ENDOCRINE DISORDERS AND THE LYMPHATIC SYSTEM: GLANDS WITH INTERNAL SECRETIONS
Apart from the genital glands and the pancreas which have been described elsewhere, the following glands belong to the endocrine system:
i. Pituitary
ii. Pineal
iii. Thyroid
iv. Parathyroid
v. Thymus
vi. Suprarenal
i. Pituitary: which lies in the sella turcica, is recognisable by iris changes in the brain sector, locally as follows—right iris 60-2′, left iris 58-60′—in the muscle zone.
There are no muscles in the brain, so the skeletal zone representing the base of the skull reaches as far as the blood zone. Thus, for example, in a case of fracture of the base of the skull the signs of damage are observed in the blood zone, here lying closer in towards the iris-wreath than would be the case with skeletal injuries of other parts. The bones of the cranial vault are represented in the skin zone.
The recognition of a disturbance of the pituitary is of greatest importance, since the pituitary is the regulator of all the remaining organs of internal secretion.
The disease-signs are shown as follows:
Lightening—as sign of over-activity, very often with a similar lightening in the areas for the corresponding sexual organs.
Pituitary tumours show clearly as dark tumour-signs extending width wise, as is characteristic of tumours of other organs.
In the iris, the pituitary area lies opposite the suprarenal area, indicating the close connection between these two organs. When one of these glands is shown in the iris, indicating abnormal disturbance, then one considers the possibilities of cure. If both organs are registered then the slightest condition must be attended to.
ii. Epiphysis (pineal): according to many other authors, the gland has its place in the iris according to the indication made on the topographical chart. I can give no iris sign for
disturbance of this gland.
iii. Thyroid gland: shows in the right iris at approx. 14′-17′ and left iris 43′-46′ in the sixth minor zone. In the case of hyperfunction, a lightening of the area appears. A thyroid hypofunction is recognised by a darkening of the area.
Clinically, there is more or less a definite picture of myxoedema with hypofunction, which in its lighter forms is more widely distributed than is generally diagnosed. In thyroid disturbance the heart can register in sympathy, and the heart area must be thoroughly scrutinised. In most cases one finds lacunae, eventually in association with white lines. Therefore, appropriate cardiac medicinal support should not be omitted. A close connection also exists between the thyroid and the abdomen (Premenstrual syndrome).
iv. Parathyroid glands: as is well known, the parathyroid glands lie behind, or near to the thyroid glands, and so we also find the iris signs in the thyroid gland areas, rather nearer to the iris-wreath. The signs are very difficult to recognise. With these organs one rather relies upon the clinical symptoms of tetany: von Recklinghausens disease, and also the significance of the contraction-rings in the iris.
v. Thymus gland: the thymus gland shows its sign in the following areas—right iris 43′ approx., left iris 17′ approx.—in the fourth and fifth minor zones. In the same place, though rather more peripherally (fifth minor zone) lies the mammary gland position. One may easily
distinguish these two signs since the mammary gland itself only develops fully when the thymus has atrophied.
vi. Suprarenal glands: these glands, whose functions have only in recent times been fully investigated, have their areas next to the kidney areas directly adjacent to the iris-wreath—right iris 30′-32′ approx., left iris 28′-30′ approx. If the suprarenal areas are lighter, then the indication is one of over-activity. We find these signs in rheumatic conditions together with an overlay in the entire muscle zone of whitish to yellowish clouds.
A dark weakness-sign (lacuna) in the suprarenal area indicates a suprarenal insufficiency. If these conditions have already occurred, one also finds besides the suprarenal sign, a lacuna in the heart area and a large dilatation of the iris-wreath.
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MEDICAL TESTS FOR CHILDREN: ECG AND EEG
Electrocardiogram (ECG)
An electrocardiogram, or ECG, is a recording of the electrical impulses of the heart. These impulses are what makes the heart beat in a regular rhythm. To make such a record, an ECG machine is attached to the patient with electrodes, metal plates that are placed on the arms, legs, and chest. These electrodes pick up the electrical impulses that move through the body. The impulses cause a needle in the machine to move on a piece of paper, as the paper moves through the machine. Where the needle touches the paper, it makes a line. The physician studies the pattern on the paper to see if the heart rhythm is normal.
