Dementia A Family Assessment Visual Report By: Kelly Closser, Natashja Kelly, & Kelly Lewis
Description of Dementia Dementia is a chronic, progressive condition which is caused by damaged brain cells. It results in increasingly marked short-term memory loss, personality changes, and eventually physical manifestations. It is not a disease, but a term that describes this wide variety of symptoms, most often seen in the elderly population. The hippocampus is the memory center of the brain, and often times, where brain cells start to die first. It can be broken down into seven stages, from “no impairment” to “very severe” (Alzheimer’s Society, 2015).
(Helping Hands, n.d.)
Diagnosis and Treatment of Dementia
(Golden Years Brain Fitness, 2016)
There is no one test to determine if someone has dementia. Doctors diagnose Alzheimer's and other types of dementia based on a careful medical history, a physical examination, laboratory tests, and the characteristic changes in thinking, day-to-day function and behavior associated with each type (Alzheimer’s Association, n.d.). Doctors can determine that a person has dementia although the type of dementia is more difficult to diagnose due to overlapping symptoms. Treatment depends on the cause. There is no cure, and no slowing down the disorder progression, but some medications can improve symptoms temporarily. Risks of developing dementia consist of genetics, cardiovascular issues (blood circulation to the brain), physical exercise activity level and diet.
Assessment of Mr. Manuel
(PHCA Medical Group, 2016)
Mr. Manuel Miranda, 78 years old, is a husband, father and grandfather in a tight-knit family. He and his wife, Dottie, 75 years old, have an egalitarian marriage and live in the same 2-story La Jolla home they raised their family in over 40 years ago. He and his wife have 2 married adult children who live locally. Their son, Marco, 44, and his wife, Vanessa, and their daughter Jessa, 39, and her husband, Brent both live within 20 minutes. There are 4 grandchildren, all in elementary school, ages 6-10. Mr. Miranda is living with Stage 4, or moderately severe, Dementia. He experiences moderate impairment which consists of increased memory loss, needing assistance with ADL’s, disorientation and getting lost easily. However, his family began noticing changes 4 years ago when Mr. Manuel began repeating himself, became increasingly forgetful and confused and began socially withdrawing. Mr. Manuel has always been active and engaged socially and physically, even into his 70’s.
Assessment of Family Structure Mr. Miranda wants to age in place in his home. He is adamant that he not move to a memory disorder living facility. His wife is no longer able to provide complete care for Mr. Manuel and she worries about his safety. She acknowledges that caring for Mr. Miranda can be draining and that she often feels overwhelmed and tired. However, she also doesn’t want him moving to a living facility. His children are divided on his care. Marco thinks he should be transferred to a facility. Marco works full-time and while able to visit his father a couple of times a week, he is unable to contribute to his father’s daily care. The daughter, Jessa, works part-time as a researcher at the local university. She is able to help care for Mr. Manuel twice a week. Mr. Miranda is a retired professor in the late adulthood stage of life. Before dementia set in, Mr. Miranda was involved and present in his family. His wife and children found his wisdom invaluable. In recent years, his role has diminished gradually, with the (Web Health Wire,2015) other family members assuming an increasing, shared role. Mr. Miranda was also an active, engaged member of society who volunteered and participated in a weekly hiking club. Due to his forgetfulness and decreasing health, he is mostly home-bound these days. While this stage is typically a time of reflection and fulfillment, Mr. Miranda is often confused and starting to forget who some of his family members are at times.
Assessment of Family Structure Mrs. Miranda is a retired school nurse in the late adulthood stage of life. With her care-giving career and experience, her role as caregiver to her husband has been invaluable over the last few years. However, with Mr. Miranda’s increasing needs, she’s physically unable to provide the increased level of care Mr. Miranda needs. Marco is in middle adulthood and has established a successful career. He has many demands on his time and attention because he also has two school age children. In his spare time, he is devoted to his family. He assists his parents by supervising their finances. He and his sister, Jessa, rotate hosting a Sunday family dinner.
