Dementia Care Medicine 1st Edition Trevor Adams

pdf download

https://ebookgate.com/product/dementia-care-medicine-1st-edition-
trevor-adams/

Get the full ebook with Bonus Features for a Better Reading Experience on ebookgate.com
Instant digital products (PDF, ePub, MOBI) available
Download now and explore formats that suit you...

Practical Dementia Care 2nd Edition Peter V. Rabins

https://ebookgate.com/product/practical-dementia-care-2nd-edition-
peter-v-rabins/

ebookgate.com

Nurse to Nurse Dementia Care 1st Edition Cynthia D. Steele

https://ebookgate.com/product/nurse-to-nurse-dementia-care-1st-
edition-cynthia-d-steele/

ebookgate.com

Emergency medicine 2nd ed Edition James Adams

https://ebookgate.com/product/emergency-medicine-2nd-ed-edition-james-
adams/

ebookgate.com

Reconsidering Dementia Narratives Empathy Identity and

Care 1st Edition Rebecca Bitenc

https://ebookgate.com/product/reconsidering-dementia-narratives-
empathy-identity-and-care-1st-edition-rebecca-bitenc/

ebookgate.com
Recent advances in anaesthesia and intensive care 22 A. P.
Adams

https://ebookgate.com/product/recent-advances-in-anaesthesia-and-
intensive-care-22-a-p-adams/

ebookgate.com

Demonstrating Your Clinical Competence Depression Dementia

Alcoholism Palliative Care and Osteoperosis First Edition
Chambers
https://ebookgate.com/product/demonstrating-your-clinical-competence-
depression-dementia-alcoholism-palliative-care-and-osteoperosis-first-
edition-chambers/
ebookgate.com

Sports Medicine for the Primary Care Physician Third

Edition Sports Medicine for the Primary Care Physician
Richard B. Birrer
https://ebookgate.com/product/sports-medicine-for-the-primary-care-
physician-third-edition-sports-medicine-for-the-primary-care-
physician-richard-b-birrer/
ebookgate.com

Intelligent Medicine and Health Care 1st Edition Chien-

Hung Yeh

https://ebookgate.com/product/intelligent-medicine-and-health-
care-1st-edition-chien-hung-yeh/

ebookgate.com

Care Bundles in Emergency Medicine 1st Edition Timothy

Williamson (Author)

https://ebookgate.com/product/care-bundles-in-emergency-medicine-1st-
edition-timothy-williamson-author/

ebookgate.com
 Dementia Care

Edited by
Trevor Adams PhD MSC RN Cert Ed CPN Cert
Lecturer in Mental Health, European Institute of Health and Medical
Sciences, University of Surrey, Guildford, UK

and

Jill Manthorpe MA
Reader in Community Care, School of Nursing, Social Work and
Applied Health Studies, University of Hull, UK

A member of the Hodder Headline Group

London
First published in Great Britain in 2003 by Arnold,
a member of the Hodder Headline Group,
338 Euston Road, London NW1 3BH

http://www.arnoldpublishers.com

Distributed in the USA by

Oxford University Press Inc.,
198 Madison Avenue, New York, NY10016
Oxford is a registered trademark of Oxford University Press

© 2003 Arnold Publishers

All rights reserved. No part of this publication may be reproduced or

transmitted in any form or by any means, electronically or mechanically,
including photocopying, recording or any information storage or retrieval
system, without either prior permission in writing from the publisher or a
licence permitting restricted copying. In the United Kingdom such licences
are issued by the Copyright Licensing Agency: 90 Tottenham Court Road,
London W1T 4LP

Whilst the advice and information in this book are believed to be true and
accurate at the date of going to press, neither the authors nor the publisher
can accept any legal responsibility or liability for any errors or omissions
that may be made. In particular (but without limiting the generality of the
preceding disclaimer) every effort has been made to check drug dosages;
however, it is still possible that errors have been missed. Furthermore,
dosage schedules are constantly being revised and new side-effects
recognized. For these reasons the reader is strongly urged to consult the
drug companies' printed instructions before administering any of the drugs
recommended in this book.

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging-in-Publication Data

A catalog record for this book is available from the Library of Congress

ISBN 0 340 81020 3

1 2 3 4 5 6 7 8 9 10

Commissioning Editor: Georgina Bentliff

Development Editor: Heather Smith
Production Editor: Anke Ueberberg
Production Controller: Lindsay Smith
Cover Design: Amina Dudhia

Typeset in 9.5/13 pt Palatino by Phoenix Photosetting, Chatham, Kent

Printed and bound in Malta

What do you think about this book? Or any other Arnold title?
Please send your comments to [email protected]
 Contents

Contributors v
Foreword ix
Introduction x

Section 1: Approaches to practice

1 Constructing dementia 3
Trevor Adams and Ruth Bartlett

2 Valuing people with dementia 22

Wendy Martin and Helen Bartlett

3 Policy and practice in dementia care 35

Jill Manthorpe and Trevor Adams

Section 2: Person-centred practice

4 Working with people in the early stages of dementia 51

Lindsay Royan

5 Managing language and communication difficulties in Alzheimer's

dementia: the link to behaviour 69
Karen Bryan and Jane Maxim

6 Counselling people with dementia 86

Elizabeth Bartlett and Richard Cheston

7 Addressing the physical care needs of people with dementia 103

Roger Watson

8 Palliative care for people with dementia 114

Kay de Vries

9 Remembering and forgetting: group work with people who have

dementia 136
Richard Cheston, Kerry Jones and Jane Gilliard
 Contents

10 Positive communication with people who have dementia 148

Jonathan Parker

11 Younger people with dementia: coming out of the shadows 164

Maria Parsons

Section 3: Practice systems

12 Helping families cope with dementia 187
Alison Marriott

13 Developing ethnically sensitive and appropriate dementia

care practice 202
Anthea Innes

14 Supporting and supervising in dementia care 213

Mark Holman

15 Elder abuse and people with dementia 225

Bridget Penhale

16 Maintaining quality in dementia care practice 240

Dawn Brooker

Index 257

iv
 Contributors

Trevor Adams PhD MSc RN CertEd CPNCert has worked in dementia care
nursing for over 25 years. During this time, Trevor has been involved in devel-
oping dementia care nursing through practice, education and research. He is
currently Mental Health Pathway Leader for the MSc in Advanced Practice at the
European Institute of Health and Medical Science, University of Surrey, UK.
Elizabeth Bartlett DipSocStud Relate Certificated Counsellor is Counsellor with
the Salisbury and District Branch of the Alzheimer's Society, UK. Before estab-
lishing this branch of the society in 1985, she was a social worker and a Relate
counsellor. The initial focus of Elizabeth's work was on practical services for
people with dementia, but the need for counselling became increasingly apparent.
As a result, she was in 1999 chosen to lead a pilot project on counselling for people
with a diagnosis of dementia.
Helen Bartlett BA MSc PhD RGN RHV is Foundation Director and Professor of
the Australasian Centre on Ageing, University of Queensland, Brisbane, Australia
and was previously Professor of Health Studies at Oxford Brookes University, UK.
Her research interests include quality measurement and policy issues in long-term
care, especially in nursing and residential homes.
Ruth Bartlett RMN BA MA is Research Consultant at the Oxford Dementia
Centre, Oxford Brookes University, Oxford, UK and a PhD student in the
Sociology Department of Oxford Brookes University. She is researching the quali-
tative dimensions of social exclusion in relation to older people with dementia
living in residential care. Ruth has also worked as a mental health nurse in a range
of clinical areas.
Dawn Brooker BSc MSc PhD CPsychol(Clin) is currently employed by the
Bradford Dementia Group at the University of Bradford, UK, where she is the
Strategic Lead for Dementia Care Mapping. She was formerly Director of the
Oxford Dementia Centre and has worked as a clinical psychologist. Dawn's
research interests include the evaluation of service quality, organizational change,
therapeutic interventions, person-centred care and emotional distress and coping
in people with dementia.

v
 Contributors

Karen Bryan BSc PhD RegMRCSLT is a Speech and Language Therapist and
Professor of Clinical Practice at the European Institute of Health and Medical
Sciences, University of Surrey, Guildford, UK. Her research has addressed assess-
ment and management of communication problems in people with dementia.

Richard Cheston MA PhD DipCPsychol is a Consultant Clinical Psychologist with

Avon and Wiltshire Mental Health Partnership NHS Trust, Trowbridge, UK as
well as a research fellow at Bath University. He has published extensively on the
experiences of people with dementia and is the co-author with Mike Bender of
Understanding dementia: the man with the worried eyes.
Kay de Vries RGN BSc(Hons) PGCEA MSc is Senior Lecturer at the Princess Alice
Hospice, Esher, Surrey, and Research Fellow at the European Institute of Health
and Medical Sciences, University of Surrey, Guildford, UK She is currently under-
taking doctoral research into dementia and dying. Prior to working in the UK, Kay
practised as a public health nurse in New Zealand.

Jane Gilliard BA CQSW FRIPH is Director of Dementia Voice, the dementia serv-
ices development centre for south-west England, having worked with and for
people with dementia for about 16 years as a social worker and a researcher. Jane
chairs the National Network of Dementia Services Development Centres and is
Visiting Professor in the Faculty of Health and Social Care at the University of the
West of England.
Mark Holman MA RN works as a Community Mental Health Nurse in
Derwentside, County Durham. He has been involved in supervisory relationships
as both supervisee and supervisor for more than 12 years, 8 of which he has spent
working in older people's services.

Anthea limes BA MSc PhD is a Research Fellow at the Centre for Social Research
on Dementia in Stirling. Her work has investigated the experiences of people with
dementia, informal care-givers and care workers. Anthea's research and publica-
tions to date have focused on marginalized groups, such as minority ethnic
groups, unqualified care staff and those living in rural areas.

Kerry Jones BSc(Hons) MA is a Research Officer at Dementia Voice, the dementia

services development centre for southwest England. Kerry has worked for 17
years with various client groups including people with dementia. Trained in social
and health care, and research and research management, Kerry has embarked
upon a diversity of health and social care related research projects, prior to her
work with Dementia Voice and the development of the Psychotherapeutic Groups
for People with Dementia project. Kerry is presently part of a three-year Europe-
funded project to assess the impact of technology on the quality of life of people
with dementia in five European countries. She also teaches and develops work-
shops on dementia-specific issues in the UK and overseas.

vi
 Contributors

Jill Manthorpe MA is Reader in Community Care at the University of Hull, where

she specializes in research and teaching in gerontology. She has worked in the
voluntary sector and is currently undertaking research into food and dementia,
intermediate care and older nurses.
Alison Marriott BSc MSc CPsychol AFBPS is Consultant Clinical Psychologist,
Manchester Mental Health and Social Care Trust, Manchester, UK and a UKCP-
registered Family/Systems Therapist. She works clinically with older people and
their families in Central Manchester and has published in a number of areas,
including family therapy and psychological intervention for the carers of people
with dementia.
Wendy Martin BSc MA RGN is Associate Lecturer at The Open University and a
research student at the University of Warwick. She was previously a researcher
for a project exploring the empowerment of older people with dementia in
different care settings at the Oxford Dementia Centre. She has worked as a
researcher on projects relating to ageing, bereavement, cancer care and family
studies.
Jane Maxim MA PhD RegMRCSLT is Speech and Language Therapist, Head of
Department and Senior Lecturer in Human Communication Science at University
College London, UK. Her research has focused on language in normal and
abnormal populations and communication training for care assistants.
Jonathan Parker BA(Hons) MA CQSW ILTM is Head of Social Work in the School
of Nursing, Social Work and Applied Health Studies, University of Hull, UK. His
research interests include dementia care and reminiscence, life story and biogra-
phical approaches. Before joining the university, Jonathan worked as a specialist
social worker for people with dementia. He is also a cognitive behavioural
psychotherapist.
Maria Parsons BA(Hons) CQSW PGCE MA, a social worker by profession, has
over 20 years experience in practice, management and lecturing. She was instru-
mental in setting up the Oxford Dementia Centre, part of the Institute of Public
Care at Oxford Brookes University. As Head of the centre, Maria is involved in
consultancy, research and training in dementia care for health and social services
and housing organizations, and in the care of older people with mental health
needs.
Bridget Penhale BA MSc CQSW is Lecturer in Social Work and Applied Health
Studies at the University of Hull, UK. She has specialized in work with older
people since 1983. Bridget has published in the areas of decision-making and
mentally incapacitated adults, social work and dementia, as well as extensively on
elder abuse. Her principal research interests are elder abuse, domestic violence
and mental health.

vii
 Contributors

Lindsay Royan CPsychol BA(Jt Hons) DipDTh is Consultant Clinical Psychologist

with North East London Mental Health NHS Trust, Essex, UK. She specializes in
working with people in the early stages of dementia and co-wrote a document on
the expanding role of memory clinics. She was a member of the mental health task
group for the National Service Framework for Older People.
Roger Watson BSc PhD RGN CBiol FIBiol ILTM FRSA is Professor of Nursing in
the Department of Nursing and Applied Health Sciences, University of Hull, UK,
where he is responsible for leading research in nursing. Roger's clinical experience
was gained working with older people with dementia, and he has a particular
interest in the assessment of eating difficulty.

viii
 Foreword

It is a pleasure to write a piece for the start of this book, a book for those who are
trying to support people in our position. We live at home, and about two years ago
Robbie was diagnosed as having memory problems. In fact, he recognized that
what was wrong could be related to his memory problem by reading a small
article in a holiday magazine for older people. He rang our GP and pushed to be
seen. Now Robbie is on anti-dementia drugs, and we are managing.
How would we like professionals to be? We would like them to be encouraging,
and we would like them to give both of us information (which doesn't always
happen). We appreciate it that if we need to see our community mental health
nurse, we can telephone her and she will come to see us. And we do welcome
people who are kind and helpful, not just those who work with memory problems,
but all those who help with other difficulties.
When nurses and doctors carry out tests, it makes a difference if they do this in
a certain way: it is best if they see the positives and don't keep emphasizing the
mistakes or failures that are going on in one's head. We like it if people have a
sense of humour, but that doesn't mean that we don't have bad days when we get
cross with ourselves and each other. We like it if people are predictable and reli-
able: it helps, for example, to get letters about appointments. We would like, too,
to be able to talk more to other people in our position.
There are some things that could be better, of course. We were very sad at the
state of the hospital when one of us broke a bone. And we found we were booked
for an assessment of an aspect of the condition when the drugs to treat it had
already been started. And, as we have said before, putting us in touch with other
people would be good.
We are able to share many good things from the past and still enjoy going out -
bowling and on holiday. That doesn't mean we have forgotten the terrible things,
the war in particular, but we are able to talk about the many good times of the past
and to enjoy the present.
We know people are very rushed, but our final point is that we do value those
who have time to listen to us and give us good advice, who are kind and pleasant.
We hope this book will equip people to support those in our position, both now
and in the future. Our best wishes to you.

Robbie and Mollie Ness

ix
 Introduction

Over the past 20 years, there have been considerable changes in the provision of
support to people with dementia, including a reorientation from institutional to
community care, an increased reliance on families as the primary source of care, a
discovery of the voice of the person with dementia and a shift from the monopro-
fessional, medically orientated provision of care to multidisciplinary teamwork.
The aim of this book is to provide professionals working with people who have
dementia and their informal carers with an account of innovative practice,
research and ideas on the contemporary provision of multidisciplinary dementia
care.
Although, not so long ago, dementia care attracted little innovation, it has now
become a dynamic and exciting area of professional development. Indeed,
dementia care is probably one of the fastest developing areas of health and social
care. These changes have not, however, been uniform throughout health and
social care, and there are still many areas in which dementia care is firmly set
within the 'old culture' of dementia care and all this conveys about institutional
models of thinking, lack of imagination and a focus on paternalistic provision. We
hope that this book will go some way to extending the 'new culture' of dementia
care, contribute to the dissemination of good practice within dementia care and
offer new ideas or support to those working or training in this area.
The book comprises three sections. The first is concerned with various over-
arching approaches to practice within dementia care relating to such issues as the
nature of dementia, ethical practice and health and social policy. In Chapter 1,
Trevor Adams and Ruth Bartlett draw on recent developments within social
constructionism and disability to provide a critical analysis of how dementia is
understood within contemporary society. This chapter broadens current thinking
about 'dementia' by calling for greater regard to how people with dementia may,
in our view, be helped by seeing dementia as a disability.
Helen Bartlett and Wendy Martin, in the next chapter, look at the way in which
people with dementia are constructed within a society that prevents their full
participation. In the last chapter in this section, the editors, Jill Manthorpe and
Trevor Adams provide a critical review of the policy developments that have
underpinned dementia care practice in the UK. Each issue raised in this section is

