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Dementia care in practice

Marjorie Lloyd MSc RN Mental Health
Senior Lecturer Mental Health Nursing
Glyndwr University Wrexham
Wales

In the treatment of dementia a holistic nursing approach is advocated towards ensuring that the needs of this vulnerable group are met and dignity and self-esteem are maintained

The chances of developing a dementia-type illness increase with age, although dementia is not an age-related illness.1 Dementia occurs with damage to the brain through trauma to the neurons - the nerve cells in the brain that transmit information and are responsible for the proper functioning of the body.

Types of dementia
All dementias affect the ability to make sense of the world, but different types require different treatment and support. Misunderstanding the difference between the different types can lead to people receiving the wrong type of treatment and support, which could be constituted as neglect or abuse under the Mental Capacity Act 2005.

Dementia falls under certain categories within diagnostic criteria such as the ICD 10 and the DSM IV, and every effort should be made to obtain the correct diagnosis as soon as possible to determine treatment options. While there are very few tests for specific dementias, using procedures such as a brain scan and full physical investigations will help to eliminate
other causes.2

The Royal College of Psychiatrists has produced some helpful leaflets that are free to print off which define the main types of dementia.3,4 It is suggested by the National Institute for Health and Clinical Excellence (NICE) that while the Mini Mental State Examination (MMSE) can be used to assess severity of cognitive decline it should also be used with caution with people who use English as a second language and for people with learning difficulties.5 This is because it is often used to determine whether people should receive medication for Alzheimer's disease depending upon their level of functioning and a score of 12 or above. The main areas of functioning that are assessed for all dementias are:

  • Aphasia (speech and language).
  • Agnosia (memory and recognising familiar objects and people).
  • Apraxia (movement and coordination).1

People may also suffer from comorbidities including anxiety, agitation, depression and physical health problems that may be complicated by the dementia.

Alzheimer's disease can be early onset with progressive decline in memory and functioning and using medication can maintain neuron function in the early stages.3-5

Vascular dementia, such as multi infarct dementia, tends to follow stepwise deterioration with some recovery at each stage and the use of blood pressure treatment is usually all that is required.6

Lewy body dementia affects particular functioning of the neurons and can be intermittent with the person more likely to have lucid moments but also psychotic delusions are more frequent. Antipsychotic treatment is required only when severe.6

Frontal lobe dementia affects emotions and can cause disinhibited behavior that increases over time. Antipsychotic medication may improve behavior but can cause other problems such as confusion.6

Interventions for dementia care
There are many ways in which family and nurses can become involved in the person's care to help maintain their dignity and self-esteem.6,7

Person-centered care
The person should remain at the centre of the care plan and every effort should be made to identify and address their needs as identified by the person or their representative.7 This is the responsibility of every health and social care professional under our legal duties within the Human Rights Act, Mental Capacity Act, Mental Health Act, Disability Discrimination Act, Carers and Disabled Children Act.

Person-centered care in dementia has been studied in Bradford by Tom Kitwood who identified malignant social psychology.8 He observed this happening on wards where people were collectively dehumanized because of their diagnosis of dementia. Bradford University continues to be a centre of excellence in this area.

Diet and lifestyle
Diet and lifestyle can affect how we all perform tasks, including our ability to concentrate and recall information and memories. Toxic substances, such as alcohol, may be used as a coping mechanism but can worsen symptoms of dementia as alcohol is a central nervous system (CNS) depressant. Assessing food preparation and ability to eat, shop, budget and travel to obtain food (and money to buy food) are essential in establishing effects of diet and lifestyle on mental health and functioning. Screening for essential nutrient imbalance, blood chemistry and organ function should be initiated as soon as possible.6

Hygiene and self-care
Alongside a healthy diet and lifestyle, good self-care prevents infections and skin breakdown as well as preserving self-esteem and dignity. Appearance is more than skin deep, and person-centered care must be used to identify personal preferences in clothes and hairstyle.7 This can be achieved by asking carers for some old photos that will help you to determine how the person likes to dress or look.

