JGs Dementia Treatment - Essay Example

JG's Dementia: A Case Study JG was referred to the agency after he was diagnosed with fronto-temporal lobe dementia two years ago. Over the last year he has been displaying challenging behaviour indicating that he needs professional help and care. The agency to which he was referred to has limited space. The social services has set financial limits for admission. Above this financial limit the patient has to pay the full cost of the placement. JG’s finances are above the limit of the social services. The financial cost is the main issue that Mrs. JG is hesitant to have JG admitted. Those that could not be admitted could still have regular respite or referred to another borough. This means that any interventions will have to be conducted in the agency/ nursing home and the patients’ residence. The interventions will be done by the student working closely with a supervisor from the nursing home and with Mrs. JG who insisted to be the carer of the patient. The student will monitor the progress of the intervention. The psychiatrist will be consulted regularly and especially when JG has exhibited strange behaviour. The student’s assessment of JG went through the usual process of looking at the diagnosis of the disease, interviewing his wife and persons involved in JG’s care, observing his behaviour, looking at risk factors, and discussion with the supervisor of the nursing home. The risk factors often mentioned include "constitutional" factors like age, sex, birth order, dementia in the family and "life style" factors like smoking and alcohol consumption, role of psychosocial factors at work and during leisure time on the risk to develop dementia( Bernhardt, T., A. Seidler, et al. (2002). They reported . “a positive association has been observed between dementia and living alone, having no close social ties, not participating in social and leisure activities, and never having married. Recent studies have found that Alzheimer's disease in particular is negatively associated with diversity of activities and intensity of intellectual activities and positively associated with psychosocial inactivity, unproductive working style, living with a dominant spouse and with physical inactivity”. There are many factors to be considered: individual factors, relationships or social context. Pratt, Clare and Kirchner (2006) found the importance of considering relationships and socio-contextual factors beyond individual factors relating to access. There are risks involved whether the patient stays at his residence or admitted to an institution. There are risks on both the patient and the carer. Institutional placement has been associated with greater severity of cognitive impairment, severity of parkinsonism and the failure of carers to adopt active coping strategies. An intervention to improve coping skills in carers may decrease the rates of residential and nursing home placement (Bannister et al. 1998). Intervention for continence problems and mobility problems has the potential to reduce the use of residential care (Weatherall, M., T. Slow, et al. (2004). JG has a problem of wanting to leave home at four o’clock in the afternoon. This reduces the advantage of using residential care for his ailment. The needs of the patient have to be met. In JG’s case, his aggressiveness has to be controlled. It has been noted that verbal or physical aggression is common (about 25%) in middle or late stage dementia. Staff is the most common target of aggression (70%) and episodes occur most often during staff-patient interactions, e.g., ADL assistance. Management of aggression in the nursing home requires careful assessment and methodical treatment to assure maximum safety for residents, nursing home residents and staff. Aggressive symptoms can be verbal, physical or sexual. Severe physical and sexual aggressive behavior may require immediate, intense therapy. “The extensive differential diagnosis for aggression in the elderly resident includes delirium, resident discomfort, environmental over-stimulation, resident fear, depression, psychosis and loss of impulse control produced by brain damage” (Alabama''s Alzheimer''s Resource http://www.alzbrain.org/quicklinks/managing/aggressivebNursinghome.htm). In the development of the care plan, the individual’s traumatic experiences have to be considered. During the interviews with the patient and the family, the student asks how the patient has survived the periods of aggressiveness and depression. She asks what they have tried, what has worked etc. An effective tool is reminiscing to bring the patient back into the present from re re-experiencing/remembering his traumatic event(s). In defining the aims of this work, the student has to first convince Mrs. JG that