The aim of this case study is to explain and discuss the nursing care of a 69 year old lady who has recently been diagnosed with early stage dementia. This case study will demonstrate my knowledge and understanding of evidence based nursing practice whilst exhibiting my ability to outline a plan of care which is based on this.
The structure of this study will adopt part of the nursing process, i.e. assessment of the client and planning of care in partnership with the client. The nursing process requires the nurse to carry out a holistic assessment of clients needs which takes into consideration the persons physical, social, psychological and spiritual being in order to produce an appropriate plan of care (Kenworthy et al, 2006). This case study shall also discus the nature and possible causes of Simone's illness. The experiences of Simone discussed in this case study will be influenced by the use of a biomedical, psychological and social approach to dementia.
This case study is based on a fictitious community psychiatric nursing assessment of a person called Simone. Simone is a 69 year old lady who has just received a diagnosis of early stage dementia. Simone lives with her daughter who is aged 40 and is a paraplegic who in the last twelve months has had two bouts of depression. Although Simone's daughter is able to look after herself to a great extent she does require some of her mothers help. It became evident from the assessment that Simone appeared very anxious about her diagnosis as well as what will happen to her daughter. Although Simone appears orientated to place she appears to get flustered at times when she cannot answer some question. There appears to be no concerns in relation to Simone's physical state of health. Simone stated that she does not need help at the moment and that she will cope. Simone has no family locally and since she began looking after her daughter 10 years ago, Simone appears to have lost touch with many of her friends. Simone's home is clean and well equipped; they both wish to continue living here although it appears as though they are anxious about coping. Simone's daughter reported that on a few occasions recently her mother had burned food while cooking.
According to National Health Service (NHS, 2009) dementia is a common condition. In the year 2000 18 million people worldwide were said to have been living with the condition with that figure projected to rise to 34 million by the year 2025 (Alzheimer's Disease International, 2010). At present there are approximately 700,500 people in the United Kingdom with dementia and although it is something which largely affects people in later life there are currently at least 16,000 people in the UK under the age of 65 who have the illness (Department of Health, 2009). Dementia can affect anyone regardless of their gender, ethnicity or class. At particular risk of developing dementia are people with learning disabilities.
Dementia is a devastating and severe illness and can be defined as a syndrome which is associated with a number of illnesses in which there is a progressive decline in many areas of functioning. These areas include memory, reasoning, communication skills and our ability to carry out daily activities (DOH, 2009). Furthermore people may experience behavioural and psychological symptoms such as psychosis, depression and aggression (World Health Organisation [WHO], 1992).
There are different forms of dementia, the most common being Alzheimer's which accounts for 62% of all cases. With Alzheimers the chemistry and structure of the brain is altered and brain cells die. The onset of Alzheimers disease is said to be slow and the decline is gradual over many years. The second most common cause of dementia is vascular dementia (VD) with the most common type being Multi Infarct Dementia (MID), this is where the brain has been damaged by repeated small strokes. MID can also be caused by high blood pressure, irregular heart rhythms or diseases which cause damage to the arteries in the brain. As a result of MID the patients condition gradually gets worse in steps and the person will usually deteriorate until they have a stroke were they will deteriorate before having another stroke and deteriorating further. Often people will have both types of dementia. Other forms of dementia include but are not limited to dementia with Lewy bodies (DLB) and fronto-temporal dementia (FTD) (Ouldred & Bryannt, 2008). Dementia with Lewy Bodies is thought to be the third most common cause of dementia. Those who have it have microscopic changes called Lewy bodies in the nerve cells of the brain which are caused by tiny protein deposits in the brain which disrupt its functioning. Visual hallucinations and delusions often occur. Fronto - temperal dementia is rarer and the person affected may have personality changes before their memory is affected.
Progression of dementia is different for each individual, for some it may be fairly rapid whilst for others it may be more gradual. Clinical features of the disease can be classified into three stages although these may not be present in every person and not all people will move through each stage (Alzheimers Society, 2007).
Simone had visited her GP recently in relation to a series of vague physical complaints however recently she also admitted that she was worried that she had been having lapses in memory as well as becoming very intolerant of her daughter at times.
According to the Scottish Government (2010) some people may be reluctant to attend their GP if they are worried they have dementia, some people may wait for as long as two years. The fear of dementia in the person or in their family is seen as the most significant barrier to seeking a diagnosis (National Audit Office, 2008). It is usual practice for General Practitioners to start the assessment process before referring the person to a local memory assessment clinic or community health team for further detailed assessment (Ouldred & Bryannt, 2008). A bio - medical approach is one way of understanding dementia and this view may have been important in ensuring Simone has a proper diagnosis.
The Mini -Mental State Examination was developed as a screening instrument for diagnosing dementia which results in assessment of things such as, memory, language and visuoperceptual function. In Simone's case, when cognitive impairment was detected, the MMSE will have been utilised to detect dementia. Whilst trying to determine whether Simone has dementia she will have been asked if she wishes to know the diagnosis as well as whom else she would like to know (NICE, 2007). A score of less that 24 out of a possible 30 points is said to indicate an abnormal result however patients with scores between 21 and 25 can be considered for re - evaluation in 3 to 6 months. Those with a score of greater than 25 reduce the probability of cognitive impairment.
