Dementia, depression and cognitive problems are few of the prevailing mental disorders affecting elderly people worldwide. In developed countries, depression in quite prevalent in elderly people and the presence of this disorder depends on the presence of several comorbid physical problems (Prince et al. 2013). Dementia, as well, is quite prevalent in old aged people and co-exists with cognitive disturbance. Presence of depression or other physical disorders causes such prevalence as cognition impairment affects those patients both physically and mentally. These cognitive impairments are reversible as well as permanent and depending on this, the depression rates vary (Dupuis et al. 2012).
Dementia generally is a brain disorder that affects the mental function of the affected person and limits his social capabilities. Dementia is generally of two types reversible and irreversible. Alzheimer’s and vascular dementia are irreversible and has no treatment to cure the disease (Brooker and Latham 2015). On the other hand, reversible dementia can be treated with proper interventions and nutritional practice. Dementia and depression together affects the patient adversely and this is the fourth most common cause of death after cardio-vascular disease, cancer and stroke worldwide (Jung 2015).
This critical analysis talks about a patient X, who is 76 year old and is suffering from dementia, depression, hyperlipidemia, coronary artery disease, agitation and hallucinations. He is not been able to move around the care home and having issues of sleeping as well. In the light of this case study, patient’s medical history and admission summary, patients care needs, holistic assessment of problems, nursing interventions and its implementations are going to be discussed in the further discussion with the support from a range of literatures.
Mr. X (76) has been admitted to the care home one week back. He is suffering from vascular dementia with depression and was admitted to hospital from where; he has been taken to the care home. Hospital physicians and nurses tried to help and support him to remain him in his own home. However, due to his chronic level of dementia, hypertension, disorientation, failing memory and lack of understanding of risk factors present in his home his family took him to this care home. According to his family members, he is kleptomaniac and therefore hesitates to socialize with people. He is having short-term memory loss and speaking imparities therefore his family member wanted him to shift to this care home. At the time of his admission, he had high Blood Glucose Level (BGL), mild fever (38.5-38.9 degree C) and high blood pressure (180/120). His respiration rate was normal and was 18-20 respirations per minute.
According to his past medical history, the patient is suffering from Coronary Artery Disease (CAD) and has two major surgeries done for his heart. The first one is Coronary Artery Bypass Graft (CABG) to remove the plaque from his arteries back in 2012 and the second surgery to replace his failing aortic valve (Aortic Valve replacement) in 2014. He is having hyperlipidemia and hence having loss of appetite. He is unable to move from one place to another and need assistance to reach bathroom or other places. He is unwilling to take shower and hence hygiene is a major issue for the nursing caretakers. He is not been able to complete the instrumental activities of daily living (IADL) and feels depressed about it. Physicians has prescribed him anti-depressants to control his agitation, frustration and anger. However, due to his cognitive loss, he is unable to take medicine on time.
As the health condition of the patient is not well, a thorough care plan should be implemented to help the patient to achieve betterment. The care plan should include pharmacological as well as non-pharmacological interventions to treat the patient’s behavioral and psychological symptoms of dementia and depression.
As the Alzheimer’s disease has no specific pharmacological interventions or treatment, the prime goals to help the patient should be maintaining his quality of life. The prime reason of depression in person affected with dementia is their fear and hallucination about their quality of life (Bernacki and Block 2014). Hence, nurses should take effective steps while helping the patient to maintain his quality of life. His care needs should also include strategies to maximize his daily activities so that his mood and cognition ability can be enhanced. Due to his movement inability, his room should be safe and risk factors should be minimal. To manage his agitation and vulnerability, social interaction can be promoted. These goals will help to foster an overall care needs to help the patient with dementia (Reuben and Tinetti 2012).
Alzheimer’s disease is irreversible and no drug can revert the process of disease progression in patients affected with Alzheimer’s or other dementia (Biessels et al. 2014). However, to treat the cognitive loss symptoms there are five drugs that can slow down the process of memory loss effectively and help for the betterment of the patient. These drugs are approved from the FDA and can be used to treat the patient’s agitation, frustration, and cognition related issues. These drugs are – donepezil, galantamine, memantine, rivastigmine and a combination drug of memantine and donepezil (Geda et al. 2013).
Depression, agitation, psychosis and aggression are collectively termed as Behavioral and Psychological Symptoms of dementia (BPSD). These are the main reasons due to which families of patient suffering from dementia seeks help from care homes. Early recognition and treatment of these symptoms of cognition can help the patient to reduce his depression and help him to maintain a quality of life (Cerejeira Lagarto and Mukaetova-Ladinska 2012).