X
 Introduction

important and has considerable implications for the everyday work of health and
social professionals working with people with dementia and their families.
The second section relates to 'person-centred approaches' to dementia care. In
this section, the term 'person-centred approach' is adopted as it is used in the
Department of Health's National Service Framework for Older People, and the
contributors provide various accounts of therapeutic approaches that are now
available within dementia care. The main aim of person-centred dementia care can
appear to identify and address the needs of a range of people associated with the
care of people with dementia. The individual with dementia must, however, be at
the centre of this process, and this is one shift in emphasis that will be a yardstick
for any evaluations of the National Service Framework and its impressive plans
for improved service delivery systems in dementia care.
In this second section, Lyndsay Royan provides detailed insights into the early
identification of people with dementia in the community and emphasizes that the
effect of this shift is to facilitate swift intervention and support for people in the
early stages of dementia and their families. Karen Bryan and Jane Maxim next
address the neglected issue of communication and people with dementia,
describing how practitioners can manage language and communication difficul-
ties among people with Alzheimer's disease. Elizabeth Bartlett and Richard
Cheston explore these processes of communication more fully in their chapter and
examine various counselling strategies that health and social care professionals
may use with people with dementia.
'Person-centred care' has, however, often been understood in psychological and
social terms, but when people have dementia, their experience of dementia is
embodied and affects how they experience their body. People with dementia may
at various times feel tired, slow, wet or untidy. Indeed, having dementia is just as
much a bodily as it is an emotional experience. This section therefore continues by
examining the physical features associated with having a dementia. Roger Watson
provides a review of the bodily needs of people with dementia. This importance
of meeting the bodily needs of those with dementia is continued by Kay deVries,
who develops a palliative care approach to people in the latter stages of dementia.
Because of the tendency within a person-centred approach to marginalize people
who are dying, the palliative care needs of people with dementia must not be
neglected. People with dementia have bodies just as much as they have emotions,
and people in the latter stages of dementia require the same standard of care as
anyone else.
There is a tendency for the idea of person-centred care to fail to highlight
various aspects of dementia care, one such area being working with groups of
people with dementia. This omission is addressed in Chapter 9 by Richard
Cheston, Kerry Jones and Jane Gilliard, who provide a description of a
psychotherapeutic approach to groups of people with dementia.
The book's third section examines various systems associated with practice

Xi
 Introduction

with people who have dementia and their families. In Chapter 12, Alison Marriott
considers the various ways in which dementia care practitioners may help fami-
lies to cope with dementia. Anthea Innes then addresses the issue of developing
ethnically sensitive practice for people with dementia. The importance of the
person with dementia is further developed by Jonathan Parker in Chapter 10 who
develops the notion of positive communication. This chapter complements the
earlier chapter by Karen Bryan and Jane Maxim and moves forward recent work
by Tom Kitwood (1997) relating to positive person work. Finally, within this
section, Maria Parsons highlights the needs of younger people with dementia and
puts forward various responses that can be made to enhance their welfare.
In Chapter 14, Mark Holman examines how clinical supervision may be used to
help practitioners to work with people with dementia and their families. This is an
important chapter as working with people who have dementia is physically and
emotionally demanding. Moreover, it frequently leads to practitioners becoming
emotionally numbed to the pain that individuals with dementia experience. We
would strongly argue that clinical supervision should be the part of the normal
experience of dementia care practitioners and should make an important contri-
bution to ensuring good practice.
The failure of service agencies to provide staff with effective clinical supervision
may lead to staff abusing people with dementia. We believe that clinical supervi-
sion is one way in which abuse may be prevented. Bridget Pendale addresses the
issue of abuse in dementia care more fully in Chapter 15, and finally Dawn
Brooker examines an important means of ensuring quality in dementia care -
dementia care mapping.
As much as anything, we believe that the response to people with dementia is
multidisciplinary: whereas all professionals will have their own distinctive contri-
bution, we believe that the future for dementia care lies in a multidisciplinary
response in combination with medical diagnosis and to accompany treatment or
to provide care when medication has no longer any benefit. We hope that this
book will contribute to the continued development of this new culture of
dementia care.

Trevor Adams and Jill Manthorpe

REFERENCE
Kitwood, T. 1997: Dementia reconsidered: the person comes first. Buckingham: Open University
Press.

Xii
 Section 1

Approaches to
practice
This page intentionally left blank
Chapter
Constructing
dementia
Trevor Adams and Ruth Bartlett

The first aim of this chapter is to examine recent approaches towards people with
dementia, the second is to describe the way in which language constructs people
with dementia, and the third is to provide a critical perspective on how people
with dementia are understood and treated within society. Underlying the chapter
is a social constructionist position by which the actions and language people use
with respect to dementia are understood as constructing dementia (Burr 1995).
The chapter addresses such questions as: How does society construct people who
are chronically confused? How do these constructions influence the way in which
people with dementia feel about themselves? To what extent do these disadvan-
tage people with dementia? The approach adopted in this chapter criticises domi-
nant oppressive and discriminatory forms of representing people with dementia
and provides a positive means of reconstructing their identity in terms that are
more advantageous to them.

DISCOURSE, SOCIAL PRACTICES AND THE

CONSTRUCTION OF DEMENTIA
Language is a system of signs through which the social world is represented.
Saussure (1974) argued that these signs comprise 'signifiers' and 'signified'. Take,
for example, the two words 'bag' and 'big'. The signifiers are the marks that are
made on the page, and the signified is the meaning made available by the signifier.
Saussure argued that there is no natural or inevitable link between a signifier and a
signified, and that signs do not possess any fixed or essential meaning. According to
Saussure, the meaning that signifieds possess arises out of their difference from
other signifieds. So 'bag' is a bag not because of its 'bagness' but because of its

3
 Constructing dementia

difference from other signifieds. This issue of 'marking a difference' is of particular

interest since the way in which people with dementia are represented in talk, actions
and the media affects how they are categorized and differentiated within society.
When people write, speak or do anything associated with people who have
dementia, they draw upon a range of culturally and historically specific signifying
practices that come together to form a discourse (Hall 1997). Foucault provides
insights into how discourse is contained within social practices that give rise to the
way in which social phenomena are understood. He defines discourses as 'practices
which systematically form the objects they speak' (Foucault 1972, p. 49). Moreover,
Foucault does not restrict discourse to refer to just verbal systems of representation,
that is spoken discourse, but instead extends discourses to include people's behav-
iours and social practices. In this sense, discourse provides a way by which the
knowledge about the social world comes to exist. Because there are many ways in
which social phenomena may be described, there are many ways of talking and
behaving with regard to people with dementia. The concern within this chapter is
therefore how people with dementia are represented within the social world.
The relationship between social practices, discourse and the construction of
social phenomena may be illustrated by an episode entitled The Rat that is taken
from the television comedy series Fawlty Towers. The story line is that Manuel, the
hotel porter, has acquired a rat that he keeps hidden away in his hotel room.
Inevitably, the rat escapes just when a hotel inspector is due to visit the hotel.
Throughout the episode, social practices occur relating to the rat, practices that
contain certain discourses and are therefore called 'discursive practices'. Two sets
of discursive practices are particularly evident. The first relates to love and affec-
tion, and provides the rat with the identity of something that Manuel adores. The
second relates to hygiene and identifies the rat as a health hazard. The presence of
one discourse rather than another makes certain features of a person (or, in this
case, a rat) more visible than if another discourse were used. It is through the use
of these discursive practices that people acquire knowledge about another. This is
true of dementia: the availability and use of different discourses within social
practices allow people to understand and experience dementia in particular ways
and also give rise to their variable treatment in society.
Traditional ways of understanding identity that have arisen since the
Enlightenment have assumed that a person's identity results from some essential
feature associated with that person. An alternative argument has more recently
developed in which identity is seen to be dependent not upon individuals them-
selves but rather upon their surrounding social setting (Antaki and Widdicome
1998). What is at issue here is the organization of conversational and discursive
materials within people's talk and other social practices that gives rise to people
occupying certain subject positions (see Wetherell 1998). The idea is that social prac-
tices within which discourses are contained allow people to occupy certain social
positions within society.

4
 Dementia as a bio-medical construction

It should also be noted that additional insights into the representation of people
with dementia may also be gleaned from a further aspect of Saussure's work. The
focus of attention here is that meaning is dependent upon marking the difference
between signifiers. Thus, the meaning of the signifier 'dementia' arises through
the difference between dementia and other social phenomena. The meanings asso-
ciated with dementia are therefore understood in terms of their difference and
relate to what it is not, leading to people with dementia being thought of as not
rational and not normal. By marking out the difference between those who have
dementia and those who do not, people with dementia are constructed as being
different from the rest of society, as marginal and part of 'the Other'. This way of
understanding people with dementia gives important insights into the injustice
that people with dementia receive within society.

DEMENTIA AS A BIO-MEDICAL CONSTRUCTION

Towards the end of the nineteenth century, various discourses became available
through the work of medical scientists that highlighted bio-medical features of
dementia. It is important to note that these discourses did not exist prior to the
work of medical science but rather arose from a particular way in which medical
scientists saw people with dementia that did not exist prior to their work. One of
these discourses highlighted the physiological nature of dementia and gave rise to
experimental studies that led to such social practices as the identification of
neurophysiological and neurochemical changes in the brains of chronically
confused people, the classification of brain pathology and the publication of
papers in acclaimed and prestigious scientific journals. Another discourse that
became available at this time related to cognitivism. This discourse constructed
chronic confusion in terms of the 'cognitive paradigm' in which dementia is
primarily understood to affect people's cognitive functioning and give rise to
memory failure (see Berrios and Freeman 1991).
Throughout the twentieth century, these two discourses were typically used to
construct people with dementia. Kitwood argues that advances in technology in
the 1960s and 70s, such as the development of computerized tomography, were
used to support bio-medical discourses and gave rise to the closing down of
psychosocial discourse about people with dementia (Kitwood 1987). In addition,
various writers, notably Katzman and Bick (2000) and Fox (1989), describe the
social and political processes that led to the increased public awareness of
Alzheimer's disease in the 1980s and helped to transform it from an obscure,
rarely applied medical diagnosis to a major cause of death.
Bio-medical discourses are contained in various social practices, such as the
standard practice that professional bodies in medicine have of giving definitions
of illnesses. The oft-quoted definition of dementia given by the Royal College of
Physicians (1981), for example, defined dementia as:

5
 Constructing dementia

the acquired global impairment of higher cortical functions including

memory, the capacity to solve the problems of everyday living, the perform-
ance of learned perceptuo-motors skills, the correct use of social skills and the
control of emotional reactions, all aspects of language and communication
and the control of emotional reactions, in the absence of gross clouding of
consciousness.

The constitution of people with dementia through the use of bio-medical

discourses has been thought to lead to the depersonalization of people with
dementia (Jonas-Simpson 2001). An example of this may be found in medical text-
books. Jacques and Jackson (2000, p. 99), for example, comment that 'At the final
stages the patient may be assumed to have no real subjective awareness, no sense
of self at all, and to be in this sense mentally "dead"'. Social scientists, Fontana and
Smith (1989, p. 36) argue that:

The Alzheimer's disease patients, in the early stages of the disease, continue
to interact on the surface as if they were sentient beings. ... This self is
increasingly devoid of content.

In publications for the wider public, the well-known evolutionary scientist

Richard Dworkin (1993, p. 234) comments that:

Demented people in the late stages have lost the capacity to recognize, appre-
ciate or suffer indignity. ... It is expensive, tedious and difficult to keep seri-
ously demented patients clean, to assure them space for privacy, to give them
the personal attention they often crave.

This last quotation, perhaps more than any of the others, displays how the
construction of people with dementia can affect their welfare. The constitution of
people with dementia through bio-medical discourses alone constitutes people
with dementia as having diminished and limited human value. Constructed in
this way, bio-medical discourse identifies people with dementia as having no
sense of self or any ability to make worthwhile decisions, thus allowing the possi-
bility that they might be seen as having no worth and being an infringement on
other people.

IMPLICATIONS FOR PRACTICE

When used in health and social care, bio-medical discourse positions people with
dementia as having a severe mental illness - dementia, chronic brain syndrome or
chronic brain failure. When dementia is understood as an illness, those with the
condition themselves recede into the background, and the disease process itself is

6
 Dementia as a behavioural problem

highlighted. This construction of dementia plays down the significance of, for
example, psychosocial features of dementia which might have contributed to its
development.
Moreover, bio-medical discourse highlights the relevance of physical treatments
such as drug therapy and creates the impression that a cure may be just around
the corner. In the absence of a cure, bio-medical discourses create therapeutic
nihilism and 'warehousing', in which those with dementia cannot be offered a
cure and are stored away in institutions in the hope that a cure may one day
appear. The bio-medical discourse that often surrounds chronic confusion there-
fore constructs the work of health and social care workers as a form of 'body main-
tenance' in which the person with dementia is merely kept clean, fed and watered.
In addition, the failure of bio-medical discourse to construct people with
dementia as sensate human beings may give cause for health and social care
workers to develop practices that distance them from people with dementia.
When this occurs, people with dementia are often treated as objects or objectified,
and are more likely to be at risk of oppressive and discriminatory practices,
including emotional and physical abuse.
The objectification of people with dementia was a consistent finding of
numerous reports on mental hospitals in the 1960s and 70s, especially notable
being Sans Everything, which focused specifically on older people. In Sans
Everything, an acting chief male nurse reported that:

after six months in certain hospitals, there are ways in which psychiatric
nurses are no longer like ordinary people. Their attitude to mental illness
changes - as it does to old age, to cruelty, to people's needs, and to dying. It
is as if they become numbed to these things (Robb 1967, p. 13).

In this way, people with dementia often found themselves placed in difficult and
sometimes humiliating situations that led to their devaluation, disempowerment
and marginalization by psychiatric nurses. One explanation why institutional
practices such as these occurred may be the dominance of bio-medical discourses
that identified people with dementia as being different from the rest of society and
constructed them as marginal, as 'the Other'.

DEMENTIA AS A BEHAVIOURAL PROBLEM

Various discourses developed within the academic discipline of psychology have
been applied to people with dementia. These have constructed people with
dementia in terms of their behaviour rather than, as with bio-medical discourse,
their diagnosis. They have given rise to dementia care practitioners regarding
some of the behaviours of those with dementia, such as wandering and aggres-
sion, as a problem. This behaviour is typically seen to be the result of prior

7
 Constructing dementia

learning, which raises the possibility of changing problematic behaviour through

techniques directed towards enabling people to relearn.
Such an approach may be seen in the work of Stokes (2000), who describes how
'problem behaviours' in people with dementia may be addressed by behavioural
analysis. This technique is sometimes referred to as an ABC analysis, in which 'A'
stands for antecedents (which activate the event or situation), 'B' stands for behav-
iour and 'C' stands for consequences (Stokes 2000).
Behavioural discourses are also present in another major intervention strategy
- reality orientation - the main aim of which is to reduce disorientation. Reality
orientation employs techniques that modify people's physical and interpersonal
environment so that individuals who are disorientated develop a better degree of
orientation (see Chapter 9 for a further discussion of this approach).

Implications for practice

Behavioural discourse highlights certain aspects of chronically confused people in
preference to others. It provides a means of identifying the difficulties experienced
by individuals and enables practitioners to develop strategies for their resolution.
However, identifying the person with dementia as someone who is having prob-
lems gives rise to a number of serious difficulties. First, behavioural discourse
highlights only the outward manifestation of dementia: what people do and what
they say. It fails to highlight the inner personal world of people with dementia and
leads to an assumption that people with dementia possibly do not have any inner
world. Second, behavioural discourse does not allow people with dementia to be
considered as possessing any interpretations, judgements or personal feelings
about the outside world. Third, behavioural discourse positions people with
dementia as a problem and does not allow people to see that their behaviour may
be a reasonable response to others' unkind and unthoughtful behaviour.

DEMENTIA AS A SUBJECTIVE EXPERIENCE

Over the past 20 years, various discourses have highlighted the subjective experi-
ence of people with dementia. One such discourse relates to attachment and draws
upon wider psychoanalytic discourses such as those developed by Bowlby (1969).
This discourse brings into prominence the disturbed and demanding behaviour
sometimes exhibited by people with dementia and identifies their behaviour to be
the result of feelings of anxiety arising from an earlier attachment figure.
Another discourse that highlights the subjective experience of people with
dementia relates to the significance of past events for the mental health. This
discourse draws upon others that were developed in the twentieth century,
initially by Freud (2002) and later by Erikson (1950). These discourses are present
in the work of Butler (1963) relating to 'life review', in which the ability to take

8
 Dementia as a subjective experience

stock of one's life is constructed as an essential feature of good mental health in

older people. They are also present in the work of Naomi Feil, who has developed
validation therapy, which attends to people's past experiences rather than
bringing people back to 'the here are now', as advocated by reality orientation (see
Morton 2000, and Chapters 6 and 10).
Without doubt, the most important and significant discourse on dementia that
has developed in the past 20 years relates to personhood. Kitwood set a discourse
of personhood against what he called 'the standard paradigm', i.e. the bio-medical
model of dementia, arguing that the bio-medical model leads to the depersonal-
ization of people with dementia. To Kitwood (1997, p. 46), the depersonalization
of those with dementia should not be blamed on any one individual but is instead
part of our 'cultural inheritance' and of the stream of thinking that has developed
since the Enlightenment.
Within this context, Kitwood saw dementia as a dialectical interplay between
neurological impairment and malignant social psychology. Underlying his
approach is the idea that the personhood of people with dementia remains intact
throughout dementia, Kitwood arguing (1997, p. 51) that individuals with
dementia are engaged in 'an involutionary spiral' that undermines their sense of
personhood. As he comments: 'When self-esteem is lacking or damaged, a person
is disastrously incapacitated in many ways, and easily falls into a cycle of discour-
agement and failure' (Kitwood 1990).
This draws on discourses that had recently been made available by Sixmith et
al. (1993) relating to 'rementia', i.e. the interruption of the involutionary spiral and
the recovery of powers that were once lost. Moreover, other writers have drawn
on discourses relating to rementia (Sabat 1994), and Kitwood (1997) puts forward
17 types of malignant psychology that can contribute to the involutionary spiral
(Box 1.1).
In his later work, Kitwood applied his approach to organizations supporting
people with dementia, his main concern once again being to maintain the person-
hood of those with dementia. First, he developed a quality assurance tool,
dementia care mapping, based on the idea of personhood (see Chapter 16). Second,
he argued that there is increasing awareness of how much can be done for people
with dementia. With this in mind, Kitwood proposed (1997) that a 'new culture of
dementia' that is 'more strongly committed, more psychologically aware, more
practical and more pragmatic than anything that has gone before is beginning to
emerge'.
Kitwood's work has had an immense impact on dementia care, probably
because of its ability to engage with popular feeling among people working in
dementia care. After years of excessive institutionalization of individuals with
dementia, many practitioners had become disillusioned with existing service
provision and were looking for an alternative that would allow a compassionate
and human approach with a focus on the person with dementia.

