Physical and Cognitive Changes in the Brain
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Normal Aging |
Dementia |
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Loss of Nerve Cells |
The brain and the nervous system undergo several natural changes in which the brain and the spinal code lose nerve cells and atrophy. As a result, the nerve cells start passing messages slower than expected and waste products can accumulate in the brain tissues during the breakdown of nerve cells (Prince et al., 2013) |
In dementia, however, physical changes occur to the nerve cells due to accidents or diseases. As a result, the flow of electrical charges to and from the affected neurons is disrupted thus interfering with the ability of the nerve cells to communicate with other brain cells. |
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Plaques and Tangles |
Individuals suffering from dementia display considerably higher densities of tangles and plaques. Plaques are not ever-present in normally aging individuals. |
Tangles are normally present in all brains above the age of 55 and increase with age. Plaques are prominent in people with dementia. |
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Slower Reactions and Decisions |
The simple reaction time of an individual is slowed with normal aging. This happens because as one gets older, there is a loss of brain connections which thus affects their simple reaction time and they thus become slower |
Persons with dementia lose their ability to solve problems and make informed judgments and decisions. They are unable to think clearly and in most cases, they may not know what to do in the event that they are out of routine. |
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Memory Changes |
An individual may occasionally experience memory lapses but would still be able to function independently. Additionally, a normally aged individual does not get lost in familiar places even though they may pause to remember some directions. |
Dementia affects the memory of an individual such that they have difficulties in recognizing places and people. They also struggle remembering things like pin and phone numbers. They have a poor short-term memory and are also unable to make new memories. |
Delirium can be described as a sudden change in the mental state of an individual thus causing problems with memory, attention, emotion, and thinking. This sudden change in mental state may occur over hours or days. An individual may also exhibit altered levels of consciousness that may include delusions and hallucinations (Prince et al., 2013). Dementia, on the other hand, develops over time and the changes in the mental state of an individual occur over months or years. Dementia is also associated with a slow progression of cognitive deterioration.
People going through depression tend to put a negative spin on things while patients with dementia will normally try to cover their shortcomings. Depressed people normally have a problem concentrating and they may even suffer occasional memory lapses. Dementia, on the other hand, affects an individual’s ability to store information (Prince et al., 2013). It is also important to note that depressed people will normally not have language problems unlike their demented counterparts who may even struggle with names of simple objects like “pen”.
Alzheimer’s disease
This is a type of dementia that affects the behavior, memory, and thinking of an individual. It is the main cause of dementia. The changes associated with Alzheimer’s disease primary affect the part of the brain responsible for learning and thus making it difficult to remember newly learned information (McKhann et al., 2011). Other symptoms of Alzheimer’s include disorientation, difficulty speaking, deficiency of reasoning, changes in personal behaviors, and unfounded suspicions about friends and families among others. The diagnosis may include a test for neurological functions, MRI test of the brain, and urine or blood test among others.
Vascular Dementia
This type of dementia occurs as a result of damage to the brain caused by a poor supply of blood to the brain. This poor supply may be as a result of diseased blood vessels. Some of the symptoms of this disease include loss of vision, disorientation, trouble speaking, confusion, and trouble understanding speech among others (Prince et al., 2013). The diagnosis for this condition may involve professional screening to assess reasoning, thinking, and memory at anyone who may be at risk of having this disorder.
Lewy Body Dementia
This disease results from protein deposits developing in nerve cells around the brain regions responsible for motor control, memory, and thinking. It causes a progressive deterioration of mental capabilities. This disease may be characterized by visual hallucinations, depression, apathy, cognitive problems, and movement disorders among others. It may lead to severe dementia, aggressive behavior and in worst case scenarios it may lead to death.
Distinguishing Normal Aging and Dementia
Early/Mild Dementia
Individuals in this stage may still function independently but they experience memory lapses that affect their everyday life. Some of the main characteristics witnessed in this stage include getting lost and misplacing objects, losing memory regarding recent events, personality changes that may involve becoming more withdrawn, difficulty in solving problems, and difficulty in expressing thoughts among others.
Moderate Dementia
The characteristics in this stage include changes in sleep patterns, requiring assistance with things like bathing and dressing, greater loss of memory, increase in confusion accompanied by poor judgment, and significant changes in personality behaviors due to unfounded suspicions and paranoia of friends and family.
Advanced/Severe Dementia
The characteristics here may include the loss of the ability to communicate, an increased vulnerability to infections like pneumonia, loss of the ability to walk, sit, hold hands, swallow, and control bladder, and the need to be assisted every time with things like eating and dressing.