One of the major reasons for Mr. X’s depression and agitation is his vulnerability and inability to talk to strangers. Hence, they become resistant to social gatherings and get together. The intervention to meet the patient’s need in this case should be creating an environment to start effective communication (Papathanasiou and Coppens 2016). This intervention can enhance the mood of the patient effectively. The caregiver can talk to the patient regarding his family or friends and any happy moments from his past so that the patient feel connected to the care providers and listen to their instructions. Alternative treatment may include interventions that can be applied outside the care home so that the monotonous life of care home cannot affect the patient’s mood negatively (Van Gorp and Vercruysse 2012).
Patients with dementia often shows progression and ruthless decline in their behavioral, functional and cognition related care needs. Therefore, assessment of this disorder is very important (Olde-Rikkert Long and Philp 2013). Assessment of this disorder depends on patient derived as well as peer and family derived collateral informations. Many assessment scales have been developed to effectively carry out researches and care giving processes. The prime aim of these assessment scales is to reduce the uncertainty in the decision making process for the dementia patients (Lichtner et al. 2014). Some of the assessment scales, used in this case study is going to be discussed below.
The Mini mental state examination scale or MSME scale is one of the best-known and widely used measurement scale of cognition in researches and clinical studies worldwide. Physicians can easily use this scale and it does not require specific training (Mitolo salmon and Gardini 2013). This scale can assess the cognitive symptoms in just 10 minutes. The cognitive areas that can be assessed using this scale are orientation, calculative abilities, memorizing abilities and attention, visual construction and language (Arevalo-Rodriguez et al. 2015). This scale rates the patients from zero to 30 depending on their performance in the assessment and there is a set cut off to determine the patient’s cognition ability, which is 24. This test is generally misunderstood as a diagnostic test whereas it is a mere screening test to judge the patient’s recognition abilities (Markwick Zamboni and De Jager 2012).
To assess the cognition abilities of Mr. X, MSME need to be performed. This MSME will assess the ability of his sense of time and date, his sense of location, his ability to memorize a small list of four things and ability to repeat, his ability to name few daily objects, his ability to recognize and draw objects and finally ability to focus and solve short mathematical questions. This will help the caregivers to assess how much attention the person needs. Mr. X scored 13/30 that clearly defines his weak cognition abilities.
The Cornell Scale for Depression and dementia or CSDD was designed to assess the depression in old aged people who are able to communicate with people. This measurement process differentiates between severity of depression and diagnostic categories used. It assesses the reliability, sensitivity and validity on patients (Knapskog Braca and Engedal 2014). This assessment takes 20 minutes and ratings are based the symptoms of depression and the signs occurring during a week prior to interview. The results also depends on the origin of the depressive symptoms. If the symptoms are originating due to any physical problem or inability, then the assessment of depression cannot be performed using this scale (Leontjevas et al. 2012).
In the case of Mr. X, the CSDD screening has been performed through direct interview with the patient in the presence of a caregiver as he is suffering from impaired speech. the interviewer need to fill up a form having all the details regarding the patient’s depression levels. For every question, the assessor can assess the patient with four outcomes, unable to evaluate, absent, mild and severe. The assessor will provide these remarks based on the patients reply and hence, will be able to measure the depression level in the patient. Mr. X scored 8 that defines his high depression and hypertension levels.
The Alzheimer’s Disease Assessment Scale or ADAS cognitive subscale is a widely used measurement tool for the patients affected with dementia. However, this scale cannot be used for the patients having milder levels of cognitive impairments (Diniz et al. 2013). This assessment takes around 45 minutes to complete and can be performed only in the presence of a trained professional. This screening test has the ability to cover all kind of dementia and it has a better sensitivity to change. However, the duration of this assessment makes in non-suitable for clinical assessments, but this assessment process leads the way in drug trials for dementia (Montine et al. 2012).
In case of Mr. X, ADAS includes questionnaires and tasks to measure the cognition and behavioral changes in patients. The first task for Mr. X includes recalling words, naming objects and constructional practices. Further spoken language, direction sense, comprehensive ability was assessed using appropriate questionnaires. Scoring pattern is also opposite to other screening tests as for ADAS assessment lower score defines the better cognition level. This measurement process us accurate and is able to differentiate between normal cognition to that of impaired cognition. the score of Mr. X on a scale of 100 was 21 and hence, it can be said that his cognition ability was too much hampered and hence, he was having hypertension and depression level.
Although the dementia in Mr. X cannot be cure but proper care regimen for him can improve the quality of life for him and can help him to do the simplest tasks and perform the daily activities.
As discussed before, there are certain interventions that can be taken up for treating the dementia patients. It is evident from the case study that Mr. X was suffering from social withdrawal due to his inability to talk to people. As a plan of care the patient’s family and the members of the palliative team has been involved to promote social gatherings where more people similar to MR. X were invited such that Mr. X could understand that there are also people like him, and the problems that he had been facing are the general signs of aging and dementia (Callahan et al. 2012). Mr. X is entrusted with a constructive task such that he remains distracted. Although he showed restlessness for several times, but it was successfully managed by the care givers. Arrangements had been done for the patients to sit and have meals together. Competitions were arranged as per the age and the severity of the disease (Ennis and Kazer 2013).
