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Slowing the progression?

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VOL: 97, ISSUE: 42, PAGE NO: 36

Tony Bush, RMN, is a staff nurse, Ty Bryn Ward, Maindiff Court Hospital, Abergavenny, Monmouthshire

Jan Holmes, RMN, is sister, Ty Bryn Ward, Maindiff Court Hospital, Abergavenny, Monmouthshire

This study aimed to evaluate the effectiveness of the nursing care given to patients with dementia in an elderly mentally ill (EMI) assessment ward by comparing skills function/deficit scores on admission with those on discharge. In effect, it compared the assessment of patients in physical, psychological and social terms on admission and at the point of discharge.

This study aimed to evaluate the effectiveness of the nursing care given to patients with dementia in an elderly mentally ill (EMI) assessment ward by comparing skills function/deficit scores on admission with those on discharge. In effect, it compared the assessment of patients in physical, psychological and social terms on admission and at the point of discharge.

Background
Traditional definitions of dementia tend to include the term 'organic brain disease' and strongly link the condition with ageing. Stokes and Holden (1990) see dementia as a collection of signs and symptoms that require further investigation rather than as a disease in its own right.

However, Kitwood (1997) acknowledges the 'overwhelming organicity' of the condition but believes that the focus on signs and symptoms is to the detriment of 'personhood' - the standing or status bestowed on one human by another.

Dementia has a physical, psychological and social impact on patients, disrupting the activities of daily living. Physical dependency on others for basic daily tasks (such as washing, bathing, dressing and eating) is increased, and psychological, behavioural and social disturbances are serious accompanying factors. Confusion, disinhibition, aggression, memory dysfunction and personality changes can severely impair a person's everyday existence and an inability to function effectively on a social basis is common.

Nursing assessment of patients' needs is crucial to providing individual care. Woods (1999) stresses the importance of holistic assessment, and the need to identify patients' strengths as well as needs. Those strengths can then be used in care plans as a method of meeting needs.

Links can be identified between confusion, accompanying symptomatic disorientation and behavioural disturbances, such as aggression, in people who have dementia. Confusion and disorientation often result in restlessness, agitation and wandering, while lack of insight may lead to patients putting themselves in potentially dangerous situations.

Cheston (1998) comments on the paucity of research evidence to support the prioritisation of psychotherapeutic work with people who have dementia, and Woods (1999) concludes that the psychological assessment of older people is preoccupied with differential diagnosis between depression and dementia.

The World Health Organization (1996) lists numerous symptoms prevalent in dementia that are likely to cause social impairment, such as disturbances of memory, thinking, orientation, comprehension (understanding), calculation, learning capacity, language, judgement, emotional control, social behaviour and motivation. Both verbal and non-verbal communication can be disrupted to progressively severe degrees. Disinhibition, aggression and lack of motivation with regard to social contact and recreation may all result in social isolation, which can be compounded by physical factors such as frailty. Diminished sensory ability and auditory and visual impairment can also have a significant impact.

Walsh (1998) emphasises that nurses should change their practice in a mutually supportive and empowering way that involves honest and critical reflection. To improve care, they need to evaluate the effects of what they do.

Methodology
The tool of data collection used in this study is an EMI ward assessment protocol devised by nurses to assess patients' needs on admission and evaluate outcomes of care and treatment on discharge. The protocol covers a range of areas (Box 1).

Questions on each key component are attributed scores on a Likert scale (Yes = 0; Sometimes = 1; No = 2). The higher the scores, the greater a patient's skill or function deficit in a particular area. The combined scores represent an overall picture of the degree of impairment or capability, which provides a 'health index' (McDowell and Newell, 1987) for the patient.

Some key components include 'special information' sections and all have a brief comments section, allowing the assessor to support the decision to tick a particular box. Comments are optional.

The assessment is divided into three stages:

- Preliminary - completed by the referring or contact agent (community psychiatric nurse, social worker);

- Core - completed by the named nurse, who will also plan the patient's care;

- Evaluatory (final) - completed by the named nurse on discharge.

For the purpose of this study, only the core and evaluatory assessments were used for data collection. There were two reasons for this. First, the study sought to evaluate the effectiveness of dementia care in a ward environment and, second, contact agents and community teams completed preliminary assessments for only 5% of patients referred for admission in the one-year period studied.

The assessment was developed from a version used in 1995-1998, the use of which declined markedly. When nurses were asked their opinions of the assessment, their comments suggested that it was unwieldy, time-consuming, inaccurate and unhelpful when planning care. This feedback resulted in the development of the current format, which is more streamlined, accurate and appropriate to the needs of both nurses and, more importantly, people with dementia.

This convenience sample included 33 men and 33 women who were admitted in the year from September 1998. All were 65 or over and had been diagnosed as having Alzheimer's disease or related dementia. All had core and evaluatory assessments and all were informal patients (not detained on a section of the Mental Health Act 1983). They appeared to be a representative sample of people with dementia.

