Patient with COPD and Vascular Dementia Scenario - Essay Example

?Managing Long Term Health Care Needs This essay will demonstrate the bio psychosocial interventions in management of long term health care needs in a case of Chronic Obstructive Pulmonary disease (COPD) and the effects of these needs to the individual, family and carers. This essay will make use of the best available evidences and strategies in meeting these needs, taking into consideration the ethical and legal perspectives in COPD health care management. This paper will explore the nature of COPD with reference to the case of a 75 year old patient diagnosed with emphysema and vascular dementia. Chronic Obstructive Pulmonary disease (COPD) COPD generally refers to a condition wherein the airways are destroyed, narrowing the airways and eventually obstructing the air flow, impairing gas exchange. This condition is a combination of chronic bronchitis, emphysema and asthma. It is an irreversible, incurable, progressive but a preventable condition (Black & Hawks, 2005; British Lung Foundation, 2007). It is estimated that 3.7 million people in the United Kingdom are suffering form COPD, while only 900,000 are currently diagnosed, leaving the remaining 2.8 million unaware of their disease (British Lung Foundation, 2007), while 25 million in the United States (National Heart, Lung, and Blood Institute, 2009). Among those who are greater than or equal to 65 years old, the occurrence is estimated to be 34 out of 1000 (Torres & Moayedi, 2007). These values tend to increase over time due to increased tobacco consumption worldwide. COPD ranks from fourth to sixth as the leading cause of sickness and death worldwide (Mathers & Loncar, 2006; Viegi et al, 2007). According to Berry and Wise (2010), mortality can be predicted by the values of forced expiratory volume in one second, ratio of inspiratory and total lung capacities, and the BODE index (body mass index, obstruction, dyspnea and exercise capacity). Despite the severity of this condition, it is frequently under-diagnosed and under-treated (Viegi et al, 2007). Almost all cases of COPD developed symptoms, more than half manifests productive cough and half of the cases passed the Global Initiative for Chronic Obstructive Lung Disease criteria for emphysema (Lundback et al, 2003). Age, gender, race, smoking history, blood type, alpha1-antitrypsin variation, socioeconomic status, occupation, pollution exposure and infections are the known risk factors for developing COPD (Cohen et al, 1977). Race is also a factor in developing COPD, wherein whites has an odds ratio of 3.1 in dying from this condition (Meyer et al, 2002) though African Americans appear to be more susceptible to the effects of COPD than whites (Chatila et al, 2004). Among those risk factors, smoking is the most prominent cause of COPD. According to the World Health Organization (WHO), 40% to 74% who die from COPD are smokers (Mannino & Buist, 2007). Meyer et al (2002) reveals more than 80% of deaths from those who experienced smoking before and during COPD morbidity, while the odds ratio of those who currently smokes versus those who stopped smoking are 6.5 and 3.7 respectively. Aside from irritants from smoking, occupational-related vapours, gas, dust and fumes exposure is also a risk in developing COPD (Blanc et al, 2009). The numerous irritants, either from cigarette smoke or from environmental pollution, stimulate inflammatory response along the bronchi and the alveoli. The COPD-related effects of this response are increased mucus production and the release of protease and elastase, enzymes that can damage the lung’s connective tissues. Without adequate alpha1-antitrypsin to counteract the effects of these enzymes, tissue destruction will be progressive. This destruction collapses the alveoli, allowing air pockets to form between the alveolar spaces. The elasticity of the alveolar walls is also altered, making expiration more difficult. These air pockets increase the lung area that cannot facilitate gas and blood exchange, thus this is where the manifestations of emphysema set in. As the gas exchange is altered, oxygen and carbon dioxide are not effectively exchanged. With decreasing oxygen concentration while increasing carbon dioxide concentration in the blood, increase in respiratory effort is stimulated, resulting to progressive dyspnea. A characteristic enlargement of anteroposterior diameter of the chest is evident due to the increased lung area, which sounds hyper-resonant upon chest percussion. Moreover, the increased lung area due to these air pockets compresses the nearby structures, which includes heart. The expansion of lung area causes the heart to deviate to the right (right axis deviation). As the heart is being compressed by the lungs, its pumping effort must be increased to maintain adequate pulmonary and peripheral circulation. An eventual result of this is the increase in cardiac muscle mass, thereby manifesting an enlarged heart. When this compensatory action of the heart fails to maintain adequate circulation, all of the body systems are affected, including the brain and the periphery. Additional manifestations, like cyanosis of the lips, clubbing of fingers and pitting oedema (true to chronic bronchitis, not to emphysema alone), will also appear (Black & Hawks, 2005). There is a large economic burden for patients afflicted with COPD. In the United States, it accounts for estimated total