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Kevin Maurice Coleman, MD

• Assistant Professor of Medicine

https://medicine.duke.edu/faculty/kevin-maurice-coleman-md

There is a short supply of expertise and experience in the field of educa tion for children with autistic spectrum disorders rheumatoid arthritis nails purchase discount etoricoxib online, and special attention should be paid to rapidly increase the capabilities of the trainers arthritis relief homeopathic order discount etoricoxib line, who may have experience in special education or related fields arthritis relief knuckles order etoricoxib in india, but not in the special skills and practices for children with autistic spectrum disorders arthritis spine purchase etoricoxib cheap. A continuing pro gram should be established from such agencies as the National Institute of Mental Health and the National Institute of Child Health and Human Development to translate their research into usable information for practitioners. Another body of research addresses diagnostic practices and related issues of prevalence. Another has examined the effects of comprehensive early treatment programs on the immediate and long-term outcomes of chil dren and their families. An additional body of research has ad dressed individual instructional or intervention approaches, with many studies in this literature using single-subject experimental methodology. Altogether, a large research base exists, but with relatively little integra tion across bodies of literature. Highly knowledgeable researchers in one area of autistic spectrum disorders may have minimal information from other perspectives, even about studies with direct bearing on their find ings. Most researchers have not used randomized group comparison de signs because of the practical and ethical difficulties in randomly assign ing children and families to treatment groups. In addition, there have been significant controversies over the type of control or contrast group to use and the conditions necessary for demonstrating effectiveness. Al though a number of comprehensive programs have provided data on their effectiveness, and, in some cases, claims have been made that certain treatments are superior to others, there have been virtually no compari sons of different comprehensive interventions of equal intensity. Across several of the bodies of literature, the children and families who have participated in studies are often inadequately described. Stan dardized diagnoses, descriptions of ethnicity, the social class, and associ ated features of the children (such as mental retardation and language level) are often not specified. Generalization, particularly across set tings, and maintenance of treatment effects are not always measured. Though there is little evidence concerning the effectiveness of discipline specific therapies, there is substantial research supporting the effective ness of many specific therapeutic techniques. Recommendations 7-1 Funding agencies and professional journals should require minimium standards in design and description of intervention projects. Osterling 1997 Early intervention in autism: Effectiveness and common elements of current approaches. Paper presented at the First Workshop of the Committee on Educa tional Interventions for Children with Autism, National Research Council, De cember 13-14, 1999. Reed *2000 Problem Behavior Interventions for Young Children with Autism: A Research Synthesis. Paper presented at the Second Workshop of the Committee on Educa tional Interventions for Children with Autism, National Research Council, April 12, 2000. Paper presented at the Second Workshop of the Committee on Educational Inter ventions for Children with Autism, National Research Council, April 12, 2000. Johnson 1998 Empirically supported psychosocial interventions for children: An overview. New York State Department of Health 1999 Clinical Practice Guideline: the Guideline Technical Report. Autism/Pervasive Devel opmental Disorders, Assessment and Intervention for Young Children (0-3 Years). Hirtz 2000 Special issue: Treatments for people with autism and other pervasive develop mental disorders: Research perspectives Editorial preface. Drew 2000 A screening instrument for autism at 18 months of age: A 6-year follow-up study. Charman 1996 Psychological markers in the detection of autism in infancy in a large population. Centers for Disease Control and Prevention 2000 Prevalence of Autism in Brick Township, New Jersey, 1998: Community Report. Drew 1997 Infants with autism: An investigation of empathy, pretend play, joint attention, and imitation. Nightengale 1999 the early diagnosis of autism spectrum disorders: Use of the Autism Diagnostic Interview-Revised at 20 months and 42 months of age. Hagberg 1999 Autism and Asperger syndrome in seven-year-old children: A total population study. Almond 1980 Behavior checklist for identifying severely handicapped individuals with high levels of autistic behavior. Rutter 2000 the autism diagnostic observation schedule-generic: A standard measure of so cial and communication deficits associated with the spectrum of autism. Wing 1975 Language, communication, and