Introduction to Dementia and Alzheimers Disease - Essay Example

Introduction to Dementia and Alzheimer's Disease In very simple terms, Alzheimer's disease is a disorder or a condition that causes a gradual, although extensive degeneration of the nervous system, often seen as a common, yet unnatural effect of ageing. Most of the cases reported involve people over the age of 60. However, a few cases have come to light where the patient was in his early fifties or even late forties. Approximately 24 million people worldwide are living with Alzheimer's (Ferri CP, Prince M, Brayne C, et al 2005). Estimates suggest that as many as 4.5 million Americans (ADERC-NIA, 2007) and 2.4 million Europeans suffer from Alzheimer's, which is considered to be the most wide spread form of Dementia in the human population. This brain and neuron disorder seriously affects a person's ability to carry out daily activities. This condition, called Dementia, which initially affects the parts of the brain that control thought, memory, and language, is taken to be a route map of the progression of Alzheimer's. From a medical perspective, the first signs of Alzheimer's disease are detectable from the lifestyle of affected individuals. However, the simplicity of these symptoms often result in them being ignored or dismissed as natural signs of old age. One of the earliest, yet most unnoticed symptoms of Alzheimer's disease is short-term memory loss. Very often, the patient appears to have skipped memories pertaining to a generation, or a similar time span, which essentially involves the present. Very recent incidents may be forgotten, while those which happened a relatively long time ago are vividly remembered, and oft quoted. Also, individuals and recent acquaintances may be completely forgotten, and may even be mistaken to be some individual the patient had acquaintance with, in the past. One hypothetical, yet practically very common, instance worth referring to is a case where a patient has no memory of his grandson's existence. On seeing the grandson, he may be mistaken to be the patient's son, and the patient may even make attempts to communicate with him in that context. Further symptoms may include problems with writing and speaking. The patient may forget simple words and make statements that don't make any sense. Familiar and routine tasks may prove difficult as time progresses. Common instruments used in daily life such as pens, towels, etc may appear meaningless to the patient. The patient may begin to dress inappropriately, completely forget to keep appointments and may even forget regularly used phone numbers. This is said to be a loss of the power of "Abstract Thinking" (Guide to Long Term Care.com). Also, repeated and unexplained mood swings and behavioural changes, quite contrary to the normal character are observed in such patients. As the disease progresses in the individual there may be a marked deterioration of control over his motor neurons, resulting in loss of mobility to considerable extents. The patient may be unable to feed himself, and incontinence may set in. 'Once identified, the average lifespan of patients living with Alzheimer's disease is approximately 7-10 years, although cases are known where reaching the final stage occurs within 4-5 years or at the other extreme they may survive up to 21 years'(Wikipedia, 2007a). Diagnosis and Clinical Perspectives Granted that the primary indications of a possibility of Alzheimer's disease in an individual are based on observations of the daily activities of the individual, the fact remains that it is primarily a clinical condition requiring diagnosis by qualified medical practitioners. Such a study shall be based on characteristic neuropsychological features and it must be ensured that no deferential diagnosis shall exist, considering the gravity of the possible result. Such a determination of the neurological feature shall consider the patient's medical history and clinical observation, while any neuropsychological evaluation will include testing and assessment of intellectual functioning over a series of weeks or months. Supplemental physical testing, including blood tests and neuroimaging, is utilized to rule out other diagnoses. Psychological testing, to include screening for depression and a mini mental state examination, can be helpful in establishing the presence and severity of dementia (Wikipedia, 2007a) At this point, it is worth mentioning the fact that all these supposed clinical trials for the purpose of obtaining a conclusive diagnosis of Alzheimer's disease is at best a very educated guess on the part of the practitioner. None of the medical tests currently in use as a test to diagnose Alzheimer's disease can be deemed conclusive. Doctors who specialize in memory disorders can provide a diagnosis of reasonable