Neuroanatomy of the brain
Presently, dementia is considered as one of the biggest health challenges (Albanese et al., 2016). According to Treves & Korczyn, (2012) it is predominantly an aeging disease and is prevalent in people belonging to the age group of 63-74 years. It is more common in people over 90 years. Currently, more than 41,000 people from New Zealand are dementia patients and estimates suggest that this number will reach 75,000 by the year 2026 (Mentalhealth.org.nz, 2017). Dementia is basically a form of neurodegenerative disorder and is characterized by a variety of symptoms that affect our mental faculties like thinking, memory, behaviour and daily activities. It has several psychological, physical and social implications on the patient and his family members. This report will focus on a case of a dementia patient Ms. Mary Mallinger, aged 89 years. It will discuss about her symptoms, risk factors involved in her condition, the diagnosis and preferred treatment and care giving strategies. It will also elaborate on any particular issue observed in the patient using proper evidence.
Type of dementia- Dementia is an umbrella term, which includes different forms of the disease. It is evident from the medical report that the patient Ms. Mary Mallinger is suffering from Alzheimer’s dementia (LASH, 2014). Alzheimer’s disease is one of the most common types of dementia and contributes to 60-80% of its incidence. Alzheimer’s disease characteristically affects the memory in patients. Patients with Alzheimer’s disease gradually begin to lose their sense of place and time (Reitz & Mayeux, 2014). It is seldom found in young people.
Neuroanatomy of the brain- Characteristic changes in the brain are observed in a patient with Alzheimer’s disease. ‘Plaques’ or deposits, which are made up of an abnormal ‘beta amyloid’ protein are present throughout the brain. Some tangles of twisted proteins also occur in the brain. ‘Beta amyloid’ is an abnormal by-product of transmembrane amyloid precursor protein (APP) and is a short peptide. The neurofibrillary tangles are aggregates of the tau-protein (microtubule associated protein). These proteins get hyperphosphorylated and cluster inside the cells. The major neuroanatomical changes are significant loss of synapse and neurons from the subcortical regions and the cerebral cortex (Serrano?Pozo et al., 2014). This neuronal loss leads to degeneration of the cingulated gyrus, frontal cortex, parietal lobe and temporal lobe. The patient’s CT scan shows small vessel ischemic changes which are responsible for motor and cognitive impairment which lead to dementia.
- Memory loss
- Difficulty in word comprehension and fluency
- Problems in performing routine tasks like organizing and planning.
- Apathy, depression and anxiety
- Changes in judgement and personality
- Repetitive verbalizations
- Misplacing items and forgetting names of relatives and close friends
Type of dementia- Alzheimer’s Dementia
Memory loss is the most noticeable symptom and it greatly affects the patients. Apathy, depression and anxiety are neuropsychiatric symptoms which persist throughout the disease (Ismail et al., 2016).
Risk factors-It can be deduced by a thorough analysis of her medical reports that certain factors made her vulnerable to this form of dementia. Cerebrovascular disease is the most common risk factor for this condition (Deckers et al., 2015). The conditions which added to the occurrence of the disease are hypercholesterolemia, hypertension, hyperventilation and ischemic heart disease. All of these conditions predispose a person to Alzheimer’s disease. Hypertension affects blood circulation and the blood vessels thereby, increasing the risk of vascular dementia (by affecting the vessels in the brain). Several studies have demonstrated that high cholesterol levels promote beta amyloid production, which increases the risk of the disease. Studies also provide evidence that heart disease of any kind leads to build-up of these proteins and increases cognitive problems in patients (Yaffe & Al Hazzouri, 2016). Therefore, the medical history of the patient suggests certain conditions, which worsened her condition and increased the risk of dementia.
Special diagnostic tests- The patient’s past medical history reveals an MMSE record of 19/30, and a current record of 26/30. MMSE stands for Mini Mental State Examination. It is also known as Folstein test and is the most frequently used screening procedure for dementia identification. It assesses the mental status of a person systematically through a series of questions (Arevalo-Rodriguez et al., 2015). The maximum score is 30. A score of 23 or below indicates presence of cognitive impairment. The patient’s medical records also show she underwent an ACE R test. It shows a past score of 63/100 and a recent score of 82/100. The ACER stands for Addenbrooke’s Cognitive Examination and assesses language, memory, attention, verbal fluency and visuo-spatial abilities. The total score is 100 (Larner & Mitchell, 2014). Any score less than 82 gives a positive diagnostic symptom for dementia. An increase in the patient’s score in both the tests indicates an improvement in her cognitive functioning.
Behavioural symptoms- Alzheimer’s disease is a neurological disorder. However, it presents some psychiatric and behavioural symptoms that create challenges for the caregivers. Some of the most common behavioural disturbances observed are paranoia, hallucinations, agitation, delusion, screaming. These behavioural disturbances are unpredictable and create discomfort in the patient. Progressive loss of neuronal cells is the main reason for these symptoms (Kales, Gitlin & Lyketsos, 2015). Certain environmental factors can also contribute to their occurrence. Sleep disturbances are extremely common and increases agitation. Affective symptoms like agitation, apathy and dysphoria are also seen.
