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For the purpose of this assignment the author will provide an example of a patient; referring to her as Mrs. A, as the NMC states that we must respect peoples right to confidentiality (Nursing and Midwifery council 2008). Mrs. A is an elderly patient who has recently received a diagnosis of vascular dementia.
Mrs. A is a 65 year old lady that lives with her 68 year old sister. Mrs. A is a widow and has no parents or children of her own, leaving her sister as her only immediate family. Over the last 30 years, Mrs. A co-owns and works in a successful card shop in town with her sister. Ever since she was diagnosed with vascular dementia 3 months ago, Mrs. A begun noticing that her memory was deteriorating and she was beginning to lose interest in activities she had once loved. Because of this, she cut down her hours at the shop from 5 days a week to 6 hours split over 2 days. Mrs A found this particularly difficult as she had worked in that shop for over 30 years. Mrs A was previously a very independent woman and took pride in her independence. Previous to her diagnosis, Mrs. A had a good social life, with friends and colleagues a major focus in her life, but due to her deteriorating memory and mood swings, Mrs. A has found maintaining these fundamental relationships more and more difficult. Mrs. A was referred to a district nurse after her sister brought her into their GP surgery following a first-degree burn to her hand. Mrs. A’s medical history included a long history of hypertension due to 20+ years of being a heavy smoker and one previous Transient ischaemic attacks (TIAs’). Prior to her visit to the GP, Mrs. A had been receiving minimal support regarding her vascular dementia diagnosis as it was considered to be in the “early stages”.
Dementia is the term used to define a number of symptoms that alter the way the brain functions. These symptoms include, memory loss, problems with communication, compromised reasoning and difficulties with performing day-to-day activities. Dementia affects the way somebody’s mind works, therefore resulting in behaviour which can hinder their ability to live independently and can also affect social relationships (Martin 2006).
Dementia is one of the most common neurological conditions among the elderly in the western world. It is estimated that in the UK alone, there are 820,000 people living with a diagnosis of dementia, with the average age of onset being over the age of 65years. However, it can also develop in younger people where it is known as young – onset dementia (Alzheimer’s Research Trust, 2010).
The type of dementia that will be discussed in this assignment is vascular dementia. Researchers have found that vascular dementia is the second most common form of dementia after Alzheimer’s disease, accounting for 20 to 30 per cent of cases. Vascular dementia is defined as a “disease with a cognitive impairment resulting from cerebrovascular disease and ischemic or haemorrhagic brain injury” (Nazarko 2011). According to the Department of Health (2009), vascular dementia is the term used to describe a number of symptoms that lead to a progressive decline in cognitive and memory function.
The brain requires a sufficient amount of blood in order for it to function properly (Beart 2007). Vascular dementia develops when the blood supply that transports oxygen and nutrients to the brain is “damaged by a blocked or diseased vascular system” (Salma 2008). This damage happens when cells die due to the fact that the blood no longer has the ability to reach the brain cells proficiently. If there is an interference of the blood supply to the brain, for even the shortest period of time, the distinctive functioning of the cortex – (which is the site in the brain responsible for language, memory and learning) will be impaired. (Thomas 2001). The effects and the speed of progression in vascular dementia vary from one individual to the next. Usually, symptoms associated with vascular dementia begin suddenly, for example after a stroke. Vascular dementia is dissimilar to other forms of dementia due to the fact that it “often follows a stepped progression”, with symptoms remaining the same for a certain period of time and then gradually getting worse (Ouldred 2010). According to Stacpole (2011), the following symptoms are typically linked to vascular dementia: visual mistakes and misperceptions, seizure, periods of acute confusion, problems with continence and psychological symptoms such as apathy. A number of medical professionals prefer the term “vascular cognitive impairment (VCI)” to vascular dementia because it is more precise in explaining the fact that vascular thinking changes can range from mild to severe. (Bamford 2010) .
The two main types of vascular dementia are multi-infarct dementia and subcortical dementia. Subcortical VaD occurs due to small vessel disease “causing lesions in the deep white matter of the brain and where the cortex of the brain is usually well preserved”. Multi-infarct dementia (MID) is the most common type of vascular dementia. MID is caused by a series of “mini-strokes” – also known as Transient Ischaemic attacks (TIA’s). (McKeith 2005).
