ABC of Dementia E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: ABC Series
• Sprache: Englisch

Seitenzahl: 267

Veröffentlichungsjahr: 2020

Beschreibung

ABC of Dementia is a practical guide, written with the needs of professionals in training in mind. Its aim is to enable readers to explore attitudes towards dementia, and find the knowledge and skills required in the important task of supporting the lives of people with dementia and their carers. This new edition is designed to assist students and practitioners working within both primary and secondary care settings with the diagnosis, treatment and provision of care. It covers the causes of dementia, diagnostic assessment, early intervention, pharmacological treatment, person-centred care, legal and ethical issues, and more.

This resource has been thoroughly revised to reflect the most recent research and evidence-based practice. New and expanded content addresses dementia and frailty in care homes, explores the role of technology in the treatment of dementia, discusses working with minority groups, and examines case studies.

• Aids healthcare professionals in developing the knowledge, skills and confidence to care for those with dementia
• Highlights the importance of person-centred care and the effects of dementia on families and carers
• Describes the cognitive changes and neurological disorders central to dementia
• Addresses the needs of younger people developing dementia
• Provides guidance on managing dementia in primary care, the acute hospital and end-of-life care settings
• Covers the Neuropsychiatric Symptoms of Dementia (NPSD)
• Features numerous full-colour photographs and illustrations

ABC of Dementia is a must-have for healthcare students, general practitioners, and other healthcare professionals caring for people with dementia. It will also be of interest to members of the general public who wish to know more about dementia.

Leseprobe

Table of Contents

Cover

List of Contributors

Introduction

Changes in society

Policy and politics

The ABC of dementia

CHAPTER 1: Dementia in the UK

Introduction

Terminology

Prevalence and demography

Economic impact

Who has dementia?

The diversity of dementia

The changing journey

Psychosis

Affective disturbance

Behavioural change

Physical disability and death

Who can help?

Conclusion

Quality statements

Further reading

CHAPTER 2: Causes of Dementia

Introduction

Alzheimer’s disease (AD)

Pathology of Alzheimer’s disease

Vascular dementia (VaD)

Mixed AD and VaD

Dementia with Lewy bodies (DLB)/Parkinson’s disease dementia (PDD)

Frontotemporal dementias (FTDs)

Normal pressure hydrocephalus

Protective factors and risks in the aetiology of dementia

Further reading

CHAPTER 3: Assessment of Dementia

Introduction

Why?

What?

How?

The story of change

What has changed?

Testing cognitive ability

Imaging

The diagnosis

Further reading

CHAPTER 4: Intervening Early in Dementia

Introduction

Exploring the concept of early intervention in dementia

Early intervention in dementia

The evolving service model

Conclusion

CHAPTER 5: Pharmacological Treatment

Introduction

Cognitive enhancers used in dementia

Efficacy

NICE guidelines on dementia, 2018 (NG97)

Adverse effects and monitoring

Interactions

Vascular dementia

Anticholinergic medication in dementia

Covert administration

Conclusion

Further reading

Acknowledgements

CHAPTER 6: Dementia and Families

Introduction

Family relationships and dementia

The family experience of dementia

Assessment with families affected by dementia

Interventions with families affected by dementia

Conclusion

Further reading

CHAPTER 7: Person‐centred Care

Personhood in dementia

Malignant Social Psychology (MSP)

Positive person work

Communicating well with people living with dementia

The challenge of providing person‐centred care

The whole organisation approach

Finally, a word about labels

Further reading

CHAPTER 8: Neuropsychiatric Symptoms of Dementia (NPSD)

Introduction

Neuropsychiatric symptoms of dementia

Affects of NPSD on the person with dementia and their families/carers

Prevention of NPSD

Assessment and management of NPSD

Conclusion

Further reading

Acknowledgements

CHAPTER 9: Dementia in Younger People

Epidemiology

Diagnosis

Aetiological subtypes

Pharmacological treatment

Comprehensive assessment and support

Social needs

Information needs

Employment needs

Carer and family needs

Physical needs

Service development

Further reading

CHAPTER 10: Dementia in Primary Care

The nature of primary care

Dementia in primary care

The role of primary care in diagnosis and management

End‐of‐life (EOL) care

Acknowledgements

CHAPTER 11: Dementia in the Acute Hospital

Introduction

Reasons for hospital admission

Preventing admission

Initial assessment

Delirium

The role of families

Care in the acute hospital

End‐of‐life (EOL) care

Summary

Further reading

CHAPTER 12: Dementia and the Law

Introduction

Legislation

Mental Capacity Act 2005

Relationship between the Mental Health Act and the Mental Capacity Act

Deprivation of Liberty Safeguards (DoLS)

