Development programme Essay

12 minutes run on the Treadmill in level 11.5 and 5 minutes cycling a steady pace.  12 minutes run on the Treadmill, in level 11.5 with 5 minutes cycling at a steady pace  Circuit training programme which we will include 1 minute cycling at a fast pace rest for 2 minutes, 1minutes sprint with 1 minute rest and back to the cycling. This will go 4 times.  And finally cycling for 5 minutes in a steady pace to get rid off lactic acid. Bicep curls, Triceps push down, Bench press, seated leg extension and seated leg curl all of this, 3 sets of 15 repetitions with 1 minute rest between sets and 2 minutes rest between different exercises. Keeping the same weight as last session.  Bicep curls, Triceps push down, Bench press, seated leg extension and seated leg curl all of this, 3 sets of 15 repetitions with 1 minute rest between sets and 2 minutes rest between different exercises. Keeping the same weight as last session. Bicep curls, Triceps push down, Bench press, seated leg extension and seated leg curl all of this, 3 sets of 12 repetitions with 1 minute rest between sets and 2 minutes rest between different exercises, this week we will only increase 1 kg in every exercise.  Passive stretches on the less flexible muscles with serious extension to see a good improvement (groin, hamstring, quadriceps, back, biceps, triceps, gastrocnemius and gluteus). All will be kept for 45 seconds. Passive stretches on the less flexible muscles with serious extension to see a good improvement (groin, hamstring, quadriceps, back, biceps, triceps, gastrocnemius and gluteus). All will be kept for 45 seconds.  Passive stretches and static stretches in every muscle (groin, hamstring, quadriceps, back, biceps, triceps, gastrocnemius and gluteus). All will be kept for 50 seconds.  I think this week really will help to maintain a good cardiovascular development and a good muscular strength. In both fitness components I’ve increased some type of resistance such as doing the really hard session in Friday for cardiovascular and adding 1 kilogram per exercise in the muscular strength training. I think the flexibility exercises I developed, will really help to see a difference in next week’s sessions. Next week I will increase 10 seconds in each stretch to see if week 4 really helped him to improve.  This wee I’m going to focus in two things, muscular strength and cardiovascular system. As its one more week left for the training programme to be finished, I am concentrate on the two major things that need improvement. To improve my cardiovascular I will do a Fartlek training session and a hard weight session by adding more weights, in Wednesday, everything it’s going to be a normal week and in Friday I will do an interval training to prepare for next week hard sessions and I will also do a very hard session for muscular endurance. For flexibility I will maintain adding seconds but won’t focus as much at it.  Monday  Wednesday  Friday  Fartlek training programme which will last 12 minutes and will be done in the athletic centre. It will have serious changes of speed every 3 minutes. A bike session of 2 minutes as harder as possible.  12 minutes run on the Treadmill, in level 12 and 5 minutes cycling at a steady pace  In this session a Interval session is being produces which will be jogging for 10 minutes, then do 3Ãâ€"100 sprint with a rest between of 1 minute jogging and finishing with another 10 minutes run. Finally cycling for 5 minutes in a steady pace.  Bicep curls, Triceps push down, Bench press, seated leg extension and seated leg curl all of this, 3 sets of 15 repetitions with 1 minute rest between sets and 2 minutes rest between different exercises. Adding 2 more kilos for the duration of the whole session. Bicep curls, Triceps push down, Bench press, seated leg extension and seated leg curl all of this, 3 sets of 15 repetitions with 1 minute rest between sets and 2 minutes rest between different exercises. Keeping the same weight as last session.  Bicep curls, Triceps push down, Bench press, seated leg extension and seated leg curl all of this, 3 sets of 12 repetitions with 1 minute rest between sets and 2 minutes rest between different exercises. Adding another 2 kilos for the duration of the whole session. Passive stretches on the less flexible muscles and static stretches on more flexible group muscles (groin, hamstring, quadriceps, back, biceps, triceps, gastrocnemius and gluteus). All will be kept for 50 seconds.  Passive stretches on the less flexible muscles and static stretches on more flexible group muscles (groin, hamstring, quadriceps, back, biceps, triceps, gastrocnemius and gluteus). All will be kept for 50 seconds. Passive stretches on the less flexible muscles and static stretches on more flexible group muscles (groin, hamstring, quadriceps, back, biceps, triceps, gastrocnemius and gluteus). All will be kept for 55 seconds.  I think this session can really help obtain a difference for the last week of the development programme. Making him work in the cardiovascular system as much, will help him psychological and physically to be more determine in sports, as he put all his effort in this week session and hopefully was done perfectly, with motivation and confidence. Flexibility stood the same but we added 5 more minutes in the last session so we can see an improvement in next weeks last session.

Comment on the various sorts of love shown in Romeo and Juliet Essay

Shakespeare’s Romeo and Juliet is a romantic tragedy based around a pair of young lovers. The play is set in 12th century Verona where a pair of families, the Capulet’s and the Montague’s have been feuding for many years. The play revolves around Romeo Montague and Juliet Capulet falling deeply in love and the events that befall these two forbidden lovers. The play covers an array of different types of love and love related issues from brotherly love to bodily lust, Shakespeare uses the characters to portray stereotyped ideas of love and how it affects people. Before even the first scene is out, the play has already touched upon the idea of brotherly love. Benvolio, the cousin of Romeo, finds Romeo in a state of near depression and says to Romeo ‘What sadness lengthens Romeos hours’? With this line Shakespeare is showing Benvolio’s concern as a man might unto his brother. Romeo is sad because he has fallen in love with a girl, Rosaline ‘In sadness, cousin, I do love a woman. ‘ However Romeo’s chosen spouse does not return the affection, as Romeo states ‘She will not stay the siege of loving terms’. Benvolio offers to Romeo the idea of looking for a different more attainable woman. He gives this advice in order that his cousin may once again be happy thus showing his affection for Romeo. Throughout the play Shakespeare writes about light when referring to love, he talks of it in the prologue before the play is even afoot ‘A pair of star-crossed lovers take their life;’ It does not stop here however, on Romeo’s first encounter with Juliet he says ‘O she doth teach the torches to burn bright’ Meaning that she brings light to his dark troubled state of mind, where there was the haze of rejection her light shines through brightening his mood. Again in scene two upon meeting with Juliet his love Romeo compares her presence to light ‘But soft, what light through yonder window breaks? ‘ To Romeo meeting Juliet is like the sun rising, just as the sun lights up the world she lights up his mood and, as the sun clears the morning mist, so Juliet clears the fog of his mind leaving it clear. I think Shakespeare uses these references to light to show that in ‘dark’ times often love can show the way. Perhaps showing that in the face of a problematic social environment love can be a beacon to those who embrace it. When Romeo first visits friar Lawrence in Act two Scene three they speak of Romeo’s newfound love for Juliet and change of heart to Rosaline ‘With Rosaline, my ghostly father? no; I have forgot that name, and that names woe’ By this he is telling the friar that he has not only stopped doting on Rosaline but, has in fact undergone a total change in spirits forgetting the woes he had over Rosaline. However the Friar speaks of the doubts he had for the sincerity of Romeo’s love for Rosaline in the first place ‘Thy love did read by rote, that could not spell. ‘ This implies that Romeo, whilst sounding outwardly convincing lacked the meaning behind his words. Shakespeare is again using a characters opinion to influence that of the audience, in this case Romeo’s love for Rosaline may well have been true but due to the friars opinionated speech the audience is cast into doubt on the matter. The friar also chides Romeo about his use of elaborate metaphorical language when talking of love, telling him to ‘be plain, good son,’ For in order for Friar Lawrence to absolve Romeo he must first be able to understand him. Yet it is not just the friar who is suspicious of Romeo’s decorative words, Juliet had already commented on the way he talks in Act two Scene two ‘O swear not by the moon, th’inconstant moon, That monthly changes in her circled orb, Lest that thy love prove likewise variable. ‘ Romeos allegorical promises do not hold well with Juliet because in his words no definition can be found merely elaborate metaphors. However Juliet’s complaints go unheeded for later Act two Scene six Romeo is again using exotic language in order to describe his love for her ‘Unfold the imagined happiness that both Receive in either by this dear encounter. ‘ Juliet however responds by saying ‘Conceit, more rich in matter than in words, Brags of his substance, not of ornament; They are but beggars that can count their worth, But my true love is grown to such excess I cannot sum up sum of half my wealth. ‘ What Juliet is saying here is that unlike Romeo she cannot sum up her love for him in words. Shakespeare uses strong negative imagery such as ‘beggars’ and ‘conceit’ to display Juliet’s exasperation with Romeos continuing usage of needless ornate speech. But despite Juliet’s doubts and Romeo’s misleading words there is an overwhelming love between the pair that cannot go unnoticed. Even upon their first meeting Romeo’s feelings for Juliet are obvious ‘Did my heart love till now? ‘ He directs this phrase at Juliet before the two have even met. Yet when they do at last meet Juliet shares with Romeo not one but two kisses, the second induced by Juliet ‘Then have my lips the sin that they have took’ These shows of affection in the time in which the play was written would be unheard of upon a first meeting. This shows just how the pair truly epitomise the phrase ‘Love at first sight’ for they did not let the fact that they were total strangers hinder the strength of their feelings even if the feeling was simply lust. However as of yet we cannot tell whether Romeo is sincere in his love this time rather than just lustfully infatuated as he was with Rosaline, the cousin of Juliet. However he proves himself later in the act by saying ‘Call me but love, and I’ll be new baptised; Henceforth I never will be Romeo’ By this he is offering to change his name if it would make Juliet love him and be with him. During Shakespearian times it was no small feat to denounce one’s name, there was a lot more weight placed upon names back then, especially if it was a name of high social standing as was Romeo’s. This proposal shows the true and serious nature of Romeo’s newfound love. However it is not simply Romeo who makes such a bold offer for earlier in the scene Juliet says ‘be but sworn my love, And I’ll no longer be a Capulet’ To the audience Shakespeare was writing for this selfless act on both their parts would have convinced the audience that their love was true. Another factor that Shakespeare played upon to influence his audience into believing that Romeo and Juliet’s love was true was his use of Religious language upon their first meeting. ‘If I profane with my unworthiest hand This holy shrine, the gentle sin is this, My lips, two blushing pilgrims, ready stand To smooth that rough touch with a tender kiss. ‘ Shakespeare deliberately uses this language to symbolise a number of things. Firstly that Juliet like a shrine is ‘untouched’ or virginal this theme is recurrent through the first two acts of the play. Secondly it However not all Shakespeare’s example’s of love are so romantic for instance Juliet’s mother The Lady Capulet says to Juliet considering the offer of marriage from Paris ‘So shall you share all that he doth possess, By having him, making yourself no less. ‘ This shows a very materialistic side to Lady Capulet it also implies that the reason she is married to Lord Capulet might not necessarily be because they are in love. It portrays a much more dutiful love between Juliet’s parents perhaps Lady Capulet loves Lord Capulet simply because they are married rather than being married because they are in love. This type of relationship was common in Tudor times because often romanticism was overlooked in the face of bettering oneself financially. Paris’ show of affection for Juliet is not without a sense of duty he, as was proper in those days, approaches Lord Capulet for his daughters hand in marriage ‘But now, my lord, what say you to my suit? ‘ At this point Capulet believes his daughter to be too young for marriage yet he encourages young Paris to ‘woo’ her in order that she may fall in love with him down the line ‘And too soon marred are those so early made. ‘ Might be referring to the marriage of himself and lady Capulet that has now become loveless and hollow. He as a loving father does not wish this upon his own only child so through Paris’ persistence Shakespeare shows another form of love, the love of a father for his daughter. Yet not all Shakespeare’s characters believed in such an ‘honourable’ love. In his opening scene there are two servant men talking between themselves, there speech although on the topic of fighting generally is rife with sexual innuendo and pun. For example ‘Ay, the heads of maids, or their maidenheads, take it in what sense thou wilt’ This line seemingly innocent to the reader of our time has a very rude meaning in Shakespearian language where ‘maidenhead’ means virginity, in this sense the two are talking of having sex with virgins, more than a little less noble than the good Paris. They speak also of pushing women to the wall because of their weaker build; this all shows little true emotion and a very physically sexual type of ‘love ‘ if indeed it can be referred to as that at all. Shakespeare’s Romeo and Juliet was a revolutionary piece when it was written because it showed just how love can move people in an age where marriage for social or financial gain was the norm. Over nearly five hundred years Shakespeare’s language and story line has captivated the hearts and minds of generations of lovers with its unique mixture of reality and fantasy. Romeo and Juliet is one piece of Shakespeare’s work that will remain a true timeless classic.

