Promoting Good Health in Patients with Dementia - Research Paper Example

Promoting Good health in Patients with Dementia Introduction Dementia is a degenerative brain condition characterized by lessened intellectual functioning, memory loss and impaired memory, language, reasoning, judgment and perception. It may also lead to emotional and behavioural instability, and lead to personality changes. Classifications of dementia are based on primarily the causative factors. The classifications may also be based on the symptomatic features of the disorder ranging from cortical problems (thinking, language, social factors and memory), sub-cortical functions (movement and emotions) and cognitive functions. Based on the causes of dementia, Alzheimer’s disease is the major cause, but secondary causes also have a role to play. This includes secondary brain conditions and injury to the brain substance secondary to trauma. Alzheimer’s disease is a degenerative brain condition affecting memory and cognitive brain functions, and is the commonest form of dementia in people over the age of 65. Vascular dementia results from cerebrovascular or cardiovascular problems which often result in strokes. Minor but important causes of dementia include HIV diseases, Huntington’s disease and Creutzfeldt-Jakob disease. Dementia is a condition whose principal prevalence is in old people over 65 years, but children and middle aged adults may suffer from dementia. Trauma, brain tumours, heart conditions, lung conditions, poisoning and some terminal infections may lead to dementia in this group. Some inherited disorders like glycogen storage diseases and mitochondrial abnormalities are specific for children, causing dementia. Whatever age group affected, dementia is a serious condition that leads to progressive memory loss and degenerative cognitive functions. Treatment will never reverse or stop the condition, but instead the treatment reduces the symptoms, thereby slowing down the disease progression. Apart from symptom alleviation, adequate rest, nutrition and hydration are very important as they reduce morbidity and mortality. In terminal dementia, the patients are unable to cater for themselves completely which calls for the input of the caregiver in providing optimal nutrition and in the correct proportion. In dementia, there is degenerative brain loss due to loss of neurons. Dementia is associated with malnutrition due to the feeding difficulties in people who suffer from the condition. Impaired cognitive functions lead to a deficit in the short-term memory making the patient forget simple tasks like feeding. The patient may also become easily distracted, thereby compromising eating functions. With the progress of the condition, there is impairment in performance of skilled movement, a condition called apraxia. There is loss of comprehension of sensory stimuli (agnosia). With apraxia, the patient is unable to use eating utensils, and with agnosia, the patient is unable to recognize the food or even have no clue on what to do with it. With dementia, there is also physical dysfunction and motor impairment. This leads to the loss of fine motor skills necessary to direct food to the mouth. There is also impaired olfaction and gestation. These reduce appetite and the urge to take food. There is also uncoordinated chewing and swallowing. Finally, dental problems compound feeding difficulties. All these contribute to poor nutrition. Moreover, the psychological depression and social withdrawal makes the patients refuse to take food. The problem is worsened when medications are subscribed to treat the depression. These medications lead to agitation which complicates feeding. As a result of this, there is need to monitor nutrition and ensure that dementia patients are compliant to eating and eat in full. Literature Searching process The author of this paper gathered information from several scientific and academic research papers as well as projects and other dementia related literature to develop a comprehensive picture on aspects related to promotion of good nutrition in dementia people. Much of research documentation and information was derived from resources available on the internet and academic websites such as EBSCO HOST/CINAHL PLUS. The terms dementia, feeding difficulties, nutrition and malnutrition were the search terms used in the databases so that information would be gathered on the ways in which caregivers can promote noteworthy nutrition in patients with dementia. After typing these terms, there were hundreds of material derived, but in order to tone down on the subject matter of the research, only those articles that were specific of dementia and nutrition were selected. There was emphasis on promoting nutrition since some articles only had information on why dementia patients have poor feeding and nutrition without giving measures necessary to avert this problem. The websites above were selected for having a noteworthy reputation of having thoroughly researched material in a wide array of topics. The databases also have academic material which is updated yearly, which ensures that the contents are accurate and up to date as per that particular subject. It is possible to develop