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Care of the Older Person – Unit 3 5N2706

Care of the Older Person

5N2706

Unit Three: Caring for the Older Person

with Specific Needs

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Care of the Older Person – Unit 3 5N2706

Following this unit, the learner will gain understanding of:

➢ Care practices required to meet the needs of older people with:

o cognitive and sensory impairment

o physical disabilities

➢ Issues related to an older person with mental illness.

➢ Conditions in an older person that require immediate attention.

➢ The impact of living with chronic illness.

➢ The individual needs of the dying older person and their families.

➢ Care of body after death.

Care of the Older Person – Unit 3 5N2706

Contents

COGNITIVE IMPAIRMENT: DEMENTIA .................................................................... 4

Dementia ................................................................................................................................................. 4

The Main Forms of Dementia: ................................................................................................................ 6

Alzheimer’s Disease ................................................................................................................................ 8

Communication in Dementia Care: ....................................................................................................... 12

Challenging Behaviour and Dementia................................................................................................... 16

Strategies for working with patients who have dementia.................................................................... 18

SENSORY IMPAIRMENT ....................................................................................... 22

Environmental Considerations .............................................................................................................. 22

Lip-Reading ........................................................................................................................................... 22

Hearing Aids .......................................................................................................................................... 23

Managing Daily Life ............................................................................................................................... 24

Visual Impairment ................................................................................................................................. 25

CONDITIONS ASSOCIATED WITH OLDER PERSONS ................................................ 29

CEREBRAL VASCULAR ACCIDENT: CVA /STROKE ................................................................................... 29

Commonly used terms related to stroke: ............................................................................................. 33

Parkinson's ............................................................................................................................................ 34

MULTIPLE SCLEROSIS ............................................................................................................................ 37

Mental Illness: Depression ................................................................................................................... 39

SCHIZOPHRENIA .................................................................................................................................... 45

CHRONIC & ACUTE ILLNESS .................................................................................. 50

Diabetes ................................................................................................................................................ 51

Epilepsy ................................................................................................................................................. 52

Muscoloskeletal Disorders: ................................................................................................................... 53

Myocardial Infarction {Heart Attack} .................................................................................................... 53

HEALTHCARE NEEDS OF THE OLDER PERSON ........................................................ 55

Nutrition & Malnutrition ....................................................................................................................... 55

Care of the Older Person – Unit 3 5N2706

Nutrition ................................................................................................................................................ 56

MALNUTRITION ..................................................................................................................................... 59

HYPOTHERMIA ...................................................................................................................................... 61

PREVENTION OF FALLS......................................................................................... 66

NEEDS OF THE DYING PERSON & THEIR FAMILIES ................................................. 67

DR. Kubler-Ross’ Stages of Dying: ........................................................................................................ 68

SYMPTOMS OF GRIEF: ........................................................................................................................... 69

Physical care of a person approaching death includes: ........................................................................ 72

Meeting a person’s emotional needs ................................................................................................... 73

CARE OF BODY AFTER DEATH ............................................................................... 75

Care of the Older Person – Unit 3 5N2706

COGNITIVE IMPAIRMENT: DEMENTIA

Cognition includes all of the processes associated with mental and intellectual functioning,

such as the ability to remember, reason, concentrate, learn, think, judge, and follow simple

orders and commands. Altered cognitions may be a part of normal ageing (age-associated

cognitive decline) or they can be the result of ‘delirium’, a symptom of depression, or a sign

of dementia.

Dementia

Dementia is an umbrella term used to describe various conditions which damage brain cells

and lead to a loss of brain function over time. Dementia causes a progressive decline in a

person’s mental functioning. It is a broad term, which describes a loss of memory, intellect,

rationality, social skills and normal emotional reactions.

Dementia usually has an insidious onset, with most people developing symptoms gradually

over a period of years. The progression of these diseases is largely unpredictable for each

individual. How and what symptoms develop depend on what parts of the brain are affected

by which illness, and the unique characteristics of each individual.

Dementia has a life changing physical, emotional and mental impact on the affected person

and their primary carer and family. There are more than 100 conditions that cause

dementia. While the risk of dementia increases with age, dementia is not a natural part of

ageing.

Dementia affects almost 44,000 people and touches the lives of 50,000 carers and hundreds

of thousands of family members. Estimates suggest that within 20 years, the numbers of

people affected will double and by 2036 104,000 people will be affected. Dementia affects

approximately one in 20 people aged over 65 years.

Care of the Older Person – Unit 3 5N2706

This rises to one in four in the 80 plus age group. While it is comparatively rare, dementia

can affect younger people. There are approximately 4,000 people under the age of 65 with

younger onset dementia in Ireland.

Dementia ranks as the fourth leading cause of death among the population aged 65 years

and over. Alzheimer's disease, the most common cause of dementia in Ireland, accounts for

66% of all cases; the second most common form is vascular dementia, which may be

preventable.

There are approximately 684,000 people with dementia in the UK. However, this figure is

expected to rise to 1,735,000 by 2051. The incidence of dementia rises with age; it affects

one in 20 people over the age of 65 and one in five over the age of 80. However, it is not a

disease exclusively of old age and there are approximately 15,000 people living in the UK,

with young onset dementia (onset before the age of 65) (London School of Economics,

2007). Prevalence studies estimate a minimum of 67 cases of young onset dementia per

100,000 population aged 30–64, with an incidence rate of 17 new cases per year (Harvey,

1998).

A person with dementia will live for an average of four to eight years, depending on their

age at diagnosis. Average life span will also be affected by gender, other medical conditions

and the severity of dementia at the time of diagnosis. Dementia is a progressive disease of

the brain that is characterised by widespread impairment of mental function. Symptoms

include:

Memory loss

Language impairment

Disorientation

Changes in personality

Impaired reasoning and judgment.

These lead to difficulties in activities of daily living and social functioning. Patients may also

have changes in behaviour (e.g. sleep disturbance) and psychological disturbance (e.g.

apathy, agitation and aggression).

Care of the Older Person – Unit 3 5N2706

These symptoms are the result of structural and chemical changes in the brain. The causes

of dementia are still not fully understood. Risk factors include increasing age and injury to

the brain (e.g. severe head injury, stroke disease and alcohol abuse).

The care and management of individuals with dementia is often complex and can be very

difficult. It is multi-dimensional and involves multiple agencies, the use of drug treatments,

non-pharmacological interventions and provision of support for carers.

People with dementia may be cared for in the acute hospital setting. Person-centred care in

dementia aims to see the person with dementia as an individual, rather than focusing on

their illness and on abilities they may have lost. Instead of treating the person as a collection

of symptoms and behaviours to be controlled, person-centred care takes into account each

individual’s unique qualities, abilities, interests, preferences and needs (Kitwood, 1997).

Guidance on dementia recently issued by the National Institute for Health and Clinical

Excellence (2006), aims to support people with dementia and their carers. This guidance

sets out good principles of care in dementia including early diagnosis, access to specialist

services and management of the symptoms of dementia, including challenging behaviour.

The guidance promotes the principle of person-centred care meaning that all treatment and

care should take into account each person’s individual needs.

The Main Forms of Dementia:

❖ Alzheimer’s disease (AD) is the commonest form of dementia seen in the over 65

population.

❖ Vascular dementia is the second commonest form of dementia.

❖ Dementia with Lewy Bodies (DLB) is also commonly seen.

❖ Other progressive forms of dementia include fronto-temporal dementia, HIV

disease and alcohol-related dementia.

Care of the Older Person – Unit 3 5N2706

Vascular Dementia

Vascular dementia accounts for up to 20% of all cases of dementia. It is caused by problems

with the supply of oxygen to the brain and diseases that contribute to vascular disease such

as hypertension, diabetes and high cholesterol increase the risk. It can occur in up to a third

of people in the year following a stroke.

However, it is more commonly caused by a series of small strokes that individually may not

cause any specific symptoms (London School of Economics, 2007). Vascular and Alzheimer's

may co-exist. This is referred to as mixed dementia. In studies patients with ‘mixed’

dementia made up about one-fifth of all dementia cases (Brown and Hillam, 2004).

Signs and symptoms

It affects people in different ways and thus the rate of progression will differ. Some of the

common clinical features associated with vascular dementia are:

❖ Stepwise progression: symptoms might plateau and then deteriorate suddenly

❖ Memory problems

❖ Depression post-stroke

❖ Physical symptoms of stroke such as paralysis and speech impairment, incontinence

❖ Epileptic seizures

❖ Difficulty concentrating

❖ Hallucinations

❖ Delusions

❖ Aggression

❖ Getting lost.

Lewy Body Dementia

Accounts for approximately 20% of all cases of dementia. Lewy body dementia is caused by

the build-up of abnormal protein deposits (called Lewy bodies) in areas of the brain that are

responsible for thinking and movement.

Care of the Older Person – Unit 3 5N2706

In addition to a decline in mental abilities, people with Lewy body dementia develop

problems controlling body movement (for example, muscle rigidity, a shuffling gait, slow

movements, and tremors), similar to those seen in people with Parkinson's disease. People

with Lewy body dementia also tend to experience visual hallucinations (that is, they see

things that do not really exist) and distinct changes in mental alertness.

Fronto-temporal Dementia

Is caused by, damage to the frontal and temporal lobes of the brain. The frontal lobe is the

area of the brain that is responsible for personality and behaviour. The temporal lobe is the

area of the brain responsible for language. As a result, a person with fronto-temporal

dementia may show extreme changes in personality and behaviour, have difficulties with

language, or both.

Caring for a person with fronto-temporal dementia can be particularly challenging. Fronto-

temporal dementia accounts for about 5% of all cases of dementia. Symptoms of fronto-

temporal dementia generally appear at a younger age than in other types of dementia,

often between the ages of 40 and 65 years. Also, unlike other forms of dementia, memory is

often spared until later in the disease process. Carter and Goldschmidt (2010).

Alzheimer’s Disease

Alzheimer’s disease is named after the German psychiatrist, Alois Alzheimer, who in 1906

first described the changes caused by the condition. He described two abnormalities or the

patient's brain, neurofribrillary tangles and amyloid plaques, the plaques and tangles that

have become synonymous with Alzheimer's disease. AD accounts for 50-60% of all cases of

dementia (Brown and Hillam, 2004).

The tangles are insoluble aggregates of tau protein. Plaques (known as senile plaques) are

deposits of another protein, amyloids. It is still not completely clear what role these two

proteins play in the development and progression of Alzheimer's disease, it is commonly

agreed that there is an association, since these plaques and tangles are present in all cases

of the condition.

Care of the Older Person – Unit 3 5N2706

Also characteristic of the disease that was named after Alois Alzheimer is the loss (atrophy)

of brain mass. Specifically associated with AD, and probably somehow linked to the plaques

and tangles, are degeneration of these critical areas of the brain. Alzheimer’s disease starts

in the entorhinal cortex. This is situated near the hippocampus and is directly connected to

it. The disease then moves to the hippocampus.

This area of the brain is essential to the formation of short-term and long-term memories. It

is where short-term memories are changed into long-term memories for storage in other

parts of the brain. The affected regions of the brain begin to shrink. It is believed that this

happens perhaps 10-20 years before symptoms develop. The first sign that AD is present is

mild cognitive impairment (MCI) or memory loss.

Signs and Symptoms

It is useful to consider the clinical signs and symptoms of Alzheimer’s disease in terms of

three stages: early stage, intermediate stage and advanced stage. However, it is important

to remember that everybody is individual and the course and progression of the disease

might be quite different in some people.

Care of the Older Person – Unit 3 5N2706

❖ Early Stage:

Memory impairment (especially short-term memory such as forgetting

conversations or repeating oneself)

Impaired concentration and judgment

Loss of interest, anxiety, depression, fatigue

Slow to grasp new ideas or try new things

Difficulty handling money or remembering to take medication

Readiness to blame others for ‘stealing’ missing things.

❖ Intermediate Stage:

Increasing forgetfulness for recent events

Become lost if away from familiar surroundings

Deterioration in reading and writing ability

Apraxia: loss of the ability to perform intentional movements even though

the person is not paralysed, has not lost the sense of touch and knows what

he or she is trying to do (e.g. a person may stop brushing their teeth)

Agnosia: loss of the ability to recognise objects even though the person’s

sight and sense of touch are normal

People may fail to recognise family members

Confusion regarding time and place

Neglect hygiene and eating

Increased anger, upset, distress

Hallucinations

Word-finding difficulty and speech impairment.