the use of symbols in normal and autistic chil dren. Elliott 1988 How children with autism are diagnosed: Difficulties in identification of chil dren with multiple developmental delays. Journal of the American Academy of Child and Adolescent Psychiatry 28(4):542 548. Chadwick Dias 1990 A longitudinal study of language acquisition in autistic and Down syndrome children. Cohen 1997 Diagnosis and classification of autism and related conditions: Consensus and issues. Tanguay 1999 Practice parameters for the assessment and treatment of children and adolescents with autism and pervasive developmental disorders. Journal of the American Acad emy of Child and Adolescent Psychiatry 38(12):32S-54S. Bryan 1989 Communicative profiles of preschool children with handicaps: Implications for early identification. Schopler 1988 Mothers and fathers of young developmentally disabled and non disabled boys: Adaptation and spousal support. Holt 1993 Maternal depressive symptoms in autism: Response to psychoeducational inter vention. Harris 1993 the effects of a play skills intervention for siblings of children with autism. Harris 1991 Hardiness and social support as predictors of psychological discomfort in moth ers of children with autism. Dunlap 1984 Collateral effects of parent training in families of autistic children. Long 1973 Some generalization and follow-up measures on autistic children in behavior therapy. Morgan 1993 Perceived competence and behavioral adjustment of siblings of children with autism. Simonsen 1994 Educational/support group for Latino families of children with Down syndrome. Ryan 1987 Chinese-American families of children with developmental disabilities: An ex ploratory study of reactions to service providers. Journal of the American Academy of Child and Adolescent Psychiatry 32(6):1292-1294. Dunlap 1984 the influence of vigorous versus mild exercise on autistic stereotyped behaviors. National Research Council 1997 Educating One and All: Students with Disabilities and Standards-Based Reform. Schreibman 1997 Multiple peer use of pivotal response training to increase social behaviors of classmates with autism: Results from trained and untrained peers.

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Methods of treatment include passive movements arthritis in fingers diagnosis discount 60 mg etoricoxib free shipping, hydrotherapy arthritis in horses back legs order etoricoxib 90mg, and reflex inhibiting postures arthritis in lower back supplements purchase 90 mg etoricoxib free shipping, standing and walking rheumatoid arthritis in upper back symptoms buy cheapest etoricoxib and etoricoxib, ice therapy, drug therapy or it may require surgical procedures by elongating a tendon or severing a nerve to reduce plasticity. It is the direct responsibility of the Physical Therapist and nursing care to lessen their occurrence by instructing parents (unless hospitalized). Spasticity It is difficult to separate these three closely linked factors in relation to the formation of a contracture. In conjunction with the passive movements a passive stretch is also given in the position of maximum correction b. Release of a muscle, elongation of the Achilles tendon, or releasing the adductor muscles are useful surgical procedures in cases of severe contractures which have not responded to conservative methods. If your child has strong spasticity, as well as contractures, other surgical procedures may be recommended 3. Osteoporosis is defined as a disease in which the bones become extremely porous, a decrease in bone tissue, structural 89 weakness, and softening of the bone. Symptoms you may see or have: pain is possible because of a fracture or vertebral collapse or may be aggravated by movement; and/or deformity and immobility because of fractures of involved bones; collapse of some vertebrae; or increasing in curvature of the spine. When examined by a Physician, he would possibly recognize a healed fracture, loss of weight, wedging of the vertebrae, and would request diagnostic studies including x rays and bone density tests. Research has shown that mineral metabolism associated with atrophy of the muscular and skeletal systems changes as a result of prolonged bed rest. These changes are more prominent when the bed rest is combined with immobilization. Considering the inevitable immobility associated with Batten Disease, it is not surprising that osteoporosis may be present to some degree in all or most children with Batten Disease. The degree of osteoporosis is considerably increased by chronic infection from any cause. Therefore, fractures/ dislocations of bones can occur as a result of exceptionally minor injuries. Due to the lack of sensation in some of our children, they may be unaware that a fracture/dislocation has occurred until the area becomes swollen, has a fever, or feels painful. To treat such cases, your child should be turned frequently to aid the circulation and some researchers feel that a diet high in protein with added Vitamin D may be helpful. Exercises whether passive or active may also be done to increase circulation and to minimize further development of osteoporosis. Scoliosis is defined as a lateral curvature