 Father’s Old Blue Cardigan  POEM VIEWS: 118 By Anne Carson Now it hangs on the back of the kitchen chair  where I always sit, as it did  on the back of the kitchen chair where he always sat.  I put it on whenever I come in,  as he did, stamping  the snow from his boots.  I put it on and sit in the dark.  He would not have done this.  Coldness comes paring down from the moonbone in the sky.  His laws were a secret.  But I remember the moment at which I knew  he was going mad inside his laws.  He was standing at the turn of the driveway when I arrived.  He had on the blue cardigan with the buttons done up all the way to the top.  Not only because it was a hot July afternoon  but the look on his face—  as a small child who has been dressed by some aunt early in the morning  for a long trip  on cold trains and windy platforms  will sit very straight at the edge of his seat  while the shadows like long fingers  over the haystacks that sweep past  keep shocking him  because he is riding backwards.

 Aim To give an overview of caring for patients with dementia in the community  Objectives To cover diagnosis, treatment, management, issues for carers and elder abuse

 Dementia is a condition which causes gradual loss of mental ability beyond what is expected by the normal aging process.  Consciousness is not affected  It causes changes in personality, decline in social function, and a decline in the ability to self care.

 Memory loss  Disorientation  Failing intellect  Personality changes  Self-care  Mood changes  Weight loss/falls  As disease progresses- loss of speech, continence, mobility, eventually leading to death.

 Mrs Muddle, 75y old is brought to see you by Neil, her son.  He is very concerned as she has become forgetful of late and recently nearly blew up the kitchen when she started to cook and forgot to light the gas stove.  What would your next steps be in assessing this woman?

 I have seen deeply demented patients weep or shiver as they listen to music they have never heard before, and I think they can experience the entire range of feelings the rest of us can, and that dementia, at least at these times, is no bar to emotional depth. Once one has seen such responses, one knows that there is still a self to be called upon, even if music, and only music, can do the calling. Oliver Sacks (2007) Musicophilia: Tales of Music and the Brain New York: Knopf (p.346)

 Driving  Wandering  Aggression  Sexual inhibition  Financial vulnerability

 History  Cognitive, mental state, and physical exam, exclude depression, reversible causes- hypothyroidism, assessment tool e.g. mmse  Investigation; fbc, esr, u&e, lft, tft, gluc, haematinics, drug levels, drug screen,hiv /syphilis Msu, ecg, ct scan, mri (unusual)  Medication review Check the patient wants to be told results

 Refer early- borderline positive patients are most likely to benefit from treatment.  Refer to memory clinic- Assess for drug tx Provide support needed

 Choline esterase inhibitors eg donepazil -specialised prescribing -Alzheimer sufferers, mmse regular reviews.  Memantine Only in clinical studies currently Reduces Ca2+ in neurones  Sedation eg haloperidol -Now frowned upon  Antidepressants -SSRI’s

 Support in the community -DN’s CPN’s SS Voluntary organisations eg AS  Reality Orientation  Cognitive stimulation  Physical activity  Reminiscence therapy  Behaviour management- reduce depression

 Aims to improve dementia services in 3 areas: Improved awareness Early diagnosis & intervention Higher quality of care  17 strategies – aims to develop early specialist assessment, improve access to support in hospital & community, end of life discussions, joint commissioning strategy for dementia, effective national & regional support

 Early recognition  Access to specialist Memory Services  acetylcholinesterase inhibitors donepezil, galantamine and rivastigmine for moderate dementia – only started by Specialist centres  MMSE recommended to be  Some debate regarding patients ability to compensate on MMSE

 The intuitive mind is a sacred gift, and the rational mind its faithful servant. We have created a society that honours the servant and has forgotten the gift. Albert Einstein

 CKS  Forgetful but not forgotten, RC of Psychiatry  NICE guidelines treatment of dementia 2007/ 2009  Patient.co.uk  Living Well with Dementia, A National Strategy  Mental well being for elder people  Heathtalkonline  Dementia Positive

 Alzheimer's Society-  Carer’s UK-  Princess Royal Trust for Carers-