❖ Advanced Stage:

Inability to remember for even a few minutes

Double incontinence

Full assistance with eating, washing, dressing, toileting

Night disturbance

Difficulty mobilizing

Care of the Older Person – Unit 3 5N2706

May be chair bound

Aggression

Restlessness: may look for long-lost relatives

Lack of communication

Minimal speech and understanding

Contractures

Fits.

Treatment

Although there is no known cure for Alzheimer’s disease, there are drug treatments, which

may stabilise the condition or slow down the progression of the disease. These treatments

(known as acetylcholinesterase inhibitors) are effective in the early and intermediate stages

of Alzheimer’s disease.

They help cognitive symptoms such as memory loss and can also have beneficial effects on

activities of daily living and behaviour. There are three drugs currently available in the UK:

donepezil (Aricept), rivastigmine (Exelon) and galantamine (Reminyl). Only about two thirds

of patients will respond to the drugs (Overshott and Burns, 2005). Memantine (Ebixa) is

licensed for the treatment of intermediate to advanced Alzheimer’s disease.

In March 2011, The National Institute for Clinical Excellence {NICE} issued new guidance

recommending that people with Alzheimer's disease should now have increased access to

the available drugs. The latest NICE guidance on drug treatments for Alzheimer's disease

recommends that people in the mild-to-moderate stages of the disease should be given

treatment with donepezil (Aricept), galantamine (Reminyl) or rivastigmine (Exelon),

including individuals with both Alzheimer's disease and learning disabilities.

This differs from the previous (2006) NICE guidance, which indicated these drugs could be

prescribed only to people in the moderate stage of Alzheimer's disease.

Care of the Older Person – Unit 3 5N2706

The 2011 NICE guidance further recommends that memantine (Ebixa) should be prescribed

as part of NHS care for patients with severe Alzheimer's disease, or for those with moderate

disease who cannot take the cholinesterase inhibitor drugs. This differs from the previous

NICE guidance, which stated that memantine should not be prescribed as part of NHS care,

but emphasised further studies as an important research priority.

The clinical care guideline on the care and treatment of people with dementia, which NICE

publishes alongside its guidance, stresses that the severity of a person's dementia should

not be determined by cognition scores alone (e.g. Mini Mental State Examination), but by a

more holistic view of the patient's condition.

Communication in Dementia Care:

❖ Encourage patient to participate in their care within their capabilities.

❖ Communicate with patients in short, simple questions. Break down tasks into

manageable chunks.

❖ Try and ensure continuity of care through the same care team and named nurse.

Establishing a rapport with your patient enables them to get to know you and so

will give them security and trust.

❖ Encourage regular visits from carers/relatives as they are often a reassuring

presence.

❖ Find out a little about your patient. What did they do for a living? What is their

normal routine? Does their carer have any coping strategies to share with you?

❖ Carers and relatives know your patients best and can often explain unusual

behaviour and how to manage it. Long-term memory is preserved until much later

in dementia so talking to your patient about the past is a stimulating pastime. It

also shows your patient that you value them as a fellow human being.

❖ Avoid confrontation. Withdraw for a few minutes, rather than persevere if it may

cause possible aggression to mount.

Care of the Older Person – Unit 3 5N2706

❖ Avoid negative body language, people with dementia will pick up on hostile body

language. If you raise your voice they may respond in a similar fashion. Likewise, if

you are kind and gentle, they are likely to follow suit.

❖ Ensure the patient has access to sensory aids such as their hearing aid and glasses.

Sensory deprivation affects communication and may exacerbate confusion.

The Four as of Dementia {According to Carter and Goldschmidt are:}

❖ Amnesia

❖ Aphasia

❖ Agnosia

❖ Apraxia

As carers it is important that we understand these 4 As in order to provide proper care for

those with dementia.

❖ Amnesia is memory loss. In the early stages of dementia short-term (recent)

memory loss is affected. Marked alterations in a person’s ability to store experience

can lead to repeated requests for information. Having heard, within moments the

information is lost and the person is motivated to ask again. As memory worsens it is

not only answers that are forgotten, but the entire experience. The question has

never been asked!! With short-term memory loss the person can recall events from

years before but might not be able to remember if they had their breakfast.

Every individual is different, but as the disease progresses and more and more brain

becomes diseased, long-term memory is also lost. Remember it is important to

provide people with memory loss with a structured routine as they have limited

ability to think through changes in their routine. Changes in routine can have a very

negative effect on a person with dementia, causing distress and further confusion. In

caring for those with memory loss carers should;

Care of the Older Person – Unit 3 5N2706

Be patient

Maintain a structured routine

Repeat information as necessary using simple language

Label everything

Use validation therapy to acknowledge a person’s reality.

❖ Aphasia is difficulty in communicating. This usually begins in the middle stage of

dementia. There are two types of aphasia: expressive aphasia which presents as

difficulty using words and receptive aphasia which presents as difficulty

understanding words. The patient may present with one or both of these types of

aphasia. As carers we need to be observant at all times, what is a person’s

expression telling us? What about their body language?

When communicating with a person with dementia, remember that even if they do

not understand your words, they will understand your tone of voice and your body

language, words are only a small part of communication. In expressive aphasia the

person may use a word associated with what they want to communicate, but it is not

the right word. They may also group word together that do not make sense at all to

the listener.

Remember when you cannot understand the words spoken, respond to the mood or

feelings that the person is conveying through their body language and tone of voice.

In receptive aphasia the patient may not respond appropriately to your questions,

directions or general conversation as they may not understand what you are saying.

When caring for a person with aphasia the carer should:

Use simple words

Allow plenty of time for communication

Eliminate distractions to communication with the person

Make eye contact with the person when communicating

Observe the person’s body language

Use non-verbal communication to convey information to the person

Care of the Older Person – Unit 3 5N2706

❖ Agnosia: refers to difficulty recognising sensory input (through the senses, eyes,

nose, taste buds, ears, sense of touch) for example a person may look at a pencil, his

eyes see a pencil, but the part of the brain that tells the person what they are seeing

is not working. By the size and shape of the pencil the person may think it is a straw

put the pencil in a drink and try to drink through it. Our senses keep us safe, for

example our sense of smell warns us of gas leaks, touch allows us to recognise hot

and cold, our sight tells us what we are looking at and what we need to do to stay

safe.

Persons with agnosia are therefore unable to protect themselves and staff need to

be aware of their condition. A person with agnosia could easily take up a bottle of

shampoo, bleach, and drink it thinking it was a soft drink. A person with agnosia may

not recognise people she knows such as family and staff. As a result, every time

there is a change of shift, a whole new set of strangers come on duty. Consider how

distressing that would be. The person may not recognise themselves in the mirror

and think that there is a person spying on them in the window. Staff should be aware

of the effect that this can have on the families and offer support and reassurance as

necessary. When caring for a person with agnosia the carer should:

Introduce himself/herself and others to the person as necessary.

Take measures to limit the person’s access to objects, supplies and

equipment that could cause the person harm if they were misused or

swallowed.

❖ Apraxia is difficulty coordinating the steps needed to complete a task. Simple

everyday activities become difficult for the person with dementia. Things we all take

for granted like dressing, eating, taking care of our personal hygiene. This can lead to

frustrations and angry outbursts. As carers, we need to observe exactly what a

person is able to do and what he/she needs assistance with. Very often it is tempting

to do something for a patient rather than assisting them to do it for themselves.

Care of the Older Person – Unit 3 5N2706

It is very important for the patient to retain the skills they have for their self-esteem,

self-worth and dignity.

Each task can be divided down into steps, at each step remind the person what they

need to do next. This is important, if you give all the instructions at once the person

will become frustrated and confused and will be set up to fail, which will have

negative effects on the person and their behaviour. Allow the person plenty of time

and give positive reinforcement. When caring for a person with apraxia the carer

should observe what steps the person can do for himself/herself and then offer

assistance as needed.

Challenging Behaviour and Dementia

Many people with dementia present with challenging behaviours. There are many

definitions for challenging behaviour. Emerson (2001) defines challenging behaviour as

behaviour of such intensity, frequency or duration, that the physical safety of the person or

others is placed in serious jeopardy, or behaviour which is likely to seriously limit or deny

access to the use of ordinary community facilities.

When a person has dementia, one or more areas of the brain are damaged with the areas of

damage different for each person. The person therefore cannot help their behaviour due to

these damaged areas of the brain. People with dementia may therefore exhibit the

following behaviours: restlessness; aggression; agitation; wandering; disinhibition; hoarding;

cursing; shadowing; anxiety; depressed mood; hallucinations; and delusions.

The behavioural and psychological symptoms of dementia (BPSD) are defined by the

International Psychogeriatric Association (IPA). Behaviour symptoms include physical and

psychological symptoms.

Care of the Older Person – Unit 3 5N2706

Physical symptoms include:

Restlessness

Aggression

Screaming

Agitation

Wandering

Culturally inappropriate behaviours

Sexual disinhibition

Hoarding

Cursing

Shadowing.

Psychological symptoms include:

Anxiety

Depressed mood

Hallucinations and delusions

Cohen-Mansfield and Billig (1986), cited in Flood (2010) state people with dementia may

behave aggressively or un an agitated manner in one or more of the following ways:

❖ Physically aggressive behaviour such as hitting; kicking; pushing; spitting; biting;

scratching; grabbing or clinging onto people; hurting themselves or others; or

throwing things.

❖ Verbally aggressive behaviour such as shouting or cursing at others.

❖ Physically non – aggressive behaviour such as pacing; restlessness; wandering;

repetitious mannerisms; inappropriate disrobing or undressing; hoarding or hiding.

❖ Verbally agitated behaviour such as repeated requests for attention, strange noises

and negativism.

Care of the Older Person – Unit 3 5N2706

Flood (2010) goes on to tell us that by understanding what may cause such behaviour,

medical professionals and caregivers can take steps to ensure such behaviour happens less

often. Only 2% of aggressive events have been found to occur without an antecedent

(trigger), so it makes sense to make an effort to understand what makes a person with

dementia behave in an aggressive manner. For example, invading an individual’s personal

space will result in defensive or resistive behaviour. Exposing a confused person to the

upsetting reality that they are unwell can also distress them or explaining that a loved one

has passed away will just upset the person and make them relive the painful memory.

An abrupt or sudden approach to a person with dementia or unexpected physical contact,

may result in the person being physically alarmed. Attempting to restrict or control the

wishes and choices of the person may provoke an aggressive response.

In some cases, aggression may be linked to delusions, for instance, they may be convinced

that the neighbours are trying to kill them or poison them.

It is therefore important to understand what might be the meaning behind the aggressive

behaviour or agitation the patient is exhibiting. This will help prevent medical professionals

and carers from doing anything that may trigger aggression or agitation in the dementia

patient.

Strategies for working with patients who have dementia

It can be very difficult to get a person with dementia to follow instructions or redirect them

away from problematic behaviour. Remember, every person is an individual and the

approach that the carer takes must be individualised. The carers approach also has the

potential to de-escalate a situation or to worsen the situation. The following strategy is

generally accepted as an appropriate strategy for dealing with challenging behaviour.

Care of the Older Person – Unit 3 5N2706

Steps:

1. Validate: Validate the emotional state of the person with dementia. For example, you

could say: "you seem upset/anxious/annoyed/frightened". Or you could say: "You seem to

be in good form today". What you are doing here is acknowledging their state of mind.

2. Align: Try to align your behaviour with the person's behaviour as much and as safe as

possible. For example, you could say:

"You’re looking for someone/something? I hate when I lose something, let’s look

together”.

If the person still feels very focused on a task such as looking for someone or something,

encourage them to reminisce about where it is they want to go or who they are looking for.

For example, you could say:

"You're trying to get home? What's your home like? Tell me about your home".

Or you could say:

"You're looking for your mother? Tell me about her".

This helps develop a rapport with the dementia sufferer and aids the person with dementia

to reminisce. Reminiscence gives the person a chance to look at their lives and shows them

that you are interested in them and their past. This allows the person to relax and also

assists the build-up of a good relationship between the staff and the patient. It helps to

build the patient's self-esteem and self-worth. However, it is important not to remind him

or her that a loved one has passed away, or that they no longer live in their childhood home.

Here is an example of what NOT to say:

"You want to go home, but this is your home now, you must miss your other home".