9
 Constructing dementia

Box 1.1 Examples of manifestations of malignant social psychology in dementia care (from
Kitwood 1997, 46-47)

Treachery - Using some form of deception in order to distract or manipulate a person, or force
them into compliance.

Disempowerment - Not allowing a person to use the abilities that they do have; failing to help
them to complete actions that they have initiated.

Infantilization - Treating a person very patronizingly (or 'matronizingly') as an insensitive

parent might treat a very young child.

Intimidation - Inducing fear in a person, through the use of threats or physical power.

Labelling - Using a pattern of behaviour (e.g. smearer, stripper) or a category such as 'organic
mental disorder', as the main basis for interacting with a person.

Stigmatization - Treating a person as if they were a diseased object, an alien or an outcast.

Outpacing - Providing information, presenting choices, etc, at a rate too fast for a person to
understand; putting them under pressure to do things more rapidly than they can bear.

Invalidation - Failing to acknowledge the subjective reality of a person's experience, and espe-
cially what they are feeling.

Banishment - Sending the person away, or excluding them; physically or psychologically.

Objectification - Treating a person as if they were a lump of dead matter, to be pushed, lifted,
filled, pumped or drained, without proper reference to the fact that they are sentient beings.
Ignoring - Carrying on (in conversation or action) in the presence of a person as if they were
not there.
Imposition - Forcing a person to do something, over-riding desire or denying the possibility
of choice on their part.

Withholding - Refusing to give asked for attention, or to meet an evident need; for example,
for affectionate contact.
Accusation - Blaming a person for actions or failures of action that arise from their lack of
ability, or their misunderstanding of the situation.
Disruption - Roughly intruding on a person's action or inaction; crudely breaking their 'frame
of reference'.

Mockery - Making fun of a person's 'strange' actions or remarks; teasing, humiliating, making
jokes at their expense.

Disparagement - Telling a person that they are incompetent, useless, worthless, etc; giving
them messages that are damaging to their self-esteem.

Although Kitwood's work has become an important means of changing

previous ways of constructing people with dementia and their care, it has a
number of drawbacks. First, it is largely anecdotal and rhetorical. Although
Kitwood refers at various times to his own empirical work, he did not, with the
exception of his study of Rose (Kitwood 1990), publish any research findings. This

10
 Dementia, voice and choice

is a major failing of Kitwood's work. If he had established his research, he would

have been able to support his findings with evidence and also provide helpful
illustrations for his ideas.
Second, the methods that Kitwood used in his work were impaired. The data
that Kitwood does reveal, from the larger body of work that Kitwood refers to but
never formally published, concern a women with dementia called Rose. This
information was collected during an open-ended interview with Rose's two
daughters, an interview that covered large areas of their mother's life, including
things that had happened long before they were born. It is therefore questionable
whether their account could really be relied upon to give a reliable and accurate
account of such events. In addition, there are a number of problems with dementia
care mapping, notably the validity of its observational techniques and whether
assumptions or inferences about people's level of personhood are possible
(Adams 1996; Harding and Palfrey 1997).
The problems associated with Kitwood's work, particularly within the context
of its acceptability as an ethical and compassionate response among progressively
minded dementia care practitioners, pose as yet unanswered questions. These are
concerned with the nature of, and the relationship between, theory, research and
practice in dementia care, and include such questions as 'What methods should be
used in research about people with dementia and their care?' and 'Should research
underpin practice?'. These questions were only touched upon in Kitwood's work
and have hardly been addressed outside this; moreover, it has to said that
Kitwood's work sits uneasily within the present context of evidence-based
practice.

IMPLICATIONS FOR PRACTICE

Discourses that highlight the inner experience of people with dementia raise the
possibility that intervention by health and social care workers could be enhanced.
This might be through the development of approaches that directly addressed the
intrapsychic experience of people with dementia, such as with reminiscence
therapy or validation therapy. Alternatively, Kitwood's construction of malignant
social psychology provides a theoretical basis for developing practice that is sensi-
tive to the feelings of people with dementia. Through his development of a 'new
culture of dementia' and dementia care mapping, Kitwood takes his approach
beyond the intra- and interpersonal approach and applies his work to organiza-
tions that deliver support to people with dementia.

DEMENTIA, VOICE AND CHOICE

Kitwood's work is mainly concerned with the links between neurological impair-
ment and malignant social psychology and the way in which a person's sense of

11
 Constructing dementia

personhood is, through this interplay, determined. However, Kitwood's illumina-

tion of the subjective nature of dementia allows people to be constructed as having
feelings that may be voiced or expressed by using appropriate methods and
strategies.
In addition, a further discourse relates to the voice of people with dementia.
There are two ways in which the voice has been used in recent work on dementia.
The first approach focuses on the inner voice of people as they try to make sense
of having dementia; the focus here is on the person's inner interpretation of
dementia. The second focuses on the political exercise of voice, the way in which
the voice maintains the power possessed by those with dementia and allows them
to exercise personal choice.

Voice as a means of making sense

This discourse was initially developed in relationship to dementia by writers such
as Robert Davis (1993) and Diane Friel McGowin (1993), who provide first-hand
accounts of what it is like to have dementia. Following the interest stimulated by
these writers, empirical work was published that illuminated the inner voice of
people with dementia. This work uses data collected from a variety of sources:
accounts of individuals with dementia (Keady and Gilliard 1999), support group
discussions (Yale 1995), clinical experience (Balfour 1995; Mills 1998) and family
experience (Crisp 1995). In addition, two books have been written about a close
relative's experience of having dementia - by Linda Grant (1998) about her
mother, and by John Bayley about his wife, the novelist Iris Murdoch (Bayley
1999).
Kitwood outlines seven 'access routes' through which insight into the subjective
world of people with dementia may be obtained:

• Reading accounts by people with dementia

• Listening to people with dementia in a specially organized interview or group
meeting
• Listening to people with dementia in ordinary conversation
• Observing the behaviour of people with dementia
• Talking to someone who has had an illness with dementia-like features
• Using poetic imagination
• Doing role play.

Cheston uses these access routes to describe a model of how people make sense
of having dementia (Cheston 1996). In addition, Cheston examines how people
with dementia use metaphors and stories to make sense of what is happening to
them. In one example, Cheston describes a man with dementia who tells a story
about being in a thick dense jungle in which he has 'difficulty of getting through

12
 Dementia as a disability

the jungle91, thick high grass and things like that'. Cheston argues that when the
man is talking in this way, he is using a metaphor for his present experience
through which he is making sense of what is happening to him.

Voice as a means of maintaining power

Various studies show that voice is a means by which personal control and power
are exerted in the social world. They construct the person with dementia as
someone who has wants and preferences and can participate in decision-making
related to his or her own care. This way of constructing people with dementia
draws on discourses that relate to voice and set the person with dementia within
a socio-political context.
Goldsmith (1996) argues that the bio-discourse has constructed people with
dementia as having little ability to make decisions about their own care. As a result
of the dominance of the professions, health and social care workers expect that
people with dementia are not able to make choices about the sort of care they
want.

Implications for practice

Discourses relating to voice highlight the fact that the person with dementia is not
silent and passive but has ideas and opinions and can express these. The implica-
tion is that health and social care practitioners should make it possible to hear the
voice of individuals with dementia. At a practical level, this means preventing
extraneous and distracting 'noise', which affects hearing what people with
dementia are saying. In addition, it means developing ways of talking that help
those with dementia to engage in conversation and implement their views.

DEMENTIA AS A DISABILITY
Discourses identifying people with dementia as having a disability may be found
in various parts of Kitwood's work as he encourages people to think of dementia
first as a disability (Kitwood 1997). The use of discourses that relate to disability
makes it difficult for people to think of someone as a 'dementia sufferer' and
gives rise to their being thought of as someone who not only has a diagnosable
illness, but also encounters a diverse range of social restrictions and barriers.
Discourses that identify people with dementia as having a disability lie, however,
very much on the outskirts of dementia care. The aim of this latter part of the
chapter is therefore to outline an approach to dementia that allows people with
dementia to be constructed by themselves and others through disability
discourses in ways that resist oppressive and discriminatory practices and lead to
their empowerment.

13
 Constructing dementia

Disability defined
Defining disability is not a straightforward issue. At the time of writing, the formal
classification, supplied by the World Health Organization (WHO) and used since
1994, is under review as a result of sustained international pressure. Unlike
previous classifications, the new WHO version of disability will incorporate
'contextual factors' such as the environment and personal circumstances, a move
that will not only please critics who found previous definitions too negative and
clinical, but also signal the extent to which disability is rapidly becoming under-
stood as a social rather than a medical phenomenon. A full account of the changes
can be found on the WHO website (http://www.who.int/icidh/index.htm).
In the UK, social problems such as unemployment and inaccessible public
buildings have long been a part of disabled people's lives (Blaxter 1976), although
since the Disability Discriminations Act (1995), it is now unlawful for large
employers and service providers to discriminate against a person because of a
disability. For legal purposes, disability is broadly defined as 'physical or mental
impairment, which has a substantial and long-term adverse effect upon a person's
ability to carry out normal day-to-day activities' (www.disability.gov.uk/dda/).
People with dementia are therefore legally protected by the Disability
Discriminations Act (1995) and could potentially use it as a protective tool if they
wished, for example, to remain in a sheltered housing scheme. According to
disability activists, however, a single piece of legislation is not in itself enough
permanently to improve the lives of people with a disability as the social oppres-
sion they face is considered far too deep-seated for that (Charlton 1998).
Another popular way of defining disability is to see it as a form of social oppres-
sion, oppression in the sense that people experience isolation and exclusion not
because they have a mental or physical impairment, but because society is
designed in such a way as to privilege those without a disability (Priestly 2001).
Steps and cobbled streets, for example, make getting around extremely difficult
for a wheelchair user. Similarly, excessive noise and activity can make life intoler-
able for someone with dementia (Marshall 2001). The idea that society is essen-
tially at the root of disabled people's problems is the basic premise of what is
commonly known as the 'social model of disability' (Oliver 1995), and it is to this
model that we now turn.

THE POLITICS OF DISABILITY

By introducing the notion of oppression into the debate on what disability means,
disability activists also introduce the realm of politics. Like the feminism and gay
rights movements, the personal becomes the political as people with a physical
disability join forces to demand that society consider the disabling barriers and
negative attitudes that people constantly face as a denial of their human rights.

14
 The politics of disability

During the 1980s, for example, people with a physical disability chained them-
selves to railings and buses to protest about how difficult it was to gain access to
the world around them (Campbell and Oliver 1996). The fact that disabled people
themselves are the driving force behind the movement reflects one of their most
strongly held beliefs, that 'empowerment is not the gift of the powerful - empow-
erment is something that people do for themselves collectively - disabled people
have decided to empower themselves' (Oliver 1995, p. 15).
This is an interesting global view of disabled people: have, and indeed can, all
disabled people really decide to empower themselves? For people disabled by any
degree of cognitive impairment, prescriptive accounts of how greater control
should be achieved and who should instigate the process would certainly seem to
disable them still further. The 'dementia' usefulness of this approach emerges,
however, following consideration of the underlying philosophy.
One of the strongest strands running through disability studies is a belief in the
'collective experience of disability', i.e. the idea that as 'disabled people' face
similar barriers, they are a more powerful force in the struggle against social
oppression than any one individual with a disability (Oliver 1995). The dominant
paradigm of 'individualism' in health and social care settings is therefore seen as
'a way of using power to oppress by separating each individual from the great
body of humanity' (Ryles 1999, p. 605).
The relevance of this for people with dementia has been questioned: would not
any devaluing of individuality turn back the clock of dementia care to the days of
simply 'warehousing' older people with mental health problems? The point that
disability writers make, however, is not that people with a disability should be
cared for as an homogenous group but that while care practices are individualized,
people with a dementia are unlikely to perceive their situation in any shared or
collective sense. Moreover, their position in society will always be governed by
other people's perceptions of what they need and ideas about how things could be
improved.
Consider for a moment the benefits that older people have derived from uniting
and being seen 'as one': a sizeable group of elderly residents recently protested in
London about the closure of residential homes. Carers of people with dementia are
also becoming a formidable group with the help of organizations such as the
Alzheimer's Society, which exist to champion their rights. At present, however,
those personally affected by dementia have a limited (if any) opportunity simply
to come together and support each other (Gilliard 2000) and possibly develop a
more powerful and positive group identity. A similar trend is developing in social
research as individual interviews are being joined by focus groups, which have the
potential 'to raise collective consciousness' (Kitzinger 1994, pp. 102-21) as popular
methods of data collection. Individual assessments lead to individualized
solutions, but whereas the new culture of dementia care undoubtedly raises the
profile of personal worth, the approach can paradoxically reduce an

15
 Constructing dementia

individual's strength. In this sense, disability studies are useful as they highlights
not only the advantages of a group identity, but also the reality of human interde-
pendence and reliance on one other (Bond 1999).

The myth of independence

Independence is a prominent feature of government strategy for older people with
mental health problems (Audit Commission 2000). Voluntary organizations and
older people themselves (Nystrom and Segesten 1994) obviously regard inde-
pendence as an important aspect of a person's life that should be maintained
regardless of age. Does independence have the same priority for people with
dementia, though? Or are other possible outcomes, such as feeling safe or feeling
a sense of belonging, more important (Davies et al. 2000)? From a disability
perspective, this is a particularly important issue to understand as the notion of
independence has the potential to stigmatize people who are not able to do every-
thing for themselves.
Oliver (1995) argues that when professionals and people with a disability talk
about independence, they are not necessarily talking about the same thing. Policy
guidelines, for example, define independence in terms of an ability to self-care
without assistance (Audit Commission 2000), whereas disabled people see it as
'the ability to be in control and make decisions about one's life' (Oliver 1995, p. 54).
This difference of opinion is supported by Baltes (1996) who in a psychological
study of older people found that older patients delegate control to others as a way
of 'reserving energy', thus maintaining and optimizing the domains that they
most value and that are in most danger of decline. Someone might, for example,
prefer to use a wheelchair to go to an activities session, and thus avoid using up
valuable energy walking, preferring to be socializing or doing something creative
and interesting. Anecdotal evidence suggests that people with dementia are also
making similar decisions about what areas of their life to let go of and what activ-
ities it is important to concentrate on (Davis 1989). Disability studies invite us to
think again about what independence means and to realize that if independence
is defined strictly in terms of how much people are able to do rather than how
much they are able to control, then people with any kind of impairment will
inevitably be stigmatized.

Stigma and stereotypes

Earlier in this chapter, we argued that language and labels (such as 'acceptable
behaviour' and 'dementia') reproduce people with dementia as somehow different
or 'less normal' than everybody else. Disability writers are also concerned about the
way in which society talks about and constructs an 'idea' of disability that is detri-
mental to those affected. For example, literary and film portrayals of 'hunchbacks'

16+
 The politics of disability

and 'cripples' as figures of fun and inherently villainous people are said to
contribute to the social stigma associated with a disability (see Campbell and Oliver,
1996). The impact of popular representations of dementia on social attitudes has yet
to be explored with quite the same vigour, although recent work reveals a
welcoming interest in this area (McColgan et al. 2000).
Something that is known to affect those with dementia and their families is the
label 'dementia'. The impact of this label is not dissimilar to the experiences of
people diagnosed as having a learning difficulty in that whereas a diagnosis can
open doors to specialist services and treatment provision, both classifications are
over-arching diagnoses that can shape identities and exclude people from
everyday opportunities (Gillman et al. 2000). People with dementia may, for
example, not be able to articulate dissent or anger related to their situation, and if
they do so, it is commonly viewed as symptomatic of the disease, so they are
offered medication. Thus, direct public action may be seen as an appropriate
response to social injustice for a person with a physical disability, but if a person
has a mental health diagnosis, displays of anger or dissent are more likely to be
viewed as symptomatic of his or her psychopathology (Sayce 2000).

The importance of place

One of the biggest decisions facing service developers in dementia care today is
whether or not to provide separate housing and care facilities for residents with
dementia. Such decisions are usually based on intuitive concerns and/or objective
measures of the best long-term location for someone with a chronic and progres-
sive illness. In other words, although much is known and felt about the features of
'quality care', little empirical work has been done on the long-term housing needs
of those with dementia. In particular, we need to know more about whether
people with dementia can, should or wish to live alongside those without any
significant cognitive impairment.
Sociologically speaking, a consideration of where people live is important as
'place' is linked to matters of personal identity and a sense of belonging. Thrift
(1997), for example, suggests that places 'form a reservoir of meanings, which
people can draw upon to tell stories and thereby define themselves'.
Unfortunately, little is yet known about how people with a diagnosis of dementia
define themselves by the places in which they live because little has been asked.
This may be because, in an increasingly mobile society, the importance of place can
be forgotten in the process of making decisions about where older people should
receive care (Reed et al. 1998).
From a disability perspective, the places in which people live and the way in
which spaces are used in general terms are matters too important to overlook.
Kitchin (1998) argues, for example, that by separating people with a disability
from their peers and local communities (as was the case with 'special' schools in

17
 Constructing dementia

the 1970s and 80s), negative ideas are perpetuated about disabled people being
'out of place' in society and somehow different from other people. The relevance
of this in terms of dementia care is that, in the short term, housing and care serv-
ices should be based on barrier-free and inclusive principles rather than 'special'
and excessively remedial initiatives, and that, in the long term, alternatives to
institutional care should be explored. In addition, for people with dementia to be
treated equally, with dignity and respect, education needs to tackle the negative
attitudes held by other service users - who do not have a disability - as well as the
training needs of care staff.

