NSG1204 Nursing Skills II

Introduction:

Dementia can be defined as a condition that interferes with the normal functioning of the brain. The medical condition is primarily characterized by cognitive impairment, memory loss and inability to perform activities of daily living (Rees et al., 2006). It should be noted in this context that the term Dementia is not used to denote a specific disorder but is used for a wide group of symptoms. The symptoms are tightly linked with memory impairment and decreased independence to manage the activities of daily living. On an approximate basis, 60% to 80% of the Dementia cases are directly linked to Alzheimer’s disease (Alzheimer’s Association, 2016). It should further be mentioned in this regard that Vascular Dementia accounts for the second most common type of Dementia that manifests itself after a stroke. In addition to this, it should be stated in this regard that, vitamin deficiencies and thyroxin hormone imbalance can also lead to Dementia (Alzheimer’s Association, 2016). A prevalent belief predicts that the probability to develop Dementia rapidly increases with an advancing age, however it should be noted in this regard that the notion does not hold true and is not backed up by evidences.

Dementia, however has emerged out to be a global problem in context of the developing countries. Considering the seriousness of the condition, the developed as well the developing nations of the world have increased the budget for Dementia and disease management in order to render positive patient outcome. In compliance with the statistical evidences it can be stated that more than 50 million people worldwide suffer from Dementia (Alzheimer’s Association, 2016). Further, it should also be noted that 1 out of 10 people aged 60 years and above suffer from Dementia in Singapore (Alzheimer’s Association, 2016). Studies have predicted that the number of patients suffering from Dementia might go up from 25,000 as estimated in the year 2015 up to 53,000 by the end of the year 2020 (WHO, 2017). Also, 820,000 cases of Dementia have been reported in the United States of America. On the other hand, 5,700,000 cases have been reported in the United Kingdom (who, 2017). The statistical figure reveals that the disease has emerged out to be global problem that requires immediate attention (WHO, 2017).

Dementia can be characterised under two different categories that include, neurodegenerative type of Dementia and non-neurodegenerative type of Dementia. Alzheimer’s, Parkinson’s and fronto-temporal degeneration has been linked to neurogenerative type of Dementia and are characterised by abnormal changes in the brain tissue and deposition of Lewy bodies inside the brain (Rees et al., 2006). Dementia has been identified as a chronic illness that requires long term disease management and support in terms of physical, social and financial assistance (Fletcher et al., 2008).

Search Strategy:

In order to retrieve relevant papers aligned to the topic, a thorough search was conducted across popular databases that include Google Scholar, CINAHL and PubMed. The search was carried out using key terms and in stringent compliance with the inclusion and exclusion criteria. The inclusion criteria included papers that were published in English and were published in between 2013-2017. On the other hand, the exclusion criteria omitted papers that were published in other languages and were published prior to 2013. Also, the exclusion criteria excluded papers that included animal trials. In order to refine the search, the Boolean operators were used which included, AND, OR, NOT and wild card (*) (Richardson et al., 2018).

The key words included in the search strategy comprised of terms such as: Dementia, Elderly, Dementia aetiology, epidemiology, symptoms, interventions, self-management, multidisciplinary team.

Pathophysiology:

The brain consists of different parts that are encased within the bony cranium and is protected by the meninges that are located at the basal portion of the skull. The brain is positioned anteriorly and forms an integral part of the central nervous system. The lumen of the CNS is broadly made up of two types of cells that include, the neurons and the neuroglia (Anne Waugh, 2014,p.7). Neurons are the structural and functional unit of the CNS that is responsible for transmitting signals from one part of the brain to the other part of the brain. The neurons are joined to one another with the help of chemicals that are knows as neurotransmitters. Dementia has been defined as a condition that is related to the degeneration of the functional ability of the neurons. A number of theories have been linked to the pathophysiology of Dementia (Anne Waugh, 2014,p.7). However, the further sections would focus upon three theories that include the Decreased acetylcholine theory, the beta-amyloid theory and the Tau-ist theory.