NICE (2007) recommend the result of this MMSE assist in determining the appropriateness of pharmacological interventions. For cognitive symptoms of Alzheimers dementia, Donepizil, Galantimine and Rivastigmine which are acetylcholinesterase inhibitors are utilised. Nice recommend the prescribing of these three for those who have a diagnosis of Alzheimers disease of moderate severity that is decided by an MMSE score of between 10 and 20 points. For non- Alzheimers dementia and mild cognitive impairment the acetylcholinesterase inhibitors and Memantine should not be prescribed for the treatment of cognitive decline (NICE, 2007). Should the use of medication be an option for Simone as past of her care plan there would be a need to assess whether Simone requires assistance with medication administration including storage of medicines ( NMC, 2010). The possibility of a pill dispenser ("dossett box") may be useful to encourage correct dosage and timing (Alzheimers Scotland, 2010). Also incorporated into the care plan would be the need to inform Simone of the side effects of the medication as well as monitoring Simone for any effects (NHS, 2007).
Dementia has been known to be referred to as having three stages. A comprehensive assessment has concluded that Simone has been diagnosed as having early stage dementia. The early stages of dementia it is also referred to as mild with the next stage known as moderate/middle and finally severe/late. Nice (2007) suggests that after Simone's received her diagnosis informing her of what this entails should be incorporated into her plan of care. As a nurse I would ask Simone if she wishes that her and her family receive this information. This information would include the signs and symptoms of dementia (NICE, 2007). Sign (2006) argue that the information should be offered to patients and their carers in advance of the next stage of the illness.
One of the problems arising from the assessment is that Simone appeared anxious about her diagnosis and what might happen to her daughter. This would be an important time for the nurse to attempt to gauge Simone's knowledge & understanding of the disease and offer information step by step depending on her ability to cope with it (Lecouturier et al 2008). ??????????????? The importance of a client centred approach is central when planning care for Simone (NICE, 2007). As a nurse it is important to recognise Simone's theory of her life, and to realise that what counts is her perception of her situation and not just what the expert may think (Rogers, 2003). In order to achieve this successfully the nurse may plan to establish a therapeutic relationship with Simone. Good communication between all those involved including the nurse, client, relatives and specialists within the multidisciplinary team must take place accordingly in order to create a holistic and individualised plan of care (Hinchliff et al, 2003).
As a nurse I could adopt the use of a model to provide a basic framework for the helping process for example Egan's skilled helper model (Hough 2006).This is concerned with obtaining the clients 'current picture', it helps clients clarify the key issues which require to be changed (Egan, 2007). The main principle is helping clients to tell their stories, whilst enabling clients to develop new perspectives that help them 'reframe' their stories, also to help clients achieve 'leverage' by determining which part to work on first (Egan, 2007). Skills the nurse could use here include basic listening skills, paraphrasing and reflecting, summarising, asking questions and using silence (Egan, 2007). These skills will underpin the therapeutic relationship (Rogers, 2003).
This model also looks at the 'preferred picture' and is concerned with helping Simone identify and choose what she wants, again the main principle here is to help her imagine a better future and help her choose realistic and challenging goals that are real solutions to the problems and unused potentials which have been identified (Egan, 2007). The third stage is concerned with the way forward, the main principle is to help Simone review and choose possible strategies, along with resources and put these into a realistic plan to achieve goals (Egan, 2007).
It is clear that Simone and her daughter wish to carry on living at home for as long as possible therefore by helping Simone recognise and understand the illness and its stages will assist in identifying her strengths and highlighting the things she can do as well as plan ahead for the future. At this moment in time Simone feels as though they are coping however respite could be part of the care package (NICE, 2007). Written and verbal information should be passed on regarding local support groups that Simone could attend on her own, or with friends and family.
It is important to encourage Simone's independence for as long as possible by encouraging her to carry on independently with those activities of daily living she still appears to be managing. Simone appears to be have isolated herself over the last few years therefore the option of attending a day hospital may be offered with transport to and from being put into place. The option of befriending may encourage Simone to get out and about in addition to support and companionship (Volunteer Centre, 2010).
As it has been reported that Simone has burned her food lately this could pose a risk to Simone and also her daughter. As part of Simone's plan of care I would be required to draw on the expertise of members of the multi-disciplinary team for example an occupational therapist who could visit in order to carry out a kitchen assessment. Simone's vulnerabilities and risks to herself and others, as a result of her cognitive impairment would be identified by carrying out a risk assessment. Part of Simone's care plan would include a risk management plan (NHS, QIS, 2007). This care plan would identify the roles and responsibilities for all members of the multidisciplinary team including Simone, her daughter, the community mental health nurse, occupational therapist, psychiatrist, social worker and also physiotherapist. Within Simone's plan of care it is vital to ensure that risk assessment is continuous as Simone's dementia progresses through the stages then so too will the risk to her and others increase. As a community psychiatric nurse I have a responsibility to draw on expertise from the relevant disciplines and make referrals accordingly (NMC, 2010) for example as Simone progresses through the stages there may be a risk of falls and therefore as part of the risk assessment and plan of care I would refer Simone to a physiotherapist.
