By TEAGAN BEWICK
Bachelor of Science (Nursing)
Edith Cowan University, WA
Dementia is not an ordinary component of normal ageing. Dementia is characterised by a progressive deterioration of cognitive ability, displaying no distinct symptoms during early development but requiring ongoing assessment as it advances (Hunter, 2016). It demands the provision of personalised treatment and is difficult to diagnose as the progression of symptoms varies with each distinct case, however still results in permanent cerebral dysfunction (Crisp, Taylor, Douglas, & Rebeiro, 2013).
The delivery of specialised care required to provide dignified treatment is consistent with the holistic care model that underpins nursing practice, which addresses all aspects of a patient’s physical, social, emotional and mental health (Crisp et al 2013). Nurses spend intensive periods with clients providing intimate care through the development of a therapeutic relationship and are educated in delivery of evidence-based practice that produces optimal outcomes for patients.
This essay addresses key nursing interventions that can enhance the quality of life of people living with dementia, including various client education and health promotion topics, support for caregivers and provision of dignified patient-centred care.
The future prevalence of dementia: why nurses need to act now
The present state of understanding affirms that dementia is incurable and only evidences that particular lifestyle factors attribute to its onset and development (World Health Organization [WHO], 2012). Furthermore, WHO (2012) projects that by 2050 there will be 135.5 million cases globally, and that minimising exposure to risk factors which are associated with the onset of dementia (including smoking, raised cholesterol levels, hypertension and under activity), could potentially prevent 50.7% of incidences. Nurses have an inherent obligation as patient advocates to inform society to develop habits that hinder the onset and advancement of dementia, and will have a fundamental role in promoting health and preventing illness through client education. The future global prevalence of dementia heightens the demand for the nurses to be proficient in providing patient-centred care that endorses optimal well-being and improves quality of life.
Client education and health promotion
The progression of dementia results in a severe impairment of cognitive capacity, and when coupled with age-related deterioration in physical performance, this can drastically inhibit the ability to coherently perform activities of daily living (ADLs) (Alzheimer’s Australia, 2016). There is extensive evidence to substantiate the health benefits associated with regular exercise for people living with dementia, including an improvement in cognitive functioning and overall well-being (Hunter, 2016; Kohn, 2016; Kwak, U, Son, & Kim, 2008). Physical exercise preserves strong muscles and joints, maintaining independence levels for longer and reduces the incidence of identified risk factors for the onset and progression of dementia, including cardiovascular disease and hypertension (Alzheimer’s Society, 2009).
Nurses are responsible for implementing and supervising most of the everyday activities for patients within care facilities and play a key role in encouraging involvement (Alzheimer’s Society, 2009). By cultivating a therapeutic relationship with clients, nurses can assist in educating patients to identify realistic exercise goals and encourage participation in regular activity (Kohn, 2016). Physical exercise is not only an appropriate nursing intervention to improve cognitive functioning and well-being, but also offers an opportunity to socialise and decrease seclusion often experienced by people living with dementia (Alzheimer’s Society, 2009).
Those living with dementia often experience feelings of isolation as the condition deteriorates memory, concentration and mental ability. Routine socialisation is essential in combating loneliness to maintain a state of vitality (Roach & Drummond, 2014) and as the nurse performs a majority of daily care activities, assumes the important role of fulfilling the omitted sentiments of attachment (Bratass, Bjugan, Wille, & Hellzeen, 2010). Those living with dementia are often fearful that their cognitive impairment will be apparent during socialisation, causing social activities to be considered an unpleasant experience and a dramatic decrease in self-esteem. Other hesitations towards participating include concerns that socialisation will require higher mental capacity than what they believe they are capable of, which results in feelings of insecurity (Bratass, Bjugan, Wille, & Hellzeen, 2010).
Nurses fulfil a unique position within the inter-professional team providing around-the-clock care and developing strong therapeutic relationships to efficiently deliver holistic care (Crisp et al 2013). This provides the opportunity to regularly engage in one-on-one interactions with clients; simple conversations while assisting with ADLs can contribute to mental stimulation that engenders positive well-being and feelings of inclusion (Bratass et al 2010).
