Research into how effective activities in memory café are for individuals with Dementia when considering cognition and dexterity.

A Research on Dementia and Memory Cafés

Introduction

In understanding the background for the research, a general introduction to the topic in question is relevant in the development of various aspects of the project. The term dementia has been commonly perceived to mean memory loss by the general public and often refers to as senility dementia (REF). However, dementia refers to a group of illnesses that result in gradual decline in the brain memory and its functions, which includes thinking, perception, communication, memory, languages, reasoning, and the ability to function to full capacity (nhs.uk, 2018). Dementia symptoms can be characterized as progressive, with changes in the disease’s dimension reported to have grown from simple to severe. Individuals may experience different specific symptoms depending on which part of the brain is affected. Dementia is incurable, however with the correct treatments and support, individuals are able to lead active lives. (Alzheimer’s Disease and Dementia, 2018)

Individuals living with dementia are often involved in programs such as memory cafés and care centers pathway as a way of making their life more meaningful (Verdelho & Gonçalves-Pereira, 2017). This forms the basis of the research and will focus on the care centers in and around Plymouth with a special interest in memory cafés for the people living with dementia. A critical analysis of the activities happening in and around these centers will be used in determining the extent of the learning and recovery process of the dementia patients, and in determining whether taking part in the activities could help improve cognitive and dexterity, with main focus on cognition in this research.

Background

Dementia is one of the biggest challenges facing society today, impacting millions of lives worldwide through extensive research; the World Health Organization (WHO) has declared that dementia is slowly taking over the charts for the most diagnosed condition over time with forty seven million cases reported worldwide. According to a report done by the Alzheimer’s society, the UK has reported spiraling rates of cases because of an aging population. In years to come numbers are expected to rise to over 1 million by the year 2025. This could soar to 2 million by 2051. 1 in 6 people over the age of 80 have dementia. The report stresses the rapid nature of dementia with estimates placing the current cost of dementia in the UK at £26.3 billion. BBC Plymouth (BBC News, 2018) report that by 2021 over 3500 individuals will be living with dementia in the Plymouth community, they also added that these numbers are expected to increase substantially over the years. With these statistics, it has become impossible to ignore the rampaging effects of dementia in the UK.

Literature Review

Prior research has shown that memory cafés are one of the major contributors to the successful management of dementia patient symptoms. According to research by Nan Greenwood and Raymond Smith (2018), caregivers in memory cafés have played a major role in inculcating a sense of psychological support for those individuals living with dementia at home and their carers. Memory Café groups are run by Alzheimer’s Society trained staff and volunteers with relevant subject, interesting activities and information on local services theses services are funded by charitable organization. Earlier research has shown that through the sharing of experiences in the meetings conducted at the memory cafés, patients, caregivers and medical staff can learn more about the condition. Here, people are allowed to share their experiences from their places of work, homes, and schools for participants who are pursuing an education at different levels. This widely creates acceptance for the people living with dementia.

In addition to this, caregivers have reported that from the knowledge gained from these meetings, they can better handle individual living with dementia (Gappah, n.d.). Active minds has been working alongside the NHS care homes and memory cafe providing resources such as jigsaw, board games, reminiscing cards, music and art activities with has proven to help with cognition. Active Minds 2016 stated they helped to improve the quality of life and wellbeing for over 52,000 people across the world living with dementia. (Active minds.org, 2018) Over the years, memory café meeting facilitators have reported through the Alzheimer’s Society, that their meetings have acted as a gateway for the lost memories of the people diagnosed with dementia, through the following;

     Offering a ‘safe’ environment through channels like art that helps the patients to recall various occurrences in the earlier stages of their lives.

     Group activities which increase the patient’s awareness necessary in their recovering process.

     Offering relevant educational information required in the patient’s day to day coping with dementia (Core.ac.uk, 2018).

A number of regulations exist that guide care giving in memory cafes, for example; The Care Act 2014 relates to people with dementia and provides various requirements for organisations who offer care and support and offers minimum eligibility threshold to those providing such care. This piece of legislation also outlines the general responsibilities of both local authorities and caregivers. (Colibaba, Colibaba, & Gardikiotis, 2015).

All factors considered, previous research has emphasised the role played by memory cafés in the handling of dementia related cases. This research is based on the need to scrutinize the measures employed by memory cafés in determining cognitive and dexterity in dementia patients. The above literature review uses a qualitative approach to analyse the existing research on dementia and memory cafes. Information provided about present studies on the topic can be viewed as reliable as they are commissioned by the Alzheimer’s Society and other reputable organisations.

Aims and Objectives

The research aims to analyse the internal environment of memory cafés, identify the various events that take place and observe, over period of time, the effectiveness of the activities through the following:

1. Keeping track of the research subject and identifying if the activities engaged in, have been effective.
2. Monitoring their progress over time by either asking question or monitoring the subject undertake an activity.
3. Comparing the progress of subjects involved in the activities.

The research will scrutinise the current practices in the memory cafés with an overall interest in improving and creating better platforms toward effective healthcare delivery. The research will identify existing activities and compare their effectiveness in relation to my activity. With the use of both qualitative and quantitative data collection methods, the research will identify any positive outcome in regard to individual cases and highlight current, poorly implemented practices. An overall analysis of the outcomes will be used to suggest possible changes that can be made in the memory cafés to ensure better service delivery altogether. This will also give the caregivers/memory café activities coordinators, an opportunity to reflect on the activities already in place.

The research is fueled by the need for improvement in health care service delivery. The outcomes of this research may support movement around finding more effective and preventative methods in the field of dementia, particularly for those who access memory cafes.

