Care of Patients with Dementia in Hospital Wards - Essay Example

Care of Patients with Dementia in Hospital Wards Introduction Dementia is a haunting problem amongst elderly who frequently get admitted to acute care settings for other health problems like fever, gastroenteritis and heart disease. Thus, nurses and other health professionals who deal with acute conditions of elderly population must possess an awareness of management of dementia. Research has shown that most hospital nurses do not have the expertise to handle behavioural disturbances like dementia which are mostly managed in mental health wards, thus making management of acutely ill elderly patients very complex and challenging. It is yet unclear whether, despite abundant literature on the management of dementia in acute care settings, the training and practice of staff meets the demands of the ageing population. Currently, most of the practice is based on biomedical model (McCloskey, 2004). Due to rise in the elderly population and simultaneous increase in the number of patients suffering from dementia, research and practice of dementia patients in acute care settings is a necessity in order to meet the needs of the patients and their families affected by dementia. The purpose of this essay is to identify current practices in the nursing care of patients with dementia in acute care settings, discuss best practice guidelines pertaining to care of this population, analyse factors influencing the care of dementia patients in acute care settings and evaluate various options pertaining to alternative modes of management. Current trends The economic, social and health status of the fast-growing elderly population poses a great challenge to all sectors. The WHO (2006) has projected that the elderly population of the world will cross the one billion mark by the year 2020 and by that time, over 700 million old people will be living in developing countries. It is unfortunate to say that little attention is paid to the enormous needs of the elderly population because the National Health Services are still preoccupied with tackling of the communicable diseases, maternal and child care and thus have no time, money and place for geriatric problems like dementia. According to the Advisory Panel on Alzheimers Disease (1996, p6), health professionals ignore patients with dementia because of "sense of impotence" pertaining to the treatment of their health problems and perception of increased cost of treatment. However, Cherry and Reid (200, p3) opined that nursing staff are aware of the fact that they are unable to deliver appropriate care to the elderly patient and thus meet their needs specifically. One of the reasons why such a deficit arises in the care of dementia patients is because of lack of measure of satisfaction to quality care and inability express preferences in view of detrimental cognitive function (Advisory Panel on Alzheimers Disease, 1996, p8). As such, most of the care in healthcare system is based on perceptions of the consumers. Dewing (2001, p18) opined that management of behavioural disturbances in acute care settings is actually either ignored or is based on few strategies which are either restricted on not elaborate. There is identified literature pertaining to the fact that care of dementia patients in acute wards as many chemical and physical restraints, triggered by specific behaviours, reflecting the oblivious ignorance of the health professionals pertaining to the needs of ageing population with dementia (McCloskey, 2004). Factors affecting the behaviour of patient with dementia in acute wards Gerdner, Buckwalter, and Reed (2002, p363) proposed that there are basically six types of stressors which have detrimental effects on patients with dementia and contribute to development of aggressive behaviours even in those with initial stages of dementia. These factors are environmental factors, excessive fatigue, caregiver factors, demands above and beyond functional capacity, variety of stimuli, physical stressors and perception of losses. Environmental factors play a major role in the development of aggressive behaviour in a patient with dementia and contribute to distress and dissatisfaction. Nurses handling elderly patients in acute ward settings must be aware of the fact that the environment of the hospital is new to the patient, the surrounding is filled with noise and the individual can feel uncomfortable in the surrounding. Some of the distressing factors in the environment include call bell, telephone calls, conversation over telephones and mobiles, noise of the equipment moved around, beeping and alarms of various monitors, activities of the doctors, nurses, visitors and other patients, conversations between health professionals, overhead announcements and many other unfamiliar aspects (McCloskey, 2004). Patients with dementia who have difficulty in adaptation to new situations may find it difficult to adjust to the unfamiliar environment and thus respond adversely. Admission to hospital also changes the normal routine of the the daily life and this can cause significant distress to the patient. This stress may in turn be expressed in an abuse, aggressive or absurd way which nurses who are inexperienced or who do not have an attitude towards dementia patients may find it