accuracy. However, the only cent percent acceptable confirmation of Alzheimer's disease is given by a microscopic examination of the suspected brain tissue. That, incidentally, is a post-mortem procedure. Overview of the Roper-Logan-Tierney Model (ADLs Approach) The Roper-Logan-Tierney Model is studied here, because the model being self explanatory may be more feasible for the nurses to familiarise themselves with, specially in the light of a form of caring required under the circumstances of degenerative disorders such as Alzheimers. Roper et al (1990:36) confirm that this model is deliberately structured so "to assist learners to develop a way of thinking about nursing in general terms." The Roper-Logan-Tierney (1990) model of living has admittedly been evolved from an existing model, it being a refined version of the Verginia Henderson model(Saliba, Vince, MUMN.n.d). The concept is based mainly on twelve activities of living which according to Roper et al (1990) are the main elements of nursing. These are the activities of living, which include maintaining a safe environment, communicating, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping, and dying. The fact that these twelve elements are conveniently observable or even to some extent measurable gains weight over the argument that there may be a marked difference between their applications on a healthy individual, as opposed to one in need of the said care. Besides the activities of daily living (ADLs), this theory also emphasises four other components, life span, dependence/independence continuum, factors influencing ADLs, and individuality in living. In brief Roper et al (1990) present the concept of the model as one which describes an individual's life span characterised by a series of activities which are performed by the same individual either independently or dependently. In case of a patient under care, this is with the help of the health care team. He/she maintains an optimum state of health or has a dignified death. These activities are individualised and are affected by physical, psychological, sociocultural, environmental, and politicoeconomic factors (Saliba, Vince, MUMN.n.d) One possible argument against the feasibility of the Roper-Logan-Tierney model, could be regarding its non-conformity to the established norms, as a task oriented and the physiological approach to nursing, the system may offer an opportunity for nursing personnel to take a holistic approach to care given to patients, as opposed to the disease specific method. Walsh points out that holistic nursing has become more common in recent years "as nurses have realised that there is more to a patient than a body." However Roper's model has been particularly prone to criticism since it does not clearly address the concept of holism in comparison to other models (Walsh 1989). It does seem that the majority of implementations of this model in practice, rather than attempting an integrated approach to the factors that influence these activities of living, tend to concentrate their nursing care towards the corresponding physical factors, which, as Roper et al(1990) suggest, is not as simple as may seem to be. As an example Roper et al (1983) considers the broad classes of the activities of eating and drinking over the sub-activities which they address, such as learning about diet, shopping, preparing, cooking, and serving food.(Saliba Vince, MUMN nd) Overview of the RCN Assessment Tool The RCN assessment tool, put forward by the Royal College of Nursing enables comprehensive assessment of an older person's health status, thus enabling identification of the need for input by a registered nurse, and through the application of a stability/predictability matrix an estimate of the level of nursing intervention needed is determined. The tool will assist nurses to both articulate and quantify the nursing contributions to care, within the context of contemporary good practice (RCN, 2004). The assessment assumes that the said practice under consideration will be delivered within the structure of an established nursing framework. But it also takes into consideration the extent to which the available skills and resources, whether within or outside the framework, is utilised. Some cases may arise where a nursing intervention may be such that it eliminates, in due course, the need for nursing care. This brings up a 'no nursing' option, where a nurse, rather than delivering the care directly, can manage a specific aspect of care or supervise others. Within this tool, ethnicity and culture are seen as integral components of every category (RCN, 2004) In the context of the care of individuals suffering from degenerative disorders such as Alzheimer's, who need long term care, it is often argued by the nursing community that undesirably fine distinctions exist between the