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Apr 20, 2024

Assignment Task

During my second year at university, as a student mental health nurse, I worked in a community dementia support team alongside a dementia specialist nurse. I worked with a service user who, for confidentiality purposes will refer to as Mary, has a diagnosis of vascular dementia and is suffering from depression. Consent was gained by Mary and her husband to utilise her circumstances in this essay ensuring confidentially is maintained. Mary is an elderly lady referred to the dementia support services by her husband, who is her main carer and experiencing carers stress and breakdown. In the referral, Mary’s husband noted that he was struggling to care for her and to manage with her recent “aggressive outbursts”. In this essay, I will present a formulation of Mary demonstrating my ability to apply and explain interventions considering factors such as risk management, person-centred care and professional collaboration. Finally, I will demonstrate how I ensured the interventions were effective through evaluation and reflect ethical and legal issues.

Through assessment using the Biopsychosocial model (Engel, 1977), I considered Mary’s biological, psychological and social needs. Biologically, she has a range of physical health conditions including diabetes, hypertension and high cholesterol. All conditions risk factors associated with the development of dementia (Gottesman et al, 2017). Kitwood and Brooker (2019) propose problems with the cardiovascular system correlate with the vascular pathology associated with vascular dementia. Admittedly, Mary stated her diet has always been poor and is an ex-smoker. Smoking, physical activity and obesity are all risk factors associated with Page 2 of 12 cardiovascular disease (Colpani et al, 2018). A review by Ikram (2017) shows a link between genetics and dementia; however, Mary reported having no known history of dementia in the family. Vascular dementia generally isn’t inherited although underlying cardiovascular conditions that contribute may be passed down through generations (Alzheimer’s Society (2022a).

Psychologically, Mary appeared low in mood. Major depression is common for people with any time of dementia (Kitching, 2015). Mary stated she is “fed-up” and her husband explained she never wants to get out of bed and described her as “tearful” and “irritable”. Leung et al (2021) concludes that depression, anxiety and apathy are highly prevalent in people with dementia regardless of what stage of progression they’re in. However, it was noted that she had battled with depression her entire life. Mary is currently prescribed 50mg Sertraline, which she feels aren’t having the desired effect. Mary’s husband reported that towards the end of the day Mary is becoming increasingly difficult to manage, she becomes restless, agitated and verbally aggressive towards him which is all recent behaviour. Symptoms of ‘sundowning syndrome’ are defined as the “worsening of behavioural symptoms in the evening in people with dementia” (Angulo-Sevilla et al, 2018). Sundowning behaviours include a sense of anxiety, agitation, confusion and can often involve shouting, pacing and arguing (Dementia UK, 2021). Mary’s short-term memory is poor, she is very repetitive during conversation asking the same questions. However, her long-term memory is intact. She was able to talk in detail about her marriage, previous employment and childhood. During Mary’s teenage years, she had an accident whereby she was severely burnt and as a result has scars all down her back and legs. She stated that this largely impacted on her self-esteem; this may have contributed to her Page 3 of 12 struggle with depression. Zhou et al (2018) found low self-esteem to be a risk factor of depression in adolescents.

Socially, Mary currently lives at home with her husband who cares for her but has raised concerns as he is now struggling to do so. Mary has two sons and a daughter however; they’re often busy or working away. Mary’s husband also mentioned that the neighbours are very supportive and would get shopping for them from time to time. However, Mary stated that she would like to go out more and interact as she does not see her friends as often and is a sociable person but is currently spending most of her time at home.

Mary is prescribed Amlodipine for hypertension, Simvastatin for high cholesterol and Metformin for her diabetes. During assessment, Mary’s physical observations were taken whereby her blood pressure read of healthy range however, her blood sugar levels were low. Mary’s husband stated she had recently lost weight due to a reduced appetite. Advice provided regarding diet and lifestyle as recommended by the National Institute for Health and Clinical Excellence (NICE, 2022). A referral to the dietician was made for advice and support managing Mary’s diabetes and weight. Dietician delivered nutrition therapy for type two diabetics is more effective than nutritional advice from other professionals (Siopisa et al, 2021). A re-referral was made back to Mary’s local community mental health team (CMHT) regarding her depression and more recent diagnosis of vascular dementia. A review of Mary’s anti-depressants by the consultant psychiatrist was made as Mary expressed, they weren’t having the desired effect. Also, due to Mary’s symptoms of sundowning and periods of agitation a request for a noncholinesterase inhibitor such as Memantine was made; evidence show Memantine is effective Page 4 of 12 against functional and cognitive decline in vascular dementia, and less likely to cause agitation than cholinesterase inhibitors (Mutsata, 2017). Lastly, when asked Mary stated she suffers knee and hip pain. Her husband stated that Mary suffers from arthritis. It was advised to give Mary 1g Paracetamol as this can frequently be the underlying cause of behavioural symptoms in dementia (Achterberg et al, 2013). Similarly, NICE (2018) recommend addressing clinical causes of agitation and aggression such as pain.

Pharmacological and non-pharmacological strategies are both important in treating depression in dementia and management of these patients requires a collaborative approach (Kitching, 2015). Using the Cornell Scale of depression in Dementia (CSDD), it was likely Mary is experiencing depression. A systematic review suggested CSDD in older adults with demetia has high diagnostic accuracy (Park and Cho, 2022). The psychological intervention Mary chose to manage depression in dementia and slow cognitive decline was reminiscence therapy (RT). Saragih et al (2022) provides evidence using a systematic review concluding RT is effective in increasing cognitive function, quality of life and reducing depressive symptoms. RT aims to engage Mary is discussing past experiences using prompts such as photographs, music, and familiar items (Norman and Ryrie, 2013). Topics of discussion included children, marriage, holidays and careers. The dementia specialist nurse would use prompts such as photos and music, a life story book was created with Mary and her husband. A referral to the Admiral Nurse was agreed for educational support regarding dementia, it’s symptoms, behaviours and communication (Gamble and Dening, 2017). Distress is common amongst family members and cares of those with dementia therefore, emotional support from an Admiral Nurse to manage Page 5 of 12 thoughts and feelings aiming to meeting physical, social and cultural needs may be of benefit (Dening et al, 2016).

