ASSIGNMENT 3 – FINAL PAPER 4,000 words graded paper
This final paper takes your narrative literature review and the themes which emerged from it and engaged in a critical discussion of the themes and their relationship to the issue you have chosen for your study.
It is expected that in this final report you will build on the information obtained in the previous two. Remember that you need to consider this an evidenced based assignment – that is you use the evidence to prepare your final paper.
Specific assessment criteria
• Critically discuss the themes from your literature review and reference the material used.
• Place your findings in context (i.e. critically reflect on how relevant the information is to aspects of public health or international development).
• Describe your main learnings from the literature review and the main implications for public health or international development practice.
The main component of the specific assessment criteria will relate to the following:
• Demonstrates a deep understanding of the evidence underpinning the selected public health/primary health care/health promotion/development issue.
• Demonstrates an ability to critically analyse and discuss the evidence and place the research into context.
• Demonstrates an ability to synthesise the evidence to discuss innovative applications to public health or international development practice.
ASSIGNMENT 3 – FINAL REFLECTIVE REPORT
Research studies have shown that the prevalence of dementia is 3 to 5 times higher among Aboriginal and the Torres Strait Islanders when compared with other Australian population. OECD statistics uphold this claim stating that 33.7 people of this particular group are known to live with dementia out off 1000 people in Australia(Oecd.org. 2019). 11 thousand deaths among elderly population found to have been caused due to dementia. Current population living with dementia only in Australia is 376 thousand, which is likely to increase up to 550 thousand by 2030. Dementia according to WHO happens to be the major cause of dependency and disability among the older population across the world. The disease affects one’s daily living that encompasses, judgment, memory, analytical thinking, learning, language and understanding. Because of the clinical manifestation of dementia, the people grow a dependency on their care providers, family members and friends(Moyle, et al., 2014).
Dementia has been creating immense social impact and public health burden. It is essential to provide adequate psychological support to Aboriginal and Torres Strait Islander people living with dementia so that their wellbeing can be improved as well as they can be kept socially included. Witnessing growing prevalence of dementia and its negative outcomes on people’s wellbeing and health especially in Aboriginal and Torres Strait Islander population, the research has undertaken the particular area to identify and analyse approaches that should be implemented in assisted living and nursing care homes for improving their wellbeing and health conditions.
Wellbeing and health of people living with dementia can be improved through effective pain management, proper food and nutrition, address social abandonment, and prevent fall related injuries in nursing homes and assisted living conditions. Therefore, the research is significant in improving the wellbeing and health conditions of people, living with dementia as it identifies strategies to minimise poor health conditions while developing conditions that may have a positive impact on patients’ health outcomes.
The research aims at developing a literature review for discussing the approaches that could be adapted to provide care and treatment to the Indigenous population who are living with dementia in assisted living and nursing care homes.
The particular research study further aims at carrying out the investigation by accessing nursing databases and academic research papers so that improved care can be provided to elderly people living with dementia. The research further aims at identifying the gap that prevails in the health outcomes of the elderly Aboriginals and the Torres Strait Islanders people with dementia as well as reviewing the potential intervention strategies that can be applied to improve health outcomes of people with dementia.
Dementia among elderly Aboriginals and the Torres Strait Islanders population, health care gaps and strategies for effective care have been accessed from a wide range of nursing databases and academic research papers. The databases that were accessed to find out the reliable and reading materials were CINAHL, MEDLINE, Emcare, PubMed, Web of Science and Scopus. These databases had been accesses as those are known for their high standards and relevant to topics. A wide array of research materials are available in the mentioned databases such as high quality peer reviewed journals, statistics, articles and data have been of immense importance in carrying my research study. Research materials were accessed in terms of keywords that were used in those databases.
In order to search and select the article for conducting the particular research study, title, abstract and the content were searched. Care in assisted and nursing homes of dementia has been selected as the specifications for the study and identifying relevant papers. A few of the keywords that were applied in searching articles and journals are“Indigenous population Australia”, “Older patients with dementia”, “Dementia care in nursing homes” and “dementia among Aboriginal population” and dementia care and gaps among the indigenous population with dementia”. “AND”, “OR”, “NOT” are the Boolean Phrases that have been taken into consideration in this particular research study.
