Dementia and Alzheimer's disease (AD) are highly debilitating conditions that afflict millions of elderly persons. In recent decades, biological evidence has implicated chronic stress in the etiology of these conditions. As a result, the relationship between widowhood, one of the most stressful life events, and dementia and AD has also received attention. However, studies are mixed regarding this association, and few have investigated whether this relationship is moderated by the context surrounding widowhood. This study extends this literature by investigating whether widowhood increases risk for dementia and AD and whether this risk is moderated by contextual factors including age at widowhood, remarriage after widowhood, manner of death, number of dependent and adult children at the time of widowhood, gender, presence of epsilon 4 allele of apolipoprotein E (APOE), and history of depression and antidepressant use. To do this, this investigation utilized data from the Cache County Memory Study (CCMS), a large population-based epidemiological study of dementia and AD, and the Utah Population Database (UPDB), one of the world's foremost linked genealogical databases. In Cox regression analyses that modeled time to onset of dementia and AD, gender was found to moderate the relationship between incident widowhood and dementia (HR = 1.74, 95% CI: 0.97-3.10), in that widowhood trended towards decreased risk among men (HR =0.72, CI: 0.45-1.16) but increased risk among women (HR = 1.21, CI: 0.83-1.75) in stratified models. In addition, history of depression and antidepressant use moderated the association between incident widowhood and dementia (HR = 2.63, 95% CI: 1.26-5.50) and AD (HR = 1.68, 95% CI: 1.11-2.53), in that widowhood was associated with decreased risk for dementia and AD among the never depressed (HR = 0.66, CI: 0.42-1.02 and HR = 0.54, CI: 0.31-0.92, respectively), a trend towards increased risk for AD among those with a history of antidepressant use but no depression (HR = 1.80, CI: 0.86-3.75), and with increased risk for dementia and AD among those with a history of both (HR = 1.93, CI: 0.98-3.81 and HR = 1.89, CI: 0.80-4.43). These findings advance clinical and scientific knowledge concerning the effects of widowhood on risk for dementia and AD, and underscore the importance of context in understanding this relationship.

The Cache County Study on Memory in Aging (CCSMA) is a longitudinal population-based study which took place in Cache County, Utah. The study followed 5092 older-adult residents (aged 65+) for approximately 12 years to examine risk and protective factors for dementia. Participants completed dementia screening and follow-up assessments across four triennial visits. Additionally, researchers gathered information regarding demographics, reproductive history (e.g. age of menopause; hormone replacement therapy [HRT]) and other health-related factors, such as physical activity. Genotyping of DNA was completed for a genetic variation of genes for brain-derived neurotrophic factor (BDNF), a protein found in the brain associated with neuronal health and survival. Estrogen has been associated with cognitive health and has been shown to interact with BDNF in the brain to promote neuronal survival. The current research investigated the associations between estrogen, BDNF, and cognitive decline in older adult women from the CCSMA. An examination of how reproductive history, including the reproductive window (age of menarche to menopause) and use of HRT, affects the cognitive health of women in older adulthood can provide a clearer understanding of how estrogen exposure across the lifespan contributes to cognition in late life. This research can be helpful in determining the implications of events such as pregnancy, breastfeeding, surgical menopause and use of HRT on cognitive decline. Additionally, an investigation of how these reproductive factors interact with BDNF genetics is important to understand gene-by-environment interactions. The results of the current project demonstrated that increased lifelong estrogen exposure, both in the form of the reproductive window and HRT use, had small cognitive benefits for women in late life. Additionally, it was shown that women who initiated HRT use closer to menopause had increased cognitive status compared to those who initiated later. The specific BDNF gene under investigation was not associated with cognitive status in late life, neither was the interaction between BDNF and lifetime estrogen exposure. This research contributes to the discussion of sex-dependent factors of cognitive health and can help provide a better understanding late life cognitive decline.

Research in the area of caregiving has tended to focus on the impact of the caregiving experience itself without consideration of continued psychological distress for caregivers after institutionalisation or death. Seven caregivers of loved ones with Alzheimer's Dementia (mostly spousal) were interviewed about their experiences of caregiving and their emotional well-being after placement of their loved one into a residential care facility or death. The nature of the carers relationship with their loved one (e.g. highly dependent), lack of social supports, inactivity and a poor experience of transition into care seemed to be factors relating to poorer outcomes for these caregivers. Utilisation of social supports, involvement in pleasant events, adequate preparation and information relating to the disease and collaboratively planned transition into care played protective roles for the remaining carers who reported decreased levels of anxiety, guilt, depression and stress post-institutionalisation/death. The implications of the current research for practise, policy change and prevention are extensive and suggest that risk factors may be identifiable and thus poorer mental health outcomes in caregivers preventable. A need for greater support to be made available to caregivers is necessary.

