Deloitte Access Economics identifies dementia as one of the leading challenges in healthcare provision in the twenty-first century. In Australia, more than three hundred and twenty thousand patients are affected by dementia, which is currently a health epidemic, and the projection is that in the next twenty years more than five hundred thousand people will have dementia (Economics, 2011, p. 14). Dementia remains one of the leading causes of death in Australia because currently there is no cure for dementia. It is an umbrella term that represents all the symptoms that eventually impair the functioning of the brain. It is a condition with a gradual onset, and it is progressive and irreversible. In the end, dementia is terminal, which necessitates palliative care for those affected and their families from the onset to the end stages of dementia (Palk et al., 2008, p. 11). Residential aged care facilities in Australia focus on the provision of the best quality palliative care for those affected by dementia together with their families. Various forms of therapy are often available in these facilities for people with dementia including person-centered and family focus therapies. However, being a terminal condition and one that involves patients whose cognitive ability is eventually impaired, the provision of these therapies may be hindered by numerous challenges. The paper, therefore, discusses behavioral problems, communication, and memory loss as challenges that may hinder palliative care for patients with dementia. It goes further to critically analyze communication as a challenge in the provision of person-centered and family-focused care in residential aged care facilities in Australia and how palliative care can be improved for those with dementia.
According to Sekerak and Stewart (2014), behavioral problems are characteristic of patients with dementia throughout dementia. These behavioral problems are usually more prominent in the advanced stages of dementia. These patients experience lethargy, apathy, passivity, hallucinations, and delusions. Patients who are in the end stages of dementia will portray resistance towards care especially during the last months of their life. These problems are often chronic or acute depending on personal characteristics and the stage of dementia the patient has reached. Patients with dementia will experience distress, and it will be portrayed through agitation. Agitation needs to be addressed with promptness and often represents a cornerstone issue in the provision of palliative care in residential aged care facilities (Sekerak and Stewart, 2014, p. 39). During the end stages of dementia, patients will be non-verbal which means that the detection of agitation will require sufficient detective work. Distress experienced by the patients can either be chronic or acute, and the patients may manifest it through various somatic symptoms like distressed facial expressions, screaming, aggressive behavior, or restlessness. These symptoms will depend on the severity of the distress the patient is experiencing. Other possible behavioral manifestations include being fearful such as the fear of being cared for, social deprivation, covert injury, restraint, and much more. Patients will be resistant to hands-on care especially if dementia is severe. It could be that they are experiencing increasing apathy and therefore prefer to be left alone. It could also be due to fearfulness where they lack understanding of what is being done to them. Depression, though emotional, could also be present in these patients and will manifest through behavioral problems like restlessness or screaming (Sekerak and Stewart, 2014, p. 40).
It is, therefore, necessary to address behavioral problems to ensure effective person-centered and family-focused therapy. The facilities and nurses caring for these patients can appropriately limit the type of hands-on care provided for the patients to maintain or increase the patient's quality of life. They may also need to gently and softly explain to the patients what is being done to them or distract the patient with something enjoyable. The facilities may employ the use of pharmacological approaches including antidepressants in case of depression and neuroleptics in case of severe agitation and fearfulness (Sekerak and Stewart, 2014, p. 40).
According to Droes et al. (2011), memory issues are usually the first indication of dementia in the patient. These problems affect the person's life in numerous ways including an impact on how people do shopping, how they use public transportation, and much more (Droes et al., 2011, p. 1770). Memory problems will also affect social functioning including the patients forgetting conversations they have just had. Such instances will significantly affect the person's well-being and self-confidence. Such mild memory problems are often visible in the initial stages of dementia. End-stage dementia will be characterized by disorientation especially regarding people, time, places, and much more. It means that the patient will have issues remembering family, friends, his or her home, and many other important aspects of their life. They could experience aphasia, which is a disorder in expressing or understanding language, and apraxia, which is a disorder in handling objects and catering for other daily living activities such as getting dressed (Droes et al., 2011, p. 1771). Patients with dementia will experience cognitive decline, but they will be at different levels of insight concerning the decline. Some will be completely aware of what is happening to their cognitive functioning while some will be less aware or completely unaware of it. These patients have to deal with numerous problems, especially in their cognitive functioning including having to come to terms with their gradually worsening cognitive impairment and accept their increasing dependency on other people. They also have to deal with the inability to maintain an emotional balance, dealing with an uncertain future and life in an institution, social isolation, maintaining contact with family and friends, and developing an effective care relationship with the healthcare provider (Droes et al., 2011, p. 1771). Memory problems in dementia will lead to insecurity in the patient concerning his or her environment of the people around. Such a reaction will hinder the type of interaction with the caregiver thus preventing the patient from receiving quality care. They may also experience changes in their perception, develop anger, frustration, and fear.