The ECG does not hurt the patient, but it is important for the patient to stay very still while the recording is done.- All muscle movements, not just movements of the heart muscle, are caused by electrical impulses. Therefore, any movement can affect the ECG recording and give an inaccurate picture of the heartbeat.
An ECG is done to check for irregular heart rhythms (arrhythmias), an enlarged heart, heart valve disorders, heart malformations, and many other heart disorders. The test can be done in a doctor’s surgery or an out-patient laboratory.
Electroencephalogram (EEG)
An electroencephalogram, or EEG, is a recording of electrical activity in the brain. It is a painless procedure similar to an ECG. The metal plates known as electrodes are attached to the patient’s head and to an EEG machine. The electrodes pick up the brain’s electrical impulses. These impulses activate a needle, which traces the pattern of the impulses on a piece of paper moving through the machine. The physician compares the pattern on the recording to patterns of normal brain activity, and determines if there is an abnormality. Recordings from opposite sides of the brain can also be compared to see if the patterns match.
An EEG is done to test for epilepsy, brain tumours, encephalitis (inflammation of the brain), and other brain disorders.
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BOWLEGS AND KNOCK-KNEES IN CHILDREN
Bowlegs and knock-knees are two conditions in which the legs are not as straight as they are in most persons. In bowlegs, the legs bend outward so that the knees are farther apart than usual. In knock-knees, the legs bend inward so that the knees are closer together.
Theoretically, when a child stands straight, the ankle bones should touch or almost touch each other, and the knee bones should touch or almost touch each other. With an infant lying on the stomach or back, the legs can be pulled straight with the toes and knees pointed straight ahead to determine whether the bones of the knees and ankles come together. If ankles touch but the knees do not, the child can be said to be bowlegged. If the knees touch but the ankles do not, the child is knock-kneed.
By these standards, however, all infants, children, and adults are bowlegged or knock-kneed to some degree, so you should not become alarmed. Most infants appear bowlegged until they walk. Then when they start to walk, they walk “cowboy” style. This condition usually corrects itself by age two. Most preschoolers stand knock-kneed, especially if they are plump. This condition also corrects itself.
True bowlegs and knock-knees either are due to rickets (vitamin D deficiency) or are inherited. Once common 50 and more years ago, rickets is now rare. An unusual form of bowlegs, often occurring only on one side, is Blount’s disease, in which the top of the tibia (shin bone) becomes deformed.
Signs and symptoms
Have the child stand with the legs straight and the toes pointed forward. Then observe if there is any distance between the knees or ankles. Remember that any distance between the ankles or the knees varies from person to person and that these differences are usually normal. If you think that there might be a problem, ask your doctor.
Home care
In most cases, no home care is needed. To prevent rickets, all children should receive about 400 international units of vitamin D daily. This amount is found in many commercial infant formulas and in most commercial milk. Some vitamin D is present in breast milk, but the amount varies. If your child is being breast-fed, ask your doctor whether the child is receiving enough vitamin D.
Precautions
• If you think your infant or child is bow-legged or knock-kneed, watch to see if, after several months, the condition worsens. If it does, consult your doctor.
• Do not use orthopedic shoes without your doctor’s prescription.
• Do not give your child vitamin D supplements unless your doctor has prescribed them. Overdoses of vitamin D can be harmful.
Medical treatment
In most instances, your doctor will examine your child and then prescribe no treatment—except to wait and watch. X rays of the knees may be required as well as blood tests for rickets. Use of orthopedic shoes or night splints is rarely necessary. For Blount’s disease, braces or corrective operations on bones may be required.
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LIVING LONG: ALL IN THE FAMILY
Though many hospitals are equipped with Orwellian, high-tech equipment that can read your genetic legacy from a single drop of blood, the easiest way to know what’s in your genes is to look at your family tree, says Dr. John J. Mulvihill of the University of Pittsburgh. “You can definitely see your prominent risk factors in your family history,” Dr. Mulvihill says. “And we’re learning more all the time. Ten years ago, we didn’t think there was any family linkage to prostate cancer. Then people started talking about it and uncovered a strong family connection. The problem is that most men don’t know their family history.”
