We all think we know a little about stress. We have all been stressed and many of us will have experienced distress, but if you are reading this blog it is likely at this point you have managed to return to a normal state of arousal – you have achieved a sense of homeostasis. Life without stress is impossible, but achieving just the right balance between good stress that arouses and stimulates with just the right amount of distress, a state that taxes and challenges but ultimately is not harmful, is a magnificent balancing act.
It is a balancing act that ultimately depends upon how our psychology, physiology, environment and present circumstances, act upon one another to allow our ‘minds’ to remain comfortable and confident that we are not in danger, that we can cope, and in certain circumstances that we can thrive.
A species with predisposition to stress
We discussed in our last blog the model of the hypothetical ‘triune brain’, so we know that our higher functions can be overridden in certain circumstances by our older basic functions – stress reactions being one of these, so perhaps we should also be looking at why we have such a strong predisposition as a species to stress, and why this is a good and a bad thing.
It is much too simple to say that in dementia stress is good or bad; it is more accurate to state definitively that too much or too little stress is bad for everyone, irrespective of the labels we place upon each other. One thing we can state, however, is that the condition of dementia certainly appears to place us in a very vulnerable place as to the effects of stress.
The term adaptation, as used originally in biology, describes both a trait with a functional role that is maintained and evolved by means of natural selection, and the evolutionary process that leads to the adaptation. Adaptation ensures survival and improvement in the face of changing environmental factors. The concept was eventually taken up by psychologists and renamed ‘adjustment’; it refers in this context to the individual’s struggle to get along or survive in their social and physical environments.
Erik Erikson (1965), in his seminal work on life stages and the tasks needing to be successfully navigated by people to allow psychological maturity and satisfaction, postulated that in our later and final years we need to travel the road between integrity and despair. To review our past life and become content within our current position is the ‘goal’ of old age.
But what if you develop a dementia, what if you have to be cared for within an institution and what if that institution regards dementia as the end?
Can you change your circumstances in this instance or is it the work of the institution to change itself to foster integrity within dementia?
Will you constantly have to struggle to change the circumstances around you to allow you to cope or thrive as your dementia progresses? When this becomes harder and harder, how will you achieve contentment – will your struggle be mistaken as behaviour that challenges?
It is my fervently held belief that it is the role of the institution to remove the need for this struggle, by recognising and adjusting to allow your adaptation and successful adjustment into an integrity within dementia.
The effects of stress
The body reacts in the first instance to a stressor like an alarm. This alarm call stimulates the body systems to prepare for fight or flight, and the sympathetic branch of the autonomic nervous system reacts by releasing adrenaline and noradrenaline.
This leads to an increase in heart rate and blood pressure and an increased blood flow to the brain and muscles. Blood is deviated away from the stomach organs to achieve this and can lead to a feeling of being ‘sick’ (Tenney, 1997).
If the stress continues over any prolonged period the body starts to resist. It burns up its entire energy stores and the person becomes exhausted. Hypoglycaemia can occur at this stage. Body repairs cease and the immune system is reduced; infection and damage becoming much less easy to deal with (Martin, 1997). If the stress continues further then the essential hormones responsible for growth, body repair, immune protection and sex drive may be turned off (Cheek & Rossi, 1985).
At this stage the person feels constantly weary and may suffer repeated illness. If the stressor is removed and the person allowed to recuperate, the system will usually return to normal function (Rossi, 1985). In dementia, however, particularly in the mid and later stages, it is questionable as to whether disturbances in memory and cognition will allow a stress-free existence and therefore a return to normal levels of biological and psychological functioning.
If further stressors are added to this weary and emotionally heightened way of being, the individual enters a third stage, that of exhaustion. At this stage resistance to all forms of stress collapses and there is widespread damage to tissues, often leading to death through infection or stroke (Welch, 1990).
An older person already has a predisposition to many of the above stress consequences. Further exhaustion to the system can prove extremely problematic.
If a person, due to prolonged states of agitation or distress, cannot move out of the stress condition, their immune system may well become greatly suppressed. Their cognitive processes could possibly also become extremely depressed. (This has as much to do with glucose and insulin depletion as to any intra – psychic forces.) This in turn could lead to a condition that moves between personally manageable levels and very confused or restricted thinking that is exaggerated and problematic and which needs external assistance to ‘normalise’.
Applying adaptive responses
Adapting our own response allows us to see these biological and psychological factors, as a natural consequences of protracted and unmitigated stressful environments and impacts. Reduce these, and a certain degree of improvement to dementia symptoms or ‘rementia’ is inevitable.
This systems approach to the unity of mind and body has a number of benefits to those working in care homes:
- It allows those with limited time and resources, to see they are making a difference by being able to physically participate in therapeutic approaches to care, even if it is just calming the environment at that one moment.
