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The Health Belief Model (Champion, 1999) is an updated version of the original model from Rosenstock et al (1994). The HBM is a health specific social cognition model that was initially introduced with four main concepts: susceptibility, perceived seriousness/severity, perceived benefits, and perceived barriers (Champion, 1999). A further three additional concepts were later added to the Model: cues to action, general health and confidence (self-efficacy). These later additions were added to address criticisms that:

1)   Health behaviours are not always rational

2)   The model only focused on the individual and ignores social/environmental factors

3)   The role of emotional factors was not considered

4)   Outcome expectancy and self-efficacy were not considered

According to the HBM, a health-promoting behaviour is more likely to occur if the individual feels threatened by her/his current behavioural patterns through perceived susceptibility and severity, and believes that a specific behavioural change will result in a valued outcome at acceptable cost where perceived benefits outweigh perceived barriers. Moreover, an internal or external stimulus to change behaviours (cues to action), desire to achieve an outcome (general health motivation), and confidence in being able to perform the desired behaviours (self-efficacy) are needed (Glanz et al, 2008).

Evaluation of the Health Belief Model:
The model has the potential to provide a comprehensive understanding of the influence of social, economic and environmental factors on health behaviours. However, when in use the HBM is primarily focused on the measurements of susceptibility and severity alone (e.g. Chen & Land, 1990)

In a study carried out by Yarbrough & Braden (2001) they used the HBA as a guide for predicting breast cancer screening behaviours. They concluded that the application of the model was inconsistent and that it explained a maximum of 47% of observed variance in screening behaviour when socio-economic status was included. Otherwise the predictive power was even lower.

Further, although the HBM may be used to derive information that may then prompt interventions designed to change health beliefs and behaviours, using the model itself cannot inform decision making as to how the interventions should be structured.

Champion, V. L. (1999). Revised susceptibility, benefits, and barriers scale for mammography screening. Research in nursing & health, 22(4), 341-348.

Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2008). Health behavior and health education: theory, research, and practice. John Wiley & Sons.

Yarbrough, S. S., & Braden, C. J. (2001). Utility of health belief model as a guide for explaining or predicting breast cancer screening behaviours. Journal of advanced nursing, 33(5), 677-688.

Chen, M. S., & Land, K. C. (1990). Socioeconomic status (SES) and the Health Belief Model: LISREL analysis of unidimensional versus multidimensional formulations. Journal of Social Behavior and Personality, 5(5), 263.

Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1994). The health belief model and HIV risk behavior change. In Preventing AIDS (pp. 5-24). Springer, Boston, MA.

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Alzheimer's disease is a neurodegenerative disease which progressively affects an individual's memory and cognitive functioning.

Women have been found to have a higher risk of the condition than men (500,000 vs 350,000). Recent evidence has suggested this may be due to higher brain connectivity levels and sex-specific genes.

nhs.uk. 2020. The NHS Website. [online] Available at: <https://www.nhs.uk/> Alzheimer's Disease and Dementia. 2016. Home. [online] Available at: <https://alz.org/>

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Adjustment to Diagnosis/ Self Management 

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Adjustment to Diagnosis/ Self Management 

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-Knowing the diagnosis: Many individuals report that once they educated themselves about the biology behind the disease it helped them come to terms with it

-Normalization: Many individuals normalize the disease, for example viewing it as a normal part of ageing to help them accept the diagnosis

-External memory aids: such as diaries, calendars and notes around the house

-Routine: Individuals in the early stages of Alzheimer’s disease create a routine for themselves to make the disease more predictable and manageable

-Medication: Many individuals have reported that medication such as anti-dementia drugs had helped them to feel as though their condition was stable. The medication may make individuals feel as though they are somewhat in control of the disease, however often individuals with Alzheimer's disease require reminders from caregivers of when to take their medication.
Park, M., Sung, M., Kim, S. K., Kim, S., & Lee, D. Y. (2015). Multidimensional determinants of family caregiver burden in Alzheimer's disease. International Psychogeriatrics, 27(8), 1355-1364.

