Managing the Care of Elderly Patients Using an Advanced Practice Framework

This document discusses the management of care for elderly patients using an advanced practice framework. It covers topics such as diagnosis, medications, pain management, and the risk of falls. The document also explores advance care practices for treatment and ethical considerations. Suitable for healthcare professionals and caregivers.

“Managing the care of elderly patient using an advanced
practice framework”
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Table of Contents
Introduction.................................................................................................................................................3
Discussion....................................................................................................................................................4
Diagnosis & Medications.........................................................................................................................4
Pain management....................................................................................................................................5
Risk of fall................................................................................................................................................5
Advance care practices for the treatment...............................................................................................6
Health evaluation and wellbeing programs.............................................................................................9
Ethical considerations............................................................................................................................10
Conclusion.................................................................................................................................................11
References.................................................................................................................................................11
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Introduction
Cognitive disability is a mental phenomenon which includes the disturbance in a person’s
memory, decision making ability, language, or attention. These symptoms can be an early signs
of a disease that could lead to Dementia (Borson et al., 2013). Dementia is a disease that is very
much prevalent among old age people. It is reported to be about six percent worldwide which
is expected to rise in future. However according to some reports decreasing trend has also been
observed. The disease is responsible for posing a significant amount of burden over the families
as well as the care givers and emerged as a very big problem in front of the health care systems
as well as the society. The most common form of dementia is the Alzheimer’s disease type
dementia which accounts for almost sixty percent of the total cases. During the course of the
disease out of six patients every five patient of dementia shows different signs of behavioral
and psychological alteration. These signs could be defined as the disturbance caused to the
thoughts, behavior, mood, or perception of an individual. All the alterations such as,
depression, delusions, hallucinations or agitation etc are very closely related to each other. One
fourth of the total individuals without any symptoms would have those symptoms from the two
years of the disease diagnosis. Additionally about half of the total patients show a significant
behavioral and psychological symptoms of dementia on a monthly basis. These changes in
behavioral pattern like agitation and depression bring about the feeling of helplessness as well
as distress among the family of the individual, these also hinder the activities and relationships.
The condition leads to a poorer quality of life and admission in nursing homes (Abraha et al.,
2017).
The given case is of an elderly patient who is majorly suffering from Dementia long with other
problems like high cholesterol, depression, bone disease etc. In the following report all the
factors related to the recovery of the patient and his care using advanced practice framework
would be demonstrated. Advance care practice is a constant, powerful procedure of reflection
and exchange between an individual, those near them and their social insurance experts,
concerning the person's inclinations and qualities concerning future treatment and care,
including end-of-life care. In spite of all inclusive acknowledgment of the significance of ACP for
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individuals with dementia, who slowly lose their capacity to settle on educated choices
themselves, ACP still just happens rarely, and proof put together proposals with respect to
when and how to play out this mind boggling process are inadequate.
Discussion
According to the given past medical history along with dementia the patient is also suffering
from the conditions like hypercholesterol, hypertension, aggression, depression, paranoia.
Since the patient has a history of pain and whole hip replacement, he cannot be made to
perform physical exercises which could also be one of the interventions to take the patient out
of this condition. The set of medication at which the patient is, can also be considered as the
catalysts in deteriorating his condition up to some extent. In order to perform advance care
practice first of all these medications should set aside after checking all the medical conditions
like cholesterol, blood pressure, functioning of heart, brain imaging any kind of pain etc.
