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EELLNNEECC Geriatric Curriculum E L N E C Geriatric Curriculum End-of-Life Nursing Education Consortium SESSION 9: End-of-Life Care for the Dementia Patient.

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Presentation on theme: "EELLNNEECC Geriatric Curriculum E L N E C Geriatric Curriculum End-of-Life Nursing Education Consortium SESSION 9: End-of-Life Care for the Dementia Patient."— Presentation transcript:

1 EELLNNEECC Geriatric Curriculum E L N E C Geriatric Curriculum End-of-Life Nursing Education Consortium SESSION 9: End-of-Life Care for the Dementia Patient Fairfield University School of Nursing ELDER Project

2 EELLNNEECC Geriatric Curriculum Objectives: Upon completion of this session, the learner will be able to… 1.Identify signs of advanced dementia. 2.Discuss effective strategies that can be used to enhance communication with patients with dementia. 3.Examine the pain experience of adults with dementia.

3 EELLNNEECC Geriatric Curriculum Hospice for Patients with Advanced Dementia Only 11% of nursing home residents with advanced dementia are referred to hospiceOnly 11% of nursing home residents with advanced dementia are referred to hospice < 1% of hospice patients have primary diagnosis of dementia< 1% of hospice patients have primary diagnosis of dementia Mitchell et al., 2004a, 2004b & 2005

4 EELLNNEECC Geriatric Curriculum Ways Dementia Can Impact the Person’s Communication AphasiaAphasia AgnosiaAgnosia AnomiaAnomia ApraxiaApraxia Losing train of thoughtLosing train of thought Word saladWord salad WithdrawalWithdrawal PerseverationPerseveration ParaphrasiaParaphrasia Using curse wordsUsing curse words Speaking lessSpeaking less Reliance on nonverbal gesturesReliance on nonverbal gestures Reverting to a foreign languageReverting to a foreign language

5 EELLNNEECC Geriatric Curriculum Patients with dementia who are eligible for hospice must have one or more dementia-related complications in past year: … Upper respiratory infectionUpper respiratory infection SepticemiaSepticemia Multiple pressure ulcers, stage 3-4Multiple pressure ulcers, stage 3-4 Fever recurrent after antibioticsFever recurrent after antibiotics Aspiration pneumoniaAspiration pneumonia Insufficient fluid/food intake with 10% wt loss in prior 6 mos or serum albumin < 2.5 gm/dlInsufficient fluid/food intake with 10% wt loss in prior 6 mos or serum albumin < 2.5 gm/dl

6 EELLNNEECC Geriatric Curriculum Signs of ADVANCED DEMENTIA MMSE score of 9-0MMSE score of 9-0 Memory & ThinkingMemory & Thinking –Severely impaired memory for recent and past events LanguageLanguage –Unable to carry on a meaningful conversation MoodMood –Appears withdrawn –Difficult to engage FunctionFunction –Has difficulty interacting/responding to surroundings –Forgets how to walk without help; may lead to eventual loss of body movement © 2011 Hospice of the Valley © 2011 Hospice of the Valley http://www.hov.org/disease_progression.aspx

7 EELLNNEECC Geriatric Curriculum ADVANCED DEMENTIA Relies totally on caregivers for:Relies totally on caregivers for: –Dressing –Grooming –Bathing –Feeding –Bladder/bowel May forget to chew food or swallowMay forget to chew food or swallow May lose ability to sit up, hold head up and/or smileMay lose ability to sit up, hold head up and/or smile © 2011 Hospice of the Valley http://www.hov.org/disease_progression.aspx © 2011 Hospice of the Valley http://www.hov.org/disease_progression.aspx

8 EELLNNEECC Geriatric Curriculum Tips for Communicating with Patients with Dementia Distract, distract, distract!!!!Distract, distract, distract!!!! Do not try to re-orient to reality.Do not try to re-orient to reality. Patient can not remember or learn new things.Patient can not remember or learn new things. Join the journey!Join the journey!

9 EELLNNEECC Geriatric Curriculum Behaviors When Talking with Patients With Dementia SmileSmile Use humorUse humor Do not argue or confrontDo not argue or confront Be positiveBe positive Know the person/residentKnow the person/resident YOU do most of the work in communicating!YOU do most of the work in communicating!

