Essay on Belonging Notes - 635 Words

QUOTES from Romulus, My Father – Raimond Gaita * † three things fed my father’s anger: his knowledge that I was lying, his fear for my character and his dismay that he had lost something precious† - accumulative listing - piles emphasis on Romulus’ strong beliefs in honesty and morals which he fears Raimond might lack to form a good character. A sense of belonging is presented in the fact that father and son are attached by social values of honesty and reputable character. * â€Å"Raimond, it doesn’t matter about the razor. But you must not lie. That is worse than any damage you might do† – imperative language – Which places powerful accentuation on Romulus’ priorities for high values and morals. Romulus believes an impregnable binding†¦show more content†¦It carries the epitaph† stating† Belief in the afterlife is the only hope for us†. – Use of biblical reference – Accentuat es the influential concept of religious beliefs evident in the European backgrounds of the Gaita’s and the two brothers. They have faith of reuniting in the afterlife without the oppression of life including mental illnesses, sorrows and financial struggles. The epitaph was written in Romanian, further empowering their sense of attachment. QUOTES from Take Me Home Country Roads – John Denver * â€Å"Country roads take me home† – use of repetition in the chorus – Employs emphasis on the persona’s aspirations to belong again to his origin of â€Å"Almost heaven West Virginia† in which he â€Å"belove†. A sense of attachment is felt from the persona’s dislocation from his â€Å"home† as absence of belonging promotes feelings of alienation and disaffection which he desires to circumvent. * â€Å"West Virginia mountain momma† – personification of mountain – The mountains are expressed to be the persona’s mother which is representative of the supreme image of belonging. * â€Å"All my memories gather round her† – use of metaphoric language – Demonstrates the persona’s depth of belonging to West Virginia as it represents the inclusiveness of his childhood memories ascending the sense of connection between his home and self. * â€Å"I hear a voice in the morning hour as she calls me† – personification of West Virginia – Expresses his delusionsShow MoreRelatedNotes for Identity and Belonging1774 Words   |  8 PagesDancing lessons – Cindy Pan Encourages Cindy’s ambitions EXTENDED ASIAN FAMILY INFLUENCES - Helps develop a child’s sense of self Quarrel – Ken Chan Dispite the dysfunction and chaos, he felt that ‘loneliness was never a problem’ THE LANGUAGE OF BELONGING: LEARNING ENGLISH AND LEARNING ‘AUSTRALIAN’ IDEAS EXPANDING IDEAS STORY QUOTE/EXPLANATION OUTSIDE EXAMPLES THE FRUSTRATION OF COMMUNICATION BARRIERS - Without being understood, you remain in the shadows of your adopted country, unable to belongRead MoreBelonging English Exam Notes1911 Words   |  8 PagesEnglish exam revision Exam One Area Of Study – Belonging. Creative Writing Belonging Essay 1. The Immigrant Chronicles- Peter Skrzynecki Migrant Hostel * Portrays emotions surrounding the experience of migrants in detainment after their arrival in Australia. THIRD STANZA. Technique: Simile- capering the migrants to.. Example: â€Å"birds of passage† who were â€Å"always sensing a change in the weather† Effect: emphasises the absence of a stanle fixed home for the migrants. They feel theyRead MoreRomulus My Father Notes for Belonging Essay2670 Words   |  11 Pagesdidn’t. His dad grew up with little money and had to work for all the money he needed where as Raimond didn’t have to work as much. Most importantly however, Raimond was able to enjoy a sense of belonging when he was growing up to his father and family. Romulus was unable to enjoy any real sense of belonging whilst growing up. Raymond would not have the same work ethic as his father; His dad thought that everything would revolve around his work. He worked before and after school. Romulus is a pragmatistRead MoreEnglish Notes Belonging – Strictly Ballroom (1992) Essay3082 Words   |  13 PagesEnglish Notes Belonging – Strictly Ballroom (1992) 1. Introduction to Belonging Strictly Ballroom | * 1 core text + 2 related texts of your own choosing * Link them by concept NOT content (i.e. don’t link by setting, character or plot/events) * Belonging to a group can establish your sense of identity e.g.: * Scott Hastings – included * Mr Hastings (Doug) – excluded * Mrs Hastings (Shirley) – included * Fran – excluded * Concept: ‘the struggleRead MoreImproving Academic Engagement And Achievement Over Time1689 Words   |  7 Pagesexperience. I also met with each of the student’s teachers to gain their perspective regarding each student’s needs and achievements. I then observed and met with the students and the teacher’s on a weekly basis throughout the study to discuss and take note of any thoughts or concerns. I also continued to observe and record anecdotal records throughout the course of the study. Group gatherings and individual and group study sessions were held throughout the year. In May 2014, I held an interview withRead MoreEssay Belonging Critical Analysis - August Rush1341 Words   |  6 PagesBelonging comes from an understanding, or the knowledge that an external sense of being comes from an internal sense of connection and safety. For one to have a sense of belonging they must first have and understanding of what belonging is and there should be a n internal connection between them and the place that they are belonging to. This critical analysis will reveal how the movie â€Å"August Rush† directed by Kirsten Sheridan, relates to the concept of belonging. August Rush is a story of drama withRead MoreThe Paradox Of Belonging : The Complex Role Of Colonialism1343 Words   |  6 PagesThe Paradox of Belonging: The Complex Role of Colonialism in Finding Identity Adrienne Clarkson the twenty-sixth Governor General of Canada once wrote: â€Å"I was, and am, a child of diaspora. I am someone who, for a while, did not belong anywhere.