Methodology

The design of the research will make use of the quantitative empirical approach method for data collection. Empirical is the term used to describe experiences as the foundation or source of knowledge, based on direct experience or observation (Punch, 2013). Quantitative data considers behaviour and interactions between people, as well as people’s perspective of their own situations. The researcher will be using a positivist approach due to the nature of dementia and the fact that each individual is different the test will have to be adapted to suit each person. The method employs both direct and indirect observation to acquire information about the topic of study (Wisker, 2009). The initial approach to the research will involve ‘snowballing’. This sampling method involves primary data sources nominating another potential primary data source to be used further on in the research. This method is based on referrals from initial subjects generating additional subjects. Therefore, when applying this sampling method members of the sample group are recruited via chain referral, the researcher will be selecting different memory cafés as they go along. (Research-Methodology, 2018)

The researcher is hoping to use a three month period to conduct this research. This will mean that the researcher has an adequate and consistent period of time within which to undertake the activity. When formulating my data for reliability and validity I will consider how objective it is and ensure that it is credible. Steps will be taken to ensure the research is reliable through the chosen method of data collection. When I present the research findings, I will use quotes that are the most representative of the research outcomes as this is qualitative research I propose that by using positivism reasoning and using the ‘bottom up’ approach. I will start the research with specific observations gained from the group observation sessions and use them to detect patterns and formulate some hypotheses that may be investigated when I correlate the information gathered this will help me to develop some theories. Mythological contributions in this research will include practical gathering of information. The researcher will randomly choose two individuals from each gender group, from each of the memory cafes to test for effectiveness. The aim of this is that it can be used in the future to try to improve outcomes for individuals with dementia. Critical Social Policy will be my critical framework, using this framework to take into consideration Social Justice within the research,

Techniques and procedures

The research will make use of data collected through interviews and a timed activity. Comparison of the different samples will allow the researcher to report from a point of equilibrium and with all factors considered (Lavrakas, 2008). In addition to other factors, gender balance will be considered in picking different case studies in the effort to curb bias in the overall findings. To eradicate interviewers’ dominance and bias in the response received; the researcher will make use of open ended questions to the carers and the consistent use of activities. This will ensure that the scope of the interviewees’ response is not limited (Fielding, Lee, and Blank, 2016).

Interviews will be conducted to help with the findings of the research. To ensure accountability in the findings, interviews will be conducted with those close to the subject. This will help in creating a wider scope for the basis of the research. Measurng the activity, will be another fundamental data collection method. The researcher will attend various meetings held at selected research points at different intervals and take notes of the events taking place this will last for about forty minutes, four individual cases will be randomly selected in a fair and equal way, from each dementia café to ensure balance in the findings and to rule out possible errors, the researcher will created a Gantt chart with the aim of monitoring the progress. The researcher will tried to factor in for issues that may arise and need more time.

Significance and Limitations

The success of this research could mean better healthcare delivery not only on the patients living with dementia but also patients with other comorbidities and severe diagnosis such as cancer, diabetes, and arthritis. Additionally, this research could be a key factor in facilitating extensive research on all the aspects of dementia related cases. This research could also act as a guideline in the handling of dementia related cases in the future.

The main limitation, however, would be to incorporate the findings of this research in different areas of health sciences. As various aspects of this research are based on the first hand collection of information from different individuals involved with dementia, the findings of this research could be prone to human error. Another limitation can be because of the nature of dementia to do with if the individual has the capability to give informed consent.

Ethical Considerations

According to (Burns & Grove 2011) ethical issues are vital and play a significant part of any research process when dealing with human participants. The researcher will seek ethical approval, the researcher will consider participants by gaining informed consent where needed and confirming that all information gathered from them will remain anonymous as well as confidential. The researcher will adhere to the ethical principles for conducting research with human participants following guidelines the British psychological society by submitting an ethics form. (British Psychological Society, 1993) The principles underlying research are universal and concern issues such as honesty confidentiality and respect for the rights of individuals taking part in the study (Welman et al. 2005).

Appendices

Appendix 1: Ethics Form

Appendix 2 Gantt chart

References

• Activeminds.org. (2018).
  
  Social Impact Report 2016 Active Minds
  
  . [Online] Available at:
  
  https://www.active-minds.org/uk/social-impact-reports/social-impact-reports-2016
  
  [Accessed 26 Oct. 2018].
• Alzheimerswa.org.au. (2018). [Online] Available at:
  
  https://www.alzheimerswa.org.au/wp-content/uploads/2017/06/Alzheimers-Memory-Cafe-Guidelines.pdf
  
  [Accessed 15 Oct. 2018].
• Alzheimer’s Society. (2018).
  
  Dementia UK
  
  
  reports
  
  . [online] Available at:
  
  https://www.alzheimers.org.uk/about-us/policy-and-influencing/dementia-uk-report
  
  [Accessed 14 Oct. 2018].
• Alzheimer’s Disease and Dementia. (2018).
  
  What Is Dementia?
  
  [online] Available at:
  
  https://www.alz.org/alzheimers-dementia/what-is-dementia
  
  [Accessed 14 Oct. 2018].
• BBC News. (2018).
  
  Study warns people of dementia
  
  . [Online] Available at: https://www.bbc.co.uk/news/uk-england-devon-12612155 [Accessed 25 Oct. 2018].
• Burns N. & Grove S.K. (2011
  
  ) Understanding Nursing research
  
  Building evidence based practice, 5th ed. Elsevier, Texas.
• Budson, A. and Solomon, P. (n.d.).
  
  Memory loss, Alzheimer’s disease, and dementia
  
  .
• Core.ac.uk. (2018). [online] Available at:
  
  https://core.ac.uk/download/pdf/71043952.pdf
  
  [Accessed 14 Oct. 2018].
• Colibaba, C. A., Colibaba, S., & Gardikiotis, R. (2015). Digital Timeline an Interdisciplinary Approach to Dementia.
  
  SEA: Practical Application of Science
  
  ,
  
  3
  
  (1).
• Cox, C. (2007).
  
  Dementia and social work practice
  
  . New York: Springer Pub.
• Fielding, N., Lee, R. and Blank, G. (2016).
  
  The SAGE handbook of online research methods
  
  . SAGE.
• Gappah, P. (n.d.).
  
  The book of memory
  
  . REF
• Greenwood, N., Smith, R., Richardson, A., and Akhtar, F. (2018). [Online] Available at:
  
  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5527402/
  
  [Accessed 17 Oct. 2018].
• Lavrakas, P. (2008).
  
