Introduction
The present case study seeks to assess and analyze the nursing interventions implemented for Mr. Lewis, a dementia patient, during his clinical placement in a geriatric ward. The intervention for this patient primarily focuses on improving independence for a patient with dementia. Dementia is a collective term describing a group of symptoms linked with a gradual decline in an individual’s cognitive abilities or functions. Symptoms of dementia include impairments such as intellect, memory, social skills, insight, and language. Dementia primarily affects individuals over sixty-five years of age, and it becomes even more prevalent with an increase in age. Throughout the world, about 50 million individuals have dementia, with the incidences increasing every year. In the United Kingdom (UK), around 750,000 persons are living with the condition, which is projected to grow to roughly 1.4 million by 2039. Therefore, the UK government is emphasizing the need to have high-quality care services to support people with dementia (PWD). Nurses play a critical role in supporting PWD by creating a favorable environment for them to undertake activities of daily living (ADLs).
Background:
Mr. Lewis, a 66-year-old gentleman, was referred to the geriatric ward of our specialty memory clinic with a 3-year history of executive function loss, memory loss, and repetitiveness. A patient’s magnetic resonance imaging (MRI) scan at age 66 detected minor generalized cortical atrophy. He is a white male with a 3-year university education and retired from employment at age 55 as a supervisor in the manufacturing sector. However, his retirement was not because of a decline in his cognitive abilities at work. A progressive decline in the patient’s cognitive abilities was revealed by frequent reports of challenges in performing ADLs over the past year before his initial memory clinic consultation. According to Mr. Lewis’s spouse, his literacy skills and word-finding have significantly deteriorated in the past three months. The patient’s past medical history revealed a deficiency in vitamin D and hypercholesterolemia. However, Mr. Lewis had no history of surgeries, alcohol abuse, smoking, and other drug use problems.
Assessment:
Upon Mr. Lewis’s admission into the geriatric ward, a rigorous assessment was conducted on his psychosocial, physical, and cognitive needs by a multidisciplinary team of healthcare providers, including physicians, nurse practitioners, neurologists, occupational therapists, geriatricians, social workers, student nurses, and neuropsychologists. Laboratory screening found no family history of dementia. However, a neurocognitive evaluation of the patient in our clinic disclosed a Mini-Mental State Examination (MMSE) score of 15 out of 30 points. Currently, clinicians utilize the MMSE instrument to track and diagnose individuals affected with disorders that cause cognitive impairment. The MMSE is a standard cognitive instrument developed in the mid-1970s as a global cognitive status assessment tool (Gluhm et al., 2013).
According to Zincir (2022), the maximum score is 30 points, indicating a perfect cognitive status, while 24 points or higher is the recommended cutoff for a normal cognitive status. Any score of 23 points and below indicates dementia (Gluhm et al., 2013). Mr. Lewis exhibited poor verbal fluency, poor executive skills, and poor visuospatial skills. For instance, the patient could give only four animal names within a minute. Also, the patient lacked fluent speech since his speech was characterized by sematic deficits. The neurological examination indicated a minor ideomotor apraxia especially in performing commands associated with motor skills. It, thus, means that Mr. Lewis needs assistance in performing most ADLs such as bathing and dressing.
Planning:
Based on this assessment by a multidisciplinary team of healthcare providers, a holistic and person-centered care plan for Mr. Lewis was developed by the student nurse with close supervision from the team members. It therefore means that the student nurse had to communicate effectively with all the healthcare professionals in the team as recommended by the NMC (2018). The care plan has specific goals focused on attending to his immediate needs while improving the patient’s overall wellbeing. According to Kim & Park (2017), patient-centered care refers to an integrative and holistic approach intended to improve quality of life and promote wellbeing for PWD and it encompasses the components of care, the patient, the family and the carers.
Therefore, person-centered care (PCC) is often viewed as a sociopsychological approach to treatment that acknowledges the patient’s individuality in relation to the care practices and attitudes of care providers (Berkovic et al., 2023). In clinical settings, PCC for dementia patients involves prioritizing client’s wellbeing, integrating personal knowledge of PWD, and promoting quality interpersonal relationships between the PWD and healthcare practitioners (Engedal, 2024). NMC (2018) requires that all the nurses provide care in a holistic, sensitive, caring, and non-judgmental manner that supports inclusion, avoids assumptions, recognizes individual choice and acknowledge diversity. The following are some of the specific goals established by the student nurse for Mr. Lewis’s care plan while also recognizing his unique needs, values, dignity and preferences as recommended in the NMC (2018):
- To encourage Mr. Lewis’s independence especially on ADLs and facilitate overall wellbeing of the patient through routine physiotherapy, promoting opportunities for self-care activities, and positive reinforcement.
