Dementia: the case of Alex

Dementia: the case of Alex Dementia: the case of Alex Mary Jo has been contacted by her maternal grandmother and asked to come and visit so that they can talk about her grandmother’s concerns about her second husband, Alex. Mary Jo is a little apprehensive as Grandma has asked her at this stage not to mention anything to her mother or to her two older brothers and their wives. [David, 33 years old, is the elder of Mary Jo’s two brothers; his wife is Maria; they have two children: Jimmy, six years old, and Thomas, four years old. Barry, the younger brother, is married to Anna; both are 30 and they have only one child, Leah, three years old. Sadly Anna miscarried last year but they are optimistic about having more children.] Mary Jo is also aware that her own mother has not really accepted her mother’s (Grandma’s) decision to marry Alex, a Mediterranean man, 12 years ago now, and eight years after her grandfather had died suddenly due to an aortic aneurism. Mary Jo has always liked Alex as he is a jovial person who clearly loves and respects her grandmother, often buying her jewellery and other presents and very often fresh flowers. Mary Jo assumed that her mum was grieving for her own father and that that got in the way of her accepting her mother’s second marriage. Mary Jo’s mother had emphasised how different the personalities of the two men were and explained that as an only child she had always been her father’s ‘princess’. These thoughts and more were going through Mary Jo’s mind as she travelled by train to her grandmother’s home to stay overnight. She knew something was wrong because Grandma had said, ‘You will understand because you are a nurse.’ Mary Jo was concerned that Alex’s ‘memory problems’ were getting worse and was worried about how she could best help her grandmother. Grandma met Mary Jo at the door; she was wearing a brace on her left arm and clearly sporting a healing right ‘black eye’. Mary Jo couldn’t contain herself and started quizzing her grandmother about what had happened. Had Alex hit her? This was no good; how could she live with domestic violence? Something had to be done! Mary Jo stopped when she realised that her grandmother was just sitting softly weeping while she had gone on and on. Mary Jo suddenly saw herself as attacking and criticising the woman she had come to help. She drew her breath and said, ‘Oh Grandma, I am so sorry for how I have just behaved! I can see that you’ve been hurt, and that has upset me because I love you. I’ll put my bag in the spare room, check on Alex and we’ll meet in the kitchen and have a cuppa. Is that OK?’ Mary Jo’s grandmother nodded and took a few breaths to steady her crying. Mary Jo was cross with herself for being so… She couldn’t find the words but knew she would not have behaved that way if she had been at work. Prompting questions, set 1 • Can you record a genogram for Mary Jo from the above information? If you have been able to do this, share its elements with your fellow students in the discussion forum. page 1 What other information would be informative? What are the benefits of a genogram in aged care? • What significance can be placed on the family dynamics? • If Mary Jo wants to let her mother know about her concerns, how should she deal with the fact that she has promised not to talk to other family members? • What might account for Mary Jo’s response to seeing her grandmother’s injuries? • How prevalent is aggressive behaviour between people with dementia and their carers? • What advice can be provided to help prevent and minimise aggressive behaviour? In the kitchen Mary Jo informed her grandmother (Matilda) that Alex was asleep in his recliner. Mary Jo and Matilda did have a cuppa, with Mary Jo listening to what Matilda said and allowing her to tell the story as she had experienced it. Mary Jo also learnt that Matilda had put off approaching her granddaughter, as she was still embarrassed that Alex had hit her and twisted her arm. It was so out of character for him but it really had scared her, and she still felt a bit on edge because it might happen again. She thought that it related to his wanting a cigarette and her saying no because she didn’t want to bother at the time. She was not able to distract him from the idea. Her grandmother continued, ‘He got up to look for his smokes and spotted them and then went to light one. But in his agitation, he tried to put the match in his pyjama pocket when it was still alight. I was trying to stop him from burning himself—thank God they were good cotton and not synthetic— and God knows what he thought but he hit out at me and grabbed my arm. Then when he saw me crying he was all ‘lovey dovey’ and not aware of what had just happened!’ Mary Jo thought about the number of smokers who are admitted to hospital but don’t get to smoke while they are there. She quietly wondered how much crankiness and worse could be attributed to nicotine withdrawal. Prompting questions, set 2 • How might you as a health professional respond to this story? • Why is Alex’s wife feeling guilty and embarrassed? • What problem-solving techniques could be employed to assist with the issue of unsafe smoking? • If one of the options selected were for Alex to undertake a quit smoking program what would be required? Further disclosure Mary Jo and Matilda got into the flow of interacting and maintaining the routine that had been pretty well established between Matilda and her husband. Mary Jo was pleased to be able to prepare the meal her grandmother had planned and observed her grandparents holding hands while watching the TV together. Although Mary Jo offered, Matilda did not accept any assistance with toileting or caring for Alex. Mary Jo was page 2 mpressed with her grandmother’s ability to help Alex maintain the skills he did have; she seemed to wind