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The care of elderly relatives with dementia is not any longer a job exclusively done by women nevertheless the care for three quarters of patients is mainly provided by women. This study comprises 70 persons consulting the "Alzheimer Advice Centre" in Leipzig. The aim was to examine the difference between nursing men and women with regard to the way they experience their situation. Independent of sex nursing persons experience their job as a strain. Especially spouses suffer from depressive disorders, states of exhaustion and pain in arms and legs. Nursing spouses differ in their ways of coping with regard to their sex. Wives experience the symptoms of dementia and the limitation of personal freedom as stressing whereas husbands pick out as a central theme the worries about their wives. Men use instrumental support in the nursing situation more often than wives. Altogether mainly women provide care. Sometimes they even take care of several persons. Therefore the resulting strains and limitations are to be regarded as special problems of women.
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PMID:["I never feel free"--women care for the demented husband, father or mother]. 901 54

We conducted two studies with medically hospitalized cancer and acquired immunodeficiency syndrome (AIDS) patients to assess the reliability and validity of a new measure of delirium severity, the Memorial Delirium Assessment Scale (MDAS). The first study used multiple raters who jointly administered the MDAS to 33 patients, 17 of whom met DSM III-R/DSM IV criteria for delirium, 8 met diagnostic criteria for another cognitive impairment disorder (for example, dementia), and 8 had non-cognitive psychiatric disorders (for example, adjustment disorder). Results indicate high levels of inter-rater reliability for the MDAS (0.92) and the individual MDAS items (ranging from 0.64 to 0.99), as well as high levels of internal consistency (coefficient alpha = 0.91). Mean MDAS ratings differed significantly between delirious patients and the comparison sample of patients with other cognitive impairment disorders or no cognitive impairment (P < 0.0002). The second study compared MDAS ratings of 51 medically hospitalized delirious patients with cancer and AIDS made by one clinician to ratings on several other measures of delirium (Delirium Rating Scale, clinician's ratings of delirium severely) and cognitive functioning (Mini-Mental State Examination) made by a second clinician. Results demonstrated a high correlation between MDAS scores and ratings on the Delirium Rating Scale (r = 0.88, p < 0.0001), the Mini-Mental State Examination (r = -0.91, P < 0.0001), and clinician's global ratings of delirium severity (r = 0.89, P < 0.0001). Thus, our findings indicate that the MDAS is a brief, reliable tool for assessing delirium severity among medically ill populations that can be reliably scored by multiple raters. The MDAS is highly correlated with existing measures of delirium and cognitive impairment, yet offers several advantages over these instruments for repeated assessments which are often necessary in clinical research.
J Pain Symptom Manage 1997 Mar
PMID:The Memorial Delirium Assessment Scale. 949 4

To investigate the effect of dementia on response to pain, 51 community-dwelling, generally healthy, cognitively intact individuals > or = 65 years old and 44 community- or nursing home-dwelling persons > or = 65 years old with varying severity of dementia were studied. Cognitive status was assessed by standardized clinical evaluation and psychometric test performance. The following responses were measured before, during and after a standard venipuncture procedure: heart rate, the amplitude of respiratory sinus arrhythmia (RSA), self-reported anxiety and pain, and videotaped facial expressions. Although RSA did not differentiate procedural phases, in both samples, mean heart rate increased in the preparatory phase and decreased in the venipuncture phase. Independent of age, increasing severity of dementia was associated with blunting of physiologic response as measured by diminished heart rate increase in the preparatory phase and heart rate increase with venipuncture. Dementia significantly interfered with the subjects' ability to respond to direct questions about anxiety and pain. Those who were able to respond were relatively accurate self-assessors: higher anxiety was associated with greater magnitude heart rate responses. Facial expression was increased in demented individuals but it could not be classified by specific emotions. We conclude that dementia influences both the experience and reporting of pain in elderly individuals.
Pain 1996 Dec
PMID:Dementia and response to pain in the elderly. 912 31

As the population ages, Alzheimer's disease and depression are becoming increasingly common concerns for primary care physicians. While the comorbidity of Alzheimer's disease and depression presents a complex diagnostic and management challenge, treatment can improve the patient's quality of life. Changes in functional status, complaints of pain and fluctuations in mental status may signify the onset of depression in a patient with dementia. Because of differences in treatment, it is important to separate depression from other disruptions in behavior. Unfortunately, screening tools for depression and cognitive function are of limited usefulness in patients with Alzheimer's disease. Improvement with antidepressant therapy is often diagnostic. The caregiver plays a large role in assisting with the diagnosis and assessing the effectiveness of therapy.
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PMID:Comorbid disease in geriatric patients: dementia and depression. 919 55

