Kitwood looked beyond the medical illness and concerned himself with the human experience of the condition. There are psychological and social influences on a person’s behavior and therefore psychological and social approaches which would promote their well being (Pace, Treloar & Scott, 2011). Pace, Treloar & Scott (2011) say that Kitwood argued that non-biological factors such as psychological and social factors had great influence on the person’s cognition and well-being.
In the movie “Away from her” the gradual dementia rips apart what seems to be a storybook marriage to Gordon Pinsent, a former college professor, in a gauzily nuanced turn. In the movie dementia offers a comparatively gentle journey into unconsciousness of the patient, a steady dissolution of memory and character. In the context of caregivers, the incident of dementia is different. The husband, on the other hand, watches as his wife disappears, stolen away piece by piece, before his eyes.
Dementia is at the core of all behavioral problems. Volicer & Hurley (2004) say that dementia causes the loss of nerve cells and other irreversible brain changes. This leads to the development of cognitive impairments, which include memory deficit, poor judgment and other impairments. Personality change may be the first symptom of dementia. It is important to note that patient’s personality may change for better or worse. In other cases, patients not only retain their per-morbid personality, but their personality characteristics are magnified by development of dementia (Volicer & Hurley, 2004).
Pathy, Sinclair & Morley (1999) say there is some evidence that premorbid personality traits are related to subsequent psychiatric symptoms. In their studies Pathy, Sinclair & Morley noted that patients who are more neurotic and less assertive before developing dementia are more likely to become depressed, while patients who are more hostile before developing dementia are more likely to have paranoid delusions (1999). In addition, Pathy, Sinclair & Morley (1999) noted that “patients who were neurotic and extroverted before developing dementia are more likely to engage in aggressive behavior while previous agreeableness decreases the probability of aggression” (p. 1137).
In the movie it can be observed that presence of functional impairment that interferes with daily activities is necessary for the diagnosis of dementia. According to Pathy, Sinclair & Morley (1999) functional impairment is a result of some deficit affecting both cognitive and physical functions. Dementia tends to increase self-centeredness and decrease flexibility. Patients are often described as having less personality than before the dementia; for example less outgoing, less assertive, less conscientious. Rodda, Boyce & Walker (2008) say that the most marked changes are decreased conscientiousness and extraversion and increased neuroticism. They argue that it is important to recognize that changes in personality may occur even before the onset of dementia.
Consequently, Rodda, Boyce & Walker (2008) indicated that in a patient with personality change, dementia is an important differential diagnosis. Also studies show that marked personality, affective and behavioral changes often precedes the development of a generalized dementia syndrome in frontotemporal dementia. Rodda, Boyce & Walker (2008) say that disinhibition can lead to socially inappropriate, reckless and impulsive behavior. As a result, a diagnosis of mood, psychotic or personality disorder may be given before the presence of frontotemporal dementia is recognized. There may be an increase or decrease in the intensity of personality disorder in dementia or the dementia may neutralize the personality disorder. Individuals with dementia, who have impaired attention span and cognitive processing, may not recognize complex cues.
Kitwood claims that the use of biography shouldbe an integral part of care planning in working with people who have dementia. Keady, Clarke & Adams (2003) established that biography provides care workers with more multi-dimensional perspective of individuals that would assist them in seeing beyond the disease a person who has had a meaningful life experiences, roles and talents.
Knowing about and valuing a person’s information can contribute towards an improvement in the way in which those around would perceive an individual with dementia. Keady, Clarke & Adams (2003) say that “many people with dementia are defined or limited by expectations related to their diagnosis of dementia” (p. 115). Using life story approach would not only serve to provide a multi-dimensional view of that individual, but it might also inspire care workers to recognize that there is an innate value in the ongoing experience of the person with dementia.
According to Keady, Clarke & Adams (2003), sensitive life story work provides a more therapeutic milieu for building a meaningful relationship between the person with dementia and those involved in his care and it might also explain some of the routines and responses otherwise deemed to be a manifestation of the dementing process. A person’s biography may also help in reinstating a person’s intrinsic value as a member of the personhood club rather than an unfortunate recipient of a disease that has rendered him helpless and hopeless.
