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Clinical features

There are a number of different types of convulsions, but they are usually characterised by the sudden onset of a stiffening of the body, followed by jerking movements, after which the child usually sleeps deeply for an hour or so. Most convulsions do not last longer than several minutes. Convulsions can be partial, affecting only one part of the body, or general, involving the whole body.

Some convulsions (petit mat) do not involve jerking body movements, but simply appear as an ‘absence’ from activities. The child stares for a few seconds, and then continues with what he was doing as if nothing has happened. Epilepsy is the term given to the condition where the child has more than one seizure, and there is an abnormal EEG and Epilepsy.

The characteristics of a febrile convulsion are similar to those of a general convulsion. The episode is usually brief, lasting less than 5 minutes, and the child makes a complete recovery afterwards, although he may be a little drowsy for an hour or so. He will also have symptoms of the condition that caused the fever, such as a runny nose or earache or cough. Occasionally the febrile seizure will be associated with a more serious condition such as meningitis so it is important to see a doctor so that this diagnosis can be excluded.

Investigations

If your child has a convulsion which is not due to fever, your doctor will suggest that an EEG be performed, and occasionally a CT scan of the brain.

Investigations are rarely indicated for febrile seizures. Sometimes blood or urine tests, or a chest X-ray, may be performed to find the condition which caused the fever. An EEG is performed if there are repeated febrile convulsions but it is usually not indicated after a single episode.

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A child who is in a coma is unconscious; that is, he is unaware of his surroundings, and cannot be woken. There are various degrees of coma, from a light coma in which the child responds to being touched, to a deep coma in which there is no response to stimuli, and in which the child may even require artificial ventilation.

Cause

There are numerous possible causes for coma in children, including drug overdose, alcohol poisoning, meningitis or encephalitis, and head injury. An extremely low blood sugar in diabetics can also lead to unconsciousness.

Investigations

Blood and urine tests may be performed, in addition to X-rays and a CT scan, to determine the cause of the coma.

Treatment

All children in a coma are admitted to hospital for assessment and treatment. The type of treatment depends on the degree and cause of the coma, but includes intravenous infusion and around-the-clock nursing care and life support facilities.

cause. It the coma is irreversible the outlook is poor. However, if the cause can be treated and the child shows improvement, this is a positive sign for recovery, which may be partial or complete. The exact treatment and outlook varies with the cause, severity and duration of the coma.

Prevention

Drugs and poisons should be kept away from children. Head injuries causing coma can be minimised by insisting on helmets for bike-riding and horse-riding.

Regular monitoring and good control in a diabetic child can prevent dramatic fluctuations in blood sugar levels, thus minimising any likelihood of diabetic coma.

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The long-term treatment of general convulsions will depend on their cause and severity.

A febrile convulsion usually lasts only a few minutes, and almost always stops by itself before any treatment is given. If the seizure is prolonged, the child is taken to the doctor or hospital where medication is given (intravenously or rectally) to stop the seizure. It is not usually necessary to hospitalise a child following a febrile seizure, unless there is concern about the condition which caused the fever (such as pneumonia or meningitis). Generally, the child is assessed, the underlying condition treated, and the child is sent home.

When to see your doctor

• if it is your child’s first convulsion;

• if your child has several convulsions;

• if convulsions occur often.

Prevention

To prevent recurrences of febrile convulsions, you should try to lower your child’s fever (for example, using paracetamol as soon as you become aware of the problem. However, sometimes the seizure will be the first indication of a fever. There is no point at all in giving your child anticonvulsant medication whenever he develops a fever, because it takes several days to build up sufficiently high blood levels of the drug.

If the child has recurrent febrile seizures, your doctor may consider prescribing anticonvulsant medications to be taken on a continual basis for several years to prevent the seizures from occurring. However, this should only be instituted and managed by a paediatrician or paediatric neurologist.

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Convulsions are also known as fits, epileptic attacks or seizures. They are states of altered consciousness which can vary in severity. About 1 in 100 people have a seizure of some kind during their lifetime, and about half of these occur during childhood.

Febrile convulsions (seizures which occur due to fever) are relatively common, occurring in approximately 4% of children between the ages of 6 months and 5 years. The majority of these children will only ever have one fit; most will occur while the child is less than 3 years old. Those children who have their first febrile convulsion before the age of 1 year have a higher risk of having recurrent febrile convulsions. This type of convulsion tends to run in families, and to affect boys more often than girls. Even though it can be very frightening to see your child having a febrile convulsion, remember that children do not die from this, nor do they suffer long-term consequences or brain damage.

