Caring For An Older Adult With Mental Illness: A Case Study Essay.

Setting

Setting: Community Setting, Client X is being looked after at home from home base provided contracted by the district health board with attendance to day program for cognitive Stimulation Therapy

Diagnosis:  Dementia – ACE-3 on 25.7.17 = 42/100,  Low B12 levels,  Chronic Kidney Disease – Stage 4 – Lithium related,  Recurrent Urinary Tract Infections,  Bipolar Affective Disorder, Past total Colectomy with Ileostomy,  Migraines,  Atopic Dermatitis, Hypertension

Medications: Diazepam, Amitriptyline, Paroxitine, Carbamazepine

Therapeutic Engagement: cognitive stimulation theraphy at day program, weekly walk with support worker, personal cares assistance from support worker

Care Provided: daily personal care and meal assistance with medication administration

Issues and concerns encountered while looking after the clien: Safety, Changes in behaviour, compliance with the service, frustrations from family and support workers

This 72 year old lady was visited in her home lives with husband present. They live in an apartment, 3 months ago their grandson moved in and is staying with them.

Allergies: Stemitil- lock jaw Tetracycline- oral blisters Lithium- renal impairment Cotrimoxazole- rash and sore mouth Oestriol- burning Valproate- increased bleeding

Cognition: Husband has reported some improvement since her dose of mood stabilisers were recently reduced stating that she is "sharper". He also reports her confusion usually around twilight is now subtle throughout the day since medications have been changed.

Memory: 1/3 recall after 5 mins ACE=3 on 25.7.17 at Older People's Health Clinic, 5/18 for attention; 7/26 for memory; 4/14 for fluency; 19/26 for language and 7/16 for visuo-spatial. Reports that sometimes she forgets to do things. Increasing difficulty with word finding and now does not read books though continues to look through magazines. Increased frequency in misplacing objects, with occasional paranoia around this. Will wash dishes over and over again, rearrange and move things around in her drawers, on the deck and in the kitchen then is not be able to find things. Will clean her teeth with the soap or hair spray. Husband makes sure her stoma bag is on correctly to reduce accidents and leakage. He also feels there are changes to the contours of her stomach and may need a different type of bag.

No longer able to use her eftpos card so husband has an account at her local coffee shop and will give her cash. Noted during assessment she would get up from time to time and wander around for no apparent reason and then return to her chair.

Mood and Behaviour: Husband reports that client’s depression is more prominent and in the past this was on a 5 year cycle though now feels she is cycling more often. He also stated that she has always had an instinctively negative response to most things though her medications prevent her verbalising and she has always talked of topping herself. Today she reported that she "occasionally thinks of doing something stupid" and when questioned further had these thoughts this morning. She denied any plan or intent though does from time to time self harm which is usually picking or scratching at her skin mostly on her arms and face, and will grab her arms and dig her nails in. When her husband is not around she is more positive and when he is around there is an increase in her negativity. He also states that when he is not as patient with her or has said his piece there is an escalation in her negative behaviours. Husband reports that she will reinterpret events to him negatively when they may actually have been a more positive experience for her. He has identified this through reports from their grandson who is now living with them.

Diagnosis and Medications

Her relationship with her children and grandchildren has never been a comfortable one and since this grandson (Chad) has moved in he has gone on a carers benefit to assist with her when husband is at work. Husband has noticed in the last few weeks she has become more reflective and shown an increased frustration and anger with her grandson. Husband reports he has his own health issues and referred to mental health issues.

Client X has presented recently with an increase in her anxiety with medication changes. She reports she gets angry and upset with herself as she does not know what is happening what she is doing and in regard to the future which increases her level of anxiety. Frustration leads to anxiety and it leads to bowel accidents. Family feels their parents are getting older and they need to keep up contact with them. She finds social interaction quite difficult especially with new people. Finding it difficult having her grandson around.

Dementia Day Care had started which did not work out and then tried another place for the program however husband reported she enjoyed her time there though refused to go so this has now not been happening. Client reported she was bored with it.

