How Dementia Stages Impact Nursing in Long Term Care

Authored by: Barbie Moore, RN

In a world of medical model institutions the opportunity for a nurse to identify and embrace a Resident's specific dementia stage is not always the easiest path to follow. In fact, many times the dementia specific nursing path is so covered with the brush and overgrowth of the traditional medical model it is not even visible to the busy nurse passing his/her medications, recording physician orders, and trying to survive the shift in general.

Therefore, it is necessary for nurses to first have a vision and belief that there is a better way to care for the seniors we serve and to establish that we, and the Residents, are capable of more than surviving or existing through the shift.

Recognition and knowledge of the specific hallmarks within each dementia stage enables nurses to again celebrate the Resident and the abilities that remain beyond the diagnoses.

This facilitates the ability to:

Define a plan of care specific to the Resident Supervise the care team and families to provide care/assistance at the just right fit To proactively address high risk areas to facilitate better outcomes

When nurses embrace and understand specific dementia stages, this serves as a roadmap to care with the Resident and their remaining abilities, becoming the focus of the journey.

Nurses become nurses to provide care and promote well-being. Through defining a Resident's specific dementia stage nurses can see abilities where disabilities would previously dominate the nursing perspective. When nurses are trained to assess Resident abilities that remain at every dementia stage it is possible to celebrate all that is right with the Resident. Knowledge of the abilities that remain within each Resident offers the hope that ignites the compassion and caring that drove most nurses to select an occupation to serve seniors.

Ironically through recognition of Resident abilities, outlined by the Adapted FAST (and/or Allen Assessments), nurses also gain a positive perspective, a sense of their

own abilities, and purpose to foster the well-being of Residents. It is around the defined, predictable Resident abilities within each dementia stage that the nursing team can develop successful interventions. Nurses gain the expertise to design a Resident specific care plan that is truly individualized only when they possess an understanding of dementia stages. The Adapted FAST tool and related abilities-based dementia training provides the missing link for nurses and families to provide care that takes advantage of the Resident's remaining abilities.

For example, nurses and care partners (CNA's) with knowledge of dementia stages would be aware that a Resident functioning within Adapted FAST 6/Allen Level 3 has the core remaining ability to follow a one step instruction. The care plan and approaches would recognize this fundamental remaining ability to enable this resident to perform at the highest ability possible. A plan of care that is individualized to the Resident and accurately represents cognitive level, replaces typical paper compliance care plans by offering a defined roadmap for successful care.

Nursing teams that gain expertise in dementia stages replace their all too common, trial and error approach for workable interventions with abilities driven, proactive approaches that promote the Resident's best ability to function and safety at every stage of dementia. Nurses, specifically, utilize expertise with dementia stages to supervise and lead care teams to provide the just right fit for achieving the Resident's best ability during ADL and leisure activities. Knowledge of dementia stages enables a nurse to identify areas of high risk so that intervention plans can be in place before the problem occurs. Knowledge of hallmark abilities and characteristics of dementia allow nurses and supervisors to conduct simple quality assurance audits during every observation and Resident interaction.

EXAMPLE: A nurse is in the midst of passing medication to a Resident in the dining room who is functioning within Adapted FAST 6/Allen level 3 and recognizes a CNA providing too much hands-on assist for eating and drinking. The nurse who is schooled in dementia stages will recognize the opportunity to educate this CNA about the fact

that a person functioning within Adapted FAST 6/Allen level 3 possesses a remaining ability to grasp familiar objects, including utensils. The Resident in this example will perform best and likely eat better with simple one step verbal, visual and/or tactile instructions. This will promote the Resident to dine with support, rather than total assist and to reduce the risk for weight loss and aspiration pneumonia.

Recognition of a Resident's best ability to function within their specific dementia stage also allows for improved time management by guiding the team to support, rather than do for the Resident. Team assignments can be more time sensitive by balancing responsibility for Residents that need set up help with those that require one to one support. In addition, it is easier to instruct the care team and family of changes in condition which should be reported to their supervisor or physician when the expectation of the Resident's best ability to perform is objectively defined by the dementia stage.

Overall, dementia staging offers nursing teams the unique opportunity to see the PERSON rather than the diagnoses. As a result we are able to see what is right with the Resident, design a care plan reflective of the person, and direct our care team of interventions to celebrate and respect the remaining abilities defined within each dementia stage. By partnering nursing expertise of dementia stages with knowledge of Resident preferences nurses have the information and skill necessary to improve clinical outcomes, reduce excess disability, and promote Resident well-being. Dementia Staging won't reverse the progression of the plaques and tangles that are characteristically blocking connections in the minds of Residents with Alzheimer's and related dementias. However, knowledge of dementia stages does reverse the nursing barriers and tangles of trial and error care, thereby, clearing the way for a strong, successful connection between the nurse and the Resident.

