Dealing With Difficult Patients Translation of Evidence and Best Practice

¶ … Difficult Patients

Mitigating Risks from Dementia

Providing adequate care for an individual suffering from dementia presents many difficulties for nurses. Patients with dementia often have debilitating conditions such as Alzheimer's or similar neurologic diseases which are progressive, thereby making it challenging for them to remember, think lucidly, communicate effectively or complete activities of daily living. Furthermore, dementia can cause rapid variations in mood or even modify personality and behavior. With the tremendous number of elderly in society more and more nurses are required to care for patients with progressive dementias. It is imperative that a diagnosis be reached early in the course of the cognitive impairment and that the patient is closely monitored for coexisting morbidities. Nurses have a central role in assessment and management of individuals with progressive dementia. This essay provides some evidence-based practical strategies for managing the behavioral problems and communication difficulties often encountered in this population.

I currently work as a nurse practitioner for a non-profit hospice inpatient facility with 36 beds in Cape Coral, Florida. On a daily basis staff must tackle issues related to difficult patients. Patient are often angry, sad, emotional and sometimes delirious and in cases with severe dementia can become combative. This forces nursing staff to be cognizant of these critical issues in order to avoid injury to staff and patients and to calm patients in distress. All medical staff at the facility is required to undergo training in dealing with difficult patients. Recently, the number of occurrences has increased dealing with injury to staff and complaints from patients. This has unfortunately led to an uptick in worker's compensation claims as staff struggle to effectively manage these patients while also being compensated for the risk involved. The key issue to be learned from my personal experience is that when dealing with problematic patients having the correct approach can help mitigate obstacles when dealing with one's patients.

Dementia is a mental state defined as a progressive deterioration in mental and physical state, a decrease in function and an increasing in the need for assistance to complete daily tasks. Individuals with this condition often have co-existing medical conditions close observation and which can impact the course of their dementia's progression. Beyond physical illness, factors such as a change of scenery and medical interventions are known to worsen the symptoms of dementia. This work will examine appropriate plans of care and treatment to manage this condition during the patient's residence in a nursing home. Nursing care should be patient-centered and strive to recognize the patient's uniqueness as well as their particular needs. Nurses should regularly and repeatedly explain the diagnosis to the older person and any family while giving relevant information about sources of help and support. During the course of a patient's stay in a nursing home, when behavioral problems occur, non-pharmacological management strategies should be sought first. Many elderly patients with dementia do not require sedation and sedatives may cause worsened delirium and increase the risk of falls. Antipsychotic drugs should be reserved for more serious problems, such as delusions and hallucinations, serious distress or agitation (Fletcher and Zimmerman, 2010).

Principles of dementia care

People with dementia and their care givers often have many needs and problems. Rather than highlighting all the possible areas of need and the numerous problems that could be encountered, it is often more useful to think of guiding principles, such as the following practice guidelines based on a variety of scholarly sources (Goodman, 2011; Kuske, et al. 2009):

Principle 1: People with dementia have the same human value as anyone else, irrespective of their degree of disability or dependence. This means recognizing the status and worth of people with dementia. People with dementia should therefore: Always be listened to; not be abused physically, psychologically or socially; be spoken to kindly, as one would expect to address a respected member of society.

Principle 2: People with dementia have the same varied human needs as anyone else. This means services should respond to the full range of their needs within the mainstream of society. People with dementia: Have the right to the same sources of health care provision as anyone else; Have the right to a secure and safe environment; should have a good diet that optimizes their health; Have the right to expect relaxation and recreation.

Principle 3: People with dementia have the same rights as other citizens. This promoting the rights of people with dementia who use services. People with dementia have the right to: Express their views about the service; be able to make choices; Independent advocacy; Expect first class care, which aims to satisfy the interests of the patient, not that of the nurse.

Principle 4: Every person with dementia is an individual. This means providing person-centered care. People with dementia have the right to: Express their individuality; satisfy their individual taste and their own clothes and belongings.

