UZWRSS153 Evidence and Research in Practice

Introduction:

Dementia is one of the neurodegenerative disorders which is affecting the lives of most of the cohorts of the older age. This often affects the quality lives of the individual as it impacts on the lives of such people as they tend to affect their memory, cognitive skills, and balance and speech capability. It also affects their ability to recognise situations, people and others and also affects their capability to perform their daily activities of life. Therefore, it often becomes challenging for the healthcare professionals to apply interventions that would not only help the individuals to help them cope up with the symptoms but also ensure a quality life which will give them new hopes to live a life worth living for.

Healthcare Professionals

Case study:

Mr. Gary Dawson is a 72 year old man who was brought to the care centre by his daughter and son in law. He was a patient of dementia and was found to be in poor health. His only daughter Sara works in a multinational company and usually remains under huge work pressure. Her husband is a civil engineer and often has to stay on long outdoor schedules. Both of them have a 10 year old daughter called Lily who studies in the convent school of the city and are attended by a house governess who stays with them. Lily and her grandfather used to be the best of friends but certain situations have occurred which had concerned Sarah and john. Over the months, both of them were looking after their old father who initially faced difficulties in memorising different things of regular activities. However they were managing him and his needs with care and affection. Over the months, the condition of Gary had deteriorated making it impossible for both the working person to take care of him. He had become entirely dependent upon them to carry on with his activities of daily lives. It was seen that the Gary had lost his memorising power completely and even cannot tell whether he had eaten his meals or not. After bidding good bye to her granddaughter when she got up the school bus, it was seen that she was asking about the whereabouts of Lily to the caretaker. Incidences have also occurred where was in loss of words to describe a particular instance and was not being able to express it properly. When Lily got irritated with his forgetfulness after a tiring day at office, it was seen that Gary all of a sudden shouted at the top of the voice and started crying asking to take him to his mother. Moreover when her daughter took him to the park for a stroll which he always loved to do, it was seen that he sat on the bench throughout and did not participate into any entertainments with the family. Moreover his daughter also noticed that he was totally unable to brush his teeth, wear his clothes properly and was struggling to remember the name of his granddaughter whom he loved dearly. This really concerned the family and they tried to help him being more compassionate. However stresses of their own lives were making it not possible for them to take complete care. Gary was often found to be confused about what he was going to do next and often leave his task incomplete and when asked later he could not remember anything. A more shocking thing to the family was that he was unable to remember the direction to his house when they were returning from a weekend trip and was constantly repeating his concern regarding what would happen if they get lost. In spite of the family trying to make him understand that they were on the correct path, he was not satisfied and constantly repeated his concern. When the house-keeper found him wandering in the roads one day, the family was really concerned and they immediately decide to take him to the nearby community setting healthcare service so that the healthcare professionals could recognise the disorders and thereby appoint nurses to take care fog the intense situations.

Diagnosis procedure of the nurse:

There is no particular test that healthcare professionals conduct to identify the presence of the disorder. Healthcare professions try to assess the medical history of the patient closely and carefully and also conduct physical examination and laboratory tests (Boots et al. 2014). Often the characteristics changes in the thinking and memory skills of the patient, evaluating the performance of the patient in the day to day functions and also different types of behavioural changes and alterations often help the professional to understand whether the patient is suffering from dementia. For proper assessments nurses can also perform cognitive testing tools that help the nurses to evaluate the patient’s concentration, memory, visual spatial awareness, problem solving skills and also counting and language skills (Richardson et al. 2013). Neuropsychological testing as well as different radiological tests helps in confirming the presence of dementia. Brain imaging testing like computed tomography, magnetic resonance imaging, positron emission tomography all confirm the presence of dementia in patient. Once the nurses conduct the proper diagnostic methods and be sure if the presence of the disorder her next step would be the setting up goals and also plan out proper interventions (Zhang et al. 2014). The researchers over the years have shown that in case of patients who suffer with dementia, person centred care has provided the best care to the patient in a way that not only helps to make the patients gradually overcome the different disorders but also helps in providing better quality life to the patient not suffering from the chronic disorder (Narme et al. 2014). However it is nearly possible for the healthcare professionals to make the patient recover from the disorder but proper compassionate patient centred care can assure that different symptoms are properly addressed and looked over to help the person live a better quality life and reduce the intensity of the symptoms (Vernooij et al. 2014).