- Repetitive behaviour
- Difficulty in completing familiar tasks (Ismail et al., 2016)
- Reduction in fine motor skills and shorter steps
- Loss of motivation and drive
- Lethargy and daytime napping increase
- Wandering
- Poor hygiene and grooming
Risk factors of Alzheimer’s Dementia
Use of drugs for dementia- As evident from the patient’s GP referral records, she is not under any dementia specific drug. However, she has been using several drugs to treat hypertension, blood circulation, bacterial infection and congestive heart failure.
Dementia pathway- The diagnosis suggests that the patient is suffering from mild stage of dementia. Clinical evidence, medical history and different behavioural assessment tools provide this evidence (Knopman & Petersen, 2014, October). The activities assessment chart confirms that her speech is good; she needs a walking frame to move and sometimes participates in social activities. The chart also reveals that she used to be involved in reading, discussion, watching television, music, instrument playing, walking and exercise. In case of mild dementia, the primary symptoms are forgetfulness of names, words, dates and addresses. Problems with recent memory appear. When the patient was admitted previously, she related her life experiences, the names of her family members and her life history. This proves that she is suffering from mild dementia.
Support at home or in aged care- Dementia is a poorly understood mental condition. Ignorance, social isolation and lack of awareness create hindrances for the patient. Family care-givers, social workers and clinicians provide care to the patients. Care provision encompasses financial assistance, hands-on care, arranging for services. These care-givers act like advocates and represent the preferences and view of the patients when they are themselves unable to communicate. Residential and adult day-care facilities provide a home-like environment and allow the patient to use his existing skills and continue daily tasks. A familiar and social environment affects the wellbeing and health of the patient (Reilly et al., 2015). It compensates for their motor, cognitive and sensory inabilities. Effective communication strategies must be developed to improve the symptoms of poor comprehension, memory loss and word framing difficulties. Cognitive stimulation therapy is effective for people with mild or moderate dementia. Different sessions enable the patient to think and increase their social skills. Family members should also explore reminiscence. Dementia patients often have clear memory of past events. Exploring events from their childhood or school life can improve confidence and communication. It helps in provoking strong emotions (Charlesworth et al., 2016).
Reason for aging in place- Aging-in place refers to the ability of people to remain in their community and home even when they face changes in health, life and their abilities. People often face issues related to health which increases with age. With old age, most people start suffering from chronic health conditions like heart failure, atrial fibrillation, and dementia. The same has occurred with the patient in this report as well. However, she is aging in place due to proper management of these conditions. She goes for medical checkups on a regular basis and is on medications to treat her heart disease, respiratory disorder and allergic condition. It can be deduced from the medical reports that she uses aspirin (for blood thinning), furosemide (for lowering blood pressure and increasing urine excretion), laxsol (for constipation) and (for angina, hypertension and irregular heart beat). Such proper management of diseases prevent health crisis and delay complications (Betterhealthwhileaging.net, 2017). The patient uses needs a walker to move, which helps in managing her physical disability. Thus, the patient is aging in place.
Diagnostic tests: MMSE and ACER
Diagnostic support provided- This was my first experience working with an Alzheimer’s disease patient. Initially I was nervous and hesitant to interact with the patient, as I was aware of her condition. I was in a dilemma figuring out ways of communicating with her. Good communication is helpful in building a therapeutic relationship in nursing care. I spoke in short, clear and simple sentences to make her understand what I intended to and tried to build a good rapport with her (Beer, Hutchinson & Skala-Cordes, 2012). That helped in building her confidence and I did not face any difficulty in making her follow my instructions. I tried to develop non-verbal communication for interacting with the patient. The two diagnostic parameters, the MMSE and ACE R tests provided evidence of mild cognitive and motor skill impairment. I showed empathy and became an active listener (Chew-Graham & Ray, 2016). It helped in developing therapeutic relationship and improved her medical outcomes. I encouraged her to exercise everyday because several studies report that exercise can drastically benefit the cognitive functioning and well-being of dementia patients. Exercise also helps in reducing progression of hypertension and cardiovascular diseases (Hoe & Thompson, 2010). I made the patient take an interest in socialization. It is evident from some studies that dementia patients are fearful of their cognitive impairment creating a hindrance in socialization. Such hesitations result in insecurities in the patients. There is no permanent cure for dementia. However, some medications are prescribed to reverse the damage caused to the brain. I administered cholinesterase inhibitors to the patient. Two such drugs were Memantine and Donepezil (Aricept) (Seitz et al., 2013). The former improves functional ability and donepezil reduces the behavioural changes. I focused on the use of these two drugs because they are acetylcholinesterase inhibitors. They help to delay the progress of the disease with mild-moderate symptoms and also reduce neuropsychiatric symptoms (Schwarz, Froelich & Burns 2012). I wanted to provide a holistic care and contribute to her mental stimulation.