Assessment of Family Structure Jessa is in middle adulthood and is enjoying a career as a part-time researcher. She works part-time to allow for more time to care for her father and so she can take Nick to speech and occupational therapy outside of the support he receives at school. She spends 2 days a week caring for Mr. Manuel by running grocery errands, taking both parents to doctor appointments and housework.
Grandkids – all are in the school age developmental stage where they are discovering their sense of industry (versus inferiority). This is a stage characterized by significant learning and refining of skills. Marco’s children are: Aela, 10, and Clara, 7. Aela is the oldest grandchild and also the most independent, assertive and loves art. Clara is easygoing and happy who loves playing with her dolls. Randall, 8, is also easy-going and good-natured. He loves baseball. His younger sibling, Nick, 7, is on the autism spectrum and requires support services through school. All 4 grandchildren adore their grandparents and the feeling is mutual. Mr. and Mrs. Miranda cherish their time with the grandkids. However, Mr. Miranda’s memory loss can be confusing to the children at times.
Assessment of Health Promotion in Family Health promotion is typically geared towards maintaining health. In this situation, education, adaptation and caregiver support are the focus. Caregivers commonly express their most pressing needs are “access to practical information”, contact information for support organizations, respite time away so they can re-charge, and a supportive system (Dening & Hibberd, 2016). Jessa want to support Mr. Miranda’s desire to age in place, but realizes some logistical changes are necessary. Marco is opposed, seeing any changes as being a hassle and insufficient to meet both his parents’ needs. It is important for the nurse to facilitate an open dialogue amongst the family members. Appropriate health promotion for the family could educate them on the number of options available. Socioeconomically, the Miranda family is able to afford the costs associated with these changes. The downstairs office can be converted into a bedroom for Mr. and Mrs. Miranda. The home has an accessible downstairs full bathroom. It needs some modifications such as safety rails and a shower bench. The shower is already a walk-in. An emergency cord can be installed in the bathroom as well. There are many ways the family could adjust the home to help better care for Mr. Miranda and there are companies that specialize in these types of home improvements.
Assessment of Health Promotion in Family
(LifeStyle Options, n.d.)
Assessment of Health Promotion in Family A video home monitoring system can be installed inside the home. This technology allows approved family members, caregivers and healthcare providers remote access to care for Mr. Miranda. Because Mr. Miranda is not (GrandCareSystems, n.d.) living alone with his stage 4 dementia, this is an acceptable accommodation to consider. This system has sensors throughout the house which can monitor unusual movements, for example, an increase in night movements concentrated in one area of the house may indicate disorientation. It can also detect regular patterns of movement, residents coming and going throughout the day, whether the medication cabinet has been opened that day. This all occurs without being intrusive. One video camera can also be permanently stationed on a whiteboard, where Mrs. Miranda can write down updates such as “going for a walk at 10am, be back by 10:30am�. These systems can start in the mid-hundreds of dollars for a 1-bedroom apartment, and monthly fees can be around $100. Costs of these systems seems to be the greatest barrier (Delmonico & White, 2010). GPS devices also abound. They can be incorporated into a comfortable pair of shoes or slippers, a wristwatch, cellphone. A pair of shoes cost $300 and monthly fees are approximately $35 (Bertolucci, 2012).
(Meinhold 2011)
Assessment of Health Promotion in Family The most important accommodation to consider is hiring a home health care provider. Around the clock care may not be necessary yet, but Mr. Miranda is needing assistance with ADL’s such as showering, dressing, meals and daily medications. He will initially need care in the early morning hours from 6am-10am and 4pm-8pm. Caregiver needs will increase as his dementia continues to progress. Mr. Miranda has become increasingly more agitated as well. This occurs because patients with dementia are increasingly unable to express the agitation trigger, such as pain, medication side effects, hunger or temperature extremes. Sometimes, a walk outside is all that’s needed to relieve feelings of agitation. Soft tones or a gentle hug can also help avoid a meltdown. Playing Mr. Miranda’s favorite music is a well-documented powerful tool. Known as “music therapy”, it can promote calmness and decrease agitation. The importance of caregiver self-care needs to be stressed to the family. Taking a walk, having lunch with a friend or connecting with other caregivers through a support group can be very beneficial and help the family member to recharge.
