The aim of this patient case study is to discuss the care and nursing interventions that an older person with dementia received in his home within the community during placement. There will be discussions focusing on normal ageing process, taking into account the relevant biological, sociological and physiological perspectives and the impact this had on this individual’s life experience. The relevant epidemiology and aetiology factors will be examined and the social and kinship support networks will be identified, how they work together to provide individual holistic patient care, and finally the impact of current legislation on the overall care provided will be analysed. The learning experience and actions that I will take in order to ensure my continued professional development and learning will be discussed, followed by the conclusion. The rationale for this is to demonstrate an understanding of the theoretical and practical links in caring for individuals with this condition in the community Confidentiality is maintained in conjunction with NMC (2010). Thus a pseudonym (Scot) is adopted where the client’s name is mentioned. Scot was chosen for the purpose of this case study because his strength of character was admired and a good relationship was established. . The patient’s permission was obtained after an explanation of the purpose and proposed content of the case study, with a CPN present.
Scot is a 67 year old man with a long term history of psychosis. Recently he had been diagnosed with Alzheimer’s disease, a type of dementia which affects the brain cells and brain nerve transmitters, which carry instructions around the brain. Scot is also a non-insulin dependent diabetic and has hypertension, both of which are controlled by oral medication and had been non-compliant of late. Due to the decline of his mental state, he has been refusing access to his main carer (his wife) and was at risk of self-neglect. His aggressive outbursts follow an unpredictable pattern where his mood could change from pleasant and content to a highly agitated in a short pace of time. More recently, he has been observed to become low in mood and isolate himself. In particular, Scot’s aggressive behaviour could put others at risk of harm, or Scot could put himself at risk of retaliation from others. He has become lost and disoriented, even within the relatively small confines of the family home. Scot and his wife had been married for over 40 years. Initially his wife managed well, but as time went by and the dementia worsened, she found it increasingly difficult to look after her husband, do her household chores and have any life for herself. She could not leave him alone while she shopped, and it was too difficult to take him along. Eventually the stress, the low morale and the frustration of caring for Scot began to toil on her (Hoe et al 2009). What seemed to have been the last straw for Scot’s wife was when he started squatting in corners and urinating on the floor. Scot began to progressively have less interest inside and outside home, which is highlighted by intellectual, emotional and memory disturbances of dementia (Dexter et al, (1999). The deterioration again led him to becoming absent- minded, forgetting appointments, forgetting about his meals and forgetting things he has left in the house. It further progressed to extreme situations where he would recall past events of his youthful days but not about the recent events. He would also get up in the middle of the night wandering around the house, which resulted in many falls and injuries to him. This major memory disturbance resulted in manifestation of confusion affecting his daily structure and routine of life.
He had been well managed on Quetiapine until he had stopped taking the medication and his psychosis had worsened. Quetiapine is an oral antipsychotic drug used for treating schizophrenia and similar disorders. Like other anti-psychotics, it inhibits communication between nerves of the brain. Frequent adverse effects include headache, agitation, dizziness, drowsiness, weight gain and stomach upset (Ballard et al 2005). There is an interaction between Scot’s medication and his behaviour which requires a more skilled professional being required to administer medication.
Dementia as a disorder, is manifested by multiple cognitive defects, such as impaired memory, aphasia, apraxia and a disturbance in occupational or social functioning Howcroft (2004). Thus disturbances in executive functioning are seen in the loss of the ability to think abstractly, having difficulty performing tasks and the avoidance of situations, which involves processing information. The brain shrinks as gaps develop in the temporal lobe and hippocampus. The ability to speak, remember and make decisions is interrupted (ADS, 2011).
Seven (7) years ago, he had a mild stroke. He has fractured both of his wrists and has no sensation of the heat or cold on his hands but can move and use his fingers perfectly fine.
Scot was referred to the CMHT on the 03 May 2011 by his General Practitioner (GP) with severe cognitive impairments due to Alzheimer’s disease for further assessment and treatment, as concerns have been raised about his vulnerability to exploitation by others.