Bodily developments
Much of dementia care is 'body-work', a term favoured by medical sociologists to
describe caring activities such as bathing (Twigg 2000). Faces are shaved, nails are
cut, hair is brushed, and teeth are cleaned, to the extent that the presentation of
well-ordered bodies comes to symbolize 'a job well done' (Lee-Treweek 1994). In
this sense, the body functions as a site of social meaning, as well as pathology, in so
far as people are defined by what their bodies can and cannot do (see Shilling
1993). The everyday life of a person with dementia is, for example, often described
using expressions such as 'got up with minimal help', 'wandering' and 'repeatedly
asking the same questions'. In other words, the emphasis is on how an indi-
vidual's body seems to be affected by the cognitive impairment. The personal
becomes the political as the language used to describe such individuals also often
renders them docile, unproductive or disempowered (Hughes and Paterson 1997).
Since the early 1990s, disability writers have begun to challenge the 'social
model of disability' on the basis that it excludes the individual's experience of
impairment. Marks (1999), for example, argues that many people with a disability
are oppressed more emotionally than socially or politically, calling for a 'mutually
constitutive' explanation of disability. By this, Marks means that, in order to
understand the true extent of oppression, a person's emotional and bodily state
should be considered in conjunction with their political and social context.

Implications for practice

Defining dementia as a disability raises a number of important implications for
service providers and health and social care practitioners. First, people with
dementia are legally protected by the Disability Discriminations Act (1995); thus,
treating those affected less favourably is not only bad practice, it is unlawful. In
other words, people with dementia have a right to the same goods, services and
facilities as other service users, so those affected should not be excluded from
some activity or from going somewhere simply on the grounds of their dementia.
A second implication of thinking about dementia as a disability is that the

18
 References

collective identity of those affected is both emphasized and regarded as a poten-

tial source of strength. It may seem counterintuitive within dementia care to see
people as being part of a 'group' rather than individuals with unique needs. If,
however, we also concentrate on what people with dementia have in common
(such as a lack of alternatives to institutional care) and focus on the barriers that
face all people with dementia (such as cognitive bias in wider society), those
affected will perhaps have an increased opportunity to empower themselves.
A third and final implication for practice relates to how well people with
dementia are supported through transitional phases of care. Little is known, for
example, about the meanings that people with dementia attach to being assessed
and monitored in a day hospital, or indeed about the extent to which residents
with dementia regard the institution they are living in as 'home'. Disability writers
remind us of the dangers of spatial segregation, of placing people with disabilities
apart from the rest of society (Kitchin 1998) and particularly of the risk of people
internalizing feelings of anger and resentment when this happens (Marks 2000). It
is therefore imperative that people with dementia have an opportunity for
extended meaningful conversation, particularly during times of transition. These
conversations would of course not necessarily have to be with care staff, as oppor-
tunities could, for example, be created and sustained in partnership with other
service users.
Finally, although these three suggestions have resource implications, the
disablement of people with dementia relates to not only the quality of care, but
also the politics of disablement and exclusion.

REFERENCES
Adams, T. 1996: Kitwood's approach to dementia and dementia care: a critical but appre-
ciative review. Journal of Advanced Nursing 23: 946-53.
Antaki, C. and Widdicome, S. eds. 2000: Identities in talk. London: Sage.
Audit Commission. 2000: Forget me not: mental health services for older people. London: Audit
Commission.
Balfour, A. 1995: Account of a study aiming to explore the experience of dementia. PSIGE
Newsletter 53: July 15-19.
Baltes, M. 1996: The many faces of dependency. New York: Cambridge University Press.
Bayley, J. 1999: Iris: a memoir to Iris Murdoch. London: Duckworth.
Berrios, G.E. and Freeman, H.L. 1991: Dementia before the twentieth century. In: Berrios,
G.E. and Freeman, H.L. eds. Alzheimer and the dementias. London: Royal Society of
Medicine, 9-27.
Blaxter, M. 1976: The meaning of disability. London: Heinemann.
Bond, J. 1999: Quality of life for people with dementia: approaches to the challenge of meas-
urement. Ageing and Society 19: 561-79.
Bowlby, J. 1969: Attachment and loss, volumes 1-3. New York: Basic Books.
Burr, J. 1995: An introduction to social constructionism. London: Routledge.

19
 Constructing dementia

Butler, R. 1963: The life review: an interpretation of reminiscence in the aged. Psychiatry 26:
65-76.
Campbell, J. and Oliver, M. eds. 1996: Disability politics: understanding our past, changing our
future. London: Routledge.
Charlton, J. 1998: Nothing about us without us: disability, oppression and empowerment. London:
University of California Press.
Cheston, R. 1996: Stories and metaphors: talking about the past in a psychotherapy group
for people with dementia. Ageing and Society 16: 579-602.
Crisp, J. 1995: Making sense of the stories that people with Alzheimer's tell: a journey with
my mother. Nursing Inquiry 2:133-40.
Davies, S., Ellis. L. and Laker, S. 2000: Promoting autonomy and independence for older
people with nursing practice: an observational study. Journal of Clinical Nursing 9:127-36.
Davis, R. 1989: My journey into Alzheimer's disease. Amersham: Scripture Press.
Dworkin, R. 1993: Life's dominion. New York: Knopf.
Erikson, E. 1950: Childhood and society. New York: Norton.
Fontana, A. and Smith, R.W. 1989: Alzheimer's disease victims: the 'unbecoming' of self and
the normalization of competence. Sociological Perspectives 32: 35-46.
Foucault, M. 1972: The archeology of knowledge. London: Tavistock.
Fox, P. 1989: From senility to Alzheimer's disease: the rise of the Alzheimer's disease move-
ment. Millbank Quarterly 67: 58-102.
Freud, S. 2002: Psychopathology of everyday life. Harmondsworth: Penguin.
Gilliard, J. 2001: The perspectives of people with dementia, their families and their carers. In:
Cantley, C. ed. A handbook of dementia care. Buckingham: Open University Press, 77-90.
Gillman, M., Heyman, B. and Swain, J. 2000: What's in a name? The implications of diagnosis
for people with learning difficulties and their family carers. Disability and Society 15:389-409.
Goldsmith, M. 1996: Hearing the voices of people with dementia. London: Jessica Kingsley.
Grant, L. 1998: Remind me who I am, again. London: Granta.
Hall, S. 1997: The work of representation. In: Hall, S. ed. Representation: cultural representa-
tions and signifying practices. London: Sage/Open University, 13-64.
Harding, N. and Palfrey, C. 1997: The social construction of dementia: confused professionals?
London: Jessica Kingsley.
Hughes, B. and Paterson, K. 1997: The social model of disability and the disappearing body:
towards a sociology of impairment. Disability and Society 12: 325-40.
Jacques, A. and Jackson, G. 2000: Understanding dementia. Edinburgh: Churchill Livingstone.
Jonas-Simpson, C.M. 2001: From silence to voice: knowledge values and beliefs guiding health-
care practices with persons living with dementia. Nursing Science Quarterly 14(4): 304-10.
Katzman, R. and Bick, K. 2000: The rediscovery of Alzheimer disease during the 1960s and
1970s. In: Whitehouse, P.J., Maurer, K. and Ballenger, M.A. eds. Concepts of Alzheimer's
disease: biological, clinical and cultural perspectives. London: Johns Hopkins University
Press, 104-115.
Keady, J. and Gilliard, J. 1999: The early experience of Alzheimer's disease: implications for
partnership and practice. In: Adams, T. and Clarke, C. eds. Dementia care: developing part-
nerships in practice. London: Bailliere Tindall, 305-24.
Kitchin, R. 1998: Out of place, 'knowing one's place': space, power and the exclusion of
disabled people. Disability and Society 13: 343-56.

20
 References

Kitwood, T. 1990: Understanding senile dementia: a psychobiographical approach. Free

Associations 19: 60-76.
Kitwood, T. 1997: Dementia reconsidered. Buckingham: Open University Press.
Kitzinger, J. 1994: The methodology of focus groups: the importance of interaction between
research participants. Sociology of Health and Illness 16: 102-21.
Lee-Treweek, G. 1994: Discourse, care and control: an ethnography of nursing and residen-
tial elder care work. Unpublished PhD thesis. Plymouth: University of Plymouth.
McColgan, G., Valentine, J. and Downs, M. 2000: Concluding narratives of a career with
dementia: accounts of Iris Murdoch at her death. Ageing and Society 20: 97-109.
McGowin, D. 1993: Living in the labyrinth: a personal journal through the maze of Alzheimer's.
San Francisco: Elder Books.
Marks, D. 1999: Dimensions of oppression: theorising the embodied subject. Disability and
Society 14: 611-26.
Marks, D. 2000: Disability. London: Routledge.
Marshall, M. 2001: Care settings and the care environment. In: Cantley, C. ed. A handbook of
dementia care. Buckingham: Open University Press, 173-85.
Mills, M. 1998: Memory, emotion, and dementia. In: Miesen, B.M.L. and Jones, G.M.M. eds.
Care-giving in dementia. London: Routledge: 48-66.
Nystrom, A. and Segesten, K. 1994: On sources of powerlessness in nursing home life.
Journal of Advanced Nursing 19:124-33.
Oliver, M. 1995: Understanding disability: from theory to practice. London: Palgrave.
Priestley, M. ed. 2001: Disability and the life course: global perspectives. Cambridge: Cambridge
University Press.
Reed, J., Payton, V., Roswell, V. and Bond, S. 1998: The importance of place for older people
moving into care homes. Social Science and Medicine 46: 859-67.
Robb, B. 1967: Sans everything. London: Nelson.
Ryles, S. 1999: A concept analysis of empowerment: its relationship to mental health
nursing. Journal of Advanced Nursing 29: 600-7.
Sabat, S.R. 1994: Excess disability and malignant social psychology: a case study of
Alzheimer's disease. Journal of Community and Applied Social Psychology 4: 157-66.
Sayce, L. 2000: From psychiatric patient to citizen: overcoming discrimination and exclusion.
London: Macmillan.
Saussure, F. 1974: Course in general linguistics. London: Fontana.
Shilling, C. 1993: The body and social theory. London: Sage.
Sixmith, A. Stillwell, J. and Copeland, J. 1993: Dementia: challenging the limits of dementia
care. International Journal of Geriatric Psychiatry 8: 993-1000.
Stokes, G. 2000: Challenging behaviour in dementia: a person centred approach. Bicester: Winslow
Press.
Thrift, N. 1997: Re-imagining places, re-imagining identities. In: Mackay, H. ed. Consumption
and everyday life. London: Sage, 159-212.
Twigg, J. 2000: Bathing: the body and community care. London: Routledge.
Yale, R. 1955: Developing support groups for individuals with early-stage Alzheimer's disease: plan-
ning, implementation and evaluation. Baltimore: Health Professions Press.
Wetherell, M. 1998: Positioning and interpretative repertoires: conversation analysis and
post structuralism in dialogue. Discourse and Identity 9: 387-412.

21
Chapter Valuing people with
dementia
Wendy Martin and Helen Bartlett

The way in which people with dementia experience disempowerment is well

documented (Goldsmith 1996; Kitwood 1997; Parker and Penhale 1998), and
assumptions that they are not capable of making decisions or choices are common-
place. When people with dementia are not viewed as autonomous individuals,
there is less opportunity for their own views and choices about care services and
everyday life to be expressed. It is not only the illness that reduces control and
influence for those affected - people with dementia experience a double disad-
vantage. First, dementia is frequently associated with old age. A person with
dementia is therefore further challenged by the negative stereotypes, images and
attitudes towards older people that prevail in an ageist society (Bartlett and
Martin 2000). Second, a dominant view of disability as a personal tragedy can
permeate many social policies and social interactions for the person with dementia
(Oliver 1990). It is therefore not only the diagnosis of dementia that 'leads to lack
of control and influence, but the attitude of others' (Parker and Penhale 1998,
p. 203).
The discourses that surround dementia are complex, but a major shift in
thinking has occurred over the past decade. Society is becoming more informed
about dementia, and the importance of valuing people with dementia is being
increasingly recognized within professional and family care domains. Dementia
research is now addressing the psychosocial aspects of dementia, with the goal of
increasing understanding of individuals' experience of the disease and their needs
and preferences. The purpose of this chapter is to explore the implications of these
developments for dementia care and the advancement of good practice. First,
developments in the policy and social context of dementia care will be outlined to
demonstrate how the perspectives of people with dementia have gained promi-

22
 Developments in dementia care

nence. Second, selected studies that have involved people with dementia as active
participants will be discussed. Third, barriers to involving people with dementia
as active participants will be explored. Fourth, the challenges to researchers and
practitioners when attempting to hear the voices of people with dementia will be
examined by drawing on findings from a 2 year project (funded by the
Community Fund) undertaken by the authors in partnership with the Oxford
Dementia Centre and Anchor Trust. Finally, the implications for good practice will
be considered.

THE POLICY CONTEXT

The increased attention paid to dementia can be located within the changing health
and social care policy context, in particular that which relates to older people and
community care (Cantley 2001 a). Many of the recent policy reforms have direct rele-
vance for those with dementia. Notions of consumerism, the empowerment of
users, and individualized and responsive care have been promoted by a series of
strategic and policy developments including Caring for People (Department of
Health 1989), the NHS and Community Care Act 1990, the Royal Commission on
Long Term Care (1999) and the National Service Framework for Older People
(Department of Health 2001). Older people are no longer viewed as dependent on
the welfare system but have become reframed as consumers and active participants
of welfare. As Gilleard and Higgs (2000, p. 171) argue, 'Whenever possible, people's
own choices are to shape the kinds of service they receive, not the paternalistic
welfare state.' Within this context, the involvement of older people in choices and
decision-making is therefore central. Less attention has, however, been paid specif-
ically to promoting these concepts for people with dementia.
Ways of including individuals in the decision-making process have been iden-
tified (Killeen 2001). These can range from involvement in the development of
services, in a representative and/or advocacy role, to having more control and
influence as service recipients within their everyday lives. As many people with
dementia are unaware of their diagnosis (Bartlett and Martin 2001 a), the promo-
tion of a collective voice for people with dementia has, however, its limitations.
Furthermore, the diversity of voices of people with dementia needs to be recog-
nized. Although an appropriate policy framework is essential, the challenge
remains for practitioners and researchers to implement policy into practice and
adopt inclusionary strategies.

DEVELOPMENTS IN DEMENTIA CARE

Dementia has been understood from a predominantly bio-medical perspective,
but psychological and sociological models of dementia care are now also

23
 Valuing people with dementia

acknowledged (Bond 2001). The bio-medical view of dementia emphasized the

disease and illness that was located within the individual. Those with dementia
were objectified and denied the opportunity to be involved in decisions about
their care (Clarke 1999). They were traditionally 'overlooked, ignored or assumed
not to exist' (Parker and Penhale 1998, p. 203). Challenges to the medical
discourses that previously surrounded a person with dementia (Harding and
Palfrey 1997; Clarke 1999; Lyman 2000; Bond and Corner 2001) have opened up
the possibility of involving people with dementia as active participants in their
own care. In particular, Kitwood's psychosocial approach to dementia care has
challenged previous assumptions that there is an erosion of the self and person-
ality of individuals with dementia (Kitwood and Benson 1995; Kitwood 1997) and
highlighted the importance of valuing their subjective experiences.
The social worlds of people with dementia were previously constructed and
mediated via the views of care-givers and family members (Clarke 1999; Stalker et
al. 1999). Now both practitioners and researchers increasingly aim to understand
the perspectives of people with dementia. A tool for eliciting their perceptions, the
dementia care mapping method, has been developed by Kitwood and Bredin
(1994) as a means of assessing care standards. Its application has been favourably
evaluated in practice (Williams and Rees 1997), although it has also been criticized
both in terms of methodology and in relation to its reliability and validity (Adams
1996).
Whereas a greater emphasis on the individual sense of self, the rights of the
person and valuing the perspectives of people with dementia has been noted
(Downs 1997), the research nevertheless suggests that a more meaningful involve-
ment of people with dementia in decisions and choices is possible (Adams 1999;
Adams and Clarke 1999; Cantley 2001b; Wilkinson 2001a). To support this change,
Cox et al. (1998) have developed a value framework to underpin dementia care
that is based on the following five values:

1. Maximizing personal control

2. Respecting dignity
3. Enabling choice
4. Preserving continuity
5. Promoting equity.

The framework has been designed to demonstrate the centrality of those with
dementia, their diverse and dynamic needs, and the differing perspectives within
the care relationship.
Practitioners and service providers now increasingly aim to involve the person
with dementia in the decision-making process. Researchers also seek to investi-
gate the subjective perspectives of people with dementia and understand how
they construct their social worlds. The various challenges faced when attempting

24
 Hearing the voices of people with dementia: insights from research

to listen to the voices of people with dementia will be explored later, but first some
of the insights from research that has involved people with dementia will be
examined.