a comprehensive picture on the promotion of good nutrition in people with dementia and anticipate the most probable developments. The picture makes it possible to derive some direct application of policies and strategies in solving risks related to malnutrition in people with dementia specifically when coupled with other related factors. Main Body of Research Dementia causes progressive loss of cognitive ability and remote brain functions, and one of the processes compromised is feeding. Not just dementia causes malnutrition and impaired feeding. In the hospital setting, malnutrition is a problem that commonly affects older people. Sixty percent of older individuals are at a higher risk of being malnourished; hence this results to the worsening of their illness, when in hospital (Age Concern, 2006). People having dementia are one of the most vulnerable individuals of society. It is approximated that 560,000 individuals in Britain do have dementia and it is expected that this trend will rise (Rafferty et al, 2007). This condition leads to the inability of an individual to feed her or himself and may change the appetite leading to deficiencies of potential nutrient. However, despite this condition leading to malnutrition, it is critical to remember that the condition is as a result of multiple factors that may be functional, physical, cognitive and service provision associated (Wikby et al, 2008).These factors may include the inability of patient to express his certain foods dislike, limited knowledge of the eating habits, lack of specific nutritional needs awareness as well as religious and cultural preferences and poor food presentation. In summary, therefore, feeding difficulties lead to malnutrition in patients with dementia. This may be problems to do with feeding initiation, problems to do with maintenance of attention in feeding, problems to do with food getting into one’s mouth, problems with chewing and finally, problems of swallowing. Factors Contributing to Malnutrition Risks Eating has critical implications for social, emotional and physical health as well as well-being. There are several factors that contribute to the increased malnutrition risk in individuals with dementia. These include: loss of interest in drinking and eating, fitting dentures that is poor, mouth discomfort as a result of teeth problems or gum disease, dry mouth that may result from medications, reduced chewing ability /or swallowing as a result of poor voluntary control, neuromuscular impairments and or poor oral motor planning, eating difficulties embarrassment and low physical activity level. Some of the possible malnutrition indicators include: Unexplained weight loss, reduced bladder quality and/or quantity and/or bowel output, loose clothing. Fluid intake that is inadequate can as well result to a range of health problems that includes: dizziness, confusion and increased fall risks. Difficulties in swallowing also referred to as dysphagia, can be experienced in individuals with dementia. Problems associated to swallowing difficulties include: life-threatening choking, chest infections, embarrassment and loss of enjoyment eating. There are several signs which might indicate an individual with dementias has swallowing difficulties: Coughing when eating or drinking, food choking, breathing difficulties after or during meals, spillage of food from mouth when eating, excessive chewing, chewing difficulties or moving food in the mouth difficulties, drooling, gurgly or wet voice after swallowing, and loss of weight. There are current researches investigating different diet aspects, as part of a active, healthy lifestyle which may contribute to reducing risk of developing dementia. Nutritional Problems in dementia care Drinking and eating are activities involving sophisticated co-ordination of mental activity and physical movement (Meijers et al 2009). In some situations, where the process of ageing merges with neuronal loss that is progressive such as perception, memory, planning, reasoning, and dementia may lead to communication skills being affected. Other dementia symptoms include disturbed eating behavior, loss of independence and disorientation. Study done by Joosten et al (2008) explored significant vitamin deficiency and weight loss in patients with Alzheimer’s condition. This weight loss can generally result to degeneration of the health of the patient, increased fracture risk resulting from poor concentration, falls, disturbed eating behavior and wandering away during mealtimes. ( Hallstrom et al, 2006) Other contributing factors to weight loss in dementia patients include: Lifestyle – if a patient stays alone, he may forget to eat or buy required healthy foods. This might be supported by limited cooking skills. The repercussions of these, together with self-neglect, may lead to being admitted to hospital. Frequent weight monitoring as well as well-balanced diet introduction may prevent further weight loss. Best practice dictates appropriate tools to be used in monitoring of weight, they include the Mini-Nutritional Assessment (Guigoz et al 2008) as well as the Malnutrition Universal Screening Tool (MUST) (BAPEN, 2003). The MUST is applicable to all adult patients in