Living with dementia yields a heteronomous and lost existence

The purpose of this study was to investigate the lived experience of dementia for spouses where one of them is diagnosed as having dementia. The study has been conducted using a phenomenological approach. Unstructured interviews were chosen in order to investigate the informants' lived experiences of dementia, both for the person with dementia and for his or her spouse. The essence of the phenomenon, the lived experience of dementia, is that the persons with dementia and their spouses live in a heteronomous existence in which they are lost and are strangers in their own world. The result of this is a life without coherence and a new but unknown meaning that can make them feel uncertain and puts them in a quandary. Whatever those with dementia and their spouses do, they have no real influence over their situation, which leads to feelings of awkwardness, perplexity, and futility.     

Alzheimer's cafe for people with and affected by dementia

Discussing emotional trauma is a central part of care in dementia and can help individuals value and make sense of their lives. The Alzheimer's cafe, started in 1997 in the Netherlands, can help facilitate this. This article reviews an adapted version of an Alzheimer's cafe focusing on eight couples where one partner was newly diagnosed with dementia. It is primarily a reflective account.     

Assessment of muscle strength and motor fatigue with a knee dynamometer in subjects with multiple sclerosis: a new fatigue index

OBJECTIVE: To measure muscle strength and motor fatigue with a knee dynamometer and to assess the intra-rater reliability of measurements for maximal isometric extensor and flexor torques and the reliability of a new fatigue index (FI) in patients with mild to moderate multiple sclerosis (MS). DESIGN: Repeated assessments with one-week intervals. SETTING: The Masku Neurological Rehabilitation Centre, Masku, and the Social Insurance Institution, Research Department, Turku, Finland. SUBJECTS: Twenty-eight MS patients. OUTCOME MEASURES: Maximal isometric torque during 5 s and fatigue of knee flexors and extensors during isometric contractions of 30 s were assessed. A new FI was established and compared with the two previously used indices (FI1 and FI2). All three indices are based on the calculated area under the force versus time curve (AUFC), with FI1 using the 30-s recording time in its entirety and F2 omitting the initial 5 s in the calculation. In the new fatigue index (FI3), the time point of maximum (TPM) torque achieved by the subject is used as the starting point in the calculation. The patient's subjective fatigue was measured by Fatigue Severity Scale (FSS). RESULTS: The intraclass correlation coefficient (ICC) was 0.97 in maximal isometric torque measurements. FI3 showed good intra-rater reliability (ICC =0.68-0.86). None of the fatigue indices correlated with FSS. CONCLUSIONS: Maximal isometric torque and motor fatigue of knee flexor and extensor muscles can be reliably measured using a knee dynamometer in MS patients. The new FI proved to be a reliable model for MS patients.     

Caring relationships with patients suffering from dementia--an interview study

The aim of the study reported in this paper was to describe and analyse care-givers' caring relationships with patients suffering from dementia. The theoretical perspective was caring science. Data were collected through interviews with six care-givers in a ward for patients with severe dementia. From the qualitative analysis of the narratives, the following factors emerged as important for the caring relationships: 'touching', mutual 'confirmation', and the care-givers' 'values in the caring culture' in the ward. We conclude that communication skills are very important in a ward where patients with severe dementia reside, and that there is always a need for formulating the basic values. Theoretical education and clinical supervision are examples of means to improve competence and skills.     

Measurement of left ventricular volumes by 3-dimensional echocardiography with tissue harmonic imaging: a comparison with magnetic resonance imaging.

We hypothesized that tissue harmonic imaging (THI) in comparison with fundamental imaging (FI) would improve endocardial border detection, and therefore in combination with 3-dimensional echocardiography (3D echo), it would be a precise method for left ventricular (LV) volume measurement. Ten healthy subjects and 18 consecutive patients with dilated hearts underwent estimation of LV volumes by magnetic resonance imaging (MRI) and transthoracic 3D echo with THI and FI. In patients, the agreement between MRI and 3D echo was closer with THI in comparison with FI for assessment of LV volumes. Thus the mean +/- 2 SD of differences between MRI and 3D echo with THI versus FI, respectively, was -6.4 +/- 40.0 mL versus -17.4 +/- 57.6 mL (P <.01) for the end-diastolic volume (EDV), and 0.0 +/- 26.6 mL versus -8.1 +/- 35.6 mL (P <.01) for the end-systolic volume (ESV). In patients, THI in comparison with FI approximately halved observer variation on EDV and ESV. In healthy subjects, only ESV showed significantly reduced observer variation by THI. In conclusion, because THI demonstrated a clinically relevant reduction in observer variation and a closer agreement to the MRI technique in patients with dilated hearts, it should replace FI in LV volume measurements.     

