NSG2TCD: Dementia Care Improvement Proposal: The Case of Tom Smith

This essay presents a comprehensive analysis of dementia care, focusing on the case of Tom Smith, a 75-year-old patient admitted to an acute care hospital with chest pain and a history of angina and dementia. The essay explores the experiences of Tom and his family during his hospital admission, emphasizing the importance of person-centered care (PCC) in managing his behavioral and psychological symptoms (BPSD). It discusses strategies for understanding and addressing Tom's needs, including non-pharmacological interventions and the involvement of family members in his care. The essay also highlights the role of nurses in providing PCC, building therapeutic relationships, and managing BPSD through accurate assessment and individualized interventions. Furthermore, it addresses the clinical resources and assessments necessary for effective dementia care in acute settings, such as the Mini-Mental State Examination and the Neuropsychiatric Inventory. The conclusion underscores the significance of social and community involvement, effective communication, and a holistic approach to care that considers Tom's values, beliefs, and personal aspects.

Transition in Dementia Care
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Introduction:
Dementia is incurable disease. Multiple factors need to be considered for providing care to
the dementia patient like Tom. In this essay, all these aspects are being discussed. Patient and
family members experience of dementia during hospital admission are mentioned.
Behavioural, psychological and functional approaches are being considered for understanding
Tom and his family members experience. Aspects related to person centred care in providing
care to dementia patients are being discussed. Requirements for nurse and clinical resources
necessary for providing person centred care to Tom are being discussed. Person centred care
is essential for providing care to both pathology and philosophy of person centred care.
Interpersonal relations need to be established between Tom and nurse to design and build
care around requirements of Tom. Behavioural and psychological symptoms are present in
almost every patient with dementia. Behavioural and psychological symptoms exist in the
form of complex cluster; however, at least one symptom should be present in patient with
dementia. Behavioural and psychological symptoms can occur due to neurobiological disease
factors, unmet needs, care giver factors, environmental triggers, and interactions of
individual, care giver, and environmental factors. Factors need to be considered while
providing care to dementia patients are being discussed.
Patient and family experience:
Tom and his family members would be going through substantial changes after admission to
the hospital. Tom was never being admitted to the hospital. Hence, he would have become
restless and agitated. In such scenario, his family members could have taken charge of him
and tried to make him calm. However, it would be difficult task for his family members
because due to dementia he would have been not identifying them. He would treat them as
un-known people. Scenario would have become serious issue because Tom would become
more agitated. His family members would have imagining that he is identifying them and
they can control his agitation. However, situation would become more difficult because
imagination of both Tom and his family members would go in the opposite direction. He
would forget to take medication for angina due to his dementia. It can lead to exaggeration of
his angina condition. His family members would have become more worried because due to
forgetfulness in medication consumption. His family members would imagine that he would
become worried because his incapability to participate in the community services. From the
case study, it is evident that he is more interested in community services (Murray, 2014).
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Most difficult situation during his admission to hospital would have been when he lashed out
at the nursing staff. Family members would be worried that nursing staff might become
disappointed due to this type of erratic behaviour. This erratic behaviour of Tom might be
due to dementia. He would forget that nursing staff are very important aspects of his care.
Due to this erratic behaviour, Tom would develop symptoms like decreased concentration,
insomnia, apathy, communication difficulties and anxiety (Fukuda et al., 2015).
All these symptoms can adversely affect Tom’s and his family members day-to-day living.
Due to this erratic behaviour, there is possibility that nursing staff and family members might
feel fear about him and these people might keep distance from him. It might lead to feeling of
loneliness and there might be development of stigma in him. Hence, he might try to keep
himself away from community. His admission in the hospital can lead to development of
financial strain on his family members. Family members of Tom would learn symptoms of
dementia and would try to manage behaviour of Tom with respect to symptoms of dementia.
Family members might get experience in decision making in his care (Helgesen et al., 2013).
