Previous Medical and Social History
The case study I’ve chosen is a 74 year old male with a history of health challenges. He will be known as John (a pseudonym) to protect the patient’s confidentiality in accordance with the Code of Professional Conduct (Nursing & Midwifery Council 2006). Prior to his admission to the Dementia Unit he worked as a plumber all his working life. He has been happily married for 54 years and does not have any children. He has enjoyed socializing with his friends and his 12 brothers and sisters. “John” has a history of ill health. He has Hypertension, Cardiac, Divaticulitise, Graphs Aortic Anuryseum, and a more recently diagnosis of Multi-Infarc Dementia. He is currently on several medications for these medical conditions current pain relief is Morphine, Sevradol, Diclofenic and Paracetamol for pain alone.
John was told 15 months ago that he was going to die within six months due to an Aortic Anuryseum. When he is in pain, he can become verbally and physically aggressive and this is difficult for people around him, his anger may be due to chronic pain. He continued to live at home but because he has become physically and verbally aggressive, it is difficult for his wife to keep him at home. Stokes (2000) states that carers often describe the difficulties they experience in coping with people who behave aggressively. This is understandable, for to be the victim of a physical attack or verbal abuse is distressing
John came to our ward for a six week assessment for his challenging behaviour. His anger may be due to chronic pain. In addition to enduring physical pain needlessly, patients with dementia can have challenging behaviours that are directly related to lack of pain management. (Cook et al 1999). The assessment informed staff that John remains independent with support from staff. He has a good diet but has a poor sleep pattern. Hoffman (2003) cited in Bephage (2005 p 2005) stated that underlying pathology of the disease such as dementia is commonly associated with poor sleep quality. On admission to the ward John was seen by the psychiatrists who carried out an evaluation on John’s memory known as a Mini Mental State Examination. This M.M.S.E. will indicates the importance of cognitive stimulation therapy that can be offered consistently to the patient. Weavers (2007, p.1). (see appendix 1).
The assessment that John received revealed that when he is in pain he is prone to be more aggressive. Staff worked with him to find strategies he could use with the pain. He received psychological assistance from Pain Management Specialists. He has been referred to the dietician to help with massive weight loss.
In the Unit we try to keep things quiet as we do not administer neuroleptic drugs not 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 p118) 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.
John receives 1:1 nursing care when he is feeling anxious and agitated. We also offer
activities tailored to the individual to help them stay as active as possible. As reported in Jacques et al (2000, p. 366). Offering patients the appropriate activity, i.e. games, exercise, sitting chatting. can often reduce boredom and agitation.
In looking at John’s case it was important to look at literature based on several areas of his care in order to make an evaluation of what we are doing as to it’s relevance and needs for the older patient.
This Case Study is broken into sections to help explain the various issues that John deals with daily and how staff and family caregivers are working to keep him independent.
According to the studies around elderly care, especially for adults older than 65 years, John is receiving the type of treatments necessary on every level. With older adults pain assessment is always an important aspect of what is done to take care of patients with dementia. John’s acting out has been a concern for everyone involved in his care. This is understandable and it is a condition of dementia. This is supported by the literature. Smith (2005) says that it is important for healthcare providers to make correct assessment of the treatment for elderly people. Deterrents to making correct assessment are many.
The fact that our culture looks at dementia as a disease that is only in the mind and that people with dementia don’t experience pain can create a problem because often doctors may not see symptoms as belonging to dementia. Also, as patients begin to loose the ability to understand their internal states, they can’t identify easily “sensations, feelings and experiences” (Smith 2005 p.2 ). This will also lead to a time when they may not be able to verbalize what they are feeling.
When these kinds of things happen it is important to take care of the comfort needs of the patient. To assess this, many healthcare providers are using The Comfort Checklist. This check list creates a way to see dementia easier (Smith 2005 p.4 ). The points of Smiths article was to show healthcare providers 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 for patients with dementia or people living with dementia by using behaviour observation methods. This literature supports that pain is “under estimated and under treated” in the older population. Assessment then becomes even more important.
Pain assessment is important in the beginning of dementia because later the individual may loose speech and be unable to let their discomforts be known. The challenge is that many dementia patients are unable to accurately describe pain (Kaasalainen,
- p.7) and therefore a system of behavioural observation can be helpful. To do this a system of criteria for behaviour indicator has been 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 back ground information about their pain needs. McClean (2000) cited in Cunningham (2006. p.5). This is one of the reason he has 1:1 nursing care to gather more information about John and to help him to calm down.
Although several observation scales have been developed, one of which is the “Discomfort Scale for Patients with Dementia of the Alzheimer Type (DS-DAT)”, Kaasalainen, (2007) has seen a few challenges with this method. 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
- Most of the new tools (and other DS-DAT) are in preliminary stages and need
- There is lack of consensus on how pain should be assessed with older adults so
verbal Reports continues to be used in most situations.
- The concept of discomfort mat 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 and how to manage the pain. He stated that it is difficult to make sure that older patients are getting enough medication to manage their pain well. Most older patients have at least one chronic condition and take multiple medications which make it harder to tell what they need. For some healthcare providers it becomes more frustrating to make sure the pain is managed properly Gloth, (2001 p188).
When giving medication Gloth (2001) cautions that it is important to understand that drugs have a different reaction in older adults than they have in younger patients’ this must be taken into consideration when prescribing. When pain is managed well, an individual will have “secondary gain” in which they feel better and it will help family members stay and visit longer. All of these things will help the patient manage their pain Gloth, (2001 p.189). Gloth (2001) also suggests that clinicians should use a variety of methods for pain management including no interventions and alternative therapies where possible.