Cause

Convulsions are due to sudden, abnormal electrical activity in the brain. There are many causes for convulsions which do not occur in relation to fever; the most common is scarring of brain tissue which may occur after head injury. Convulsions in some children may be triggered off by flashing lights, such as a strobe light, or looking at patterns on a screen. There is usually a family tendency towards having convulsions.

Febrile convulsions occur as a direct result of a high fever which may accompany an infection. For reasons that are unclear, the rapid rise in temperature causes an abnormal electrical discharge in the brain, which results in the seizure.

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All parents will know that no two children are alike in terms of their temperament and personality. Often parents will say that the differences are noticeable from birth; in other children they become more noticeable over time. The term temperament is now used to describe these individual differences. Temperament is believed to be intrinsic but also to be modified by the environment.

A child’s temperament is like a filter through which he experiences and interacts with the environment. It is the behavioural style of the child. Babies with a difficult temperament are more likely to be reported as having colic, sleep problems, and excessive crying, and as they grow older more likely to have temper tantrums and a slower school adjustment. Children with an easy temperament are less demanding of their parents, and generally easier to manage. They settle quickly into a predictable routine, are easily adaptable, and far more easy going. There are also those who have a slow-to-warm-up temperament. They may be somewhat difficult initially because they do not adapt easily to change, and take some time to get used to things.

It is not the child’s temperament alone which is important, but rather, the interaction of his temperament characteristics with the child-rearing style of his parents which determines whether there will be difficulties. A baby or child with a difficult temperament may make some parents anxious and insecure about their parenting. They may blame themselves for the fact that the child seems quite difficult to manage. Other parents may be able to be more accommodating of their child’s temperament. They will be more flexible in their parenting style, so that consequences of the child’s difficult temperament are minimised.

Similarly a child who has a slow-to-warm-up temperament also needs the understanding of parents. He will tend to hold back from new and unfamiliar situations, and react by crying or hanging onto the parents. Sensitive parents and teachers will be aware of this, and not push the child until he is ready.

As parents, you will achieve the best results by modifying your child-rearing style to take into account your child’s individual temperament characteristics. It follows then that there is no single way to approach children, whether it be feeding, toilet training, discipline, or any other area of functioning. Each child must be treated as an individual.

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Bunions are thought to develop because we squeeze our feet into shoes which are too narrow for the forefoot. Coupled with this may be an inherited tendency for the first metatarsal or long bone of the foot to splay medially or inwards.

The first deformity is a hallux valgus. The joint of the great toe (hallux) is forced laterally, or outward, so that the toe turns inward, crowding the other toes.

An exostosis, or bony projection, develops on the medial or inner side of the head of the metatarsal, where it forms the big toe joint.

Osteoarthrosis usually develops in this joint and causes pain and stiffness and overgrowth of bone at the joint edges.

The bunion is a small bursa or fluid sac which forms on the medial side of the joint over the projecting bone. It may become inflamed or infected. The second toe gets crowded out and may over or under-ride the first toe.

A foot with all these deformities doesn’t look good but may not, at first, be painful. Doctors are reluctant to operate for cosmetic reasons only and usually wait until the person is inconvenienced by progressing pain.

*358/71/1*

Even drinking large amounts of any fluid, usually water, will relieve the discomfort. But although the symptoms are eased, this does not mean that the condition is cured. It may, and often does, recur.

That is why it is necessary to go to a doctor if you have cystitis and for the doctor to treat it seriously.

In true cystitis or infection of the bladder, germs have usually entered from the urethra, which has been contaminated from the bowel or a vaginal discharge.

The proper treatment involves taking a sample of urine under sterile conditions and looking at it under the microscope. A culture is set up, and any germs present are grown and matched against a number of antibiotics.

It may take three days for the results and a woman should not be expected to suffer discomfort for this length of time.

*108/71/1*

A great physician, Christoph Wilhelm Hufeland, who lived in Berlin about 150 years ago, wrote a book to which he gave the title Makrobiotik—»The art of prolonging human life.» Now, after 150 years, macrobiotics have become suddenly very popular in the United States. What are macrobiotics?