Making decisions for the future: Advance Care Planning (ACP)

Health decisions

Financial decisions

Difficulties around capacity

Treating a person who lacks capacity

Covert medication prescribing

Dementia, driving and the law

Conclusion

Further reading

Acknowledgement

CHAPTER 13: End‐of‐life (EOL) Care in Dementia

Introduction

Six core capabilities for care and support toward the end of life

Conclusion

Further reading

CHAPTER 14: Dementia in Other Settings

Introduction

Supporting people with dementia at home

Moving from home into long‐term care

The Intermediate Care Service for Dementia (ICSD)

Admission to hospital

Further reading

Index

End User License Agreement

List of Tables

Chapter 2

Table 2.1 Classification of primary neurodegenerative pathologies causing dem...

Table 2.2 Main causes of dementia (relative proportion in percentage).

Table 2.3 Other types of dementia.

Table 2.4 Possible primary prevention.

Chapter 5

Table 5.1 Medicines to avoid in dementia and suggested alternatives.

Chapter 6

Table 6.1 Factors contributing to or mediating the risk of negative outcomes.

Chapter 9

Table 9.1 Aetiological subtypes of YOD based on their earliest or most promin...

Chapter 14

Table 14.1 Technology as support.

Table 14.2 Points to consider for dementia‐friendly homes.

Table 14.3 Examples of services offered by ICSD.

List of Illustrations

Chapter 7

Figure 7.1 Who do you see when you are asked to assess a person living with ...

Figure 7.2 One of the richest accounts of what it is like to live with demen...

Figure 7.3 Is the communication style indicative of Malignant Social Psychol...

Figure 7.4 The VIPS definition of person centred care (Brooker and Latham 20...

Figure 7.5 NICE Guidelines on Dementia 2018.

Figure 7.6 The VIPS framework for implementing person centred care across a ...

Figure 7.7 Care Fit for VIPS is a free, online toolkit to help care homes im...

Figure 7.8 The way health care professionals use language can have a big imp...

Chapter 8

Figure 8.1 Flow chart for management of patients with neuropsychiatric sympt...

Chapter 9

Figure 9.1 Early‐onset dementia diagnostic subtypes.

Chapter 11

Figure 11.1 Causes of delirium.

Guide

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Table of Contents

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ABC of Dementia

Second Edition

EDITED BY

Felicity A. Richards, MBChB, MRCPsych, DGM

Dorset HealthCare University NHS Foundation TrustDorsetUK

Bernard Coope, MBChB, MMedSci, MRCPsych

Dorset HealthCare University NHS Foundation TrustDorsetUK

This edition first published 2020 © 2020 by John Wiley & Sons Ltd

[Edition History 1e, 2014]

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

The right of Felicity A. Richards, Bernard Coope to be identified as the author of editorial work has been asserted in accordance with law.

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Library of Congress Cataloging‐in‐Publication Data

Names: Richards, Felicity A. (Felicity Ann), 1979‐ editor. | Coope, Bernie, 1964– editor.Title: ABC of dementia / edited by Felicity A. Richards, Bernard Coope.Other titles: ABC series (Malden, Mass.) Description: Second edition. | Hoboken : John Wiley & Sons, 2020. | Series: ABC series | Includes bibliographical references and index.Identifiers: LCCN 2020001248 (print) | LCCN 2020001249 (ebook) | ISBN 9781119599395 (paperback) | ISBN 9781119599357 (adobe pdf) | ISBN 9781119599333 (epub)Subjects: MESH: Dementia–diagnosis | Dementia–therapy | United KingdomClassification: LCC RC523.2 (print) | LCC RC523.2 (ebook) | NLM WM 220 | DDC 616.8/31–dc23LC record available at https://lccn.loc.gov/2020001248LC ebook record available at https://lccn.loc.gov/2020001249

Cover Design: WileyCover Image: © DrAfter123/Getty Images

List of Contributors

Carol BannisterDorset HealthCare University NHS Foundation Trust Dorset, Dorset, UK

Peter BenthamBirmingham and Solihull Memory Assessment Service, Birmingham, UK

Andy BroganEasier Inc.

