Changes and Care Needs in Older Person with Dementia

INTRODUCTION

In this assignment, the author will endeavour to define what Dementia is; describe what the Physiological and Psychological changes that occur for the older person with Dementia; explore the Individuals’ Needs in relation to the condition; describe the Role of the Carer and the Multidisciplinary Team in assisting the Individual with Dementia, what Practices need to be Implemented and what Care Settings are available; state the Current Approaches towards Developing Quality Services for people with Dementia.

The Methodology the author will use will be independent research via the internet and tutors’ notes.

WHAT IS DEMENTIA?

THE PHYSIOLOGICAL AND PSYCHOLOGICAL CHANGES THAT OCCUR FOR THE OLDER PERSON WITH DEMENTIA

DEMENTIA:

Dementia is a disease marked by a gradual loss of cognitive functioning such as memory capacity which can also incorporate losses/impairment of language, attention, orientation, emotional, motor (fine and gross skills), social functioning and spatial skills.

It is a progressive, degenerative and permanent neurological disease that eventually leaves the individual dependent; dementia is caused by different diseases that damage the nerve cells in the brain; the experience is not the same for every individual.  The diseases affect the parts of the brain which are normally used for learning, memory and language.

There are three stages of dementia: In the Early stages, individuals’ display difficulties in judgement, problem solving, decision making, orienting to time and space, personality changes, including, becoming agitated, irritable, manic episodes and depression where the individual can suddenly burst into tears for no apparent reason.

The middle stage can be characterised with the individual unable to remember names, loss of short term memory, be agitated, anxious, have obsessive behaviour, being delusional and will require assistance with their ADL’s.

In the late stage individuals’ will typically lose the ability to communicate, mobilise, be doubly incontinent, are unresponsive to most stimuli and have extended sleeping patterns. At this stage, the individual is 100% dependent on the carer for their ADL’s.

Dementia can affect younger people as well and this is called younger or early onset dementia. There are over 100 types of dementia, the most common being Alzheimer Disease, Vascular Dementia and Lewy Body Dementia.

Alzheimer Disease:

Alzheimer Disease accounts for between 50-70% of people with dementia. The symptoms develop slowly, usually over a period of several years. In the early stages, is difficult to differentiate the mild forgetfulness to the normal aging process; individuals’ have difficulty in making new memories for recent events; have difficulty working out problems, finding the right words, making decisions, finding their way to familiar places and judging distance.

What is happening in the brain: with Alzheimer Disease is that there is a build-up of plaques and tangles in the brain that the author will elaborate on in the physiological changes.

Vascular Dementia:

Vascular Dementia occurs following a series of mini-strokes or TIA’s (Trans Ischemic Attacks), it is the second most common type of dementia. It can occur on a gradual basis, like Alzheimer, over a period of several years. The symptoms are very similar to Alzheimer and other forms of dementia: difficulty with communication, memory loss, and being disorientated. However, with Vascular Dementia, individuals have difficulties with concentrating, planning and they can experience short periods of deep confusion.

What is happening in the brain: of an individual with Vascular Dementia is that the reduction in blood supply to the brain is reduced due to either blockages or narrowing of the blood vessels resulting in the brain cells being damaged.

Lewy Body Disease:

Lewy Body Disease sufferers have a marked difference in how they walk, they shuffle and have a tendency to fall, symptoms very similar to individuals with Parkinson’s Disease; they can experience periods of being severely confused; have hallucinations, hearing or seeing things that are not really there; sleep patterns and swallowing may be affected, individuals sleep easily during the day, however, then have a very disturbed night’s sleep.

With Lewy body disease, movements may be affected so people might shuffle as they walk, and be more prone to falls. Some of the symptoms are similar to those who have Parkinson’s disease. People with Lewy body disease may experience periods of severe confusion. They can have hallucinations, seeing or hearing things that aren’t really there. Swallowing and sleep patterns can also be affected; people can fall asleep easily during the day but then have disrupted sleep at night.

