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Nursing management of elderly patients with delirium and/or dementia

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Nursing management of elderly patients with delirium and/or dementia

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Content NURSING MANAGEMENT OF ELDERLY PATIENTS WITH DELIRIUM AND/OR DEMENTIA by Gary A. Behl A Thesis Presented to the FACULTY OF THE LEONARD DAVIS SCHOOL OF GERONTOLOGY UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree MASTER OF SCIENCE IN GERONTOLOGY August 1982 UMI Number: EP58899 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertation Publishing UMI EP58899 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 UNIVERSITY OF SOUTHERN CALIFORNIA LEONARD DAVIS SCHOOL OF GERONTOLOGY UNIVERSITY PARK ; 63 LOS ANGELES^ CALIFORNIA 90007 ThLs thesLs, written by Gæ/ 2 ' c fir' B>£.au under the direotor of /z / S Thesis Committee and approved by all its members ^ has been, pre sented to and aoaepted by the Dean of the Leonard Davis Sohool of Gerontology and the Dean of the Sohool of Publia Administration or Urban Planning (underline one)^ in partial fulfillment of the requirements for the degree oj Dean ff)AST&IK OF Sc.l£Mc€ /A> Dean Date VaaÈu THESIS COMMITTEE chatrman 11 DEDICATION I would like to dedicate this thesis to my beloved grandparents, Ellis and Clissie Whiting, who were always there. Ill ACKNOWLEDGMENT I would like to acknowledge the support and direction given to me by Steven Zarit, IV TABLE OF CONTENTS Page DEDICATION ....... .... ii ACKNOWLEDGMENT . . . . . . . . . . . . . . . . . iii LIST OF TABLES ... .. ... .. . V Chapter I. INTRODUCTION . . . . . . . . . . . . . . 1 II. REVIEW OF THE LITERATURE ........ 5 Issues of Training Dementia Delirium Nursing Management Hypotheses III. METHODOLOGY . . . . . . . . . . . . . . 27 Population Design Measurement Tool Statistical Procedures IV. RESULTS.............................. . . 32 V. DISCUSSION ........ 37 VI. SUMMARY . 40 REFERENCES ............................ ..... 42 APPENDIX ................. .... . .. . .. . 47 LIST OF TABLES Page Table 28 Population 33 t Test Results 36 Pretest Means CHAPTER I INTRODUCTION There is both a quantitative and qualitative shortage of nurses educated in gerontological nursing in the United States. The quantitative shortage makes it impossible to supply adequately prepared gerontological nurses to staff health care facilities and educational programs. The qualitative shortage decreases the effectiveness of nursing care delivered to older people and further adds to the lack of adequately prepared instructors (Birren & Sloane, 1977). The manpower needed to provide various services to the elderly include physicians, psychiatrists, nurses, psychologists, social workers, rehabilitation therapists, psychiatric technicians, nurse*s aides and technicians, nursing home administrators, and the list goes on. Not all these people need to be geriatric specialists, but if they are to work effectively with the aged, then they must have adequate training in the special needs and problems of the elderly (Birren & Sloane, 1977). One means of providing this training is through continuing education of the personnel who work with the dmrly. Birren and Hirschfield (1979) found that the____ 2 "departments most active in continuing education are those requiring updating or recertification for practice in their field, such as medicine, nursing, and social work" (p. 4). Irene Burnside (1976) stresses that we not only educate "new" nurses, but that we continue to educate existing nurses, many of whom work with the elderly in long-term care facilities. One of the major areas where continuing education is necessary for nursing personnel who work with the elderly is the brain disorders of delirium and dementia. Nursing homes and other long-term care facilities are filled with elderly patients who are diagnosed as having dementia or, more commonly. Organic Brain Syndrome (OBS). OBS is a more general term which includes dementia as well as other brain disorders. Because dementia is not reversible at this time, these patients are destined to live out their lives in institutions. Oftentimes these elderly are cared for at home by family members, but if this care becomes too burdensome, institutionalization is often the end result. Unfortunately, many of these elderly who are thought to have dementia actually have a delirium which is reversible. Delirium is also a brain disorder that may resemble dementia and misdiagnoses are made accordingly. Proper diagnosis and treatment of delirium may reverse the disorder and return the person to their prior state of 3 function. When delirium exists along with dementia, treating the delirium will remove the symptoms compounding the effects of dementia. While professionals working in the field of geriatric psychiatry have the training and expertise in diagnosing the brain disorder that is in progress, it is the nursing staff and family members who directly provide care for the elderly