it would be better for JG to be admitted in a nursing home. Mrs. JG preferred to take care of her husband herself at their home since the nursing home is far away. The student has to cite the work of Braekhus, A., A. R. Oksengard, et al. (1998) that twenty-five per cent or more of the spouses reported often/always having problems with the following: being depressed by the situation, having difficulties getting away on holiday, social life being affected, household routines being upset, and sleep being interrupted. The wife should be prepared for this change in life style. JD’s degenerative brain disease, Alzheimer's disease (AD), is a different kind of illness. “AD is more disruptive to, and has greater impact on, the family than other chronic diseases. AD caregiving carries with it a high financial, social, and emotional price. Families must work toward effectively coping with the disease, decreasing the harmful effects on the family, and keeping family conflicts to a minimum. Support groups can provide families with much-needed information on the disease, emotional and practical support, and an expressive or advocacy outlet. Formal services can help relieve some of the burden of caring for an AD patient. Family members must remember that there is no "right" way to care for a person with AD, and each family must determine, with the help of the appropriate professionals and services, how to best meet its own needs. Given the burdens of care, however, even small interventions may translate into improvements in the quality of life or confidence of the caregiver” Gwyther, L. P. (1998). Safety in the home of dementia patient is another concern. Horvath, K. J., A. C. Hurley, et al. (2005) used the Home Safety/Injury Model as a frame work to describe the domain of caregiver competence, one of the model's key constructs. “ The factors most influential for effective caregiver prevention of home injury were family support, an acceptance and ability to make role changes, teaching and role modeling from professionals, and long-standing values and family traditions. No single factor was sufficient to achieve effective caregiving for making the home safer, but the strength of one or two factors could compensate for the absence of others”. There are other reasons for reluctance on the part of families toward community services. According to Coudin, G. (2004), the community service should be more than professional care,. It should be “caring about” . “First, family care has to be contextualized in family history, disease trajectory as well as in cultural values. Second, the main task of "caring about" consists of maintaining the self-image of the demented subject as long as possible. Caregivers also experience conflict between contradictory needs: instrumental and identity maintenance of the demented. The discussion focuses the role of, among others, gender, family history and cultural norms in the caregivers' reluctance”. Empowering the family: Farran, C. J., D. Loukissa, et al. (2004) found that “caregiver skill-building interventions may be more effective than information/support interventions”. Negotiations with the family: Before any intervention program could be designed, there should be negotiations between the carer or nursing home and the patient’s family. This will promote a good caregiving relationship between the carer , the patient and the family. In the study of Grand et al (1999) in France, the caregiver’s relationships consist of: 1) the caregiver/cared-for's relationship, which is characterized by the establishment and maintenance of a "tacit contract" and 2) the relationships with other eligible caregivers, which are marked by the "designation" of the principal caregiver. This analysis shows that a failure in the negotiation process can induce a designation and/or a weak tacit contract-the result of which is the caregiver's expression of stress. This expression is closely linked to the caregiver's perception of a negative balance in his/her exchanges with the with the partners. This study should help break away from the one-way arrow model currently dominating the field of caregiver stress research.” Problems in negotiations becomes bigger when someone else in the family does the decision-making because in the patient is no longer able to make decisions himself. Family caregivers also have their expectations Voutilainen, P. and S. Korpiniitty (1997). They found that “family caregivers expect information concerning dementia, its causes as well as care possibilities. Above all the family caregivers expressed the need to know about the existing support services: domestic help, day care or respite care, voluntary nursing services etc. Also the severe need for psychological support was revealed. Family caregivers