of the spine, usually consisting of two curves, the original one and a compensatory curve in the opposite direction. Symptoms that may be present include: pain radiating from the back to the extremities; joint stiffness with hip or knee flexion contractures; deformity and immobility; rib cage deformity; or 90 hamstring tightness (the higher the location of scoliosis, the more severe the deformity); sensory changes with decreased sensation to the lower extremities. A Physician may see a limited spinal range of motion; fatigue or tired back; hair patches, dimples and pigmentation on the back; decreased chest expansion; impaired pulmonary or cardiac function (hypoxia, cyanosis, or possibly a lung disease-refer to glossary); one scapula, breast or flank more prominent than the other; shoulders and hips not level. Children and adolescents are in particular danger because of continuing growth and extreme joint mobility. When a child spends a high proportion of time in an abnormal, incorrect posture for functional activities, for convenience, or for comfort, deformities are likely to develop. To minimize or treat such deformities, correction must be made for your child who spends a lot of time in bed or in a wheelchair by: strengthening the weaker or less used muscle groups; stretching the muscles tending to shorten; maintaining a passive stretch in the overcorrected position for the muscles tending to shorten; re-education of posture; corrective sleeping patterns; and the possible use of braces or splints. Surgical correction for scoliosis the spine is composed of many small bones called vertebrae, which are lined up one on top of another, creating a bony column in which the spinal cord rests. Moving from head to toe, the spine is divided into 4 areas: cervical, which refers to the neck area; thoracic, which refers to the chest area; lumbar, which refers to the lower back; and sacral, which refers to the pelvic area. In Batten Disease, it is usually caused by complication of the neuromuscular tree rather than a congenital issue. Children with a very mild degree of scoliosis most often do not require surgical treatment. However, these children will need regular followup to check whether the curvature is increasing with time. A moderate degree of scoliosis can be treated with bracing (a molded plastic jacket or a chair insert). If untreated, a spinal curvature can interfere with sitting, walking and self-care skills. Severe scoliosis and gradually increasing scoliosis despite bracing may require surgery, especially if it is affecting the diaphragm and breathing. If surgery is needed, it is called a spinal fusion where the use of Harrington rods are wired along the spine to maintain proper alignment while bone graft material fuses the spine in position. The goal is to straighten the curve as much as possible and to prevent the vertebrae from shifting further. It is possible a body jacket is worn for 6-8 months after surgery until the spine is completely healed. It cannot be overemphasized that pressure sores are caused in bed or in a wheelchair through prolonged pressure, which prevents adequate circulation to the area. Symptoms you would see are first redness of the area, followed by blisters and breakdown of skin. If untreated, further development of an ulcer would appear, associated with a possible unpleasant odor and drainage of the wound. He/she is not only unaware of the discomfort normally felt, but due to his/her immobility, he/she is unable to shift his/her position to relieve it 2. Ischemia, due to local pressure, therefore, pressure sores may occur more readily 3. Effects of posture sores develop mainly over bony prominences, which are exposed to unrelieved pressure in the lying or sitting position. The most vulnerable areas are the sacrum, hips, knees, fibula, heels and the fifth metatarsal or little toes. If for some reason your child should end up with a plaster cast, pressure sores readily occur under splints, casts and braces applied over immobile areas b. First Stage In this stage, skin stays red for 5 minutes after removal of pressure and may develop an abrasion of the epidermis (the top layer of skin). The sore is usually reversible if you remove the pressure, and the underlying tissues are still soft. Penetrating to the subcutaneous fat layer, the sore is painful and may be visibly swollen. The skin becomes necrotic (dead) with exposure of 93 fat which extends into the muscle; the sore may develop a black, leathery crust or eschar, at its edges and eventually at the center. The sore is not painful because 94 95 fat which extends into the muscle; the sore may develop a black, leathery crust or eschar, at its edges and eventually at the center. Fourth Stage Necrosis extends through the fat layers to the muscles followed by further fat and muscle deterioration to bone destruction with periostitis and osteitis progressing to osteomyelitis with the possibility of sepsis, arthritis, pathologic fracture, and septicemia. The surrounding tissues are rapidly involved if infection occurs, and a very small skin opening may be the only visible sign of a deep cavity reaching down to the infected bursa, and usually to bone c.

