Dementia in Residential Aged Care Setting Essay

Introduction

Over recent times, Dementia has been increasingly reported as a worrying health problem across the world. According to Hickman et al. (2007), approximately 24.3 million people in the world had dementia in 2005, and an estimated 4.6 million new cases are reported every year. This scholarly study by Hickman and his fellow researchers further reports that going by the current trends, by 2040, this number will rise to about 81.1 million people—which really is a perturbing figure, to say the least.

In another study by Wotton and Crannitch (2008), it is believed that Dementia will be experienced more in the developing countries which are already experiencing rapidly-growing life expectancy rates. In the UK alone, 700,000 out of 61 Million people are reported by Alzheimer’s Society (UK) to have dementia. By 2021, researchers are expecting this number to reach 940,000 people (International Longevity Center UK, 2009). These grim statistics have raised global concerns across the world with a good number of researchers coming up, slowly but surely, to try finding ways of curbing Dementia before it reaches unmanageable levels. But before delving into such intricacies, what really is Dementia?

Dementia is a health condition which is defined by Bidewell & Chang, (2011) as the progressive decline in cognitive function or, simply, the worsening of a person’s ability to process thought. Dementia is mostly prevalent in old people (Barnes et al., 2004). Nonetheless, Hickman et al. (2007) argue that it may affect adults of any age.

In Residential Aged Care Facilities (RACFs), Bidewell & Chang (2011) say that nurses tend to face various issues in the care of patients with dementia. In solving these challenges, many approaches have been proposed—as will be explicatively detailed later in this paper (Brown, 2002). A detailed analysis of these issues is embodied in the discussion given below.

Malnutrition and dehydration issues in patients with dementia in RACFs

In older adults, malnutrition is defined by Gaskill et al, (2009) as inadequate dietary intake that leads to the insufficient nutritional condition, weight loss and muscle wasting. According to Turner (2005), approximately 85% of nursing home residents suffer from malnutrition while 60% suffer from malnutrition.

In explaining the high percentages of dehydration and malnutrition in patients suffering from dementia, Barnes et al., (2004) support Reed et al., (2004) by saying that Dementia is a syndrome normally caused by a variety of diseases that produce disturbance of cortical functions with severe loss of cognitive ability and functional capacity. As a result, this leads to malnutrition and weight loss because of increased energy demand due to factors such as wandering, food refusal due to agitation, lack of appetite and declining capacity to chew, swallow (dysphasia) or feed independently (Reed et al., 2004).

Additionally, malnutrition is caused by difficulties with eating due to loss of ability to recognize food, eating low amounts, refusal to get involved or cooperate during feeding time, or forgetfulness about food and (Hines et al., 2008).

Moreover, the shortage of staff to attend to each one of the patients is cited as a cause of poor health and malnutrition. Chewing and swallowing problems make it difficult for them to eat their meals well. These swallowing problems make them easily prone to aspiration of fluids into the lungs and consequently water restrictions are set in place for certain patients. This restriction on fluids leads to the risk of dehydration in patients with swallowing disorders suffering from dementia (Reed et al., 2005).

Recommended Solutions

According to Gaskill (2009), nurses should consider soft or vitamised meals as a solution to chewing and swallowing problems. Reed et al, (2005) further say that poor oral hygiene, lack of teeth, infections in the gums, teeth decays and poorly fitting dentures may prevent them from having enough food to make up a nutritional value. In these cases, oral nutritional supplementation may be a solution (Levi, 2005).

In a study conducted by Levi (2005) in aged care and assisted living facilities, it was remarkably revealed that food and fluid intake increases among residents if they are monitored by staff during meals, have their meals in public dining areas rather than in their bedroom, the facility provides an environment with no institutional features, free of environmental distractions and there is enough staff to provide assistance in the room. For this reason, it is advisable for nurses and the management in RACFs to inculcate such endeavors and programs into their facilities so as to orient these positive results.

On another note, Barrat (2004) outlines interventions such as fortified food, supplements and meal planning as other solutions to RACFs. In addressing malnutrition and dehydration, nurses and other staff education programs need to be designed on nutrition assessment procedures and early nutrition intervention methods (Manthorpe & Watson, 2002). This is, in order, to equip them in awareness, screening and assessing the residents’ nutritional status (Gaskill et a., 2009).