health care needs and the social engineering needed to make sure that no rejection takes place, in either direction. However, most of this work is "invisible". These 'hidden' aspects (McKenna, 1995) can encompass highly intricate assessment, detection, monitoring and evaluation techniques, as well as subtle communication skills, which can help a patient to balance their health needs with their chosen lifestyle. Relevance in the face of diverse user groups There is no denying the fact that Alzheimer's disease bears a direct link to the lifestyle of individuals, and a major assessment of the risk of an individual towards contracting the disorder is based on an analytical study of the person's lifestyle. However, on a parallel, it is to be noted that no individual can be reliably said to be free of the risk. The disease may affect individuals from a variety of backgrounds, and this is a major factor in the identification of the appropriate nursing framework. This is because the needs of an Alzheimer's patient are considerably different from those of a patient suffering from other disorders. The most important point to take note of here is that unlike most degenerative diseases, the patient suffering from Alzheimer's is most often unaware of his situation. This often causes the patient to resist any form of external care, simply because he does not see any reason for the same. The externally appointed nurse is seen by him as an intruder. This very difference calls for a different approach to the care given to the Alzheimer's patient. Interestingly, the Roper-Logan-Tierney model of nursing, in spite of a number of arguments against the non conformity to established norms, has been noted for promoting a holistic approach to nursing care. This much criticized point, ironically, provides the ideal setting for the care of Alzheimer's patients, where a holistic approach is more suited than the specific treatment which my often prove inappropriate. Difficulties in daily life activities and the solutions(HEANSF,2000) Dressing Dementia patients often have trouble remembering the clothes and the manner one should put them on. They often even fail to recognize the need to change clothes with time or even by situation. They may choose to wear inappropriate clothing - for example, going out in the daytime in their nightwear. Possible solutions to this include laying out clothes in the order they have to be put on and on time. Also, simple clothes with Velcro, elastic, etc would be preferable over zips, fasteners, buckles, etc. Washing and Bathing Patients may often forget to wash, or may be unable to. Using taps maybe a problem. This may be exaggerated in incontinent patients where frequent washing may be necessary. Here, the care giver may try to establish and maintain a routine for washing. Rather than directly ordering the patient to wash, the pleasant aspects of the washing or bathing maybe highlighted and thus make the patient want to do it. Step by step instructions or even a demonstration may be required in some cases. Eating/Feeding The main problem in this aspect is that often the patient may forget whether he/she have eaten. They may develop strong dislikes of certain foods and cravings for others. They may also forget how to eat and in some cases they may even not know that food is meant to be eaten through the mouth, thus ending up playing with it. Solutions include having regular times for eating being built into the internal timetable, and the care giver eating with the patient in a bid to show them how to eat, as well as providing company. Food must be kept simple and easy to eat with minimal or no cutlery. Dehydration must be avoided. Socialising The main problem here is of wandering. The patient may venture out on his own without supervision. This is not a conscious effort to escape from the strict supervision of the care giver. Rather, the patient may not realize that he/she needs supervision or is being supervised. As far as outdoor wandering is concerned, traffic presents a threat on even the quietest roads and crowded, busy streets or shopping centers which were originally familiar can cause confusion and alarm. The most evident solution to this is for the care giver, or any person assigned for it to accompany the patient at all times. Some cases have been reported where trained dogs were used for accompanying them. Ensure the patient carries proper identification that is obvious to volunteers on streets. Alcohol and Cigarettes Generally speaking, there seems to be no reason to stop a person who is in the habit of drinking alcohol in moderation from doing so, just because he/she is diagnosed with Alzheimer's. Having a drink may be one of their last remaining pleasures, and is best had in the company of the caregiver or other individual the patient feels at ease with. However, it