NURSING IN THE CASE OF ALZHEIMER’S DISEASE: THE SIDE-EFFECTS OF MEDICATION
If a change occurs in the behaviour of people with dementia or they seem otherwise to be behaving abnormally, it is important to consider whether or not the change is the result of a side-effect of any medication that is being prescribed. Older people are much more sensitive to unwanted effects of prescribed medicines and also those that you can buy over the counter without a prescription. Medication ought not to be repeated indefinitely, every month say, without a formal review taking place from time to time. The frequency of the review will depend to a certain extent on the problems being treated and the nature of the drugs being prescribed. Many older people, even those not suffering from a dementing illness, can be prescribed a medicine for a particular problem and then three years later it is discovered that they are still taking the same drugs even though the problem may long ago have receded.
Every so often, people with dementia may refuse to take their pills. If a medicine is being taken two or three times a day, it probably doesn’t matter very much if an occasional dose is omitted. This is best checked with the doctor who prescribed the pills as there are some exceptions. If refusal to take medication is a consistent and protracted problem, it may be necessary to ask the doctor to prescribe an alternative form of the drug, for example a liquid that can be mixed with a cold drink or a capsule containing a powder such that the capsule can be opened and the powder mixed with jam, honey, or something else that is palatable.
It is better always to assume that a person who is confused and forgetful will need to have his or her drug-taking supervised. In the early stages, if this is impossible, there are various tricks that may help to ensure that medication is taken properly. Some drugs come in calendar packs and if not, it is possible to buy a similar gadget, such as a plastic box divided up into compartments, each labelled with the day of the week. In some such boxes the compartments are further divided into three or four subsections so that the medicines for morning, noon, and night can be placed in their own compartment. This is helpful to those supervising the medicines as it may give an indication of how frequently the pills are being forgotten.
Finally, there are three types of side-effect that commonly occur when a medicine is given to try to control abnormal or difficult behaviour in a person with dementia, and which you should look out for. These are: difficulty in walking — a tendency to fall or stumble, especially after rising from a chair or getting out of bed; increased sedation, i.e. sleepiness in the daytime; and restlessness.
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BEHAVIOURAL AND PSYCHOLOGICAL PROBLEMS IN THE CASE OF ALZHEIMER’S DISEASE: AGGRESSION
Some people with dementia can become extremely aggressive, irrespective of the underlying disease that is causing the illness. Although spouses are often very expert at managing the aggression, the involvement of children can be a very serious problem. An aggressive or violent, confused adult can cause major distress to children and even teenagers who don’t understand what is going on. When children are affected it is a natural reaction to become angry with the sufferer, but although the situation must be resolved, it is important not to lose sight of the fact that the aggression is not a conscious, considered action of the sufferer. It results from brain damage and something has triggered off an abnormal behavioural response. This ‘something’ may be a misinterpretation of events going on around the sufferer, a feeling of inadequacy that is exaggerated by the attitude of younger people, or a hundred and one other things. The main thing is to stay calm and this will usually be a help to other people. As is the case with so many other abnormalities of behaviour in these circumstances, the best approach is often that of diversion, distracting attention in another direction and gently persuading the sufferer to become interested in an alternative activity.
Try to work out what it is that might be precipitating the outbursts and hope to avoid similar situations in the future. Above all, if this type of behaviour becomes a real problem, seek advice earlier rather than later. Very rarely, aggressive behaviour is consistently directed against one person for no obvious reason, with threats of harm or even expressions of intent to kill. This situation has arisen many times, but actual physical violence occurs exceptionally rarely. Nevertheless it is absolutely essential that carers seek support and help as soon as they find themselves threatened. Having to live in fear of being attacked will affect not only carers, but also their relationship with the demented relative. Aggressive behaviour can usually be treated successfully by the careful administration of medicines.
Never react to violence with violence or anger, as this won’t prevent a further occurrence; try to avoid aggressive situations developing and step back out of reach if there is any obvious evidence that you are about to be assaulted. If threats of physical harm become a reality, seek medical help at the first opportunity.