Principle 5: People with dementia have the right to forms of support, which do not exploit family and friends. This means safeguarding the quality of life of families and other caregivers. People with dementia have the right to expect that: The care they require will not place an excessive strain upon the people they love and respect; Their informal caregivers receive the appropriate professional support; Their informal caregivers receive the information they require about dementia and services; Available and appropriate referral to agencies from nursing staff (Purnell and Paulanka, 2008).

Management of Confusion

The following guidance, developed primarily for patients with acute confusion (delirium), is also relevant to patients with dementia. Management should also be directed at the reduction of the symptoms of confusion. The patient should be nursed in a good sensory environment, with a reality orientation approach and with involvement of the multi-disciplinary team (Williams, et al., 2009). This includes: Good lighting levels; Regular and repeated visible and verbal clues to orientation (e.g. clocks, calendars); Reassurance and explanation to the patient and care giver of any procedures or treatment, using short simple sentences; Sensory aids should be available and working where necessary; Avoidance of inter and intra-ward transfers; Continuity of care from nursing staff; Avoidance of physical restraints; Maintenance or restoration of normal sleep patterns; Approach and handle gently; Eliminate unexpected and irritating noise (e.g. pump alarms); Ensure fluid balance and meeting nutritional needs; Attend to bowel and bladder elimination; Encouraging visits from familiar friends and relatives may help to calm an agitated patient. Communication with the relative regarding the nature of the confusion is essential (Aud, et al., 2011). Where relatives are asked to assist in the care of a disturbed or agitated patient, an explanation of why their involvement is necessary and how they can help should be given by the nursing staff.

Wandering and Agitation

Patients who wander require close observation within a safe and reasonably closed environment. It is often preferable to try distracting the agitated wandering patient rather than using restraints or sedation. Relatives could be encouraged to assist in this kind of management. Attempts should be made to identify and remedy possible cause of agitation - e.g. pain, thirst, and need for toilet (Care, 2010). Patients with dementia often exhibit confused speech; it is usually preferable not to agree with confused communications but to adopt one of the following strategies: Tactfully disagree (if the topic is not sensitive); Change the subject; Acknowledge the feelings expressed - ignore the content (Purnell and Paulanka, 2008).

Sedation

All sedatives may cause delirium in patients with dementia, especially those with anticholinergic side effects (such as chlorpromazine). The use of sedatives and antipsychotics should therefore be kept to a minimum. Drug sedation may be necessary in the following circumstances: In order to carry out essential investigations or treatment; to prevent patients endangering themselves or others; to relieve distress in a highly agitated or hallucinating patient. It is preferable to use one drug only, starting at the lowest possible dose and increasing in increments if necessary after an interval of 30 minutes. The preferred drug is haloperidol -- Orally, as tablets or liquid, up to a maximum of 2 mgs daily in divided doses, or by intramuscular injection to a maximum of 2 mgs every 6 hours. It is important to note that there is clear evidence of an increased risk of stroke in elderly patients with dementia who are treated with risperidone or olanzapine. Patients with dementia should therefore not be started on these drugs. Careful consideration should also be given to prescribing these drugs for patients with a history of cerebrovascular disease (Zimmerman, et al., 2010).

Complications

The main complications of dementia for which nursing staff must be prepared to encounter are: Psychiatric and behavioral disturbance; Delirium and Depression (Kleinpell, 2009).

Psychiatric and behavioral disturbance

People with dementia are likely to present with a wide range of psychiatric and behavioral problems and these difficulties in the context of cognitive impairment constitute the main burden for relatives and the greatest challenge for the caring professions. The following may feature in people with dementia: Hallucinations (Visual, auditory); Delusions (especially of theft or persecution); Anxiety; Emotional labiality; Aggressive behavior (especially in the context of resisting intimate care); Activity disturbance (agitation, restlessness, apathy, inertia); Eating disturbances (decreased/increased food consumption and weight variability, eating inedible substances) and disturbances of diurnal rhythm (Mateo and Kirchhoff, 2009).

Research Methodology

It is essential to precede any planned review with a search to establish the existence of extant reviews. Such a search will typically identify both quantitative and qualitative systematic reviews. In formulating a review question an existing qualitative systematic review is a helpful starting point because:

1. It may help in identifying key issues that have a bearing on the acceptability or effectiveness of a programme or intervention;

2. It may help in identifying barriers or facilitators to the implementation of a programme or intervention.

3. It may help in identifying important perceptions of the experience of the condition that may help in either the selection or targeting of a candidate intervention.