This thesis characterises the cortical pattern of degeneration in progressive supranuclear palsy (PSP) and its consequences. Global atrophy was first examined using a recently developed staging scheme in pathologically-proven PSP cases compared with other tauopathies: gross atrophy was not observed in PSP. Quantification of regional volume loss throughout the brain was then used to determine the magnitude of more focal tissue atrophy in PSP, cortical dysfunction was investigated by measuring cerebral blood flow (CBF) changes, and several cortical cellular pathologies were analysed. Any changes observed were related to each other and clinical assessments of motor, cognitive and behavioural abnormalities. At mid-stage PSP, frontal and subcortical atrophy related to decreased CBF in the frontal cortex and cognitive decline. Parietocerebellar CBF increases were also identified (related to frontal CBF deficits) and related to motor and non-motor deficits. By end-stage PSP, focal atrophy had advanced from frontal and subcortical structures to include atrophy in the parietal lobe. Parietal lobe atrophy related to behavioural abnormalities. Histopathological analysis at end-stage revealed that the cortical atrophy and cell loss does not relate to tau deposition. The focal cortical cell loss related exclusively to motor deficits whilst the more widespread cortical tau deposition related to cognitive and behavioural impairments. Both the tau deposition and these non-motor impairments increased in severity over time. The results show that frontal atrophy and dysfunction occurs rapidly and early in PSP and relate to increasing cognitive deficits. Such deficits appear to cause compensatory CBF enhancement in parietocerebellar regions which then also undergo rapid and severe neurodegeneration. These later changes occur in concert with the more classic PSP symptoms, such as oculomotor features. Throughout the disease, the progressive increase in frontotemporal tau deposition contributes to cognitive and behavioural deficits which become most marked late in the disease. The findings strongly suggest that progressive clinical dysfunction in PSP is directly related to progressive cortical degeneration. Cortical degeneration appears to occur in two independent functional networks. Increased CBF in PSP may be a useful early indicator for future neurodegeneration, although the cellular mechanism leading to cell death requires further investigation.

The prevalence of chronic pain is known to increase with advancing age, with over 50% of community dwelling older adults (aged 65 years and over) and up to 80% of those residing in nursing homes estimated to be suffering some form of persistent or recurring pain complaint. In addition to a greater likelihood of pain, advancing age is associated with increased reports of pain interference. It is possible to ascribe age-related changes in pain report and impact to increased disease prevalence and severity in older people. However, there is also evidence that ageing has effects on pain perception, central pain processing, and plasticity of pain responses that are not explained by co-morbid disease. / The increased prevalence of chronic pain in older adults represents a major public health concern. As a result of increased life expectancy and the post-World War II baby boom, there will be a dramatic change in the demographic structure of our population over the coming decades, with older adults representing the fastest-growing segment of our communities. The proportion of the total population over the age of 65 in Australia has risen from 9% in 1976, to 12% in 2001, and is predicted to reach 16% by the year 2016. Pain that is undetected or under-treated can adversely affect quality of life for older adults, leading to diminished mood, impaired cognition, behavioural problems, as well as increased functional dependence. This in turn contributes to greater demands for daily personal care and a resultant increase in health-care costs. / Pain management is a particularly salient issue in the case of older adults with dementia, who are at increased risk of undetected pain on account of impaired cognition and communication skills. Indeed, clinical reports show that patients with Alzheimer’s disease (AD) are routinely administered fewer pain-relief medications compared with their cognitively-intact peers. Understandably, reports of reduced analgesia in AD have sparked considerable research interest, and over recent years there has been a marked increase in the number of studies aimed at better characterising the experience of pain in patients with AD. However, despite these efforts, the effects of neurodegeneration on pain processing, and the specific ways in which the disease process impacts on brain responses to noxious stimulation and the ensuing experience of pain have not been previously determined. / Improved management of pain is fundamental to the clinical care of older adults, particularly those with dementia. However, the potential to adequately counteract pro-nociceptive processes and facilitate endogenous inhibitory mechanisms in the treatment of ongoing pain in older adults will only become possible once the effects of ageing and age-related neurodegeneration on central pain processing are identified and described. The overarching goal of this thesis was therefore to improve current understanding of the ways in which normal ageing and Alzheimer’s disease impact on the perception and central nervous system processing of pain. The findings of this thesis provide valuable new insights into the impact of ageing and AD on the central mechanisms contributing to pain perception, and may therefore contribute toward better management and treatment of pain in this vulnerable and rapidly growing sector of our community. / Thesis outline: Chapter 2 provides a review of the background literature and rationale for the thesis. The chapter begins with a discussion of current understanding of pain as a multidimensional phenomenon shaped by sensory, emotional and cognitive components, and leads into a description of neural mechanisms of nociception, as well as the supraspinal processes involved in the elaboration of nociceptive signals into these aspects of pain. The impact of ageing on the structure and function of central nervous system regions underlying these processes are discussed, along with the findings from previous clinical and empirical data which suggest age-related changes in pain perception. Current understanding of the neuropathological and clinical aspects of AD is reviewed, with particular emphasis on potential ways in which the disease may impact on central nociceptive processing and the behavioural response to pain. This is followed by a review of the previous clinical and empirical literature examining pain perception in AD. Finally, the aims of the current thesis are outlined. / Chapter 3 describes the general methods which were employed in the subsequent empirical chapters in order to address the aims of the thesis. The equipment and psychophysical procedures used to assess pain perception in healthy young and older adults and patients with AD are described. The basic principals of magnetic resonance imaging (MRI) are then outlined, and the utility of structural and functional MRI for assessing age-related and disease-related changes to brain regions involved in pain perception and processing are discussed. The empirical studies which were undertaken to identify the impact of ageing and AD on central pain processing are presented in the next three chapters. / Chapter 4 begins with psychophysical studies comparing sensory and emotional responses to pain in healthy young and older adults, and follows with MRI investigations of age-related differences in brain volumetry and pain-related brain activity. Studies of pain sensitivity and pain-evoked brain activity in patients with AD compared with age-matched controls are presented in Chapter 5. Following on from these findings of AD-related differences in pain-evoked brain activation, the study described in Chapter 6 used functional connectivity analysis in order to assess the impact of AD on the functional integration of brain regions underlying the sensory, emotional, and cognitive aspects of pain. / The key findings presented in the preceding three chapters are summarized in a general discussion in Chapter 7. The implications of the findings, in terms of the clinical management of pain in older adults with and without Alzheimer’s disease are discussed. The opportunity is also taken to discuss some of the limitations of the present research, and finally, recommendations are made for future research directions.

