Всё о Гипертензии(гипертонии)-About Hypertension

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.

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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.

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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.

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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.

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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.

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