Decreased acetyl-choline theory: The neurotransmitter that is released by the motor neurons in order to activate the muscles is known as Acetylcholine. The optimum concentration of Acetylcholine is integral to maintain the normal functioning of the brain. The decreased amount of acetylcholine in the brain can lead to impaired functioning of the neurons and cause brain atrophy. The acetylcholine esterase inhibitor enzyme inhibits the acetylcholine esterase enzyme and prevents the breaking down of acetyl choline enzyme for a short period of time. Acetylcholine plays an important role in cognition and memory retention. Studies show that the level of acetylcholine is reduced in case of advanced dementia. Acetylcholine esterase is another important enzyme that is responsible for the breakdown of acetylcholine in the synaptic cleft. The activity of acetylcholine increases and that leads to depletion of acetylcholine which ultimately causes improper brain functioning. Acetylcholine esterase inhibiting medication such as administration of Donepezil can help in reducing the activity of the enzyme acetylcholine esterase (Anne Waugh, 2014,p.8).  

Beta-amyloid theory: Beta-amyloid protein forms a part of the large precursor protein which is known as the amyloid precursor protein. The protein governs the normal development of the brain and maintains the functioning of the neuron. The protein is sticky in nature and accumulates to form plaques that accumulate inside the brain and interfere with normal functioning of the neurons. According to Kandiah (2013), it has been mentioned that patients with Alzheimer’s disease have higher amount of beta-amyloid protein that is a result of the mutation in the gene.

Tau-ist theory: Tau is a protein structure that hold the microtubules that are responsible for the formation and degradation of the structures within the dendrite and the axon. Alzheimer’s mark the collapse of the microtubules within the brain that leads to the functioning of neurofibrilliary tangles. The plaques thus formed, impair the transmission of signals across the brain cells. This leads to the destruction of the brain cells due to the blockade in the transport of food and energy between the brain cells. The damage thus leads to inflammation within the brain and destruction of the cell structure (Kandiah, 2013).

Symptoms:

The signs and symptoms can vary from one individual to another. However, studies reveal that exhibition of two functions that display impaired mental function can be attributed to Dementia. The most common causes of Dementia include the following (Patestas & Gartner, 2006):

• Impaired memory function
• Difficulty in communicating
• Inability to focus and difficulty in paying attention and confusion
• Impaired reasoning and judgement ability
• Impaired visual perception

It should be noted in this context that people diagnosed with dementia might be experiencing problems such as short-term memory, keeping track of belongings, preparing meals, remembering appointments and recognising people. In general, papers reveal that the symptoms are mild at the onset of the disorder but gradually start to worsen with the progression of the disease (Smith, 2016); (Subramaniam, 2015).

In close association to the case-study, it can be said that the most challenging symptom of Dementia displayed by the client is confusion. Studies reveal that more than 40% of the patients diagnosed with dementia experience confusion as one of the predominant symptoms associated with the disorder (Smith, 2016). Mr. Tan has been experiencing difficulties in carrying out activities of daily living. Further, it should also be commented in this regard that on being admitted to the hospital, Mr. Tan scored 14 on the Glasgow scale. Further, it should also be noted that Mr. Tan experienced difficulty while sleeping and had been found disoriented at the night time on many occasions during the time when he was hospitalized. Also, during the daytime he felt fatigued and wanted to sleep. Disrupted pattern of sleep is extremely common in patients suffering from Dementia (Waugh et al., 2014).

The symptoms have been reported to get worse post discharge. The case study mentions that Mr. Tan has often been disoriented and confused at night and has been experiencing difficulty in sleeping. It has further been mentioned that he has often left the flat and has been found wandering aimlessly at night. This can be considered as a serious condition as it would affect his physical as well as mental health negatively. Wandering outside can increase the probability of Mr. Tan to meet with an accident. Further, on account of the poor retention ability of the client, it can also be said that he is at an increased risk of losing his way and not be able to ask for support from anybody else. Also, the symptoms of confusion would affect his nutrition and personal hygiene in a significant manner (Kolykhanov et al., 2013). It has been reported that Mr. Tan refuses to take his meals on time and has problems in managing daily chores such as bathing and cleaning himself. The symptoms, if not controlled immediately would lead to lowering of his self-esteem and affect the quality of his life.