Furthermore, Keady, Clarke & Adams (2003) claim that lifestyle profile is a constantly changing document and should never be seen as completed. However, a growing body of literature is arguing for the use of life story work to be considered an essential part of any care planning exercise for people with dementia across a range of formal care settings. It is clear that by the time the person with dementia requires such services his ability to contribute may already be hampered by several obstacles (Keady, Clarke & Adams, 2003). The earlier an individual profiling is carried out, the greater the contribution a person can make towards development of his own care planning needs (Keady, Clarke & Adams, 2003). This process places the person with dementia at the center of the care process, proactively engaged in negotiation of all their central needs with those around them as opposed to being passive recipients of a neatly presented collection of photographs and memories that although attractive, offer little to assist in the recognition of their day to day values and needs.
Health status of an individual with dementia is explained in terms of his having the disease and therefore requiring no response other than symptom control. Biernacki (2007) says that from the diagnosis the person with the disease becomes a fully fledged victim of it, having no ability to control or influence the course or outcome of his dementia and dependent on others to control his lives for him. In his studies, Biernacki (2007) indicated that the medieval interpretation of dementia is that everything that happens to the patient, the losses, changes in behavior and emotional expression is caused by the damage of brain dementia brings.
Health status should focus on the individuality of the person with dementia, not the diagnosis of dementia, and give recognition to the influences that his past history may have on his response to the lived experience of dementia (Keady, Clarke & Adams, 2003). The health status of a dementia patient should have a complete picture as possible of the past and present functioning, hopes and dreams, desires, ambitions and coping strategies. Biernacki (2007) says that there have been some adverse consequences of thinking of dementia as the illness, the main one being that the medicalization of dementia has resulted in the medicalization of an individual with it and a narrowing of the focus of approach to both the disease and the individual, where uncovering pathology, seeking the cause, treating symptoms and striving for a cure are the only goals.
Aneshensel (1995) says that before considering the influence of institutionalization, it is important to take into account other factors that contribute to mortality, especially the impact of health status and age. Three indicators of the underlying dementia are included as explanatory factors, presence of a specific diagnosis of AD, early age of onset and severity of cognitive impairment. Aneshensel (1995)pointed that two indicators of poor physical health include perceived physical health status and recent hospitalization. Patient age and gender are also taken to account for aging effects and male-female differences in life expectancy.
In addition, Aneshensel (1995) noted that the risk of dying depends mainly upon most of these health-related factors. There are three dementia-related variables and each contributes independently to mortality, but two of these relationships are counterintuitive. Aneshensel (1995) noted that the risk of death at any given point since illness onset, given that one has not already died, is lower for care recipients who have received a specific diagnosis and for those with early onset. The risk of mortality becomes greater as the severity of cognitive impairment intensifies, physical health status worsens and the patient ages. Aneshensel (1995) says that caregivers who institutionalize their relatives are about twice likely to become bereaved than those whose relative continues to live at home, even when patient status is controlled.
Neurological impairments associated with dementia affects memory function, the ability to use and understand spoken and written language, the ability to carry out practical everyday tasks (Brooker, 2007). Neurological impairment also affects the ability to perceive the world as others and to plan course of actions so as to see things from people’s viewpoint. These impairments are quite subtle and easy to misunderstand at first, but become more obvious as the dementia progressive over time.
Dementia is marked by cognitive impairments, specifically of episodic memory and including other domains such as attention, executive function, language and praxis. Papathanasiou, Coppens & Potagas (2011) say that administering mini mental state examination can be used to perform tasks designed to test orientation, memory, verbal fluency and visual spatial skills. Also dementia can result from large vessel disease by large territory cortical infracts or strategically located infracts and small vessel disease, dementia often stems from lacunar infracts (Papathanasiou, Coppens & Potagas, 2011).
Radiological lesions associated with dementia include bilateral anterior cerebral artery territory, posterior cerebral artery territory, including paramedian thalamic infarctions and inferior medial temporal lobe lesions. Papathanasiou, Coppens & Potagas (2011) claim that the second part associated with dementia includes cortical association areas, including parietal temporal regions, temporal-occipital regions and angular gyrus; also the watershed carotid territories in the superior frontal and parietal regions are associated with dementia.