Given the low rate or absence of type 1 diabetes in many non-Caucasians arthritis relief big toe etoricoxib 60mg mastercard, the impact of ethnicity on the relationship between proteinuria and other diabetic complications was examined only in those with type 2 diabetes arthritis diet tips purchase cheapest etoricoxib. Cardiovascular disease is related to the level of proteinuria or albuminuria in diabetic kidney disease (Table 127 and Figs 51 and 52) (R arthritis pain relief drugs buy etoricoxib australia,C) arthritis uk knee examination cheap etoricoxib 60 mg with amex. Increased cardio vascular mortality was linked with elevated urinary albumin excretion in type 2 diabetes in 1984578,579 and with type 1 diabetes in 1987. Crude association of microalbuminuria and cardiovascular morbidity or mortality in type 2 diabetes. The results are presented with (total) and without (subtotal) the study that included subjects with clinical proteinuria. The association between diabetic kidney disease and cardiovascular disease is gener ally considered stronger in type 2 than in type 1 diabetes at all levels of albuminuria/ proteinuria, due in large part to the older age of the type 2 diabetic patients. These results may be influ enced by the racial/ethnic mix of the sample cohort, since some populations included in the cohort with high rates of type 2 diabetes, such as the Pima Indians, have lower rates of cardiovascular disease than Caucasians with type 2 diabetes. In this review, patients with microalbu minuria had an overall crude odds ratio for cardiovascular morbidity and mortality of 2. Retinopathy is related to the level of proteinuria or albuminuria in diabetic kidney disease (Table 128) (R,C). Review articles evaluated for this guideline in cluded patients from clinic and population-based studies of type 1 and type 2 diabe tes. Stratification 235 quently,603,604 particularly in type 2 diabetes, because of the coexistence of nondiabetic kidney disease. Nevertheless, the incidence of proliferative retinopathy increases dramati cally with the development of elevated urinary albumin/protein excretion. Less is known about the strength of the association between urinary albumin/protein excretion and neuropathy than about the other complications of type 1 and type 2 diabetes. The review articles evaluated for this guideline comment briefly that some studies found a relationship whereas others did not. In 1988, consensus was achieved on a standardized classification scheme (vide supra), but there are still few reviews available that comment on the relationship between albuminuria/proteinuria and diabetic neuropathy by these criteria. A large number of published guidelines and position statements are avail able to guide the practitioner in the prevention,detection,evaluation and treat ment of diabetic complications (Table 129). Guidelines regarding angiotensin converting-enzyme inhibitors or angiotensin-receptor blockers and strict blood pressure control are particularly important since these agents may prevent or delay some of the adverse outcomes of both kidney and cardiovascular disease (R). Moreover, after the development of kidney failure, much of the available data do not differentiate type 1 from type 2 diabetes. Much of the excess mortality, particularly in type 2 diabetes, is attributable to cardiovascular disease rather than kidney failure, indicating the importance of identify ing and treating the other complications of diabetes in these patients and the importance of close monitoring of proteinuria and kidney function to identify those at increased risk. The evidence reviewed to date suggests that the appearance of elevated albuminuria/ proteinuria is associated with a higher risk of the non-kidney complications of diabetes even as patients progress towards chronic kidney disease. The association between albu minuria/proteinuria and cardiovascular disease, diabetic retinopathy, and diabetic neu ropathy described in this guideline supports the recommendation that patients with diabetic nephropathy be carefully examined for the presence of other diabetic complica tions and that proper care for these complications be initiated. This recommendation is based on opinion derived from a review of the available evidence. Stratification 237 garding management of diet, exercise, glycemia, blood pressure, lipids, neuropathy, reti nopathy, and cardiovascular disease must all be considered in addition to those for kidney disease. Although the challenges for health care providers are formidable, they may seem overwhelming to those with diabetes. One of the objectives of the National Diabetes Education Program, a Program managed jointly by the National Institute of Diabetes and Digestive and Kidney Diseases and the Centers for Disease Control and Prevention, is to promote an integrated patient-centered approach to diabetes care with the goal of reducing the morbidity and mortality associated with diabetes and its complications ( Since race/ ethnicity may influence not only the risk of diabetes, but the severity and type of diabetic complications that develop, further characterization of the impact of diabetes in different populations is needed. Moreover, the extent to which aggressive treatment of diabetic complications modulates the progression of kidney disease needs to be examined, since recent studies suggest that improvements in the treatment of cardiovascular disease in patients with type 2 diabetes have contributed to an increase in diabetic kidney failure. Previously the National Kidney Foundation convened a Task Force to evaluate the epidemic of cardiovascular disease in patients with chronic kidney disease. Guideline 14 addresses the risk of cardiovascular disease in patients with diabetic kidney disease. Therefore, this guideline focuses