The Essay On Dementia's Pathophysiology And Impact On Patients.

The learning outcomes are as follows: 

Evaluate the evidence-base underpinning current practice in the management of people affected by chronic diseases.
Examine the social and psychological impact of conclusive diagnosis of a chronic disease on people and their family/ carers.
Explore the role of the multidisciplinary team in promoting self-management to enable people to live positively with a chronic disease.
Analyse current local practice and identify possible changes to improve psychological symptoms and health, and well-being for people living with one or more chronic diseases.

Briefly introduce your allocated condition in your introduction. This should include a definition of what a long-term condition is and an explanation of your allocated condition along with a brief overview of its epidemiology and aetiology. The introduction must also outline how you searched for academic evidence to support this portfolio to answer the learning outcomes for this assessment. 

A search strategy outlining the relevant search terms you used, the research databases you searched and the number and type of results you obtained should be provided. This can be given in a table format to ensure you stay within the word count for this section.  

Chronic diseases are long-lasting clinical condition in which effects of the disease persist for long time. Chronic disease such as diabetes, stroke, cancer and stroke are the major cause of mortality worldwide. It is the major cause of poor health outcome, disability and activity limitation in affected people (World Health Organization, 2017).

Dementia is also a chronic disease or persistent disorder characterized by cognitive impairment, personality changes and memory disorders in an individual. Alzheimer’s disease is the most common form of dementia found in about 60-8-% individuals. As dementia is a brain disease order, at least two mental functions such as memory, communication, visual perception, attention and reasoning and judgment are affected. It is regarded as a progressive disease as symptoms appear slowly and worsen with time. Gradual changes and damage to the brain cell is considered to be common cause of dementia (Kandiah, 2013). In case of Alzheimer’s disease, shrinkage of brain cells results in damage of brain functions. Dementia is found in millions of people mostly older adults. Nationwide epidemiological study done in Singapore has revealed that dementia was prevalent in about 10% of the elderly population above 60 years old. It is also estimated that since Singapore has the fastest ageing population and about 15-20% people above 65 years, so number of dementia patient is likely to increase to 53,000 in 2020 compared 25,000 in 2013. This implies that likelihood of dementia increases with age and links were also found with education level and employment (Subramaniam et al., 2015).

To complete the portfolio, search terms like ‘dementia’, ‘cause of dementia’, ‘dementia pathophysiology’, etiology of dementia’ and ‘treatment for dementia’ was used. Data regarding chronic disease was searched from World Health Organization website, whereas journal articles related to the assignments were retrieved from databases like Google Scholar, ProQuest, CINAHL and Cochrane library. Article and websites between 2008 to 2017 were taken to incorporate information in the portfolio. 

Impact of Cognitive Impairment on Dementia Patients

Portfolio Entry 1 

Describe the pathophysiology of the allocated condition, supported by relevant academic literature.

You must demonstrate your ability to understand the anatomical and physiological changes that occur for your allocated condition. This should include describing normal physiology and the changes that occur at the cellular, tissue/organ or bodily system level in relation to your allocated condition. This must be evidence based using appropriate academic sources.

Pathophysiology of dementia

There are two type of dementia. Alzheimer’s disease is the most common type of dementia and vascular disease is the second most common cause of dementia. Signs of beta-amyloid plaques and neurofibrillary tangles in the brain give indication of the pathophysiology of Alzheimer’s disease (Kumar & Singh, 2015). Brain is the complex organ and structure that is responsible for functions like senses, communication, memory, language, emotions and feelings. Understanding the function of different sections of the brain can be useful in understanding the mechanism of changes in brain due to neurological disorder like dementia. The brain consists of four sections such as cerebrum, cerebellum, pons and the medulla. Cerebral hemisphere is the structure that controls conscious emotions, spatial computation body orientation, language, memory and attention. The cerebral hemisphere consists of the frontal lobe, parietal lobe, temporal lobe and occipital lobe. Hippocampus is the structure located in the temporal region which regulates emotion (Hydrocephalus Association, 2017). 

 As dementia is neurodegenerative disorder, structural and functional alterations are seen in the cortical and sub-cortical region of brain. In case of the most common dementia of the Alzheimer’s type (AD), the pathology of dementia is centred around the prefrontal cortex and the lateral cortex (Brand & Markowitsch, 2008). Investigation of brain structure of patients with dementia has showed changes in the structure of medial temporal lobes and hippo-campal formation. Brain structures found in the medial temporal lobe are involved in memory processing, however AD firstly results in damage to the hippo-campal region of the brain. This is the reason for loss of memory and poor orientation in patients. The damage to the region is evident by signs of neurofibrillary tangles and beta-amyloid plaques in brain. Senile plaques also results in protein deposits in the brain. Formation of such tangles and plaques results in poor synaptic connection and neural loss or atrophy (Kumar & Singh, 2015). Hence, dementia of AD type is caused by damage to the hippocampus region of brain and volume loss in the temporal lobe differentiates AD patients from healthy adults.