difficult to handle and respond. Thus environmental factors provoke aggressive behaviour in patients with dementia and pose a challenge to the staff handling them. These factors may go unrecognised by nurses because of their familiarity of the hospital environment which is highly stimulating. Care of patients with dementia in acute ward settings In view of the complexity of management of dementia patients in acute wards, biomedical model based reactive approach is unaffordable and researchers have recommended a proactive approach in the management of patients with dementia. One of the popular models of approach to such patients is the Progressively Lowered Stress Model of care or the PLST Model proposed by Hall and Bockwalter (1987; cited in McCloskey, 2004) about 2 decades ago. PLST model has be been used as a framework for many studies and health related programs and has proven efficacy in improving the quality of life of patients and level of care for dementia patients by health professionals. According to the PLST model, elderly patients suffering from dementia have difficulties related to reception, perception and response to various environmental stimuli including the stimuli in acute care wards (McCloskey, 2004). It is because of these difficulties that the patients suffer from progressive deterioration of affective, cognitive and many functional abilities that are associated with dementia. In fact, researchers are of the opinion that behaviour of a patient with dementia at any given point of time actually depends on the perceptions of the various environmental stimuli and also on the stage of the dementia. When the patient is in initial stages of dementia, there is minimal cognitive impairment and the functional disabilities are also minimal, thus the patient is calm. In such a state, perception of loss of control or stress leads to various anxious behaviours like avoidance. Persistence of anxious behaviour because of excessive environmental stimuli lead to dysfunctional behaviours like verbal abuse, verbal outbursts and aggression. However, addressing of demands in this stage and making the individual comfortable and adjusted leads to re-bounce of normal functional behaviour (McCloskey, 2004). The first and foremost step in appropriate management of patients with dementia in acute care setting is identification of the disease process and careful assessment of the various factors in environment of the patient that contribute to stress. Identification of factors helps in the modification of future care whereas lack of understanding of these aspects leads to frustration, inappropriate care and stress not only for the patient but also for the nursing staff. It is due to such a lack of understanding that many physical restraints are employed in acute wards handling dementia patients and these contribute to patient mortality and increased burden of work for the nurses (McCloskey, 2004). One of strategies to prevent distress due to physical restraints is adoption of alternatives to physical restraints (McCloskey, 2004). Some such alternatives include adoption of door knob covers instead of doors, employment of various electronic devices like wandering system, bed alarms, door alarms and electronic monitors to monitor the movements of the patient, change in the regimens of medication in such a way that they offer comfort to the patient and cause minimal disturbance and distress, placing the patient in strategic regions which are compatible to the patient and are familiar to the patient, place safety mattress on the floor to enable safe locomotion, remove tubes and drains in a prompt manner, assist and pursue routine toileting, decrease scope for environmental hazards, prevent falls, employ various aids for seating and positioning and usage of lower beds and employment of split side rails (McCloskey, 2004, table-1). Other alternatives include involvement of volunteers, family members, sitters and hospice workers in the care of the patient, hight time sleep enhancement programs, making interdisciplinary team responsible for the safety of the patient, education of the staff pertaining to dangers of physical restraint, use of belts when on wheel chair and use of wedge cushion (McCloskey, 2004, table-1). Thus employment of suitable alternatives to physical restraints not only makes the patient feel comfortable but also helps the nurse provide care without stress. According to the PLST model, several strategies enhance the comfort level of the patient (McCloskey, 2004, table-2). One such strategy is maximising safety of the patient by modifying certain aspects of environment which compensate for the cognitive losses. Other strategies include controlling of factors which increase stress, planning and maintaining a consistent and familiar routine, implementation of periodic and regular rest periods which compensate for loss of reserve energy and decrease fatigue, provision of unconditional regard which is positive in nature and employing a non-judgemental strategy about the appropriateness of the behaviour of the patient except those who challenge the safety of the patient and others (McCloskey, 2004, table-2). Nurses must be trained to recognise signs and expressions of fatigue, increasing stress and anxiety in the patients and administer interventions which