To find out the current studies and strategies in the recent studies, all the studies searched and accessed for the particular literature review were between 2014 till date. In order to identify the current approaches specifically, the above mentioned timeframe has been chosen for the conducted literature review. The current study further has accessed information and data on current nursing strategies and approaches for providing effective care to people with dementia and meet the needs of the Indigenous population that are culturally sensitive. Information from the mentioned timeframe has assisted in finding latest data and knowledge on dementia and effective care strategies in nursing homes and assisted care and assess how approaches help in improving the health and wellbeing of the Aboriginals and the Torres Strait Islanders population living with dementia.
Materials that are published between 2014 to present were included that have chosen health care approaches to the Aboriginals and Torres Strait Islander people living with dementia. Articles that included different care approaches and strategies in improving wellbeing and health outcomes of people living with dementia had been included. The health needs of the chosen population had been determined in the context of the nursing homes and assisted care system. Not only articles based on the Aboriginals and Torres Strait Islander people in regards to dementia were considered but some form of articles from the general population and dementia care and treatment procedures also were included that assisted in understanding the degree and level of the issues and how it is affecting the people globally. News articles, qualitative studies and book reviews were included in determining the dependability of the findings.
The articles that were not based on dementia, its care strategies and approaches, dementia among elderly people, dementia among the Aboriginals and Torres Strait Islander, care approaches in nursing homes and supported care and gaps in dementia care among the Aboriginal population were excluded from the search outcomes. Articles that were published before 2014 also had been excluded from the study as those studies do not contain updated findings on this area of research and current approaches to dementia care. Articles that include health care issues other than dementia have been excluded from the research.
Finally, after extensive research and inclusion and exclusion process, 15 most relevant articles were chosen to identify and analyse most effective care approaches to treat people with dementia in the nursing homes or assisted care system in Australia. Since the study has undertaken Aboriginals and Torres Strait Islanders as the target population to carry out this study, some of the selected studies conducted with the particular population are included. Different studies that were conducted in a different geographical region in the context of nursing approach were included in the particular research. Relevant studies either in terms of nursing care approaches or dementia or dementia among Aboriginals and Torres Strait Islanders people or care gaps among identified groups were identified throughout different above mentioned databases. Different approaches that were identified in different articles included various nursing approaches for effective care to people with dementia are Pain Management, Social Inclusion, Fall Prevention, Food and Fluid Management, and Prevention of Medication Error before those elements were considered for thematic analysis.
Followed by identifying the nursing approaches, data analysis was accomplished with the application of thematic analysis. Thematic analysis is the initial stage of analysing data. Information and data that has been collected from wider knowledge and information sources have been contrasted and analysed(Saunders, Lewis, & Thornhill, 2015). The collected information and data have been included for thematic analysis so that themes can be acquired through the data. The keywords that were achieved through the literature review process have been applied for data collection. 235 articles were available in the primary stage of selection of articles. However, the number of relevant articles were reduced to 137 after keywords are applied in the selection criteria. Finally, 15 appropriate articles were chosen for the research study and those have been included in the final literature review.
Some of the articles that were available in the initial search were relevant with the general population. However, the articles that only were appropriate to a public health issue or relevant to research questions were taken into consideration. I have identified relevant themes after the primary research of finding articles was conducted. I have gone through a good number of articles that were developed on the growing issue of dementia, which has enabled me in developing my knowledge about the research area. I further have found how people with dementia are prone to different health issues and they experience detrimental outcomes such as lack of adequate nutrition, harm and injury, disability and dependability on others in performing daily activities and errors in medications.