wished to have more opportunities to discuss the oppressive matters with the nursing staff. Health professionals need to know more about the family members as well as their expectations and perceptions. That enables them to intervene more effectively to ease the burden of adjustment and facilitate the continuous involvement in care”. The agreed aims: Mr. JG will have a regular respite in the agency. Mrs. JG is the main carer. The student will maintain contact with Mrs JG and offer support until appropriate accommodation can be sought. Links with the Consultant Psychiatrist Community Psychiatrist Nurse were arranged through the student’s supervisor. Issues: The student has to work hard to prove her worth and overcome biases on her race (being black serving a white family), being a student as against a professional, and being a female and other biases. Regarding the gender issue it has been found that “male caregivers adopt a task-oriented approach to their duties and carry out their activities in a linear fashion; female caregivers use a parent-child approach and nest activities inside one another in a constant stream of work” Corcoran, M. A. (1992). The student is competing or working in partnership with another female, the wife of JG. She has to prove that with her background as a student she can share new intervention techniques learned in school. She can empower JG’s wife through role-training intervention Ballard, E. L. (1999). As a student she has to work under a supervisor who can give orders and assignments that may run in conflict with her scheduled interventions with JG. This conflict can be resolved through proper time management. The role of the family cannot be overlooked. Mitrani et al. (2006) found that family structural functioning as one contributor to the caregiver stress process. Caregiver’s stress include burden, depression, anxiety and perceived health of the caregiver. Student’s Interventions: Since medication has not been effective, the student may try one or combination of several interventions that suits the patient’s personality such as: 1. Touch interventions (Kim and Buschmann, 2004) The Progressively Lowered Stress Threshold (PLST) and Touch Model or Touch-Stress model was found to improve care of patients with Alzheimer’s disease suffering from emotional and behavioral disturbances, and increase the quality of life for the caregivers and families of patients with Alzheimer’s disease. 2. Creativity activities (Hannemann BT) : ex. Non-verbal therapy methods such as painting, music, etc. Theory of cognition, the principle of being creative as a basis for human life. “This specific principle is effective for the aged as well. In the long-term, the creative potential of old patients will be unblocked in individual and group therapy sessions.” Dementia patients take the initiative to combine creativity and arts and to define his/her feeling for aesthetical matters. Group therapy sessions help against isolation and lack of life perspective and hope. This can only be done in nursing homes during the patient’s regular visit. 3. BACE intervention (Kovach, Teneli et al. 2004) BACE (Balancing Arousal Controls Excesses) intervention controls the daily activity schedule so that there is a balance between a person's high-arousal and low-arousal states. BACE used in an individualized approach effectively decreased agitation levels of people with dementia. 4. Interpersonal counselling can be utilised as a general practice to reduce psychological symptoms, restore morale, improve self esteem and the quality of the patient's social adjustment and interpersonal relationships Judd et al (2004). Intervention is most effective when it enables both the impaired person and the primary caregiver to manage the secondary symptoms of dementia (Corcoran, M. A. (1992). 5. Comprehensive cognitive-linguistic intervention program (Mahendra, N. and S. Arkin (2003)) For mild to moderate Alzheimer's disease (AD) patients that provided communication skills practice in the context of health-enhancing and esteem-building community-based activities: physical fitness training and supervised volunteer work. Medication may still be needed during dangerous episodes of aggressive behavior by the patient. “Rapid sedation of the acutely aggressive, dementia resident can be achieved with IM or PO neuroleptics. Chronic aggressive behavior is sometimes improved with antipsychotic medications, especially when the symptoms result from psychotic beliefs. The resident who believes that he is being attacked, robbed, beaten, and stalked may improve with typical or atypical antipsychotic medications. The newer atypical antipsychotic medications have fewer side-effects but few of these medications have injectable forms. All antipsychotics