Preparing and exam taking Research Paper Example | Topics and Well Written Essays - 1000 words

Preparing and exam taking - Research Paper Example Preparation for exams starts during the first class. The classes that the student attend, various contributions made in class by the students, and assignments that students complete will help in preparing for any questions that an examiner may set in the future (Kesselman-Turkel & Peterson, 2010). The semester involves the addition of information to a students’ knowledge base. Essay questions normally involve information that one may have found irrelevant during class, which could be used as a supporting point to the thesis. Students who are involved in class have to cram less than those who skip class. Students should also note the topics that the lecturer finds interesting. Not surprisingly, the specific topics noted make up a significant proportion of the exam that the lecturer administers (Kesselman-Turkel & Peterson, 2010). Thus, it is important to note the topics in which the lecturer spends more time discussing. This will aid students in remembering important highlights when preparing for an exam. The students should also keep their syllabus. Losing the course syllabus is a big mistake since it is an important paper. It aids the students in organizing the information that they take in and will give the students ideas regarding the topics that the exam will emphasize. The syllabus will also act as a guide when studying for the exam. The students should also add notes to the syllabus as the lessons progresses, circling themes, topics, and books that appear most likely to be contained within in the exam (Kesselman-Turkel & Peterson, 2010). In addition, participation in class is a good way of preparing for exams. It aids the students in being better acquainted with the course material, as well as letting the lecturer know the areas that students are interested while in class. Test grades seem to reflect one’s attendance in class and the

Stratigy mangement Essay Example | Topics and Well Written Essays - 2500 words

Stratigy mangement - Essay Example The quality of the human resource management in any company greatly influences its activity and competitiveness. Generally, human resource management changes the way the company operates and supervises its people. The main task of HR department is to supervise, employ and instruct workers in the way that helps the company meet its goals. Human resource officials are challenged with developing new incentive plans capable of attracting and retaining highly qualified individuals with fewer financial resources than in times past. Many human resource managers are meeting this challenge by developing internal reward systems that are based on intrinsic needs. The ability to monitor and measure performance has the greatest impact on organizational performance. Global and national competition has forced many healthcare organizations to look for new ways to enhance organizational performance without significantly increasing costs. Performance management enables human resource management by regulating employee motivation and ability. When used correctly, performance management aids human resource managers in the areas of formal performance evaluations, objective setting, and developing a linkage between performance and rewards. Well-developed performance management systems utilize input and feedback from a variety of sources, including employees, organizational management, and outside stakeholders. Performance management systems allow human resource managers to quickly identify those behaviors that help the organization achieve its goals and those behaviors that are detrimental to productivity. These systems regulate employee performance by focusing on employee behavior, skills and outputs. In order for these systems to be beneficial to the human resource department, they must be flexible and capable of rapid change in response to changes in the internal or external environment. Tawam Hospital,

Asian Theatre and Drama Essay Example | Topics and Well Written Essays - 1000 words

Asian Theatre and Drama - Essay Example Decked up with a number of psychological and social issues, the play brought a remarkable fame to Tagore not only within the nation but across the globe as well. The combination of pathos and the humor operating hand-in-hand within the plot of the play enables a huge scope for a prolific presentation of the play on stage. Owing to this scope, a lot of modernization and improvisations have been incorporated within the plot of the original text while performance by various dramatists. PETA’s Ang Post Office which was performed in the 4th Day of the month of September in 2010, Directed by Grady Labad and Dramaturgy framed by Rustom Bharucha and the adaptation was done by Rody Vera. The entire play gives a different dimension to the language of humanity but the presentation of the ending scene, where the protagonist Amal is lying on the bed dying builds a spectacle unforgettable. The light, sound and action of the characters the moving of the bed, and the association of all the ch aracters on stage transformed the macabre of death into a panorama worth viewing that has the strength to percolate through the mundane inhibitions and comprehension of human mind and transport the audience into some space belonging to cosmic realm . Thesis Statement This essay intends to focus on the ending scene of the performance of Tagore’s ‘Post Office’ by PETA and the intensity of its presentation through which the group is able to take the viewers on a cosmic ride almost. Before analyzing the ending scene of the PETA’s ‘Post Office’ performance, it is very eventual to introspect into the original text from which the play has actually evolved; its themes, motif and most importantly a thorough judgment of its backdrop and context should also taken into consideration. Tagore’s ‘Post Office’ is a play from the pantheon of symbolic theatre. One can trace another plot running through the main plot of the play which is allegorical nature. The allegory inherent in the play, ‘Post Office’ by Tagore les at the pivotal motif of the play or the most potent theme considered. Illusion and reality at the end of the world and the eternal battle of life and death is the crux of the play. Tagore’s own fascination for the mysticism associated with death and life after death actually glossed the play, ‘Post Office’. Tagore’s idealism for the spiritual death finds profound expression through t he presentation of Post Office. The dynamics of skepticism regarding the physical and spiritual death all through his life gets a proper expression in the play, ‘Post Office’. Amal dies a physical death, but his physical death is not his actual death. Amal seems to die, but his physical extinction does not lead an end to life’s unceasing voyages2. The village doctor was about to maltreat and put him to death, but Amal feels that when a patient is visited by the royal physician, then no one can fall into the clutches of death so easily. Through the fabric of metaphors Amal awaits the King’s letter to come to him directly pondering upon the window through which he can see the Post Office. The door or the route to the endless road opens at the closing scene of the play. The royal physician himself brings the message for Amal, but the message of emancipation from the hands of the royal physicia

Robinson-Patman Act Assignment Example | Topics and Well Written Essays - 250 words

Robinson-Patman Act - Assignment Example It required that the seller offer the same price terms to customers at a certain given level of trade. It is meant to cub discrimination on the sale of goods to equally-situated distributors when the effects of such sale are aimed at reducing competition (American Bar Association, 2002, p. 463). Large stores and wholesalers can undercut small stalls selling similar products and services in such a way that can attract customers to buy from them. This can force such small retailers to go out of business; hence the Act can stem the vice of undercutting other small general business. Wholesalers and chain stores have to operate under the same business environment with the small retailers so as to offer the same prices to the end users of the products. Without the law, competition will be lessened and monopolies created in the line of commerce hence injuring small retailers and granting huge benefits to the large stores. This law applies to goods and services of the same grade, calibration, and quality (American Bar Association, 2002, p. 495). Such big multinationals like Pepsi and its competitor Coca Cola are the two major soft drink manufacturers in the world. They enjoy wider market coverage around the world which can be considered to be monopolies in some cases, especially if one of them operates, and the other is not in that market. Their market positions have been considered harmful as they enjoy huge capital outlay and wider market coverage. These enable them to cause undesirable competition to small manufacturers. They yield harmful price controls which they can manipulate markets in their favor to reduce competition by reducing prices at will across their products; soft drinks, juices, bottled water, sports drinks, and snacks. Such antitrust law as Robinson-Patman Act is meant to prevent such multinational from creating restraints on trade and commerce and

Immanuel Kant Moral Theory Essay Example | Topics and Well Written Essays - 1000 words

Immanuel Kant Moral Theory - Essay Example Emotions and desires should not hinder one from doing what is morally right. Such a stand raises several questions that Kant failed to state clearly. By emphasizing the superiority of reason, Kant seems to underrate the influence of emotions in decision making (Haidt 93). In some instances, it is difficult to separate emotions from reasoning. To understand this, other critics use an example of a situation where Kant's ambiguous claim is shown. The example goes that if one was to find their mother and another complete stranger drowning, Kant's moral duty theory fails to explain why one would choose to save their mother first. The theory is also not in a position to provide insight as to why that would not be the proper thing to do. Kant’s claim leads to another question. Which between emotion and reason is superior? Plato was of the opinion that the reason was the greater of the two, claiming that the reason was the king of the soul and the controller of passions (Haidt 189). O ther philosophers and psychologists however differ with Plato. David Hume claimed that the reason was the slave of passions whose sole role was to serve continually and obey them (Hume 173-196). Reasoning was just rationalization whereas the ego was the servant of the id. More researchers took to investigate the matter with differing results and findings. According to (Kagan 304), there existed a set of states in a society that formed the basis for various moral categories in which moral judgment and reasoning is embedded.

Post traumatic stress Essay Example | Topics and Well Written Essays - 500 words

Post traumatic stress - Essay Example The current state of literature suggests that numerous events and factors can trigger posttraumatic stress in children, from a minor physical injury to earthquakes and wars. Psychological treatment has a potential to reduce the symptoms and complications of posttraumatic stress in children. The current state of empirical literature suggests that a whole range of factors and events can trigger the development of posttraumatic stress experiences in children. Dozens of studies confirm that children are particularly vulnerable to the risks of PTSD. Aaron, Zaglul and Emery (1999) explored posttraumatic stress in children after acute physical injury. The researchers interviewed forty children 8-17 years old and concluded that many children hospitalized with physical injuries met diagnostic criteria for PTSD (Aaron et al, 1999). In a similar vein, Thabet and Vostanis (1999) analyzed posttraumatic symptoms investigating Palestinian children who suffered the emotional effects of war. War was found to heavily contribute to the development of posttraumatic experiences in Palestinian children: 72.8% of children in the sample reported posttraumatic reactions to war traumas (Thabet & Vostanis, 1999).