3. Establish a Common Goal or Interest: Once a common goal or interest is established,

such as looking for something together, it will be much easier to distract the person from

their task. For example, you could say:

Care of the Older Person – Unit 3 5N2706

"I'm getting tired now, how about you? Will we have a cuppa?"

4. Redirection: Now that the person has been distracted from their original

task without becoming distressed it is easier to redirect the person to another task. To do

this you could say something like:

"Come to the kitchen and give me a hand making the tea" .

"Sit down on the couch and I'll turn on the TV so we can watch a programme

together".

REMEMBER: VALIDATE TO EMPOWER AND REMINISCE TO DISTRACT

This technique can take a little while to master, and you may have to go over the align step

a number of times to help make the person with dementia feel listened to and more in

control of the situation.

Carter and Goldschmidt (2010) remind us that as a person’s dementia progresses, they will

need more and more help with all activities of daily living (ADLs). In addition to physical

needs, the person will have emotional and social needs that must be met as well.

They give us the following guidelines

For a person with dementia, accomplishing every-day tasks such as bathing, dressing,

eating, and using the bathroom can be difficult. The inability to remember how to do these

things can be very frustrating for the person. Sometimes the person will resist doing what

you need her to do. This can be challenging for the nursing assistant who has been assigned

to provide care! Several factors can cause a person to resist care:

The person may not remember where she is, or who you are (amnesia).

The person may not recognise you (agnosia).

The person might not be able to understand what you are asking her to do (receptive

aphasia).

Care of the Older Person – Unit 3 5N2706

The person might feel threatened or rushed.

The person may feel as if she has no choice in the matter.

When you are helping a resident with dementia with her ADLs, there are several

general things you can do to gain the resident’s co-operation and help the task go

more smoothly:

Take the time to help the person to feel comfortable with you before beginning the

task. For example, introduce yourself as necessary, and talk with the person a little

bit before turning your attention to accomplishing the necessary task.

Speak clearly, in a calm tone of voice. Try not to appear rushed, busy, or impatient.

Remind the person at each step what she needs to do next.

Use hand gestures in addition to spoken instructions.

Plan for the procedure in advance. Being prepared and having everything you need

before you begin a procedure will allow you to accomplish the task efficiently, which

can help to reduce the amount of stress the person feels.

Keep to a regular schedule. Following an established routine also helps to reduce the

amount of stress the person feels.

Care of the Older Person – Unit 3 5N2706

SENSORY IMPAIRMENT

Sensory information helps people to communicate and carry out fundamental tasks in daily

life. The incidence of sight and hearing problems increases in older adults but can occur in

any age groups or exist from birth. Hearing impairments or deafness can result from a

variety of causes including heredity, disease, physical trauma, and exposure to loud noises.

Although hearing aids and cochlear implants are improving and can increase the ability to

hear, difficulties communicating may continue, particularly within noisy environments.

HCAs need to be aware of the problems that people with hearing impairment encounter

when trying to listen to or take part in a conversation.

Environmental Considerations

Background sound, even in a quiet environment, can add to communication problems. This

can be minimised if staff pay attention to some basic principles, namely good lighting,

managing group situations, methods of enhancing hearing, alternative methods of alerting

and good acoustics. Lighting should be ambient and at an adequate level to assist with

general communication and lip reading. People with hearing impairments can find it difficult

to communicate well, specifically in understanding conversations and hearing alarm alerts,

due to problems identifying and distinguishing between sounds.

Lip-Reading

Often, lip-reading is vital for a person with a hearing impairment. Lip-reading is an acquired,

not an inherent skill, but some people manage better than others. Lip-readers observe the

movements of the lips and the tongue together with facial expression, gestures and body

language. Speech should be delivered at a measured, but normal speed.

Care of the Older Person – Unit 3 5N2706

Communicating successfully with someone who is deaf or hard of hearing:

❖ Even if someone is wearing a hearing aid it does not mean they can hear you, ask if

they need to lip-read.

❖ If you are using communication support, always remember to talk directly to the

person you are communicating with, not the interpreter.

❖ It is important to make sure you have face-to-face or eye-to-eye contact with the

person you are talking to.

❖ Make sure you have the listener’s attention before you start speaking.

❖ Speak clearly but not too slowly, and do not exaggerate your lip movements.

❖ Use natural facial expressions and gestures.

❖ If you are talking to a deaf person and a hearing person, do not just focus on the

hearing person.

❖ Do not shout. It is uncomfortable for a hearing-aid user and it looks aggressive.

❖ Of someone does not understand what you have said, don’t keep repeating it. Say it

a different way.

❖ Find a suitable place to talk, with good lighting and away from noise and distractions.

❖ Check that the person you are talking to can follow you. Be patient and

communicate properly.

❖ Use plain language and don’t waffle. Avoid jargon and unfamiliar abbreviations.

Hearing Aids

Hearing aids operate by amplifying sound. This includes all sound, including background

noise, which can be problematic for some patients. If a patient uses a hearing aid, check that

it is working correctly and the battery does not need replacing. Although their function and

appearance has improved, they rarely restore hearing to normal, and some do not increase

the ability to interpret sound. Several people with hearing loss use other means of

communication, as well as lip-reading or signing.

Care of the Older Person – Unit 3 5N2706

Managing Daily Life

Today’s lifestyle is heavily reliant on auditory clues to carry out tasks. Within the home or

workplace, difficulties with hearing can affect a person’s life and cause problems with many

daily activities. There is an increasing range of equipment to assist people to cope within

their homes, workplaces and social settings.

Table 1. Assistive devices

Problem areas Solutions

Hearing the doorbell ➢ Extra loud doorbell or one with a different sound

➢ Additional bells sited in strategic places ➢ Flashing doorbell (visibly placed) ➢ System that flashes all or some of the

lights in the house ➢ Portable vibrating doorbell

Alerting to dangers ➢ Smoke and CO2 detectors with bright flashing lights or a vibrating pager/alarm

Waking up ➢ Vibrating pillow alarm ➢ Flashing alarm clock ➢ Vibrating wrist-watch

Hearing the telephone or mobile

phone ring

➢ Adjustable ring volume that increases the sound or alters the pitch

➢ Placing the telephone on a hard surface can amplify the sound

➢ Loud speaking bells or additional bells ➢ Phones installed in other rooms ➢ Flashing light or vibrating alert ➢ Mobile phones notify if there is a missed

call

Communicating ➢ Telephones with an inductive coupler in the handset that is hearing-aid compatible (used with the ‘T’ setting) that makes sound clearer and reduces background noise

➢ Using a hands-free kit or listening accessories such as neck and ear loops to enhance hearing

➢ Mobile text-phones ➢ Fax machines ➢ Text-phones that allow typing and provide

a reply on screen

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➢ Texting ➢ Web-cams and video-phones

supplemented by instant messaging conservations

➢ Using type-talk systems (a means of communicating between a textphone and a standard phone, for example, text relay)

Listening to the TV, radio etc ➢ Headphones including remote headphones

➢ Personal loop system or room loop system ➢ Subtitles on TV, video and DVD

Hearing a baby crying ➢ Flashing or vibrating alert unit

Visual Impairment

Visual problems can occur at any age and cause many difficulties including loss of visual field

and problems with focusing. Many people have good vision until they reach their mid-40s;

when reading small print and viewing distances can become difficult, this is termed a loss of

visual acuity. Ageing also decreases accommodation owing to loss of elasticity of the lens,

which causes problems coping in poor light or when there is glare. Older people are slower

at processing visual stimulation and need to look for longer before they can accurately

define what they are seeing.

When vision is impaired, there is an increased reliance on other senses, for example,

hearing and touch. Regular eye-tests are important as the assessment tools used by

opticians can detect serious medical problems that require attention.

Conditions that cause visual loss include:

Glaucoma

Cataract

Age related macular degeneration

Diabetic retinopathy.

Care of the Older Person – Unit 3 5N2706

Glaucoma: is caused by a build- up of fluid in the eye that causes pressure on the optic

nerve. Visual loss with eventual blindness occurs. Glaucoma can occur in one or both eyes. It

is extremely important that all people are checked for signs of glaucoma. If diagnosed in

time medication and surgery can control the condition but damage that has already

occurred cannot be reversed.

Cataracts: The lens of the eye is made mostly of water and protein. Specific proteins within

the lens are responsible for maintaining its clarity. Over many years, the structures of these

lens proteins are altered, ultimately leading to a gradual clouding of the lens. The person

may describe their vision as trying to look through a waterfall. Signs and symptoms of

cataract include:

Cloudy, blurry or dimmed vision, colours are faded. Blues and purples are hard to

see.

Sensitivity to lights and glares.

Halos around lights.

Double vision in one eye.

Cataracts can easily be removed by a simple surgical procedure, giving the person back their

vision.

Age related macular degeneration: this disease blurs central vision, in other words what

you can see straight ahead is blurred. Laser surgery may be of benefit to some people.

Diabetic retinopathy. With diabetic retinopathy tiny blood vessels in the retina are

damaged. The condition is a complication of diabetes and is a leading cause of blindness. It

usually affects both eyes. Vision blurs, often the person sees spots floating. There are very

rarely any warning signs. A person with diabetes needs to control their diabetes, blood

pressure and cholesterol.

Care of the Older Person – Unit 3 5N2706

The majority of people with visual impairment are able to manage well within their

environment and can cope with activities with the help of prescription lenses. Visual

problems can affect general safety and cause slips, trips and falls. Personal safety should be

addressed, particularly within the bathroom and kitchen. Items should be easy to identify

and noxious or dangerous chemicals should be stored in a separate place to personal items

to avoid accidental misuse.

Caring for patients with sight loss

If the person has very poor sight it is important to ensure that their environment is not

changed without their knowledge and agreement. The person will know where everything is

in their own area and will be able to manage without assistance. If, however, someone

moves their chair it could easily cause an accident. Sorrentino et al (2010) give us the

following important points when caring for a person with visual impairment.

The Environment:

Keep doors fully opened or closed.

Keep chairs pushed in under tables.

Ensure that all wires and cables are tidy and not a danger.

Provide adequate lighting.

When eating use the face of the clock to explain the position of the different foods

i.e. “your meat is at 3 o'clock and the potatoes are at 9 o'clock.

Orient the person to the environment.

Ensure that the person has a drink within reach.

Ensure that they have their phone within easy reach.

Report any faults in the environment to the manager.

The person:

Encourage the person to use the railing when climbing stairs.

Check shoes are comfortable and fit properly.

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Assist the person to walk as required. Have the person lightly hold onto your arm

just above your elbow. Have the person walk about ½ a step behind you. Never

push, pull or guide the person in front of you. Walk at a pace appropriate to the

person.

The carer:

Face the person when speaking, speak slowly and clearly.

Use a normal tone of voice.

Identify yourself when you come into the room, give your name, title and reason

for being there.

Ask the person how much he/she can see. Do not assume that the person is totally

blind or that they have some vision.

Identify others.

Address the person by name, this tells the person that you are speaking to them.

Encourage the person to do as much for him/herself as possible.

Offer to help and respect the person’s answer.

Warn the person of dangers.

Listen to the person and give them verbal cues that you are listening, say ''yes'',

''OK'', ''I see'' etc.

Give specific directions say “right behind you”, “on your left”, “on your right” avoid

statements such as “over there” or “over here”.

Prior to working with any patient, always check the care plan. The care plan will have the

person’s full assessment and you will be able to check just what the person's condition is,

how much assistance they require, and any special procedures or ways that will aid the

person. Loss of sight can mean loss of independence for some people. It is important that

we facilitate the person to continue to be as independent as possible. This is important for

their sense of worth and self-esteem.

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CONDITIONS ASSOCIATED WITH OLDER PERSONS

CEREBRAL VASCULAR ACCIDENT: CVA /STROKE

Stroke is the 3rd major cause of death and disability in the developed world. It is a

devastating condition both for the client and family. The yearly incidences of stroke is

estimated at 2 in 1,000 of the population. It is now, and will continue to be, a major public

health issue, with 2/3 of patients with a CVA being over 60years. A stroke can happen

suddenly, or be of a gradual onset, with a bleed or a blockage being the two main causes.

Rudd et al (2000) describe clinical types of strokes as:

Cerebral haemorrhage (accounting for around 20% of all strokes): this is a rupture

of an artery. It can be caused by an injury or a slow bleed (perhaps from an

aneurysm) that causes bleeding into or around the brain.