What’s happening in the brain: of an individual with Lewy Body Disease is that there are clumps of protein that have built up over time in the brain. The protein deposits interfere with the nerve cell connections and result in changes in thinking, alertness, behaviour and movement.

The Physiological Changes that occur for the Older Person with Dementia:

The aging process affects everyone, changes including grey hair due to lack of pigmentation, wrinkles due to lack of collagen, loss of hearing and sight, tooth loss resulting in wearing dentures. However, in addition to these changes an individual with dementia, particularly with Alzheimer disease will have the following physiological changes: they develop Neurotic Plaques and Neurofibrillary Tangles in their brain.  The Plaques and Tangles were discovered through autopsy.

The Neurotic Plaques are commonly found in the brains of elderly people but appear in excessive numbers in the cortex of an individual with Alzheimer disease. The cortex is surrounded by deteriorating neurons that produce acetylcholine and neurotransmitter that is essential for processing and controlling responses to the input from the rest of the central nervous system: emotion, voluntary movement, planning and execution of behaviour, memory, intellect, writing and speech. The Hippocampus is part of the Limbic system in the brain. It plays a vital role in in retrieval and encoding of information. In Alzheimer disease, damage to the hippocampus produces global retrograde amnesia, which renders the individual unable to retain newly learned information.

The Neurofibrillary Tangles are twisted remains of a protein which is essential for maintaining the proper cell structure. It is unknown whether the tangles and plaques are the cause of Alzheimer disease or if they are part of the results of the disorder.

The Psychological Changes that occur for the Older Person with Dementia:

Loss of intellectual and memory function are common symptoms in the older person, however, an individual with dementia also have changes in mood and behaviour. Around 90% of individuals with Dementia will develop psychological and behavioural and emotional

Psychological and emotional impact of dementia

The impact that dementia has on a person is not limited to the practical effects of the condition. The person still experiences feelings, thoughts and responses just as a person without dementia does. However, living with dementia will affect these. It is important to recognise and respond to the person’s emotional needs and responses.

An individuals’ reaction to diagnosis:

A Diagnosis of Dementia has a major effect on an individual and their family. Their reaction could include: shock, anger, fear, disbelief and grief. It can also be a sense of relief. Individuals’ can struggle a lot with their emotions; may be afraid about their future, really scared about being forgetful and confused. Really upset about the impact of their Dementia will have on their family and friends.

Symptoms that include:

• Mood disturbance, e.g. depression
• Repetitive behaviour, e.g. clapping hands, calling out
• Social inappropriateness, e.g. stripping off clothes, masturbation
• Agitation, e.g. fidgeting, pacing
• Wandering, e.g. aimlessly
• Sleep disturbance, e.g. thinking day is night and vica versa
• Psychosis, e.g. hallucinations or delusions
• Physical aggression, e.g. hitting out, kicking

An individual with Alzheimer Disease may have changes in their behaviour in the early evening or late afternoon. Doctors refer it to a syndrome called Sun Downing Syndrome. Individuals often look for their Mum or Dad to bring them home. The fading light often appears to be the trigger. Their symptoms usually get worse as the night progresses and normally improve by morning.

Symptoms of sun downing include: Restlessness, Agitation either anxious or upset, Irritability, Confusion, Disorientation and being Suspicious.

There is another syndrome, Magpie Syndrome, whereby, the individual will take items from other residents and stockpile them in their room, usually in their wardrobe. The items they take vary, could be anything from hair brushes to cigarette butts.

EXPLORE THE PERSONS NEEDS IN RELATION TO THE CONDITION

An individual with Dementia is a Valuable and Unique human being. They face challenges due to changes in how they think, communicate, remember and to do every day things.

