Всё о Гипертензии(гипертонии)-About Hypertension

Heart signs are seen in the second major zone: Blood and Muscle zone—locally at left iris:

10′-15′, right iris: 45′-50′—commencing directly at the iris-wreath.

With heart signs, as with the entire iris, a lightening of colour signifies over-activity

= inflammation, and darkening indicates underactivity = weakness.

With all cardiac conditions, more so than with other organ signs, one has to consider the entire iris, and in particular the blood zone, brain, liver, lung and kidney areas. In addition, the finger-nails, legs and lips should be examined, since these often give early indications.

Heart signs for individual conditions are:

1. Endocarditis (inflammation of the endocardium): shows small white flakes in the heart area, or short white lines, especially close to the iris-wreath in the blood zone.

2. Myocarditis (inflammation of the heart muscle): is recognised by the appearance of small white flakes or clouds in the muscle zone: in the middle of the heart area, or further outwards towards the skeletal zone. These signs are very often apparent during the course of, or following an infectious disease, and must then be regarded as very grave indications. These signs are also frequently to be found with so-called ‘rheumatic’ patients. With such people the whole iris is too white, and these patients complain of generalised rheumatic pains, e.g. in shoulder, neck, back muscles, etc.

With such patients one often observes merely a thick, white zigzag line in the heart area which shows a small white flake at its termination in the mucous membrane zone. In such cases it will be found that the patients suffer severely from changes in the weather, and complain of great uneasiness and anxiety from stormy weather.

3. Pericarditis (inflammation of the pericardium): the pericardium registers approximately at left iris: 15′-17′, showing clouds in the lower margin of the heart signs when there is pericarditis. Since pericardial disease very easily gives rise to adhesions, one should always give careful attention to the fine white adhesion-signs (transversals) in this area, as well as to the adjacent pleural area below.

4. Cardiac neuroses: are widely spread in these times of increased tensions, haste and anxiety. Since in many cases of neurotic disturbance no clinical evidence can be found, iris-diagnosis becomes an especially important help.

In the early stages, nervous disturbances of the heart are shown by a very fine white line which runs out over the heart area from the iris-wreath, roughly horizontally. The patients complain of disturbance and sudden palpitations (the heart beats ‘up into the throat’). If this white line takes on a more acutely zigzag form, then stronger disturbances are probable. Patients with such signs usually have enlarged ‘moons’ on the finger-nails.

If near these fine white lines contraction rings are observed (i.e. nerve rings), which interrupt at the heart area, then there is a risk of cardiac spasm, resulting in the appearance of praecordial anginal attacks.

If the nervous heart disturbances have existed for some time, then the fine white lines become darker, i.e. grey to black; usually there is only a dark line to be seen, known as ‘irritation line’. Patients with such signs have constant heart disturbance as a result of irritation, grief or fear. If the lines become somewhat wider apart and give rise to lacunae, then the patient will complain of an anxiety state. If these signs lie at about 10′-12′ (left iris) then according to Frau Flink there is a condition of heart oppression and dyspnoea; if they lie at 16′-17′ then agitation and excitement will give the patient the feeling as if the heart was being strangled. Patients with these signs have nail ‘moons’ which are too small, or are wholly or partly missing.

5. Cardiac myasthenia (heart muscle weakness): is shown by a darkening of the heart area, appearing as dark wisps, clouds, and closed or open weakness-signs. The iris fibres no longer run radially, but more or less in arc form. For so long as the dark signs are small (narrow) and the fibres only slightly separated, then the condition is one of simple debility of the heart muscle, but if not treated this becomes a heart muscle weakness. The weakness-sign itself is usually evidenced above or below (also above and below) by a light well-defined arc. Frau Flink interpreted a well-defined upper arc as a tendency to asthmatic symptoms, which arise on slight exertion. In the case of a lower arc, then according to Frau Flink the patient can eat only little.

When in addition to these signs the stomach and intestinal zones are coloured brown, then every excitement affects the stomach of such a patient.