Dawn BrookerAssociation for Dementia Studies, University of Worcester, Worcester, UK

Rachel Christian‐EdwardsDorset HealthCare University NHS Foundation Trust, Dorset, UK

Bernard CoopeDorset HealthCare University NHS Foundation Trust, Dorset, UK

Saskie DormanForest Holme Hospice, Dorset, UK

Paul FrenchDorset CCG, Dorset, UK

Michelle HughesDorset HealthCare University NHS Foundation Trust, Dorset, UK

Tanya JacobsWorcestershire Health and Care NHS Trust, Worcestershire, UK

Jelena JankovicBirmingham and Solihull Mental Health Foundation Trust, Birmingham, UK

Ranjeev JaswalDorset HealthCare University NHS Foundation Trust, Dorset, UK

Francis JohnsonDorset HealthCare University NHS Foundation Trust, Dorset, UK

Rod KershRotherham Hospital and Manor Field Surgery, Maltby, UK;

Yorkshire and Humber Clinical Network for Dementia, UK

Jenny La FontaineCentre for Applied Dementia Studies, University of Bradford, Bradford, UK;

Institute of Applied Health Research, University of Birmingham, Birmingham, UK

Felicity A. RichardsDorset HealthCare University NHS Foundation Trust, Dorset, UK

Georgios TheodoulouWorcestershire Health and Care NHS Trust, Worcestershire, UK

Introduction

Bernard Coope and Felicity A. Richards

The past few decades have seen a rapid growth in the scientific understanding of dementia and the brain diseases that cause it, including developments in neuropathology, aetiology, imaging, and the role of genetics. In turn, this knowledge has led to the introduction of pharmacological treatments, and, consequently, an evidence base for their limited effectiveness. As yet, no available treatments modify the brain diseases causing dementia and there is no evidence to support screening programmes.

Continued research has also led to the discovery that many of the treatments that have been used for decades with the clinical aim of helping people with dementia do more harm than good. Sedating medication such as antipsychotics are of little clinical effectiveness and are known to increase mortality in those patients prescribed them. Fortunately, we are moving away from pharmacological treatments towards a range of non‐medical interventions to help those most distressed or most challenging to care for. Central to this has been the flourishing of research and theory in the field of person‐centred care.

A final illustration of the changing evidence base is the demonstration of the effectiveness of service interventions. Supporting carers by providing information and emotional support can prolong a carer’s ability to provide care at home, reducing the need for a move to longer term placement. A well‐made and well‐communicated early diagnosis, backed by post‐diagnostic support, can improve the quality of care for people with dementia and their families as well as reducing the risk of crises in the future.

Changes in society

Dementia is a condition that gets commoner with age. More than half of those with dementia in the UK are over 80. It is this age group that is growing in countries across the world, and with this growth, the number of people with dementia is climbing.

As the number of people with dementia has been rising, the structure of families has been changing. Close members of the family have traditionally stepped in to provide care for people with dementia, with the majority of carers being either spouses or daughters. There is an increasing trend for people to enter old age separated, and for children to be living at a greater distance from their parents and to be in full‐time work. The capacity of family members to take on a caring role will have an impact on what is expected from professionals in health and social care.

At least as important as demographic growth is the changing expectations of a new generation of people with dementia, illustrated by the relatively modern demand for early diagnosis. The past decade has seen a dramatic shift from individuals ‘turning a blind eye’ to changes in their mental performance to concern about whether these changes could represent the onset of dementia. Crucially, this concern is often accompanied by a wish to know if this is the case and asking for assessment. This new openness has revealed another fact; people over 50 now fear getting dementia more than they fear cancer.

Policy and politics

Dementia became a political issue in 2007 following publication of the report by the National Audit Office ‘Improving Services and Support for People with Dementia’. Included in this report was an economic analysis that showed that dementia costs the UK more than heart disease, stroke, and cancer combined. Most of this cost was for care, either through Social Services or directly by patients and their families, rather than NHS costs. No longer was dementia a minor matter; it has become the most expensive health condition the country faces.