The Health of the Nation (DOH, 1991), Our Healthier Nation (DOH, 1998), and more recently, Living Well with Dementia (DOH, 2009) use information from the public health domain to look at trends and set targets for improvement. It aims to secure continuing improvement in the general health of the population by adding years to life and life to years.
Overall, about 5% of the population over 65 has dementia, and the prevalence increases markedly with age (PSSRU 2007, ADL 2011)(Appendix 1).
A new ‘dementia map’ of the UK shows stark variations in the number of people suffering from the disease and those who have actually received a medical diagnosis (Appendix 1). Dementia Care Mapping (DCM), an observation tool designed at Bradford University, is a process internationally recognised for promoting a holistic approach to improving life for each individual because it evaluates the quality of the care being provided from the perspective of the person with dementia (BBC 2011)
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These prevalence rates have been applied to Office of National Statistics (ONS) population projections of the 65 and over population to give estimated numbers of people predicted to have dementia to 2025. The number of people with dementia nationally is forecast to increase by 38% over the next 15 years and 154% over the next 45 years. The estimates for early-onset dementia (onset before the age of 65 years) are comparatively small but, according to national statistics, are significantly under reported. Dementia is a major cause of disability in older people. According to the 2003 World Health Report Global Burden of Disease estimates, dementia contributed 11.2% of all years lived with disability among people aged 60 and over; more than: Stroke (9.5%), musculoskeletal disorders (8.9%).Cardiovascular disease (5.0%) and all forms of cancer (2.4%). Dementia costs the health and social care economy more than cancer, heart disease and stroke combined. Fewer than half of older people with dementia ever receive a diagnosis (DOH, 2009).
A health needs assessment was carried out using my placement tool called CAREBASE and Observation. Assessment is a systematic process that aims to provide a framework for the collection of information relevant for the client’s health experience, engage the client in a therapeutic relationship, and identify appropriate care, interventions and services (Thompson and Mathias, 2002). Psychiatric assessment therefore is the attempts to attribute a person’s suffering to an underlying illness and thereby identify appropriate treatment (Barker, 2004). Scot’s assessment took a form of an assessment interview in consultation with his wife and children. The areas which were assessed included a clear description of his current symptoms; a detail and precise description of the problems that he is experiencing and a description of his social, occupational and domestic circumstances. Some other areas of importance were the support available and level of dependence as well as a comprehensive risk assessment. These enabled me to elicit important information for a good clinical judgement (Guthrie and Lewis, 2007).
A relaxed environment was facilitated in Scot’s home. Open questions were asked to gather as much information as possible to build a holistic picture of Scot, his needs and his community. I then transferred the details onto the University Tool as its contents met my expected learning outcomes.
The model chosen to assess Scot’s needs was an adaptation of Roper Logan Tierney (RLT) model (1983) and the actual and potential problems based on the 12 activities of living were highlighted. This model was chosen as Walsh (1998) suggests it is trying to promote maximum independence and meet Scot’s needs. Haggart (1994) suggests the Neuman’s systems model seeks to involve patients in their health care and focuses on prevention. This is congruent with the needs of community nursing.
Scot’s baseline observations on assessment were: temperature: 37.4 degrees Celsius, her pulse was 105 beats per minute and her blood pressure was 145 millimetres mercury systolic and 90 millimetres mercury diastolic. Scot’s Body Mass Index (BMI) was calculated and he scored 26, which classified him as being overweight. The lifespan of an obese person is 9 years less than someone of lower weight (Netdoctor, 2004). Obesity causes raised blood pressure and raised cholesterol levels which lead to CHD and stroke. It also fosters inactivity and generally involves an unhealthy diet which together contributes to cancer, diabetes, gall bladder disease, arthritis and musculoskeletal problems (NAO 2001).
