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Father’s Old Blue Cardigan
POEM VIEWS: 118
By Anne Carson
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Now it hangs on the back of the kitchen chair
where I always sit, as it did
on the back of the kitchen chair where he always sat.
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I put it on whenever I come in,
as he did, stamping
the snow from his boots.
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I put it on and sit in the dark.
He would not have done this.
Coldness comes paring down from the moonbone in the sky.
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His laws were a secret.
But I remember the moment at which I knew
he was going mad inside his laws.
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He was standing at the turn of the driveway when I arrived.
He had on the blue cardigan with the buttons done up all the way to the top.
Not only because it was a hot July afternoon
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but the look on his face—
as a small child who has been dressed by some aunt early in the morning
for a long trip
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on cold trains and windy platforms
will sit very straight at the edge of his seat
while the shadows like long fingers
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over the haystacks that sweep past
keep shocking him
because he is riding backwards.
Aim
To give an overview of caring for patients with
dementia in the community
 Objectives
To cover diagnosis, treatment, management,
issues for carers and elder abuse
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Dementia is a condition which causes gradual
loss of mental ability beyond what is expected
by the normal aging process.
Consciousness is not affected
It causes changes in personality, decline in
social function, and a decline in the ability to
self care.
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Memory loss
Disorientation
Failing intellect
Personality changes
Self-care
Mood changes
Weight loss/falls
As disease progresses- loss of speech ,
continence, mobility, eventually leading to
death.
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Mrs Muddle, 75y old is brought to see you by
Neil, her son.
He is very concerned as she has become
forgetful of late and recently nearly blew up
the kitchen when she started to cook and forgot
to light the gas stove.
What would your next steps be in assessing
this woman?
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I have seen deeply demented patients weep or
shiver as they listen to music they have never
heard before, and I think they can experience the
entire range of feelings the rest of us can, and that
dementia, at least at these times, is no bar to
emotional depth. Once one has seen such
responses, one knows that there is still a self to be
called upon, even if music, and only music, can do
the calling.
Oliver Sacks (2007) Musicophilia: Tales of Music
and the Brain
New York: Knopf (p.346)
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Driving
Wandering
Aggression
Sexual inhibition
Financial vulnerability
History
 Cognitive, mental state, and physical exam,
exclude depression, reversible causeshypothyroidism, assessment tool e.g. mmse
 Investigation;
fbc, esr, u&e, lft, tft, gluc, haematinics, drug levels,
drug screen,hiv /syphilis
Msu, ecg, ct scan, mri (unusual)
 Medication review
Check the patient wants to be told results
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Refer early- borderline positive patients are
most likely to benefit from treatment.
 Refer to memory clinicAssess for drug tx
Provide support needed
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Choline esterase inhibitors eg donepazil
-specialised prescribing
-Alzheimer sufferers, mmse 10-20
-regular reviews.
 Memantine
Only in clinical studies currently
Reduces Ca2+ in neurones
 Sedation eg haloperidol
-Now frowned upon
 Antidepressants
-SSRI’s
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Support in the community
-DN’s CPN’s SS Voluntary organisations eg AS
 Reality Orientation
 Cognitive stimulation
 Physical activity
 Reminiscence therapy
 Behaviour management- reduce depression
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Aims to improve dementia services in 3 areas:
Improved awareness
Early diagnosis & intervention
Higher quality of care
17 strategies – aims to develop early specialist
assessment, improve access to support in
hospital & community, end of life discussions,
joint commissioning strategy for dementia,
effective national & regional support
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Early recognition
Access to specialist Memory Services
acetylcholinesterase inhibitors donepezil,
galantamine and rivastigmine for moderate
dementia – only started by Specialist centres
MMSE recommended to be 10-20
Some debate regarding patients ability to
compensate on MMSE
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The intuitive mind is a sacred gift, and the
rational mind its faithful servant. We have
created a society that honours the servant and
has forgotten the gift.
Albert Einstein
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CKS
Forgetful but not forgotten, RC of Psychiatry
NICE guidelines treatment of dementia 2007/
2009
Patient.co.uk
Living Well with Dementia, A National
Strategy
Mental well being for elder people
Heathtalkonline
Dementia Positive
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Alzheimer's Society-www.alzheimers.org.uk
Carer’s UK-www.carersuk.org
Princess Royal Trust for Carerswww.carers.org