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Application of Cultural Competence in the Care of Alzheimer’s Patients Maria Luisa Faner, MSN, APRN, FNP-C.

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Presentation on theme: "Application of Cultural Competence in the Care of Alzheimer’s Patients Maria Luisa Faner, MSN, APRN, FNP-C."— Presentation transcript:

1 Application of Cultural Competence in the Care of Alzheimer’s Patients Maria Luisa Faner, MSN, APRN, FNP-C

2 Objectives Demonstrate an awareness of diversity and culture on concepts surrounding the care of Alzheimer’s patients. Recognize the importance of cultural diversity in communicating and planning an effective plan of care for Alzheimer’s patients. Define expected treatment outcomes in terms of the culture, values, and ethical perspective of the healthcare consumer. Adapt cultural awareness and competence in formulating a holistic approach toward the Alzheimer’s patients and their family


4 What is Alzheimer’s Disease? Discovered in 1906 - Alois Alzheimer Hallmark - beta-amyloid plaques Neurodegenerative disease - progressive, irreversible cognitive decline Mild Alzheimer’s- cortical shrinkage, moderately enlarged ventricles, shrinking hippocampus Severe Alzheimer’s- severe cortical shrinkage, severely enlarged ventricles, severe shrinkage of hippocampus

5 10 Warning Signs of AD 1. Memory Loss 2. Difficulty performing familiar tasks 3. Problems with language 4. Disorientation to time and place 5. Poor or decreased judgment 6. Problems with abstract thinking 7. Misplacing things

6 10 Warning Signs of AD 8. Changes in mood or behavior 9. Changes in personality 10.Loss of initiative (Source:Alzheimer’s Association)

7 Stages of AD Early = MCI, sense of smell Mild =getting lost, financial, repetitive, takes longer with tasks, poor judgment, personality Moderate = memory loss, confusion, decreased ability to recognize, unable to learn new things, tasks with multiple steps, coping, behavioral changes Severe = communication difficulties

8 Progression Disease spreads throughout cerebral cortex  decline in language, judgment, behavior, bodily functions  decline in memory until death

9 By the numbers 5.4 million Americans 2014 500,000 added yearly By 2050- 12.5 billion Etiology- Genetic, environmental, lifestyle, CV disease, HTN, High cholesterol, diabetes Prognosis- death 8-10 years after diagnosis “Early Stage”, “younger onset”

10 By the numbers Costs for care - $214 billion in 2014 *$150 million to Medicare/Medicaid Projection - $1.2 trillion by 2050 Cost to families: 2013 - 15.5 million families provide 17.7 billion hours of unpaid care= $220 billion 80% care by unpaid caregiver

11 By the numbers 30% of US population= non-Caucasian of various races or ethnic origins Largest = Hispanic/Latino and African- Americans 2050 = 394 million non-whites 90% = Asians, African-Americans, Hispanics

12 Management of AD Medications - may help maintain memory/ speaking skills, certain behavioral problems Mild-moderate Moderate-severe Day-to-day care - ADLs Social, mental, physical stimulation Physical activities - continue/modify

13 Management of AD Exercise, nutrition, diet supervision Managing behavioral symptoms: sleeplessness, agitation, wandering -Redirection -Engaging methods -Prevent wandering Make patient comfortable  “care easier”

14 Management of AD Culturally specific interventions- music, food, language Reminders -who they are, what they used to do Validation Therapy Listening, responding to questions Priest/Minister/Lay counselor Caregiver relief/Community support

15 Definitions Culture - values, beliefs, traits, traditions, and/or language shared by members of a group -A predominant force that shapes behavior, values, institutions -Lenses through which people view the world, how they relate to it

16 Definitions Ethnicity = belonging to or distinctive of a particular racial, national, cultural or language division of mankind Cultural awareness = understanding how persons are shaped, issues that influence reactions Acculturation = participation in values, language, practices of an ethnic group

17 Definitions Diversity = distinctions such as culture, race, religion, ethnicity, gender, language, any observed differences common to a group of individuals