10 EELLNNEECC Geriatric Curriculum Barriers of Palliative Care Lack of awareness of the end stage Identifying and addressing symptoms Lack of knowledge about patient wishes Lack of care planning Pressure for aggressive treatments Not acknowledging that Dementia is terminal (Nursing & Residential Care, August 2009, Vol 11, No. 8, page 400)

11 EELLNNEECC Geriatric Curriculum Decision-Making Advance directivesAdvance directives Care planningCare planning Care decisionsCare decisions CPR CPR Invasive medical procedures & tests Invasive medical procedures & tests Hospitalizations Hospitalizations ICU/ventilators ICU/ventilators Artificial nutrition & hydration Artificial nutrition & hydration Use of antibiotics Use of antibiotics Use of preventive health screenings Use of preventive health screenings

12 EELLNNEECC Geriatric Curriculum Is it Pain? Pay particular attention to changes from normal behaviors

13 EELLNNEECC Geriatric Curriculum Behavioral Symptoms Changes in attention spanChanges in attention span Changes in level of arousalChanges in level of arousal AgitationAgitation Changes in mood/affectChanges in mood/affect HallucinationsHallucinations Withdrawal from othersWithdrawal from others Groaning/calling outGroaning/calling out Facial grimacingFacial grimacing Striking out or other physical gestures of discomfort and distressStriking out or other physical gestures of discomfort and distress

14 EELLNNEECC Geriatric Curriculum Behavioral/Observational Cues Obvious: Grimacing or wincingGrimacing or wincing BracingBracing GuardingGuarding RubbingRubbing Less Obvious: Changes in activity levelChanges in activity level Sleeplessness, restlessnessSleeplessness, restlessness Resistance to movementResistance to movement Withdrawal/apathyWithdrawal/apathy Increased agitation, anger, etc.Increased agitation, anger, etc. Decreased appetiteDecreased appetite VocalizationsVocalizations

15 EELLNNEECC Geriatric Curriculum Pain Associated with agingAssociated with aging Co-morbiditesCo-morbidites ImmobilityImmobility Urinary tract infectionsUrinary tract infections Decubitus ulcersDecubitus ulcers

16 EELLNNEECC Geriatric Curriculum Reference: Warden, V., Hurley, A.C. & Volicer, L. (2003). Development and psychometric evaluation of the Pain Assessment in Advanced Demetia (PAINAD) scale. Journal of the American Medical Director Association, 4(1), 9-15.

17 EELLNNEECC Geriatric Curriculum Empirical Trials in Nonverbal Residents Behaviors suggest it could be pain Try pain medicine Behaviors decrease It’s probably pain!

18 EELLNNEECC Geriatric Curriculum Nutrition and Hydration Progressive loss of appetiteProgressive loss of appetite Loss of ability to swallowLoss of ability to swallow Increase risk of aspirationIncrease risk of aspiration Become resistive and indifferent to eatingBecome resistive and indifferent to eating Have difficulty handling food in their mouthHave difficulty handling food in their mouth Increased risk for chokingIncreased risk for choking

19 EELLNNEECC Geriatric Curriculum The use of is not associated with good outcomes! The use of feeding tubes is not associated with good outcomes! do not prevent malnutrition pressure ulcers, or aspiration pneumonia. Feeding tubes do not prevent malnutrition pressure ulcers, or aspiration pneumonia. have not been proven to promote comfort or prolong survival. Feeding tubes have not been proven to promote comfort or prolong survival. Care givers are encouraged to feed patients as long as possible!

20 EELLNNEECC Geriatric Curriculum Infections Common in end-stage dementiaCommon in end-stage dementia Use of antibiotics is controversial at EOLUse of antibiotics is controversial at EOL Frequently prescribed in the last 2 weeks of lifeFrequently prescribed in the last 2 weeks of life

21 EELLNNEECC Geriatric Curriculum Some things family can do… 1.Moistening the mouth 2.Massaging hands and feet 3.Play music 4.Read to their loved one 5.Bring in familiar objects and pictures 6.Hand holding 7.Life review (next slide)

22 EELLNNEECC Geriatric Curriculum Life Review - Everyone’s life has a story to tell! post “biography” cards with a photo and a brief description of the highlights of a resident’s life. post “biography” cards with a photo and a brief description of the highlights of a resident’s life. Sometimes this information is posted outside the patients’ door or in his room. Sometimes this information is posted outside the patients’ door or in his room.

23 EELLNNEECC Geriatric Curriculum Case Discussion Activity

24 EELLNNEECC Geriatric Curriculum Opportunities for High-Quality EOL Care in Nursing Homes Daily intensive interaction over timeDaily intensive interaction over time Family-like relationships between residents and staffFamily-like relationships between residents and staff Home-like atmosphereHome-like atmosphere History of caring for the dyingHistory of caring for the dying Expertise in dementia careExpertise in dementia care Ersek & Wilson, 2003; Hanson & Ersek, 2006

25 EELLNNEECC Geriatric Curriculum References City of Hope & the American Association of Colleges of Nursing, 2007; Revised, 2010. The End-of-Life Nursing Education Consortium (ELNEC)- Geriatric Training Program and Curriculum is a project of the City of Hope (Betty R. Ferrell, PhD, FAAN, Principal Investigator) in collaboration with the American Association of Colleges of Nursing (Pam Malloy, RN, MN, OCN, Co-Investigator). The Resource Center of the American Alliance of Cancer Pain Initiatives 14 © University of Wisconsin Board of Regents 2006 © 2011 Hospice of the Valley http://www.hov.org/disease_progression.aspx Supported by DHHS/HRSA/BHPR/Division of Nursing Grant # D62HP06858


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