Cancer
Caring for a demented cancer patient can be a very challenging task. The cancer treatment in this situation will depend on the patient’s condition and the stage of dementia. In most cases, the patient may be required to make a decision regarding the treatment procedure they should undergo (Prince et al., 2013). However, dementia affects the reasoning ability of an individual and thus you may not know what they would want. As a result, a healthcare practitioner may be forced to seek consent from the patient’s spouse or close family member.
Diabetes
Diabetes is a condition that increases an individual’s risk of developing other conditions. Diabetes makes caring for demented patients a very challenging experience. The brain normally uses glucose as the primary source of energy but diabetes affects the production and regulation of insulin which is responsible for the uptake of glucose into the blood. This implies that for diabetic patients, the amount of glucose taken to the brain is insufficient thus the brain becomes energy starved making the caring of demented patients difficult.
Person-centered Care for Mrs. Smith
I would try to involve Mrs. Smith by giving the choice of food at mealtimes. This can be made simpler by asking her what she would like to eat or by showing her pictures to aid in making a choice of food. Additionally, I would involve her in knitting, an activity that she usually enjoyed. This could make her feel more in control of her own life. I would try to see the world in her eyes and view things in her perspective. Such an approach to care will also ensure that she is treated with respect and dignity.
The Symptoms and Stages of Dementia
Notable Changes
Mrs. Smith stopped attending social activities as frequent as she used to. This was the onset of dementia and the signs of withdrawal were evident. Withdrawal from social activities and the tendency to be quiet are some of the signs of early dementia. There was also a point when she forgot she had already taken lunch and was very furious when she thought she had not eaten. This is an implication of loss of memory regarding recent activities.
Changes in Needs
Mrs. Smith needs started to change and she needed assistance with most of the activities like making meals and communicating. These changes were due to worsening of dementia that affected her motor control and memory.
Effects of Changes
The result of the changes was a loss of trust and the feeling of suspicion towards Jane. This can be confirmed from the moment she was furious with Jane when she forgot she had already eaten.
Changes in Each Stage
During the early stage, Mrs. Smith starts having feelings of withdrawal from social activities. She starts attending them less frequently. As a carer, I would try to remind her what these social activities meant to her. I would even accompany her to the sites of these activities. Another change during this early stage was in communication. She started becoming quiet and withdrawn. Through person-centered approach, I would engage her in conversations that I know excite her so she could feel like she is a part of something.
During the moderate stage of dementia, she stopped performing holistic wellbeing. She would start knitting before ensuring that everything was clean and in order. Additionally, her communication deteriorated further and she started experiencing difficulties in communicating her needs. To address this as a caregiver, I would engage her in choice making regarding her needs by sometimes using images of the things she loves to make it easier for her.
During the advanced stage of dementia, Mrs. Smith experienced changes with her feelings. She became suspicious of Jane especially when she thought she had not eaten and she became very furious. She also lost her ability to remember some activities like the issue when she thought she had taken lunch. As a caregiver, I would offer her what she requests to build trust with her.
Cognitive Effects
The first ADL that is changed by this effect is dressing. Cognitive effects of dementia affect an individual’s ability to make the right choice regarding the type of dress to put on. Another ADL affected by this effect is personal hygiene since the patient is not in a position to make an informed judgment regarding their hygiene.
Functional Effects
The first ADL, in this case, is a slower reaction. A demented individual will react slower to things that happen around them. Another ADL is managing finances, which is also affected by dementia.
Behavioral Effects
The first ADL affected in due to behavioral effects is socialization. An individual gradually losses their social skills and become more withdrawn as dementia chips in. another ADL is over-activity, where an individual becomes overactive in how they respond to environmental changes.
Psychological Effects
The first ADL, in this case, can be said to be anger and frustration with others. During this time an individual exhibits signs of anger towards just about anything. Another ADL that is affected is an individual’s personality. Demented patients start experiencing personality changes.
Meaningful Activity
One meaningful activity that I have used before to care for a demented patient is engaging them in community sports especially bullfighting.
Importance of Activity
I realized that this activity effectively compensated for lost abilities and provided an opportunity for social contact, pleasure, and enjoyment. This activity also helped to improve the self-esteem of the patient as he felt more involved and he felt he was a part of something big.
Relationship of the Activity with the Individual’s Personal Plan
The main reason for choosing this activity was how it related to the patient’s background and culture. He always participated in this sport and he is one of the people who ensured that it grew to be a very likable activity within the community. I, therefore, believed that organizing such an event would impact on him positively.