Diagnosis & Medications
A test for total blood count and its chemistry ought to be done to recognize iron deficiency,
diabetes, any issues with liver or kidney or any kind of infection. Routine tests for thyroid
capacity, nutrient B12 lack, and raised blood calcium. A cerebrum check utilizing either CT scan
or MRI would be incorporated into the standard assessment for dementia. CT and MRI
examines, which uncover the anatomic structure of the mind, will be utilized to discount such
issues as tumor, drain, stroke, and hydrocephalus, which can take on the appearance of
Alzheimer's sickness. These outputs can likewise demonstrate the loss of cerebrum mass
related with Alzheimer's illness and different dementias. In Alzheimer's illness, the locale of the
cerebrum known as the hippocampus might be excessively decayed Psychologists or
neuropsychologists (therapists with particular preparing in mind issue) may manage extensive
neuropsychological tests, either as meetings or as paper-and-pencil tests. These tests, which
take a few hours, will be utilized to figure out what territories of subjective capacity are
disabled and what regions are as yet flawless. They survey memory, thinking, composing,
vision-engine coordination, understanding, and the capacity to express thoughts.
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Risperidone which is used for the treatment of various mental disorders has been found to be a
potential reason of putting elderly patient suffering from dementia or its related psychosis at an
increased risk of death (risperidone and Consta, 2019). It has been reported that usage of
medicines could even deteriorate the mental health of a patient (Jordan et al., 2015).Since the
patient is having high cholesterol level so it should be made sure that he is not given those
medication for controlling the cholesterol level which increases the risk of dementia. For that
matter many reports suggest that use of statins had a 29% reduced risk of developing dementia
(Schultz, Patten and Berlau, 2018). Atrovastatin which is in the medicinal setup of the patient is
also a form of statin though but there are no studies that have significantly shown the
association among individuals above 80 years of age (Wanamaker et al., 2015). It has been
established since earlier times that hypertension leads to heart stroke and they both have also
been found to be associated with dementia (Christiane Reitz and Jose A. Luchsinger, 2007).
High cholesterol levels, high blood pressure, hypertension, strokes, these are all interrelated
with each other and they can be treated together by making informative and result oriented
changes in diet. The medicines used for controlling these conditions have also been reported to
be associated with decrease in the cognitive abilities. It is better to replace these medicines
with healthy diet regime. Patient should be given those foods which do not contain saturated
fatty acid. Foods like, oats, okra, beans, soy, apple, grapes, strawberries etc. should be included
in the diet and it should be made sure that the diet is strictly followed.
Pain management
A dementia patient conveys the feeling of pain regularly communicated through conduct
aggravations. Pain is believed to be a standout amongst the most significant causal variables of
conduct and mental side effects of dementia. However it is hard to recognize the link between
these two because of the complexities of these indications, which change over the phases of
dementia and are increasingly visible in the later phases of the disease (Benbow, Jolley and
Greaves, 2015). Social and mental indications of dementia emerging because of pain, for
example, fomentation and hostility, can be very troubling for both the individual and their
guardian, and can prompt the unseemly endorsing of antipsychotic drug rather than sufficient
treatment for pain. While these prescriptions do have their place in the treatment of extreme
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or tireless mental indications, they are related with generous reactions including expanded
mortality, cerebrovascular occasions, and falls. Additionally another significant and regularly
overlooked issue is the effect of the neuropathological changes in dementia on torment
observation. The symptomology of dementia likewise implies that appraisal of torment is
especially testing because of the loss of correspondence capacity, which for the most part
happens amid the condition. Accordingly, normally utilized evaluation instruments are neither
substantial nor solid and are hard to utilize (Achterberg et al., 2013).
Risk of fall
Dementia patients have very high risk of falling resulting in several serious injuries. So their
environmental review should be done. Environmental review here means that the surroundings
of the patient should be checked and if there are changes to be made in furniture, floors, stair
case etc. are done immediately (Safetyandquality.gov.au, 2019). In this case vitamin D is used
as one of the interventions in order to avoid fall. However there are many interventions that
can be used. Exercise is also one of the interventions but considering the age of patient it
cannot be recommended that to when patient is already having a hip replacement. Meditation
could be considered as one of the interventions or other technological interventions can also be
used. Chairs fitted with alarms can be used or low beds should be used instead of high beds
because many injuries have been reported due to falling from the bed (Cameron et al., 2018).