Currently, dementia has a high political profile, with David Cameron, the then Prime Minister launching his own Dementia Challenge, with a vision to improve dementia care in the UK by 2020. One criticism of the approach is the focus on diagnosis rates as a key performance indicator for Clinical Commissioning Groups. Measuring the number of those diagnosed with a dementia says nothing about the accuracy of the diagnosis, the experience of those going through the process, or the value gained through post diagnosis support and advice.

The ABC of dementia

The aim of this book is to enable readers to find the knowledge that will help them with the important task of supporting the lives of people living with dementia. It has been written with the needs of professionals in training mostly in mind, but would also hopefully be of value to a general readership. The first edition of The ABC of Dementia (2014) was chosen as one of the ‘Reading Well Books on Prescription for Dementia’ (2015) books – a scheme delivered by The Reading Agency, offering a resource for anyone who felt the need to learn more about dementia.

Some of the chapters are inevitably technical. The common diseases that affect the human brain and lead to the disability of dementia, the process of diagnostic assessment and medical treatment all have their place, but the main purpose of this book is as a resource for anyone helping those with dementia, and those supporting them, to continue to live their lives as well as possible. The chapters should also help readers consider some of the attitudes that can have a significant impact on people with dementia. At present, all medical treatments offer only limited benefit, and often this is finely balanced with side effects or other risks. The value of an early diagnosis therefore is more about providing the person with dementia and those family and friends around him or her with an opportunity to find the best way of living with dementia and to have a chance to develop the knowledge and skills that will help them as well as an opportunity to think about and plan their future. Those chapters on person‐centred care and dementia in families bring attention to this.

For professionals in health and social care, working in a person‐centred way in partnership with the person with dementia must be the foundation of what we do. Both in Primary Care and acute hospital settings, this can mean rising to the challenge of changing the way we work. It is easy for an individual with dementia to become a passive recipient of care, and for family carers to be seen as visitors rather than true partners. From both an ethical and legal perspective, this may not be ideal. The very important aspect of caring for a person with dementia who is reaching the end of his or her life means addressing attitudes more than gaining specific skills, and the final chapter on end‐of‐life care will hopefully be thought provoking.

The National Dementia Action Alliance campaigns to drive the improvement in the lives of people with dementia. Two of its campaigns deserve special attention at the start of this book.

1. ‘Dementia Words Matter’

‘Dementia Words Matter’ addresses the way that language can have a significant impact on those with dementia. It is common to hear words like ‘dementia sufferer’ or ‘dement’ when referring to individuals with dementia. The issue of dementia facing the UK can variously be described as a tsunami, a time bomb, or a growing burden. Whilst the intention may be to bring attention to the seriousness of dementia, these terms can also have a damaging effect on those who prefer to think of themselves as ‘living with dementia’.

2. Dementia standards

These statements were developed by people living with dementia and their carers. The person with dementia is at the centre of these statements, and represents everyone living with any type of dementia regardless of age, stage, or severity.

The ‘we’ used in these statements encompasses people with dementia, their carers, their families, and everyone else affected by dementia. These rights are enshrined in the Equality Act, Mental Capacity legislation, health and care legislation, and International Human Rights law.

We have the right to be recognised as who we are, to make choices about our lives, including taking risks and to contribute to society. Our diagnosis should not define us, nor should we be ashamed of it.

We have the right to continue with day‐to‐day and family life without discrimination or unfair cost, to be accepted and included in our communities, and not live in isolation or loneliness.

We have the right to an early and accurate diagnosis, and to receive evidence‐based, appropriate, compassionate, and properly funded care and treatment from trained people who understand us and how dementia affects us. This must meet our needs, wherever we live.

We have the right to be respected and recognised as partners in care; provided with education, support, services, and training, which enables us to plan and make decisions about the future.

We have the right to know about and decide if we want to be involved in research that looks at the cause, cure, and care for dementia and be supported to take part.

The dementia standards, notes, and guidance to accompany these statements can be found at: www.dementiaaction.org.uk/nationaldementiadeclaration.

CHAPTER 1Dementia in the UK

Bernard Coope

Dorset HealthCare University NHS Foundation Trust, Dorset, UK

OVERVIEW

There are currently 835 000 people with dementia in the UK.

Dementia is the most expensive healthcare issue the country faces. The economic impact for 2014 was over £26 billion, more than heart disease, stroke and cancer combined.

The syndrome of dementia consists of impairment of cognitive skills, resulting from disease of the brain, which is severe enough to impair daily functioning.

