# data[].attributes.body
Timeline

Identity/ symptoms

Consequences

Cause

Control and Cure

# data[].attributes.headline
Social Comparison / Response Shift (Gibbons, 1999)

# data[].attributes.subject
Social Comparison / Response Shift (Gibbons, 1999)

# data[].attributes.body
information and advice on the adaption and adjustments.

# data[].attributes.body
Memory Loss

Life with Alzheimers can become very stressful for an individual, specifically the effect of memory loss which becomes worse and time goes on. Adapting to this is best done with the help of a professional carer for support and reassurance.

Remaining Independent

Many people want to remain independent by staying in their homes for as long as possible. This may require adaptions to their home such the addition of certain equipment or assistive technology which aims to make life easier whilst promoting autonomy.

Legal and Financial

After diagnosis, individuals may want to organise their finances in a way that will remain organised. Individuals may also be interested in claiming the financial benefits and assistance they are legally entitled to.

# data[].attributes.body
What are the key features of Alzheimers?

Alzheimer’s disease is a “progressive mental deterioration that can occur in middle or old age, due to generalised degeneration of the brain” and is the leading cause of dementia.

There are currently over 525,000 people diagnosed with Alzheimers in the UK.

Diagnosis is difficult in early stages as symptoms are mild to begin with and differ greatly; two people with Alzheimers are unlikely to experience the disease in the same way.

What are the main effects of Alzheimers on the individual?

In it’s simplest form, Alzheimers affects the individual’s memory due to damage to the hippocampus. In its early stages Alzheimers will only affect short-term memory but long-term memories of family members and life events may be unable to be recalled in later stages.

Alzheimers also affects the individual’s ability to verbally communicate, their visuospatial skills, orientation and ability to concentrate, plan or organise, making many day to day tasks very difficult.

During the course of the disease, proteins build up in the brain to form structures called 'plaques' and 'tangles'. This leads to the loss of connections between nerve cells, and eventually to the death of nerve cells and loss of brain tissue.

People with Alzheimer's also have a shortage of some important chemicals (such as choline which helps to maintain cell membranes) in their brain. These chemical messengers help to transmit signals around the brain. When there is a shortage of them, the signals are not transmitted as effectively.

# data[].attributes.body
What is a chronic illness?

Chronic illnesses are “long-term medical conditions that are generally progressive” “for which there is currently no cure” such as heart disease, diabetes, stroke and chronic respiratory problems.

What is the prevalence of chronic illness in the UK?

About 15 million people in the UK (23% of the population) have a long-term condition. This graph shows the distribution of people with one or more chronic illnesses by age showing that elderly people are most vulnerable (58% of people over 60 compared to 14% under 40).

Which chronic illnesses are the most prevalent in the UK?

Hypertension, Asthma, Diabetes and Coronary heart disease are some of the most prevalent chronic illnesses in the UK. However, chronic depression is projected to become the most common long-term condition in the UK.

# data[].attributes.attachment_link.description
Alzheimer's disease is the most common cause of dementia. Learn about the symptoms, how it is diagnosed, and factors that can put someone at risk of developing it. We also look at treatments and support currently available for the condition.

# data[].attributes.body
Dementia Friends

# data[].attributes.body
Biological interventions

# data[].attributes.attachment_link.title
Latest Medication for Memory Loss | Alzheimer's Association

# data[].attributes.attachment_link.description
Learn about drugs for Alzheimer's and dementia memory loss, how cholinesterase inhibitor medications Exelon, Namenda, Cognex, Razadyne and Aricept work and treatments on the horizon.

# data[].attributes.body
Psychosocial interventions

# data[].attributes.attachment_link.readable_text
Introduction

Psychiatrists who treat patients with Alzheimer's disease (AD) should be aware of recent research on the nonpharmacological as well as pharmacological interventions that may help these patients. Current treatment guidelines uniformly stress, for example, that clinicians use nonpharmacological interventions prior to using medication for behavioral symptoms.

There are obvious reasons. The benefits from medications may, for instance, be limited and may pose serious risks. If, for example, these patients are highly agitated, atypical antipsychotics may be helpful, but they also may increase these patients' risk of death.