Advance care practices for the treatment
Taking all the conditions into consideration a proper advance care practice framework should
be prepared in order to treat the patient for his betterment and well-being. As the condition of
the patient is getting deteriorated day by day so the process of advance care practice should be
initiated as early as possible. Ideally these practices should be started before the onset of any
kind of cognitive decline but as in this case the condition of the patient has already started
getting worse so there should not be any further delay in the initiation of the process
(Shanagher and Lynch, 2017). If possible the process should be started on various moments and
occasions and the piece of conversation involved could be shorter or lengthier depending upon
the patient’s inner feeling. These can be random or preplanned sometimes, however there are
several moments or can be termed as the crucial points at which these conversations should be
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started as reported by many researchers (Harrison Dening, Sampson and De Vries, 2019). Every
individual and his situation are different so it is very necessary to understand the person as well
as the situation very specifically.
It is very necessary to evaluate the mental capacity of the patient and dementia should never
be considered as a case of total loss of capacity. There are certain points which should be kept
in mind like, the patients mental capacity should be considered as full along with the accretion
that it keeps itself in a non-static state that is why it keeps fluctuating. So it is the duty of the
care provider that we should look for those windows or the moments when we can start u a
conversation based on advance care practices. When there is a disagreement between the
patient and some one very close to them then we care givers should act as a bridge for them.
We should take their responsibilities and other decision making authorities on us. There should
be a proper clinical assessment as well as neuropathological test should be done. People with
dementia have a lost or decline in their cognitive activity, abstract thinking and also their
abilities to think about their past. They also develop a tendency of living in the resent and
become anxious by thinking about the future. So in this case it becomes necessary that the
patient should be made to converse in his way, the communication style should be adjusted in
such a way that it matches the patients frequency and rhythm. While establishing such
conversation the principle of person centered care should be kept in mind (Raymond et al.,
2013).
In this case the patients daughter can be made his surrogate decision maker as she is the only
one left who i.e. the most closest to him. She should be explained about the fact that she would
only be the alone decision maker in case the patient is no longer able to make any decision. The
conversation should be very clear and precise because the patient, due to loss of his abilities of
decision making, diminishing capacity to process a new information can no longer be able to
understand the conversation related to advance care practices. Things lie books, CD’s etc. can
be used a supporting materials to keep your point in order to make them understand. During
conversation one should try to explore the fact that what is the awareness level of disease
among the patient is. Weather the person knows about the disease that he is suffering from or
he is totally unaware of the fact (de Boer et al., 2012). However there is no need to enhance
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their knowledge on disease if they are unaware of it. Every individual has their own references
of knowledge and information so it is better to give importance to the individual’s general
values and concerns instead of updating him over disease.
The points that should be included in the process of conversation are to know more about the
patient’s resent fear that are in their minds regarding their future and the end of life. They
should be asked about the specific decisions regarding their end of life care and treatment. One
should try to know a person suffering from dementia that what kind of a person as whole he or
she is. Advance care practices not only include future perspective but also involves past and the
resent. The story of the patient should be heard properly. One must know about the life
changing events of a patient’s life that has either given meaning to their lives or changed the
whole meaning of their lives. If feasible then the individual should be counceled for the
formulation of his care which include the comfort, quality of life, good health (van der Steen et
al., 2013). They should also be made aware about the fact that these prescription could also be
altered during the case of disease trajectory. People should be asked not so clearly but in a way
that it makes clear that what they want to happen after their life ends (Burlá, Rego and Nunes,
2014). They should be asked for the wishes and things that they want to do before they hand
over themselves to death. Patients of dementia do not side suddenly. There are many decisions
attached to their end of life care like, the usage of antibiotics, myths regarding artificial food
and fluid should be made clear during the conversation sessions based on advanced care
practices.