In solving the problem related to the aspiration of fluids caused by dysphagia, Hines et al., (2008) proposes increasing the viscosity (thickness) of drinking fluids. This idea is supported by Manthorpe & Watson (2002) who found out that thickened fluids were easily accepted by older people compared to dilute ones. Barrat, (2004) however, refutes this by saying that thickened fluids were not accepted by patients in his study since thickening agents were thought to suppress flavors of drinks. Debates on this issue are still ongoing and a decisive solution (through research) is yet to be found.

Other general solutions proposed to solve malnutrition include reducing noise in the RACFs (since patients consider it distractive), increasing light in the facilities (because patients love to see what they are eating), and providing meals on time. As for dehydration, nurses promoting fluid consumption in their daily meal routines is additionally encouraged.

Communication with aged care residents with dementia

Communication is very important in all human relationships and, in people with dementia, it is extremely critical to their well-being (Hickman et al., 2007). Patients with dementia are believed to experience numerous communication challenges. In most cases, they cannot express themselves coherently, and in worst cases, they may lose the communication function completely (Kohn & Surti, 2008).

As we all know, communication is a broad concept and can happen in a myriad of ways. The most common categories are verbal and non-verbal communication. Regardless of the category, caution and professionalism should be taken when communicating to these patients since they are normally very delicate and any wrong communication can be very detrimental to them. The fact that old people tend to slow to understanding complex issues, utmost professional discretion and patience—as was already mentioned—should be adherently observed.

Recommended Solutions

To have a quality life and receive the care they need, dementia patients just need to be consulted consistently, but in a loving and patient way. This might see seems difficult, but it is realistically achievable.

Moreover, intervention measures have been developed at individual and group levels to help the patients directly and indirectly with family members, friends and healthcare professionals (Borbasi et al., 2011). This is aimed at mainly improving the communication between the victims and those around them.

In order to improve communication for quality care, nurses should use communication that enhances decision making. Here, the nurse should show genuine interest and engagement of the patient in making everyday simple decisions such as what to wear, in bathing and even what to do (Tilly & Reed, 2004). This is supported by Harding, (2005) who says that cheeriness and warmth towards the patient as well as concern and seriousness display the same responses interest and engagement. This will make the patient to recognize familiar pattern around the facility for care without apprehension of the next activity.

Another way of encouraging communication with patients with dementia could be less focus on routine and obsession with time while intermittently giving them “monitored’ freedom to do things like walking and reading. When the nurses display a manner of communication that shows his/her focus on finishing with one resident so as to get to the next one or follow procedures, this is felt by the patient and may not be able to take care of the needs of the patient neither allow him/her to make decisions on the same (Hickman et al., 2007; Harding, 2005).

Dementia agitation in people with dementia living in RACFs

Agitation in dementia is recognized as a common and difficult issue among aged care residents. Nguyen et al. (2008) explicates this by estimating that 80% to 90% of patients with dementia develop at least one distressing behavioral problem at some point in the course of the disease.

Agitation is such a symptom and is characterized by inappropriate verbal, vocal or motor activities that result from unmet needs or confusion in the patient. Agitation can be displayed by several types of behavior as outlined by Nguyen & Paton, (2008). These include; verbal non-aggressive where the patient just complains, voices a lot of negativity, repeats questions or statements and regular uncalled for requests for help. Verbally aggressive behavior such as screaming, strange noises, cursing etc, physical non-aggressiveness characterized by doing inappropriate things and physical aggressiveness such as sexual advances, throwing things and grabbing among others (Levi, 2005).

Recommended Solutions

Agitation needs to be diagnosed properly in order to rule out delirium and appropriate intervention measures to be applied. Besides pharmacological interventions, non pharmacological measures should be administered first as (Detweiler et al., 2008). These could include providing an environment that is as close to a home environment as possible in the facility.

In addition to this, bright lighting could be used in the surroundings even during the day so as to avoid a misconception of stimuli (Neugroschi, 2002). Moreover, the environment should also be calm and with familiar things to soothe the patients (Bidewell & Chang, 2011).

A daily plan of activities, which the residents can engage in, will also help calm down and reduces stress. It is also important to provide adequate training to nurses on skills such as communication, managing behavior without confrontational manner and other support techniques and the planning and engaging the patients in activities in their care (Vink et al., 2003).