PIETER HUGO EXHIBITION Essay Example | Topics and Well Written Essays - 500 words

PIETER HUGO EXHIBITION - Essay Example His photo exhibition at the Henri Cartier Bresson Exposition was brilliant and breathe taking. The primary reason I liked these photos is because they always have stories behind them. The exhibition showcased Hugo’s latest series Kan. Hugo stated that this series illustrates the failure of colonialism in his South African homeland. As such, the pictures represent issues of racial diversity, economic disparity and colonization in South Africa. Although these topics and subjects are often complex to decipher, Hugo tackles them from an artistic point of view. 2The clichà © â€Å"a picture speaks a thousand words† best describes Hugo works at the Henri Cartier Bresson Exposition. The photographs cover subjects and topics which in most instances are personally significant to the artist such as contested farmlands, important political sites and cramped townships. Also, some of the photographs at the exhibition capture people in their homes, the homeless and drifters. Further, Hugo captures intimate moments showing his pregnant wife, their domestic servant and his child after being born. Thus, the photographs alternate between the public and private space s to present a clear narrative. Mostly, Hugo’s photographs at the Henri Cartier Bresson Exposition focus on the growing economic disparity between people who are often rich and the poor. Thus, Hugo focuses mostly on the dark side of his homeland and subsequently offers a personal exploration and depiction of the complex issues affecting his country South Africa. South Africa as a country is plagued with a widening gap between the rich and the poor. Additionally, the nation is struggling to come to terms with its apartheid past. To reiterate and illustrate these topics (economic disparity, colonization, modernity and apartheid) clearly and extensively, Hugo includes them in each and every photograph. For instance, there is a photograph depicting a homosexual couple which has been

Feminist Movement Research Paper Example | Topics and Well Written Essays - 500 words

Feminist Movement - Research Paper Example This discussion will not only focus aspects of changing gender roles among females and males over the last 40 years. Before the 1960’s, a large percentage were only accepted in programs that were perceived as simple and involved social aspects of interaction for instance: Teachers, convent sisters, nurses and secretaries (tavaana.org). However, with the increased advocacy of equality in job opportunities for women in more technical programs in the 1960’s, a significant percentage of women began accessing enrolment in medical schools as well as colleges that provided, many women also began accessing employment in manufacturing industries; however at a lower wages compared to men (tavaana.org). In article published by the United States History, Arts & Archives, it is indicated that women were not given the right to vote before the introduction of the Women’s Suffrage movement. With the introduction of this movement, women were given the right to vote and occupy political offices (history.house.gov). These rights have since saw a shift in political power and decision making issues, leading to a scenario where women can lead the society and make pertinent decisions just like men. In a research undertaken by the Pew Research on Social and Demographic Trends, it was noted that the United States’ Labor Force accounts for 38% women and 62% men since that 1970’s. The research indicated that the number was attributed to the wide range of public consensus concerning the changing role of women and men in the society. Additionally, the study indicated that approximately 75% of the American populace agree that women should not go back to their traditional roles as home cares, but should work equally like men and contribute to their families’ income (www.pewsocialtrends.org). This is another aspect of a change in role between men and men. Over the last four decades, men and women have take almost equal roles in provision of responsibilities in

Psychopathy Case Study Essay Example for Free

Psychopathy Case Study Essay Psychopathy is a personality disorder it’s also known as sociopathic personality or psychopathic personality or antisocial personality disorder. Psychopaths can’t be understood in terms of antisocial rearing or development. Sadly they are seen as â€Å"Monsters† in our society. They are unstoppable and untreatable predators whose violence is planned, purposeful and even emotionless. The violence continues until it reaches a plateau at age 50 or so then it tapers off. It’s evident when a person has an enduring way of thinking, acting and feeling that is significantly different. It’s a longstanding illness, and inflexible. They act in such a way that’s classed as not socially excepted. There are ten types of personality disorders. Paranoid, Borderline, Schizoid, Schizotypal, Histrionic, Narcissistic, Avoidant, Obsessive, Dependant, Anti Social. Those who struggle with a personality disorder have a great difficulty dealing with others. They tend to be inflexible, rigid and unable to respond to the changes and demands of life. Although they feel that their behaviour patterns are normal or right, people with personality disorders tend to have a narrow view of the world and find it difficult to participate in social activities. Personality disorders are grouped into three major groups: Group A: includes paranoid, Schizoid, Schizotypal disorders identifies odd or eccentric personality disorders. Paranoid personality disorder (PPD) is characterized by persistent feelings of distrust and suspicion against others. Schizoid personality disorder (SPD) is defined by detachment and lack of interest in relationships with others. An individual with SPD may prefer solitary activities and emotionally detached from others. They can also believe in magical or unconventional beliefs, as in someone with Schizotypal disorder may believe he or she has magical powers. Group B: the second group of personality disorders contains emotional disorders. Anti-social personality disorder (APD) is characterized by an apparent disregard for the safety and feelings of others. People with APD may engage in criminal or reckless behaviour. Borderline personality (BPD) is indicated by an unstable sense of self impulsivity and tendency towards strict Black and White thinking. BPD’s have histo ry of unstable relationships and engage in self destructive behaviour. As in self mutilation, reckless, spending obsessions, or binge eating. Histrionic personality is characterized by extreme theatricality and a constant need to be centre of attention. Narcissistic disorder is indicated by an inflated sense of self-importance and entitlement. Group C: the last group are classed as fearful or anxious like a person with avoidant personality disorder thee people may be afraid of criticism or rejection, and withdraws from social situations. The second of the fearful and anxious personality disorders is also known as dependant personality disorder (DPD) unlike avoidant personality disordered patients. A person with DPD is intensely dependant on other people. Obsessive compulsive personality disorder is characterized by pre occupation with lists and orderliness often to the point it interferes with interpersonal relationships. It has been said that psychopaths with lower intelligence or poor education are more likely to end up in our prison systems than Psyc hopaths with a higher level of education. Treatment for this disorder is very limited; patients with a Psychopathic disorder could take place in a variety of in-patient settings such as special hospitals, regional secure units, and intensive Psychiatric care units. Treatment in prison’s governor responsible therapy for those with mental a illness. There are medications that could be used for patients with personality disorders such as your common forms of anti depressants, Lithium, Benzodiazepines, Psychostimulants and Anti convulsants, Neuroleptics. All or some may affect patients in many different ways. These are known as your Pharmacological treatments. There are other forms of treatments such as physical treatments, behaviour therapy, cognitive approaches, Individual and group psychotherapy, therapeutic community approaches, are also available.