Psychosocial interventions may be particularly efficacious for agitation and other behavioral symptoms, because even when these patients have become cognitively impaired, they may remain remarkably responsive to interactions with other people. Patients with AD who are agitated may respond, for example, not only to others when they interact with them personally, but also may respond beneficially to videotapes or audiotapes of others whom they know. AD patients may also respond to music, though the music should be selected on an individualized basis because some AD patients may respond best to music for which they have acquired positive associations from earlier in their lives.

Similarly, AD patients may respond exceptionally well to social activities specially structured to meet their individual capacities and needs. A representative example recently developed is a group reading program that uses a Montessori approach. These reading materials are simplified and specifically tailored to AD patients' capacities. Their readings are also about age-appropriate topics (e.g., the dancer, Gene Kelly). Patients with milder illness are, at the same time, trained to lead these reading groups, comprising patients with AD who are more severely ill.

On a more general level, these patients may retain substantial capacity to learn implicitly or indirectly from cues that are incidental, as opposed to direct. AD patients may not be able to state explicitly what they have learned, but they may learn and acquire new skills nonetheless. These skills may involve, for instance, an AD patient responding "appropriately" to others when he or she doesn't understand what they are saying. If a patient can do this, he or she may enjoy interacting with others more.

An AD patient may, with this kind of training, even acquire the ability to respond safely during emergencies, such as those that can occur if he or she is alone in the house. This skill, acquired through repeated role-playing, may allow a patient to live alone longer in his or her own home, as opposed to needing to enter an institution at an earlier time for his or her safety.

Since AD patients may remain responsive to even subtle emotional cues, when an AD patient's behavior deteriorates, the psychiatrist should be cautious in assuming that this deterioration is due to an irreversible progression of his or her AD. This deterioration may instead be functionally caused and reversible. This deterioration may result from the patient having perceived a new cognitive loss that he or she cannot articulate. The psychiatrist may be successful in reversing this source of deterioration by providing the patient with emotional support.

Helping Caregivers of AD Patients

The people who interact most with AD patients are their primary caregivers and/or the patients' spouses. The degree to which psychiatrists can help the caregivers interact more effectively with their AD patients may not only benefit the caregivers but the AD patients as well.

Psychiatrists should inform the caregivers that, in general, they should try to not be negative or confrontational, but that this may be difficult at times. One caregiver reported, for instance, that it was easier to suppress all negative responses, as opposed to only some.

Psychiatrists should give caregivers supportive information and ongoing feedback whenever they believe this may be helpful. This information may include, for example, suggestions for caring for AD patients, such as providing the patients with clothing that has elastic waistbands, sweaters with zippers instead of buttons, and shoes with Velcro, or hanging arrows in the house that point toward toilets and installing brightly colored toilet seats. Feedback may include more sophisticated interventions, such as suggesting that the caregivers use nouns rather than pronouns whenever they speak to their AD patients.

Most importantly, however, psychiatrists should teach caregivers to observe their AD patients' responses closely so that they can discover changes they can make on their own. For example, a caregiver may observe that when she raises her voice, it has a negative effect on her AD patient. So, she may find that, as is often the case with children, if her AD patient becomes upset, she can diffuse a potentially hostile situation by responding in a more soft-spoken manner.

Psychiatrists' Relationships with AD Patients

Psychiatrists can have profound interpersonal effects on their AD patients. For example, an AD patient who has a positive relationship with his or her psychiatrist and who is refusing optimal care by the primary physician may be influenced by the psychiatrist to accept a treatment that he or she dislikes or does not understand. The positive relationship with the psychiatrist may be the only factor that influences the patient to accept the treatment.

Psychiatrists, accordingly, should remain attentive to countertransference feelings and thoughts. This is particularly important because these patients may evoke nihilistic emotions. If this occurs, even though these patients are cognitively impaired, they still may be able to fully detect psychiatrists' despair. Psychiatrists should also remain attentive to adverse responses they may inadvertently evoke in these patients. For example, one patient with AD refused to continue seeing her psychiatrist because he tested her "too much, too often" for impaired memory. She found this too painful. Psychiatrists who feel they must continue to do this testing to give optimal care face a dilemma. Still, they cannot treat a patient who refuses to see them!