- The approach is transferable from setting to setting as it is the carers who are required to do the work, and it is easy to teach as it has only a few key principles – there are no obscure or abstract suppositions.
- Carers instinctively know it is ‘authentic’ because they have all felt the pressures of stress in their own lives, and have all felt the out- of- control psychological fear and physical distress that stress exerts.
In this last sense it also helps to break down ‘ageism’, as it allows everyone to feel a connection with these stress-response systems that are still fully active within the people they are caring for. There can be no hiding behind an us and them shield, as daily processes and reactions are likened to the carers’ own day-to-day experiences. This also helps to break down major ‘perceptual’ barriers; if older people living with dementia have the same feelings and reactions to stress as we do, surely they cannot be different; if these emotions, feelings and reactions are further compounded by one of the dementias, surely we can no longer see the person as a passive recipient of care and we certainly can no longer ever see them as ‘childlike’ or as returning to a second childhood!
Awareness and insight
It should be easy to see the benefits of an adaptive-type approach to the care of people living with dementia in its early and mid-stages, but what about the more advanced stages of a dementia? When a person’s higher cognitive functions are severely compromised, is it still sensible to refer to care in terms of psychological goals and models?
Much recent brain research has focused upon the emotional brain and the central core of structures that govern our emotional responses to external stimuli, as well as the hormonal cascades that accompany our biological responses. It may have come as a surprise in our last blog that these structures seem to react autonomously, without any conscious effort from ‘us’ and release their cocktail of hormones split seconds before ‘our’ higher functions even become aware of the external stimuli.
This of course makes sense in evolutionary terms, as it helped to stop us from being eaten, but it is often a surprise when people learn these responses are still very much present in modern brain function.
When an external stimuli is received two functions appear to occur in quick succession: the limbic system reacts and then the higher cortical functions access memories and previous responses stored away in various memory resources, and make appropriate and measured judgements as to how to react in accordance with these ‘stored’ learned responses as we discovered in the last blog.
Of course we just need to think back to times in our own lives when we have done something in quick response that we later look back on and wonder why on earth we did it. Well, that’s hormonal hijacking for you (at least you did not get eaten).
With awareness and training we can have better control of these responses, but we can never completely override these autonomic systems.
It is not too difficult to understand why then, when damage occurs to our higher brain functions that the emotional responses of those affected begin to take sway.
The dementia experience + stress
The stresses of the changes to psychological functioning associated with brain alterations of the dementia type are immense. Dealing with changes to memory, cognition, recognition and communication, produce untold problems and when physical problems of motion and coordination are added the experience by brain system failures, the outcomes appear almost too dreadful.
When external stress is further added to this equation, which we have begun to reveal is an inevitable consequence of the progression of the dementing process, raised general levels of arousal and catastrophic reactions become a constant feature. Tension, anxiety and depression, which are the features of general levels of arousal anyway (Byrne, 1979), may help to explain aggressive outbursts as a natural consequence of constant arousal and the need to release pent- up energies.
Behaviour may become disturbed not just as a result of the person becoming frustrated in their ability to interpret stimuli appropriately, their memory difficulties and the confusion these combinations produce, but also through the exhaustion of constant stressful arousal. The person may experience the feeling of being highly disorientated, physically and psychologically exhausted and socially compromised or abandoned and may either retreat into withdrawal, or conversely, may adapt behaviours that are challenging simply to cope.
This idea that an inability to successfully adjust and the person’s desire to avoid the stressors these attempts cause, may help to explain why individuals develop such dependence on routine and why repetitive rituals develop.
A type of behaviour is often exhibited when this overwhelmed state occurs, which has been characterised by the analogy of the confined zoo animal, where pacing over the same route again and again is evident.
In actuality this is a defence mechanism created unconsciously (or consciously with regards to unmet need) by the individual to avoid the stressor of being unable to control the stimuli, change the circumstances and predict future outcomes when using any other approaches.
This type of coping response in the threat of continued stress can be seen as self-protective, but it can also of itself be damaging and limiting if it persists for prolonged periods. It has been proposed that one of the results of dealing with prolonged stress is a gradual decline into mental illness (Halpern, 1995).
It is disturbing to think that some of the more psychotic presentations of the dementia syndrome could be being perpetuated by unresolved stress reactions and that we, as professionals, are missing the vital clues.
Stress kills. It is our job as professional carers to reduce the stress levels of those living with a dementia among us as much as is realistically possible. While not all procedures can be made stress free, we should at all times be mentally assessing our interventions. If they could produce a stressful reaction, we must plan to settle and reassure the person as soon after the event as possible. A person should never be left until you as the agent of intervention have ensured their stress level has been returned to as normal a level for them as possible.
Time is not of the essence but, as we have shown, saving someone’s life and sanity is.
Till next time
Paul Smith – Dementia Care Expert