The wider the separation of the fibres in the muscles zone of the heart area, the greater the tendency to cardiac dilatation. If the weakness-signs are closed, then according to Frau Flink, the condition should be regarded as one of cardiac dilatation and cardiac weakness. Such patients must always be treated as for a heart condition, especially with feverish infections—e.g. rheumatic and renal conditions. If the weakness sign is not closed, but is open as far as the iris margin, then the condition is one of hypertrophy (Frau Flink). If besides the weakness-sign in the heart area one finds an overgrowth of the nail-quick on the fingers, then the patient suffers cardiac anxiety and oppression. In children this is a sign of fearfulness.

As is well known, a heart muscle-weakness leads to stasis in the systemic and pulmonary circulation. With left cardiac insufficiency this gives rise to dyspnoea with cough and catarrh, whereas with right cardiac insufficiency there is liver and portal stasis, haemorrhoids and hydropericardium. Thus, with weakness-signs in the heart area, one always pays attention to the lung areas. Stasis here makes the lung fields appear dark, the patient complaining of cough and dyspnoea, especially at night. Cardiac asthma and pulmonary oedema are possible dangers.

In proportion to the extent of cardiac weakness, stasis signs may be found in the areas for liver and kidneys, together with a dark neurasthenic-ring, haemorrhoidal signs in the rectum area, and stasis signs in the extremity areas. These areas become dark and the iris fibres separate.

Small lacunae in the heart area are sometimes found even in small children, in which case the cause is attributable to the mother. If during pregnancy the mother suffered much irritation and worry then the child is liable to have a heart-area lacuna. Such children are very nervous, and remain affected throughout the whole of life.

6. Cardiac valve lesions: show in the iris as small black points in the heart area in the vicinity of the iris-wreath, lying in the upper part of this area. There may be one to three black points. The appearance of a fourth point is a presage of death. Struck wrote on this matter in

Iris-Korrespondenz as follows: a visible fourth heart point renders hopeless any measures to counter impending death. This iris indication is diagnostic of the last stages of struggling man.

Another sign in the heart area which is difficult to interpret is the black wedge-sign. It lies in the blood zone with its base to the iris-wreath and the apex pointing into the muscle zone. It indicates that the patient may suffer a sudden cardiac arrest.

If in the heart area one or more black points are observed in the blood zone (indicating valvular defects), or in the muscle zone (indicating callosities), then one must not neglect to make a thorough examination of the mouth-throat area. Dark points in this area will suggest that the heart damage is secondary to a focal infection arising in the teeth or tonsils (angina, diphtheria).

7. Coronary sclerosis: was earlier the privilege of elderly and aged persons. Today, however, it not infrequently affects persons between 30 and 50 years of age. In the iris it is recognised by the following signs: At 15′ the iris-wreath shows a thicker white margin, conjoined with the lower arc of a cardiac weakness sign, and extending with it to the muscle zone.

Sometimes a fine white line can be observed running obliquely from this white margin to the spleen area. This line is a sign of threatened cardiac infarct.

8. Roemheld syndrome: is shown in the iris as a strong dilatation of the colon (i.e. iris-wreath) in the direction of the heart area. This dilatation may lie above or below the heart area.

9. Coloured flecks in the heart area: Such colour or toxin flecks in the heart area are small light to brownish-red pigment flecks. These indicate that the patient suffers mentally, and such patients tend strongly to brooding (melancholy, true depression, religious delusions, etc.). These signs very often go together with abdominal disturbances —usually affecting persons of

Sepia-type (yellow glistening of the nose, dirty ring around the mouth, unable to get going in the mornings yet gay and lively in the evenings.)

*20\78\2*

First visit

A baby’s first visit to the doctor’s office is usually between two and four weeks after birth and this visit serves several purposes. For one thing, it gives the parent, the doctor, and the child an opportunity to meet together and begin a relationship. The parent can get to know the doctor and the customs of the practice, the doctor can get basic information about the family, and the child’s general health can be evaluated. At this first visit the doctor will take the baby’s physical measurements. This initial information is necessary so that the child’s development can be followed from the beginning of life. The doctor will also examine the baby for abnormalities. Some babies are born with physical problems and abnormalities that are obvious right away. Other inborn problems do not show up until a few weeks after birth.