  Encyclopedia
  
  
  of Survey Research Methods
  
  . 1st ed. Sage Publications.
• Mendez, M. and Cummings, J. (2003).
  
  Dementia
  
  . Philadelphia, Pa.: Butterworth-Heinemann.
• nhs.uk. (2018).
  
  Dementia with Lewy bodies
  
  . [Online] Available at:
  
  https://www.nhs.uk/conditions/dementia-with-lewy
  
  bodies [Accessed 23 Nov. 2018].
• O’Brien, J., Ames, D., and Burns, A. (2010).
  
  Dementia
  
  . London: Hodder Arnold.
• Punch, K. (2013).
  
  Introduction to Social Research: Quantitative and Qualitative
  
  . 3rd ed. London: SAGE.
• Research Methodology. (2018).
  
  Snowball Sampling
  
  . [Online] Available at:
  
  https://research-methodology.net/sampling
  
  in primary data collection/snowball-sampling/ [Accessed 28 Oct. 2018].
• Verdelho, A. and Gonçalves-Pereira, M. (2017).
  
  Neuropsychiatric Symptoms of Cognitive Impairment and Dementia
  
  . Cham: Springer International Publishing.
• Welman, J C., Kruger S J & Mitchell B. (2005)
  
  Research Methodology
  
  . 3rd ed. Oxford
• University Press, Cape Town.
• Wisker, G. (2009).
  
  The Undergraduate Research Hand Book
  
  . Basingstoke: Palgrave Macmillan.
• World Health Organization. (2018). Dementia: A public health priority. [Online] Available at:
  
  http://www.who.int/mental health/neurology/dementia/
  
  [Accessed 18 Oct. 2018].
• Wortmann, M. (2018). [Online] Available at:
  
  https://doi.org/10.1186/alzrt143
  
  [Accessed 17 Oct. 2018]

Word Count 2071

University of Plymouth Colleges

Application for Ethical Approval of Research

Section 1

Title of Project:

Research into how effective activities in memory café are for individuals with Dementia when considering cognition and dexterity.

Duration of the Project: 26.04.2019

Aims and objectives of the Research:

1. Keeping track of the dementia individual involved in the different activities, identifying if those activities has been has proven to be effective offered within the memory cafés.

2. Monitoring individuals progress over time by observation  and asking  simple question relating to what is done at the start of the session and at again at the end.

3. Comparing the progress of patients involved in different programs within the memory cafés in the efforts to determine treatment reception among different patients.

Brief Description of methods including:

A) Participants (sample frame)

This is a piece of primary research and will be involving human participants.

B)




B) Method of recruitment (sampling methods)

The approach to this research is qualitative done in the form of observation and interviews.

C)




Details of Measures (i.e. how will data be collected)

Recording taking short hand notes

Section 2

Please indicate how you will ensure this research addresses each of the following:

Informed Consent

Participants will be provided with verbal explanations of the research project, they will be given opportunity to ask questions. Inform consent will be given to primary caregiver if individuals lack the capacity. I will also make sure that they are clear about the project and its potential implications for the participant before any interview takes place and reiterate the information contained in the consent form.

Openness and honesty

I will be open and honest what and doing by making my intension known

Right to withdraw

Participants have the right to withdraw at any time but because of the nature of the subject to do with capacity this will be done by the primary care giver. I will have an email address available so participants can reached me.

Protection from harm

The researcher endeavor to ensure that research participants are protected from undue intrusion, distress, indignity, physical discomfort, personal embarrassment, or psychological or other harm.

Debriefing

The researcher will let the participants know that she will be around after each session to ask question or discuss any concern.

Confidentiality

The researcher will seek ethical principles for conducting research with human participants following the guidelines of the British psychological society, the researcher will consider the participants by gaining informed consent if they have the capacity to confirming that all the information gathered from them will remain anonymous as well as confidential.  All data  obtained during this research project will be subject to the provisions of the Data Protection Act and will be stored on the computer of the researcher in password protected files to which only the researcher has access and will not be shared with anyone else.

Relevant Professional Body whose ethical policies apply to this research

The researcher will seek ethical principles for conducting research with human participants following the guidelines of the British psychological society

Declaration

To the best of our knowledge and belief this research conforms to the ethical principles laid down by the University of Plymouth and by any professional body specified above.

CHAPTER I

INTRODUCTION

“There is this to be said in favor of drinking that it takes the drunk and first out of society then Out of the world.”



– Ralph Waldo Emerson

Alcohol is a central nervous system stimulant at low doses, and depressant at higher doses. Alcohol beverages come in range of different strengths. Alcohol can include beer, wine, spirits (e.g. vodka, gin, whiskey, brandy, rum etc.).In India spirits, i.e. government licensed country, Indian made foreign liquors like rum, whiskey, vodka, gin and illicit distilled spirits constitute more than 95% alcohol consumption. (Jerald .K and Allan .T, 2006)

Alcohol use disorders are among the most prevalent psychiatric disorder. Data from several epidemiological studies suggest that lifetime prevalence of alcohol use disorder in US is around 8 %.with as many as 25% suffering severe psychiatric disturbances. The most prevalent psychiatric symptoms are

anxiety

and

depression

disorders. (Hasin et al., 2007)

According to current concepts alcoholism is considered a disease and alcohol a “disease agent” which causes acute and chronic intoxication, cirrhosis of the liver, toxic psychosis, gastritis, pancreatitis, cardiomyopathy and peripheral neuropathy. Alcohol is an important etiological factor in suicide, automobile and other accidents and injuries and deaths due to violence. The health problem for which alcohol is responsible is only part of total social damage which includes family disorganization, crime and loss of productivity. (Morgan, M. Y. & Ritson, E. B, 2009)

The pattern of drinking in India has changed from occasional and ritualistic use to social use. These developments have raised concerns about the health and the social consequences of excessive drinking. Nearly 30% of Indian men and 5% of Indian women are regular users of alcohol. (Balakrishnan. D and Subirkumar Das, 2006)

Canvin Rebecca, (2012) reported that social factors such as affordability and availability of alcohol, peer pressure and buying of rounds in groups may have a role in causing alcohol dependence.