HEARING THE VOICES OF PEOPLE WITH DEMENTIA:

INSIGHTS FROM RESEARCH
Until recently, social research into dementia focused almost exclusively on the
needs of family and professional carers (Adams 1999). People with dementia are
now, however, increasingly the focus of research that aims to understand not only
how people with dementia construct and experience their own social worlds, but
also how they mediate their way through the barriers and power relations within
society (Wilkinson 2001b). Achieving this level of understanding inevitably
requires direct engagement with the person with dementia, preferably using
participatory methods, in which the person with dementia is actively involved in
the research process.
Although there is a limited amount of empirical research in which people with
dementia are involved, some important insights have been gained from recent
studies (e.g., Gilles 1995; Goldsmith 1996; Gwyther 1997; Keady and Gilliard 1999;
Bamford and Bruce 2000; Barnett 2000; Allan 2001; Wilkinson, 2001a). Key findings
from a selected number of studies will now be summarized.
The importance of communication is highlighted by Goldsmith (1996), whose
study involved interviews with service providers and people with dementia.
Strategies to help health and social care professionals involve people with
dementia in decisions concerning their care were identified. These included the
development of diverse and effective communication skills, the recognition of
verbal and non-verbal cues, group work, eliciting life stories and promoting an
environment conducive to communication.
Keady and Gilliard (1999) undertook a study of people with an early diag-
nosis of dementia. The research showed how people with dementia used two
interdependent strategies in order to cope with the inherent uncertainty of
dementia, namely 'taking stock' and 'sharing the load'. The first strategy of
'taking stock' occurs when the person starts to become aware he or she has a
problem. This can involve an intense and private process of adjusting to a new
everyday reality, the development of a number of coping behaviours and the
concealment of symptoms, for example through the use of lists and memory
aids. In contrast, the strategy of 'sharing the load' is a process of unburdening
in which those with dementia reveal their covert activities to a person close to
them, who tends to be a family member rather than a health care professional.
The work of Keady and Gilliard provides an important insight into how people
with an early diagnosis of dementia construct their social worlds in the
everyday context of uncertainty. Furthermore, the strategies developed by the

25
 Valuing people with dementia

participants suggested that they were aware of and responded to prevalent atti-
tudes to dementia within society.
Barnett (2000) also sought to promote the participation of people with dementia
in both research and decisions relating to their care. Of particular note to valuing
the perspectives of people with dementia were the themes that emerged from the
interviews of participants with dementia who either attended the day hospital or
were residents in long-term care. Barnett was interested in the participants' own
concerns, and she first explains the awareness of the participants - of themselves,
of their memory loss, of their own situation and of important relationships. Other
people were significant to their everyday lives, although the participants experi-
enced this both positively and negatively. Many described further their own expe-
riences of 'loss' and bereavement within their lives, in particular the loss of their
home and of key relationships. Finally, the participants described their own
subjective meanings associated with the experience of dependency. Although they
recognized their dependence on others, the participants also spoke with concern
and care about the people who cared for them, which, for Barnett, points to the
interdependence of the care relationship. Moreover, Barnett suggests (2000, p. 129)
that 'a new way of framing the care relationship, so that it is not about passive
receipt but a two-way, mutual process' could be developed. Achieving this goal
would certainly involve valuing the person with dementia as an active and impor-
tant partner within the care relationship.
Ways in which staff can consult and promote the views and opinions of service
users with dementia have been explored in a study conducted by Allan (2001). The
research clearly shows the importance of diverse and individualized approaches
to communication, through which important understandings and views can be
elicited. Also highlighted was the value of promoting the staff's confidence and
self-esteem, and of acknowledging the sophistication of their communication
skills. As sustained and effective communication is emotionally demanding and
consuming in terms of both time and energy, the support of staff was therefore a
very significant issue for service providers. Although Allan promotes communi-
cation in the everyday worlds of service users with dementia, she also recognizes
the tension that arises between individualized care and the everyday routines of
organizations.
Identifying desired care outcomes from the perspective of the person with
dementia has also been the focus of recent studies. Bamford and Bruce (2000), for
example, consulted people with dementia and their carers about community care.
A key outcome that they identified was maximizing a sense of autonomy. Their
work highlights the limitations of relying solely on carers as proxy respondents. In
another study, Gwyther (1997) identified a range of other outcomes relevant to
people with dementia, including a sense of control, inclusion, reciprocity, mean-
ingful activities, feeling safe and secure, maintaining self-esteem, and maximizing
physical well-being through health care.

26
 Methodological issues

Although such studies are relatively few in number, they provide crucial
insights into the experience of dementia and, importantly, illustrate the quality of
the interactions that can be achieved between researcher and participant.
Implicit in this is a focus on valuing people with dementia - their experiences and
perspectives.

METHODOLOGICAL ISSUES
The term 'active participation' suggests a closer, honest and reciprocal relationship
between researchers and participants. As a detached approach to the research rela-
tionship is increasingly being rejected, researchers now aim to involve participants
in all aspects of the research process (de Laine 2000; see also Bartlett and Martin
2001a; Clarke and Keady 2001; Wilkinson 2001a, b). This promotion of active
participation is an ethical stance in which researchers are explicit about their
research goals, undertake a process of informed consent and respect the privacy of
the respondents (de Laine 2000). It is further argued that participants may find the
experience of participating in research to be empowering. Although research that
involves people with dementia increasingly attempts to be participatory, it does
not necessarily embrace the characteristics of emancipatory research (Wilkinson
2001b). Although both aim to be inclusive and democratic, and both question the
power and expertise within the researcher-participant relationship, emancipatory
research is part of a wider process in which the goal is the liberation of disabled
people as active participants and citizens within society.
Involving people with dementia in the research process can be a considerable
challenge for researchers. The issues are complex and there are no definitive
guidelines, but a number of criteria can be formulated from the collective
wisdom of researchers such as Bartlett and Martin (2001 a, b), Bond and Corner
(2001), Clarke and Keady (2001), Martin and Bartlett (2001) and Wilkinson
(2001a, b):

1. Be creative and positive in the approach to data collection.

2. Allow people with dementia to articulate and express their own perspective
and to ensure the data are trustworthy.
3. Develop rapport and mutual trust within the research relationship.
4. Allow plenty of time and ensure that an ongoing process of consent is main-
tained.
5. Be reflexive about the research process.
6. Pay attention to the research design, for example the use of multiple methods
and/or maximizing engagement within the research relationship.
7. Be aware of verbal and non-verbal cues to ensure that the participant is not
experiencing distress.
8. Value the person with dementia within the research relationship.

27
 Valuing people with dementia

PRACTICE INSIGHTS FROM A STUDY OF EMPOWERMENT

A recent study completed by Bartlett and Martin will now be drawn upon to
inform practice development. The purpose of this study was to explore how deci-
sions are made for older people with dementia by focusing on these issues from
the perspective of older people with dementia and their carers. The study was
concerned with identifying the opportunities that exist for older people with
dementia to be involved in how they live, the barriers to realizing these opportu-
nities, and practices that can overcome these barriers. In particular, the aim was to
examine how the rights and choices of people with dementia can be balanced with
possible concerns that people have for their safety and well being. Comparisons
were made between different care settings - residential homes, sheltered housing
and the community. Eighteen case studies were completed, involving interviews
with older people with dementia, participant observation, and focus groups with
key staff and family members.
Involving participants in all aspects of the research process can be difficult to
achieve, as this study found (Bartlett and Martin 2001 a). In the process of negoti-
ating access, multiple layers of protection surrounding the older person with
dementia had to be penetrated. In addition to the usual requirement of ethics
committee approval, a wide range of other gatekeepers, including senior and
middle management, service providers, care staff and family members, were
involved in giving permission to proceed with various stages of the study.
The process of obtaining informed consent required the active participation of
the respondents. In this study, the question of competency obviously arose
(Bartlett and Martin 2001 a). Lack of competence to consent could not, however, be
assumed just because the participants had a diagnosis of dementia. One partici-
pant had, for example, previously worked in a university and, when negotiating
the process of informed consent, asked about funding, the key aims of the research
and how the research would be written up. Although, because of her short-term
memory loss, she needed on a return visit to be reminded about the purpose of the
research, it was evident that she was active in the process of informed consent. A
well-designed information sheet also assisted with this process. The process of
informed consent is, therefore, ongoing rather than a single event.
Another issue in obtaining informed consent is whether or not individuals are
aware of their diagnosis (Bartlett and Martin 2001 a). When introducing the project,
we used the term 'memory problems' rather than dementia for fear of causing
undue distress and harm to the potential participant. True participation is there-
fore less likely when a participant may not be aware of the real focus of the study.
At the same time, there is an ethical obligation for researchers not to cause harm.
It was therefore necessary to balance the opposing notions of 'empowerment' -
involving the older person with dementia in the decision-making process - and
'risk' - by being aware of potential harm and distress.

28
 Challenges to participation in practice

CHALLENGES TO PARTICIPATION IN PRACTICE

The partnership model of dementia care promotes the active participation of the
person with dementia within the care relationship. This represents an ethical
stance in which the voice of the person with dementia is valued. It is therefore
important to develop practices that are inclusionary, attention being given to
hearing the diverse and dynamic voices of people with dementia. Examples of
inclusionary practice, and challenges to achieving this ideal, will be illustrated
by extracts from interviews with older people with dementia, and focus groups
with health and social care staff, that have been taken from the empowerment
project.
The first illustration explores a participant's perspective on her case review
when a decision was made for her to move from her own home to a nursing
home. Christine was a 74-year-old retired shop owner who had recently been
diagnosed with dementia. She had been a widow for many years and had lived
in the same village for most of her life, where she had always been actively
involved in community activities. She had one married daughter who lived
nearby. The interview took place in a hospital setting 1 week after her case
review.
Christine had found the case review meeting especially difficult and upsetting.
Despite being articulate and able to express her views effectively, she felt that her
voice had not been heard. First, she described the reason why a decision had been
made for her to move into a nursing home: They said I was not fit to be left all
night, I couldn't be left, I suppose that is it.' At the same time, she questioned the
reasons given for moving accommodation: T was diagnosed as short term
memory - short term memory and that was one of those things, but I didn't think
it was enough - just short term memory but apparently it was ... I was able to
manage up to then.'
Although Christine was included in the case review meeting, she felt that she
had not been prepared. Her own view had not been represented, she had been
disempowered by the number of staff present, and she had not felt involved in the
decision-making process. Although her family members were present, she had not
realized the difficulty they were finding in taking care of her. The following extract
describes her experience of the case review meeting:

People I had never seen before. I suppose it was quite fairly done but I didn't
think it was. I know the doctor was on my side because he said he wanted to
thank me for being so brave about it all. But I wasn't brave, but I just didn't
say anything because I didn't know what was going to happen.

Christine clearly felt unable to voice her opinion at the meeting and felt that she
had not been able actively to participate in a key decision about her future.

29
 Valuing people with dementia

The second illustration involves a 69-year-old widow called Sue who lived in a
residential home and details the extent to which she felt involved in decisions
related to participating in organized activities. Sue first described how she enjoys
participating in organized activities:

Interviewer: I saw you doing some gardening a couple of weeks ago.

Sue: Oh, I like doing that.
Interviewer: You like doing that?
Sue: Well yes, I have always done it.

Sue's enjoyment of gardening and her involvement in other activities organized

by the residential home did not mean, however, that she wished to participate in
all the activities:

Interviewer: Do you like art as well?

Sue: No, I don't really. But they are making me come and do it now.
Interviewer: They make you do it?
Sue: Well, they come and ask me and I can't say no.

Despite being consulted on making a decision regarding her everyday life, Sue felt
unable to voice her opinion and found it difficult to say 'no' within the social
context of the residential home.
In the study, health and social care staff, family members and older people were
interviewed in focus groups and were asked how people with dementia partici-
pated in decision-making, as well as being asked to describe possible barriers to
their involvement. The staff raised a number of issues, highlighting circumstances
that made it difficult to involve people with dementia. A key theme identified was
the tension between ideal and reality when involving older people with dementia
in decisions about their care and everyday life. The interviews included the use of
prompt cards covering key decision-making areas (Brown and Benson 1997) such
as 'Eating food you like', 'Choosing how you spend the day' and 'Having
someone to represent your interests when important decisions are made about
your life'. Of particular interest was the discussion about the interview prompt
card 'Having people talk over your head as though you are not there'. Some
responses by staff to this prompt were as follows:

Not intentionally, we don't do it on purpose b u t . . . you are discussing some-

thing, so you tend to get on and talk, and then forget that the resident is
listening.
I think one of the things that make it difficult is because of how mentally
impaired our residents are. So that just in an ordinary personal everyday way
... when you are setting out your work, it can be quite lonely if you are

830
 Conclusion

working with somebody that you can't actually speak to about anything
social, ... but you always try to focus it through this other person, but they
are not always able to join in.
Well, because they take longer to give out what they want to say sometimes
you feel there isn't time to spare, and so sometimes you can have a conversa-
tion that doesn't include them. So it does happen. It shouldn't but it does.

Although the staff were aware of good practice and of the importance of
involving older people with dementia in decision-making, there were significant
barriers to achieving these goals. The barriers included staff shortages, daily
communication patterns between staff, the routines of institutional life, lack of
time and the emotional stress of communicating with and involving older people
with dementia. The working environment and staff practices can in such ways
affect the extent to which older people are actively involved in decision-making.
It is therefore important to recognize the barriers to good practice. In this way, the
gap between research and practice, between ideal and reality, can be reduced and
the quality of life of older people with dementia promoted.

CONCLUSION
The way in which people with dementia are considered and the care they receive
have undergone significant change. The work of Kitwood and others has had a
major influence on promoting person-centred care, and social research has empha-
sized the importance of valuing the person with dementia as a participant in the
research process. New insights into the capacity of people with dementia to
engage in decision-making have been revealed, and some progress in practice
development has been documented. Nevertheless, further education and support,
in particular the translation of theory into practice, are still needed for practi-
tioners and the carers of people with dementia. Good practice can be built only if
there is an understanding of the individual's rights, of how to balance empower-
ment and individual risk, of the importance of gaining appropriate consent and of
assessing competence in everyday situations.
A number of good practice principles that promote valuing people with
dementia can be formulated from both the research literature and recent practice
developments:

• Understand the stages of dementia and the nature of the social worlds of
people with dementia.
• Acknowledge that people with dementia have their own perceptions of self,
memory loss and ageing.
• Promote the rights of the individual person with dementia.
• Recognize individual diversity, and don't assume that everyone is the same.

31
 Valuing people with dementia

• Seek to locate individuals within the context of their life history and become
familiar with their life interests and skills through biographies.
• Focus on the strengths that people with dementia still have rather than on
their losses and dependency.
• Foster communication through group work, life stories and a conducive envi-
ronment.
• See all forms of behaviour, including verbal and non-verbal cues, as commu-
nication.
• Encourage people with dementia to articulate and express their own perspec-
tives.
• Allow sufficient time for effective interactions.
• Balance the pursuit of empowerment and the avoidance of risk-taking with
the needs and desires of the person with dementia.

Several key points for managers can also be identified:

• Develop strategies that promote the involvement of people with dementia in

decision-making and choices about their services, their care and their
everyday lives.
• Consider how staff can be supported to promote communication with people
with dementia.
• Develop a value framework for care and service provision that promotes the
involvement of people with dementia.
• Be aware of barriers to involving people with dementia in decision-making
and choices.
• Provide ongoing education and training for staff on how to value people with
dementia.
• Balance the tensions between individualized care and the organization of insti-
tutional life, as well as between 'risk' and 'empowerment'.
• Be familiar with the research evidence to inform practice.
• Value the person with dementia within the partnership of care.

REFERENCES
Adams, T. 1996: Kitwood's approach to dementia and dementia care: a critical but appre-
ciative review. Journal of Advanced Nursing 23: 948-52.
Adams, T. 1999: Recent developments in dementia care. Nursing Times Clinical Monographs no.
33. London: Nursing Times Books.
Adams, T. and Clarke, C. eds. 1999: Dementia care: developing-partnerships in practice. London:
Bailliere Tindall.
Allan, K. 2001: Communication and consultation: exploring ways for staff to involve people with
dementia in developing services. Bristol: Policy Press.

