HEALTH ISSUES FOR OLDER ADULTS.
The Case Study
Previous History: Social
The case study chosen is that of a 74 year old male patient with a history of challenging health issues. John (an assumed name in order to protect the patients identity in accordance with the Code of Professional Conduct as per the Nursing & Midwifery Council, 2006) has been happily married for 54 years and does not have any children. He does belong to a large extended family – he has twelve siblings. He has spent his working life as a plumber. He has been a sociable person enjoying the company of friends and family. Before admission to the Dementia ward he was living with his wife in their family home. His wife is finding it increasingly difficult to deal with John’s behaviour and condition as recently he has become significantly cognitively impaired. On admission, John was clean and tidy and it was obvious that his wife takes very good care of him despite the considerable effort that is required by her. During his stay on the ward John did receive regular visitors and his family and friends showed a great deal of affection for him.
Previous History: Medical
On admission it was noted that John has a long history of ill health.
His main conditions are:
Multi-Infarct Dementia: “MID is a common cause of memory loss in the elderly. MID is caused by multiple strokes (disruption of blood flow to the brain). Disruption of blood flow leads to damaged brain tissue.” (NINDS). This was diagnosed three months ago after John exhibited trademark symptoms such as short term memory loss, confusion, shuffling feet. He also started losing bladder and bowel control. MID is usually found within the 60 – 74 year age group, more often in men than women. A MRI scan showed up this condition.
Cardiac Diverticulitis: a rare congenital heart malformation
These conditions cause John great pain and distress. He is currently being administered several pain relieving medications – Morphine, Sevradol, Diclofenic and paracetamol. He also received medication for the hypertension.
John was told 15 months ago that the prognosis for the treatment of his Aortic Aneurysm was not good and it was anticipated that his life expectancy was six months.
The severity of the pain experienced by John results in very aggressive physical and verbal behaviour. This aggression is very difficult for his loved ones to deal with.
He was admitted to the dementia ward for a six week assessment with a view to providing suitable pain relief which could then lessen his challenging behaviour to an extent.
On admission to the ward, John was attended by psychiatric staff who carried out an evaluation on John’s memory. This is known as a Mini Mental State Examination. The MMSE indicates the importance of cognitive stimulation therapy that can be consistently offered to the patient. (Weavers (2007, p.1) (see Appendix 1). The MMSE is a series of questions and tests designed to establish whether a drug treatment would be appropriate. NHS guidelines state that the patient should score 12 points or more out of a maximum of 30 points to be considered for medication. The tests cover orientation to time, registration, naming and reading skills. (Alzheimer’s Society information sheet 436).
John was also assessed in terms of diet and sleep.
The Discomfort Scale-Dementia of the Alzheimers’s Type (DS-DAT) was carried out with John. DS-DAT measures discomfort in elderly patients with dementia who are losing cognitive capacity and communication skills and are increasingly reliant on nursing staff. It was originally conceived to measure discomfort but it can be used to assess pain.
Assessment on John revealed that when he is in pain he is prone to be more aggressive. Staff worked with him to find strategies he could use to alleviate the pain. He received psychological assistance from the Pain Management Specialists. According to research on care of the elderly pain assessment is always an important aspect of what is done to take care of patients with dementia. The pain manifestation in John’s case has been a concern for everyone involved in his care. This is supported by Smith (2005) who says that it is important for healthcare providers to make correct assessment in the treatment of elderly people. There are many deterrents to making correct assessment. The fact that our culture looks at dementia as a disease that is only in the mind and that people with dementia do not experience pain can create a problem because often doctors may not see symptoms as belonging to dementia. Also, as patients begin to lose the ability to understand their internal states, they cannot identify easily “sensations, feelings and experiences” (Smith 2005 p.2). This will also lead to a time when they may not be able to verbalise what they are feeling. When the condition gets to this stage it is important to take care of the comfort needs of the individual. Many healthcare providers assess this by means of a Comfort Checklist. Smith (2005) was able to show professionals that there are several assessment tools that can be used to assess pain levels in patients with dementia.
Kaasalainen (2007) presents another idea of how to assess the pain of patients with dementia by using behaviour observation methods. This literature supports that pain is “underestimated and undertreated” in the older population. Assessment then becomes even more important.
Early pain assessment is important because the patient may start to lose the cognitive ability to let their discomforts be known. A system of behavioural observation would be useful. In order for this to be accurate a system of criteria for behaviour indicators can be set. Some indicators include “rapid blinking and other facial expressions, agitation or aggression, crying or moaning, becoming withdrawn and guarding the body part “
(Kaasalainen, 2007 p.7).