In identifying related nursing studies an existing qualitative systematic review is a useful source of possible studies for inclusion, capitalising on a previous review team's search processes.

An existing qualitative systematic review may also assist in interpretation of an effectiveness review in exploring possible explanations regarding any heterogeneity identified across quantitative studies: in informing tactical decisions on splitting the review, on which subgroups to analyse and in justifying a review team's position on 'lumping vs. splitting'. It can also identify possible explanations for unexpected findings such as where effects are greater or lesser than the review team had anticipated or, indeed, where there is no effect when some demonstration of effect is predicted.

Finally it is important to identify whether an existing review already satisfactorily addresses the question of interest as this removes the need for replication or, at the very least, provides a starting point for an update process.

Methods for identification of systematic reviews

Methods for identifying existing reviews will include the following:

1. Searches of databases of reviews

2. Searches of general databases using the publication type "review" or review-related terms (e.g. "overview" or "systematic review") (See Table 1)

3. Looking through the reference lists of policy documents, editorials, or statements from professional bodies.

You should note that qualitative systematic reviews employ a similarly diverse range of terminology as reviews in general. For this reason you will need to employ an imaginative variety of terms. A search strategy illustrating a majority of these more specialist terms is provided in Table 2.

Table 2 Search terms to identify existing qualitative systematic reviews

1. Qualitative systematic review* OR (systematic review AND qualitative)

2. evidence synthesis OR realist synthesis

3. Qualitative AND synthesis

4. meta-synthesis* OR meta synthesis* OR metasynthesis

5. meta-ethnograph* OR metaethnograph* OR meta ethnograph*

6. meta-study OR metastudy OR meta study

7. OR/1-6

Because your review team may be interested in perspectives on the disease in general or on experiences (of either providers or recipients of care) of the intervention you may choose to conduct sensitive search strategies (i.e. maximising your chances of retrieval) that combine the string of terms from Table 1 with the condition or the intervention separately rather than focus only on the intersection of both condition and intervention (See Table 3). Note too that the term "qualitative systematic review" is occasionally used more loosely (e.g. within analgesia or pain relief studies) to describe those reviews where it was not possible to perform a quantitative meta-analysis. Use of this term may therefore result in unexpected "false hits."

Table 3 Searching for qualitative systematic reviews of Condition OR Intervention

1. Qualitative systematic review* OR (systematic review AND qualitative)

2. evidence synthesis OR realist synthesis

3. Qualitative AND synthesis

4. meta-synthesis* OR meta synthesis* OR metasynthesis

5. meta-ethnograph* OR metaethnograph* OR meta ethnograph*

6. meta-study OR metastudy OR meta study

7. OR/1-6 {Combining qualitative systematic review synonyms}

8. 7 AND Postnatal Depression {Combining review terms [1-6] with Condition}

9. 7 AND Cognitive Behavior Therapy {Combining review terms [1-6] with Intervention

10. 8 OR 9 {Reviews of Postnatal Depression or Reviews of Cognitive Behavior Therapy}

Current Cochrane guidance states that:

"The formulation of a question to be addressed by a Cochrane review will often usefully be informed by qualitative research. This statement carries no implication that the qualitative research should be subject to systematic review."

The emphasis of this Section is thus on the identification of relevant individual studies that are closely associated with the question to be addressed by a Cochrane Review. As Chapter Two makes clear qualitative research may contribute to many of the elements of a focused PICO question. For ease of reference these are summarised in Table 4.

