Gerotalk : Alzheimer's

The Psychology of Pain

Brian Garavaglia — Fri, 16 Oct 2009 13:40:00 GMT

Read my latest Gerotalk column on the ADVANCE web site: The Psychology of Pain.

Doing More to Assist with Pain Management

Brian Garavaglia — Fri, 18 Sep 2009 14:33:00 GMT

Pain management is a prominent issue in long-term care. For many years providing pain medication on a regular basis was irrationally feared based on risking a potential addiction to the resident. As we have become more enlightened, the fear of addiction has abated and our focus has become more rationally directed toward maintaining resident comfort. However, are we doing all we can to assist in pain management?

For sure we are using important pharmacological agents that have important pain killing effects to enhance the comfort of our residents. Also, providing a pill often provides a quick remedy to the situation. However, is pain management dependent on more than just pharmacological intervention? Does providing a pain medication always enhance the best practice in addressing pain? Moreover, does this type of pain management in exclusivity enhance the quality of life that is sought for long-term care residents?

Although monitoring and assessing pain has become a greater focus in long-term care and although many individuals are much more skilled today in detecting pain than was often the case in years past, there still exists a considerable dearth of knowledge and skill in pain management. In nursing care facilities the nurses are often the key individuals that are suppose to be responsible for pain management. In reality, pain management is the responsibility of all individuals who work in the nursing home. This may be controversial, but it is a very important mindset to be put in place.

Many nurses today are still ill trained in pain assessment and management.Furthermore, many other individuals such as nurse assistants and rehabilitation specialists are even in need of more training in this area. In addition, individuals such as administrators, housekeepers, maintenance, social workers, and business office staff get little, if any, training in this area. Since pain can often manifest itself suddenly, such as breakthrough pain, frequently when other members who are not part of the clinical staff are with residents, this makes it even more important that all staff is trained in recognizing and assisting in the pain management process.

Currently the pain management process is almost exclusively the purview of the medical staff. We have strongly medicalized pain management and subsumed this important topic under the physician and nurse. As a result it should be no surprise that we have so many individuals that can contribute to the process, yet fail to receive any training in pain management whatsoever. As many parents know, you do not have to be a physician or nurse to know when your children are ill or in pain. Furthermore, as many parents will tell you as well, they have often managed their children's pain and sickness without the intervention of physicians or nurses. This is in no way to deny the importance of physicians and nurses in the pain management process, but to say that these are the only two professionals that should be involved in pain management prevents the pain management process from being fully actualized.

We need to accept the pain management process as not just a medical intervention, but a social intervention as well. How can this be a social process? One may state that pain is a biological and biochemical process, and since it is a biochemical process, a type of biochemical intervention, especially pharmacologically based, is the only sensible approach to address this type of issue. However, pain in itself is far from an objective process, which can be empirically measured with pinpoint accuracy. Individuals experience pain differently, and pain is not just influenced by a person's biological threshold, but is also influenced by their perception, their culture, and their psychological state of being. Therefore, pain in itself is often quite subjective in its nature, and how it is perceived, reported and demonstrated is strongly individual, predicated upon the phenomenological nature of each person.

We have all heard of the "placebo effect," in which a patient is provided with a supposed medication and experiences results that are highly efficacious. The person often subjectively creates pain, and the same subjective process often abates it. I am not contending that pain is not real for many of the residents that we service. In fact, I am arguing for the exact opposite: since pain is highly individualized among all individuals, including long-term care residents, we need greater intervention to deal with this important problem, more than just intervention by a physician, nurse and a pill.

Because the phenomenology of pain is so complex and multifaceted, the way that it is addressed also has to complement this complexity. In limiting the nature in which we treat pain, using only the medical model of physician, nurse and pill, we continue to fall short in treating the resident holistically. As the placebo effect has demonstrated, pain is more than just a biological and biochemical feature of the body. It is based on the subjective and phenomenological states of the resident that we cannot always reach with medicinal agents. All heath care centers underutilize the range of approaches that can be used to address pain, but the long-term care industry is not doing much to enhance their productivity in this area.

