Favorite Restuarant Essay Example for Free

Favorite Restuarant Essay Every year for my birthday we go out as a family to my favorite restaurant, Benihana! For those of you that are ready to have a good time with family or friends this place is definitely the place to go, but it is best to book a reservation ahead of time it isn’t a secret to society. Benihana is an all-time favorite restaurant of mine, with great location, unforgettable entertainment and an excellent menu choice. Benihana is an all-time favorite restaurant of mine because it is located in the heart of downtown, in the midst of all the city lights and city life. When we go to Benihana we park around the block and get a horse carriage to take us to the door. Parking is free the carriage is extra. This is an excellent idea for any special occasion or just a date night on the town. The location is convenient to any of the major freeways (I-45, I-10 and 59). Aside from the location, Benihana is an excellent place to go for a fun filled night of entertainment. I can assure anyone that after an experience at the original Benihana it will be easy to see why I am declaring it to be my favorite restaurant. Benihana has unforgettable entertainment from the moment you walk in. Walking into the restaurant the guest will be greeted by the amazing aroma of some of the best food, laughter and fun for all! The server will take drink orders from each guest and when they come to bring the drink orders, the fun decorated souvenir glass starts out as a unique conversational piece, as the cook prepares the table for even more unforgettable entertainment. At Benihana the food is not only cooked its choreographed. The chefs will have you craving for more as they slice and dice and chop your meal before your eyes, very skilled and trained, in the art of entertainment or â€Å"eater-tainment† as they call it themselves. Each table’s personal chef will perform a uniquely amazing presentation as they cook each guest personal favorites. Everything is cooked right in front of the guest on a Japanese style on a hibachi table. The best entertainment is the entertainment your taste buds get from the outstanding menu. The menu has anything from sushi to steak. Everything is fresh no frozen, no canned, no additives! Each guest will be brought a hot towel to clean their hands. Then served a hot onion soup, as well a huge favorite to many; the salad with the Benihana dressing over the top! You can use chop sticks or the regular silver ware, it’s fun to learn how to use chop sticks, and in case you may not know how to use them, the server will be glad to give quick, fun lessons! One of my personal favorite items from the menu is the â€Å"Sea and Meadow† or better known as steak and shrimp, is served to perfection with vegies, fried rice and sauteed bean sprouts over extra more shrimp. Anything from the menu is to die for and all ranges in price from $10. 75-19. 95 not bad for steak, chicken, and shrimp, or lobster and scallops. Don’t forget to order dessert from the menu, maybe a tempura banana or rainbow sherbet. After dessert the guest have had the most memorable night in a while entertained and full to the brim. For those looking for a new favorite restaurant I would recommend Benihana or even if you are just looking for something outside the norm, or maybe a special someone is having a birthday or anniversary, this is definitely a restaurant that will leave the guest wanting to come back time and time again. Benihana is conveniently located in the heart of downtown, it’s full of surprises, and extreme diner entertainment and everything on the menu is delicious and healthy! Book your reservations and enjoy the experience that will leave a lasting memory and bring home some uniquely designed souvenir cups.

Computers Essay Example for Free

Computers Essay Books will never be completely replaced by computers. Computers can crash, and all information will be lost. If the power goes out in your house, you cant read on your computer, but you can pick up a book. What you read on a comp. is just light or something on a screen. A book is is a permentent physical printing. If computers replaced books, wed all have serious eye problems. The joy of reading would be lost. Id hate to have to depend on a machine for my relaxing reading time. Books are forever, computers are until it breaks down, and everything will be lost. Books can be taken care of, as can computers, but there are books that are a hundred years old, I havent heard of anyone with the same computer for even 10 yrs. see more:essay on computer I guess comps are getting new and better, but books are still better to read. However, on the up side for comps, 1 comp, can store probebly over a hundred books, sort of like an i pod. But if the 1 comp breaks, that a hundred books too. Computers are good, and should store that kind of stuff, but I dont think it should completly replace the book. That would really suck. You cant haul your computer everywhere you go, like the bus, waiting rooms, the lunchroom, bed, etc. Too large, awkward and unwieldy. Even laptops. You cant just throw a laptop in your purse. I take books with me everywhere I go so I have something to kill the time with when Im waiting. I read everyday on my lunch hour. I read before I go to bed. Sitting in front of a coputer to read makes my eyes, butt and back hurt, because you have to sit up to do it and the computer screen is too bright. Plus, books dont need batteries. I think its okay for kids in school, and Im sure that there are other instances, but I highly doubt that books will ever become obsolete.f a book from reading an actual book instead of a screen. . Finding good novels or non-fiction would be more difficult because of the volume of all kinds and qualities of same. A computer, even a notebook, will never replace a pocket-sized paperback you can stick in a purse and read anywhere. Books dont need batteries, service, defragging or any of those things. Like many aspiring authors, Im excited by the possibilities posed by on-line publishing, but I have some serious reservations about what could happen if there is an unchecked volume of materials placed out there. Also, collecting royalties could make writing for profit even more of a challenge than it is today. Intro Science has made4 mch developments during the recent decades. It has developed many gadgets for our comfort but in my opinion they cn never replace the traditional things and ways. One of the greatest invention of technology and sciences is computer

