Caregiver Training Courses

Caregiver Training Ebooks

The caregiver training e-book gives a training course on how to provideassistance to another person who is ill, disabled or needs help with daily activities. It can also serve as a useful guide to the individuals in the need of help. The product deals in physical, mental, social, and psychological needs and well-being of both the caregivers and the elderly person requiring care. Everyone needs a little help from time to time and while many seniors lean on the friends and family members for support, there may be some instances in which it's necessary to seek additional assistance or long-term care which was why this product was created by the author. This caregiver product is a practical guide created by the author who is an expert in the field. This product embeds in it several training sections in which each section gives detailed information on how to provide assistance to people who are ill, disabled, or aged. This product is a trusted and 100% guarantee to provide the necessary details needed in caring for the physically challenged, aged and ill individuals. The product is also an essential overview of issues from Alzheimer's to diabetes to strokes. More here...

Caregiver Training Ebooks Summary


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The Caregiver Role In Managing Ad

The efficient diagnosis and successful management of AD depends on identifying a caregiver. Typically, family members and friends take on some part of the role and self-identify at the time of the initial presentation by providing a history of the cognitive problem. At this early stage, it is important to establish permission to speak openly with the caregiver to acknowledge and reinforce the notion that the caregiver is the advocate for the patient. Caregivers may be spouses of affected individuals however, in many instances, they are other family members or friends. Because AD is a long, progressive illness, many may be unprepared for the difficulties associated with caring for the demented patient. In addition, because many caregivers maintain and implement interventions for patients, their health status can become the concern of the patient's doctor (Lucero, Pearson, Hutchinson, Leger-Krall, & Rinalducci, 2001). Caregiver burden can be described in emotional, physical, and social...

Future Needs And Resources Of Family Caregivers

The family will continue to be the primary source of physical, social, emotional, and financial support for its members. Demographic changes such as increased life expectancy, the large baby-boom cohort, and fewer age peers suggest that there will be more older family members to be cared for by fewer younger family members. Although caregiving in aging families brings to mind images of younger members providing care for older members, care tends to flow from older to younger members as well. Older people provide care for each other, their children, and their grandchildren. Siblings also provide care for other siblings who have no spouses or children to rely on. Moreover, unless gender-role socialization practices change, women will still be considered the primary caregivers to both the young and old. To further complicate both ethical and practical issues surrounding family social care, women are now also more likely to be working outside the home. Consequently, they are likely to...

Family Social Caregivers

Care is principally provided by a single individual, the primary caregiver, with assistance from one or more others, secondary caregivers. The majority of the primary caregivers for spouses are their wives or husbands (Older Women's League, 1989 Stone, Cafferata, & Sangl, 1987 E. M. Brody, 1981). Most older men are married and thus receive needed care from their wives. If the older person is not married or the spouse is ill, an adult daughter or daughter-in-law most often assumes the caregiving role, followed by a sister, niece, or granddaughter. This order represents a preference based on the care-giver's relationship with the older person, geographical proximity, and traditional gender roles. Adult children are primary caregivers to older widowed women and older unmarried men and serve as secondary caregivers for married couples. The type of assistance given is influenced by the older person's functional level, place of residence, and the gender of the caregiver. For example,...

Caregiver Burden

Caregiver burden is well described in dementia in general. Several studies illustrate, however, that caregiver burden and depression may be amplified when caregivers care for patients who have both dementia and depression (Donaldson, Tarrier, & Burns, 1998 Teri, 1997). However, as it has been shown that even slight improvements in patients' function can enhance quality of life for the caregiver, diagnosis and treatment of depression in dementia can make a clear impact. Caregiver overwhelmed 0- Thus, the diagnosis and treatment of depression in dementia is not only worthwhile, it is an area where physicians and health care providers in a variety of disciplines can make a clear difference in quality of life for the patient as well as the caregiver.

Caregiver Issues

The use of caregiver informants can aid, as well as complicate, the diagnosis of depression in dementia. Caregivers themselves are prone to high levels of burden and depression. Depression-related behaviors may be among the most distressing to caregivers of patients with dementia (Donaldson et al., 1998). The occurrence of depression in dementia patients has been found to correlate strongly with caregiver burden and their own depression (Donaldson et al., 1998 Shua-Haim, Haim, Shi, Kuo, & Smith, 2001 Teri, 1997). There is some suggestion that some caregivers may overstate mood symptoms in the patients they are caring for secondary to their own issues of burden and depression, carrying their own baggage into the interview room (Schulz & Williamson, 1990 Schulz, O'Brien, Bookwala, & Fleissner, 1995). Teri and Truax (1994) found significant correlations between caregiver Ham-D and Ham-D ratings of their impaired relatives however, no association of caregiver depression with videotaped...

Nonpharmacological Approaches To Treating Alzheimers Disease

Nonpharmaceutical approaches for AD examine managing behavioral and cognitive symptoms without the use of medication. A secondary goal is to lessen caregiver burden. Nonpharmcological treatment approaches may be advantageous when medications are unavailable, the patient cannot tolerate the side effects of medications or does not comply with medication labeling instructions, or medications are contraindicated. These approaches may also supplement pharmacological treatment for the optimal patient management. Behavioral disturbances often lead to earlier placement of individuals in nursing homes and long-term care facilities. When caregivers can effectively manage behaviors at home, time to nursing home placement may be

How Older Adults Contribute To The Health Of Their Communities

As noted above, older adults, particularly women, are frequent volunteers in urban communities, bringing services and support to many others. Older people who do not do paid work or formal volunteering often serve as informal caregivers, providing important care to spouses or to grandchildren. Thus, older adults bring substantial social and financial capital, as well as neighborhood stability, to urban communities.

Frontotemporal Dementia

Two neurotransmitter deficits are controversial (Francis et al., 1993 Litvan, 2001 Sparks & Markesbery, 1991). An open label trial of serotonin selective reuptake inhibitors (SSRIs fluoxetine, sertraline, paroxetine) in patients with FTD has demonstrated improvement of behavioral symptoms in some patients (Swartz, Miller, Lesser, & Darby, 1997). Specifically, SSRI treatment improved disinhibition, depression, carbohydrate craving, and compulsions in at least half of the subjects tested. Trials of cholinesterase inhibitors in FTD have not been reported. Although not tested specifically in FTD, some have speculated that dopamine agonists such as bromocriptine may improve executive cognitive function in FTD as has been shown in patients with closed head injuries (McDowell, Whyte, & D'Esposito, 1998). Treatment of psychosis, agitation, sexually inappropriate behavior, and aggression has not been studied in FTD specifically, but medications used in patients with these behaviors caused by...

Patient And Family Education

Patients should be advised to keep a diary or journal and to write down questions and prioritize their concerns. This can result in office visits that are less frantic and can reduce the number of phone calls. Patients should be urged to bring someone with them to all appointments. Information should be provided in a calm and comforting manner. The key is to maintain an open line of communication between the team, the patient, and the patient's family over the course of the illness and to ensure that the communication and information is comprehensive and consistent. Continual teaching and reinforcement of previous teaching as well as interpretation of outside information is key to an open line of communication between everyone. The focus is on answering questions, providing information, and constantly repeating information. It is imperative to involve the family and other caregivers at all times. Patients will do better with complex treatment if...

Clinical Characteristics in Psychosis of AD

Hallucinations are defined as false sensory perceptions that are not distortions or illusions (misinterpretation of a sensory stimulus). Visual and auditory hallucinations are most common with varied prevalence between 5 and 20 in different studies. Hallucinations in AD are more frequently visual than auditory (Holroyd, 1996) the reverse is true for schizophrenia. Typical schizophrenia delusions (e.g., hearing multiple voices speaking at once or hearing one voice with a running commentary on the patient's actions) are rare in AD. A number of groups have found that delusions or hallucinations are commonly associated with aggression, agitation, and disruptive behavior (Flynn et al., 1991 Rabins, Mace, & Lucas, 1982 Rockwell, Krull, Dimsdale, & Jeste, 1994). Often, however, patients do not seem to change their behavior because the delusions or hallucinations are not upsetting. Family members are, however, often very upset by having a loved one with delusions or hallucinations, and...

Surveys of Sick Individuals about their Use of OTC Healthcare Products

A study by Johnson et al. (2005) measured purchase (versus use) of an OTC product and the timing of purchase. In a survey of the caregivers for 78 children visiting an emergency department (ED) for an acute infectious illness, they found that caregivers purchased an OTC product for 32 (41 ) of the children prior to the visit. On average, the caregivers made the purchase 1.88 (95 confidence interval CI , 1.4-2.3) days prior to bringing their child to the ED. Of 29 children with cough and fever, caregivers purchased an OTC medication for 18 (62.1 ). Of 30 children with vomiting or diarrhea with fever, caregivers purchased an OTC medication for 19 (63.3 ). A limitation of this study is that it examined only children who presented to an emergency department, as opposed to the other surveys we have discussed, which conducted telephone interviews of a more representative sample of the population. The Walter Reed Army Institute of Research is conducting a similar study in adults (Pavlin,...