In order to prepare a proper plan of care for the dementia patients it is necessary to inform the patient regarding the disease. As a health care professional one should have the ability to inform the patient regarding the progression of the disease. In order to do this, it is necessary to adopt a collaborative approach by the caregivers (Ryan et al. 2012). Specific programs were arranged where some dementia patients along with Mr. X and they were imparted knowledge regarding the pathophysiology and the symptoms of the ailment. They were informed about the self management techniques such that it becomes easier for the patients to conduct the daily tasks without seeking help from others (Ryan et al. 2012). In general the patients suffering from dementia suffer from social withdrawal as they have to seek help from others, due to which they suffer from inferiority complex, which makes them distant from their loved ones. Learning of the self management techniques would have helped Mr, X to carry on with the daily tasks and had helped to increase his self confidence.
Letting Mr. X come under the social umbrella had helped him to gain self confidence and have reduced his depression.
It had already been mentioned that the patient have had several episodes of agitation and aggression. In order to mitigate the psychotic attitudes, medications like Cholinersterase and Memantine drugs had been provided (Corbett et al. 2012, Cornegé-Blokland et al. 2012). It had been advised to the family of Mr.X to avoid the situations or the incidents that can trigger agitation and anger in him.
Many dementia patients suffer from short term memory loss. In order to help them out notes, remainders, cues and calendars have been taught to use. It was advisable to talk with the clients regarding then recent incidents such that he could recall the recent incidents.
It can be seen from the case study that Patient X was suffering from impaired speech, due to which he hesitates to visit the social gatherings. The family of Patient X was instructed to anticipate what the patient tries to say and do not make fun of this (Corbett et al. 2012). It was advised to provide words to the patient for sentence construction. It is necessary to remain tolerant to the repetitive statements or words uttered by the patient (Corbett et al. 2012).
As evident from the case study, Patient A have even shown kleptomaniac attitude. The patient’s family had been advised to deal the matter sensitively such that Patient X does not get frightened (Ryan et al. 2012). Later on single counseling sessions were organized where the patient is applied with dialectal behavioral therapy (Ryan et al. 2012). These sessions helped Mr. X to control his kleptomaniac attitude.
Furthermore , the nurse in charge of Patient X, helped the patient in doing his daily tasks, like helping him to move or taking him out on a walk or helping him to bath. Mr. X was encouraged to maintain a proper food diet and regular activity (Farina, Rusted and Tabet, 2014). Proper exercises help in improving the physical and the cognitive function in patients. Mr. X was encouraged by the nurse, to take shower every day and was taught how to maintain hand and hygiene (Farina, Rusted and Tabet 2014). The patient was taught to take care of his own belongings and adhere to the medications. The patient’s family and the caregivers ensured that Mr. X takes medicines on time. In such a way, the patient was taught to take care of his own medicines.
In the former part of the report, it has been mentioned that Mr. X suffered from many other co morbidities, like coronary heart disease and he have had two major surgeries. It should be noted that the patient is already suffering from a physical burden of heart disease, in addition to this dementia has also set paws on him. Among the nursing intervention s to manage dementia, care was also taken that his heart disease remains in control. In order to accomplish this, it is necessary for maintain a routine check up as and when required (Farina, Rusted and Tabet, 2014).
It is very difficult to evaluate the nursing interventions in the dementia patients, as the symptoms often remains latent or can relapse with time. In general the interventions were evaluated by keeping a record of the daily activities of the patient and tallying it with his previous activities (American Psychological Association, 2012). The cognitive status of the dementia patient can be determined by the IQ adjusted testing (American Psychological Association, 2012). This test can be performed during the assessment for the dementia, although in this case this test was being performed once more to determine the cognitive status of the patient after the treatment. It should be said that the cognitive result did not show drastic change from the previous report, but it was successful in bringing some changes in the life style of patient X. Specific algorithms are there for the evaluation (American Psychological Association, 2012).
Conclusion
In the conclusion, it can be said that, dementia and depression affects the patient physically as well as mentally. This critical analysis discusses the health condition of an old patient Mr. X and discusses his health imparities. He is having a complicated medical history and has gone through two major surgeries to treat his arterial disease. After a set of health and mental problems, he has been taken to the care home. This report discusses his admission summary and past medical history elaborately. After that, the care need of the patient has been discussed clearly. The assessment tools that has been used to assess his depression, dementia and cognitive symptoms has been discussed. Further, the nursing interventions needed to treat him or to reduce his cognition imparities has been mentioned. The methods to implement those interventions has also been discussed.
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