† For nearly everyone who has ever lived in the wake of colonialism, it can be painstakingly difficult to find a sense of belonging with two distinct cultures being juxtaposed together. This colonization process had devastating effects for those upon whichRead MoreIs there more to the concept of belonging than the superficial meaning of the ownership of one’s1200 Words   |  5 PagesIs there more to the concept of belonging than the superficial meaning of the ownership of one’s possessions? Is there a constant need for human beings to feel as though they are a part of something? Do the pressures of belonging lead to conformity? What are the negative and positive effects of conformity? Is there such thing as a nonconformist? All of theses questions stem from the perplexing topic of belonging. M any famous philosophers have spent ages analyzing and discussing this concept. I wasRead MoreThe Role of Belonging in Film and Print Essay921 Words   |  4 PagesBelonging has many aspects several of which can be seen in the following texts. The texts â€Å"The Crucible† (â€Å"TC†) by Arthur Miller, â€Å"Rockstar† by Nickelback and â€Å"The Pursuit of Happyness† is a movie starring Will Smith display several different aspects of belonging. The concept explored by Arthur Miller in â€Å"TC† is the conflict between different groups and the ramifications of belonging to a group. Meanwhile in â€Å"Rockstar† the composer explores the concept that people will wish to belong to variousRead MoreRelationshipsand Sense of Belonging in Charles Dickens Great Expectation1043 Words   |  5 Pagesdiscovers a sense of belonging and acceptance. Gary Ross director of the movie â€Å"Pleasantville† uses an adolescent males point of view to sh ow the varying aspects of belonging in quite literally in this instance different ‘worlds’ which displays the destruction of being accepted and the positives of inclusion. Both texts show collectively that a need for a sense of belonging rarely changes over time in which the two texts are set. Relationships can be detrimental to our sense of belonging as they can alienate

The Story Of Joseph, Recorded - 1498 Words

The story of Joseph, recorded in Genesis 37-50, is common in multitudinous places of worship throughout the world. For the most part, the story is one of a forgiving, strong man. After years of hardship as a result of a decision made by nine of his brothers, Joseph was blessed by God and forgave those nine brothers. What those places of worship don’t tend to discuss, however, is the fact that Joseph, throughout the story, tended to pick favorites amongst his brothers and hold grudges against the nine that made the critical decision, causing the character to seem slightly hostile and unforgiving, a counter-narrative of the typical story told in churches and synagogues everywhere. In Genesis 42-43, the Bible gives six examples of Joseph dealing and speaking harshly to his brothers. For example, he interrogated them upon their arrival in Genesis 42:7, and later, in Genesis 42:9, he acted like he suspected them of coming to spy on the land of Egypt. â€Å"And he put them all toge ther in prison for three days (Genesis 42 17 NRSV).† If Joseph’s true intention was to forgive and forget the wrong caused by his brothers, then all of these actions would be unnecessary and serve no purpose. The only reason Joseph would treat his brothers so is if he had been harboring a grudge for all those years against his brothers and was enjoying the opportunity bring them difficulty. Genesis 42:19-20 says this: â€Å"...if you are honest men, let one of your brothers stay here where you are imprisoned.Show MoreRelatedAnalysis Of The Book Genesis 36-50 958 Words   |  4 PagesAccording to the book of genesis 36-50, it sustains significant narratives focusing on Esau’s descendants, which describe Esau’s family members and the stories of them, two wives and twelve sons. Esau’s was one of Abraham grandsons, and as such, part of some material blessings. One was that Esau became â€Å"father of the nation† the nation of Edom. I argue tha t Esau’s were experiencing God’s blessings, in conform to his promises. The abundance of goods is due to the divine blessing of God. They wereRead MoreThe Accounts of Birth of Jesus as Found in the St.Matthew and St.Luke861 Words   |  4 PagesThe Accounts of Birth of Jesus as Found in the St.Matthew and St.Luke The story of the birth of Jesus is recoreded in two books of the new testament, the Gospels according to St.Matthew and St.Luke. We find the accounts of Jesus birth in them. Lukes account, the most popularly known, includes the angels visit to Mary, the world-wide census, the birth in the manger in Bethlehem, the angels visit to the shepherds, and the shepherds visitation to the stable MatthewsRead MoreChristian Writing : The Dead Sea Scrolls950 Words   |  4 Pagesother writing that seem to be written about the same or story that appears to be similar. If we examine the Quran, we see that there is some evidence that is indicating that it utilizes some biblical stories, which were recorded within the Old Testament Bible. The interesting fact is that most of the Old Testament was written well before the Quran was invented by a group of Mohammed s followers. The Quran uses the stories of Jonah, Joseph, and Mary in a special way to further or benefit Mohammad’sRead MoreThe Dead Sea Scrolls1073 Words   |  5 Pagesunderstand other writing that seems to be written about the same story or ones that appear to be similar. While we examine the Quran, we are able to see that there is some evidence indicating the use of some Bible stories, which were first recorded within the Old Testament. The interesting fact is that most of the Old Testament was written well before the Quran was invented by a group of Mohammed s followers. It contains the stories of Jonah, Joseph, and Mary, which in a unique way tend to further or benefitRead MoreThe Infancy Gospel Of James1684 Words   |  7 Pageswith his money, but is prevented from offering gifts to Israel because he has yet to produce offspring for Israel. Joachim decides that he will go into the desert and fast and pray in the effort to receive a message from God about offspring. He is recorded as saying that he â€Å"shall not go down either for food or for drink until the Lord my God visits me.† In the fourth chapter, the angel of the Lord who informs her that she will conceive a child who will be known throughout the world visits Anna. NearRead MoreTwo Weeks before John F. Kennedy Died917 Words   |  4 Pages9 was a fairly uneventful day for the president, and not a lot of it was recorded. There were, however, things going on behind his back. A Miami police informant, William Somerse tt, met with Joseph Milteer, a right-wing racist activist, and secretly recorded Milteer’s conversation as the man unexpectedly defined Kennedy’s assassination. An article written on this said, â€Å"The tape, later turned over to Miami police, recorded Milteer as saying, ‘[During Kennedys impending visit to Miami] You can betRead MoreThe Inethical Reporting of Michael Jackson1282 Words   |  5 Pagesthrough choice or otherwise. There is no question that ‘celebrity sells’, but there has to be a burden of responsibility on each journalist to ensure that simply because the ‘public has an interest’ in an individual celebrity does not mean that every story is ‘in the public interest’. Journalists are required to adhere to the same set of principles irrespective of the individual or group upon which they are reporting and this includes ‘celebrities’. However, people may argue that ethics in journalismRead MoreSherlock Holmes By Conan Doyle1158 Words   |  5 PagesSherlock Holmes is the main character of four novels and more than sixty short stories by Sir Conan Doyle (1859-1930).