Dialectical Analysis For Person-Centered Dementia Care Discussion Paper
Dialectical Analysis For Person-Centered Dementia Care Discussion Paper
Discussion
Discuss about the dialectical analysis that will facilitate the process of delivering care to a dementia patient in a person centred way.
This report will elaborate on a dialectical analysis that will facilitate the process of delivering care to a dementia patient in a person centred way. Following a patient assessment with the use of this enriched model that focuses on neurological impairment, biography, personality, health and social psychology, the report will further use supporting evidences to propose an intervention for the patient being studied.
The Dialectics of Dementia model
The Enriched Model of dementia, formulated by Tom Kitwood has been used to gain a sounn understanding of the patient being studied, which in turn will help in recognising the attributed of personhood (Brooker and Latham 2015). The case study being discussed in this report is of Dorothy Borgart (pseudonym), who has resides in a hospice care since the year 2014. Each element that participates in a complex interaction, thereby resulting in dementia as discussed as follows:
Personality (P) = The basic personality attributes of Dorothy encompass presence of memory impairments that make it difficult for her to remember recent events. Some of the coping skills that are utilised by the patient include accepting the changes and not showing reluctance while asking for assistance from her family members and the employees at the assisted care facility. Poor quality of life and behavioural disturbances have also made her develop symptoms of generalised anxiety disorders. She takes efforts to defend herself from such anxiety by remaining engaged and active in leisure activities and also responds to the basic challenges, in order to maximise independence. Dialectical Analysis For Person-Centered Dementia Care Discussion Paper
Biography (B) = Dorothy has been born and brought up in Nijmegen, in the Dutch province of Gelderlan. She is 79 years old and had three brothers. Following her graduation at the University, she got married and relocated to Australia, where her husband used to work as a manager for a textile firm. She got a job at a local daily. They had one son who is currently in the US. However, she got diagnosed with diabetes in the year 1998, and also had the habit of heavy smoking and alcohol consumption. She was greatly devastated by the loss of husband and failed to meet the emotional challenges in her life. Upon being diagnosed with vascular dementia, her son took the decision of keeping her in a hospice care facility that provides a quality and compassionate care.
The Dialectics Of Dementia Model
Health status (H) = Dorothy suffered from complex health problems and the onset of dementia seemed to be a part of her overall age related frailty. Her blood glucose levels were also on the rise, after the death of her husband. This can be attributed to the mental and physical turmoil that she was going through. However, she had shown an abstinence from smoking and alcohol consumption since 2009. Dorothy suffered from a stroke in 2011 that led to a deterioration of her condition. Age related changes in health status also include development of cataract and cognitive impairments since 2012.
Neurological impairment (NI) = A CT scan and MRI showed that Dorothy suffered from a plethora of neurological impairment such as presence of noticeable lesions in the blood vessels present in the brain. The blood vessels also showed a damage, followed by an accumulation of several substances such as lipids in them (atheroma). This was followed by severe atrophy of white matter. The arteries also showed calcification that contributed to severity of the symptoms.
Social psychology (SP) = Some of the most common malignant social psychology that were seen to exert a negative influence on her personhood, thereby increasing her sufferings include treachery, discrimination and intimidation. Before being sent to the hospice centre she was stigmatised by her son and his family and was outcast for suffering from this neurological disorder. Disempowerment that prevents the patient from using her abilities and treating her in a patronising manner leads to infantilisation, in the current care setting.
Use of supporting evidence
Searching appropriate literature involved adoption of a systematic approach that helped in a thorough investigation of high quality, reliable literature to identify quality references that were relevant to the topic being investigated. The search strategy used included several key terms that were combined with the use of Boolean operators. The search terms used for the literature search included ‘dementia’, ‘elderly’, ‘cognitive’, ‘prevalence’, ‘intervention’, ‘exercise’, ‘physical’, ‘activity’, ‘decline’ and ‘impairment’. Dementia refers to the neurological disorder that is associated with a progressive loss of higher mental abilities and memory that are severe enough to interfere with the daily activities of the affected individual. The neurological disorder is generally associated with the process of normal ageing (Hendriks et al. 2014). This fact contributes to the increased provisions of care for people having dementia, in the ageing societies.