every care settings. It employs a body mass index scale with indicators that are color-coded for guiding the user to determine if the patient is malnourished or not. Medial temporal cortex atrophy– is a deterioration of the brain which impacts the eating behavior, emotions and memory in patients with Alzheimer’s condition. There appears to be an association between the atrophied brain area and body mass index, reduced cognitive functions and body weight (Meijers et al 2009). Dysphagia that results to difficulties in swallowing may occur because of several factors that include: Parkinson’s disease, poor dental health, cancer and stroke. Regardless of the cause, the nutritional status of the patient may be affected due to reduction in nutritional intake. People with dementia might have extra problems on top of those related to the process of ageing. Incidences of choking are more often in psychiatric hospitals, specifically in older patients with disease of organic brain as well as those prescribed with medication of antipsychotic (Green et al 2006). Other difficulties faced at the oral digestion stage might include overfilling the mouth, hoarding food in the mouth, swallowing without chewing and prolonged chewing, drooling saliva at times. These might result due to oral dyspraxia and agnosia. (‘‘Dementia Services Development Centre’’, 2002) It is critical to employ a multidisciplinary approach in the dysphagia management. Language and speech therapists can play a role in care planning and assessment, dieticians can give advice and assess on necessary dietary requirement and occupational therapists can avail information on seating position, cutlery, posture as well as appropriate furniture. (Crowe V, 2003). Strategies of Solving Malnutrition problem among Dementia patients Inadequate staffing at meal times as well as inadequate training levels may as well act as barriers to good nutrition. Archibald (2003) noted that patients having conditions like Alzheimer’s condition were never given enough food to eat in hospital.(Crowe, 2003).It is critical to continually modify and evaluate several approaches for the sake of accomplishing the changing needs of the dementia people. The holistic approach needs to be adopted by care plan, and consider factors interaction to get best outcomes. For example, enhancing the physical activity might assist in improving the appetite of a person, reduce the chances of constipation, enhances sleep and therefore probably reduce the level of agitation Food provision during a stay in hospital is a critical component of recovery and healing process (Archibald, 2006), and insufficient nutrition may raise the pressure ulcers risk or fractures risks and delays hospital discharge. It is important to take into consideration a robust feeding and nutritional evaluation pertaining nutritional status of a patient to offer optimum care. Malnutrition in hospitals is a big problem that has been explored extensively in the ‘‘National Service Framework for Older People ’’ (Department of Health (DH), 2001a), ‘‘Clinical Governance Review Framework’’ (Commission for Health Improvement 2001). ‘‘Essence of Care’’ (DH, 2001). These papers explores the benefits of ensuring conducive environment for patients to eat, nutritional screening, as well as monitoring and assessment of the amount of food patients eat and to encourage eating habits that is healthy. In the provision of a person-centered approach during hospitalization of the patient, it is critical to ensure that enough attention is provided to the individual requirement of the patient which include his food preferences. This is specifically critical after surgery when a patient exhibits negative characters such as refusal of medication and food (Archibald, 2006). For the dementia patient, particularly, those recovering from surgery, it is critical to adopt a positive approach to good practices and care (Amaral et al, 2007). Examples of best practices in the promotion of good health include: use of nutritional screening tools, dietary assessment on admission, Communication with other multidisciplinary team members such as language and speech therapists, dieticians and physiotherapists. (Caroline Walker Trust, 2008) The role of nurses in the promotion of good nutrition Nurses have a big role to play in the good nutrition promotion in hospitalized patients. They can offer assistance with drinking and eating, record fluid and food intake, monitor the temperature and amount of meals provided, offer supervision and support during mealtimes and minimize noise and distractions, thus assisting to ensure that the eating environment is conducive (Archibald, 2006). To encourage best practice within care provision, three components have to be taken into consideration as identified by the Royal College of Nursing (RCN) (2011): Leadership and management, accountability, responsibility. These principles should be embraced by Nurses to ensure best optimal care is provided for older patients, and specifically to those with extra vulnerability like dementia as a condition. Accountability This can be attained through providing nutritional care aspect that may range from decision making to direct care delivery at the level