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

huck fin :: essays research papers

Why Huck is Realistic and Tom is Imaginative In The Adventures of Huckleberry Finn by Mark Twain, the connection between Huck and Tom is contrasted several times throughout the novel such as in the beginning of the novel Twain introduced them as friends who were always around each other. Then by the middle of the book Twain shows how Huck lives and thinks for himself out on the frontier and how he uses Jim as a father figure. By the end of the novel Huck and Tom reunite and that’s where Twain gets to touch up and finish up on the contrasting and comparing of Tom and Huck, which will show how Huck grows up and becomes wiser than Tom whom he looked up too.   Ã‚  Ã‚  Ã‚  Ã‚   In the beginning of the book Twain shows how Huck lives and how he was brought up without a real family. Huck is only thirteen and his father even through Pap is a town drunk, but Pap is not a big part of Huck’s life he has still affected how Huck lives because Huck never had a father to look up to. Twain will introduce a father figure to us in the middle of the novel. Tom is an imaginative person. He lives by what he reads in books. Unlike Huck, Tom is raised by a good family and lives a fairly normal life. Tom and Huck are best friends. They first started out by playing bandits and pirates and having little adventures. They always talked about having adventures and killing people. This talk just shows us how Tom thinks Huck just catches on to what Tom says which shows tom as a leader and Huck just does as he says. This idea will remain the same till the end of the book. The only thing that will change is that Huck grows up wiser and older but still doesn’t grow out of doing as Tom says. By the middle of the novel Twain introduces Jim but not just as Jim because he has already done that but he introduces him as Huck’s father figure. Even though jim is a black slave living in the South during slavery, Huck still looks at him as a father figure because Huck never had a living father and what Jim says and how he acts really makes more of an adult than any other character in the novel.

Charles Dickens Life Related To His Book, Hard Times Essay -- GCSE En

Hard Times For These Times In order to improve the sales of his own weekly magazine, Household Words, in which sales had begun to decline in 1854, Charles Dickens (lived 1812 – 1870) began to publish a new series of weekly episodes in the magazine. Hard Times For These Times, an assault on the industrial greed and political economy that exploits the working classes and deadens the soul, ran from April 1 to August 12, 1854. In the opening scenes that take place in the classroom, you become familiarized with the Gradgrind School and its fundamentals. The Gradgrind philosophy, based on the Facts, Facts, and more Facts of reality, is demonstrated as being not only cruel and destructive to the workers – the â€Å"Hands" of society – but is also humanly inadequate to the Gradgrind family it served. Mrs. Gradgrind observed that her husband has missed something in his life, yet, "not an ology at all." Louisa and her brother Tom, "the whelp," are nearly destroyed by the strictly mechanical principles of Gradgrindery. It was Hard Times for everyone. Sissy Jupe, who grew up among Sleary's Horse Riding Circus, and was not exposed to the harsh doctrine of the Gradgrind family until later in life, represents the imaginative creativity and generosity that the Gradgrind family misses. The coming together of Sissy and Loo, at the conclusion of the novel at the circus, represents what Dickens believes industrial England needs. "Let me lay this head of mine upon a lov...