This is considered as a major health concern and has led to the formulation of several policies that provide bulk of care to the patients. According to the World Alzheimer’s Report 2016 there were an approximate 36 million people worldwide, who suffered from dementia. Estimates suggest that this number would rise to 66 million people by the year 2030, with maximum increase expected to occur in the low- and middle-income countries (Prince et al. 2016). Dementia is an expensive health problem. Dementia care is found to consume resources more than cancer care. The total economic costs for dementia in the 15 European countries before 2004 were an estimated €189 billion, when compared to €117 billion for cancer treatment (Hurd et al. 2014).
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Use Of Supporting Evidence
Needs assessment encompasses a systematic process that helps in the determination and address of the gaps or needs between current and desired conditions (Nichols et al. 2013). An analysis of the patient assessment indicates that there exists discrepancies between the current condition that she is residing in and the favourable conditions that would facilitate her survival. Research evidences have identified needs as desires that improve current performance, thereby bringing about improvements in the individual (Li et al. 2017). The major healthcare needs of the patient include cognitive impairment, behavioural changes, communication problems and ataxia. The needs assessment in this scenario focusses on improving the cognitive functioning in the patient (Miranda-Castillo, Woods and Orrell 2013).
Mild cognitive impairment (MCI) refers to the intermediate stage that exists between expected cognitive decline, as a result of normal aging and more-serious decline in dementia. It often involves problems with language, memory, thinking and judgment, which are generally found to be higher than age-related changes (Johnson et al. 2013). Research evidences have established strong correlation of dementia with cognitive impairment where the individuals begin to forget important information that would have been recalled easily, such as, conversations, appointments or recent events (Mitchell et al. 2014). A deterioration in the cognitive faculties have also been related to poor thinking skills that affects the ability of the patient to make sound decisions. There is an interplay of factors that results in the manifestation of behaviour associated with cognitive impairment. Current evidences state that similar forms of cognitive impairment are observed in all kinds of dementia (Richard et al. 2013). Some of the most common neuronal changes that lead to cognitive decline are abnormal clumps or aggregations of the beta amyloid protein, in the form of plaques in the brain, in addition to neurofibrillary tangles or clumps of tau protein.
Furthermore, reduced blood flow through the blood vessels in the brain are also considered as a major risk factor that contributes to the risks of suffering from cognitive decline (Roberts et al. 2014). Brain imaging studies have established correlation of cognitive impairment with several changes such as, shrinkage in the hippocampus, the region that plays an important role in memory storage, and retrieval (Koivisto et al. 2016). Short term memory loss and disorientation, both of which are common symptoms of cognitive decline in dementia occur due to damage to the hippocampus (La Joie et al. 2013). In addition, several researchers have established an association of enlargement of the ventricles or fluid filled spaces present in the brain with reduction in cognitive functioning.
This health need also contributes to failure in judging the time or sequence of events that are required for accomplishing a complete task. Further effects have been observed on the visual perception capability of the patients. There is mounting evidence that have identified history of cardiovascular diseases, high cholesterol, diabetes mellitus and depression as major risk factors that might contribute to vascular dementia, and subsequent cognitive impairment (Baumgart et al. 2015). These supporting evidences led to the identification of cognitive disability as the primary healthcare need.
Intervention
Suggesting an intervention for the health need identified in the previous sections will be based on a person-centred care that encompasses placing due focus on the elements of support, care and treatment that are of utmost importance to the patient, and family members. Adoption of this person centred approach will involve demonstration of respect, dignity and compassion towards the dementia patient. The intervention that has been selected for reducing cognitive impairment in the patient Dorothy is adherence to a regimen of exercise and moderate physical activity that will improve the impaired cognitive faculties in the patient. Research evidences have established the beneficial role of exercise on the physical and mental health of aged individuals, which in turn improves the quality of life. Physical activities are defined as those that elevate the heart rate and result in rapid breathing.
Physical exercise has been identified crucial for maintaining an appropriate blood flow to the brain, thereby resulting in new growth of neuronal cells and survival (Joseph et al. 2014). The benefits of exercise have been clearly mentioned by a wide range of research articles that focused on considering major factors that are associated with risks of developing dementia. Evidences suggest that people who participate in regular exercise are less likely to experience stroke and cardiovascular diseases, both of which are associated with increased likelihood of developing dementia. Exercise is also important in reducing the risk of high blood pressure, type 2 diabetes and obesity, all of which are risk factors for dementia (Grande et al. 2014). The association between dementia and physical activity was demonstrated by a study conducted in the elderly population in Rotterdam.