At the first visit, the doctor will ask questions about the parents’ health and health history as well as examine the baby. Some medical problems can be inherited, and some can run in families. It is important for the new baby’s medical record to show such background information. If the child later shows signs of problems that have appeared before in the family, the doctor will be able to make a diagnosis more quickly.

The first visit will also include checking to see that the umbilical cord is healing as it should, that the circumcision (if it was done) is healing, and that the child has had no ill effects from labor and delivery. Feeding schedules, vitamins, and immunizations will be discussed as well. Usually a schedule of regular return visits is made up at the first visit. The number and spacing of the visits will depend on the baby’s health, the parents’ needs and wishes, and when the baby should have immunizations.

If the baby’s health and development seem to be normal, some or all of the later visits may be handled by a pediatric nurse practitioner, a physician’s assistant, or another health professional. These people are specially trained to be an extension of the doctor. They can work with you to clear up any questions you have about taking care of your baby. Of course, any question or problem that the nurse or assistant cannot handle is referred to the doctor.

Later visits

As the child grows past babyhood, questions will come up about how to handle toilet training, rivalries with brothers and sisters, obedience, temper tantrums, and the like. These are areas where your doctor and the staff can help. Go ahead and ask about them. A child’s doctor is not concerned only with the child’s physical body. Social and psychological development is also a part of every child’s growth and affects health in many ways.

*266/84/5*

Many children cannot remain dry through the night before they are four or five. About 10 percent of all children over the age of five are bedwetters. Children of any age may have occasional accidents at night, especially if ill or in exhausted sleep—conditions that do not represent true bedwetting.

Five to 10 percent of children who bed-wet have a physical disease, such as an infection or abnormality of the urinary tract, diabetes, or a neurological (nervous system) disorder. If a trained child suddenly begins bedwetting, the cause may be physical. If bedwetting develops a year or more after night training has been established, or if a child wets himself both day and night, a physical disease is likely.

However, most cases of bedwetting are not caused by an identified physical disorder. Some cases seem to be hereditary, with brothers, sisters, and parents also having been bedwetters. Some are caused by overemphasis by the family on toilet training. Others are caused by taking children out of their night nappies too soon or by waking children to urinate in an effort to train at night. Some children have emotional problems that cause bedwetting. Still, the cause of many cases of bedwetting remains unknown.

Signs and symptoms

A child who frequently and consistently wets the bed after age five has a bedwetting problem.

Home care

Before beginning any home treatment of bedwetting, see your doctor. The doctor can perform tests to determine whether bedwetting is being caused by a physical disease, such as a urinary infection or diabetes.

If the doctor finds no physical cause, then the best home treatment is to ignore bedwetting as much as possible and to try to avoid it. Do not take a child out of night nappies until the child consistently remains dry. Do not make a big fuss about daytime training. Do not try to shame a child into remaining dry at night.

Consult your doctor before using devices which awaken the child as urination starts. Withholding liquids during late afternoon and evening hours is not usually successful and may seem like punishment to the child. Behavior modification techniques (rewarding success and reacting neutrally toward failure) rarely work. Rubber sheets and plastic pants are helpful until the child stops bedwetting. Until then, patience, calmness, and understanding may be the best treatment.

Precautions

• Do not let a minor problem like bedwetting become a major destructive factor in your relationship with your child. Anger and frustration between parent and child are more costly than extra laundry.

• Do not allow other children to taunt a bedwetter.

Medical treatment

Your doctor will insist first upon conducting a physical examination and urinalysis. The doctor may suggest X rays of the urinary tract or consultation with an urologist; imipramine (an antidepressant) by mouth at bedtime for a trial period; dextroamphetamine, phenytoin, or caffeine also on a temporary basis; or a program of behavior modification. Although many of these treatments are not always effective, they may be worth a try.

*20/84/5*

Don’t Take My Wife, Please

Comedians have been getting cheap laughs at the expense of the old ball and chain for as long as there have been women and steel. The funny thing is that as much as we joke about women driving us to our graves, the fact is that they actually add years to our lives. Finding a mate and being happily married is about as good as, if not better for our health than, quitting smoking, maintaining healthy blood pressure, eating a low-fat diet, or exercising more than 60 minutes a day.