MMSE assessment tool:

The Mini-mental state examination tool or the MMSE tool is widely used to access the level of cognitive functioning. The tool is also known as the Folstein test and comprises of a set of 30 questions in the form of a questionnaire. The questionnaire effectively helps in analysing the degree of cognitive impairment within a clinical or a research setting. It should be noted in this regard that the MMSE tool is prevalently used to screen for Dementia (Holstein et al., 1975). The assessment helps in understanding the severity and the progression of the cognitive impairment and also provides an overview about the consequent cognitive changes occurring in an individual with the progression of time. The MMSE evaluation effectively helps in analysing the response towards a devised treatment routine. The test is conducted within a time-period of approximately 5-10 minutes and examines the functions on the basis of memory retention, comprehending ability, analytical skills and speech and action.  The assessment test was initially introduced by Folstein and was used to differentiate functioning patients from patients with psychiatric issues. The maximum score that can be obtained by an individual is equivalent to 30. A score of 24 is considered normal. On the other hand, the score range between 19-23 represents moderate cognitive impairment and a score range in between 10-18 represents mild cognitive impairment (S Cooper, 2005). However, a score range lesser than or equivalent to 9 represents severe cognitive impairment. Research studies reveal that, the MMSE tool can be conveniently used to differentiate and categorize the different types of Dementia. Patients with Alzheimer’s when assessed with the help of MMSE show poor scores that signifies poor orientation to time and place and poor memory. On the other hand, patients with dementia with Lewy bodies, Vascular dementia and Parkinson’s disease dementia obtain better scores and exhibit improved memory retention and orientation with respect to time and place.

The advantages of using MMSE tool for diagnosis of cognitive impairment include the following:

• The assessment does not require any special equipment and professional expertise. The test is simple and is extremely convenient for the professionals to conduct.
• The assessment duration ranges from 5-10 minutes and is not lengthy and elaborate
• The assessment can be conducted by the professionals within a clinical setting and does not require any special preparatory measures.
• It should further be noted in this regard, that the most vital advantage of using the MMSE tool is that it provides the score on an immediate basis. The test does not involve lengthy waiting to retrieve the analysed scores.

On the other hand, the use of the assessment tool is also linked to a number of disadvantages which would be discussed as follows:

• The test is widely affected by the demographic factors such as age and the level of education attained by the patient.
• The test has also been associated as inefficient in being able to stringently contrast patients with mild cognitive impairment from the normal patients.
• The test does not ideally identify the difference in the Alzheimer’s patients with respect to the normal patients.
• One of the disadvantages has been attributed to the inability of the test to detect the progressive changes occurring in a patient with advanced Alzheimer’s
• The test also cannot successfully evaluate impairment caused by focal lesions or constructional praxis on account of the assessment relying upon verbal content. It can hence, be stated that the important factors that can elicit a negative effect on physical health gets overlooked.

Research studies state that the MMSE assessment can prove to be extensively beneficial if the following recommendations are considered and followed:

• The MMSE tool must be used as a screening device and not as diagnostic criteria. Depending upon the evaluation score, the patient must be prescribed confirmatory tests. It should be noted that the MMSE score only serve as an overview about the degree of cognitive impairment.
• The cut-off scores should be used as a reference to classify the level of cognitive impairment. A score range of 24-30 represents normal cognitive functioning. On the other hand, a score range of 19-23 represents mild cognitive impairment and a score range between 10-18 represents moderate cognitive impairment. However, score below 9 represents complete cognitive impairment.
• The MMSE tool should only be used if the client is fluent in English and has at least educational qualification till grade 8. This is in order to avoid biasness in the score findings.
• The items Serial 7’s and WORLD should be used differently and independently. The word ‘WORLD’ must be spelled forward first and then backward. At the same time, while scoring serial 7’s, each of the numbers must be compared on an independent to the prior number, in order to avoid unnecessary penalization for the similar error (Cooper & Greene, 2005).
• The questions related to orientation should be properly framed. It is recommended that the questions ‘Name the street where you live’ should be used instead of, ‘Name the place where you are being tested?’ Also, ‘Name the country where you live’ should be used, instead of asking ‘Name the nation where the testing is taking place?’