Lower risks of dementia were found related to higher levels of physical activity during the research follow up period of four years (HR 0.82; 95 % CI 0.71–0.95) (de Bruijn et al. 2013). This was consistent with previous findings that established an inverse relation between risks of cognitive decline in dementia and physical activities. The role of regular physical activity such as, simple aerobic exercise on reduction of cognitive impairment was also emphasised by another systematic review that was successful in correlating between reduced risks of cognitive decline and the intervention (RR 0.65, 95% CI 0.55-0.76) (Blondell, Hammersley-Mather and Veerman 2014). Long term benefits of physical activities on dementia and other chronic health disorders were explained by another review. Findings suggest that physically active people exhibit lower risks of developing cognitive impairment. Furthermore, such people were also found to possess higher cognitive ability scores. In addition, activities, such as walking, were related to low incidence of dementia and Alzheimer’s disease (Cheng et al. 2014).
Similar evidences were also provided by people who participated in leisure time physical activity. High levels of LTPA reduced the risks of dementia among individuals (HR, 0.16; 95% CI, 0.06–0.41) (Tolppanen et al. 2015). Another metaanalysis of randomised controlled trials also suggested presence of an association between increased physical exercise and reduction in poor dementia related cognitive functions (SMD [95% confidence interval] = 0.42 [0.23; 0.62], p<.01) (Groot et al. 2016). Aerobic exercises increase blood circulation in the brain, thereby reversing the cognitive deficits that are commonly prevalent in dementia, regardless of the type. This beneficial effect was found to be independent of dementia diagnosis and frequency of intervention. Other authors opined that physical activity is a promising non-pharmaceutical intervention that can reduce or eliminate age-related decline in cognitive functioning that is commonly associated with the neurological disease being investigated.
They established strong correlation between late life moderate physical exercises with lowered risks of mild cognitive impairment in dementia patients by as much as 32% (Bherer, Erickson and Liu-Ambrose 2013). Thus, higher fitness levels are related to larger brain volume, and reduced rates of neuronal atrophy. These physical activities have also demonstrated significant positive effects on muscle strength of dementia patients who suffer from lack of motor coordination. Another long term follow-up study of adult twins suggested that physical activity is directly responsible for decreasing the occurrence of dementia among individuals [0.48 (95% CI 0.17–1.32)] (Reiner et al. 2011). Therefore, the above presented results indicate that regular physical activities are an important and potent factor that will prevent or reduce cognitive decline in dementia patients, thereby enhancing their health and overall quality of life.
Comparison with another intervention
Cholinesterase inhibitors and memantine have been considered as the mainstay of treatment for Alzheimer’s disease, a type of dementia. The basic advantage of cholinesterase inhibitors can be associated with the fact that they prevent breakdown of the neurotransmitter acetylcholine at the synaptic cleft, by the enzyme acetylcholinesterase, thereby increasing availability of acetylcholine (Zemek et al. 2014). Dialectical Analysis For Person-Centered Dementia Care Discussion Paper Cognitive decline symptoms are generally attenuated due to the role of the neurotransmitter in maintaining cognition in the CNS. Further advantages of memantine are also related to its action on the glutamatergic system, which is facilitated by blocking of the NMDA receptors (Gauthier and Molinuevo 2013). However, the potential disadvantages of these two pharmacological intervention in improving the identified health need of the patient can be related to lack of adequate research studies on the same. Moreover, they are not recommended for treatment of vascular dementia due to the fact that the drugs have not received regulatory approval in the United States (Herrmann, Lanctôt and Hogan 2013). These facts help in selection of physical activity and moderate exercise as the primary intervention in this context.
However, certain disadvantages of physical intervention include pain and strain in the bones, joints or ligaments that can take a toll on their health and exacerbate their chronic health condition.