Ethical Issues in Family Care

Families tend to create enduring patterns of reciprocal support between older and younger members. Family social care is provided both by younger family members for older family members and by older people for younger. The focus of social care is providing assistance that increases a person's competence and mastery of the environment, rather than increasing his or her dependence (Hooy-man & Kiyak, 1996). From a life-course perspective, social care begins with nurturing and socializing the young for participation in society. At the other end of the life course, social care provides assistance with tasks of daily living and personal care in cases of extreme disability. The specific type of assistance is determined by the family member's functional ability, living arrangements, and the gender of both caregiver and receiver. A discussion of ethical issues related to family social care must take into account different types of assistance, family structure, gender, age, and racial ethnic...

Gender And Family Social Care

They provide social, emotional, and instrumental care to the young, the old, the ill, and the disabled sometimes simultaneously to various types of dependents. Men seldom engage in primary personal care and tend to provide personal care and instrumental aspects of care such as cooking and cleaning only when no women are available (N. J. Finley, 1989 Foster & Brizius, 1993 Kaye & Applegate, 1990 B. Miller & Cafasso, 1992). Sons are less likely than daughters to provide care in their own homes for a dependent parent. In general, men tend to focus on financial and concrete assistance (Hooyman & Kiyak, 1996). Many men, however, are primary care-givers (E. M. Brody, 1985 B. Miller & Cafasso, 1992), especially husbands for their wives. A discussion of the ethics involved in family social care must address this unequal gendered division of caregiving responsibilities. Furthermore, power differentials within patriarchal families may complicate ethical...

Reproductive biology

Genital Callithrix

Carrying the heavy offspring is a strong, energetic burden. Studies of captive cotton-top tamarins have shown that carrying males may lose up to 10 of body mass in the weeks after the birth of infants, even though they do not have to travel and search for food. It is thus evident that in the wild, where tamarins may have to travel 0.6-1.2 mi (1-2 km) per day to find sufficient food, infant carrying represents a considerable cost to the caregivers. In pygmy marmosets, infants

Behavioral Management Techniques

Behavioral therapy has demonstrated efficacy in managing difficult behaviors, agitation, and aggression, and mood can be elevated through identification and involvement in pleasant activities, while matching activities to the individual's cognitive status (Holmberg, 1997 Teri, 1994). In a comparison of behavioral management strategies, Teri, Logsdon, Uomoto, and McCurry (1997) examined behavioral treatments for depressive symptoms of AD patients. Two behavioral treatments, one emphasizing maximizing pleasant events and the other emphasizing caregiver problem solving, were compared to two control conditions, standard care and wait-list. Two active treatment groups involved identifying pleasant activities for the AD patient to participate in and allowed caregivers more flexibility and input in the treatment. The Pleasant Events Schedule (PES) AD (Teri & Logsdon, 1991) was created to help caregivers identify activities that AD patients would enjoy, based on the stage of the disease. A...

Clinician Rating Scales

Clinician rating scales are typically completed after interactions with persons with dementia, with family and or professional caregivers, and after clinician observation of behavior. In many ways, then, these assessments may be the most complete and objective. Limitations of these scales, however, include Statements and views of the person with dementia are always overridden by caregiver report. The Cornell Scale is a 19-item measure whose items were constructed so that they could be completed based on interviews and direct observation (Alexopoulos, Abrams, Young, & Shamoian, 1988). This rating scale was created especially for assessment of depression severity in dementia patients. The authors examined the literature for depression phenomenology common in dementia patients and then elicited feedback from 11 experts on the categories they chose. The rater is to first interview the dementia patient's caregiver in an in-depth manner and then briefly interview the patient. Internal...

Self Report Measures Geriatric Depression Scale GDS

Two more recent studies have provided further support for the importance and validity of using the report of persons with dementia in any evaluation of mood. In a study mentioned earlier (Espiritu et al., 2001), dementia patients' self-report of depression was a unique and significant predictor of the caregiver reports of patients' IADL scores. These findings held even when the sample was further divided into the more severely cognitively impaired (MMSE 15). Perhaps the most intriguing findings about the GDS are the ones made by Mast (2002). The internal consistency of the GDS was examined among 580 geriatric patients with four levels of cognitive impairment as defined by the Mattis Dementia Rating Scale (Mattis, 1988) cognitively intact (DRS 126+), mild cognitive impairment (DRS 103-125), moderate impairment (DRS 90-102), and severely impaired (DRS 90). Surprisingly, the internal consistency did not decline as cognitive impairment increased. Conbach's alpha estimates were as follows...

Adaptive Equipment and Environmental Changes

Occupational therapists can often recommend adaptive equipment to make activities of daily living easier, such as modified eating utensils, reaching aids, and dressing aids to facilitate ease of performance. Both PT and OT therapists can assist and educate the patient and caregiver on changing the environment of their home to make it easier to maneuver in the home and to enhance safety and reduce falls. As the patient's function warrants, grab bars may need to be installed to assist with sit-to-stand transfers from the toilet and other low surfaces. Other equipment to consider includes high-rise toilets and shower chairs. A home visit can be helpful to identify risks for falls and recommendations to eliminate throw rugs and clutter on the floor, and placement of nightlights.

Nonpharmacological Treatments Focus on Unmet Needs

Are unable to convey basic needs such as hunger, thirst, or need for toileting, much less the need for companionship or affection. Further, for some individuals, a need for independence or autonomy may be expressed as aggressive or agitated behavior. Finally, individuals who exhibit problem behaviors may be suffering from either a lack or an excess of environmental stimulation. Because the person with dementia may not be able to communicate his or her needs in traditional ways, caregivers must attempt to determine whether a need is not being met. Subsequently, caregivers must exercise patience and persistence in an often-frustrating, trial and error attempt to determine the root of the individual's behavior problem.

Overcoming Language Barriers

A particularly challenging situation faces caregivers when persons with dementia speak a language that is different from that of the caregivers. For example, Runi, Doyle, and Redman (1999) note that persons with dementia of a non-English-speaking background (NESB) are at substantial risk for having unmet needs. They note that if English was acquired as a second language, it is often lost or impaired to a greater degree than their first language. Understimulation in terms of not taking part in activities or communicating regularly with staff is a typical concern in caring for NESB persons with dementia. Runi et al. described a case study in which a person with dementia had resorted to speaking Italian, her first language, and was exhibiting aggressive verbalizations and or repetitive verbalizations not directed toward visible persons. Music was used as an intervention, in which both English-language and Italian-language music were played. They found that disruptive vocalizations were...

Relationships The Development Ofattachments

Freud (1940 1963) described the infant-mother relationship as unique, without parallel, established unalterably for a whole lifetime as the first and strongest love-object and as the prototype of all later love-relations. (p. 45) Although the typical conditions of early care in Western cultures have changed significantly since Freud's day (i.e., fathers, child-care providers, babysitters, and extended family members now share infant care with mothers), Freud's famous assertion draws attention to the importance of the initial attachments a baby develops to caregivers and to their potentially enduring significance. An attachment can be described as an enduring affectional bond that unites two or more people across time and context, and the development of attachment relationships between infants and their caregivers is one of the hallmarks of early socioemotional growth (Ainsworth, Blehar, Waters, & Wall, 1978 Bowlby, 1969 1982 Cassidy & Shaver, 1999).

Methodological Issues

Some deaths are sudden but even where there has been a period of forewarning it may be seen as sudden by those bereaved. Anticipatory grief was described by Lindemann (1944) and the concept was refined by Rando (1988). The term originated to describe the experience of grieving so fully before an expected death that emotional ties are relinquished - the missing soldier returns but finds no welcome. A different view is that attachment strengthens in the face of loss and anticipatory grief is not the same as the grief felt subsequently. A preparatory period can offer advantages but if the final illness is of a protracted and uncertain duration then this brings different stressors. A study of 73 caregivers bereaved by the death of an elderly relative identified that quality of support prior to the death was more important in adjustment to bereavement than subsequent support (Bass, Bowman & Noelke, 1991).

Symptom Distress in Patients with Advanced Cancer

Although entire chapters in this text are dedicated to the topics of pain management, patient support, and psychosocial issues, the regularity with which patients and their caregivers confront pain, dyspnea, and anxiety depression at the end of life suggests that these topics merit brief discussion here as well. When interpreting the reported prevalence of symptoms, it is important to note that despite the availability of many effective treatment strategies, there is strong evidence from a multiplicity of sources that these management techniques are underused. Thus, in regard to prevalence rates, the challenge is to define both the true prevalence rates and the prevalence of undertreatment of symptoms. pice Study reported that dyspnea was present in 70 of 1,754 patients during the final 6 weeks of life,52 and a study of 86 cancer patients by Higginson and McCarthy found that in 21 of the patients, dyspnea was a severe symptom near death.53 The SUPPORT study reported dyspnea as...