This section will look at two types of carers–those who work in clinical settings and the family members who must care for a chronically ill family member.
Rasin & Kautz (2007) created a study that focused on caregivers in assisted living facilities. The National Center 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 & 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: behaviour 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 & Kautz, pps. 33-34)…
They felt that the Person Centred knowledge was the strongest and most effective for patient with dementia. From their study, they made several recommendations for nursing:
- Get to know the resident so you can determine what might be causing the
- Giving individualized care for the residents can increase their quality of life.
- Care givers 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 & Kautz, p. 36
Another way of educating families that was effective was researched by Hepburn, et al (2007). They looked at transportable psycho- education program geared towards helping to reduce caregivers stress. Several programs are spotlighted in the article. What they found was that a one on one behaviour management program given by home support team help to reduce the burden of caregivers and help to reduce depression. This program combined education with counselling. With the knowledge given to families, they were able to delay the hospitalization of the patient with dementia. (Heburn et. al, pp31-35).
Most caregivers are women 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 caregivers were higher than in 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 have decreased as experience from reading previous articles would reflect this. 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 parent to the set of tasks they already perform.
End of Life
The last area to research when looking at elderly care is the quality of care for those who have dementia as they move into end of life situations. Bright (2008) explored practices and guidance for patients in the U.K. He pointed out that palliative care isn’t as developed for dementia as it is for cancer, so level of care will vary.
Another point he made is that the National Council for Palliative Care has a project to look at policy and practice in this area. They had a conference to shed light on what has happening now and what needs to be done. This information and The National Dementia Strategy (2007) helped professionals learn the issues (Bright 2005, p.40).
Lewis & Trzinski (2006) added to this information the need for counselling for the older adult dealing with dementia and death. They offer several techniques to help. A couple of techniques they suggested were Space Retrieval (SR) which helps them learn and recall new information (Lewis & Trzinski, p. 779) and the use of “Group Buddies”. Group Buddies is a form of play therapy for adults where they are given puppets or stuffed animals to work with inside and outside the group. The study found that through the Group Buddies, patients with dementia were able to deal with their feelings of grief from loss of a spouse
The question now becomes “How does this information relate to John?”. In order to look at a way to evaluate care for him, it was interesting to look at it next to a standard of suggestions for care. According to the National Institute for Health and Clinical Excellences (2006), (NICHE), there were 700,000 cases of dementia in the U.K. in 2006 and approximately a million caregivers for them. With this in mind they came out with recommendations when dealing with patients who have dementia. It was interesting to look at this information as it related to John.
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 is receiving care that coordinated between his doctors for physical needs, the psychological services from Pain Management Nurses and he receives 1:1 nursing where necessary. His wife receives education and assistance with techniques on how to handle his aggression at home. She is his main carer when at home.
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 very important for us to 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 they have no children. It is difficult for someone like John knowing that he will die sooner rather than later. Schulz et al (2003) cited in Ouldred & Bryant (2008) has found that the progression of dementia confronts families with difficult decisions and need to be supported through this difficult period. The more social carers receive pre bereavement, the better adjusted they are post-bereavement.
It is also difficult for his wife to deal with the stress that comes from living with a man she has known all these years as his life deteriorates. We have helped her gain support where needed and encouraged her to be in support groups in the community. Jacques & Jackson (2000) have identified group work as a valuable way to providing education, advice and support to carers. Also this 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’s Care: Through the Pain Management team and abbey rating scale, the nursing staff kept close observation and weekly medication evaluations on John and we managed to get his pain under control. (see attachment 2). Wood (2002), states that the nurses role in pain management is vital, therefore, nurses should be educated to recognize when patients are in pain.
NICHE Recommendation 4: People with dementia shouldn’t be denied services they need because of their age.
John’s Care: Our unit works with the elderly population with dementia. All healthcare workers on the ward are trained to work with this type of patient and they understand what is needed in each situation. Staff work with John on a regular basis and many get to know him well. At this point, we can see when he is getting anxious and angry so that we can intervene where necessary. As stated by Fitzpatrick & Roberts (2004), Healthcare assistants 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.
John fits all the literature that has been discussed in this paper, especially as it deals with dementia. We find that he gets along and remains independent. He enjoys his independence and when in pain, staff are able to identify and intervene quickly, administer medication promptly to ensure John is pain free. Aggressive outbursts are less frequent and know John is able to enjoy the time he has left happily with his wife.
Elder care is a very important area to work within and we are very aware of the needs that older adults have that may not be the same as younger adults. Dementia is very difficult for families and we have support for families within our ward. We think it is very important to know the patient as well as we can beyond their medical conditions, because we have found it helps us when we can change their focus when there are behavioural issues. We hope that our ward will be able to be the place where families will always be comfortable bringing their family members because it is necessary for someone with dementia to be in a program that understands what they and their caregiver is experiencing.
We also need to stay on top of the literature that is available for us in dealing with patients with dementia. There may be new techniques that develop and we can give more formal training to some of our staff who may not have it at the present time. This is suggested in Carers South Australia (2005) The flexibility of the care plan for John and his wife means they are receiving the best care we can provide within our services. John’s health needs could change at any moment and so an adaptable care plan is essential to insure that his health needs are being met.
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