(please find the exact amount-needs to be hard fact) Doyle used inspirations from his reality to help strengthen his description of the fictional detective series of Sherlock Holmes. The author used actual descriptions, mostly of late Victorian London. Experiences from the accurate time period made Holmes’s stories come to reality. Author Ignatius Conan Doyle was born on May 22 1859, inRead MoreDreams And Visions : Is Jesus Awakening The Muslim World?1675 Words   |  7 Pagesit weeks later. Stories of Muslims around the world similarly having dreams like Ibrahim raise the question, is God continuing to reveal Himself today by way of dreams and visions to the Muslim world? In 2012, Tom Doyle wrote the book Dreams and Visions: Is Jesus Awakening the Muslim World?, in which he retells numerous stories from around the world of Muslims coming to faith in Christ due in part to an experienced dream or vision. Storytellers such as Doyle are making these stories readily availableRead MoreEgyptian Religion s Influence Over Christianity1588 Words   |  7 Pagesseveral thousands of years. Egypt is one of the first known and recorded civilizations in the world and has been studied for as long as its artifacts have been founded. In the discoveries of these artifacts, historians have found religious-like stories with Gods and supernatural elements. This is one of the first ever recorded religions in the world and the religions that followed Egyptian religion have taken some influenc e from these stories, including Christianity. Christianity, arguably founded in

Fundamental Techniques In Handling People Free Essays

He or she also does not want to let the unhappy result to be happened. Hence, the first part has taught me that prudence which is a value known as practical wisdom ought to be implemented by anyone of us. I have learned that someone has to think twice or thrice before he or she behaves and talks. We will write a custom essay sample on Fundamental Techniques In Handling People or any similar topic only for you Order Now This is because people will remember what we talked to them especially the complaint and praise. Criticism and blaming will make people feel very down, angry, and even to be discouraged. Besides, I learnt to think deliberately with unhurried manner in order to give out the most appropriate responses when dealing with different people under different situations. Prudence is the exact opposite of impulsiveness and rashness. If we do not think deeply before our every action or speech, we may hurt someone’s fragile feeling as humans are creatures of emotion who have high self-esteem. Humans are always afraid of criticism, prejudices, and complaint. Most of us are not willing to face the imperfect side of us but always wish to hear good words from others. M trying not to blame others of their faults even the serious ones. However, I try to stand in their shoes and understand their difficulties by showing loving kindness. We should not expect any forgiveness from the God f we are not willing to forgive others’ offenses. From this, have learned to forgive people without any criticism, complaint, and judgment. I learnt to speak good words of others instead of l earning how to gossip about people and talk about their bad words. Like what Benjamin Franklin has mentioned about that he only speak all the good things he know of everybody and would not speak ill of anyone. I was so amazed by the way of Bob Hoover in giving response to the careless young man after the mechanic fueled in jet fuel rather than gasoline to propeller plane. This famous pilot, Bob Hoover gave a second chance to that young man in servicing his F-51 on the next day. Bob knew criticism and scolding only can produce futility and resentment. This will cause the person who is being criticized tends to just#y’ himself or herself even lose their confidence when having daily performances in workplaces, at home, in school, and et. Tetra In other words, criticism may bring out unpleasant past experiences to some people, this may push them into a wrong route which involve in various illegal activities. I have realized anger can be aroused by criticism. Thus, people would be demoralized as anger sakes a bad situation to be worse. I will avoid criticizing people. On the other hand, honesty has to be shown in praising and appreciating others’ effort. Never ignore the good deed s people have done to us. Showing our appreciation actually is a kind of gratitude. Sense of appreciation and thanks for people’ generous acts are able to satisfy the desire to be important in human. The desire to be great is the strongest natural craving of everyone. Have learned to encourage my surrounding people with sincere appreciation because the one who receives the encouragement and appreciation will keep n doing the right thing. If one does not get any attention from anyone after giving so much, that person will definitely feel very disappointed because all of their effort came out with nothing. Being sincere and not fake in praising people, this is also showing approval to a person. Flattering people to win friends is an act of doing harm to people. I learnt to understand people’ feelings of not being acknowledged, so honest and sincere appreciation are like very important gifts to everyone. A great man should not be self-centered as he or she should always care about others. We need to care about others’ needs and help people to solve their problem are the acts to arouse in the other person an eager want. By expressing our enthusiasm and passion to find out the root reason of causing someone’s problem as well as their wants, we can be a friendly and helpful person. I also learnt to be thoughtful of people’ point of view without mention and emphasize my own ideas only. I am trying to make my ideas to become others’ inspiration in creating more great ideas. If we are really wanting and hoping to get the helping hands from others, we must know about what they ant at first. While confronting any disagreement, the wise action is keeping a cool-head which means to be rational in handling the particular situation. We need to calm down in order to think of the best way in coping with the difficult condition. To avoid any argument, I have learned that we have to give priority to the other party instead of ourselves. The author, Mr.. Dale Carnegie described his past experience of negotiating with a hotel manager. The manager increased his rent for the ballroom to 300 percent. Then, he communicated with the hotel manager in a polite way by stating out all the advantages and disadvantages that were going to accrue the manager. In the end, both parties gained what they wanted. Carnegie merely discussed what the other person wanted and how he could get it without throw tantrum to the manager in office. Before persuading people, ones must clearly know the benefits and disadvantages of both parties. In brief, I am so sure that the several basic skills in handling people I have learned in this chapter will enable me to get a good job after graduated as the employers nowadays are searching for employees who are able to deal with people skillfully. 