Marriage may also be the key to disease survival, say experts. When researchers at the Veterans Administration Medical Center in Miami checked the survival rates of 143,969 men with prostate cancer, they found that those who were married lived almost three years longer than those who either were never married or were separated or divorced. Marriage is even better for your health if you do it only once. Researchers found that the trauma of divorce can be bad enough to negate the benefits of being remarried.

«But the findings are pretty consistent that being married has plenty of health benefits for men,» says study author Joan Tucker, Ph.D., assistant professor of psychology at Brandeis University in Waltham, Massachusetts. «Women traditionally do things for men that have health benefits. Things like improving his diet, reducing his risky behavior, providing stress relief, and helping him remember to take medication are all strong health supports.»

You are what you eat

Remember the tired old «an apple a day» cliche? Well, a 20-some-year study of almost 10,000 people in Finland confirmed it. Those who ate the most flavonoids, which are natural antioxidants found in many fruits and vegetables, had lower risks for all cancers and half the risk for lung cancer than those who ate the least. The clear winner for lowering lung cancer rates? You guessed it: apples.

But apples aren’t the only fruit of paradise for your health. A study of more than 2,000 Welsh men demonstrated that those who ate the most of any kind of fruit had half the risk for all cancers compared to those who ate the least.

Hell, it’s becoming so hip to eat healthy that major-league ballpark stadiums are even hawking fruits and vegetables next to the weenies and fries these days. Busch Stadium, the Astrodome, Dodger Stadium, Jacobs Field, Oriole Park at Camden Yards, Riverfront Stadium, and Shea Stadium all offer vegetables, garden salads, or fruit and vegetable platters. Others, including Candlestick Park and Wrigley Field, offer garden burgers and other healthful stadium snacks.

Laughing in the Face of Death

Though Bobby McFerrin almost drove us all to an early grave in 1988, with his incessant and insipid «Don’t Worry, Be Happy,» his advice was scientifically sound. If you can laugh in the face of adversity, you can live better, longer.

A Japanese researcher studying 157 men and women ages 65 and older has found a strong connection between maintaining a general sense of well-being and having low levels of total cholesterol, low levels of artery-blocking low-density lipoprotein (LDL) cholesterol, and high levels of healthful high-density lipoprotein (HDL) cholesterol. Lifting your spirits, he concluded, is important in caring for your heart.

Any moves that men can make to relieve their stress and lighten their moods will probably decrease their risks for heart attack, says Dr. Ichiro Kawachi of the Harvard School of Public Health.

*14/36/5*

If you’ve ever wondered how, precisely, people die, we can tell you the one place you should not look for answers: television. On TV, sometimes folks die an agonizing death from the slightest case of sniffles. Other times, the helicopter slams into the bridge and the whole A-Team emerges unscathed.

«It’s hard to answer the question of whether death itself hurts because nobody really knows,» Dr. Iserson says. There can be pain and discomfort at the initial onset of a fatal event, especially with trauma or where a heart attack or a terminal illness is involved. «But it’s not likely that the final moments are very painful since the brain is shutting down. In fact, some dying processes, like drowning, can actually be quite peaceful,» says Dr. Iserson, a near-drowning victim himself. Here’s a quick look at how we die.

The big three. The three top causes of death-heart disease, cancer, and stroke-are also the easiest to understand. They cause death by shutting down vital organs. Most heart attacks occur because the heart is not getting enough oxygen through plaque-constricted coronary arteries. The heart stops, and the lights go out. Stroke is similar but occurs when the brain, not the heart, fails to get enough blood (which is why some doctors now refer to stroke as brain attack). And cancer kills by impairing the functions of the organs it invades.

Bang! You’re dead. Fatal events such as car crashes, falling from high places, or being shot cause trauma. More than half of the time, death in trauma cases is actually the result of injury to the heart, a major blood vessel, the brain, or the spinal cord, which causes blood loss and shock or massive injury to the brain or other vital organs. «That’s why the Safety Council folks are so adamant about people wearing seat belts, helmets, and other protective gear,» says Dr. Wecht. «Often if you can protect your head, you can stay alive.»