Socioemotional Development In Context

Must understand also the broader caregiving context. This sentiment, illustrated by Winnicott's celebrated statement that there is no such thing as an infant (Winnicott, 1965), sets the framework for this chapter. By its very definition socioemotional development invokes relationships. The mother-infant relationship is central to popular and scientific images of social and emotional development in infancy. This emphasis occurs because of cultural and theoretical traditions emphasizing that the sensitivity, warmth, and responsiveness of this first and primary relationship shapes a baby's initial, and in some conceptualizations continuing, social dispositions and expectations for others. Later in this chapter we examine research concerning this relationship, especially within the context of attachment theory. It is important first, however, to establish a broader framework for our discussion of early socioemotional development by considering how social and emotional responding and the...

Developmental Aspects of Attachments

Except in highly unusual conditions of neglect or abuse, virtually all infants develop close emotional ties to those who care for them. These initial attachments are as biologically basic as learning to crawl and talk because they have been crucial to the protection, nurturance, and development of infants throughout human evolution (Gould, 1977 Tobach & Schnierla, 1968). Bowlby (1969 1982) placed special emphasis on the role of distress-relief sequences as key interactions for the development of attachments, with attachment behaviors eliciting caregiver proximity and care for a vulnerable, dependent infant. Attachment theorists believe that these infant-caregiver relationships address two fundamental needs of the infant (see Ainsworth et al., 1978 Cassidy & Shaver, 1999). First, a caregiver's support reduces a young child's fear, distress, or anxiety in novel or challenging situations and enables the child to explore with confidence and to manage negative emotions (Ainsworth, 1967...

Theoretical Formulations

Avoidance that functions to decrease sympathetic arousal to perceived threat and to inhibit emotional processing thereby preventing extinction of the fear response (Borkovec, Ray & Stoeber, 1998). It is an attempt to avoid the anxious arousal or anticipated catastrophe associated with negative events or deeper level emotional concerns and to the extent that this succeeds its role as a coping response is strengthened through a process of negative reinforcement. The deeper level concerns are thought to be predominantly interpersonal in nature. Borkovec (1994) suggests that insecure attachments to primary caregivers, as well as psychosocial traumas in early childhood, may be strongly related to the sense of uncontrollability of negative events that is so characteristic of GAD.

Diffuse Lewy Body Dementia DLBD

The diagnosis of depression in dementia is complicated by several factors overlap symptoms, the question of symptom persistence, cohort effect, ageist myths, communication difficulties in later stages of dementia, ag-nosonosia, and reliability of caregiver reports (Thorpe & Groulx, 2001).

Analytical Strategies Models And Paradigms

In contrast to both act and rule utilitarianism, which emphasize the implications of a person's action for others, ethical egoism bases morality on what promotes a person's own self-interest. This is obviously a very self-centered basis of morality but may nevertheless have important implications for family caregiving. Many decisions that people make concerning themselves have ramifications for other people. For example, lifestyle decisions concerning eating habits, smoking, drinking, and exercise may result in disease and or disability requiring care provided by others. As previously mentioned, the perception of the care receiver's responsibility for the disability or illness influences his or her access to care. Thus the person who defines his or her own good as eating nutritious meals, exercising regularly, and not smoking cigarettes may receive better care than the person who defines his or her good as drinking excessively or smoking cigarettes. 1964, p. 88) and ''act in such a...

Psychiatric Assessment and Treatment of Nonpsychotic Behavioral Disturbances in Dementia

In addition to core cognitive and functional deficits, neuropsychiatry symptoms, emotional disorders, and behavioral alterations are ubiquitous among patients with dementia syndromes. Clinicians should be concerned with the behavioral signs and symptoms of Alzheimer's disease (AD) and other dementias because they are prevalent, distressing to the patient, and upsetting to caregivers. Often they contribute significantly to the need for institutional care. A previous cross-sectional multicenter study of several hundred outpatients with AD found that no patient had been free of behavioral signs or symptoms in the preceding month (Tariot, Mack, et al., 1995). A population-based study of dementia found a point prevalence of psychopathology of more than 60 and asserted that the lifetime risk of psychopathology for a patient with dementia approached 100 (Lyketsos et al., 2000). These figures make clear that it is important to know how to recognize and manage the behavioral manifestations of...

Services Funded By the OAA

Preventive health services, which educate and enable older persons to make healthy lifestyle choices. Every year, illness and disability that result from chronic disease affects the quality of life for millions of older adults and their caregivers. Many chronic diseases can be prevented through healthy lifestyles, physical activity, appropriate diet and nutrition, smoking cessation, active and meaningful social engagement, and regular screenings. The ultimate goal of the OAA health promotion and disease prevention services is to increase the quality and years of healthy life. The National Family Caregiver Support Program (NFCSP), which was funded for the first time in 2000, is a significant addition to the OAA. It was created to help the millions of people who provide the primary care for spouses, parents, older relatives and friends. The program includes information to caregivers about available services assistance to caregivers in gaining access to services individual counseling,...

Observational Methods Parent Child Relations

A commonly used measure of the attachment relationship, Ainsworth, Blehar, Waters, and Wall's (1978) Strange Situation Procedure, frequently is used to activate the attachment system for observational purposes. From the attachment perspective, when an infant experiences distress, separation, fatigue, illness, fear, or other types of stress, the child's attachment system motivates him or her to seek security from a caregiver (Boris, Aoki, & Zeanah, 1999). An unfamiliar situation is believed to heighten such attachment reactions. In the Strange Situation, the infant participates in eight different episodes in an unfamiliar laboratory room where the parent and a stranger are present in varying combinations. The observations from the Strange Situation Procedure are later coded for type of attachment securely attached, insecure-avoidant, insecure-resistant, and disorganized or disoriented (Main & Solomon, 1986). Impairments in the infant-parent attachment relationship as assessed with such...

Alternativecomplimentary Treatment

The Glioma Outcome project or GO was a physician directed project with the goal of improving the care of brain tumor patients. A total of 788 HGG patients were enrolled. The project collected data on the use of alternative therapies by glioma patients. An abstract of this data was presented at the Society for Neurooncology meeting in 2000 (61), which evaluated data from the first 520 patients. Patients were asked about alternative therapy use within 3 wk of glioma surgery and at 3-mo intervals after that. Forty-nine percent of patients used at least one alternative therapy during their treatment. The most frequently used treatments included meditation and prayer (28 ), high-dose vitamins (23 ), and herbs (18 ). Interestingly, alternative therapy use at some point (49 ) was greater than the use of chemotherapy (25 ), or those who enrolled in clinical trials (21 ). An earlier study by Verhoef et al. (62) out of Canada also found that alternative therapy in glioma patients is common (24...

Assessing Behavioral And Psychiatric Symptoms

To use in clinical practice, they can provide important guidelines for assessing behavioral symptoms via clinical interview. For example, it is important to ask about specific behavioral and psychiatric disturbances, encouraging reporting of even mild symptoms. In a cohort of longitudinally followed patients with AD, symptoms were likely to persist even with medication once they appear (Devanand et al., 1992). Given this finding, clinicians may choose to provide education to caregivers and to assess their ability and preparedness for coping with these problems. The Neuropsychiatric Inventory, a tool often used in research, has been adapted for use by clinicians (Kaufer et al., 2000). This instrument, which is administered to an informant (usually a family member or someone else providing care and supervision), consists of questions about a wide range of behavioral and psychiatric symptoms and assesses how disturbing each symptom is. This may provide an introduction into assessing the...

Assessment of Psychosis in Alzheimers Disease

The NPI is a caregiver-based instrument (Cummings et al., 1994) that has become widely used in the research setting. The NPI is a valid and reliable means of assessing neuropsychiatric symptoms (e.g., agitation, apathy, depression, anxiety, delusions, hallucinations, irritability, and delusions) in patients with dementia, with a decision tree approach making it very useful (Cummings & McPherson, 2001). The NPI's psychometric properties include strong reliability and validity established in a number of studies and a variety of settings and demonstrated sensitivity to change in several clinical trials evaluating psychopharmacologic approaches to treat behavioral complications in dementia or AD (McKeith, Fairbairn, Perry, & Thompson, 1994 Street et al., 2000, 2001 Tariot, Solomon, et al., 2000). The NPI can be administered at every visit by a trained evaluator, monitoring for symptom improvement. The Neuropsychiatric Inventory Nursing Home Version (NPI NH) is a caregiver-rated scale...