Many complementary nondrug methods such as acupuncture, biofeedback, distraction, imagery and visualization and meditation are very seldom, if ever, used in these types of environments. One may say that is because of the type of clientele found in nursing homes, which often have a large number of fail, dying, and demented individuals. However, this type of argument is often weak. Many long-term care residents can be quite receptive and workable with these types of interventions and yet they often never get the opportunity to benefit from these types of intervention. Others argue that these types of therapies should not exist in a medical environment. Yet again, this argument is just the same type of rhetoric that needs to be disposed of in regards to resident pain, especially if we want to address this important resident concern in a holistic manner.

In conclusion, this author is arguing for a greater breadth and depth of pain management and intervention by the staff. Pain is more than just a biological process than can only be targeted by medical personnel who are able to write prescriptions or dispense medications. Pain management is a social enterprise. It is a uniquely subjective state that needs to be recognized, and because of the social factors involved in pain, pain management should also become a process of social intervention. Currently, too many nursing homes continue to treat pain one-dimensionally, failing to recognize the multidimensional makeup of this complicated process.

Changes in the Hippocampus Underlie Memory Changes with Age

Brian Garavaglia — Tue, 08 Sep 2009 13:34:00 GMT

The hippocampus is a region of the brain located in the medial temporal lobe, which is that area located on each side of person's head. If you look at your head and take the region where your ears are located, and pass an imaginary line into your skull from your ear region inward, you would pass through the hippocampal formation where the hippocampus is located. The derivation of the name, hippocampus, comes from its seahorse appearance that early neuroscientists noted during anatomical investigations of the brain.

The hippocampus has been known for some type to be instrumental in memory. For a number of years it was thought of as being the key anatomical site in the brain for memory. However, more current research has found that it is far from being the only part of the brain involved in memory. The hippocampus is still understood to be a very important part of the brain instrumental in memory. However, in reality, the hippocampus is one part of a large circuit in the brain that is important for memory.

Recent research has found that as memories age, different parts of the brain become involved in memory, working in a compensatory manner to apparently take the burden off of the hippocampus. In an article in the September/October 2009 edition American Scientific-Mind, the research findings of Larry Squire of the University of California at San Diego are discussed. Using functional MRI studies, Squire and his team were able to examine the changes in the neurophysiology of the brain and how these changes were related to memory.

What Squire and his team found was that activity in the hippocampus area declined when the study's participants had to recall information for progressively longer periods of time, ranging from more immediate information up to many years. The team found that activity in the hippocampus region continued to decline up to about 12 years. However, participants that had to recall information that was over 12 years old appeared to demonstrate hippocampal activity that stabilized after the 12-year period. Therefore, it appears that memory components connected to the hippocampus demonstrate progressively less neurological investment by the hippocampus in the energy it uses. Furthermore, it also appears that the hippocampus becomes less and less responsible for maintaining the currency of memory.

However, this is not the end of the story. With the plasticity that the brain has it appears to shift responsibility to for recalling those memories for that 12-year period to other areas of the brain. In particular, activity appears to increase in the frontal, temporal and parietal areas for recalling information for that period of time when the hippocampus is reducing its activity.

What is interesting is that many memory diseases of old age, such as Alzheimer's disease, start at the subcortical level, or the more evolutionarily primitive allocortical region. The hippocampus is one of the important brain areas that make up part of the deep inner allocortex. This can be another reason why many older adults with Alzheimer's disease often face shorter-term memory deficits at the start of the disease, with many of their long-term memories being preserved until later in the disease. I say "another reason" becomes we do know that Alzheimer's disease also influences a closely associated neural pathway that connects with the hippocampal region called the entorhinal cortex.

The new research results by Squire, although not specifically addressing memory and the aging adult, does have implications for this age group. Although memory is a very important part for human existence, as we age memory becomes a more sensitive topic. Having greater knowledge of the inner workings of memory is essential for all professionals working with older adults. Squire's research does raise some interesting questions for this age group.

First, are many of the normal forms of forgetfulness that we attribute to aging, often quite stereotypically, part of the same processes that are found among all ages? In other words, if this process of a progressive reduction in activity found in the hippocampus is found among all age groups, are many of the supposed memory tests for more short and immediate term memory given to older adults demonstrating any appreciably different results than would be found among other age groups and if so, what is the quantifiable difference?