As a nurse I should always seek valid consent from the person to share the information obtained via assessment with other agencies that may be involved in the care planning process (NMC consent). Simone has been presumed to have capacity to make decisions regarding her care and treatment however as the dementia progresses this may no longer be the case. If a person appears to lack capacity to make a decision then the provision of the Adults with Incapacity Act must be followed. This Act sets out principles which must be adhered to in addition to a Code of Practice, these principles include, presumption of capacity, supporting a person to make decisions, an individuals right to make unwise decisions, the best interests of the person and ensuring the least restrictive alternative (Griffith & Tenhnah, ????). As Simone appears to have been diagnosed early this allows time to discuss and plan for the future. This may include discussing the provisions of the above mentioned act for example, while Simone still has capacity she may nominate a spokesperson (attorney) to make decisions regarding her personal welfare including healthcare and consent to treatment should she become incapable. This is known as lasting powers of attorney (LPA).
Another provision under the Mental Capacity Act that may be discussed with Simone is that of Enduring Power of Attorney (EPA) where Simone could appoint someone which would give them the legal right to manage Simone's financial affairs.
As a nurse it is important to discuss the use of an advanced statement as part of the plan of care as this would enable Simone, while she is still well enough to do so, to write a statement which outlines the way in which she wishes to be treated should she become unwell and no longer have capacity (????).
Dementia is a terminal illness and NICE (2007) recommend a palliative care approach from the time of diagnosis until death. As a result the care plan should incorporate Simone's wishes in relation to end of life care for example a preferred place to die. The provision of palliative care in the UK is said to favour those with cancer (Fallon & Hanks, 2006) although those with dementia can have equally as severe symptoms and similarly poor prognosis. Therefore planning ahead for Simone's end of life care may result in a good quality service with improved experiences for Simone and her daughter (Scottish Government, 2008). Discussions might also take place around the possibility of a do not resuscitate decision, if Simone felt this was appropriate it could be documented. This would ensure that no attempt is made to resuscitate Simone in the event of cardiac arrest if this is her wish (National Health Service Scotland, 2010).
People who care for relatives with dementia are said to suffer higher levels of stress and ill health than the general public (Scottish Dementia Strategy). This may well be a significant change for Simone's daughter. As Simone wishes to stay at home it is vital that a carers assessment is carried out and appropriate support and information is provided as it may become too difficult for her daughter to sustain otherwise and could result in Simone requiring admission to care services. The option of respite should be a vital part of the care plan (NICE, 2007).
In conclusion, this essay has provided an explanation and discussion regarding the nursing care of a 69 year old lady who has recently been diagnosed with early stage dementia. This case study has demonstrated my knowledge and understanding of evidence based nursing practice and demonstrated my ability to utilise this in order to outline a plan of care.
Alzhiemers Scotland (2010)
National Health Service Choices (2009) Your health your choices: Dementia. [Online] Available from: http://www.nhs.uk/conditions/dementia/Pages/Introduction.aspx [Accessed 04th August, 2010]
Alzhiemers Society: Demography, Alzheimers Society position statement. [Online] Available from:http://www.alzheimers.org.uk/site/scripts/documents_info.phpcategoryID=200167&documentID=412 [Accessed 04th August, 2010]
Alzheimers Society (2007) Information Sheet: The Progression of Dementia. Alzheimer's Society. London. [Online] Available from: http://www.alzheimers.org.uk/factsheet/458 [Accessed on 3rd August 2009]
Department of Health (2009) Living well with dementia: A National Dementia Strategy. London. [Online] Available from:http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_094051.pdf [Accessed 3rd August, 2009]
Fallon, M., & Hanks,G ABC of Palliative Care. British Medical Journal. Blackwell Publishing.
Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-198.
Egan, G. (2007) The Skilled Helper. (8th Edn) USA: Thomson Brooks/Cole
Hinchliff, S., Norman,S., Schober, J. (2003) Nursing Practice and Healthcare (4th Edn) London: Arnold.
Hough, M. (2006) Counselling Skills and Theory. (2nd Edn) Great Britain: Hodder Arnold.
Kenworthy, N., Snowley, G., Gilling, C. (2006) Common Foundation Studies in Nursing. (3rd Edition) Churchill Livingston:USA.
NHS QIS 2007
Ouldred, E., & Bryant. C. (2008) Dementia care. Part 2: understanding and managing behavioural challenges. British Journal of Nursing. Vol 17. No 4.
Scottish Government (2008) Living and Dying Well - A National Action Plan for Palliative and End of Life Care. Edinburgh.
The Volunteer Centre
World Health Organisation (1992) The ICD-10 Classifications of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. WHO. Geneva.