Kirsten Halse spring 2005 Caring for people suffering from dementia Class 3A 2005.

Kirsten Halse spring 2005

Caring for people suffering from dementia

Class 3A 2005


Definisjon off dementia

Dementia is a syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is a disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgement. Consciousness is not clouded. Impairments of cognitive function are commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behaviour or motivation. (Warner et al 2002 p. 90)


Definition of dementia

Dementia come from the Latin word demens. It means: without mind.

Alzheimer's disease has been given the name after the doctor who first described the illness in 1910. His name was Alzheimer.

(Burns in Jacoby & Oppenheimer 2002 p. 501)


Who is the person suffering from dementia


History

1920 Born

1930 Economic bad times, unemployment

1940 Second world war, In her twenties, married.First child born

1950 Building up the country after the war The next two children born

1960 Cars, telephone and Television more common for everybody

1970 Women start working, welfare society growing Start working part time in a store. Grandchildren.

1980 Heart attach, diabetes, hypertension

1990 Computer. Mobil telephone Retired, husband dies

1995 First symptoms of dementia


What happens

First there is the gradually advancing failure of mental powers such as memory. Reasoning and comprehension. Much here can be attributed directly to the brain being less efficient; its function has declined and usually there is degeneration in its actual structure.


What happens

Second there are changes in the social-psychological environment – in patterns of relationship and interaction. Those changes can be part of the disease or they can occur because of the responses the person gets from the surroundings. (Kitwood 1997 p. 20)


Symptoms or characteristic features of the disease dementia.

Cognitive impairment- Decline in memory

Short-time memoryLong-term memory, e.g. semantic memory,

episodic-memory, procedural memory.– Abstract memory

Recognise, identifyRecall, call back to mind

– The memory for making plans


Cognitive Impairment - continued

Decline in comprehensionDecline in the ability to orientates

oneself in relation to time, person and place.

Decline in the ability to learnDeficit in language, anomia, aphasia


Cognitive Impairment - continued

ApraxiaAgnosisDecline in the function of the will, the

ability to decide for something and do it.All those different impairment results in

a decline in the ability to care for oneself in the daily life. Reduced ADL.


Psychological impairment

Tendency to isolate oneself, to withdraw from people

The interest in ones surroundings falls, less interested in other people and things

The person can become apathetic psychological unstable, more irritated Decline in judgment


Psychological impairment

Depression Anxiety Aggression towards other people –

catastrophic reactions Personality characteristics are maintained or

exaggerated in some persons and may otherwise be altered in others

Forgetting of feelings connected to incident


BPSD

90% of all patients suffering from dementia will have some kind of BPSD symptoms

BPSD = Behavioural and Physical Symptoms of Dementia

These symptoms can both be of psychological and behaviour character


BPSD

Delusions Misidentification

syndrome Hallucinations Depression, mood

changes Anxiety Unrestrained behaviour Physical and verbal

restlessness Aggression, treats or

violence

Call out, cry out Wandering Sleep disturbance Wandering (20%) Excessive motor activity,

restless, purposeless activity

Collecting things Conspicuous eating and

sexual behaviour (Thomas and O‘Brien inJacoby and Opperheimer

p. 512- 518, Matteson et..al 1997 p. 297-298


Anxiety

Associated with dementia. Anxiety reactions can be manifested in various ways;

somatic complaints, rigidity in thinking and behaviour, insomnia, fatigue, hostility, restlessness, pacing, fantasizing, confusion, increased dependency. (Eliopoulos 2005 p.454)

Patients without speech often shows their anxiety in behaviour pattern, sometimes as physical aggression.


Anxiety

Treatment of patients with dementia, anxiety and delusions are;- environmental - medications

The goal is to reduce both the anxiety and the psychiatric symptoms as delusions and hallucinations


Depression

Prevalence of depression:– 15 to 25% in community based elders– 25% in older adults who are residence of long-

term care facilities Depression can occur in the early stage of

dementia as the patient becomes aware of declining intellectual abilities (Eliopoulos 2005 p. 452)


Depression - symptoms

Insomnia Fatigue Anorexia, weight loss, Constipation, Guilt, Apathy, remorse Hopelessness, Helplessness

Feeling of being a burden Loss interest in people Physical complaints,

headache, indigestion Altered cognition

The symptoms of depression can mimic those of dementia (Eliopoulos 2005 p.449-453)