A second question that the new research raises is if, during the hippocampal reduction, there is a compensatory increase in activity in other areas of the brain, especially the frontal, temporal and parietal lobes, is this activity increase equipotent for all ages? Does the compensatory neurological enhancement found among these areas for recalling information during this period of time exist on equally quantifiable levels for all ages? Or is a neurological enhancement in activity also found to exist among older adults but at an activity gradient that is much lower than that found among younger individuals. Hence, are the roadways for travel of information still found to exist among older adults, but with a much narrower road carrying less information?

I find the current information very interesting, possibly leading to many answers to questions that have been posed in neuroscience, especially related to the aging brain. However, I also find the research posing other questions as they relate to the elderly that can as yet not be answered. Good research often answers many questions while raising many more. In particular in dealing with the brain, an organ we still know so little about, the questions continue to arise. As an organ, the brain is far from being static and the changes that can exist with age are numerous. We know that the brain has a level of plasticity that continues to exist even as we age. Therefore, it becomes important to understand the impact of Squire's research and how it can be used to help understand the aging brain.

The Genetics of Alzheimer’s: Be Careful About Inferring Too Much

Brian Garavaglia — Tue, 14 Jul 2009 22:35:00 GMT

Many individuals often refer to the underlying genetic basis of Alzheimer's disease. The inference that many individuals make is genes are destiny. In other words, once a person holds the given genetic makeup they ultimately assume or infer the underlying quality that the gene has coded for will undoubtedly manifest itself in the phenotypic quality, which in this case is Alzheimer's disease. However, one has to be cautious about inferring an inevitable cause and effect between genes and disease.

In understanding the underlying genetic basis of Alzheimer's disease, we do know that genes play an important role. During the last couple of decades genes discovered on chromosomes 14, 19, and 21 have been implicated in this disease. However it appears that the genetic influence on chromosome 19 appear to be the most significant. On chromosome 19 there are a family of genes called the APO genes, which is short for the apolipoprotein genes. The subfamily of genes called the epsilon genes, often referred to as E2, E3, and E4, are the ones that appear to be the most significant for memory. In fact, these genes are also related to controlling triglycerides and cholesterol in the body and are therefore pleiotropic, meaning that a single gene can have an affect on many different body areas.

Of the above epsilon genes, the E4 type appears to be the most insidious, especially toward Alzheimer's disease. Genes come in pairs called alleles. Having one E4 allele is bad but having two matching E4 genes is highly problematic, or as many have come to infer, a death sentence. But one has to remember that genes do not automatically dictate cause and effect qualities for diseases. Genes, like switches, have to be turned on. If they are not turned on they cannot express themselves. Most individuals do not carry two E4 alleles. For those that do the probability for getting Alzheimer's increases dramatically, but, and this is an important but, some individuals do have two E4 alleles in old age yet are fully competent and have acute intellectual ability. Therefore, the first thing that this demonstrates is there is not an automatic, 100 percent likelihood of obtaining Alzheimer's disease even if you have two E4 alleles.

Also, people of Asian descent often have the least likelihood of having two E4 alleles, followed by the white population and the African American population. Subsequently, one would therefore expect then that African Americans would have a greater likelihood of obtaining Alzheimer's disease, especially the early-onset type, given their greater predisposition for holding two E4 alleles. But here again, things do not fit nicely into the larger scheme of the disease. Those who are most likely to acquire Alzheimer's disease are white individuals. Furthermore, just as some individuals who have both the E4 alleles do not acquire Alzheimer's disease, some individuals that do not even have one E4 end up developing Alzheimer's disease quite early in their lives. What this appears to be demonstrating is that Alzheimer's disease is polygenetic, with often more than just one type of gene involved in the process.

What I hope that I have demonstrated is that many individuals that think their genetic predisposition is ultimately their destiny are wrong. Yes, we do know that certain genetic profiles, such as being homozygous for the E4 allele (having both the alleles), make a person more likely to develop Alzheimer's disease and possibly earlier in life than others. However, one's underlying genetics are not a mandate that ultimately provides 100 percent certainty that a person will acquire the disease. There are too many more elements that appear to be involved in developing Alzheimer's disease, and although genetics is important, it by know means provides the total picture.