National institute of alcohol abuse and alcoholism (NIAAA, 2000) reported that Tolerance, impaired control, withdrawal and compulsive use are the elements of alcohol dependence and also they reported that 40% of genetic factors and 60% of environmental factors plays a role in consuming alcohol.

A serious problem with the treatment of alcohol dependence individuals is very low rate of compliance abstinence about 20%.( Noda et.al 2001) and treatment success rates are 30-60% depending on outcome measures like abstinence, heavy drinking and social functioning.

Alcohol detoxification can be defined as a period of medical treatment, usually including counselling, during which a person is helped to overcome physical and psychological dependence on alcohol (Chang and Kosten 1997).

The immediate objectives of alcohol detoxification are to help the patient to achieve a substance free state, relieve the immediate symptoms of withdrawal, and treat any co- morbid medical or psychiatric conditions. Alcohol detoxification can be completed safely and effectively in both inpatient and outpatient treatment settings. The process of detoxification in either setting initially involves the assessment and treatment of acute withdrawal symptoms, which may range from mild (e.g., tremor and insomnia) to severe (e.g., autonomic hyperactivity, seizures, and delirium).Medications are provided to help the patient to reduce the withdrawal symptoms. Benzodiazepines (e.g., diazepam and chlordiazepoxide) are the most commonly used drugs for this purpose, and their efficacy is well established. Benzodiazepines not only reduce alcohol withdrawal symptoms but also prevent an alcohol withdrawal seizure, which is estimated in 1 to 4% of withdrawal patients (Schuckit, 1997).

Disulfiram (Antabuse) is used as an adjunct to enhance the probability of long-term sobriety. Although patient compliance is problematic, disulfiram therapy has successfully decreased frequency of drinking in alcoholics who could not remain abstinent. A study of supervised disulfiram administration reported significant periods of sobriety of up to 12 months in 60% of patients treated. (Hester., R.K and Miller, W.R., 1989)

Additional components of alcohol detoxification may include education and counselling to help the patient prepare for long-term treatment, attendance at Alcoholics Anonymous meetings, recreational and social activities, and medical or surgical consultations. (Boyd, M.A, 2005).

For patients with mild-to-moderate alcohol withdrawal syndrome, characterized by symptoms such as hand tremor, perspiration, heart palpitation, restlessness, loss of appetite, nausea/ vomiting, outpatient detoxification is as safe and effective as inpatient detoxification and is much less expensive and less time consuming. Among the drawbacks associated with outpatient detoxification is the increased risk of relapse resulting from the patient’s easy access to alcoholic beverages. In one of his study of 164 patients randomly assigned to inpatient or outpatient detoxification, significantly more inpatients than outpatients completed detoxification. (Hayashida et al. 1989)

Miller et al. (1996

)

conducted a time expensive prospective study on post discharge functioning of 180 alcoholic patients. They concluded that relapse is a multidimensional construct that may be better understood if assessed in its multiple dimensions.

Relapse promoting factors include anxiety, craving negative mood, childhood sexual abuse and psychological distress. (Gordon et al., 2006).

Relapse inhibiting factors are self efficacy, social suppression, coping (Brown et al., 1995), spirituality, peer support, group attendance, continuing care and progressive involvement (Miller et al., 1999)

The warning signs of relapse are Denial, Avoidance, Crisis, Confusion,

Depression

,

Loss of Control regarding Behavior

, Struggling with Personal Schedule and

Self-Pity

.(Ballard,K.A.,Kennedy,W.Z and O’Brien 2008).

An analysis of 48 episodes of relapse revealed that most relapses were associated with three high-risk situations: (1) frustration and anger, (2) social pressure, and (3) interpersonal temptation. (Cooney. 1987)

Desai et al, (1993) conducted a treatment outcome study of alcoholism and reported that among those who relapsed, the most common factor for drinking was negative emotional states.Among treated individuals, more severe alcohol-related problems and depressive symptoms, lack of self-efficacy and poor coping skills have been associated with short-term relapse.

Terence T. Gorski & Merlene Miller, (1982) Relapse does not begin with the first drink. Relapse begins when a person reactivates patterns of denial, isolation, elevated stress, and impaired judgment.

Polich J.M, (1981) Relapse is so common in alcohol dependence patients and that it is estimated more than 90% of those trying to remain abstinent have at least one relapse before they achieve lasting sobriety.Foster et al (2000) report a study of 64 alcohol-dependent patients admitted for either 7 or 28 days of alcohol detoxification treatment. About 60% relapsed over the 3-month follow-up period.

Marlatt G.A and Gardon J.R (1980) Another way to reduce drug relapse is through relapse prevention strategies. Relapse prevention attempts to group the factors that contribute to relapse into two broad categories: 1. Immediate determinants 2. Covert antecedents. Immediate determinants are the environmental and emotional situations that are associated with relapse, including high-risk situations that threaten an individual’s sense of control,andexpectancies. Covert antecedents, which are less obvious factors influencing relapse, include lifestyle factors such as stress level and balance, urges and

cravings

. The relapse prevention model teaches addicts to anticipate relapse by recognizing and coping with various immediate determinants and covert antecedents.

NEED FOR THE STUDY

APA (2000), reported that Alcohol dependence, or alcoholism, is often a progressive chronic disorder and recognized as a disease. It is a common disorder posing a heavy burden on patients, their families, and society. It has a high prevalence rate compared with many other diseases and highlights the public health significance.

At international level

, GISAH (2005). The Global Information System on Alcohol and Health reported that the harmful use of alcohol results in the death of 2.5 million people annually. There are 60 different types of diseases where alcohol has a significant causal role. It also causes harm to the well-being and health of people living around the drinker. In 2005, the worldwide total consumption was equal to 6.13 liters of pure alcohol per person at 15 years and older. Unrecorded consumption accounts for nearly 30% of the worldwide total adult consumption. (

Pratima Murthy

, 2010)

Alcohol dependence is recognised as mental health disorders by the World Health Organization. It ranked alcohol as the third most important risk factor for the increase in the number of disability-adjusted life years in Portugal, as well as in Europe, preceded by tobacco smoking (second risk factor) and hypertension (first risk factor) .

