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Mr X is a 78 years old gentleman who has been admitted to a busy dementia unit six months ago. He was admitted from home following increasing lethargy, depression and reduced mobility. Prior to the admission he was diagnosed inter alia with Vascular Dementia. He communicates verbally with no difficulties, using very wide vocabulary however can mix up words and situations. He was assessed as lacking capacity to make informed decisions. Mr X has one daughter who is of the opinion that her father lacks insight into the difficulties he was having at home believing that he was managing fine. Mr X’s wife (Eva) died few months ago, in a hospital suffering from breast cancer. Mr X was very involved into her care throughout the illness and cannot accept the loss.
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Mr X, does appear to have an understanding of the sourroundings albeit he is very quiet most of the times almost like having no intrest of what is happening around him. He appears unable to generate any enthusiasm.
Mr X remains independent in terms of personal care, use of facilities, eating and drinking and requires minimum assistance and maximum encouragement and prompting. He is able to mobilize with a zimmer frame, though seem to feel best sitting in a chair in his room, even at “meals or activities times”.
In relation to the above three main problems that interlock have been identified
1. Depression and its effects
Mr X cannot reconcile yourself to the loss of his wife, changes in life his physical and mental health resulting in depression and progress in dementia. He appears isolated, lost a lot of weight; apathy and withdrawal are present affecting seriously his ability to perform everyday tasks.
According to him, to his daughter and to the information gained on assessment using Initial Dementia Assessment (IDA) he used to enjoy reading books, travelling and had an outgoing personality. The IDA indicated that the dramatic change and deterioration in his condition was noted when his wife passed away and he was told that he is having dementia. On the Mini-Mental State Examination (MMSE) Mr X scored 20/30 which could suggest that his dementia is not severe and that there may be other reasons for his withowal. His score could have been slightly inflated because well educated people like Mr X find thequestions “easy” to answer (Marshal at al 1983) but he could be described as “ mildly confused”.
One of the MMSE questions related to language skills was about writing a sentence about anything. Mr X wrote a short statement “Eva is not here and I have dementia”.
Research show that coping and getting along with the diagnosis of dementia is a time-consuming process often related to a range of emotions such as: fear, shame, guilt, sadness, bitterness, isolation and helplessnes. (Alzheimer Europe, 2009) Mr. X appeared to feel overwhelmed by those emotions.
Paying attention to non verbal signs of Mr X bevaiour helped staff to investigate his case further. He often avoided eye contact, showed no inattentiveness his appetite decreased and his posture expressed “tiredness of living”. Studies of nonverbal behaviour indicators in show that this type of signs are often related to post traumatic stess disorder ( PTDS) and that men are more likely to show depression in a form of isolation and withrowal (Stratou at al, n.d.).
2. Upset family relationships
Assessment tools demonstrated that family was very important to Mr X.
When communicating with the daughter lack of understanding dementia, depression and PTDS were identified as an important factor contributing to Mr X situation. Evidence show that above named health issues have an impact on family members; relationship difficulties are common and it it not easy to understand the “loved one”. ( Alzheimer’s Society, 2013). The main concern was no communication with the father and unwillingness to spend time with him to enable him to accept his chalanging situalion. She could not imagine that her normally happy and sociable father was so depressed, and in addition diagnosed with dementia which meant he became “a stranger” to her.
3. Challenging behaviour
Whilst staff members were doing their best trying to motivate and encourage Mr X to get more involved into his care and the care home life, Mr. X refused everything or simply ignored them. The efforts had a negative impact on him and caused reactions such as pretending to be dependent and irritating staff. These types of reaction have been identified by Wallbridge as types of aggression called “ active resistance” ( Wallbridge, n.d.). Staff then presented negative attidude and disaffection towards Mr X. Evidence suggests that behaviours, including uncooperativeness, staff find difficult to cope can lead psychological stess amongst staff and discourage them to deepen knowledge related to the health problem of the patient. ( Brodaty at al, 2003)
From the above assessment a list o goals have been created in order to improve the quality of life for mr X which is aimed to be archived through:
- creating an environment where Mr X could feel emotionally safe, supported and understood
- helping him understand, manage and accept his condition .