High Risk Guide FAST 4/ Allen High 4 (High Early) agitation behaviors contractures dehydration depression/isolation elopement excess disability falls impaction incontinence pneumonia polypharmacy skin breakdown social conflict transfer trauma uncontrolled pain uti's weight loss x x x x x x x x x x x x FAST 5/ Allen Low 4 (Low Early) x FAST 6abc/ Allen High 3 (High Middle) x x x x x x x x x x x x x x x x x x x x x x x x x x FAST 6de/ Allen Low 3 (Low Middle) x x x x x x x x x x x x x FAST 7/ Allen 2 (Late Stage) x x x x x x x x x x x x x x x x x x x x FAST 8/ Allen 1 (End Stage)

*Note: The High Risk Guide reflects categories for which Residents at each Adapted Fast Stage/Allen Cognitive Level are at greatest risk based on their Cognitive Function. When comorbidities are present additional risks may be identified for individual Residents.

SYNTHESIS
In view of this literature in this study, the nurses play an essential role in the personal development of Nursing Care to all Dementia patients. Based on evidence provided under the Interventions and Care Strategies in this chapter specifically, use of the individuals that provides a framework for the nursing care of individuals with dementia. Their goal is Nurses become nurses to provide care and promote well-being. Through defining a Resident's specific dementia stage nurses can see abilities where disabilities would previously dominate the nursing perspective. When nurses are trained to assess Resident abilities that remain at every dementia stage it is possible to celebrate all that is right with the Resident. Knowledge of the abilities that remain within each Resident offers the hope that ignites the compassion and caring that drove most nurses to select an occupation to serve seniors.

Nurses gain the expertise to design a Resident specific care plan that is truly individualized only when they possess an understanding of dementia stages. The Adapted FAST tool and related abilities-based dementia training provides the missing link for nurses and families to provide care that takes advantage of the Resident's remaining abilities. Recognition of a Resident's best ability to function within their specific dementia stage also allows for improved time management by guiding the team to support, rather than do for the Resident. Team assignments can be more time sensitive by balancing responsibility for Residents that need set up help with those that require one to one support. In addition, it is easier to instruct the care team and family of changes in condition which should be reported to their supervisor or physician when the expectation of the Resident's best ability to perform is objectively defined by the dementia stage.

The long term care resident with dementia is by very nature complex. It is not easy for the care team to determine "best ability to function" as remaining abilities are often masked behind obvious disabilities and challenging behaviors. Therefore, a person often does not achieve their functional and emotional potential. And, therefore, it may be considered reasonable and necessary for the therapist to intervene. One of the skilled components of the intervention is to identify best ability to function, then to enable the resident to achieve this best ability through

interventions such as (a) environmental modifications, (b) activity simplification, (c) maintenance program design, and (d) caregiver training.

A barrier many therapists face in this process is obtaining follow through from the care team (CNA's, nurses and activities) in implementation of the maintenance program as educated. Partnership between the care team and therapist is critical for the resident's well being and function, and overall program success. Therefore, I will review some of the key components for a successful interdisciplinary dementia model. The rapid growth of the aging population is associated with an increase in the prevalence of progressive dementias. It is imperative that a differential diagnosis be ascertained early in the course of cognitive impairment and that the patient is closely monitored for coexisting morbidities. Nurses have a central role in assessment and management of individuals with progressive dementia. Patient Outcomes: The patient remains as independent and functional in the environment of choice for as long as possible, the co-morbid conditions the patient may experience are well managed, and the distressing symptoms that may occur at end of life are minimized or controlled adequately. Caregiver Outcomes (lay and professional): Caregivers demonstrate effective care giving skills; verbalize satisfaction with care giving; report minimal caregiver burden; are familiar with, have access to, and utilize available resources. Institutional Outcomes: The institution reflects a safe and enabling environment for delivering care to individuals with progressive dementia; the quality improvement plan addresses high-risk problem-prone areas for individuals with Dementia, such as falls and the use of restraints.

Reaction
As we know, the number of people with Alzheimer's and related dementias is dramatically rising. As a result, the number of people with dementia choosing a long term care environment is also rising sharply. Sadly, I have found that long term care communities tend to be rooted in the medical model. The very nature of the name "nursing home" embodies the typical philosophy and emphasis of care simply meeting nursing and medical needs at the expense of quality of life needs. However, there are many changes occurring in long term care. I have found one of the key elements to facilitate quality of life outcomes and for implementation of a social model is for the person with dementia to be enabled to perform valued activities at their highest performance level. The feelings of "success" and "purpose" appear to have a significant impact on behavior and mood. The very act of "doing" appears to have impact on reducing common medical complications such as reducing contractures, reducing falls, reducing risk for pneumonia, reducing weight loss and skin breakdown. A quality dementia program involves much participation from the interdisciplinary team. The most critical team members are administration/owners, therapists, nurses, CNA's and activities. All of these team members must understand the goals of quality dementia care and what role they play in delivery of this care. Owners and administrators must totally buy in and support a dementia program or it will not succeed. Their participation is important as they are the drivers of the program. They will need to provide adequate staffing numbers and hours, adequate dedicated hours for staff training, adequate training/consulting tools and resources, and constant encouragement. A quality dementia program can make money. Often, all that is initially recognized by owners and administrators is the need to add staff or ask staff to spend more time in education programs, all of which can be looked at as a financial drain on an already slim bottom line. But, a QUALITY dementia program can facilitate a large profit. Effective and efficient strategies need to be designed in order to turn passive learners into learners who take an active responsible role in the learning process. Positive feedback can motivate them to greater effort because it makes their goal seen attainable.