When John starts getting aggressive it can be an indication that he is in pain. “ It is important to find out how patients with dementia communicate about their pain and to determine relevant background information about their pain needs.” McClean (2000) cited in Cunningham (2006) p.5. In order that a full assessment could be made of John and his pain communication and management, he was allocated a nurse to be with him all of the time to achieve an accurate record.
The Discomfort Scale for Patients with Dementia of the Alzheimer’s Type (DS-DAT) previously referred to has been challenged by Kaasalainen (2007). Some of the challenges she stated include:
“ * some of the items measured may be due to other situations and not only dementia.
· the way the tools are scored can be difficult and therefore not easy to use in the clinical setting
· most of the new tools (and other DS-DAT) are in preliminary stages and need more testing
· there is lack of consensus on how pain should be assessed with older adults so verbal reports continue to be used in most situations.
· The concept of discomfort may be due to other facts like infection, hunger, depression or anxiety which means that behavioural observations cannot be the sole basis for giving medication.” (Kaasalainen, 2007 p.8)
Gloth (2001) presented information about pain management in older adults. He stated that it is difficult to make sure that older patients are getting enough medication to manage their pain adequately. Most older patients have at least one chronic condition and take multiple medications which make it harder to tell what they require. For some healthcare providers it becomes more frustrating to make sure the pain is managed properly. Gloth (2001 p.188).
It is important to understand when giving medication that drugs have a different reaction in older adults that they have in younger patients. This must be taken into account when prescribing. When pain is managed well an individual will have ‘secondary gain’ whereby he will feel better and it will help family members stay and visit longer. All of this will help the patient manage his pain. (Gloth 2001 p.189). Gloth (2001) also suggests that clinicians use a variety of methods for pain management including no interventions and alternative therapies where possible.
In the ward the environment is kept as quiet as possible as it is policy not to administer neuroleptic drugs unless really necessary. Pharmacological treatment options are recommended only if behaviour poses an immediate risk to the individual or to others Weaver (2007), McShane et al (1997) cited in Narzarko (2007 p.118) states that researchers have found that people with dementia who are treated with neuroleptic drugs deteriorate more quickly than those who are not treated with such drugs.
Besides having his own individual nursing care, John is offered activities to help him stay as active as possible. It was reported in Jacques et al (2000 p.366) “offering patients the appropriate activity, i.e. Games, exercise, sitting and chatting can reduce boredom and agitation. John responds well to this individual attention and it does have a settling effect. During his working life, John was always working with his hands so he is keen to participate in games and exercise. He does try to engage in social contact with other patients but unfortunately this interaction has not been reciprocated so it has caused him upset and frustration and after a few attempts he now only talks with the nurse caring for him. His physical activity is also hindered by his pain.
John has lost a lot of weight recently so he has been seen regularly by the dietitian who is ensuring that he is eating a healthy nutritional diet. He does have a good appetite.
John’s sleep pattern has been erratic the last several months. “Many people with dementia are restless at night and find it difficult to sleep. Dementia can affect people’s body clocks so that they might get up during the night, get dressed or even go outside. Ensure that the person has enough exercise during the day and that they use the toilet before bed.(Alzheimer’s information sheet 525). John was gently reminded that it was night-time and that he should go back to sleep. A sleep diary was also kept to record the level of restlessness.
There are two types of carers involved in looking after John – those who work within the clinical setting and those family members who must care for a chronically ill family member. The family member is predominately John’s wife.
Rasin and Kautz (2007) carried out a study that focused on caregivers in assisted living facilities. The National Centre for Assisted Living (NCAL) estimates that “42% to 50% of residents in assisted living facilities have dementia and 34% of them exhibit behavioural symptoms of dementia at least once a week.” NCAL (2006) cited in Rasin and Kautz (2007 p.2). They found that caregiver training was different depending on the state in which the individual lived and many were not formally trained to work with dementia patients – instead they received training either on the job or through life experience. The study used focus groups for data collection. Carers said that there were two types of knowledge that caregivers had that were effective in dealing with dementia patients: behavior centred knowledge – knowing recommended approaches to use with specific behavioural symptoms of dementia and person centred knowledge – knowing the residents well enough that they could look beyond the behaviour of the person (Rasin and Kautz. 2007 p.33-34).
They felt that the person centred knowledge was the strongest and most effective in caring for a person with dementia. From this study they made several recommendations for nursing:
· get to know the resident so you can determine what might be causing the disruptive behaviour.
· Giving individualised care for the residents can increase their quality of life.
· Caregivers should be taught how to incorporate patients life stories into their treatment plans to help them understand why the behaviour is being exhibited.
· Caregivers who understand and use person centred knowledge need to be acknowledged (Rasin and Kautz p.36).