After each arranged or spontaneous session, social insurance experts ought to record the result
in the patient's therapeutic/care documents, for example the qualities, wishes or care
objectives of the individual and, where pertinent, subtleties of a development order or lawful
agent (Bernacki and Block, 2014). In the event that the individual wishes, bolster them in
defining explicit wishes and advance choices concerning an amazing finish, investigate whether
they have made a formal composed development mandate before or in the event that they
need to make one now and give data about the favorable circumstances and detriments of
development orders. It is suggested that ACP documentation is assessed routinely as a major
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aspect of the ACP procedure, for instance fully expecting a 'reaction move'. Choices can be
modified consistently (Ashton et al., 2016).
However only verbal demonstration od decision making capabilities is not enough, these
decision regarding their end of life care should be well documented. These decisions in the
form of document can be very helpful to the physicians, care giver or the person closely
associated with the patient. These documents can be really fruitful as they are the result of
continuous and in depth conversation with patient. If the patient is not at all in condition to
communicate verbally then there are different aspects which should be taken into
consideration.
Instead of increasing the dependency of the patient on pharmacological intervention, it is
better to show our inclination towards psychological interventions for the treatment of
dementia. It has been very well established that music therapy can give significantly positive
results in the treatment of dementia patients. Involvement of elderly patients in different
recreational activities can provide better results. However these kind of recreational and leisure
activities have not been paid much attention. They can be a crucial dimension in enhancing the
quality of life of older dementia patients. These kind of activities lighten up the mind, provide
opportunities to meet new friends, develop skills and competencies (Carmeli and Imam, 2014).
Patients must also be provided with social opportunities, as the patients feel derived off all the
social engagement because of their mental and physical disparities. Due to which the feeling of
living the life also gets lost somewhere in the daily monotonous routine. A group of well-built
aged elderly people should be made and they should be trained in order to provide a healthy
and light environment for the treatment of those old age people who are battling with
dementia. The same age group factor could bring wonders to the treatment regime. They will
find them much healthier and happier in their company.
Health evaluation and wellbeing programs
There should be certain solutions to treat these mental health conditions they should be able to
consider the following aspects.
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1. Complete appraisal that intends to distinguish both physical medical issues and natural
factors that may add to the etiology of emotional wellness issues is vey important.
2. Such guidelines should be developed by the government which emphasizes on devising
strategies for the elderly patients suffering from any kind of mental disabilities.
3. Suitable living plans must be made. Elderly people with any psychological instability
ought to have their very own place to inhabit and a decision with whom they need to
live.
4. There should be appropriate job opportunities for this group of population. As these are
the most derived members of the society in terms of having jobs and have the lowest
rate of employment.
5. Providing preparing to paid emotional wellness care staff and non-paid parental figures
can give way a superior fitness in the executives of mental issues which is additionally
significant for improving the personal satisfaction and lessening the predominance of
those psychological issue.
6. If an arrangement should be made powerful, there ought to be a "common
methodology" that is customer focused. The program should concentrate on
counteractive action, and be down to earth and manageable. The "multifaceted
methodology" ought to incorporate likewise meds, psychotherapeutic, psycho tactile
engine treatment, ecological administration, social help, and family training.
Ethical considerations
There are some ethical issues that come with the process of managing and taking care of an
elderly patient of dementia. In this case patient is very old and dependent, he is not able
perform his daily routine work properly (Smebye, Kirkevold and Engedal, 2015). He needs an
all-time support with him. He does not likes her daughter which is another issue in the process
of providing care that the person does not wants to be looked after by their near and dear
ones. There are following ethical dilemmas that would arise during this case.
1. Dilemma of having consent for the end of life decision
It is a very big point to think that, instead of his daughter who is there some other erson
who is not even closely related to him is required to get all those necessary documents
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signed. All the necessary decisions like the lace of care during there last moments of life,
the things that they want to keep, the things that they want to give away, their wishes,
all these decisions are made by the one who is just a care giver not the member of the
family.
2. Dilemma of installing any kind of technological gadget at home for safety
It is also a thing that comes into mind while working with such cases that how the
settings of someone’s house can be altered. It is a total breach of one’s privacy protocol.
Installing instruments like alarms at every such place where there can be harm detected
for the patient. For e.g. Alarms in the bathroom, alarms in the resting chair, alarms in
the kitchen etc.