Cerebral thrombosis/embolism (around 80% of all strokes): this is owing to a blood

clot, plaque or emboli; perhaps from another part of the body that causes blockage

of blood vessels in the brain.

Transient Ischaemic Attacks (TIAs) also termed ‘mini-strokes’, can result from a small

thrombosis or emboli, and the symptoms resolve in 24 hours (Rudd et al, 2000). TIAs arise

from clots elsewhere in the body that have dislodged and travelled to the brain, or they can

be owing to weak cardiac walls, resulting in a reduced output of blood.

The risk of developing a stroke after a hemispheric TIA can be as high as 20% within the first

month, with the greatest risk being within the first 72 hours (Intercollegiate Stroke Working

Party, 2004). TIAs should be viewed as warnings of an impending, more severe or a

permanent stroke.

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The warning signs

It is possible to have a ‘silent stroke’ that can go unnoticed; however, for most people the

effects of a stroke are life-changing. Many stroke victims may have warning signs that go

unheeded such as:

Sudden weakness, numbness or paralysis of the face, arm or leg (especially on one

side of the body)

Loss of speech or trouble talking or understanding language

Sudden loss of vision, particularly in only one eye

Sudden severe headache with no apparent cause

Unexplained dizziness, loss of balance or co-ordination (especially if associated with

any of the above symptoms)

(Stanford Stroke Centre, 2008).

RISK FACTORS:

Age {over 60yrs}

Hypertension

Obesity

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Gender {men at greater risk}

Diabetes

Cardiac disease

Ethnicity

Previous TIA

Family history

Smoking.

SIGNS & SYMPTOMS OF CVA {STROKE}:

Numbness/weakness/paralysis on one side of the body

Drooping mouth/eye

Floppy arm/leg

Slurred speech

Sudden blurred vision/loss of sight

Confusion/unsteadiness

Severe headache.

F.A.S.T GUIDE IN RECOGNISING STROKES

F – Facial weakness, the person is unable to smile and the mouth and eye may be

droopy

A – Arm weakness, the person is only able to raise one of their arms

S – Speech problems, the person is unable to speak clearly or may not understand the

spoken word

T – Test the sign and call 999/112 for emergency help if you suspect the person has had a

stroke

{Ref: Irish Heart Foundation, 2010}.

The brain is the control centre for the body and everything we do. The brain is divided into

two halves, one side controls the opposite side of the body. For example, the left side of the

brain controls the right side of the body. Each side of the brain has specific functions.

Care of the Older Person – Unit 3 5N2706

How the body is affected by a stroke depends on how much brain tissue has been damaged

and where.

The effect of a stroke varies depending on the area of the brain that is affected, the extent

of the impairment of blood supply, and the degree of collateral blood supply.

Some strokes (including TIAs) only produce a short period of muscle weakness; but many

strokes cause paralysis down one side of the body (hemiplegia), balance problems, loss of

sensation, personality changes, and communication problems. Perceptual and visual

problems may occur. A dense hemiplegia can result from a stroke.

Severe strokes can lead to difficulty in eating and breathing, to unconsciousness, and even

death. There can be considerable psychological problems stemming from adjustment to the

incapacity and changes that a stroke can bring.

Care of the Older Person – Unit 3 5N2706

Commonly used terms related to stroke:

❖ Aneurysm: A weakened or thin part of an artery wall that has stretched or ballooned

out from the wall and filled with blood, or damage to an artery leading to pooling of

blood between the layers of the blood vessel walls. An aneurysm may burst causing

a haemorrhage.

❖ Anti-coagulant: Medication used to prevent the formation of blood clots that can

become lodged in cerebral arteries and cause strokes.

❖ Aphasia: The inability to understand or create speech, writing, or language in general

due to damage to the speech centres of the brain.

❖ Apraxia: A movement disorder causing difficulties using everyday objects or carrying

out purposeful activities, generally caused by a stroke in the area that controls

voluntary movement.

❖ Arterial hypertension: High blood pressure.

❖ Ataxia: Loss of control of muscle function producing abnormal movement patterns.

❖ Atheroma/atherosclerosis: Fatty deposits in blood vessels that restrict blood flow.

❖ Arterio-venous malformation: A congenital disorder characterised by deficits of the

circulatory system.

❖ Atherosclerosis: Deposits of lipid material on the inside of the walls of large to

medium-sized arteries which make the artery walls thick, hard, brittle, and prone to

breaking.

❖ Dysarthria: A disorder characterised by slurred speech due to weakness or poor co-

ordination of the muscles involved in speaking.

❖ Dysphagia: Difficulty swallowing.

❖ Hemianopia: Loss of half the visual field in both eyes.

❖ Hemiparesis: Weakness or partial paralysis on one side of the body.

❖ Hemiplegia: Complete loss of power or voluntary movement on one side of the

body.

❖ Infarction: Sudden loss of blood supply causing damaged tissue.

❖ Intracerebral haemorrhage: A blood vessel within the brain leaks blood into the

brain.

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❖ Ischaemia: A loss of blood flow to tissue, caused by an obstruction of the blood

vessel, generally due to plaque, stenosis, or a blood clot.

❖ Plaque: Fatty cholesterol deposits found along the inside of artery walls that lead to

atherosclerosis and stenosis of the arteries.

❖ Spasticity: Increase in muscle tone causing impaired movements.

❖ Stenosis: Narrowing or blockage.

❖ Subarachnoid haemorrhage: Bleeding within the meninges, or outer membranes, of

the brain into the clear fluid that surrounds the brain.

❖ Thrombosis: Clot of blood in one of the cerebral arteries that can cause blocking of

an artery.

Parkinson's

Parkinson's disease is a progressive neurological disorder that causes muscle tremors,

stiffness and slowness of movement. Parkinson’s disease was first described by a London

physician James Parkinson in 1871. Common among older persons it affects more men than

women. It affects 1% of the population over 50years. Today there is still no cure.

Parkinson’s disease is a neurological condition affecting the nervous system. It is referred to

as progressive, meaning it gradually affects the body more as time goes on. It involves the

degeneration of nerve cells in the part of the brain that controls movement, called the basal

ganglia. Normally, these nerve cells produce dopamine – a chemical messenger or

neurotransmitter, which is used by the brain to control movement. In Parkinson's disease

the production of dopamine is reduced.

The part of the brain that controls movement is reliant on the presence of a chemical called

dopamine, which is produced by other brain cells. Although the reasons are unknown,

dopamine producing cells begin to deteriorate in those developing Parkinson's disease.

Care of the Older Person – Unit 3 5N2706

Once around 70% of the cells have been lost, the condition's symptoms can be seen

(Parkinson's UK 2011). Dopamine levels will continue to decrease over many years, leading

to new and further developed symptoms.

Symptoms

Parkinson’s disease is a fluctuating condition, meaning that a person’s symptoms can vary

and change at any time. A person with Parkinson’s disease can look and seem well one day,

but not the next. Symptoms can vary from day to day, or even from hour to hour. The main

symptoms are tremors, muscle rigidity (stiffness) and slowness of movement. It can affect

everyday activities such as talking, walking, swallowing and writing.

Other less visible symptoms may include sleep difficulties, tiredness, depression, anxiety

and memory loss, which themselves can have a significant impact on day-to-day life. The

person may feel frustrated and isolated by their condition, a loss of skills and a reduced

ability to complete everyday tasks. Not everyone with Parkinson’s disease has a tremor—

only around 70% experience this symptom (Parkinson's UK, 2011).

A tremor is an uncontrollable shaking movement that affects a part of the body, usually the

hand. Anxiety or stress can make a tremor worse, and Parkinson’s disease drugs, such as

levodopa, can reduce or stop a tremor. Parkinson’s disease can also prevent the muscles

from stretching or relaxing. Simple movements, for example, rolling over in bed or fastening

buttons, can become difficult or impossible to manage. It is common for a person with

Parkinson’s disease to suddenly stop when making a movement like walking (referred to as

'freezing').

Rigidity in Parkinson’s disease means the stiffness or inflexibility of the muscles and can

cause pain or cramping. It may be difficult for people with Parkinson’s disease to move as

quickly as they would like, which can also be extremely frustrating. They may find it difficult

to start a movement, such as getting out of a chair. This can change quickly, however, and at

times the client with Parkinson’s disease can move easily.

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Diagnosis:

❖ No specific test

❖ Detailed medical history

❖ Rule out other diseases

❖ Referred to neuro- specialist.

Treatment:

❖ No cure

❖ Symptoms can be controlled by medication

❖ Physiotherapy

❖ OT therapy

❖ Speech therapy

❖ Healthy diet

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❖ Exercise

❖ Safety needs

❖ Socialise

❖ Family support.

Problems can occur with many daily living activities, and although different techniques

(Swann, 2007a; 2008) can help, equipment can considerably enhance a person’s level of

ability. Often a combination of an alternative technique and an assistive device is needed.

Assistive devices can also enable carers to manage moving and handling tasks more easily,

more ergonomically and more safely.

MULTIPLE SCLEROSIS

MS is a chronic disease of the central nervous system. It causes gradual deterioration which

results in a progressive deterioration in various functions controlled by the nervous system =

such as vision, speech and movement. In MS the body's immune cells attack the myelin

sheet [i.e. the cover of the nerves in the brain and the spinal cord}.

The myelin sheath is damaged and nerve messages are sent more slowly, thus with less

effect. Scar tissue develops over the affected area which further damages the nerves.

It is caused by the body’s own attack on its immune system. It is not fully understood why

this happens. It may be linked to hereditary and environmental factors. 600 people are

estimated to be affected by MS in Ireland, it is more prevalent in women and develops

between the ages 20 to 40. There is no cure for MS, learning how to manage the disease

and adapt lifestyle is the key to coping with the illness.

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Types of MS:

RELAPSING – REMITTING MS: is where there are periods of attacks followed by

periods when there are no symptoms. This can last for days, months and can vary

from mild to severe.

PRIMARY – PROGRESSIVE MS: never have distant relapses or remissions, but

symptoms become steadily worse and they become progressively disable.

BENIGN MS: starts with small number of mild attacks and is followed by complete

recovery there is no permanent disability.

Diagnosis:

Is difficult

No single test for the disease

History is taken

Test include = CT SCAN, MRI, CSF ASPIRATION.

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Treatment:

Symptoms are so varied they can be managed separately as and when they arise

Medication

Physiotherapy

Occupational therapy

Diet

Assistive devices.

Mental Illness: Depression

To understand what is abnormal we must have a concept about the normal behaviour of

man. Psychology is defined as the measurement of normal behaviour. Attainment,

intelligence, and personality are key areas of psychological measurement.

When individuals fall outside the normal range, the psychologist may refer them to a

psychiatrist who may treat them by using a variety of techniques ranging from

psychotherapy/counselling/hospitalisation/medication. The World Health Organisation

defines health:

‘As a state of complete physical, mental and social wellbeing not merely in the absence of

disease or infirmity‘.

Physical health is concerned with the normal functioning of the body. Mental health may be

defined as the ability to think clearly and coherently.

A mentally healthy person has a positive attitude towards life, welcomes new experiences

and ideas, and does not fear change. They enjoy a challenge, are aware of their own

limitations and shortcomings. They enjoy simple everyday pleasures and are not

overwhelmed by disappointment if something does not turn out as hoped.

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A mentally healthy person experiences a whole range of emotions - anger, fear, love, hate,

joy, guilt, jealousy, pleasure, but is not overcome by any of them. He/she respects

themselves and others, can communicate freely and honestly with the other people in their

lives.

They are open to liking and trusting others. They can form satisfying and lasting friendships.

He/she is neither aggressive nor domineering and equally, does not see himself/herself as a

victim. They accept and tolerate the faults and shortcomings of others. They identify with

and feel part of the various groups to which he/she belongs. In order to maintain our mental

health we need to pay attention to:

❖ Lifestyle - we need a good balance between work or study and leisure pursuits.

❖ Social contact - with others whose company we enjoy helps to develop social

interaction.

Reviewing our lives from time to time - this involves considering what our aims and goals in

life are and whether we are taking steps to achieve them. Problems can arise which can

affect physical health, the reverse is also true. If diet, sleep, and exercise are neglected and

inadequate, not only our bodies will suffer, but also our minds. We should be aware of

problems and seek help if necessary.

It is important for us to realise that tiredness and irritability if ignored, might lead to more

serious stress related problems.