is of utmost importance to ensure that alcohol is not left out where the patient can help themselves. Also, it must be ensured that the drugs they are taking as part of the treatment are safe in combination with alcohol. The use of cigarettes represents a greater danger. People with dementia may not be safe with matches, and they may smoke in bed, leave lighted cigarettes on the edge of armchairs, or throw them away on flammable material. Losing things and accusations of theft Many people with dementia really do forget where they have put things; others deliberately hide things and then forget. In either case they may accuse people of stealing the missing items. The charges mustn't be directly denied. Any argument may cause them to be upset. Regular hiding places may be identified and replacements of any important articles such as spectacles maybe kept handy. Incontinence Incontinence can be the most embarrassing and most inconvenient aspect of Alzheimer's. Occasional incontinence may be caused by the fact that the patient may not realize the concept of a toilet existing for the purpose. Or they could be having trouble locating it or undressing. Possible solutions include regularly taking them to the toilet, making sure the toilet is close by and easily accessible and using easily removable clothing. Portable toilets or bedpans may be used. Also, washable covers on furniture make cleaning easier. Delusions and Hallucinations Although we know delusions and hallucinations to be imaginary, to the one experiencing it, they seem real enough. They may imagine people trying to kill them and these experiences can make life difficult for the others since it changes the attitudes of the patients towards them. When the patient is experiencing a delusion or hallucination, its best not to argue with them. Violence and Aggression All the difficulties faced by a person facing Alzheimer's give rise to a lot of frustration, which may come out as anger or violence. When it is directed at the carer it is especially distressing. The person may also show anger or aggression towards other family members. Several carers mentioned a particular problem with teenage children, whom people with dementia often seem to resent, perhaps because they represent youthfulness and hope that they know is over for them. Any response to aggression with aggression is to be avoided. If episodes of violence and aggression become frequent, medication may be necessary. Failure to recognize people A person with dementia often lives in the past. If a man thinks of himself as still in his forties, it is not surprising that he denies he is married to someone in her sixties or seventies or that he thinks his 40-year-old daughter is his wife. Possible solutions include keeping out large photographs of family occasions through the years, so that the person with dementia sees that he or she has also grown older has helped some families. Government Policy- NSF Standards & Major Projects The National Service Framework for older people proposed by the Department of Health, United Kingdom puts forward a set of eight standards, which my be enumerated as below Rooting out age discrimination Person-centred care. Intermediate care General hospital Stroke Falls Mental health in older people Promotion of health and active life in older age (NSF, 2007) The Department of Health, United Kingdom also initiates a number of projects for the purpose of imparting care to the individuals who suffer from Alzheimer's disease and other forms of Dementia. The Bradford Health Action Zone project, Salford Mental Health Services & Trafford Health Authority Old Age Mental Health Services review, Age Concern Oxfordshire Flexible Care-givers Service, South Manchester Memory Clinic, Teeside Young Onset Dementia Team, Rotherham Active in Later Life, East Leicester HImP and HAZ, Age Well programme in Sandwell Health Action Zone, Wolverhampton Health Action Zone's Older People's Forum, North Nottinghamshire Health Authority, Services for Older People in Thanet, etc are some of these projects focused on the primary care and rehabilitation of such individuals, on a regional community basis(Good Practice Examples, 2007). The salient features of these programmes are enumerated as below: Culturally sensitive support group providing learning materials for use by other facilitators in the future, resulting in increased coping ability for family care givers participating in the support groups, and an increased levels of understanding of dementia and dementia care Development of a facilitator support group course Increasing knowledge of existing services for people with dementia Conducting accredited training for primary care nurses in the identification and initial management of mental health problems in older people, including dementia, depression and other conditions