CHAPTER I PREFACE

Alzheimer dementia is not the hottest topic in the philosophy of psychiatry. The excuses for this are several. In some countries, after all, it is dealt with by physicians (geriatricians or neurologists), not by psychiatrists. This is probably because it is readily thought of as a brain disease and not as a mental illness. In addition, the symptoms of a condition such as schizophrenia seem more likely to raise issues of interest to philosophers: thought insertion, delusions, hallucinations and the like. But the tendency to overlook the philosophical issues raised by Alzheimer dementia is a mistake. For one thing, as the practitioners in this volume make plain, it is not just a brain disease. It affects the whole person. For this reason, as the philosophical discussions in this volume show, it is a condition that raises in a dramatic form issues about personhood. For example, do people with Alzheimer dementia lose their minds? Do they lose their selfhood? What are the criteria employed in answering these questions and what supporting evidence is provided? Would our belief that such people have lost their minds and selfhood affect the ways in which we treat them? Does our treatment of them affect people with Alzheimer dementia and if so, how? If our behaviour does affect them in particular ways, what would that mean for them? Furthermore, as Alzheimer dementia becomes more common, society at large needs to think clearly about how it views and treats people with Alzheimer dementia. Psychoanalytic Psychotherapy: In its purest form, two types of problems bring an individual to a psychologist's office: Problems emerging from a patient's past life (the patient's developmental trauma and experiences) and problems which appear to arise from current internal and external stressors. It is rarely, if ever, that this separation of problems is that pure. In reality, current problems are superimposed on old and chronic problems which the patient has carried for an extended period. The skilled 1

doctor is able to see the impact of the past upon the response to present stressors. An initial means of conceiving of psychotherapy is understanding that it is a means of creating a professional atmosphere in which old feelings and fantasies can be brought to the surface so that they may be studied, understood and resolved. Psychoanalysis therapy refers to the use of behavioral and psychological therapies. Several therapies are used. Especially in the early stage of Alzheimer's disease, psychotherapy may be helpful for the individual with AD. Therapy can help the person cope emotionally with accepting the illness and with other problems, such as depression. Most commonly, Psychoanalysis therapy involves strategies used by careproviders to manage problem behaviors. Psychoanalysis strategies vary with each individual and as the disease progresses. In the early stages of AD, memory aids are helpful. Large clocks and calendars, lists of daily plans, simplifying tasks and having written directions on how to use common household items can help with day-to-day living. As the disease progresses, there are strategies to make bathing, eating and other routines easier. These are only a few examples from many helpful behavioral management approaches. I hope it will be read by people from various disciplines and none. Inevitably, then, some people will know more about Alzheimer dementia, but will be unfamiliar with philosophical writings; others will be interested in philosophy, but know little about Alzheimer dementia. We hope so! I must thank for God and my parent who have remained remarkably friendly none the less.

CHAPTER II CONTENT
Alzheimers Disease Alzheimers disease is an irreversible, progressive brain disease that slowly destroys memory and thinking skills, and eventually even the ability to carry out the simplest tasks. In most people with Alzheimers, symptoms first appear after age 60. Most common cause of dementia among older people. Dementia is the loss of cognitive functioningthinking, remembering, and reasoningto such an extent that it interferes with a persons daily life and activities. Alzheimers disease is named after Dr. Alois Alzheimer. In 1906, Dr. Alzheimer noticed changes in the brain tissue of a woman who had died of an unusual mental illness. Her symptoms included memory loss, language problems, and unpredictable behavior. After she died, he examined her brain and found many amyloid plaques and neurofibrillary tangles. Plaques and tangles in the brain are two of the main features of Alzheimers disease. The third is the loss of connections between neurons in the brain

Changes in the Brain in Alzheimers Disease Although we still dont know what starts the Alzheimers disease process, we

do know that damage to the brain begins as many as 10 to 20 years before any problems are evident. Tangles begin to develop deep in the brain, in an area called the entorhinal cortex, and plaques form in other areas. As more and more plaques and tangles form in particular brain areas, healthy neurons begin to work less efficiently. Then, they lose their ability to function and communicate with each other, and eventually they die. This damaging process spreads to a nearby structure, called the hippocampus, which is essential in forming memories. As the death of neurons