Mental illness is probably best understood by reference to:

❖ The individual

❖ The cultural context within which they live their lives and what is normal for them

Up to the late 18th century, the causes and treatment of mental illness were based upon

superstition, demons and witchcraft. Today there is a better understanding, however there

is still a stigma attached. Worldwide, it is estimated that 400million people are suffering

from various types of mental illness.

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The Mental Health Act 1983 divides mental disorder into 2 categories:

[A] Serious disorders - Mental illness and severe mental impairment.

[B] Minor disorders - Non severe mental impairment; and psychopathic disorders.

The main difference in terms of legal powers is that a client suffering only minor disorders

cannot be compulsorily admitted or detained for treatment unless the treatment will

benefit him/her (Brayne and Martin, 2001). We are inclined to think of mental health as

being unrelated to physical health, but if we consider, for example, the effects of injury,

illness, weight problems and lack of sleep, on how we feel and on our mood in general, we

can see that this is not so.

If we neglect our physical health, eventually we may experience not only physical problems,

but also mental and emotional problems; with for example, mood swings, lethargy, poor

concentration and little enthusiasm for life. Conversely, if we eat and sleep well and take

some form of exercise, our emotional and cognitive functioning is enhanced. It is well

established that exercise releases chemicals in the brain, which can improve our mood and

general well-being.

Ultimately therefore, safeguarding physical health helps to maintain mental health and vice

versa. When mental health is threatened, we often neglect our physical health. Similarly, if

we neglect physical health, we may become worried about our lack of fitness and the

possibility of serious future problems.

Mental health problems can result from a range of adverse factors associated with social

exclusion and which can also be a cause of social exclusion. THE WORLD HEALTH

ORGANISATION 2001 has noted nine of particular relevance:

❖ Depression.

❖ Unemployed are twice as likely to have depression as people in work.

❖ Children in the poorest households are three times more likely to have mental

health problems than children in well-off households.

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❖ Half of all women and a quarter of all men will be affected by depression at some

period during their lives.

❖ People who have been abused or been victims of domestic violence have higher

rates of mental health problems.

❖ Between a quarter and a half of all people who use night shelters or who are

sleeping rough may have a serious mental disorder, and up to half may be alcohol

dependent.

❖ Some black and minority ethnic groups are diagnosed as having higher rates of

mental disorder than the general population; refugees are especially vulnerable.

❖ There is a high rate of mental disorder in the prison population.

❖ People with drug and alcohol problems have higher rates of other mental health

problems.

❖ People with physical illnesses have higher rates of mental health problems.

What is Mental Illness?

It is a term used to refer to all the different types of mental illness.

The Mental Health Act {2001} defines it: as a state of mind of a person which affects the

person's thinking, perceiving, emotion, or judgment and which seriously impairs the

mental function of the person to the extent that he or she requires care or medical

treatment in his or her own interest, or in the interest of other persons.

Causes:

Genetics – schizophrenia

Environmental

Chemical imbalance in brain

Complications during pregnancy/childbirth

Depression

Communicating with a person suffering from depression

When communicating with a person who is depressed, be patient, and make eye contact as

much as possible.

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Making eye contact will help you to tell whether or not the person is paying attention to

you, and you will also be able to see if the person is starting to get irritated. If you sense that

the person is starting to get irritated or angry, do not take it personally and do not try to talk

the person out of his feelings. Encouraging a person who is depressed to be more cheerful

will only make the person feel more isolated and misunderstood.

A more appropriate response would be to acknowledge what the person is experiencing and

allow him some control. For example, you could say something like, “Mr. Joseph, I seem to

be upsetting you with my questions. I apologise. I don't mean to upset you. I want to help

you, but if you would rather, I come back later, I can do that” or “Mr. Joseph, I understand

that you are feeling very upset right now. Would you like to talk about what is bothering

you?”. These responses show the person that you are aware of his feelings, that you care,

and that you are respecting him by allowing him some control.

Carter and Goldschmidt (2010)

SAD [Seasonal Affective Disorder]

Is a type of winter depression that affects certain people every winter between September

and April. It is caused by a biochemical imbalance in the hypothalamus due to the

shortening of daylight hours and the lack of sunshine in winter. For many people, SAD is a

seriously disabling illness, preventing them from functioning normally without continuous

medical treatment.

For others, it is a mild but debilitating illness causing discomfort, but not severe suffering.

The main difference between SAD and other types of depression is that SAD occurs only

during the winter months. In many types of depression, people generally eat and sleep less

and lose weight. However, people with SAD usually eat and sleep more and gain weight

when it is cold and dark outside.

SAD affects an estimated 1 in 2O adults, with as many as four times more women than men

affected, and it is most common in younger adults between the ages of 20 to 4O years.

Care of the Older Person – Unit 3 5N2706

Symptoms:

❖ Sleep problems - usually desire to oversleep and difficulty staying awake but, in

some cases, disturbed sleep and early morning wakening.

❖ Lethargy - feeling of fatigue and inability to carry out normal routine.

❖ Overeating - craving for carbohydrates and sweet foods, usually resulting in weight

gain.

❖ Depression - feelings of misery, guilt and loss of self-esteem, sometimes

hopelessness and despair, sometimes apathy and loss of feelings.

❖ Social problems - irritability and desire to avoid social contact.

❖ Anxiety - tension and inability to tolerate stress.

❖ Loss of libido - decreased interest in sex and physical contact.

❖ Mood changes - in some sufferers extremes of mood and short periods of

hypomania (over activity) in spring and autumn.

Treatment

Light therapy has been shown to be effective in up to 85 per cent of cases. That is, exposure

of up to 4 hours a day of very bright light, at least 10 times the intensity of ordinary

domestic lighting. This therapy consists of sitting two to three feet away from a specially

designed light box, usually on a table, allowing the light to shine directly through the eyes.

Treatment is usually effective within three to four days and the effect continues provided it

is used every day.

ANTIDEPRESSANT DRUGS - in more severe cases of SAD, antidepressant drugs may be

needed. Traditional drugs are not usually helpful for SAD as they exacerbate the sleepiness

and lethargy that are symptoms of the illness. The non-sedative drugs e.g. paroxetin

(seroxat) and fluoxetine (prozac) are effective in alleviating the depressive symptoms of SAD

and combine well with light therapy.

PSYCHOTHERAPY - counselling or any other complementary therapy which helps the

sufferer to relax, accept their illness and cope with their limitations are extremely useful.

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Self-help approaches to SAD include keeping warm, getting up early rather than lying in bed,

getting out in the open air for exercise as much as possible, and eating little and often

during the day. It may help to eat a low-glycaemic diet concentrating on wholegrain cereals,

root vegetables, legumes, oily fish and cheese - the latter two foodstuffs contain

tryptophan, a substance needed to make serotonin in the brain.

DISCHARGE PLAN - The aim is to build upon the progress made during in-patient stay, and

work towards the treatment, prevention or management of recurrent depressive episodes

(MAGO, 1999). The carer's/nurse's focus will be on improving long-term outcomes for the

client who is at risk of lifelong and multiple recurrences which may be chronic and

unremitting. The community team should help the client to establish social links in the hope

that with good community interaction a relapse may be prevented.

SCHIZOPHRENIA

Affects 24 million people worldwide, within the age group 15-35. It is a severe chronic brain

disorder. The person finds it very difficult to adapt to their environment. Withdrawal and

loss of contact with reality are the main characteristics.

Symptoms:

❖ Hallucination

❖ Delusion

❖ Lack of emotion

❖ Lack of interest

❖ Difficulty communicating

❖ Neglect of basic hygiene needs

Treatment:

❖ Focuses on eliminating the symptoms

❖ Drug therapy

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❖ Psychosocial therapy which deals with communication, motivation, self-care.

Working with People with Mental Illness

Physical - Using the activities of daily living according to Roper, Logan, and Tierney. The

carer will look after the physical needs of the client, according to Maslow’s hierarchy of

needs. A psychologist will devise a programme for the specific need of the individual; each

member of the healthcare team will be made aware of their responsibilities in assisting the

client in the same.

Maintaining a safe environment is paramount for the safety of all concerned. A risk

assessment will be carried out by the manager and evaluated weekly. Any hazards identified

will be rectified as soon as possible to prevent injury to all. Social, emotional and

recreational aspects - are all interrelated. If one's social needs are met through recreational

facilities, than the emotions are more or less kept on an even keel; even those who

demonstrate aggressive behaviour.

All healthcare facilities have an occupational therapy unit, where different programmes are

devised to suit individuals' needs. The occupational therapist will also demonstrate to carers

how to carry out these programmes to better meet clients' needs. Clients may take part in

swimming, music evenings, bingo, cards, reminiscence therapy, to name a few. Carers

should look beyond the illness or impairment and support the client to achieve self-

actualisation.

All service users/clients will receive some form of monetary entitlement; this will be held in

the manager's safe and given to them as they need it. Usually there is a shop within the

healthcare facility where they can buy what they need. If clients are in social housing, then

they will have a house manager with them, he/she will assist them with shopping, etc.

Environmental issues - as already mentioned, safety is vital, good hygiene practices need to

be carried out. Central heating is safer than open fires and should be kept at the right

temperature for the client.

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A multi-sensory room can be beneficial to some clients, especially those who suffer

challenging behaviour; this is a room that has different lights moving, glowing in glass tubes,

reflecting different images on the walls. Soft music may also be played. Seating is soft,

comfortable, washable, and wall to wall.

Spiritual issues - as all service users must be treated holistically, all religious denominations

must be respected, and provision made for them to practise their faith as they see fit.

Safe working relationships - knowing your client and gaining his/her trust is one way of

keeping safe. Knowledge of their conditions, being aware of the dangers that may occur,

and following the guidelines set down by the authority for safe work practices, e.g. NEVER

ALLOW SERVICE USERS TO BLOCK THE EXIT at any time.

Remain aware of the client's physical space or territory, do not trap the client. Use the

intercom or mobile phone to summon assistance if required. Good communication skills are

essential when working with people, especially when working with people who have a

mental health disorder.

Apart from verbal communication, good eye contact is necessary; your body language could

display if you are comfortable in the situation or not. As part of our daily care plan for

clients, effective communication within the medical/ nursing/care disciplines is of huge

importance if we are to better meet the client's needs.

When evaluating the care plan, sometimes family members may be present, it is good

practise to communicate effectively with them, allowing freedom of speech, and treating

their input with dignity and respect.

Care of the Older Person – Unit 3 5N2706

The Flower Approach

This approach is an excellent way to demonstrate the essential skills of active listening:

F FACE - the person you are talking to in a way that shows you are really listening.

Sitting face to face, at a comfortable distance will allow the person to relax and be

open to you.

L LEAN - towards the person who is talking to you. This shows you are interested in

what he /she is saying. However, do not invade a person’s private space.

O OPEN - posture is important. This shows you are interested in the person.

W WATCH - the person carefully. Should you sit with arms folded or legs crossed this can

be seen as a barrier.

E EYE - contact is also very important. However, do not stare, this can be seen as

threatening and can make a service user feel uncomfortable.

R RELAX - ensure you are positioned comfortably. Do not fidget as the person may

assume you are not giving them your full attention.

The FLOWER approach will help you to become an active listener.

Individualised Care

As already demonstrated, all clients/service users on admission have a care plan set up for

them by the care team. Care plans are part of models of nursing; a nursing model provides

the basis for the framework of nursing practice; and the direction for nursing research.

Current philosophies reflect the trend to address the total person as an individual in

interaction with the family and the community.

Team meetings are carried out weekly to assess the client’s needs and progress. All staff

working with the service user will attend and should have an input into this review; family

members may also be present. The service user may be present or may have a private

meeting with the psychiatrist/ward manager alone. The client is encouraged to discuss how

he/she feel about their treatment or progress, if they are well enough to do so.

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Dignity - people generally like to be treated with respect and dignity, therefore it is only

right that our service users be treated with respect from all members of the

multidisciplinary team and from their fellow residents.

Choice - all service users have a choice today. They have individual rights as laid down in THE

PATIENT'S CHARTER 1992 by Dr. John O’Connell and implemented by Minister Brendan

Howlin in 1993. This document is on view in all healthcare facilities for all to read and

become aware of their rights.

Self-esteem - clients have the right to feel good about themselves; it is the duty of the carer

to help them to achieve this through the basic needs and helping them to express sexuality.

Maslow’s hierarchy of needs comes into play here.