Vascular dementia is the second most common cause of dementia. It mainly occurs due to disruptions in the supply of blood to the brain. This is mainly associated with cognitive decline. Multiple cortical infarcts are regarded as the process behind vascular dementia. The ischemic infarcts affect the function of multiple areas of brain such as parietal lobes or hippocampus in rare cases.  This has an impact on the neural nets which leads to cognitive decline in affected person. People with stroke are found to be at risk of developing vascular dementia.  As there are different subtypes of dementia, the disease is categorized on the criteria of homogeneity, predictability and reproducibility (Roh  & Lee, 2014).

1. Explore how this could affect your patient (500 words)
2. Evaluate 1 assessment tool (consider advantages/ disadvantages) (750 words)
3. Based on best evidence discuss the nursing management required to enable the patient to maximise their health and well-being and self-manage their condition.

This must demonstrate a holistic approach (physical, emotional, social and spiritual).  You should include reference to the support of family/carers and the role of other members of the multidisciplinary team and the voluntary sector where relevant.

Impact of cognitive impairment on dementia patient

Dementia is a progressive disorder that mainly alters the function of brain involved in memory, language, judgment, reasoning and visual processing. There are different symptoms of dementia which can be categorized into cognitive impairment, behavioral problem, mood disorder, psychological changes and other common symptoms. Signs of disorientation, memory loss, difficulty in speaking, taking decision and identifying common things are examples of cognitive symptoms of dementia. Behavioral symptoms found in dementia patients include aggression, restlessness, and personality changes. People tend to have mood swings and symptoms of loneliness and anger. Dementia patients are affected psychologically too as they experience hallucination and depression. Apart from these, common issues found in patients include insomnia, nervousness, jumbles speech and risk of fall. Although dementia is associated with many symptoms, however cognitive impairment is one symptom that is found in all patients. Hence, the main purpose of this report is to critically analyze the signs and symptom of cognitive impairment in dementia patient and discuss its overall impact on patient.

In dementia patient, symptom of cognitive impairment is one specific challenge that affects daily life and functioning of people. Cognitive impairment related symptoms like memory changes and disorientation results in loss of skills in affected person. They struggle to compete in professional work and carry out daily life activities. The impact of the disease on younger working people is huge as their occupational performance is affected and they struggle to cope with work demands due to memory loss and disorientation. Social changes in life are also huge as cognitive impairment prevents them from completing basic life activities and they are dependent on others for common activities. Due to dependence on others and inability to cope with the disease, people develop frustration. The common reason for frustration is decrease in self-confidence, feelings of embarrassment and tension about inability to fulfill social or family role (Liu-Seifert et al., 2015). Hence, change in social life and increased dependence on others has a negative impact on dementia patients.

The burden of disease for dementia is high because of significant affect on quality of life of patient. The cost of health service and informal care due to dementia is huge. Apart from physical and psychological issues for patient, the carers of dementia patients are also affected by the burden of disease (Hugo & Ganguli, 2014). Due to the continuous need to support dementia patient in basic activities of living and loss of support in family roles, family members also experience emotional distress and depression (Kasper et al., 2015). Major challenges for patient also arise because of changes in verbal reasoning and verbal memory of patient. They are prone to many risk and disadvantages. Hence, cognitive decline is highly linked with quality of life as patient’s capacity to perform daily life activities are affected and they are emotionally disturbed by the loss of skills and decision capacity. Due to loss in cognitive ability and function, people also lose interest in activities that they enjoyed previously. Overall, quality of life is seriously affected as feelings of frustration, anger, shame and embarrassment becomes common for them (Giebel et al., 2014). Hence, it is very important to assess dementia patients and support them to live a better life by means of appropriate treatment and therapy.

Evaluation of one assessment tool for dementia

Before planning treatment or therapy for dementia patient, it is necessary to conduct assessment in patient to get details about severity in different domains such as cognition, quality of life, behavior, functioning and depression in patients. Different assessment scales are available for dementia patient and Mini-Mental State Examination is one of most widely used assessment tool for assessment of dementia patient. The scale is specifically beneficial for dementia patient as it measures level of cognition in patient. The scale has set of questionnaires where patients are evaluated on a scale of 0 to 30 points. Tee questionnaires used in the tools assess cognitive function of an individual in the areas of memory, orientation, calculation, visual perception, language, attention and memory. On the basis of score obtained in the MMSE scale, cognitive impairment is categorized into four type- mild, moderate, severe and questionably significant (Sheehan, 2012).

