Monday, September 15, 2008

Symptoms and biological consequences of dementia

The person with dementia is frail: premorbid, at risk for biopsychosocial issues; there is an inability to maintain physical, social, and emotional needs.

Twaddle et al. (2007) believe that prompt referrals with planned admissions to the best settings ameliorate the need for placements in facilities such as intensive care units and promote early discussions in situations such as palliative care for greater clarification of treatment goals. They found that palliative care study patients were more likely to access medical care through emergency departments. These patients were discharged from American academic/university hospitals at a rate of 42% without follow-up home care services, despite histories of severe illnesses.

This model of crisis intervention is replicated amongst the friends that I know. My father’s discharge from the ER with a urinary tract infection after radiation therapy with no diagnosis in July, 2006, is a prime example of this situation.

Seniors do not like this term, yet “frail” paints a very complex and complete picture for family members and caregivers. Dementia can be caused by trauma (falls, broken hips) due to frailty, leaving the senior unable to meet ADL. Nutritional issues can then worsen an already frail senior. (An empty refrigerator is an eighty-percent predictor of problems with dementia.)

Dementia leads to an inability to communicate, and comorbidities such as infections, infarctions, or subcortical issues, such as plaque and damaged brain cells, will remain undiagnosed. For some seniors, aphasia (language disturbance), apraxia (impairment in motor activities), agnosia (failure to recognize objects), or affective disorders such as depression, Alzheimer’s disease, or sleep disorders (insomnia or hypersomnia) can result in those who must receive more support than might be obvious to outside observers or even close neighbours. For some, impairment of the senses (hearing, vision, olfactory, touch, taste) results in a quality of life that creates frustrations to both care recipients and caregivers.

A frail senior who has had surgery will have a higher risk of infections due to the immune system that is compromised, as well as to the frailty of skin and tissue. For those with delirium, drugs are purported to be responsible for eleven to thirty percent of hospitalized patients (Feil, et al., 2007). Nutritional inadequacies, such as a lack vitamins or minerals, can result in dementia, and can be identified or prevented with liver function tests, calcium, and glucose tests (Wenger, et al., 2007).

For those seniors who live in their own homes, it is my belief that family members must be contacted to provide them with information. My friend Kristin said to me, “Geriatrics or pediatrics: the only difference is body mass.” We have the right as well as the responsibility as parents to care for our children. We regulate workers in day care and nursery schools. We must protect them and advocate for them. Why is this not the same for seniors? Why do we not regulate long-term and private home care? Once an outside agency becomes involved in the care of a senior, privacy laws should not supercede the rights of adult children to ensure that their parent’s needs are being met.

Seniors are often placed in LTC due to dementia. Of those with dementia, fifty-five to seventy-seven percent have Alzheimer’s disease. There is a high correlation with depression (and caregivers as well are at high risk for depression). It can be ameliorated with improved social outcomes with cognitive screening tests, and medical, behavioural, and social interventions. It can be prevented or lessened by these measures, but it will not be cured. It must be diagnosed by medical professionals who take a history of the resident within two weeks of entering LTC (Feil, et al., 2007).

Quality indicators for medication use in seniors demonstrate that seniors fill an average of twenty prescriptions per year (Shrank, et al., 2007). Once a senior has a need for hospitalization, he/she may be sent home with an additional prescription and might not think to ask his/her GP if he/she really needs these medications. In addition, those in LTC do not always have the benefit of seeing a doctor. An RPN may simply phone a doctor without any assessment or review of other medications. There are some lucky institutions with Nurse Practitioners who have the ability to prescribe medications, but health care is so closely guarded by self-serving physicians that many health-care providers are finding it hard to access clients. Government legislation controls many providers of services: pharmacists, midwives, and providers of holistic services such as massage and reflexology.

Wenger, et al. (2007) recommends the clock drawing test, Beck’s depression test, and medication reviews and adjustments, as well as other measures they call Assessing Care of Vulnerable Elders (ACOVE). The impact on seniors, their families, and friends in an aging population requires that we seek to identify more of the signs, symptoms, and causes of dementia, as well as other infirmities of the aging body.

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