Those living with dementia often view themselves as a hindrance due to the deterioration that threatens their independence and self-managing capabilities, two attributes that are existential components of daily living (Hunter, 2016). The meaningful connections fostered by the nurse through socialisation coupled with compassionate nursing care increases general well-being of people living with dementia and presents the opportunity for clients to be included in treatment decisions, heightening their self-worth and cognitive stimulation (Tranvag, Petersen, & Naden, 2013).
Encouraging mental stimulation
Various cognitive impairments associated with early to moderate dementia include memory loss, confusion, and deterioration of attention span (WHO, 2012). Research reveals that the human brain requires regular exercise and incitement, and by frequently challenging its capabilities can reduce the onset and progression of dementia (Harvard Medical School, 2005). A nursing assessment involves the holistic evaluation of all facets of a patient’s lifestyle, including a comprehensive review of current functioning levels, mental abilities and limitations (Crisp et al 2013). Moderate cognitive impairment is occasionally viewed as an ordinary contaminant of ageing, and therefore frequently denied appropriate interventions which could assist in increasing a client’s satisfaction of living (Hunter, 2016). This solidifies the nursing assessment as an integral component of dementia care, by allowing the nurse to ascertain where a decrease in cognitive functionality is deviating from the norm to intervene with suitable mediations (Hunter, 2016).
Encouraging meaningful activity and cognitive stimulation
Intellectual and perceptual impairments affect a person living with dementia’s capacity to cope with normal daily stressors as they begin to misunderstand surroundings and misinterpret their environment (Pulsford & Thompson, 2012). Nurses can incorporate a range of stimulation activities into daily undertakings including puzzles, word games, and baking. Research indicates that participation results in positive wellness outcomes for those living with dementia including improved memory and concentration stimulation, and increased sense of purpose. Nurses can educate families and caregivers of these practices, making these appropriate interventions for outside residential care facilities.
Cognitive stimulation activities can be achieved as the nurse employs a holistic and personalised approach to treatment in daily nursing care by incorporating conversations that require people living with dementia to recall past and present events (Woods, Aguirre, Spector, & Orrell, 2011). With various reports demonstrating improved mental ability and quality of life, enhanced cognitive functioning through continuous stimulation is vital for people with dementia to maintain their independence levels throughout their dementia journey (Woods et al 2011).
Encouraging people with dementia to maintain independence
The advantages of a person living with dementia endeavouring to maintain functional independence are numerous, including keeping active which preserves muscle tone, enhances well-being and decelerating the progression of symptoms (Hunter, 2016). An absence of significant activity intertwined into daily living has a direct impact on a person living with dementia’s quality of life by diminishing their sense of personhood (Roach & Drummond, 2014).
During the early stages of dementia as the frontal lobe deteriorates the ability to cohesively perform tasks such as planning and organising is compromised and hinders the capacity to carry out ADLs autonomously (Pulsford & Thompson, 2012). Nurses perform the majority of the intimate care requirements of people living with dementia, with 97% reporting daily interactions. Given the significant amount of assistance required from nurses in dementia care and their exposure to the debilitating nature of its advancement, nurses play a vital role in maximising independence and functionality of clients, contributing to an optimal client satisfaction (Pulsford & Thompson, 2012; Roach & Drummond, 2014).
Nurses can offer limited assistance when providing treatment to ensure the utmost self-determination is promoted. When cognitive ability is severely impaired, individuals’ emotional responses are still directed towards maintaining sense of self, therefore is it vital that the nurse is able to encourage independence and educate carers throughout the entire dementia journey (Hunter, 2016).
In advocating autonomy and allowing the individual to participate in their own care to their maximum potential functioning, the nurse is able to offer relief to the family and friends volunteering care to loved ones with dementia.
Providing support for families and carers
The profound dwindling of personhood experienced by a person living with dementia also has detrimental effects on the families and caregivers, and with readily accessible research available to nurses, they perform a central role in providing comfort and support (Roach & Drummond, 2014).
Family often bear moral obligation to care for their loved ones throughout their journey to provide familiarity as their memories begin to dissipate (Pulsford & Thompson, 2012). It is not uncommon for them to experience guilt for admitting the strain experienced through caring for their deteriorating family members. Family can also be hampered by overwhelming feelings of grief for the impending loss, and in later stages, a sense of relief knowing that the journey is coming to an end. A nurse equipped with knowledge and specialised dementia education is capable of providing crucial aid and reassurance to the family throughout all stages of the dementia journey.