<p>The aim of this littrature review has been to describe how you can satisfy the need of nourishment for older people who suffer from dementia. Data has been retrieved by searches in Academic Search Elite, Sience Direct, Blackwell, PubMed and in the Journal Vård i Norden. The studies show that most of the people with dementia have a hard time to satisfy the nourishment. The results show that through different preventive measurement you can improve the nourishment for these people, to set the table, play calm music and to have a table companion. By taking the food oneself created a good meal environment and the individually need was provided for. A good oral status improved the nutritional status. Patients who got nourishment addition put on weight or retained their weight. Nursing staff wished and needed more education in nutrition for older people with dementia.</p>

<p>Syftet med studien var att beskriva hur vårdtagarens samt vårdpersonalens agerande/beteende, (verbalt/kroppsspråk) påverkade matintaget hos demenssjuka vårdtagare. Hur omgiviningsfaktorer påverkade matintaget har också observerats. En observationsstudie genomfördes på en demensavdelning under 5 luncher med hjälp av en observationsmall. Resultatet visade på att de flesta verbala påpekanden/instruktioner från personalen gavs till vårdtagarna de luncher då de åt minst, samt att personalen visade på stor följsamhet gällande att känna av hur vårdtagarna önskade hjälp under måltiderna. Interaktionen mellan vårdare/vårdtagare upplevdes "tryggt". Beteenden som kunde observeras hos vårdtagarna var att 2 av dem somnade några gånger under måltiderna, samt att sväljproblem förekom hos 2 av dem. Omgivningsfaktorerna påverkades av "gamla" rutiner som fanns kvar på boendet sedan förut. Att maten lades upp på diskbänken, att tillbehör till maten inte fanns på bordet/erbjöds vanemässigt till vårdtagarna (dessa lades också upp på bänken) kan eventuellt påverka matintaget negativt. Matintaget varierade mellan 30-100% hos vårdtagarna under de 5 luncherna. Slutsats: Personalens bemötande av demenssjuka personer påverkades av dennes erfarenhet av dem och vilken relation de hade. Kände vårdtagaren och vårdgivaren varandra, uppstod ett samspel, som underlättade vid måltiden/matsituationen vilket påverkade matintaget positivt. Måltidsmiljön hade också stor betydelse för matintaget, den påverkade också trivseln runt måltiden.</p>