An ethical question that often has come up with our new knowledge of genetics, especially gathered in tracing the entire genome, is if we are able to know where the genes are located for this type of disease, why not test the person for them to provide individuals with information about their potential genetic predisposition for the disease. However, one question that needs to be posed is what potential benefit would be gained if someone knew his or her genetic makeup? Given that there currently is no cure for the disease, could harboring the knowledge that one carries the genetic predisposition actually cause more harm? Harboring the knowledge of having the genetic predisposition could lead to psychological turmoil for a person, often impairing the quality of their life as they continue to live out their days waiting for the first evidence of the disease.

Also, as was mentioned, even if the genetic testing revealed that the person had the most insidious genetic makeup, there is no guarantee that the person will ultimately get the disease. The genetic makeup often creates a predisposition, not a guarantee, yet we often view the predisposition of the genetic makeup as an inevitable end result of certainty. Therefore the person that obtains the test results and spends his or her days waiting for the first impending signs of the disease may be doing so for no reason, since the test cannot predict with certainty that you will acquire the disease.

In an age when there are many tests that are available and are very important and well used for preventative purposes, our current ability to test for a genetic basis of Alzheimer's disease may not be one of them. Given that there are currently no cures for the disease, that a positive test is not a guarantee of acquiring the disease, and that there are probably numerous other factors that work in concert with a genetic predisposition, the ethical implications for harming the individual psychologically could be great. Although our current knowledge to pinpoint important genes is great, and often this scientific knowledge can be quite beneficial, we also have to be aware that sometimes attempting to interject too much science in our lives can do more harm than good.

Blood Sugar Levels May Be Critical to Preventing Memory Loss

Brian Garavaglia — Tue, 12 May 2009 19:14:00 GMT

Click here to read Brian's column "Gerotalk" on the ADVANCE for Long-Term Care Management Web site.

In the May 2009 edition of Scientific American Mind, a short article is provided on the research conducted by Scott Small at Columbia University. The article entitled, An End to Senior Moments: Lowing blood sugar levels may thwart forgetfulness, addresses the impact that higher blood glucose levels may have on proper brain function. The article also may help explain why exercise is a powerful component to healthy aging, including a healthy brain.(1)

It has been known for some time that as we age there is an increased likelihood for blood glucose levels to increase. Although the brain is a glucose hungry organ, consuming 20 percent of the glucose needs of the body, too much excessive blood sugar can be potentially problematic for the body and the brain. It appears that as we age the cellular membrane becomes less sensitive to insulin, which in turn prevents this important sugar from properly moving into the cells for energy and subsequently leading to elevated levels in the older adult's body. When this happens many older adults are susceptible to Type II diabetes.

Levels of blood sugar have been tied to potentially reversible memory issues at all stages of life. Those that suffer from hypoglycemic or hyperglycemic reactions often report problems with their levels of consciousness as well as with memory. The brain, although very dependent on glucose for its function, needs to strike a balance between not flooding itself with excessive levels of glucose as well as failing to not take in too little glucose. Yet, the brain is a very resilient organ that can often recover from excesses in either direction.

In the recent study completed by Small, he found that as we age the probability for increased blood sugar levels affecting memory can be considerable, and can help explain many of those periods of forgetfulness or less efficient functioning of memory that many individuals experience, and complain about, as they age. In fact, many of these factors that are related to less efficient metabolism of glucose start to happen fairly early in life-in our late 30s and early 40s. This becomes quite interesting. One hypothesis that this leads to is what are the cumulative effects on the brain of uncontrolled blood sugar levels, and do those that have less control over their blood sugar levels become more prone toward dementia as they age due to the cumulative insults on the brain of unchecked blood sugar levels.

Small's study goes further in targeting the part of the brain that the higher blood sugar levels may disrupt, leading to memory problems. Although the hippocampus is known for being an important part of the brain for memory, a particular part of the hippocampal area known as the dentate gyrus appears to be particularly sensitive to higher glucose levels. According to Small's research this area, when inundated with excessive levels of glucose, appears to lead to problematic forgetfulness.