suitably decrease the stressors and increase comfort levels of the patient (McCloskey, 2004, table-2). Only those therapeutic interventions which are appropriate for safe functioning of the patient must be employed. Some reassuring forms of therapy like reminiscence and music may be useful to bring comfort and soothe the patient (McCloskey, 2004, table-2). Strategies to increase comfort levels of the patient must be individualised and based on the need of the hour, person and place. A strategy which has worked once may not work the next time for the same patient and thus nurses must use common sense in delivering interventions to patients with dementia in an acute care setting. Before delivering any intervention to a patient with dementia and distressing behaviour, nurses must rule out physical causes for such behaviours. This is of utmost importance because patients with dementia have difficulty in expression by virtue of cognitive dysfunctioning and thus they may be suffering from some discomfort which they are unable to communicate. Some unnoticed health conditions like infection, hypoxia, constipation, pain, drug toxicity, renal impairment and liver dysfunction can also contribute to distress in the patient and thus these health conditions must be ruled out. Thus, any abnormal behaviour warrants complete evaluation, review of medications and evaluation of laboratory studies (McCloskey, 2004). Another important reason why patients become agitated is loss of personal space, i.e., the distance between themselves and others. As such, the personal space of those suffering from dementia is four times that of normal. Research has shown that invasion of personal space by care givers like while coaxing the patients to eat, bath, dress, reposition or relocate causes aggression in the patients. This is because, the patients are unable to gather as to what is happening around them, get confused and in response strike out in an aggressive manner. Attempts on the part of staff to stop the aggressive behaviour only further exaggerates it. In an acute care setting, basic care activities, performance of invasive procedures, changing of dressings, and care of drains and tubes triggers aggressive reactions and cause disturbances in effective care. It is important for the nursing staff to identify triggers of such behaviour and take measures to decrease and handle such behaviour so that proper care is delivered and optimum recovery of the patient is possible. Nurses must manage behaviours also to prevent various complications of hospital treatment like malnutrition, infection and declination in functional status. Respect to personal space can be upheld by allowing the patient to perform some tasks himself and by using simple one step instructions for the task. While performing distressing procedures like wound dressing and invasive procedures, the patient can be encouraged to grab the railings of the bed during turmoil. This will automatically decrease striking out behaviour. One important means of decreasing excessive stimuli and preventing agitation is minimising distractions which can be accomplished by minimising the number of people in the patients room, restricting the number of visitors and by closing the door of the patients room. Other techniques of minimising distractions are being organised, using soft tone and gentle language while conversing with the patient and in front of the patient, performing the task with efficiency in a calm and non-provocative manner and explaining the procedure to the patient in a simple language which the patient can understand. Nurses must be flexible and be creative in making the patient feel comfortable and safe. One of the strategies which makes the patient feel comfortable is music of the patients choice. Research has shown that music creates a relaxing and soothing feeling to the patients. Nurses must avoid tubes, drains and intravenous lines as much as possible as they can be a source of irritation to the patient. They must be kept for minimal duration. Hiding tubes may be useful and nurses can request family members to distract the patients from the tubes. The best care that has been proved by research is the restraint-free care that can be achieved through individual plan of care. This can be achieved by knowing the patient well, understanding the needs and demands of the patient, recognition of factors which precipitate stress and agitation, acknowledging the right of the patient to refuse care and make his or her own choices, establishing a good rapport with family and other informal supports and by collaborating with other health care professionals involved in the care of patient. The nurses have to be patient to provide the fullest support to the patient and his family members. Taking care of environmental aspects The environment of acute care system is complex and can be a source of confusion to patients with dementia. These stimuli can be a contribute to stress for the patient because of their inability to process and understand the proceedings of their environment. The impact of environment on the patient depends on the degree and nature of activity at a given point of time. According to a study by Carmel and Hunter (1989, cited in McCloskey, 2004), "disruptive behaviour" usually occurs "between 7 and 10 AM, noon