Delirium - symptoms

The onset of symptoms tends to be rapid

Disturbed intellectual function

Disorientation of time and place

Altered attention span Worsened memory Labile mood Meaningless chatter

Poor judgement Altered level of

consciousness, mild drowsiness

Disturbance in sleep-wake cycles can occur

Physical signs such as slower psychomotor activities

(Eliopoulos 2005 p.442-444)


Other symptoms

Neurological symptoms, more primitive reflexes late in Alzheimer's disease

Instability IncontinenceWeight loss (people with Alzheimer's

disease lose weight over 3.5 times the rate of healthy age-matched controls (Thomas & O'Brian in Jacoby & Oppenheimer p. 519).


Different types of dementia

Alzheimer's disease is the most common cause of dementia in the older adult 60%.

The symptoms of this progressive, degenerative disease develops gradually and progress at different rates among affected individuals.


Dependency over the years


Developmental of the disease

Although staging of the disease can help predict its general course and anticipate plans or care, it must be appreciated that many factors affect the progression of the disease and that there will be individual variations.


Different types of dementia

In addition to Alzheimer's disease, dementia may be caused by a variety of pathologies.

Vascular dementia 25%.


Vascular dementia

This form for dementia results from small cerebral infarctions.

Damage to the brain tissues can be diffuse or localised.

The onset is more rapid and the disease progresses more predictably than Alzheimer's disease.

The risk factors are smoking, hypertension, hyperlipidemia, inactivity and a history of stoke or cardiovascular diseases


Frontotemporal dementia

The characteristic of this form of dementia is that the frontal lobes of the brain is affected.

Behavioural rather than cognitive abnormalities in the early stages are common.

Rather than poor memory early cognitive changes can include impairment in the abstract thinking, speech and language skills.


Other types of dementia

Lewy body dementia Parkisons`s disease Creutzfeldt-Jacobs disease Wernicke encephalopathy


Other types of dementia

Potentially Reversible causes of Dementia Emotional disorders Metabolic and endocrine disorders Eye and ear dysfunction Nutritional deficiencies Tumor and trauma Infections Arteriosclerotic complications

(Linton &Matteson p293 in Matteson et.al 1997)


Presence of cognitive impairment

The prevalence rate across Europe are estimated as 4.5% of men and 6.5% of women over 60.

Over 90 years of age the rate are estimated as 32% of men and 35 of women (Warner et al.2002, p. 95)

In Norway there are around 70.000 people with dementia. The number will increase because the amount of elderly people will increase.


Alzheimer's disease - Prevalence


Treatment

There is none specific treatment for the disease dementia

Treatment focus on: Milieu therapy All diseases must be taken care of Medication


What do people with dementia need

Comfort Attachment InclusionOccupation IdentityLove (Kitwood1997)


What do people with dementia need

(Kitwood1997)


What do people suffering from dementia need - identity

To have an identity is to know who one is, in cognition and feelings.

It means having a sense of continuity with the past; a “narrative” to present to others.

It involves creating a kind of consistency across the different roles and context of present life. (Kitwood 1997p. 83)


What do people suffering from dementia need - identity

Help the person to remind who his is by using- photographs of the patient and family- personal possessions in the room- dressed like they use to- talk with the patient about his life. Can be done individually and in groups - Reminiscence.


What do people suffering from dementia need - inclusion

Everybody has a need for being part of society.

The need for inclusion comes poignantly to the surface in dementia in so-called attention-seeking behaviour. Tendency to cling.

Person with mental impairment are not easily included in everyday life.


What do people suffering from dementia need – occupation

The need for occupation is present in people with dementia. It is manifested, for example, when people want to help or take part in activity.

Helps the person to feel part of life and valuable


What do people suffering from dementia need - Occupation

Help and support the person in relation to self-care – involving the person.

The person does as many daily activities as his is able to. (Eliopoulos 2005 p 447)

The purpose is to:- promote mastering- make sure the patient do have meaningful day- increase quality of life


What do people suffering from dementia need - comfort

The word comfort carries meanings of tenderness, closeness, the soothing of pain and sorrow, the calming of anxiety, the feeling of security.

To comfort another person is to provide a kind of warmth and strength which might enable the person to remain in one piece when his is in danger of falling apart.