Policy structure
Delivery of a person centred care to the dementia patient Dorothy is in accordance to the National Framework for Action on Dementia that acts as a guiding document for the government, which focuses on forming a strategic, cost effective and collaborative response towards dementia. The intervention identified for delivery of a person centred care approach is based on the fact that these policies identify the need of redefining dementia programs for supporting a healthy living for the people (Agedcare.health.gov.au 2018). The intervention is also in accordance with the National Strategies To Address Dementia, that emphasises on the need of community care packages, training for staff, support and information, and dementia behaviour management services, with the aim of reducing the suffering of the patients (Dementia.org.au 2018).
The Dementia Initiative is also taken into consideration, while implementing the identified intervention of physical activity for the patient. This can be attributed to the fact that it focuses on making a substantial contribution to support patients living with dementia, and their carers (Dementia.org.au 2018).
Conclusion
To conclude, use of the Kitwood Enriched Model for dementia care is one of the essential steps of enabling healthcare professionals to develop their competence in delivering optimal person centred care to patients with dementia, in clinical practice. The basic advantage of this model lies in the fact that it takes into consideration the decline of cognitive abilities that are a direct manifestation of dementia such as, slower processing of information, memory loss, confusion, abstract thinking, language comprehension problems, and motor incoordination. It also takes into account the other illness, long standing or temporary, which might impact the functional abilities of the patients. The dialectics model should be used by caregivers since it will help in placing a due focus on the life history and personality of the patients, thereby helping in identification of risk factors that might increase the susceptibility of the individual from suffering from dementia. It will also help in building respect for the patient and would enhance their personhood. The dialectics model will also assist in gaining a sound understanding of the social psychology of the patient, thereby enhancing the person centre care
References
Agedcare.health.gov.au., 2018. Dementia | Ageing and Aged Care. [online] Available at: https://agedcare.health.gov.au/older-people-their-families-and-carers/dementia [Accessed 23 May 2018].
Baumgart, M., Snyder, H.M., Carrillo, M.C., Fazio, S., Kim, H. and Johns, H., 2015. Summary of the evidence on modifiable risk factors for cognitive decline and dementia: a population-based perspective. Alzheimer’s & dementia: the journal of the Alzheimer’s Association, 11(6), pp.718-726.
Bherer, L., Erickson, K.I. and Liu-Ambrose, T., 2013. A review of the effects of physical activity and exercise on cognitive and brain functions in older adults. Journal of aging research, 2013.
Blondell, S.J., Hammersley-Mather, R. and Veerman, J.L., 2014. Does physical activity prevent cognitive decline and dementia?: A systematic review and meta-analysis of longitudinal studies. BMC public health, 14(1), p.510.
Brooker, D. and Latham, I., 2015. Person-centred dementia care: Making services better with the VIPS framework. Jessica Kingsley Publishers.
Cheng, S.T., Chow, P.K., Song, Y.Q., Edwin, C.S., Chan, A.C., Lee, T.M. and Lam, J.H., 2014. Mental and physical activities delay cognitive decline in older persons with dementia. The American Journal of Geriatric Psychiatry, 22(1), pp.63-74.
de Bruijn, R.F., Schrijvers, E.M., de Groot, K.A., Witteman, J.C., Hofman, A., Franco, O.H., Koudstaal, P.J. and Ikram, M.A., 2013. The association between physical activity and dementia in an elderly population: the Rotterdam Study. European journal of epidemiology, 28(3), pp.277-283.
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Gauthier, S. and Molinuevo, J.L., 2013. Benefits of combined cholinesterase inhibitor and memantine treatment in moderate–severe Alzheimer’s disease. Alzheimer’s & dementia: the journal of the Alzheimer’s Association, 9(3), pp.326-331.
Grande, G., Vanacore, N., Maggiore, L., Cucumo, V., Ghiretti, R., Galimberti, D., Scarpini, E., Mariani, C. and Clerici, F., 2014. Physical activity reduces the risk of dementia in mild cognitive impairment subjects: a cohort study. Journal of Alzheimer’s Disease, 39(4), pp.833-839.
Groot, C., Hooghiemstra, A.M., Raijmakers, P.G.H.M., Van Berckel, B.N.M., Scheltens, P., Scherder, E.J.A., Van der Flier, W.M. and Ossenkoppele, R., 2016. The effect of physical activity on cognitive function in patients with dementia: a meta-analysis of randomized control trials. Ageing research reviews, 25, pp.13-23. Dialectical Analysis For Person-Centered Dementia Care Discussion Paper