Worse, even when they do know, most don’t give it a second thought. Of the 58 people interviewed for one study, nearly half of those having family members who suffered from heart disease or cancer did not believe that their family history had any bearing on their own risk. And men were much less likely than women to think that having a family member afflicted with cancer was relevant to their own risk for the disease. Despite their disbelief, studies show clear connections. In Japan, for instance, researchers comparing 363 people with colorectal cancer with an equal number of people who were cancer-free found that those having one first-degree relative (a parent, sibling, or child) with colorectal cancer had almost twice the risk of developing the disease as those with no family history of colon cancer. In a similar Canadian study, researchers found that 15 percent of 640 men with newly diagnosed cases of prostate cancer had at least one blood relative who also had the disease, while only 5 percent of 639 men who did not have prostate cancer had any family ties to the disease.
And almost nowhere is family history a stronger link than it is for heart disease. As mentioned earlier, just inheriting one tiny bit of faulty DNA from both Mom and Dad can double your risk for developing heart disease In the final analysis, we’re all likely to be at genetic risk for something, concludes Reed E. Pyeritz, M.D., Ph.D., professor of human genetics, medicine, and pediatrics at Allegheny University of the Health Sciences in Pittsburgh. “I’m fairly convinced that, to some degree, all disease is genetic. So far, the major common diseases to which we’ve identified genetic links include Alzheimer’s disease; arteriosclerosis and all that comes with it, like heart disease, hypertension, and stroke; diabetes; and, of course, most forms of cancer. There’s surely more to come.”
That’s all the bad news. The better news is that studies show these genetic risk factors can be largely offset by making appropriate lifestyle changes or by seeking early medical help in some cases.
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General Health
HEART SAVING TIPS: EXERCISE IS VITAL
We all know that exercise is good for us, but you may not know just how much it can save your life. If someone could bottle the positive effects exercise has on our bodies and sell it as a drug, they would make a fortune because we’d all be taking it! Interestingly enough there was a weight loss supplement on the American market called “Exercise in a Bottle”; the US Federal Trade Commission has permanently banned the manufacturer of this supplement from marketing products for weight loss because of false and unsubstantiated claims made about this supplement. There’s nothing like the real thing!
Exercise has the following benefits for your heart:
• It makes your heart muscle stronger, so that it can pump more blood with less effort.
It helps you maintain a healthy weight by speeding up your metabolism and increasing your muscle mass.
• Reduces your chance of having high blood pressure.
• Strengthens your immune system and improves your ability to fight off infections.
• Exercise reduces LDL “bad” cholesterol and triglycerides, and is one of the few ways you can increase your HDL “good” cholesterol.
• It improves glucose tolerance, thus reduces your chance of developing Syndrome X and diabetes.
• Exercise helps you cope with stress and reduces anxiety and depression. It reduces tension, anger and fatigue, and helps to lift your spirits.
• Exercise improves your self esteem and makes you more motivated to eat well and look after yourself well.
• It causes your artery walls to release nitric oxide, which dilates your blood vessels, improving blood flow; reducing inflammation of the artery walls and reducing the tendency of blood clots to form in the arteries.
• Exercise makes you smarter! Yes it’s true; studies have shown that exercise helps thinking and decision making abilities, and speeds up brain activity.
• It helps you to live longer.
Clearly exercise is one of the easiest, least expensive things you can do to reduce your risk of heart disease. An ideal amount of exercise would be 30 to 60 minutes most days of the week. If you can’t fit it all in one go, you can split this into two or three sessions. For example, two fifteen minute walks would be just as good. If you don’t have time for formal exercise, you can still stay active by gardening, doing vigorous housework, walking to the shops instead of driving, taking the stairs instead of the lift, going out dancing, or having energetic sex. Find some way to be more active; it will be well worth it.
If you have diagnosed heart disease it is vital that you check with your doctor before starting an exercise program.
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LIVING LONG: THE QUEST FOR IMMORTALITY
Legend has it that young James J. Kilroy was like any other working stiff in the 1940s, loading freight ships day in and day out. Then one day he had a flash of how he could be just a little bit more. Chunk of white chalk in hand, he scrawled, “Kilroy was here” on a mother lode of crates full of blue jeans waiting to sail to harbors across the globe. When that slogan- generally accompanied by a face peeking over a wall-started popping up around the country, including such inaccessible places as the Statue of Liberty’s torch, the once-anonymous Kilroy achieved immortality.
“We all have a little Kilroy in us,” says Dr. Walter M. Bortz II of Stanford University School of Medicine. “We want to leave a legacy to show we were here. We have an inherent want for immortality. And that’s a healthy thing.”