Sigmund Freud and the Psychodynamic Perspective

Sigmund Freud and the Psychodynamic Perspective Introduction The origins of The Psychodynamic Perspective can be traced to the early work of Sigmund Freud. Using sub headings this essay will identify the main tenets of Freud’s approach to the understanding of human behaviour: his views on determinism; his use of hypnosis as therapy; his belief that human behaviour is controlled by separate yet interlinked layers of the mind (conscious and unconscious); his views on sex and aggression; and the importance he placed on unresolved and unseen conflict involving the ‘ego’, the ‘id’, and the ‘superego’ (Cave: 1999, p.31/2). The work will then explore how the perspective might be used in a healthcare setting, and will assess inherent strengths and weaknesses. Determinism Determinism, the belief that ‘every state of affairs, including every human event, act, and decision is the inevitable consequence of antecedent states of affairs’ (GuruNet: for details see References) greatly influenced Freud who sought to identify hidden causes for human behaviours. His theory is a dynamic process from the early years of a human’s life where the first interactions with others affect the development of the personality, through to the adult years where the person learns and adopts social values. Hypnosis During his time in France, Freud observed the work of Jean Charcot whose use  of hypnosis led to his ‘inducing and curing hysterical paralyses by means of direct  hypnotic suggestion.’ (Gay: 1998, p.49). Later work with Josef Breuer involved hypnosis where patients recalled traumatic experiences and expressed their emotions as a way to release the conflict within; this was the cathartic method. Freud began to develop his idea that emotionally disturbed patients had problems that were sexually orientated, and, as a development on his work in hypnosis he worked on the idea of ‘free association.’ (Nye: 1975, p.11). Instead of sending patients into a trance using his voice, Freud altered the technique of hypnosis so that the patient independently drew forth words and feelings which might be analysed or explained by the analyst. Unconscious and Conscious activity ‘Freud himself regarded the concept of the unconscious as fundamental to psychoanalysis. It is what makes the psychoanalytic approach distinctive; it is the defining characteristic of the Freudian perspective towards human action.’ (Bocock: 2002, P.32) One of the fundamental beliefs behind Freud’s work was indeed his distinction  between the unconscious, preconscious, and conscious areas of the human mind. He stipulated that the unconscious was the governing force where dreams, habits, thoughts and feelings originate from. In order to investigate these phenomenon he used psychoanalysis; as Nye phrases it in The Three Psychologies ‘it is the role of psychoanalysis to unravel the mystery by seeking the sources of thoughts, feelings, and actions in hidden drives and conflicts.’ (1975, p.10). Through using this technique Freud aimed to identify the nature of crucial communications occurring in early childhood which would affect adult behaviour. Dream interpretation is another of Freud’s infamous techniques; occurring when a person is asleep and unguarded he claimed that this was an opportunity for  unconscious drives and desires to manifest themselves through symbolic images. The  waking human mind however is conscious, meaning that it is aware of what is  immediate to it, and the preconscious is the level between. As Nye summarises it: ‘the unconscious consists of all aspects of our personalities of which we are unaware. The preconscious consists of that which is not immediately at the level of awareness  but is fairly accessible.’ (1975, p.13). The id As part of his understanding of human behaviour Freud identified the human personality as constituting three different structures: the id, the ego, and the superego. The id is what the human child is born with instinct which contains base biological drives; the id seeks immediate satisfaction of primitive impulses, and operates on the ‘pleasure principle’ (Freud: 1927, p.30), seeking to avoid pain and maximise gratification. The instincts that a person is born with remain with them for life: life energy and death energy, which exist side by side, respectively concern the drive to survive (eat, drink, reproduce), and the primitive tendency to return to the ‘inanimate state’ (Nye: 1975, p.14) which has its origins in the prehistory of the world where life forms were unstable. Sex and Aggression ‘In proposing two psychological entities: our animal selves, in the form of the id, and our social selves, the ego and super-ego, (Freud) directly addressed the relationship between biology and socialisation, and the dynamic between them. For Freud, being human was individual peoples endless negotiation between the two.’ (Bland: 2003). It is precisely such negotiation that causes the varieties and extremes of behaviour seen in human beings. As well as the life and death instincts, humans are driven by their sexual drive and their aggressive drive; these being underlying causes of human behaviour. Freud made no distinction between what people might class as ‘everyday’ feelings and sexual feelings. Because humans are animals they are driven to  experience primal urges and desires but simultaneously live in a society where  standards contain and condition human behaviour. Thus, this is where the conflict arises between the drives of the id and the learnt morality of the superego so that anxiety, fear, and neuroses can all be traced to a basic incompatibility of the human  instinct with the socialised world which has evolved around it. The nature of Freud’s concept of aggression is that it is innate and thus a natural state. As one of the most powerful energies within the human mind aggression can cause serious damage mental and physical if it is not released in some way. Freud’s claims that some of the innate destructive energy is never released and so a person harbours the death instinct which eventually overcomes the other drives resulting in death. (Nye: 1975). Ultimately, the emotional life of a human being is destined to be a turbulent one: powerful energies conflict and override each other, and it is the role of psychodynamic therapy to uncover and understand the layers and symbolism within the psyche. A further understanding of these complex processes may be achieved through examining Freud’s concept of the ego and the nature of its functions. The Ego Freud suggested that the ego is a form of mediation between the urges of the id and the learnt morality in the super-ego, evolving as a person grows older in order to help them cope with the world. As the ego develops so does the person’s perception of reality, and a wider view is attained than simply the pleasures of subjective gratification. Freud’s pleasure principle thus becomes replaced by the ’reality principle’ (Stoodley: 1959, p.169). The desires of the id cannot always be realised, so the ego causes humans to convert them into other modes of behaviour;  not only in cathartic sport activities but also in people’s careers. Understanding the work environment in the context of the Psychodynamic Perspective will be discussed later. Freud likens the ego to a ‘a man on horseback, who has to hold in check the superior strength of the horse; with this difference, that the rider seeks to do so with  his own strength while the ego uses borrowed forces. () Often a rider, if he is not to be parted from his horse, is obliged to guide it where it wants to go; so in the same  way the ego constantly carries into action the wishes of the id as if they were its own.’ (Freud: 1927, p.30). Freud’s approach was radical for his time because he saw psychology very much through the same eyes as he saw evolution; as a process involving accumulative and transferable energy. Freud suggested that the energy levels in a person originating from the id and controlled, to an extent, by the ego (depending on circumstances) were affected by restrictions placed on that person by those around them. If these energies were not allowed to have an outlet then the person might suffer from anxiety. A strong ego will therefore develop as the person’s circumstances allow them to adjust to the real world while also going part of the way to satisfying the demands of the id. The Superego The superego incorporates the values and morals of society which are learnt from a person’s parents and other influential figures, and develops as a result of rewards and punishments as the individual grows up. The superego provides the personality with a conscience; a form of overview concerning right and wrong actions, which can cause a person to feel guilty. Freud termed the superego’s internal standard of what a person should be as the ‘ego-ideal’. (Nye: 1975, p.20). The superego is responsible for extremes of behaviour such as introvert behaviour, where  it will concern the person with too many of society’s rules, inhibiting the id and ’immobilizing the ego’s attempts to achieve satisfaction in the real world (Nye: 1975, p.20). On the other hand it can also cause extrovert behaviour where the individual abandons the expected standards of society. Anxiety and defence mechanisms When anxieties develop they can often be explained through the processes which  Freud termed ‘anxiety or defence mechanisms.’ The problem is to do with the  desires of the id they can be controlled by the superego and directed by the ego, but they still remain as very strong inclinations within the psyche. A desire of the id to act in a particular way may be thought of as wrong or punishable and thus creates guilt and tension anxiety within the person. The impulse might be expressed in a disguised form that society does approve of for example becoming a racing car driver or boxer as an outlet for aggression. Other ways of coping with the presence of inner energies are: Repression This is the phenomenon of forcing the uncomfortable desires, painful feelings and memories into the unconscious, only for them to affect our behaviour and mental states on a subliminal level, maybe emerging as Freudian slips or as symbolic imagery in nightmares. It is the job of the ego to try and prevent the ‘forgotten’ thoughts from returning to the conscious mind. Projection This occurs when someone assigns their own negative thoughts to another in order to  absolve themselves of the feeling. Denial Negative aspects of a situation may be avoided if the ego simply does not  acknowledge that they are there; this may be conscious or unconscious. Sublimation When forbidden impulses are channelled into socially acceptable behaviour or a socially beneficial situation for example, an aggressive man might choose to become  a martial arts teacher or a soldier. Alternatively, when a substitute action or transfer  of energy replaces the reaction to the person or object that originally caused the upset it is called displacement. The Psychodynamic Perspective in a healthcare setting Freud’s work has been influential not just in the field of psychology but also in conjunction with the sphere of mental health and social care. His group dynamics where he suggests that a group of people admit the same person a leader into their superego and identify with each other (Cave: 1999, p.57) can help individuals to understand the sometimes complex relations between work colleagues. For example, when a new worker joins a team it takes time to become integrated: Freud would say that this was due to the ‘personal space’ barrier (Cave: 1999, p.58) not yet being broken. Once the person is accepted then the group directs hostility to others outside of it, the barrier changing to a ‘group space’ barrier. More importantly an awareness of group processes can help ‘inform, promote insight, change behaviour or alleviate suffering.’(Cave: 1999, p.50). Understanding the relationships between individuals within a group is crucial for healthcare professionals who work in hospitals and care homes. For example, it could be beneficial to understand what facilitates group cohesion when working with discussion/therapy groups. Alternatively, a patient who is afraid of group work may  be best understood in isolation Freud’s psychoanalytic approach is commonly used in counselling and therapy for drug users, those who have been/are abused, and can be  beneficial to those suffering from obsessions and neurotic disorders. It is vital to have a good rapport and understanding between healthcare workers and patients to provide the best professional environment for recovery. Difficult situations often arise which require tact and discretion such as bereavement and can be understood in terms of Freud’s distinctions between the ego and the id and the conscious and unconscious mind. For example, an unusual pattern of behaviour (possibly anger or guilt) seen in a bereaved person might be attributed to a  defence mechanism which is masking the hidden conflict or upset associated with the death. Critical evaluation of the Psychodynamic Perspective Like all psychological theories, Freud’s is susceptible to heavy criticism because it is one of many perspectives all of which are formed by people trying to study other people making it difficult to attain complete objectivity. Skinner’s behaviourist theory criticises Freud for his belief that many guilt and anxiety complexes are sexually orientated (Nye: 1975, p.52), and there is also conflict between Freudian theorists and those psychologists who view behaviour as controlled by external factors: an example being the issue of suggestion in psychoanalysis and hypnosis. Take for instance, the case study of ‘Dora’ (Cave: 1975, p.37) whose abuse was suggested by Freud to be imagined, the consequence being that after counselling sessions with Freud she showed no signs of improvement. There is discrepancy about the meaning of dream symbols, and the outcome of hypnosis and psychoanalysis is often ambiguous and unreliable. Further problems occur when using hypnosis as therapy because the patient might not be properly under, and, as Freud himself found, they may even fall asleep. Nye notes that Freud used a restricted sample while developing his theory so  that it was not fully representative, and therefore his ideas only have limited applicability. (1975, p.146). Freud’s studies might also have been selectively chosen  to represent his ideas considering the complex nature of concepts such as the Oedipus complex it is unlikely that his findings were reliably consistent. As Webster says in criticism of Freud: (He) made no substantial intellectual discoveries. He was the creator of a complex pseudo-science which should be recognized as one of the great follies of Western civilization. In creating his particular pseudo-science, Freud developed an autocratic, anti-empirical intellectual style which has contributed immeasurably to the intellectual ills of our own era. (Webster: 1995, p.438) A large amount of Freudian theory is indeed based around hypothetical concepts such as the id and the ego, and is restricting in the sense that all behaviour can be traced back to some hidden primal source. Yet it is necessary to bear in mind that much of Freud’s theory has found its way into everyday language such as the ‘unconscious’ and ‘conscious mind‘, the ‘ego‘, etc, and this in itself suggests that the theory makes adequate sense to the human mind. Thus, we are left with a theory that is at the very least plausible but left very much open to interpretation: like many opposing theories evidence can be found for and against it, and it is left to the individual to determine whether or not the theory is acceptable to them. References Bland. J., 2003, About Gender: Freud, the Father of Psychoanalysis. Available from URL (http://www.gender.org.uk/about/01psanal/11_freud.htm). Bocock, R., 2002, Sigmund Freud. London: Routledge. Cave, S., 1999, Therapeutic Approaches in Psychology. London: Routledge. Gay, P., 1998. Freud: A Life for Our Time. New York: Norton. GuruNet, online dictionary, available from URL (www.questia.com). Freud, S., 1927. The Ego and the Id. Contributors: Joan Riviere transltr. London: Hogarth press, and the Institute of psycho-analysis. Messer, D., and Meldrum, 1995, Psychology for Nurses and Healthcare Professionals. Prentice Hall: London. Nye, R., 1975, The Three Psychologies, 3rd Ed. California: Brooks. Stoodley, B., H., 1959, The Concepts of Sigmund Freud. Glencoe: Free Press Webster, R., 1995, Available from URL (JavaScript:parent.bookWindow(../books/bookstz.html l WebsterR_1995) Background Reading Fine, R., D., 1962, Freud: A Critical Re-Evaluation of His Theories. New York: David Mckay. Jones, E., 1953, The Life and Work of Sigmund Freud: The Formative Years and the Great Discoveries, 1856-1900. Volume: 1. New York: Basic Books. Levine, M., P., 2000, The Analytic Freud: Philosophy and Psychoanalysis. London: Routledge. Mansfield, N., 2000, Theories of the Self from Freud to Haraway. St. Leonards, N.S.W: Allen Unwin.