Assessment Of Pain In The Nursing Home

Several assessment tools have been developed to assess for behaviors and patient features that might be associated with pain in patients with advanced dementia, including the Discomfort Scale and the Assessment of Discomfort in Dementia (29,30). The MDS has also been suggested as a useful instrument for the cognitively impaired because it does not rely on patient self-report (13). However, a recent study demonstrated that a three-item pain questionnaire administered to certified nursing assistants was a more sensitive measure of pain and was more strongly associated with analgesic use than the MDS (31). Whether using a specially designed instrument or monitoring for specific behaviors, nursing aides, family members, and other caregivers are generally able to offer useful insight on pain in cognitively impaired patients.

The Real World of Health Policy

The Administration on Aging (AoA), an agency in the U.S. Department of Health and Human Services, is one of the nation's largest providers of home- and community-based care for older persons and their caregivers. Its mission is to promote the dignity and independence of older people, and to help society prepare for an aging population. Created in 1965 with the passage of the Older Americans Act (OAA), AoA is part of a federal, state, tribal and local partnership called the National Network on Aging. This network, serving about 7 million older persons and their caregivers, consists of 56 State Units on Aging 655 Area Agencies on Aging 233 Tribal and Native organizations two organizations that serve Native Hawaiians 29,000 service providers and thousands of volunteers. These organizations provide assistance and services to older individuals and their families in urban, suburban, and rural areas throughout the United States.

Case Study III Psychological Perspectives

This case, which began as a seemingly straightforward case of progressive dementia, demonstrates the influence of multiple comorbidities (depression and delirium) that are integral to dementia care. As Mrs. Walker experienced significant loss ( her best friend) and stress ( her husband's illness and daughter's divorce), she became depressed. It is interesting to note that along with Mrs. Walker's overt vegetative symptoms of depression (e.g., not eating, losing weight, not bathing), she was also reporting mood problems as indicated in her statement I'm not worth a damn. In addition to the anti-depressant medication, there was some implicit behavioral treatment as well. Mrs. Walker began socializing more at the senior center and was likely engaging again in more day-to-day pleasant events than she had been before depression treatment. This, in addition to a focus on increasing her functional activity, would be psychological complements to the medication treatment. In addition, perhaps...

The Influence Of Setting Home Settings

Although behavior problems among persons with dementia are traditionally associated with long-term care settings, such problems exist among persons with dementia residing in the community (Teri, Borson, Kiyak, & Yamagishi, 1989). Care to persons with dementia residing at home is typically provided by family caregivers, home health aids, or some combination of the two. Managing behavior problems at home can be challenging to family members for a variety of reasons, one of which is that home environments are not typically designed to maximize the functioning of a person with dementia. For instance, a room crowded with furniture or other clutter may increase confusion and agitation in a person with dementia (Skolaski-Pelliteri, 1985). Gwyther (1994) notes that persons with Alzheimer's disease can become suspicious of caregivers. 'Accusations of theft or infidelity often result from feelings of loss of control, fear of abandonment, or confusion over lost or misplaced items (p. 111). She...

Nonpharmacological Treatment For Depression In Dementia

Nonpharmacological treatment for depression in dementia has focused on the dyad of both the caregiver and the person with dementia. In a randomized controlled trial of short-term supportive counseling aimed at reducing caregiver burden (not depression in persons with dementia), Mittelman, Ferris, Shulman, Steinberg, and Levin (1996) reported that the intervention led to delayed nursing home admissions for the person with dementia. caregivers, they could help increase the amount of pleasant events for persons with dementia. Teri, Logsdon, Uomoto, and McCurry (1997) extended this research through a clinical intervention study, which compared behavioral treatment, support group intervention, and a wait-list control group. In all, 42 caregivers of depressed persons with dementia received one of two behavioral therapy groups (pleasant events focus or problem-solving focus), 10 caregivers were in the support group, and 20 were on the wait-list control group. Depression, as measured by the...

Theoretical Components Of The Model

Interpersonal reconstructive therapy draws heavily on Bowlby's (1969, 1977) observations on the role of attachment in human development. His perspective is clinically compelling and has received broad support in many research contexts (Cassidy & Shaver, 1999). Applications of attachment theory in IRT concentrate on two of Bowlby's propositions. First, basic security is most affected by reliable proximity to the caregiver and by what Harlow and Harlow (1967) called contact comfort. Second, experiences with caregivers shape children's internal working models of self and others. The case formulation method in IRT requires that presenting problems be linked to internal working models and that internal working Children who treat themselves as the parent or other caregiver treated them engage in similar emotional logic.

Summary And Conclusions

The interpersonal reconstructive therapy (IRT Benjamin, 2003) case formulation method requires that problem patterns be linked to learning with important early loved ones via one or more of three copy processes (1) Be like him or her, (2) act as if he or she is still there and in control, and (3) treat yourself as he or she treated you. The processes are respectively named identification, recapitulation, and in-trojection. The copying is maintained by fantasies that important persons' internalized representation (IPIR) ultimately will provide the desired love if the patient's living testimony to the IPIR's rules and values is good enough. Such consistent implementation of perceived parental values suggests a continuing wish to please that parent or other important caregiver. Because the relationship with the internalization sustains the problem patterns, treatment must focus sharply on grieving and letting go of these fantasy residuals of early attachments. In IRT, there are...

Separation anxiety disorder

Environmental stimuli and internal cues from the child himself interact in the presentation of separation anxiety disorder. Separation anxiety disorder is defined by the primary expression of excessive anxiety that occurs upon the actual or anticipated separation of the child from adult caregivers most often the parents. Significant problems in daily functioning for the child and parents can result from the disorder. Common fears observed in the presentation of separation anxiety include concerns about the parents' health or well-being (less frequently the child's own health), general catastrophes, natural disasters, or the child becoming lost separated from the parents. Disrupted sleep, difficulty falling asleep alone, fear of monsters, or nightmares are also commonly experienced by children with separation anxiety disorder. Children experiencing separation anxiety disorder display significant distress upon separation from the parent or other primary caregiver. Separation anxiety...

Pathogenesis And Transmission

Food-borne viral or bacterial disease typically causes a gastroenteritis-like syndrome. The onset of symptoms may be within hours if preformed toxins are present (e.g., Staph enterotoxin B and Bacillus cereus), hours to days if viral (e.g., Norwalk agent) or due to toxins formed within the alimentary tract by bacteria (e.g., enterotox-igenic E. coli), or days if caused by invasive bacteria (Salmonella, Shigella, Cam-pylobacter, and E. coli spp.). Infection with Salmonella typhi may cause enteric fevers and generate a prolonged carrier state. Enteric bacteria and viruses also are spread silently among close contacts, food handlers, and caregivers, making their area of impact even broader.

Assessment And Intervention

Klatt (1991) states 'It is not illness or death which are a challenge but the failure to find meaning in life.' Bereavement may provoke an existential crisis only if it challenges the sense of meaning and a new sense of meaning is not developed. Some become more aware of life's transience and can identify positive change (Landsman and Spear, 1995). This perspective reminds us that a crisis is also an opportunity for growth. One young woman bereaved traumatically by the death of a partner for the second time acknowledged this had changed and deepened her personal philosophy of life but was able to smile and remark ruefully 'If this is being wise, I'd rather be foolish.' A study of 30 caregivers whose partners had died of AIDS reported that those who found meaning in their caring were less depressed and were more likely to demonstrate positive wellbeing at bereavement and better recovery at 12 months (Stein etal., 1997).

Psychosocial Concerns

Cancer survivors with preexisting anxiety or affective disorders appear to be at greatest risk for ongoing distress.25 Changes to body image from cancer therapy, such as that resulting from mastectomy or colostomy, can be a source of problems with psychological adjustment.72 Distress appears to dissipate with time, however. There are a small proportion of patients who experience ongoing effects characteristic of posttraumatic stress disorder.73 Having a spouse or partner decreases the risk of psychological sequelae,74 although these caregivers may also themselves be adversely

Examination screening specific to children

Childhood health record books provide an excellent opportunity for communication between different health care givers parents should be provided with the record books and encouraged to bring them to every visit. Various recommendations for screening are made under the following headings. Height weight head circumference. Record height from age 3 and weight at regular intervals to age 5 years. Record head circumference at birth and then up to 6 months. The adequacy of a child's growth cannot be assessed on one measurement and serial recordings on growth charts are recommended. Head circumference recordings may provide further data about a child's growth. Hips. Screen for congenital dislocation at birth, 6-8 weeks, 6-9 months and 12-24 months.

Mood and Behavioral Disturbances

Overall, the behavioral and psychological symptoms of dementia are such a salient feature of the disease that there is now a push to include this as a diagnosis or syndrome in the International Classification of Diseases (ICD Zaudig, 2000). Depression and anxiety are common in dementia, and these can be the first symptoms of a dementia in the absence of initial cognitive deficits (Reding, Haycox, & Blass, 1985). The clinician should suspect a mood or anxiety disorder in individuals presenting with possible dementia, most particularly in persons who are aware of their memory and cognitive failings, compared to patients whose relative or caregiver is noticing the cognitive difficulties (U.S. Department of Health and Human Services, 1996). An individual in the early stages of dementia is more likely to experience a Apathy can be a burden to caregivers because they must work all that much harder to get the individual to initiate behavior. In addition, indifference to a person's own...