Individuals’ with Dementia need for their loved ones and carers to Understand Dementia, We have to have the ability to step into their world as they do not have the ability to step into ours! Loved ones and carers need to understand that the individual is not going to get better; individuals’ need Support and Reassurance; they need to feel Loved and Secure, this can be achieved by maintaining a familiar environment and having routine as set out in the care plan; they need to Trust their carer; they need the people around them to do everything in their power to Maintain their feelings of Self-worth and Identity.

It is Vital for carers to understand that Each Individual with Dementia is Unique and have their Individual Life Experiences, likes, dislikes, feelings and needs; that they will be affected by the condition in a different way and that they need to be responded to in a Sensitive and Flexible manner.

Individuals’ need to know that their Quality of Life will be Maintained at the Highest Level; they need to be Respected and their Dignity to be Maintained at All times; they need to be Communicated with Effectively, they need their carer to adjust how they are interacted with as appropriate: to be Listened to Patiently, Good eye contact, Gentle approach, using short sentences with appropriate language.

Individuals’ need for others to Empower them to Maintain their Independence, e.g. offering two choices of clothes to wear, would they like a shower or a wash by the sink; They need to be offered assistance with their ADL’s, as appropriate. They need to be Given the Time to Reminisce, as they often remember details in their past fondly and have forgotten something they have had for dinner five mins ago. This will give individuals’ a feeling of Comfort and Belonging.

WHAT IS THE ROLE OF THE CARER AND THE MULTIDICIPINARY TEAM IN ASSISTING THE PERSON WITH DEMENTIA AND WHAT PRACTICES NEED TO BE IMPLEMENTED AND WHAT CARE SETTINGS ARE AVAILABLE?

THE ROLE OF THE CARER IN ASSISTING THE PERSON WITH DEMENTIA

Caring for someone with dementia can be both emotionally and physically challenging. Dementia influences an individuals’ behaviour including: being anxious or agitated, wandering, depression, having hallucinations and displaying socially inappropriate behaviour such as stripping off and masturbation.

COMMUNICATION:

The carer will notice changes, in which the individual with Dementia communicates, for example, on occasion, they may find it difficult to find a word; comprehend; speak fluently; express emotions; lose the normal way that people interact and interrupt or may disregard what the carer is saying.

As a carer’, you should always remain calm and afford as much time as the individual needs to respond to you and for the individual to understand you; to use simple, short sentences; help to orientate them, for example, today the author was caring for a resident aged 98 years old and was in a confused. At one stage she mentioned that her Mum and died last year at the age of 90. The author asked the resident how old she was and although confused, after a few minutes “Oh, nurse that can’t be right!”  She then said “Don’t mind me; I must be away with the fairies!”; the carer should never be condescending, argue, speak in front of them to other members of staff or anyone bout them as if they weren’t there; use verbal and non-verbal communication, for example, a gentle approach, good eye contact, and touch (holding hand); the carer should be consistent avoid communicating in a noisy environment.

NUTRITIONAL NEEDS:

For an individual with Dementia, their nutritional needs have to be monitored by the carer. They may forget to eat or drink, have difficulty in swallowing and chewing. The carer should prompt the individual to eat and drink; only offer one course at a time; offer food that they are familiar with; avoid using plates with patterns; offer meals and snacks regularly, maybe 5-6 times a day; encourage fluids.

HYGIENE NEEDS:

An individual with Dementia may lose interest or simple forget about maintaining their own personal hygiene.

A carer has to be very Patient with the individual and Encourage them and give them options: to have a shower or a wash; empower them to do as much as they can by themselves by gentle prompting to promote their independence; Put out the things they need in order of sequence; routine is important as per care plan for each individual; the carer may to offer assistance with shaving, toileting, offering two choices of clothing, provide dental care and with personal grooming.