Dementias Effect on the Visual System

Dementias Effect on the Visual System Abstract Recent evidence indicates that memory impairment and visual dysfunction are clearly linked in dementia, and that special testing for visual dysfunction can improve the early diagnosis and treatment of dementia. Visual function is divided in terms of anatomic, functional and cognitive areas respectively. Under normal circumstances these functions perform seamlessly together to produce a visual reality of what we call the external world. Alzheimers disease is the most common form of dementia and past research into this area has shown that sufferers show visual deficits in several key areas. Namely contrast sensitivity, motion, colour, depth perception as well as visual hallucinations. Thus by approaching the patient in a appropriate manor with regards to dementia, clinical professionals can detect visual dysfunction and memory impairment whilst also providing a vital role in secondary and tertiary preventative measures. Furthermore clinical professionals can provide aid in the treatmen t of dementia linked visual disorders. With current demographic trends, dementia is becoming increasingly prevalent due in the ageing population. Consequently there is an increased need for practitioners to have a sound knowledge of such dementia conditions. Improving the sufferers quality of life should be the practitioners main concern. By providing thorough treatments and suggestions on patient tailored environmental modifications this can be achieved. (1) Introduction Dementia is a loss of mental function in two or more areas such as language, memory, visual and spatial abilities, or judgment severe enough to interfere with daily life1. Dementia is not a disease itself, sufferers show a broader set of symptoms that accompany certain diseases or physical conditions1. Well known diseases that cause dementia include Alzheimers disease, Creutzfeldt-Jakob disease and multi-infarct dementia1. Dementia is an acquired and progressive problem that affects cognitive functions, behavior, thinking processes and the ability to carry out normal activities. Vision is one of the most important primary senses, therefore serious or complete sight loss has a major impact on a individuals ability to communicate effectively and function independently. Individuals who suffer from both dementia and serious vision loss will inevitably be subject to profound emotional, practical, psychological and financial problems. These factors will also influence others around the sufferer and will extend to the family and the greater society. As we get older both dementia and visual problems inevitably become much more prevalent. Current demographic trends show the increase of the number of very old in our population. Therefore it is inevitable that dementia and serious sight loss either alone or together, will have important consequences for all of us1. The vast majority of people are aware that dementia affects the memory. However it is the impact it has on the ability to carry out daily tasks and problems with behavior that cause particular problems, and in severe cases can lead to institutionalization. In the primary stages of dementia, the patient can be helped by friends and family through ‘reminders. As progression occurs the individual will loose the skills needed for everyday tasks and may eventually fail to recognize family members, a condition known as prospagnosia. The result of such progression is that the individual becomes totally dependent on others. Dementia not only affects the lives of the individual, but also the family2. Dementia can present itself in varying forms. The most common form of dementia in the old is Alzheimers disease, affecting millions of people. It is a degenerative condition that attacks the brain. Progression is gradual and at a variable rate. Symptoms of Alzheimers disease are impaired memory, thinking and changes in behaviour. Dementia with Lewy bodies and dementias linked to Parkinsons disease are responsible for around 10-20% of all dementias. Dementia with Lewy bodies is of particular interest as individuals3 with this condition not only present confusion and varying cognition, but also present symptoms of visual hallucinations2. Another common condition that causes dementia is multi-infarct dementia, also known as vascular dementia. It is the second most common form of dementia after Alzheimers disease in the elderly. Multi infarct dementia is caused by multiple strokes in the brain. These series of strokes can affect some intellectual abilities, impair motor skills and also c ause individuals to experience visual hallucinations. Individuals with multi infarct dementia are prone to risk factors for stroke, such as high BP, heart disease and diabetes. Multi infarct dementia cannot be treated, once nerve cells die they cannot be replaced1. In most cases the symptoms of dementia and serious sight loss develop independently. However some conditions can cause both visual and cognitive impairments, for example Down syndrome, Multiple sclerosis and diabetes. Dementia is most prevalent in the elderly, as is sight loss. Therefore it is inevitable that a number of people will present dementia together with serious sight loss. There have been many studies into the prevalence of dementia in the UK. An estimate for the prevalence of dementia in people over 75 years of age is 15% of the population2. The Alzheimers society suggest that 775,200 people in the UK suffer from dementia (figures taken 2001). The Alzheimers society also calculates that the prevalence of dementia in the 65-75 years age group is 1 in 50, for 70-80 years 1 in 20 and for over 80 years of age 1 in 5. Estimates suggest that by 2010 approximately 840,000 people will become dementia sufferers in the UK. Estimates suggest that around 40% of dementia sufferers are in residential institutions. One study from 1996 showed that dementia sufferers are 30 times more likely to live in an institution than people without dementia. At 65 years of age men are 3 times more likely than women to live in an institution and at 86 men and women are equally likely to be institutionalized4. Visual impairments are not associated general diagnostic features of dementia. However recent research has shown the change in visual function and visual processing may be relevant. Alzheimers disease patients often present problems with visual acuity, contrast sensitivity, stereo-acuity and color vision. These problems are believed to be more true of cognitive dysfunction rather than any specific problems in the eye or optic nerve9. Early diagnosis is essential to both dementia and sight loss patients, as drug treatments are becoming more and more available. Therefore maximizing the treatment and care for the individual. On the other hand early diagnosis of visual conditions is also essential, so that progression is slowed and treatment is commenced, therefore further progression is prevented if plausible2. The Mini-Mental State examination MMSE, is the most commonly used cognitive test for the diagnosis of dementia. It involves the patient to undertake tests of memory and cognition. It takes the form of a series of questions/answers and uses written, verbal and visual material. Poor vision or blindness is the most common cause of poor performance on this test other than dementia itself2. Visual deterioration can occur simultaneously with memory loss in most dementia sufferers. Therefore early recognition of dementia through vision tests has become of importance. Table 1 shows few possible tests that might be useful for such purpose Table 1 : Vision tests for possible early detection and monitoring of Alzheimers disease Use Benton visual retention test Might be able to predict risk for AD 10-15 years before the onset of the disease Tests visual memory Contrast sensitivity AD patients have selectively reduced CS for distinguishing large objects and faces Useful field of view Tests processing speed, divided attention and selective attention Facilitates detection of â€Å"attentional dysfunction†; patients suffering from this problem complain of poor vision and inability to identify someone in a group or an object on a patterned background Could be useful to assess fitness to drive Facial recognition AD patients do not recognize faces with large features and low contrast AD patients do not recognize familiar faces (due to impaired memory) Tests that use facial expressions with progressively diminished degree of contrast The aim of this paper is to provide information about current knowledge on the topic of visual function dementia. With regards to Alzheimers disease, there will be an inclination to several main foci of research. Namely anatomical/structural changes, functional visual changes, cognitive brain changes and other changes such as the effects of diagnostic drugs on Alzheimers disease patients. (2) Alzheimers disease Alzheimers disease is the most common cause of dementia amongst older adults. The Alzheimers research trust estimates that 700,000 individuals in the UK currently are afflicted. This number will inevitably increase exponentially in the near future with the trend of an increasingly aging UK population. Therefore it must be of the utmost of importance worldwide to have an understanding all behavioral, anatomical and physiological aspects of this disease. Alzheimers disease is a degenerative disease that attacks the brain, it begins gradually and progresses at a variable rate. Common signs are impaired thinking, memory and behavior. Health professionals and care givers agree that the memory deficit is usually the initial sign of the disease. However researchers have long known that Alzheimers disease is characterized by impairments of several additional domains, including visual function5. However these findings have not yet appeared in the diagnostic guides consulted by healthcare professionals, for example the most recent addition of the Diagnostic Statistical manual of mental disorders states that few sensory signs occur in early Alzheimers disease2. Therefore we still have a limited understanding of the true extent to which visual impairments affect Alzheimers disease sufferers. The current web site of the Alzheimers association1 and National Institute of Aging6 make no mention of the topic of sensory changes in Alzheimers disease. It has even been said that patients with Alzheimers disease report visual problems to their healthcare professionals less frequently than do healthy elderly individuals7. Nevertheless visual function is impaired in Alzheimers disease8. In terms of cognitive changes, the neuropathology of this disorder affects several other brain areas which are dedicated to processing low level visual functions, as well as higher level visual cognition and attention5.These neuropathological cognitive changes are more dominant however in the visual variant of Alzheimers disease known as posterior cortical atrophy. However visual problems are also present in the more common Alzheimers disease. Alzheimers disease begins when there are deposits of abnormal proteins outside nerve cells located in the brain in the form of amyloid. These are known as diffuse plaques, and the amyloid also forms the central part of further structured plaques known as senile or neurotic plaques1. Buildup of anomalous filaments of protein inside nerve cells in the brain can also take place. This protein accumulates as masses of filaments known as neurofibril tangles. Atrophy of the affected areas of the brain can also occur as well as the enlargement of the ventricles1. There is also a loss of the neuro transmitter Serotonin, Acetylcholine, Norepinephrine and Somatostatin. Attempts have been made to try to slow the development of the disease by replacing the neurotransmitters with cholinesterase inhibitors, such as donepezil (Aricept), rivastigmine (excelon), galantamine (Reminyl) and memantine (Namenda)1. These drugs work by increasing the levels of transmitters between cells, which otherwise beco me lacking in Alzheimers disease. The National Institute for Clinical Excellence NICE conducted a review of these drugs in March 2005 and concluded that none of these drugs provided sufficient enough advantages to the patient in order to justify their cost. They recommended against the use of such drugs in the Nhs, though the Department of Health later overturned this ruling. (3) Visual Changes in Alzheimers Patients Loss of vision is a key healthcare dilemma amongst the elderly. By the age of 65 approximately one in three people have a vision reducing eye disease. Dementia, Alzheimers disease patients and elderly patients, consequently have many visual conditions in common. Alzheimers disease impairs visual function early in the course of the disease and functional losses correlate with cognitive losses. There are several common visual functional deficits that are frequently identified in Alzheimers disease. There is evidence for deficits in Motion perception9,10 contrast sensitivity11 colour discrimination of blue short wavelength hues34 and performance on backward masking tests31.In Alzheimers disease the secondary point of damage is usually the visual association cortex and other higher cortical areas, as well as the primary visual cortex 13,14. (3.1) Some of the main changes that occur in the eye with aging include: The crystalline lens increases in thickness, therefore decreasing its transparency and elasticity; therefore there is a tendency for cataracts to appear. The conjunctiva can become thicker and wrinkled, therefore is subject to deposits such as pinguecela. The iris can atrophy, therefore pupils become constricted and their response to light becomes sluggish. The eyes ability to dark/light adapt is affected. Refractive index of the cornea decreases and it becomes less transparent. Arcus senilis can appear. The ocular globe and eyelids can shrink leading to conditions such as entropian, ectropian and trichiasis. Also while the lachrymal production is reduced the puncta lachrymalis can become stenosed and provide less drainage which gives rise to chronic watering of the eyes Anterior chamber usually becomes more shallow and the sclera more rigid, increasing the prospects of glaucoma. (3.2) Visual changes due to Alzheimers disease reported in literature are outlined below: (3.2) Anatomic Abnormal nerve fiber layer and retinal ganglion cells (Blanks et al, 1989); (Tsai et al, 1991); (Hedges et al, 1996 Imaging of the nerve fibre layer can be conducted via three techniques. These include Optical coherence topography (OCT), Scanning laser polarimetry and Confocal laser topography. Parisi et al16 conducted