Initial evaluation of the patient with suspected dementia

Dementia is a common disorder among older persons, and projections indicate that the number of patients with dementia in the United States will continue to grow. Alzheimer's disease and vascular dementia account for the majority of cases of dementia. After a thorough history and physical examination, including a discussion with other family members, a baseline measurement of cognitive function should be obtained. The Mini-Mental State Examination is the most commonly used instrument to document cognitive impairment. Initial laboratory evaluation includes tests for thyroid-stimulating hormone and vitamin B12 levels. Structural neuroimaging with noncontrast computed tomography or magnetic resonance imaging also is recommended. Other testing should be guided by the history and physical examination. Neuropsychologic testing can help determine the extent of cognitive impairment, but it is not recommended on a routine basis. Neuropsychologic testing may be most helpful in situations where screening tests are normal or equivocal, but there remains a high level of concern that the person may be cognitively impaired.     

三维能量多普勒血管成像在诊断甲状腺功能亢进中的应用

目的探讨三维能量多普勒血管成像(3D-PDA)及其定量参数在甲状腺功能亢进(简称甲亢)诊断中的应用。方法应用3D-PDA对30例未经治疗的甲亢患者(病例组)和30例排除甲亢的患者(对照组)的甲状腺进行观察,通过勾勒感兴趣的范围,获得直方图及定量指标:平均灰阶(MG)、血管指数(VI)、血流指数(FI)和血流血管指数(VFI),进行对比分析。并对各参数与血清游离甲状腺素(FT4)、游离三碘甲状腺原氨酸(FT3)、促甲状腺激素(TSH)等甲状腺功能指标作Pearson相关分析。结果病例组30例MG(51.24±4.15)、VI(22.29±2.57)、FI(41.34±3.15)及VFI(10.54±1.65)4项检测参数均较对照组MG(50.27±2.87)、VI(11.65±0.24)、FI(22.07±1.98)及VFI(0.33±0.06)明显增高(P0.05),且MG、VI、FI和VFI与FT3水平呈正相关,VI、VFI与TSH呈负相关。结论 3D-PDA可以定性定量判定甲状腺腺体的回声水平和血流情况,可作为二维超声的有益补充,对正确诊断甲亢和指导临床治疗有重要意义。     

Person-centred care for people with dementia: a quality audit approach

This paper addresses the concept of person-centred care for people with dementia by consideration of an audit process using dementia care mapping as the audit tool. It is argued that this tool is best for identifying the lived experiences of the people in receipt of care. As a result it is able to identify the overall culture of care and its level of 'person-centred' approach. The audit was conducted on 12 units, half of which were day units and the others catering for inpatients. Five patients were mapped on each day for a 4-day period. The results give some idea of the quality of care and identify where improvement is necessary. Scores such as well-being values and the Dementia Care Index give clear signposts to the level of person-centred care and highlight where staff development is necessary. Recommendations are given to aid on-going planning.     

“Just see the person who is still a person (…) they still have feelings”: Qualitative description of the skills required to establish therapeutic alliance with patients with a diagnosis of dementia

Establishing a relationship is considered the foundation of providing person‐centred care (PCC) when working with a person who has a diagnosis of dementia. Currently, there is a lack of consensus about the how to develop this relationship. This aim of this study was to explore the key skills adopted by clinicians to establish an effective care relationship, referred to as therapeutic alliance, specific to working with patients who have dementia. Participants were clinicians (nursing and allied health professionals) from two older person’s mental health service teams (inpatient and community) who routinely provided clinical care to patients with a diagnosis of dementia. Participants self‐selected from a purposive sample to complete a semi‐structured interview about their provision of care to, and strategies used to engage with, people with a diagnosis of dementia. Exploratory qualitative thematic analysis was conducted using mixed inductive and deductive procedures. Five themes were identified as the interpersonal skills used to develop relationships with patients including the following: empathy, unconditional positive regard, congruence, psychological flexibility, and communication. Findings from this study provide direction for training of clinicians employed in a dementia setting and can also be generalized to other non‐specific clinical settings where clinicians may incidentally provide treatment to patients with a diagnosis of dementia.     

