This week we take a second look at a concept introduced during the past series of blogs and pursued more deeply in last week’s blog. We have asked you to seriously consider environmental pressure – both built and social and to consider these as stressors. In today’s blog, which is deliberately short as it is information dense, I ask you to see through someone else’s eyes and change your practices accordingly. You will want to – I promise
For genuine non-harmful dementia care to become possible it seems obvious that we should always assess how our own, and others behaviours and actions will have upon the other person – the intended recipient of your care intervention: but I wonder how many of us actually do this minute by minute, day by day? It is also vitally important to remember that where there is group living: we must also constantly assess the impact of the person’s living environment and their own behaviour on others within it – and other’s behaviour upon them.
If either of these areas can be perceived to have possible stressful consequences that may result in a negative stress response, for either the person living with dementia or those around them, changes must be considered in both approach and the environment itself.
Not so easy to look at the lounge or the dining room in the same old way now, is it?
There is a further factor for you to consider: a highly significant process that determines how the person responds to any given situation, and that takes caring for someone with a dementia out of the run-of-the mill caring practices and turns it into a specialised arena of caring – I would argue a highly developed art form. Between the impact of the stressor on the person and the resultant physiological or psychological consequence lies the appraisal.
Understanding and facilitating appraisal
With damage to many of the regions of the brain thought to be responsible for the storage and retrieval of memory, people with dementia may lose the ability to be able to accurately respond to a stressor because they are unable to predict the consequences beyond that stressor.
Let me explain a little. Because the brain is so complex we need to simplify a few of its more hidden abilities to make useful sense of the following information.
Perhaps the simplest and most emotive description of the human brain is Paul MacLean’s triune brain. The triune model, as the name suggests, distinguishes just three regions: the neocortex, the limbic system, and the reptilian brain. For ease we can call them our ‘three brains’.
The theory, although purely hypothetical, as of course the brain is one super connected structure, does fit very closely with the evolutionary theories of the brain.
Three brains?
MacLean (1990) says that ‘three brains’ operate like ‘three interconnected biological computers’, and each has its own special intelligence, subjectivity, sense of time and space and its own memory. These ‘three brains’ are labelled as if they developed as part of our species’ evolutionary journey from the reptile through the early mammals and into modern humans.
The neocortex becomes the ‘neo-mammalian’ brain; the limbic system becomes the ‘paleomammalian’ system; and the brainstem and cerebellum, the ‘reptilian’ brain.
Each of the three brains is connected by nerves to the other two, but each, according to MacLean, seems to operate as its own brain system with distinct capacities.
This hypothesis has become very influential, particularly in popular science and psychology writing, and has forced a rethink of how the brain functions, and how this new understanding changes the way we view how people respond to threat – real or perceived.
It had previously been assumed that the latest additions to the brain in evolutionary terms, and the highest functioning in terms of cognition, the outer (neo) cortex, dominated the older and lower levels. This is not the case however, and we now know that the evolutionarily older limbic system, which rules emotions, can hijack the higher mental functions when it needs to – in times of acute stress or threat.
The emotions rule – so change your approach
When under stress or threat the limbic system acts much faster than the frontal cortex where the brain runs through remembered scenarios in milliseconds whenever there are new challenges. The frontal cortex ‘dials up’ the regions where memories are stored and looks for memories from previous similar encounters or experiences and computes if the situation is a threat or if it is safe and manageable.
Dependent upon this appraisal (and the availability of these memories) the person then reacts with either a repeat of a previous set of responses or uses available memory, plus new reasoning to plot response to successfully cope and manage the current threat.
But – by what you already know about dementia, and especially the primary dementia’s of which you will be most familiar as you are likely to be providing care to people living with one of these – both memory storage and retrieval are damaged very early within the disease. It is the higher cortical features and functions that are eroded and damaged significantly as the disease progresses. Therefore, a person living with a dementia can spend much longer in the appraisal of a stressor than is normal, and they may feel no ability to control or predict and put an end to their distress.
Also, because the emotional centres of the brain are fully activated in fight, flight or freeze mode, without a fully functioning, rational cortex to dampen the flood of hormones down, the person becomes easily and dramatically overwhelmed.
It has been demonstrated that unpredictable events are much more stressful than those that can be predicted (Glass, 1973), and that when control is felt to be absent the stressor becomes catastrophic.
FIGURE 1.1 The three aspects of the stress process (adapted from McAndrew)
The inability to cognitively define consequences creates an intolerable strain for the person living with dementia and can often result in a catastrophic reaction, both physiologically and psychologically, and of course this may have an impact on the person’s social standing or status.
Time, and as much information as possible (in small, bite-size chunks), must be given to the person living with a dementia whenever a stressor is experienced or when a possibly stressful procedure is performed or required. A modification to either you, the caregiver’s, approach or the environmental load will be required to allow stress deceleration to occur.
Next week we will look at the physiological and psychological effects of stress but please re-read todays blog. It is incredibly important you understand your role in intervening in dementia care to reduce to burden, take off the pressure and reduce the demands to a point where the person copes and thrives.
In later blogs we will look at techniques for you to use to walk in the shoes of someone living with a dementia, but for now rethink your environments and rethink your approaches. See the world through the resident’s eyes and wake up in a new world – 21st century dementia care.
Till next time
Paul Smith – Dementia Care Expert