Psychiatrists may, on the other hand, enhance their relationships with these patients and perhaps enhance these patients' self esteem by taking care to respond to capacities within these patients that remain essentially intact. A psychiatrist can, for example, ask his patient how she feels her caregiver is doing. Regardless of how she responds, a psychiatrist merely asking this question connotes a continued respect for the patient's point of view. In addition, a patient may see changes in his or her caregiver's behavior better than the caregiver does. Thus, the patient's answers may benefit the caregiver, which in turn and in time may also benefit the patient.

Psychiatrists, likewise, may enhance their relationships and benefits to AD patients by continuing to share humor with them. I recall, for example, leaving my notebook in another room. The patient and I joked that maybe it was I who had the memory problem!

A Case Example

The general guidelines I have discussed here may be particularly helpful when psychiatrists face crises with these patients and aren't sure what they should do. An example of how these guidelines helped me occurred in the following case:

I had been seeing a patient with AD and his wife for several years. He came in one day feeling enraged. He was convinced his wife had stolen his money. He told her that he felt like killing her. She felt angry also, but more than this, she felt afraid. He was clearly paranoid and delusional, and he was wholly opposed to taking any antipsychotic medication.

I found myself imagining, nihilistically, when I first saw them, that the time may have come that I could no longer treat him at home with his wife as his primary caregiver. I thought that I might have to involuntarily hospitalize him, but otherwise I had no idea what to do.

I started by asking him how he thought his wife was doing. She was angry, he said. I said that I agreed. She looked really angry. I told him that I thought this was because she loved him and was really scared.

His wife had been repeatedly speaking to him using logic and in an angry tone. Thus, I asked her what she hoped to achieve by talking to him in this way. She understood immediately and then softened her tone and manner.

Somehow, during this session, they reacquired closeness and, in fact, left my office hand in hand. His wife called me later, thanking me for "this miracle." A greater miracle for me is that they have sustained this intimacy since that time.

I don't know exactly what it was that happened. The patient reported later the only thing he remembered from that session was that I asked him if I could help and that he answered, unequivocally, "No." He laughed as he recalled this. Maybe the good outcome occurred because I responded to a part of him that was intact; for example, he was still quite able to observe how his wife was behaving and to report this. It may be also that my feedback to his wife interrupted and altered the destructive, vicious cycle they were in.

Recent research suggests that AD patients retain a need for an intact self identity, especially within their families, throughout this illness. AD patients who maintain their family roles may be "dependent on interactions with others that allow identity to be expressed." These "others" may include the psychiatrist, as well as the caregiver.

This example illustrates how responding to the "healthy parts" of the AD patient and helping his or her caregiver respond more appropriately may help the patient not only in the long run, but in the short run when the psychiatrist is in doubt about what step to take.

In sum, nonpharmacological interventions may help these patients greatly, in large part because the patients tend to remain responsive to interpersonal cues. Accordingly, psychiatrists should explore ways in which AD patients, though cognitively impaired, can still learn. The psychiatrist should also explore with caregivers ways in which they, the caregivers, can be more interpersonally effective.

Finally, psychiatrists should pay close attention to their own feelings and try to avoid those that are nihilistic. A psychiatrist's positive regard may affect a patient significantly, even when nothing else will.

References

3. Boustani M, Sachs G, Callahan C. Can primary care meet the biopsychosocial needs of older adults with dementia? J Gen Intern Med. 2007;22:1625-1627. [ PMC free article]

11. Runci SJ, Redman JR, O'Connor DW. Language-relevant interventions for verbally disruptive behaviors in dementia. Int Psychogeriatr. 2006:181-184.

15. Tondi L, Ribani L, Bottazzi M. Validation therapy (VT) in nursing home: A case-control study. Arch Gerontol Geriatr. 2007;(Suppl 1):407-411.

# data[].attributes.attachment_link.title
Key Psychosocial Interventions for Alzheimer's Disease: An Update

# data[].attributes.attachment_link.description
Psychiatrists who treat patients with Alzheimer's disease (AD) should be aware of recent research on the nonpharmacological as well as pharmacological interventions that may help these patients. Current treatment guidelines uniformly stress, for example, that clinicians use nonpharmacological interventions prior to using medication for behavioral symptoms. There are obvious reasons.