32
Another Random Scribd Document
with Unrelated Content
 DIET LIST
Albumin Water.—Take white of 1 egg, stir until separated. Add a
little lemon juice and 1 pint of water. Ice and serve. Sugar or salt may
be used.
Barley Water.—Wash 2 ounces of barley with cold water. Boil for
5 minutes in fresh water. Strain. Then cover with 2 quarts of water
and cook slowly down to 1 quart. Flavor with thinly cut lemon rind
and sugar. Do not strain unless patient requests.
Beef Juice.—Cut into cubes 1½ inches each, 1 pound round
steak. Place in a clean, ungreased pan, and fry one and one-half
minutes on each side. Pour into hot meat press and apply pressure.
In absence of a press, a potato ricer may be used. Season with salt
and pepper. May be served iced or heated by putting in double boiler
and stirred all the time. Do not allow to curdle.
Beef Tea.—Put 1 pound of finely chopped round steak into a
quart glass jar, fill with cold water. Place jar in kettle of warm water.
Leave over slow fire for four hours. Strain, season with salt and
pepper.
Champagne Whey.—Boil 8 ounces milk for fifteen minutes.
Strain through cheesecloth. Add 1½ ounces champagne.
Chicken Broth.—Skin and chop in small pieces one small or one-
half large fowl. Boil bones and all with one blade of mace, a sprig of
parsley, and 1 tablespoonful of rice, 1 crust of bread and 1 quart of
water, for one hour. Skim from time to time. Strain through coarse
colander and season to taste.
Cinnamon Water.—One-half ounce stick cinnamon, 2 cups
boiling water.
Break sticks in small pieces. Add water, boil twenty minutes.
Strain and serve hot or cold.
Clam Broth.—Wash thoroughly 6 large clams in shell. Put in
kettle with 1 cup of cold water, bring slowly to boil, and keep
temperature for one minute. Pour off broth and serve hot. Add salt
and pepper.
 Eggnog.—Beat an egg, white and yolk separately. Add to the yolk
1 dram of vanilla extract, a pinch of salt and 4 oz. fresh milk, and 1
dram of sugar. Add ½ dram of sugar to white of egg, stir a portion
into the glass and heap remainder upon top of glass.
Egg Cordial.—One egg white, 1 teaspoon sugar, 1 tablespoon
brandy, 2 grains salt, 2 tablespoons cream.
Beat white until stiff. Add cream, continue beating, add other
ingredients, and serve cold.
Egg Lemonade.—Beat 1 egg and 1 teaspoonful of sugar until very
light, add ¼ cake of yeast dissolved in one-fourth cup of water, two
tablespoonfuls of sugar, pour into bottles with patent stopper, fill
bottles only two-thirds full, cork tightly. Shake well. Allow to stand
on ice twenty-four hours.
Flaxseed Tea.—One ounce of whole flaxseed, 1 ounce powdered
sugar, ½ ounce licorice root, 1 ounce lemon juice. Pour over these
materials 1 quart of boiling water and allow to stand four hours.
Strain off liquor.
Gum Arabic Water.—Dissolve 1 ounce of gum arabic in 1 pint
boiling water. Add ½ ounce sugar, a wineglassful of sherry, and juice
of one lemon. Serve with ice.
Junket.—Take ½ pint of fresh milk in a saucepan. Add 1
teaspoonful of essence of pepsin, stir just enough to mix. Pour into
custard cups. Let stand until firmly curded. Serve plain or with
grated nutmeg. Sherry may be added.
Koumiss.—Heat four cups of milk, then cool; when lukewarm,
add ¼ cake of yeast dissolved in one-fourth cup of water, two
tablespoonfuls of sugar, pour into bottles with patent stopper, fill
bottles only two-thirds full, cork tightly. Shake well, allow to stand on
ice twenty-four hours.
Milk Shake.—White of 1 egg, 1 ounce sugar, 1 ounce chipped ice,
1 ounce cream. Shake in milk shaker two minutes. Add milk to fill
glass. Flavor with vanilla and lemon.
Mutton Broth.—Boil slowly 1½ pounds of lean loin mutton,
including the bone. Add a little salt and ½ onion. Pour broth into a
basin. Skim off fat when cool. Warm as used.
Oatmeal Gruel.—One teacup oatmeal flakes, cover with 1 quart
cold water. Place on slow fire and soak three hours. Strain, add 4
teaspoonfuls of sugar and 1 teaspoonful of salt.
Oatmeal Water.—Cover 1 teacupful oatmeal with 1 quart cold
water. Let it stand two hours. Stir often. Strain. Serve with salt, sugar
and ice.
Peptonized Milk. Warm Process.—Dissolve the contents of
Fairchild’s peptonizing tube in 4 tablespoonfuls cold water. Add to 1
pint of milk. Put in glass jar, and place jar in vessel of warm water.
Heat slowly to 115° F. Stir slowly and allow it to remain thirty
minutes. Place on ice at once to check further digestion.
Peptonized Milk. Cold Process.—In a clean quart bottle, put
one peptonizing powder (Fairchild). Add 1 teacupful of cold water.
Shake. Add 1 pint fresh cold milk. Shake well. Place on ice. Do not
heat before using.
Rice Water.—Pick over and wash 2 tablespoonfuls of rice. Put in
a saucepan with 1 quart of boiling water; simmer two hours. When
rice is dissolved, strain. Add teaspoonful salt. Serve warm or cold.
Sherry may be added.
Rum Punch.—Two teaspoonfuls powdered sugar, 1 egg well
beaten, warm milk, 1 large wineglassful; 4 ounces Jamaica rum.
Flavor with nutmeg.
Scraped Beef.—Place on breadboard a round steak. Scrape with
table-knife but do not take any shreds of muscle. Salt and pepper.
Spread on thin slices of bread. Place in toaster until seared.
Toast Water.—Three slices of stale bread well browned, but do
not burn. Put in a pitcher, pour over them 1 quart boiling water.
Cover closely, and allow to stand until very cold. Strain. Wine and
sugar may be added, to stimulate.
Wine Whey.—Put 1 quart new milk in a saucepan and place over
fire. Stir until nearly boiling. Add 2 ounces of sherry wine. Boil slowly
for fifteen minutes. Skim off curds as they arise. Add 1 tablespoonful
sherry. Skim again, then strain through gauze.
 CHAPTER XXV
SOLUTIONS AND THERAPEUTIC INDEX

Acid, Boric. 5 dr. in a pint of water makes a 4% solution, or 1:25.

Acid, Carbolic. 15 ♏︎ in a quart of water makes a 0.1% solution, or 1:1000. 5 dr. to the quart makes a 2% solution; and
1¼ oz. to the quart, a 5% solution.
Chinosol. 15 gr. to the quart of water makes a solution of 1:1000.
Formalin. 1 dr. to the quart of water makes a solution of about 1:500.
Mercury Bichloride. 15 gr. to the quart of water makes a 0.1% solution, or 1:1000. 1½ gr. to the quart makes a 0.01%
solution, or 1:10,000.
Normal Salt Solution. 2 dr. of salt to the quart of water, or 0.9%.
Physiological Salt Solution. Take normal salt solution as given above and to every 3½ oz. add 15 gr. of carbonate of
soda.
Potassium Permanganate. 2½ dr. to the quart makes a 1% solution. 3 gr. to the quart makes a 1:5000 solution.
Silver Nitrate. 4½ gr. to the ounce of water or 1 gr. to 1–7/10 dr. makes a 1% solution.
Ziratol. 2½ teaspoonfuls to a quart of water makes a 1% solution.
For general reference the following valuable table is appended:
PERCENTAGE SOLUTION TABLE

By Alfred I. Cohn, Phar. D., in Merck’s Report

Quantity
of GRAINS OF SALT OR DRUG REQUIRED TO MAKE SOLUTIONS OF PERCENTAGE STRENGTH I
solution
to be 0.5% 1% 2% 3% 4% 5% 6% 8% 10% 15% 20% 25% 50% 1:500 1:1000 1:2000
made
½ fl. oz 1.15 2.3 4.6 6.9 9.3 11.7 14.1 19. 24. 36.8 50.2 65. 151.2 0.46 0.228 0.12
1 fl. oz 2.3 4.6 9.2 13.9 18.6 23.4 28.2 37.9 47.9 73.5 100.3 130. 302.5 0.91 0.456 0.23
2 fl. oz 4.6 9.2 18.4 27.8 37.2 46.8 56.4 75.8 95.8 147. 200.6 260. 605. 1.8 0.91 0.46
3 fl. oz 6.9 13.8 27.6 41.7 55.8 70.2 84.6 113.7 143.7 220.5 301. 390. 907.5 2.7 1.37 0.68
4 fl. oz 9.2 18.4 36.8 55.6 74.4 93.6 112.8 151.6 191.6 294. 401.2 520. 1210. 3.64 1.82 0.91
5 fl. oz 11.5 23. 46. 69.5 93. 117. 141. 189.5 239.5 367.5 501.5 650. 1512.5 4.55 2.28 1.14
The table shows the quantity of drug required to yield a given volume of solution of the percentage
strength desired. Thus, to make one fluid ounce of a 5 per cent solution it is merely necessary to dissolve
23.4 grains of the salt in sufficient water to make one fluid ounce.
 THERAPEUTIC INDEX

Young’s Rule for Dosage: The age of the child is divided by the age
of the child plus 12, and the result is the appropriate dose for the
child. The doses given below are for the adult unless otherwise
specified.
Absorbent. A medicine or dressing that promotes absorption, such as
potassium iodide, Tr. iodine, glycerine, or hot vaginal douches.
Adrenalin. The blood-raising principle of the suprarenal glands. It is
hæmostatic and astringent. Acts somewhat like digitalis on the heart.
Uses.—Vomiting of pregnancy, increased glandular activity, hæmorrhage,
inflammation of mucous membranes.
Dose.—Internally, 5–10 m. of the 1:1000 solution. Externally, the solution of
1:1000 or 1:10,000 may be applied.
Albolene. An oily white substance obtained from petroleum. It is used on the
nipples and skin of the mother and to remove the vernix caseosa from the
skin of the child.
Aloin, Strychnia, and Belladonna. A laxative pill which usually contains
aloin ⅙ gr., strychnia sulph. 1/60 gr., and Belladonna 1/12 gr.
Ammonia Carbonate. Antispasmodic, stimulant, and expectorant.
Uses.—Stimulant to heart. Stimulating expectorant in pneumonia and
bronchitis.
Dose.—5–20 grains in mucilage or syrup.
Anæsthone. A mixture of adrenalin chloride (0.1%) and chlorotone (5%) in an
ointment base of wool fat and petrolatum. Astringent, antiseptic, anesthetic
and germicide. Useful application to swollen mucous membranes or in
coryza.
Argyrol (Silver Vitellin). Antiseptic and germicide.
Uses.—Like Silver Nitrate, but less irritating to the tissues. 3–5% solution in
water is an injection for gonorrhœa. 15% solution dropped in the eyes of the
 newborn may prevent ophthalmia. 25% solution may be used twice a day as
a remedy for existing ophthalmia, but the strength should be reduced after
three or four days. 10–15% solution is used as an injection in cystitis. An
ounce or more of the solution may be left in the bladder until the next
evacuation.
Asafœtida. A fetid gum resin. Carminative, antispasmodic, mild stimulant, and
expectorant.
Uses.—Gas pains of adults and infants. Hysteria and indigestion.
Dose.—5–10 gr. t.i.d. For infantile colic, an emulsion called the mistura of
asafœtida may be used in 2–4 dram doses. For adults 1–2 tablespoonfuls.
Belladonna. Nervine, mydriatic, sedative, narcotic, antispasmodic and
anodyne. Makes the throat dry and dilates the pupils.
Uses.—Night sweats, nervous cough, pain, incontinence of urine and to
restrain glandular activity.
Dose.—Fl. ext. 1–3 ♏︎; dry ext. ½–1 gr. Tincture 8–20 ♏︎. Solid ext. ½¼ gr.
All for adults. For infants, proportionately less. See Rule for Dosage.
Benzoin. Antiseptic and externally a styptic and protective for sores.
Uses.—Sore nipples and urticaria. Lard is also benzoinated for use in
removing vernix caseosa. Compound Tr. of benzoin contains, benzoin,
purified aloes, storax, balsam of Peru, and alcohol.
Benzoinal. Albolene mixed with benzoin.
Bismuth Subnitrate. A white heavy powder. Antiseptic and astringent.
Uses.—Subacute gastritis, pyrosis, diarrhœa and vomiting of pregnancy.
Particularly desirable in infancy because it is free from arsenic, lead and
silver.
Dose.—5–60 gr. in the adult.
Boric Acid (Boracic Acid). A white crystalline powder. Antiseptic.
Uses.—As a dressing and lotion for eyes, navel, mouth, nipples, and all
mucous surfaces. In solution to preserve the sterility of rubber nipples until
they are needed.
Dose.—Internally, 5–15 gr. Solutions are usually about 4% or 5%. A
saturated solution in water is about 6%. In hot water 25%.
Boroglyceride. An antiseptic paste of boric acid and glycerine. When an
excess of glycerine is present the preparation is called boroglycerol.
Uses.—An oxydizer in endometritis. It is applied to the cervix on cotton
tampons.
Calcium (Lime). Stomach sedative, soothes the irritated or burned skin,
corrects hyperacidity, increases the clotting power of the blood (?).
Lime water is a saturated solution of calcium hydrate and is used for
nausea, to break up the curds of milk, and to increase its digestibility. It is
mildly constipating.
Calomel. See Mercury.
Camphor. A solid volatile oil. Nerve sedative. Anaphrodisiac. Antispasmodic.
Stimulant.
Uses.—The monobromated camphor is given internally for hysteria,
neuralgia, and as a hypnotic.
Dose.—1–10 gr.
Camphorated Oil. A solution of camphor in cottonseed oil. Rubefacient and
stimulant.
Uses.—Internally in collapse. Externally as an application to the child for
colds of chest and nose.
Dose.—5–20 ♏︎ hypodermically in collapse. The injection should be made
deep into the muscle.
Carbolic Acid (Phenol). Derived from coal tar. Antiseptic, deodorant and local
anæsthetic.
Uses.—Vomiting of pregnancy, pruritus, eczema, sterilization of
instruments. Usual solution is 2½% to 5%. For sterilization of knives,
scissors and other sharp instruments the 95% is used. In pruritus, the
following wash will aid: carbolic acid, 12 dr., glycerine 2 dr., alcohol, 4 ʒ
water q.s. 1 pt. Apply.
Cascara Sagrada. Stimulant laxative, and cathartic. Useful in pregnancy, but
after labor there is evidence that it may go over in the milk to the child.
Dose.—Fl. ext. 10–20 ♏︎. The Hinkle pill contains cascara.
Castor Oil. Oil expressed from the seeds of the castor plant. A cathartic. Acts in
four or five hours.
Dose.—For adults, ½ oz. to 1 oz. For infants 10 to 60 drops given with a
dropper—not with a spoon.
Castor oil cocktail.—Rinse out the glass with lemon juice or whiskey. Pour in
teaspoonful of lemon juice and a teaspoonful of whiskey, add castor oil in
amount required, cover with whiskey and give.
A paste is made from the mixture of castor oil and bismuth subnitrate in
equal parts, which is an excellent preparation for sore nipples.
 Cerium Oxalate (and Cerium Valerianate). Sedative and nerve tonic. The
oxalate is a white crystalline powder, odorless and tasteless.
Uses.—Vomiting of pregnancy, seasickness.
Dose.—2–10 gr. several times daily.
Charcoal. Administered in tablet form or as a powder between two slices of
buttered bread.
Uses.—Acid stomach. Vomiting of pregnancy.
Chinosol. Nonpoisonous, nonirritating and odorless. Antiseptic deodorant,
styptic and analgesic. Dissolves instead of coagulates secretions.
Uses.—Antiseptic solutions for hands and sponges, deodorizing wash for
vagina post partum, intrauterine douche, wash for gonorrhœa and cystitis.
Dose.—For douche or hand solution 1:1000 or 1:5000. For dusting powder,
1 part to 10 or 20 of starch, talcum, boric acid, or bismuth subnitrate.
Chinosol will corrode unplated steel. It may be mixed with salt, but not with
soap.
Choral Hydrate. White crystal masses. Pungent in odor and taste. Hypnotic,
antispasmodic, antiseptic and analgesic.
Uses.—Insomnia, eclampsia, convulsions, and to restrain secretion of milk.
Dose.—By mouth, 10–30 gr. By rectum, not to exceed 60 gr. In infants 1–2
gr. by rectum in an ounce of water.
Chymogen. A preparation of rennin (10%) made by Armour & Company.
Coagulen Ciba. A physiological nontoxic styptic, prepared from the natural
coagulants of the blood. A 10% solution in water will hasten the beginning
and end of coagulation. May be applied to bleeding surfaces directly, or
given under the skin, into the muscle, or into a vein. 3½% to 5% solution in
distilled water, should be sterilized by boiling 2–3 minutes. Do not filter.
Inject.
Cocaine Hydrochlorate. Anæsthetic, sedative, anodyne, anti-pruritic.
Uses.—Vomiting of pregnancy, with caution.
Dose.—Internally ½–1½ gr. Externally a 4%–10% solution in water.
Codeine. Alkaloid of opium. Less narcotic than morphine.
Uses.—After-pains and pain of over-distended breasts.
Dose.-¼–1½ gr. by mouth. ¼–¾ gr. hypodermically.
Compound Licorice Powder. See Senna.
Condylomata.
 Use—
℞ Acid. Salicyl. gr. x
Acid Boric. gr. xxx
Calomel. ʒ i
M.
Sig.: Apply twice daily.
Digitalis. Cardiac tonic. Diuretic. Stimulant.
Uses.—Weak heart. Syncope. Collapse.
Dose.—For adult: of the tincture, 5–15 ♏︎, fl. ext. 1–3 ♏︎, ext. gr. 1/6½.
Digipuratum. A preparation of digitalis from which the inactive substances
have been removed. It is used in the same conditions as digitalis.
Dose.—The tablets contain 1½ gr. and one is given four times daily until ten
are taken. Then stop. Hypodermically. Each viol contains 1 c.c. of fluid and
equals 1½ gr. of digipuratum. Each dose contains enough of the active
principle of digitalis to kill a 30 gm. frog.
Ergot (Fungus of Rye). Contracts unstriped muscle fiber.
Uses.—To check hæmorrhage after labor. To promote involution. Must not
be given in labor until the uterus is empty.
Dose.—By mouth 15–60 ♏︎of the fl. ext. Hypodermically, 10–20 ♏︎.
Ergotole, Ergotine. Concentrated solutions of ergot, 2½ times as strong as
the fluid extract. They are sterilized and preserved in glass ampoules.
Uses.—See Ergot.
Dose.—30–60 ♏︎.
Green Soap. A soap made of linseed or other oil, potash, alcohol and water.
“The adoption by the U. S. Pharmacopoeia of the term Sapo Viridis (green
soap) is unfortunate, since soft soap even if made from green hempseed oil
will become brown-yellow unless artificially colored.”—U. S. Dispensatory.
Hæmophilia. A condition of the blood wherein its clotting power is
diminished or absent.
Coagulen, horse serum, or diphtheria antitoxin may be given
hypodermically. Direct transfusion of blood from another is best.
Hyoscine, Morphine, and Cactin. (H. S. & C. Tablets). A proprietary
combination of drugs. The action is said to be similar to that of morphine
and scopolamine.
Iodine, Tincture.
 Uses.—To sterilize the skin before operation. In vomiting of pregnancy it is
sometimes effective. Drop doses may be given well diluted. Externally it is
applied to ulcers, as in Bednar’s disease, and sometimes as a dressing for
the cord. In pruritus vulvæ it is a valuable application.
Iron. Tonic emmenagogue.
Uses.—To increase the number of red blood corpuscles. To raise blood
pressure and to increase the secretion of milk.
Dose.—3–5 gr. Blaud’s pill contains the carbonate in a form that is easily
assimilated.
Laxatives. Laxatives are unirritating and excite moderate peristalsis. Sulphur,
magnesia, cassia, manna, cascara sagrada, the Hinkle pill, and the A, B, & S
pill are usually mild in action.
Lysol. Disinfectant and antiseptic for hands and instruments. It is a brown
syrupy fluid made from coal tar oil, which is distilled and mixed with fat,
soap, etc. It has a creosote odor and contains 50% cresol. Readily soluble in
water. Prepared in ½–4% solutions.
Magnesia, Calcined. Antacid and cathartic. Comes in white cakes.
Uses.—Acid stomach, vomiting of pregnancy, “heartburn,” and constipation.
Dose.—30–120 gr.
Magnesia, Milk of. A mixture of magnesia and water. Has the same
properties as the above.
Dose.—For adults, 2–3 teaspoonfuls. For infants, ¼–2 teaspoonfuls.
Magnesia Sulphate (Epsom Salts.). Saline cathartic.
Uses.—The profuse watery stools produced by magnesia are valuable aids to
elimination when the kidneys are overworked or defective. In congestion of
the breasts and threatened eclampsia, or in any case where it is desirable to
drain off waste or dehydrate the system.
Dose.—1 teaspoonful daily in hot water before breakfast. ½–1 oz. as a single
dose or 1 oz. by rectum, as in the 1–2–3 enema.
Menthol (Mint Camphor, Japanese Peppermint). Analgesic, antiseptic,
anæsthetic, and vascular stimulant.
Uses.—In pruritus vulvæ, vomiting of pregnancy, and hæmorrhoids.
Dose.—By mouth 3–5 gr. In tampons, one part to five of oil. In ointments
one part to sixteen. To the vulva for pruritus, use the spirits in 5% solution.
Mercury (Hydrargyrum). Cathartic, alterative, antisyphilitic, antiseptic and
disinfectant. Readily absorbed by the unprotected mucous surface and
relatively inert when the membrane is covered by a discharge. Solutions of
the bichloride when used as a lotion unite with the albumin of a mucous
 discharge and form an albuminate of mercury, which is inactive. Bichloride
solutions have small place in obstetrics. They are hard on the hands and
destructive to instruments. Other agents like lysol, ziratol and chinosol have
satisfactory germicidal properties and in addition are nonpoisonous,
lubricative and cleansing.
Mercury should only be given to the infant in the form of calomel (the mild
1
chloride). The dose is 12 -⅛ gr., repeated if necessary.