Martin et al (2012) suggested 5 Self Management Techniques, however they do come with challenges.

1.Relationship with Carer/Family: Carer should encourage people with dementia to self manage and they should do activities together as acouple. However, care roles may not always be clear.

2.Maintaining an active lifestyle: People with Alzheimer’s want to be able to take basic care of themselves. Elderly people are not encouraged to stay active and often do not have access to activities

3.Psychological Wellbeing: Increasing security, self-efficacy and self-esteem. Some have more difficulties than others with this and many may be in denial or completely give up on themselves

4.Memory Techniques: Memory techniques are not routinely taught

5.Information: Being informed about their disease and what outcome to expect. Often individuals may not take on board the information of their illness due to memory issues or denial
Martin, F., Turner, A., Wallace, L. M., & Bradbury, N. (2012). Conceptualisation of self-management intervention for people with early stage dementia. European journal of ageing, 10(2), 75–87.

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Lee et al, 2014) discovered that individuals reacted in a multitude of ways and in no particular order:

-Acceptance: Many participants accepted that Alzheimer’s disease was just another challenge in life or just a part of ageing to help them accommodate to the condition

-Consequence of life changes: Many participants made statements such as ‘its probably from all the head injuries from when I played rugby’ or ‘I knew it was coming, my mother had it’

-Uncertainty: Some individuals did not have a good understanding of what Alzheimer’s disease was or what was happening to them

-Loss: All participants experienced feelings of loss with regards to their loss of cognitive abilities or loss of self

-Frustration: All participants reported feeling frustrated upon diagnosis and frustrated that they could not recall specific memories

-Denial: Many individuals experienced denial upon diagnosis, attributing their memory loss to a normal part of ageing
Cheng, S. T., Chow, P. K., Song, Y. Q., Edwin, C. S., Chan, A. C., Lee, T. M., & Lam, J. H. (2014). Mental and physical activities delay cognitive decline in older persons with dementia. The American Journal of Geriatric Psychiatry, 22(1), 63-74.

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Physical Exercise
Strengths:

-Cost effective

-Proven to slow down cognitive decline and improves mood regulation (Panzaet al, 2018)

-Combining different types of exercise to improve strength, fitness and balance may help individuals to become more mobile and more able to carry out everyday activities independently

-Limitations

-Those who take part in exercise programs may be more prone to injury and hospitalization, as exercise can often be too much for someone of this age group

-Individuals with mobility issues may need someone to supervise them during their exercise making it a difficult intervention to implement on a large scale basis

-Exercise has been proven as a successful outlet for aggression and frustration (O’connor et al, 1999), however it does not directly solve the initial problem of why the individual is initially frustrated
Validation Therapy

Strengths

-Individuals feel valued and less of a burden

-Has been found to slow down the progression of cognitive decline and lower the risk of depression (Pinquart& Forstmeier, 2012)

-The individual is made to feel that their emotions and frustrations are valid

Limitations

-Could prove expensive

-Only as affective as the caregiver / therapist administering the therapy

-There is insufficient evidence from trials to draw any reliable conclusions about the effectiveness of validation therapy

-Much of the research focuses on caregiver wellness rather than the benefits that the therapy has on patients

-It has been found that validation therapy can agitate some individuals as much as it helped others, therefore results are often inconclusive and are dependent on personality types of the individual (Erdmann & Schnepp, 2016).

Multi-Sensory Stimulation Therapy
Strengths

-Has proven to enhance mood, cognitive functioning and alertness during sessions and at short term (Prettymanet al, 2004)

-Enables positive interactions between patient and caregiver Limitations

-Has not shown long term effectiveness in mood enhancement (Cornell, 2004)

- Is not cost effective

-Difficult to access for those not in care homes with a Multi Sensory Room

-Can be difficult to access for individuals living alone and not in an care home setting

Pinquart, M, Forstmeier, S. (2012) Effects of reminiscence interventions on psychosocial outcomes: A meta- analysis. Aging & Mental Health, Vol.16(5), p.541-558

Panza, G. A., Taylor, B. A., MacDonald, H. V., Johnson, B. T., Zaleski, A. L., Livingston, J., ... & Pescatello, L. S. (2018). Can exercise improve cognitive symptoms of Alzheimer's disease?. Journal of the American Geriatrics Society, 66(3), 487-495.