- Lowering the level of lethargy and depression and stimulate functional ability, social contact and activity by encouraging him to talk and listen to what he is saying
- Stimulating and motivating Mr X to create new habits related to maintain his physical independence, eating and help him use his potential
- involving Mr X’s daughter into care and help her understand the complexity of her father’s condition to make the psychosocial interventions better and improve Mr X behaviour and mood as well as increase his acceptability of the care home settings. Encourage her to let Mr X know that she cares about him and to stay in contact with him by visiting him, taking him out, calling etc to minimise the isolating experience
- training for staff in relation to challenging behaviour and dementia awareness, communication, behaviour and work related stress management
The desired outcome is partially based on the outcomes from the research done amongst people with mild dementia and suffering on depression that have successfully managed to improve their lives, that was done was done by the social work department of University of Stirling for the Scottish Executive. (Scottish Executive Social Research 2005)
In relation to problem 1
Assessment using IDA and MMSE indicated that Mr X condition is affected by depression. Further investigation has been done. GP and the Liason Psychiatric Nurse have been contacted and involved.
Mr X scored 23/30 in the Geriatric Depression Scale (GDS) indicating severe depression. (Yesavage et al, 1982)
It has been decided that his depression should be addressed first because it was the major factor preventing Mr X from enjoying life similarly to like he used to. It is known that the effects of depression go far beyond the mood ( Smith at el. 2014).
In Mr X case this had an impact not only on his energy, appetite, and physical activity but also on his relations with family and staff.
In relation to the weight loss Malnutrition Universal Screening Too (MUST) (BAPEN, n.d.) has been used. Initial MUST score was 0 with healthy BMI but due to his poor appetite the score rose to 1 within 3 months. Therefore his dietary intake was documented in a form of Food and Fluids Record Chat ( Care NHS UK, n.d) and his weight was monitored every two weeks.
In relation to diet intake Mrs X was offered meals according to his likes suggested by his daughter and accepted by himself which significantly increased the likehood of an “ consumed meal” .
After 2 months his weight stabilised. He remains “ poor eater” and therefore his meals contain more calories. His weight is currently monitored once a month and is not a concern anymore. Changes are documented in his care plan that is evaluated every month.
Studies show an association between depression and increased mortality in older adults. Factors identified in Mr X case included poor adherence , lack of physical activity, cognitive impairment. ( Gallo et al 3013)
From the point of his medication, a rviewd was requested by the GP and and it has been suggested to discontinue Paroxetine(Seroxat) and commence on Amitriptyline. Both belong to antidepressants but vary in side effects. ( NHS Choice, 2013). In addition it has been requested to commence Mr X on regular laxatives as episode of constipation have been noted. Currently Mr X bowels are monitored and documented on bowels chart on daily basis. No concerns have been noted.
In relation to problem 2
Reduced sense of purpose was identified as the main co-existing factor
To help Mr X overcome this problem (which he expressed clearly during the MMSE mentioning the loss of his spouse and dementia diagnosis) his daughter was asked to participate and although she was initially sceptical she brought meaningful memoralia and small pieces of furniture to help him feel like home. Staff gave her assistance and explanation in relation to dementia and depression. She was also offered help and given reassurance in a form of Family Support Meetings organised by the home. The initial scepticism disappeared with gaining awareness of the illness. She became Mr X advocate and currently holds medical and financial power of attorney for him. ( Office of the Public Guardian, Scotland, n.d.) Furthermore her two sons come regularly to visit Mr. X, they often take him out for a meal or call him to find out how he is.
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Staff has also managed to discuss one the most sensitive matters related to Mr. X’s End of Life such as DNACPR certificate that is present in Mr X file in the event of need. Mr. X’s relationship with his daughter and grandsons appears happy. The daughter stated that this helped also her to resolve personal problems she feels acknowledged by her father and therefore valued. There is a Family/Relatives Communication part in Mr X care plan and a book in Mr X room where any suggestions, complaints or comments can be made by staff members or by the family .(U.S National Library of Medicine, 2011)
The relation with staff can be defined as very good. A person’s family is often the most important, long-standing connection in their life. Therefore, the ability of staff to work positively and inclusively with families and carers is a core staff skill.
In relation to problem 3
Most of the staff required training to help them understand the nature of behaviour that challenges. The importance of the training this became so vital that it is now one of the mandatory trainings every member of staff has to attend. Skills that were aimed to be improved included addressing challenging behaviour, person centred approach and communication skills (Skills for Care, 2013) Many staff showed the need to be trained in related to stress management (Wallbridge, n.d.) The future aim is to create a team that focuses on people’s assets and life outcomes. A team that is confident of their roles and impact on Mr X and any other client, willing to contribute and encouraging new members of staff to learn.
Summarising, Mr. X case has been an example of mostly successful process of assessment and implementation of the planned actions. There was and so called “multi agency” approach to Mr X needs. Assessment tools helped in the identification and articulation of the needs and contributed to positive changes leading to holistic, personalised approach to them. Recent changes to the social care management and the need to comply with the Public Services Reform Scotland Act 2010 contributed to the awareness in relation to staff due to the accent on the importance of systematic and sensitive assessment.