Personal Restraint
This is when a caregiver uses their body to prevent the demented person from moving. An example of this restraint is planned personal restraint.
Physical Restraint
This type of restraint is when equipment such as a chair is used to limit the normal freedom of movement of a demented patient. An example is strap and lap belt restraints.
Environmental Restraint
This is when the surrounding of a patient changes thus limiting their movement. An example is the use of bed rails.
Seclusion
In this type of restraint, the amount of social interaction of a demented individual is reduced due to the risk of injuring themselves or those around them. An example of this restraint is locked doors.
Medication
In this type of restraint, a drug is administered to the demented patient to limit their movement or to sedate the patient. An example is the use of antipsychotic drugs.
Dignity
The patient under my care must receive the respect and dignity they deserve. I can ensure this by respecting their rights to make choices, listening to their concerns, and involving them in most of the decisions.
Privacy
My patient’s right to privacy can be maintained by closing the door every time I am helping them to dress, knocking at the door before going into their room, and ensuring that any personal thing that we may discuss remains confidential.
Support
Even during restraint, I have to show support to the patient by allowing them to make choices and seeing sense in their choices and why such choices could be important to them.
Communication
The patient must be included in any conversation that involves them and not just talking about their condition as they are not present. I would, therefore, make them part of all conversations regarding their wellbeing.
Safety
I will have to weigh the risks associated with using restraints to avoid any form of physical or psychological trauma that may come as a result of the unsafe use of restraints.
- Informed consent
- Evaluation and review
- Assessment
- Documentation
Disability Discrimination Act 1992
This act exists to protect everyone against any form of disability-related discrimination. It thus ensures safety by ensuring that no one irrespective of their disability is treated less favorably.
Health Records Act 2001
This act protects the health privacy of an individual. Health information about a patient cannot be collected by an organization unless the patient has consented to such. Additionally, the collection must be required, permitted, and within the jurisdictions of the law. In doing so, the safety of the patient is protected.
Medical Treatment Act 1998
This act provides clarity regarding the patient’s right to refuse a medical treatment. Additionally, it provides the procedures necessary in making decisions that involve refusal of treatment.
- EPA comes into effect if a family court or a healthcare practitioner determines that the patient is mentally incapable and thus cannot make crucial decisions concerning their welfare. A certified health practitioner is the only person qualified to carry out an assessment and ascertain the mental capacity of an individual. Thereafter, the health practitioner issues a certificate indicating whether or not the EPA can come into effect.
- Once there are doubts regarding the mental capacity of a patient, a qualified health practitioner is called in to perform an assessment on the patient. Once the assessment is complete and the mental capacity of the individual has been ascertained, the practitioner may issue a certificate indicating that the said person has become mentally incapable. EPA then comes into effect.
- EPA gives the person you trust the powers to make crucial health decisions regarding your welfare when you become unable to do the same. The person with this power may be a family member or a very close friend. This, therefore, has an association with an individual’s personal care as it transfers all decision making tasks to the attorney.
Daily Activities
The first person I assisted was Mr. Johnson from Pasifika. He was a demented patient in the moderate stage and he, therefore, had lost some of his abilities. I assisted him with personal hygiene cares. Another person I assisted was of P?keh? decent. I assisted him with mobility need as he had already lost some of his capacity to freely move from one place to another.
I tried to support Mr. Johnson to have a meaningful life by engaging him in meaningful activities. The main activity that I engaged him in was in social activities such as community sports. In such activities, he met and interacted with different people. This was related to his personal plans that he used to engage in. In the case of the second patient, I noticed that he loved watching football on TV. I would, therefore, engage him in this hobby every weekend to ensure that he felt like he was a part of something. Our workplace culture demands that we ensure our care is patient-centered to improve health outcomes just like in the above case.
I also carried out some routine clinical observations for the patients. Like in the case of Mr. Johnson, I always observed his blood glucose level, bowel management, heart rate, and diastolic and systolic blood pressure. The blood glucose level was useful in managing his case of dementia as the brain needs glucose energy for proper performance. Bowel management was helpful since he has lost some of his abilities to defecate on his own. I also had to observe the heart rate and the blood pressure to assess the rate of blood supply to the brain. For the case of the second patient from P?keh?, I observed temperature and heart rate. I also performed other tasks like administration of medication and bowel management.