- To enable the PWD to maintain an active lifestyle through frequent physical exercise.
- To engage the patient in cognitive related activities by implementing strategies that encourage cognitive functions such as simplifying tasks and instructions or commands into smaller steps.
- To offer necessary assistance on accessing local resources and services about mental, physical and social activities.
Intervention:
Besides the usual care for dementia patients, Mr. Lewis will receive PRIDE intervention that encompasses manualized cognitive, physical, and social domains for individuals with dementia. The student nurse ascertained that intervention is customized to meet Mr. Lewis’s unique needs. The student maintained effective communication with the patient and allied healthcare professionals to ensure all parties work collaboratively to realize the goals of the intervention. The student nurse also prioritized Mr. Lewis’s intervention measures based on his immediate needs and preferences. Also, the student is self-aware such that he recognizes his limitations in skills and knowledge and thus collaborate with registered healthcare professionals. The following intervention strategies for Mr. Lewis were performed by the student nurse under supervision of professionals in the team:
- Occupational therapy – The student nurse in collaboration with the occupational therapist created a personalized training program for the patient. The training manual focuses on physical exercises to improve gait, balance and practice ADLs in a safe space (Maneval et al., 2022).
- Breaking down tasks – The student nurse in collaboration with the registered nurse broke down complex instructions and tasks into smaller steps. For instance, the student nurse provided cues to Mr. Lewis on how to dress.
- Positive reinforcement – This was achieved when the student nurse acknowledged Mr. Lewis’s efforts and small achievements such as wearing a cap.
Conclusion
The increasing prevalence of dementia especially among the older population worldwide has prompted the need to develop and implement novel intervention strategies which are effective and acceptable globally. Providing psychosocial interventions tailored to promote self-management such as performing ADLs and facilitating overall wellbeing of the patient can help in dementia management. Person-centered care (PCC) is usually recognized as a sociopsychological approach to treatment that acknowledges the patient’s individuality and promote inclusion and dignity of PWD throughout the treatment. The present case study shows the valuable role that a student nurse can play to promote independence of PWD. In other words, nurses play a critical role in supporting PWD by creating a safe environment for them to undertake ADLs. The student nurse has also gained valuable skills and knowledge by applying crucial nursing skills and developing fundamental self-management abilities.
References
Berkovic, D., Macrae, A., Gulline, H., Horsman, P., Soh, S., Skouteris, H., & Ayton, D. (2023). The delivery of person-centered care for people living with dementia in residential aged care: A systematic review and meta-analysis. The Gerontologist. https://doi.org/10.1093/geront/gnad052
Engedal, K. (2024). Editorial perspective: Person-centered care for people with dementia. International Journal of Person Centered Medicine, 12(2), 3-6. https://doi.org/10.5750/ijpcm.v12i2.1112
Gluhm, S., Goldstein, J., Loc, K., Colt, A., Liew, C. V., & Corey-Bloom, J. (2013). Cognitive performance on the mini-mental state examination and the Montreal cognitive assessment across the healthy adult lifespan. Cognitive and Behavioral Neurology, 26(1), 1-5. https://doi.org/10.1097/wnn.0b013e31828b7d26
Kim, S. K., & Park, M. (2017). Effectiveness of person-centered care on people with dementia: A systematic review and meta-analysis. Clinical Interventions in Aging, 12, 381-397. https://doi.org/10.2147/cia.s117637
Maneval, J., Woods, J. K., Feany, M. B., Miller, M. B., Silbersweig, D. A., Gale, S. A., Daffner, K. R., & McGinnis, S. M. (2022). Case study 3: A 58-Year-Old woman referred for evaluation of suspected Alzheimer dementia. The Journal of Neuropsychiatry and Clinical Neurosciences, 34(4), 307-315. https://doi.org/10.1176/appi.neuropsych.20220113
NMC. (2018). Standards for competence for registered nurses. https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-for-competence-for-registered-nurses.pdf
Zincir, S. (2022). Evaluation of cognitive functions in schizophrenic patients with the Montreal cognitive assessment scale and mini-mental state examination. Black Sea Journal of Health Science, 5(3), 553-557. https://doi.org/10.19127/bshealthscience.1110688
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