increases, affected brain regions begin to shrink. By the final stage of Alzheimers, damage is widespread and brain tissue has shrunk significantly : 1. Very early signs and symptoms Memory problems are one of the first signs of Alzheimers disease. Some people with memory problems have a condition called amnestic mild cognitive impairment (MCI). People with this condition have more memory problems than normal for people their age, but their symptoms are not as severe as those with Alzheimers. More people with MCI, compared with those without MCI, go on to develop Alzheimers. Other changes may also signal the very early stages of Alzheimers disease. For example, brain imaging and biomarker studies of people with MCI and those with a family history of Alzheimers are beginning to detect early changes in the brain like those seen in Alzheimers. These findings will need to be confirmed by other studies but appear promising. 2. Mild Alzheimers Disease As Alzheimers disease progresses, memory loss continues and changes in other cognitive abilities appear. Problems can include getting lost, trouble handling money and paying bills, repeating questions, taking longer to complete normal daily tasks, poor judgment, and small mood and personality changes. People often are diagnosed in this stage. 3. Moderate Alzheimers Disease In this stage, damage occurs in areas of the brain that control language, reasoning, sensory processing, and conscious thought. Memory loss and confusion increase, and people begin to have problems recognizing family and friends. They may be unable to learn new things, carry out tasks that involve multiple steps (such as getting dressed), or cope with new situations. They may have hallucinations, delusions, and impulsively.

4.

Severe Alzheimers Disease The final stage, plaques and tangles have spread throughout the brain and brain tissue has shrunk significantly. People with severe Alzheimers cannot communicate and are completely dependent on others for their care. Near the end, the person may be in bed most.

What Causes Alzheimers Scientists dont yet fully understand what causes Alzheimers disease, but it is

clear that it develops because of a complex series of events that take place in the brain over a long period of time. It is likely that the causes include genetic, environmental, and lifestyle factors. Because people differ in their genetic make-up and lifestyle, the importance of these factors for preventing or delaying Alzheimers differs from person to person.

How Alzheimers Disease Is Diagnosed Alzheimers disease can be definitively diagnosed only after death by linking

clinical course with an examination of brain tissue and pathology in an autopsy. But doctors now have several methods and tools to help them. To diagnose Alzheimers, doctors: ask questions about the persons overall health, past medical problems, ability to carry out daily activities, and changes in behavior and personality Category Orientation to time Orientation to place Registration Attention and calculation Recall Language Repetition Complex commands Source : http://zulliesikawati.staff.ugm.ac.id/wp-content/uploads/alzheimers3 2 1 6 Possible points 5 5 3 5 From broadest to most narrow. Orientation to time has been correlated with future decline From broadest to most narrow. This is sometimes narrowed down to streets, and sometimes to floor Repeating named prompts Serial sevens, or spelling "world" backwards It has been suggested that serial sevens may be more appropriate in a population where English is not the first language. Registration recall Name a pencil and a watch Speaking back a phrase Varies. Can involve drawing figure shown. Description

disease.pdf conduct tests of memory, problem solving, attention, counting, and language (Mini Mental State Examination) carry out medical tests, such as tests of blood, urine, or spinal fluid perform brain scans, such as computerized tomography (CT) or magnetic resonance imaging (MRI)

source:http://zulliesikawati.staff.ugm.ac.id/wp-content/uploads/alzheimersdisease.pdf These tests may be repeated to give doctors information about how the persons memory is changing over time. Early diagnosis is beneficial for several reasons. Having an early diagnosis and starting treatment in the early stages of the disease can help preserve function for months to years, even though the underlying disease process cannot be changed. Having an early diagnosis also helps families plan for the future, make living arrangements, take care of financial and legal matters, and develop support networks.

source:http://zulliesikawati.staff.ugm.ac.id/wp-content/uploads/alzheimersdisease.pdf

Therapy What is sparse the gerontological literature is a focus on the treatment of the

actual patient with Alzheimers disease. As of yet, there is no known effective treatment to address the brain deterioration of this disease, the physiological processes which cause the primary symptoms. Efforts to treat the effects of the disease-the secondary symptoms-have largely been of three types: environmental, managerial and behavioural. Environmental and managerial treatments include vital attention to the caregiver; vital not only for the care givers well being in their own right, but also because