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RISK FACTORS FOR DEVELOPING ALZHEIMER’S DISEASE: OTHER POSSIBLE FACTORS
One potential cause is a past head injury that resulted in unconsciousness. There is a direct link here between the changes that are found in the brain of some boxers who develop neurofibrillary tangles, and the pathology of Alzheimer’s disease. At the moment the evidence is probably insufficient to link firmly head injury with the development of this type of dementia, but this evidence is slowly accumulating. The families of people with Alzheimer’s disease are often worried that the disease has been caused because the brain has been worn out by excessive use or conversely, that it has wasted away because of too little use. There is no evidence at all to indicate that either of these possibilities is true.
Environmental toxins have been linked to certain conditions. Parkinson’s disease which, like Alzheimer’s, is caused by degenerative processes within the brain, has been linked in a specific sub-group of sufferers to a toxin that is present in the environment. A group of drug abusers inadvertently dosed themselves with a substance called MPTP. Unfortunately it proved to be very toxic to those parts of the brain which if damaged lead to Parkinson’s disease. The substance was discovered because doctors in America began to wonder why Parkinson’s disease suddenly seemed to be occurring in patients who were forty or fifty years younger than the age group that normally suffers from it.
The chemical structure of MPTP has been well characterized and it is known to be similar to other chemicals, including some weedkillers. Although it is unlikely that Parkinson’s disease is actually caused by toxic chemicals introduced into the environment, this possibility needs to be eliminated. Since Alzheimer’s disease is also a chronic degenerative condition of the brain, the search is on for toxic substances, other than aluminium, which might be responsible. So far there is no obvious candidate.
There have been, and probably will continue to be, other factors under investigation as potential causes of Alzheimer’s disease. The quality of the scientific evidence in support of many that have evoked much interest in the media has been poor and the hypotheses associated with them have died, either for lack of proof or because under careful scrutiny the evidence has been discredited. Although it is extremely important that the search proceeds for environmental agents that might contribute to the development of Alzheimer’s disease, it is equally important that we don’t jump to the wrong conclusions too readily.
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SYMPTOMS OF ALZHEIMER’S DISEASE: DEPRESSION
The manner in which the symptoms of Alzheimer’s disease occur in many people is complicated by the coexistence of depression.
This is usually assumed to be a reaction to the disease – the result of patients realizing that something has gone seriously wrong with the way in which their mind works. This may well be an oversimplification because we know that some of the biochemical changes in the brain that are found in Alzheimer’s disease are similar to those that are found in the brain of people with depression. These biochemical changes may occur in the Alzheimer brain when the person concerned did not appear to be depressed while alive. It may also be that in some people these depressionlike biochemical changes are sufficiently severe to result in depression. As the disease progresses, the depression will often lift. Doctors have to be very careful if they try to treat an Alzheimer’s disease sufferer for depression since many of the drugs that are used can actually make memory function worse.
Depression may also mimic a dementia, including Alzheimer’s disease. If there is any doubt about the nature of the depressive symptoms, careful assessment by a psychiatrist is essential and sometimes a trial of treatment is also needed.
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THE NORMAL BRAIN AND HOW IT AGES: THE STRUCTURE OF THE BRAIN
The brain can be divided in simple terms into four parts. Two of these are the cerebral hemispheres, a left and a right, stretching from just behind the eye to the back of the head. Each hemisphere is divided into four different lobes. The lobe at the front – that which is just behind the eye – is called the frontal lobe, and among its many functions is the control of our behavioural pattern.
