Running Head: Dementia in older adults

The issue of dementia in older populations is a very prevalent and growing issue. Memory loss and dementia are increasingly prevalent issues that affect older adults and their spouses (McClive-Reed 2010). Due to the fear that surrounds dementia in older patients, a prognosis could lead to a diminished sense of self and reduction in the quality of life, not just for said patient but also for the families or caregivers. In order to better understand dementia and those who suffer from it, let’s look at potential strategies and challenges to engage dementia clients, how to conduct a biopsychosocial assessment of dementia clients, and take ethical consideration into account in respect to a single client that I have chosen, EP.
EP is a sixty-nine year old African American female who was previously diagnosed with dementia as well as depression. I met EP after she was admitted to the short-term involuntary psych unit at the hospital to which I am employed as a mental health associate, making me one of her immediate caregivers. She was admitted after proving to be a danger to herself during screening, where it became known that the patient stopped taking appropriate dosages of her medication and became unable to appropriately care for herself as a result. When EP is doing well with her medications, she is able to live a very independent and healthy lifestyle, but this lasts only temporarily as this is not the first time that she has been admitted here. Her independence is very important to her. EP was born and raised in lower- middle class New Jersey, used to be a nurse, was previously married only once, has two kids and several grandkids. It seems that she does not maintain close ties with anyone in her immediate family because they don’t ever seem to answer her phone calls or come to visit. She enjoys jazz music and not much else, and is very preoccupied with the idea of reaching out to her family. In spurts of confusion, EP is very easily agitated, aggressive and hyper verbal. She lacks insight into her diagnosis, and doesn’t believe she has memory loss or any of the characteristics associated with dementia. When EP becomes aggressive or hostile, she can always be calmed down by a little bit of jazz music, which she greatly enjoys.
EP’s biopsychosocial characteristics could be used to both assist in engaging the client in a supportive relationship, but can also hinder the development of said relationship. One of the major strategies to use in reminiscence therapy is the “ Life Story Book”, where the client, and often their spouse or family, gathers significant memories from the past in the form of photos, journals, mementos etc. to create a life book that tells the client’s story to help them regain their sense of self and self- identity by highlighting, organizing, and making sense of moments that shaped the individual’s life (Scherrer 2013). The goal through creating a “Life Story Book” is to focus on reconstruction of the client’s understanding of himself through creating a narrative with visual triggers and cues (Scherrer 2013). A major challenge here is getting the client to focus on their overall story as opposed to the cognitive gaps in the memory (Scherrer 2013). Another challenge is how to incorporate loss into “The Life Book” with out bringing emotional distress to the client who may not remember the tougher times (Scherrer 2013). When applied to EP, a “Life Story Book,” while potentially being a great aid in reestablishing a sense of self, may also create more depression or agitation for her. For example, EP is no longer in regular contact with her family and by creating this book for herself, she may experience feelings of isolation, loneliness, or feel more lost because she cannot understand why she no longer plays an active role in her family. EP may also find the process in creating the book is very stressful and anxiety promoting because she does not have many photos, journals or mementos to add to the book, further verifying confusion about her life and diminished sense of self. Though the “Life Story Book”, has proven to be a very effective tool in building supportive relationships, it may not work for everybody, specifically EP.
Another strategy to aid with engagement is cognitive behavioral therapy (CBT), in which triggers, behaviors and reinforces are identified and analyzed (McClive-Reed 2010). Even in cases of severe impairment, trained responses can be elicited and maintained (McClive-Reed 2010). The strategies used in CBT concentrate on increased repetition, transferring focus on negative thoughts to alternative ones, using concrete examples, and providing memory aids such a cue cards and session notebooks, but require a very structured format (McClive-Reed 2010). As far as EP, CBT would be very beneficial to engage her in a more supportive relationship. Repition would help her gather appropriate responses, while session journals or cue cards would help her recall her familiarity with the caregiver and location. If one could eliminate the amount of time it takes to reestablish a sense of comfort and positivity about the session, more time can be spent focusing on therapeutic effective activities. By analyzing triggers, behaviors and reinforces, when EP starts to get agitated, aggressive or hostile, the caregiver could quickly use a trigger that elicits a calm and controlled response to get her back on track, like playing her jazz music for example.
Another effective technique in engaging the client is by using Sensory simulation therapies like art, music, aroma, or animal assisted therapies to aid in building a strong supportive relationship (McClive-Reed 2010). Art and music therapies improve social interactions, emphasize personal choice, teach new skills, and can also trigger old memories all aiding in improved self-esteem, mood, and pleasure (McClive-Reed 2010). A challenge for patients who aren’t particularly artistic is that these activities might actually increase anxiety or depression due to feelings of failure or confusion regarding their work of art (McClive-Reed 2010). For EP, music therapy specifically is very effective in regulating her mood, and she seems to responds mostly to jazz music or music therapy in general better than to any other therapy. Art therapy is not effective for her, but when I play jazz music, her mood noticeably gets brighter, more positive and optimistic, which allows more time to be spent on building a supportive relationship and engaging in therapeutic activities. Without the music, it is very difficult for EP to get past her negative or angry mindset and focus on any task that is given to her. I would love to see how EP responds to animal assisted therapy or aromatherapy, because these types of therapies are not offered at the hospital, it is difficult to speculate on how EP would respond.