Because Scot has a chronic illness such as diabetes and is overweight these factors contribute to delay in healing. King (2001) suggests people with diabetes experience more wound healing problems. However, this does not affect Scot as he had no wounds. A recent study by Brown et al (2004) indicates that majority of people who are obese have some form of skin problems. In Scot’s case dryness, broken skin, red patches and itchiness were identified.
A moving and handling assessment derived by Pilling (1993) score of 5 was obtained for Scot due to his body weight being above 17 stones. Scot is fully mobile and therefore no equipment was needed. Pilling and Frank (1994) report that this is a tool and should not be substituted for professional judgement or knowledge of correct handling techniques. With regards to sleep, it was identified that he has unstructured and lesser sleep patterns which is a contributing factor to his restless and agitations during the day. He also has difficulty in hearing.
Furthermore, assessment of other age related physiological and psychological degeneration of vision, auditory, speech, impaired cognition etc. are essential for baseline assessment and understanding the effects of physical and mental capabilities of an older person.
All identified needs of Scot, which were highlighted as personal hygiene, nutritional intake, safe environment and sleeping (Roper et al, 1996). , were integrated into his care plan approach and the appropriate interventions were taken. The care plan was for Scot to be given one to one counselling sessions each day and encouraged to discuss topics related to reality such as current affairs, his family, home life or social life. The rationale for this action is supported by Schultz and Videbeck (2002), who assert that familiarity with, and trust in staff members can decrease a client’s fears and suspicions, leading to decreases anxiety. Discussing familiar topics also stimulates patients to maintain contact with the real world and their place in it (Stuart and Laraia, 1998). He is to be monitored on his medication and mental state in order for him to maintain optimum level of physical and mental wellbeing. This was to include exercise, social group activities and a good balance of fluid and food intake. He was also to be encouraged and engage in social activities during the day to help him have adequate sleep during the night. It was also included that Scot should be on primary observation to ensure his safety.
Scot’s family are his main carers. His daughters visit him regularly. Twigg (1994) suggests that the largest provider of care services in the community is the army of family, friends and neighbours who are reported to number over six million people.
The National Strategy for Carers (1990) defines an informal carer as ‘someone providing care without payment for a relative or friend who is disabled, sick, vulnerable or frail’ (Cooper et al, 2008).
Fitting et al (1986) found that women more often feel obliged to give care than men and have more difficulty in coping with the dependency of their dementing relative.
Following Scot’s initial assessment, certain problems were identified and her care plan was initiated. Scot’s identified problems were nutrition, safety, sleep, pain, medication and dying. The agreed goal for Scot’s problem of nutrition was to ensure adequate dietary and fluid intake and this was to be achieved by referring Scot to the dietician and offering Scot small, appetising meals and monitor dietary intake. Nutritional assessment according to Harris and Bond (2002) should be integrated with the overall nursing assessment and the plan of care and implemented and evaluated and involves identifying and evaluating patient’s nutritional status using assessable techniques to quantify any impairment or risk, such as food record charts and risk assessment scores.
The degree of Scot’s safety was assessed due to his potential risk of falling and causing harm to himself. To promote safe environment for Scot, all potential hazardous objects were removed, and that familiar objects including pictures, calendars, activity sheets were rather put in place to orientate him to his surroundings. To reinforce this, he was discussed with what was happening around him. All interaction with Scot also involved communicating clearly about one topic at a time so that he is not confused with excessive information (Holden et al, 1982). He was given hearing aid equipment, which was constantly checked for proper functioning. This was emphasised with effective verbal and non-verbal communication. During these times it was imperative to use tone of voice which was conductive to his hearing, appropriateness of touch, good eye contact, gestures and allowing Scot to express his fears and desires, all in an atmosphere of acceptance and reassurance. This was to build a rapport and maintain a trusting therapeutic relationship with him (Egan 2002).