of executive board. Accountability involves planning, evaluation, assessing and implementation of the patient’s nutritional and hydration needs, in addition to regular monitoring and reviewing the delivery using clinical and audit governance systems. (Manthorpe & Watson R 2003) Quality care needs to be effective and flexible to the social, emotional and physical needs of a person. A personalized approach needs to involve service providers, carers and families to continually check on the care being offered. It is critical in recognizing that a currently working care strategy may not work in the future. The behaviors and responses of the dementia person are the best current indicators of a strategy. We have principles which can guide service providers, families and careers in delivering quality care that includes person-centered care. The major principle of such approach is to make ensure the needs of the person, careers and their family is integrated into the care strategy as well as respected. Responsibility It relates to the evidence-based care and person-centered provision. Nursing staff must ensure that individual nutritional requirement are managed and identified. Some patients with religious and cultural preferences related to food preparation might affect them (Wensing et al, 2004). Special needs might include vegetarian Kosher, or halal meals and some meat such as beef and pork or shellfish may not be permitted. The report made by National Survey of NHS Staff noted that more than 60 percent of staff never received any diversity training that included religious and cultural practices (Healthcare Commission 2007). However, nursing staff need proper understanding and awareness of individual food preferences and nutritional needs to offer person-centered care as well as maintain optimum nutrition levels, respect and dignity. It is also critical to be informed on any changes in practice and policy by using and accessing quality evidence and information regarding hydration and nutrition through progressing professional development. Nurses need to challenge bad practice in relation to hydration and nutrition, evaluate mealtime environment and make sure it is contributing to good nutritional care. It is the responsibility of a nurse to assess hydration and nutrition care plans and establish relevant changes. (Alzheimer’s Society, 2011) Nurses are required to contribute to multiagency and multiprofessional working that meets dedicated time and nutritional care that is holistic to designate the patient’s nutritional needs, such as, mealtimes that is protected. Nurses are supposed to clearly show an understanding of the valid process in every organization to record, minimize, as well as report nutritional risks posed on patients.(Amella E ,2004) Management and leadership As part of their responsibility, all nurses have responsibility of persuading others to offer best nutritional care. Executive nurses need to ensure that nutritional care is a priority. It should be supported at board level (Alzheimer’s Society, 2004). Team leaders have a responsibility of ensuring effective care on patients. This contributes to care which meets perceived and actual requirement. Effects of Protected mealtimes The RCN (2012) defines protected mealtimes as a moment in a ward when all non urgent clinical activity is halted, patients are able to eat without interruption and staff may provide any help needed. Research carried out by Food Standards Agency (2006) indicated that protected mealtimes resulted to increased contact of staff-to-patient, weight gain of patients and conducive atmosphere surrounds the mealtime. Gaining of weight was met in patients with severe and moderate dementia through the mealtime environment adjustment to the individual’s need. Education promoted competence and skills; it as well encouraged staff to adopt a person-centered approach to care. The Food Standards Agency (2006) states that protected mealtimes have ‘‘... the capacity to enhance the safety of the patient through making sure those patients gets the right meal at the correct time with the required help’’. Focus group study done by Dickinson et al (2006) indicated that the protected mealtime’s value for staff and patients. Educational sessions that employed role modeling in staff development and practice were developed as a result of the research outcome. Staff developed action plans, identified problems and assessed the effect of the changes. (NICE/SCIE (2006) .The action plans were identified to have a positive impact on the rehabilitation and recovery of the older persons in the study. Enjoying the opportunity and mealtime experience for socialization were reported. It is critical to ensure patient dignity is safeguarded and to be consultative and open during the transition process. Certain issues have been adapted from Personage et al, (2011) and need to be taken into consideration during protected mealtime’s implementation: All team members need to be engaged in ward observations like the condition of the lighting, noise levels, environment and other activities that happen during mealtimes. It might be of benefit to evaluate documents associated to nutrition, for instance, is the menu easy and