Mohammed T. Abou-Saleh

314 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYin personal hygiene may amount in due course to alarmingsqualor.LIVING WITH OTHERSDementia may develop in those already living with their family—aspouse or a son or (most often) a daughter. Crises then arise fromthe dependant’s growing infirmity and the increasing burden onthe carer(s) 3 . Acute exacerbations of the dementia intensify thestrain. These may arise from:. The swift progression of the dementia from one stage to thenext 4 . This is said to be characteristic of multi-infarctdementia 5 , but may also occur in Alzheimer’s disease.. Events affecting bodily health, such as heart failure, a urinaryor respiratory tract infection, a fall leading, perhaps, to headinjury; even impaction of faeces may all add to the patient’sconfusion.. Depression may have a similar but more prolonged effect.Dementia is no protection against depression, especially wherethere is some preservation of insight 6 .. The dynamics of the household may have altered because ofsome comings or goings or change in the attitudes or wellbeingof one of its members. Marital strain can cause, as wellas arise from, disturbed behaviour in a demented member ofthe household.The demented person may have moved to be with familybecause of increased infirmity and dependency. Occasionally, oneof the family moves in with the demented person, as when a sonreturns home after being divorced. Such a move may be the resultof some critical failure in self-care—getting lost, having anaccident, being bereft, coming out of hospital unable to cope. Bymoving, the demented person gains safety and security, butdependency increases, autonomy dwindles, friends and familiarhaunts are now at a distance and the activities necessary for dailyliving are much reduced. The carer has gained peace of mind atthe cost of privacy and some disruption of the household 7 . Thearrival of a confused grandparent, repeating him/herself, disapprovingand getting in the way, may be less than welcome to thecarer’s adolescent children. Also, confusion in the demented iscommonly aggravated by a move, so the earliest days are not theeasiest.Occasionally the strain on carers can erupt into ‘‘elder abuse’’ 8 .This may take the form of physical violence, as well as angryoutbursts and verbal abuse. The commonest form is when therehas been mutual dependency between the demented parent andthe abusing son or daughter, now at the end of his/her tether andfeeling trapped in the situation.HOSPITAL, SHELTERED HOUSING AND HOMESDemented people are, because of their accident-proneness anddeficiencies in self-care, far more prevalent among the elderly ingeneral hospital wards than in the population at large 9 . Here theirproblems may be exacerbated by sudden admission, hasty andinadequate communication, the discomfort and disability ofwhatever they have been admitted with and sometimes, unfortunately,the indifferent, dismissive, patronizing and even hostileattitudes of staff, wary of another ‘‘social admission’’ or ‘‘bedblocker’’10 . Medication may add to confusion by lowering bloodpressure, causing drowsiness, or through anticholinergic sideeffects.In the setting of a busy medical or surgical ward, anapparently able-bodied but deranged older person may beperceived as a threat—disturbing sick patients by being noisyand interfering—or an undue responsibility, liable to wander offand become lost. Consequently it is still not unknown for physicalrestraint—binding hands, body or feet, trapping the patient in a‘‘geriatric’’ chair, using cot-sides—to be added to sedation 11 .A move into sheltered housing seems to have much to commendit for those who are now too forgetful and erratic to managereadily at home but not in need of full-time care. However, such amove is better made sooner than later. Otherwise, the strangenessof the new environment aggravates the confusion, and problemsmay arise in the use of the alarm cord or bell to call the warden,who is summoned frequently in error. Too often the stay insheltered housing proves quite brief, before a further move intoinstitutional care is necessary.Although most demented people are in their own or relatives’homes, they are also major users of residential and nursing homes,some taking all comers, others specializing in the elderly mentallyinfirm (‘‘EMI’’). Even in ordinary homes, as many as 60–70% ofthe residents may be found to be demented 12 . Homes which werealready looking after the old person before the onset of dementiausually cope very well, but where someone is admitted because oftheir dementia there may be clashes because the parties have nothad time to get to know each other. Demented people can, ofcourse, be difficult, demanding and highly irrational, but sometimes‘‘it takes two to make a quarrel’’ and tactless, hasty,overbearing staff may provoke escalation of a minor dispute intoa major row. Other problems that may arise from communalliving include fights between residents, say where one accuses theother of going off with his/her belongings or of wandering intohis/her room and interfering with the bedding (which may well betrue!), and antisocial behaviour such as stripping, masturbation,sexual advances, noise and disgusting eating habits. Another crisisis that the money runs out for costly care and there are urgentdemands to find the resident another place!ACUTE MANAGEMENTAcute problems may be lessened by early identification of thedementia, taking account of how it is managed at that time, who is(or may become) the key carer and designating a key worker toguide, advise and support that person. If no key carer isidentifiable among family or friends one may need to be enlisted,such as a home help or a paid ‘‘good neighbour’’. Sucharrangements are highly dependent on good, well-organizedprimary health care and social services, with support fromvoluntary agencies and a well-resourced psychogeriatric service,all working well together. A ‘‘case manager’’, generally someonewith a background in nursing or social services may be the bestperson to assemble a ‘‘package of care’’ 13 , but is more effectivewhen the client is merely elderly and infirm 14 than significantlydemented 15 .Where dementia is identified early as the result of a screeningprogramme (e.g. for the over-75s) 16 , some discretion as to how,when or, indeed, whether to impart that information. There is thepossibility of an adverse reaction to the label ‘‘dementia’’; thefamily may feel that the task of caring will prove too much—beforehand they thought they were just helping someone who wasageing normally—while demented persons may be distressed bythe diagnosis. However, there is the possibility of involving themwith the carers in plans for their future, to prefer one kind ofmanagement to another, make a will, give an enduring power ofattorney and feel that they retain some control over their owndestiny 17 . The advent of the oral anticholinesterases for Alzheimer’sdisease 18 demands informed consent to their use.Key carers need respite before they feel burdened by theircontinuous responsibility. ‘‘Sitters-in’’ enable them to take a fewhours out of the home alone. Meals on wheels and home helpsshould not be reserved solely for demented people living alone;