# data[].attributes.body
Non-Drug interventions

# data[].attributes.attachment_link.authors[].name
Institute for Quality and Efficiency in Health Care (IQWiG, Germany)

# data[].attributes.attachment_link.title
Non-drug interventions for Alzheimer's disease - Alzheimer's disease - informedhealth.org

# data[].attributes.attachment_link.description
Non-drug interventions for Alzheimer's disease include memory training, mental and social stimulation, and physical exercise programs.

# data[].attributes.attachment_link.description
Alzheimer's disease is the most common cause of dementia. Dementia is a group of symptoms associated with a decline in the way your brain functions, affecting your memory and the way you behave.

# data[].attributes.attachment_link.description
Alzheimer's disease is the most common cause of dementia. Learn about the symptoms, how it is diagnosed, and factors that can put someone at risk of developing it. We also look at treatments and support currently available for the condition.

# data[].attributes.attachment_link.readable_text
About 15 million people in England have a long-term condition (1). Long-term conditions or chronic diseases are conditions for which there is currently no cure, and which are managed with drugs and other treatment, for example: diabetes, chronic obstructive pulmonary disease, arthritis and hypertension.

Long-term conditions

Long-term conditions are more prevalent in older people (58 per cent of people over 60 compared to 14 per cent under 40) and in more deprived groups (people in the poorest social class have a 60 per cent higher prevalence than those in the richest social class and 30 per cent more severity of disease) (1).

People with long-term conditions now account for about 50 per cent of all GP appointments, 64 per cent of all outpatient appointments and over 70 per cent of all inpatient bed days.

Treatment and care for people with long-term conditions is estimated to take up around £7 in every £10 of total health and social care expenditure (1).

Projections for the future of long-term conditions are not straightforward. The Department of Health (based on self-reported health) estimates that the overall number of people with at least one long-term condition may remain relatively stable until 2018. However, analysis of individual conditions suggests that the numbers are growing, and the number of people with multiple long-term conditions appears to be rising (1).

Most individual long-term conditions are more common in people from lower socio-economic groups, and are usually more severe even in conditions where prevalence is lower - for example, stroke. General Household Survey data (2006), analysed by the Department of Health below, shows those from unskilled occupations (52 per cent) suffer from long-term conditions more than groups from professional occupations (33 per cent).

Key: I Professional, etc, occupations, II Managerial and technical occupations, III Skilled occupations, (N) Non-manual, (M) Manual, IV Partly skilled occupations, V Unskilled occupations.

Source: Department of Health analysis of General Household Survey 2006

Some people living in a deprived area will have multiple health problems 10-15 years earlier than people in affluent areas.

The number of people with three or more long-term conditions is predicted to rise from 1.9 million in 2008 to 2.9 million in 2018 (1).

The ageing population and increased prevalence of long-term conditions have a significant impact on health and social care and may require £5 billion additional expenditure by 2018 (1).

Multi-morbidity is more common among deprived populations - especially those that includes a mental health problem (2) - and there is evidence that the number of conditions can be a greater determinant of a patient's use of health service resources than the specific diseases (3).

There will be rising demand for the prevention and management of multi-morbidity rather than of single diseases (2).

Patterns of selected co-morbities between most affluent and most deprived deciles

Source: Barnett K, Mercer SW, Norbury M, Watt G, Wyke S and Guthrie B (2012). Research paper. Epidemiology of multi-morbidity and implications for health care, research and medical education: a cross-sectional study The Lancet online
Next page: Care demands and dementia

References

1. Department of Health (2012). Report. Long-term conditions compendium of Information: 3rd edition

2. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B (2012). Research paper. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study The Lancet online

3. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S and Guthrie B (2012). Research paper. Epidemiology of multi- morbidity and implications for health care, research and medical education: a cross- sectional study The Lancet online

# data[].attributes.attachment_link.description
About 15 million people in England have a long-term condition (1). Long-term conditions or chronic diseases are conditions for which there is currently no cure, and which are managed with drugs and other treatment, for example: diabetes, chronic obstructive pulmonary disease, arthritis and hypertension.