3. Dilemma of giving a whole time support to the patient.
In this case the patient requires someone with him all the time, in such a condition the
dilemma that comes in mind is weather I will be able to manage the patient full time.
What if I have to go for any emergency for some days? What if something happens in
my absence? There comes a sense of fear sometimes which is not correct from the point
of this profession.
I should try to stay positive about all the situation and should give my best in managing and
caring about the patient. It is true that there are and there will be some ethical dilemmas that
would come during the course of treatment and care, but they would be handled appropriately
and be managed. The care of the patient would be the foremost priority and it would be done
by incorporating all the advance care practice processes.
Conclusion
Mental illness has become a very big cause of concern worldwide. There is a need of devising
some effective and significant programs which majorly aim upon providing proper care and
treatment to the patients suffering from the disease. The disease comes with various other
problems like pain, high blood reassure, high cholesterol, falls etc. These are all the companions
of disease, the medication used for the treatment of these condition also play a crucial role in
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deterioration the condition even more. In order to lessen the hazardous impacts of these
medications, we should opt more for psychological interventions as compared to the
pharmacological interventions.
The patient of dementia also suffers from pain. There is a requirement for a proficient strategy
for evoking and incorporating all agony related data for patients with dementia, which is
conveyed in time and between staff. Such a strategy should give a general image of a patient's
agony which is quickly open to all associated with their consideration. This would give a
genuinely necessary premise to settling on choices to help the compelling administration of the
torment of more established individuals with dementia (Lichtner et al., 2016). There is need of
proper executable plans and schemes by the government in the favor of these old age people
who need care and support at this stage of life. Taking the given case only, the patient was a
self-suffice healthy and responsible individual all his life. But once he got stuck by this mental
condition, his life was totally changed, this gives us an example that anyone can need help at
any stage of life. So there should be some policies devised in the benefit of these individuals
which could be executed beforehand. The policies which include all kind of documentations
related to the wishes, desires of these elderly patient before getting into this disease. So that
these documents could be further referred at the time of practicing advance care techniques.
References
Abraha, I., Rimland, J., Trotta, F., Dell'Aquila, G., Cruz-Jentoft, A., Petrovic, M., Gudmundsson,
A., Soiza, R., O'Mahony, D., Guaita, A. and Cherubini, A. (2017). Systematic review of systematic
reviews of non-pharmacological interventions to treat behavioural disturbances in older
patients with dementia. The SENATOR-OnTop series. BMJ Open, 7(3), p.e012759.
Achterberg, W., Pieper, M., van Dalen-Kok, A., de Waal, M., Husebo, B., Lautenbacher, S., Kunz,
M., Scherder, E. and Corbett, A. (2013). Pain management in patients with dementia. Clinical
Interventions in Aging, p.1471.
12

Ashton, S., Roe, B., Jack, B. and McClelland, B. (2016). End of life care: The experiences of
advance care planning amongst family caregivers of people with advanced dementia – A
qualitative study. Dementia, 15(5), pp.958-975.
Benbow, S., Jolley, D. and Greaves, I. (2015). Improving diagnosis of dementia in primary
care. Progress in Neurology and Psychiatry, 19(1), pp.4-4.
Bernacki, R. and Block, S. (2014). Communication About Serious Illness Care Goals. JAMA
Internal Medicine, 174(12), p.1994.
Borson, S., Frank, L., Bayley, P., Boustani, M., Dean, M., Lin, P., McCarten, J., Morris, J., Salmon,
D., Schmitt, F., Stefanacci, R., Mendiondo, M., Peschin, S., Hall, E., Fillit, H. and Ashford, J.
(2013). Improving dementia care: The role of screening and detection of cognitive
impairment. Alzheimer's & Dementia, 9(2), pp.151-159.
Burlá, C., Rego, G. and Nunes, R. (2014). Alzheimer, dementia and the living will: a
proposal. Medicine, Health Care and Philosophy, 17(3), pp.389-395.