WHO ,(2005

)

Alcohol related hospital admissions increased by 85% between 2002/03 and 2008/09, accounting for 945,000 admissions with a primary or secondary diagnosis wholly or partly related to alcohol in 2006/07 and comprising 7% of all hospital admissions. (

North West Public Health Observatory, 2010).

(

Pratima Murthy

, 2010)

Manickam, (1994) reported that in

Kerala

the approximate number of people being de addicted would be 255 in a year at one centre. Through all the centres, the number of people de addicted would be 308557.

After the first month following an alcohol detoxification, relapse rates range between 19% for inpatients and 34% for outpatients and increase to about 46 and 48% respectively, after 6 months (Hayashida et al.,

1989

) in

California

In national alcohol survey

to assess the risk of relapse in people with remitted alcohol dependence, they assessed 17772 adults of alcohol use and alcohol use disorder and followed for 3 years. At the baseline interview, 25% of subjects drank risky amounts, 38% drank lower-risk amounts, and 37% abstained. They concluded that relapse is common among people in remission from alcohol dependence and much more likely if they are drinking risky amounts. The results support the need to carefully monitor and support abstinence in people with remitted alcohol dependence.

NIAA (2000)

National Institute on Alcohol Abuse and Alcohol

reported approximately 90% of alcoholics will experience one or more relapses during the four years after treatment. By understanding what the common relapse triggers are, we will be better prepared to maintain sobriety and live the healthy life we want.

Prasad (1996) in a treatment outcome study reported a relapse rate of 41% at 6 months follow up of alcohol dependence patients which was conducted in NIMHANS, Bangalore.

Prakash et al. (1997), conducted a study on relapse in alcoholism, found negative emotional states as a major interpersonal trigger for relapse in Bangalore.

Elis and McClure, (1992)

conducted a meta analysis and found that about 6 of 10 patients with alcohol dependence will relapse in the 6 months following detoxification, as estimated by the median of 61% relapse rate obtained in several studies. This high rate of relapse in a relatively short period is a reason for searching for the factors that better predict treatment outcomes.

During the observational visit, in Kasturba deaddiction centre, the researcher came across many alcohol dependence patients. There she identified the relapsed cases of alcohol dependence patients and she enquired with the relapsed patients about their return to drinking. They said many of the reasons like family problems, financial problems, participation in ritual functions, peer pressure and unable to control their thoughts of drinking. This triggers the researcher to reduce the relapse cases by identifying the risk factors earlier by using the relapse risk assessment tools during their follow up periods in deaddiction centre. So the researcher undertook this study as a stepping stone to identify or to explore the risk of relapse of alcohol dependence patients under detoxification treatment.

STATEMENT OF THE PROBLEM

A study to explore the risk of relapse in alcohol dependence patients who are under detoxification treatment in kasturba deaddiction centre, Coimbatore.

OBJECTIVES OF THE STUDY

• To assess the risk of relapse in alcohol dependence patients under detoxification treatment
• To associate the risk of relapse in alcohol dependence patients who are under detoxification treatment with selected demographic and clinical variables.

OPERATIONAL DEFINITION

Relapse

• Refers falling back into a state of previous drinking after detoxification treatment which is measured by alcohol relapse risk scale.

Alcohol dependence patient

• Alcohol dependence is a substance related disorder in which an individual is addicted to alcohol both physically and mentally, and continues to use
  
  alcohol
  
  despite significant areas of dysfunction. In this study it refers patients who are coming for follow up under detoxification treatment in kasturba deaddiction centre.

Detoxification treatment

• Refers to a treatment in alcohol dependence patients for removal of existing toxins from the body which is accumulated because of alcoholism by using drugs like Librium, Diazepam, and Lorazepam.

ASSUMPTION

• Relapse may be common and predictable in alcohol dependence patients under detoxification treatment.

CONCEPTUAL FRAMEWORK

A conceptual framework is used in

research

to outline possible courses of action or to present a preferred approach to an idea or thought. Also its a theoretical

structure

of

assumptions

,

principles

, and

rules

that

holds

together the

ideas

comprising a broad

concept

.

The

transtheoretical model


of behavior change

assess an individual’s readiness to act on a new healthier behavior, and provides strategies, or processes of change to guide the individual through the stages of change to Action and Maintenance.

James O. Prochaska

of the

University of Rhode Island

and colleagues developed the transtheoretical model of behaviour change in 1977


^.


It is based on analysis and use of different theories of psychotherapy, hence the name “transtheoretical.”

STAGES


OF CHANGE

There are 5 stages in transtheoretical model.

Change is a process involving progress through a series of stages.

STAGE I: PRECONTEMPLATION (NOT READY)

The process of change of alcohol drinking behaviour of an alcohol dependence individual starts with consciousness- raising about ill effects of alcohol by public medias like television, radio, and internet and also through newspaper, health magazines etc.

STAGE II: CONTEMPLATION (GETTING READY)

The alcohol dependence individual evaluates himself about his alcohol drinking behaviour and imagines how he will be when he stops the alcohol drinking behaviour.

STAGE III: PREPARATION (READY)

The individual realizes that the society is also not supporting the unhealthy behaviours like alcohol drinking. So he makes commitments to change this unhealthy behaviour by believing his ability to change.

STAGE IV: ACTION

The alcohol dependence individual makes discussion with his family and friends about changing the alcohol drinking behaviour.With family and friends support he approaches deaddiction centre to change his alcohol drinking behaviour.

STAGE V: MAINTENANCE

After getting inpatient detoxification, the alcohol dependence individuals are coming regularly for follow up visits to deaddiction centre and they are teaching about cue control measures,mainteneance of self efficacy and how to manage high risk situations.

After the maintenance the alcohol dependence individual will enter either into:

TERMINATION – the alcohol dependence individual possess zero temptation and craving and they are sure they will not return to their old unhealthy habit as a way of coping.