I have identified different nursing approaches and strategies that are related to dementia care especially in a nursing home and assisted care process. Gradually I have proceeded towards developing my search and investigation to identify the themes more elaborately. From the application of keywords in finding out relevant articles to develop my literature review, I have gathered in-depth information and data on dementia and various nursing approaches towards people living with dementia in nursing homes. I have gained extensive knowledge and insights about developing literature and learned about all the different methods and procedures that I have followed to carry out the literature review. Additionally, throughout the conduction of literature review, I have developed knowledge about different databases that I should access to conduct a public health issue research, about finding appropriate and relevant articles to the selected topic, inclusion and exclusion methods and significance of selecting timeframe.
|Databases||Primary search found||After applying keywords||Shortlisted||Cited|
|Web of Science||70||20||7||00|
Nutrition is critical to health, maintaining independence and wellbeing of people living with dementia. With the progression of dementia, eating and drinking becomes difficult for people living with this mental health problem and leads to unwanted weight loss. Studies have shown that the nutritional status of people with dementia is linked with their cognition, functioning and behaviour. However, it has been found from various studies that Aboriginal people with dementia are more likely to suffer from malnutrition due to inadequate knowledge about nutrition and financial status that effect on their food accessibility(Giudice, et al., 2016). Low food intake happens to be a key reason for malnutrition among the people with dementia.
Keller & Ducak, (2014) have identified that care providers and professional social workers in the supported care systems and nursing homes can encourage people with dementia, their family and friends about the needs of nutrition in their body and educate them about its importance in performing their daily activities. Nurses would also be able to make diet charts that include nutritious foods and adequate fluid or support of nutritionists also can be taken if accessible in nursing homes. In case of care users immobility or dysphagia, alternative feeding options can be adopted such as assisting the care users to lunch area and tube feeding technique.
Bosaeus & Barazzoni, (2015) have supported that when health care staffs provide nutritious meals and overcome the barriers to food consumption, improper nutritional status of people can be addressed among the people with dementia. Poor food intake and weight loss among the people with dementia have been found in a number of studies to have resulted from depression, loss of appetite, decreased taste, difficulties with eating, and decreased the ability to meal preparation. The mentioned issues may result in dependence on others for eating food, inability to identify taste when they consume it and dysphagia.
As there remains a range of factors for poor food intake intervention need to be developed in a manner that modifies more than one domain such as food access, quality of food and mealtime experience. Oral supplements for nutrition are the common approach of improving nutritional condition and intake of food in individuals with dementia. Meijers, et al., (2014) have identified interventions for people with dementia in the residential care homes through improving the taste of food, food service delivery, homelike furnishings, the colour of tableware and staffs to be more aware of eating difficulties and malnutrition. Effective ways to intervene are providing support for eating, self-feeding training to care for persons with dementia and staffs training on eating assistance. Keller, et al., (2014) have shown that older people with dementia who are unable to communicate their thirst accurately because of the Alzheimer’s diseases and depend on the nursing staffs for their intake of fluid are at risk of growing dehydration. Patients refusal to food and fluid can be address through effectively planned and well managed services to the people with dementia(de Souza-Talarico, de Carvalho, Brucki, Nitrini, & Ferretti-Rebustini, 2016).
Persons with dementia may experience pain due to similar reasons as everyone else. However, due to their lack of proper cognitive skills and deteriorating brain functioning, they may not be able to communicate their pain with the care providers. This may lead to under treatment and poor management of pain while declining life quality. People with dementia are at increased risk of experiencing pain as dementia increases the possibilities of fall, accidents and injury although dementia has no direct association with pain(Warren, Shi, Young, Borenstein, & Martiniuk, 2015). Elderly people including those who are with dementia are more likely to go through a different medical condition that may cause physical pain. Previously it used to be thought that since dementia damages the brain functionality of persons, they do not feel pain, which has been refuted in the following studies.
A study conducted in Melbourne, applied functional magnetic resonance imaging (MRI) to monitor and identify pain in people with dementia have demonstrated that brain activities is similar to those as those without dementia(Veldsman, 2017). It has been conducted by the study that people with dementia feel pain exactly the same as those without dementia. Nonetheless, they face difficulties in expressing their feelings of pain. Moyle, et al., (2014)have shown that people with dementia, report less pain and thus obtain lower pain main management medications, especially in the residential care homes. In the advanced stage of dementia, a wide number of people with dementia lose their abilities to communicate their pain to the care providers in residential care homes, which however, may be identified from their nonverbal signs. Some of the nonverbal signs of pain are gestures that demonstrate distress, frowning, unwilling to move, slow movement or limited motion, increased heart rate, sweating or blood pressure, social exclusion, lethargy, disturbed sleep, aggression, anger or irritability, decreased appetite and restlessness(Savundranayagam, 2014).