Intervention that was used:

After visualising the symptoms of the patient, the nurse took up the intervention of applying the correct medication to that of the patient in order to handle the condition of the patient. A large number of nurses still rely on the concept of application of psychotic drugs that they believe to act as a supportive therapy in order to treat the various problems of dementia. Researchers have stated that  large number of antipsychotic drugs have been found to be effective in the reduction of the different types of aggression that are usually shown by the patients and are also found to be helpful where there remains  risk of the patients  harming themselves as well as others (Eritz et al. 2016). These medications often act as the short term intervention like around six weeks in place of a systematic basis. The nurse who had treated the patient n the case had first provided the patient with anti-anxiety medications that typically helps patients who are suffering from agitation as well as restlessness. Moreover the nurse had also provided several antidepressant medications so that she can help the patient in order to treat depression symptoms. Treating the depression symptoms are found to be extremely important because this type of medication helps the patient in overcoming depression which in turn helps the person to remember things and at the same time enjoy life (Cotteli et al. 2014). There are many nurses who even in the present date believes that such psychotic drugs can result in significant improvements in the treatment of depression s the patient’s mood can be altered towards betterment and will help them to develop the ability of participation in social activities and help in leading a better quality life.

Challenges and efficacy level of the intervention:

However while applying the medication; the nurse was not aware of the doses and the side effect of the different psychotic drugs. Recent researchers are of the opinion that there are many factors that should be kept in mind while administering such medication and therefore this intervention often becomes strenuous to apply for the nurses. The medications should be administered very cautiously to patients who suffer from dementia and should be given in lowest possible doses so that any sort of side effects can be prevented. Proper supervision of the doses is also required. As different side effects and risks are associated with the medication administration to dementia patients, a careful risk benefit evaluation is very necessary to conduct not only before treatment initiation but also continue it throughout treatment on a regular basis. Therefore there remains a high chance of medication administration error which might lead to potential adverse effects. Moreover there had been very few evidences in the evidence based journals where these interventions had been found to result in the best results in the patients. When such medication was applied to the patient, it was found that there had been side effects in the patient like stiffness of joints especially in elderly and resulted in shaking. Researchers have pointed side effects which matched with the patient’s symptoms like slowing down of the thinking capability and also resulted in a general sluggish feeling. It also causes restlessness and tardive dyskinesia that involves continual mouth, tongue as well as jaw movements. Moreover this intervention is very difficult to maintain as a small difference often becomes harmful. It results in sleepiness as well as general slowness and also weight gain. Moreover it never helps in overall behavioural modification entirely as the social cognitive skill still remains impaired and quality life is not been achieved as each and every symptom can never be addressed and cured.

Failure of the biomedical model of treatment and success of biopsychosocial model:

Recent researches have been conducted by eminent researchers who have come to a conclusion that following a biomedical model of treatment in case of dementia does not yield proper results. They have advised healthcare professionals to follow more evidence based researches on the effectivity of following other important interventions that will result in following a biopsychosocial model of treatment. Many researchers are of the opinion that psychotherapy is of immense help (Ouichi et al. 2014). These are behavioural approaches that are used to reduce the severity as well as the frequency of the problematic behaviours. This includes managing aggression as well as socially problematic behaviours. The nurse should first identify the instances which are triggering the behaviours and then prepare interventions that will help in managing the problematic environment. Often breaking down complex task into simpler steps like dressing, daily tasks and others will help in avoiding confusion and hence agitation will be more effectively controlled than medication alone.

Other interventions: Environmental modification:

Other than the psychotherapeutic intervention, environmental modification is another intervention that can be provided. Modification of the environment will help in the increase in the safety and will also help to comfort the patient and thereby decrease agitation. Removals of harmful and sharp objects, keeping necessary things within reach of the patients, application of bedrails as well as bathroom safety rails are extremely important. These modifications of the environment will reduce threats to his life and make him free from nay danger (Gitlin et al. 2015).

Other therapies: Cognition-oriented therapies, Simulation based therapies and Physical therapy:

Other than this, several other new interventions are being established which yields and overall successful results in treatment of such patients. Besides the behavioural therapies mentioned above as well as modifications of the environment, emotion based therapies are very important as they address the issues of loss of memories while improving mood and behaviour at the same time. Cognition-oriented therapies help the nurse to include cognitive retraining, reality orientation as well as skills that focuses on cognitive deficits. Simulation based therapies are recently researched by scientists and are considered to be one of the best ways to develop their quality lives. They mainly include exercise therapy, art therapy as well as music therapy (Quin et al. 2016) . They are very much helpful in reduction of behavioural issues. Physical therapy mainly involves the teaching of such dementia patients about how to improve mobility by the use of canes or walkers or helping them to show how to get in or out of chairs. All these interventions should be combined along with the medication intervention in order to assure that an overall successful treatment is provided to patient for making him enjoy a quality life.