Population Aging and Kinship Structure

The family and kinship implications of rapid population aging in Japan, China, and South Korea have received some attention (Jiang 1995 Martin 1990 Zeng and George 2001). In these countries, as well as in other Asian countries, the long tradition of elderly people coresiding with an adult child is being challenged by population aging. In Japan, for example, the proportion of people over age 65 who live with a child declined from 77 in 1970 to 52 in 1991 (Brown et al. 2002 Martin 1990). In countries where adult children have provided most of the care for dependent older people, the changing supply of children challenges existing caregiving arrangements. The average number of children available to provide care for parents aged 65 to 69 in urban areas of China will decline from 3.1 in 1990 to only 1.1 in 2030 (Jiang 1995). Changing intergenerational relationships related to population aging are also occurring in the United States and Europe. their aging parents who experience...

Who Becomes The Decision Maker For The Judgment Impaired

In case A, the decision maker could be any of the following in order of involvement and or availability in the case family (spouse, adult children, parents, siblings), court-appointed guardian, or caregivers. In this sort of case, moral problems can arise when or if the decision maker's interests or concerns diverge from the views (if known) or the best interests of the patient. Such patients are particularly vulnerable because they and their care are totally dependent on the decisions of others whose interests may diverge from theirs. It is vital that all those involved in such cases be alert to the needs of the patient and the benefits and burdens of care and interventions provided, keeping consideration of the best interests of the patient clearly in mind. All who are providing patient care when surrogate decision making is involved have a moral obligation to ensure the soundness of these decisions. In troublesome cases, one alternative that can protect family standing and at the...

Megan R Gunnar And Elysia Poggi Davis

In this chapter we review what is known about the development of activity and regulation of the two arms of the stress system, the (L-HPA) and brain-stem norepinephrine sympathetic-adrenomedullary (NE-SAM) systems. We begin with an overview of the neurobiology of the L-HPA system and the autonomic nervous system, emphasizing the SAM system. Next we describe limbic and cortical circuits involved in the ability to anticipate threat and engage in preparatory responses and the way these circuits modulate and may be modulated by the L-HPA and SAM systems. This is followed by a discussion of what is known about the ontogeny of these systems and of the way individual differences in the development of reactivity and regulation of these systems may be related to temperament and caregiving. We conclude with some thoughts about the need for basic research examining the development of stress systems in order to better our understanding of the origins of individual differences in stress reactivity...

Principle 1 Accurate Assessment of Both Cognitive Abilities and Noncognitive Behaviors Is Based on Thorough Knowledge

Practitioners need to know the strengths and weaknesses of scales used in the assessment of noncognitive behaviors as well. In particular, the value of the input (self-report) from the person with dementia or suspected dementia must be balanced with the ratings of family or professional caregivers. In the assessment of depression, for example, obtaining some aspects of self-report from the person with dementia (e.g., mood, withdrawal) can provide unique and useful information that adds to the report of the caregiver. Similarly, the person with dementia's own report of suspicions, delusions, or hallucinations can be useful and can add unique information to that provided by the caregiver.

Principle 2 Comorbidity Is Common in Dementia

In discussing interdisciplinary teams and how models of functioning can lead to conflicts, Lichtenberg (1994) reported that whereas the medical model emphasizes a ruling out ' ' of influences until a diagnostic entity is determined, the psychosocial model emphasizes a ruling in of influences on behaviors. In applying the psychosocial model to dementia, psychological practitioners need to be aware of the relatively common occurrence of comorbidities. Depression often accompanies dementia. Delirium occurs more frequently among those with dementia. Environmental stresses, such as caregiver burden, relocation, boredom, or overstimulation, can heighten behavioral disturbances among those with dementia. Caregiver functioning impacts the care recipient's cognitive and noncognitive behaviors. Further, as the disease progresses, so do comorbidities. Thus, memory decline is associated with functional decline, risk of delirium episodes, and loss of independence in self-care abilities. These...

Principle 3 Treatment Interventions Should Be Based on Conceptual Frameworks and Tested Empirically to Determine

Behavioral and psychosocial interventions with persons with dementia and with family and professional caregivers are based on the conviction that persons with dementia, similar to those with any chronic disease, can have an improved quality of life. Because dementia attacks both cognitive and noncognitive aspects of functioning, interventions are geared to both. Learning theory and cognitive-behavioral theory are the underpinnings of many successful interventions with persons with dementia. Learning theory has been applied to cases of dementia, demonstrating how best to maximize cognitive abilities, use whatever cognitive strengths remain, and integrate all of this into daily life. Behavioral theory has been applied to the understanding of mood and depressive disorders in those with dementia demonstrating clinical effectiveness in reducing depressive symptoms. Each of these interventions has as its aim to affect the patient's behavior and to improve the psychosocial and physical...

Depression And Excess Disability In Dementia The Activity Limitation Framework

A major issue of scientific and clinical importance to understanding dementia is determining in what ways depression affects cognitive and noncognitive symptoms. Family caregivers report that the noncognitive symptoms of dementia (e.g., apathy, agitation) have greater impact on the family unit's day-to-day life than do the cognitive symptoms of dementia (Riley & Snowden, 1999). Of concern, then, is how depressive syndromes affect the behaviors of the person with dementia and whether depression Espiritu et al. (2001) used slightly differing methodology but reported findings similar to the Hargrave study. The group investigated caregiver reports of functional abilities using self-reported depression and the MMSE in more than 200 demented elders. Whereas the Hargrave study used rate-based depressive determination, self-report depression was significantly related to ADL skills in the Espiritu sample beyond the effects of demographic and cognitive factors. Thus, the significant...

Epidemiology And Prevalence

Hallucinations are also common in dementia, with a prevalence between 21 and 49 in different studies (Burns et al., 1990 Mega et al., 1996). Visual and auditory hallucinations are most common. Varying degrees of agitation occur in one-third to one-half of AD patients (Cohen-Mansfield, Marx, & Rosenthal, 1989 Devanand et al., 1997), with aggressive behavior being less common (Swearer, Drachman, O'Donnell, & Mitchell, 1988). The large ranges in prevalence rates may be explained, in part, by the various settings where the information was gathered (e.g., outpatient, assisted living, nursing home) and differing methods of assessment. Delusions are most prevalent during the middle phase of illness (Cummings et al., 1987 Mega et al., 1996 Wragg & Jeste, 1989) and are a common precipitant of institutionalization (Stern et al., 1997). The informant (e.g., direct clinical interview with the patient, interview with the caregiver, or chart review), criteria for diagnosis of...

Multicultural Issues In Assessing And Managing Ad

There are a number of multicultural issues in dementia care and the AD patient, including cultural differences in disease presentation and the caregiver experience. Disease presentation may vary according to race. In a large observational study, Shadlen, Larson, Gibbons, McCormick, and Teri Studies suggest cultural variations in the role of the caregiver. Questions arise as to whether the needs of minority populations are similar to Caucasian populations. A recent review article by Janevic and Connell (2001) compared 20 studies involving ethnic minorities and Caucasians on a number of variables, including caregiver demographics and psychosocial factors. Many of the studies reviewed were interviews or self-report formats, and minority populations were African American, Asian, and Latino. In African Americans and Latino populations, caregivers were more likely to be family members other than a spouse, such as a daughter or son. A similar finding was seen in Korean caregivers. These...

Modeling Other Behavioral Conditions

AD is characterized by a number of behavioral disturbances beyond cognitive function, particularly in the mid- to late stages of the disease. These include sleep disturbances, depression, wandering, and aggressiveness, which are frequently the cause of nursing home placement. These are conditions that also occur in the absence of AD symptoms. There is some question as to whether they are different in the presence and absence of dementia. This is an area in which better therapeutics could make a significant impact on quality of life for the patient and the caregivers. These behavioral problems are currently addressed by add-on medications, but the

Vulnerability And Research Consent In The Nursing Home

Nursing home residents have significant health care needs and are accustomed to the continual presence of professionals charged with meeting those needs. They (and their families) do not typically regard the nursing home as a research site teaching and research nursing homes are uncommon. When research is conducted in the same environment as the one in which persons typically receive health care, they may assume that the research is related to their care and that it is in their best interests to participate (Lidz et al., 2002). This assumption, the therapeutic misconception, can result in a consent based on misunderstanding. Ethical researchers take steps to prevent such mistaken assumptions. To prevent such misconceptions, it may be important to have someone not identified as a regular caregiver to discuss consent with the subject and proxy and to conduct any interventions that are related to the study protocol.