To reduce some of the night time disturbances, Scot was involved in a sleep hygiene programme which included maintaining regular times for rising and going to bed, avoiding stimulants such as alcohol and tobacco and using the bedroom only for sleep. Taking him for a walk, attending OT sessions and other social group activity also increased his daytime activity. Relaxation and breathing exercises was part of the caring process for Scot, which were intended to give him mastery over his symptoms especially when he became anxious or unable to sleep. And although there seemed to be no significant process being made by Scot on the breathing exercise, the programme continued to be reassessed and reviewed.
His care programme also took into account some of the normal ageing process associated with old age such as the presence of pathology affecting the overall functioning of the individual. For instance, during Scots assessment for nutritional intake it was important to take into account the fact that many older people have a reduced food intake as result of being less active and reduced lean body mass which leads to a low intake of nutrients such as vitamins and minerals (Norman, et al 1997).
A further factor considered was that of the medication which when used to treat certain conditions can in fact cause depression, which is brought on by the toxicity of the drugs. ‘The elderly are more prone to toxicity because of their impaired absorption, metabolism, and excretion of drugs’ (Cosgray and Hanna, 1993). It was imperative to note that the older person tend to take medication errors such as omission of doses and incorrect dosage when they are self-administering a drug and many elderly people tend to take a number of different drugs for different ailments which causes further confusion. Thus all non-prescription medications such as bottles, out of date prescription items were also removed from the reach of Scot. This was to prevent Scot having access to potentially dangerous medication and inadvertently taking them incorrectly. Until his condition improved, his medication was given to staff in the community.
Scot constantly brought up the issue of dying during every one to one session with him. Although he did not want to end his present condition by committing suicide, he accepted death as an invertible end, which he anticipates will inevitably come soon for him (Sampson et al 2011, Samson 2010). His main concern was to be able to work and spend time in his garden again before he died. However, he did have the tendency to be rather depressed of what he saw as not doing much in his prime days to fulfil his ambitions. This sometimes brought on a sense of guilt and sadness to Scot.
The National Service Framework for older people (DoH, 2001) emphasised the need to support carers in their role. Scot’s wife was therefore educated about how to handle the decline capabilities of her husband including how to provide safe environment for Scot and help him with respite programmes that will give her a break from her care-giving responsibilities. Scot’s wife also received education and information about how and why her husband behaves in his condition and how she can reduce the feelings of anxiety, tension and loss of control that has resulted from the impact of Scots deterioration.
From this study, I learnt that, assessing the health needs of patients like Scot can be beneficial to him and his family. By conducting a thorough assessment and involving patient participation, a satisfactory package of care was made available to meet Scot’s health needs. Furthermore, I learnt patients can be fully aware of all the services that are available and the capacity of making choices at the time of assessment
The NHS plan (2000) was a modernisation strategy where 19 billion pounds was invested for a ten-year plan 2000-2010. It introduced the National Service Frameworks (NSF), which set national standards and identify key interventions for a defined service or care group, put in place strategies to support implementation and established ways to ensure progress within an agreed time scale. The plan was developed to shift the balance of power from ‘top down’ to ‘bottom up’ and involve patient participation.
The impact of the policy related directly to patient care and all patients including Scot are entitled to a basic package of care by being a member of a PCT. Scot benefits from an enhanced package of care, as the NSF for older people (2001) and NSF for diabetes (1999) is available. Local community facilities such as a bowling club and voluntary services such as Alzheimer’s Society and Age Concern are also used by Scot. By the end of my placement, evaluations showed that although there have not been significant changes in Scot’s mental and physical state, it is also imperative to note that he has been supported and maintained well to carry some of the daily activities of living. Whilst Scot’s care plan continued to be reviewed, there is also an on-going support and educational programmes for his wife, which will enable her to effectively care for Scot. I have understood that whenever I undertake care, I must take a holistic view of the person’s physiological, psychological and social circumstance in order to provide effective and continuous care. The model of care used on the (activities of living) worked fairly well for Scot. However, I do not feel it is a holistic model of care and focuses largely on the biomedical model of health.
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