Importance of patient centred care in dementia:

In order to achieve the above mentioned interventions, traditional medical model of treatment cannot be applied. Researchers suggest that patient centred care is extremely important for dementia patients. Researchers suggest that patient centred care is a practice of caring for different patients in a different number of ways which would not only be valuable for the patient but also be meaningful in a way that would provide the best benefit to the patient (Zabalegui et al. 2014). The nurse need to follow Picker’s eight principles if patient centred care as that will help the nurse to attend each and every need of the patients. The important factors that the nurse needs to include in her interventions are respecting the patient’s needs even when he is not able to perform his activities himself. The patient has completely lost his usual self and is undergoing tough phase in his life where he is not being able to maintain his identity and has lost his own characteristics therefore the nurse needs to coordinate properly with the patient and the family member and design the integration of care (Eritz et al. 2016). The nurse should ensure that the planning she makes should ensure that the patient should have the maximum amount of physical and emotional comfort. The nurse should also ensure that she respects the involvement of family and relatives to respect the dignity of not only the patient but also of the family member. The nurse should also ensure that she maintains continuity of care and help that’s so the patient to get the best access to care (Huang et al. 2013).

The intervention strategy that was applied to the patient with all successful interventions:

By applying the above mentioned interventions that had been discussed in details, the nurse planned intervention strategies which yielded successful results. The patients is seen to be suffering from issues where he cannot recall even recent events that occurred in case of his forgetting about his granddaughter’s name and often tend to forget about his daily activities that he had conducted. In this case the nurse would mainly help by using reminder in the form of notes, cues, and single day calendars (Sakamoto, Ando and Tsoutsu 2013). She should also ensure that she constantly talks with the patient about recent events so that his memory can remain active. Moreover, the patient is also seen that he is having great difficulty in conducting different tasks and therefore he is gradually withdrawing from different activities (Groot et al. 2016). Moreover he has also developed intolerance to ideas that are given by his daughter as he often has mood swings. A nurse can effectively manage it by avoiding stressful situations and she should never ask for anything more than the patient can do. Trying to engage him in interesting activities will help him to gradually get over the mood swings (Liu. Cheon and Thomas, 2014). As the client is facing difficulty in finding words, the nurse should try to anticipate what exactly the client is trying to say and help him in providing words so that he can effectively respond or thought and feeling. This would make him feel less agitated and aggressive as he would be able to make himself understand. To handle his repetitive statements, the nurse should not only be tolerant but compassionately respond to him like it is the first time the patient stated and heard (Mclaren, Lamantia and Callahan 20130. As the patients is often getting lost, the nurse should always accompany him on his walks and make sure that he would provide a safe as well as a securing walking area. The nurse should try to overlook and ignore the different inconsistencies that the patients face in his daily activities. In place, she would maintain consistency by keeping all the important items near him and within in his view so that the routines can be maintained (Vasionyte and Madison 2013). The patients is also found to be living in the past where he had instances where he had travelled in the past and behaved in an improper way asking for his mother. Therefore in this case the nurse would make sure that the patient maintains familiar social, physical, mental and also different work activities (Livingstone et al. 2014). Increased forgetfulness should be handled by placing food where the client can easily see them and try to have them on their own will. The nurse should encourage coming forward and try to perform his activities but she should not force him anyway. In case, the nurse sees that the patient is failing to achieve it, she should come forward and do it (Huntley et al. 2015). The patient is seen to have developed apathy and does not feeling like things that he used to enjoy in his youth. This should be handled by the nurse with care and she would provide materials to the patient that he used to enjoy during his life. Moreover the nurse can also keep pictures and albums that have old pictures. The nurse should also keep the room of the patient intact everyday and keep his regular necessities in the same place so that the patient can get utilised to it and therefore keep the room layout unchanged (deVugt and Verhey 2013). All these interventions should be taken only after assessing each and every symptom. Symptoms of agitation and aggression are also present within the patients and with growing stages, these symptoms are often found to intensify. Therefore the nurse’s interventions should include strategies which would help the patients to overcome his fits of anger, agitation and depression (Coon et al. 2014). Moreover such mood swings may often lead the patient to harm him or others which is often recorded in other cases of dementia as well. Therefore the nurse should make sure that where arises no situation where intensification of agitation or aggression is promoted. The nurse should also be careful to remove away any objects which can develop a risk for self harm or harming of the caregivers (Calalhan et al. 2014).

