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Yang 1 Kelsey Yang 23 April, 2011 Service Learning Report I chose to volunteer at the Elizabeth and Tab Williams

Adult Day Center (231 Melrose St, Winston-Salem, NC 27103), a Senior Services program for those needing daily supervision and assistance with tasks in their everyday routines, specializing in individuals with Alzheimers and dementia. Members are provided medical care, as well as optional grooming services. The staff is comprised of a director, registered nurses, certified nursing assistants, and activity coordinators, all of whom have training and experience with dementia patients. The building is one-story, with three main rooms for members to spend their time: a dining and sitting room (with an outdoor patio connected), den, and sunroom behind a code-locked door. For families of members, Senior Services ensures a safe environment from 7:00 a.m. to 6:00 p.m. for their loved ones while providing them flexibility to go about their work day and other responsibilities. Funding for the center comes from state, federal, and private sources, including Veterans Administration, Project C.A.R.E., Social Services Block Grant, Home and Community Care Block Grant, Family Caregiver Support/Area Agency on Aging, CAP-DA (for mentally challenged adults), fundraisers, and private pay. In 2010, the National Adult Day Services Association awarded the Williams Center as "the most outstanding and innovative adult day center in the nation. I dont necessarily have a defined role at Senior Services, but my duties include feeding those who need assistance, running and overseeing group activities, and simply interacting with members through conversation or shared individual activities. On top of about four or five

Yang 2 nurses, a custodian, and a manager on staff at a given time, Senior Services also has many volunteers, so the job is about individualized attention to a member for the most part. I usually arrive at the center during lunch time (around 1 p.m.), in which case I put on gloves and approach anyone I notice having trouble with utensils or not touching their food at all. As everyone finishes up, I pick a table to chat with. After lunch, members fitness walk, doing laps around the dining room while music plays. During this time I help clean up the tables and try to encourage those still sitting or who need extra support to walk with me. After walking, there is an organized group activity (commonly bingo, trivia, or a guest speaker) which most members migrate to the den to participate in. For those who opt-out of the group activity, smaller games are sometimes organized (such as a version of kickball where players sit in the dining room with their chairs in a small circle, keeping a ball going between them but still sitting down), while others can nap. Once the large group is finished with their activity, a snack is passed out, and afterwards they tend to stay in the dining room, sitting and maybe visiting with their friends until they are picked up for the day. Given that most members spend the whole day every day (except weekends) at Senior Services, the center is a main source for the elderly members social networks. Though the set-up of the atmosphere and schedule encourages social interaction between membersa dining room with tables that sit four each, sofas and recliners grouped together, games and activities for the groupAlzheimers and dementia makes forming bonds difficult for most members. When approaching a table at lunchtime, occupants of the table tend to eat in silence. This is understandable when taking into account the fact that it is unlikely members remember each other from the day before (or five minutes ago, depending on the severity of their memory loss), and some have lost verbal abilities to the extent that they cannot communicate at all. I first

Yang 3 noticed this loss when visiting with two members who speak quite often. One woman, Stacy, strongly protests when anything is taken from her (a spoon she is finished with, a ball during kickball), but mostly in the form of babbling and sometimes things that sound close to words thrown in. Another member named Mary stays in her wheelchair in the same spot every day. She is sleeping or silent all day, except for when anyone gets within a foot of her, in which case she reaches out, grasping them and repeating nononononononono until they walk away. Stacy and Mary are some of the more extreme examples, and most individuals at Senior Services retain enough verbal abilities to use recognizable words. There is also a small community within the center that act just as a group of old friends do, socializing with full communication skills, gathering at the same table every day, and embracing Senior Services as a hang-out. Still, from a visitors standpoint, conversation can be challenging when spending time with less fortunate members because many basic topics and questions could be hard for a member to answer, pointing out their memory loss and leading to frustration or confusion. With increasing severity of a members disease, maintaining fluid conversation becomes harder as their knowledge of what came previously in the talk slips. Considering that these disruptions of communication are hard to form relationships with, social networks suffer as a result of Alzheimers and dementia. In class, we emphasized the importance of physical and mental exercise in late adulthood and beyond to minimize developmental declines, perhaps delaying, preventing, or even reversing some losses. Such measures are clearly observable in the setup of the Williams Center. Every day has a reserved time for fitness walking, and the overwhelming majority of members participate with enthusiasm. Many members are in wheelchairs, so the center also organizes creative ways to incorporate non-walking exercises. Throughout the day, basket-weaving is an option for