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Dementia in UK free essay sample

There are currently 800,000 people withdementia in the UK. There are over 17,000 younger people with dementia in the UK. There are over 25,000 people with dementia from black and minority ethnic groupsin the UK. There will be over a million people with dementia by 2021. Two thirds of people with dementia are women. The proportion of people with dementia doubles for every 5 year age group. One third of people over 95 have dementia. 60,000 deaths a year are directly attributable to dementia. Delaying the onset of dementia by 5 years would reduce deaths directly attributable to dementia by 30,000 a year. The financial cost of dementia to the UK will be over ? 23 billion in 2012. There are 670,000 carers of people with dementia in the UK Family carers of people with dementia save the UK over ? 8 billion a year. 80% of people living in care homes have a form of dementia or severe memory problems. Two thirds of people with dementia live in the community while one third live in a care home. Only 44% of people with dementia in England, Wales and Northern Ireland receive a diagnosis UK dementia statistics Affects 820,000 people in the UK Financial cost is over ? 23bn pa, that is twice that of cancer, three times the impact of heart disease and four times that of stroke Two thirds (425,000) of people live in the community, one third (244,000) in a care home Two thirds of people with dementia are women (446k) and one third men (223,000) Affects 1 in 100 people aged 65-69, 1 in 25 aged 70-79 and 1 in 6 people aged over 80 Key risks from assessment are falls and walking about (60% experience walking about) 25 million people, or 42% of the UK population, are affected by dementia through knowing a close friend or family member with the condition. (Source: Alzheimers Research Trust / YouGov poll, 2008) 163,000 new cases of dementia occur in England and Wales each year one every 3. 2 minutes The number of people in UK with dementia is expected to double in the next 40 years to 1. 7million people Statistics courtesy Alzheimers Research Trust and www. alzheimers. org. uk Government Policy The National Dementia Strategy The objectives of the project are to develop a national dementia strategy and implementation plan for publication in October 2008. The strategy will address three key themes raising awareness, early diagnosis and intervention and improving the quality of care. For more information: visit National Dementia Strategy Dementia affects 820,000 people in the UK. 25 million of the UK population have a close friend orfamily member with dementia. As well as the huge personal cost, dementia costs the UK economy ? 23 billion a year, more than cancer and heart disease combined. Despite these figures, dementia researchis desperately underfunded. Impact of dementia in the UK There are over 820,000 people living with dementia in the UK today, a number forecast to rise rapidly as the population ages. Just 2. 5% of the government’s medical research budget is spent on dementia research, while a quarter is spent on cancer research. One in three people aged over 65 will die with a form of dementia. Dementia costs the UK economy ? 23 billion per year. That is twice that of cancer, three times the impact of heart disease and four times that of stroke. Combined government and charitable investment in dementia research is 12 times lower than spending on cancer research. ?590 million is spent on cancer research each year, while just ? 50 million is invested in dementia research. Heart disease receives ? 169 million per year and stroke research ? 23 million. 1. What is dementia? The term ‘dementia’ is used to describe a collection of symptoms, including a decline in memory, reasoning and communication skills, and a gradual loss of skills needed to carry out daily activities. These symptoms are caused by structural and chemical changes in the brain as a result of physical diseases such as Alzheimer’s disease. Dementia can affect people of any age, but is most common in older people. One in ? ve people over 80 has a form of dementia and one in 20 people over 65 has a form of dementia. Researchers are still working to ? nd out more about the different types of dementia, and whether any have a genetic link. It is thought that many factors, including age, genetic background, medical history and lifestyle, can combine to lead to the onset of dementia. Dementia is a progressive condition. This means that the symptoms become more severe over time. Understanding how this progression happens can be useful in helping someone with dementia anticipate and plan for change. The way each person experiences dementia, and the rate of their decline, will depend on many factors – not just on which type of dementia they have, but also on their physical make-up, their emotional resilience and the support that is available to them. Typically symptoms will include: †¢ Loss of memory – for example, forgetting the way home from the shops, or being unable to remember names and places. †¢ Mood changes – these happen particularly when the parts of the brain which control emotion are affected by disease. People with dementia may feel sad, angry or frightened as a result. †¢ Communication problems – a decline in the ability to talk, read and write. There are different types of dementia caused by different diseases of the brain. Because these diseases affect the brain in different ways, they produce different symptoms. Some of the most common forms of dementia are listed below: 1. 