Environmental Strategiesmodifications

Another approach to modifying behavioral disturbances is modification of the environment to accommodate the AD patient. Products may focus on alleviating difficult behaviors, such as wandering, as well as provide opportunities for enjoyable activities for patients. Activities that naturally serve as recreational activities may also provide sensory stimulation, for example, the game Bingo (Sobel, 2001). The therapeutic kitchen has been used to support day programs in residential facilities (Marsden, Meehan, & Calkins, 2001). The kitchen is a supportive environment for the patient where safety is a main concern. Potentially dangerous items, such as cleaning agents, food processors, and utensils are stored in locked cabinets, and access is restricted. Cabinets are lower for easier access, countertop corners are rounded, cabinets are labeled, floors are nonslip, and lighting is ample. A five-session home environment program investigated by Gitlin, Corcoran, Winter, Boyce, and Hauck (2001)...

Effects on Short Term Outcomes

Most evidence on the effects of antibiotics for acute AOM address their effects on short-term outcomes. A 1994 metaanalysis of 33 randomized, controlled trials involving 5400 children (Rosenfeld et al., 1994) found that antibiotics increased complete clinical resolution within 7-14 days after the start of treatment by 13.7 (95 CI 8.2-19.2 ). Rosenfeld's metaanalysis included studies which used various outcomes, not all of which would be directly relevant to patients or their caregivers. A recent and more stringent Cochrane review (search updated in March 2003) identified ten randomized trials comparing antibiotics with placebo (Glasziou et al., 2004). Only the eight studies which assessed patient-relevant outcomes (e.g., pain, fever) involving 2,287 children were analysed in the review. Most children with AOM recovered rapidly regardless of whether antibiotics were prescribed - two-thirds were better by 24 hours from the start of treatment, and 80 at 2-7 days. However, antibiotic...

Technology And Longterm Care

The health of the caregivers and the health of the care receiver must be jointly considered. What benefits the caregiver can result in less staff turnover. For example, the technology that can be employed for patient lifting and moving may not be immediately perceived as having such a beneficial effect, but the reciprocal nature of the provision and the receipt of care is too often lost. The incorporation of technology into long-term-care settings thus plays a dual role that enhances the environment from both the perspective of the patient and the care provider.

Raceethnicity And Family Social Care

The preceding discussion highlights general patterns of caregiving. However, there are subcultural differences. For example, multigenerational households are more prevalent among African American, Latino, and Asian families (R. W. Beck & S. H. Beck, 1989 Tennstedt et al., 1993). Social support and various types of assistance are exchanged within these extended-family households (Sil-verstein & Waite, 1993 Speare & Avery, 1993). Although such households may be formed on the basis of need, research indicates that even when controlling for need, racial ethnic minorities are more likely to live in extended families. They provide assistance with finances and activities of daily living as well as social support between generations (Silverstein & Waite, 1993 Speare & Avery, 1993). For example, a larger proportion of black grandparents than white grandparents care for grandchildren (U.S. Bureau of the Census, 1991). Horwitz and Reinhard (1995) found that black siblings report more caregiving...

Biodemographic Research

One further interesting aspect, which is unique to the honeybee model, is the connection between social structure and individual life history and aging. Isolated studies have indicated that the caregiver-to-dependent (worker-to-brood) ratio is of crucial importance to the individual longevity of the progeny (Eischen et al., 1982), and possibly all other workers (Winston and Fergusson, 1985). The amount of brood and resources in a colony, and the age structure of the worker force, influence the age of foraging initiation of individual workers, and thus their lifespan (Winston, 1987). Furthermore, larger colony size confers a longevity advantage to the individuals presumably because individual workers in smaller colonies work harder, raising more offspring per adult bee (Harbo, 1986). These plastic reactions to social conditions are ultimately the result of dynamic colony-level resource allocation and optimization (Oster and Wilson, 1978). However, comprehensive quantitative models and...

Types Of Family Social Care

Another change in the structure of the family that impacts family caregiving is the existence of fewer age peers within a single generation (i.e., siblings and cousins) and more relationships across generational lines (Bengtson, Rosenthal, & Burton, 1990). Consequently, there are fewer younger family members available to care for older members. In addition, as a result of divorce and remarriage, adult children may find themselves caring for their biological parents, current parents-in-law, and former parents-in-law to whom they are still emotionally attached. These middle-aged adults may also find their young adult children

Administration on Aging

Skilled Nursing Organizational Chart

In 2000, OAA was amended and reauthorized AoA through 2005. The amendments established the National Family Caregiver Support Program, which is intended to help people who are caring for older family members who are ill or who have disabilities. Family caregivers have always been the mainstay underpinning LTC for older persons in the United States. Among noninstitutionalized persons needing assistance with activities of daily living (ADLs), two-thirds depend solely on family and friends and another one-fourth supplement family care with services from paid providers. Only a little more than 5 percent rely exclusively on paid services (AoA 2005).

Ethics Aging And Mental Health

To reflect about mental health, ethics, and aging is also to ask, what is the territory for such reflection For the past decade, as ethicists have considered aging and gerontologists and geriatricians have deepened their interest in and knowledge about biomedical ethics, ethics has tended to focus on bracketed moments when individuals must make decisions. In this thinking, ethics became a ''decision-procedure for resolving conflict-of-choice situations'' (Hauerwas & Burrell, 1977, p. 8). Moral issues remained invisible until a quandary arose. A person with dementia, for example, regularly forgot to turn off the stove or took off in the car and got lost. Caregivers appropriately worried about safety should they take away the car keys or insist that mother can no longer live alone This ''dilemma,'' generally framed in terms of autonomy versus beneficence, obscures other moral aspects of the person's unique situation. She must reshape the ongoing course of her life in radically different...

Family Members and Friends

Although most caregivers (primarily family members) are highly motivated and are committed to providing care, caregivers involved with patients who have cancer experience substantial burdens.67-76 Not only are caregivers called upon to provide emotional support for the patients through periods of stress, they are also increasingly being required to provide medical and nursing care in the home as a result of the shifts in care from inpatient to outpatient settings. Moreover, particularly in developing countries, the family caregiver may be the only caregiver toward the end of a patient's life, with little or no access to health care professionals. For patients with germ cell tumors, who are often young, caregiver issues are somewhat different from those for patients who are older. Caregivers may be parents, siblings, young spouses, or friends, and although their concerns overlap with those of caregivers of older patients, their experience is clearly also somewhat different from that of...

Pursuing A Good Death

Attention to a variety of domains of patient and family care in the end-of-life setting for patients with many diseases, including those with germ cell tumors. Such domains include those of pain and symptom management, family support, caregiver support, patient preferences, care across cultures and for minority groups, systems-based barriers to care, and many other issues. Many of these are addressed in this chapter. Although these studies were focused on older populations than those with germ cell tumors, the concepts raised are noteworthy. Both the University of Toronto and Duke University studies demonstrated that patients, care givers, and health care providers are concerned with much more than pain control and symptom relief. Both studies emphasize that most

Assistance For Cancerrelated Problems

And practical help to people with cancer and their loved ones. As the oldest and largest national nonprofit agency devoted to offering professional services, Cancer Care has helped over two million people nationwide through its toll-free counseling telephone line (1 -800-813-HOPE) and teleconference programs, its office-based services, and via the Internet. All services are provided free of charge and are available to people of all ages, with all types of cancer, at any stage of the disease. Cancer Care's reach, including its cancer awareness initiatives, also extends to family members, caregivers, and professionals, providing vital information and assistance. The NCCS focuses on survivorship since the impact of cancer is a lifelong phenomenon. The advocacy policies of the NCCS include care of the patients and their families confronting all of the trying issues of living with cancer. The organization supplies resources such as the Cancer Survival Toolbox, a free award-winning audio...

The elements of a therapeutic professional relationship

All these terms are used to describe the same qualities and as they are all used it is important for the counsellor to be familiar with their meaning. Winnicott's explorations of the mother and infant identified the 'good-enough' mother as having particular qualities - an attitude of being emotionally available, supportive, aware and understanding of the infant's vulnerability. Winnicott (1988) used the term 'holding' to refer to the actual physical holding of the infant by the mother and also the emotional holding of attunement in the mother's mind. That relationship could then become 'facilitating' for emotional growth and development. These ideas can be transferred to a professional consultation and the empathic understanding of a patient's anxiety. Winnicott emphasised that constructive relaxation could take place in the confidence of a living relationship. Further a well-timed interpretation of correct understanding 'gives a sense of being held, that...