Cameron, I., Dyer, S., Panagoda, C., Murray, G., Hill, K., Cumming, R. and Kerse, N. (2018).
Interventions for preventing falls in older people in care facilities and hospitals. Cochrane
Database of Systematic Reviews.
Carmeli, E. and Imam, B. (2014). Health Promotion and Disease Prevention Strategies in Older
Adults with Intellectual and Developmental Disabilities. Frontiers in Public Health, 2.
Christiane Reitz and Jose A. Luchsinger (2007). Hypertension, Cognitive Impairment and
Dementia: An Epidemiological Perspective. Current Hypertension Reviews, 3(3), pp.166-176.
de Boer, M., Dröes, R., Jonker, C., Eefsting, J. and Hertogh, C. (2012). Thoughts on the Future:
The Perspectives of Elderly People with Early-Stage Alzheimer's Disease and the Implications for
Advance Care Planning. AJOB Primary Research, 3(1), pp.14-22.
Harrison Dening, K., Sampson, E. and De Vries, K. (2019). Advance care planning in dementia:
recommendations for healthcare professionals. Palliative Care: Research and Treatment, 12,
p.117822421982657.
13

Jordan, S., Gabe-Walters, M., Watkins, A., Humphreys, I., Newson, L., Snelgrove, S. and Dennis,
M. (2015). Nurse-Led Medicines' Monitoring for Patients with Dementia in Care Homes: A
Pragmatic Cohort Stepped Wedge Cluster Randomised Trial. PLOS ONE, 10(10), p.e0140203.
Lichtner, V., Dowding, D., Allcock, N., Keady, J., Sampson, E., Briggs, M., Corbett, A., James, K.,
Lasrado, R., Swarbrick, C. and Closs, S. (2016). The assessment and management of pain in
patients with dementia in hospital settings: a multi-case exploratory study from a decision
making perspective. BMC Health Services Research, 16(1).
Raymond, M., Warner, A., Davies, N., Nicholas, N., Manthorpe, J. and Iliffe, S. (2013). Palliative
and end of life care for people with dementia: lessons for clinical commissioners. Primary
Health Care Research & Development, 15(04), pp.406-417.
risperidone, G. and Consta, B. (2019). Risperdal Consta (Risperidone): Side Effects, Interactions,
Warning, Dosage & Uses. [online] RxList. Available at: https://www.rxlist.com/risperdal-consta-
drug.htm [Accessed 22 May 2019].
Safetyandquality.gov.au. (2019). [online] Available at:
https://www.safetyandquality.gov.au/wp-content/uploads/2009/01/30458-Guidelines-
RACF.pdf [Accessed 23 May 2019].
Schultz, B., Patten, D. and Berlau, D. (2018). The role of statins in both cognitive impairment
and protection against dementia: a tale of two mechanisms. Translational Neurodegeneration,
7(1).
Shanagher, D. and Lynch, M. (2017). Guidance for healthcare staff: Advance Care Planning and
Advance Healthcare Directives with People with Dementia. International Journal of Integrated
Care, 17(5), p.118.
Smebye, K., Kirkevold, M. and Engedal, K. (2015). Ethical dilemmas concerning autonomy when
persons with dementia wish to live at home: a qualitative, hermeneutic study. BMC Health
Services Research, 16(1).
14

van der Steen, J., Radbruch, L., Hertogh, C., de Boer, M., Hughes, J., Larkin, P., Francke, A.,
Jünger, S., Gove, D., Firth, P., Koopmans, R. and Volicer, L. (2013). White paper defining optimal
palliative care in older people with dementia: A Delphi study and recommendations from the
European Association for Palliative Care. Palliative Medicine, 28(3), pp.197-209.
Wanamaker, B., Swiger, K., Blumenthal, R. and Martin, S. (2015). Cholesterol, Statins, and
Dementia: What the Cardiologist Should Know. Clinical Cardiology, 38(4), pp.243-250.
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