research upon the optic nerve fibre layer thickness using OCT. 17 Alzheimers disease individuals and 14 age matched healthy individuals were used. The findings of this study showed a definite relationship between the thickness of the nerve fiber layer and the prevalence of Alzheimers disease. There was a significant decrease in the nerve fiber layer thickness in Alzheimers individuals when compared to healthy age matched particpants. Macular cell loss (Blanks et al, 1990) Research has shown a definite decrease of the number of retinal ganglion cells located in the maculae of Alzheimers disease sufferers in comparison to age matched control individuals. It was found that the loss of retinal ganglion cells varied with eccentricity from the central macula17. Results obtained by Blanks et al, 1990 showed a 28% loss of neurons from retinal ganglion cells at 0-0.5mm from the foveola, 24% loss at 0.5-1.0mm and 47% loss at 1.0mm to1.5mm from the foveola. These losses of retinal ganglion cells were constantly greater than those seen in age matched healthy individuals. Supranuclear cataract (Goldstein et al, 2003) Cataract removal could improve not only the visual acuity but may be an important tool in helping those patients suffering from visual hallucinations (Chapman et al, 1999); however, no prospective study has been carried out to prove the role of vision improvement through cataract surgery on the well-being of patients suffering from AD; Exfoliation (Janciauskien and Krakau, 2001) Abnormal pupillary innervation [109-113] Glaucomatous optic nerve cupping (Bayer et al, 2002) (3.3) Functional Decreased visual acuity (Holroyd and Shepherd, 2001) Rapid loss of visual field in patients with AD and glaucoma (Bayer and Ferrari, 2002) Visual field loss (inferior) (Trick et al, 1995) Reduced contrast sensitivity (Holroyd and Shepherd, 2001) Abnormal colour discrimination (blue, short-wavelength hues) (Cronin-Golomb et al, 1991) Abnormal flash visual evoked potentials (VEPs) (Holroyd and Shepherd, 2001) Delayed saccadic eye movements (Holroyd and Shepherd, 2001) (3.4) Cognitive Abnormal visual sustained/divided/selective attention and visual processing speed (Rizzo et al, 2000) Inability to recognize depth (Holroyd and Shepherd, 2001) Impaired face recognition (van Rhijin et al, 2004) (3.5) Other Excessive pharmacological mydriasis/miosis [109-113] These changes summed together not only diminish the quality of vision, but many of them also make the examination of the eye much more complicated. In conjunction with the general visual symptoms of aging, Alzheimers patients can also experience visual disturbances caused by the brain rather than the visual system alone. This means that they can have problems and difficulties perceiving what they see rather than how clearly they see it3. Difficulties are usually experienced in the areas mentioned earlier, namely depth, motion, color, and contrast sensitivity. Visual hallucinations are also a common problem linked to loss of vision in Alzheimers disease patients18. Another common disorder linked to patients with Alzheimers disease is a variant of motion blindness. The patient can appear to be confused and lost; the individual will see the world as a series of still frames19. Visual changes in Alzheimers disease may also be dependent upon which brain hemisphere is more severely damaged; this factor can often be overlooked. An individual with Alzheimers disease could have damage to a greater extent on their left brain hemisphere from plaques and tangles. This would therefore cause subsequent retinal changes in only the left hemi-retinas of each eye i.e. the right visual fields. The right eye visual field would be affected in the temporal side (right) and the left eye visual field would be affected nasally (right)20. When only half the retina is impacted, smaller regions of the optic nerve and nerve fiber layer show losses. The left eye with affected temporal retina would show optic nerve damage in differing regions of the nerve than the right eye with nasal retinal damage20. Alzheimers patients commonly show selective degeneration of large ganglion cell axons located in the optic nerves. This suggests that there would be impairment of broadband channel visual function. Conversely studies have shown that broadband visual capabilities are not selectively impaired in Alzheimers disease. The magnocellular and parvocellular neurons are greatly affected in Alzheimers patients, this has been proved by studies of the dorsal Lateral geniculate nucleus(LGN)1. The geniculostirate projection system is split both functionally and anatomically into two sections. They include the parvocellular layers of the Lateral geniculate body and also incorporates the magnocellular layers. These systems are mainly divided in the primary visual cortex and go through further segregation in the visual association cortex. They conclude in the temporal and paritetal lobes1. The parvocellular layers contain smaller, centrally located receptive fields that account for high spatial frequencies (acuity), they also respond well to color. On the other hand these cells do not respond well to rapid motion or high flicker rates. The magnocellular cells have larger receptive fields and respond superiorly to motion and flicker. They are however comparatively insensitive to color differences. The magnocellular neurons generally show poor spatial resolution, although they seem to respond better at low luminance contrasts. To summarize the parvocellular system is superior at detecting small, slow moving, colored targets placed in the centre of the visual field. Meanwhile the magnocellular system has the ability to process rapidly moving and optically degraded stimuli across larger areas of the visual field1. The parvocellular system projects ventrally to the inferior temporal areas, which are involved in visual research, pattern recognition and visual object memory. The magnocellular system projects dorsally to the posterior parietal and superior temporal areas. These are specialized for motion information processing. The cerebral cortical areas to which the parvocelluar system projects receives virtually no vestibular afferents. Alternatively the cerebral areas to which the magnocelullar system projects receives significant vestibular and other sensory inputs. These are believed to be involved in maintaining spatial orientation. Research shows shows that the magnocellular system is more involved in Alzheimers disease1 Oddly, many individuals experience difficulties at low spatial frequencies instead of high frequencies as in old age. This suggests that areas controlling the low spatial frequency processing in the primary visual cortex would be affected more than those for higher frequencies processing21 After neuropathilogical studies in 1997 by Hof et al were carried out on brains with visual impairments they concluded that cortical atrophy dominated on the posterior parietal cortex and occipital lobe22. Glaucoma is also a neurodegenerative disease that has similar effects on the visual system. Lower spatial frequencies in the contrast sensitivity, deficits in the blue short wavelength color range as well as reductions in motion perception are all linked to glaucomatous patients23. When patients diagnosed with Alzheimers disease also have glaucoma, the deterioration of vision related to glaucoma is much more rapid and progression is more aggressive than in people with glaucoma solely and not Alzheimers disease as well24.Glaucoma is different from Alzheimers disease in that it affects the visual function at the early sites of neural activity, namely, the retinal ganglion cells. Glaucoma destroys the afferent axons at the nerve fiber layer in the retina. This loss of axons ultimately leads to added atrophy further up the visual pathway due to decreased neuronal input. Alternatively Alzheimers disease impacts the cells that are located terminally or intermediary in the visual pathway of the brain. The result is again reduced neuronal input due to loss of nerve fibre connections and atrophy along the visual pathway. When the two diseases exist in the same individual together it can be seen that there is likely to be a greater disruption to the visual system25. One key difference between the two diseases is that they affect the visual pathway at different points. Glaucoma is a degenerative disease starting at the beginning of the visual pathway, whereas Alzheimers disease is a degenerative process starting relatively late in the visual pathway. When the two diseases coexist then the neuronal and functional losses of vision are cumulative. (4) Optometric examination of dementia patients Dementia patients present special problems for optometrists. A standard eye test can be an audile to even the best of us. The patient is placed in an unfamiliar environment surrounded by unusual equipment, machinery and is subjected to probing questions about their medical history which will without doubt tax their already flawed memory. Dementia patients are most likely to be from the elderly. Therefore several difficulties are presented while conducting an ocular examination. The patient is required to sustain a position and has to maintain concentration throughout the testing procedures, which can be very difficult. Subjective examination requires responses from the patient, they are expected to remember and follow complex instructions given to them by the optometrist as well as make many precise discriminatory judgments in a short space of time. The multiple tasks required to be completed during the examination are often beyond dementia patients as they are limited by the disease . Therefore it is common that patients with even a minor degree of dementia fail to provide valid answers, provide unpredictable responses to the subjective examination and retreat into an apathetic state1,2. During the visual examination of Alzheimers disease patients, several key visual problems can be detected. Moderate dementia patients will often experience problems such as topographic agnosia, alexia without agraphia, visual agnosia and prospagnosia1. Such patients often cannot describe individual components of photos and routinely fail to recognize family members. The degree to which such problems are experienced is consistent with the level of cytochrome oxidase deficits in the associated cortical area. In conjunction with these problems dementia patients often have problems with texture discrimination and blue violet discrimination1. Throughout the examination of the elderly dementia patients there are two contradictory requirements, firstly is ‘assurance. The patients responses will be delayed and the patient may feel anxious in such an unfamiliar situation. Thus constant reassurance is required and they cannot be rushed. Alternatively time constraints are important, a dementia/elderly patient is likely to have a short attention span. Consequently the two factors above much be considered and balanced. The examination must be thorough yet carried out as quickly as possible. Often when examining a dementia patient a family member of the carer must be present in order to aid the communication between optometrist and patient, for example difficulties are likely to occur when recording history and symptoms without a carer present. All factors need to be considered such as family history, medication, eye treatment and knowledge of any medical conditions and if so how long they have suffered from them. In terms of an external examination firstly, gross observations should be recorded for example does the patient have an abnormal head position or is there any lid tosis. Many external observations can also be detected with the aid of pupil reflexes. Upon carrying out the external examination the optometrist must be carful to explain exactly what each procedure will involve so as not to intimidate the patient. (4.1) Internal ocular health examination Internal examination of an elderly patient often presents many problems. Older patients tend to have constricted pupils and often opacities in the media such as cataract. All of which make opthalmoscopy a much more complex task for the optometrist. Patients with dementia also show poor fixation as well as lack of concentration. Pupil dilation is often used to aid external examination however many older patients can have a poor response to the insertion of mydriatic eye drops. fddfdffdg There have been many studies into the affects of diagnostic mydriatic and miotic drugs. Many studies have shown excessive mydriatic pupil response to trompicamide (a pupil dilating drug) in patients with Alzheimers disease when compared to control individuals26-30. On the other hand studies into the use of Miotic drops, particularly Pilocarpine have shown an increased response of pupil constriction in Alzheimers disease patients upon comparison to normal control patients. These findings suggest a defect in pupillary innervation with Alzheimers disease individuals. Studies of post mortem individuals with exaggerated mydriatic pupil responses to Tropicamide found a definte disruption to the Edinger-Westphal nucleus. The Edinger-Westphal nucleus is one of the key structures of the brain involved in the autonomic nervous system, it mediates the sympathetic and para-sympathetic pupil responses. Research by Scinto et al found amyloid plaques and neurofibrillary tangles in all individuals t ested with excessive mydriatic pupil responses. The conclusion was that the Edinger-Westphal nucleus is targeted early in the progression of Alzheimers disease. In terms of intraocular pressures use of the goldman an Perkins tonometers will be limited for the elderly dementia patients, due to health and safety reasons. Sudden movements whilst carrying out pressure tests on such equipment may be dangerous. Therefore this can be overcome to a degree by the use of handheld instruments such as the pulseair. However even with the pulseair problems can still be faced with uncooperative patients. (4.2) Objective Refraction examination With uncooperative and awkward patients objective refraction through retinosopy may be difficult. Factors such as opacified media, miotic pupils, and poor fixation will influence the accuracy of the refraction. The recent introduction of hand held optometers has contributed to somewhat overcoming such problems. Instruments such as thee Nikon Retinomax are excellent for obtaining an objective refraction of the elderly patient with miotic pupils and cloudy media. When presenting the Snellen chart to a patient, the quality of their response will inevitably depend upon the degree of their dementia. Depending on which stage of dementia they are suff