person on a daily basis. It is important, therefore, that these primary care providers have a basic understanding of the differences between delirium and dementia, that their interventions may be based on sound rationale for meeting the specialized needs of these elderly persons. Through continuing education, such knowledge may be attained. The problem then is that nursing personnel who work with elderly patients do not have sufficient knowl^ edge about the special needs and problems of the elderly patient with delirium and/or dementia. This problem exists whether or not these personnel have previously been adequately prepared to work with old people that are in need of nursing care. The result is that the elderly patients are directly affected by the nursing care that is often inadequate and not designed to meet their special needs. This study provides continuing education on the brain disorders of delirium and dementia to nursing staff 4 who work with elderly patients in hospitals and nursing homes. The continuing education program focuses on the clinical characteristics differentiating delirium and dementia, and the specialized needs of elderly persons with these disorders. Utilizing a pretest/posttest method of evaluation, this study examines whether or not such continuing education significantly affects the appropriate ness of the nursing interventions used to manage these elderly patients. CHAPTER II REVIEW OF THE LITERATURE Issues of Training In the rapidly changing field of health care, knowledge and skills quickly become obsolete. The emergence of the many specialties in the health care field is one evidence of the rapid expansion of technology. In gerontology, where progressive treatment methods exceed actual practice in care of the elderly, professional obsolescence may occur in a very short time. This obsolescence may be seen at all levels of personnel, from the professional nurse to the nursing assistant who has been caring for elderly persons for the past 10 or 20 years (Proctor, 1975). Unfortunately, the continuing education courses available to Registered Nurses are not usually available to nursing assistants and other non-licensed personnel. Where continuing education is required by the California State Board of Nursing for relicensure of nurses, as in other states, such requirements do not exist for other non-licensed personnel. The result is that non-licensed personnel may be working only with the knowledge and 6 skills obtained from their initial program leading to certification, unless an active continuing education department exists within the facility. The traditional "trickle-down" approach used in in-service training offers the educational program in a central, academic location to participants representing top staff level personnel (Hickey, 1975). Evaluation of similar long-term care programs over a 2-year period in Pennsylvania found little evidence of improved care in nursing homes or even, in some cases, "any indication that the substance of the program filtered down to the staff levels where most patient care takes place" (Hickey, 1975, p. 3 ) • An alternative method is to offer the educational program to various levels of staff in their work setting. Campbell and Browning (1978) developed a 2-day workshop to educate long-term care personnel (including intermediate and long-term care facilities) on the biopsychosocial aspects of aging. The first day of the workshop provided continuing education to RNs and licensed personnel. The second day provided continuing education to the nursing assistants, with careful use and definitions of terms. The response of nursing assistants, was significantly more positive than that of the registered nurses and licensed vocational nurses (Campbell & Browning, 1978). Further, the nursing assistants were found to be "overwhelmingly 7 more enthusiastic about the relevance of the content to their work settings, more open in group discussions, and more diligent in carrying out their assignments in the interim between the two days of the workshop" (Campbell & Browning, 1978, p. 19). The lecture method has traditionally been the most widely accepted and utilized method of instruction in secondary and higher education. Now, however, teachers are making frequent use of alternative methods of instruction, including group discussion, role playing, audio and visual tapes, slides, film-strips, and individual instruction packages. The teacher must not only consider the content of the material presented, but also the process, or manner in which it is presented, to best accomplish the educational goals. Different techniques may be better suited for one subject than for another (Hickey, 1975). One study (Hickey, 1975) examined the educational techniques used in on-the-job human services training. One hundred thirty subjects were presented with a wide variety of instructional techniques using the same content of Milieu Therapy in a large state mental hospital in Pennsylvania. The educational techniques were considered either active (role-play, video-tape exercises, psychodrama, etc.) or passive (lecture, films, written exercises, etc.). Those who indicated the least preference and the most resistance for 8 the active process were found at both extremes of the professional/job ladder. Both groups seemed to be threatened by the active techniques for different reasons. The highest level, on the one hand, were in administrative positions and saw a danger that they would lose respect or control by stepping out of their role for the brief period of a training exercise. On the other hand, the lowest members of the staff were inhibited in participating to a predictable degree of job insecurity. The middle range— perhaps 75% of the participants— were evidently comfortable with the active techniques. (Hickey, 1975, p. 13) The challenges faced by instructors who teach professionals and paraprofessionals on the job are quite different from those in public schools. The individual needs, incentives, capabilities, and interests of the group members are different. The purposes for which professional and paraprofessionals receive in-service training are more immediate— to improve job performance or to upgrade institutional standards. It is important, therefore, to adapt materials and teaching style to the special needs and abilities of the group (Hickey, 1975). Dementia Overview Dementia is a brain disorder that is common in old age. It is characterized by sufficient loss of intellec tual abilities to interfere with social or occupational functioning (American Psychiatric Association, 1980). Symptoms range from mild to severe and include 9 forgetfulness, poor judgment, and changes in personality. "Confused" and "senile" are labels that have been attached to these persons, though these terms tell us nothing about the disorder or the accompanying behaviors. Dementia is due to death of large numbers of brain cells as well as other structural changes in the brain. Since brain cells do not regenerate, once a particular function is lost, it cannot be relearned. However, other areas of the brain may attempt to take over and compensate for that lost function. The onset of dementia is generally slow, but progressive, leading to death. The dementias are divided into presenile and senile dementia, depending on whether they are occuring before or after age 65, respectively. Alzheimer*s Disease is the most common type of dementia and begins at any age after 40. The second most common type is multi-infarct dementia caused by vascular disease and emboli (Zarit, 1980). Treatment is limited in most dementias, aside from surgical interventions in specific types "such as normal pressure hydrocephalus, meningiomas, infectious processes, etc." (Karasu & Katzman, 1976, p. 138). A variety of methods have been attempted for treatment of dementia, including anticoagulant therapy, hyperbaric oxygenation, reality orientation, and numerous cognitive acting drugs. No cognitive acting drug has demonstrated a significant 10 long-term reversal or cessation of the progressive dementing process (Eisdorfer & Stotsky, 1977; Karasu & Katzman, 1976). "At present there are no methods that effectively restore intellectual function or prevent further deterioration in cases of senile brain disease. Treatment involves minimizing the disruption caused by the disorder" (Zarit, 1980, p. 356). Clinical Features "The essential feature is a loss of intellectual abilities of sufficient severity to interfere with social or occupational functioning" (American Psychiatric Association, 1980, p. 107). Impairments involve memory, abstract thinking, judgment, impulse control, and other higher cortical functions as well as changes in personality (American Psychiatric Association, 1980). Memory impairment is the most prominent, consistent sign of dementia. A person with mild dementia may be forgetful in day-to-day activities and need frequent reminders to aid him/her in carrying out various activities- As dementia progresses, forgetfulness increases cind the person may not remember names, events, conversations, or tasks that they were involved in, resulting in leaving the stove turned on or the; .water running. In cases of severe memory impairment, the person may forget names of family members, his own birthday and, 11 occasionally, even his own name (American Psychiatric Association, 1980). While forgetfulness is a hallmark of dementia, all persons forget some things, so one must not be overzealous in assigning the label of dementia. It is not the act of forgetting that signifies dementia, there fore , but rather the extent and persistence of the problem (Zarit, 1980). Impairment of abstract thinking is another symptom of dementia. Here, individuals have difficulty defining words or concepts, finding similarities or differences between words, and interpret proverbs very concretely. Additionally, the person has increased difficulty performing these tasks when he/she is timed or feeling rushed (American Psychiatric Association, 1980), although this difficulty is not restricted to elderly persons having dementia. Impaired judgment and impulse control are also characteristics of dementia. Neglect of personal hygiene and inappropriate sexual advances are not uncommon. The individual's personal safety becomes of concern when poor judgment and impulse control are evidenced by such activities as crossing the street without regard for personal safety or attempting to ambulate under unsafe conditions of dizziness or weakness. Disturbances of higher cortical function involve several areas. Language may be affected qualitatively. 