and 2 PM, and 4 and 7 PM" which are periods of high activity involving doctors rounds, changes of shift and other important activities. Additional disturbing stimuli in the form of procedures, medical interventions, wound dressing, location shifting, meals and changing clothes further cause distress to the patient and initiate provocative behaviour. Hence, all activities pertaining to the patient must be scheduled in a time when the environment is calm and comfortable. Another important aspect of patient environment which needs to be taken care of is the room lighting. Dim lights cause shadows which can be weary and be a source of confusion and frustration to the patient. They even frighten the patients and trigger aggressive behaviours. Hence bright lights, preferably fluorescent lights must be used in the patients room (McCloskey, 2004). Another advantage of bright light is that it makes it easy for the nurses to assess and observe the patient. However, for older patients, whose eyes are sensitive to bright light, dim light must be employed with caution to prevent shadows and falls. Mirrors can be source of distress to patients with dementia who have defects in recognising their own reflection and thus may assume that there is some other stranger in the room. Thus mirrors can be a source of distress to the elderly person. To avoid such disturbances, nurses must cover mirrors with blankets in rooms of patients with dementia (McCloskey, 2004). In wandering patients, the environment should be adjusted in such a way that there is no cluttering of objects in the path of wandering and there are no sharp or dangerous objects around, so that even in case of falls, the patient does not get injured seriously. Also, the main doors of the nursing unit must be kept closed so that wandering of the patient beyond the scope of observation of the nursing staff is prevented. Self- opening of the doors can be prevented by covering the door knob with cloth. If possible, it is always better to engage the patients in some useful activities of the ward like folding laundry clothes, sweeping the floor and doing some small help to the nursing staff (McCloskey, 2004). It is very important not to restrict the movements of the patient because it will only lead to frustration and aggressiveness. Though excessive stimuli is distressing to patients with dementia, leaving the patient alone in single rooms is also dangerous. This is because, sensory deprivation leads to increased confusion which further contributes to distress and agitation. Hence patients with dementia must not be allocated single private rooms and even if allocated must be accompanied by a suitable caregiver. At the same time, general wards act as source of excessive stimuli and can overstimulate the patient. Thus the most ideal wards for these patients are semi-private wards. However, the room mates must be properly selected. Persons who can socially interact in an appropriate way are the best room mates for patients with dementia (McCloskey, 2004). Care giver aspects For most of the patients with dementia, admission to hospital implies change in caregivers which can be stressful. The stress is mainly caused by change in usual routine and methodology of care. Thus, it may be useful for nurses taking care of patients with dementia to discuss important aspects of care and preferences of the patients from their caregivers. Another strategy which may help the patients is allowing the caregivers to be beside them as much as possible, especially during the initial days of admission when familiarity and rapport between the nurses and the patients is yet not established. Such a strategy not only helps in maintaining a consistent routine of activities, it also helps in keeping the distressed patient calm and increases sense of security. Families of the patient must be enquired about the routines of the patients, preferences and rituals and these must be incorporated into the care of the patient as much as possible. Medication regimens and activities must be scheduled as per the input derived from the family members and caregivers. This is very important because, research has shown that patients with dementia prefer routines and are distressed when their routines are changed (McCloskey, 2004). Nursing staff behaviour Procedures on patients with dementia must be performed by one health professional as much as possible to avoid confusion. In case more than one professional is needed to perform any task, then only one professional must enter the room first and engage the patient before the entry of another professional. Also, the health professionals must display appropriate attitude and mannerisms while dealing with the patient and they must be sensitive to the cognitive disabilities the patient possesses. A patient with dementia must be spoken to softly, directly and in a pleasing manner, even if the patient is unable to respond back to ones gestures and speech (McCloskey, 2004). The professionals must talk slowly and in a calm manner without using confusing complex words. If the patient responds in an agitated manner, the nurse must remain calm, composed and repeat the sentence slowly and softly using the same words. When making requests, it is important to keep the patient in a non disturbing surrounding (McCloskey, 