There are a whole lot better ways to have your name live on than etching your John Hancock on a bathroom wall. Many can actually leave the world a better place. Others are just plain fun. So strap on some of these suggestions and rocket into eternity.
Sign a donor card. “The absolute best way for anyone to live on after their death is to make an organ, tissue, or whole-body donation,” says Dr. Kenneth V. Iserson of the University of Arizona College of Medicine. “There is a dearth of organ donors in this country, and the need for transplantable organs and tissues is enormous-and getting bigger.”
The number of people who have died while waiting for available organs has increased more than 2 1/2 times during the past eight years, according to the United Network for Organ Sharing in Richmond, Virginia. And every 16 minutes, a new person is added to the national transplant waiting list. Donor families consistently report that they feel their loved one is living on in someone else through their organ donation. Considering that about 25 different organs and tissues are transplantable, that’s a lot of immortality.
You can get a donor card from a local or regional organ or tissue bank, or you can fill out a donor card when you renew your driver’s license. Even if you have the sticker on your driver’s license, doctors most likely will still check with your family before donating your organs.
Make a carbon copy. Though God knows it shouldn’t be your only motivation, one of the benefits of having children is that you leave behind a living legacy. Your kids will not only carry on your tale about that 36-inch walleye you reeled in last summer but also pass on the only part of you that is truly immortal-your genes.
“The bottom line in life is that for a species that reproduces sexually, immortality has already been achieved through its genes,” says Dr. S. Jay Olshansky of the University of Chicago.
If you should decide to reproduce, you want to be sure that you’re passing along healthy, undamaged genes. You can help protect those mighty little mailmen of immortality by not smoking and by getting plenty of vitamin C, say experts. Studies show that nicotine damages sperm and reduces sperm count. Vitamin C, on the other hand, has been shown to protect the little guys from free-radical damage.
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PREVENTIVE MEDECINE: PSYCHOSEXUAL PROBLEMS
Sexuality is simply one aspect of a person’s personality and women who get pregnant when they know they shouldn’t often have some kind of psychosexual problem of which they may be unaware. The types of psychosexual disorder involved are numerous. An example of one of the commoner ones is a woman who believes that reproduction is the only justification for sexual pleasure. Such women may have had several babies yet deny that they are interested in sex. A second category includes those women who unconsciously believe that sex is sinful and that pregnancy is a punishment for their sin. This means that there must be a risk of pregnancy if they are to enjoy sex. Other women believe that sex is something done to them by a man and is therefore something for which they have no responsibility, so they don’t bother with contraception because to do so would be a contradiction. Many young women who believe that love is the only justification for sex refuse contraception until they are sure of the man (as a kind of denial that they are having sex) and get pregnant in the intervening time. Some women who don’t accept their sexual drives deny them consciously yet unconsciously try to indulge them (by getting drunk, losing control and then getting pregnant, for example). A small proportion of women cannot tolerate any sort of contraception because they feel guilty enjoying any form of sexual pleasure. Some women are so filled with shame about their sexual drives that they don’t seek contraceptive advice. Another common fear is that to accept effective contraception is to open the floodgates to promiscuity. Such women (especially when they are unmarried) refuse all contraception and then get pregnant. Some women are unconsciously incited to pregnancy by their mothers (who want a baby for themselves) but then regret the conception when it has occurred.
Lastly there is the teenage girl who has just started having intercourse. Such adolescent girls frequently refuse to accept that their status has changed and even though they are not virgins can’t bring themselves to accept the fact and continue to live with the fictitious belief that they are virgins. Many such ‘part-time virgins’ say that they are better able to keep up the lie to their parents and themselves that they are virgins if they don’t use contraception. Such a girl believes she is still a virgin (albeit a part-time one) and for this reason doesn’t really need contraception. Such a delusion in a part-time virgin unfortunately leads, all too often, to unwanted pregnancies.
Clearly an apparently simple thing like an unwelcome pregnancy is in fact enormously complex, and the unconscious mind plays a substantial part in almost all the mechanisms I have outlined. Consciously the woman says she doesn’t want to be pregnant. Contraceptive services are one of the most widely publicized and available of all the preventive services, yet still unwanted pregnancies abound.