2 Who is affected and how? Dementia can affect anyone regardless of gender, ethnicity, socio-economic situation and residential status. Nearly two-thirds of people with the disorder live in the community, while the other third reside in a residential home. A small number of people with dementia are from black and minority ethnic (BME) groups. This is due to the current younger age profile in London’s BME communities. As this population ages, with a higher prevalence of physical conditions which may contribute to dementia, the rate of dementia is expected to increase. A detailed analysis of the London population segments affected by dementia is available in appendix 1. This highlights that most cases of dementia are late-onset and therefore affect people aged 65 and over. Approximately one in 40 cases is early-onset dementia and occurs before the age of 65. Many factors, including age, genetic background, medical history and lifestyle can combine to lead to the onset of the disorder. Key points to emerge from recent studies and consultations with people with dementia and their carers showed: †¢ Dementia is poorly understood, it remains a stigmatised condition and those affected often experience social exclusion and discrimination. †¢ Seeking help is frustrating; access to services typically includes contact with the NHS, local councils and the third sector; sometimes being referred elsewhere and often duplicating activities. †¢ Current services do not meet the needs of people with dementia. †¢ Services are fragmented and lack robust integration and strong partnership working. †¢ There are gaps in provision and the quality of specialist services remains inconsistent. †¢ Reliability and continuity of services are compromised because many staff lack the requisite knowledge and skills to respond appropriately to those affected. †¢ Most health and social care services are not delivering the outcomes that are important to people with dementia: early diagnosis and treatment, easily accessible services, information and advice and high quality support. 8 Healthcare for London IntroductionDementia services guide 9 3 Source: Based on Dementia UK prevalence rates applied to GLA populations Introduction THE DIFFICULTY OF DIAGNOSING ALZHEIMERS Most diagnoses of Alzheimers are delayed until more than two years after symptoms first appear because patients and families ignore, deny, or dont recognize common signs of early Alzheimers, according to a 2006 Alzheimers Foundation of America survey. Fifty-seven percent of caregivers who answered the poll said they put off seeking diagnosis for symptoms of memory loss, confusion, and language difficulties because they — or the person they cared for — were in denial about having the disease, or because they feared the social stigma associated with AD. Another 40 percent didnt seek a diagnosis because they knew little about Alzheimers or its symptoms, they said. 38 percent of those surveyed said it was the patient who resisted going to see a doctor; 19 percent of caregivers admitted they themselves didnt want to face the possibility that something was wrong. Spouses were three times less likely than children of people with Alzheimers to delay seeking diagnosis, the survey found. What Is Dementia? by Maureen Dezell with Carrie Hill, Ph. D. Dementia itself is not a disease but a term that describes different brain disorders that cause memory loss and other symptoms of cognitive decline. While various kinds of dementia are more common the longer we live, none is a part of normal aging. Dementia specialists recommend you see a doctor to evaluate any of these problems or symptoms, which may point to dementia: Problems retaining recent memories and learning new information, losing and misplacing objects, regularly forgetting appointments or recent conversations, or asking the same question over and over. Problems handling complex tasks; trouble balancing a checkbook, following a recipe, or performing routine tasks that involve a complextrain of thought. Trouble reasoning. Difficulty dealing with everyday problems, such as a flat tire. Uncharacteristic rash behavior, including poor financial or social judgment. Difficulty with spatial ability and orientation. Driving and navigating familiar surroundings becomes difficult; trouble recognizing local landmarks. Difficulty with language. Problems speaking, listening, and following or participating in conversations. Behavioral or personality changes. An active, engaged person seems listless and unresponsive. Trusting people become suspicious. What Is Dementia? by Maureen Dezell with Carrie Hill, Ph. D. . While various kinds of dementia are more common the longer we live, none is a part of normal aging. Dementia specialists recommend you see a doctor to evaluate any of these problems or symptoms, which may point to dementia: Problems retaining recent memories and learning new information, losing and misplacing objects, regularly forgetting appointments or recent conversations, or asking the same question over and over. Problems handling complex tasks; trouble balancing a checkbook, following a recipe, or performing routine tasks that involve a complextrain of thought. Trouble reasoning. Difficulty dealing with everyday problems, such as a flat tire. Uncharacteristic rash behavior, including poor financial or social judgment. Difficulty with spatial ability and orientation. Driving and navigating familiar surroundings becomes difficult; trouble recognizing local landmarks. Difficulty with language. Problems speaking, listening, and following or participating in conversations. Behavioral or personality changes. An active, engaged person seems listless and unresponsive. Trusting people become suspicious. Who gets dementia? . Rarely, dementia affects younger people. Dementia is said to be early-onset (or young-onset) if it comes on before the age of 65. There are some groups of people who are known to have a higher risk of developing dementia. These include people with: Downs syndrome or other learning disabilities. People with Downs syndrome are more likely to develop Alzheimers disease. Parkinsons disease. Risk factors for cardiovascular disease (angina, heart attack, stroke and peripheral vascular disease). The risk factors for cardiovascular disease (high blood pressure, smoking, high cholesterol level, lack of exercise, etc) are risk factors for all types of dementia, not just vascular dementia. Severe psychiatric problems such as schizophrenia or severe depression. It is not clear why this is the case. Lower intelligence. Some studies have shown that people with a lower IQ and also people who do not have very high educational achievement are more likely to develop dementia. A limited social support network. Low