Morphine. Alkaloid of opium.

Antispasmodic, hypnotic, analgesic and narcotic.
Uses.—To relieve pain, produce sleep, check diarrhœa, and to control the
pain, as well as the contractions of abortion. To relax a rigid os.
Dose.—In “Twilight Sleep” and rigid os the first dose is Morph. sul. 1/6¼ gr.
and scopolamine Hydrobromid 1/200–1/150. The scopolamine to be
repeated if required, in one-half or three-quarters of an hour. The usual
1
dose of morphine hypodermically is 12 ½ gr.
Nitroglycerine (Glonoin). Vasomotor dilator, arterial stimulant.
Uses.—For the prostration following hæmorrhage.
Dose.-½00–1/50 gr. hypodermically.
Novocaine. Local anæsthetic, similar to cocaine, but less toxic. For local
anæsthesia in solutions of 0.25% to 2% usually in association with adrenalin
(5–10 drops of the 1:1000 solution to each 10 c.c. of novocaine solution).
Nux Vomica. The plant from which strychnia is derived. Tonic, stomachic, and
stimulant to muscle, nerve, and heart.
Uses.—Bitter tonic and stimulant. Vomiting of pregnancy and agalactia.
Dose.—Ten drops of the tincture in water before meals.
Opium. The concrete juice of the poppy. Relieves pain. Constipates.
Uses.—Hæmorrhoids in adults, colic and diarrhœa in infants.
Dose.—One grain in suppository night and morning for adult. For infant, as
paragoric only. Two to five drops only, not repeated. Children bear opium
badly.
Pepsin. A ferment in the gastric juice that digests proteins. In commerce it is
obtained from the pig.
Uses.—Imperfect digestion.
Dose.—For adult, 10–15 grs. For infant, 2 gr.
Phenolphthalein. A nonofficial coal tar derivative. Mild laxative.
 Dose.—2–3 gr. Phenolax and chocolax are preparations of the drug.
Pituitary Extract (Pituitrin). A substance derived from the infundibular
portion or the posterior lobe of the hypophysis cerebri. Nontoxic, stimulant
to unstriped muscle.
Uses.—Uterine inertia, post partum hæmorrhage, Cæsarean section and
tympany. Will not produce abortion nor premature labor. May be tried in
acute anæmia to raise the blood pressure.
Dose.—5–15 ♏︎. Repeated if necessary.
Potassium (or Sodium) Bromide. White granular powder. Soluble, 1 to 5 in
water. Sedative, hypnotic, antiepileptic.
Uses.—Neurasthenia, convulsions, nymphomania, vomiting of pregnancy.
Dose.—20–60 gr. In enema with chloral. Pot. bromide 40 gr. and chloral 20
gr. in several ounces of water or milk.
Potassium Iodide. Alterative emmenagogue. Uric acid solvent.
Uses.—Syphilis rheumatism, swellings, slow inflammations, excessive
secretion of milk.
Dose.—2–10 gr. increased as required.
Potassium Permanganate. Dark purple opaque prisms. Soluble in water 1 to
16. Disinfectant, deodorant, antiseptic, astringent.
Uses.—As an injection in leucorrhœa and gonorrhœa, 1:5000 solution.
Purgatives. Simple purgatives produce free discharges from the bowels with
some griping. Senna, aloes, rheubarb, castor oil, and calomel are examples.
Saline purgatives are followed by profuse watery evacuations. Magnesia
sulphate, and citrate, potassium and sodium tartrate, and sodium
phosphate belong to this class.
Drastic purgatives bring about a violent action of the bowels with much
griping and tenesmus. Such are jalap, colocynth, elaterium, and croton oil.
Hydrogogue purgatives combine the results of the salines and drastics. They
have much griping with profuse watery stools. The hydrogogues are
elaterium, gamboge, croton oil, and potassium bitartrate.
Quinine Sulphate. (Derived from Cinchona bark.) Antipyretic, tonic,
antiperiodic, antiseptic, emmenagogue and ecbolic.
Uses.—Valuable stimulant in a slow first stage. It is combined with castor oil
to bring on labor at term. Castor oil 1 oz. and quinine sulphate 10 gr. is
given as the first dose, followed in an hour by another 10 gr. of quinine, and
an hour later by another.
Dose.—2–20 gr.
Regulin. A mixture of agar-agar in dry form with extract of cascara sagrada.
Uses.—A laxative in chronic constipation.
Dose.—Teaspoonful to tablespoonful in stewed fruit or mashed potatoes,
once daily.
Russian Oil (Liquid Petrolatum). Laxative in pregnancy and puerperium. Acts
mechanically and as a lubricant. Not unpleasant to take.
Dose.-½ oz. at bedtime, and, if necessary, before each meal. May be given to
breast-fed babies in doses of gtts. xv three times daily.
Senna. Laxative and purgative. Acts especially on the large intestine.
Sometimes passes over in the milk to the child.
Dose.—Fl. ext. 1–4 teaspoonfuls. In compound licorice powder the dose is
30–80 gr. (about 10 gr. of senna to the dose).
Silver Nitrate. Caustic, antiseptic, stimulant, irritant and antigonorrhœic.
Table salt neutralizes it.
Uses.—2% solution in water for pruritus vulvæ. 1% solution dropped into
the eyes of the newborn to prevent ophthalmia neonatorum. Do not
neutralize the 1% solution. ¼ gr. silver nitrate with 2 gr. of pepsin in
capsule for pernicious vomiting of pregnancy.
Sodium Bicarbonate (Baking powder). Antacid, antirheumatic.
Uses.—Gout, dyspepsia, acid stomach, acidosis, vomiting of pregnancy.
Soothes the skin when burned.
Sodium Chloride. (Salt.)
For normal saline use 10 gr. to 3½ oz. of water. For physiological salt
solution, add 15 gr. of Sod. Carb. to every 3½ oz. of normal saline as made
above.
Sodium Citrate. A white odorless, granular powder with cooling salty taste.
Uses.—Diuretic, antipyretic and refrigerant. Retards the coagulation of
albumin in milk and aids the digestibility of proteins. May be indicated in
gout and cystitis.
Dose.—Internally, 15 to 60 gr. In the modification of cow’s milk about two
grains should be used for each ounce of the mixture.
Spirits of Nitre, Sweet (Spirit Nitrous Ether). 4% solution of nitrous ether in
alcohol. Diaphoretic, diuretic, antipyretic, stimulant, antispasmodic.
Uses.—Fever, dropsy, vomiting of pregnancy, colic, anuria.
Dose.—For adult, 20–60 gtts. For infants small doses often repeated.
Stramonium (Jimson Weed). Hypnotic, narcotic, antispasmodic.
 Uses.—For hæmorrhoids take Ung. Stramonii and Ung. Galli in equal
amounts and apply.
Urotropin. A white powder soluble in water. Urinary antiseptic, diuretic.
Uses.—Cystitis, typhoid bacilli in urine, gout. It makes the urine irritatingly
acid when given long. It does not act in alkaline media.
Dose.—7½–10 gr. well diluted.
Valerian. Anodyne, stimulant, antispasmodic and nervine.
Uses.—Hysteria, hypochondriasis, headache.
Dose.—30–60 ♏︎of the fl. ext. by mouth, or by rectum 2 oz. of the following
mixture may be used P.R.N. for hysteria:
Pot. Brom. 1 oz.
Ext. Valerian fl. dr. vi.
Normal saline q.s. oz xii.

Veratrum Viride (Hellebore). Sedative, emetic, diaphoretic, diuretic. Retards

the heart’s action without weakening it.
Uses.—Eclampsia.
Dose.—1 to 4 ♏︎ of the fl. ext. is given hourly until the pulse comes down to
80.
Veronal. Safe, reliable hypnotic.
Uses.—Insomnia from hysteria, neurasthenia, and mental disturbance.
Dose.—5 to 15 gr. dissolved in hot tea, milk, or water. May repeat.
Zinc. Tonic, astringent, antispasmodic.
Uses.—Stearate of zinc is a valuable dressing in excoriations of buttocks and
external genitals.
Zinc Ointment. It is indicated for bedsores (decubitus) eczema, herpes, and
intertrigo. Zinc ointment contains one part of zine oxide to four parts of
benzoinated lard.
Ziratol. A mixture of phenols in soap, water, and glycerine. Antiseptic,
deodorant and germicide. Relatively odorless, easily soluble and does not
injure hands, instruments, or rubber. It is said to be only ⅐ as toxic as
carbolic acid. Used in solutions of 0.5% up to 5%.
 GLOSSARY

[Adapted from Dorland and Standard Dictionaries]

Ab-nor´mal. Not normal; contrary to the usual structure or condition.