Similar situations operate in all kinds of other health areas-not just those to do with sex. At certain times in our lives we might have an unconscious need to be ill as an escape from something or as a way of gaining attention or being cared for. A smoker may have quite unconscious needs for oral gratification, as does many an over-eater and no matter how good the preventive medical information is, nor how good his or her motivation, little progress can be made until the individual can confront and understand the underlying psychological drives that make him or her smoke or eat. Similarly, a man with a poor sense of his male self-esteem who smokes because he considers it manly to do so may be quite unable to stop smoking until this part of his personality can be satisfied in other ways.
It is only by confronting the psychological realities that it is possible to begin to understand why it is that even in the face of good information and motivation, most of us find it difficult or impossible to modify our behaviour in a way which prevents disease. And in this respect social class has little or no part to play-we are all ruled to a variable extent by unconscious motives and drives over which, by definition, we have no control until they are brought into the conscious mind and confronted.
Whilst we frequently hear that ‘prevention is better than cure’ hardly anybody behaves as though he or she believes it and it has now become such a piece of fashionable cant that it should be relegated to the waste-bin along with ‘health is better than wealth’ and other such empty phrases. Not until the medical and health educational fraternity come to terms with the reality of people’s health needs will prevention ever be anything other than a subject of lofty rhetoric.
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TREATMENT STRATEGIES OF ALZHEIMER’S DISEASE: DRUGS TO IMPROVE MENTAL FUNCTIONING
The discovery that the brain lacks adequate quantities of important chemicals such as the neurotransmitter acetyl choline resulted in a search for medication that would rectify either the deficiencies concerned or the results of these deficiencies. Traditionally there are three approaches to trying to deal with a situation in which a chemical is missing from the brain.
The first approach is to give the body more of the chemical in the hope that it will be passed to the brain, where it can carry out its normal function, or to provide the brain with other substances that it may be able to convert into the missing chemical. This approach has been tried for Parkinson’s disease and has been very effective in treating the symptoms in many people, although it doesn’t prevent the progress of the disease. For the treatment of Alzheimer’s disease, however, the results have been disappointing. Perhaps the best-known substance to have been tried is lecithin for which there have been many trials, some attempting to show an improvement in intellectual function and others with the more modest objective of showing that it might prevent or slow down further deterioration. There has however been very little evidence that lecithin and similar compounds have been beneficial.
A second approach to help the brain cope with a reduction in the level of an essential substance is to try to ensure that the little that is available lasts for as long as possible. Like most tissues in the body, the brain has the chemical processes to enable it to destroy most chemicals it is designed also to produce. This is essential in biological systems where a balance between production and destruction has to be maintained. We know that there are some drugs that slow down the destruction of acetyl choline and similar compounds, and it was hoped that the administration of these might result in a prolonged life for the small amounts of neurotransmitter produced, with an improvement in intellectual function.
Until recently this technique also seemed to be disappointing, but a new substance called tetrahydroaminoacridine (THA) has proved worthy of further evaluation. Significant improvements in intellectual ability were originally claimed for THA, but although these have failed to be substantiated by subsequent trials, it is beginning to look as if a proportion of patients with Alzheimer’s disease, but not other dementias, may acquire modest improvements in ability and behaviour with this drug. It is, unfortunately, a drug that produces many side-effects which may preclude its ever being generally available on prescription. It may, however, show us the way to development of more effective and safer drugs. Perhaps we have our feet one or two rungs up from the bottom of the long ladder of drug development for Alzheimer’s disease.
The third approach to dealing with a reduction in the amount of a neurotransmitter in the brain is to try to make the brain structures that are switched on by the depleted chemical more sensitive to the reduced amounts available. Although this approach is used in other neurological diseases with a modest degree of success, it has so far failed to be of much benefit to people with Alzheimer’s disease.