A person centred approach was used in John’s treatment. He was encouraged to talk about his past and his wife was able to provide a lot of useful details which allowed John to be seen and treated as a ‘whole person’. It did also allow staff to make sense of some of the behaviour displayed by John.
Hepburn et al (2007) researched another way of effectively educating family members. They looked at a transportable psycho-education program geared towards helping to reduce caregivers stress. Several programs are spotlighted in this article. What they found was that a one to one behaviour management program given by home support team help to reduce the burden on caregivers and help to reduce depression. This program combined education with counselling. With the knowledge given to families, it was possible to delay the hospitalisation of the patient with dementia. (Hepburn et al, p.31-35)
Most caregivers are women, at least partly because it is a role that all women are expected to play in most societies. Doress-Wortens (1994) researched the effects of caregivers’ stress on women who already had multiple roles. They found that the stress in certain types of care giving situations were higher than others – e.g. when the caregiver involved personal care or dealing with a family member with dementia, they tended to experience more stress. A family member who was physically frail and needed minimal help was less stressful. John’s wife stress levels decreased with experience of looking after him – this information was apparent from reading of previous case notes. From this study it was apparent that women handle many different situations and they need coping strategies when they add the care of an ill family member to the set of tasks they perform.
It is important to evaluate John’s care plan with regard to establishing the best possible attention for him. This has been done with reference to the National Institute for Health and Clinical Excellences (2006). According to NICHE (2006) there were 700,000 cases of dementia in the United Kingdom and there are approximately a million caregivers for them. As a result of these figures NICHE provided recommendations for those dealing with patients who have dementia.
NICHE Recommendation 1 : A coordinated and integrated approach between health and social care to treat and care for patients with dementia and carers.
John’s care : John has received the care of a specialist team who are trained to coordinate the day to day assessment and management of his condition. This comprised doctors, nurses, psychiatric team. Each professional provides guidance and support both for John and his family. His wife receives education and assistance with techniques on how to handle his aggression at home. Because she is his main carer at home, she has been given details of support groups where she will be able to get additional advice.
NICHE Recommendation 2 : The needs of carers should be assessed and support should be offered as part of the overall plan.
John’s care : It is important for staff from the dementia ward to offer support and help John’s wife deal with his physical and verbally aggressive behaviour. Caplan, G.A. Et al (2006) states that families need to be given clear information about the disease trajectory , complications of dementia and limited treatment available.
John and his wife have been married for 54 years and have no children. The emotions of the medical prognosis need to be dealt with. Schulz et al (2003) cited in Ouldred and Bryant (2008) has found that the progression of dementia confronts families with difficult decisions and they need to be supported through this difficult period. It is important to receive pre-bereavement counselling which can lead to better adjustment post-bereavement. Bright (2008) researched the quality of elderly care of those who have dementia as they move into end of life situations. He pointed out that palliative care is not as developed for dementia as it is for cancer so levels of care will vary between different geographical regions.
It is difficult for John’s wife to deal with the stress that comes from living with a man she has known for so many years as his life deteriorates. She has been advised where to gain support where needed. Support groups can bring enormous relief and help to deal with some of the challenges of the caring role.
NICHE Recommendation 3 : Memory assessment should be given to all patients with dementia.
John’ care : The Pain Management Team kept close observations using the Abbey Rating Scale and weekly evaluations on John were used to get his pain under control (see attachment 2). Wood (2002) states that the nurse’s role in pain management is vital, therefore, nurses should be fully educated and trained to recognise when patients are in pain.
NICHE Recommendation 4: People with dementia should not be denied services they need because of their age.
John’s care : The dementia ward is staffed by healthcare workers who are trained to work with patients with dementia and there is an understanding of what is required in each situation. This works on the person centred approach. Staff work with John on a regular basis and many get to know him well. The staff can see when he is getting anxious and angry and can intervene as appropriate. As stated by Fitzpatrick and Roberts (2004) healthcare professionals caring for older people require a range of core skills and knowledge, with explicit attention to the principles of patient and family-centred care, promoting autonomy, dignity and respect, along with good communication skills.
In conclusion, there has been a positive outcome after John’s assessment on the dementia ward. Aggressive outbursts are less frequent and this makes a better quality of time for John with his wife, family and friends. He still tries hard to be independent.
Alzheimer’s Society Information sheet 436, 525. Available to download from:
Bright, L. (2005). Palliative care for people with dementia. Management Matters Available to download from
http://. [28 March2008}
Bephage, G. (2005). Quality sleep in older people: the nursing care role. British Journal of Nursing. Vol. 14 (4) pp.205-210
Bephage, G. (2007). Care approaches to sleeplessness & dementia. Nursing & Residential Care. Vol. 9 (12) pp. 571-573.