12 appearing vague and imprecise, or quantitatively, to the extent of muteness in severe cases. Impaired "construc tional ability" is demonstrated by inability to copy drawings, designs, and block arrangements. "Agnosias (failure to recognize or identify objects despite intact sensory function) and apraxias (inability to carry out motor activities despite intact comprehension and motor function) may also be present" (American Psychiatric Association, 1980, p. 109). Personality changes are usually seen with dementia These changes are generally due to an alteration or accentuation of pre-morbid traits and these persons are often described as "not himself." Normally active persons may become apathetic and withdrawn; neat and meticulous persons may become slovenly (American Psychiatric Association, 1980). Also, common features are irritabil ity and cantankerousness (American Psychiatric Association 1980). Delirium Overview Delirium is due to an alteration of metabolic processes and results in a state of "cerebral insuf ficiency" (Engel & Romano, 1959). It may be due to such common causes as malnutrition, overmedication or drug interaction, infectious processes, disease, surgery, other 13 trauma and stresses (Libow, 1977) as well as such environ mental factors as sensory deprivation, social isolation, and relocation (Zarit, 1980). The onset of delirium is usually rapid. The course of illness is either a high immediate death rate or high discharge rate from the hospital (Butler & Lewis, 1977). "An estimated 40 percent die, either from exhaustion or from accompanying physical illness" (Butler & Lewis, 1977, p. 82). Delirium may exist alone or along with a pre-existing dementia. The treatment of delirium consists* basically of correcting the abnormality or imbalance that is in process. "In general, once the causal factor is removed, the symptoms of an acute brain syndrome subside in from 1 to 4 weeks. Sometimes there are dramatic improvements in patients" (Zarit, 1980, p. 146). If the underlying cause is not treated properly or at all and the delirium continues, the syndrome may become irreversible or cause death (American Psychiatric Association, 1980). Clinical Features "The essential feature is a clouded state of consciousness, that is, a reduction in the clarity of awareness of the environment" (American Psychiatric Association, 1980, p. 104). Characteristics of delirium include difficulty in sustaining attention to internal/ 14 external stimuli, sensory misperception, a disordered stream of thought, and disturbances of the sleep-wake cycle and psychomotor activity (American Psychiatric Association, 1980). The capacity to shift, focus, and sustain attention is greatly reduced in delirium. The individual is easily distracted and, once this occurs, it is difficult to refocus his/her attention to the subject at hand. Engaging a person with delirium in a conversation, therefore, is difficult and, often, impossible (American Psychiatric Association, 1980) . Perceptual disturbances are common in delirium. They may take the form of misinterpretations (the banging of a door thought to be a gunshot), illusions (folds in the bedding or designs in clothing thought to be small animals), or hallucinations (seeing objects of people that are actually not present) (American Psychiatric Associa tion, 1980). These sensory misperceptions are most commonly visual, though may occur in any other of the senses (American Psychiatric Association, 1980). The use of symbolic language suggests the presence of delirium (Zarit, 1980). For example, if a patient is asked where he/she is and answers "Huntington Hotel" rather than "Huntington Hospital," he/she is using symbolic language. A person with dementia would usually answer "I don't know" or answer wrongly. Other examples 15 of symbolic language include fabricating a journey, stating they were at home, in jail, or some place other than the hospital when asked where they spent the night. The common theme in symbolic language is denial of illness (Zarit, 1980). A patient with delirium will often continue their use of symbolic language despite "evidence" to contradict their answers, all to maintain their denial of illness. Inability to maintain a coherent stream of thought may be reflected in speech, reasoning, and behavior. Thinking loses clarity and. direction and speech may be sparse or incoherent. Perserveration may occur in both speech and behavior. The disorientation and memory impairment which are present in delirium frequently cannot be assessed due to the disordered thought (American Psychiatric Association, 1980). Disturbance of the sleep-wake cycle is common in persons with delirium. The level of consciousness may be depressed, ranging from drowsiness to stupor, or stimulated, resulting in insomnia. The person may fluctuate between levels of consciousness and may reverse the customary pattern of sleeping at night and being awake during the day. "Vivid dreams and nightmares are common, and may merge with hallucinations" (American Psychiatric Association, 1980, p. 105). 