Hufeland’s definition of macrobiotics was «the art of living longer.» In the present technological and atomic age, macrobiotics means more than just «living longer.» It is the study and application of fundamental factors essential for optimum health and longer life free from disease. Due to improved sanitation, reduction in infant mortality and modern surgery, man’s average life expectancy has increased. But simultaneously, with the advance of technological and chemical sciences, the harmony between man and his natural health-giving environment has become disturbed. This disharmony has brought upon man a host of so-called degenerative diseases. Denatured, devitalized foods, a polluted and poisoned environment, the mental and physical stresses of the competitive world, have resulted in a gradual deterioration of health which has now reached catastrophic proportions.

It is hardly worthwhile to learn how to live a long life, if you have to live a life of miserable suffering from one agonizing disease after another. A long life would make sense only if it could be lived in vibrant health, enjoyed in the active productive pursuit of one’s most treasured interests. The fact is that very few people now really enjoy perfect health. Most are sick, semi-ill or «fictitiously healthy.» living in a chronic state of mesotrophy, or half-health. Therefore, the modern meaning of macrobiotics is «the art of living longer in good health» or, in other words, the art of living younger longer!

I have referred previously to the International Society for F-e-search on Nutrition and Vital Substances. The Scientific Counsel of this Society is composed of over 400 great scientists from 75 countries, representing doctors of medicine, bio-chemistry, nutrition, natural sciences, etc. A great many of these are Nobel Prize Winners. This most authoritative scientific forum conducts objective, scientific studies and research, and through its annual conventions disperses recommendations to various governments and their health organizations, as well as to the World Health Organization.

This Society has conducted a seven-year study of macrobiotics, or the fundamentals of healthier and longer life in our modem technological society. Its findings and conclusions in regard to macrobiotics were adopted at the Society’s 7th International Convention.

Note this: you may read any number of popular health books or listen to the subjective, personal opinions of this or that health lecturer—usually with each one of them offering a different road to glorious health and long life—and you are no wiser in the end. But here is the united consensus of a large body of responsible and respected scientists, based on the objective study and research of all available scientific data. It would be wise to listen to them.

The following resume is based on Resolution No. 25 of the International Society for Research on Nutrition and Vital Substances.

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Multiple sclerosis is most prevalent in the so-called highly civilized (read: chemicalized!) countries. It is rarely encountered in Italy and the South American countries. Italians and South Americans living in the United States and eating the American diet show, however, the same incidence of the disease as other Americans. Researchers feel, therefore, that there must be a relationship between diet and the incidence of multiple sclerosis. Some surveys in Europe show that the disease seems to increase in areas with a higher consumption of animal fat and milk. Diets low in fat were tried on patients at McGill University in Montreal, Canada, with encouraging results.

In England it was observed that there was an unusually high incidence of the disease in lead-mining areas, which prompted many investigations. It was also shown that the lead content of the teeth of patients with multiple sclerosis was «significantly» higher than that of the control groups.

Many other researchers have linked lead poisoning to multiple sclerosis. The Finnish researcher, Martti Salmi, believes that the incidence of multiple sclerosis is closely related to the occurrence of lead in the soil and the environment. It seems that there is a higher incidence of the disease in the northern hemisphere, with the number of cases increasing as one goes farther north. It has been shown that glacial ice distributed lead-bearing materials to the soils in the northern countries. Also, lead in the air from leaded gasoline is suspected as the cause of the disease.

*102\58\2*

(SIX MINOR ZONES)-1ST MAJOR ZONE—STOMACH AND INTESTINAL ZONE

In considering the topography of the organs we commence with the first minor zone—the stomach zone. The stomach zone has already been indicated as the first zone in the circular division of the iris. It is now necessary to identify the parts of the stomach in the right and left iris.

If the body is divided down the middle by a perpendicular line we have: Pylorus with about one-third of the stomach in the right half of the body. Cardia and two-thirds of the stomach in the left half of the body.

All organs on the right side have their place in the right iris, and all organs on the left side have their place in the left iris, thus:

Pylorus and one-third of the stomach in the right iris. The remaining two-thirds with cardia in

the left iris.

By dividing the stomach horizontally through the middle we obtain an upper and a lower part for each iris. Considering the right upper part of the stomach, this will include an anterior and posterior view of the upper part of the pylorus with the right side of the lesser curvature. Since we have in both upper and lower halves of the iris a representation of the anterior, posterior and lateral views, we may determine precisely the different regions of the stomach from the iris. Similarly, we place the right lower part of the stomach in the right iris, and both upper and lower left regions of the stomach correspondingly in the left iris.