physical activity levels. A lack of physical activity can increase your risk of dementia. (See separate leaflet called Physical Activity for Health for more details. ) Dementia also seems to run in some families so there may be some genetic factors that can make someone more likely to develop dementia. We do know that a few of the more rare causes of dementia can be inherited (can be passed on through genes in your family). Can medication help people with dementia? There is no cure for dementia and no medicine that will reverse dementia. However, there are some medicines that may be used to help in some causes of dementia. Medication is generally used for two different reasons. Firstly, as treatment to help with symptoms that affect thinking and memory (cognitive symptoms). Secondly, as treatment to help with symptoms that affect mood and how someone behaves (non-cognitive symptoms). With improved nursing care and more widespread use of antibiotics to treat intercurrent infections, individuals now commonly survive 10 years or longer with dementia. This was not always the case – in the 1950s, the pioneering geriatric psychiatrist Sir Martin Roth and colleagues used distinctions in duration of illness to show that dementia differed from other severe psychiatric syndromes, notably depression, in the elderly. At that time, most elderly people hospitalized with dementia in the UK survived for approximately 2 years; Sex. All prevalence studies show that women are more often affected by dementia than are men. Typically, health services treat twice as many women as men with dementia. This contrast is explained only partly by the longer life expectancy of women because, even when this is taken into account, a slight excess of incidence is still evident in women. 2009 Health Press Ltd. Fast Facts:Dementia Lawrence J Whalley and John CS Breitner SOCIAL MODEL OF DEMENTIA While the clinical model of dementia presented above describes the changes occurring within the brain, the way that dementia affects a person in day-to-day life will vary from one individual to the next. For many years, people with dementia were written off as incapable, regarded as little more than ‘vegetables’ and often hidden from society at large. During the 1980s and 1990s, there was a move away from regarding people with dementia as incapable and excluding them from society, and towards a ‘new culture of dementia care’, which encouraged looking for the person behind the dementia (Gilleard, 1984; Kitwood Benson, 1995; Kitwood,1997). People with dementia could now be treated as individuals with a unique identity and biography and cared for with greater understanding. Building on this work, others (notably Marshall, 2004) have advocated that dementia should be regarded as a disability and framed within a social model. The social model, as developed in relation to disability, understands disability not as an intrinsic characteristic of the individual, but as an outcome produced by social processes of exclusion. Thus, disability is not something that exists purely at the level of individual psychology, but is a condition created by a combination of social and material factors including income and financial support, employment, housing, transport and the built environment (Barnes et al. , 1999). From the perspective of the social model, people with dementia may have an impairment (perhaps of cognitive function) but their disability results from the way they are treated by, or excluded from, society. For people with dementia, this model carries important implications, for example: ? the condition is not the ‘fault’ of the individual ? the focus is on the skills and capacities the person retains rather than loses ? the individual can be fully understood (his or her history, likes/dislikes, and so on) ? the influence is recognised of an enabling or supportive environment ? the key value is endorsed of appropriate communication ? opportunities should be taken for rehabilitation or re-enablement ? the responsibility to reach out to people with dementia lies with people who do not (yet) have dementia (Gilliard et al. , 2005). The social model of care seeks to understand the emotions and behaviours of the person with dementia by placing him or her within the context of his or her social circumstances and biography. By learning about each person with dementia as an individual, with his or her own history and background, care and support can be designed to be more appropriate to individual needs. If, for example, it is known that a man with dementia was once a prisoner of war, it can be understood why he becomes very distressed when admitted to a locked ward. If care providers have learned that a person with dementia has a strong dislike for a certain food, it can be understood why the person might spit it out. Without this background knowledge and understanding, the man who rattles the door may be labelled a ‘wanderer’ because he tries to escape and cowers when approached, or the person who spits out food is labelled as ‘antisocial’. Moreover, a variety of aspects of care may affect a person as the dementia progresses. Some extrinsic factors in the care environment can be modified, for instance noise levels can be highly irritating but are controllable. Other intrinsic factors, such as the cultural or ethnic identity of the person with dementia, may also have a bearing on how needs are assessed and care is delivered. Some aspects will be more important or relevant to one person than to another. The social model of care asserts that dementia is more than, but inclusive of, the clinical damage to the brain. ), and while we do not know what precise forms of training are effective, it is reported to lead to better identification of abuse (a random controlled trial by Richardson and colleagues (2002) provides good evidence of this). Agreed multi-agency policy and practice guidance is available at local level and identifies the approaches to be taken when abuse or neglect are suspected. A national recording system for referrals of adult abuse has been piloted (Department of Health, 2005b), which found that older people with mental health problems were among those referred to local authorities’ adult protection systems; a variety of interventions were adopted, although information on the outcomes is not available. Recommendations from a series of high-profile inquiries into care settings in hospitals (for example, Rowan Ward, Department of Health/Care Services Improvement Partnership, 2005) are relevant to commissioners, regulatory bodies and practitioners in seeking to lower the risk of abuse. The law in this area is developing