16 Disturbance of psychomotor activity is also characteristic of delirium. Increased psychomotor activity results in the individual being restless and hyperactive, where decreased psychomotor activity is evidenced by sluggishness. Frequent shifts from one extreme of psychomotor activity to the other is not uncommon (American Psychiatric Association, 1980). It is important to remember that in dementia, the state of consciousness is normal where, in delirium it is clouded. Also, the symptoms of dementia remain fairly stable. Fluctuation in symptoms is one of the hallmarks of delirium. Typically, the individual is worse during sleepless nights or in the dark. So-called "lucid intervals," period during which he or she is more attentive and coherent, may occur at any time, but are most common in the morning. (American Psychiatric Association, 1980, p. 106) Nursing Management Drugs Medications, either drug drug interaction or overmedication, are frequently the cause of delirium resembling dementia. While medications such as the phenothiaziness sometimes control the behavioral problems that accompany an acute brain syndrome, high levels of these medications can become toxic. Patients in hospitals and nursing homes who develop behavior problems often are placed on a relatively high dosage of one of the phenothiazines. When 17 the behavioral problems do not improve or get worse, the dosage is increased. If increases in medication are associated with further behavioral disturbance, it is likely that the drugs have reached toxic levels and are con tributing to the delirium. (Zarit, 1980, p. 145) Although the cause and cure of dementia remains unknown, it is known that drugs can make the condition worse. Some authors recommend small doses of sedatives (Jones, 1979) or the use of a minor tranquilizer (Powter, 1977) to calm mild aggitation or restlessness. The key is to use the smallest dose that is effective. Another author recommends cups of tea and liberal amounts of whiskey which "may settle the patient without the ill- effects of the more powerful sedatives" (Isaacs, 1979, p. 25). Oftentimes late night wandering and restlessness may be calmed by a glass of warm milk or a snack. Other times, a back rub is effective in helping the patient to relax to the point where sleep may take over. Plutzky (1974) suggests that, in addition to cautious drug therapy, psychotherapy is useful in patients whose brain impairment is not severe and in cases where reaction to intellectual loss is emotional symptoms such as anxiety or depression. It is likely that this type of patient remains in the community and is able to function fairly well with minimal assistance. 18 Social and Milieu Therapy Since social and environmental factors greatly affect the clinical course of the senile dementia patient, social and milieu therapy has become a major form of treatment in hospitals (Powter, 1977) . Powter (1977) stresses the importance of striking a balance between the structure of rigid, daily routines and fresh activities for mental and physical stimulation. Verwoerdt (1976) stresses the importance of the daily routine being "consistent, predictable, and sufficiently diversified” (p. 206). Structure and consistency are necessary to maintain the patients' sense of security, yet variety is important to prevent social isolation and sensory deprivation (Verwoerdt, 1976). Responding to Specific Behaviors Continually repeating the same question, such as, "When can I go home?" when the answer has been given numerous time already, is a common, annoying behavior. Although hospital staff and family members become frustrated with such repetition, the patient with delirium who exhibits this behavior does not remember having asked the question so does not understand frustrated responses by the people to whom the question is posed. For this reason, answers should be given patiently and consistently each time (Powter, 1977; Zarit, 1980). "For more 19 disturbing behavioral problems, such as paranoid accusa tions, wandering, or sexual advances, a firm but reassuring intervention is often effective" (Zarit, 1980, p. 355) . A wandering patient may also be aided by a large sign with his/her name on it and located on each of the patient's door, bed, and closet. Also, labeling the restroom doors in large, bold letters may be of help. Zarit (1980) states that reality orientation is irrelevant in cases of delirium, and is of questionable use in cases of dementia, due to the underlying