If the pain of a person with dementia go unnoticed and untreated, patients will needlessly suffer as well as there are possibilities that wrong medications are prescribed due to their changed behaviour. Chronic pain may make care users depressed, which again can be avoided through effective pain management interventions. Once it is identified that person with dementia has pain, health physicians must be consulted who would determine the accurate approach to treat and manage pain. Paracetamol can be used for minor issues such as headache. However strong remedies and medications, which also is known as analgesic might be needed for constant or stronger pain. Different medications that can be prescribed depends upon the pain type and severity are ibrufen, which is a nonsteroidal anti-inflammatory drug that contains aspirin and paracetamol, morphine and code in those are types of opioids.
Special care is required to be taken as elderly people are sensitive to certain medications and thus they must be prescribed with a minimum dose. Pain management medications are needed to be administered after considering and assessing other medications that may have interaction or side effects when taken with analgesics. Nondrug therapies also can be considered such as relaxation, gentle stretching and exercise, application of cold and heat packs, physiotherapy and massage. To people with dementia who suffer from ongoing pain, pain management becomes an essential aspect of the care plan. Treatment should be design in accordance with the care needs of a person’s health and severity and type of pain should be evaluated and monitored regularly(Cohen-Mansfield, 2014).
Although engagement inexpressive, active and social activities are linked with improved quality of life, residential patients are at higher risk of not being engaged in individualised and engaging activities. Engagement of residents through positive communication through behavioural intervention and interaction with care providers have the potential to achieve improved outcomes, wellbeing and higher survival rate. Higher residents’ engagement has various positive outcomes such as minimised depression, aggression, frustration, improved satisfaction and positive mood(Edvardsson, Petersson, Sjogren, Lindkvist, & Sandman, 2014). Healthcare professionals ideally encourage residents to engage with positive activity through effective interaction with them and developing opportunities to be engaged. In contrast, some healthcare staffs feel that multiple tasking act as a barrier in interacting and engaging with residents staffs despite their ability to improve their interaction with residents.
Quality of life is essential across lifespan as at every stage of their life, individuals have felt that their needs are met, to have a sense of belongingness and comfort. Persons with dementia become less able to care for themselves because of their more impaired health and their sense of self minimises. Care providers may treat their diseases more than perceiving who they are. Persons living with dementia in residential care are associated with quality of life and how this influences their wellbeing. Persons living with dementia may not be able to carry out strenuous activities that they have taken part in the past, however, to reap their benefits, persons can be engaged in the less strenuous activities in the residential care units. Stage of dementia that a person is currently, must be considered before selecting the physical activity. Persons in the moderate to later stage of dementia may face declining in their physical activities due to their ineffective movement and function(Cheng, et al., 2014). Persons with dementia may have experience of outdoors to be positive who find it valuable and is associated with the feelings of self-worth.
Research has shown that 62% of residents in residential care unit engaged in outdoor walks as a part of their daily activities and they have experienced a higher quality of life and functional abilities when compared with those who did not take part in such regular activities. Social engagement and social activity are essential throughout the lifespan. A person living with dementia who participated in social activities have experienced improved levels of attentiveness and positive attitude than those who engaged in non-social activities. Persons with dementia, wellbeing and overall health can be improved with the application of patient education and CBT technique implementation. Massage, aromatherapy, acupressure and light therapy are sensory stimulation therapy that care providers can adopt for treating and providing care in managing aggressing and depression among the persons with dementia.
Risk of fall increases as a person ages according to World Health Organization owing to various factors such as changes in cognition, sensory input and physical ability(Giebel, Sutcliffe, & Challis, 2015). A person with impaired cognitive ability is two to three times higher to experience a fall and experience serious injury. People with dementia are four to five times likely to fall than older people who do not experience cognitive impairment. Persons with dementia are at three times higher the risk of fracture and people who fall are five times more likely to be in long term care settings or hospital settings than older people who do not fall but are living with dementia. Decreased quality of life, fear, mortality and minimised functionality also results alongside serious fractures from falls. Eleven percent of the population ages 65 and older and thirty two percent of the population ages 85 and older are living with dementia(Cheng, et al., 2014).