Reflection of the nurse:

I was appointed as the nurse with the responsibility to take care of Mr. Gary. As a nurse my duty was to help the patient to improve his function thereby making him to engage him in different daily activities as much as it could be provided as the diseases gradually progresses. My main motive was the restoration of the functional decline that had taken place due to the occurrence of the disease as well as provide the best education to the family member thereby increasing their knowledge about the diseases and also help them to grasp different skills which would help them to prepare a supportive environment at home and at the same time reduce excess disability as well. While applying interventions, I have faced several challenges that had been mentioned above. It was extremely difficult for me to keep up with the different interventions that were needed to be taken to properly conduct the behavioural changes in order to address functional as well as performance abilities. This is mainly because close monitoring of each and every symptoms of the patient, noting them down, researching them about the cause of such symptoms and evidence based interventions that can possible address them were becoming much strenuous for me. Often I have faced difficulty in handling the situations where Gary has complained of pain but he was unable to point out where he was having issue with the pain. Often identification of such pain becomes difficult and I was not being able to understand what to do about it or how to precede it unless I provided him a painkiller as I was not being able to understand that to do with it. Interventions for tackling fatigue and sleeping disorder are very difficult to apply as patients often face issues while sleeping as they are unable to sleep with ease. Continuous tackling of the anxiety, fear as well as loss of control of the patient becomes a physically as well as a mentally challenging job for the nurse and it used to drain a lot of energy from me as I had to continuously monitor his health to prevent him from any risky behaviours. Besides, I also had to take care of the fact that as the patients were unable to stay with their family at a regular basis, whether he was developing any sort of clinical depression or any short of psychotic symptoms. Further development of such symptoms may lead to intensification of the symptoms which might in turn result in varieties of other psychological symptoms. It also becomes difficult for the nurse to face the different areas of symptoms of old age which adds up to the consequences of dementia further intensifying the situation. While Gary was staying in the residential care, I also saw that he was declining gradually in somato-tensory system as well as reduced visual efficiency. As the patient was too aggressive, it was also a very big barrier for conducting the various interventions as he was always protesting against each and every symptom and therefore communication barriers often became a prime issue in the maintenance of the care regimen for the patient.

Conclusion:

Dementia is a neurodegenerative disorder that is affecting a large portion of older population. The main symptoms of the disorder include loss of cognitive skills, memory, decisive power, communication power, power to conduct daily activities. It also accompanies mood swings, tendencies of self harm as well as loss of memory and speech. Often healthcare professionals also face huge challenges while treating such patients as the symptoms often seem to vary and the entire treatment procedure is very strenuous and energy draining. However as healthcare professionals, it is extremely important for them to overcome such barriers and treat such patients with analytical skill, affection and compassion that will assure a better quality life for such individuals.

References:

Boots, L.M.M., Vugt, M.E., Knippenberg, R.J.M., Kempen, G.I.J.M. and Verhey, F.R.J., 2014. A systematic review of Internet?based supportive interventions for caregivers of patients with dementia. International journal of geriatric psychiatry, 29(4), pp.331-344.

Callahan, C.M., Sachs, G.A., LaMantia, M.A., Unroe, K.T., Arling, G. and Boustani, M.A., 2014. Redesigning systems of care for older adults with Alzheimer’s disease. Health Affairs, 33(4), pp.626-632.

Chancellor, B., Duncan, A. and Chatterjee, A., 2014. Art therapy for Alzheimer's disease and other dementias. Journal of Alzheimer's Disease, 39(1), pp.1-11.

Coon, J.T., Abbott, R., Rogers, M., Whear, R., Pearson, S., Lang, I., Cartmell, N. and Stein, K., 2014. Interventions to reduce inappropriate prescribing of antipsychotic medications in people with dementia resident in care homes: a systematic review. Journal of the American Medical Directors Association, 15(10), pp.706-718.

Cotelli, M., Manenti, R., Brambilla, M., Petesi, M., Rosini, S., Ferrari, C., Zanetti, O. and Miniussi, C., 2014. Anodal tDCS during face-name associations memory training in Alzheimer's patients. Frontiers in aging neuroscience, 6, p.38.

de Vugt, M.E. and Verhey, F.R., 2013. The impact of early dementia diagnosis and intervention on informal caregivers. Progress in Neurobiology, 110, pp.54-62.

Eritz, H., Hadjistavropoulos, T., Williams, J., Kroeker, K., Martin, R.R., Lix, L.M. and Hunter, P.V., 2016. A life history intervention for individuals with dementia: a randomised controlled trial examining nursing staff empathy, perceived patient personhood and aggressive behaviours. Ageing and Society, 36(10), pp.2061-2089.