Person centred care (PCC):
Nurse need to know Tom for providing person centred care to him. Tom is experiencing chest
pain in addition to his dementia condition. This chest pain might be exaggerating his
dementia condition due to lack of concentration. Nurse also need to know his past and present
values, beliefs, interests, abilities, likes and dislikes. These can be helpful in effective
communication with Tom and his family members because in PCC, effective communication
is very important aspect. Nurse need to recognize and accept Tom’s reality. Nurse need to
think from the perspective of Tom. His current behaviour need to be taken into consideration
while communication with him. It can be helpful in understanding his feelings and it can
connect effectively with him. Meaningful engagement with the patient can improve outcome
of PCC (Edvardsson et al., 2014).
Identifying and supporting ongoing opportunities can be helpful in establishing meaningful
engagement with Tom. Tom’s ongoing behaviour is erratic. Hence, nurse need to consider
this behaviour and implement intervention to control his erratic behaviour and improve in his
dementia condition. Upto some extent, nurse need to support his erratic behaviour because it
might give pleasure, joy, comfort and meaning in life to him. It can be helpful in improving
his dementia condition. Nurse need to build and nurture authentic and caring relationship
with Tom. Tom become restless, agitated and erratic due to his pain. Hence, it might give him
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feeling of dis-respect for himself and others. However, nurse need to treat him with dignity
and respect and his individuality need to be supported. It can be achieved through effective
interaction with Tom instead of solely concentrating on medical tasks for improving his
medical condition. Nurse need to provide intervention to Tom by incorporating his family
members in his care. Nurse need to assist in creating and maintaining supportive community
for Tom and his family members (McGreevy, 2015).
It is evident that Tom is interested in lot of community services. Supportive community can
be helpful in improving comfort level and creating opportunities for improving dementia
condition of Tom. Community engagement can value Tom’s requirements and respect Tom.
It can also be helpful in improving his engagement in care and providing him autonomy.
Nurse need to evaluate dementia care interventions provided to him on regular basis and
should make necessary changes based on the outcome of the provided intervention. Nurse
need to discuss outcomes with other healthcare professionals and his family members
(Manthorpe & Samsi, 2016).
Managing Behavioural and Psychological Symptoms (BPSD) of Dementia:
In dementia patients, prevention of BPSD is very important because only few BPSDs can be
recognised and other BPSDs cannot be recognised easily. Hence, assessment of BPSDs is
very important aspect in providing intervention for it. Accurate assessment can also be useful
in deciding frequency and type of intervention to be provided to Tom. Family members need
to be included in his care and PCC need to be provided for preventing his BPSDs. BPSDs in
Tom need to be managed by non-pharmacological intervention rather than pharmacological
intervention (Jones et al., 2014). In few patients, it can be prevented by antipsychotic drugs;
however, little evidence is available for this. Different therapies like music therapy, pet
therapy and hand massage or touch therapy can be implemented in him to prevent occurrence
of BPSDs in Tom (Trivedi et al., 2013). However, there is little evidence available for
prevention of BPSDs using these therapies.
Structured therapies proved to be beneficial in improving BPSDs in dementia patients. These
structured therapies can be considered as the non-drug interventions for preventing BPSDs.
These structured therapies include distraction, redirection, reassurance and reorientation.
These core behavioural interventions require extra effort from the nurse because nurse need
to spend extra time other than the staff time. Nurse need to provide these interventions on the
individualised basis and triggers for occurrence of each of the BPSDs need to be considered
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while providing intervention to prevent BPSDs. Nurse need to identify, trigger behind his
erratic, restless and agitated behaviour and also need to identify time for the occurrence of
this behaviour (Livingston et al., 2014). Nurse need to focus on reducing triggers. This can be
achieved by actively listening, responding and reassuring the patient. Nurse need to
implement both verbal communication and non-verbal cues for BPSDs. Multiple assessments
and interventions need to be avoided and intervention need to be provided by single staff only
because it can be helpful in establishing therapeutic communication with Tom. In case of
failure of non-pharmacological treatment only, nurse need to provide pharmacological
treatment for Tom for preventing his BPSDs. BPSD symptoms are complex cluster; however,
intervention for one symptom might not cure another symptom. Nurse need to consider
history of Tom and his cultural and social aspects for providing intervention for his BPSDs.