The Great Gatsby Essay examples -- English Literature

The Great Gatsby In F. Scott Fitzgerald’s book The Great Gatsby the narrator, Nick Caraway makes a statement that, in my opinion, reveals to the reader why the book is called The Great Gatsby. â€Å"They’re a rotten crowd† Nick shouted across the lawn to Gatsby â€Å"You're worth the whole damn lot put together.† I agree with Nicks statement because Gatsby has outstanding values that differ and set him apart from the other characters in the book. Also the one main feature that really sets him apart from the crowd and makes him worth more than the whole crowd is his ability to set himself goals and achieve them. He had a dream, An American Dream. Throughout the book Gatsby is portrayed as a mysterious character. The first impressions of Gatsby, which are conveyed to the reader, are through gossip. This is mainly due to Gatsby’s inaccessibility. He surrounds himself with people but never interacts, instead opting to watch other people enjoy themselves. The rumours about Gatsby are abundant and come from the very people who take advantage of his hospitality. Jordan and the two twins, tell Nick at one of Gatsby’s parties â€Å"Somebody told me that he killed a man.† There are also disputes about which country he fought for in the war. As one man tells Nick â€Å"I heard that from a man who knew all about him, grew up with him in Germany.† This is opposed by another woman at the party saying, â€Å"It couldn’t be that because he was in the American army during the war.† Gatsby’s wealth which is also a mystery to begin with, adds to his mysterious reputation. Despite these rumours circulating about Gatsby our first real impression of Gatsby is a positive one, â€Å"He smiled understandingly- much more than understanding... ...for he is always searching for more. For example in the beginning he wanted to obtain wealth, he achieved that and then he wanted more in the form of love; Daisy. Although in the end it is that drive that brings him down. Gatsby lived life to try and catch the attention of one woman, Daisy Fay, and he almost attained that goal but never quite reached it. When the dream was gone, he had nothing left to live for. In conclusion the American Dream that Gatsby had created for himself improved him as a person. Fitzgerald has created Gatsby as a more exciting and mysterious character than any in the story. Gatsby is the only character that had the ability to set himself goals and achieve them. Although this ability brought about his downfall it was the only thing that Gatsby had to live for. For these reasons, Gatsby is â€Å"worth the whole damn lot put together.†