<p><strong>Abstract</strong></p><p>The aim of the study was to describe the level of understanding of nursing staff regarding the expression of pain by patients suffering from dementia. A further aim was to examine what help and support is available to nursing staff in aiding assessment of pain levels in these patients.</p><p>The study is descriptive in character and has a qualitative perspective.</p><p>Six interview subjects, who were strategically chosen for convenience, were selected to help in this study. The criteria used for selection was that all should have a minimum of three years experience caring for patients suffering from dementia. As an aid to the interview process, semi structured questions and an interview guide were used. The material gathered was then literally transcribed, analysed and divided into eight categories and sub categories.</p><p>Interviewees report that patient express pain in a variety of different ways. Some patients use body language where they become withdrawn and their facial expressions and posture alters. Mood changes are also described, with patients becoming restless and anxious and sometimes aggressive. Verbal expressions of pain, such as wailing and screaming, are also described as well as the observation that patients suffering from dementia sometimes develop difficulties in sleeping and can wander off.</p><p>Further observations from the study show that combined importance of really knowing and being familiar with the patient and his/her background, a good relationship between nursing staff and the patients relatives, and finally, the need of pain assessment tools.</p><p> </p>

With aging of the baby boomer population, older adults living longer, and no known cure for dementia, the prevalence of dementia in older adults will inevitably rise. Dementia is a terminal illness, although it may not be recognized as such. Family caregivers to persons with dementia provide invaluable care, often at the expense of their own health and well-being. Over the past two decades there has been an abundance of research that examines the various and complex aspects of caring for a relative with dementia. However, there is a paucity of research that has been conducted on the experiences of family caregivers providing end-of-life care. The conceptual framework that guides this research is based on the work of Martin Heidegger. A thorough search of the literature reveals that the main themes of this end-of-life experience studied to date are the experience of grief and loss, and the manifestations of depression in family caregivers. A number of gaps in the literature remain that limit our understanding of the end-of-life care experience. The purpose of the present study is to begin to address this neglected area of research. As a result, the research question is: What is the meaning of the lived experience of family caregivers who provided end-of-life care for a relative who died with advanced dementia? This question was addressed using an interpretive phenomenology based on the work of Munhall. The study utilized a purposeful sample of family caregivers (n = 11) whose relative with dementia died in the last year. Two to three in-person, unstructured interviews were completed with each participant as a way to glean an understanding of their experiences and offer opportunities for the participant to verify their end-of-life caregiving story. A total of 27 interviews were recorded and transcribed verbatim. Transcripts were hermeneutically analyzed in order to create individual narratives for each participant, reveal the essence of this experience, discuss the influence of the life worlds, consider the taken for granted, and generate an overall study narrative. These findings reveal the complex nature of the end-of-life caregiving experience with dementia.

Sammanfattning Syftet med denna litteraturstudie var att göra en sammanställning och beskriva vad som fanns i vetenskaplig litteratur gällande sömnfrämjande interventioner för äldre personer med demenssjukdom.  Metoden var en deskriptiv litteraturstudie baserad på 14 vetenskapliga artiklar från sju länder, publicerade mellan år 2005- 2010.  Artikelsökning gjordes i databaserna Medline och Cinahl, även en manuell sökning ingick. Inkluderade artiklar i resultatet är granskade och kvalitetsbedömda.  Huvudresultatet visade att det fanns olika interventioner som ljusterapi, melatonin, akupressur, social aktivitet, utbildning och örtmedicin för att främja sömnstörningar för personer med demenssjukdom. De olika interventionerna uppvisade lite skiftande effekt för att främja sömnen, ingen av interventionerna ansågs övertygande däremot upptäcktes andra positiva effekter gällande agitation, dygnsrytmstörningar och vakenheten under dagen. Slutsatsen av denna litteraturstudie är att mer riktad forskning behövs om olika interventioner för att främja sömnstörningar hos äldre personer med demenssjukdomar. Förbättring av sömnkvalitet, livskvalitet och återhämtning är målsättningen med interventionerna. Sjuksköterskan kan förbättra sömnkvaliteten hos patienterna med hjälp av icke farmakologiska interventioner. Sömnhygien, sociala aktiviteter och att förstärka exponeringen av solljus och klart ljus är förstahandsval vid behandling av sömnstörning hos personer med demenssjukdom. / Abstract  The aim of this literature study was to describe the scientific literature for sleep disorder interventions for older people with dementia. The method was a descriptive study based on 14 scientific articles from seven countries, published between the years 2005 - 2010. Article search was made in the databases Medline and Cinahl, and manual searches were included. Included articles in the results were reviewed and quality estimated. The main result showed that there were various interventions as light therapy, melatonin, acupressure, social activity, education and herbal medicine to promote sleep disorders for people with dementia. The various interventions showed varied effect to promote sleep, none of the interventions was convincing, although other positive effects on agitation, circadian rhythm and day- time wake was discovered.  The conclusion of this study is that more research is needed in different interventions to promote sleep disorders for older people with dementia.  The goal of the measures is to improve quality of sleep, quality of life and recovery. Nurses can improve quality of sleep in patients with non-pharmacological interventions. Sleep hygiene, social activities and increase exposure of sunlight and bright light is first choice to treat sleep disorders among persons with dementia.