caring for the care-givers is a way of caring for the patient. Nurture and support of care-givers make them more available for the difficult task of caring for a Alzheimer patient. We can help care-givers express their feelings about their impaired relative, their frustation when they feel helpless in the face of this disease. We can invite them to join groups in which they will find out that they are not alone, and in which they learn how other families managed in similar situations. In addition we can counsel them on how to respond to their demented relative, how best to arrange the environment, how to find good substitute care-givers, how to chose doctors, day centres and nursing homes. Attention in the literature that is directed to the Alzheimers patient him or herself most often focuses on pharmacologic interventions, environmental manipulation, behaviour modification and reality orientation. Pharmacologic treatments aimed at agitation, sleeplessness, depression, anxiety and paranoid ideation can improve the quality of life of a person suffering from Alzheimers disease. Manipulating the environment-making it safer and more orderly, while reducing overstimulation-makes the world more comprehensible and help a demented person feel more in control of it, particularly at the beginning and middle stages of the disease. Behaviour modification can train the patient himself to keep more order in his or her life, and can sometimes alleviate embrrassment by such factors as incontinence, wandering, forgetfulness, dangerous kitchen practices-giving the patient more of a sense of control and providing the patient the maximum amount of independence for the longest possible duration. 4.1 Psychoanalytic therapy Psychoanalytic therapy is based upon psychoanalysis but is less intensive, with clients attending between three to seven sessions a week. Psychoanalytic therapy is often beneficial for individuals who want to understand more about themselves. It is particularly helpful for those who feel their difficulties have affected them for a long period of time and need relieving of mental and emotional distress. In its purest form, 9

two types of problems bring an individual to a psychologist's office: Problems emerging from a patient's past life (the patient's developmental trauma and experiences) and problems which appear to arise from current internal and external stressors. It is rarely, if ever, that this separation of problems is that pure. In reality, current problems are superimposed on old and chronic problems which the patient has carried for an extended period. The skilled doctor is able to see the impact of the past upon the response to present stressors. An initial means of conceiving of psychotherapy is understanding that it is a means of creating a professional atmosphere in which old feelings and fantasies can be brought to the surface so that they may be studied, understood and resolved. 4.2 Behavior therapy

Behavior therapy is a combination of the systematic application of principles of learning theory to to the analysis and treatment of behavior. It involves more than principles of learning and conditioning, however, and uses the empirical findings of social and experimental psychology. The emphasis is placed upon the observable and confrontable and not inferred mental states or constructs. The doctors seeks to relate problematic behaviors (symptoms) to other observable physiological and environmental events. This involves behavioral analysis of what is occurring (and has occurred) and means of altering the behavior. The early development of behavior therapies occurred in the 1960s and 1970s and at that time, this mode of psychological care was defined as the systematic application of learning theory to the analysis and treatment of behavioral disorders. This is too narrow of a definition and today, behavior therapy draws not only upon principles of learning theory and conditioning but upon empirical findings from experimental and social psychology. The doctor relates that patients and their disorders to to observable events from physiological or environmental factors rather than inferring that they arise as a result of unseen/unrecognized/unconscious conflicts or trauma. Behavioral analysis, noting the events which lead to motor or verbal behaviors, is used to assist the patient

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in understanding cause-effect relationships and means of disrupting/discontinuing the maladaptive or counterproductive behaviors. Behavior Therapies have a wide range of application in phobic, maladaptive habit, and compulsive behaviors. 4.3 Group psychotherapy

Group psychotherapy is effective and appeals to many patients and doctors. The same number of doctors can treat more patients, and it may be combined with individual psychotherapy. In some countries, the group psychotherapeutic approach has exceeded the individual approach. As the nuclear family and religion has become diverse, and in some instances, fragmented, the psychotherapy group may meet the strong need to belong, affiliate and assist others. Many doctors see a group size of 8 to 10 patients as optimal, but groups may vary in size from 3 to 15. Weekly or twice monthly sessions of 1-2 (1 most common) hours seems to be the average. Groups of differing ("heterogeneous") patient needs may be helpful, but there are some group psychotherapy where all share the same expressed need or disorder. In some instances the group is thought of as a doctor who is expressed through other group members: as each group member grows stronger, he/she provides assistance in interpretation, insight and decision making to other group members. 4.4 Psychopharmacotherapies

Psychopharmacotherapies are based upon the realization that the brain is not chemically responding in a functional fashion. This has to do with chemicals within the brain and central nervous system called neurotransmitters which must not only exist but exist in balance for thought, emotion and behavior to have regulation. Vigorous research on these chemical agents have existed since the mid 1950s. As a result of this research, we better understand how the brain's function is regulated and how best to assist those who suffer from dysregulation of these neurotransmitters. Acetylcholine and norepinephrine were among the first investigated followed by dopamine (dihydoxyphenylethylamine) and indoleamine serotonin. Quantitatively, these are only 11

minor transmitters in the brian but they serve major roles in emotional behavior. The anticonvulsants, neuroleptics, antidepressants and anxiolytic agents are ever being refined. They are not addictive agents although some patients become dependent upon the anti-anxiety (anxiolytic agents) when they are not prescribed in an appropriate schedule. Non-medical abuse of the anti-anxiety drugs is actually uncommon. These anxiolytic agents were excessively prescribed in the past, and some clinicians became hesitant to prescribe them. Appropriately used, the drugs are both safe and beneficial.