Dementias Effect on the Visual System Dementias Effect on the Visual System Abstract Recent evidence indicates that memory impairment and visual dysfunction are clearly linked in dementia, and that special testing for visual dysfunction can improve the early diagnosis and treatment of dementia. Visual function is divided in terms of anatomic, functional and cognitive areas respectively. Under normal circumstances these functions perform seamlessly together to produce a visual reality of what we call the external world. Alzheimers disease is the most common form of dementia and past research into this area has shown that sufferers show visual deficits in several key areas. Namely contrast sensitivity, motion, colour, depth perception as well as visual hallucinations. Thus by approaching the patient in a appropriate manor with regards to dementia, clinical professionals can detect visual dysfunction and memory impairment whilst also providing a vital role in secondary and tertiary preventative measures. Furthermore clinical professionals can provide aid in the treatmen t of dementia linked visual disorders. With current demographic trends, dementia is becoming increasingly prevalent due in the ageing population. Consequently there is an increased need for practitioners to have a sound knowledge of such dementia conditions. Improving the sufferers quality of life should be the practitioners main concern. By providing thorough treatments and suggestions on patient tailored environmental modifications this can be achieved. (1) Introduction Dementia is a loss of mental function in two or more areas such as language, memory, visual and spatial abilities, or judgment severe enough to interfere with daily life1. Dementia is not a disease itself, sufferers show a broader set of symptoms that accompany certain diseases or physical conditions1. Well known diseases that cause dementia include Alzheimers disease, Creutzfeldt-Jakob disease and multi-infarct dementia1. Dementia is an acquired and progressive problem that affects cognitive functions, behavior, thinking processes and the ability to carry out normal activities. Vision is one of the most important primary senses, therefore serious or complete sight loss has a major impact on a individuals ability to communicate effectively and function independently. Individuals who suffer from both dementia and serious vision loss will inevitably be subject to profound emotional, practical, psychological and financial problems. These factors will also influence others around the sufferer and will extend to the family and the greater society. As we get older both dementia and visual problems inevitably become much more prevalent. Current demographic trends show the increase of the number of very old in our population. Therefore it is inevitable that dementia and serious sight loss either alone or together, will have important consequences for all of us1. The vast majority of people are aware that dementia affects the memory. However it is the impact it has on the ability to carry out daily tasks and problems with behavior that cause particular problems, and in severe cases can lead to institutionalization. In the primary stages of dementia, the patient can be helped by friends and family through ‘reminders. As progression occurs the individual will loose the skills needed for everyday tasks and may eventually fail to recognize family members, a condition known as prospagnosia. The result of such progression is that the individual becomes totally dependent on others. Dementia not only affects the lives of the individual, but also the family2. Dementia can present itself in varying forms. The most common form of dementia in the old is Alzheimers disease, affecting millions of people. It is a degenerative condition that attacks the brain. Progression is gradual and at a variable rate. Symptoms of Alzheimers disease are impaired memory, thinking and changes in behaviour. Dementia with Lewy bodies and dementias linked to Parkinsons disease are responsible for around 10-20% of all dementias. Dementia with Lewy bodies is of particular interest as individuals3 with this condition not only present confusion and varying cognition, but also present symptoms of visual hallucinations2. Another common condition that causes dementia is multi-infarct dementia, also known as vascular dementia. It is the second most common form of dementia after Alzheimers disease in the elderly. Multi infarct dementia is caused by multiple strokes in the brain. These series of strokes can affect some intellectual abilities, impair motor skills and also c ause individuals to experience visual hallucinations. Individuals with multi infarct dementia are prone to risk factors for stroke, such as high BP, heart disease and diabetes. Multi infarct dementia cannot be treated, once nerve cells die they cannot be replaced1. In most cases the symptoms of dementia and serious sight loss develop independently. However some conditions can cause both visual and cognitive impairments, for example Down syndrome, Multiple sclerosis and diabetes. Dementia is most prevalent in the elderly, as is sight loss. Therefore it is inevitable that a number of people will present dementia together with serious sight loss. There have been many studies into the prevalence of dementia in the UK. An estimate for the prevalence of dementia in people over 75 years of age is 15% of the population2. The Alzheimers society suggest that 775,200 people in the UK suffer from dementia (figures taken 2001). The Alzheimers society also calculates that the prevalence of dementia in the 65-75 years age group is 1 in 50, for 70-80 years 1 in 20 and for over 80 years of age 1 in 5. Estimates suggest that by 2010 approximately 840,000 people will become dementia sufferers in the UK. Estimates suggest that around 40% of dementia sufferers are in residential institutions. One study from 1996 showed that dementia sufferers are 30 times more likely to live in an institution than people without dementia. At 65 years of age men are 3 times more likely than women to live in an institution and at 86 men and women are equally likely to be institutionalized4. Visual impairments are not associated general diagnostic features of dementia. However recent research has shown the change in visual function and visual processing may be relevant. Alzheimers disease patients often present problems with visual acuity, contrast sensitivity, stereo-acuity and color vision. These problems are believed to be more true of cognitive dysfunction rather than any specific problems in the eye or optic nerve9. Early diagnosis is essential to both dementia and sight loss patients, as drug treatments are becoming more and more available. Therefore maximizing the treatment and care for the individual. On the other hand early diagnosis of visual conditions is also essential, so that progression is slowed and treatment is commenced, therefore further progression is prevented if plausible2. The Mini-Mental State examination MMSE, is the most commonly used cognitive test for the diagnosis of dementia. It involves the patient to undertake tests of memory and cognition. It takes the form of a series of questions/answers and uses written, verbal and visual material. Poor vision or blindness is the most common cause of poor performance on this test other than dementia itself2. Visual deterioration can occur simultaneously with memory loss in most dementia sufferers. Therefore early recognition of dementia through vision tests has become of importance. Table 1 shows few possible tests that might be useful for such purpose Table 1 : Vision tests for possible early detection and monitoring of Alzheimers disease Use Benton visual retention test Might be able to predict risk for AD 10-15 years before the onset of the disease Tests visual memory Contrast sensitivity AD patients have selectively reduced CS for distinguishing large objects and faces Useful field of view Tests processing speed, divided attention and selective attention Facilitates detection of â€Å"attentional dysfunction†; patients suffering from this problem complain of poor vision and inability to identify someone in a group or an object on a patterned background Could be useful to assess fitness to drive Facial recognition AD patients do not recognize faces with large features and low contrast AD patients do not recognize familiar faces (due to impaired memory) Tests that use facial expressions with progressively diminished degree of contrast The aim of this paper is to provide information about current knowledge on the topic of visual function dementia. With regards to Alzheimers disease, there will be an inclination to several main foci of research. Namely anatomical/structural changes, functional visual changes, cognitive brain changes and other changes such as the effects of diagnostic drugs on Alzheimers disease patients. (2) Alzheimers disease Alzheimers disease is the most common cause of dementia amongst older adults. The Alzheimers research trust estimates that 700,000 individuals in the UK currently are afflicted. This number will inevitably increase exponentially in the near future with the trend of an increasingly aging UK population. Therefore it must be of the utmost of importance worldwide to have an understanding all behavioral, anatomical and physiological aspects of this disease. Alzheimers disease is a degenerative disease that attacks the brain, it begins gradually and progresses at a variable rate. Common signs are impaired thinking, memory and behavior. Health professionals and care givers agree that the memory deficit is usually the initial sign of the disease. However researchers have long known that Alzheimers disease is characterized by impairments of several additional domains, including visual function5. However these findings have not yet appeared in the diagnostic guides consulted by healthcare professionals, for example the most recent addition of the Diagnostic Statistical manual of mental disorders states that few sensory signs occur in early Alzheimers disease2. Therefore we still have a limited understanding of the true extent to which visual impairments affect Alzheimers disease sufferers. The current web site of the Alzheimers association1 and National Institute of Aging6 make no mention of the topic of sensory changes in Alzheimers disease. It has even been said that patients with Alzheimers disease report visual problems to their healthcare professionals less frequently than do healthy elderly individuals7. Nevertheless visual function is impaired in Alzheimers disease8. In terms of cognitive changes, the neuropathology of this disorder affects several other brain areas which are dedicated to processing low level visual functions, as well as higher level visual cognition and attention5.These neuropathological cognitive changes are more dominant however in the visual variant of Alzheimers disease known as posterior cortical atrophy. However visual problems are also present in the more common Alzheimers disease. Alzheimers disease begins when there are deposits of abnormal proteins outside nerve cells located in the brain in the form of amyloid. These are known as diffuse plaques, and the amyloid also forms the central part of further structured plaques known as senile or neurotic plaques1. Buildup of anomalous filaments of protein inside nerve cells in the brain can also take place. This protein accumulates as masses of filaments known as neurofibril tangles. Atrophy of the affected areas of the brain can also occur as well as the enlargement of the ventricles1. There is also a loss of the neuro transmitter Serotonin, Acetylcholine, Norepinephrine and Somatostatin. Attempts have been made to try to slow the development of the disease by replacing the neurotransmitters with cholinesterase inhibitors, such as donepezil (Aricept), rivastigmine (excelon), galantamine (Reminyl) and memantine (Namenda)1. These drugs work by increasing the levels of transmitters between cells, which otherwise beco me lacking in Alzheimers disease. The National Institute for Clinical Excellence NICE conducted a review of these drugs in March 2005 and concluded that none of these drugs provided sufficient enough advantages to the patient in order to justify their cost. They recommended against the use of such drugs in the Nhs, though the Department of Health later overturned this ruling. (3) Visual Changes in Alzheimers Patients Loss of vision is a key healthcare dilemma amongst the elderly. By the age of 65 approximately one in three people have a vision reducing eye disease. Dementia, Alzheimers disease patients and elderly patients, consequently have many visual conditions in common. Alzheimers disease impairs visual function early in the course of the disease and functional losses correlate with cognitive losses. There are several common visual functional deficits that are frequently identified in Alzheimers disease. There is evidence for deficits in Motion perception9,10 contrast sensitivity11 colour discrimination of blue short wavelength hues34 and performance on backward masking tests31.In Alzheimers disease the secondary point of damage is usually the visual association cortex and other higher cortical areas, as well as the primary visual cortex 13,14. (3.1) Some of the main changes that occur in the eye with aging include: The crystalline lens increases in thickness, therefore decreasing its transparency and elasticity; therefore there is a tendency for cataracts to appear. The conjunctiva can become thicker and wrinkled, therefore is subject to deposits such as pinguecela. The iris can atrophy, therefore pupils become constricted and their response to light becomes sluggish. The eyes ability to dark/light adapt is affected. Refractive index of the cornea decreases and it becomes less transparent. Arcus senilis can appear. The ocular globe and eyelids can shrink leading to conditions such as entropian, ectropian and trichiasis. Also while the lachrymal production is reduced the puncta lachrymalis can become stenosed and provide less drainage which gives rise to chronic watering of the eyes Anterior chamber usually becomes more shallow and the sclera more rigid, increasing the prospects of glaucoma. (3.2) Visual changes due to Alzheimers disease reported in literature are outlined below: (3.2) Anatomic Abnormal nerve fiber layer and retinal ganglion cells (Blanks et al, 1989); (Tsai et al, 1991); (Hedges et al, 1996 Imaging of the nerve fibre layer can be conducted via three techniques. These include Optical coherence topography (OCT), Scanning laser polarimetry and Confocal laser topography. Parisi et al16 conducted