Individualized music played for agitated patients with dementia: Analysis of video-recorded sessions

Many nursing home patients with dementia suffer from symptoms of agitation (e.g. anxiety, shouting, irritability). This study investigated whether individualized music could be used as a nursing intervention to reduce such symptoms in four patients with severe dementia. The patients were video-recorded during four sessions in four periods, including a control period without music, two periods where individualized music was played, and one period where classical music was played. The recordings were analysed by systematic observations and the Facial Action Coding System. Two patients became calmer during some of the individualized music sessions; one patient remained sitting in her armchair longer, and the other patient stopped shouting. For the two patients who were most affected by dementia, the noticeable effect of music was minimal. If the nursing staff succeed in discovering the music preferences of an individual, individualized music may be an effective nursing intervention to mitigate anxiety and agitation for some patients.     

Managing fecal incontinence: self-care practices of older adults

Little is known about the ways in which community-dwelling elderly individuals manage fecal incontinence (FI) in their daily lives. In this study, community-dwelling elderly individuals were surveyed at clinics of a health maintenance organization (HMO) to describe the self-care practices used to manage FI and to examine factors that influenced the number of self-care practices used and the reporting of FI to a health care practitioner. Responses of 242 elderly individuals who reported that they had FI several times per year were analyzed. The self-care practices used most commonly were changing diet, wearing a sanitary pad/brief, and reducing activity or exercise. Elderly women and those with a greater severity of FI and more chronic health problems engaged in more self-care practices. Factors associated with reporting FI to a clinician were considering FI to be a problem, uncertainty about the cause of FI, and changing diet to avoid FI. There is a need to promote effective management strategies for FI to older individuals living in the community.     

Phase inversion harmonic imaging improves assessment of renal calculi: a comparison with fundamental gray-scale sonography

PURPOSE: To compare phase inversion harmonic imaging (PIHI) with fundamental imaging (FI) in the evaluation of renal calculi. METHODS: Thirty adult patients with renal calculi (17 men, 13 women; mean age 44 years [range, 25-71]) underwent transabdominal sonographic examination of the urinary system. Both kidneys and renal calculi were examined with PIHI and FI. Overall renal conspicuity, calculus visibility, and clarity of posterior shadowing were assessed subjectively using a 4-point scale (0 being the worst, 3 being the best). The maximum diameter of the calculi was measured using both techniques. The effect of body mass index on qualitative scoring and quantitative measurements was evaluated. RESULTS: PIHI improved overall renal conspicuity compared with FI (p < 0.001). The visibility of the calculi and clarity of posterior shadowing were significantly better with PIHI than with FI (p < 0.001 for both parameters). The maximum diameter of calculi was larger with PIHI than with FI (p < 0.001). The superiority of PIHI over FI regarding overall conspicuity of the kidney, visibility of the calculus, and clarity of posterior shadowing scores increased in the obese group (p < 0.001 for all 3 parameters). The mean calculus diameter difference between the 2 techniques was significantly higher in the obese group. CONCLUSION: The routine use of PIHI is recommended in the evaluation of renal calculi.     

Implementing family intervention following training: what can the matter be?

Family interventions (FI) have been established as an effective treatment for psychosis. Training in this intervention is now widely available in the UK. This paper reports a review of published literature that investigates whether, following this training, graduates provide this evidence-based treatment for individuals with psychosis and their caregivers. It further seeks to identify the barriers to implementation in cases where the treatment is not provided and assess benefits for service users and carers when it is. The review was conducted using the MEDline, PsycINFO, CINAHL and Embase databases. Studies that have attempted to evaluate the rates of implementation of FI by graduates of FI training programmes were identified, retrieved and reviewed. Six studies investigating the rates of implementation upon graduation were identified. The findings of these six studies were generally consistent. Rates of implementation by graduates of training programmes are usually low and a small number of graduates work with most of the families who are seen. The studies reviewed failed to assess service user and carer outcomes or consider the full range of likely impediments to the implementation of this evidence-based intervention. A key barrier to the implementation of FI is the reliance upon professionally developed and facilitated approaches. Alternative models that are service user and carer-led may provide a potential solution to the problem of implementation. Implications for future research and practice are considered.     