Advantages:

The advantage of the MMSE scale can be understood by validity, reliability and acceptability of the tool. Several research has used the tool in dementia patient to understand its reliability and validity. The first advantage in relation to acceptability is that it does not consume much time and the assessment can be completed in about 10 minutes. It is brief screening tool that is inexpensive as well as simple to perform too. Research on reliability of the tool also showed high test-retest reliability, high interrater reliability, consistency and concurrent validity of the tool. Good interrater reliability indicates that two or more raters using the same scale in same population got the same score, whereas good test-retest reliability is understood by obtaining same score when the rate used the scale in the same subject on other occasion (Sheehan, 2012).

For instance, Baek et al., (2016) used the tool in patients with mild cognitive impairment and Alzheimer’s disease. Test-retest reliability was assessed by readministering the tool one-two months after initial assessment. Secondly, inter-rater reliability was assessed by intraclass correlation coefficient. With such method of analysis, good test-retest and inter-rater reliability was found (Baek et al., (2016). Another research proved the accuracy of MMSE score by comparing the score obtained by general practitioner to those obtained by Alzheimer’s Evaluation Unit (EVA). The result showed good accuracy of MMSE score in identifying cognitive impairment in patient (Pezzotti et al., 2008). From the above evidences, it can be said that the MMSE scale is not useful for formal diagnoses, however it helps in the screening process to detect cognitive impairment in patient.  

Other important criteria that give idea about the usefulness of assessment scale include face validity and construct validity. Face validity is obtained when patients, clinician and other careers agree with the questions used in the tool. Secondly, construct validity is proved when it can effectively measure the construct it was designed to measure (Sheehan, 2012). The face and construct validity was also proved by research on dementia patient (Baek et al., 2016). Hence, from the review of evidence on effectiveness of MMSE tool for cognitive assessment, it can be said that it is a reliable and valid tool for cognitive screening of dementia patients

Disadvantages:

Apart from advantage of the MMSE tool in the area of validity and reliability, limitations of the scale is found in the area of sensitivity. This can be said because evidence has showed that it is difficult to differentiate patients with mild cognitive impairment from older adults (Baek et al., 2016). Hence, when comparison is done with older patients who normally experience memory related problem, the tool is found to be insensitive. This also indicates that the MMSE score can be affected by age, education and cultural background of patient. For instance, inappropriate score was obtained when the MMSE scale was used to evaluate mental state abnormalities in a cohort of  Adult Nigerians. Discriminating result was found for mild cognitive impairment in patient (Onwuekwe, 2012). Hence, the MMSE scale may not be reliable in screening of a cohort.

Another disadvantage of the tool is that biasness has been reported in the use of tool because of changes in score by age, education and socio-cultural background of participant. When the aim of assessment is to identify people with cognitive impairment in a large and diverse population group, misclassification may take place. Hence, it can be said that low sensitivity of the tool reported in several research studies is one of the greatest limitation of MMSE (Brodaty et al., 2016).

Nursing management to promote health and well-being in dementia patient

As performance of basic life activities, social skills and decision making skill is significantly affected in dementia patient, comprehensive support and management by nurse is critical to promote health and well-being of dementia patient. Due to presence of symptoms like cognitive decline, functional limitation and challenging behaviour, nurses have the responsibility to therapeutically respond to the health care needs of dementia patient (Zabalegui et al., 2014). As cognitive impairment and behavioural changes often results in hospitalization of patients, nurses play a role in taking preventive measures to reduce health care cost.

For dementia patient, chronic cognitive decline leads to great dependence in activities of daily living (ADL). Nurse plays a role in supporting patient in ADL and preventing fall. In case of chronic cognitive decline, they provide assistance to patient in walking, dressing, washing and movement. They monitor ADL of patient regularly and accordingly provided support and assistive device to promote independence of patient. Nurse also modify environment around patient to support ADL function (den Ouden et al., 2017). In this way, they promote safety and efficiency of patient and prevent patient from deterioration of health due to fall or other cognitive issues.

Many dementia patients tend to suffer because of poor knowledge and awareness about dementia and coping with the disease. In such situation, nurse plays a role in providing client education related to self-care and positively living with dementia. For instance, education about providing patient and family member’s education about impact of dementia on behaviour and function can help patient to understand specific physical environment or assistive support required for them. Nurse in consultation with occupational therapist also builds skill of patient in daily activities. They also implement and supervise patient in daily activities and achieving physical activity goals on a daily basis.