There is more to dementia than memory impairment.

Not all old people have dementia and not all people with dementia are old.

Introduction

Dementia is a clinical syndrome. This chapter examines the definition of ‘dementia’ and explores a number of issues related to dementia as it is experienced in the UK.

Definition: The syndrome of dementia

The syndrome of dementia consists of three components:

impairment of cognitive skills,

resulting from disease of the brain,

which are severe enough to impair daily functioning.

It is worth taking time to look at the implications of this definition.

Dementia as a syndrome

. Central to the definition is a change in mental skills. To diagnose dementia, these changes need to be confidently identified, which usually means obtaining a careful history supported by an assessment of mental skills. Dementia relates to how well a person’s brain is working rather than the presence of pathology, and can’t be diagnosed from a brain scan any more than a plain X‐ray of an arthritic joint can show pain. The diseases that cause dementia are covered in

Chapter 2

.

Cognitive functions are a diverse assortment of brain activity

. The term ‘cognitive functions’ covers memory encoding, long‐term stores of knowledge, word finding, language comprehension, face or object recognition, planning and organising of activity and judgement. Different brain diseases lead to different patterns of cognitive change. There is more to dementia than memory impairment.

To diagnose dementia, there must be good reason to suspect disease of the brain

. Brain imaging may help, but in practice, brain disease is usually inferred from change in mental skill.

It is quite possible to have brain pathology without dementia

. As imaging techniques develop, it may soon be common to diagnose Alzheimer’s disease years before any symptoms have developed. Vascular changes on imaging are very common, and on their own, don’t mean vascular dementia.

Impairment of daily functioning is an important but imprecise term

. Very minor changes in mental skills are not usually referred to as dementia, although there may be a difference of opinion among patient, carer and clinician about when the change of functioning has occurred. For those with some detectable changes in mental function that are not impacting on daily functioning, the term ‘mild cognitive impairment (MCI)’ is sometimes used.

When discussing dementia, we should be careful not to use syndrome and pathology as interchangeable concepts.

Terminology

In the 1970s, the late geriatrician Bernard Isaacs encouraged the use of the term ‘chronic brain failure’ as an alternative to ‘dementia’. The aim was to emphasise organ failure and to bring the definition in line with other commonly used terms, such as heart failure. ‘Acute brain failure’ represented delirium. Ultimately, the term was dropped as it had too many negative connotations, but the principle is worth reflecting on. Dementia is what we experience when changes in brain function impact our day‐to‐day life.

The National Audit Office, in its groundbreaking report Improving Services and Support for People with Dementia, took a more blunt approach and chose the simple term ‘progressive and terminal brain disease.’ Whilst this may not respect the syndrome/pathology distinction, it had the merit of communicating the seriousness of dementia to a wide range of opinion formers and politicians.

Prevalence and demography

The Alzheimer’s Society collated the following facts about dementia in 2014.

There are currently 835 000 people with dementia in the UK.

There are over 25 000 people with dementia from black and minority ethnic groups in the UK.

Two‐thirds of people with dementia are women.

There are 670 000 carers of people with dementia in the UK.

Family carers of people with dementia save the UK over £11 billion a year.

Approximately 69% of people living in care homes have a form of dementia.

Two‐thirds of people with dementia live in the community, while one‐third live in a care home.

There is significant variation in diagnosis rates, ranging from one‐third in some areas to >75% in others.

Economic impact

Until the National Audit Office published its report on dementia in 2007, dementia had never been considered a priority. It was the impact of dementia on the UK highlighted in this report that brought about a new political will to address the condition. The report detailed the real situation about dementia – not only how much the NHS and Social Services were spending on dementia, but also what individuals spent on their own care and how much lost earnings could be attributed to carers taking time off work to provide care. The answer was a little over £17 billion.

The significance of this sum was that if other conditions underwent the same analysis, dementia cost the UK more than heart disease, stroke, and cancer combined. Dementia is the most expensive healthcare issue the country faces, and it will continue on an upward trajectory. The economic impact for 2014 was over £26 billion; 670000 people act as carers in the UK, saving the state £11 billion/year.

Who has dementia?