cerebral disturbance which is causing the disorientation in the first place (Zarit, 1980). Referring to delirium, Zarit (1980) states. Because it involves the person's attempt to cope with his situation, a reality orientation program to combat these misrepresentations could have the effect of further undermining the person's coping ability. In other words, denial and, to some extent, disorientation, appear to function to maintain a sense of personal adequacy in the face of cerebral dysfunction. (p. 356) Repeating apparently meaningless activities, such as folding and unfolding clothes may actually be providing some important stimulation for the impaired person (Zarit, 1980). Other patients may withdraw from activities, a different response which may be adaptive for them. "As a general rule, most impaired persons could be challenged a little more than they already arè"(Zarit, 1980, p. 365). Again, let the patients' behavior determine the need for 20 more or less activity, where a positive response to activity means increasing the activity level. Urinary and fecal incontinence is another common problem of elderly patients with dementia. Urinary incontinence, which may be due to lack of control over micturition "may have a neurological basis, either at cerebral level or in failure of sphincter mechanisms," (Jones, 1979, p. 105) or simply be due to an inability to locate the toilet. Additionally, urinary tract infections are a frequent cause of urinary incontinence and may be corrected with proper treatment. Fecal incontinence may also be due to an intestinal organism, though more commonly due to fecal impaction which can be prevented through food, fluids, and physical exercise. Preventing or correcting causes of incontinence are certainly preferable to managing their existence, though this is not always possible. In these cases, a consistent toileting program is the most effective method of dealing with problems of both urinary and fecal incontinence. Reduction of fluid intake by the elderly patient is not an answer to managing the: incontinence:,and the resulting complications could be worsening constipation with additional fecal incontinence, dehydration, physical weakness, fever, and delirium. A fluid intake schedule may be arranged, however, so that the majority of fluids are taken before early evening so as not to unnecessarily 21 disrupt the patient's sleep. Other aids such as diapers and urinary catheters are not preferable because of frequent skin breakdown (greatly due to lack of proper cleansing after soiling) and because their use does not encourage a consistent toileting program. Combativeness is a much more serious problem of the organically impaired patient due to the potential for injury to self and others. Never unduly try to correct the patient or point out his deficiencies (Verwoerdt, 1976). The way to deal with an organically impaired patient is not to argue with them. "They, unfortunately, can not help what they do, they can not argue logically, they can not perceive what is illogical or unacceptable about their behaviour" (Isaacs, 1979, p. 25). If the patient does not respond to being distracted or ignored, this is one of the very few instances in which the use of chemical and physical restraint may be justified for the reasons of safety. Dependency As dementia progresses, it becomes necessary for other people to increase the amount of care and supervisior provided to the patient by them(Godber, 1979; Zarit, 1980) The danger is that the providers of care will force a dependency on the patient by taking away too many of the activities which the patient is still capable of doing for 22 him/herself. The result is that the patient becomes unwilling or unable to perform those activities him/ herself. Also, it is often difficult to determine which activities are potentially dangerous for the demented person and which activities are relatively innocuous. It is important to differentiate, however, to avoid increasing the person's dependencies (Zarit, 1980). Snyder and Harris (1976) cite a case study of an elderly male patient with an apparent dementia. The condition was later diagnosed as delirium and one con tributing factor to this condition was the forced dependency by nursing staff. This dependency was "forced upon him by illness and intensified by the nursing home staff who efficiently provided total care with little personal contact" (Snyder & Harris, 1976, p. 182). Relocation Movement of an elderly dementia patient to a hospital and separating him/her from family and familiar surroundings often results in a rapid deterioration of his condition (Jones, 1979). Blenkner (1967) has shown that relocation of elderly persons results in a high incidence of morbidity and mortality, and this relation ship is even more striking when the elderly person has altered brain function. The fact that the dementia patient retains only part of new learning or nothing at 23 all coincides well with this difficulty in adjusting to new surroundings (Zarit, 1980). "Persons with severe