Yang 4 members to exercise their fine motor control. Sometimes the staff organizes Sitersize, where they lead members in following the instructions of some basic stretches and movements (all done while seated) that play on a CD with music. During a Sitersize session, the movement was quick hand gestures that mimicked milking a cow. I watched as Mickie, a member, moved her fingers quickly, yet gradually slumped over to one side of her chair, forgetting to sit up and support herself. It seemed almost like an opposite example of the ortho-genic differentiation growth principle (specifically hierarchical integration), where her simple skill of keeping her back straight was forgotten instead of the more refined hand movements in trying to put together the complex motion of milking a hypothetical cow. For mental exercise, members usually play hangman (led by staff or a volunteer) at the end of the day as they wait to be picked up. The visual aspect of the gameseeing blank spaces and keeping track of guessed lettersallows for problem-solving (and the use of fluid intelligence) without requiring much memory, while categories are always basicusually types of foodto assure participating members will be able to know the word (tapping into their crystallized intelligence that has not yet been effected). A common symptom that differentiates Alzheimers and dementia from normal memory loss is change in an individuals personality. I was curious to see how the content from our lecture about changes in the big five from adolescence to adulthood would compare to information focusing solely on adults with Alzheimers and dementia. Where we learned adults in general may show change in neuroticism, extraversion, and openness, a study titled Personality Changes in Alzheimers Disease from the Archives of Neurology, found

Yang 5 Caregivers observed more neurotic, less extroverted, and less conscientious behavior. To a smaller extent, patients with Alzheimer's disease were reported as becoming less agreeable and less open (Chatterjee, Strauss, Smyth & Whitehouse, 1992). As I didnt know members before they came to the center or I started volunteering, I cant measure any behavioral changes correlated with the disease. However, one member in particular shows a high level of neuroticism through her notorious hoarding habits. Louiza keeps everything she acquires throughout the day in her purse. When she opens it to put in her latest possession, napkins, a milk box and roll given during lunch, paper towels, and toothpaste may fall out at any given time. Occasionally, custodians or nurses might try and distract her while emptying out her excess baggage, but she guards the purse compulsively. For other members, goodness-of-fit seems evident, having an easier adjustment with a high degree of match between their new temperament and setting. For example, for his first couple of days at the center, Karl spent the day passively in his wheelchair, asleep or watching others. After feeding him during a couple of lunches, I was able to talk with him, and eventually he would initiate conversation (though Im not sure he remembered who I was each time). Where he used to opt-out of most group activities, he has recently been participating in even the more active ones like kickball. He has an awareness of his resourceshe knows he can ask staff or volunteers to wheel him up to a group activity and shows interest in daily eventsand seems to spend much more time awake and functioning than before adjusting. One aspect of the Williams center that I find the most interesting is the allegorical dynamics of the staff-member relationship. As I adjusted to the program, I observed the good humor and sensitivity of the staff in their interactions with members. In many ways, the

Yang 6 relationship is much like that of a caregiver and child. Biologically, the deterioration of neural functioning from Alzheimers and dementia is associated with memory impairment, declines in tested intellectual ability, poor judgment, and decreasing abilities to think abstractly. The progression of the disease means a digression of cognitive development, bringing its victim back in time to childhood abilities in a sense. Gradually, what an individual has built themselves into physically and socially is eroded, as Alzheimers or dementia rewinds a lifespan of development in a distorted way.

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Reference Page Chatterjee, A., Strauss, M. E., Smyth, K. A., & Whitehouse, P. J. (1992). Personality changes in Alzheimers disease. Archives of Neurology, 49 (5), 486-491. Retrieved from http://archneur.ama-assn.org/cgi/content/abstract/49/5/486

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(muscle controlsome cant use utensils, some cant walk, some active and seem to function normally) and socially (cant establish deepness of intimacy, loyalty, trust really, so regress to others behaviors in Damons steps of friendship) in the process.