The present study was made not only to clarify endogenous factors (physical and psychological factor of the subjects) and exogenous factors (caregiver residential environment, social assistance) in the urinary incontinence of elderly persons at home undergoing public visiting nursing, both by sexes and by age-groups [65-74 years (young old), 75-84 years (middle old), more than 85 years (old old)], but also to examine nursing care problems at home. The subjects were 252 elderly persons > 65 years (46.8% of all subjects), who were detected for urinary incontinence by incontinence screening examination from among 538 subjects (224 males, 314 females), who underwent visiting nursing by Public Health Centers, and the health and welfare department of intra-metropolitan S Ward from April 1992 to August 1994. The screening examination was made via visiting interview and hearing by Public Health Nurses in charge, about items for examination such as disease, treatment, degree of independency for ADL, residence, utilization of social resources. nursing burden sensation, etc. The analysis was made comparatively by age-groups and by sexes, as mentioned above. The following information was obtained; 1) In terms of the incidence of urinary incontinence, female subjects showed higher incidence for higher age-grade (36.5%, for YO group, 45.1% for MO group and 61.4% for OO group), and male subjects showed higher incidence than female subjects (56.8% for YO group, 54.4% for MO group and 74.5% for OO group). 2) A few subjects were found within 3 months of the onset of urinary incontinence. Incontinence-favorite time zone was predominantly the midnight zone of 0-6 o'clock a.m. (23.5-52.2%). Care approach by caregiver was predominantly "use of diaper" (52.2-90.2%) and "use of diaper even with micturition" represented 30-50%. 3) Endogenous factors involved onset of cerebrovascular disease or dementia, narrow range of ADL, symptoms such as numbness and pain, bedsores, constipation, low social activity, etc. 4) Exogenous factors involved elderly caregiver persons, residual care fatigue sensation, inconvenient toilet and other housing condition, etc. 5) Endogenous-exogenous compound factors in possible urinary incontinence involved paralysis, contrature, social activity, start of visiting for morbid state observational nursing, guidance and utilization of social services for YO group, suggesting strong factor involving the care rather than physical problems of the subject concerned for elder group. From the above, suggestions for the subject concerned were made as follows; 1) start of visiting aiming at the prevention and improvement of urinary incontinence in early stage of onset of cerebrovascular disease (especially for males) or dementia (especially for females) and 2) promotion of rehabilitation for tension provocation of pelvic muscular group and enlargement of ADL and walking distance, and suggestions for caregiver were made as follows; 1) giving appropriate advice for excretory nursing at home and 2) assessment of the relationship with the subject concerned. From the viewpoint of housing environment, reconstruction of such a toilet as is easily usable by both an elderly person and its nursing person and from the viewpoint of regional system, necessary preparation of 24-hour approach to diminution of nocturnal excretory nursing burden was suggested.
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PMID:[A study of endogenous-exogenous factors in urinary incontinence and home care nursing of the elderly at home]. 928 14

We report a 76-year-old man who developed blurred vision and dementia. He was apparently well until April 4, 1990 (70-year-old at that time) when he had a sudden onset of bilateral loss of vision. Corrected vision was 0.1 (right) and 0.09 (left). He was admitted to the ophthalmology service of our hospital on April 9, 1990, and neurological consultation was asked on April 11. Neurologic examination revealed alert and oriented man without dementia. Higher cerebral functions were intact. He had bilateral large visual field defects with loss of vision; he was only able to count the digit number with his right eye and to recognize hand movement with his left eye. Otherwise neurologic examination was unremarkable. General physical examination was also unremarkable; he had no hypertension. Cranial CT scan was normal on April 11; lumber spinal fluid contained 1 cell/microliter, 63 mg/dl of sugar, and 97 mg/dl of protein; myelin basic protein was detected, however, oligoclonal bands were absent. He was treated with methylprednisolone pulse therapy and oral steroid, however, no improvement was noted in his vision. He started to show gaze paresis to left, ideomotor apraxia, agnosia of the body, and dementia. Cranial CT scan on June 11 revealed a low density area in the deep left parietal white matter facing the trigonal area of the lateral ventricle. He was discharged on July 2, 1990. Hasegawa dementia scale was 2/32.5 upon discharge. In the subsequent course, he showed improvement in his mental capacity and Hasegawa dementia scale was 22.5/32.5 in 1991, however, no improvement was noted in his vision. In 1994, he started to show mental decline in that he became disoriented, and showed delusional ideation of self persecution and depersonalization with occasional confusional state. He also showed unsteady gait. Cranial MRI on February 13, 1996 revealed a T2-high signal intensity lesion on each side of the parietal deep white matter more on the left and another T2-high signal intensity lesion in the left pons as well as in the right thalamus. He complained of right hypochondrial pain and was admitted to another hospital on April 22, 1996. He was markedly confused and demented. He continued to show bilateral loss of vision, but no motor palsy was noted. Cranial CT scan on April 23, 1996 revealed diffuse cortical atrophy and ventricular dilatation in addition to the low density areas in both parietal deep white matter. He developed jaundice in the middle of May. Abdominal CT scan revealed multiple low-to iso-density areas in the liver and marked iso-to high-density swelling of the right kidney. The patient expired on June 9th, 1996. The patient was discussed in a neurological CPC and the chief discussant arrived at the conclusion that the patient had had a carcinomatous limbic encephalitis with optic neuropathy and a choleduct carcinoma. Other opinions entertained included acute disseminated encephalomyelitis with optic neuritis, and granulomatous angiitis of the central nervous system. Some participants thought the primary site of the carcinoma was the right kidney with metastasis to the liver. Post mortem examination revealed a mixed type carcinoma in the right kidney with liver metastases. Neuropathologic examination revealed an incomplete softening in the optic chiasm and the left optic nerve, and in the left parieto-occipital areas. (The right hemisphere was frozen for future biochemical assay.) One of the adjacent cortical arteries had an organized thrombus. Other arteries and arterioles also showed sclerotic changes. Some of the leptomeningeal arteries were positive for Congored staining as well as for beta-amyloid immunostaining. Many senile plaques were seen diffusely in the cerebral cortex and neurofibrillary tangles were seen in the CA1 area and the parahippocampal gylus. No cellular infiltrations or demyelinated foci were seen. The neuropathologic features were consistent with circulatory disturbance based on the amyloid angiopa
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PMID:[A 76-year-old man with loss of vision and dementia]. 928 74