This new research could have very important implications for the need to continue to remain active as one ages. As stated, issues of glucose metabolism start fairly early in life, in ones third and fourth decades of life. Although the current research did not answer any questions on the cumulative effect of unchecked blood sugar levels on the brain, it does lead one to make hypothetical assumptions that need to be answered through future research. However, more important to the current research is the continued support it provides for the need for regular exercise.

Small extrapolates from his current study that exercise may be potentially a very powerful tool for warding off many of the common age-related memory declines that are found among individuals as they age. In fact, due to the potential increase in blood sugar levels starting relatively early in life, the need for regular exercise may actually be more important as we age. Especially as it relates to brain health, as our normal metabolic processes decline with age, exercise can actually enhance the movement of glucose into cells and help reduce the excessive blood sugar levels that may lead to age related memory problems. This is actually very good news since many of the transient memory problems that plague us as we age can be reversed through exercise, leading to greater memory efficiency.

The article in itself does not provide a great epiphany. It has been known for some time that sugar metabolism can dramatically effect memory. Moreover, it has been known that exercise is an important source for warding off illness as we age. More recently, exercise has also been associated with helping to improve cognitive functioning and possibly enhancing neurogenesis.

However, Small's study helps to illuminate and provide some sound, empirical understanding of how glucose metabolism may be implicated in the aging brain. It also addresses the specific area in the brain that inadequate blood-glucose metabolism targets and disrupts, leading to many age related memory issues, and this new finding may aid us in advancing brain health for the elderly. Although many know about the positive benefits of exercise on the body, especially for enhancing cardiovascular, pulmonary, and muscular strength and functioning, less often is exercise associated with the positive benefits it has on brain functioning. The implications that it has for getting more individuals involved in regular exercise are very important.

Since cells become less sensitive toward moving glucose into the intracellular apparatus as we age, leading potentially to higher blood-glucose levels, which in turn can lead to excessive glucose targeting brain sensitive areas, and since exercise is an important mechanism for helping to move this biochemical molecule into cells, it is very important to make sure that individuals are getting the proper level of physical activity and exercise to compensate for age related reductions is glucose metabolism. With increased activity we may be able to ward off those so-called "senior moments" that many have come to assume as inevitable parts of the aging process. Therefore, with this knowledge in hand we know that we need to get up, move around, and pay attention to our carbohydrate intake, which in turn may move us into those later years with a more youthful and better functioning memory that is not inevitably consigned to increased levels of forgetfulness.

Reference

1. Nikhil Swaminathan (2009). An End to Senior Moments: Lowering blood sugar levels may thwart forgetfulness. Scientific American Mind, 20(2): 9.

Need for Greater Neurocognitive Rehabilitation in LTC

Brian Garavaglia — Tue, 09 Dec 2008 16:25:00 GMT

In long-term care rehabilitation is a very important part of treatment for many residents. Rehabilitation is a very important part of the interdisciplinary team process that focuses on helping those with physical impediments regain much, it not all, of their physical ability that is often lost through a myriad of physical problems. However, a great deal of rehabilitation focuses on regaining the physical problems that were lost, such as fine motor movement and gross motor movement.

Even when individuals have cerebral infarcts (strokes), the emphasis is often on gaining, to some level, the lost physical function that often accompanies this problem. Many rehabilitation programs will often emphasize that they do provide some level of neurological rehabilitation, but this is often based on the neuromuscular innervations that take place during physical movement exercises.

What is often missing in many rehabilitation programs for residents is a true neurocognitive rehabilitation program that focuses on enhancing the brain and overall nervous system. With this type of program the focus in not just on enhancing the physical mobility that is often lost through illness and disease, but also the neurological and cognitive loss that is often part of disease, illness, and even inactivity.

Neurocognitive rehabilitation is a multidisciplinary approach, which is not just dependent on any one area of specialty. Unfortunately, most individuals in long-term care environments are not informed about the need for neurocognitive rehabilitation and furthermore, most fail to have any training in this area. This is quite perplexing, especially since our brain is the essence of who we are. With damage to our neurocognitive resources, we can strengthen the limbs through rehabilitation yet fail to improve the individual as a human entity.

