Dealing With Difficult Dementia Patient Synthesis of the Evidence and Methodology of Search

¶ … Dementia and Alzheimer's Disease

Dealing with Dementia and the progression of Alzheimer's disease through its three stages is often a daunting and distressing task. Most often relatives feel isolated and without help as if they were to be left alone, having no help to deal with the "unknown." They are also afraid of having to watch their loved ones become more and more distant, potentially losing a horrible battle with this disease. In order to help with this fear of the "unknown" you need to first understand Dementia, Alzheimer's disease and the three stages that accompany Alzheimer's.

The search for information on this issue used multiple sources available. Searches were conducted through the Cochrane Library, PubMed, the Cumulated Index of Nursing and Allied Health Literature (CINAHL), the Institute for Healthcare Improvement and Dynamed. Keywords for searches included: difficult patient, dementia and management. The broader search term "dealing with difficult patients" netted larger numbers of hits ranging from 10 to 5,000. By narrowing the search and using the term "dementia management," more applicable results returned ranging from zero to 300 hits. Articles were selected for inclusion if they were applicable to patient management and the prevention of dementia related complications.

In regards to summarizing the literature on the challenges facing the management of dementia, two major thrusts of research exist: how best to categorize patients and how best to treat them. Aud (2001) found that by breaking down specific categories of de-identified resident data including behavioral symptoms, activity participation, medication use, health conditions, pain, falls, emergency room visits, and hospitalizations help result in better predictive patient outcomes. In a similar vein, Zimmerman (2010) suggested that the physical and psychosocial care environment, such as the characteristics of the nursing staff, influence the well-being of people with dementia, more than any other modifiable factor. In fact, the importance of the quality of nursing care staff has been echoed elsewhere, notably in Care (2010). This work examined the development of an educational tool which facilitates learning and professional development around the issues of person and relationship-centered dementia care and dramatically improved quality of care in dementia patients. From a different perspective, Gould (2010) there is a significant but small benefit in developing scripted training programs for staff in learning how best to manage dementia patients. In short, a general synthesis of this first area of research strongly promotes the understanding that quality nursing staff and a supportive psychosocial environment are critical to patient outcomes.

Regarding the best treatment of dementia, there is much less consensus. Defilipi (2000) found that typical antipsychotics have a modest effect on psychosis and behavioral symptoms, and preliminary studies suggest that atypical agents are effective. Yet, Steinmetzd (2010) argues that the patients considered difficult often are not in need of medical intervention and are not the ones experiencing major medical problems. Instead, they are the people who behave rudely and want a secondary gain. Patients with multiple non-specific complaints and those with psychosomatic problems are often the most challenging to manage long-term. Lastly, Williams (2009) argued that when discussing a treatment plan the probability of receptiveness to care varied significantly with communication acumen of the practitioner. An increased probability of receptiveness to care occurred with elderspeak compared with normal speak. Individuals with dementia slowly progress from forgetfulness to a stage of confusion which brings them to a new, different, initially strange and threatening mode of being. The patient's want and desire to keep up on their appearances and previous life is abandoned and their memory dissolves progressively more. They tend to live more in their own, dreamlike "world" which mingles the present and past together and the rules and structures of the "old world" looses its importance. During an increase of loss of memory, tends to derive limited vocabulary and verbal communication (Kuske, 2009).