Care giving for a patient living with dementia
Majority of patients suffering from dementia are cared for in community settings either by their spouse, children or significant others. Care giving has its merits and demerits on both the persons with dementia and on the caregivers. Whilst in some few cultures it is viewed in positive light and as something that brings satisfaction for the caregivers, care giving especially for the elderly is a strenuous responsibility and families which are involved in care giving feel this strain. Nevertheless, members who participate in giving care to those who are terminally ill must not let their burn out affect the quality of their care. Dementia is a mental illness in which the patient pose a little bit of a challenge to handle and therefore a stable family support system is necessary. Care giving-related stressors as well as evidence-based interventions for remedying these problematic areas in the care of Samuel, a patient with dementia and being cared for by the daughter and son-in-law will be explored below.
Body
In reference to the Evelyn Duvall’s staging of family development cycle, the family is at stage 8. Samuel is aging and has been caught up by dementia. The spouse, Anne, is already deceased. The communication pattern in this family is dysfunctional characterized by lack of open communication about issues and avoidant strategies. The family covers up cues that could spell embarrassment to them in the face of a visitor. For example, Sharon maintains that there is no unease between them even when it is apparent the opposite is the truth. This is an attempt to preserve the dignity of the family. In addition, Glen and Sharon avoid discussing the issues affecting them such as the economic and physical strain they are experiencing in caring for Samuel. Communication between Sharon and Glen is characterized by yelling and sarcasm. Samuel on the other hand resorts to humor to avoid discussing thorny issues.
Culturally, the wife is the one to run the household in the Native American Indian culture, the wife in this case is deceased. Nevertheless, Sharon, the daughter who takes care of their father Samuel, is also much in control of the household. Sharon makes most decisions in the house. Samuel, the father, also depends on the decisions made by the daughter. The family is spiritual even though they attend only the occasional mass, Sam actually prays before meals and at bedtime. The economic frustrations of the family may also contribute to the communication pattern. The family members seem to have indulged in alcoholism in order to subvert family economic frustrations. This seems to inform the dysfunctional nature of communication pattern in the family.
Whilst the Native American Indian Culture strongly values caring for the elderly viewing it as reciprocity for the care the elderly provided to their children, this does not seem to be the case for Samuel’s family. Additionally, according to the native Indian culture, caring for the elderly is a way of conveying respect to the elderly who are considered a source of wisdom and wealth for the community (Jervis, Boland & Fickencher, 2010). This is despite the economic hardships prevalent amongst such communities. In contrast, Glen and Sharon view caring for Samuel as a burden particularly because of his cognitive and behavioral deficits such as forgetfulness and wetting himself. Glen in particular is very frustrated with Sam and this rubs negatively on Sharon who becomes impatient with her father. They also do not seem to show much consideration for his opinions with Sharon making most decisions affecting him unilaterally although she seeks the opinions of her brothers and sisters sometimes. Glen and Sharon have also made little adjustments to the structure and manner of functioning of their family despite the fact they have the added responsibility of caring for Samuel who is suffering from dementia. This is contributing to the dysfunctional coping and role strain the family is experiencing.
Ineffective coping related to care giving burden and limited resources in caring for Samuel as evidenced by conflicts between Glen and Sharon, role strain, ineffective communication, mistreatment of Samuel and verbalized complains such as the family’s belief that they do not have enough resources and Sharon’s complains that caring for her father prohibits her from engaging in the activities she enjoys. Observations further reveal that the family has no real coping strategies yet despite the fact that Sam was diagnosed with dementia more than a year ago. The goal in this case is the attainment by the caregivers of an optimal level of coping. Evidence-based nursing interventions for enhancing coping of the caregivers encompass psychoeducational, cognitive behavioral, psychotherapy, respite care, behavioral management, supportive strategies as well as interventions for improving the competency of the recipient of care. Majority of these interventions embody aspects of King’s goal attainment theory in that their primary focus is on the care of the patient and the caregiver and their goal is to promote the health of two parties. The primary caregiver is seen as an open system/person who is experiencing psychological distress related to the care giving process. The interaction between the nurse and the caregiver leads to exchange of information, setting of goals, planning for the implementation of the identified interventions and ultimately transaction and the attainment of the set goal of enhancing the coping skills of the caregivers.
Psycho-education entails providing caregivers with information relating to the patient’s disease process, available support services and resources as well as the training of the caregivers on how to respond effectively to disease-related issues. Cognitive behavioral therapy focuses on teaching caregivers skills in self-monitoring, enhancing their problem-solving capacities, identification of negative thoughts or assumptions that contribute to caregiver’s maladaptive coping as well as helping the caregivers to participate again in pleasurable activities. Psychotherapy on the other hand entails establishment of a therapeutic relationship between the nurse and the caregiver in which the caregiver is assisted to explore strategies for managing distress. The latter aspect of allowing the caregiver to identify strategies for coping is congruent with King’s theory of goal attainment (Zarit, Fernia, Kim & Whitlach, 2010, p. 220).