We are seriously behind in the area of neurocognitive rehabilitation. This is unfortunate since there have been tremendous advancements made in the neurosciences. We now know the brain is not a post-mitotic organ, fixed with all the brain cells and connections one needs for the rest of their lives. Research has demonstrated that active neurocognitive activity can lead to growth of brain cells in certain areas of the brain as well as changing the cerebral landscape of the brain by making new connections to enhance our ability to cognitively engage in many tasks with greater proficiency. Therefore the brain is not a fixed organ and can change. However, when it is negatively changed through disease, we often feel that we cannot reverse these changes, or that if a neurocognitive reversal does happen, it will be predicated on the person's own healing mechanisms.

Given our knowledge of the regenerative potential of the human brain and its ability to adapt and change through developing alternative pathways even when the previous ones can no longer function, it becomes incumbent on long-term care professionals to become more involved in the neurocognitive rehabilitation potential that remains untapped in this area. However, inserting this new type of paradigm to deal with enhancing a person's life will not be an easy task. Since most individuals are not familiar with this area, and are even less familiar with the brain and its hidden capacity for change, it will take a considerable amount of training and education to foster the growth of this area.

Brain science has come too far to not employ much of the knowledge that we have gained to assist in rehabilitating long-term care residents' brains. We now know that many pathways and alternative pathways can help with many of the neurocognitive deficits that exist among many individuals. Like an open patch of ground surrounded by a weeded area, the open area will be taken over by weeds if the patch of ground is not cared for.

This is somewhat similar in the brain. An insult to a particular area of the brain will be grown over with other areas that are adjacent to it. However, if we target the neurological areas that need to be addressed a territorial invasion will not happen and the landscape that was faced with a physical insult will start to respond. Moreover, in some cases if the area cannot respond new pathways are created.

So it only makes sense to start addressing many of the important brain rehabilitation needs that exist among this population. However, to do so it requires a great deal of teamwork, starting with the rehabilitation therapists, to activities, social services and nursing. Furthermore, this type of intervention is not only for those that need rehabilitation services. It is a type of intervention that should at some level exist for all residents. Because of the special needs that many older adults face on this level, one has to wonder how many more residents would lead more alert lives and possibly forestall the impacts of dementia for a few more years if they were provided with this service. All staff needs to be involved in producing a paradigm shift that starts to focus in greater detail on the resident's neurocognitive needs. This will be a daunting task to implement but the benefits will surely outweigh any costs.

Recognize Alzheimer’s as a Social Disease

Brian Garavaglia — Thu, 19 Jun 2008 14:52:00 GMT

Alzheimer's Disease is a progressive and debilitating disease that often leads to a person's inability to understand and be aware of their conscious existence. As a disease it is incurable and due to its inevitable progression, leads to one of the most frightening human conditions that exists. However, Alzheimer's disease and many associated dementias is more than just a progressive neurological disorder. Too often long-term care professionals come to view this as a physical disease, a disease that disassembles that normal neurological structure of the cerebral cortex. However, in addition to the physical manifestations that are part of its pathology, it is a disease that leads to the destruction of the social soul, which behavioral scientists have often referred to as the self.

The "self" is a unique component of human beings. We are not born with a sense of self (Handel, Cahill & Elkin). Our sense of self emerges with our overall development. Individuals are born as biological entities with some primitive biological reflexes, but at birth we have no understanding of what we are and how we are separate and unique entities from our environment (Handel, Cahill & Elkin; Santrock). Therefore, at birth we are living and breathing biological entities but with no self we fail to hold many of the qualities that we come to equate with being "human." This is especially evident from many studies, both in humans and other primates that have unfortunately been victims of severe abuse, neglect, and isolation.

As individuals develop our sense of self through social interaction, we come to develop into social beings, or as Elliot Aronson has come to refer to humans as a "social animal."(Aronson) It shapes our consciousness, how we come to view the world and ourselves, how we come to think and feel about ourselves, and most importantly, how we come to obtain those traits that we come to view as making us "human." However, possibly the most important part of our sense of self is the concept of "reflexivity." This shapes our mind to come and view ourselves as an "object" to itself. As conscious human beings our ability to see ourselves as others would see themselves is critical.