According to Alm et al. (2007), dementia is associated with various memory problems including short-term memory loss, which means that the patient will find it difficult and eventually impossible to hold conversations with the caregivers, family, and those around him or her. However, because their long-term memory is usually well-preserved end-stage dementia patients have the potential to hold conversations only through reminiscence. It is however clear that the impacts of dementia are often devastating on the patient, the family members, and the healthcare professionals especially in the provision of person-centered and family-focused therapy in the facilities. Many social and personal activities and interactions are dependent on the patient's short-term memory. Dementia has its effects on the memory from its progression up to its severe stages. It means that those with dementia will encounter numerous difficulties including social isolation and other social interactions. It means that there will be a continued strain on the provision of healthcare, on the patient and his or her family members (Alm et al., 2007, p. 35).
According to Jootun and McGhee (2011), patients with dementia will demonstrate varied impaired ability in communication throughout the disorder. During the early stages of dementia, many patients will have difficulty in finding the right words to use particularly for names of objects. In the course of communication, the patient will substitute the word he, or she needs to say with an incorrect one, or he or she may lack a word to use (Jootun and McGhee, 2011, p. 44). Though it starts with such mild symptoms, the patient will gradually progress to forgetting important names of friends and family, and they may be confused over family relationships. It reaches a point where the patient lacks the ability to recognize family and friends, which is often frustrating to the family and the patient. The gradual decline in their ability to communicate will pose a challenge to the nurse offering healthcare to the patient and will eventually compromise the quality of care the patient gets. Due to such reasons, there may arise frustration between the patient and the nurse, therefore, leading to avoidance of interactions. It is however clear that patients with dementia are not always similar and the behavior they portray may not be fully attributed to dementia. Cognitive impairments and the communication deficits the patient encounters will eventually result in the patient lacking the ability to initiate a conversation. Therefore, it is solely the responsibility of the nurse and in some instances the family and friends to help the patient communicate.
Jootun and McGhee (2011) further believe that the necessary knowledge on how dementia progresses will be necessary for providing the best care for the patient. When applying person-centered and family-focused therapies, the healthcare provider must identify the individuality and uniqueness of every patient in the course of assessing their ability to communicate. The value-driven characteristic of the person-centered approach means that the patient's values are at the forefront of the approach, the patient has their level of independence, he or she needs to be empowered and cared for. The approach, therefore, requires that the nurse will focus on the remaining ability of the patient to communicate other than the communication deficits that have developed in the patient due to dementia. Doing so will encourage interaction that is founded on the patient's ability to communicate. It is critical for the nurse to take a step towards listening to and understanding the patient because effective communication will improve the quality of life and care for the patient (Jootun and McGhee, 2011, p. 44).
Jootun and McGhee (2011) identify that nurses will often have reduced interaction with patients with compromised communication ability compared to other patients who seem to be lucid. Communication impairment is characteristic of patients with dementia, which means that the nurses will experience difficulty while working with dementia patients. It is, therefore, necessary that the nurse is aware of how dementia progresses and the deterioration of the patient's communication ability at various stages of the disease. The health care providers may experience both satisfaction and frustration as they care for patients with dementia. The gradual increase in the patient's cognitive impairment often presents significant demands on the nurse. It means that without the necessary knowledge and skills, the nurse will find it difficult to interact and care for these patients. He or she could encounter misunderstandings with the patients, and the nurse may not fully meet the needs of the patient (Jootun and McGhee, 2011, p. 44).
The patients will need supportive listening, which involves the use of comforting messages specifically through the expression of condolence, sympathy, and legitimizing the feelings of the patient (De Vries, 2013, p. 32). It is also necessary for the nurse to use various behavioral manifestations including leaning forward while communicating with the patient, nodding off...
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