Phinney, A., Chaudhury, H., & O’connor, D. L. (2007). Doing as much as I can do: The meaning of activity for people with dementia. Aging and Mental Health, 11(4), 384-393.

Erdmann, A., & Schnepp, W. (2016). Conditions, components and outcomes of Integrative Validation Therapy in a long-term care facility for people with dementia. A qualitative evaluation study. Dementia, 15(5), 1184-1204.

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Little is known about how stress interacts with Alzheimer's disease, however many individuals claim that their Alzheimer's disease symptoms began shortly after a prolonged period of intense stress, however there hasn't yet been any research to support this.
Individual's with AD are likely to face prolonged stress which is understandable due to their mental and cognitive functioning declining. However, there are a number of Stress  management techniques that are suggested for these individuals. These include:

Meditation

Guided Imagery and Visualization

Hypnosis

Deep Breathing

Massage

https://alzheimersprevention.org/4-pillars-of-prevention/pillar-2-stress-management/

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When an individual is in the mid to later stages of Alzheimer's Disease they may begin to behave differently which can be distressing for the individual, as well as the caregiver/family members.
Common behaviour changes include

repeating the same behaviour or question

restlessness- wandering and fidgeting

Sleep disturbance

Following loved ones around everywhere

Loss of self-confidence

https://www.nhs.uk/conditions/dementia/behaviour/

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The Frustration - Aggression- Displacement Theory (Dollard et al, 1939)

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The Frustration - Aggression- Displacement Theory (Dollard et al, 1939)

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This theory states that frustration and aggression experienced by an individual is a result of being unable to attain a goal despite the individual's best efforts.

When individuals with Alzheimer’s disease become less independent, it can not only due to neurological decline, but also because of ‘excess disability’ rooted in stigma, a sense of loss of autonomy and confidence, and restricted beliefs of what they can do (Reiffel& Larson, 1990) People with dementia report challenges to creating a positive narrative around “life with dementia” as other people treat them in a condescending or overprotective manner

The opportunity for independence and participation is vital in decision making post-diagnosis (Katsuno, 2005). However, as the individual’s  decision making capacity may deteriorate over time, supporters can often become more involved in the acts of care and decision making processes (Livingstone & Boyd, 2010) by making choices regarding safety, practical tasks and the upkeep of health and social care.

Dollard, J., Doob, L., & Miller, N. (1939). Mowrer, 0., & Sears, R. Frustration and aggression.

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Very often, the reason that Alzheimer’s patients experience frustration due to the inability to carry out daily tasks that they used to be able to do with ease

The intervention that I am proposing is providing patient care but promoting independence among Alzheimer’s patients

This intervention is aimed at Alzheimer’s patients who require minimal-medium care

Some examples of this type of care would include:

The carer showing the individual how to carry out personal grooming and they then copy with guidance

Making a cup of tea or dinner with the patient rather than for them

It is expected that this intervention would decrease frustrations in sufferers because they will feel as if they’re capable of small tasks and will feel a sense of accomplishment. Further, helping the carer to carry out these tasks provides social stimulation and would be expected to make them feel less of a burden.

With this intervention, carers would receive training and a manual on promoting more independence for individuals with early to mid stages of Alzheimer’s disease

This intervention would work better than those discussed previously as it addresses why many individuals face frustration, which is often the inability to carry out daily activities

Rather than provide a short term outlet for frustration which is provided through exercise and sensory rooms, this intervention deals with the root cause of where the frustration begins

This intervention would be cost effective as it would just mean a newer more advanced training style for caregivers, it would also enable the caregivers to carry out other tasks whilst the individual is showing independence

Furthermore, the more care companies that take on board this independence promotion technique, the more large scale this can be, helping more individuals to feel less useless

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Biopsychosocial Aspects To Alzheimer's Disease