Culture & Religious Traditions The family is Catholic and attends Mary Star of the Sea parish Sunday mornings at 9am. Mrs. Miranda is the most devout family member and would like to go to mass everyday during the week but has not been able to due to Mr. Miranda’s care requirements.
(Theo, 2007)
Recently it has become hard for the family to attend mass together on Sundays because Mr. Miranda sometimes talks loudly during the service. In a few instances he has become confused and angry and it was hard for his family to get him to step outside and calm down. The Miranda family is very proud of their family heritage, which they can trace back to a Mexican soldier who settled in San Diego County in 1830. Over the years the family has made a respectable amount of money from real estate that they inherited. Mr. and Ms. Miranda speak Spanish. Marco and Jessa only remember a little Spanish from their childhood and regret not keeping up with it. They have chosen to send the grandchildren to an English-Spanish immersion school. The family cooks some traditional mexican dishes and celebrates catholic holidays.
Assessment of Family Unit’s Strengths & Challenges Relevant to Illness Strengths: ● ● ● ● ●
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Two family caregivers- Mrs. Miranda and Jessa Strong family bond Family members provide each emotional Live close to each other Family has a desire to do what they think is best for Mr. Miranda and the family The family has the financial means to retrofit the house, provide in-home care, or place Mr. Miranda in a memory care facility The family’s faith helps them cope with Mr. Miranda’s illness. The family is well educated
Challenges: ● ●
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Differing ideas of how to best take care of Mr. Miranda Difficulty with shared decision making related Mr. Miranda’s care Jessa’s son Nick needs extra care Mr. Miranda’s dementia is progressing Mrs. Miranda is fatigued and physically unable to provide all of the care that Mr. M needs. Family traditions, such as mass on Sundays, are being negatively impacted by Mr. Miranda’s condition Grief over loss of Mr. Miranda’s memory, personality etc.
Subjective Communication History Reported by Family “A systematic family assessment requires awareness of the verbal and nonverbal communication of those interviewed and observed.” (Denham et al., 2016, p.116) Method- Each family member was asked individually to describe their family’s communication. Mr. Miranda: Stated that he lets his wife and children make more family decisions. On his “bad days”, he will sometimes get confused, forget names and people, or have difficulty getting the words out. At those times, he withdraws from the conversation and focuses his attention inward, as he becomes increasingly anxious and panicked. Those feelings will escalate until he lashes out at those closest to him. On his “good days,” he often sees his situation from a different perspective and feels embarrassed and self conscious about his behavior and his need for care. Mrs. Miranda: Stated that her children often have disagreements. Mr. Miranda does not engage in conversation or take part in discussions the way he used to and this saddens her. She feels that she is able to be more of an advocate for her husband, due to nursing care being her area of expertise and because she knows Mr. Miranda’s needs and preferences so intimately. She also reported having to include her children in discussions and decisions that used to be only between her husband and herself. She feels that her children often insert themselves in the decision making process.
