• Age – 85yrs
• Sex – Female
• Diagnosis – Alzheimer disease

The purpose of the presentation is to discuss and outline

• The potential impact of aging on the psychological health of an individual
• Defining dementia and distinguishing between the presentations of common dementia
• The legal and ethical issues surrounding people with dementia

It should be noted that all names of individuals and places in this report have been changed in order to protect the patients’ confidentiality (Nursing & midwifery council 2009).Therefore the patient will be known as Mrs.Brown.Mrs Brown is an 86 year old lady who lives with her elderly husband. According to Mrs Brown husband they have two sons together and 3 grandchildren, they both visit occasionally. She used to work as a secretary until she retired in her early 60s.She clearly had a good memory. She enjoyed travelling abroad, with her husband .For many years she had attended services at the local church where she was well known .as a kind, warm-hearted popular lady in her town for the good things she did.Mrs Brown clinical notes written by her community mental health nurse states that she was diagnosed with dementia the Alzheimer disease 12 years ago. Alzheimer’s is a brain disease that causes problems with memory, thinking and behaviour. Symptoms usually develop slowly and get worse over time, becoming severe enough to interfere with daily tasks (online www.alz.org/alzheimers_disease 21/02/11).Her husband has been her main carer ever since. She attends a day centre once a week and has carers coming in twice a week to assist with personal care. The staff at the day centre has also reported that Mrs Brown now showed no interest and was reluctant to comply with activities which showed that she had lost sense of pleasure.

Mr Brown stated that before the diagnosis, they were several episodes when she got lost and was picked up by police to be returned at home.Mrs Brown become disorientated about where she was because of her dementia. She became confused about time. She will also miss her doctor’s appointments .Mrs Brown couldn’t even remember her son’s names later on recognise her husband and would lose track of conversations.Mr Brown stated that he made an appointment then to see the general practitioner (GP) who then referred them to the memory clinic where she was diagnosed with Alzheimer.

In the last year Mrs Brown mental and physical health has deteriorated rapidly. She can no longer do her activities of daily living and she needs support with personal care. Her behaviour has gradually become more and more eccentric that her husband is no longer copying.Mrs Brown was recently admitted to hospital with chest and urinary tract infection, which would also increase her level of confusion and lack of orientation (Adams 2008).Although now discharged from hospital Mrs Brown’s sleep pattern was disturbed, she now wanders around at night.

She has become more physical and verbally aggressive towards her husband, Mr Brown has raised concerns’ that he can no longer cope with her behaviours to her CPN.The community mental health team have been monitoring Mrs Brown condition for some time now and liaising with the family, GP, social worker and psychiatrist regarding her care and support as required by the Department of health (DOH 2001), in relation to older people (over 65yrs) with mental disorder.Mr Brown was considering looking for permanent placement in a nursing home for his wife.

Mrs Brown was prescribed the following for her dementia

Donepezil hydrochloride/Aricept 10 mg once daily at bedtime: is a reversible inhibitor of acetylcholinesterase.They are for the adjunctive treatment of moderate Alzheimer’s disease. Like all other medication donepezil has its side effects which are nausea,vomiting,anorexia,diarrhoea,insomnia,dizziness and agitation just to mention a few.(Source :British National Formulary 2007)

There is currently no cure for Alzheimer’s disease. However, they are some drug treatments are available that can ameliorate the symptoms or slow down the disease progression in some people such as donepezil, Exelon ,reminyl and galantamine these drugs maintain the supplies of the acetylcholine

The (National Institute for Health and Clinical Excellence: NICE 2011) available online, states that these drugs are recommended as an option for people in the mild-to-moderate stages of Alzheimer’s disease.

Older person presentation

Dementia “is the general term used for diseases affecting the brain, including Alzheimer’s disease it is characterised by progressive cognitive impairment and the emotional and behavioural problems that result from the cognitive decline” (Sungaila & Crockett,1993 citied in Tappen,R 1997).

There are many different types of dementia although some are far more common than others. They are often named according to the condition that has caused the dementia. They are Alzheimer disease which is the most common cause, followed by the vascular dementia, dementia with lewy bodies and fronto temporal dementia these are the common ones.

To rule out that someone has dementia test has to be carried out .Winter (et al 2001) states that there are different illnesses that appear to affect the brain in ways that can cause symptoms similar to dementia. Winter (et al 2001) describes these as people with underactive thyroid gland, deficiencies of certain vitamins and general physical illness can give rise to symptoms of dementia, poor concentration and poor memory

ln the case study Mrs Brown was diagnosed with Alzheimer’s below the author describes what Alzheimer is and its features which lead to the diagnosis.

Miriam (1994) describes Alzheimer’s disease as a brain disease accompanied by characteristics microscopic structural changes in the brain tissue leading to the death of brain cells.lt is the most common cause of dementia in the UK.

The first signs of Alzheimer’s disease include lapses in memory and problems with finding the right words (Alzheimer society available on line)

.In normal ageing memory lapse are common as we get older. Also the person mood changes: Particularly as the parts of the brain that control emotion becomes affected by disease. Memory loss is the most common potential impact on the psychological ageing. Remembering everyday tasks becomes a chore.

People with dementia may also feel sad, frightened or angry about what is happening to them.

The person with Alzheimer’s may start to have communication problems like inability to recall names quickly, decline in co-ordination and control of speech and action.

Feeling and becoming lost in familiar surroundings. Some of these symptoms where noticed in Mrs. Brown.