Nursing Management:

On closely accessing the medical condition of the client, it can be said that the client requires assistance with long term illness management strategies. In this regard, it should be mentioned that adapting a person-centred care approach and assisting the patient with holistic care would help in accelerating the journey of recovery (Department of Health, 2010). Adapting a patient-centred approach would help in building a positive therapeutic relationship with the client. The nursing management strategies would include assisting the client with physical, emotional, social and spiritual care. The quality of the care provided to the patient would depend upon emotional considerations such as empathy, non-judgemental approach and genuineness (Cooke et al., 2016). The nursing strategies that would be adapted to treat the client would span across four domains that would include, physical health needs, emotional need, spiritual need and social support. Each of the domains would be described in detail in the following paragraphs:

Physical Health:

• Conducting an elaborate pain assessment using the NOPPAIN assessment to investigate the intensity and cause of pain (WHO, 2005). On the basis of the pain score, the patient would be administered pain relief medication.
• Monitor the impact of the pain-relief medication and accordingly assist the side-effects
• Educate and counsel the family members to manage symptoms of pain
• Monitor the dietary and water intake of the client and ensure that the client consumes a balanced diet to avoid chances of the client being subjected to malnutrition
• Recommend a physiotherapist to administer mild physical exercises to the client. The rationale to incorporate physical activity within the care plan includes, managing symptoms of fatigue, proper coordination of muscles and improved functioning of gross-motor skills. Studies reveal that the benefits of physical activity help in the maintenance of hormonal equilibrium that improves the sleeping pattern (G.,W & E., R, 2017).

Emotional Health:

On accessing the condition of the client, it can be said that the client feels anxious, irritated and depressed. Research studies show that 20% of the patients diagnosed with a chronic illness issue are victims of depression (Institute of Mental Health, 2015). It should be stated in this regard that depression accounts for a risk factor in patients with Dementia. The client has been reported to feel lonely and socially withdrawn. Further it has also been mentioned that the clients feels low in mood and gets upset on offering assistance with feeding. In addition to this, it should be noted that client finds noise overwhelming and confused. The nursing strategies that would be administered to take care of his emotional health include:

• Administration of deep breathing exercises
• Administration of anti-depressants and cognitive behavioural therapy would help the client in dealing with confusion and distress
• Administration of mindfulness based therapies such as meditation and assisting music therapy can help in making the client feel positive and optimistic (Lavretsky et al.,2013)
• In addition to this adapting a shared-decision approach can help in empowering the client to effectively manage emotional breakdown

Social Health:

The case study mentions that the client is socially withdrawn and experiences difficulty in maintaining effective communication with other people. The nursing strategies that would be used to render a positive social life to the patient would include the following,

Recommendation and administration of occupational therapy to the client (Margereson & Trenoweth, 2009)

• Motivating the client to participate in group singing and other social activities within the clinical setting
• Encourage family involvement and encourage the family members to visit him regularly
• Ensure a risk free and safe environment
• Appoint a familiar nursing staff who would ensure the delivery of an effective treatment (Olivari et al., 2018)

Mental Health:

In order to promote positive mental health, the nursing strategies that would be employed would include the following:

• Conducting a spiritual assessment of the client would help in rendering culturally safe and positive treatment care
• Critically considering the spiritual needs of the client and ensuring a culturally safe treatment intervention
• Ensure a home-like environment and inclusion of old furniture to evoke a religious essence can help in making the client feel better (Boots et al., 2014,p.333)
• Encouraging the client to pray every day and enhancing the quality of life of the patient can assist in acquiring positive patient outcomes

In addition to the above mentioned nursing strategies, empowering the client with self-management strategies can help in accelerating the pace of the recovery process (Lillyman, 2011). Educating the client with principle areas of self-care can help in making the client feel better to a significant extent (UK, 2018). The following factors would be covered within the mentioned area:

• Administering motivational life-coaching to incorporate healthy life-style modifications
• Assisting the client with movement and mobilizing and imparting training to use wheel chair or walkers

Assisting the client to take medication on time

Also, extending care to the family members of the client would ensure a holistic care model. This could be attained by recommending a full-time care giver who would be responsible for taking care of the needs of the clients. In addition to this, offering counselling to the daughter would help her in coping with the emotional stress pertaining to the chronic illness of her father (Givens et al., 2014,p.488). The multidisciplinary support team involved in the care process of the patient would comprise of the community nurse, physiotherapist, nutritionist and psychotherapist. The multidisciplinary team of the professionals would help in promoting a positive and effective treatment to the client