Social: Client X gets anxious about going out and talking to people. She has always enjoyed going out for walks, her husband does not accompany her and Support Worker take her weekly for a walk and as Dementia Day Care has not worked out for her then walking should be increased to daily as she gets lonely, depressed and is becoming more isolated at home. Husband works 8.30 to 5pm, he will come back to the house during the day if he is able and grandson is around though spends most of his time in his room. IADL’S: Meal Preparation - Husband cooks dinner, prepares breakfast and grandson organises lunch if husband not able to return home to do this. Housework - couple that board with them do some of the cleaning. Otherwise private help. Finances - Husband manages the finances. Medications - Husband puts tablets out in a container for the week and prompts her to take them. Phone use - independent with answering calls though not able to accurately take messages and needs assistance to dial numbers. Stairs - independent Shopping - Husband and/or daughter will do the grocery shopping. Transportation - client does not use public transport and is driven where she needs to go, she can easily get in and out of the car. ADL’S: Showering - Needs prompting as husband questions her level of hygiene, use of soap and he reports he needs to supervise her cares around her ileostomy. When she is anxious she is unable to manage herself. Personal hygiene - husband reports she is not as fussy as she used to be especially around washing her hands. Will use only water and not soap and husband is now trying Sterilising Gel instead. She will use soap and hair spray on her toothbrush rather than toothpaste and requires supervision for cares.

Dressing upper and lower body - independent with dressing though needs supervision to choose clothing.

Walking/locomotion - independent and steady.

Toilet transfer and use - independent with transfers though needs supervision with use. Has an ileostomy and needs supervision with this. Bed mobility - independent. Eating - supervision needed. No falls. Shortness of Breath on climbing stairs and ? anxiety. Husband reports that different memories get muddled into one day. No hallucinations Client X reports that she had great difficulty sleeping and he will give her 3.25mg Zopiclone some nights.

Write a case study on an older adult with mental illness or mental health issues, who you have recently cared for.  Your case study should include all key clinical data such as history; diagnosis(es), medications, treatment and care provided and an evaluation of care.  Your case study should demonstrate advanced nursing practice that includes skills in assessment, therapeutic engagement, diagnostic frameworks and care planning inclusive of the socio-cultural perspective.

Write a critical reflective account of the clinical case study discussing some of the issues, concerns, you encountered when caring for this patient.  Use research evidence and related literature to develop your discussion.

Setting

Diagnosis- The case study encompasses a 72 year old woman X (pseudonym), who lives with her husband and grandson. Recent reports from her husband suggests that she often fails to find appropriate words while speaking and also misplaces objects, accompanied with paranoia. Some of her presenting complaints include rearranging things and washing them several times, showing persistent depressed mood and negative response to her medications. Reports from her husband also suggests that she has recently resorted to behaviour that make her inflict self-harm. Lack of comfortable relationship with her children and grandchildren have made her more frustrated and anxious in recent times, concomitant with getting upset and irritated. Although the client used to enjoy her walks earlier, she does not engage herself in such activity in recent times. Loss of contact with the community members have directly resulted in her social isolation and made her depressed. This is accompanied by need of supervision for selecting clothes and toilet transfer. Following retrieval of a vast information about the client, her medical history and presenting complaints, she has been diagnosed with dementia. Dementia diagnosis was done with the use of Addenbrooke's Cognitive Examination III, a tool that aims to evaluate the neuropsychological state of an individual. An MRI and CT scan was performed, following which presence of symmetrical atrophy in the frontal lobe determine the presence of dementia in the patient. Thus, atrophy along with focal lobar predominance helped in narrowing down the condition to the specific neurodegenerative disease. This screening test has been validated for use in dementia diagnosis and determines several aspects of cognitive functioning that encompass language, fluency, attention, memory and visuospatial functions (Noone, 2015).