Subjective Communication History Reported by Family Jessa: Stated that Marco will often become argumentative and disagree with her and the rest of the family. She believes that this stems from his competitiveness and sibling rivalry, and his inability to take an active part in their father’s care. Her father used to be very assertive and a more active participant in family dialogue. Now he seems to be less confident in social situations and will often become quiet and withdrawn from conversations or have outbursts that can be embarrassing. She tries to coordinate more with her mother regarding her family’s plans and how they play into her parents’ changing needs. Stated that it is difficult to talk about her father’s end of life care and death with the rest of the family because it upsets her mother. Marco: Stated that Jessa had always agreed with their father, but now also sides with their mother, now that their mother is making more of their father’s decisions for him. He resents this and feels that the family is “ganging up” on him. He also feels that he needs to involve himself more in decisions by the rest of the family so that they take the best course of action. Grandchildren: Were at school during initial family assessment with nurse. Spouses: Jessa’s husband comes to most family meetings and participates in discussions, although not as much as Jesse and Marco. He will support his wife’s perspectives but one time he did side with Marco on a family matter. Marco’s wife does not attend family meetings. Marco’s says that she does not feel comfortable involving he self in her in-laws personal matters.
Objective Communication Observed by Nurse Mr. Miranda- You can tell by Mr. M’s eye contact whether or not he is engaged with the conversion. When he is engaged, he is more assertive and will state his views and feelings. When he is not engaged the conversation he often stares off or looks down at the floor. This will usually be followed by him interrupting the conversion with angry outbursts. Mrs. Miranda - She often speaks for her husband and answers questions on his behalf. She often places her hand on his arm or his leg. She studies his face throughout the conversation to pick up on emotional cues. She is hesitant to discuss the progression and end result of his condition. When the subject is raised she gives short answers, denies having any questions, and looks down while fidgeting with her wedding band. Marco - His posture is more aggressive than that of other family members. He will often lean in and use his hands and arms to make gestures and accentuate what he is saying. He will sometimes interrupt. He also has a tendency to talk more loudly and “talk over” other family members. Jessa - She crosses her legs and/or arms and leans back in her chair when Marco talks at family meetings for an extended period or raises his voice. When issues of her father’s condition and care are discussed she will actively participate in the conversation and volunteer information that she has learned from her experience of caring for her son, Nick. She rarely speaks directly to Marcos.
Development and Family Life Cycle Theory The Development and Family Life Cycle Theory establishes developmental stages that the family, as a whole, typically experiences over time. This theory asserts that the developmental stages of the individuals in the family unit affect the family's overall development and visa versa. The Miranda family is in the ‘aging families’ stage. Some of the tasks for the family at this stage include: establishing grandparent roles, navigating the death of a spouse, and learning to live alone. Family changes that happen in the expected order and are associated with these predictable tasks are considered normative or “on-time”. But illness, such as dementia, is not predictable and is therefore a nonnormative change or “off-time”. The Development and Family Life Cycle Theory acknowledges that families develop and change over time and that these changes, whether normative or nonnormative, can cause stress for the family members and affect their achievement of normal developmental tasks. The nurse can use this construct to conduct a targeted screening of the family’s development. For example, the nurse could ask: - How does this illness affect Mr. and Mrs. Miranda’s role as grandparents? - How is Mrs. Miranda preparing to adjust to the death of her spouse? - When Mr. Miranda does go to a memory care facility or passes away how can I help Mrs. Miranda adjust to living alone?
Family Problems & Outcomes Knowledge deficit r/t increase in Mr. Miranda’s care needs AEB Marco expressing inaccurate information regarding the costs of home care, Jessa and Mrs. Miranda expressing anxiety about inadequate resources to care for Mr. Miranda at home, and Jessa and her husband requesting information about options for Mr. Miranda’s care in his home. Outcome: Each adult family member will verbalize understanding of the financial costs, possibilities, advantages, and disadvantages of home care and a memory care facility at the end of the family meeting with nurse the nurse and social worker Thursday at 5pm. Caregiver role strain r/t increase in Mr. Miranda’s care needs AEB Mrs. Miranda states that she is unable to attend daily mass and that she often feels drained and tired. Outcome: Mrs. Miranda will report being able to attend daily Mass and feeling less overwhelmed by Mr. Miranda’s care within one month. Interrupted family processes r/t shifting roles within the family and the progression of Mr. Miranda’s dementia AEB family can no longer attend Sunday Mass together, Mrs. Miranda and Jessa are now acting as caregivers for Mr. Miranda, and Marco has taken control of his parents’ finances Outcome: Family will express their feelings regarding the change in their family structure and activities, and will identify ways to effectively cope with those changes at the end of the family meeting with nurse the nurse and social worker Thursday at 5pm.