The five nurse assessors were all RMNs.

Patients with dementia are vulnerable and special consideration must be given to the integrity of any research in which they are involved. Their dignity and human rights were maintained at all times and the avoidance of harm was considered a priority. To maintain confidentiality, patients' names and personal details were not used.

Results
Overall total scores for both men and women on admission and discharge were calculated (Fig 1). As a group, men were slightly physically deteriorated or less able on discharge (average 2.5% deterioration). There was a more significant physical improvement among women (average 8.5% improvement). Psychologically, both groups showed improvement, men by an average of 11% and women by an average of 9%. Socially, women showed an average improvement of 5% while little improvement was indicated in men, with an average of 0.5%.

Physically, men improved in the areas of mobility, respiratory function, diet and fluid intake, auditory function, visual function, dressing, personal safety and sleep pattern. Hygiene skills, urinary and faecal continence and skin care showed noticeable deterioration.

Women improved in mobility, diet and fluid intake, auditory function, hygiene, dressing, sleep pattern, personal safety, skin care and cardiac function. Areas of deterioration were respiratory function, visual function and urinary and faecal continence.

In psychological terms, men improved in all areas except comprehension, memory and orientation. Women showed a comparable overall improvement, except in memory and orientation. A negligible increase in aggressive behaviour was noted.

Socially, men showed slight improvements in all areas apart from verbal communication, interaction and external social contact. Women improved in all areas except external social contact.

Discussion
Although our results seem to indicate no dramatic improvements as a general outcome of receiving nursing care on the ward, they do not indicate a significant level of deterioration either. Perhaps this is the most surprising finding, considering that dementia is by nature a progressive illness, perhaps severe enough in the latter stages to be classified as terminal.

Most patients admitted to the ward have already been diagnosed and have been living in the community for some time. They are elderly, often physically frail and sometimes have multiple physical pathology. A 1999 survey found that the average length of stay on the ward was 86.7 days. Despite the absence of clear improvements, nursing care may have helped to prevent serious deterioration.

The mobility of women was poorer on admission than that of men but improved more clearly by discharge. Nursing intervention in the form of encouraging and supporting patients in walking, helping them to use walking aids correctly and referring to physiotherapy and podiatry might have been influential. Increased physiotherapy input may bring further improvements.

There was a slight improvement in respiratory function in men but some deterioration in women. Considering the high incidence of patients who were former miners or smokers and already had respiratory problems, this is perhaps to be expected. Again, increased therapeutic exercise and physiotherapy input might help.

Minor positive changes in diet and fluid intake were noted in both men and women. On admission, women were assessed as having greater dietary problems and showed little improvement during their stay. It may be useful to consider whether nurses intervene often enough to feed patients who cannot feed themselves and encourage all to eat sufficient amounts. Should referrals to the dietetic services be more widespread and the prescription and administration of dietary supplements more common?

With regard to general hygiene, women improved slightly but men showed a slight deterioration. However, levels of urinary and faecal incontinence increased notably in both groups.

It would be useful to investigate whether nurses devote more time to helping women with their hygiene needs than men. The issue of how soon continence products, such as pads and sheaths, are used might also have some bearing. There may be a tendency to act too quickly, which could inadvertently encourage continence problems.

Skin care noticeably improved in women, but showed a marked deterioration in men. Do nurses help men with washing, drying and changing to the same degree as women after episodes of incontinence? Is enough time allocated to supporting patients' attempts to care for their personal hygiene needs independently?

Dressing capabilities improved marginally in both groups. The implementation of dressing assessments and greater emphasis on helping patients to relearn basic self-care skills might result in improvement.

Disturbed sleep pattern was a significant problem for women on admission, but much less so for men. The introduction of night sedation and the fact that nurses encourage patients to remain awake during the day may explain the improvement shown in women.

Personal safety was seen as a bigger problem for women on admission and was noticeably better on discharge. It was less of a problem for men and therefore less improved on discharge. In a controlled nursing environment, where physical risks are minimised and staff are present, this seems a reasonable outcome to expect.

In psychological terms, men improved in all areas apart from comprehension, memory and orientation. Women also deteriorated in both memory and orientation, and their behaviour was seen as less acceptable to others, despite an increase in comprehension. Theoretically, they could have gained a better understanding of their situation, liked it less as a result and become more resistive or disturbed.

Conclusion
The results of this study should be interpreted in the context of a number of important considerations. These include the progressive nature of dementia, the fact that most patients are elderly, often physically frail and spend long periods in hospital, and the fact that wards with high patient numbers and low staff-to-patient ratios are the norm in dementia care. Against this background, the nursing care of people with dementia on this ward appears to be effective in helping to prevent dramatic physical, psychological and social deterioration.

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