Bleeding to death. We tend to think of bleeding as something we do on the outside. But internal organs such as the spleen, liver, and lungs are like miniature blood banks. Rupturing such organs can cause massive internal bleeding, which takes precious amounts of blood out of circulation. A quick loss of 40 to 50 percent of your blood, which is approximately five to six pints in a 170-pound man or four to five pints in a 130-pound woman, is enough to cause coma and death. When too much blood is taken out of circulation, the heart speeds up to try to compensate for the loss. But once the pressure and volume get too low, the person falls into a coma, and the oxygen-deprived heart stops.

From gallows to swallows. Finally, there’s asphyxiation. One sure way to put your heart to rest and your brain to sleep for good is to cut off your air supply. When you can’t breathe, whether a chicken bone is lodged in your throat or cement shoes tied to your feet haul you down to drown, you experience asphyxia. During asphyxia, the pulse quickens, the blood pressure rises, and the amount of carbon dioxide in your blood shoots up due to the lack of new air coming in, or of old air being expelled. In a few minutes, the heartbeat becomes irregular from lack of oxygen and then stops.

Though death accounts are predictably grim, experts say that your final moments, if you are dying from a chronic, natural illness, probably aren’t all that bad-even if they aren’t exactly pretty. «In many cases, it’s just a slip out of consciousness,» Dr. Iserson says.

*25/36/5*

Most people know that if they stopped smoking, drank very moderately, ate the right food, exercised regularly and got enough sleep they would live longer and be healthier. Yet most of us continue to do all or most of the things we know we shouldn’t. True, mortality rates for heart disease and strokes have been falling in the US (heart attack deaths have fallen by 30 per cent over the last 10 years), but the number of people having heart attacks has not fallen as dramatically. Clearly at least some of these improved statistics are the result of better medical care, once a heart condition is apparent.

In the face of unhealthy pressures all around us it would be surprising if self-help methods unfailingly succeeded in improving the health of the individual. But how reasonable is it to place the burden on the individual when cigarette and alcohol advertising continue to bombard him or her from all sides? Can children be brought up to take control of or responsibility for their health when they learn so soon that what they try to do has so little impact? And supposing our man described above did cut out all his vices, what would he do instead – and might it not be even more hazardous?

So if individuals often cannot help themselves, how about the State lending a hand? This only works if the public is ready for the legal restrictions. Prohibition in the US did not work because people weren’t ready for it, yet penalties for driving when under the influence of drink and for not wearing seat-belts are apparently acceptable in the UK and elsewhere. Increased taxation on illness-producing habits works at least to some extent but research shows that real devotees simply give up other things (a healthy diet perhaps) to fund their addictions. Anyway, how far does a government have the right to impose its will on the masses? In other words there is a considerable ethical dilemma involved in preventive medicine. Should 1 be allowed to behave in any way I want, even if it affects others adversely? We all want to see laws such as those that prevent drunken driving, but a balance must be struck between measures like this, which benefit us all, and the reasonable liberty of the individual And then there is the question of individual freedom to act in ways that don’t directly affect others. It could be argued that the man who smokes heavily in private is doing society a favour in several ways. First, he is relieving the society of the cost of the drugs that might otherwise be consumed if he were not smoking and being tranquillized by his cigarettes. Second, his habit will kill him younger, and relatively quickly, by lung cancer (the average lung cancer victim lives only eight months from the discovery of the tumour) or heart attacks-the other major smoking disease. Both kill very quickly, so reducing his capacity to be a burden on society and its medical facilities. Lastly, he will probably not live long enough to collect his old age pension-another saving to society.

Looked at coldly, then, a case could be made for allowing people to do what they want if it kills them quickly and prematurely, if only because we have so many old people and too large a burden of chronically ill already.

My approach to prevention, then, is not a dictatorial one, mainly because after fifteen years of preventive medical experience I know that forcing it on people does not work. In the last analysis everyone must be free to choose his or her way of death-and most of us will do so whatever governments or health educators do. Some kill themselves with overwork, some on the road, some through their hobbies, while others smoke themselves to death, and so on. What I as a health educator can do is to make them aware of the dangers of these harmful pursuits so that they have a choice. I never tell a patient to stop smoking. That’s his or her choice. I don’t expect patients to tell me to stop driving my car-and that could kill me. What I do is to lay before them the facts as they are currently understood about the harmful effects of smoking. The choice is then theirs.