CONTINENCE NEEDS:

An individual with Dementia, due to a decline in their mental functions, may become incontinence at varying stages. The carer has to manage any incontinence and to protect the individuals’ dignity and privacy that could cause them any humiliation. In order to manage their continence needs, the carer should: observe the patterns when the individual empties their bladder and bowel and prompt them at regular intervals to go to the toilet offering assistance as appropriate; watch for non-verbal cues, for example, being increasingly agitated and pulling on clothes. Then using simple words asking if they would like to go to the toilet; the use of nightlights to enable the individual to find their way to the toilet; ensure that the toilet is clearly marked, that the bed is at a level that they can get in and out of safely; that their clothing is easily pulled up and down; and use continence pads, if necessary and appropriate.

SLEEPING HABITS:

Individuals’ with dementia tend to get confused between day and night. The carer should be aware that this can make it difficult for them to have a normal sleeping pattern. The carer should try to engage the individual and encourage them to participate in activities to prevent them from prolonged napping; ensure the individual has adequate lighting and draw the curtains especially in winter when it gets dark so early; the carer should try to encourage the individual not to go to bed too early and not to deviate from their normal routine.

CARE OF THE INDIVIDUAL IF CONFUSED:

 The carer should not make any changes to the individuals’ familiar environment, if possible; remind the individual to take their medication; the carer should update the notice board writing the day, weather and what activities are on that particular day; have large clocks and calendars to help orientate individuals’  to time and date.

THE ROLE OF THE MULTIDICIPLINARY TEAM IN ASSISTING THE PERSON WITH DEMENTIA

The role of the Multidisciplinary team in assisting an individual with Dementia is central to Dementia care along the range of detection and diagnosis , whether it is caring for the individual in their home, residential setting and outpatient clinic or in hospital. The individual with Dementia is the Most Important member of the MDT, and the family and friends are a Critical part of the team and come a very close second.

There are a number of healthcare professionals that form the MDT including: the GP, physiotherapist, occupational therapist, dietician, social worker and nursing. All of the disciplines work together to deliver individual client centred care to meet the needs of the individual with Dementia in a holistic manner.

GP’s are crucial in the care process as they are usually the first individuals in diagnosing Dementia; the public health nurse is also vital as they are most likely to visit the individual with Dementia, at their most vulnerable, living at home; they provide guidance to the individual and their carer to support services that they value and need; the speech and language therapist works with the individual to improve their communication; the physiotherapist works with the individual to achieve their optimal mobility, thereby, promoting their independence; the Occupational therapist works with the individual to ensure they have the correct equipment to enable to them to complete tasks etc.; the nurses and health care assistants follow the care plan and contribute using Individualised Centred Care.  Each individual and discipline is involved in compiling the Individualised Care Plan; should record, report and updates any changes identified. The Care Plan is evaluated in a minimum of three months, however, if the individuals’ specific needs have dramatically changed, it is evaluated and updated straight away.

The MDT is a vital element of a shared approach in the delivery of services to individuals’; effective communication between the various disciplines ensures that the best possible secondary care is provided seamlessly. There is a national training programme for all professionals who work with individuals with Dementia both on a primary and secondary level of care in St. James’ Hospital, Dublin. Here they have established an Information and Development Centre in Dementia Services.

WHAT PRACTICES NEED TO BE IMPLEMENTED?

In Ireland, the effective management of Dementia requires an action plan to be developed including the points of view of all the major stakeholders. The plan highlights how individual and unique each person with Dementia is; the individual with Dementia is placed at centre of the planning process in a Client Centre Care model developed by Dr Tom Kitwood (1997), where he looked for a “new culture of Dementia”. The plan will serve as a model of Best Practice to guide policy makers that are involved in the planning and provision of services and support the providers of flexible and local services for individuals with Dementia. The 32 HIQA standards need to be implemented in line with the recommendations in the National Dementia Strategy.

Most of the needs of the individual with Dementia and their carers should be acquired at the Primary and Community level of care. This should include providing a flexible network of services for the individuals with Dementia and their carer’s. The Autonomy and Dignity of individuals with Dementia can be maintained by developing individualised care plans facilitated through case management structures.