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Biopsychosocial Aspects To Alzheimer's Disease

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Biological:
- Change in sleeping pattern
-Change in appetite
Psychological:
- Hallucinations and delusions
-Mood instability
-Prone to anxiety and depression
-Lowered self esteem
-Stress
Social:
- Withdrawn from usual hobbies
-Withdrawn from friends and family
-More reliance on loved ones
-Feeling guilt towards loved ones
https://www.alzheimers.org.uk

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Little is known about the affect of AD on QoL over time, as studies have provided contradicting results. Lyketsos et al (2003) detected an overall decline in mean QoL scores at 2 years, although nearly half the QoL scores remained unchanged or were higher at follow up, suggesting QoL is preserved in some people with advanced dementia despite progression of the disease. However, Selwood et al (2005) found no difference in QoL scores in people with dementia at 1 year follow up, further suggesting that QoL does not necessarily decline over time and baseline QoL was the only predictor of future QoL.

Selwood, A., Thorgrimsen, L., & Orrell, M. (2005). Quality of life in dementia—a one‐year follow‐up study. International journal of geriatric psychiatry, 20(3), 232-237.

Lyketsos, C. G., Gonzales‐Salvador, T., Chin, J. J., Baker, A., Black, B., & Rabins, P. (2003). A follow‐up study of change in quality of life among persons with dementia residing in a long‐term care facility. International journal of geriatric psychiatry, 18(4), 275-281.

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Lee et al (2014) found the following self- management techniques for AD patients:

1)  Knowing the diagnosis
2) Normalisation (viewing it as a normal part of ageing etc.)
3)External memory aids (Diaries and Calendars)
4)  Routine
5) Medication (anti-dementia drugs have been shown to help individuals feel that they are somewhat in control)

Martin et al (2012) proposed the following self-managment techniques:

1) Relationship with Carer/Family
2) Maintaining an active lifestyle
3) Psychological-wellbeing
4) Memory Techniques
5) Information

As shown in the presentation, these two sets of self-management factors, challenges may arise. For example, both proposals state that when the individual is informed about their disease they're able to cope better, however due to the nature of the disease individuals may not take on board the information or simply forget. It's also a possibility that some individuals may be in denial.

Martin, F., Turner, A., Wallace, L. M., & Bradbury, N. (2012). Conceptualisation of self-management intervention for people with early stage dementia. European journal of ageing, 10(2), 75–87.

Park, M., Sung, M., Kim, S. K., Kim, S., & Lee, D. Y. (2015). Multidimensional determinants of family caregiver burden in Alzheimer's disease. International Psychogeriatrics, 27(8), 1355-1364.

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Two thirds of the cost of dementia is paid by people with dementia and their families. Unpaid carers supporting someone with dementia save the economy £11 billion a year.

Dementia research is desperately underfunded. For every person living with dementia, the annual cost to the UK economy is over £30,000 and yet only £90 is spent on dementia research each year.

https://www.alzheimers.org.uk

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The family members of an individual with AD may face many types of emotions including sadness, loneliness, anger, hope, sadness or depression. Family members may also face feelings of guilt when deciding whether to care for their relative or whether to look at other care options/homes (Mace & Rabins, 2011). Support groups are often useful in these situations as they can make individuals feel less alone.

A 2005 study found that almost 25% of family caregivers for Alzheimer's experienced anxiety and 10% experienced depression. The quality of the relationship between the caregiver and the sufferer was found to be a significant predictor for these negative emotions.

Mace, N. L., & Rabins, P. V. (2011). The 36-hour day: A family guide to caring for people who have Alzheimer disease, related dementias, and memory loss. JHU Press.