The difficulties come when another person’s behaviour affects my life and health adversely, and most of us agree that the State should step in here. But here again the problems are formidable. Should the State, for example, pass laws to prevent any form of extramarital sexual activity on the basis that it harms innocent third parties? Such a suggestion seems preposterous yet we happily go along with similar laws that stop people polluting the air of innocent third parties with cigarette smoke on far flimsier evidence.

*20/72/5*

Exercise is very important, not only for a person with dementia but also for yourself. If you are the main carer for a person with dementia you may very well have to take exercise together. Not only does this help with physical well-being, but it also has a beneficial effect on the mind, relieving tension and promoting psychological health.

Without doubt the easiest form of exercise for older people, particularly older people with dementia, is walking. This needn’t necessarily be a gentle amble, pleasant though this can be, but a brisk stroll. If physical disabilities allow, walking briskly for about half an hour, sufficient to raise the pulse rate a little and to feel a little hot, will be of constitutional benefit.

Even if it is possible for you to manage it, it is probably best to avoid exercise that leaves you short of breath and perspiring heavily. If you have any doubts about the exercise tolerance either of yourself or of the person you are looking after, it is very important to consult your doctor. Exercise needn’t be taken every day; two or three times a week is probably enough.

There are many different games that involve exercise, but the physical content of these is less important than the personal interaction that they usually generate with other people. Although they tend to be played in a day centre or a day hospital there is no reason why they can’t be practised at home if there are enough people. They can be simple games such as passing a ball around by gently throwing or rolling, or more demanding ones, such as skittles, depending on the severity of the dementia. It is usually not difficult to devise simple activities of this kind which not only involve a certain amount of physical exercise, a feeling of enjoyment, and social interaction with others, but also result in the participants practising coordination.

Some people advocate the sort of physical exercises that young people used to do in gymnastics classes — stretching, bending, jumping, and so on. In my experience these don’t very often appeal to people with dementia and it is also important to stop them falling off-balance. Nevertheless they may be appropriate for some dementia sufferers.

*103\138\2*

Many people still find it difficult to discuss sexual matters even within a normal and loving relationship. When one partner has dementia it can seem totally inappropriate and perhaps wrong even to think about such things. This is a mistake. Most people, if not everybody, need loving, physical contact, both sexual and otherwise.

Often people with dementia can remain affectionate for some considerable period into the course of their illness. They may well respond to the same cues as they have done in the past, the familiarity of which may give them confidence and satisfaction. Sometimes, however, sexual responses change, the physical side of a relationship lapses, and the matter is buried in an attempt to relegate it to the subconscious.

As mentioned before, taking a more active role may help, but usually this is only beneficial in the earlier stages of the illness. The sexual and physical aspects of a relationship are such a personal and intimate part of one’s life that it is unlikely a carer will wish to talk about them, other than with a specially trained counsellor. Some doctors may be able to help, but few are trained in this field. They should, however, be able to help you contact a person with the appropriate training.

For many people, sexual intercourse itself is not what is missed most. It is the physical and asexual expression of an affectionate relationship that means so much.

*81\138\2*

The local authority has to provide many different services. These range from home helps — often the mainstay of a care network that enables an old person with dementia to continue living alone or a family to carry on coping — to day-care provision.

Among these services is meals-on-wheels which aims to ensure at least a basic standard of nutrition on several or most days of the week. Remember, however, that although the meals-on-wheels service may deliver food, many elderly people with dementia don’t eat it! Sometimes this is for practical reasons such as ill-fitting dentures, but often it is because of lack of supervision. I can remember visiting one lady in her mid-eighties, whose dementia had been a problem for three or four years, but who was still living at home. Her general practitioner had asked me to see her because she was losing weight and becoming more frail. The house smelt awful and when I went into the scullery, a little room behind the kitchen, I discovered 123 of the meals-on-wheels service’s foil containers, most unopened, none empty, of those which had been sampled, most looked as if no more than a forkful or two of food had been consumed from them.