For instance, we develop important emotions such as pride, envy, and embarrassment because we are able to see ourselves as an object, viewing ourselves as others come to see us. However, as those long-term care personnel who have worked with individuals that suffer from this disease know, as the disease progresses, many of the person's social skills rapidly deteriorate. Patients suffering from this disease fail to be able to view themselves as an object, and this is often found in many forms of social behavior becoming compromised, such as undressing in public or taking their teeth out and placing them on the dining room table while others are eating.

What is happening in these instances is they lose their ability for shame and embarrassment, higher level social emotions that requires the reflexivity of the self. These emotions develop when we are able to see ourselves as others do, and they allow most people to understand what is appropriate or inappropriate behavior in any given situation. With a sense of self, it allows us to understand what others expect of us and how others will view us if we fail to live up to the social norms of particular situations. The person with Alzheimer's disease, whose self is slowly dying, is unable to understand these implications.

Furthermore, it is also very frustrating for many caregivers and family members to watch, since most cannot comprehend why their resident, or why a son or daughter's mother or father, is unable to understand may of these simple social graces that most of us take for granted. They fail to realize that the disease is more than just biological, but with the slow death of self, the important social nature of the person, that which makes are truly human, is slowly degenerating as well.

Long-term care staff often face continued needs to address older adults with this disease and the antisocial behavior that is often found among these elderly as the regressive spiral leads to a infantile level of self-consciousness, which further leads to behaviors such as disrobing, wandering without any concern for themselves, or urinating in public places. What is happening here? Again, the self, which allows us to control our behavior by seeing ourselves as others do; the part of ourselves that is important for higher level emotions such as pride, envy, embarrassment, shame, empathy, and even love; the part of ourselves that is important for understanding social situations and expectations that others hold; is dying along with the neurological tissue.

This is often noticed by many who care for residents that suffer from this disease when they attempt to explain to those who suffer from the disease their socially compromised behavior and its antisocial manifestations. In the earlier stages of the disease the explanation does revive some remnants of the self, as is evidenced by the resident demonstrating some awareness of their social transgressions when they are made aware of them by the long-term care worker. However, in the later stages, as workers attempt to explain their behavior to the resident, the resident often will stare blankly at the worker, similar to very young children being reprimanded for inappropriate behavior, both of whom are not able to understand the consequences of their actions due to not having the appropriate requirements for a truly social self.

In the child's case, their self will continue to develop and they will eventually be able to understand the social significance of their behavior. However, the person with Alzheimer's will never be able to understand the ramifications of their behavior and will only continue to spiral downward. For the child the self will mature and grow; for the person will Alzheimer's, the self will continue to regress and die. Therefore, Alzheimer's disease is more than a physical disease, but also a social disease, robbing the person of the essence of their humanity.

In summary, many individuals have come to view Alzheimer's disease as an exclusively biological condition. However, probably it most egregious impact is on the social nature of the human individual. With Alzheimer's disease comes the demise of what makes us human, our social self, and with it the ability to reflexively see ourselves as an object to ourselves. This becomes such an essentially important fact to understand about our human nature, and how Alzheimer's disease obliterates our human nature through its assault and eventual destruction of the self, that to not understand it leads clinicians and practitioners that deal with this population empty in their own right.

The implication to understand the social aspects of dementia, and the obliteration of the self, makes this disease as mentioned previously not just a neurocognitive disease but a social disease as well. The implications for treatment also should follow as well toward viewing it as a social disease with needed social intervention by long-term care professionals. Although biological treatments are still essential, by themselves they do very little to humanize individuals with these diseases that are ultimately so dehumanizing. Therefore, long-term care facilities must also invest more time in keeping those with this disease engaged in their social surroundings to slow and minimize the demise of the social self, the most egregious and frightening condition that is found in humans.

References

Aronson, E. (1980). The social animal. New York, Freeman Press.

Handel, G., Cahill, S., & Elkin. F. (2007). Children and society. Los Angeles, Roxbury

Publishing.

Santrock, J. W. (2006). Life-span development, 10^th ed. Boston, McGraw-Hill