2004). Nurses must avoid asking the patient informative questions. General care The nurse should maintain an awareness of the age related problems and act accordingly. In view of vision and other sense organ problems, the nurse must make sure that all objects in the patients room are well within the limits of vision of the patient. Also, large lettering must be used for labelling. While talking to the patient, the nurse must face the person directly so that he can lip lead. Gestures and objects must be used to help with verbal communication. He/she must be served food attractively as per the needs of his taste. Oral hygiene must be taken care of. The nurse must keep objects within the reach of the old man and all precautions must be taken to prevent falls like giving assistance while moving around, avoiding slippery floors and avoiding objects in the walk way. The patients blood pressure should be monitored regularly and physician consult and medications advised accordingly. All measures must be taken to prevent infections. Also, in case of any possible infection, early diagnosis and treatment must be instituted (Baillie, 2005, p.234). Regular exercise must be encouraged keeping in mind the limitations of the old patient. Keeping in view of decreased creatinine clearance, drugs that are cleared through kidneys must be given in decreased dosage. Also, the adverse effects and toxicity of the in taking drugs must be closely monitored. Due to dry skin problems, the aged individual must be advised to avoid excessive use of soap. The patient must be advised to wear appropriate clothes as per the climate. If the old person presents with an acute change in cognition, behaviour or function, the nurse must have a high index of suspicion for any underlying disease (Nettina, 2006, p191). The goal of treatment in dementia is to maintain the quality of life as long as possible. The patients functional abilities should be maximized and the quality of life should be improved by enhancing mood, cognition and behaviour. Drugs which are prescribed should be encouraged to be taken. In view of complications which may arise as a result of the mental condition of the patient, the nurse must perform cognitive assessment for orientation, insight, abstract thinking, concentration, memory and verbal ability (Nettina, 2006, p191). The patients nutrition, hydration, weight, skin turgor and meal habits must be evaluated (Baillie, 2005, p236). Adequate rest must be provided. The family members must also be assisted to find resources for solace like community groups, church groups, social service programmes or hospital based support (Nettina, 2006, p192). Pain management Challenges exist for adequate pain management for people with dementia. Though historically people with dementia have not received palliative care, there is an actual need for such care. Palliative care needs to integrate all domains of supportive care. The nurse must be aware of the physical, psychological, social and physical needs of the elderly patient with and help him/her attain them. There is an emerging recognition of peoples spirituality and their requirements for spiritual care. Mere physical health would not be indicative of a person’s happiness and the health professionals must be aware that emotional security is another essential aspect for the well being of elderly persons. People, particularly in old age, need continued social interaction, due respect, affection and spiritual satisfaction (WHO, 2006). The challenge for providing spiritual care for people living with an incurable illness is for the carers and the health professionals to identify their own spirituality. This requires a reflection on lifes meaning, beliefs and values held. While assessing pain, it is important for nurses to remember the fact that patients with dementia are not in a position to ascertain the level of pain and the change of the level of pain subsequent to medication and treatment. Hence while monitoring and evaluating pain in patients with dementia, scales useful for patients with cognitive disability must be used,. Also, nurses must use their won common sense while judging response to treatment. Patients who have early stages of dementia will be able to use the regular pain rating scales and these patients must be able to do so only after assessing the ability of the patient to rate. Assessment and evaluation Accurate assessment is very critical in the care of the elderly (Nolan and Tolson, 2000, p.39). Thus health professionals dealing with patients with dementia must collect not only objective data but also obtain as much subjective information as possible not only from the patients but also from their caregivers and family members. There are some tools which effectively allow evaluation of the status of the patient and nurses must employ these tools as much as possible. Some such tools are Delirium Rating Scale and Mini-Mental State Examination. Connolly, Pedlar, MacKnight, Lewis and Fischer (2000, p.34) conducted extensive research on patients with dementia and developed some guidelines to help nurses, doctors, caregivers and family members. These guidelines took the form of Functional Assessment Staging Tool. The main advantage of these guidelines are that they correlate each stage of cognitive declination with appropriate