Pylorus is exactly in the middle, lying between the upper and lower halves of the right iris. Thus:

Upper half pylorus—Right iris nasal side—n’-is’—anterolateral aspect. —Right iris temporal side—45′-48′—posterolateral aspect. Lower half pylorus—Right iris temporal—42

‘-45′—anterolateral aspect. —Right iris nasal—15′—18′—posterolateral aspect.

The cardia, lying in the left side of the body, is represented only in the upper half of the left iris, at:

Left iris nasal—45′-50′—antero-lateral aspect.

Left iris temporal—10′-I5′—postero-lateral aspect. In my view we cannot place the cardia in the lower half of the left iris.

The second small zone is designated the Intestinal zone, which includes the duodenum, small intestine, and the large intestine with sigmoid flexure. We shall again require to identify the regions of the right side intestine in the right iris, to show right upper and lower intestine with anterior, posterior and lateral views.

Of especial interest to us here is the duodenum. Since this, and that part of the stomach lying in the right side of the body is more frequently affected, there must be reserved to this area a large part of the iris. We find on considering the indications that the proximal part of the

duodenum lies over the pylorus.

For this part of the duodenum we have shown in the iris the area 10/-15′ and 45′-50′ in the upper half, corresponding to the anterior, posterior and lateral aspects. The part of the duodenum which lies below the pylorus is seen in the lower half of the iris from 15′-20′ and 40 ‘-45′.

The junction of the duodenum with the small intestine lies in the left half of the body, so the area for it is found in the lower half of the left iris from 40′-45′. That part of the small intestine lying in the right half of the body is found in the right iris from 5 ‘-35′ with an intermediate position for a part of the duodenum.

At 35′ in the right iris, the ascending colon commences with the caecum, and extends to 50′, allowing for the insertion of a part of the duodenum. Here the right flexure indicates the commencement of the transverse colon which extends to 5′. Where there is a diseased appendix (it possesses much lymphatic tissue as is well known) the signs are to be seen outside the intestinal zone at 35′.

In the left iris, the area for small intestine extends from 35′-55′, with inclusion of that part of the duodenum which lies on the left side of the body—as already referred to above under Duodenum.

The transverse and descending colon is to be found in the area 55′-25′. The sigmoid and rectum then extend from 25′-35′. The last part of the rectum with ampulla and anus lies at 32-34′ in the muscle, bone and skin zones.

*12\78\2*

Although most of the medications your child will take will be on a doctor’s prescription, there are certain items every parent ought to have on hand at home. Some of these are nonprescription medications that you can buy over the counter at your drugstore. These are usually called OTC medications. Other items, like a thermometer, are basics of a home health care kit. You’ll also need antiseptics, ointments, gauze pads, and bandages in preparation for the inevitable bangs, bruises, scrapes, cuts, and other minor crises of childhood.

When you’re assembling this kit, however, remember a few safety rules:

•     Do not buy or administer any but the most basic drugs without the advice of a doctor.

•     Only buy medications in containers that have child-proof caps. Keep all medications in their original, clearly-labeled containers.

•     Unless your child takes a prescription medication on a regular basis, do not keep leftover medicines. Flush liquids and pills or capsules down the toilet and throw out the containers.

•     Keep all medications locked away from children. If you and your young child are visiting friends who do not have children, make sure that no dangerous substances are within reach of the child.

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Animal bites that break the skin are cuts, puncture wounds, or scrapes. However, animal bites may result in serious complications. First, animal bites often become infected by the bacteria in the animal’s mouth. Second, animal bites may cause tetanus (lockjaw) or rabies.

Tetanus (lockjaw) is a serious disease caused by a germ that lives in soil, dust, and the intestines and intestinal wastes of animals and humans. It can easily enter the body through puncture wounds or scratches caused by animal bites and claw wounds. A vaccine to prevent tetanus is available.

Rabies is unknown in Australia. It is a fatal disease of the central nervous system that may affect any mammal. It is caused by a virus that can be identified within the brain of an affected animal. Rabies is transmitted through the saliva of the sick animal.

Signs and symptoms

Even in younger children, an animal bite is usually obvious from its appearance. It is sometimes difficult to tell a bite from a claw wound; however, claw wounds should be treated in the same way as bites because a claw wound can also contain bacteria from the animal’s saliva. U the bite has caused a bruise, but there is no break in the skin, you do not need to worry about tetanus.