Interventions and Evaluation Intervention 1: Provide teaching to Mrs. Miranda and her children regarding care options, financial costs, the advantages, and disadvantages of both home care and a memory care facility. This will allow the family to make an informed decision regarding Mr. Miranda’ s care. Intervention 2: Arrange for periods of “respite care” for Mrs. Miranda (Ackley and Ladwig, 2014, p. 194). This will allow her attend daily mass and take time to care for herself. Intervention 3: Address family stress concerns and the future of the family in a family meeting and encourage them to identify the feelings and coping mechanisms that may help them through this period of change. Evaluation 1: Met. Each adult family member has verbalized understanding of the financial costs, possibilities, advantages, and disadvantages of home care and a memory care facility at the end of the family meeting with nurse the nurse and social worker on Thursday at 5pm. Evaluation 2: Met. Mrs. Miranda reported being able to attend daily Mass and feeling less overwhelmed by Mr. Miranda’s care within one month. Evaluation 3: Met. Family expressed their feelings regarding the change in their family structure and activities, and identified ways to effectively cope with those changes at the end of the family meeting with nurse the nurse and social worker on Thursday at 5pm.
References Ackley, B. J., and Ladwig, G. B. (2014). Nursing Diagnosis Handbook (10th ed.). Maryland Heights, MO: Mosby Elsevier. Alzheimer’s Association. (n.d.). What is dementia [web page]? Retrieved from http://www.alz.org/what-is-dementia.asp Alzheimer’s Foundation of America (AFA). (2016). Education and care. Retrieved from http://www.alzfdn.org/EducationandCare/ Musictherapy.html Alzheimer’s Society. (2015). The progression of Alzheimer's disease and other dementias [web page]. Retrieved from https://www. alzheimers.org.uk/site/scripts/documents_info.php? documentI D=133 Bertolucci, J. (2012, July). Tchnology Helps Seniors Stay at Home. Retrieved from http://www.kiplinger.com/article/retirement/T066 -C000-S001-technology-helps- seniors-stay-at-home.html Family Caregiver Alliance (FCA). (n.d.) Caregiver's Guide to Understanding Dementia Behaviors Retrieved from https://www.caregiver.org/caregivers-guide-understanding -dementia-behaviors Delmonico, M. and White, B. (2010, April). Incorporation of Information Technology into Assisted Health Care: An Empirical Study. Journal of Information Systems Applied Research, 3(9). http://jisar.org/3/9/JISAR.3(9).Delmonico.pdf
References Dening, K. H., & Hibberd, P. (2016). Exploring the community nurse role in family-centred care for patients with dementia. British Journal of Community Nursing, 21(4), 198-202. doi:10.12968/bjcn.2016.21.4.198 Golden Years Brain Fitness (2016). Understanding dementia [web page]. Retrieved from http://www.gybf.com.au/dementia.html GrandCare Systems. (n.d.). A comprehensive care solution. Retrieved from http://www.grandcare.com/ Helping Hands (n.d.). Living in the past: A guide to Dementia care at Home [web page]. Retrieved from http://www.helpinghandshome care.co.uk/condition-led-care/dementia-care/dementia-homecare-guide/ Hsu, M. H., Flowerdew, R., Parker, M., Fachner, J., & Odell-Miller, H. (2015). Individual music therapy for managing neuropsychiatric symptoms for people with dementia and their carers: A cluster randomised controlled feasibility study. BMC Geriatr BMC Geriatrics, 15(1). doi:10.1186/s12877-015-0082-4 LifeStyle Options, Inc. (n.d.). When home care is what matters [web page]. Retrieved from http://www.lifestyleoptions.com/
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