The local authority also employs social workers who are highly trained professionals with a wide range of skills and responsibilities. The social worker, unless based in a geriatric or psy-chogeriatric department, is very unlikely to work only with the elderly, but nevertheless will be very knowledgeable about the provision of local services. He or she will be trained to advise about welfare entitlements, can provide a list of local nursing and residential homes, and can liaise with the home-help and meals-on-wheels services.

Social services also run day-care centres. Some of these are specifically for the elderly with dementia. As well as providing some welcome daytime relief for carers, they can also provide a stimulating and pleasant environment for the elderly people who attend. Sadly, however, they are unable to cope with the more severely demented people and may require those attending to be mobile. Unless they are specifically established for people with dementia, they may not be able to deal with confused people who wander or those who are aggressive or otherwise more difficult to manage, socially.

As well as providing day care, some social services, and also voluntary bodies, provide sitting services, either at night or in the daytime. This enables a hard-pressed carer to escape from the house and have some freedom without having to make arrangements with day centres or day hospitals. More importantly, a night-sitting service allows the carer the opportunity of getting a full night’s sleep. Continually broken rest at night wears one down and can be the final straw for many carers.

Voluntary organizations tend to provide the same sort of facility and support as those social services already mentioned. These voluntary services often come into being because of a lack of provision by the local authority or health service. They usually spring up as a result of the initiative of an enterprising individual who is or was a carer. They range from day centres, sitting services, lunch clubs, and drop-in centres for confused elderly people, to support groups for the carers. The latter are described in more detail in a later chapter.

*59\138\2*

The reader will already be aware that there is little one can do in most cases to guarantee the return of the intellectual function that has been lost. Treatment measures fall, in broad terms, into two categories. The first of these of course is the treatment of any underlying cause: making sure that high blood pressure is brought down to normal levels and kept there; that the blood sugar level is kept within normal limits if the patient has a diabetic tendency; or that the blood is thinned if there is a danger of small blood clots entering the circulation from the heart.

In addition to treating any underlying cause it is often possible to try to help a patient regain as much function as possible after having had a stroke. When the stroke affects the limbs it is easier to assist since physiotherapists, occupational therapists, and others can do a lot to help in a practical manner. When the stroke affects a part of the brain that is involved with mental functioning, however, the problems are greater. Nevertheless a speech therapist and an occupational therapist can sometimes assist people with this type of stroke to maximize recovery or to find means of dealing with their difficulties. It is, however, very often difficult to know when another stroke has occurred although it is often easier to help a person with multiple infarct dementia than a person with, say, Alzheimer’s disease.

Since the course of multiple infarct dementia is much more erratic than that of most of the other conditions that cause intellectual decline and since it depends mainly upon the rate at which strokes occur and the structures within the brain that they affect, it is more difficult to give guidance to families as to what the future holds. It is important that families should know, however, that whereas most people with an Alzheimer’s type dementia eventually die of pneumonia, a significant proportion of MID sufferers, because of abnormalities in arteries outside the head, die as a result of heart failure or coronary thrombosis.

*37\138\2*

It has already been mentioned that dementia is separate from the acute confusional state caused by an intercurrent illness such as pneumonia, a urinary tract infection, or the side-effects of drugs. These conditions are usually marked by a sudden onset rather than by the more slow and gradual onset of dementia. Careful inquiry from a relative, friend, or other person who knows the person under investigation well will help determine this and also whether there are any other current medical problems that make an acute confusional state more likely. An example of the latter is the repeated bouts of pneumonia to which people with chronic bronchitis, particularly heavy smokers, are prone. There are, however, many other medical conditions that can be responsible and unravelling these is best left to a general practitioner or, if necessary, a doctor in hospital.

Mrs Smith

A woman of seventy-three was admitted to the casualty department of a hospital at three in the morning one bitterly cold January night. She was brought in by the police who had been alerted by her neighbours, in whose garden she had been found wandering in a confused and dishevelled state wearing nothing but a thin nightgown. Mrs Smith, as we will call the patient, lived alone and was too confused and muddled to be able to answer any of the doctors’ or the nurses’ questions. She had no close relatives but appeared to be a respected and active member of the local community. Like many people of her age she had been noted as becoming a little more forgetful on occasions, but nothing out of the ordinary.