TIA’s are known to occur when the blood flow to a particular part of the brain stops for a brief period of time. Transient ischaemic attacks are caused by a temporary loss of blood flow (ischemia) to the brain as well as momentary impairments of consciousness or sight; TIAs share the same underlying aetiology as strokes: a disruption of cerebral blood flow but without actually causing any acute tissue death like that found in a stroke. (Bamford et al. 2004).
A single transient attack or stroke episode does not necessarily mean the individual will go on to develop vascular dementia. However, if the individual has or has had more than one stroke, transient ischemic attack, or has been diagnosed with small vessel disease, then they may have an increased risk of developing vascular dementia. (Bryans et al 2003).
Risk factors of vascular dementia may include hypertension, atrial fibrillation, hypercholesterolemia, smoking and diabetes (Jolley 2009).
Although vascular dementia is one of the most common neurological conditions among the elderly in the western world, the exact cause still remains unclear. Vascular dementia is a disorder that cannot be reversed, the progression of the disorder, can however be slowed. Using drugs, along with lifestyle changes to prevent more strokes from occurring, can be an effective way of slowing the progression of vascular dementia. (Knapp and Prince; 2007).
The symptoms of vascular dementia are individual to each person, thus highlighting the necessity for holistic nursing assessment, care and management. These symptoms can vary from; loss of memory; poor judgment and reasoning; apathy, confusion and mood disturbances. (Judd et al; 2004).
There are major impacts on the person due to vascular dementia; because vascular dementia cannot be cured, it is considered a long-term neurological condition in which the person and family have to come to terms with the initial diagnosis, which can be devastating. Living with a long-term condition has a significant impact on a person’s quality of life and poses particular challenges for the individuals’ family members and health-care providers. (Carers UK 2007).
With regards to Mrs. A, the district nurse that took over her care found that the diagnosis of vascular dementia had caused her to feel as though she had no sense of self-worth, her self-identity had been taken away from her and from here on out there would need to be major lifestyle changes that Mrs. A, her sister and friends would need to adhere to. Therefore in order for Mrs. A to achieve levels of recovery; and to live well in the presence or absence of her symptoms; the nurse had to provide a major supportive role in the care of the lady with vascular dementia throughout this process to optimise her and her families’ quality of life. (Keady 2004).
Dementia is a life changing diagnosis, and the person and family should be supported as holistically as possible by the nurse and healthcare providers at the time of diagnosis. (Barber and Murphy 2011 ). Mrs. As’ sister and close friends found it very difficult to accept this life changing diagnosis especially in regards to her sister, as it proved to cause significant changes in their relationship; research shows the role of “informal carer” is rarely chosen, but thrust upon family members such as Mrs. A’s sister as a consequence of incapacitating illness. (NICE 2006). However due to the bond between the two sisters, they managed to adapt with the support of the nurse and the healthcare team, and eventually came to terms with the altered circumstances. This lady and her family were supported in this transition by a referral to relevant agencies for counselling and other suitable support services.
This was useful for Mrs. A’s sister as she was not experienced in regular caring duties, and was used to her sister being a strong independent and self-reliant woman. The nurse in charge of Mrs. A’s care recognised this and saw that the sister required guidance and education to provide this care, which in turn assisted in reducing any stressors for Mrs. A and her sister, as well as a care of package being put in place for Mrs. A. (Nain 2006). If they both had not been supported at an early stage, and not been provided with the access to information and support, there could have been consequences of ill health, and stress for Mrs. A’s sister, as well as generating more ill health for Mrs. A herself (Pews 2005).
The nurse also made a referral to local support groups so that Mrs. A’s sister could have other people who were going through the same feelings and changes in their lives to talk to. These groups aim to support people living with dementia and those who care for them. By referring her to these support groups, the nurse aided in helping Mrs. A’s sister to maintain some form of independence and time away from her caring duties , as recent research shows that family members tend to neglect their own social life and health, once they become carers (Beart 2008). The nurse worked closely and monitored the lady with vascular dementia, and her family to provide a support network, and treat them holistically, thus encouraging an optimum environment for the acceptance of the diagnosis (Roy and Gillespie 2011).