Behind the frontal lobe is the parietal lobe and behind that, at the back, is the occipital lobe. The parietal lobe has many functions and is probably best considered as one of the most important parts of the brain for the interpretation and correlation of sensory input — what we can feel when we touch something or are touched. It is also responsible for our interpretation of our body image, that is, our image of our own bodies. Damage to this system may result in an individual neglecting a useful limb or failing to recognize that a limb is paralysed, as occurs after some strokes. The parietal lobe is also responsible for coordinating some functional activities, so that damage to it may result in an inability to execute planned movements, for example doing up buttons. This should be distinguished from a similar difficulty that can result from damage to nerves and muscles. The occipital lobe is important for the interpretation of visual sensation and damage to it will result in disturbance of vision.
The fourth lobe of the brain, the temporal lobe, which lies a little below the parietal lobe and behind that part of the skull that is often referred to as our ‘temple’, is important for many of the dementias, especially Alzheimer’s disease. In lower forms of animal life it is particularly concerned with taste and smell, as it is also in humans. In us, however, it is most important for the organization and processing of memory and has close connections with other areas of the brain. Loss of memory is of course one of the first signs in the development of a dementing illness. The temporal lobe is also important for some aspects of hearing and speech.
As well as connections occurring within the brain between one part and another, each of the hemispheres sends out nerve fibres to the rest of the body, mainly to control what the muscles in the limbs do. They also receive fibres from sensory organs, such as those that are hidden in the skin that tell us about sensations of touch, pain, and temperature. Strangely – and nobody really understands why – each hemisphere makes its connections with the other side of the body; in other words the left hemisphere controls movements in, and receives information from, the right side of the body.
At the back of the brain, sitting below the hemispheres, is a small structure about the size of a man’s thumb. This is called the brain-stem and it joins the hemispheres to the spinal cord. As well as being a structure that has fibres passing through it, to and from the hemispheres and the body, it also has its own specialized functions. These include many of the nerve cells that control the muscles of our face, the muscles that move our eyes and those that are responsible for eating and swallowing, etc. It is also to this area of the brain that sensation from the face is first sent. In addition, the brain-stem contains special centres that are responsible for controlling our breathing, our heartbeat, and other body functions automatically. These are, of course, vital centres that help to keep us alive and as they and many other structures are crammed together in a very small area of brain tissue, damage in the brain-stem can have a very profound effect upon the integrity of the rest of the body. The brain-stem is affected in many of the illnesses that cause dementia, but probably to a lesser extent than the cerebral hemispheres.
Sitting beneath the occipital lobes and behind the brain-stem is the cerebellum, whose importance lies in the control of the reflexes that determine our posture and the state of contraction of the muscles. It is essential for maintaining the body’s equilibrium and for the performance of smoothly coordinated muscular actions. It is involved in some types of dementia, but not very much, if at all, in the commoner illnesses that cause intellectual impairment.
Within the brain are hollow spaces that contain the same fluid, the CSF, that has been mentioned already. The CSF in these hollow spaces, which are called ventricles, escapes through small openings to join the CSF that is contained within the membranes surrounding the brain. A disturbance to this system can result in a particular form of dementia that will be described in a later chapter.
The brain is, roughly speaking, also divided up into white matter and grey matter. The grey matter is not really grey in the living brain but is so described because of the appearance it takes on when it is treated in a particular way after a person has died. It is these grey areas that contain the bodies of the nerve cells, as described below. The largest collection of grey matter lies on the outside of our brains, rather like the rind of an orange, and it is called the cerebral cortex. This structure is affected in many of the dementing illnesses. Buried deep within the brain are other collections of grey matter, some of which are also affected in some of the conditions that cause dementia.
The white matter is only white because it contains a lot of fatty material. This is made up of nerve fibres which pass from the cell bodies to other areas of the brain or the body – the arms and legs for example. Most of these nerve fibres are surrounded by a fatty material which has an important function in helping messages travel down the fibres. It is this fatty material that is white, giving the brain its characteristic appearance. In summary, therefore, the brain can be considered to contain grey matter, which is the cell body of the nerve cells, and white matter which is made up of the fibres either connecting different nerve cells, or parts of them, or travelling to the rest of the body outside the brain.
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