Supportive interventions focus on establishing rapport and creating opportunities for caregivers to discuss their feelings and other issues related to care giving. These interventions encompass measures to equip caregivers with problem solving skills as well as teaching them how to utilize these skills in meeting the care needs of the patient. In this interaction, the nurse will identify the problems and needs of Samuel and his family. Samuel and his caregivers working together with the nurse will then identify the goals as well as explore the means via which the identified goals will be achieved. Respite care entails incorporating the efforts of other caregivers in the management of the patient so as to give the main caregiver Sharon in this case time off from care giving responsibilities. It entails interactions at the level of interpersonal systems as per King’s theory of goal attainment. Other members of Samuel’s family need to be integrated in the care of Samuel. Interventions aimed at improving the recipient competence include activity therapy programs for enhancing everyday competency and referral to memory clinics (Honea et al., 2007). Behavioral management is targeted at helping caregivers manage the behavioral and psychological signs of dementia better (Zarit, Fernia, Kim & Whitlach, 2010, p. 220).
Impaired communication related to anger and frustration secondary to caregiver role strain and family dysfunction as evidenced by yelling, making of sarcastic and incongruent statements, authoritarianism, strained relations between Glen and Sharon who are always irritated with each other and with Sam and use of avoidance strategies of coping like Glen resorts to alcohol. The goal of the intervention is to promote cooperative communication in the family whereby issues and concerns will be discussed openly. Achievement of this goal requires the identification of an evidence-based approach for improving interactions in the family. The family-based structural multisystem in-home intervention (FSMII) which uses a family systems approach is one such approach that can be employed. The nurse in this case would need to interact with Samuel and his family so as to identify the existing gaps in how they communicate and facilitate changes in the manner in which they communicate. Bilingual therapy sessions for the family may be provided to the family. Improved interactions in the family will not only reduce caregiver distress, the expected goal, but also improve family functioning by encouraging caregivers to gather and manage more effectively the available family and community resources. The process of change in FSMII focuses on interactions between an individual and his/her environment. These transactions are in turn embedded within the larger social-cultural systems (Belle et al., 2008).
Caregiver role strain related to inadequate adaptation to the care giving role as evidenced by impatience when caring for the patient, Sharon’s and Glen’s frustration with Sam’s forgetfulness and other behaviors like wandering and verbalized complains like Sharon stating that her family does not help enough in caring for her father and the negative impact that care giving has on Sharon’s health like she forgets to monitor her sugar levels and her blood pressure has gone up. The goal is to ensure that the primary caregiver and the rest of the family adjust appropriately to their new care giving role. Interventions aimed at fostering positive adaptation of the family members to the caring of their elderly father include development of a collaborative plan that integrates the various family members in the care of the patient. The nurse needs to hold family sessions with all the family members whereby they will be encouraged to raise all the issues relating to the care of the patient as well as to develop a mutually agreeable care plan that involves all the family members. In addition, the nurse may need to counsel the primary caregiver to accept the fact that not all family members will be willing to care for the patient. As such, she needs to expedite her energy not in judging others but on what she and the rest of the willing caregivers can do to assist the patient. Respite care whereby other caregivers other than Sharon assist the patient with activities of daily living and other care needed so as to give Sharon time off from the caring is another intervention that can be explored to reduce caregiver role strain. Another useful strategy is to teach the caregivers to blame the nature of the disease instead of the patient for instance by showing them images of the brain and discussing with them the alterations in the brain causing the symptoms in their patient (Austrom & Lu, 2009).
Sleep pattern disturbance related to the patient problem behaviors such as confusion, wandering at night and wetting himself as evidenced by voiced concerns. The goal in this case is to ensure that the family members get at least six hours of rest every night. Behavioral management which entails education and equipping of caregivers with the skills to manage the patient’s problem behaviors better is the intervention appropriate for ensuring adequate rest for the family members. The nurse needs to hold targeted counseling and educative sessions with the caregivers to identify the problem behaviors that the patient is exhibiting such as wandering at night and the activities the patient needs assistance with that may be contributing to the problem. The caregivers should then be taught strategies and interventions for coping better with these problem behaviors. Continued nurse support for caregivers through home visits and telephone calls is also important (Belle et al., 2008).
Conclusion
In conclusion thus, Samuel’s family is at stage 8 of Duvall’s theory of staging the family, the last stage occurring between retirement and death. Samuel is experiencing dementia, a condition associated with aging. Communication pattern in this family is generally ineffective and dysfunctional. There are economic and cultural factors that are responsible for this. Poverty and alcoholism seem to worsen the existing problems. The Indian American culture where the woman runs the house is evident in Sharon taking charge of the household. The nursing diagnoses for this family include ineffective coping related to care giving burden, impaired communication related to anger and frustration, caregiver role strain related to inadequate adaptation and sleep pattern disturbance related to the patient’s behavioral problems. Nursing interventions for improving communication, coping, sleep patterns and reducing caregiver burden for Samuel’s family encompass psychoeducational, cognitive behavioral, psychotherapy, respite care, behavioral management, FSMII, supportive strategies, interventions for improving the competency of the recipient of care amongst others. Inherent in these interventions is the need for ongoing transactions between the personal, interpersonal and social systems in this case the patient, caregivers and the nurse. These interactions will facilitate the identification of the problems plaguing Samuel’s family as well as exploration of measures for remedying these problems in order to foster effective coping.
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