may lessen these symptoms and improve behavior. Residents with significant depression or anxiety may become aggressive as a consequence of altered mood. Antianxiety medications, e.g., Xanax, Valium, rarely improve long-term aggressive behavior and sometimes disinhibit or confuse the resident sufficiently that aggressive symptoms worsen. Many demented residents are unable to describe depressive mood and staff must assess behaviors like social withdrawal, weight loss and crying. The depressed, aggressive resident should be treated with appropriate antidepressant medication and alleviation of depressive symptoms may substantially improve anxiety. Pharmacological management of aggressive behavior requires that staff document potential harm to the resident, other individuals, or severe disruption of the therapeutic environment. Medications are not appropriate for annoying behavior” (Management of Aggressive Behavior in the Nursing Home). Future research: The research of Buchanan et al. (2004) provides an insight on the profiles of male and female patients that could guide future research: male resident patients with Alzheimer's disease (AD) are more likely to be married. There are minimal gender differences in cognitive impairment among these residents with AD, although women are more likely to understand and be understood by others. Male residents with AD are more likely to exhibit behavioral symptoms, whereas female residents with AD tend to be more physically impaired and dependent on others for activities of daily living. Significant differences in comorbidities were found between the sexes, with greater proportions of male residents with AD having cardiac-related conditions, stroke, cancer, and other life-threatening chronic conditions. Male residents with AD were more likely to receive care in AD special-care units; daily antipsychotic medications; and intervention programs for mood, behavior, and cognitive loss than female residents with AD. In this study of nursing home residents identified using the MDS, key differences were found between male and female residents with AD, including age; cognitive and communicative abilities; and mental health, mood, and behavioral patterns (Buchanan, Wang and Graber, 2004). Stress-adaptation modeling approach (Corbeil and Quayhagen, et al. 1999) can guide intervention research on caregivers and patients coping with Alzheimer's disease. They declared that Caregiver satisfaction can attributed to an attenuation of the behavioral stressor effects through increased use of a problem-focused coping strategy, namely, positive reappraisal of the stressful situation. The family also plays a role in the stress process (stress-process model) of dementia caregivers (Mitrani et al., 2006). Research on how to empower families to take care of their patients could focus on (Farran, C. J., D. Loukissa, et al. (2004): (a). dealing with change, (b). managing competing responsibilities and stressors, (c). providing a broad spectrum of care, (d). finding and using resources, and (e). experiencing emotional and physical responses to care. Further work is needed concerning the focus and methods of future caregiver skill-based interventions. “Presently, Behavioral and psychologic symptoms of dementia BPSD research opportunities are at their greatest. The increasing worldwide social and economic impact of BPSD, however, requires that researchers, clinicians, and scientists develop a global network focused on collaboration and innovation. In particular, research must address cross-culturally applicable methods for assessment, exploration of the environmental relationships of BPSD and the underlying biologic and psychologic substrates, longitudinal evaluation, determination of the frequency and underlying pathogenic mechanisms, and development of a clearly defined treatment method profile with specific reference to different types of BPSD” (Finkel, S. I. (2003). Dementia is a very costly disease. According to O'Shea, E. and S. O'Reilly (2000) “the economic and social burden of dementia on society is the value of all the resources used to prevent, diagnose, treat, and generally cope with the illness. There is increasing pressure to define the cost components of dementia with a view to improving resource allocation and accountability in this area in the future. We have assessed the overall resource implications of dementia in Ireland. Six main areas are covered in the cost analysis as follows: mortality and life years lost, in-patient acute care, in-patient psychiatric care, residential long-stay care, family care, and primary and social care in the community. While the results indicate that the baseline cost of illness associated with dementia is substantial at just under IR pound250 million, the