Home care

Scrub the wound with soap and water for five to ten minutes and flush with water. Apply antiseptic to minor wounds. Report the wound to your doctor immediately for advice concerning tetanus, and repair of the wound. Let your doctor know when your child was most recently vaccinated against tetanus.

The chance of an animal bite becoming infected is very high. If redness begins spreading out from the wound, or if the wound becomes more tender, call your doctor.

Precautions

• Be sure your child has regular tetanus boosters.

• Always contact your doctor about treatment in the case of animal bites.

Medical treatment

Because of the high possibility of infection, your doctor may decide not to stitch the wound. However, if the wound is located where scarring is not desirable (such as on the face), the doctor may choose to stitch the wound. Before stitching, treatment first includes removing the injured tissue and a thorough cleansing. Antibiotics taken by mouth may be prescribed. If necessary, your doctor may give the child a tetanus booster or antitoxin (a substance that counteracts the poisonous effects of the tetanus germ).

*12/84/5*

Back in biblical times, longevity wasn’t such a big deal. Heck, Moses lived 120 years without missing a step, according to the Bible. Noah kept trekking 350 years after the flood-living a colossal 950 years. And we hardly need mention Methuselah’s claim to fame. At 969 years of age, he’s credited with being the oldest man in history.

How’d they do it?

With all due respect, they most likely didn’t. Theologians have mulled this question for years. By considering traditions of the time, they have developed very human explanations for what appear to be superhuman life spans.

«No one really has the answer, but there are two very plausible explanations,» says the Reverend Glenn Asquith Jr., Ph.D., professor of pastoral theology at Moravian Theological Seminary in Bethlehem, Pennsylvania. «One is that the Israelites counted time differently. Some have theorized that they followed a lunar rather than a solar calendar.»

An even better explanation is that the Israelites loved their heroes much in the way we do-by making them larger than life. It’s like all of the embellishment surrounding George Washington, the Reverend Dr. Asquith says. «Most of these stories were passed down orally. So, with each telling, they likely became embellished. Since longevity was a sign of God’s blessing to the ancient Israelites, it makes sense that they would make their heroes out to be ancient.»

*4/36/5*

Although a physical examination and detailed medical history can tell a great deal about the likelihood of OSA, confirmation of the syndrome can only be done in properly equipped sleep laboratories which are now established in many large public hospitals and some private institutions. Formal sleep studies (technically referred to as polysomnography) make it possible to observe the patient in a clinical setting under the supervision of trained personnel.

Many of the functional and physiological changes mentioned previously, such as airway obstruction, hypoxaemia and irregularities of heart rate, are monitored during the study, giving investigators enough information to decide on the best course of action for the hapless snorer. Most people are apprehensive about the need for hospital admission and comprehensive testing procedures, and it is important that they be informed and reassured of the non invasive nature of these procedures. A nervous patient is likely to have a poor night’s sleep from which little useful information can be extracted.

Oxygen saturation

Probably the single most important measure of the severity of OSA is the level to which blood oxygen falls. Blood oxygen concentration, or saturation, can be estimated quite accurately by attaching a probe to either a finger or ear lobe. A special light emitted from the probe is able to detect oxygen saturation in the blood supply of the site to which it is attached, which in turn reflects the circulating oxygen level.

Sleep states

Airway obstruction is more pronounced in deep sleep, particularly during REM, and it is therefore important to document sleep stages to confirm that the patient slept soundly, preferably with several episodes of REM. Sleep states are monitored via several electrodes which are glued to various sites on the head which detect electrical activity °f the brain, eye movements and muscle tone, all of which help to define sleep states.

Chest wall movement: Obstructive and Central

The two broad categories of sleep apnoea, central and obstructive, are defined by the type of respiratory efforts made. One way of measuring this is to look at the movement of the chest wall as it expands and contracts with each breath, in conjunction with a detector of airflow at the opening of the nasal passage. When the upper airway collapses in obstructive sleep apnoea, the chest wall continues to move but there will be no detectable airflow through the nose. Falling oxygen levels stimulate the patient to take bigger breaths resulting in ever increasing signals from the monitor of chest wall movement. Eventually, the obstruction is overcome, airflow is again detected and breathing returns to normal until the next obstructive event. With central apnoea, the chest wall shows little or no sign of movement, indicating an absence of respiratory effort. This is also accompanied by a cessation of airflow.