clear to follow? What other information on nutrition is present for patients on diets associated to their condition. This information can be associated to benchmarks of patients. Essence of Care gives an overview on nutrition and food with indicators for best practice (Department of Health, 2001). It is critical to cooperate with patients as well as individual views on quality, content, amount and the meals served presentation. Ward observations results need to be discussed with all team members. It is critical to establish how things might need to change to protected mealtimes implementation. The various staff members’ roles during the protected mealtime’s implementation need to be outlined. Changes of environment, like use of a dining table or classical music playing need to be considered. Practicalities like what may occur with the staff breaks; drugs rounds and any other activities that normally happen at mealtimes need to be discussed. Visiting times might be required to be adjusted. Discussion need to be held with other staff in non-clinical and clinical areas on promotion of good nutrition. For instance, with any nearby wards. It is critical discussing most probable changes with hotel services, for instance, the laundry delivery to the ward. The changes might impact the way these services function. (NHS Confederation 2010) After an agreement has been reached on the implementation of protected mealtimes, a decision on when to start the new procedure has to be made. It is critical to avoid starting the new system on a busy day of the ward (Thompson, 2011).It is critical to decide what information, for instant, leaflets and signs, is going to be availed to visitors, staff, patients as well as other departments. Suggested plans need to be discussed with relatives and patients prior to protected mealtimes introduction. Relatives may not comply with visiting times, running late of ward rounds and emergencies that might occur. (Scottish Government, 2011).This needs persistence. There should be regular review of protected mealtimes. It is critical to resolve barriers and obstacles on promotion of good nutrition and positive feedback need to be provided on the function of the system. (NICE/SCIE , 2006).Observation and audit need to be repeated as a way of demonstrating improvements and changes highlighting areas that need further development. Positive outcome need to be shared among every member. (‘‘NHS Quality Improvement Scotland’’, 2003) Best Practice in Addressing Malnutrition For dementia patients, it is critical to take into consideration the social significance of mealtimes as well as the wellbeing of a patient relative to the mealtime experience and the dementia symptoms. (Archibald , 2006) Best practice includes implementation, assessment, planning, screening and nutrition and food programmes evaluation; engagement of multidisciplinary at board level is essential in fighting malnutrition among older people. It’s economically sensible in consulting older people on special requirements, hospital menus and preferences. (Parsonage & Fossey, 2011). Patients with dementia, stroke or a learning disability might need special needs in relation to drinking and eating as a result of cognitive impairment or difficulties in swallowing (Healthcare Commission 2007). NHS Trust, a trust that operates a ‘food group’’ and normally meets once in a year, it consists of patient representatives. The representatives normally taste the food then agree on the changes to be made on the hospital menu. (Wales NHS, 2010) The Queen Elizabeth Hospital Trust, is a trust that invites pensioners of Greenwich forum members to discuss the hospital food quality and tour any of the older patient’s wards. (‘‘Royal College of Psychiatrists’’ 2011) To be ‘food aware’ at admission time, care need to be considered to find out what type of foods that is usually eaten by the patient. This information need to be shared with all multidisciplinary team members. (Barratt et al, 2001).Healthcare assistants at Homerton Hospital, London, are nominated to play a role in monitoring nutritional status of the patients and provision of appropriate training. Food charts of the patients are completed in a shortest time possible and the healthcare assistants makes sure that patients that require assistance with eating are assigned a nurse during mealtimes (Age Concern, 2006).Commitment of all multidisciplinary team members is critical to ensure that standards implementation on aspects related to food is given a first priority, as specified by the NICE/SCIE (2006).The Midwifery and Nursing Council (NMC) ‘‘Code of Professional Conduct’’ (NICE, 2010) sets out the standard for performance, conduct and ethics: To enlighten the professions on professional conduct standards needed of them in their activity. Every dementia person has his or her own interests, preferences, personal history and values. The dementia experience differs for every individual because of variability in the symptoms and forms of dementia. Quality care needs to be responsive and flexible to the social, emotional and physical needs of a person. A personalized approach needs service providers, carers and families to continually reflect on the care