The dreaded ‘Care of the Elderly’ Placement
A long time ago, during my nurse training days I was allocated to go and do an eight week placement in a care of the elderly home. Being so young at the time (only around 18 years old) this prospect did not, to be perfectly honest, fill me with joy.
The main reason for this was that I had heard that care of the elderly was difficult, back-breaking, messy and quite simply, hard work.
I started my allocation in January and in the first couple of weeks the tales from the previous students proved only too true. A lot of the full time staff were exhausted, irritable and de-motivated and appeared to have forgotten that these elderly patients that they spoke over and called ‘dear’ were all people, rich in life experiences and knowledge.
I carried one patient from that elderly unit in my heart for many years and I would like to tell you a little about her care, her condition and her life. Iris was around 72 years old when I first met her and was suffering with moderate to severe Alzheimer’s disease.
What is Alzheimer’s Disease?
In the first couple of weeks, amongst the hustle and bustle of a busy home for the elderly I barely noticed Iris. It seemed like a constant round of washing, dressing, feeding and toileting with barely a moment to catch your breath. It always takes a little time to get familiar with each patient and their individual ways.
At the time of our first meeting Iris had problems with severe memory loss, was not always aware of where she was in time and place and needed support with the activities of daily living such as eating, drinking, dressing, bathing and going to the toilet.
Iris, like many patients suffering from Alzheimer’s disease had good days and bad days. Well, really for her bad days and worse days. Iris would become very frustrated and confused at times, believing herself to be in London at the time of the blitz.
She would become terrified and very pre-occupied about the whereabouts of her handbag as she constantly prepared to leave the ward.
Occasionally, if she could not find her bag would she would accuse other patients or members of staff of taking it and become very distressed and sometimes aggressive. Some days she recognised her grown up children when they came to visit and other days she didn’t. This was particularly upsetting for everybody concerned.
One day whilst sitting and helping Iris eat her lunch she suddenly became very lucid and started reminiscing about her past. In these moments, her memory of long ago events was incredible. She described so vividly the bombing of London; the atmosphere of fear tinged with courage and defiance, the smell of the smoke,the noise of the sirens and of the bombs .
Iris described how she would round up all the children and always had some soup and snacks at the ready. She could recall exact dates and which of her neighbours and their children didn’t survive. It was like sitting reading a novel or watching a film about a huge historic event.
As we fell into an easy routine and helping Iris at mealtimes became a regular task, sometimes we would just sit quietly and sometimes I would be rewarded with a lucid period and a little snippet into the life and loves of this amazing woman who had been through so much already.
Music and reminiscence therapy such as looking at old photographs or other thought provoking objects can help Alzheimer’s sufferers to have lucid periods whereby they may remember their early lives, or briefly become orientated to time, place and person.
Anyway, time passed and I developed a habit of always popping in to see Iris before I left to wish her a good night and show her where her handbag was (in the bedside locker) in case of confusion or nightmares over the night shift. I knew that she probably wouldn’t be able to remember the location of said bag a few moments later, but sometimes it helped settle her to sleep.
Just before my placement was about to finish, I popped in as usual, Iris was all tucked up in bed. I went over and showed her the handbag and gave her a small peck on the cheek.
“Good night, Iris” I said
and she looked deeply into my eyes completely lucid, took my hand, smiled and said,
“Yes, I know where my handbag is dear and No, it’s not good night, it’s good bye.”
I didn’t really think too much of it at all, imagining to myself that she would probably be off wandering in the night to find the bomb shelter again, handbag firmly in tow
The next morning I came to work and there was the empty bed.
Iris had passed away quietly in her sleep that night. This wonderful lady taught me so much.
Instead of mourning their death, celebrate their life.
The brain of a person with Alzheimer’s disease has gradually become atrophied, which means it looks a little shrivelled. It has gradually lost tissue over time. What causes that? Well, we know that there is a build up of proteins that have leaked into the extra-cellular spaces, and there are neurofibrillary tangles when viewed under the microscope. But what causes that?
It’s normal for small molecules (like small protein molecules) to leak out of blood vessels into the extra-cellular spaces. It happens in small amounts, constantly to everyone. No problem there. But once those small proteins are outside of cells and outside of blood vessels, what happens next? Normally, there would be a gradual slow flow of extra-cellular fluid, flowing between the brain cells, that slowly sweeps all the proteins away. First, they would be swept into the Cerebrospinal fluid (CSF) that surrounds the brain, and later, reabsorbed back into the blood stream.
BUT, suppose something prevents the slow-flow of extra-cellular fluid. Then, those leaked proteins just hang around in the space between cells, and over months and years, they harden and chemically change and clump together into a material we call amyloid. When you see amyloid protein under the microscope, when looking at brain tissue, you know that proteins had been hanging around for a long, long time.
Why would the slow-flow of extra-cellular fluid be reduced, or ineffective? That’s the key question. I think it’s two factors: 1) No pulses of over-hydration. 2) No intense brain activity. Let me explain:
There is a condition called “Water intoxication”, whereby if you over-hydrate yourself by drinking too much water, you can become, at first, a little mentally stimulated, but later, mentally somnolent and sedated. Drinking too much water, leads to too much water inside your bloodstream (and your kidneys notice and start working making urine at a fast rate), and too much water inside your bloodstream leads to water leaking out of bloodvessels into the extra-cellular spaces of the brain.
At first, too much water leaking into the extra-cellular spaces of the brain, is a good thing. That water will flow and carry-away debris like proteins that were hanging around. It’s similar to having a rainstorm that makes a creek run faster, which carries away the garbage and tree branches that were accumulating along the banks of the creek. So, a little pulse of over-hydration is good. It clears away garbage proteins that were outside of brain cells, and at first, your brain likes it and thinks better. ( Warning, a rainstorm is good, but a flood is way too much).
The second factor, is brain activity itself. When parts of your brain are actively “thinking”, they open up the blood flow, A LOT. This is the principle of functional MRI (fMRI). fMRI notices areas that are having increased blood flow from brain activity. Brain-activity causes increased blood flow in that part of the brain. Whenever there is increased blood flow, there is more leak of fluid into extra-cellular spaces.
More leak of fluid into extra-cellular spaces, can be just like that rain-storm from over-hydration. It can, at first, be beneficial and carry away the debris from the spaces between cells.
The problem? I think some people fall into gradual patterns of living their lives, of not exercising their brains enough. Mental challenges, experiencing excitement and strong emotions, being reminded of diverse memories from the past, doing unusual physical activities, having complex problems to figure out. All these things are good for the brain. IF we don’t use parts of our brain for a long time, they don’t get the intermittent exercize of mental activity, they don’t get the benefit of pulses of increased blood flow, and slowly those leaked proteins build up and slowly those areas of the brain under atrophy.