To address Mary’s social needs, information and leaflets were provided regarding dementia cafés; they are a place for individuals living with dementia and their family/carers to discuss diagnosis, learn from others, share experiences and make friends (Alzheimer’s society, 2022b). This may be beneficial to Mary to encourage her to socialise whilst relating to others in similar circumstances. During discussion, Mary and her husband were both open to having daily carers in their home to help manage Mary’s needs and take the pressure off her husband. Both and her husband consented for a referral to be made to adult social services for a care needs assessment; whereby a social care professional (typically a social worker) will visit Mary’s at home to assess how well her and her husband are managing activities of daily living (ADL’s) (Age UK, 2022). On completion of assessment a decision will be made to weather Mary has an ‘eligible care need’ and is deemed eligible care and support will be arranged and potentially funded depending on finances (Alzheimer’s society, 2022c). Meanwhile, our team implemented weekly respite sits to provide Mary’s husband a break from his caring role. Roberts and Struckmeyer (2018) emphasise the importance of respite for carers in sustained resilience when caring for an individual with dementia.

Clarke and Mantle (2016) highlight the importance of risk assessment in dementia care whilst maintaining a person-centred approach. The four key areas of risk assessment including harm to self, harm to others, harm from others, and self-neglect, where used to assess Mary’s current risk (Clarke and Walsh, 2009). Using RAG traffic light system for risk assessment Page 6 of 12 (Croucher and Williamson, 2013) green being low risk, amber being moderate risk and red being of high risk. Mary was ranked green in risk meaning she was of low risk. Despite her low mood, Mary expressed no thoughts of self-harm or suicide. Although Mary often becomes agitated, she has never been physically aggressive towards her husband or anyone. Her risk of harm from others is low as she is living in quiet, friendly neighbourhood with supportive neighbours. She is with her husband at all times who carers for her and is meeting all her basic needs/ ADL’s despite feeling overwhelmed.

To ensure that Mary’s needs are being met effectively, a Care Programme Approach (CPA) review was conducted. The CPA is a statutory framework that has been part of the mental health services for many years intended to facilitate a collaborative, multi-professional service whereby a range of professionals will work in partnership with the service user. The CPA aims to assess needs, create a joint plan to meet them sharing responsibility and review the plan with the service user to see if their needs are being met (Norman and Ryrie, 2013). During Mary’s CPA she reported her mood has improved since her Sertraline was increased from 50mg to 100mg, her husband reported that she has been spending less time in bed and they’ve been regularly attending the Dementia Cafe and going on days out to the garden centre. Mary chose RT over Cognitive Stimulation Therapy (CST), her and her husband believed this would be more beneficial in aiding her low mood as well as enhancing cognition and functional skills. Mary said she looks forwards to her RT sessions, her husband stated Mary seems cheerful and a lot less agitated after sessions. Mary rated her mood 7/10. Since the increase in anti-depressant there has been no incidence of falls. Both Mary and her husband stated they would feel comfortable to contact the CMHT or disclose to the Admiral Nurse if Mary’s mood significantly declines.

Mary gave consent to trial memantine and her titration has begun. She is currently on 10mg and has reported no adverse side effects. Her blood pressure is being monitored weekly and has been in normal range for the past four visits. Her blood pressure will continue to be monitored regularly. Mary stated she feels “more with it”. After having input from the dietician Mary’s husband is making an effort to prepare well-balanced, nutritious meals, Mary and her husband are both making healthier food choices, having been provided with adequate knowledge. Mary’s weight has stabilised and her BM’s have been within normal range for the past three visits. Mary’s husband has been administering 1g paracetamol on a regular basis of a morning and evening, since doing so Mary’s husband stated although she continues to have agitated periods, but less frequent and manageable. Mary is still awaiting a care needs assessment from social services, this can take up 6 months as there is currently a long waiting list, although Mary’s husband would still like some extra support in the future, he stated he is happy to continue being Mary’s full-time carer since receiving the support and treatment has made it easier and manageable. Both Mary and her husband where very grateful and appreciative of the care provided by all professionals.

During Mary’s care, there were no legal or ethical issue that had arisen nevertheless they were considered throughout. Following the Nursing and Midwifery Council’s code of conduct Mary’s consent was gained for all referrals made and any treatment implemented (NMC, 2018). Mary was given autonomy throughout her care; she was able to make decisions for example which psychotherapy if any, promoting a person-centred approach. Mary was able to make these decisions herself, as she was deemed to have capacity under the Mental Capacity Act (MCA, 2005). Despite Mary’s diagnosis of dementia at the time of assessment there was no reason to Page 8 of 12 believe she was unable to make a decision regarding preferences in care. Principle one of the MCA states that “a person must be assumed to have capacity unless it is established otherwise” (MCA, 2005). Finally, during assessment Lasting Power of Attorney (LPA) was discussed and Mary’s husband stated that he is currently has LPA for both health and finances should Mary ever be unable to make a decision in the future due to the progressive nature of her condition. In conclusion, this essay presented a case report on a service user, identifying their needs using the biopsychosocial model (Engel, 1977) before discussing a range of biological, psychological and social interventions to meet those needs including any identified risks. Furthermore, providing an account of how all multi-disciplinary professionals ensured the effectiveness of the care provided via a CPA review. Finally, considering any legal or ethical issues encountered throughout the process.

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