RELAPSE-The alcohol dependence individual return from Action or Maintenance stage to his earlier unhealthy alcohol drinking behaviour because of stimulus induced vulnerability factors,emotionality problems,compulsivity for alcohol,lack of negative expectancy for alcohol and positive expectancy for alcohol.

It has been 100 years since the first case of developmental dyslexia was described. Hitherto numerous researches had shed light on the causes and consequences of this disorder but the debate concerning its definition is still highly contented. In this essay, I will first answer the question of what is dyslexia and then move to the debate of whether it has a genetic basis.

• Firstly, I will introduce what has been done in the early research of dyslexia and then tried to find a definition for us to understand dyslexia properly. Secondly, I will introduce the research for supporting the view that dyslexia has a genetic basis.

1.1 Early history of research on dyslexia

Reading, a complex behavior that requires a set of cognitive skills, has been highly valued by society and is a key component to education. An inability to read has profound social and psychological consequences. Several scholars in the 19th century studied the loss of the ability to read or understand writing.

Kurrmaul in 1877 describe the reading difficulties of literate brain-damaged patients as word-blindness. It is only in 1887 that a German ophthalmologist, R Berlin, first used the word ‘dyslexia’ to describe reading difficulties caused by cerebral disease or injury. However, having read articles published by Hinshelwood in the 1890s and early 1900s, W.P Morgan (1895) points out that a patient can be suffering from ‘dyslexia’ without cerebral disease or injury. He quotes the case of a boy who has reading difficulties even though he has suffered no apparent brain damage. Though for a long time, the problem of dyslexia is widely studied, dyslexia was not a common knowledge for more than half a century and the concept of dyslexia was not familiar and unclear to many people. People need to understand what dyslexia is in order to help ones inflicted with the disease.

1.2 The definition of dyslexia

Dyslexia is a neurological disorder with a genetic origin and behavioral signs which extend beyond problems of written language. Early research confined the dyslexia into a medical model and thus clinical practice fail to distinguish a dyslexia patient from normal readers. In the 1968 World Federation of Neurology meeting, a definition of dyslexia formally introduced and stated that dyslexia is a disorder manifested by difficulty in learning to read despite conventional instruction, adequate intelligence and socio-cultural opportunity. It is dependent upon fundamental cognitive disabilities which are mostly of constitutional origin. Many scholars criticize this definition. Firstly, the terms are vague as there are insufficient examples to illustrate conventional instruction or to point out the criteria of adequate intelligence and to explain the meaning of socio-cultural opportunity. These scholars point out that the biggest weakness of this definition is exclusion. The definition only states what a person with dyslexia should not be and does not include criteria for its positive diagnosis other than to state that it is a reading difficulty dependent on fundamental cognitive disabilities (Snowling, 2004). Although its definition debatable, it is applied by the diagnostic and statistical manual of mental disorders and the international classification of mental and behavioral disorders for many years.

Researchers have never stop on the medical model. Without positive diagnosis criterion, doctors cannot differentiate children with specific reading difficulties and children who have reading difficulties because of a more general learning problems. Scholars have adopted tests through the comparisons of verbal IQ (intelligence quotient) and performance on reading tests of children with reading retardation and skilled reader in a hope that it could identify the children with dyslexia. Nonetheless, a number of findings such as Morton and Frith (1995) highlighted that it is not correct to assume that literacy problems are the only symptoms of dyslexia. These tests are purely behavioral definitions and the diagnosis is relative. For instance, there are many examples that show discrepancies with the predictions carried out by those researches. Some dyslexia children after receiving highly effective training in decoding non-words would score well and many children with reading problems can improve their reading ability by having a better relationship with their teachers. Overly depending on these tests as a short cut to diagnosis would run the risk of excluding dyslexic children with reading problems and involve children who only show mild positive signs of dyslexia. The definition that concerns dyslexia as synonymous with specific reading difficulty has failed to be self evidence because it only focuses solely on reading and IQ-test performance and other tests.

One way out of this dilemma is to consider dyslexia as a disorder that has multi-levels of description. Rutter and Yule (1975) pointed out that the specific reading retardation is usually multi-factorially determined opposed to the claim that dyslexia is a unitary condition. Being a developmental disorder, dyslexia can be expected to have behavioral features that will change with maturation and response to environmental interactions (cf.Bishop, 1997). It may therefore be unrealistic to agree upon a simple and unchanging definition of dyslexia. Frith (1997) argued that there are causal links from brain to mind to behavior that must be considered when attempting to understand dyslexia. It is important to seek explanations at the three different levels in this causal chain namely the biological, the cognitive and the behavioral, in order to develop a comprehensive theory of why some children fail ‘unexpectedly&tsquo to learn to read(Morton and Frith, 1995). Moreover, the environmental factors will act as a stimulus to intensify or meliorate the condition of these three levels.

The common ground of the study of dyslexia, agrees that dyslexia is a neuro-development disorder with a biological origin and behavioral signs which extend far beyond problems of written language (Frith, 1997). The idea of dyslexia as a syndrome with a neurological basis springs from the work of Tim Miles, Elaine Miles and many intelligent students. It helps to solve the paradoxes that exist in defining dyslexia. Morton and Frith (1997) had developed a framework with three levels and environmental influence in a neutral view to describe a descriptive definition of dyslexia.

The past 15 years have seen a continuing increase in research effort aimed at identifying the biological underpinnings of dyslexia. Galaburda (1989) demonstrated abnormal symmetry in the structure of the planum temporal; Livingstone et al. (1991) identified cellular migration abnormalities in the magnocellular system of the brain which have been related to behavioral findings by Cornelissen et al.(1995). Genetic linkage studies with dyslexic families have identified regions on chromosomes 15, 1 and recently 6 (Cardon et al., 1994). Thus, restricting the discussion to behavioral observation is no longer necessary. This gap has been widened by cognitive neuro-science which insists that there is a space for the scientific study of the mind and brain and not just behavior (Frith, 1995). Cognitive level of explanation can be a bridge that links brain and behavior together. Cognitive abilities can be explained by Cognitive theories through observable behavior. The poor reading performance can be termed as a cognitive dysfunction which in turn can be explained by a brain dysfunction. In addition, this causal links chains from brain to mind to behavior has to be set within the context of environmental and cultural influences.