on the risk of cardiovascular disease in patients with nondiabetic kidney disease, and specifically to address the question whether chronic kidney disease is a risk factor for the development of cardiovascular disease. In addition to the Task Force summary, other recent review articles, where necessary, were used as a source of information for the following rationale statements. Stratification 239 Nondiabetic patients with chronic kidney disease have an increased preva lence of cardiovascular disease compared to the general population (R). In a report from the Framingham Heart Study, the prevalence of various manifestations of cardiovascular dis ease were examined in participants with elevated serum creatinine (serum creatinine 1. Cardiovascular disease is the leading cause of death in patients with chronic kidney disease, regardless of stage of kidney disease. Approxi mately 40% of all deaths in the United States are secondary to cardiovascular disease. Cardiovascular disease mortality is more likely than development of kidney failure in nondiabetic patients with chronic kidney disease (R). Using the same dataset, the prevalence of diabetes and hypertension in subjects with elevated serum creatinine levels (1. In this cross-sectional study, 19% of subjects with elevated serum creatinine were known to have diabetes mellitus, and 70% had high blood pressure. Compared to the general population, the percent prevalence of lipoprotein abnormalities in patients with chronic kidney disease is also increased (Table 131). The prevalence of tobacco use in patients with chronic kidney disease does not appear to be markedly different from the prevalence in the general population. The reader is also referred to reviews which discuss factors such as homocysteine, inflammatory markers, thrombo genic factors, and oxidative stress in more detail. Damsgaard643 Cr (1990), Friedman645 (1991), Matts641 (1993), Shulman510 (1989), Beattie644 (2001), and Schillaci635 (2001): data not provided to present risk with confidence intervals. Some of this variability may be explained on differences in baseline demographics, severity of kidney disease, and the overall cardiovascular risk of the study sample. There is insufficient evidence to support an association with incident congestive heart failure, possibly because the number of congestive heart failure events is low. Proteinuria is a risk factor for cardiovascular disease in individuals with out diabetes (Tables 134,135,and 136 and Figs 54,55,and 56) (C). Again, the results for all studies are not completely consistent but the weight of evidence is very supportive. The identification of chronic kidney disease as a risk factor for cardiovascular disease does not prove causation. A temporal relation with chronic kidney disease and incident cardiovascular disease has been identified in many of these studies, but other criteria for causation are lacking, including consistency and biologic plausibility. An alterna tive hypothesis is that chronic kidney disease is a marker for the burden of exposure to 244 Part 7. Jager651, Kannel12, Culleton648: some diabetics included, but results shown are adjusted for diabetes. Grimm228: (a) proteinuria positive once; (b) proteinuria positive more than once over 6 years of follow up. Grimm228: (a) proteinuria positive once; (b) proteinuria positive more than once over 6 years of follow-up. Risk factor reduction is likely to be effective in reducing morbidity and mor tality due to cardiovascular disease in patients with chronic kidney disease (O). In the absence of this high level evidence, extrapolation of evidence from clinical trial results in the general population to patients with chronic kidney disease is necessary. Smoking cessation programs should be no less effective in patients with chronic kidney disease than in the general population. Second, adverse effects of risk factor reduction do not appear substantially greater in patients with chronic kidney disease than in the general population. Third, the life span of most patients with chronic kidney disease often exceeds the duration of treatment required for beneficial effects.

In contrast to delirium rheumatoid arthritis uptodate cheap etoricoxib 120mg on-line, which involves an acute derangement of brain function arthritis treatment kerala cheap 120mg etoricoxib fast delivery, dementia is associated with progressive neuronal loss rheumatoid arthritis in feet pictures order etoricoxib cheap online. Dementia always involves some loss of memory (learning new information and recalling previously learned information) rheumatoid arthritis wrist x ray buy 90 mg etoricoxib visa. Other cognitive disturbances include: a) aphasia b) apraxia c) agnosia d) executive function disturbance (planning, organisation, sequencing and abstraction). Associated features include spatial disorientation, impaired judgement and insight, and disinhibition. Dementia may be complicated by the development of depression (especially early in the course when a person retains insight into his or her condition), anxiety, delusions (especially persecutory), hallucinations (most commonly visual) and delirium. Dementia is sometimes associated with motor disturbances of gait and slurred speech. People with early dementia may experience intense anxiety upon having their declining intellectual function made evident (catastrophic reaction). Suferers may complain of the problems themselves, or they may deny or try to rationalise them. The onset is usually acute and cognitive impairment often fuctuates throughout the day. In contrast to dementia, delirium generally has an acute onset and is characterised by an altered or fuctuating level of consciousness. A dementia secondary to neurosyphilis, for example, should gradually improve with treatment. The course