Behavior maintained under fixed-interval and second-order schedules by intravenous injections of endogenous noncatecholic phenylethylamines in dogs

The effectiveness of i.v. injections of the endogenously occurring amines beta-phenylethylamine (PEA), N-methyl phenylethylamine (NMPEA) and phenylethanolamine in maintaining schedule-controlled behavior was investigated in dogs. Behavior was maintained under either a fixed-interval (FI) 5-min schedule of i.v. drug injection or a second-order FI 5-min schedule where every fifth response (FR 5) resulted in a 2-sec visual stimulus and the first FR 5 completed after the interval elapsed resulted in both the visual stimulus and i.v. drug injection [FI 5-min (FR 5:S)]. Experimental sessions, with 10 intervals per session, were conducted 5 days/week. Each drug injection was followed by a 5-min timeout period to minimize the direct effects of the drugs on responding. As the dose per injection increased, rates of responding maintained under both schedules by PEA and NMPEA first increased and then decreased. When saline was substituted for drug, responding occurred at very low rates. PEA and NMPEA were approximately equieffective and equipotent in maintaining responding under the FI 5-min schedule. PEA maintained somewhat higher rates under the FI 5-min (FR 5:S) schedule; rates maintained by NMPEA under the second-order schedule were comparable to those maintained under the simple FI schedule. Phenylethanolamine failed to consistently maintain responding under either schedule. Injections of PEA and NMPEA controlled overall patterns of positively accelerated responding under both schedules, whereas the local pattern of responding under the second-order schedule was under the control of both the brief stimulus presentations as well as drug delivery.(ABSTRACT TRUNCATED AT 250 WORDS)     

The role of percutaneous endoscopic gastrostomy in patients with dementia

Percutaneous endoscopic gastrostomy (PEG) is an accepted technique for long-term enteral feeding. Its use has increased because of its relative technical simplicity and low complication rate. As a result, the demands for gastrostomy insertion have risen and now encompass indications where the long-term outcomes are uncertain. One example of this, are patients with end-stage dementia who may be unable or unwilling to eat. For this reason, dementia has become one of the most common indications for gastrostomy feeding. This article reviews the current evidence relating to PEG feeding in dementia as well as work from the authors' own group. The purpose of this review is to provide the reader with an overview of the published literature and suggest a practical approach for this difficult clinical situation. The changes which the authors have implemented and described (including audit data), may be something which any practising healthcare professional in this field may choose to incorporate into their own clinical practice.     

Drug Treatment of Depression Associated with Dementia or Presented as ‘Pseudodementia’ in Older Adults with Down Syndrome

The response to antidepressant drugs, mainly the selective serotonin reuptake inhibitors (SSRIs), was evaluated in adults with intellectual disability (ID) and Down syndrome (DS) who presented with depression and decline in activities of daily living (ADL) skills. Among other patients with ID referred to a specialised clinic for diagnostic work-up, 37 adults with DS over the age of 40 and a mean age of 51.4 years were evaluated and 34 were followed-up. Depression associated with dementia was diagnosed in 16 cases, and depression presented as functional decline ‘pseudodementia’ was found in four cases. Recommendations for treatment with antidepressants were followed in 10 cases with a marked improvement in functioning compared to a rapid decline in the 10 cases where treatment was refused. Treatment with the SSRIs antidepressant drugs resulted in improved quality of life, differentiated ‘pseudodementia’ from dementia, and possibly delayed the dementing process in adults with DS and presentation of depression associated with dementia.     