support, intervention and management that are most appropriate to the patients and their family members. This tool mainly concentrates on Alzheimers disease but can be applied to other causes of dementia. The main principle behind this tool is the importance of continuity of care and provision of information at all stages of dementia. Patients with dementia need to be assessed frequently because they do not have the ability to report changes in their condition promptly. According to Cummings et al (1999, p249), evaluation of family members should be be part of the process of care of patients with dementia. Family is the most important untapped resource of support for acute care team dealing with dementia. According to Brauner, Muir and Sachs (2000, p3230), it is important for identify subtle behavioural changes in the patient which are markers for change in the condition of the patient. Such changes are increased restlessness, decrease in the activity of the patient and decrease in appetite. Nutrition Nutrition is an important aspect of management of patients with dementia in an acute care setting. This is because the unfamiliar atmosphere may make the patient eat less and consume decreased fluids leading to malnutrition and dehydration. At the same time, coaxing the patient to eat and drink may cause confusion and distress and lead to agitative behaviour. Thus nurses must monitor intake of nutrition and create an individualised nutritional plan based on personal tastes and preferences. Holmes (2000, p42) proposed a Mini Nutritional Assessment tool to measure nutritional status of the patient effectively in a small time frame. The tool is useful in identifying causes of nutritional declinations and assist in appropriate interventions at the right time, thus contributing to effective clinical outcomes. Legal and ethical considerations When political correctness demands that we embrace change with enthusiasm there is a strongly held view that nursing, along with many other professions, struggles with a theory gap practice (Rolfe et al, 2001, p120). The nurse has a duty to promote what is best for the patient, ensure that the patients needs are met and protect the patients rights (Nettina, 2006, p.198). Each country or state has its own rules and regulations as far as legal considerations in the provision of care for the elderly is concerned. The nurse must be aware of these and implement them in their daily practice. The resident has the right to be from any physical restraint imposed or psychoactive drug administered. In case physical restraint is necessary for the well being of the old person, consent must be taken either from him or his legal representative. The nurse must be aware of the fact that though restraining is done to benefit the patient, unnecessary restraint can lead to increase in falls, patient strangulation, patient confusion, pressure ulcers, nosocomial infections and social isolation. There can also be an emotional burst which can lead to anger, fear, resistance, humiliation, demoralization, discomfort, resignation and denial (Nettina, 2006, p199). Other legal issues which need to be kept in mind and followed are accountability, confidentiality, and informed consent (Nettina, 2006, p199). The nurse has to take responsibilities for actions taken and omissions. Implications for practice It is important for every nurse to have an understanding of management of dementia in hospital wards. The understanding must be accompanied by development of a sensitive attitude towards the functional limits and cognitive disabilities of the patient. Whenever nurses come across patients with dementia in the wards, which is likely to happen quite often, they must be alerted about the functional limits and deficits they have and take care of the environment, care giving aspects, personal aspects and many other factors which stimulate the patients and cause distress, dissatisfaction and stress. Conclusion Patients with dementia admitted to acute wards must receive care of all aspects of health. Nurses must have an understanding of the fact that patients with dementia have behavioral disturbances. Whenever a patient with dementia is admitted to an acute ward setting some behavioural disturbances must be anticipated and the nurse must act accordingly. Stimuli and factors which worsen distress of the patient must be minimised and a calm, safe and composed environment must be created to help the patient feel comfortable and recover as much as possible. At the same time high standards of care must be maintained by using creativity and common sense. Special attention must be paid for nutrition, fluid intake, pain management and medication regimens. Nurses dealing with dementia patients must be sensitive to the needs and demands of the elderly population and behave with patient, compassion and professionalism. References Advisory Panel on Alzheimer’s Disease (1996) Alzheimer’s Disease and Related Dementias:Acute and Long-Term Care Services. NIH Pub. No. 96-4136. Washington, DC: Supt. Of Docs. U.S. Govt. Print. Off. Baillie, L. (ed.) (2005) Developing Practical Nursing Skills. (2nd ed.). London: Hodder Arnold. Brauner, D., Muir, J., and Sachs, G. (2000) Treating Non-dementia Illnesses in PatientsWith Dementia. 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