Proxy Designation Clause

Caution is always in order in assessing the sources of evidence. Families and friends, intentionally or not, may misrepresent or overstate the incompetent individual's views. More and more physicians and other caregivers are not well acquainted with the patient's values when he or she was competent, and this lack of independent evidence raises a shadow over the substituted-judgment standard. Given that families may have a serious conflict of interest that could distort their testimony, special care and institutional safeguards are The use of advance directives needs to be encouraged as a method for the elderly to have their wishes regarding end-of-life care honored. A major educational effort is necessarily directed at the general public, caregivers of all sorts, and especially physicians in order both to increase execution of advance directives and to ensure their impact on clinical practice. Improvement of legislation may be needed to provide penalties for those who refuse to follow...

Responsibility Of The Individual

The most effective way to assure that patient choice is supported is advocacy. When decisions are being made, caregivers should act as advocates and honor the wishes of the patient. The advocate pleads the cause of the patient. He or she supports the patient's decision and calls for its hearing in the health care system. Various groups have identified themselves as patient advocates (self-help groups, friends, and several health groups, e.g., social workers, nurses, and hospital ethics committees). If the patient's choice is to be carried out, advocates must recognize the person within the patient. They must keep uppermost the inherent dignity of the individual, seeing the person within the context of caring.

Practical Stepwise Preventiveethics Approach To Longtermcare Decision Making

Invite recognition of gender bias in the family's distribution of caregiving burden and expectations of who can and ought to provide long-term care. c. Elicit the elder's views about the obligation to prevent unreasonable caregiving burdens on family members, especially female family members.

Current Longtermcare Policy And Legislation In The United States

Burden of caregiving becomes an ethically significant issue in long-term-care decision making. (3) Federal and state funding, provided through multiple program categories, results in fragmentation of benefits for the separate but interrelated medical, social, and income needs of older people. The result is that long-term-care decision making is a demanding and often stressful process. (4) Public financing of long-term care has been heavily biased toward payment for institutional long-term care and medical needs and not for formal home and community care. In our view, public policy expects, exploits, and reinforces family caregiving at home as a matter of obligation, almost without limits. Setting ethically justified limits on family caregiving thus becomes one of the central ethical concerns in long-term-care decision making. Long-term care should not be based on the ''value'' of endless self-sacrifice.

Implications Of Preventive Ethics For Longtermcare Policy And Planning

Long-term-care decision making by elders, family members, and professionals calls for nuanced, flexible responses because the changes that prompt long-term-care decisions dislodge elders and family from the nexus of relationships, achievements, sacrifices, and other factors from and in which human beings sustain their identities and worlds of meaning. A spouse dies or a child reaches the limits of caregiving obligations, and support networks unravel. Previously accommodated levels of dependence can no longer be accommodated. The elder confronts a world in which self-identity must be adapted to increased levels of dependence. The adult child confronts a world in which endless sacrifice may shape or shatter his or her self-identity. An elder hospitalized with pneumonia experiences worsening of her congestive heart failure and mental-status changes. The discharge planner suggests to the patient's daughter that her mother will need a significant level of support and supervision if she is...

Breathing Management of respiratory distress

The recognition of tension pneumothorax, its primary treatment by needle thoracostomy and definitive treatment by tube thoracostomy are essential at all hospital-level facilities that handle trauma. This implies sufficient training of the principal caregiver in the diagnosis of tension pneumothorax and in the safe performance of the relevant procedures. It also implies the ready availability of the needed materials, including a basic trauma pack, chest tubes and underwater seal drainage bottles.

Jane M Ingham Mb Bs Fracp

This chapter addresses the epidemiology of the end-of-life experience for those patients whose germ cell tumors do not respond to curative therapy and also focuses on the spectrum of problems faced by these patients and their caregivers. The components of optimal end-of-life care will be outlined, and some approaches for optimizing this care are provided. While it must be acknowledged that the experience of cancer varies widely among countries, much of the epidemiologic data reported in this chapter relate to the experiences of cancer patients in the United States. Nonetheless, much of the discussion, particularly in regard to the components of optimal end-of-life care, has broad applicability worldwide. Finally, although there has been a recent

Emotional Distress and Social Support Issues

Diagnosis of a malignant brain tumor is a stressful and traumatic event for patients and families with a wide range of responses from anger, withdrawal, isolation, guilt, anxiety depression, and hopefully, acceptance. Adjustment to the many changes can take a dramatic toll on patients, family and caregivers (19). Patients require varying levels of support depending on the stage of their illness. As care has been shifted from the hospital to the home, caregivers must master a range of tasks that they are often unprepared to assume (5). Caregivers must often assume duties previously performed by the patient. Caregivers overwhelmingly describe the work of providing care as mentally and physically exhausting and expressed feeling angry, frustrated and guilty for losing patience with the care recipient (20). They must build a support system, find community resources, understand insurance and financial benefits, and get legal affairs in order. Other tasks include identifying and reporting...

Medications and Chemotherapy

Patients and families should be educated regarding all medications and treatments prescribed. The drug's indications for use, expected outcomes, appropriate dosing schedules, potential side effects, and symptoms oftoxicity should be reviewed. Patients and families who receive adequate education are more likely to be compliant regarding their medications and treatments. Potential interactions with foods and other drugs including alcohol and over-the-counter (OTC) medications, such as vitamins and supplements, should be included. Caregivers and patients should be educated on the importance of reporting all alternative health practices to their health care providers (5). They should also be provided with legitimate sources for complementary and alternative treatments.

Internet As Sentinel Iii Monitoring Usage Of Health Websites And Healthrelated Queries To Search Engines

The goal of ProMED-e-mail and GPHIN are similar to detect an outbreak or unusual events close to the time that astute observers or news media report them. In this section, we explore the potential of analyzing patterns of Internet utilization by sick individuals (or their caregivers) to detect events even earlier. This area of research is predicated on the assumption that sick people (or their caregivers or doctors) turn to the Internet early during the course of an illness. At present, it is known only that individuals frequently turn to the Internet for health information, but not that they turn to the Internet early in their illnesses. According to a 2004 Harris Interactive Poll, almost 33 of American adults say they often or very often'' search for health information online (Harris Interactive, 2004).A survey by Pew Internet found that on any day as many as 7 million American adults look for health information online. There have been no surveys of the timing of searches relative...

Health Care Utilization

Patients with coexisting depression and dementia were found by our group to use inpatient health care and nursing home care at a significantly higher rate than patients with either condition alone (Kales, Blow, Copeland, Bingham, & Kammerer, 1999). From a health services perspective, the combined comorbidity appeared to function as the worst of both worlds with high inpatient medical and psychiatric and nursing home utilization and low outpatient utilization. It was our hypothesis that there might be barriers to effective outpatient care in these patients, such as low rates of depression detection and treatment in primary care and the impact of caregiver issues such as caregiver burden and prioritization of medical issues by the caregiver.

Moral concepts Emotions in Moral Cognition

Further evidence for this conclusion comes from the literature on moral development (see Eisenberg, 2000, for review). The most effective means of training children to be moral are parental love withdrawal, power assertion, and the induction of sympathy through drawing attention to the consequences of action (Hoffman, 2000). All of these methods affect a child's emotional state. Love withdrawal is especially effective. It induces sadness in children by convincing them that they may lose the affection and support of their caregivers. Elsewhere I have argued that this becomes the foundation for guilt (Prinz, 2003). Guilt is a species of sadness directed at one's own transgressions. Eventually the sadness induced by love withdrawal is transferred to the action, and we become sad about what we have done, rather than being sad about the consequences. This transfer can be driven in part by mechanisms as simple as classical conditioning. Other moral emotions may be learned by emulating...

Social and Economic Differences

The social interests of women are not limited to family members and friendships but extend to the wider community and larger geographical units. Career-oriented women are more likely to enter helping professions such as child care, teaching, nursing, and social work than other fields (Eagly & Crowley, 1986). On a nonprofessional level, women are more likely than men to be called upon as caregivers. Many participate in community service, religious, and volunteer activities of various kinds. In the political sphere, their greater concern with the disadvantaged leads women to vote more often to support the Democratic platform and to vote for Democratic candidates in elections. This is particularly true when matters of great concern to them, such as abortion or child care, are at issue.

Reactive attachment disorder of infancy or early childhood

In reactive attachment disorder, the normal bond between infant and parent is not established or is broken. Infants normally bond or form an emotional attachment, to a parent or other caregiver by the eighth month of life. From about the second through the eighth month, most infants will respond to attention from a variety of caregivers, if the caregivers are familiar. By the eighth month, however, normal infants have established a strong emotional preference for one or two primary caregivers. They are distressed if separated from these caregivers for even a few hours, even if another familiar per- Loss of parents. The most common cause of reactive attachment disorder is being orphaned or put in foster care at a very early age. The infant may receive care from many people or be moved from place to place often. A bond to a single consistent caregiver cannot be formed. Neglect or impaired caregiving. If the infant is not cared for consistently, it will not learn to trust. This includes...