and pilot training schemes for social workers, home care givers Defining basic protocols to assist primary care staff in making appropriate referrals Providing improved access to psychology, occupational therapy and counselling Provision of mental health/primary care liaison to promote mental health in older people and facilitate an effective primary/secondary care interface. Initialisation and further follow up visits at home by a member of the nursing staff Detailed neuropsychological assessment of the individuals who are supposedly at risk Medical review of the disorder, causes and care Diagnostic interview with the patient and their family Conclusion In conclusion, the most common problems faced by an Alzheimer's patient may be enumerated as below, to facilitate an 'at a glance' view: Loss of memory and a decline in the power of thought Inability to verbally convey ideas Loss of motor co-ordination Embarrassment and frustration out of realization of disability On a parallel, the steps to be taken by the care giver to counter these problems, thus enabling a better existence for the patient may be summarized as below: Keep things normal and as it has been familiar to the patient Retain the independence of the patient and avoid any feelings of inferiority Avoid confrontation and direct arguments Avoid crises and unfamiliar situations Establish routines the patient can adapt to or identify with Attempt to make things simpler, by finding new methods for old tasks Make sure all equipment and apparatus are safe Keep all channels of communication open for the patient to express his anxieties Maintain general fitness and health Alter the diet of the patient to facilitate self feeding, such as using finger food, while ensuring that the nutritional needs are met Use memory aids to induce familiarity with activities(HEANSF,2000) The table shows the number of individuals reportedly affected by Alzheimer's Disease in Europe (Health Action, 2006). The numbers have been rounded off to the nearest hundred. A marked increase is seen in the number of affected individuals between the age of 60-79. The first group, although composed of a larger span of 30 years, as opposed to 20 year spans in the other groups, have fewer numbers. The last group, 80-99 also shows a decrease in comparison to the 60-79 group. However, this is most likely due to the mortality of the individuals rather than any miracle cure as may be perceived at first sight. Also, men are seen to be more prone to the disease than women. This may also be a misrepresentation, because in most communities, the symptoms of Alzheimer's in a woman are often erroneously dismissed as post menopausal disorders. References 1. Ferri CP, Prince M, Brayne C, et al (2005). "Global prevalence of dementia: a Delphi consensus study". Lancet 366 (9503): 2112-7. DOI:10.1016/S0140- 6736(05)67889-0. PMID 16360788. 2. Alzheimers Disease Education and Research Centre, National Institute on Aging (ADERC-NIA), "Alzheimer's Disease Fact Sheet", Updated Aug 29, 2007 3. Guide to Long Term Care.com "Alzheimer's Disease: Possible Early Warning Signs" (http://guidetolongtermcare.com/alzheimers.html) 4. Cai D, Netzer W, Zhong M, Lin Y, Du G, Frohman M, Foster D, Sisodia S, Xu H, Gorelick F, Greengard P (2006). "Presenilin-1 uses phospholipase D1 as a negative regulator of beta-amyloid formation.". Proc Natl Acad Sci U S A 103 (6): 1941-6. PMID 16449386. 5. Wikipedia, The Free Encyclopedia. "Alzheimer's disease" (2007, August). (http://en.wikipedia.org/w/index.phptitle=Alzheimer%27s_disease&oldid=15245 9923) 6. Wikipedia, The Free Encyclopedia. "Dementia". (2007, August). (http://en.wikipedia.org/w/index.phptitle=Alzheimer%27s_disease&oldid=15245 9923) 7. Saliba, Vince, "The Roper, Logan and Tierney Model of Living in relation to the Intensive Care set up", The Malta Union of Midwives and Nurses 8. Walsh M (1989) Model Example. Nursing Standard. No.22 Vol.3 pp.22-24. 9. About Alzheimer's Care, Psychological Aspects of Challenging Behavior in Alzheimer's Disease 2007, The New York Times Company (NYTC) 10. "Nursing assessment and older people - A Royal College of Nursing toolkit", Royal College of Nursing, 20 Cavendish Square, London,W1G 0RN, 2004 11. McKenna H, "Nursing skill mix substitutions and quality of care: an exploration of assumptions from research literature", Journal of Advanced Nursing, 21 (3), 1995 12. National Service Framework(NSF), Department of Health, UK, Crown Copyright 2007 13. Good practice examples in the National Service Framework for older people, Department of Health, UK, Crown Copyright 2007 14. "Nest Egg Europe: Dementia in numbers", Health Action, Aug 2006 15. Health Education Authority, National Service Framework for Mental Health, 2000, "Who Cares: Information and support for the carers of people with Dementia" (HEANSF,2000) Read More