Today: Ricks roamingopposite of cephalocaudal growth principle (head to tail, grow top down, use hands before able to do things with legs)

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p. 264: normal forgetfulness vs. abnormal memory changes. Most people show some changes in memory and information-processing. Three criteria used to flag atypical: memory noticeably worse over past 6 months, memory problems interfering with everyday life at home or work, family and friends concerned about individuals memory problemsmajority of patients at Senior Services ask for/look for/are concerned about when their family is coming to get them and when they can leave. One woman in particular, only sits in chair by door and gets up any time staff goes in and out of it, trying to escape (multiple times an hour, all day). Tried to distract her, take her into another

Yang 10 room for an activity, but gets extremely nervous and even after agrees to, darts right back to door. Starts to hyperventilate, asked her why she was sad, couple times she says she doesnt know. Eventually comes up with a story, she needs to be out there she will never find her family again. No matter how much I explain to her her family is coming, they know she is here, she is safe, she cant be soothed. Even another woman sitting at the same table explains she is fine in here, but she starts to cry. After a while, forgets how upset shes gotten, but still as soon as someone opens the door she gets up to leave. normal to forget where you put something but abnormal to forget how to use it.play bingo a couple times a week, usually have to help most patients remember how to use the card (slide back so all numbers are uncovered). More severe disordersforget number immediately after called out or have trouble recognizing numbers/letters at all. One woman always sucks on top of spoon as if it is a straw, forgot how to use the utensil. 3rd type of memory loss: mild cognitive impairment (significant memory problems, but do not appear to suffer from dementia. Majority with mild cognitive impairment will eventually develop forms of dementia such as Alzheimers disease. Research also suggests that patients with mild cognitive impairment display deficits on other cognitive tasks as well, which could mean their problem is more general than memory impairment

Age-related memory loss may be preventable and some losses reversible. The earlier identified and receive treatment, the better. a couple patients at the center seem to have been identified relatively early as they seem mostly aware of their surrounding and their condition. Ex: one of the oldest women there, 96 years old, just recently diagnosed. Though older, she is much less far

Yang 11 into disease than most other patients there. said to me, I see these other people and just hope I never get like that. Overheard another woman (Claire) speaking to a new patient explaining when my family first took me here, I didnt want to stay either. Of course I wanted to be in my home. But it really is a good place, especially for our situation. There are always things to do and people to talk to instead of staying home alone and worrying about what is happening to me.

p.540: Dementia: progressive deterioration of neural functioning associated with cognitive declinememory impairment, declines in tested intellectual ability, poor judgment, difficulty thinking abstractly, and often personality changes as well. ) NOT a normal part of aging process, yet rates of dementia increase with age (affects less than 1% in 60-64 age group, 6-8% of elderly adults age 65 and older, jmps to 30% for 85 and older).

Dementia-not a single disorder. Different conditions can produce symptoms associated with senility, some curable or reversible.

Having sense of humor. Clear reminder of loss hard to accept.

Yang 12 Alzheimers disease: most common cause of dementia, about 70% of all cases. Can strike in middle age but increasingly likely with advancing age. Life expectancy increasing, more ending up with Alzheimers until way to prevent or slow its progression discovered.

Evidence in brain: senile plaques (masses of dying neural material with toxic protein beta amyloid at core that injures neurons) and neurofibrillary tangles (twisted strands of neural fibers within bodies of neural cells). Though elderly adults without alzheimers have both, distinguished by the number, type, and location.

Effects of dementia/Alzheimers (deterioration of neurons, increasingly impaired mental functioning, personality changes) are progressive. (not reversible or curable)

Disease affects brain in early/middle adulthood (possibly earlier) before cognitive functioning affected/before disease diagnosed. First noticeable signs of disease usually difficulties learning and remembering recently encountered verbal material (names, phone numbers)2-3 years before dementia can be diagnosed. Problem diagnosing---many people would qualify at first

Early stages: free recall difficult, but cued memory good. Overtime, recall with cues become harder and individuals increasingly frustrated.