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Alzheimer's patients often have less control over their feelings and how they communicate them. For example, someone may be irritable, or prone to rapid mood changes

These changes are often difficult for carers to deal with. It can help if carers remember that they are partly caused by damage to the person's brain. Someone may react more emotionally to a situation than might be expected (eg by becoming tearful or agitated) because some of their factual memories or ability to think clearly about the situation have declined. It is important to look beyond the words or behaviours you can see to the feelings that the person might be trying to express. Strong emotions may also be caused by unmet needs. Carers should try to work out what these needs are and meet them where possible.Frustration is a common emotion that individuals with Alzheimer’s disease experience, and often on a daily basis. (Alzheimer’s Society, 2020)

Internal Environment: It can be extremely frustrating for a person with Alzheimer’s disease as they experience changes in both their physical and cognitive abilities. Feelings of loss of control is also thought to add to the frustration that they face.

Physical Environment: The physical environment can act as a contributing factor to a person’s emotional reactions. Clutter, overstimulation and poor sensory environment can often be confusing, adding to a person’s frustration

Psychosocial environment: The approach of caregivers can contribute to a person’s accumulating frustration. For example, expecting too much or too little of the individual

https://www.nhs.uk/conditions/alzheimers-disease/

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The Alzheimer Disease-related Quality of Life (ADRQL) (Black et al, 1999) scale was developed to assess quality of life in people with AD using assessments from family caregivers or professional staff. Validity and reliability of the ADRQL in its original were assessed in a sample consisting of 3 residential settings (community, assisted living, nursing home). The instrument evaluates five QOL domains: social interaction, awareness of self, feelings and mood, enjoyment of activities, response to surroundings and incorporates preferences that reflect caregiver judgments about the contribution of individual items to health-related QOL. The ADRQL was intended to discriminate differences in QOL among individuals with AD, as well as to being responsive to change over time.
A strength of this assessment is that it has the ability to examine performance in people with Alzheimer’s disease across three residential settings. Although, when the ADRQL was performed across all sub-samples, there were differences. These variations support the importance of a multi-dimensional approach to evaluating quality of life.
Use of the instrument as people change settings (e.g. move from community to assisted living) also has the potential to help evaluate the impact on well-being of changes in environment.

A factor that often interferes with this report method is lack of insight among family/ caregivers which is extremely prevalent and increases with dementia severity (Sabe et al, 1997). However, little is known about whether lack of insight affects patient reports in the same way.

Moreover, studies have found that mental health conditions such as depression may affect the reports of family/caregivers (Burgener & Twigg, 2002).

Therefore, further research is needed to address factors that may alter the validity and reliability of data provided by patients and caregivers.

Alzheimer’s Disease (QOL-AD) (Gibbons et al, 1999) is a 13- item scale that measures the domains of physical health, mood, memory, functional abilities, interpersonal relationships, financial situation, ability to take part in activities and QOL overall. A strength of this scale is that it relies on reports from patients and caregivers. However, some researchers criticise the measure for being vague as it takes into account memory and functional abilities.

Logsdon, R. G., Gibbons, L. E., McCurry, S. M., & Teri, L. (1999). Quality of life in Alzheimer's disease: patient and caregiver reports. Journal of Mental health and Aging, 5, 21-32.

Burgener, S., & Twigg, P. (2002). Relationships among caregiver factors and quality of life in care recipients with irreversible dementia. Alzheimer Disease & Associated Disorders, 16(2), 88-102.

Starkstein, S. E., Chemerinski, E., Sabe, L., & Kuzis, G. (1997). Prospective longitudinal study of depression and anosognosia in Alzheimer's disease. The British Journal of Psychiatry, 171, 47.

Kasper, J. D., Black, B. S., Shore, A. D., & Rabins, P. V. (2009). Evaluation of the validity and reliability of the Alzheimer Disease-related Quality of Life Assessment Instrument. Alzheimer disease and associated disorders, 23(3), 275–284.

Rabins, P. V., Kasper, J. D., Kleinman, L., Black, B. S., & Patrick, D. L. (1999). Concepts and methods in the development of the ADRQL: an instrument for assessing health-related quality of life in persons with Alzheimer's disease. Journal of Mental Health and Aging.

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There is no cure for Alzheimer's disease or any other type of dementia, however The Alzheimer's Society is committed to spending at least £150 million over the next decade on dementia research to improve care for people today and to eventually find a cure.
https://www.alzheimers.org.uk