The Day Care centres are also key for providing care. Individuals’ at the earlier stage of Dementia, with no behavioural problems are generally managed in general Day Care centres. However, individuals with more severe Dementia who have issues with wandering need specialised Dementia day care centres at Primary Care Level. The Alzheimer Society currently provides this service in some parts of Ireland.

Respite care both at home and in nursing homes is of vital importance to carers as there is tremendous pressure on them on a daily basis and they need respite care to recharge their batteries. The important element in Primary and Community Care is the flexibility of supply of services following the needs of the individual and their carers being expressed.

The majority of individuals with Dementia in Ireland are cared for in residential homes that are generic facilities for older people. However, their needs differ greatly to that of other residents’. Training programmes for the MDT should be implemented specific to the care and needs of an individual with Dementia;  the training should adapt the Client Centred Approach to their care and delivery service; more investment should be implemented in all residential care facilities for Ireland to catch up with international trends adapting safe, small homely style long term accommodation; Various psychosocial interventions should be implemented, including: validation therapy, reality therapy and reminiscence therapy for individuals with early stage Dementia. It is a vital to implement training in the delivery of these interventions for effective residential care for individuals’ with Dementia.

WHAT ARE THE CARE SETTINGS THAT ARE AVAILABLE?

At the early stages of Dementia, most individuals’ will benefit by being cared for in their own home. The familiar environment, sights and sounds makes the individual feel more secure. A carer in under a huge amount of stress on a daily basis; they need support and relief regularly to promote their health and well-being. A lot of carers turn to family, friends and/or neighbours for a break, however, there are a variety of formal Respite Care that includes:

• Day Care centres specifically for Dementia and Alzheimer Disease, allow individuals to socialise in a safe environment, they offer structured programmes and activities like art and/or music therapy. They also provide transportation and meals.
• There are home health services both private and HSE that provide HCA’s that care for the individual in their own home, companionship and can help with shopping and housework.

As the disease progresses, many carers consider the option of Assisted Living, and then Residential Care for their loved one; as their needs mount,  they require twenty four hour care, it becomes almost impossible for the carers even with intermittent assistance to continue delivering the care required.

Assisted living, in an option for individuals that do not require skilled medical care but do need assistance with some of their ADL’s; The residents either have their own apartments or share; have the assistance of 24 hour staff; have services such as laundry, transportation and recreational activities provided.

A Nursing home is the option that cares consider when their loved one needs skilled nursing care, supervision and medical care 24 hours a day. The individual and their family will be very involved with the MDT in their care planning and delivery of care. There are specialised care units that are Dementia specific available to individuals, e.g. Lucan Lodge and Kiltipper Woods Nursing Home. The Health care professionals’ on these units has received specialised training in order to care for the individuals’ needs.

The Programme for Government (2011-2016) has given a commitment to develop a Dementia Strategy. The key principles are to reinforce and inform the variety of social and health care services that can be provided to individuals with Dementia and their loved ones.

The HSE will develop a local and national Dementia care pathway to clearly signpost and describe the optimum way through the system going from the initial symptoms, diagnosis and to the levels of appropriate intervention required in their journey.

As part of the strategy, certain material will be made available to GP’s: guidance on local and national pathways from investigation to diagnosis; reference material that is Dementia specific is made available to widen their skills base; information about social and health supports that are available within the community.

STATE THE CURRENT APPROACHES TOWARDS DEVELOPING QUALITY SERVICES FOR PEOPLE WITH DEMENTIA

Research into the needs of individuals’ with Dementia has shown that they require residential care as the disease progresses. There is a movement towards caring for individuals with Dementia from traditional nursing homes to that of them being cared for in Dementia villages.

This ingenious pioneering notion has come after De Hogeweyk, Holland, developed a cutting edge elderly care facility in a village setting since 2009. It is located on the outskirts of Amsterdam where all the residents have Dementia and have the chance to live highly social and almost normal lives.