Yang 13 Disorder progresses, both recently acquired and old information hard to remember, see individual has trouble coming up with words they want during conversations, forget what to do next midway through actions (maing a sandwhich, getting ready for bed). On test: unable to answer where they are, what the date is,current events, president of the united states. Eventually-incapable of caring for self. No recognition of loved ones, lose all verbal abilitiesa couple patients simply do not talk. One woman in a wheel chair stays in a certain spot, mostly sleeps all day. Whenever walk by, reaches out and grabs onto arm and repeats something that kind of sounds like nonononono but not so much the word no as babbling Another woman, stacy, babbles sounds strung together with intonation and non-verbal gestures that disguise what she is saying as a sentence. She interacts in a conversation-like manner and really enjoys talking (one time I shifted my attention from talking with her to another patient next to her, and she tapped my arm continuously until I turned back to her). Once in a while, she will repeat words I give her or even come up with one that sounds similar. For example: I said that is a pretty color on you and she replied with babbling ending with onions. Then, reverts back to babbling.

Death on average: 8-10 years after onset.

Aside from abilities to function, hard for caregiver (impatience) with nature of forgetfulness, may wander and get lost, acuse people of stealing misplaced items, may take off clothes in

Yang 14 public. Highly agitated and uncontrollable, often suffer from depression and become apathetic, some experience psychotic symptoms (hallucinations). Stacyvery belligerent. Playing kickball (sit in chair in circle, kick ball back and forth to move legs and focus on game, keep it moving), point and yell (in her babbling) at anyone who kicked it towards her. Inconsistently gets mad at nurses when they want to move her to take her to the restroom. Bill-Wanderer-rarely ever sits down the entire day. Hard for him to support his head, so usually paces around facility with head hanging down.

CAUSES/CONTRIBUTORS: Genetic basis but no single Alzheimers gene. Strikes repeatedly and early in some families. Analyze blood samples from families with many alzheimers victims, located gene for disease on 21st pair of chromosomes. Inheriting one of apparently dominant genes means will develop disease. For late-onset, genetic contributors not as clear cut or strong. Instead of making the disease inevitable, a number of genes only increase a persons risk slightly. Overall, genes account for about 60% of variation in alzheimers (environmental factors account for rest). More p. 542 one variant of a gene..

Yang 15 PREVENTIOn/TREATMENT: focus on earlier detection in hopes that drugs can prevent or delay changes in brain associated with disease. Victims have deficit in neurotransmitter acetylcholine (essential for normal learning and memory), drugs developed to correct this problem/related problems in neural functioning. No pill to prevent or reverse has been discovered, but some drugs are regularly prescribed (Aricept, and Namenda) that modestly improve cognitive functioning, reduce behavioral problems, slow progression of dease in some patients. Other approachescobat buildup and effects of beta-amyloidantioxidants such as vitamin E, C, statin drugs prescribed to combat high cholesterol. Still, therapeutic effects not clearly demonstrated. SAME LIFESTYLE FACTORS contributing to cardiovascular disease (eating too much, not enough exercise) contribute to dementia. Physical and mental exercise shown to delay cognitive decline in later life and may slow progression of dementia.

Physical and mental exercises: Mental exercises: games, puzzles, activities (basket weaving) always available. Group organized games such as bingo, trivia (usually related to time of year such as irish trivia during st. patricks day), hangman. Physical exercises: Everyday after lunch when I come, walk for fitness, play music and walk around dining area. Small groups that work on motor skillskickball is common (sit in circle, kick ball keep it going for a while), sometimes given coins and try and throw it in pot in center of circle. Pet therapy about 3 days a week in morningbring dog around, let those who want to pet it, according to what dog it is, allow patient to give them commands for dog to do some type of trick (high five, jump up and get something, etc).

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Behavioral management techniques and medicationsbehavioral problems Educational programs and psychological interventionspatients AND caregivers to help understand and cope with dementia and function better.

GENDER DIFFERENCES: what I see: more female patients than male patientsBUT could be because higher life expectancy for womengreater age, greater risk of alz. More women patients in wheel chairs than men. INDIVIDUAL DIFFERENCES: wide varianceone of oldest patients there seems to be most mentally together. However, senior services home for all types of dementia, and not allowed to know each patients medical info, so possible that she does not have Alzheimers and is starting to exhibit mild cognitive impairment. CULTURAL DIFFERENCES: way we treat old age in general. Also, large number of African American patients.

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Anjan Chatterjee, MD; Milton E. Strauss, PhD; Kathleen A. Smyth, PhD; Peter J. Whitehouse, MD, PhD Arch Neurol. 1992;49(5):486-491.

http://archneur.ama-assn.org/cgi/content/abstract/49/5/486