they are offering. It is critical to be able to identify if a currently working care strategy is working properly or be able to work in future. The behaviors and responses of the dementia person are the best indicators of a strategy performance. We have principles which can guide service providers, families and careers in delivering quality care that includes person-centered care. The major principle of such approach is to make sure the needs of the person, careers and their family is integrated into the care strategy as well as respected. Person-centered care is a partnership with shared responsibility and power among the person receiving care and service provider. The care quality normally is better when directed on an individual as a whole instead of the illness. Independence and participation needs to be encouraged through working with the individual’s abilities and strengths, and the care environment needs to offer positive experiences which can enrich the dementia person life. As a result of the unique experience of dementia people, it means that not every techniques of care will be achieved for all people. It is critical to continually modify and evaluate approaches for the sake of accomplishing the changing needs of the dementia people. The holistic approach needs to be adopted by care plan to get best outcomes. For example, enhancing the physical activity might assist in improving the appetite of a person, reduce the chances of constipation, enhances sleep and therefore probably reduce the level of agitation. Conclusion It is a matter of concern that the general practices of nutritional care advised by international guidelines (ASPEN 2005,) apparently are still not practiced in European hospitals. It is evident that rising consciousness of nutritional care practices importance among policy makers and healthcare professionals is required in addressing the malnutrition problem (Meijers et al. 2009). Before the implementation of the changes to practices of nutritional care with regards to the available evidence, several barriers need to be considered. These might include a lack of prioritization, interest, knowledge or clearly defined responsibilities, poor implementation facilities, attitudes towards nutritional care or lack of authority by nurses within the organization. These barriers might explain these low figures to some extent on adequate practices of nutritional care (Mowe et al. 2008). Globally, malnutrition is a big problem in wards of hospitals. The employment of nutritional care practices such as nutritional screenings and evaluation, employing a nutritional protocol or using a standardized screening instrument are suboptimal in hospitals. A high consciousness of nutritional care importance among hospital policy makers and healthcare professionals will contribute to further development of nutritional care quality. The possibility of being malnourished can be well explained by the admission to a particular ward. Being empathetic is critical in the provision of good quality care. It is critical to try and imagine the experience the patient faces when he or she requires assistance with eating. Hospitals can be scaring places for anyone, in particular for dementia patients who are not able to recall where they are and in other cases who they are. While several nurses have nutritional academic knowledge for older people, they might be under-skilled on the side of practical mealtime care delivering aspects (Dewing 2003).Food provision during a stay in hospital is a critical component of the recovery and healing process (Archibald 2006), and insufficient nutrition may raise the pressure ulcers risk, delays and fractures in hospital discharge. Recommendations There are several approaches of improving the quality and amount of drink and food consumed by dementia people: •Contacting a health professional to make sure there is no any medical related cause for the lack of appetite like medications, depression or acute illness.. •Consult a speech pathologist, doctor or dietitian on any concerns related to nutrition and safe swallowing. • Oral health Check (teeth, mouth, dentures, gums,), and other identified problems should be treated. •Provision of balanced diet that includes supplements and energy rich foods if needed. It is critical to contact doctor before taking a supplement because some do react with other medications. • Involvement in food preparation practically might stimulate appetite. •Provision of meals in form of discrete elements, can enable one part to be completed before the next one. •Provision of nutritious snacks such as fruit and drinks. It should be available for the entire day, and regular consumption should be encouraged. • Finger foods should be considered as an option. • Sufficient time should be allowed for meals as well as other distractions should be avoided. • Increased physical activity should be encouraged; it includes activities like social activities, walking and formal exercise with a physical involvement degree such as bocce or dance. For those individuals with a tendency of gaining weight and overeating they require different strategies to limit calorie or food intake. 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