For patients with sleep disturbances, lack of enough sleep may cause agitation and intervention should involve addressing the underlying causes of sleeplessness (Hickman et al., 2007). First, there should be no excessive sleep expectations since, daily sleep requirements do not increase with age. This is echoed by Wilkes et al. (2005) who say that, daytime napping should be limited by engaging the patients in activities that are specially designed for dementia patients and physical exercises. In order to prevent agitation, Wilkes and his colleagues suggest a structured day should be provided so that a predictable routine is maintained. This should be done by providing orientation materials such as calendars, clocks and family pictures which should be kept in prominent places. Care should be taken when structuring a day so as to avoid rushing the patient because as it may result into agitation (Turner, 2005).

Pain in people with dementia

Research has shown that pain prevalence in elderly people is a common problem with 60 years and above adults experiencing twice as much pain as younger persons (Smith, 2007). Further, Smith says that 50% of institutionalized elderly people in the US have dementia and in European countries such as Austria and UK, 60% of institutionalized people have dementia. This is an indication of how pain assessment in RACFs is a challenge to the nurses.

Pain assessment in dementia patients is further complicated by unique barriers such memory loss, language problems, abstract thinking, loss of personality and judgment among others (Harding, 2005). Moreover, absence of behaviors associated with pain or difficulties in interpreting them make assessment even worse.

In pain assessment among patients with dementia, self reporting which is considered a ‘gold standard’ may not work since it will require the patient to understand the task and communicate about the patient (Brown, 2002).

Recommended Solutions

Primarily, agitation and other behaviors displayed by dementia patients may be an indication of pain (Maslow, 2004). Care should be taken though not to interpret these symptoms as pain indicators thereby complicating pain assessment even further (Harding, 2005).

In instances where the “gold standard” (mentioned above) does not work; other assessment tools will come in handy. This will require developing non-verbal assessment tools that will base their assessment on behavior observation (Maslow, 2004). One such tool nurses should use could be an observation chart for changes in the sleep patterns, appetite, physical activity, mobility and body/facial language of the patient at a given period of time (Harding, 2005).

Nurses or caregivers at the facility could also use physiological charts where the details of a patient’s especially those identified with problems in the first measure, such as heart rate, blood pressure will be recorded and monitored (Maslow, 2004). Though this has not been researched fully due to limitation validity and practicality, as reported by Fallon et al. (2006), with more research and a mixture of other interventions, it can significantly lessen pain.

Hygiene for people with dementia living in residential aged care facilities

Dementia often affects a person’s hygiene in that, they may loose interest or forget to wash or change their clothes and also bathing. This presents a different kind of a challenge to nurses in RACFs as the patients may require help toileting, getting dressed, brushing their teeth and general grooming (Kohn & Surti, 2008).

In addition to this, nurses face problems such as resistance or confrontations from patients to be assisted in caring for them due to the embarrassment of losing their privacy (Tilly & Reed, 2004). If at all the well-being of this patients is to be facilitated, these issues should be addressed as detailed below.

Proposed Solutions

In order to assist such patient, the nurse should exercise patience and avoid confrontations. The nurse should also try to maintain a level or a feeling of privacy by closing doors and pulling the blinds down. If the patient does not recognize himself/herself, cover the mirrors in the room and show a great deal of reassurance and patience while approaching the patient (Borbasi et al., 2011).

Another thing to address is the environment in which bathing or dressing is taking place. This can be bettered by making the room warm and attractive, providing adequate light and playing soft music in the background to get a calming and relaxing environment (Fallon, et al., 2006).

Conclusion

Dementia has become an increasingly common health problem that healthcare providers have to deal with in Residential Aged Care Facilities (RACFs). Patients of dementia have problems ranging from lack of attention, ability to tackle problems, language, ability to concentrate, ability to recall, think and behavior among others which become obstacles to living a normal social life. This is made worse by other medical and psychiatric conditions associated with dementia such schizophrenia, anxiety disorders, bipolar affective disorder and agitated depressive disorder.

However, by blending all the solutions discussed above, great improvements can be made not only by the dementia patients but the entire constitution of RACFs. In turn, the medical world will be monumentally bettered thus making the world a much better place than it is now.

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