most important aspect of the work is the distribution of the burden. The critical role of carers in maintaining people with dementia in their own home is reflected in the results showing that family care accounts for almost 50% of the overall resource burden, based on an opportunity cost valuation of carer time”. Policy research Newcomer, R. J., P. J. Fox, et al. (2001) indicated that “ Policy research into the service needs of persons with dementia had its origin looking at challenges confronting caregivers--extended hours of instrumental task assistance, social isolation, fatigue, depression--and how public policy might support informal care-giving while saving public expenditures from nursing home care. This paper, drawing on the experience of the Medicare Alzheimer's Disease Demonstration and other work, provides suggestions for extending care and financing considerations to include health care use and the medical management of chronic health conditions. Basic research is needed to document current use and risk factors, as is experimentation with clinical and other interventions designed to achieve desired quality of care and cost outcomes. This section of the paper will be of direct interest to both US and international readers. The second half of the paper reviews the US state role in regulating and financing nursing homes, home and community-based care, and residential care. All these sectors have high rates of staff turnover, staff shortages, and concerns with quality of care. The international community and US states provide naturally occurring opportunities for delivery system experimentation and innovation. Research taking advantage of these opportunities could greatly inform public policy”. References: Ballard, E. L. (1999). Social work perspectives: issues in caregiver research: the family. Alzheimer Dis Assoc Disord, 13 Suppl 1, S88-92. Bannister, C., Ballard, C., Lana, M., Fairbairn, A., & Wilcock, G. (1998). Placement of dementia sufferers in residential and nursing home care. Age Ageing, 27(2), 189-193. Bernhardt, T., Seidler, A., & Frolich, L. (2002). [The effect of psychosocial factors on risk of dementia]. Fortschr Neurol Psychiatr, 70(6), 283-288. Braekhus, A., Oksengard, A. R., Engedal, K., & Laake, K. (1998). Social and depressive stress suffered by spouses of patients with mild dementia. Scand J Prim Health Care, 16(4), 242-246. Buchanan, R. J., Wang, S., Ju, H., & Graber, D. (2004). Analyses of gender differences in profiles of nursing home residents with Alzheimer's disease. Gend Med, 1(1), 48-59. Corbeil, R. R., Quayhagen, M. P., & Quayhagen, M. (1999). Intervention effects on dementia caregiving interaction: a stress-adaptation modeling approach. J Aging Health, 11(1), 79-95. Corcoran, M. A. (1992). Gender differences in dementia management plans of spousal caregivers: implications for occupational therapy. Am J Occup Ther, 46(11), 1006-1012. Farran, C. J., Loukissa, D. A., Lindeman, D. A., McCann, J. J., & Bienias, J. L. (2004). Caring for self while caring for others: the two-track life of coping with Alzheimer's disease. J Gerontol Nurs, 30(5), 38-46. Finkel, S. I. (2001). Behavioral and psychological symptoms of dementia: a current focus for clinicians, researchers, and caregivers. J Clin Psychiatry, 62 Suppl 21, 3-6. Grand, A. G., Myckatyn, T. M., Mackinnon, S. E., & Hunter, D. A. (2002). Axonal regeneration after cold preservation of nerve allografts and immunosuppression with tacrolimus in mice. J Neurosurg, 96(5), 924-932. Horvath, K. J., Hurley, A. C., Duffy, M. E., Gauthier, M. A., Harvey, R. M., Trudeau, S. A., et al. (2005). Caregiver competence to prevent home injury to the care recipient with dementia. Rehabil Nurs, 30(5), 189-196; discussion 197. Newcomer, R. J., Clay, T. H., Yaffe, K., & Covinsky, K. E. (2005). Mortality risk and prospective medicare expenditures for persons with dementia. J Am Geriatr Soc, 53(11), 2001-2006. O'Shea, E., & O'Reilly, S. (2000). The economic and social cost of dementia in Ireland. Int J Geriatr Psychiatry, 15(3), 208-218. Pratt, R., Clare, L., & Kirchner, V. (2006). 'It's like a revolving door syndrome': professional perspectives on models of access to services for people with early-stage dementia. Aging Ment Health, 10(1), 55-62. Voutilainen, P., & Korpiniitty, S. (1997). [Family caregivers' expectations of respite care of patients with dementia]. Hoitotiede, 9(1), 25-32 Dementia and Aggressive/Abusive Behavior Summit. (June 4 – 5, 2002). from http://www.dhfs.state.wi.us/aging/dementia/proceedings.pdf#search='dementia%20aggressive%20behavior' Information for Professional Caregivers: Management of Aggressive Behavior in the Nursing Home. from http://www.alzbrain.org/quicklinks/managing/aggressivebNursinghome.htm Read More

 

Read More