economic costs of $23.9 billion in 1993, having $14.7 billion due to direct treatments while the rest as the loss in future earnings (Sullivan et al, 2000). In the United Kingdom, each patient spends ?163,908 of both direct and indirect costs yearly, while it accounts an overall cost of loss of productivity by 41% (Britton, 2003; Wouters, 2003). Functional limitations like lower extremity function and weaker muscle strength are also aftermaths of COPD (Eisner et al, 2008), contributing to occupational limitations. Patients suffering from COPD are affected psychosocially. It is associated with a low quality of life scores (median modest impairment in overall quality of life of 52), associated with the distressing physical and psychological symptoms of the disease (Blinderman et al, 2009). Among the psychological distresses in COPD patients, anxiety and depression are significantly associated with poor quality of life (Barcells, 2010). Quality of life tends to be the same or became better after treatment (Wildman et al, 2009). Vascular (Multi-infarc) Dementia Vascular (multi-infarc, multi-stroke or arteriosclerotic) dementia is a condition where the patient suffers an irreversible memory loss, including reasoning judgment and language, caused by an irreversible destruction of brain neurons, impairing cognitive function (Black & Hawks, 2005). About 5 out of 10,000 people suffer from dementia while 48 out of 10,000 people among those who are above 65 years old (Molsa, Marttila & Rinne, 1982). Only 16% of dementia cases are vascular type (Lobo et al, 2000). About 13% of those with dementia have co-existing COPD (Formiga et al, 2008). Age, stroke episodes, arterial hypertension, diabetes mellitus, alcohol consumption, smoking and cardiac diseases are risk factors for vascular dementia (Yoshitake et al, 1995; Skoog, 1994). Smoking has a relative risk value of 1.8 for vascular dementia (Anstey et al, 2007). More than half of dementia cases have history of hypertension, wherein the increased risk is more of vascular dementia, with a rate ratio of 1.8, compared to Alzheimer’s disease (Posner et al, 2000). Vascular dementia occur secondary to stroke being an aftermath of brain ischemia and infarction within the brain’s hippocampus where memories are encoded. Brain tissue hypoxia occurs when blood flow is inadequate to meet the demands of the brain. The effect of COPD to the circulatory system is the probable cause of inadequacy of oxygen supply in the brain. Without adequate oxygen, brain ischemia and eventual infarction will occur. The high susceptibility of penumbral neurons contributes to neurological deficits manifested by stroke victims, and when it occurs at the hippocampus, cognitive function is also impaired (Black & Hawks, 2005). The prognosis of vascular dementia is poor, and the mortality is higher than other cognitive impairments due to its cardiovascular involvement (Ostbye, Hill & Steenhuis, 1999). National Frameworks In relation with COPD management in a national level, the Equity and Excellence: Liberating the NHS (2010), the Government aims to reduce morbidity and mortality and improve patient outcomes. Also, according to the High Quality Care for All: NHS Next Stage Review Final Report (Department of Health, 2008), one of the challenges that the NHS is facing in this century is the changing nature of disease related to choices of people make, which includes smoking. In a community level, awareness-raising, smoking cessation services, diagnosis, treatment and care are aimed to be improved by the NHS, in efforts to treat COPD as early as the mild stages before it becomes progressively severe (British Lung Foundation, 2007). Strategies for Organising Nursing Care The Department of Health implemented the National Strategy for COPD (including asthma) to improve care for those who have this condition and reduce its morbidity, having three goals: health and social services for those who are diagnosed, COPD prevention and support for patients and their carers. This strategy does not only address the condition, but also the ways on preventing it, and minimising its debilitating effect should it be irreversible. The health and social services for those who are suspected to be having COPD is composed of assessment, diagnosis, planning, intervention and evaluation of care. History taking focuses on smoking history, age over 35 years old, breathlessness, cough and exercise intolerance. Diagnosis begins with head-to-toe physical examination, peak expiratory flow readings, spirometry, reversibility test (response to corticosteroids), chest radiograph, complete blood count, ECG readings and pulse oximetry (Currie & Legge, 2006). The interventions for management are aimed in improvement of ventilation, removal of secretions, and prevention of complications, delay the progression and promote health (Black & Hawks, 2005). Future trends in COPD management involve the development of new bronchodilators, more effective smoking cessation strategies, treatment of inflammation of airways and lung repair (Barnes, 2006). Prevention strategies for COPD are composed of COPD awareness campaigns, smoking cessation programs, and others. A number of recommendations are presented by the British Lung Foundation (2007): (1) Government action on information dissemination about importance of lung health, (2) improve awareness, diagnosis, treatment and care of people with the disease, improve quality of life and reduce