Nurse need to consider other health issues in Tom while providing intervention for BPSDs.
Tom is associated chest pain. It might exaggerate his BPSDs. Hence, nurse need to plan
intervention to him considering his chest pain (Azermai et al., 2012).
Acute care:
Mini-Mental State Examination can be useful in measuring cognition in Tom. This scale can
be easily implemented with minimal training and it takes around approximately 10 minutes.
This scale can be useful in assessing orientation, memory, attention and calculation, language
and visual construction. These areas are useful in establishing effective communication with
the Tom for providing PCC to him. This scale can be effectively translated in terms of
severity of dementia (Carnero-Pardo, 2014).
Neuropsychiatric Inventory can be helpful in assessing wide range of behaviours associated
with dementia. It can also be helpful in identifying frequency and severity of these
behaviours. Behaviours like delusions, agitation, depression, irritability and apathy can be
assessed using Neuropsychiatric Inventory. This scale can be implemented within time of 10
minutes in acute care settings. This test has good psychometric properties and it can be
effectively used in patients with limited behavioural issues. Tom is also exhibiting limited
behavioural issues like agitation, restlessness and erratic behaviour (Mao et al., 2015).
Clinical nurse consultant need to be provided for Tom. It allows to initiate discharge plan at
the earlier stage and to provide information related to the rehabilitation services. Accurate
assessment need to be carried out for determining care needs and planning intervention.
Multi-disciplinary care need to be designed for providing high quality care to dementia
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patients. Optimum care pathways need to be implemented in the acute care hospitals which
can be helpful in reducing complications and improving hospital efficiency. Communication
with carers need to be improved for understanding patient experience and improving patient
outcome. Communication need to be improved for providing effective care to patients with
dementia because it is difficult to communicate people with dementia like Tom. Nurse need
to use short sentences with Tom and should exhibit empathy and care towards him. It can be
helpful reducing frustration of both patient and nurse. Nurse need to follow simple
communication steps like introducing themselves, maintaining eye contact, remaining calm
and not allowing patients with multiple choices at one time. Nurse need to minimize use of
antipsychotic drugs to prevent occurrence of adverse reactions in Tom because most of the
antipsychotic drugs are associated with multiple adverse reactions. Instead of using
medication treatment, nurse need to use psychosocial interventions for providing care to
Tom. Psychosocial intervention can be more useful in Tom because he is more inclined
towards community. It can be helpful in providing PCC and individualised care by increasing
monitoring and supervising by the staff (Thompson, 2015).
Conclusion:
Change in Tom and his family members are considered while providing care to dementia
patients. His care was designed based on his current health condition like agitation, erratic
behaviour. His social and cultural aspects are considered while providing care to the patients.
Social and community involvement proved helpful in dementia symptoms. Nurse considered
personal aspects of Tom for providing person centred care to him. It includes values, beliefs,
interests, abilities, likes and dislikes of Tom. Effective communication proved useful in
providing patient centred care to Tom. Consideration of current behavioural and
psychological aspects of Tom helped in establishing effective therapeutic relationship with
him. Accurate assessment of BPSD proved useful in providing specific care to the BPSD
because BPSD is complex cluster and most of the symptoms are overlapping with each other.
First preference was given to the non-pharmacological intervention for BPSD.
Pharmacological intervention was avoided to eliminate risk of adverse reactions.
Multifactorial interventions were avoided in BPSD. Mini-Mental State Examination and
Neuropsychiatric Inventory were used as assessment tools for dementia in acute care setting.
These tools were used because these are rapid tests and relevant to Tom condition.
Multidisciplinary care was provided for him in acute setting.
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