Relatively low use of nonsteroidal anti-inflammatory drugs (NSAIDs) and other analgesics has been noted in patients with probable Alzheimer disease (AD). Although this finding has been explained by a decline in patients' capacities to communicate about pain, self-report on pain of cognitively impaired elderly have been shown to be just as reliable as those of cognitively unimpaired elderly. However, previously published studies were aimed primarily at quantifying pain. Considering the various limbic areas affected in AD, a change also in the more qualitative, affective component of pain might be the cause of the low use of analgesics. Because affective disorders are highest in the early and middle stages of AD and decrease in the final stage, it was hypothesized in the present study that not only would the number of AD patients using analgesics would be lower than among a control group but, moreover, analgesic use would be lower in the early and middle stages of AD than in the final stage. The hypothesis was tested by comparing drug use (NSAIDs and analgesic non-NSAIDs) among 66 AD patients with that among 70 elderly people without dementia. The percentage of AD patients using analgesics was indeed significantly lower than among controls, but drug use was not dependent on the stage of AD. Consequently, our findings only partly support the hypothesis.
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PMID:Is decreased use of analgesics in Alzheimer disease due to a change in the affective component of pain? 930 3

Agitation is a frequent clinical problem that adds significant morbidity to the hospital course. Agitation is usually part of an ambiguous constellation of cognitive and psychiatric symptoms, with a fluctuating clinical course. Observation of vastly different symptoms occurring at different times leads to misdiagnosis or underrecognition of serious underlying disorders. The most common causes of agitation include delirium, dementia, and acute psychosis. Risk factors attributable to hospitalization include pain, anxiety, and stressors endemic to intensive care. Agitated states may have multiple causes, and each potential contributor must be pursued and treated independently. Definitive diagnosis is dependent on a comprehensive history, patient observation, physical examination, and selective diagnostic studies.
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PMID:Agitation. 931 72

This paper reviews recent literature concerning the use of music and music therapy in health care. Focusing particularly on the elderly, the use of music in relation to patients with dementia and Parkinsonism is examined. Brief reference is also made to the use of music in pain control. Although in this case, literature is not specific to care of the elderly settings, the results are still relevant to gerontological nursing. Projects which achieved positive results in controlling pain perception could be transferable to a care of the elderly scenario, where chronic pain is often part of daily life.
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PMID:The therapeutic use of music in a care of the elderly setting: a literature review. 935 67

Idiopathic Parkinson's disease (IPD) is a common and universal condition. Although its cause is still unknown, we now have some insights into pathogenetic mechanisms and genetic factors that may be important in causing the selective neuronal loss and presence of Lewy bodies that characterize its pathology. Clinically, as well as the classic features of akinesia, rigidity and often rest tremor, patients may present a wide range of other symptoms including pain, other sensory symptoms, impaired olfaction, personality change, mild executive cognitive deficits, dementia and depression, an extraordinary richness of symptoms and signs rendered even more extraordinary by the long-term effects of drug treatment. While there may be little difficulty recognizing typical cases of IPD, there has been, at least until recently, a considerable misdiagnosis rate in both atremulous (confusion with ageing, vascular disease, multiple system atrophy (MSA) or progressive supranuclear palsy (PSP)) and tremulous (confusion with essential tremor (ET), dystonic tremor, and MSA) forms. However, increasing awareness of the clinical features of all these conditions, together with adherence to exacting diagnostic criteria, is leading to improved diagnosis, which is crucial for patients (who want to know what the future holds for them), for their treatment (giving them the right drug and not the wrong one) and for research (since all the different diseases above have different aetiologies and pathology).
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PMID:Parkinson's disease: clinical features. 942 65


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