The challenges of retrieving qualitative research are well-documented (Evans, 2002, Barroso et al., 2003). These include non-meaningful titles, poor quality and unstructured abstracts, a superficial depth of indexing, and poor description of qualitative method used. Several authors, such as Campbell et al. (2003), describe the difficulties they encounter when trying to retrieve all of the literature relevant to their work

Scoping searches are now an accepted stage of most types of systematic review (Jones, 2004). As Chapter Two demonstrates scoping searches can identify contextual information important to the protocol. Provided that reviewers do not allow themselves to be prematurely exposed to the results of studies for inclusion it is frequently helpful, and rarely harmful, to investigate the quantity and likely quality of the evidence available for the topic as well as the different study designs available for a particular question. This stage helps to conceptualise the review in terms of the language and concepts used in the literature and also to manage the logistics in terms of the yield and likely workload for the review team. The review team may also find it useful to engage in some form of "area scanning," that is to identify major organisations in the field, significant international or national policy reports and traditional reviews to orientate themselves to the main issues relating to the disease condition or the intervention. The aim is to develop a rounded out (holistic) picture of issues associated with the intervention.

It may well prove useful to identify, or alternatively, to construct a "logic model" to guide the development of the background section of a Cochrane Review and to assist in defining, and indeed refining, the review question. A sufficiently robust logic model may already be present in the identified literature, it may be constructed de novo as part of the scoping process or, indeed it may be a synthetic product of refining an existing model in the light of other relevant literature.

How might searching help to inform this scoping process? Scoping is envisaged primarily as a three-stage process:

1. Identification of existing systematic reviews (identified above as prerequisite in any review context)

2. Identification of key items of existing primary research

3. Elicitation of the views of stakeholders for the potential review

A review team will not always view it as desirable or feasible to undertake all three stages of the process. At a minimum they should undertake the first stage. They should then review the extent to which there is added value in proceeding to each subsequent step.

Conclusion

Caring for a patient with dementia poses many challenges for caregivers. People with dementia often suffer from progressive disorders that make it difficult for them to remember things, think clearly, communicate with others or take care of themselves. In addition, dementia can cause mood changes and even affect a person's personality and behavior. The rapid growth of the aging population is associated with an increase in the prevalence of progressive dementias. Nurses have a central role in assessment and management of individuals with progressive dementia. This essay provides some evidence-based practical strategies for managing the difficulties often encountered when caring for a person with dementia.

Reference List

Aud, M.A., Oliver, D., Bostick, J. And Schwarz, B. 2011. Effectiveness of Social Model Care Units for Dementia. International Nursing Research Congress 2005.

Care, N.D. 2010. Teaching and Learning. Pulse. Winter Edition.

Fletcher, S. And Zimmerman, S. 2010. Trainee and trainer reactions to a scripted dementia care training program in residential care/assisted living settings and nursing homes. Alzheimer's Care. 11(1): 61-70.

Goodman, C. 2011. The organizational culture of nursing staff providing long-term dementia care is related to quality of care. Evidence-Based Nursing. 47:1274-1282.

Gould, E., Cox, T. And Johnson, M.A. 2010. Best Practices-Dementia Care Training in Nursing Homes and Assisted Living Settings. Alzheimer's Care Today. 11(2).

Kleinpell, R.M. (2009). Outcome assessment in advanced practice nursing (2nd ed.). New

York, NY: Springer.

Kuske, B., Luck, T. And Hanns, S. 2009. Training in dementia care: a cluster-randomized controlled trial of a training program for nursing home staff in Germany. International Psychogeriatrics. 1(21): 295-308.

Mateo, M., & Kirchhoff, K. (2009). Research for advanced practice nurses: From evidence to practice. New York, NY: Springer.

Purnell, L.D., & Paulanka, B.J. (2008). Transcultural health care: A culturally competent approach (3rd ed.). Philadelphia: F.A. Davis.

Williams, K.N., Herman, R., Gajewski, B. 2009. Elderspeak communication: impact on dementia care. American Journal of Alzheimer's Disease and Other Dementias. 24(1): 11-20.

Zimmerman, S., Mitchell, C. And Reed, D. 2010. Outcomes of a dementia care training program for staff in nursing homes and residential care/assisted living settings. Alzheimer's Care. 11(2): 83-99.

Matrix

Author

Year

Question

Design

Sample

Data Collection

Findings

Limitations

Level of Evidence

Aud

Effectiveness of Social Model Care Units for Dementia

2011

To evaluate the first two years of the demonstration project, an interdisciplinary team of researchers investigated the impact of organizational, programmatic, and environmental factors on resident health and well-being, staff satisfaction, and family satisfaction.