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Narrative Methods for the Human Sciences

This review of age-related brain microvascular pathologies focuses on topics studied by this laboratory, including anatomy of the blood supply, tortuous vessels, venous collagenosis, capillary remnants, vascular density and microembolic brain injury. Our studies feature thick sections, large blocks embedded in celloidin, and vascular staining by alkaline phosphatase. This permits study of the vascular network in three dimensions, and the differentiation of afferent from efferent vessels. Current evidence suggests that there is decreased vascular density in ageing, Alzheimer's disease and leukoaraiosis, and cerebrovascular dysfunction precedes and accompanies cognitive dysfunction and neurodegeneration. A decline in cerebrovascular angiogenesis may inhibit recovery from hypoxia-induced capillary loss. Cerebral blood flow is inhibited by tortuous arterioles and deposition of excessive collagen in veins and venules. Misery perfusion due to capillary loss appears to occur before cell loss in leukoaraiosis, and cerebral blood flow is also reduced in the normal-appearing white matter. Hypoperfusion occurs early in Alzheimer's disease, inducing white matter lesions and correlating with dementia. In vascular dementia, cholinergic reductions are correlated with cognitive impairment, and cholinesterase inhibitors have some benefit. Most lipid microemboli from cardiac surgery pass through the brain in a few days, but some remain for weeks. They can cause what appears to be a type of vascular dementia years after surgery. Donepezil has shown some benefit. Emboli, such as clots, cholesterol crystals and microspheres can be extruded through the walls of cerebral vessels, but there is no evidence yet that lipid emboli undergo such extravasation.

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Review: cerebral microvascular pathology in ageing and neurodegeneration.

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Qualitative Nursing Research: A Contemporary Dialogue

From Practice to Grounded Theory: Qualitative Research in Nursing

Vascular dementia (VaD) is recognised as a neurocognitive disorder, which is explained by numerous vascular causes in the general absence of other pathologies. The heterogeneity of cerebrovascular disease makes it challenging to elucidate the neuropathological substrates and mechanisms of VaD as well as vascular cognitive impairment (VCI). Consensus and accurate diagnosis of VaD relies on wide-ranging clinical, neuropsychometric and neuroimaging measures with subsequent pathological confirmation. Pathological diagnosis of suspected clinical VaD requires adequate postmortem brain sampling and rigorous assessment methods to identify important substrates. Factors that define the subtypes of VaD include the nature and extent of vascular pathologies, degree of involvement of extra and intracranial vessels and the anatomical location of tissue changes. Atherosclerotic and cardioembolic diseases appear the most common substrates of vascular brain injury or infarction. Small vessel disease characterised by arteriolosclerosis and lacunar infarcts also causes cortical and subcortical microinfarcts, which appear to be the most robust substrates of cognitive impairment. Diffuse WM changes with loss of myelin and axonal abnormalities are common to almost all subtypes of VaD. Medial temporal lobe and hippocampal atrophy accompanied by variable hippocampal sclerosis are also features of VaD as they are of Alzheimer’s disease. Recent observations suggest that there is a vascular basis for neuronal atrophy in both the temporal and frontal lobes in VaD that is entirely independent of any Alzheimer pathology. Further knowledge on specific neuronal and dendro-synaptic changes in key regions resulting in executive dysfunction and other cognitive deficits, which define VCI and VaD, needs to be gathered. Hereditary arteriopathies such as cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy or CADASIL have provided insights into the mechanisms of dementia associated with cerebral small vessel disease. Greater understanding of the neurochemical and molecular investigations is needed to better define microvascular disease and vascular substrates of dementia. The investigation of relevant animal models would be valuable in exploring the pathogenesis as well as prevention of the vascular causes of cognitive impairment.

/pdf/neuropathological-diagnosis-of-vascular-cognitive-impairment-5ehwx3gsto.pdf

Neuropathological diagnosis of vascular cognitive impairment and vascular dementia with implications for Alzheimer’s disease

A range of issues surrounding admission to either residential or nursing home care are considered from the perspectives of older people and their family carers. Drawing on the literature and a number of studies conducted by the authors, the processes and perceptions that shape and influence admission to care are identified. On the basis of the interaction of these factors a four-stage typology of admission is suggested: the positive choice, the rationalized alternative, the discredited option, and the fait accompli. The characteristics of each admission type are discussed and the implications for professionals, particularly nurses, working with older people and their carers are addressed.

Entry to care: positive choice or fait accompli? Developing a more proactive nursing response to the needs of older people and their carers*

https://journals.sagepub.com/doi/pdf/10.1177/1471301206062247

Editorial The narrative voice of people with dementia

This paper outlines the use of a new qualitative research approach, Co-Constructed Inquiry, to develop a personal theory of the experience of living and adjusting to an early diagnosis of Alzheimer...

`Making mistakes': Using Co-Constructed Inquiry to illuminate meaning and relationships in the early adjustment to Alzheimer's disease — a single case study approach

Discharging frail older people from acute hospital settings has been an issue of concern for over 40 years and recent studies suggest that enduring problems remain. This paper explores the experiences of discharge from three different units: an acute surgical ward, an acute medical ward and a specialist ward for older people. Based on extensive data from interviews with older people, their family carers and ward‐based staff, a grounded theory of the discharge experience is presented. This suggests that the quality of discharge hinges largely on whether the focus of efforts is on ‘pace’ (the desire to discharge older people as rapidly as possible) or ‘complexity’ (where due account is taken of the complex interaction of medical and wider social issues). When pace is the focus, ‘pushing’ and ‘fixing’ are the main processes driving discharge. However, when attention is given to complexity, far more subtle processes of ‘informing’ and ‘brokering’ are in evidence. These latter processes are conceived of as forms of ‘relational practice’ and it is argued that such practices lie at the heart of high quality care for older people.

Relational practice as the key to ensuring quality care for frail older people: discharge planning as a case example

Discharge of older people from hospital has been an area of concern for over 20 years. The present emphasis on rapid throughput of patients in acute care settings is likely to exacerbate existing problems. Improving current practice will mean addressing a number of complex issues to do with communication between agencies and professions. Despite different welfare systems, many of the challenges of discharge planning are shared in different countries. This paper describes attempts to involve patients and carers in discharge planning in Sweden and the UK and identifies a number of areas which require attention if the ideals of patient and carer empowerment are to be achieved.

Sion Williams

Papers

Entry to care: positive choice or fait accompli? Developing a more proactive nursing response to the needs of older people and their carers*

Editorial The narrative voice of people with dementia

`Making mistakes': Using Co-Constructed Inquiry to illuminate meaning and relationships in the early adjustment to Alzheimer's disease — a single case study approach

Relational practice as the key to ensuring quality care for frail older people: discharge planning as a case example

The challenges of improving discharge planning in Sweden and the UK : different but the same