This test was conducted as per the guidelines provided in the framework for dementia care, New Zealand that focuses on the need of conducting a cognitive assessment with the use of validated screening tools (Ministry of Health, 2013). Sum of the items that a patient X scored in each of the five domains was 42/100. Research evidences suggest that a cut off score of 82-88/100 is considered appropriate for the diagnosis of dementia in patients being administered the screening tool (Hsieh et al., 2015). Thus, an analysis of the patient scores and reports from her husband suggested that she did not meet the cut-off for confirmed dementia diagnosis. Deficiency of vitamin B12 has often been associated with neurological disorders and anaemia (Stabler, 2013). Furthermore, the kidneys perform the function of absorbing vitamin B12, in addition to other vitamins, Moreover, people suffering from chronic renal disorders are also found at a higher risks of B12 deficiency (Kozyraki & Cases, 2013). Thus, low B12 levels acted as an indicator for the presence of chronic renal disease. Lithium is a medication, commonly used for treating people suffering from mental disorders. Long-term use of lithium interferes with the functioning of the kidneys and results in acute or chronic kidney disease (Kessing et al., 2015). The diagnostic tests confirmed the stage 4 lithium associated CKD in X, which in turn can be accounted for the presence of urinary tract infections. Positive results for bipolar affective disorder tests also illustrate the fact that the patient often experiences isolating, frightening and debilitating experiences, as validated by her husband’s reports. This psychological illness contributes to her frequent mood swings. Diagnostic tests also reveal hypertension, Colectomy with Ileostomy and migraines, all of which suggest that she requires a comprehensive care planning. Obtaining health related histories and conducting comprehensive physical assessments of a patient is imperative for gaining a sound understanding of the functional, psychosocial and physical status of the client (Munroe et al., 2013). Thus, the laboratory results and diagnostic tests were interpreted in a manner that facilitates delivery of optimal care services to the patient.

Diagnosis and Medications

Medications- The patient X is currently on a medication of diazepam and amitriptyline. Belonging to the family of benzodiazepines, diazepam has been administered with the aim of bringing about a calming effect in the patient, due to her frequent mood alterations. This drug acts as the mainstay treatment in anxiety, seizures, muscle spasms and alcohol withdrawal syndrome. The anxiety relieving effects of the drug works by acting in specific GABA receptors in the brain that result in the subsequent release of GABA neurotransmitters (Ravenelle et al., 2014). GABA neurotransmitters acts as natural nerve calming agents and help in maintain balance in neuronal activity, thereby inducing sleepiness, relaxing the muscles and reducing anxiety symptoms. The fact that X reports sleeping difficulties and an increase in anxiety and frustration might be considered as the primary reasons for prescribing diazepam. Her migraine problems are treated with the administration of amitriptyline that belongs to the class of tricyclic antidepressants (TCA). In addition to migraine, the drug has also been found effective in the treatment of depressive, bipolar and anxiety disorders. The drug acts on SNRI by creating moderate impacts on the norepinephrine transporters (Powers et al., 2013). It directly acts to inhibit re-uptake of serotonin and norepinephrine by presynaptic neuronal membrane in CNS, thereby elevating their synaptic concentration.

Furthermore, paroxetine and carbamazepine are also administered to the patient. Administration of paroxetine can be attributed to its role on treating depression, anxiety, obsessive compulsive disorders, and panic attacks (Stidd et al., 2013). This selective serotonin reuptake inhibitor binds to the allosteric regions of serotonin transports and inhibit norepinephrine reuptake. Furthermore, carbamazepine has been prescribed with the intent of treating bipolar disorder. This sodium channel blocker preferentially binds to voltage-gated Na⁺ channels in an inactive state, thereby preventing the sustained and repetitive firing of action potentials (Yatham et al., 2013). Thus, it can be stated that the medical history and presenting complaints of the patient X have been taken into consideration before prescribing proper medications.

Treatment- Therapeutic engagement refers to the endeavor that allows patients to participate in activities that enhance the overall sense of wellbeing and also promote the cognitive, physical and emotional health of the service user. In addition, caring for this patient X, suffering from bipolar disorder encompassed taking steps that are able to maintain optimal psychosocial and cognitive health, by creating provisions for connections, which in turn activated the brain abilities. The rationale for selecting therapeutic engagement with the client is the fact that it occupies a fundamental place in advanced nursing practice and the makes oneself accountable for the role of a practitioner (McAndrew et al., 2014). Effective communication with the client provided the opportunity to better know the patient and also simplified the development of a therapeutic relationship. This acted as the foundation for an operative nurse -patient relationship (Fager & Burnfield, 2014). Absence of clear communication makes it difficult to provide optimal care, make decisions, ensure client safety and offer comfort. Cognitive stimulation therapy was selected as an appropriate intervention for the patient. The therapy was implemented as a part of her day care program and was conducted by an occupational therapist and a nursing professional over several weeks in order to improve her higher mental faculties. This therapy is usually applied among individuals suffering from mild to moderate forms of dementia. The therapy involved 14 sessions comprised of themed activities, conducted bi-weekly. The aim of engaging the patient in CST was to actively stimulate her, while delivering an optimal learning environment that includes social benefits of a group (Orrell et al., 2014). The sessions covered different topics and were conducted with the objective of improving X’s memory and mental abilities. Evidences have established the benefits of CST, when compared to dementia drug treatments (Aguirre et al., 2013).