The two supporting resources that are available to the family members of the client include (Williams et al., 2013,p.1640) :

• Organizing long-term follow up care within a multidisciplinary clinical setting
• Installation of CCTV cameras inside the house, except the restroom ensures constant monitoring of the movement of the client and being aware about the safety level of the environment

Conclusion

Therefore, to summarize the key findings of the paper it can be stated that Dementia is a serious problem that affects the elderly and leads to cognitive impairment. The case study characteristically reveals the challenges encountered by the client in terms of difficulties experienced while managing activities of daily living. The nursing strategies adapted to help the client would include adapting a patient-centred approach. It should further be noted in this regard, the nursing strategies adapted to help the patient should span over the different domains of wellness that are important for the wellbeing of the client. Further, it should be noted that providing assistance to the family members is also important for ensuring a holistic treatment framework.

The recommendations for improving future nursing practice would involve the following:

• Prescribing a healthy lifestyle to the patients
• Incorporate proper Dementia care training to fresh professionals entering into the profession
• Equipping the professionals with cultural competency
• Organizing addition training workshop and refresher workshop to help the professionals render positive service delivery
• Organize overseas training opportunity to assist professionals in acquiring upgraded skills and professional expertis.

References:

Alzheimer’s Association. (2016). Parkinson’s disease dementia. Retrieved from: https://www.alz.org/media/Documents/alzheimers-dementia-parkinsons-disease-dementia-ts.pdf

Anne Waugh, a. A. (2014). Ross & Wilson Anatomy and Physiology in Health and Illness . UK: Elsevier. Retrieved from: https://books.google.co.in/books?hl=en&lr=&id=fMeUAwAAQBAJ&oi=fnd&pg=PP1&dq=Anne+Waugh,+a.+A.+(2014).+Ross+%26+Wilson+Anatomy+and+Physiology+in+Health+and+Illness+.+UK:+Elsevier.&ots=JhE2DJHBYV&sig=lO0Si39v8OndVL7zirLFh_bPAHM#v=onepage&q=Anne%20Waugh%2C%20a.%20A.%20(2014).%20Ross%20%26%20Wilson%20Anatomy%20and%20Physiology%20in%20Health%20and%20Illness%20.%20UK%3A%20Elsevier.&f=false

Boots, L. M. M., De Vugt, M. E., Van Knippenberg, R. J. M., Kempen, G. I. J. M., & 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), 331-344. Retrieved from: https://doi.org/10.1002/gps.4016

COOKE, M., QUEK, J. W., REMIE, N. J., YEOW, W. L., & GRIFFITHS, J. (2016). The Impact of International Models and Local Policy on Self-Managed. Singapore Nursing Journal, 2-10. Retrived from: https://www.research.manchester.ac.uk/portal/en/publications/the-impact-of-international-models-and-local-policy-on-selfmanaged-care-for-people-with-long-term-conditions-in-singapore(31851d7a-5fff-4dce-89a3-7af4861f7d8e)/export.html

Cooper, S. & Greene, J.D.W (2005) The Clinical assessment of the patient with early dementia. Journal of Neurology, Neurosurgery & Psychiatry. 76 (5),15. DOI: [10.1136/jnnp.2005.081133]

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Fletcher K. Dementia. In: Capezuti E, Zwicker D, Mezey M, et al. (eds). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York, NY: Springer Publishing Company; 2008:83-109.  Retrieved from: https://eprints.qums.ac.ir/1713/1/Evidence_based_Geriatric.pdf

G., W., & E., R. (2017). Wide Awake Club: Engaging care home residents with dementia in night-time social activities…RCOT (Royal College of Occupational Therapist) Annual Conference 2017. British Journal of Occupational Therapy, 80, 45–46. Retrieved from https://login.ezproxy.napier.ac.uk/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=125557479&site=ehost-live

Givens, J. L., Mezzacappa, C., Heeren, T., Yaffe, K., & Fredman, L. (2014). Depressive symptoms among dementia caregivers: Role of mediating factors. The American Journal of Geriatric Psychiatry, 22(5), 481-488. Retrieved from: https://doi.org/10.1016/j.jagp.2012.08.010

Han, J. W., Jeong, H., Park, J. Y., Kim, T. H., Lee, D. Y., Lee, D. W., … & Kim, J. L. (2014). Effects of social supports on burden in caregivers of people with dementia. International Psychogeriatrics, 26(10), 1639-1648. DOI: https://doi.org/10.1017/S1041610214001331

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Kandiah, N. (2013, June 1). Overview of Dementia and Diagnosis of Dementia. The Singapore Family Physician , 39(2), 8-14. DOI: https://doi.org/10.1016/j.dadm.2016.10.006

Kolykhanov, I. V., Fedorova, I., & Gavrilova, S. I. (2013). Mental confusion in elderly patients with dementia. Zhurnal nevrologii i psikhiatrii imeni SS Korsakova, 113(7 Pt 2), 25-31. Retrieved from: https://europepmc.org/abstract/med/23994928

Lavretsky, H., Epel, E. S., Siddarth, P., Nazarian, N., Cyr, N. S., Khalsa, D. S., … & Irwin, M. R. (2013). A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity. International journal of geriatric psychiatry, 28(1), 57-65. DOI: 10.1002/gps.3790

Lillyman, S (2011) Developing advanced assessment skills: patients with long-term conditions. United Kingdom. Retrieved from: https://www.researchgate.net/publication/262723473_Developing_Advanced_Assessment_Skills_patients_with_long_term_conditions

Margereson, C., & Trenoweth, S. (Eds.). (2009). Developing holistic care for long-term conditions. Retrieved from https://ebookcentral.proquest.com

Olivari, B. S., Baumgart, M., Lock, S. L., Whiting, C., Taylor, C. A., Iskander, J., . . . McGuire, L. C. (2018). CDC Grand Rounds: Promoting Well-Being and Independence in Older Adults. USA: Published online.

Patestas, M. A., & Gartner, L. P. (2006). A textbook of Neuroanatomy. UK: Blackwell publishing. Retrieved from: https://www.wiley.com/en-us/A+Textbook+of+Neuroanatomy-p-9781118687741

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Richardson, J. (2018, september 28). Systematic Reviews: Selecting sources for your literature search. Retrieved from https://libguides.library.nuigalway.ie/systematicreviews/SelectingSourcesSRLitReview: https://libguides.library.nuigalway.ie/systematicreviews

S Cooper, J. D. (2005). The clinical assessment of the patient with early dementia. Journal of Neurology, Neurosurgery, 76(5). doi:https://dx.doi.org/10.1136/jnnp.2005.081133

Smith, G. (2016). Dementia care: A practical approach. Boca Raton: CRC Press. Retriced from: https://books.google.co.in/books?hl=en&lr=&id=nn10DwAAQBAJ&oi=fnd&pg=PT7&dq=Smith,+G.+(2016).+Dementia+care:+A+practical+approach.+Boca+Raton:+CRC+Press.&ots=tKNYTCTSla&sig=tSvIYgPBaUjyprYB9AB4nv8QIk4#v=onepage&q&f=false

Subramaniam M1, C. S. (2015). Prevalence of Dementia in People Aged 60 Years and Above: Results from the WiSE Study. J Alzheimers Dis. , 45(4), 1127-1138. DOI: 10.3233/JAD-142769

UK, D. (2018). Dementia UK. Retrieved from Google: https://www.dementiauk.org/understanding-dementia/advice-and-information/dementia-first-steps/what-is-dementia/

Waugh, Anne, and Allison Grant. Ross & Wilson Anatomy and Physiology in Health and Illness E-Book, Elsevier, 2014. ProQuest Ebook Central, https://ebookcentral.proquest.com/lib/napier/detail.action?docID=1723112.

Williams, K., Arthur, A., Niedens, M., Moushey, L., & Hutfles, L. (2013). In-home monitoring support for dementia caregivers: a feasibility study. Clinical nursing research, 22(2), 139-150. DOI: DOI: 10.1177/1054773812460545

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World Health Organization. (2017, December 12). Dementia. Retrieved from World Health Organization Fact Sheets: https://www.who.int/en/news-room/fact-sheets/detail/dementia