In dementia the need for comfort is likely to be especially great when a person is dealing with a sense of loss.

(Kitwood 1997 p. 81)


What do people suffering from dementia need - attachment

The need for attachment remains when a person has dementia; it may be as strong as in early childhood.

Life for persons with dementia are overshadowed by new uncertainties and anxieties.

People with dementia are continually finding themselves in situations that they experience as “strange” and that this activates the attachment need. (Kitwood 1997 p. 82)


Maintaining Personhood

Maintaining Personhood

When physical needs have been met, this is the central task of dementia care. It involves enabling the exercise of choice, the use of abilities, the expression of feeling, and living in the context of relationship


Communication with a person suffering from dementia

Communication can be affected early on in dementia.

A reduced ability to communicate has an impact on relationship as well as on the well-being of the patient and on the early stages of management.

(Pearce in Jacoby & Oppenheimer 2002 p. 584)


Communication with person suffering from dementia

To a person in a nursing home the nurse talks about something which is going on now. The person does not answer regarding what the nurse talks about.

Why not ??? – maybe he or she is another place in his life


Communication with a person suffering from dementia – reality orientation

Reality orientation were designed to help reduce confusion and disorientation in people suffering from dementia

The idea was to orientate people to who they were, where they were and present time.

Reality orientation can be useful


Communication with a person suffering from dementia - reminiscence

Reminiscence means the use of recall of events of ones life.

This can be done in two ways:- individually- in groups.


Communication with people suffering from dementia - reminiscence


Communication with a person suffering from dementia - validation

Naomi Feil

Between 1963 and 1980 she developed Validation as a response to her dissatisfaction with traditional methods of working with the disoriented old people.



To validate is to acknowledge the feeling of the person. To validate is to say that their feelings is true. Denying feelings invalidates the “other”.

A “fantasy” is based on memory and wishful thinking. It is a personal view of the world. It is seeing with the mind's eye and it is an inner realty. (Feil 1989 p. 1-3)



To validate means to accept and appreciate the person the way the person experience the world.

It is important to create assurance for the person by respecting and accepting the persons feelings and experiences.


Communication with a person suffering from dementia – validation, general rules

Take part in a retrospective view with the person. Do not contradict the mistaken view of the

person. Allow the person to show his feelings. Respect and appreciate the persons feelings, all

feelings are allowed. Do not ask “why” questions. It can be difficult for

the person to answer and can create anxiety and insecurity.


Communication with a person suffering from dementia – general rules

Use a environment which is free of distraction

Improving sensory input, by maximizing both hearing and vision

Use face to face contact or touch when initiating and during conversation

Simplifying the matters to be discussed Presenting the ideas as one idea at a time


Communication with a person suffering from dementia – general rules

Orientation to the topic of conservation, written reminders may be helpful.

Assist the person when she get ”stuck”. For example can sentence completion helps.

Reassurance and support can help when the person becomes frustrated.

(Pearce in Jacoby and Opperheimer 2002 p. 584)


Communication with person suffering from dementia – use of music

Literature review suggest that music therapy is a useful intervention to help patients deal with a range of behaviour problems. (Lou, M.F. 2001 Scandinavian

Journal of Caring science Vol. 15)


Communication

In communication with people suffering from dementia is it important to use all the senses in communicating with the person


Communication

Interaction with person suffering from dementia is not only a question about responding to signals but also to catch the meaning the other person communicate; it involves reflection, hunch, expectation and creativity (Kitwood 1997).


Management behavioural disturbance – Risk assessment

In dementia there are risks of harm occurring both to the patient and to others.

Is there a risk of harm? If so, what sort of harm, to whom, and what is the likely

severity? How likely is it to happen? How immediate is the risk and how long will it last? What factors contribute to the risk? How can these factors be modified or managed?

(Pearce in Jacoby and Opperheimer 2002 p. 578)


What kind of competence is necessary for the nurse to care for the person suffering from dementia ??

Validation uses empathy to tune into the disoriented old person.

Empathy - walking in the shoes of the “other” – builds trust.

Validation means each person is unique. Workers do not judge (Feil 1989),

For Travelbee empathy is also essential in nursing (Travelbee 1999)

Kirsten Halse spring 2005 Caring for people suffering from dementia Class 3A 2005.

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Transcript of Kirsten Halse spring 2005 Caring for people suffering from dementia Class 3A 2005.