emergency hospital admissions, (3) advertising, direct mail and telephone, (4) smoking cessation services, (5) mobile breathing tests, (6) spirometry for smokers age 35 and above, (7) training of those who will provide spirometry and (8) confirmation with a lung specialist once severe COPD is identified. Enabling Patient with COPD and Vascular Dementia Like the patient described in the scenario, COPD patients in the UK are diagnosed only when it became severe (British Lung Foundation, 2007). The current condition would have been prevented if she and her family are aware that she has the disease even before she begin complaining the late manifestations for 3 months. There was no information available about her past illnesses three months before, whether she suffered acute exacerbations or even stroke episodes. She would have a better prognosis if the progress of COPD was detected at an earlier stage. This time, she was diagnosed with two irreversible conditions which would mean that she is already on her end of life stage. COPD and vascular dementia are irreversible, but it is possible to delay the progression of COPD and memory loss thru a tertiary level of prevention: minimise complications associated with the disease process. Among the nursing diagnoses applicable for her and her family are: ineffective cerebral and peripheral tissue perfusion, impaired gas exchange related to emphysema, ineffective airway clearance, ineffective individual therapeutic regimen management, self-care deficit, impaired cognitive processes, ineffective coping, interrupted family process and caregiver role strain. In a larger scale, the problem would be ineffective community therapeutic regimen management due to the low profile of COPD in the United Kingdom according to British Lung Foundation (2007). Ineffectiveness of tissue perfusion is secondary to impaired gas exchange, thus interventions that will promote an improved gas exchange are suggested: continue oxygen administration, place on High-Fowler’s position and continuance of bronchodilators (salmeterol and tiotropium). Ineffective airway clearance can be addressed by effective coughing techniques and chest physiotherapy (Black & Hawks, 2005). The coexisting vascular dementia is responsible for the impairment of cognitive processes. By this stage, wherein the patient is still able to smoke 10 cigarettes per day, the patient’s memory hasn’t deteriorated totally. It is important that advanced directives and living wills are settled before the mental capacity of the patient eventually deteriorates to make these legal decisions possible. The daughter may consider gaining a power of attorney concerning the health care of her mother in case her cognitive ability progressively worsens. Although it is also important to assess the psychosocial aspect of the patient, there is not enough information that can be obtained, considering the progressive memory loss she is experiencing. The problem in terms of psychosocial aspect is more evident on her carer, her daughter, who is starting to feel that she can no longer cope with caring for her mother. Her mother’s self-care deficit is augmented by her daughter, but the interruption of family processes and caregiver role strain must be addressed by nursing intervention. To address this, the nurse can plan with the patient and her significant others about the interventions that she can consider. Her daughter cannot do this alone, thus a wider social support is needed, which could come from her family and/or her friends. Smoking cessation helps in preventing the further progression of COPD and dementia. The patient must understand that her situation is because of smoking, and it is recommended for her to stop it immediately if she wants her to delay the progression of her condition. Ethical and Legal Considerations In management of severe COPD with vascular dementia, ethical and legal issues might arise, especially with a deteriorating mental capacity to make decisions. The patient, if still capable, can make an advanced decision, for example, to stop respiratory therapy (Horfarter & Weixler, 2006). In case the dementia progresses to the point that she can no longer makes decisions, she and her family is ready on how will the plan of care goes during the end stage of her disease. Ethical issues in COPD are not uncommon. There is no current clinical factor to identify those who will not benefit from intubations and ventilation support devices (American Thoracic Society, 2009). In case she is no longer able to make decisions and there was no advance decisions made, ethical dilemma will set place, whether to withdraw an ineffective respiratory support or not. The principle of non-malefiscence prevents causing harm that the withdrawal of those devices may do, but the principle of justice would suggest that treatments that do not make improvement of patient are unnecessary and costly for the family. Advanced decisions, if the patient is still capable of making decisions, will lessen these ethical dilemmas. Conclusion Managing health care needs of a patient with Chronic Obstructive Pulmonary Disease, complicated by a co-existing vascular dementia, poses as a challenge for the public and health professionals, especially in the United Kingdom. The Government aims to reduce the morbidity and mortality of COPD and improve the outcomes of those who already have this condition. 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