Valk, Barkhof & Scheltens (2002) noted that “cortical lesions and U-fiber involvement are frequent MR findings in MS and such lesions are likely to have an effect on cognitive function” (p. 234). Cortical and juxtacortical lesions may be more conspicuous on FLAIR images. Other MRI correlates of dementia in MS include ventricular enlargement, atrophy of the corpus callosum and less commonly cortical atrophy. McLean (2007) says that dementia affects cognition and is associated with memory impairments. People tend to experience problems with cognitive abilities. The first possible sign of dementia is difficulty with short-term memory. Affected persons may also have difficulty recalling material they previously knew well and may be impaired in their ability to learn new things.
Being aware of the manifestation of these neurological impairments is a key element of good dementia care in enabling care workers to respond appropriately. Brooker (2007) says that the aim is to find a response that supports the person with dementia while not undermining their remaining abilities. Brooker (2007) says that common cognitive impairments in dementia, such as poor learning of new information, dysphasia, dyspraxia and visual-perceptual deficits, mean that people with dementia will interpret their social and physical environments in a unique way. If these interpretations of the environment are not understood and compensated for then the person with dementia will experience excess disability.
Social psychology is the common and psychosomatic environment in which people with dementia fins themselves. Primarily it is about the relationship between people (Brooker, 2007). Kitwood’s view of person centered care for people with dementia was that it took place in the context of relationships. As individual’s verbal abilities are lost, the importance of warm, accepting human contact through non-verbal channels becomes even more important than before.
Studies show that social psychology of residential homes is enough to drive people demented (Biernacki, 2007). In effect, the conclusion is that the psychosocial environment that has been created to care for people with dementia by the process of dehumanizing the individual and relating to the individual in a way that detracts from their personhood has the consequence of exacerbating the dementing process.
Keady, Clarke & Adams (2003) argue that once a person begins to experience memory loss, a whole sequence of events would take place that, in turn, serves to undermine, demoralize and ultimately leads to exclusion. This exclusion is experienced in the person’s immediate social milieu and also in the day to day decision making about their needs and desires. When social psychology occurs in formal care settings, such as hospitals, day centers and care homes it is influenced not only by professionals but also society at large. Keady, Clarke & Adams (2003) say that depersonalizing impact of malignant social psychology is already well established long before a person with dementia is admitted into a formal care setting.
Studies indicate that large proportion of people with dementia will never enter any form of institutional care, but that the majority of published work outlining person centered care has been aimed at care workers in secondary care settings. Keady, Clarke & Adams (2003) noted that this aspect leaves a huge gap in knowledge among those working in primary care, especially if there has been inadequate development work exploring the relevance and impact of person centered approaches. People with dementia tend to be given information about symptoms of the diseases along with an explanation that these are simply a part of the ageing process (Keady, Clarke & Adams, 2003).
Whilst there may be a number of non-malign reasons for this disparity, not least the wish to protect the person with dementia from loss of hope, it has also been argued that people with dementia need firstly time to explore the meaning and impact of their diagnosis and support of friends or relatives during early discussion of the person. Secondly, demented people need the provision of right information at an appropriate time and in an accessible format for both persons with dementia and family members (Keady, Clarke & Adams, 2003). Social psychology demands the recognition that people with dementia need to have the expression of emotional distress validated as well as maintaining the possibility of hope for their future (Keady, Clarke & Adams, 2003).
With the onset of dementia individuals are very vulnerable to their psychological defenses being radically attacked and broken down. Brooker (2007) says that as the sense of self breaks down, it becomes increasingly important that it is held within the relationships that the person with dementia experiences. These relationships cannot be developed through the traditional therapy hour as in person-centered psychotherapy.
Evaluate the Impact of Intervention
As a result of the inevitable progression of dementia, nonmedical interventions are focused on promoting the client’s safety, comfort and productivity for as long as possible helping the family or other caregivers to be capable of managing stress that often accompanies their role (Corcoran & Walsh, 2010). The majority of psychosocial interventions are widely accepted by professional caregivers as effective. Psychosocial interventions include communication and Montessori based interventions. Montessori based interventions were developed to generate structured, stimulating environments for patients with dementia. They therefore play an important role in reducing the impact of dementia.