All these methods of engagement should be used to aid the caregiver in being able to accurately assess the patient. When assessing a patient, one should include a clinical interview that focuses on current symptoms of the clients and an overall sense of their life story, as well as standardized instruments that look at aspects of living with dementia such as “quality of life, activity levels, understanding of the disease, stigma and fear associated with the disease, and values and preferences regarding their life and care” (Mast 2012). First one must look at the client’s traits and abilities, then look at the clients needs, values and goals, and then address the clients narrative story as they see it or tell it (Mast 2012). By looking at these levels, the caregiver is able to gain a better understanding of the client, which is imperative to the way they experience their dementia, which leads to specific care planning for the client (Mast 2012). Because many look at these kinds of assessment with great fear or vulnerability, focusing on their downfalls may cause people to feel devalued or diminished, so the caregiver should try to focus on the person, first to build trust and establish that this person continues to be of value, despite cognitive changes, and to show they are truly interested in learning more about the client (Mast 2012). You want to ask question that allow you to gain a long term over all view of your client while also listening for relevant information that addresses “ a person’s premorbid functioning, past mental health concerns, availability of social support, and preferred ways of spending time” without explicitly focusing on their symptoms or deficiencies (Mast 2012). An example of this would be instead of asking directly ‘have you ever been treated for depression,’ one could say ‘describe the most unhappy period in your life’ or ‘describe the main difficulties you’ve experience as an adult’ and then follow up with more direct questions as necessary (Mast 2012). The interview portion of assessment is all about asking the right question without making the client feel deficient.
Moving on to the standardized assessment of mood and cognitive functioning, clinicians have a variety of tests to chose from. The Quality Of Life- AD scale (QOL-AD) measures “physical health, energy, mood, living situation, memory, family, marriage, friends, self as a whole, ability to do chores, ability to do things for fun, money and life as a whole” (Mast 2012). This is a great starting place for the standardized feature of assessment because it shows aspects of the client that may not have been apparent during regular interview. The next step is to look at participation in pleasurable events which uses the Pleasant Event Schedule (PES-AD), a 20 item survey that represents pleasant enjoyable activities that can be engaged in by the client, how often they engage in each, and how much enjoyment it brings them. This is intended to be used as a baseline assessment to measure the person’s activity level and begin the process of increasing pleasant and enjoyable activities in the clients day to day routine (Mast 2012). This would be ideal for EP because she has that diagnosis of depression. Another important scale is the Values and Preferences Scale which asks about family and social environment, sense of purpose, sense of being burdensome, and being a part of decision making (Mast 2012). This is important to gauge the client’s quality of life and understand their thoughts on how they’d like to live or be cared for. All of these scales would be beneficial when applied to EP. Caregivers would be able to better understand her wants, and needs, her level of discomfort about her disorder, and really how much she understands it. It would tell us activities she enjoys and doesn’t enjoy and how much time is ideal to be doing said activities, which is imperative for her depression management. We would gain greater insight on her ideals and views on how she would like to maintain her life and care. All of the results from each of the measures would be taken into account to create a personalized treatment plan most likely to benefit EP, and if the treatment plan encompasses her needs and desires, she will more likely actively participate in the plan.
Having the client actively partake in their care plan is also vital when making ethical considerations. When looking at a care plan from an ethical standpoint, one must look at facts relevant to the case, appropriate interpretation and application of those facts, and look at other relevant situations to find ethically relevant comparisons (Hope 2009). It is important to ensure that you as a caregiver are promoting the clients sense of autonomy and maintaining the sense of self and values (Hope 2009). There should always be available support and education for caregivers to be able to stay updated about ethical considerations as they are often changing with times (Hope 2009). Its is absolutely necessary to ensure that the guidelines within the care plan are ethically sound with the clients desires to ensure that the client will feel valued and fulfilled, but also to follow through with the recommendations in their care plan. Cultural differences should be taken into account because often time’s people of different cultures hold different ideals and also portray ailments differently. “Access to supportive care, including appropriate information, emotional support and practical support, is essential for people to live well with dementia. Such care must be flexible, recognizing the different needs, preferences and values of different individuals (Hope 2009).” As far as EP, by using the information that we can gain from assessment, we can more appropriately use her values to create a care plan that she would be agreeable to. By learning about her culture, beliefs, values, preferences, we can customize a care plan for EP that she would not only be happy and fulfilled with, but that will aid her in living remainder of life to the fullest in terms of developing appropriate coping skills to deal with her dementia and depression and still maintaining autonomy which is very important to her.
By using EP as an example, one can see how imperative it is to appropriately engage and assess clients, while still making ethical considerations and taking their desires and needs into account. A care plan works best when both the caregiver establishes techniques to increase quality of life and positive sense of self, and the client still feels fulfilled in their sense of self or self identity. The best way to ensure this is by using engagement strategies like reminiscence, cognitive behavioral, or sensory stimulation therapies and appropriate biopsychosocial assessments like interviews or scales like Quality of Life or Pleasant Events scales to gain a better overall understanding of the patient when creating an appropriate care plan. If we can better evaluate care plans and methods used to make them, then we can tackle the growing problems that surround dementia in elderly populations.

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