Nurses can prepare families with educational material relating to respite services and community support services that are available within the community (Hunter, 2016). Through holistic assessment and therapeutic communication, the nurse can recognise and address caregiver role strain and coping mechanisms by encouraging regular reflection and maintenance of personal welfare (Hunter, 2016). Finally, the lack of awareness surrounding dementia treatment provision tests the resilience of the family unit as it increases their financial and legal vulnerability (WHO, 2012).
Despite the increase in prevalence of dementia globally, a significant gap still remains in the knowledge and understanding of the syndrome, and this lack of awareness has resulted in the marginalisation of those living with dementia (WHO, 2012). Universal misconceptions commonly associated with dementia include fear, shame and frustration (Hunter, 2016), and have the potential to interfere with appropriate interventions that could improve the provision of care for those living with dementia.
Stigmatisation is the most powerful obstacle to a timely diagnosis and presents a significant health problem which could be prevented with appropriate health promotion (Bratass, Bjugan, Wille, & Hellzeen, 2010). The nursing code of ethics states that nurses act as patient advocates to promote health legislation that encumbers social justice and better health outcomes for all, including those living with dementia (Nursing and Midwifery Board of Australia, 2008). The guidelines informing nursing practice denotes an inherent obligation to educate society and heighten awareness of dementia; without overcoming marginalisation, the health system cannot provide optimal care or prepare for the impact its prevalence will have globally (WHO, 2012).
Stigmatisation has attributed to the phrase ‘dementia sufferer’, implying that there is no possibility for a higher quality of life (Alzheimer’s Society, 2009), and it is here that nursing interventions and compassionate care can contribute to confronting relegation and social exclusion of those living with dementia (Hunter, 2016). By recognising and promoting that all patients are still worthy of, and entitled to respectful personalised care, marginalisation can be reduced for clients to receive a better quality of life throughout their dementia journey (Alzheimer’s Society, 2009).
Palliative care and the registered nurse
Developing and implementing dignity-preserving palliative care is critical for addressing challenges that the prevalence of dementia presents to the health care system (Tranvåg et al 2013). Clinicians who lack skills required to provide holistic treatment pose the risk of a person with dementia dying an undignified death (Alzheimer’s Society, 2009). Nurses are in a unique position to offer care that maintains dignity and comfort throughout all stages of dementia including when individuals can no longer meet their own personal care requirements (Alzheimer’s Society, 2009). By applying the principles of person-centredness, respect for individual needs and compassion into care, which is a fundamental aspect of nursing care, nurses can preserve the self-worth of people living with dementia (Crisp et al 2013).
The impact of providing dignified dementia care is emphasised throughout the Nursing Code of Ethics, requiring RNs to actively preserve patient dignity through compassion and recognition of client vulnerability owing to their illness (Nursing and Midwifery Board of Australia, 2008). Furthermore, a nurse’s obligation to engage in reflective practice can result in a genuine empathy for individuals through enhanced awareness of their own needs if they were in a similar situation, contributing to the delivery of respectful care (Tranvåg et al 2013).
Nurses can improve the provision of dignified dementia care by exhibiting genuine respect for the patient, understanding that they are a unique individual in a distinctive situation, and possessing an inherent desire to help achieve a better quality of life (Tranvåg et al 2013).
Dementia has a detrimental impact on a person’s self-worth as it progressively deteriorates their ability to independently perform daily activities, affecting both mental and physical capacity. Nurses offer a unique contribution to improved living standards for those living with dementia as they provide a majority of the personal daily treatment requirements and embrace a holistic care model focusing on person-centredness. Through client education and health promotion, nurses can incorporate interventions that have demonstrated increased wellness outcomes for patients and their families including regular physical activity, socialisation, maintaining functional independence and promoting the delivery of dignified treatment. Nurses as patient advocates have a fundamental responsibility to promote public awareness of dementia as its prevalence is expanding rapidly on a global scale, and poses significant implications for the health care system. Nurses look past the debilitating medical condition consuming a person living with dementia, and instead recognise each individual who is deserving of compassion, dignified treatment and a better quality of life: this is why nurses can make all the difference.
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