Models to Predict Patients at Risk for Neutropenia and Patients Who Will Benefit From Prophylactic Pegfilgrastim

A cheaper drug is more cost-effective even if it requires more frequent injections and risks patient compliance. How do payors account for the hidden costs such as days missed from work or transportation costs to medical facilities for patients or their caregivers, in addition to the disruption of lives already tormented by cancer

Economic Models Incorporating Indirect and Outof Pocket Costs

Limited information is available pertaining to direct nonmedical and indirect costs, which would provide a more societal perspective on the economic impact of neutrope-nia and CSF. A survey reported on 26 women with ovarian cancer experiencing severe or FN, including time lost from work for patients and caregivers and out-of-pocket

The Plan Of This Volume

In the chapter by Thompson, Easterbrooks, and Padilla-Walker, the authors examine the dynamics of individual and context in key constructs of early socioemotional development attachment relationships, self-understanding, and emotional regulation. The ways in which these constructs and developmental processes emerge and take character are examined from a relational context (primarily that of the infant and close caregivers). Gunnar and Davis apply a dynamic systems approach to the study of the stress and emotion in the early years of life. The chapter emphasizes the biological roots of developing emotion systems and the scope and limitations of developmental plasticity. The authors navigate the fundamental tenets of the psychobiology of stress and emotion, outlining developmental integration across infancy. In addition, Gunnar and Davis place these developmental systems in the context of the relationships between infants and their caregiving environments. Issues of caregiving...

Patient Selection

A thorough physical assessment, psychological evaluation, and test dose trial must be performed before scheduling the actual surgery for pump placement. Medical history, physical assessment, and appropriate imaging tests allow one to determine the type of pain that the patient is experiencing. Baseline pain rating can be assessed with a visual analogue scale (VAS), numerical pain rating, verbal pain scale, patient and caregiver questionnaires, and pain drawings.

The importance of early attachment pattern and the effect of an early disruption being exposed in genetic counselling

Of a particular event in the family history no emotion is expressed, then it is wise to suspect a denial of feelings as covering unprocessed grief. The important determining factor in a child's recovery from loss of a caregiver is the quality of care given to support a child at that time (Rutter, 1987). Unfortunately, this woman was not offered support at the loss of her mother. Paradoxically, the woman's upset at her genetic test result helped her as it resulted in her having extra counselling. That enabled her to express and contain the emotions triggered by the present upset and those resurrected from the past.

Clinical Assessment Scales for the Elderly

The CASE is used to determine the presence of mental disorders in an elderly person as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (2000), which is also called DSM-IV-TR. The DSM-IV-TR is the basic reference work consulted by mental health professionals when making a diagnosis. The CASE, which is used with adults between the ages of 55 and 90, consists of a self-report form in which the person answers questions about himself or herself related to various scales. If the elderly adult is unable to complete the form because of cognitive or physical deficiencies, an other-rating form is provided for use by a knowledgeable caregiver, such as a spouse, child, or health care worker.

Selecting A Medication

Target symptoms to drug class is, in fact, appropriate. One was based strictly on published data (American Psychiatric Association APA , 1997), while the other was based on expert clinical consensus (Alexopoulos, Silver, Kahn, Frances, & Carpenter, 1998). After we select a class of medications, we choose from within it one for which there is reasonable evidence of efficacy and limited safety and tolerability problems. A simple dosing regimen is helpful optimal dosing in general is kept to one or two times daily. After starting treatment, monitoring treatment effects is based on the clear baseline that has been established. Usually, the best we can hope for is a reduction in the frequency or severity of symptoms rather than a full resolution. It may be helpful to ask the caregiver to keep a record of the frequency and severity of target behaviors. Several scales are available for this purpose, which are reviewed in other chapters. A general principle is Start low, go slow. Medication...

Identification Of Barriers

If patients are unable to speak, it is essential that a caregiver be available to provide insight into patient behavior and sleep patterns, which often are influenced by the patient's pain. Also, physical activities may provide valuable clues to a patient's pain because pain will limit an elderly patient's activities, such as walking, functions of daily living, or other activities the patient may enjoy doing when pain free. In an inpatient setting, some of these barriers might be overcome if these vulnerable patients are identified and immediately assessed and managed by an interdisciplinary team of social workers, caregivers, physicians, pharmacists, rehabilitation therapists, discharge planning coordinators, and nurses in an effort to coordinate the patient's care. Such an approach is vital in transitioning the patient from inpatient status to the ambulatory environment (54-62).

Phenomenology Of Depression In Dementia

Chemerinski, Petracca, Sabe, Kremer, and Starkstein (2001) evaluated how well mood as rated by both caregiver and dementia patient accounted for depressive syndromes in 253 persons with AD, 47 persons with depression but no dementia, and 20 healthy controls. Depressed mood as rated by both caregivers and patients was a powerful predictor of a host of other depressive symptoms including apathy, anxiety, insomnia, loss of interest, agitation, and psychomotor retardation. These data further supported the importance of assessing mood in persons with dementia.

Pharmacologic Treatments Antidepressants

Experts contend that given the more benign side-effect profile, a trial of an SSRI in cases of possible sustained depression in dementia is often warranted (Raskind & Peskind, 2001). Successful treatment of depression in dementia might decrease individual suffering, improve function at a given level of cognition (Fitz & Teri, 1994), remove depressive contribution to memory problems (Cole, 1983), reduce caregiver burden, and potentially delay nursing home placement.

Location of Patient Being Treated

The location of the patient (nursing home, assisted living, or outpatient) does not alter the choice or dose of medication to be considered in treating psychotic symptoms in dementia. The residential status of a patient is partly dependent on the patient's clinical state and partly on the ability of the caregiver to manage the patient at home. Whether and when the patient is admitted to a nursing home are highly variable factors that may depend as much on the caregiver's tolerance threshold and available resources as the patient's clinical state. Furthermore, the range of semi-independent, assisted living, intermediate nursing care, and specialized dementia facilities has created a spectrum of caregiving that defies simple categorizations and overlaps with intensive in-home services. In both outpatients and nursing home patients, the results of trials comparing antipsychotic medications in AD (De Deyn et al., 1999) and dose-comparison studies of individual antipsychotic medications...

Multicultural Issues

Help-seeking and help-accepting in caregivers can be heavily influenced by culture. For example, Valle (1998) describes situations involving cultural paralysis, in which help is neither sought nor accepted by care-givers of persons with dementia in large part because of cultural expectations. For example, Hispanic female caregivers may see their role of caring for an elderly relative with dementia as part of their deber (sense of obligation) to the relative. Cultural differences between persons with dementia and their caregivers can inhibit effective delivery of care, create behavioral disturbances stemming from such differences, or prevent persons with dementia from having unmet needs addressed. This is especially true in institutional settings. Crose (2000) notes The older women and minorities who currently live in nursing homes grew up in a time of unquestioned White male rule and have experienced discrimination throughout most of their lives. Many arrived in this country as...

Case Study I Psychological Perspectives

The onset of new psychosis, such as exhibited by Mrs. Regal, is terribly difficult for family caregivers. Indeed, the fluctuations of both her cognitive and psychiatric symptoms typically leave caregivers feeling overwhelmed and frustrated. It is critically important to begin the educational and support process for caregivers during the time of the neurological work-up and treatment planning. The family can also be taught some strategies to help reduce Mrs. Regal's feelings of anxiety and depression.

Developing Emotions And Sociability

It is difficult to conceive of early social development apart from the emotions that color social interactions in infancy. Emotions have been called the language of infancy, and infants as emotion detectors (Tronick, 2001). Infants signal their emerging social discriminations and preferences according to which partners can most readily evoke smiles and cooing, and adults become engaged in social play with babies because of the animated, exuberant responses that they receive. Caregivers attune to the preemptory sound of the infant cry and the hunger, pain, or startled fear it reflects, and the baby's developing sensitivity to the emotional expressions of others reflects achievements in an emerging understanding of people. In short, the study of socioemo-tional development reflects how interwoven are the processes of early social and emotional growth, each of which provides a window into psychological development.

Summary of Frontotemporal Dementia

That are severe enough to interfere with daily functioning. These behavioral and cognitive distinctions may be difficult for caregivers (not to mention patients) to discern. For example, family members may interpret inactivity and withdrawal as forgetting to attend to daily tasks rather than apathy and neglect. Not surprisingly, research suggests that better discrimination may be achieved from questions that solicit specific and detailed information than from general and broad information (Barber et al., 1995).

Detection and Assessment

In a clinic-based study, the detection of depressive symptomatology in patients with PD more than doubled (21-44 ) when patients were screened using the Beck Depression Inventory (BDI) (15). The assessment and recognition of depression has been ranked highly as an indicator for improving care of PD patients (103). All PD patients should be screened periodically to detect clinically significant depressive symptomatology. If self-reported disability is out of proportion to findings on the neurologic exam, depression should be suspected (73). Caregivers or family members are often valuable sources of information about the patient's psychological well-being, especially when self-report may be unreliable (104).

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