18 Definitions Cultural competence = understanding, listening, obtaining information, applying information *Whatever it takes to respond effectively/with sensitivity to cultural, racial differences as they impact healthcare delivery, outcomes *Commitment to provide quality services to all

19 Difficulties Viewing others’ cultures, behaviors through own lens Ethnocentricity - superiority of one’s own ethnic group, viewing others’ cultures from own perspective Lack of understanding of different political, ideological agendas Lack of time

20 Developing Cross-cultural Mindset Be aware of aspects of culture not visible Pay attention to your thoughts Maintain cultural humility Be willing to adjust your behavior Take time to learn and explain Arrange for translator if necessary

21 Diversity Non-Hispanic whites/ Europeans African-Americans Hispanics Asians/Pacific Islanders Middle eastern

22 Diverse beliefs History/Immigration/Language barriers Difficulty in asking for help Filial piety, familial hierarchy/obligation Taboos- illness, death/dying, hospitals, physical contact, staring, evil spirits, curse, soul loss, food/animal sacrifices Sense of time control Internal cultural support mechanisms

23 Culturally-based Beliefs Personalistic = illness caused by intervention or a supernatural being, deity, dead ancestor Naturalistic = health closely tied with natural environment; balance/harmony. *Three approaches: Humoral (hot and cold), Ayurvedic (herbs, minerals), Vitalistic (imbalance in vital energies) Biomedicine = body-as-machine metaphor

24 Testing Methods Neuropsychological tests - impairment of performance in memory and 2 other cognitive domains MMSE – racial, ethnic, cultural differences Benton Visual Retention Test Few cognitive measures validated for use among ethnic minorities = cognitive impairment

25 Cognitive Testing Variability Factors: Level of acculturation Years of education, occupation, income Non-verbal abstraction abilities Life experiences Place of birth - border/interior “Cognitive reserve”, compensation, more efficient use of brain networks

26 Non-Hispanic whites/ Europeans Polish - stoic, suffer in silence, pain comes from God; communicate condition to family German - self-control in response to pain, cause of illness: lack of cleanliness, self-abuse Russian – Friday, 13 th, stoic, patient care = family responsibility, “intrusion” from HCP Italians – Pts. want to know about their health condition, touching is OK

27 African Americans Alzheimer’s Prevalence- 14-100% > than whites Risk Factor- CV disease, silent infarcts (decrease in cognitive reserve) Fear /mistrust of medical matters Low participation in research Religion/Spirituality

28 Hispanics Prevalence of Alzheimer’s - higher DM (small vessel disease  AD pathology) Number could increase > 6x by 2050 (< 200,000  1.3 million) Belief in leaving things to God Traditional family roles/parental hierarchy Less education, poor assimilation

29 Asians/Pacific Islanders Ethno-cultural groups - Chinese, Japanese, Filipinos, Vietnamese, Cambodians, Koreans, East Asian Indians, Samoans, Hmong, Thai Religious beliefs, taboos, traditions Expected support of elderly family members Reluctance to seek care Perception of stigma, shame for condition Distrust of government

30 Asian/Pacific Islanders Buddhism - health beliefs affected by Taoism Confucianism - respect for authority, filial piety, justice, benevolence, fidelity Ayurveda principles - Hindu philosophy Chinese traditional concepts of yin and yang Christianity/Catholicism Behavior symptoms - natural consequences of aging, exacerbated by migration, culture shock

31 Middle Eastern Majority - Muslims (7M in America) Amulets against evil eye, incense, prayers Emphasis - maintaining good health, diet* Generally prefer male doctors (except Gyn) Recovery from illness - seeking Tx, God’s will Elders have prestigious status, paternalism Generally look down on mental illness

32 Communication in AD Lengthy explanation -PCP  stages of dementia, impending future decisions Encouraging questions, dialogues on eventual choices Value-oriented discussions - patients, family, surrogate Involvement with community groups, support groups