into her conversation with him the suggestions and cues about what needed to be done or focused on. There wasn’t that babying approach that Mary Jo had so often seen and sometimes knew she resorted to at the hospital just to get the task done. Later that evening Mary Jo and Matilda were able to spend time together again. At this time Matilda revealed that their GP had suggested that she needed to start thinking about putting Alex into residential care. This was her worst fear as they had in fact made part of their marriage vows to care for each other in their latter years. She did not deny that he had hit her but felt that with more help and information she could do better. The doctor had given Alex a definite diagnosis of dementia, and probably Alzheimer’s disease. Matilda wanted to know whether the type of dementia made any difference to what she should do. The doctor was also reluctant to discuss how long this might go on for. Matilda understood that no one had a crystal ball but felt that it would help her if she knew some of what was in store and had some timeframe to work from. She was thinking of visiting relatives in Holland before she got too old to manage such a trip but didn’t know what was best to do. Matilda said that she hadn’t properly answered the doctor’s questions about Alex‘s incontinence because that would have just made things worse. She explained that Alex had had some urinary incontinence for a year or more but this had been mostly at night or he had just used the wrong place or thing to urinate in. But over the past month he had been wetting himself and was now occasionally incontinent of faeces as well. Again Mary Jo disciplined herself from jumping in and answering the parts of the questions she could answer. She was feeling that her grandmother had a new level of trust in her and she wanted to live up to that trust. Somehow it also really mattered to understand what her grandmother was experiencing. Their conversation extended beyond ‘Alex’s problems’ to Mary Jo’s learning more about her own (and Alex’s) extended family in Europe and some catching up about what Mary Jo was up to at work and in her rather inactive social life. Towards the end of the evening Mary Jo said that she felt that the Alzheimer’s Association was the best source of information for her grandmother and that she would be happy to go along with her and support any steps or stages she chose along the way. When her grandma was ready Mary Jo was also willing to approach the social worker and get the full information about nursing home assessment and admission and what that entailed. Prompting questions, set 3 • What influence does the type of dementia have on the onset, progression and prognosis of the condition? • What factors contribute to the likelihood of aggressive behaviour in people experiencing dementia? • Identify what community resources are available in your community to answer Matilda’s questions. • What could account for the changes in Alex’s continence issues? page 3 What resources and advice could be made available to Alex in his own home? • How would you as a health professional support Matilda’s plans to travel to Europe? Epilogue Matilda did explore the information and community resources available to her and Alex. She found that the carers’ support group was very welcoming and good at sharing helpful information. The continence nurse specialist did an assessment and Alex was found to be constipated, with some faecal overflow, and his dietary habits and exercise regime were adjusted under her supervision. Mary Jo became a regular visitor and support to her grandmother. The range of topics that they discussed together expanded and sometimes even surprised Mary Jo. What you need to do to meet your learning outcomes ? Explore these websites Explore the following websites, which provide information about dementia. Australian Government Department of Health and Ageing 2007, Dementia, http://www.health.gov.au/dementia. AIHW 2007, Dementia in Australia: national data analysis and development, AIHW Cat. No. AGE 53, AIHW, Canberra, http://www.aihw.gov.au/publications/index.cfm/title/10368. Dementia Training Study Centres: http://www.dtsc.com.au/ Bridges-Webb, C & Wolk, J 2003, Care of patients with dementia in general practice: guidelines, NSW Department of Health, Sydney, http://www.health.nsw.gov.au/pubs/2003/pdf/care_dementia_guide.pdf. Dementia Care Australia: http://www.dementiacareaustralia.com Alzheimer’s Australia: http://www.alzheimers.org.au Simons, LA, Simons, J, McCallum, J & Friedland, Y 2006, ‘Lifestyle factors and risk of dementia: Dubbo study of elderly’, Medical Journal of Australia, vol. 184, no. 2, January, pp. 68-70, http://www.mja.com.au/public/issues/184_02_160106/sim10682_fm.pdf Department of Human Services, Victorian Government Health Information 2004, A guide for assessing older people in hospitals, developed by the Centre for Applied Gerontology, Bundoora Extended Care Centre, Northern Health, http://www.health.vic.gov.au/acute-agedcare/assessing-older-people.pdf. This guide provides one of the major discussions in the field regarding the pros and cons of assessments and other tools that are available. Tameside Council, The single assessment process for older people, frequently asked questions, http://www.tameside.gov.uk/sap. This web resource about the single assessment process (SAP) was developed by the Department of Health in the UK. It discusses different types of assessment scales and social problems facing the older person. Ministry of Health [NZ] and New Zealand Guidelines Group 2003, Best practice evidence-based guideline summary, ‘Assessment of older people with complex needs’, New Zealand Government, http://www.nzgg.org.nz/guidelines/0030/Specialist_summary.pdf. PLACE THIS ORDER OR A SIMILAR ORDER WITH US TODAY AND GET AN AMAZING DISCOUNT :)