Mr X’s continuing care did not require up to now any specific nursing interventions.
The difficulty consisted of identifying the roles and the division of work.
Mr X’s case proved that there are different functions staffs have to complete that contribute to the optimum health and overall wellbeing of older people such as:
- psychosocial and emotional support enabling life review – where the family support was crucial but required time to function
- work aimed at maintaining his independence and functional ability that continues to be improved through the aspiration of a well functioning team work.
- educative – teaching self-care activities by encouraging physical activity
- managerial- directions in terms of who and when undertakes the administrative and supervisory responsibilities could have been improved.
All the above reduces to good knowledge, awareness, and experience, will power to change things for the better and to a well functioning team work. Many things would have been done sooner or could have been dealt with better if we were aware of the need and knew how. This is why it would be recommended to pay more attention to training needs in relation to new regulations, staff assessments, achieving and evidencing outcomes, person-centred care planning.
Office of the Public Guardian( Scotland)( n.d.) http://www.publicguardian-scotland.gov.uk/whatwedo/power_of_attorney.asp
Care NHS UK ( n.d.) Food and Fluid Record Chart http://www.glos-care.nhs.uk/images/Food_and_Fluid_chart_-_attachment_31_copy_copy_copy.pdf
(BAPEN, n.d.) Malnutrition Universal Screening Tool http://www.bapen.org.uk/pdfs/must/must_full.pdf
Skills for Care (2013) Supporting staff working with people who challenge services Guidance for employers http://www.skillsforcare.org.uk/Document-library/Skills/People-whose-behaviour-challenges/Supporting-staff-working-with-challenging-behaviour-(Guide-for-employers)vfw-(June-2013).pdf
U.S National Library of Medicine (2011) no author Communicating with families of dementia patients Can Fam Physician Joulrnal Vol 57(7): 801–802 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3135450/
NHS Choice ( 2013) Antidepressantshttp://www.nhs.uk/conditions/Antidepressant-drugs/Pages/Introduction.aspx
Melinda Smith, M.A., Lawrence Robinson, and Jeanne Segal, Ph.D. Last updated: February 2014. Depression in Older Adults & the Elderly http://www.helpguide.org/mental/depression_elderly.htm
Gallo, J., Morales, K.H.,Bogner, H.R, Raue, J.P, Zee,J, Bruce M.L and Reynolds C.F(2013) BMJ Helping doctors making better decisions Long term effect of depression care management on mortality in older adults: follow-up of cluster randomized clinical trial in primary care http://www.bmj.com/content/346/bmj.f2570
Scottish Executive Social Research (2005) Effective Social Work with Older People http://www.scotland.gov.uk/Resource/Doc/47121/0020809.pdf
Wallbridge, H. ( n.d.) When pushed to the limit:Moving beyond a difficult situation http://www.alzheimer.mb.ca/handouts/When%20Pushed%20to%20the%20Limit…Moving%20Beyond%20a%20Difficult%20Situation.pdf
Alzheimer Society (2013) Understanding and respecting the person with dementia file:///C:/Users/GEORGE/Downloads/Understanding_and_respecting_the_person_with_dementia_factsheet.pdf
Stratou,G., Scherer,S., Gratch,J. and Morency, L.P. (n.d) University of Southern California, Institute for Creative Technologies, Los Angeles Automatic Nonverbal Behavior Indicators ofDepression and PTSD: Exploring Gender Differences http://ict.usc.edu/pubs/Automatic%20Nonverbal%20Behavior%20Indicators%20of%20Depression%20and%20PTSD-%20Exploring%20Gender%20Differences.pdf
Alzheimer Europe (2009) no author Facing the diagnosis Diagnosis of dementia http://www.alzheimer-europe.org/Living-with-dementia/After-diagnosis-What-next/Diagnosis-of-dementia/Facing-the-diagnosis
Marshal F. Folstein, MD; Lee N. Robins, PhD; John E. Helzer, MD (1983) The Mini-Mental State Examination JAMA Network Journal Archives of General Psychiatry Vol 40, No. 7 http://archpsyc.jamanetwork.com/article.aspx?articleid=493108
National Chronic Care Consortium and the Alzheimer’s Association (2003) Tools for Early Identification,Assessment, and Treatment for People with Alzheimer’s Disease and Dementia http://www.alz.org/national/documents/brochure_toolsforidassesstreat.pdf
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