Heart monitoring

The final obligatory assault comes in the form of a heart monitor (or ECG), the electrodes of which are attached to the chest. The ECG records the heart rate and provides information about the electrical impulses which stimulate the heart to beat regularly.

The process of «wiring up» for a sleep study can be an intimidating experience for those with an innate fear of hospitals and high technology. A small percentage of patients never relax enough to get a good night’s sleep, but most adapt quickly to the novel circumstances and sleep soundly enough for the purpose of the investigation. In this respect, patients with advanced OSA have no problems, often falling asleep while being attached to their monitoring equipment.

The capacity to measure oxygen saturation, sleep states, chest wall movement, nasal airflow and heart rate is a minimum requirement for a unit specializing in sleep-related breathing disorders. Some units, however, are capable of measuring other parameters of sleep and breathing and have the resources to screen several patients on the same night.

*12/51/5*

The large differences in health and illness behaviour between groups and cultures suggest that it must be learned. Research shows that Jews and Italians claim that their mothers were over-protective and over-concerned about their children’s health and participation in sports and that they were constantly warned to avoid colds, fights and other threatening situations. Perhaps this kind of upbringing fosters a type of personality which is particularly concerned and even anxious about illness.

First-born and only children are more likely to want the company of another person when they face stress in adult life-probably because they are so much more psychologically dependent than later-born children. This is interesting in the light of studies which show that early-born children use more medical services than do later-borns (in whatever size of family).

We have already seen that psychological manoeuvres that are going on, usually quite unconsciously, are much more complex. Illness behaviour is part of a well-defined social pattern and we all have our views of how doctors (them) and patients (us) behave. I firmly believe, to paraphrase Shakespeare, that, ‘All the world’s a surgery and all the doctors and patients merely role-players.’ It is my view that many of those going to their doctors are quite unconsciously playing a role-the sick role. Studies suggest that only about four out of ten people going to a general practitioner have anything physically wrong with them and that about 80 per cent of all ailments are self-limiting. So what are we all playing at?

Illness behaviour (adopting the sick role) is a very effective way of being relieved from social expectations, and is an excuse for failure, a way of obtaining privileges and sympathy, and so on. For those who have few social ties, poor support and feel isolated, the medical system is a well-recognized and comfortable way of obtaining at least some of these. Thirty or more years ago perceptive doctors realized that what their patients came to them for was often quite unimportant but what it did was to establish a relationship with the doctor who would then confirm them in the sickness role. Doctors need people like this to make them feel wanted so that they, the doctors, can live out their role as health-givers. Unfortunately, many doctors do not understand this role-playing and as a result go along with their patients’ endless demands for medical care. This results in numerous return visits, many if not most of which would be unnecessary if the patient’s real problems and motivations had been perceived and adequately dealt with by the doctor at the first consultation.

Just as certain people unconsciously retreat into the sickness role because it is a release from unpleasant or unacceptable situations, others sacrifice their health to ambition, expediency or the good of others. Young parents overwork in the full knowledge of what they are doing, sometimes also going without things ‘because of the children’ and so on. The health of general practitioners is perhaps a good example. British GPs have alarmingly high rates of alcoholism, drug abuse, broken marriages, coronary artery disease and suicide, yet they presumably know all the answers. To some extent at least, they are choosing to sacrifice their own health in favour of that of their patients.

But closely allied to all this illness and sickness behaviour is society’s concept of what is normal, and how it defines ill health. Mental illness for example, has been seen, at different times over the centuries, as demonic power, witchcraft and madness. The labels, the treatments and the social attitudes are all different and yet the ‘reality’ of the illness in question may well have been the same. Alcoholism is another example. When does social drinking become an illness? Sexual deviations and hypochondriasis or malingering are especially difficult to define yet somewhere along the line is a point beyond which sufferers could be said to be ‘ill’. Certainly fashions and fads are all-important when trying to define behaviour of any kind, let alone illness behaviour. Forty years ago oral sex was a ‘perversion’-today it is a fashionable pursuit that raises few eyebrows. Today we accept the fact that 30 per cent of the population has backache-it is ‘nor-mal’-and that thousands are killed on the roads every year. In developing countries parasitic diseases, infectious diseases, civil war or poverty may be similarly accepted as ‘normal’.

*12/72/5*

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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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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