research upon the optic nerve fibre layer thickness using OCT. 17 Alzheimers disease individuals and 14 age matched healthy individuals were used. The findings of this study showed a definite relationship between the thickness of the nerve fiber layer and the prevalence of Alzheimers disease. There was a significant decrease in the nerve fiber layer thickness in Alzheimers individuals when compared to healthy age matched particpants. Macular cell loss (Blanks et al, 1990) Research has shown a definite decrease of the number of retinal ganglion cells located in the maculae of Alzheimers disease sufferers in comparison to age matched control individuals. It was found that the loss of retinal ganglion cells varied with eccentricity from the central macula17. Results obtained by Blanks et al, 1990 showed a 28% loss of neurons from retinal ganglion cells at 0-0.5mm from the foveola, 24% loss at 0.5-1.0mm and 47% loss at 1.0mm to1.5mm from the foveola. These losses of retinal ganglion cells were constantly greater than those seen in age matched healthy individuals. Supranuclear cataract (Goldstein et al, 2003) Cataract removal could improve not only the visual acuity but may be an important tool in helping those patients suffering from visual hallucinations (Chapman et al, 1999); however, no prospective study has been carried out to prove the role of vision improvement through cataract surgery on the well-being of patients suffering from AD; Exfoliation (Janciauskien and Krakau, 2001) Abnormal pupillary innervation [109-113] Glaucomatous optic nerve cupping (Bayer et al, 2002) (3.3) Functional Decreased visual acuity (Holroyd and Shepherd, 2001) Rapid loss of visual field in patients with AD and glaucoma (Bayer and Ferrari, 2002) Visual field loss (inferior) (Trick et al, 1995) Reduced contrast sensitivity (Holroyd and Shepherd, 2001) Abnormal colour discrimination (blue, short-wavelength hues) (Cronin-Golomb et al, 1991) Abnormal flash visual evoked potentials (VEPs) (Holroyd and Shepherd, 2001) Delayed saccadic eye movements (Holroyd and Shepherd, 2001) (3.4) Cognitive Abnormal visual sustained/divided/selective attention and visual processing speed (Rizzo et al, 2000) Inability to recognize depth (Holroyd and Shepherd, 2001) Impaired face recognition (van Rhijin et al, 2004) (3.5) Other Excessive pharmacological mydriasis/miosis [109-113] These changes summed together not only diminish the quality of vision, but many of them also make the examination of the eye much more complicated. In conjunction with the general visual symptoms of aging, Alzheimers patients can also experience visual disturbances caused by the brain rather than the visual system alone. This means that they can have problems and difficulties perceiving what they see rather than how clearly they see it3. Difficulties are usually experienced in the areas mentioned earlier, namely depth, motion, color, and contrast sensitivity. Visual hallucinations are also a common problem linked to loss of vision in Alzheimers disease patients18. Another common disorder linked to patients with Alzheimers disease is a variant of motion blindness. The patient can appear to be confused and lost; the individual will see the world as a series of still frames19. Visual changes in Alzheimers disease may also be dependent upon which brain hemisphere is more severely damaged; this factor can often be overlooked. An individual with Alzheimers disease could have damage to a greater extent on their left brain hemisphere from plaques and tangles. This would therefore cause subsequent retinal changes in only the left hemi-retinas of each eye i.e. the right visual fields. The right eye visual field would be affected in the temporal side (right) and the left eye visual field would be affected nasally (right)20. When only half the retina is impacted, smaller regions of the optic nerve and nerve fiber layer show losses. The left eye with affected temporal retina would show optic nerve damage in differing regions of the nerve than the right eye with nasal retinal damage20. Alzheimers patients commonly show selective degeneration of large ganglion cell axons located in the optic nerves. This suggests that there would be impairment of broadband channel visual function. Conversely studies have shown that broadband visual capabilities are not selectively impaired in Alzheimers disease. The magnocellular and parvocellular neurons are greatly affected in Alzheimers patients, this has been proved by studies of the dorsal Lateral geniculate nucleus(LGN)1. The geniculostirate projection system is split both functionally and anatomically into two sections. They include the parvocellular layers of the Lateral geniculate body and also incorporates the magnocellular layers. These systems are mainly divided in the primary visual cortex and go through further segregation in the visual association cortex. They conclude in the temporal and paritetal lobes1. The parvocellular layers contain smaller, centrally located receptive fields that account for high spatial frequencies (acuity), they also respond well to color. On the other hand these cells do not respond well to rapid motion or high flicker rates. The magnocellular cells have larger receptive fields and respond superiorly to motion and flicker. They are however comparatively insensitive to color differences. The magnocellular neurons generally show poor spatial resolution, although they seem to respond better at low luminance contrasts. To summarize the parvocellular system is superior at detecting small, slow moving, colored targets placed in the centre of the visual field. Meanwhile the magnocellular system has the ability to process rapidly moving and optically degraded stimuli across larger areas of the visual field1. The parvocellular system projects ventrally to the inferior temporal areas, which are involved in visual research, pattern recognition and visual object memory. The magnocellular system projects dorsally to the posterior parietal and superior temporal areas. These are specialized for motion information processing. The cerebral cortical areas to which the parvocelluar system projects receives virtually no vestibular afferents. Alternatively the cerebral areas to which the magnocelullar system projects receives significant vestibular and other sensory inputs. These are believed to be involved in maintaining spatial orientation. Research shows shows that the magnocellular system is more involved in Alzheimers disease1 Oddly, many individuals experience difficulties at low spatial frequencies instead of high frequencies as in old age. This suggests that areas controlling the low spatial frequency processing in the primary visual cortex would be affected more than those for higher frequencies processing21 After neuropathilogical studies in 1997 by Hof et al were carried out on brains with visual impairments they concluded that cortical atrophy dominated on the posterior parietal cortex and occipital lobe22. Glaucoma is also a neurodegenerative disease that has similar effects on the visual system. Lower spatial frequencies in the contrast sensitivity, deficits in the blue short wavelength color range as well as reductions in motion perception are all linked to glaucomatous patients23. When patients diagnosed with Alzheimers disease also have glaucoma, the deterioration of vision related to glaucoma is much more rapid and progression is more aggressive than in people with glaucoma solely and not Alzheimers disease as well24.Glaucoma is different from Alzheimers disease in that it affects the visual function at the early sites of neural activity, namely, the retinal ganglion cells. Glaucoma destroys the afferent axons at the nerve fiber layer in the retina. This loss of axons ultimately leads to added atrophy further up the visual pathway due to decreased neuronal input. Alternatively Alzheimers disease impacts the cells that are located terminally or intermediary in the visual pathway of the brain. The result is again reduced neuronal input due to loss of nerve fibre connections and atrophy along the visual pathway. When the two diseases exist in the same individual together it can be seen that there is likely to be a greater disruption to the visual system25. One key difference between the two diseases is that they affect the visual pathway at different points. Glaucoma is a degenerative disease starting at the beginning of the visual pathway, whereas Alzheimers disease is a degenerative process starting relatively late in the visual pathway. When the two diseases coexist then the neuronal and functional losses of vision are cumulative. (4) Optometric examination of dementia patients Dementia patients present special problems for optometrists. A standard eye test can be an audile to even the best of us. The patient is placed in an unfamiliar environment surrounded by unusual equipment, machinery and is subjected to probing questions about their medical history which will without doubt tax their already flawed memory. Dementia patients are most likely to be from the elderly. Therefore several difficulties are presented while conducting an ocular examination. The patient is required to sustain a position and has to maintain concentration throughout the testing procedures, which can be very difficult. Subjective examination requires responses from the patient, they are expected to remember and follow complex instructions given to them by the optometrist as well as make many precise discriminatory judgments in a short space of time. The multiple tasks required to be completed during the examination are often beyond dementia patients as they are limited by the disease . Therefore it is common that patients with even a minor degree of dementia fail to provide valid answers, provide unpredictable responses to the subjective examination and retreat into an apathetic state1,2. During the visual examination of Alzheimers disease patients, several key visual problems can be detected. Moderate dementia patients will often experience problems such as topographic agnosia, alexia without agraphia, visual agnosia and prospagnosia1. Such patients often cannot describe individual components of photos and routinely fail to recognize family members. The degree to which such problems are experienced is consistent with the level of cytochrome oxidase deficits in the associated cortical area. In conjunction with these problems dementia patients often have problems with texture discrimination and blue violet discrimination1. Throughout the examination of the elderly dementia patients there are two contradictory requirements, firstly is ‘assurance. The patients responses will be delayed and the patient may feel anxious in such an unfamiliar situation. Thus constant reassurance is required and they cannot be rushed. Alternatively time constraints are important, a dementia/elderly patient is likely to have a short attention span. Consequently the two factors above much be considered and balanced. The examination must be thorough yet carried out as quickly as possible. Often when examining a dementia patient a family member of the carer must be present in order to aid the communication between optometrist and patient, for example difficulties are likely to occur when recording history and symptoms without a carer present. All factors need to be considered such as family history, medication, eye treatment and knowledge of any medical conditions and if so how long they have suffered from them. In terms of an external examination firstly, gross observations should be recorded for example does the patient have an abnormal head position or is there any lid tosis. Many external observations can also be detected with the aid of pupil reflexes. Upon carrying out the external examination the optometrist must be carful to explain exactly what each procedure will involve so as not to intimidate the patient. (4.1) Internal ocular health examination Internal examination of an elderly patient often presents many problems. Older patients tend to have constricted pupils and often opacities in the media such as cataract. All of which make opthalmoscopy a much more complex task for the optometrist. Patients with dementia also show poor fixation as well as lack of concentration. Pupil dilation is often used to aid external examination however many older patients can have a poor response to the insertion of mydriatic eye drops. fddfdffdg There have been many studies into the affects of diagnostic mydriatic and miotic drugs. Many studies have shown excessive mydriatic pupil response to trompicamide (a pupil dilating drug) in patients with Alzheimers disease when compared to control individuals26-30. On the other hand studies into the use of Miotic drops, particularly Pilocarpine have shown an increased response of pupil constriction in Alzheimers disease patients upon comparison to normal control patients. These findings suggest a defect in pupillary innervation with Alzheimers disease individuals. Studies of post mortem individuals with exaggerated mydriatic pupil responses to Tropicamide found a definte disruption to the Edinger-Westphal nucleus. The Edinger-Westphal nucleus is one of the key structures of the brain involved in the autonomic nervous system, it mediates the sympathetic and para-sympathetic pupil responses. Research by Scinto et al found amyloid plaques and neurofibrillary tangles in all individuals t ested with excessive mydriatic pupil responses. The conclusion was that the Edinger-Westphal nucleus is targeted early in the progression of Alzheimers disease. In terms of intraocular pressures use of the goldman an Perkins tonometers will be limited for the elderly dementia patients, due to health and safety reasons. Sudden movements whilst carrying out pressure tests on such equipment may be dangerous. Therefore this can be overcome to a degree by the use of handheld instruments such as the pulseair. However even with the pulseair problems can still be faced with uncooperative patients. (4.2) Objective Refraction examination With uncooperative and awkward patients objective refraction through retinosopy may be difficult. Factors such as opacified media, miotic pupils, and poor fixation will influence the accuracy of the refraction. The recent introduction of hand held optometers has contributed to somewhat overcoming such problems. Instruments such as thee Nikon Retinomax are excellent for obtaining an objective refraction of the elderly patient with miotic pupils and cloudy media. When presenting the Snellen chart to a patient, the quality of their response will inevitably depend upon the degree of their dementia. Depending on which stage of dementia they are suff