Gitlin, L.N., Marx, K., Stanley, I.H. and Hodgson, N., 2015. Translating evidence-based dementia caregiving interventions into practice: State-of-the-science and next steps. The Gerontologist, p.gnu123.

Groot, C., Hooghiemstra, A.M., Raijmakers, P.G.H.M., van Berckel, B.N.M., Scheltens, P., Scherder, E.J.A., Van der Flier, W.M. and Ossenkoppele, R., 2016. The effect of physical activity on cognitive function in patients with dementia: a meta-analysis of randomized control trials. Ageing research reviews, 25, pp.13-23.

Hilgeman, M.M., Allen, R.S., Snow, A.L., Durkin, D.W., DeCoster, J. and Burgio, L., 2014. Preserving Identity and Planning for Advance Care (PIPAC): Preliminary outcomes from a patient-centered intervention for individuals with mild dementia. Aging and mental health, 18(4), pp.411-424.

Huang, H.L., Kuo, L.M., Chen, Y.S., Liang, J., Huang, H.L., Chiu, Y.C., Chen, S.T., Sun, Y., Hsu, W.C. and Shyu, Y.I.L., 2013. A home-based training program improves caregivers' skills and dementia patients' aggressive behaviors: a randomized controlled trial. The American journal of geriatric psychiatry, 21(11), pp.1060-1070.

Huntley, J.D., Gould, R.L., Liu, K., Smith, M. and Howard, R.J., 2015. Do cognitive interventions improve general cognition in dementia? A meta-analysis and meta-regression. BMJ open, 5(4), p.e005247.

Liu, W., Cheon, J. and Thomas, S.A., 2014. Interventions on mealtime difficulties in older adults with dementia: a systematic review. International Journal of Nursing Studies, 51(1), pp.14-27.

Livingston, G., Kelly, L., Lewis-Holmes, E., Baio, G., Morris, S., Patel, N., Omar, R.Z., Katona, C. and Cooper, C., 2014. Non-pharmacological interventions for agitation in dementia: systematic review of randomised controlled trials. The British Journal of Psychiatry, 205(6), pp.436-442.

McLaren, A.N., LaMantia, M.A. and Callahan, C.M., 2013. Systematic review of non-pharmacologic interventions to delay functional decline in community-dwelling patients with dementia. Aging and mental health, 17(6), pp.655-666.

Narme, P., Clément, S., Ehrlé, N., Schiaratura, L., Vachez, S., Courtaigne, B., Munsch, F. and Samson, S., 2014. Efficacy of musical interventions in dementia: Evidence from a randomized controlled trial. Journal of Alzheimer's Disease, 38(2), pp.359-369.

Ouchi, K., Wu, M., Medairos, R., Grudzen, C.R., Balsells, H., Marcus, D., Whitson, M., Ahmad, D., Duprey, K., Mancherje, N. and Bloch, H., 2014. Initiating palliative care consults for advanced dementia patients in the emergency department. Journal of palliative medicine, 17(3), pp.346-350.

Quinn, C., Toms, G., Anderson, D. and Clare, L., 2016. A review of self-management interventions for people with dementia and mild cognitive impairment. Journal of Applied Gerontology, 35(11), pp.1154-1188.

Richardson, T.J., Lee, S.J., Berg-Weger, M. and Grossberg, G.T., 2013. Caregiver health: health of caregivers of Alzheimer’s and other dementia patients. Current psychiatry reports, 15(7), p.367.

Sakamoto, M., Ando, H. and Tsutou, A., 2013. Comparing the effects of different individualized music interventions for elderly individuals with severe dementia. International Psychogeriatrics, 25(05), pp.775-784.

Vasionyt?, I. and Madison, G., 2013. Musical intervention for patients with dementia: a meta?analysis. Journal of clinical nursing, 22(9-10), pp.1203-1216.

Vernooij-Dassen, M. and Moniz-Cook, E., 2014. Raising the standard of applied dementia care research: addressing the implementation error.

Zabalegui, A., Hamers, J.P., Karlsson, S., Leino-Kilpi, H., Renom-Guiteras, A., Saks, K., Soto, M., Sutcliffe, C. and Cabrera, E., 2014. Best practices interventions to improve quality of care of people with dementia living at home. Patient education and counseling, 95(2), pp.175-184.

Zhang, S., Edwards, H., Yates, P., Li, C. and Guo, Q., 2014. Self-efficacy partially mediates between social support and health-related quality of life in family caregivers for dementia patients in Shanghai. Dementia and geriatric cognitive disorders, 37(1-2), pp.34-44.