Housing and social care
Most people, when asked, prefer to stay in their own home and in their own community for as long as possible. This is also important to maintain memories and to avoid further confusion in strange surroundings. Referral to a memory clinic should be the first point for assessment who can assist by linking in with local groups and arranging support workers to help the person maintain skills. Carers may also need respite in order to facilitate homecare and this must be addressed by finding respite accommodation and suitable day services.7 Employing staff to stay with the person to give the carer a break may also be possible by applying for direct payments through social services.9

Relationships and cultural care
Maintaining relationships helps us to maintain our memories as we talk with family and friends about past events. Keeping the brain active in this way helps to slow down the deterioration process and allow the individual to stay in their own home. Personal belongings and memories can be used as communication tools when assessing the person and when carrying out personal care and other self-care activities. This maintains dignity and respects the person as a person, not just a patient or client. Attempts to reduce agitation and fear can be addressed in this way that also avoids the use of medication.1,7

Involving family and friends in this process maintains long-term relationships and helps them to feel involved. However, family and friends should not be used as an alternative to care provided by health and social services and their involvement should be by valid consent and not by coercion out of guilt. This can lead to resentment and intolerance causing more distress to the patient.

Community awareness
Stigma and stereotyping prevents most people with a mental health problem (and their families) from seeking help. This can lead to a total breakdown in relationships and activities before help is even offered. A crisis occurs and everyone is left feeling traumatised, staff feel pressured to do something quickly and are less able to make a full assessment of the person's needs. Hospitalisation often occurs as the first point of contact with health and social services, increasing the trauma of the event.

Early diagnosis and intervention can slow down the deterioration process and provide the person with the opportunity to plan their health and social care needs.7 To prevent such traumatic events every effort must be made to share concerns and to help local communities to provide care for people who wish to remain in their own home. This can include good team working skills and involving other charitable organisations and helping them to obtain funding and support.

Medication
Medication can sometimes be used to alleviate symptoms and to slow down the progression of the illness. It should never be used to control behavior unless in the most extreme risk situations and this should be for as short term as possible.7 Careful monitoring of side-effects is also required.
In many older people medication can add to the confusion they are already experiencing causing them more distress, it can lead to more problems than before it was taken including constipation, confusion, distress, poor mobility, falls, less ability to self-care and converse with family and friends leading to isolation and depression. Discomfort and agitation were found in a research study to have a direct effect upon one another.1

NICE suggests that antipsychotic medication should not be used because of the increased risk of stroke and even death. End-of-life care should also be planned as soon as possible and when the person is most lucid. This will coincide with developing general coping skills for the person and for their carers. It also helps the person to identify what they would like to happen in a crisis and how they would like to be treated if they lose the capacity to consent.7

Conclusion
Dementia care should involve a holistic assessment of the person's needs and the coping skills and resources available to them to help them do this. Early intervention and diagnosis will help the person to be more involved in their care and to maintain their dignity and self-esteem.

Medication is only used where it can help to slow down the progress of the dementia or in extreme risk situations. Medication can cause more problems than the person already has to cope with and should be used with caution seeking advice from pharmacists where necessary for the potential side effects it may cause.

Developing community awareness of dementia and identifying support systems and organisations will help the person to stay at home and in their local community for as long as possible.
Remembering the person as a human being, a husband, wife, father, son, daughter, mother, sister, brother, grandmother, grandfather or friend will enable everyone to ensure that the person has total control over what happens to them even when they can no longer remember themselves.

References
1.    Pelletier IC, Landreville P. Discomfort and agitation in older adults with dementia. BMC Geriatr 2007;7:27.
2.    Department of Health (DH). Living Well with Dementia. Dementia Care Strategy Implementation Plan. London: HMSO; 2009.
3.    Royal College of Physicians. Dementia Key Facts. Available from: www.rcpsych.ac.uk/mentalhealthinfo/alzheimersanddementia/dementiakeyfact...
4.    Royal College of Physicians. Memory Problems and Dementia. Available from: www.rcpsych.ac.uk/mentalhealthinfo/alzheimersanddementia/memoryproblemsa...
5.    National Institute for Health and Clinical Excellence (NICE). TA111 Alzheimer's disease - donepezil, galantamine, rivastigmine(review) and memantine. Understanding NICE guidance. London: NICE; 2007.
6.    National Collaborating Centre for Mental Health. Dementia: A NICE-SCIE Guideline on supporting people with dementia and their carers in health and social care. London: Alden Press; 2007.
7.    NICE. Dementia: Supporting people with dementia and their carers in health and social care. London: NICE; 2006. Available from: www.nice.org.uk/nicemedia/pdf/CG042NICEGuideline.pdf
8.    Kitwood T. Dementia Reconsidered. Buckingham: Open University Press; 1997.
9.    Social Care Institute for Excellence. Direct Payments: Answering Frequently Asked Questions. Guide 10. Available from: www.scie.org.uk/publications/guides/guide10/index.asp