Another problem commonly found in dementia patient is that they experience psychological issues and social isolation due to deterioration of concentration and decision making capability and dependence on another. Social isolation might lead to chronic depression in patient. They address fear of socialization in patient by entering into therapeutic communication with patient. With an inter-professional team, they make maximum contact with patient to mentally stimulate and facilitate feelings of inclusive and well-being in them. By one-on-one interaction with patient, they play a role in reducing internal and external stressors of patient and teaching them strategies to promote good quality of life (Dam et al., 2016).  Hence, nurse plays a role in encouraging patients to combat loneliness and increase socialization.

In many case, patients also develop agitation and resistive behaviour. Hence, apart from physical and mental health, promoting spiritual health of patient is also necessary. This can be done when patients remain mentally stimulated. Research has shown that regular exercise and engagement in activities reduce progression of disease. Hence, nurses play a role in assessment of cognitive function and implementing suitable intervention to promote their functioning level. They engage patient in many stimulation activities such as word game, group activity and puzzle game (Surr et al., 2016). The advantage of such kind of stimulation is that it improves sense of purpose and promotes spiritual well-being in patient. Nurses also fulfil the criteria of holistic care by supporting personal carers or family members of patient in overcoming distress. For example, they provide specific information and crucial aid relayed to dementia patient (Cabrera et al., 2015). They also refer them to good education material or respite services or community support service available in community to promote health and well-being of client. Evidence has proved that skilled dementia special nurse play a major role in improving core outcome of dementia patient (Griffiths et al., 2015).

In this final section, summarise the key aspects discussed in the portfolio and make recommendations on how learning may influence your future practice (approx. 500 words)   

Conclusion

The completion of portfolio activity on dementia gave an insight into the burden of disease and high health care cost associated with dementia globally. The neurodegenerative disorder characterized by cognitive impairment, behavioural problem, disorientation, psychological disturbance and other common symptom has been found to significantly affect quality of life of patient. The prevalence of dementia and increase in number of patients with dementia suggest that screening measure and education and health promotion related intervention is necessary to prevent deterioration of symptoms. The portfolio has provided useful and evidence based information related to pathophysiology, etiology and prevalence of dementia. The pathophysiological understanding of the disease is essential to understand the reason for functional and cognitive decline in patient. Such knowledge is useful to understand clinical issues in dementia patient and implement intervention accordingly.

As the number of patients with dementia is increasing due to increase in ageing population, screening process has become essential to identify people with symptoms of mild cognitive impairment. The portfolio exercise has been effective in providing knowledge regarding use of MMSE tool for assessment of patient. It is a brief and simple tool whose validity and reliability was established in the portfolio by reviewing peer-review research articles. Many research evaluated the effectiveness of tool by using it on patients with dementia. However, the critical evaluation of MMSE tool also gave insight into its limitation which is the poor sensitivity of the tool in cohort study. Due to this limitation, it is recommended that health care providers and carers assess severity of symptoms by using other validated tool that has high sensitivity too. The portfolio exercise also gave an insight into the crucial role of nurse in supporting patient with dementia and promoting health and well-being in people. 

From the completion of portfolio, I have found several limitations related to knowledge awareness in dementia patient. Hence, it is recommended that we must develop the skills to effectively communicate with patient and support patients in positively living with the disease. Secondly, while using assessment tool for screening and assessment of patient, it is necessary that we use most validated and reliable tool to prevent any error in diagnosis. Furthermore, skill development in identifying cognitive impairment and developing coping skills of dementia patient is necessary to promote their recovery.  

References

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Zabalegui, A., Hamers, J. P., Karlsson, S., Leino-Kilpi, H., Renom-Guiteras, A., Saks, K., ... & Cabrera, E. (2014). Best practices interventions to improve quality of care of people with dementia living at home. Patient education and counseling, 95(2), 175-184, Retrieved from: https://s3.amazonaws.com/academia.edu.documents/45898760/j.pec.2014.01.00920160523-25022-1sz53rp.pdf?AWSAccessKeyId=AKIAIWOWYYGZ2Y53UL3A&Expires=1512648939&Signature=99wTUiPkG2478%2FxGmRUwZ%2FyP00w%3D&response-content-disposition=inline%3B%20filename%3DBest_practices_interventions_to_improve.pdf

Zabalegui, A., Hamers, J. P., Karlsson, S., Leino-Kilpi, H., Renom-Guiteras, A., Saks, K., ... & Cabrera, E. (2014). Best practices interventions to improve quality of care of people with dementia living at home. Patient education and counseling, 95(2), 175-184, Retrieved from: https://s3.amazonaws.com/academia.edu.documents/45898760/j.pec.2014.01.00920160523-25022-1sz53rp.pdf?AWSAccessKeyId=AKIAIWOWYYGZ2Y53UL3A&Expires=1512649276&Signature=lbkkoT10grpuAvh0zj8ReRQNTjA%3D&response-content-disposition=inline%3B%20filename%3DBest_practices_interventions_to_improve.pdf.