life.
2.2 It is important to record and report possible signs of dementia or symptoms of dementia in a person in line with policies & procedurs for there well being and so appropriate action can be taken if and when needed For example they may need to see a Doctor and it may only be a u.t.i that they have and need antibiotics, or it may be early on set dementia and if diagnosed early the correct medication or treatment may improve there quality of life. Recording all occurances & the time of day things occure will help you & all members of the team build a picture of the person’s mental & physical health & looking back will help you ascertain if there memory is failing. Having involvement from the family could be beneficial they see the person more than you so there insight can be helpful in how you support the person. Keeping a diary of the persons day will also help. The persons doctor or specialist will also benefit from information recorded in altering the persons medication. Things that need to be recorded are fact about memory, behaviour, personality, ability to cope with daily living tasks, activities the person has enjoyed, medications they have taken & the time of day taken.
2.3 In cumbria care we report any changes we see to our supervisor, making them aware of the persons situation and the changes we see in them, giving fact not what we think. We also record in the communication book that is in the persons home to make our co-workers aware so they can also monitor and report back to the supervisor with updates. We record times that we visit so that a pattern of the persons behaviour can be built up. The persons social worker would be informed along with the family if they are not already aware. An assessment by the community psychiatric nurse as well as the persons doctor would be arranged. All of the recording that we do helps with the persons history when it comes to receiving the care that they need when they need it.
2.4a The possible impact of diagnosis could be relief that they now have a reason for the difficulties they have been having. Or they could be devestated and think there life has now come to an end. Some people may be in denial and refuse to believe there diagnosis. While most will go through a range of emotions, lack of insight, emotional crisis related to anticipated loses associated with dementia, fear, insecure, denial, anger, barganing, depression,acceptance. They may not experience these symptoms in this order they can be any order and repeted.
2.4b Possible impact on family and friends could be fear they are losing there loved one. Worry about how they will cope, will they recieve any support financial and practical. Will they have to leave there job, how much
will there life change. How long will there loved one know them and be able to hold a conversation with them.
3.1 Person centered approach would be to work with the person to make there care plan, making them the main focuse not the dementia. Always recognising there individuality and drawing on there personal history, there family, there interests and there hobbies to better understand them. We strive to understand the world from the persons perspective. When a person behaves in a way that could be perceived as difficult, inappropriate or aggressive it is our role to try to understand why they are behaving like that, especially if they are unable to explain why or express them selfs well. Knowing there past history, relationships and interests and trying to see from there perspective can help in this. We must always give the person choices of what they would like to do, drink, eat, wear, ect.
A non-person centered approach would be to treat every one the same, make them all get up at the same time, wash, dress, eat at the same time like they used to do in days gone by. Not giving the person any options or choices, telling people what they can and can’t do for the benefit of the support worker or care home not the individual. Not caring about the persons history there interests or there individuality.
3.2 Different techniques could include keeping the individuals support plan up to date with any strategies that will help to calm an individual if they become agitated. Have alternative methods which have been proven to work when the individual has fluctuating moods also document them. Communicate and share information with other support workers sharing methods that have worked for you so they can try them, equally you can try any methods that others have tried with success. Look out for triggers and share this information with others. Always try and have consistancy and familiar faces and surroundings. Have a regular routine. Encourage activities that they like, encourage hobbies they used to like doing. Light exercise so they feel tired at night. Always try to strive to improve your oun knowledge and understanding so you can better support the needs of the person.
3.3 It can create an unrealistic hope in the person and their family when
they see cures being offered or prevention on the internet or in magazines because there is no cure and it can’t be prevented. It can also make people feel vulnerable, fearfull and isolated when they appear normal but have early signs of dementia and people may not believe them. It can often be the persons own stereotyping of dementia they fear the most and only through education and acceptance can this be resolved. It is often ignorance where peoples views of dementia come from when all they see on tv for instance is late stages of dementia not so much the earlier stages.
3.4 Dealing with a diagnosis of dementia is not going to be easy but there is support out there. Information on dementia and how it will affect the person read up on it so that you are prepared when the dementia gets worse, a carers needs assessment, a benefits assessment to see you are both recieving the benefits and support you are both entitled to, has the person you care for been given a community care assessment, have you begun the prossess of writing wills and implementing lasting power of attorney, have you been given the names of support groups for your self and day care or similar for the person, do you both need counselling, plan for the future.