Corcoran & Walsh (2010) say that many dementia patients cannot tolerate the drug because of the side effects and only 30% of consumers experience its perceived benefits. Other types of medication may be effective for treating the symptoms of psychosis, agitation and depression in persons with dementia. It should be noted that all psychotropic medications are prescribed in lower doses for elderly clients than for other age groups because of their slower metabolism and rates of clearance through kidneys (Corcoran & Walsh, 2010).
Describe Intervention and Impact of Dementia
At minimum, interventions for individuals with dementia should be based on theory and evidence and should be tailored to individual needs. Also Jones & Miesen (2003) noted that ensuring effective SLP interventions for individuals with degenerative dementia requires a clinical focus beyond the progressively worsening impairment in cognition, which is defining characteristic of most common types of dementia. Corcoran & Walsh (2010) argues that antidepressant drugs play an important role in reducing the effect of dementia because they are used for the symptoms of depression and agitation often experienced by dementia clients.
Analysis Content of Intervention
Any intervention aimed at improving opportunities for social conversation must be paired with the use of effective communication strategies (Jones & Miesen, 2003). The commonly recommended strategies are those that compensate for cognitive impairments through linguistic modifications such as slowing speech rate, simplifying syntax and limiting the number of propositions. Jones & Miesen (2003) researched that “Montessori based intervention plays a fundamental role in dementia because it promotes learning through procedural memory processes, utilizes concrete everyday stimuli to facilitate action and memory and reduces demands on episodic and working memory by using structured tasks and repetition” (p. 413)
Studies indicate that it is important to maintain communication with the dementing elderly people as they reach the final stages (Jones & Miesen, 2003). This decreases their own frustration and feelings of discomfort and impotence. According to Jones & Miesen (2003), through connecting with certain preserved senses, care givers let the severely demented elderly people express their emotions. Communications affect care-givers’ attitudes positively and guarantee a way of responding to the needs and feelings of the patient. Jones & Miesen (2003) say that in this way the patient and the care giver can continue to communicate or meet non-verbally late in the course of dementia.
In synthesis intervention, ten people with dementia and their caregivers participated in a trial which started in 2010. An already established ten day memory retraining and activity program was delivered to people with dementia.Marshall (2005) says that the caregivers were randomized to receive intensive residential training. The two year survival analysis indicated that the people whose caregivers received training stayed at home longer rather than being admitted to institutional care and tended to live longer. A further study involved a meta-analysis of 30 studies of interventions with caregivers of people with dementia. The conclusion drawn from this synthesis was that some interventions could reduce stress experienced by caregivers and help them to continue caring dementia persons for longer periods.
Intervention Supports Person-Centered Care
The above interventions have taken into account quality of life of the individuals involved in its widest sense. Marshall (2005) says that the interventions support person centered care because they adopt strategies appropriate to the level of impairment. For people with mild to moderate difficulties, there may well be a benefit in adopting an intervention approach grounded in restoration of physical function and maintenance of cognitive abilities (Marshall, 2005). The interventions support person-centered care because they focus on providing a safe environment that promotes the quality of life of the individual and maintains their sense of person, both for themselves and the people caring for them.
Intervention Relates Policy and Practice
The translation of intervention policy into action is taking place at a rapid rate. Marshall (2005) says that the policy and practice applied in these interventions have confirmed that people with dementia can benefit from hospital led rehabilitations as well as from rehabilitation delivered under the auspices of social care. The psychosocial interventions relate to policy and practice because they allow people with dementia to be included in new ways of thinking and consequent service developments rather than being marginalized (Marshall, 2005).
The policy now emphasizes a shift from service-led to needs-led assessment and care provision. Marshall (2005) argues that the policies and practices applied in these types of interventions have confirmed the importance of adopting an open mind regarding what might be achieved with people with a diagnosis of dementia. The interventions related to policy and practice because they take into account the new avenues that technology and alternative forms of interventions are opening up.