A-bor´tion. 1. The expulsion of the fœtus before it is viable. 2. Premature
stoppage of a morbid or a natural process.
Ab-ra´sion. 1. A rubbing or scraping off. 2. A spot rubbed bare of skin or
mucous membrane.
Ab´scess. A localized collection of pus in a cavity formed by the disintegration
of tissues.
Ac-couch´e-ment. Delivery in childbed; confinement.
Ac´e-tone. 1. A colorless liquid found in pyro-acetic acid and in naphtha. 2.
Any member of the series to which the normal or typical acetone belongs.
A´ci-do´´sis. Acid intoxication of the system from the elaboration or too much
acid by faulty metabolism or the imperfect disposition of normal amounts of
acid.
A-ci´nus, pl. acini. One (acini, more than one) of the smallest lobules of a
compound gland.
Al´bo-lene. An oily white substance derived from petroleum.
Al´bu-mi-nu´´ri-a. The presence of albumin in the urine.
Al´ka-line. Having the reaction of an alkali.
A´men-or-rhœ´´a. Absence or abnormal stoppage of the menses.
Am-mo´ni-a. A colorless alkaline gas, NH3, of penetrating odor, and soluble in
water, forming ammonia-water. Ammoniacal urine contains ammonia, which
is one form of nitrogen excretion.
An-æ´mi-a. A condition in which the blood is deficient in quantity or in
quality.
An´æs-the´´si-a. Loss of feeling or sensation, especially loss of tactile
sensibility, though the term is used for loss of any of the other senses.
An´æs-thet´´ic. 1. Without the sense of touch or of pain. 2. A drug that
produces anæsthesia.
An´al-ge´´si-a. Absence of sensibility to pain.
An-aph´ro-dis´´i-ac. A drug that allays sexual desire.
An´a-sar´´ca. An accumulation of serum in the cellular tissues of the body.
An´en-ceph´´al-ous. Having no brain.
An´ky-lo´´sis. Abnormal rigidity or stiffness of a joint.
An´o-dyne. A medicine that relieves pain.
An´te par´tum. Latin for “before delivery.”
An-te´ri-or. Situated in front of, or in the forward part of.
An´ti-pe´ri-od´´ic. A drug that tends to prevent recurrent attacks of disease.
An´ti-sep´´tic. 1. Preventing decay or putrefaction. 2. A substance destructive
to poisonous germs.
A-pe´ri-ent. Mildly cathartic.
Ap-nœ´a. The absence of respiration—especially that form which occurs in a
child delivered by the Cæsarean operation.
A-re´o-la. The darkish ring around the nipple.
As-ci´tes. Dropsy (an accumulation of fluid) in the abdomen.
A-sep´sis. Absence of septic matter, or freedom from infection.
As-phyx´i-a. Suffocation.
As-trin´gent. 1. Causing contraction and arresting discharges. 2. An agent that
arrests discharges.
At´e-lec-ta´´sis. Imperfect expansion of the lungs at birth; partial collapse of
the lung.
At´on-y. Lack of normal tone or strength.
A´tri-um. (L., a hall.) The point of entrance of a bacterial disease.
At´ti-tude. A posture or position of the body. The relation which the various
parts of the child’s body bears to its own long axis. The attitude of the fœtus
normally is complete flexion.
Aus´cul-ta´´tion. The act of listening for sounds within the body.
Bac-te´ri-a. The vegetable microorganisms (Schizomycetes) especially the
short-rod forms.
Bal´an-i´´tis. Inflammation of the glans penis. It is usually associated with
phimosis.
Bal-lotte´ment. The diagnosis of pregnancy by pushing up the uterus by a
finger inserted into the vagina so as to cause the embryo to rise and fall again
like a heavy body in water.
Bar´tho-lin glands. The vulvo-vaginal glands.
Bleb. A skin vesicle filled with fluid. A blister.
Breg´ma. The point on the surface of the skull at the junction of the coronal
and sagittal sutures.
Cæ-sa´re-an sec´tion. (Named from Julius Cæsar, who is said to have been
thus born). Delivery of the fœtus by an incision through the abdominal and
uterine walls.
Ca´put. Any head, or head-like structure.
Ca´put suc´ce-da´´ne-um. A swelling formed on the presenting part of the
fœtus during labor. It is due to the effusion of fluid into the subcutaneous
tissues of the scalp and its retention there.
Car-min´a-tive. Drugs that stimulate the circulation, the mental faculties, and
intestinal peristalsis. Asafœtida, camphor, capsicum, cardamon, chloroform,
ether, ginger, horseradish, mustard, and the oils of anise, cloves, spearmint,
nutmeg and valerian are carminatives.
Car´ne-ous. Fleshy.
Cath´e-ter, tra´che-al. A long slender tube designed for introduction into the
babe’s trachea as a means of sucking out mucus.
Cath´´e-ter-ize´. To introduce a tube and draw off fluid, as urine or mucus.
Caul. 1. The great omentum. 2. A piece of amnion which sometimes envelopes a
child’s head at birth.
Cell. 1. Any one of the minute protoplasmic masses which make up organized
tissue.
Ceph-al´ic. 1. Pertaining to the head. 2. A medicine for the head.
Ceph´al-hæ-ma-to´´ma. 1. A tumor or swelling filled with blood beneath the
pericranium.
Cer´vix. The neck or any neck-like part.
Chlo-as´ma. The yellowish brown spots or patches that appear on the skin of
pregnant women.
Cic´a-tri´´cial. Pertaining to, or of the nature of, a cicatrix.
Ci-ca´trix. A scar; the mark left by a sore or wound.
Cil´i-a. 1. The eyelashes. 2. Minute lash-like processes that characterize certain
cells.
Cli´mac-ter´´ic. A particular epoch of the ordinary term of life at which the
body is believed to undergo a radical change—especially applied to the
menopause.
Cli-ni´cians. Men who teach and explain diseases by showing actual cases.
Clit´o-ris. The sensitive organ of the female, homologous with the penis in the
male.
Coc´cyx. The small bone situated at the end of the sacrum. The very last
portion of the spine.
Col-lapse´. A state of extreme prostration and depression with failure of
circulation.
Col´les’ mem´brane. A layer of tough sensitive fascia back of the perineum
and on either side of the vagina.
Co-los´trum. The first fluid secreted by the mammary glands after functional
activity begins. It contains casein and more albumen than milk, as well as
numerous fatty globules.
Col´peu-ryn´´ter. A dilatable bag, used to distend the vagina.
Co´ma. Profound stupor occurring in the course of a disease or after severe
injury.
Co´ma-tose. Pertaining to, or affected with, coma.
Com´pli-ca´´tion. A disease or diseases concurrent with another disease.
Con-cep´tion. The fecundation of the ovum.
Con´dyl-o´´ma. A wart-like excrescence near the anus or vulva. It may be as
large as a cauliflower.
Con-gen´i-tal. Born with a person; existing at or before, birth.
Con´ju-gate. The anteroposterior diameter of the pelvic inlet.
Cor´o-nal. Pertaining to the crown of the head, as the coronal suture.
Cra´dle cap. The dirty looking patch of epithelial scales and sebaceous
material that develops over the anterior fontanelle of babies who have the
exudative diathesis.
Cra´ni-ot´´o-my. The cutting in pieces of the fœtal head to facilitate delivery.
Cre-dé Expression. The maneuver in which the uterus is grasped in the
hollow of the hand and squeezed and pressed down upon to aid in the
expulsion of the placenta.
Cre-dé Treatment. The instillation of a 1% solution of nitrate of silver into the
eyes of the newborn to prevent ophthalmia.
Curd. The coagulum of milk, consisting mainly of casein.
Cy´an-o´´sis. Blueness of the skin, often due to cardiac malformation causing
insufficient oxygenation of the blood.
Cys-ti´tis. Inflammation of the bladder.
De-cid´u-a. The membranous structure produced in the uterus during
gestation and thrown off after parturition. D. reflexa, the part of decidua
which is reflected upon and surrounds the ovum. D. serotina, the late
decidua; the part of the decidua vera which becomes the maternal portion of
the placenta. D. Vera, the true decidua; the portion of the decidua which lines
the uterus.
De-cu´bi-tus. 1. An act of lying down. 2. A bed-sore.
De-hy´drate. To remove the water.
Di´a-be´´tes. A disease marked by an habitual discharge of an excessive
quantity of urine and the presence of sugar therein.
Di´´aph-o-re´sis. Perspiration, and especially profuse perspiration.
Di´´aph-o-ret´ic. 1. Stimulating the secretion of sweat. 2. A medicine that
increases the perspiration.
Di-ath´e-sis. Natural or congenital predisposition to a special disease.
Dif´fer-en´´tial. Pertaining to a difference, or differences.
Dis-crete´. Separate lesions which do not blend or coalesce.
Di´u-re´´sis. Increased secretion of urine.
Dor´sum. The back or any part corresponding to the back as the dorsum of the
penis or foot.
Duc´tus ve-no´sus. A fœtal blood vessel connecting the umbilical vein with
the post-cava.
Dys-cra´si-a. A depraved state of the system, and especially of the blood, due
to constitutional disease.
Dysp-nϫa. Difficult or labored breathing.
Dys-to´ci-a. Painful or slow delivery or birth.
Ec-bol´ic. An agent that accelerates labor.
E-clamp´si-a. A sudden attack of convulsions, especially one of a peripheral
origin.
Ec-top´ic. Out of the normal place.
E-de´ma. Swelling due to effusion of watery liquid into the connective tissue.
Em´bo-lism. The plugging of an artery or vein by a clot or obstruction which
has been brought to its place by the blood-current.
Em´bry-o. The fœtus in its earlier stages of development, especially before the
end of the third month.
Em-men´a-gogue. A drug that aids or stimulates menstruation.
E-mul´sion. An oily or resinous substance divided and held in suspension
through the agency of an adhesive, mucilaginous, or other substance.
En´do-me´´tri-um. The mucous membrane that lines the cavity of the uterus.
En-gage´ment. The head is said to be engaged when the largest diameters
have passed the inlet.
En´si-form. Shaped like a sword.
Ep´i-si-ot´´o-my. Surgical incision of the vulvar orifice laterally for obstetric
purposes.
E-ro´sion. An eating or gnawing away.
Er´y-the´´ma. A morbid redness of the skin due to congestion of the
capillaries, of many varieties.
E´ti-ol´´o-gy. The study or theory of the causation of any disease.
Ex-co´´ri-a´tion. Any superficial loss of substance such as that produced on
the skin by scratching.
Ex´os-mo´´sis (Ex-os-mose). Diffusion or osmosis from within outward.
Ex-san´guin-a´´tion. An exhaustion of the blood from a part or the whole of
the body.
Ex-trac´tion. The process or act of pulling or drawing out, particularly the
removal of a child by pulling either with hands or forceps.
Ex´tra-u´´ter-ine. Situated or occurring outside of the uterus.
Ex´´u-da´tive di-ath´e-sis. A congenital predisposition to eczema in various
parts of the body, as well as to infections of the respiratory tract.
Fæ´ces (or fe´ces). The excrement or undigested residue of the food discharged
from the bowels.
Fen´es-tra-ted. (L., fenestrum, a window.) Pierced with one or more openings,
like windows.
Fer´ment. Any substance that causes fermentation in other substances with
which it comes in contact.
Fi´brin. A substance which, becoming solid in shed blood, plasma and lymph,
causes the coagulation of these fluids.
Fil´let. 1. A loop-shaped structure. 2. A loop, as of cord or tape, for making
traction.
Fis´sure. A cleft or groove, normal or other.
Fis´tu-la. A deep, sinuous ulcer, often leading to an internal hollow organ.
Flu´id ex´tract. A concentrated solution of the active principle of a drug in
such strength that 1 c.c. of the product equals 1 gr. of the crude drug. The fluid
is a mixture of alcohol, water and glycerine in varying proportions. One may
be omitted.
Fœ´tus (or fe´tus). The unborn offspring of any animal that brings forth living
progeny; the child in the womb after the third month.
Fon´ta-nelle´´. Any one of the unossified spots on the cranium of a young
infant. It is so named because it rises and falls like a fountain.
Fo-ra´men. A hole or perforation, especially a hole in a bone.
Four-chette´. The fold of mucous membrane at the posterior junction of the
labia majora.
Fræ´num (or fre´num). A fold of the integument or of the mucous membrane
that checks, curbs, or limits the movements of an organ in part—as the
frænum of the tongue.
Func´tion. The normal or proper action of an organ or set of organs.
Func´tion-al. Of or pertaining to a function.
Fun´dus. The base or part of a hollow organ remotest from its mouth.
Ga-lac´tor-rhœ´´a. Excessive secretion of milk.
Ga-vage´. Feeding by the stomach tube; also the therapeutic use of a very full
diet.
Gen´it-als. The reproductive organs.
Ger´´mi-cide´. An agent that destroys germs.
Ges-ta´tion. Pregnancy.
Glans cli-tor´i-dis. The distal or outside end of the clitoris.
Glans pe´nis. The head, or terminal end, of the penis.
Gon-or-rhϫa. A contagious catarrhal inflammation of the genital mucous
membrane.
Graaf´i-an fol´li-cle. Any one of the small spherical ovarian bodies, each of
which contains an ovum.
Hæm´o-phil´´i-a. A condition of the system wherein bleeding occurs readily,
and the blood clots slowly or not at all.
Hæm´or-rhage. A copious escape of blood from the vessels; bleeding.
Accidental h., hæmorrhage during pregnancy, due to premature detachment
of the placenta. Post partum h., that which occurs soon after labor, or
childbirth. Unavoidable h., that which results from the detachment of a
placenta prævia.
Hæm´or-rhoid. A pile, or vascular tumor of the rectal mucous membrane.
Hy-dat´id. An encysted vesicle containing an encysted fluid. From the Greek
“Hydatis,” meaning a drop of water.
Hy-dat´i-form. Resembling a hydatid in form.
Hy-dram´ni-os. Dropsy of the amnion.
Hy´dro-ceph´´a-lous. A fluid effusion within the cranium. This disease is
marked by enlargement of the head, with prominence of the forehead, atrophy
of the brain, mental weakness, and convulsions.
Hy´giene. The science of health and of its preservation.
Hy´men. The membranous fold which partially or wholly occludes the external
orifice of the vagina, at least during virginity.
Hy´per-em´´e-sis. Excessive vomiting. H. gra-vi-da´rum, excessive
vomiting of pregnancy.
Hy´per-æ´´mi-a. Excess of blood in any part of the body.
Hy-per´tro-phy. The morbid enlargement or overgrowth of a part.
Hyp-not´ic. A drug that induces sleep.
Hy´po-der-moc´´ly-sis. The introduction, into the subcutaneous tissues, of
fluid in large quantity.
Hy´po-gas´´tric. Of or pertaining to the lower anterior region of the abdomen
in the middle line of the body. The hypogastric arteries arise from the internal
iliac in addition to the branches given off from those vessels in the adult.
Hy´po-phos´´phite. Any salt of hypophosphorous acid.
Ic´ter-us. Jaundice.
Id´i-o-syn´´cra-sy. An effect abnormal to the one usually produced. An effect
peculiar to the individual.
Im-mu´ni-ty. The condition of being immune or exempt from disease,
especially the condition arising from inoculation, or from a peculiar resistance
of the organism.
Im´preg-na´´tion. 1. The act of fecundation or of rendering pregnant. 2. The
process or act of saturation, a saturated condition.
In´farct. A mass of substance extravasated either into the substance of an
organ or into a vessel due to the obstruction to the circulation.
In´´fan-tile´ pel´vis. A pelvis which has not responded to the developmental
stimulation of the sexual glands at puberty, and therefore remains in its
infantile shape. A masculine pelvis.
In´´fan-tile´ u´ter-us. An undeveloped uterus.
In-fec´tion. The communication of disease from one person to another,
whether by effluvia or by contact, mediate or immediate; also the implantation
of disease from without.
In´fil-tra´´tion. To cause a liquid or gas to penetrate or enter by pores or
interstices.
In´flam-ma´´tion. A morbid condition characterized by pain, heat, redness
and swelling.
In-nom´in-ate. Not having a name, as the innominate bone.
In-som´ni-a. Inability to sleep; abnormal wakefulness.
In´ter-sti´tial. Pertaining to, or situated in, the interstices or interspaces of a
tissue.
In´ter-tri´´go. A chafe, or chafed patch of the skin; also the erythema or
eczema that may result from a chafe of the skin.
In-tro´i-tus. The entrance to any cavity or space.
In-ver´sion. A turning inward, inside out, upside down, or other reversal of the
normal relation of a part.
In´vo-lu´´tion. 1. A rolling or turning inward. 2. The return of the uterus to its
normal size after parturition. 3. A retrograde change, the reverse of evolution.
Is-chu´ri-a par-a-dox´a. A condition in which the bladder is over-distended
with urine, although the patient continues to urinate, generally in dribbles.
Jaun´dice. Yellowness of the skin, eyes, and secretions, due to the presence of
bile pigments in the blood.
La´bi-a. Lip-shaped organs. The external folds of the vulva, labia majora, and
the internal folds of the vulva, labia minora.
Lac´e-ra´´tion. 1. The act of tearing. 2. A wound made by tearing.
Lac-ta´tion. 1. The secretion of milk. 2. The period of the secretion of milk. 3.
Suckling.
Lan-u´go. The fine hair on the body of the fetus.
Lav-age´. The irrigation or washing out of an organ, such as the stomach or
bowel.
Le´sion. Any hurt, wound or local degeneration.
Leu´cor-rhœ´´a. A whitish, viscid discharge from the vagina and uterine
cavity.
Light´en-ing. The sense of lightness and easier breathing that follows the
descent of the head into the pelvis during the last three weeks of pregnancy. It
is most likely to occur in primiparas.
Lo´chi-a. The vaginal discharge that takes place during the first week or two
after childbirth.
Lymph. A transparent slightly yellow liquid of alkaline reaction which fills the
lymphatic vessels.
Mal-aise´. An uneasiness or indisposition, discomfort or distress.
Mal´po-si´´tion. Abnormal or anomalous position.
Mam´ma. The mammary gland; the breast.
Mam´ma-ry. Pertaining to the Mamma.
Ma-ras´mus. Progressive wasting and emaciation, especially such a wasting in
young children when there is no obvious or ascertainable cause.
Mas-sage´. The systematic, therapeutic friction, stroking and kneading of the
body.
Mas-ti´tis. Inflammation of the breast.
Me-a´tus. A passage or opening, as the meatus urinarius.
Me-læ´na ne-o-na-to´rum. The passage of dark pitchy stools containing
blood pigments and blood that has been extravasated into the alimentary
canal of the newborn babe.
Mem´brane. A thin layer of tissue which covers a surface or divides a space or
organ.
Men´o-pause. The period when menstruation normally ceases; the change of
life.
Mis-car´riage. Abortion; premature expulsion of the fœtus; birth of the fœtus
before the twenty-eighth week.
Milk leg (Phlegmasia Alba Dolens). A condition developing in one, and rarely,
in both, legs, after delivery. It is due to occlusion of the veins of the pelvis and
leg by thrombosis or to septic inflammation of the pelvic connective tissue.
Mole. 1. A fleshy mass or tumor formed in the uterus by the degeneration or
abortive development of an ovum. 2. A nevus; also a brownish spot on the
skin.
Mons ven´er-is. A rounded prominence at the symphysis pubis of a woman.
Mor-bid´i-ty. The condition of being diseased or morbid.
Mor´cel-la´´tion. Division and piecemeal removal.
Mu´cus. The viscid watery secretion of the mucous glands.
Mul-tip´ar-a. A woman who has borne more than one child.
Mum´mi-fi-ca´´tion. Dry gangrene; also the drying up and shrivelling of the
fœtus.
Myd´ri-at´´ic. A drug that dilates the pupil.
Nau´se-a. Tendency to vomit; sickness at the stomach.
Ne-cro´sis. Death of a tissue, especially of a bone.
Ne-phri´tis. Inflammation of the kidney.
Neu-rot´ic. 1. Pertaining to or affected with a neurosis. 2. Pertaining to the
nerves.
Neu´tra-lize. To render neutral or ineffective.
Ni´tro-gen. A colorless gaseous element found free in air.
Nod´u-lar. 1. Like a nodule or node. 2. Marked with nodules.
Nu´cle-us. 1. a spheroid body within a cell, forming the essential and vital part.
2. A mass of gray matter in the central nervous system. 3. In chemistry, the
central element in the molecule of a compound.
Nu´tri-ent. Nourishing; affording nutriment.
Nym´phæ. The labia minora.
Ob-stet´rics. The art of managing childbirth cases; that branch of surgery
which deals with the management of pregnancy and labor.
Ob-ste-tri´cian. One who practices obstetrics.
Oc´ci-put. The back part of the head.
Ol´i-go-hy-dram´´ni-os. Scantiness of the liquor amnii.
Ol´i-gop-nœ´´a. A delay following the birth of a child before the first
respiration is established.
Oph-thal´mi-a. Severe inflammation of the eye or of the conjunctiva.
Or´gan. Any part of the body having a special function.
Os. (L., a mouth.) The orifice in the uterus or vagina.
Os-mo´sis. The passage of a fluid through a membrane.
O´va. Latin plural of ovum, egg.
O´vu-la´´tion. The formation and discharge of an unimpregnated ovum from
the ovary.
O´vule. 1. The ovum within the Graafian vesicle. 2. Any small egg-like
structure.
O´vum. 1. An egg. 2. The female reproductive cell which, after fertilization,
develops into a new member of the same species.
Ox´y-di´´zer. Anything that combines with oxygen.
Pal-pa´tion. The act of feeling with the hand; the application of the fingers
with light pressure to the surface of the body for the purpose of determining
the consistence of the parts beneath in physical diagnosis.
Par-al´y-sis, Erb’s. 1. Same as birth-palsy. 2. Partial paralysis of the brachial
plexus affecting various muscles of the arm and chest-walls. It is revealed by
an inability to lift the arm toward the head.
Par-al´y-sis facial (Bell’s). Paralysis of the face, due to lesion of the facial
nerve or of its nucleus.
Par´a-me-tri´´tis. Inflammation of the parametrium, or cellular tissue about
the uterus.
Par´a-phi-mo´´sis. Retraction of a narrow or inflamed foreskin which can not
be replaced.
Pa-ren´chy-ma. The essential or functional elements of an organ as
distinguished from its stroma or framework.
Pa-ri´e-tal. Of, or pertaining to, the walls of a cavity.
Par´o-nych´´i-a. Infection and suppuration about the junction of nails and
skin.
Par´ox-ysm. A sudden recurrence or sudden intensification of symptoms.
Path-o-log´ic. Pertaining to pathology.
Pa-thol´o-gy. That branch of medicine which treats of the essential nature of
disease, especially of the structural and functional changes caused by disease.
Pel-vim´e-ter. An instrument for measuring the various diameters of the
pelvis.
Pel-vim´e-try. The act of determining the dimensions of the pelvis by means of
a pelvimeter.
Per´i-ne-or´´rha-phy. Suturation of the perineum, performed for the repair
of a laceration.
Per´i-ne´´um. The space or area between the anus and the genital opening.
Pe-riph´e-ry. The outward part or surface.
Per´i-to-ne´´um. The serous membrane which lines the abdominal walls.
Per´i-to-ni´´tis. Inflammation of the peritoneum.
Welcome to Our Bookstore - The Ultimate Destination for Book Lovers
Are you passionate about books and eager to explore new worlds of
knowledge? At our website, we offer a vast collection of books that
cater to every interest and age group. From classic literature to
specialized publications, self-help books, and children’s stories, we
have it all! Each book is a gateway to new adventures, helping you
expand your knowledge and nourish your soul
Experience Convenient and Enjoyable Book Shopping Our website is more
than just an online bookstore—it’s a bridge connecting readers to the
timeless values of culture and wisdom. With a sleek and user-friendly
interface and a smart search system, you can find your favorite books
quickly and easily. Enjoy special promotions, fast home delivery, and
a seamless shopping experience that saves you time and enhances your
love for reading.
Let us accompany you on the journey of exploring knowledge and
personal growth!

ebookgate.com