The houses are designed to look like houses from different eras from the 1950’s to 1970’s; residents and their families can also choose different lifestyle models including Christian, Urban, Indonesian and Artisan.

The Dementia village currently have 152 residents; is mostly state funded; has its own post office, supermarket, town square, garden and theatre. The residents live longer, eat better, require fewer medications and enjoy a higher standard of living than those in the traditional nursing homes.

In response to the success of the former, countries worldwide, including Ireland, are being inspired to follow suit. According to Journal.ie, (2016), Irelands’ first purpose built village is under construction for individuals with Dementia in Bruff, Co. Limerick. Care Bright Community, the company behind the development has stated that it will “change the face of Dementia Care in Ireland”.

Although it is on a smaller scale, 18 homes, the village is based on a similar community that De Hogeweyk designed; the village includes a gym, talking sheds, café, beauty salon, sensory garden and an orchard. The carers and/or their loved ones can stay overnight should they wish to do so, making it feel like a home from home.

Moving forward, it appears that there will be a shift from the current traditional Nursing homes by developing this New Innovative Approach towards Quality Services for individuals’ with Dementia and their families in the future.

CONCLUSION

In this assignment, the author has given an Explanation as to what Dementia is; what the Physiological and Psychological Changes that occur for the older Individual with Dementia; Explored the Individuals’ Needs in relation to the condition; Described the Role of the Carer and the Multidisciplinary Team in assisting the Individual with Dementia,  the Practices Need to be Implemented and the Care Settings that are available; She also Described the Current Approaches towards Developing Quality Services for people with Dementia.

On completion of this assignment, the author has gained a greater insight into Dementia and how the individual and their loved ones are Key players in the Planning, Implementing and Evaluating as part of the Multidisciplinary Team to ensure the Quality and Delivery of care is of the Highest Standard.

WEBOLOGY

• Alzheimer.ie (2017) Available at: https://www.alzheimer.ie/About-Dementia/What-is-Dementia/Treatments-available.aspx, Accessed: 7^th Oct. 2017
• Mydr.com (2017) Available at: http://www.mydr.com.au/seniors-health/dementia-behavioural-and-psychological-symptoms, Accessed: 7^th Oct. 2017
• My Aged Care (2017) Available at:https://www.myagedcare.gov.au/caring-someone-particular-need/caring-someone-dementia, Accessed: 2^nd Oct. 2017
• Ncaop.ie (2017) Available at: http://www.ncaop.ie/publications/research/reports/54_Action%20Plan%20for%20Dement.pdf, Accessed: 2^nd Oct. 2017
• Mydr.com (2017) Available at: http://www.mydr.com.au/seniors-health/dementia-behavioural-and-psychological-symptoms, Accessed: 3^rd Oct. 2017
• Alzheimeimers.org.uk (2017) Available at: https://www.alzheimers.org.uk/info/20046/help_with_dementia_care/31/understanding_and_supporting_a_person_with_dementia/4, Accessed: 4^th Oct. 2017
• Webmd.com (2017) Available at: https://www.webmd.com/alzheimers/guide/manage-sundowning#1
• ww.understandtogether.ie/about-dementia/what-is-dementia/diagnosis/, Accessed: 4^th Oct.2017
• myagecare.gov (2017) Available at: https://www.myagedcare.gov.au/caring-someone-particular-need/caring-someone-dementia. Accessed: 3th Oct. 2017
• health.gov.ie (2017) Available at: http://health.gov.ie/wp-content/uploads/2014/12/30115-National-Dementia-Strategy-Eng.pdf, Accessed: 4rd Oct. 2017
• thejournal.ie (2016) Available at: http://www.thejournal.ie/dementia-village-bruff-2922387-Aug2016/, Accessed: 5^th Oct. 2017)