During the time I was caring for Johnson, I noticed some changes in his conditions and symptoms. He became more withdrawn and quiet with time, lost some of his motor abilities and became extremely paranoid about just about every situation. I recorded these observations in an Electronic Health Record system and stored them on my computer for future reference. To respond to these changes, I had to remind him of some of the activities he used to enjoy. I also involved him in most decision making to build trust between me and him. I additionally observed changes in symptoms and condition of the second patient from P?keh?. These changes included the loss of memory and he could no longer remember some of the most recent activities. Just like in the case of the first patient, I recorded these changes in an Electronic Health Record system and store this information in my computer. I administered medication to him to counter this memory loss.
Barriers to Communication
In Johnson’s case, I experienced some barriers to communication as I interacted with him. The first barrier was due to changes in his brain. Dementia affected his region of the brain that is responsible for communication and he had difficulty with speech and completing words. The second barrier was his health status that had massively deteriorated and he could no longer engage in a constructive communication. Another barrier to communication was the environment. The environment seemed strange to him and this affected his comfort levels thus acting as a barrier to communication. Finally, sensory losses due to death of some nerve cells as a result of dementia also affected his communication skills and thus becoming a barrier.
For the case of the second person, I also experienced some communication barriers that affected how we communicated. One of the barriers was culture. He was from a P?keh? culture which was different from my culture and thus communication became difficult due to different beliefs and values. Another barrier was that as the condition got worse, he started reverting to his original language which I clearly did not understand. This made communication between us difficult. His age was also another barrier because he had different interests to mine due to the age difference. Finally, he also had changed with his brain because the condition affected the region of the brain that is responsible for communication.
Communication Skills
During my interaction with the two patients, I applied some communication skills that would ensure a successful conversation with the two patients. In the case of the first patient, I decided to use simple but clear step-by-step instructions. These instructions were both verbal and non-verbal and I relayed them in a manner that would ensure Mr. Johnson easily understood my message. For the case of the second patient, I had to avoid coercion and patronization. This ensured that conversation was person-centered so he did not feel the pressure of being forced to communicate.
Effects on Family
There are several effects that come with providing support for demented patients. Some of these effects directly affect the families of the patient. Like in the case when I was caring for Mr. Johnson who is of Pasifika origin, I noticed that his family members who were also aiding with care were affected. Some of the effects included stress, burnout, loss, and role change. Stress, in this case, was caused by the unending demands of providing care and support because Mr. Johnson was becoming more dependent. This stress became so excessive over an extended period of providing care and it led to burnout. Burnout was evident from the constant frustrations and feelings of irritability that was witnessed within the family. There was also role changing within the family as the elder children had to take more commanding roles in organizing things within the family. There was also the loss of freedom to plan for things like travel and vacations as one has to stay back home and provide support.
These effects were also evident within the second family where I was able to witness the same effects. Firstly, there was the loss of physical presence when the demented patient was moved from their home to a residential care facility. This loss led to stress among the family members because they were worried about not keeping a close eye on the patient. Stress overload eventually led to burnout which further affected other family members leading to detachment and withdrawals. There was also the aspect of changing roles as people had to adapt to performing tasks that they were not familiar with.
Changes in the Family
Some of the changes I observed in the first family included a general feeling of detachment and withdrawal caused by stress overload. Additionally, I observed that there was a feeling of fatigue due to extended periods of providing support. I noted down these observations and reported them to the general practitioner. I applied stress management strategies such as healthy diets and making the family member informed regarding dementia. This helped in lowering the stress levels. I also advised them to have some rest and get away from all the task of support for a while to regain energy and let go of fatigue.
Just like in the first family, I observed stress and fatigue in the second family. I recorded this using an electronic health record and forwarded the same to the general practitioner. I applied strategies like rest where I insisted that everybody required adequate rest and other stress management tools like exercising.
Services for the Family
Some of the support and advocacy services that are available for the first family include residential care facilities. These facilities are provided in a variety of places that include rest homes and dementia care facilities. The services offered may include doctor’s visits, cleaning, food, and laundry among others. The purpose of these services is to offer a safe and high quality type of care for demented patients who cannot be adequately cared for at home. These services are certified by the ministry of health.
In the case of the second family, one of the support and advocacy services available is Alzheimer’s New Zealand. The main purpose of this service is to educate demented patients, their families and supporters about dementia. It also provides a national advocacy for all demented patients and their supporters in addition to raising the needs of these people to the government. Some of the services offered include daycare programs and resource information.