Issue related to the patient and its analysis- This part of the assignment focuses on the management and treatment facilities that should be provided to a dementia patient at home or aged care. Following dementia diagnosis, one of the primary steps to be taken is social and health care assessment. This assessment involves the ways by which a dementia patient gets support and help form social service authorities and their family members. Most of the people with dementia stay at their own house provided they get adequate support from their family members, community nurses or paid caregivers. A comfortable stay in a surrounding, which is familiar to them helps them to cope with their conditions faster. Some dementia patients need support from residential care centres. These centres are generally nursing homes or aged homes. The rooms in the aged homes should be made as familiar as possible for a comfortable stay. Some dementia patients are also in need of palliative care in a hospice, where they are subjected to proper nursing and pain control methods (Livingston et al., 2014).
Symptomatic behaviour of Alzheimer’s Dementia
The way the house is laid out and designed creates a large impact on the mind of a dementia patient. Such patients generally face difficulty in learning new things and forget their place of residence or their relatives. Presence of familiar objects is reassuring and provides them a safe environment to live independently. Dementia affects aged people with poor eyesight. The patient in this report wears glasses. Such patients get a feel of disorientation in the dark. Leaving a nightlight switched on can help them to a certain extent. Better lighting at homes benefits them greatly. Use of high watt bulbs boosts the lighting at home, reduces risks of falls and avoids their confusion. Natural light in the home can be increased by keeping the curtains open and removing unnecessary blinds or nets. The electric switches should be easily accessible for the patients.
Reduction of noise also helps these patients. Cushions, carpets and curtains absorb background noise and help in improving the acoustics of a particular room. It is quite common for dementia patients to suffer from hearing impairment and they may put on hearing aids. Such devices magnify the sounds and give them an uncomfortable sensation. Shiny and reflective flooring should be avoided (Müller et al., 2017). A dementia patient may perceive it to be wet and may struggle to walk there. Rugs and mats should be removed from the floor as patients get confused and think them to be some object. This leads to falls or trips.
Presence of contrast colours on the floors and the walls of a room gives a patient a sense of depth and perspective. They are easily able to locate furniture in contrasting colours. Toilet seats in colours contrasting to the room help them to find the toilet easily. They are able to locate their food faster if the tablecloths are in a colour different from the plates. Bold colours should be used for towels, bed linen and soft furnishings in place of pastels. Such patients find patterns in furnishing disturbing and confusing as they may see shapes or faces in the patterns (Chew-Graham & Ray, 2016).
Mirrors should always be covered with a curtain or blind because a dementia patient often fails to recognize their own reflections. On seeing themselves in a mirror, they may consider that to be a reflection of some stranger. This leads to distress. Labelling different items like cupboards, doors and drawers inside a house helps the patient to know what is inside them. It will help them to get around. Some household objects are specifically designed for dementia patients. These items are clocks with large displays, cups with many handles, telephones with large buttons, devices to open the mouth of tins and jars (Müller et al., 2017).
Use of drugs for Alzheimer’s Dementia
Dementia patients lose interest in maintaining personal hygiene. The caregiver should encourage the patient to bathe and make sure there is enough light in the bathroom. By addressing their fear of water or of falling, a sense of understanding about hygiene maintenance can be developed in them (Hoe & Thompson, 2010). They should be provided fresh clothes, toiletries and shaving kits and should also be ,ade aware of their uses wellness.
A nurse or family member should carefully monitor the drinking and eating habits of a dementia patient. This is because dementia patients often forget to drink and eat and also face difficulty in chewing and swallowing their food. Foods which are familiar to them should be served in small portions, 5-6 times a day. The caregiver should eat with the patient to allow them to imitate the process of chewing and swallowing the food. Plates with patterns should not be used. Nurse and caregivers can create awareness among the family members by providing educational material that are related to respite services. Sometimes family members experience grief thinking about the impending loss in later stages of the patient (Müller et al., 2017). A nurse who is well equipped with knowledge about dementia education can provide reassurance and crucial aid to the family though all stages of the patient. Caregivers should allow the patient to participate in utilizing their best potential for their own care and should also advocate for the rights of the patients. Thus, nurses, caregivers and family members play an important role to maximize independence and client functionality. They contribute to optimal satisfaction of their clients, the dementia patients.
Conclusion
It can be concluded from this report that dementia is not an ordinary aspect of ageing. It is characterized by neuronal loss and deterioration in motor and cognitive skills. The report shows that certain risk factors like hypertension, high levels of cholesterol and cardiovascular diseases were responsible for predisposing the patient to dementia. It also concludes that dementia requires personalised treatment provisions, which can be provided by nurses, social workers and relatives.
References
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