Caplan, G.A., Meller, A., Squires, B., Chan, S., Willet, W. (2006). Advance care planning and hospital in the nursing home. Age Ageing. Vol. 35 (6) pp. 581-585.
Chambers, M. & Conner, S.L. (2002). User-friendly technology to help family carers cope. Journal of Advanced Nursing. Vol. 40 (5) pp. 568-577.
Cook, A.K., Niven, C.A., Downs, M.G. (1999). Assessing the pain of people with cognitive impairment. International Journal of Geriatric Psychiatry. Vol. 14 (6) pp.421-425.
Cunningham, C. (2006). Managing pain in patients with dementia in hospital. Nursing Standard. Vol. 20 (46) pp.54-59
Doress-Wortes, P.B. (1994). Adding elder care to women’s multiple roles: a critical review of the caregiver stress and multiple roles literatures. Journal of Research. Vol. 31. pp.1-6.
Fitzpatrick, J.M. & Roberts, J.D. (2004). Challenges for care homes: Education and training of healthcare assistants. British Journal of Nursing. Vol. 13 (21) pp.1258-1260
Gloth, F.M. (2001). Pain management in older adults: prevention and treatment. Journal of the American Geriatric Society. Vol. 49 (2) pp.188-199.
Jaques, A. Jackson, G.A. (2000) Understanding Dementia 3rd ed Churchill, Livingstone, London. pp.235-269, p. 336
Hepburn, K. Lewis, M. Tomatore, J. Sherman, C.W. & Bremner, K.L. (2007). The savvy caregivers program: The demonstrated effectiveness of a transportable dementia caregiver psycho education program. Journal of Gerontological Nursing.(2007)
Vol. 33 pp. 30-37.
Kaasalainen, S. (2007) Pain assessment in older adults with dementia: Using behavioural observation methods in clinical practice.Journal of gerontological Nursing Vol. 33 (6) pp. 6-10
Lewis, M.M. & Trzinski,A. (2006). Counselling older adults with dementia who are dealing with death: Innovative interventions for practitioners. Death Studies. Vol .30 (8)npp. 777-787
National Institute for health and Clinical Excellence (NHS) and Social Care Institute for Excellent (SCIE) (2006) NICE SCIE guidelines to improve care of people with dementia. Available to download from http://www.nice.org.uk/nice/media/pdf/2006-052 [Assessed 13/03/08]
National Institute of Neurological Disorders and Stroke NINDS Multi-Infarct Dementia Information Page. Available to download from http:/wwwninds.nih.gov/disorders
Nazarko, L. (2007). Behaviour that challenges: types and treatment. British Journal Of Healthcare Assistants. Vol. 1 (3) pp116-119
Ouldred, E. & Bryant, C. (2008). Dementia Care. Part 3: end-of-life care for people with advanced dementia. British Journal of Nursing. Vol. 17 (5) pp. 308-314
Rasin,J & Kautz, D. (2007). Knowing the resident with dementia: Perspectives of assisted living facility caregivers. Journal of Gerontological Nursing. Vol. 33 (9) pp.30-36.
SA Carers. (2005). Understanding the role of the family carers in healthcare. Available to download from http://www.carers-sa.asn.au/pdf_files. [Assessed 15/03/08]
Scottish Intercollegiate Guidelines Network (2006)Guideline 86: Management of Patients With Dementia. Edinburgh, SIGN.
Smith, M. (2005). Pain assessment in nonverbal older adults with advanced dementia.Perspectives in Psychiatric Care. Vol 41 Available to download from http://www.questia.com
Stokes, G. (2000). Challenging Behaviour In Dementia. A Person Centred Approach. Oxon Winslow-press Ltd. pp.206
Weaver, D. (2007). Behavioural Changes: Dementia & Its interventions. Nursing & Residential Care. Vol. 9 (8) pp. 375-377
Woods, S. (20020. Nursing care & implications for nursing. Nursing Times. Vol. 98 (40) pp. 39-42
Abbey, J. (2004).The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. International Journal of Palliative Nursing. Vol.10 (1) pp6-13
DeWaters, T. & Popovich, J. (2003). An evaluation of clinical tools to measure pain in older people with cognitive impairment. British Journal of Community Nursing. Vol. 8 (5) pp226-234
Dingwall, L. (2007). Medication issues for nursing older people (part 1). Nursing Older People. Vol. 19 (1) pp25-35
Evers, C. (2008). Positive dementia care: taking perspective. Nursing & Residential Care. Vol. 10 (4) pp184-187
Hobson, P. (2008). Understanding dementia: developing person-centred communication. British Journal of Healthcare Assistants. Vol. 2 (4) pp162-164
Kirkwood, T. Dementia Reconsidered: A person comes first. (2004). Open University Press U.K.