Confidentiality - this is a must for all service users. It is part of the nurses’ code of practice

and if not adhered to, it can be a reason for suspension on the part of the nurse. Medical

staff take an oath of allegiance to their clients, confidentiality comes under that oath. It is

very important that staff members do not discuss clients when off duty.

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CHRONIC & ACUTE ILLNESS

The word "chronic" is typically used for conditions, illnesses, and diseases lasting three

months or more. Often, chronic conditions are characterised by lasting symptoms and/or

pain that persists, sometimes even despite treatment. Chronic illnesses are the opposite of

acute illnesses; acute conditions come on fast and usually don't last a long time. This isn't to

say that people with chronic conditions are continually suffering; rather, a chronic condition

is one that is expected to last a long time. Many patients, in fact, are able to manage their

disease to live relatively healthy and normal lives. Others often have conditions that go into

remission - that is, the symptoms disappear for a time.

Chronic illness/conditions (a number of which are discussed below) include:

Asthma

Diabetes

Chronic obstructive airways disease

Epilepsy

Alzheimer’s

Heart disease

Cancer

Osteoporosis

Arthritis

Heart attack/myocardial infarction.

CHRONIC OBSTRUCTIVE AIRWAYS DISEASE:

Is a collective term for three disorders of the respiratory system:

❖ Asthma: Is the narrowing of the airways. It results in shortness of breath and can be

triggered by: allergies, stress, smoking, infection, exertion. Symptoms include:

wheezing, cough, SOB, rapid pulse, cyanosis, fear, gasping for breath. Treatment

involves: drugs, nebulizers, oxygen therapy and education.

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❖ Bronchitis: Inflammation of the bronchi of the lung, smoking is a major cause. Others

include, infection/air pollution/industrial dust. Symptoms include: morning cough,

dry cough, productive cough, SOB, lethargic. Treatment involves oxygen therapy,

stopping smoking, deep breathing exercises, medication/antibiotics.

❖ Emphysema: The alveoli in the lung enlarge and becomes less elastic, air becomes

trapped and the exchanges of gases is obstructed. Smoking is a major cause.

Treatment: oxygen therapy, medication, stopping smoking.

Diabetes

Diabetes mellitus is a condition characterised by a chronically raised glucose level in the

blood known as hyperglycaemia. Glucose is used by the body for energy production and

comes from carbohydrate food sources, e.g. sugars and starch. Digestion breaks down the

carbohydrates into glucose, which is then released into the blood. The pancreas is a gland in

the body situated behind the stomach.

One of the functions of the pancreas is to make a hormone called insulin. Insulin moves

glucose from the bloodstream into the cells of the body where it is needed, for example,

muscle cells. Raised blood glucose levels are caused by a lack of the insulin or by the body’s

inability to use the insulin properly, known as insulin resistance. Whichever the cause, the

blood glucose levels remain high and not enough energy gets to the cells and muscles

(Williams and Pickup, 2005).

Care of the Older Person – Unit 3 5N2706

The two main types of diabetes are type 1 and type 2. Type 1 diabetes is caused by an

autoimmune destruction of the insulin-producing beta cells in the pancreas, resulting in

absolute insulin deficiency. This is more common in children and young adults, but it is also

identified in adults.

Type 2 diabetes is much more common, representing about 90% of cases in developed

countries. Onset usually occurs after the age of 40 with the peak age at 60 years. Monitoring

of diabetes is essential. It is important that all individuals with diabetes receive at least

annual reviews at their local hospital or GP surgery. The purpose is to determine if

treatment is satisfactory and to identify any evidence of longer-term complications. People

with diabetes have up to a fivefold increased risk of cardiovascular disease (heart attacks,

strokes and blockages to the vessels in the feet and legs) compared with those without

diabetes (Williams and Pickup, 2005).

When caring for older persons it is important to be aware, as Jones et al (2004) suggested,

that the decreased experience of thirst, which is often present in elderly people, may mask

the presence of hyperglycaemia and glucose may not be detected in the urine.

Epilepsy

The word 'epilepsy' is derived from the Greek word meaning 'to be seized, to be

overwhelmed by surprise'. To have epilepsy is to have a tendency to have recurring seizures.

Anyone can have a seizure, if the brain is exposed to a strong enough stimulus. We know

that about 1 in every 20 people will have a single seizure at some time during their lives.

Official figures by Brainwave estimate that there are 30,000 to 40,000 people with epilepsy

in Ireland. Epilepsy is a generic term used to define a family of seizure disorders.

It is a common chronic neurological disorder. A seizure is a brief disturbance of electrical

activity within the brain. The WHO estimate that there are 40-50 million people with

epilepsy throughout the world.

Care of the Older Person – Unit 3 5N2706

Muscoloskeletal Disorders:

Arthritis is the name for joint disease from a number of causes. Arthritic disease causes

painful inflammation of one or several joints with the inflammation destroying the cartilage

in the joints. Osteoarthritis and rheumatoid arthritis are the most common. The majority of

Irish people over the age of 55 have evidence of osteoarthritis at some joint in their body. It

concentrates in one or several joints, usually the fingers, feet, knees, spine, hips.

It develops when cartilage in the joint deteriorates, as the disease progresses the cartilage

loses elasticity and becomes increasingly prone to damage, leaving the end of the bones

unprotected. Rheumatoid arthritis is an autoimmune disease that causes chronic

inflammation of the joints. It may be caused by infection, genetic or environmental factors

may be involved and it usually begins between the ages 30 to 40, more commonly in

women.

Treatment can be difficult, as it depends on the type of arthritis, and there is no cure.

Treatment is aimed at reducing joint pain and inflammation, and can include drug therapy –

steroids, analgesia, anti- inflammatory, change of lifestyle factors, joint injections and

surgery.

Myocardial Infarction {Heart Attack}

A heart attack or myocardial infarct is caused by a sudden obstruction of the blood supply to

part of the heart muscle, for example due to a clot in a coronary artery which is known as a

coronary thrombosis. The main concern is that the patient’s heart will stop beating.

It is important that all HCAs are aware of the signs and symptoms of a heart attack.

Signs and Symptoms include:

Persistent vice like central chest pain, often spreading to the jaw and down one or

both arms, unlike angina the pain does not ease when the patient rests

Breathlessness

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Discomfort occurring high in the abdomen, which may feel similar to severe

indigestion

Collapse often without warning

Sudden faintness or dizziness

Patient feels a sense of impending doom

Ashen skin and blueness at the lips

A rapid, weak and irregular pulse

Profuse sweating

Extreme gasping for air (air hunger).

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HEALTHCARE NEEDS OF THE OLDER PERSON

Nutrition & Malnutrition

Older persons are particularly vulnerable to malnutrition. Moreover, attempts to provide

them with adequate nutrition encounter many practical problems. First, their nutritional

requirements are not well defined. Since both lean body mass and basal metabolic rate

decline with age, an older person’s energy requirement per kilogram of body weight is also

reduced.

The process of ageing also affects other nutrient needs. For example, while requirements

for some nutrients may be reduced, some data suggest that requirements for other

essential nutrients may in fact rise in later life. There is thus, an urgent need to review

current recommended daily nutrient allowances for this group. There is also an increasing

demand worldwide for WHO guidelines which competent national authorities can use to

address the nutritional needs of their growing elderly populations.

Many of the diseases suffered by older persons are the result of dietary factors, some of

which have been operating since infancy. These factors are then compounded by changes

that naturally occur with the ageing process.

Dietary fat seems to be associated with cancer of the colon, pancreas and prostate. Risk

factors such as increased blood pressure, blood lipids and glucose intolerance, all of which

are significantly affected by dietary factors, play a significant role in the development of

coronary heart disease.

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Degenerative diseases such as cardiovascular and cerebrovascular disease, diabetes,

osteoporosis and cancer, which are among the most common diseases affecting older

persons, are all diet-affected.

Deficiencies are often common in elderly people due to a number of factors such as their

reduced food intake and a lack of variety in the foods they eat.

Nutrition

Nutrients are chemical substances in food that:

❖ Provide energy

❖ Build and maintain cells

❖ Regulate body processes.

Essential Nutrients:

❖ Carbohydrates

❖ Starch

❖ Cellulose

❖ Proteins

❖ Lipids (fats)

❖ Water

❖ Fibre

❖ Vitamins

❖ Mineral salts.

All essential vitamins, minerals etc. must be used in all diets and selected from the food

pyramid.

Care of the Older Person – Unit 3 5N2706

Client nutrition is the responsibility of the nurse/carer and an HCA should always be aware

of clients who need assistance with feeding.

Ten Point Nutrition Plan:

Client risk of malnutrition assessment

Ongoing nutritional assessment must inform care planning and delivery

Care environment must be conducive to eating

Necessary assistance with eating and drinking should be supplied

Clients and carers must understand how to obtain food

Clients should receive food that meets their individual requirements

Clients should get a replacement meal if they miss one and snacks at any time

Food must be presented in an appealing way

Food consumption must be monitored, recorded and acted upon if there is cause

for concern

Clients must be encouraged to eat to promote health.

Care of the Older Person – Unit 3 5N2706

Supporting Clients' nutritional needs:

❖ Ensure the patient receive the 'right' nutrition for their circumstances (that is

appropriate for their diagnosis or status e.g., soft diet, clear fluids, low fat diet).

❖ Ensure the patient receives nutrition at the 'right 'time' (at times when they are

likely to be hungry or that is appropriate for any treatment/procedure they might

be undergoing).

❖ Ensure the patient receives nutrition via the 'right' route (by mouth or feeding tube

or other route appropriate for their condition).

❖ Ensure the patient receives nutrition in the right place/manner (i.e. appetising

presentation, correct temperature, within their reach etc.).

Protected Mealtimes

Protected mealtimes are periods of time when patients are able to eat their meal without

unnecessary interruptions and when nursing staff and the ward team are able to provide

safe nutritional care. The key principle of protected mealtimes is making sure patients are

‘ready’ to eat. HCAs have a vital role here, making sure patients have had the opportunity to

use the bathroom and wash their hands. Patients must be in the right position for eating

(either sitting up in bed or a chair) and that they have the right equipment (like special

cutlery, slip proof mats etc.).

Activity should be focused on patients and their meals. Patients/clients should not be

unnecessarily disturbed during mealtimes. The environment should encourage eating and

the place where clients eat should resemble a dining area as much as feasibly possible.

Appropriate assistance must be provided for those who need it.

Finally, take note of what clients have eaten – recording this in charts, particularly when

they are on food/fluid measurement charts. This will ensure any changes are noticed early,

reducing the risk of a client/patient developing malnutrition and dehydration.

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MALNUTRITION

National Institute for Clinical Excellence (NICE, 2006) defines malnutrition as:

‘... a state in which a deficiency of nutrients such as energy, protein, vitamins and minerals

causes measurable adverse effects on body composition, function or clinical outcome’.

It is important to note that a person can be underweight or overweight and be

malnourished.

The World Health Organization (WHO) states that malnourishment is difficult to define

because it is not a single condition.

In adults, the risk of malnutrition rises with age. A person of 80 years is five times more

likely to be malnourished than a person of 50 years. Around 14% of people aged 65 and over

are malnourished. Malnourished people are more likely to become unwell and to require

hospital admission. Around 40% of older people admitted to hospital are malnourished (Age

Concern, 2006). People living in nursing homes are vulnerable to malnutrition and around

30% are clinically malnourished (Elia, 2005). Malnutrition can set up a vicious cycle of ill

health and it increases the risk of infection.

Risk Factors:

Poverty = Insufficient money for food.

Poor mobility = lack transport causing difficulty getting to the shops and buying

food.

Poor physical health = May not be able to cook, may have altered sense of taste or

difficulty eating, chewing or swallowing. May have difficulty absorbing food or have

higher nutritional needs than normal.

Poor mental health = May be depressed and de-motivated and no longer bothered

about food.

Alcohol abuse = The person may be alcoholic. Alcohol can reduce appetite and the

person may spend money on alcohol rather than food.

Medication = Can affect appetite, can cause nausea.

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Assessment

When people enter hospitals or care homes or are seen as outpatients, height and weight

are checked. These are used to work out the person’s body mass index (BMI). To determine

if a person is underweight, of normal weight or overweight.

Signs & Symptoms:

Physical appearance: the person looks gaunt and thin, clothing is loose and ill-

fitting, rings are loose.

Observation: the person is not eating or eats little.