Figure2(Mortan and Frith 1995)

An illustration of the causal modeling of dyslexia with the hypothesis of a phonological deficit hypothesis now shows in figure 2. In this figure, Morton and Frith in 1995 argued that when we try to explain a developmental disorder, we have to make a distinction between different levels of description. In the biological level and environmental level, we can look for causes and cures and in the behavioral level we can observe and assess the patient. Then the cognitive level lies in between these levels and have links with the rest of the levels. Here, the intuitive clinical impression can be captured and that the presenting disorder is a distinct and recognizable entity despite variable symptoms. This notation enables different theories about a disorder to be represented in a neutral fashion (Frith, 1995). The proposal of a phonological deficit as the cognitive basis of dyslexia has a strong theoretical and empirical support that it has been widely accepted. Starting on the biological level of figure 2, it is supposed that there is a congenital dysfunction of left-hemisphere perisylvian brain areas which affects phonological processing (Galaburda, 1989; Paulesu et al., 1996; Rumsey et al., 1992). Furthermore, the evidence for a genetic origin of dyslexia is increasingly compelling (Pennington, 1990). However, this theory also has its pitfalls. One of the biggest weakness of the phonological theory is it does not effectively explain the occurrence of sensory and motor disorders in dyslexic individuals. People who support the phonological theory typically have dismissed these disorders as not part of the core features of dyslexia. They consider their co-occurrence with the phonological deficit as potential markers of dyslexia instead of treating them as a causal role in the aetiology of reading impairment (Snowling, 2000).

In the domain of neauro-cognitive causes study of dyslexia, there are two other theories: the cerebellar theory and the magnocellular theory. The former one is that the dyslexic’s cerebellum is mildly dysfunctional and that a number of cognitive difficulties ensue, whereas the latter one postulates that the magnocellular dysfunction is no restricted to the visual pathways but is generalized to all modalities (Ramus et al, 2003). These three theories do not contradicted each other but potentially compatible. When it refers to the cognitive level, three theories imply a processing deficit. Fast temporal processing may be a basic characteristic of all perceptual systems, visual as well as auditory, object-based as well as speech-based. On the other hand, the slower-than- normal perceptual processing might affect the development of a phonological system (Frith, 1997).

1.3 Conclusion

Any definition should be seen as a hypothesis and to be rejected if future findings disprove it. As Tim Miles said that, a diagnosis of dyslexia is, in effect, a sort of bet. The definition in the framework of biological, cognitive and behavioral level within the interaction of cultural influences depict the dyslexia as a neuro-developmental disorder with a biological origin, which affects speech processing with a range of clinical manifestations (Frith, 1997). In this definition, it appears that the cognitive level of description provides a unifying theory of dyslexia. Such a theory is necessary to pool together the numerous different observational strands in this most intriguing and subtle disorder.

After the discussion of definition issues in dyslexia, we turn to focus on the approval that dyslexia has its genetic basis. We will first look at the study of heritability in dyslexia and then to talk about the genetic findings for supporting dyslexia has a genetic basis.

The rapidly accumulating evidence suggests that developmental dyslexia is one of many common familial disorders. The genetic explanations of dyslexia are rather convinced by research that uses the newly genetic techniques and statistical methods in the genetic study of dyslexia. Although most findings cannot be replicated as there are many variants need to be identified. We still can believe that dyslexia has a genetic basis by the evidence of the genetic study of dyslexia.

2.1 Famaliality of Dyslexia

The question of whether dyslexia has a genetic basis has been studied for a very long time. Numerous researches have been conducted. Among them, there are a number of findings that suggest developmental dyslexia is hereditary. Orton in 1925 hypothesizes that children born in a family of dyslexia have great chance of being dyslexia. According to a recent estimation made by Gilger, Pennington and Deferies in 1991, the risk of a son with a dyslexia father to be a dyslexia is approximate 40% and about 36% if the mother is dyslexia. Moreover, if both parents are affected, the risk and severity of dyslexia in the child would greatly increase. Nevertheless, for the girls, this ratio is relatively lower, at about 20% regardless of the gender of the affected parent (Childs&finucci,1983;Deferies&Decker,1982;Pennington,1991).However,the higher familial aggregation of reading problems is insufficient to prove that dyslexia has genetic basis. The environment shared by families are strongly influence their reading ability.

2.2 Twins Studies

The twins studies can help us understand the complexity of the interaction between genes and environment in some degree. The first kind of twin studies is the comparison of concordance rates that could evaluate the hereditary basis of dyslexia as a clinical condition. The second evaluates the reading performance of twins for estimating heritability coefficient by analyzing various indicators of reading performance. Thus, it is important to diffrentiate these two types of twin studies.

In the first kind of twin study of dyslexia, researchers compared the concordance rates in monozygotic (MZ) twin pairs the identical twin pairs and dizygotic(DZ) twin pairs the fraternal pairs. Regression counted in the research dues to the assessment of environmental factors and its interaction with genes in reading disabled. The results show that at least one member of every pair had reading problems. Moreover, MZ has a higher concordance for reading disability than in DZ twin pairs (Hermann, 1959; Zerbin-Rudin, 1967;Decker and Vandenberg,1985). By comparing the findings of the concordance rates in twin pairs we can imply that developmental dyslexia has a genetic aetiology.

In the second type of twin pairs, a vast number of studies have reported MZ and DZ twin correlations for various measures of reading performance (Grigorenko, 1996). MZ correlations implied the presence of genetic influence through the comparison with DZ correlations. However, heritability estimates are varied. Some of the variability can be due to the fact that the sample size of those main researchers was relatively small. In addition, some twin studies suggest that only certain reading-related skills are inherited. Thus it has been shown that word recognition, phonological coding show important genetic influence, whereas reading comprehension and orthographic coding do not (Olson, Wise,Conners,Rack,&Fulker, 1989). Because the latter one significantly influenced by the environmental factors.