MRI成像Dixon-VIBE序列定量评估退变性腰椎侧凸患者椎旁肌退变程度的可行性

目的探讨MRI多回波三维容积内插水脂分离快速扰相(three-dimensional multi-echo Dixon volumetric interpolated breath-hold examination,Dixon-VIBE)序列在退变性腰椎侧凸(degenerative lumbar scoliosis,DLS)患者椎旁肌退变程度定量评估中的价值。方法20例DLS患者为观察组,同期20例体检健康者为对照组,2组均行腰椎MRI成像Dixon-VIBE序列扫描。分析横断位图像L4-5椎间盘中心层面椎旁肌横截面积(cross-sectional area,CSA)和脂肪浸润度(fat infiltration,FI),并于7 d后重复测量。采用同类相关系数(intra-class correlation coefficient,ICC)双侧随机模型评估研究者间信度和复测信度,比较观察组凸、凹侧椎旁肌CSA、FI,计算椎旁肌CSA、FI不对称度,统计椎旁肌形态异常例数。结果观察组和对照组椎旁肌CSA测量的组间ICC分别为0.78~0.94、0.88~0.93,组内ICC分别为0.79~0.97、0.81~0.97,FI测量的组间ICC分别为0.78~0.91、0.82~0.98,组内ICC为0.76~0.95、0.91~0.97,组内及组间测量结果均具有较好一致性;观察组多裂肌、竖脊肌FI[(32.6±10.0)%、(30.5±8.8)%]均高于对照组[(22.4±8.5)%、(24.4±8.0)%](P<0.05);腰大肌FI[(17.6±5.4)%]及多裂肌、竖脊肌和腰大肌CSA[(7.9±1.8)、(13.6±2.6)、(9.8±2.9)cm2]与对照组[(14.9±3.3)%、(8.1±1.5)cm^2、(13.3±2.2)cm^2、(10.5±3.0)cm^2]比较差异无统计学意义(P>0.05);观察组凸侧多裂肌、竖脊肌和腰大肌CSA、FI与凹侧椎旁肌比较差异无统计学意义(P>0.05);观察组多裂肌、竖脊肌、腰大肌CSA不对称度分别为[(7.6±5.3)%、(9.6±6.2)%、(10.7±8.7)%],FI不对称度分别为[(6.1±4.7)%、(7.4±4.2)%、(3.7±2.0)%],多裂肌、竖脊肌和腰大肌CSA不对称度>10%者分别有7、9、12例,FI不对称度>10%者分别有3、5、2例。结论MRI成像Dixon-VIBE序列可定量评估DLS患者椎旁肌形态改变,DLS患者椎旁肌退变主要表现为多裂肌和竖脊肌脂肪化程度增加、凹凸侧椎旁肌群CSA不对称改变。     

Tissue harmonic imaging in the diagnosis of small hepatocellular carcinoma: Usefulness for detecting posterior acoustic enhancement

We attempted to evaluate the usefulness of ultrasonic tissue harmonic imaging (HI) in the diagnosis of small hepatocellular carcinoma (HCC) and compare its effectiveness with that of conventional fundamental imaging (FI) prospectively. Nine patients with 16 nodules of HCC measuring less than 20 mm in diameter were evaluated with both FI and HI. The boundaries of 14 nodules were more clearly visualized on HI than on FI. Posterior acoustic enhancement, which is diagnostic of HCC, was not detected on FI, although it was detected in 5 nodules on HI (p<0.05); however, one nodule located in a section of the liver that was 8 cm below the abdominal wall was visualized only by FI. We conclude that HI is more useful than FI in the diagnosis of small HCC nodules, although HI has minor limitations of the applicable location.     

Counteracting fragmentation in the care of people with moderate and severe dementia

Symptoms such as amnesia, agnosia, apraxia, and aphasia may lead to a fragmented experience and actions among people with moderate and severe dementia. The aim of this study was to explore the interactions where fragmentation occurred and how caregivers counteract fragmentation. The observation notes from participant observations were analyzed using interpretive content analysis. Fragmentation was noted if the patients showed that they did not recognize what was going on, the people involved, the things used in the action, or did not recognize themselves in the situation. Care providers could counteract fragmentation by a caring based on attentive interest in the interaction, valuing the person behind the dementia disease, using an individual perspective considering the impact of the dementia disease, and striving for mutual interpretation of the shared situation. Caring based on these assumptions could help the patients to keep their world together.     

How education can improve care for residents with dementia

Meeting the needs of people with dementia is topical in health and social care. However, the care of older people, including those with dementia, has received much negative media coverage over the past few years. Colten Care, a care home group in the south of England, asked staff from the School of Health and Social Care at Bournemouth University to develop and deliver an educational programme to 20 staff working at three of the group's care homes. The programme adopted a person-centred approach to residents and staff and focused on empowering staff to influence practice in the homes where they worked. This article explores the content of the programme and how aspects of it were incorporated in participants' care homes. The programme was positively evaluated and formed the basis for the development of Colten Care's inhouse two-and-a-half day education programme.