Observation: the person may have difficulty managing to eat, problems with eating,

chewing or swallowing.

The person reports unintentional loss of weight.

The person reports lack of appetite and disinterest in food.

The person reports nausea.

The person appears depressed or upset.

Treatment:

Providing a suitable diet.

Encouragement.

Reminding the person about the food, serving it and encouraging the person to eat.

Identifying food likes/dislikes.

Nutritional supplements.

Addressing eating difficulties , cutting up food, swallowing difficulties, ill-fitting

dentures.

Identify oral health problems.

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HYPOTHERMIA

Hypothermia is a life- threatening condition which can be fatal if it is not treated

immediately. Increased death rates and poor recovery from illness caused by hypothermia,

can largely be prevented (Nano, 2005; NICE, 2008). It is associated with the elderly, the cold

winter months or exposure to a cold environment; but not necessarily associated with

patients in hospitals or healthcare settings. Up to 90% of surgical patients will experience

hypothermia perioperatively and many other people are treated for it (Neno, 2005; Cooper,

2006; Davis and Byers, 2006).

The National Institute of Health and Clinical Excellence, (NICE) recently published a

comprehensive clinical practice guideline on managing hypothermia in surgical patients

were they warned ‘Anyone whose ability to thermoregulate is impaired (or control their

temperature) is at risk of becoming hypothermic. Hospitals are usually colder than a

person’s home so people are also likely to become hypothermic there too’ (NICE, 2008).

The body’s temperature is controlled by the hypothalamus, a small gland in the base of the

brain that acts rather like a thermostat. Normally this is set to approximately 37° Celsius or

98.6° Fahrenheit. A cooler skin temperature brought about by the environment, triggers a

person to alter their behaviour to maintain a comfortable core temperature. This involves

increased activity; putting on clothes or turning on the heating, and shivering to maintain

the body’s core temperature (Gourd and Bursztyn, 2005). Failure to raise the core body

temperature, for whatever reason, results in hypothermia (Bennett et al, 2004).

Definition

Hypothermia is a condition where the normal body temperature drops abnormally below

35°C (95°F).

Care of the Older Person – Unit 3 5N2706

Causes

Hypothermia is usually caused by being in a cold environment. It can also be triggered by

prolonged exposure (staying outdoors in cold conditions for a long time). Your body’s own

automatic defence system will try to prevent any further heat loss by:

Shivering to make sure major organs stay at normal temperature

Restricting blood flow to the skin

Releasing hormones to generate heat (Bennett et al,2004).

In hypothermia, these responses fail to maintain body temperature, and energy reserves are

exhausted. When this occurs, hypothermia is potentially life-threatening. This can happen

very quickly, so it is vital that hypothermia is treated as a medical emergency.

At Risk Groups:

THE ELDERLY

BABIES, because their body’s ability to regulate temperature isn’t fully developed

THE IMMOBILE

THE HOMELESS

DRUG ADDICTS/ALCOHOLICS as these substances affect the body’s ability to retain

heat

PERSONS WITH MENTAL ILLNESS, people with Alzheimer’s disease may not be able

to recognise the symptoms of hypothermia or tell when they are cold.

Diagnosis

If someone has been exposed to a cold environment (including being in hospital) and is

distressed, confused or has shallow breathing, hypothermia should be suspected and an

urgent assessment arranged. The symptoms of hypothermia depend on how cold the

environment is and how long the person was exposed to it for.

Care of the Older Person – Unit 3 5N2706

Signs & Symptoms for Mild Hypothermia:

❖ Shivering

❖ Feeling cold

❖ Low energy

❖ Less able to tolerate the cold than normal

❖ Cold, pale skin.

For Moderate Hypothermia:

❖ Violent, uncontrollable shivering

❖ Confusion

❖ Difficulty moving around or stumbling

❖ Feeling fearful

❖ Memory loss

❖ Fumbling hands

❖ Drowsiness

❖ Slurred speech

❖ Listlessness and indifference

❖ Slow, shallow breathing and weak pulse.

For Severe Hypothermia:

❖ Loss of control of hands, feet, and limbs

❖ An absence of shivering

❖ Unconsciousness

❖ Shallow or no breathing

❖ Weak, irregular or no pulse

❖ Stiff muscles

❖ Dilated pupils.

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Treatment & Care

Hypothermia is treated by preserving body heat and preventing any more being lost. The

main aim of care is to return the person’s core body temperature to normal. This is done

through re-warming either through warm blankets, warmed air or in extreme situations

heart-lung bypass. Re-warming should ideally take place at the same rate at which the

person became hypothermic.

This is to reduce the likelihood of potentially fatal re-perfusion injuries where the body

warms too rapidly and this can include heart arrhythmias and kidney failure when treating

someone with hypothermia.

You should not:

Re-warm an elderly person using a bath as this may send cold blood from the

body’s surfaces to the heart or brain too suddenly and may cause a stroke or heart

attack.

Apply direct heat (hot water, a heating pad etc.) to the arms and legs as this forces

cold blood back to the major organs, making the condition worse.

Rub or massage the person as, in severe cases of hypothermia, there is a risk of

heart attack.

Give the person alcohol to drink, as this will decrease the body’s ability to retain

heat.

Forced-air warming is a recognised and effective method for the prevention of intra-

operative and ward-based hypothermia (Bräuer et al, 2002). The warming blanket is made

of two layers; a paper one with holes across its length and a plastic-like inflatable layer that

connects to a heating unit via a large hose. Warmed air, at a predetermined temperature, is

then passed into the blanket, which is laid directly onto or underneath the patient.

Within a hospital setting, giving intravenous warm fluids (through a vein) can also be used in

conjunction with warm air.

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When the patient has become very ill as a result of the hypothermia, then haemodialysis

(filtering the blood using a specialist machine) is performed. People with hypothermia take

longer to recover, spend more time in hospital and are more likely to die.

The symptoms of hypothermia can be easily overlooked. Accurate recording of observations

and the application of simple nursing care interventions can promptly identify it and prevent

hypothermia from worsening.

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PREVENTION OF FALLS

Ageing affects vision, balance and gait. This means that older people are less likely to be

aware of hazards than younger people. They also find it more difficult to adjust to hazards

than younger people. The older person who stumbles on uneven flooring may find it difficult

to recover balance and may fall. Older people are more sensitive to environmental hazards

than other groups of people. This sensitivity may be because of illness, age-related changes

or simply the fact that the older person has changed location and is in unfamiliar

surroundings.

There are several reasons why people might fall. Which can be broken into intrinsic

(personal) and extrinsic (environmental) risk factors for falls. Intrinsic factors are potential

causes of falls, which depend on the individual and are not necessarily the same for

everyone. Extrinsic factors are those which might cause people to trip or stumble.

Falls are a major cause of disability and the leading cause of death by injury in older people

aged over 75. The incidence and severity of falls rises steadily after the age of 60. Falls have

a detrimental effect on quality of life and cause loss of confidence and independence (Parry

et al, 2001).

They are also associated with premature admission to long-term care (American Geriatric

Society et al, 2001). Further, there are psychological and financial problems associated with

falls.

INTRINSIC/ PERSONAL FACTORS:

Decreased mobility and strength

Medical conditions e.g. dementia,

depression,

Parkinson’s disease

Impaired gait and balance

Prior history of falls

Care of the Older Person – Unit 3 5N2706

Medication e.g.

sedatives/tranquilliers

Multiple medication

Impaired vision

Cognitive impairment/delirium

Poor nutrition

Hypotension (low blood pressure)

Height of beds and chairs

Foot problems such as

untrimmed toe nails

Infection, especially urinary tract

or chest infection

Urinary and faecal incontinence

Syncope

Dizziness/vertigo

EXTRINSIC / ENVIROMENTAL FACTORS:

Inappropriate or poorly fitting

footwear and clothing

Inadequate or poor lighting

Inappropriate use of side rails

that patients might climb or fall

from

Steep stairs and lack of grab rails

Slippery floors

Loose mats and floor covering

Pets

Height of beds and chairs

Electrical wires and appliances,

e.g. a television

Uneven pavements

Adverse weather such as snow or

rain

Overcrowded public areas

Public transport – e.g. buses

which jolt suddenly.

Care of the Older Person – Unit 3 5N2706

Falls Assessment Tools

There are several validated tools for the assessment of falls within different settings.

In situations where the HCAs provide the majority of hands-on care, their role in

helping identify and reduce potential falls risks is valuable. This includes making basic

checks of the environment and patient, with reference to the risk factors listed

above. Simple risk assessment tools are available which can also be used.

Assessment of Risks:

❖ Identification of falls history: time of day, situation, injuries and frequency

❖ Assessment of gait and balance

❖ Assessment of mobility and muscle weakness including use of mobility aids

and safety

❖ Activities of daily living assessment to assess functional ability

❖ Fear of falls

❖ Visual impairment

❖ Cognitive impairment/memory impairment

❖ Neurological examination

❖ Continence assessment

❖ Home hazards

❖ Assessment of osteoporosis risk

❖ Cardiovascular examination

❖ Medication review.

Care of the Older Person – Unit 3 5N2706

NEEDS OF THE DYING PERSON & THEIR FAMILIES

Death is defined as the final stage of life. Healthcare staff will need to develop a

realistic attitude toward the topic of death to meet the physical and psychological

needs of the resident and the family as they experience the dying process. We all

possess our own beliefs and values which we attain through our upbringing, our

religious beliefs etc.

We also acquire beliefs and values through the training we receive and our

interactions with other members of the healthcare team and our patients. As with all

care that you give, you must remember that each person is an individual with their

own set of values and beliefs. It is essential that you respect these values and beliefs

when attending to their needs.

As a HCA you will have the opportunity to care for many people as they come to the

end of their lives. Some patients will slip away quietly in their sleep, some will die

suddenly, some will die due to old age, others will die as a result of an acute illness

i.e. pneumonias.

A person who has been diagnosed with a terminal illness or indeed a patient who is

aware of the fact that their death is approaching, will experience grief. The families

of such patients will also experience grief. By understanding what is involved in the

grieving process, healthcare staff will be in a better position to fully meet the needs

of both the family and the patient.

DR. Kubler-Ross’ Stages of Dying:

❖ Denial - Shock and disbelief.

❖ Anger - Hostility and resentment.

❖ Bargaining - Looking for a way out.

Care of the Older Person – Unit 3 5N2706

❖ Depression - No longer able to deny, patients experience sadness and loss.

❖ Acceptance - Acceptance of the inevitability of death with peace and

detachment.

Though not all people experience all stages in the same order, discussion of death

helps to move toward acceptance. The Kubler Ross stages of grief, also known as the

5 stages of grief, were first outlined in 1969. Her work was a reflection of the grief

process of patients who had been diagnosed with terminal illness.

As an instructor in psychiatry at the University of Chicago, Elisabeth Kubler-Ross

began working with terminally ill patients. During this time, terminally ill patients

were not always told they were dying, and death was not generally a topic of

discussion. Her research was controversial. Kubler-Ross began to study patients’

reactions to their terminal illness and found that most people experienced certain

emotional states.

DENIAL: “This can’t be happening to me’’ In this stage, the world becomes

meaningless and overwhelming, life makes no sense. Denial is a conscious or

unconscious refusal to accept facts, information, reality, etc., relating to the situation

concerned. It's a defence mechanism and perfectly natural. Some people can

become locked in this stage when dealing with a traumatic change that can be

ignored.

ANGER: Realising that the change is real, denial usually turns to anger. People get

angry and look to blame someone or something else for making this happen to

them. Anger can manifest in different ways. People dealing with emotional upset can

be angry with themselves, and/or with others, especially those close to them.

Knowing this helps one to keep detached and non-judgemental when experiencing

the anger of someone who is very upset.

Care of the Older Person – Unit 3 5N2706

BARGAINING: The bargaining stage for people facing death can involve attempting

to bargain with whatever God the person believes in. People facing less serious

trauma can bargain or seek to negotiate a compromise. This is a natural reaction of

those who are dying. It's an attempt to postpone what is inevitable.

DEPRESSION: It's a sort of acceptance with emotional attachment. It's natural to feel

sadness and regret, fear, uncertainty, etc. It shows that the person has at least

begun to accept the reality.

ACCEPTANCE: This stage definitely varies according to the person's situation,

although broadly it is an indication that there is some emotional detachment and

objectivity. People dying can enter this stage a long time before the people they

leave behind, who must necessarily pass through their own individual stages of

dealing with the grief.