References
1. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR (4th ed.). Evidence Level VI: Expert Opinion. 2. Richie, K., & Lovestone, S. (2002). The dementias. Lancet, 360(9347), 17671769. Evidence Level VI: Expert Opinion. 3. Hebert, L. E., Scheer, P. A., Bienias, J. L., Bennett, D. A., & Evans, D. A. (2003). Alzheimers disease in the U.S. population: Prevalence estimates using the 2000 census. Archives of Neurology, 60, 11191122. Evidence Level IV: Nonexperimental Study. 4. Ferri, C. P., Prince, M., Brayne, C., Brodaty, H., Fratiglioni, L., & Ganguli, M., et al. (2005). Global prevalence of dementia: A Delphi consensus study. Lancet, 366(9503), 21122117. Evidence Level IV: Nonexperimental Study. 5. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-mental state. Journal of Psychiatric Research, 12, 189198. Evidence Level IV: Nonexperimental Study. 6. Han, L., Cole, M., Bellavance, F., McCusker, J., & Primeau, F. (2000). Tracking cognitive decline in Alzheimers disease using the mini-mental state examination: A meta-analysis. International Psychogeriatrics, 12 (2), 231-247. Level I: Systematic review. 7. Parker, C., & Philp, I. (2004). Screening for cognitive impairment among older people in Black and minority ethnic groups. Age and Aging, 33, 447452. Evidence Level VI: Expert Opinion. 8. Royall, D. R., Mulroy, A. R., Chiodo, L. K., & Polk, M. J. (1999). Clock drawing is sensitive to executive control: A comparison of six methods. Journal of Gerontology & Psychological Science and Social Science, 54B(5), 328333. Evidence Level IV: Nonexperimental Study. 9. Borson, S., Scanlan, J., Brush, M ., Vitaliano, P., & Dokmak, A. (2000). The Mini-Cog: A cognitive vital signs measure for dementia screening in multilingual elderly. International Journal of Geriatric Psychiatry, 15(11), 10211027. Evidence Level IV: Nonexperimental Study. 10. Borson, S., Scanlan, J. M., Chen, P., & Ganguli, M. (2003). The Mini-Cog as a screen for dementia: Validation in a population-based sample. Journal of the American Geriatrics Society, 51, 14511454. Evidence Level IV: Nonexperimental Study. 11. Pfeffer, R. I., Kurosaki, T. T., Harrah, C. H., Chance, J.M., & Filos, S. (1982). Measurementof functional activities of older adults in the community. Journal of Gerontology, 37(3), 323329. Evidence Level IV: Nonexperimental Study. 12. Galasko, D., Bennett, D. A., Sano, M., Ernesto, C., Thomas, R., Grundman, M., et al. (1997). An inventory to assess activities of daily living for clinical trials in Alzheimers disease: The

Alzheimers Disease Cooperative Study. Alzheimers Disease and Associative Disorders, 11 (Suppl. 2), S33S39. Evidence Level IV: Nonexperimental Study. 13. Zubenko, G. S., Zubenko, W. N., McPherson, S., Spoor, E., Marin, D. B., Farlow, M. R., et al. (2003). A collaborative study of the emergence and clinical features of the major depressive syndrome of Alzheimers disease. American Journal of Psychiatry, 160(5), 857866. Evidence Level IV: Nonexperimental Study. 14. Bedard, M., Molloy, D. W., Squire, I., Dubois, S., Lever, J. A., & ODonnell, M. (2001). The Zarit Burden Interview: A new short version and screening version. Gerontologist, 41(5), 652 657. Evidence Level IV: Nonexperimental Study. 15. Robinson, B. (1983). Validation of a Caregiver Strain Index. Journal of Gerontology 38, 344348. Level IV: Non-experimental. 16. Smith, M., Hall, G. R., Gerdner, L., & Buckwalter, K. C. (2006). Application of the progressively lowered stress threshold model across the continuum of care. Nursing Clinics of North America, 41(1), 5781. Evidence Level V: Case Study.

Merleen Kaye D. Malit

Student

3- ACN - CON