Therapeutic Engagement

Additionally, each group comprised of 5-8 people and was carried out in the day centre, under the guidance of a trained professional. Some of the topics that were presented in the sessions include food, childhood, current affairs, and monetary transactions. Efforts were taken to provide a supportive atmosphere where the patient was made to conduct the activities, which stimulated multi-sensory experiences. CST was an effective strategy in enhancing higher mental faculties and also creates significant effects on skills associated with language such as, comprehension, word-finding and naming. The treatment programs also encompassed weekly walking support. Longevity has been found to create negative impacts on the mobility of older person and rehabilitation interventions often have the potential of holding back rates of functional decline, thereby preventing the mobility of older patients (Rosso et al., 2013). Thus, the walking support program acted as a major step that contributed to the procedure of maintaining mobility of X. All efforts were taken to maintain safety of the patient and prevent all forms of unintended injuries and harms. The treatment took into consideration the fact that older adults staying active and successful in maintaining their functional abilities have enhanced quality of life. Functional abilities commonly encompass self-care activity performance, and are also governed by the capability of the affected individual to mobilise. Thus, the walking support program was initiated with the aim of assisting the patient X to walk, stand, change position, move or sit.

This structured rehabilitation program had the capacity of preventing the deterioration in mobility. Thus, the weekly walks with support was advantageous to the wellbeing of the patient and enabled her to get mobilised on a regular basis. Furthermore, the role of personal care assistants or caregivers encompass providing aid to patients who are ill, fragile, and physically or mental disabled (Griffiths et al., 2013). In other words, the past medical history and presenting complaints of X were considered to provide her assistance in regular small and big tasks. Assistance was provided to her to help with activities that involved bathing, dressing, and medication administration, transferring in and out of the bed, physical therapy, medication appointments and meals. This was facilitated by learning about the patient diagnosis to understand about the illnesses she was suffering from.

Care provided- Adoption of a logical and rational approach helped in understanding the health situation prevalent in the current scenario and also enhanced a sense of appropriateness for compliance to the medications, and treatment options. Communication problems were one of the most upsetting aspects encountered while caring for the patient. Aggression in the patient was typically triggered due to environmental factors, poor communication or physical discomfort (Mondimore, 2014). Thus, the care planning strategy involved evaluation of the cause that resulted in aggression and anxiety in the patient. The primary role of the caregiver was to engage in a therapeutic conversation to eliminate the event the resulted in the onset of aggression. Deterioration of the neuronal cells also contribute to poor judgment or thinking errors in patients with bipolar disorder. Thus, the extent of the diagnosed problems were assessed in order to identify the strengths and weaknesses of the patient, thereby resulting in the formulation of the caregiving journey. Incorporating the practices and beliefs of the patient while providing care services helped in the recognition of cultural issues that might have created an impact on the way by which X accepted the psychiatric diagnosis. Furthermore, the cultural background of the client was also respected to provide care that was individualised for the patient X and was true to her needs.

Care Provided

Adequate attention was provided to the nutrient and caloric intake of the patient while providing her help in meal assistance. The major tasks comprised of bringing lunch and dinner trays to the patient, while facilitating an engaging conversation. Nutritious and regular meals often pose challenges to older patients with dementia, or bipolar disorder. A decline in cognitive function was found to create an overwhelming sense that directly resulted in forgetting to eat or problems with eating utensils. This food assistance program was implemented with the aim of maintaining and facilitating oral drink and food intake, hydration and nutrition status in the patient (Young et al., 2013). Thus, the aim of the meal assistance to conduct mealtimes at ease was effortlessly accomplished. Daily personal care for the old patient encompassed grooming, bathing and hygiene that directly exert an impact on the way a person feels about personal appearance. A good level of hygiene was maintained for ensuring the wellbeing of the patient. Attending to the toileting needs and providing assistance regarding medication intake also greatly helped the patient in her daily living. The prescribed medications were administered to the client in order to prevent any errors or non-compliance. The patient was involved in the process in the maximum way and complete attention was given to adhere to appropriate medication reconciliation processes. Additionally, assisting X in getting dressed for the day also formed an essential component of caregiving. All possible efforts were taken to ensure maintenance of dignity of the patient by empowering her and promoting her independence.