Radford, et al., (2018) have found out that disease progression and issues in behaviour lead to increased risk factor for falls in persons living with dementia. Given the high risk of falls and difficulties in recovery prevention of fall is necessary. Polypharmacy is common among elderly people, especially who are living with dementia. Drugs that increase risk of fall are antipsychotics, sedatives or hypnotics and antidepressants. Antidepressants are sedating but a few of them have anticholinergic side effects that increase risk of fall. The decline in cognitive functioning, cerebrovascular falls, abnormalities in gait, sedation and mortality are caused by antipsychotics.
A study conducted in the UK has demonstrated that carpeted and wooden floors in nursing homes have diminished rates of falls significantly. Individually tailored programs that include injury reduction and fall prevention have the highest success rates with reduced fractures and falls. A study has included a combination of staff training, problem solving initiatives post fall, medication management, aids for mobility, individualised exercise and minimization of environmental hazards. (Giebel, Sutcliffe, & Challis, 2015). Residential settings for dementia care must ensure adequate lighting, safety of footwear, keeping pathways clear, improve the safety of the bathroom, and noise level reduction so that the persons with dementia who are in the nursing homes can be prevented from falls and related injury.
In studies conducted on medication administration to elderly people in residential care with dementia, errors were found to be very common. In a number of observational studies, omission error is the most common error in residential settings without any justified reason and an inappropriate sign of administering a medicine. Monitoring and assessment of medication administration is very essential as persons with dementia especially in the residential care are significantly vulnerable. Persons with dementia most of the times will have inadequate ability to be provided with information about medications and they also may be not be complaining about their medications errors. Elderly inpatients often are living with a number of comorbidities and are frail, requiring medications for physical as well as mental health issues. To minimise errors in medication in the inwards dementia care units, different strategies that should be adopted are interactive training for all staff nurses, filling up of Adverse Drug Reaction (ADR) profile and coding of medications put in the medication trolleys in the dementia care units.
Further studies have concluded that increased nursing monitoring and improved systems for vigilance, persons with dementia may minimise adverse effects of medications administration. Filling up of Adverse Drug Reaction (ADR) takes 20 -25 minutes that includes assessment of monitoring and signs. Filling and monitoring of ADR profile have been found to have enhanced care for all service users that will improve fluid intake, the introduction of new therapeutic regimes, development of new care plans to improve over-sedation, constipation and fluid intake, according to the monitoring and assessment of medications and processes.
A few effective approaches to have improved healthcare outcomes inAboriginal & Torres Strait Islander elderly persons with dementia in assisted living residences and nursing homes in Australia are proper nutrition and fluid consumption, prevent from fall, error in medication, effective pain management and social engagement. Different effective strategies have been identified that can be implemented in residential care homes to ensure proper nutrition and fluid consumption of Aboriginal & Torres Strait Islander elderly persons with dementia are feeding plan of nutritious foods and adequate fluid or support of nutritionist. In case of care users immobility or dysphagia, alternative feeding options can be adopted, oral supplements for nutrition, improving taste of food, homelike furnishings, colour of table ware and staffs to be more aware of eating difficulties and malnutrition, support for eating, self-feeding training to care users with dementia and staffs training on eating assistance.
Different medications that can be prescribed to manage pain in persons with dementia are ibrufen, which is a non-steroidal anti-inflammatory drug that contains aspirin and paracetamol, morphine and codeine those are types of opioids with a minimum dose. Non-drug therapies also can be considered such as relaxation, gentle stretching and exercise, application of cold and heat packs, physiotherapy and massage. Persons with dementia must be engaged in outdoor walks as a part of their daily activities, involve in positive communication through behavioural intervention and interaction, provide massage, aromatherapy, acupressure and light therapy, sensory stimulation therapy in managing aggressing.
To prevent the fall of persons with dementia in residential settings, adequate lighting, the safety of footwear, keeping pathways clear, improve the safety of the bathroom, and noise level reduction should be ensured. To minimise errors in medication in nursing homes and residential dementia care units, different strategies that should be adopted are interactive training for all staff nurses, filling up of Adverse Drug Reaction (ADR) profile and coding of medications put in the medication trolleys in the units so that those can be referred while administering medications.