33 ETHNIC Framework E- Explanation T- Treatment, home remedies H- Healers, friends N- Negotiate mutually acceptable treatment plan I- Intervention, incorporating alternative treatments, spirituality, healers C- Collaboration

34 Cultural Aspects of Communication Speaking too loud Standing too close Reluctance to speak/maintain eye contact No answer to simple question, metaphors Refusing care “Non-compliance”, “no show”

35 Limited English Proficiency English is a difficult language! Keep it simple Feedback - give/seek NOT understanding/misunderstanding Speak slowly/clearly/ NOT loudly Repeat as necessary Avoid acronyms/idioms/abbreviations Write it down/demonstrate/EXPLAIN!

36 Treatment Outcomes for AD Longevity Care - do everything! Functional Care - do what is required Palliative Care - “Comfort Care”

37 Timely End-of-life Talks for AD Where to begin? When? Do I have answers to questions? Primary care - identify high-risk patients, communicate prognosis, clarify values, involve surrogate decision-makers Estate planning, advance directives, living will, register resuscitation orders

38 Cultural shift in EOL care Burden –partially on medical providers, large burden on culture as a whole Shift in attitudes to EOL Approaching/discussing death more openly Intervention within cultural centers, churches

39 AD Caregiver Care Day-to-day care-physical, emotional, financial Changing family roles Difficulty making decisions- placement Guilt, blame, regrets

40 Caregiver Support Do you regularly... 1. Feel like you have to do it all yourself and that you should be doing more ? 2. Withdraw from family, friends and activities that you used to enjoy? 3. Worry that the person you care for is safe? 4. Feel anxious about money and healthcare decisions?

41 Caregiver Support 5. Deny the impact of the disease and its effects on your family? 6. Feel grief or sadness that your relationship with the person isn't what it used to be? 7. Get frustrated and angry when the person with dementia continually repeats things and doesn't seem to listen? 8. Have health problems that are taking a toll on you mentally and physically?

42 Caregiver Support Join a support groupsupport group Get strategies to manage stressmanage stress Learn new care-giving skills as the disease progressescare-giving skills When people offer to help, let them Know what community resources are available community resources Respite care

43 Community Caregiver Support Area Agency on Aging- stress management techniques, relaxation, coping strategies Alzheimer’s Association- education programs, culturally, linguistically sensitive outreach programs National Institute of Aging- innovative programs and initiatives to close racial/ethnic gaps support

44 Alzheimer’s Association of El Paso Education Programs: -Conversations about Dementia -Know the 10 signs- early detection -The Basics- memory loss, dementia, AD -Living with Alzheimer’s- People with Alzheimer’s/Younger onset/Caregivers -Legal and Financial Planning -Diversity Outreach Programs

45 Alzheimer’s Association of El Paso 24/7 Helpline: 1-800-272-3900 ALZConnected- online community Alzheimer’s Navigator Alzheimer’s Association Trial Match Community Resource Finder Care Team Calendar Approaching Alzheimer’s: First Responder Training

46 Alzheimer’s Association of El Paso MedicAlert+Alzheimer’s Association Safe Return- 24 hour Nationwide Emergency Response Services Online: Call: 1-888-572-8566 Telephone Caregiver Support Group: Contact Kelli Moorhead 1-800-272-3900

47 Interdisciplinary Team in AD Care Administration, Supervisors Staff - nurses, PT, OT, Speech Therapist, recreational, social workers, home care providers, family Support staff - dietary, outreach, community resources, daycare

48 “Grandma doesn’t know me anymore”

49 References Frederick, D., Marinelli, M. (2014). Achieving cultural competency: Adapting to diversity improves patient care. OR Nurse 2014. 28-33. Manly, J., Mayeaux, R. (2004). Ethnic Differences in Dementia and Alzheimer’s Disease. NCBI Bookshelf. McCullough, D (2008). My Mother, Your Mother. Harper Collins, NY,NY

50 References You, J. (2014). Just ask: discussing goals of care with patients in hospital with serious illness. CMAJ 2014; 186 (6): 425-432.’s

51 Questions?

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