Effects on Support Worker
The first effect on a support worker offering support to a demented patient is stress. This can be due to the patient constantly demanding the same thing and asking the same question. Additionally, the demented patient may be unable to clearly communicate their needs and so it will be difficult to know what they want. Stress overload eventually leads to burnout since one is exhausted due to constantly caring for someone who has lost most of their abilities. Additionally, there is abuse sometimes by the demented patient who may seem paranoid about everything and thus turn violent. Finally, they experience personal loss because the support worker lives everything to take care of one person.
Managing Effects
In my case, I managed to identify two effects that were taking their toll on me. These effects were stress and abuse. I however devised strategies to deal with these effects. One of the strategies was self-reflection in which I wrote a diary documenting all the stressful experiences that I had. I evaluated myself and my capabilities to properly care for a demented patient. I even went as far as attending a seminar to be more informed regarding dementia. This seminar was so fruitful since I learned a lot. The second strategy that I employed was self-advocacy where I had to stand up for myself and make informed decisions on crucial matters. I additionally had to take responsibility for the results of my decision.
The two strategies I used to manage the two effects included managing my feelings and taking part in physical exercises. I had to manage some of my feelings to avoid retaliating when I was physically abused in the line of duty. Physical exercises also helped me in fighting stress and get my mind off some of my daily tasks.
Managing Behaviors
Wandering
This behavior can be described as the act of moving around aimlessly from one place to another. This behavior is very common among demented patients and it becomes worrying because dementia causes memory loss and the patient may struggle to trace their way back home.
Hoarding
This is when a demented patient searches for something that they may think is lost. They normally engage in this activity with the aim of safely keeping whatever they are searching for.
Catastrophic reactions
During this situation, the patient may overreact to an ordinary occurrence. The result of this behavior may be an outburst, crying, screaming, shouting, or even an uncontrollable laughter.
Sundowning
This term is used to describe the condition of experiencing increased agitation, relentlessness, or confusion during the day.
Factors that Influence Behaviors
Changes in the brain
The deterioration of the brain capacity may raise an alarm to the patient and this raises anxiety. Dementia affects particular regions of the brain that may cause visual hallucinations and changes in personality that may lead to withdrawal characteristics.
The environment
The environment has a very big influence on the behavioral changes of a demented patient. Factors such as lighting, simulation, large crowds, and noise may raise agitation and frustrations.
Anxiety
Anxiety can result from the constant frustrations of daily activities compounded by feeling unwell and the pressure of wanting to perform way beyond the current capabilities.
Sensory issues
Dementia interferes with the patient’s visual and hearing abilities which may further affect their ability to communicate.
Cultural factors
Culture affects the things the people enjoy doing, food preferences, and communication among others. The onset of dementia can affect how an individual responds to cultural factors. This can further make communication difficult especially if the person reverts to their original language.
Loss of choice
The demented patient continuously relies on others for the support thus the patient may be left with little choice and this can further affect their confidence level regarding their abilities. The result of this loss of confidence may be stress and anxiety.
Strategies
Some of the strategies that I applied to manage the behavior of the first person included debriefing, stress management, avoidance of triggers, timeouts, diversion, and positive relationships. During the debriefing, I could ask questions to analyze serious events like aggressions and find the root cause. Stress management involved activities such as relaxation, meditation, and exercise to reduce the stress levels of the patient. I also avoided engaging in activities that would trigger negative reactions. I also tried to prevent the patients from being overloaded with information as this could change their behavior. Diversion tactic was useful in distracting the patient and taking their attention from a negative behavior. It was also important to build a personal relationship with the demented patient by trying to know his preferences and dislikes.
For the second patient, I applied an individualized service plan, communication techniques, staff education and training, individualized action plans, spoken language, and body language. The individualized service plan involved every person having an individual plan that focusses on the support of positive behavior. Good communication techniques were also useful by keeping our communication simple. Staff education and training also helped in learning new ways of handling patients with difficult behaviors. Individualized activity plans included activities such as leisure, outings, daycare and group activities. Spoken language ensured that care was shown through the tone of the voice and by explaining and simplifying tasks. Body language was also used as a strategy by appropriately using physical affection.
References
McKhann, G. M., Knopman, D. S., Chertkow, H., Hyman, B. T., Jack Jr, C. R., Kawas, C. H., … & Mohs, R. C. (2011). The diagnosis of dementia due to Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s & dementia, 7(3), 263-269.
Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W., & Ferri, C. P. (2013). The global prevalence of dementia: a systematic review and metaanalysis. Alzheimer’s & Dementia, 9(1), 63-75.
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