and the Mental Capacity Act 2005 introduces a new criminal offence of ill treatment or neglect of a person who lacks capacity. DISCLOSURE/STIGMA Assessment and reaching a conclusion about the diagnosis leads to a point where this information should be shared with the person with dementia. This is especially challenging in dementia for a number of reasons: ? the difficulty of accurate diagnosis ? the challenge of imparting ‘bad news’ ? uncertainty about whether or not the person will understand what is being said ? uncertainty about whether or not the person will retain what is said ? lack of follow-up support. Studies, in which people with dementia have been invited to tell the story of how they reached a memory assessment service and what the assessment process felt like, indicate that this is not an easy journey for them (Keady Gilliard, 2002). Often, they have been aware of their memory difficulties for some time before sharing this information with others (usually, but not always, their close family). This awareness may occur in quite private activities, like doing crossword puzzles. In the meantime, those who are closest to the person may also have been aware of the difficulties but have fought shy of sharing their concerns. Disclosing their concerns to each other is often what triggers a visit to the GP and referral to a memory assessment service (Keady Gilliard, 2002). People have reported that their visits to the memory assessment service can also be quite an ordeal (Keady Gilliard, 2002). This is often like no other outpatient clinic. The doctor may speak to the carer separately from the person being assessed, leading to suspicion about what is being said. The assessment process itself may prove embarrassing, even humiliating. People report that they are aware that some of the questions are simple and feel foolish that they are unable to answer. They may establish strategies for managing this (Keady Gilliard, 2002). Whilst recognising that most people are seeking to make sense of what is happening to them, it is important to acknowledge that some will find it hard to listen to their diagnosis and there will be some who will not want to be told at all. They know they have a problem with their memory and that they are not able to function as they once did or as their peers do. They want to know what is wrong with them, and they need the clinician to be honest with them. Telling someone that he or she has a memory problem is only telling him or her what he or she already knows. People should be told their diagnosis as clearly and honestly as possible. The moment of sharing the diagnosis may not be comfortable for any of those concerned – neither the clinician, nor the person with dementia, nor his or her carer (Friel McGowan, 1993). Without this knowledge, people cannot begin to make sense of what is happening, nor can they plan effectively for their future. They should be given a choice of treatments and need information about practical support and entitlements, like Lasting Powers of Attorney and advance decisions to refuse treatment (more information can be found in Section 4. 9. 4 and in the Mental Capacity Act 2005 [The Stationery Office, 2005]). They will want to make decisions about how they spend their time before life becomes more difficult for them (for example, visiting family abroad). Following the disclosure of the diagnosis, people with dementia and their families may want further support and opportunities for talking. Pre- and post-assessment counselling services should be part of the specialist memory assessment service. Recent work (Cheston et al. , 2003a) has shown the value of psychotherapeutic support groups for people with dementia, allowing them space to share their feelings with others. Joint interventions with the person with dementia and family carers, such as family therapy, recognise the fact that the diagnosis does not impact on just one person but on a whole family system (Gilleard, 1996). Other services have used volunteer ‘befrienders’ to maintain contact with people who are newly diagnosed and who can offer both practical support and information together with a ‘listening ear’. People with early dementia are also taking responsibility for their own support by forming groups, which may meet regularly or may be virtual networks using the internet (see, for example, www. dasninternational. org). Sensitivity is required in ensuring that information about the diagnosis is given in a way that is easily understood by the person concerned and acceptable to the family. Gentle questioning at an early stage will help to ascertain what people can, and want, to be told. There is much we can learn from earlier work on sharing the diagnosis with people with cancer (for example, Buckman, 1996). It is especially important to be aware of different cultural sensitivities and the stigma that dementia holds for many people. This can range from subjective feelings of shame to a real exclusion from community and family life. Age and ethnicity are both factors in the sense of stigma associated with a diagnosis of dementia (Patel et al. , 1998). 4. 9 BASIC LEGAL AND ETHICAL CONCEPTS IN CONNECTION WITH DEMENTIA CARE 4. 9. 1 Introduction The ethical problems that arise in the context of dementia mainly relate to autonomy, which is compromised in dementia to varying degrees. Respect for autonomy is recognised as a key principle in health and social care (Beauchamp Childress, 2001). Many of the ethical tensions that arise in looking after people with dementia do so because of, on the one hand, the requirement that autonomy ought to be respected and, on the other, the reality of increasing dependency, where this entails a loss of personal freedom. Person-centred care is a means of respecting personal autonomy wherever it is threatened (Kitwood, 1997). As Agich has stated, ‘Autonomy fundamentally importantly involves the way individuals live their daily lives; it is found in the nooks and crannies of everyday experience’ (Agich, 2003). Hence, respecting the person’s autonomy will involve day-to-day interactions and will be achieved if the person with dementia is not positioned in such a way as to impede his or her remaining abilities. Such ‘malignant positioning’ can be the result of inappropriate psychosocial structures. The fundamental way to combat this tendency, which undermines the person’s selfhood, is to encourage good-quality communication (Kitwood, 1997; Sabat, 2001). Another way in which selfhood might be undermined is through structural or procedural barriers to good-quality care, and service providers should take an active role in promoting the individual’s autonomy and his or her legal and human rights. Furthermore, services may discriminate against people with dementia if eligibility criteria are drawn up in such a way as to exclude them or because of an assumption that people with dementia cannot benefit from a service because staff lack confidence and skills in working with this group. Discrimination may also occur if a service does not offer people with dementia the support they may need in order for them to be able to make use of the service. The Disability Discrimination Acts (1995 and 2005), which include dementia within the definition of disability, aim to end the discrimination that many disabled people face in their everyday lives by making direct or indirect discrimination against disabled people unlawful in a range of areas including access to facilities and services and buying or renting property. The discussion that follows will briefly focus on human rights, consent, capacity and confidentiality. 