SYMPTOMS OF GRIEF:

❖ Shock and disbelief – Right after a loss, it can be hard to accept what

happened. You may feel numb, have trouble believing that the loss really

happened, or even deny the truth. If someone you love has died, you may

keep expecting them to show up, even though you know they’re gone.

❖ Sadness – Profound sadness is probably the most universally experienced

symptom of grief. You may have feelings of emptiness, despair, yearning, or

deep loneliness. You may also cry a lot or feel emotionally unstable.

❖ Guilt – You may regret or feel guilty about things you did or didn’t say or do.

You may also feel guilty about certain feelings (e.g. feeling relieved when

the person died after a long, difficult illness). After a death, you may even

feel guilty for not doing something to prevent the death, even if there was

nothing more you could have done.

Care of the Older Person – Unit 3 5N2706

❖ Anger – Even if the loss was nobody’s fault, you may feel angry and resentful.

If you lost a loved one, you may be angry at yourself, God, the doctors, or

even the person who died for abandoning you. You may feel the need to

blame someone for the injustice that was done to you.

❖ Fear – A significant loss can trigger a host of worries and fears. You may feel

anxious, helpless, or insecure. You may even have panic attacks. The death

of a loved one can trigger fears about your own mortality, of facing life

without that person, or the responsibilities you now face alone.

❖ Physical symptoms – We often think of grief as a strictly emotional process,

but grief often involves physical problems, including fatigue, nausea,

lowered immunity, weight loss or weight gain, aches and pains, and

insomnia.

It is important to realise that these stages are not definite. Each person is an

individual and how we grieve is personal. Not everyone passes through all the stages

of grief, nor do they do so in order. By understanding and recognising the stages of

grief, the HCA is in a better position to afford the proper care and support to the

client and their family.

Physical care of a person approaching death includes:

Care of the skin

Care of the mucous membranes

Positioning

Pain management

Other considerations

Skin care: More frequent skin care and linen changes are needed because of the

urinary or bowel incontinence and the moist skin that often occur as the person

nears death. The person will need to be checked regularly for incontinence of both

urine and faeces.

Care of the Older Person – Unit 3 5N2706

His skin will need to be cleaned gently, and soiled clothing and linens must be

changed. The pressure areas must be checked for bed sores. Gentle handling is

essential as the skin can be very fragile.

Mucous membranes: Frequent oral care helps keep the mouth moist and more

comfortable, especially if the person is unconscious or not taking food or drink.

Sometimes as death nears, the person does not blink as often, and a mucus crust

may form around the eyelids. Gentle cleaning with a warm, wet washcloth helps to

remove the dried mucus. Ointment can be applied to keep the eyes moist. If the

person is unconscious, moist eye pads may be used for protection.

Medical equipment, such as oxygen cannulas, may cause irritation and crusting of

mucus around the nostrils. Gently removing the mucus crust with a warm, wet

washcloth and applying a lubricant can help to keep the person comfortable.

Positioning: As the person's condition worsens, the person may not be able to

reposition herself without assistance. Frequent, regular position changes help to

prevent pressure ulcers and promote comfort. The use of pillows or other

positioning devices helps to maintain the body in proper alignment. If the person is

in pain, you will need to be extra gentle and slow with position changes. A person

who is having difficulty breathing, will probably be more comfortable positioned

with her head elevated.

Pain Management: Be observant, watch for signs of pain in facial expressions, and

moaning for example. Always tell the nurse if the person seems to be in pain so that

necessary medications can be administered.

Other considerations include:

❖ Environment

❖ Family

Care of the Older Person – Unit 3 5N2706

❖ Privacy

❖ Lighting

❖ Temperature

❖ Personal wishes

❖ Companionship.

The environment should be pleasant. It should be at a comfortable temperature and

well lit.

Whenever possible, a patient should be facilitated in a private room as death

approaches. This provides privacy and dignity. Remember too that hearing is the last

sense to go and always talk to your patient. Tell them what you are going to do for

example, “I am just going to turn you on your right side now”. Adhere to the

person's personal wishes

Meeting a person’s emotional needs

The way in which individuals approach death is extremely individualised. Some

people may fear death, they may not believe in an afterlife. They may be afraid that

they will lose their dignity during the dying process i.e. becoming incontinent. Others

may fear being in pain. They may be anxious about their families and those they

leave behind.

They may be worried that they have not finished business matters. Many people

have a fear of dying alone. Being aware of the different fears that people may have,

can assist us in relieving some of these fears. As healthcare workers, we must be

good listeners.

Listening

Many dying people facing death are well aware of their situation. Some of them may

wish to talk about their fears, or indeed recap on their lives. As a HCA you should be

open to this.

Care of the Older Person – Unit 3 5N2706

Let the person know that you are available to talk if they so wish, but do not try to

force the person to talk. Be observant and let the person know that you are available

if they want anything.

Spiritual and cultural needs

The HCA should ensure that the person’s wishes in these matters are adhered to.

Any requests that the dying person makes must be passed on to the nurse so that

the appropriate arrangements can be made. Remember that people can be spiritual

without belonging to any particular religion. This spirituality gives the person inner

strength to face the challenges ahead.

Support resident’s religious/spiritual practices even if different from that of

staff.

Listen respectfully to religious/spiritual beliefs.

Participate in religious practices if asked and acceptable.

Priest, rabbi, minister or other clergy may be contacted at request of

resident or family.

Privacy to be provided when clergy with resident.

Treat religious objects with care and respect.

Encourage family and friends to be included.

The HSE (2009) tell us that it is not appropriate to display icons of one religion when

a deceased person and bereaved family from another religion are present in the

mortuary. An alternative, respectful practice is to store the crucifix cross candles,

other traditionally used icons such as Mary, mother of Jesus, as well as icons from

other diverse religions and use them as needed.

Ways to comfort and support the family:

Ensure good communication between the family and the healthcare team.

Care of the Older Person – Unit 3 5N2706

Allow family members to stay with the dying person and to participate in

their care.

Ensure that the family members' basic needs are met.

Be readily available to provide needed care to the resident without being

intrusive on the family's privacy.

Remember that while you have responsibilities to the family, your main

concern is the welfare of the client.

Steinhauser et al (2000) identified six characteristics of a good death:

Pain and symptom management

Clear decision making

Preparation for death

Completion

Contributing to others and affirmation of the whole person

Preparation for death and completion can clearly be related to patient care

after death.

Elizabeth Kubler-Ross said of carers:

“Those who have the strength and love to sit with a dying client in the silence that

goes beyond words, will know that this moment is neither frightening or painful,

but a peaceful cessation of functions of the body”.

Care of the Older Person – Unit 3 5N2706

CARE OF BODY AFTER DEATH

The laying out of the dead can be traced back 50,000 years. It is essential that HCAs

have a good understanding of what is required in order to provide intelligent,

professional and holistic care that focuses on the individual needs of the patient and

their loved ones as a final mark of respect (Amene and Travis, 2000).

The interventions of last offices begin soon after a doctor certifies the cause of death

(Mason and McCall Smith, 1991). Although correct compliance with recommended

practical procedures for last offices is important, equally being sensitive and

respectful is paramount. Respect for a patient's dignity is epitomised by closing the

curtain around his or her bed immediately after death (Green and Green, 1992).

Talking to other patients who may have seen the patient die will help allay their

fears. No confidential information should be imparted.

Before beginning the last offices, the HCA/nurse should put on plastic gloves and an

apron to reduce the risks of infectious contamination to staff and cross-

contamination to patients from body fluids (Amene and Travis, 2000).

The main risk of infection is via body fluids (Nearney, 1998a), so intravenous devices

need to be carefully removed and disposed of. Entrance sites must be covered with a

waterproof dressing. Sometimes the body can continue to excrete fluids after death,

so pressure should be applied to the lower abdomen to express any residual urine.

As further excretion of bodily waste is not expected, the routine packaging of orifices

is unnecessary (Nearney, 1998b).

Death can alter a patient's appearance, and friends and relatives might find this

disturbing. The following course of care is suggested as a means of preparing a

patient's body for those who wish to pay their respects and to preserve dignity

(Amene and Travis, 2000).

Care of the Older Person – Unit 3 5N2706

This intervention can be justified on the basis that the patient would have adjusted

his or her own appearance had he or she been able to.

The eyes should be closed with downward pressure and the jaw closed and

supported by a bandage tied around the head. Amene and Travis (2000) suggest that

a pillow may be used instead of a bandage. This seems a more appropriate and

dignified intervention and has less potential to cause harm or leave pressure marks

on the patient's face or neck (Green and Green, 1992). The patient's dentures should

then be removed and cleaned, the inside of the mouth cleaned and the dentures

replaced. This ensures that any unpleasant odours are eradicated (Green and Green,

1992).

After undressing, the patient should be washed and dressed in a shroud according to

hospital policy. Bed linen should be removed and replaced with clean sheets, and the

bedside area tidied.

Dressing the patient in a shroud can make him or her look inappropriate and

unnatural. There is no obvious reason that patients should not be dressed in their

own, or even in hospital clothes, other than it is not always hospital policy. Next the

patient's head should be placed on a pillow and the arms and legs straightened.

Before removal of the body to the mortuary, it should be wrapped tightly in a sheet,

to avoid damage during transfer. It is fortunate that other patients do not have to

suffer this dehumanising intervention when being transferred by trolley around the

hospital; a set of bedrails and a careful porter would seem to suffice.

The body is then taken away in a special hospital trolley designed to secrete the

body, a protective gesture, but one that some might argue only furthers the

perception of death as a subject to be avoided.

Care of the Older Person – Unit 3 5N2706

Advocacy role

When patients are unable to express themselves, nurses represent their point of

view (Sutor, 1993). Therefore, advocacy must be continued after a patient's death.

Death is a pertinent example of when a health professional must represent the

patient's best interests in the absence of the individual's ability to do so for

themselves. When there are no obvious religious or cultural rituals to observe and

consultation with the patient's significant others is not possible, nurses should

perform last offices, but should do so on an individual basis rather than follow a

traditionally practiced ritual.

Family and friends

A respect for the patient and an awareness of the needs of the patient's friends and

relatives can have great therapeutic value at a time of grief and later (Speck, 1992).

It is essential to consult relatives and friends about procedures concerning the body

and any personal effects. This ensures any nursing interventions are acceptable to

the patient from a spiritual and cultural perspective, thus avoiding emotional

damage and possible litigation (Clark and Jacinta, 1995).

Spiritual and cultural considerations

According to Amene and Travis (2000): 'Few of us are whole-hearted in our

acceptance of the ways of our own religious or cultural groups'. Some ethnic and

cultural groups have procedures for caring for the dead that differ. The HSE have

produced an Intercultural Guide to assist staff when caring for a patient from a

different ethnic/cultural background.

The final intervention involves providing a means to easily identify the patient's body

and taking an accurate record of all the personal belongings. Attaching hospital

identity bands to a patient's wrist and ankle aids identification. A notification of

death certificate can also be attached to the sheet in which the patient is wrapped.

The certificate should be attached with tape, rather than with a pin, as this may

present a hazard to staff handling the body (Amene and Travis, 2000).

Care of the Older Person – Unit 3 5N2706

All personal items should be documented in the patient's property book in the

presence of another staff member. Care should be taken that the descriptions of

items are accurate: for example, a gold ring should be described as 'a gold-coloured

metal ring' to avoid any confusion when the property is returned to the patient's

family (Dimond, 2001). The property should be placed in the patient's own bag,

documented, and returned to the next of kin or the executor of the will.

Caring for the dead is a unique aspect of nursing because the deceased will never be

aware of it. Although the necessity of providing a high standard of care on the basis

of upholding and enhancing the good reputation of the professions (NMC, 2002) is

reason enough to provide excellent care. It is respect for the dignity and individuality

of all patients that will ultimately ensure that high standards of care are provided

whether a patient is alive or dead.

All staff should familiarise themselves with the HSE Intercultural Guide, in order to

gain greater understanding of the various cultural and religious beliefs, thus

enabling them to facilitate other people's practices.

When we work in long-stay residential settings, we can become very attached to the

patients we are caring for. When a patient dies it can be very difficult for us to deal

with that loss. The affection that we have for our patients will ensure that we

provide holistic care for the patient as they approach the end of their lives.

End of Unit 3.

Care of the Older Person – Unit 3 5N2706

NOTES: