SNPG 955 Dementia Care Across Settings

Answers:

Introduction

Dementia is a neurodegenerative disorder causing progressive decline in the mental and cognitive function of the individual suffering from it. Research indicates that dementia’s fit with the social model of disability implies that care for dementia patients goes beyond clinical approaches. The hallmarks of person-centered care are approaches for addressing physical dexterity, loss of recognition ability, and cognitive impairments. At the core of person centered care lays the need of conducting an accurate assessment of the patient to understand his current mental and physical health status. The rationale is that a whole-person approach is ideal since it takes into consideration all ability, needs, preferences values and qualities of the individual. A dialectical analysis is helpful in the process of providing dementia care since it helps in clarifying the interventions adopted as per the best interests of the people. The present paper constructs an assessment of a dementia patient using the dialectic model and discusses how one area of need had been addressed. The patient considered for the assessment was Mrs. Jones who had been diagnosed with dementia and struggling to cope up with it. The paper includes the dialectics of dementia as applicable to the patient. One area of health need was identified through thorough analysis. Literature review has been done to understand the effectiveness of interventions applicable for the client. Implementation and evaluation of activities form the next part of the paper. Implementation for practice and conclusion ends the paper in a systematic manner.

Dialectic of dementia

The research of Kitwood indicates that diagnosis of dementia is linked with changes physical and mental changes. Different factors that influence the persona of a dementia patient are personality, biography, neurological impairment and social psychology (Manthorpe and Iliffe 2016). 

Personality- Patients suffering dementia are often seen to undergo personality changes. Such changes are a key feature of the disease and chances of undergoing such changes increases as the diseases progresses (Terracciano et al. 2017). Mrs. Jones had a drastically different personality previous to her diagnosis of dementia. She had been a social personal all her life. She was a working woman who opines that she had a fulfilling career. This indicates that she had a healthy relationship in the workplace, a feature that is a result of pleasing and warm personality.

Health status- Changes in health status of a dementia patient is linked with a number of other factors such as physical exercise and mobility. The extent to which the patient is functional influences the progress of the disease (Dewing and Dijk 2016). In the present case Mrs. Jones had retired long back thus implying that she developed a sedentary lifestyle that progressed with the passing years. Living alone also brought limited scope to carry out extensive activities in daily lives. She also received limited support with the activities of daily living. All these factors contributed considerably to the poor health status. The risk of fall is essentially linked with impaired mobility as in case of Mrs. Jones. It is also noted she had suffered urinary tract infection in the recent past along with previous history of chest infections. These two diseases also have lead to poor health status.

Neurological impairment- Neurological impairments are due to decreased functionality of body parts with passage of time. Such impairments usually develops over a considerable period of time which be resisted under certain circumstances. For the case of Mrs. Jones it can clear that the life events had a direct relation to her neurological impairment. She mentions that she has no major role in her household after her retirement. This had been the situation for more than ten years, a time frame adequate to increase the risk of poor neurological condition.

Social psychology- Social isolation and feelings of being lonely are associated with the higher chances of decline in clinical dementia condition in later stages of life. Such social psychology has been noted to be a major risk factor for depression, vascular diseases and other conditions. Signs of depression are a signal to a prodromal stage of dementia. Vulnerable populations need appropriate interventions to reduce depressive symptoms (Butcher et al. 2018). Mrs. Jones has been living alone in her apartment with minimal visits from her only son. Due to decreased mobility her social life is not noteworthy. It was clear from the patient assessment that feelings of depression were a result of social isolation as she lacked contact with family members and other members of the community. It is rightfully an objective state as her condition could be measured by her statements.

Intervention delivered and evaluation

A thorough analysis of the condition of the patient brought into focus that the primary patient health need was mobility and ability to perform daily activities of living in an independent manner. Based on current knowledge of dementia care practices it was understood that physical exercise therapy could act as the suitable intervention for Mrs. Jones.

Literature review of physical exercise therapy

Physical exercise therapy brings significant improvement in balance, strength, endurance and mobility in patients suffering from dementia and cognitive impairment. A number of studies have indicated physical exercise training is beneficial for improving the quality of life of patients. Exercise training has been denoted to bring positive changes in physical as well as cognitive functions. As pointed out by de Souto Barreto  et al. (2017) effects of physical exercise on physical functioning has been noteworthy in case of dementia and the main areas of development include balance, step length, improvement of strength, TUG, and walking speed. Though the evidence supporting improvement in BMI, and dual-tasking ability as a result of physical exercise therapy is poor, the evidence supporting reduction of falls is valuable. It is to be remembered that specific training is more importance for impairment level outcomes. Thus, it is crucial to carry out a comprehensive assessment of the patient’s physical functioning for determining the particular areas of deficit. The rationale is that such an assessment ensures that the appropriate form of exercise is integrated into the program for addressing the impairments that the patient faces (Lamotte, et al. 2017). 

Lam et al. (2018) carried out a systematic review with studies with meta-analysis of randomized trials to understand whether physical exercise training is effective in improving quality of life of patients suffering from dementia. The study also aimed at understanding which training protocols are useful for improving physical functioning. The key inference drawn from the study was that regular multimodal exercise in adjunct with aerobic, resistance, balance, functional and flexibility training for one hour a day, 3 days a week, brings in much improvement in physical function. The chosen intervention is thus a feasible option for dementia patients as the benefits clearly outweigh the risks. Long term effects of the intervention are to be further analyzed through research. Suttanon et al. (2010) carried out a study to assess whether balance exercise programs can improve balance as well as related physical performance measures in dementia patient. The systematic review considered studies where participants were assisted with physical, balance or exercise activities. Findings suggested that feasibility of conducting exercise programs with older dementia patients is justified. Balance performance is improved in patients as a result of whom the risk of suffering falls is reduced significantly.

The study of Zeng et al. (2016) was based on the research that activity in a suitable clinical environment is responsible for exciting the brain on a cognitive and bodily level which is beneficial for achieving improved brain plasticity in dementia patients. The meta analysis focused on assessing the impact of physical exercise on dementia patients. It was concluded that physical activity training can successfully improve the condition of Time up and go (seconds), Function Reach (cm), NPI-caregiver total score, steps/min, Cadence, and Berg Balance Scale. The studies also reflected that physical activity training brings in a number of advantages for dementia patients such as better athletic ability, balance ability. For healthcare professionals, the outcome is beneficial since they reduce the burden on the care givers to a considerable extent. In this regard the study of Lindelof et al. (2017) is to be brought into limelight. A qualitative interview study was conducted to explore the experiences and views of dementia patients who underwent high-intensity functional exercise (HIFE) program in nursing homes. 21 individuals took part in the study. All of whom were older dementia patients, and the program comprised of exercises performed in functional weight-bearing positions. These included movements used by individuals in everyday tasks. The exercise was individually designed and performed during four months in the respective nursing homes. The four themes that emerged from the interviews were “Exercise is challenging but achievable; Exercise evokes body memories; Exercise gives pleasure and strength; and Togetherness gives comfort, joy, and encouragement”. The study was a valuable one since it was clear from the results that the tailored exercise enabled the patients to adapt to it. Further, the exercises gave them pleasures and patients could rediscover bodily capabilities. The study emphasized that the patients were given an opportunity to develop feelings of safety, coherence and encouragement.

Lamb et al. (2018) recommends that exercise training program is carried out by a professional who can supervise the program with desirable skills and knowledge. For those who suffer from mild to severe dementia, the training is to be received from those who have received training in the same field. It is further required to focus on the training protocol and adhere to the guideline outlined for different patient scenarios.

Implementation

The literature review highlighted the suitability of implementing physical exercise therapy for Mrs. Jones given that she needed improvement in her mobility and ability to carry out daily activities of life. The exercise training implemented thus had three crucial considerations. The first consideration was to minimize the problems arising due to the decline in the physical health of the patient that is decreased mobility. The second consideration was to recognize behavioral changes that might arise when the patient is agitated with the intervention implemented. The third consideration was to support the patient’s willingness to continue with the exercise program. Assessing the condition of Mrs. Jones and her age, it was thought appropriate to implement a low-intensity exercise program at the usual level of activities of daily living. Aerobic exercise was the mode of training for the patient in order to address her condition. This included enjoyable aerobic activities that involved large muscle exercises. The patient was also encouraged to walk on a regular basis. The goal was to bring improvement in the functional health of the patient. Further, such exercises increase endurance that is necessary for community ambulation (Brooker and Latham 2015). The sessions continued for 40-60 minutes and such sessions were carried out three times a week. The sessions were broken down into smaller 20 minutes activities. The emphasis was on enjoyment perceived by the patient so that adherence to program was achieved. Further focus was also given to increase the duration by increasing the time of walking exercise. The program continued for two months.

Evaluation

During the early stage of the program, it is recommended to support to patient to take part in the physical activities. Motivation is pivotal to commence with the program. In case of dementia patients, this is more crucial since patients tend to show distracting behaviors (Muller et al. 2017). In the present case the patient did not show any such reluctance to take part in the activities outlined. Willemse et al. (2015) highlight that vital problems related to implementation of training programs for dementia patients is that patients suffer memory loss. As a result they forget how to perform certain activities or the series of activities to perform. In order to avoid such scenarios a reminder session was taken at the end of each meeting for making the process effective. Mrs. Jones at certain points in time showed depressive symptoms and did not show much faith in the potential of the exercise program. Keeping in mind this concern empathy and emotional support was provided to her. The cornerstone of the whole program was patience, enjoyment and consistency (Sullivan, Mannix and Timmons, 2017). As a professional it was appreciable to provide verbal encouragement to maintain interest of the patient in the program. At one certain session the patient showed outburst of aggression. However the behavior lasted for only few minutes and later on she forgot about the incident. It was acknowledged that the outburst was only a symptom of the disease suffered. Professionals are not to take emotional outbursts of dementia patients personally and act in an unprofessional manner.

At the end of the session Mrs. Jones demonstrated better functional mobility and behavior. Her physical fitness was found to be improved as she was better able to carry out activities such as personal care. She could dress and clean without support from care giver. Maintaining independence for a longer time was an achievement. Further, there was improvement in sleeping behavior. She could sleep adequately at night when provided with a peaceful environment. The other noted changes were increased confidence and low signs of depression.

Implementation for practice

Dementia care entails person centered care as in the present scenario it was vital to reflect on how the quality of life of Mrs. Jones could be improved. While caring for her, collaboration with physical exercise therapist was valuable in achieving patient outcomes. Clinical settings demand professional collaboration between individuals that promotes service delivery in the same direction. Strategies for care intervention are to be aligned with the input of professionals who are highly skilled and efficient (Brazil et al. 2018. The patient assessment and care planning gave a valuable opportunity to understand how dementia patient needs can be addressed. Difficulties faced and successes achieved have important implications for future practice. In future, I would ensure to show more empathy and affection towards my patients to fulfill goals of interventions within the stipulated time frame. I plan to engage in continual learning to understand more about how physical exercise training programs can be modified as per the evolving needs of the patients. Professional development is based on continuous research and translation of theory into practice (Gilbert, Ward and Gwinner 2017).

Conclusion

Converging evidence suggest that dementia is linked with a number of cognitive and physical health changes leading to comorbid conditions. The condition is an impairment which cannot be reversed through pharmacological and non-pharmacological interventions. Present practices revolve around behavioral and psychological approaches that aim to address the comprehensive care of patients. Treatment of a dementia patient as a collection of symptoms is not appropriate. Nursing care for dementia has to be responsive to the care needs of the patient and has to be culturally sensitive at the same time. The present scenario focused on implementing physical training exercise as the intervention for addressing the primary health need of the patient which was mobility. The completion of the goals highlighted that person-centered care could be delivered that was sensitive to the needs of the patients. In future, improvements can be brought about in such interventions so that comprehensive client needs could be addressed after a dialectic assessment of the patient.

Biography

Dementia care has the key feature that in addition to physical health status it is elementary to understand the cognitive status and mental health status of the individual. For this purpose the care giver is obliged to understand the life history of the individual prior to commencement of treatment. The understanding of the life history helps in understanding how different life events and societal factors have influenced dementia diagnosis and progression (). Mrs. Jones is a 73 year old lady who lived alone in her two storey apartment after her husband died thirteen years back. The couple has one son and two grandchildren who live in the nearby city, coming to visit her occasionally. She states “I had a fulfilling career as a secretary until I retired a decade back. I so miss my workplace”. She further mentions that she enjoyed her life as she travelled to many places and had a busy social life. What further kept her active was that she had attended services at the local church. “Everyone calls me as a kind and warm hearted person. I am so glad for that”.

Mrs. Jones was diagnosed with dementia five years back. Prior to the diagnosis, she states that she had suffered more than one episode in which she could not find the way to her house and the police had to help her get back home. She had become disoriented and could not differentiate between places due to her condition. Mr. Jones mentions that she thinks her condition has deteriorated in the past ten months. She often misses the appointments made with the doctor. Further, she faces difficulty in remembering her husband’s name and her son’s name.

While conversing, Mrs. Jones lost track of the conversation. This was a sign of the decline in her cognitive ability. At present she is no longer able to carry out the daily activities of life. She needs support with personal care. “I feel so depressed all the time”, she reports. Mrs. Jones is found to be in a low mood and does not show much interest in conversing. She understood that her behavior was not the same as before. Moving further with the conversation it was noted that Mrs. Jones had recently been admitted to the local healthcare unit for urinary tract infection and chest infection. This further increased her lack of orientation and significant level of confusion. Mrs. Jones remembers that she has poor sleeping habits and has disturbed sleep at night. As a result she moves about in the house at night. This increased her risk of suffering injury. She had recently suffered a fall from the stairs and suffered injury to her legs. This has reduced her mobility as she faces difficulty in moving about. She urges to mention that she had not shown any aggressive behavior towards any individual in the recent past. Upon asking about personal interest it was noted that she enjoys reading and knitting. She also likes spending time with her son though he comes to visit infrequently.

References

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