for vascular dementia is sometimes described in textbooks as having a step-wise deterioration, but is in fact quite variable. Educating the family about the nature of the illness, its signs and symptoms, its prognosis, and the available supports will help alleviate some of these reactions and enable the family to make informed decisions about future care. Many of the interventions discussed below require family involvement or are directed at minimising the burden of care. Complications of dementia include delirium (including drug-induced delirium), physical illness, depression and psychotic symptoms. Psychotropic medication may sometimes be indicated for treating co-morbid illness. Treatment of cognitive impairment Younger suferers, who are living at home and sufer mild to moderate symptoms, may beneft from treatment with an anti-cholinesterase inhibitor. Though these drugs do not alter the progression of the disease, in clinical trials people treated with anticholinesterase inhibitors showed less deterioration in cognitive functioning than those on placebo. Unlike tacrine, it is generally well tolerated and does not cause hepatic toxicity. Side efects (including nausea, diarrhoea, insomnia, vomiting and loss of appetite) tend to be mild and often resolve over the frst weeks of therapy. Fortnightly liver function tests are required over the frst four weeks to monitor for elevations in alanine transaminase. Monitoring is then required monthly for three months, and every three months for the duration of treatment. Full blood examinations are required every six weeks for the frst six months of treatment, and then every three months. Gastrointestinal side efects (nausea, vomiting and diarrhoea) may be troublesome and often lead to cessation of treatment. Since there is no evidence for the efcacy of these drugs in severe dementia, they should be ceased when the illness progresses to this stage. North Melbourne:Victorian Medical Postgraduate Foundation Therapeutics Committee, 1995. A Manual of Mental Health Care in General Practice 159 Organising fnances Testamentary capacity While the person still retains testamentary capacity, he or she should be encouraged to make out a will. The assessment of whether a person retains this capacity depends on his or her ability to understand the nature and purpose of a will, to have a broad understanding of his or her fnancial assets, and to be able to name the people who might legitimately have a claim to assets in the will. He or she must be free of delusions that might directly infuence the content of the will and must be under no undue infuence from others on the disbursement of his or her assets. Enduring power of attorney the following discussion refers to current Queensland law. It enables him or her (the principal) to grant an enduring power of attorney to a named individual or individuals (the attorneys). The date or occasion upon which the power of attorney becomes activated is specifed on the form. The power of attorney is enduring because it continues when the person loses the capacity to make decisions. Under the Queensland Powers of Attorney Act 1998, an Enduring Power of Attorney can authorise the attorney to make both fnancial and health care decisions on behalf of the other person. Forms are available from newsagencies, GoPrint bookshops, Commonwealth Government Bookshops and legal stationers. The Public Trustee In Queensland, if a person who has not appointed an enduring power of attorney becomes incapable of managing his or her fnancial afairs, the Adult Guardian should be contacted. Consent for medical procedures this matter is dealt with by diferent laws in each state/territory. The Queensland Powers of Attorney Act of 1998 defnes the ways in which health care decisions can be made on behalf of people whose decision-making capacity is impaired. Advance health directive this document allows the individual to give general instructions about his/her future health care, including end-of-life decisions, such as refusal of life-sustaining medical treatment, if he or she is terminally ill. In Queensland, this does not include instructions for a doctor to help a person die. Enduring power of attorney As mentioned above, a person (the principal) can appoint another (the attorney) to make future health care decisions on his or her behalf if at some time in the future the principal loses the capacity to make such decisions. Statutory Health Attorney In the case of a person who develops a decision making disability, but has not appointed an enduring Power of Attorney, the Queensland Act makes provision for a close relative or carer who is readily available and could be expected to take responsibility to be able to make health care decisions on his or her behalf. This replaces the previous informal practice of having the next-of-kin make these decisions. Work Repetitive tasks may remain within the capacity of someone with early dementia. Jobs that carry responsibility for others, include an element of risk and require clear judgment, must be discontinued. Relatives will often want a clear description of the prognosis so that decisions afecting the long-term interests of the family can be made. Relatives of people with dementia need a clear description of the prognosis so that decisions affecting the long-term interests of the family can be made. Disability support this involves decreasing the need for functions lost while maximising the use of residual functions. Structured activities that take place at regular times each day will minimise disorientation in time. Maintaining a person in familiar surroundings will minimise disorientation in place. Similarly, carers must tolerate being asked the same questions repeatedly (perseveration).

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