4. 9. 2 Human rights Human rights are enshrined, as far as the United Kingdom is concerned, in the Convention for the Protection of Human Rights and Fundamental Freedoms (Council of Europe, 2003). The relevant UK legislation is the Human Rights Act 1998, which came into force in 2000. The principle of respect for autonomy is implicit throughout the Convention. A number of the articles of the Convention are potentially relevant to people with dementia. For example, Article 2 asserts that everyone has a right to life, Article 3 prohibits torture, but also â€Å"inhuman or degrading treatment†, and Article 8 concerns the right to respect for the person’s private and family life. Article 5 asserts the right of people to liberty and security. It states that â€Å"No one should be deprived of his liberty†, except in very specific circumstances. It also asserts that if someone is deprived of his or her liberty, there should be recourse to a court. Article 5 was central to the ‘Bournewood’ case. The European Court declared, amongst other things, that the man concerned (who had a learning disability) had been deprived of his liberty, in contravention of Article 5 (see Department of Health, 2004, for further information). The crucial distinction to emerge from the case was that between deprivation of liberty and restriction of liberty. Whilst the former is illegal, except insofar as there are legal safeguards of the sort provided by the Mental Health Act 1983 (HMSO, 1983), the latter may be permissible under the sort of circumstances envisaged by Section 6 of the Mental Capacity Act 2005 (TSO, 2005). This discusses using restraint as a proportionate response to the possibility of the person suffering harm. Guidance on the distinction between ‘restriction’ and ‘deprivation’ of liberty has been provided by the Department of Health and the National Assembly for Wales (Department of Health, 2004). 4. 9. 3 Consent In brief, for consent to be valid it must be: ? informed ? competent ? uncoerced ? continuing. Each of these concepts requires interpretation and judgement, as none of them is entirely unproblematic (Department of Health, 2001a). For instance, people can be more or less informed. The ‘Sidaway’ case (1984) established that the legal standard as regards informing a patient was the same as for negligence (see the ‘Bolam case’, 1957). In other words, the person should be given as much information as a ‘responsible body’ of medical opinion would deem appropriate. However, since then, there has been a shift away from a professional-centred standard towards a patient-centred standard. In the ‘Pearce’ case (1998), one of the Law Lords declared that information should be given where there exists ‘a significant risk which would affect the judgement of a reasonable patient’. Department of Health guidelines (Department of Health, 2001c) have pointed out that, although informing patients about the nature and purpose of procedures may be enough to avoid a claim of battery, it may not be sufficient to fulfill the legal duty of care. There may be other pieces of information relevant to the individual patient that it would be negligent not to mention. Hence the General Medical Council (GMC)’s insistence that doctors should do their best ‘to find out about patients’ individual needs and priorities’ (GMC, 1998). The GMC guidance goes on to say: ‘You should not make assumptions about patients’ views’. These points are very relevant when it comes to consent in the context of dementia. It should be kept in mind that consent is not solely an issue as regards medical procedures. The ‘nooks and crannies of everyday experience’ (Agich, 2003) – what to wear or to eat, whether to go out or participate in an activity and whether to accept extra home or respite care – are all aspects of life to which the person with dementia may or may not wish to consent. If the person has capacity with respect to the particular decision, but does not wish to consent, he or she should be supported in making an autonomous decision. 4. 9. 4 Decision-making capacity In England and Wales, a lack of capacity has been defined thus: ‘. . . a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain’ (Mental Capacity Act 2005 [TSO, 2005, Section 2]). A person is further defined as unable to make a decision if he or she is unable: ‘(a) to understand the information relevant to the decision, (b) to retain this information, (c) to use or weigh that information as part of the process of making the decision, or (d) to communicate his decision (whether by talking, using sign language or any other means)’ (Mental Capacity Act 2005 [TSO, 2005, Section 3(1)]). The Mental Capacity Act 2005 (TSO, 2005), which will apply in England and Wales31, sets out a framework for making decisions for people who are unable to make decisions for themselves. Its detailed provisions, along with its Code of Practice (currently in draft form [DCA, 2005]), should be referred to by all those involved in such decision making. In outline, the main provisions of the Act: ? offer a definition of lack of capacity (Sections 2–3) ? outline a process for the determination of a person’s best interests (Section 4) ? create Lasting Powers of Attorney, which allow a person to appoint a donee to make decisions about his or her health and welfare (Sections 9–14) ? establish the Court of Protection in a new form, with powers to make declarations and appoint deputies in difficult cases or where there are disputes concerning decisions about a person’s health and welfare (Sections 15–23) ? bring under statute and clarify the law regarding advance decisions to refuse treatment (Sections 24–26) ? set out safeguards co