There were also financial implications on the family, because of loss of earnings due to changes in the Mrs. A’s health. Her sister had to reduce her hours working in their shop dramatically, in order to become a part-time carer. The nurse was supportive, as this had a major impact on the family as the sister begun to have bouts of anxiety and stress within this period of change. The nurse assisted in these matters by referring them to the social work department for advice and guidance on welfare benefits and financial matters; this was a great relief for the two sisters and reduced the amount of financial pressure brought by the dementia diagnosis (Manthorpe and Iliffe 2007).
Mrs. A was given a clear and concise explanation of vascular dementia, enabling her to preserve some independence and empower her to make informed decisions concerning her care, where possible. By providing her with access to relevant information, both at the time of diagnosis and throughout the course of the disease, Mrs. A and her family (/friends) felt as though they were understood and valued, this in turn significantly improved the quality of life for Mrs. A, throughout providing her choices regarding her own care (Pinner and Bouman, 2003).
In order to provide Mrs. A with optimum care the nurse observed that providing continuity of care would be of great benefit to her. Continuity of care provides a patient with a level of trust and understanding, as well as reduction of medical errors and negligence (Freemon et al; 2003). Mrs. A found that, having different nurses/ carers and other health care professionals coming in and out extremely distressing, in the community setting. Seeing the same doctor, nurse or carer on each visit can increase patient satisfaction, but however in reality in any clinical practice or area, any nurse or healthcare practitioner will find that this may not be feasible at all times and prove to be very challenging. This may be due to a number of reasons such as staffing levels, sickness or holidays (Hope 2009). The nurse in charge of Mrs. A’s care assisted in the continuity of care to the best of her ability, by effective case management of the lady and delegating the caseload effectively, and optimum communication with the nurses, social work and family (Benison 2009).
Once the nurse had overcome the challenges of diagnosis and continuity of Mrs. A’s care, the nurse begun to notice that at each visit Mrs. A seemed uninterested in anything that was being said or that was happening around her. When the nurse had raised these concerns to her sister and received confirmation that in-fact Mrs. A had lost interest in most things over the last few weeks; the nurse observed this symptom as apathy in vascular dementia.
Some of the ways that the nurse treated apathy in vascular dementia was to actively involve Mrs.A, her family, and carers in the treatment process; this helped to lessen the misconception of lack of interest in any activities proposed to Mrs. A. The nurse also made the decision to educate Mrs. A’s family and carer’s about apathy; this helped them understand that apathy is not just “laziness” s or Mrs. A being difficult, but that the symptom was in fact a part of vascular dementia (Levy et al; 1998). The nurse also ensured that other factors that would influence apathy such as; pain, insufficient sleep, disrupted sleep patterns, and fatigue were managed effectively through the use of appropriate medication and/or therapy. (Braine 2010).
In conclusion, this essay has provided an insight into the aetiology and pathophysiology of vascular dementia, and has defined the two main types of vascular dementia, as well as explaining how vascular dementia is a neurodegenerative diseases that unlike most forms of dementia, follows a stepped progression, with symptoms remaining the same for a certain period of time and then gradually deteriorating. This essay also shows that vascular dementia, can be a devastating and overwhelming experience, to the individual and their family, and how it impacts the quality of life for the family, and not just the individual with vascular dementia. Examples on what type of implications having a “carer” role thrust upon a family member, has on the family member’s self-worth and self-identity are also discussed by the author. This essay highlights the importance of caring and supporting the family, and not just the individual, as a whole, and explains how this can be an incessant challenge.
One recommendation for future nursing practice is for all dementia training/ education to be implicated universally; this training should not be limited to solely mental health nurses as dementia is becoming more prevalent in the western world. This education/ training should convey an emphasis on the importance for the nurse to have tangible interpersonal skills, constantly incorporating compassion during challenging times such as; throughout diagnosis, providing continuity of care and throughout the numerous signs and symptoms vascular dementia presents. The nurse should promote patient and family empowerment and act as an advocate for them both as the NMC code (2009) states that nurses have a great responsibility and a duty of care; In the course of learning all the above skills, nurses should be taught that providing care to an individual with dementia is very different from giving personal care to an elderly person who has all their cognition and understands what you are trying to say or do. The intersection of dementia makes even the simplest task a challenge. Dementia care is not just “personal/social care” only; or attending to hygiene and feeding requirements. Because in reality it is not comfort but growth that makes life worth living and people with dementia have the ability to grow too, given the right care and conditions. Therefore, one of the main focuses in dementia care should be to promote an enhanced quality of life for the individual with dementia.
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