2.3 Pattern of Transmission of Dyslexia

Researchers had conducted a number of segregation analyses, fitting different statistical models corresponding to various patterns to investigate the transmission of genes in families with reading disability. Some observers have concluded that familial dyslexia is transmitted in an autosomal (not sex-linked) dominant mode (Childs& Finucci, 1983; Hallgren, 1950), whereas others have found only partial (Pennington et al.,1991) or no support for an autosomal or codominant pattern of transmission. These findings were interpreted as suggesting that specific reading disability is genetically heterogeneous (Finucci et al.,1976; Lewitter, DeFries, &Elston, 1980). In here, Quantitative trait loci (QTL) mapping also has been applied (Cardon et al., 1994;Fulker et al.,1991) in order to localize individual genes that contribute to the development of dyslexia.

2.4 Genetic Localization

The researchers passionately set an ultimate goal of genetic study that is to locate and isolate the responsible gene for dyslexia. Once the genes responsible for dyslexia is located, the protein product encode by the gene may permit a physiological explanation for its role in normal processes or diseases and finally contributed to a gene therapy for dyslexic. However, some researchers like Snowling (2000) consider the location of genes is a wide goose chase. The human genome has a rough estimation of about 35 000 genes which distributed over 3 billion bp of DNA and half of them is related to brains. Even when researchers limited the number of candidate genes to screen by using different biological hypotheses, they still need to work with thousands of genes. Thus, considering the risk of failing to match any given hypothesis, researches adopt the linkage and association analysis these two types of mapping strategies. The principle underlying both genetic linkage and association mapping is to test for non-random relations between phenotypic similarity across many individuals and haplotype sharing between them. With more generations the analysis become more powerful and accurate because each meiosis provides another opportunity for spurious genotype-phenotype relations to decompose. Linkage analysis refers to the analysis of individuals for whom family relations are known, whereas association analysis is used for large samples of unrelated individuals. Now, linkage analysis is generally less effective than association analysis in detecting genotype-phenotype relations within a study sample size. However, linkage mapping can be done with much fewer genetic markers and is hence easier to use in practice than association analysis. Genome-wide linkage can be carried out by analysis of about 400 highly polymorphic DNA markers. By contrast, association mapping has the power to focus on the specific causal DNA variants that influence phenotype variability but in most case it must use much more times that use to analyse DNA polymorphisms then linkage mapping used.

Using current molecular techniques of linkage analysis to carefully study selected family trees of dyslexic individuals in which developmental dyslexia reoccurs in different generations, some early results showed that a major gene for dyslexia was located on the short arm of chromosome 15 (Pennington et al.,1991;Smith, Pennington, Kimberling,& Ing,1990). Fulker and his colleagues in 1991 replicated the same result of chromosome 15 though selecting a sample of siblings with reading problems in the study of original extended-family. Others like Lubs in 1991, Rabin in 1993 and Cardon in 1994 did not find the same results.

From a recently review of genetic study of dyslexia, we can see that the candidate genes DCDC2 the double cortin doman containing protein 2 and K1AA0319 show strongest links to the dyslexia among severely affected individuals. However, the candidate genes chromosome 15 and ROBO1 roundabout Drosophila Homolog of 1, which were identified through breakpoint mapping in Finnish patients, seem to be less involved in the development of dyslexia across different populations. However, their research is limited to a few families in the Finnish population and to date, no specific cognitive processes are known to be influenced by the proposed susceptibility genes. Some studies have already started to include neurophysiological and imaging procedures in their phenotype characterization of patients. The molecular genetic studies conducted so far have not considered gender-specific genetic effects. A satisfactory power to detect such effects can be provided only when gender is taken into account during the analysis of results, and this should be a feature of future studies (Schumacher et al, 2008)

2.5 Conclusion

Although, scientific research has yet to prove that dyslexia is a gentic disorder, many researchers and evidence have show that it is a high possibility. In my opinion, dyslexia is a genetic disease and its symtoms can be aggravated or mitigated by the environment. Nevertheless, more research into the correlationship of the genetic factor and the environment needs to be conducted to verify this claim.

Reference:

Beaton,A.A(2004). Dyslexia, Reading and the Brain: a sourcebook of psychological and Biological Research. East Sussex: Psychology Press.

Francks.C, MacPhie,L.I, & Monaco,P.A(2002). The genetic basis of dyslexia. Lancet Neurology 2002, 1, 483-490.

Frith.U(1999). Paradoxes in the definition of dyslexia. Dyslexia, 5, 192-214.

Hulme. C,&Snowling.M(1997). Dyslexia: biology, cognition, and intervention. San Diego: Singular Pub.

Miles,E.(1995).Can there be a single definition of dyslexia? Dyslexia, 1, 37-45.

Raskind, H.W (2001). Current understanding of the genetic basis of reading and spelling disability. Learning Disability Quarterly, 24(summer), 141-157

Olson, R.K(2002). Dyslexia:nature or nurture. Dyslexia, 8(3), 143-157

Ramus. F, Rosen.S, Dakin,C.S, Day,L.B., Castellote,M.J., White.S &Frith.U(2003). The theories of developmental dyslexia: insights from a multiple case study of dyslexic adults. Brain, 126, 841-865.

Sladen,K.Brenda(1970). Inheritance of dyslexia. Annals of Dyslexia. 20(1), 30-40.

Snowling,J.M(2000), Dyslexia. Massachusettes: Blackwell Publishers Ltd.

Siegel,L.S.(1992). An evaluation of the discrepancy definition of dyslexia. Journal of Learning Disabilites,25, 618-629.

Sternberg,J.R &Spear-Swerling.L(1999). The perspectives on learning disabilities. Colorado: Westview Press.

Schumacher. J., Hoffmann. P, Schmal. C, Schulte-Korne. G, & Nothen,M.Markus(2007). Genetic of dyslexia: the evolving landscape. J med Genet 2007, 44, 289-297.

Wood, B. F., & Grigorenko, L.E (2001). Emerging issues in the genetics of dyslexia: a methodological preview. Journal of learning disabilities, 34(6), 503-511