source:http://zulliesikawati.staff.ugm.ac.id/wp-content/uploads/alzheimersdisease.pdf 5 Strengths Many clinicians have observed that demented patients can be reached affectively long after they cease to be able to be reached cognitively. The affective responses in the limbic system seem to be the last to go, which be the reason that a persons lifelong style of affect seems to remain intact except in the very late stages of this disease. The skill of recognition, which remains long after the ability to recall, can be worked with. A persons ability to form relationships, at least in all but the last

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stages of this disease, can be utilized, and is a major component of therapeutic action. The transference often develops very rapidly in demented patients, and is another strength which can be used.

Conducting Psychotherapy The Alzheimer patients ability to benefit from psychotherapy will depend

mainly on the relationship with the therapist. The earlier in the progression of the disease this relationship is formed, the better the chance of using it to help bring about movement toward the other goals. Many demented people develop relationships with the therapist easily and quickly because of their unmet need for someone who is accepting, empathic and trsutworthy. Sometimes people who have endure multiple losses have to test the relationship, to ascertain that it is trustworthy. If the relationship feels safe, non-threatening, accepting, honest and respectful, the patient will be able to move toward the highest level of functioning possible for him or her at the particular stage of his or her disease. If such patients are not afraid, they will be able to hear interpretations better try new ways of coping with a minimum amount of defensiveness, know that their efforts to communicate will not be criticized. They will have an empathic ally. A patient can accept painful information from a therapist he or she has learned to trust. Knowing that the demented patient can still be reached affectively gives direction to the treatment. When the therapist reacts to the patients feeling, the patient will know he or she is cared about. The therapist does not try to change the patient or to get him or her to operate in a cognitive mode that has been lost. Such acceptance of the patient as he or she is in stark contrast to the approach of many family members, who have a poignant investment in getting the patient to be the way he or she used to be. 6.1 The Therapist 13

Countertransference phenomena exist in all therapists, no matter how wellanalysed they are. When recognized and understood, countertransference is a very useful tool. Countertransference has come to have a broader meaning than the classical definition-relating to the patient as if he or she were a significant person from the therapists past. It includes all the feelings aroused in the therapist during the clinical work. Unexpected and often unrecognized countertransference problems abound with geriatric patients. The therapists own child-parent relationship is likely to be a factor. Feelings of hostility, frustration and helplessness often come into play when working with patients who have irreversible illness and will not get better. With Alzheimers patients, countertransference phenomena multiply. In the therapists mind the question Will this happen to me? to keeps arising. Patients of background and education similar to the therapists intensify such identification. The deeply rooted archaic feelings of helplessness that we all have become intensified when working with demented people. Some activities called for on the therapists part when working with an Alzheimers patient are far from what a therapist normally does in the course of his or her work, and make the therapist feel more like a careprovider than a professional. Before we could engage in any kind of therapy, the room had to be straightened, and must with enough motivation to do so. Another patient had two instance of incontinence during sessions. Resentment over the need to spend many extra hours talking to doctors (we), nursing-home personnel and family easy to angry, frustration and give up, but we must work together for Alzheimers patient because that is a part of our jobs. Inexperienced therapists dismiss demented patients too soon because of their own self-concept problems when they find themselves doing more of these case management tasks and less of the therapy they were trained to do. 6.2 The Patient

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The two major obstacles within the Alzheimers disease patient when egaging in dynamic psychotherapy are in the areas of communication and defences. The application of psychotherapeutic techniques needs communication channels, and the normal channels are impaired in Alzheimers patients. After all, the target of psychological techniques is the brain, and the brain of Alzheimers patients is permanently impaired. Injury to the cerebral cortex means injury to the autonomous ego functions of thought, memory, speech and perception. Lost, to one degree or another, are: the ability to abstract; the ability to compare and thereby think in as if terms (so necessary when working with transference phenomena); the existence and use of the observing ego; the ability to be accountable for ones acts; the ability to problem-solve. Because of all these losses and changes, the demented patient often calls in inappropriate primitive defences which can compound the problem of engaging in dynamic psychotherapy. Rather than try to change, a demented patient clings to and tries to be even more of the way he or she was before. An aggressive ambitious person may try to defend against the threat of loss of control by becoming even more aggressive and controlling. The compulsive person may become more rigid and set in Alzheimers patient usual ways. The primitive defence of splitting, described above, in which everything and everyone is seen in extreme terms, often comes into play during the course of this disease. Projection, with its accompanying accusatory behaviour and withdrawal, which feels passive-aggressive, alienate those whose support is needed. Loss of secondary processes causes regression to primary process thinking and the need for immediate gratification, sometimes snowballing to aggression, psychotic symptoms (delusions and hallucinations), combativeness and other catastrophic reactions. These lead to further alienation of careprovivers (not to mention alienation of the therapist).