The doctors examined her but were unable to find very much that was wrong. They therefore had to rely upon routine tests to try to discover the nature of her illness. An X-ray of her chest revealed that she had pneumonia even though there were no signs of this on stethoscope examination. In addition, testing her blood showed that the level of sugar was much higher than it should be. Mrs Smith was therefore considered to have diabetes and a chest infection.

The following morning the hospital managed to make contact with her next-door neighbours. They confirmed that they knew her quite well, and had noticed that for about a week she had been thirstier than usual. Otherwise, apart from seeming a little muddled the day before she was admitted to hospital, they had noticed nothing amiss.

This confirmed the impression of the hospital doctors that Mrs Smith had previously undiagnosed diabetes and that this was complicated by a chest infection. Both the diabetes and the pneumonia were sufficient cause for her to have become acutely confused and it didn’t appear, from what her neighbours had said, that she had a progressive dementing illness.

Treatment for her diabetes and her pneumonia resulted in a dramatic improvement and after a fortnight she was back home just as well as she had been before her admission to hospital.

It is important to realize that even a person with a long history of dementia may also be the subject of an acute confusional state, as they may also have an infection or other illness. This has to be considered when the person with dementia suddenly appears to get worse.

Mrs Jones

Mrs Jones had been looking after her father who had had Alzheimer’s disease for several years. He and her mother had lived in their own old people’s bungalow until she had died. Mrs Jones was consulting her doctor to seek some treatment for her father because he had become more agitated and aggressive during the last week. Their general practitioner, however, declined to prescribe any form of treatment until he had had the opportunity of examining Mrs Jones’s father, and he arranged to call later that day. When he examined him, he discovered that her father’s abdomen was much more swollen than it ought to have been and that it was tender and uncomfortable. It appeared that this was because the bladder was unable to drain its contents because of an obstruction caused by enlargement of the prostate gland, not uncommon in elderly men. The doctor therefore arranged for a catheter (a tube) to be inserted via the penis into the bladder, allowing it to drain. When he was relieved of the discomfort caused by his distended bladder, Mrs Jones’s father became his normal self again and did not require any form of medication for his disturbed behaviour.

It can be very difficult to be certain whether the apparent early signs of dementia are really abnormal or whether the person concerned just has more marked age-related memory loss than most other people. There is no definite cut-off point between the effects of normal ageing and the onset of dementia and it is probable that, even if there were, it would differ in different individuals. The only way to be certain is to compare a person’s intellectual ability with what he or she had been like in the past and unless there is a reliable estimate of this it can be very difficult.

For this reason many doctors prefer to observe the person with a suspected but not definite dementing illness over a period of time to see whether there is any further deterioration in intellectual ability of the sort that is typical of dementia. This will often mean that the person concerned will have to undergo careful memory-testing and assessments of other aspects of mental function — often undertaken by a psychologist. A lot of the tests are administered nowadays with the help of a computer which often makes them easier for the subject and more reliable for the psychologist. At the same time the doctor will need to have accurate information from a close relative or friend, if one exists, about any changes they have noticed in the person’s ability to cope with day to day life over the same period.

As well as investigating different aspects of memory function, such as memory for recent events, events that have happened many years ago, and speech memory, the tests may cover other areas including assessment of concentration, the ability to carry out simple calculations, the ability to draw or copy geometric shapes, and to identify simple objects, for example different types of coin held in the hand with the eyes closed. There are of course many other types of test of intellectual function and in general they help to show whether a wide variety of different aspects of mental functioning are affected, even though this has not been suspected in the day to day life of the person suffering from possible early dementia. If there is indeed evidence to confirm suspicion of an early dementia, the pattern of the abnormal function may indicate which of the underlying causes is most likely, although it will rarely pinpoint a specific condition.

For a person in whom the abnormal mental functioning is more florid and for whom the presence of dementia is unequivocal, the tests described above are often still necessary; they will help to determine the rate at which the disease is progressing if they are administered on more than one occasion over a period of time, and are also helpful in assessing the severity of the condition. Again, although some of the simple and short tests can be easily undertaken by a doctor or nurse, if it is necessary to use the more complicated tests these are usually best administered by a psychologist, whose training fits him to assess and advise about such matters.

*15\138\2*