Health Service Provision for Older Patients - Essay Example

Health Service Provision for Older Patients Introduction Dementia is one of the haunting problems that occurs frequently in the elderly (Advisory Panel on Alzheimer’s Disease, 1996). There are several causes for dementia and the most frequently encountered cause is Alzheimer's disease. Dementia is frequently encountered in elderly patients admitted to hospitals for any other health issues and hence health professionals like nurses must be aware of this condition to facilitate holistic and appropriate management of these patients. There is enough evidence to suggest that many nurses working in hospitals do not have adequate experience and knowledge in handling elderly patients with dementia, making management of acutely ill elderly patients very difficult and complex (Dewing, 2001). The current rise in elderly population due to improvements in health care systems (WHO, 2006) has caused an increase in the number of patients suffering from dementia and hence more research, education, understanding and training with regard to management of dementia patients in hospital setting is warranted. In this essay, the most common cause of dementia in the elderly, Alzheimer's disease, will be discussed through review of literature. The signs and symptoms of the disease, the pathophysiology and various aspects of nursing intervention will be elaborated. Alzheimer's disease Alzheimer's disease (AD) is a common degenerative disease of the brain that leads to dementia (Anderson, 2010). Infact, it is the most common cause of dementia and is incurable. The disease is an acquired condition in which there is impairment of cognition and behavior of the individual that is severe enough to disrupt normal occupational and social functioning of the individual. AD is a major public health problem associated with significant morbidity, impairment and economic consequences (Anderson, 2010). More often than not, the disease is mainly diagnosed after 65 years of age, although, an early-onset variety of AD does exists which presents much early. According to Brookmeyer et al (2007), 1 in 85 people in the world are likely to suffer from AD by 2050. The course of the disease is different for different individuals and thus is the prognosis. The most common early symptom, which is often ignored as an aging feature or stress consequence is the lack of ability to acquire new memories. Other symptoms include changes in cognition and behavior of the individual like irritability, confusion, aggression, mood swings, breakdown in language, withdrawal and long term loss of memory. As the age advances, various functions of the body are gradually lost, terminating in death. AD imposes severe burden on the caregivers and can influence various aspects of the life of the caregiver detrimentally. Diagnosis of AD is mainly established through tests for cognition and assessment of behavior. Brain scan is often used as an adjunct to establish the diagnosis. The mean life expectancy of the individual following the diagnosis is about 7 years (Molsa et al, 1995). Pathophysiology The exact cause of AD is still not understood well and there is no treatment which can either cure the disease or prevent the progression of the disease. Even the prevention of the disease is unknown although some researchers are of the opinion that regular exercise, balanced diet and mental stimulation prevent AD (Anderson, 2010). There is some evidence to tell that AD is associated with tangles and plagues in the brain (Ding et al, 2007). Previously, it was hypothesized that decrease in the synthesis of acetylcholine causes the disease. Infact, several treatments for AD were based on that. However, since patients did not respond well to those treatments, the hypothesis could not be maintained. Subsequently, the amyloid hypothesis was developed, according to which, deposits of amyloid beta were the cause for development of the disease. The gene for amyloid beta precursor protein has been identified on chromosome 2. The fact that patients with Down syndrome having an extra copy of this gene definitely develop this disease is an extra support to this hypothesis. There is some evidence to show that APOE4, one of the risk factors for AD, contributes to increased deposition of amyloid in the brain, much before the onset of symptoms. From these facts, it is evident that deposition of amyloid beta is the main cause for development of AD (Thambisetty et al, 2010). Research in mice has shown that transgenic mice acquired with mutated APP gene of humans develop plaques of fibrillar amyloid which are similar to those found in human AD brains (Lalonde et al, 2002). Another theory is the mitochondrial cascade hypothesis which is yet in research stage (Swerdlow and Khan, 2009). Nursing interventions 1. Assessment and evaluation of the patient Accurate assessment is very critical in the care of the elderly (Nolan and Tolson, 2000). 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) 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 Alzheimer's 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), 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), 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. 2. Assessment and management of environmental factors which contribute to stress One of the important steps in the management of elderly patients with dementia in a hospital setting is assessment and identification of various factors present in the environment of the patient that have the potential to contribute to stress (Maier-Lorentz, 2000, Maas, 1988). This is because; dementia patients have cognitive impairment and functional disability and environmental triggers can increase confusion and stress and lead to disruptive and abusive behaviour. Such a behaviour can in turn cause frustration and burnout of nurses leading to inappropriate care and increased mortality (McCloskey, 2004). Identification of stress-causing factors helps the nurses avoid and remove the factors, thus, decreasing stress. Some of the disturbing environmental stimuli are nursing shift change chaos, doctors rounds, proceures and medical interventions, wound dressing, dim lights and noise. Dim lights can cause shadows and lead to frustration and confusion in a patient with dementia and hence they must be avoided. In those who are sensitive to bright light however; dim light may be used. Mirrors are also source of distress and they must be covered with blankets. When procedures are done, only one health professional must enter the room as much as possible to avoid confusion. Nurses must speak to the patients softly, slowly and in a pleasing manner without using complex words to avoid confusion.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. 3. Taking measures for the safety of the patient Nurses must make sure that there are no dangerous or sharp objects in and around the area of wandering of the patient so that even if the patient falls, no serious injury occurs (McCloskey, 2004; Sand, 1992). At the same time, nurses must make every effor to prevent falls. When procedures are done, only one health professional must enter the room as much as possible to avoid confusion. Nurses and other health professionals must speak to the patients softly, slowly and in a pleasing manner without using complex words. 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. 4. Providing general care to the patient The nurse should maintain an awareness of the age related problems and act accordingly (Cherry and Reid, 2001). In view of vision and other sense organ problems, the nurse must make sure that all objects in the patient's 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 (Holmes, 2000). 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 patient's 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). 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). The goal of treatment in dementia is to maintain the quality of life as long as possible. The patient's functional abilities should be maximized and the quality of life should be improved by enhancing mood, cognition and behavior (Rolfe et al, 2002). 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). The patient's nutrition, hydration, weight, skin turgor and meal habits must be evaluated (Baillie, 2005). 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; Roper et al, 2001). Government laws pertaining to patients with Dementia In UK, government policy with reference to dementia patients has an objective "to improve outcomes and the quality of life for people with dementia and their family carers by: 1. improving public and professional understanding enhancing help-seeking and help-offering; 2. providing diagnosis early in the illness so that available support and treatments (including those which will prevent harm later in the disease) can begin as soon as needed; and 3. quality improvements in dementia services following diagnosis through to the end of life." The policy encourages to rely on the National Health Service and its related partner organizations for care of patients with dementia. The policy also orders to implement promptly all the recommendations made and to make recommendations based on evidence. According to the Alzheimer society of UK (2007), "Dementia must be made a publicly stated national health and social care priority. This must be reflected in plans for service development and public spending." Evaluation of the government policy pertaining to dementia by the Commission for Social Care Inspection indicated that the policy enhanced the intermediate care for elderly dementia patients. The patient receive informal care and more and more specialist health services have come up. More and more facilities have come up for delivering nursing and residential care for patients with dementia and this includes community based support, extra care housing and mental health services. However, a large majority of population do not have access to many services. Conclusion Patients with dementia admitted to hospital settings 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 minimized 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. Anderson, H.S. (2010). Alzheimer Disease. Emedicine from WebMD. 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