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Prognosis and Complication A person with Alzheimer's disease can experience the following complications: Falls (from impaired coordination) "Sundowning" (withdrawal or agitation in the evening) Malnutrition and dehydration Infection (from urinary tract infections or pneumonia) Asphyxiation (stopped breathing) Harmful or violent behavior toward self or others Poor health and support due to caregiver burnout Physical and emotional abuse, including neglect Coronary disease There is no known cure for Alzheimer's disease; the disease naturally

progresses and worsens over time. People with the disease can survive for many years, however. While most people with Alzheimer's die within 8 to 10 years, some live as long as 25 years. Some people decline steadily during their disease, while others reach major plateaus where their symptoms advance quite slowly. Men and people with a long-standing history of high blood pressure are more likely to decline rapidly. Additionally, the older a person with Alzheimer's disease becomes, the more likely he or she is to decline rapidly. An accurate, early diagnosis gives affected individuals a greater chance of benefiting from existing treatments. CHAPTER III CONCLUSION

3.1

Conclusion

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Alzheimer's Disease is the leading cause of brain cell loss in the elderly population. This loss of brain cells is so severe that it causes loss of memory, difficulty with speech, and disorientation. As of yet, researchers do not know exactly what causes Alzheimer's Disease, but fortunately, there are prescription medications available today to help treat the symptoms. There are care facilities for people who are afflicted with this illness, but many people are cared for by a member of his or her family in their homes, or by a hired nurse or qualified caretaker. Wherever the Alzheimer's patient is placed, the important thing is that he or she recevies the type of care that they need. For example, a person who is suffering from Alzheimer's Disease needs plenty of time to organize their thoughts and put them together in order to communicate with their caretaker. The caretaker must be patient and not interupt while waiting for either a response or a statement. The careprovider needs to speak clearly. Also,the caretaker needs to make a special effort to use eye contact and gentle touching methods in order to help the patient understand that they are being heard, or that the caretaker wants their attention for some reason. Sufferers of Alzheimer's Disease also have a need for familiarity an repetition in their daily lives. Because of their illness, they tend to become easily confused or disoriented. Their bedroom should not be re-arranged after they have become accustomed to the locations of things in the room. Ideally,their room should either have an attached bathroom or be near a bathroom so the patient can find it more easily. Caretakers of Alzheimer's patients must arrange a schedule every day for their patient to follow. The schedule should list routine activites such as eating, bathing, taking medications, and so forth. It should also include doctor's appointments, hair care appointments, as well as any other times that the person will be leaving the house or doing something out of the ordinary routine. If time allows in the daily schedule, recreational activities as well as exercise periods should be encouraged for the Alzheimer's patient. Most sufferers cannot comprehend complex games with many rules, so simple games are recommnded. 17

Playing games helps to stimulate the patient's mind. If they are physically able, they should be encouraged to perform simple exercises in order to keep their physical bodies limber. In conclusion, Alzheimer's patients are exactly like any other patients in that they need plenty of care, support, patience, and love. A caretaker must keep in mind that the patient did not ask for this illness, and they, as well as the caretaker, must deal with it on a daily basis. 3.2 Suggestion As older members experience age-related health declines, families provide the majority of help enabling impaired elderly to remain living in the community. Families do not dump their older members in institutions. However, should institutionalization become necessary and appropriate, families continue to be actively involved in the lives of institutionalized relatives. The suggestions made in this chapter for supporting both the client and resource roles are by no means exhaustive. Rather, they indicate tremendous scope and direction for the professionals who provide health care to the elderly. The incorporation of families in the planning and implementing of care, in both community and institutional settings and can only benefit both patients and their families. I hope my paper will prove helpful in assisting health proffesionals and family of Alzheimers patient understand and respond to the Alzheimers patient.

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