My clinical expertise and the knowledge gained over the years have helped me realize that nursing professionals are imperative in providing care to older people. We nurses are at the forefront of healthcare services and need to demonstrate necessary expertise and skills while caring for older people. While caring for the patient X, I intended to fulfil the special requirements and needs that were exclusive to the patient. I took into consideration the fact that older patients need assistance with daily living activities, which in turn increases their risk of losing independence. One major challenge that is generally encountered is patient safety. This can be attributed to the fact that elderly patients are more vulnerable to medication errors (Metsälä & Vaherkoski, 2014). Such preventable adverse did not occur in any instance due since there was no unknown drug reaction in the patient, upon administration of the prescribed medications. Evidences have established the fact that frailty in older people acts as a biologic syndrome of reduce resistance to a range of stressors that lead to cumulative decline in the physiologic system and causes vulnerability to adverse health outcomes (Joseph et al., 2014). Increased tendency for medication errors has also been recognised as a major indicator that associates frailty with mortality (Kwan et al., 2013). However, the client did not pose any such challenges in treatment.

The initial behavioural and psychological symptoms presented by the client comprised of agitation and mood disorders. I tried to counteract the problem by adopting a person-centred care approach where I attempted to obtain a sound understanding of her behaviour by facilitating effective communication to find solutions to the problem. Showing respect towards the functional status and dignity of the client proved successful in meeting her preferences and demands. Implementation of the cognitive behavioural therapy, assistance with meals and proper medication administration showed significant positive impacts on the overall health and wellbeing of the patient. The benefits were observed few weeks after beginning the treatment and showed that the patient had significantly improved in her cognitive functioning skills, as evident through the results of the Mini-Mental State Examination. She showed remarkable improvements in her visuospatial abilities and language skills, thereby enhancing her quality of life. Her responses suggested that she had positive experiences in the non-threatening and supportive environment and showed an improvement in her concentration, mood and confidence. Data reports suggest that prescription of more than three drugs are quite prevalent in the elderly that directly interferes with their memory (Hwang et al., 2013). Medication adherence is a common issue encountered in dementia care, where administration of multiple drugs for the health disorders present problems. However, the patient did not create the most common challenges associated with forgetting about drug intake, and showed strict adherence to the medication schedules. However, X showed complete compliance to the prescribed medications and the therapy.

Issues and Concerns

I tried to adopt meaningful communication style to unravel the reasons that made her miss her medication doses. While caring for the patient, I also received complete support from her and her family members that created a positive impact on her health. Assisting her in the daily activities of living such as, bathing, eating and dressing gradually became easy, with time. I tried to educate her family members and support workers on the necessity of promoting patient independence and also encouraged X in her efforts of upholding independence for a longer time. Positive impacts of the interventions resulted in a positive experience that helped in maintaining the health and safety of the patient, whilst promoting her independence. She was progressively able to conduct some of the activities of daily living without much assistance such as, feeding and dressing. This in turn acted beneficial in alleviating stress of the family members. I was responsible for assessing and coordinating care of the client. I designed the interventions and care plan in a way that was able to meet the individual needs of the client, in addition to prioritising prevention of further decline in cognitive capabilities and supporting her independence at her home. I took all possible efforts to identify the preferences and needs of the client in order to optimise the carer’s support and outcome of the recipient. I ensured that all interventions matched those suggested or preferred by the support workers and also reviewed the services in an annual basis. Upon observing a sudden deterioration in the mobility function of the client, I immediately made a referral to a physiotherapist and the in-charge of the cognitive stimulation therapy program, for assessing the patient.

While working independently to coordinate care for the client, I ensured that all services and providers such as, the geriatrician, physiotherapist and coordinators of the day care program worked together in an integrated manner. This greatly improved the service and quality value by well ensuring that all clients gain an advantage from precise mix of health and allied care services that are available.

References

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