Since approaches aimed directly at affecting the missing chemicals have been unsatisfactory, although as mentioned THA is under further evaluation, researchers have turned to other methods of trying to improve brain function. One of the most exciting of these is the attempt to prevent or slow down the rate of cell death of the factory cells that produce the neurotransmitter chemicals. In other words, rather than trying to replenish the brain’s level of neurotransmitters by using tablets or injections that contain the missing chemicals or those that can be made into them, an attempt is being made to see whether it is possible to discover why the factory cells are dying or not working properly, in the hope that they can be made to fulfil their normal function once again. A modest degree of success has been achieved in understanding what is happening to these factory cells although it is not yet known whether this knowledge can be translated into an effective therapy. It seems as if some of the cells in the brain that make neurotransmitters need substances called trophic factors in order to carry out their normal functions and there is a suggestion that in some degenerative diseases of the brain, including Alzheimer’s disease, these trophic substances may be missing. It is hoped that it may be possible to supply the appropriate trophic factors to enable the cells to work properly, so that they in turn may produce the neurotransmitters that are required for normal brain functioning. Although this field of research holds great promise, it is too early yet to know whether it will be an effective form of treatment.
As well as the specific attempts to try to put right the biochemical abnormalities that occur in the brain in Alzheimer’s disease, there have been many other, rather more general approaches to developing drug treatments that may improve dementia, almost irrespective of the underlying cause. All sorts of drugs have been tried. Many of them were originally developed as vasodilators — medicines that would cause dilation of the blood vessels thereby improving the blood circulation to the brain. It is now known that this type of approach is unlikely to be of any benefit since it does not improve any of the conditions that cause dementia. Other drugs were thought to improve the metabolism — the biochemical processes — within cells and these too have proved disappointing. Many other methods have been tried, but so far, with the exception of people who have a treatable cause for their dementia such as a vitamin deficiency, there is no evidence that any medicine that is generally available is of any benefit in improving intellectual performance. This situation may change, however, within the next two or three years.
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NURSING IN THE CASE OF ALZHEIMER’S DISEASE: USING THE TOILET
As a demented person becomes less steady on his or her feet, it is essential to ensure that rails are provided around the toilet area. Most falls occur when a person is in the process of standing up or sitting down; it is possible to get raised toilet seats that make it easier to get on and off.
For night-time use it may be better to have a commode put at the bedside. This is most useful if the bathroom is on a different floor to the bedroom. For men, a bottle-urinal may be helpful not only at night, but also during the day. It can be discreetly placed in a container at the side of the chair in which he is sitting, and regularly emptied.
When a man with dementia begins to forget to go to the bathroom and when, having got there, he has difficulty in remembering the routine, it may be easier for him to sit on the toilet to pass water than to stand up. This can be less problematical and less embarrassing for a wife or other carers.
Problems with using the bathroom and toilet, and many others such as dressing, are an area where the occupational therapist can give invaluable support and advice. This can usually be arranged through the general practitioner or health visitor.
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BEHAVIOURAL AND PSYCHOLOGICAL PROBLEMS IN THE CASE OF ALZHEIMER’S DISEASE: PROBLEMS AT NIGHT
Those suffering from a dementing illness may well disturb other people’s sleep. Sometimes it is because they have a tendency to wander; sometimes they are disorientated and think that it is time to get up; sometimes they are frightened at night. Often, having gone to the bathroom they are unable to find their way back to the bedroom or have their attention diverted to something else with which they then become involved.
Many people with dementia are less active than they used to be during the daytime and may take more daytime naps than before. Try to make sure that they get adequate physical and mental activity during the day, to help promote sleep. It is also a good idea to try to ensure that they go the bathroom last thing before going to bed; restricting fluids during the evening, say after supper if this does not cause distress, can also help. Leaving a light on in the bathroom and having a low-wattage bulb on the landing can assist a confused person in getting around at night.
The bed needs to be comfortable and some relatives find that continental quilts are easier for a person with dementia to manage than blankets and sheets. It is probably best not to use cot-sides as they rarely manage to deter a wanderer and can be irritating. Sometimes, however, they can be helpful in preventing a person from falling out of bed if this is a problem.
If sufferers decide to get dressed and you have difficulty dissuading them, don’t worry — let them get on with it. They may well be prepared to go back to bed, even though fully clothed. Sometimes a warm drink works as it is often associated with the going-to-bed routine.
Finally, there are two important points. First, if wandering at night is a real problem, make sure there are no hazards to safety, like gas taps that could be turned on. Secondly, a step that can be taken is to ask the doctor to prescribe some sleeping medicines. These should be avoided except as a last resort and should only be tried for a few weeks at a time. Sometimes it can be left to the carer’s discretion to administer them intermittently, perhaps after having had two or three bad nights in a row. All medicines have side-effects and you must ask the doctor what to watch out for if they were to affect the person you are looking after.
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