Depression is other symptom for dementia (Tappen R, 1997) states that many individuals in the early stages of Alzheimer’s disease are also clinically depressed. Some of the behavior exhibited by Mrs. Brown may have been caused by that she was depressed.

Some of these features led to the diagnosis that Mrs Brown was suffering from Alzheimer as she was exhibiting these problems. Once a diagnosis of dementia has been made, the next stage will be to assess its cause.Mrs Brown had a series of tests and examination to exclude disease in the rest of the body and to rule out some other brain conditions. The person’s memory will be assessed, initially with questions about recent events and past memories. Given these problems Mrs Brown was exhibiting, and the in-put from the community nurse it was agreed that she required further assessment to determine her level of cognitive impairment. This was done by using the mini mental state examination (MMSE) developed by Folstein et al (1975), with consent; Mrs Brown scored 12, which indicated severe cognitive impairment. According to Miller (1999) to examine specific cognitive impairment a Mini Mental state examination is used .The National institute of health and clinical excellence (2011) recommends that this tool be used for determining a person’s suitability for the anti-dementia drugs such as Aricept which was prescribed to Mrs Brown.Aronson M,k (1994) suggests that it is appropriate to include a short list of complete blood count, vitamin B12 level, thyroid function test and brain scan as MMSE may not offer clues to their presences.

A brain scan may be carried out to give some clues about the changes taking place in the person’s brain. There are a number of different types of scan, including computerized tomography (CT) and magnetic resonance imaging (MRI).

Vascular dementia

Alzheimer society (2010) describes vascular dementia as a type of dementia caused by problems in the supply of blood to the brain. There are two main types of vascular dementia: one caused by stroke and one caused by small vessel disease. It is the second most common form of dementia The risk factors associated with Vascular dementia, as indicated ,are those associated with cardiovascular disease and include

High blood pressure

Diabetes

Deficiencies of certain vitamins

High cholesterol levels

Dieses in arteries elsewhere in the body and rhythm abnormalities

(Soucers: Martin 1998, Gould 2002, Taylor 2006).

People with Vascular dementia may experience these symptoms

problems concentrating and communicating

depression accompanying the dementia

symptoms of stroke, such as physical weakness or paralysis

epileptic seizures

Periods of acute confusion

hallucinations (seeing things that do not exist)

delusions (believing things that are not true)

physical or verbal aggression

restlessness

Incontinence.

Dementia with Lewy bodies

Dementia with Lewy bodies (DLB) is a form of dementia that shares characteristics with both Alzheimer’s and Parkinson’s diseases

Person with lewy bodies may have these symptoms

A person with DLB will usually have some of the symptoms of Alzheimer’s and Parkinson’s diseases.

fall asleep very easily by day, and have restless, disturbed nights with confusion, nightmares and hallucinations

Faint, fall, or have ‘funny turns’.

(Source: Alzheimer society 2010)

Legal and ethical issues surrounding people with dementia

Dementia raises difficult ethical issues for people with dementia, for their formal and informal carer and for society in general. Formal carers are paid and trained to perform their caring role; those involved in Mrs Brown care were GP, community mental health nurse, and social worker. Informal carers’ usually is provided by family and in Mrs Brown case it was her husband and children.

Tappen R (1997) states that ethical issues include the often painful decisions that must be made about restrictions on freedom, or end of life decisions and the legal issues include patients’ rights, abuse, neglect and incapacity.

Myron F and Wiener M (2004) suggested that legal issues are best addressed while patients still have the capacity to understand and communicate while ethical issues begin at the time of diagnosis and may include whether to tell patients about their diagnosis.

The key pieces of legislation surrounding people with dementia

The Mental health Act 1983 amended 2007:-it protects the rights of people who have been assessed as having mental disorder including dementia.lf a person with dementia is behaving in a way that is risking other and his/her health can be detained in hospital using this act.

The Mental capacity act 2005 (implemented 2007) – designed to protect people who can’t make decisions for themselves or lack the mental capacity to do so.Recognised that in some circumstances ,being placed in a hospital or care home may deprive someone of their liberty.

Deprivation of liberty safeguards code of practice (2008)-DOLS in practice provide guidance for professionals involved in administering and delivering the safeguards. The Code is also intended to provide information for people who are, or could become, subject to the deprivation of liberty safeguards, and for their families, friends and carers, as well as for anyone who believes that someone is being deprived of their liberty unlawfully (department of health online).

Before Mrs Brown dementia became severe, when she still had capacity, they had sat down with his husband .They discussed about future plan on what to do with everything including her care.Mrs Brown choose her husband to be her durable power of attorney for all her health care needs and property. Myron F & Weiner, M (2005) states that with appropriate durable power of attorney, Mrs Brown’s husband can consent to her medical care, but the patients wishes if known, must be respected.

Mrs Brown capacity was limited to live independently or make her own choices, inorder to respect her autonomy her husband and family were involved in taking active steps to act as advocates and to try and promote her autonomy.

As Mrs Brown diagnosis was early she and her family had time to plan about her preferences on treatment and facilitate support from community organisation.Mrs Brown was treated or care for justly by everyone involved in her care. Everyone worked together to create an environment that is safe, sustaining her dignity and optimizing opportunities for independent decision making and functioning.

Ethical problems carers

Balancing risks and freedom

Avoiding telling the truth to prevent distress

How to manage conflict between caring for the person with dementia and other commitments.

Those caring for people with dementia face ethical problems in caring out day to day care, these problems are important and stressful, those providing care receive little support and providing such support will improve good dementia care.

Conclusion