The diseases that cause dementia get more common as age advances, so the majority of those living with dementia are over age 80. But not all old people have dementia, and not all people with dementia are old. Dementia can occur in people under 65, when specialist skills are needed to address the complexities of diagnostic diversity, complex personal and family responses and age‐related issues such as employment. The needs of younger people and their families are examined in Chapter 9.

As men tend to die younger than women, two‐thirds of those with dementia are women. Age discrimination is gender discrimination! This can mean that care settings for people with dementia may have a greater proportion of woman – both residents and staff. Male residents may feel less comfortable in these environments, and are more likely to be perceived as challenging.

Dementia in learning disability is another area that requires specialist skills – from diagnosis to helping that person live well. Dementia is more likely to develop at a young age in those with learning disability, especially Down’s syndrome. The observation that people with Down’s syndrome commonly developed dementia in their 40s indicated a link to chromosome 21, and ultimately to the discovery of the amyloid precursor gene.

Black and Minority Ethnic Groups: Dementia is more likely to have a younger onset in black and minority ethnic groups (BAME groups), but these groups are underrepresented in services for dementia. The number of people from BAME groups with dementia is expected to rise significantly as the population ages. It is estimated that there are 25 000 people living with dementia in England and Wales from BAME backgrounds, set to rise to 50 000 in 2026 and 172 000 in 2051 – a seven‐fold increase in 40 years, compared with a two‐fold increase in the number of people with dementia across the whole UK population in the same period of time. Services need to take active steps to make sure that they reach out to minority communities and tackle barriers in assessment and support. The technical aspects of making a diagnosis have to take into account language, with testing being carried out in the person’s preferred language where possible. Consideration needs to be given to educational background and also the cultural preconceptions embedded in many cognitive tests. Even a simple question like ‘What is the season?’ may be influenced by an individual's background.

The diversity of dementia

It is common for professionals to classify dementia into three stages of severity: mild, moderate and severe. However, it may be better to think of dementia as a journey a person is moving along, rather than a spectrum of disease severity – from what that individual previously considered as ‘normal’, through noticeable changes in mental skills that become consistent and then clear enough to warrant the use of the term dementia. As the person moves through the different stages of the condition, there is loss of mental skills. Other features may come and go, and quality of life is not closely linked to dementia severity. As an incurable condition, the person’s journey will end in death resulting from dementia or other causes.

The journey of dementia is rarely made alone. Usually, close family support the person with dementia, and inevitably their lives are also altered by it. Relatives start to be referred to as ‘carers’, although many are unhappy with that description. Carers’ research commonly states the negatives of this role, such as burden, strain and stress, but there are also the positives. It is more useful to think about how the presence of dementia in a family changes relationships and how dementia is experienced in its entirety. This intricate interplay is addressed in detail in Chapter 6.

The changing journey

Loss of cognitive skills is the core feature of the dementia syndrome, but there is much more to it. A range of non‐cognitive features can be experienced.

Psychosis

The presence of delusions (fixed, false beliefs) and hallucinations (perceptions without a corresponding object) are common at some point in dementia, although these experiences may be transient. Complex visual hallucinations are a core feature of dementia with Lewy body disease. Such features sometimes have little impact on the person with dementia, and have even been known to be enjoyable; however, they can also be extremely distressing and the cause of risky or aggressive behaviour. A person with dementia who believes that their spouse is an imposter may become understandably angry or violent toward them. Seeing dismembered bodies or snakes in the house can be frightening and lead a person to run out of the home. No longer believing your home is your own can be upsetting.

Affective disturbance

Depression commonly accompanies dementia, and again may be transient. The cause may be multifactorial, from the subjective experience of finding the world a bewildering place, having insight into their loss, the behaviour of others or directly due to brain disease. Depression is especially common in care home residents. It is usual to use antidepressant therapy, although there is little supportive evidence for this. Strategies aimed at improving quality of life through person‐centred care and meaningful activity may be more productive.

Behavioural change

Behaviour that is out of character or challenging to others is distressing to loved ones and can be a major issue for those providing care. It is important not to see it as a symptom of dementia, although clearly the dementia is influencing it. Anger or shouting may arise from boredom or pain. Behaviour is a communication, and we should ask ourselves what is being communicated. The agitated woman looking for her mother can easily be seen as just forgetful and mistaken, or instead can be thought of as expressing the need for comfort and familiar attachment, leading to attempts to meet that need. The issue of behaviour that challenges is explored in Chapter 8.

Attachment