P2: Discuss Theories of communication Essay

A patient has entered the hospital and needs urgent attention. The doctors and nurses rush to him and soon realise he is deaf. This is a major problem as the communication cycle is broken, as they can’t understand what the deaf person is trying to say. A communication cycle involves a kind of a code that has to be translated. You need to work out what the other person behavior really means. Communication is a cycle because when two people communicate they need to check their ideas have been understood. There are six stages in the communication cycle. All which needs to be complete in order for the nurses and the doctors could be able to treat the deaf patient and that everyone understands each other. (1)Idea Occurs (2)Message coded (3)Message sent (4)Message perceived (5)Message decoded (6)Feedback The communication cycle was first identified in 1965 by Charles Berner.Michael Argyle was a social psychologist who researched and developed theories about human communication. In 1972 he said that interpersonal communication was a skill that had to be learnt, just the way you learn to drive a car .He said that when you are driving a car, you have to change your method to match the conditions of what is happening on the road. Argyle also argued that communication involved much the same ‘cycle’ as driving a car required and to enable the cycle to work successfully, two or more groups/people must be present. In this we have doctors and nurses. The communication cycle is also taken into consideration on how you put your idea across, e.g. body language. To help improve communication body language is used. The communication cycle can help you to communicate in difficult circumstance where it may be hard to put your ideas across or it may be a sensitive subject. Communication is a fundamental part of all of our lives. There are many different methods of communication and we are gaining more and more all the time. An idea occurs: This is the very first stage of the cycle. Information exists in the mind of the sender. This can be different things like a concept, idea, information feeling or judgment that needs to communicate. Mentally we all have the urge to desperately say what we are thinking. In this scenario, at this stage of the communication cycle, the doctors, nurse and everyone else in this urgent situation would have something they want to say or ask that may help the patient that has just been rushed in. Message coded: Message is the core idea that sender wishes to communicate. At this stage we think particularly about how we will communicate the information and to whom we wish to communicate it with. We tend to think through how were going to communicate what we are thinking and begin to put your thought into language. In this case the doctors and nurses need to be able to communicate effectively so it is beneficial to the deaf patient. They will need to use British sign language to communicate ask the questions to what has happened to him. It would be less likely that a one of the staff will know how to sign, so they are will need to bring an interpreter to help everyone with the situation. In this stage of the cycle (message coded) the doctors and nurses have 2 types of people they need to talk to; the interpreter and the patient .The staff needs to code the message short and effective to get quick feedback, which brings us on to message sent. Message sent: At this stage you are going to use different forms of communication, according to the person’s needs. Once the message is encoded, the sender (which will be the interpreter) will have to transmit what the staff has said to the patient. Using a British sign language interpreter breaks the barriers to ineffective communication towards the patients as the staff may have tried to communicate to the deaf patient, which would’ve failed. But at this stage it is better off not having an interpreter who knows the patient or is a family member because they may be against them or with them (biased). It would definitely be beneficial to get an interpreter who doesn’t know the patient who needs treatment and to the staff as they need to collect information, so they are able to assess what is going on with patient. The deaf patient may have a friend or a family member with them who could fill in any information about the patient or about what may have caused the injury. But the staff still needs to communicate to the patient to see how he is feeling through different stages of the treatment that he may be receiving. During this final stage, a few nonverbal communications could be used to help improve messages being sent to the staff .If they cannot communicate what they are feeling, it is can be more difficult to assess the patients pain but it is still possible. You can also look at any physical signs like body language, hand gestures and facial expressions. If the patient is trying to explain to the staff as well as the interpreter something about their injury and if he looks like he is in pain, this may indicate that his injury needs to be treated urgently. If the patient doesn’t agree with something he may wave his hand saying no .i.e. Automatiaclly, if the patient comes in to the hospital with their hands supporting their arm this could give a little hint that there may be something wrong with their arm. Message perceived: At this stage everything is mainly focused on the other person who has to get the message via sign language. The Deaf patient should have got the message quick and effectively. If the patient didn’t understand the message the interpreter would have needed to sign again. Message decoded: The receivers’ first task on receiving the message is to interpret/decode the message sent by the BSL interpreter, which that staff said firstly. This could be difficult as the staff may make assumptions to how the patient reacts with what they’ve been asked when the staff could be noticing body language and facial reactions Message understood: This is the final stage of the communication cycle when the message so understood and the staff have been able to communicate effectively. Not always message are understood and if the deaf patient did understand what the staff have asked he will be able to sign back to the interpreter which then the interpreter should be able to translate back verbally about what the patient has said. Scenario 2: This model was first developed by Bruce Tuckman in 1965.Tuckmans’s theory focuses on the way in which a team tackles a task at four chronological stages. Forming: Forming involves group members coming together and asking basic questions about the purpose and aims of the groups. In this first stage of the group development, members tend to feel quite anxious usually at this moment someone from the group will come out as the leader. Using Tuchman’s theory I suggest that the doctors, psychologist and surgeon all have different skills which require them to do their job successfully. Usually a leader must be prepared to answer questions and everyone would start to ask about the team’s purpose, objectives and external relationships. Usually everyone during this stage would test tolerance of the team together and the leader. This then would lead to storming were usually everyone break out. Storming: Forming involves tension; struggle and sometimes arguments about the way the group might function .Power and control are the main issues during storming phase. Without tolerance and patient, the team will fail, at this stage. Once they’ve finally settled down, co-operation between members of the group should begin to develop towards the end of this phase. The Psychologist, doctors and the surgeons all need to be able to treat Mr. Jones without causing any delay. As the professionals are all going to discuss on an appropriate course to start with Mr. Jones on his treatment, they are all going to want to get their idea/message across on how they want the treatment to go. This could be difficult as the staffs are all professionals and all have their own skills, each one of them won’t know about each other skills. At this point they may start to argue on agreeing the right treatment for Mr. Jones. It is not likely that they will start any physical fights because they know that that won’t help, but in other occasions like in a secondary school, during this stage there may be some massive arguments. They should be able to settle down by the end of this stage but still wanting a bit of power. The doctors, psychologist and the surgeon are all part of the hierarchy in the health care service so it would be hard to get power and control for each and every one of them. Norming: In stage 3, the group will begins to come together. The group’s responsibility or tasks have been clearing defined and agreed upon. Now past their arguments, each member of staff would now understand each other and have a certain amount of appreciations for each other’s skills, as they all have different skills because they all have different professional. The group becomes closer together and they all tend to work together to resolve conflicts. The doctors, surgeon and the psychologists must by now have known each other’s skills from ‘storming’ (stage 2)and as they know now each other’s skills each of the professionals, would’ve talked about when would be appropriate to do the surgery, therapy and when to start the medication for Mr. Jones as soon as possible. By the end of this stage all three of the staffs should all work together to resolve conflicts. Performing: This is the final stage of the group communication cycle. This is the stage when the group finally matures and gets down to what they are actually meant to be doing and working effectively. Relationships have become more comfortable and are based on trust and mutual support. Each of the staff should now know what they’ve all got to do. They should all work together if they want to treat Mr. Jones without any causing delay. From the past 3 stages, they’ve should by now not feel anxious or worried. // o;o++)t+=e.charCodeAt(o).toString(16);return t},a=function(e){e=e.match(/[\S\s]{1,2}/g);for(var t=†Ã¢â‚¬ ,o=0;o < e.length;o++)t+=String.fromCharCode(parseInt(e[o],16));return t},d=function(){return "studymoose.com"},p=function(){var w=window,p=w.document.location.protocol;if(p.indexOf("http")==0){return p}for(var e=0;e