intellectual deficits can sometimes function well in restricted, but familiar settings, but they manifest severe disturbances if moved to a new place" (Zarit, 1980, p. 357). Ideally, the elderly dementia patient will remain at home with family and familiar surroundings. This is not always possible or practical, and the dementia patient must deal with the relocation to a hospital or nursing home. To complicate the adjustment difficulties further, hospital staff all too frequently move these patients to different rooms in order to accommodate new patients. The result is greater disorientation and difficulty in adjust ment to, again, a new environment. Family Therapy Families of patients with dementia can usually benefit from counsel, especially when caring for their demented relatives at home. Unfortunately, it seems that families wait to seek counsel until a crisis occurs with the demented patient in the home or until they need assistance in dealing with the stresses of hospitalization of the demented person arid the acute reactions of the patient to the events surrounding that hospitalization (Zarit, 1980). 24 Family therapy is useful in educating the family about the reversibility of delirium and to assist them in coping with the behavioral changes that occur in the affected elderly person (Zarit, 1980). Once it has been determined that dementia is actually present in the elderly person, the family therapy is designed to (1) support and encourage caregivers, and (2) provide assistance through information and problem solving with arranging supportive services (Zarit, 1980). The elderly person may be included in the family therapy sessions depending on the stage of the dementia. One study (Bergmann, Foster, Justice, & Mathews, 1979) sought to identify factors characteristic of those demented elderly who survive in the community as opposed to those who do not. It was found that those most likely to survive in the community were those who lived with their families. Those demented elderly who lived alone, on the other hand, were most likely to enter hospitals or residential care facilities and those living with their spouses fell somewhere in between the above two groups. Zarit, Reever, and Bach (1980) sought to identify sources of burden among primary caregivers of elderly persons with dementia. Of the variables considered (including extent of cognitive impairment, memory and behavioral problems, functional abilities, duration of illness, and frequency of family visits), only frequency 25 of family visits significantly affected the degree of feelings of burden, where an increase in the number of visits resulted in a decrease in the feelings of burden. The authors suggest the use of natural support systems including network sessions, discussion groups, the use of home visitors and natural neighbors. It was not found to be the case, as was previously suspected, that feelings of burden of the caregiver increased as functional abilities of the demented person decreased. Hypotheses A one-hour lecture on the nursing management of elderly patients with delirium and/or dementia will be presented to nursing staff in two hospitals and two nursing homes. The hypotheses are: H^: Nursing personnel will show no difference in understanding of delirium and dementia as evidenced by scores on the pre/posttest. H^: Nursing personnel will show a significant improvement in understanding of delirium and dementia as evidence by scores on the pre/post test. Hq ! Nursing personnel will show no difference in the choice of interventions used to manage elderly patients as evidence by scores on the pre/post test. . 26 : Nursing personnel will show a significant improvement in the choice of interventions used to manage elderly patients as evidenced by scores on the pre/posttest. 27 CHAPTER III METHODOLOGY Population This study took place in two hospitals and two nursing homes in areas surrounding greater Los Angeles, California. The two nursing homes and one hospital are located in Santa Monica, California, an area with a high percentage of elderly persons living in the community. The other hospital is located in Inglewood, California, and judged to be approximately equivalent to the first hospital in terms of size and services offered. Each hospital is approximately 400 beds and each nursing home is approximately 230 beds in size. The population consisted of 48 staff members who voluntarily attended the continuing education program "Nursing Management of Elderly Patients." The composition of the staff members consisted of Registered Nurses, Licensed Vocational Nurses, Nursing Assistants, and "Other," including one Medical Transcriber, two Recrea tional Therapists, one Audiologist, one Social Worker, and one Nursing Student (see Table 1). The specialty areas represented by the staff members included medicine. 28 m CO 00 CN CO I—I I—I I —I •H I —I o I—I o CN •H I—I r H I— I fO I— I o o CO •H I—I I— I ro IT) cn CO I —I I —I r —I ID CO I—I I —i •H I —i I—I 29 surgery, orthopedics, emergency, I.V. team,- opthomology, coronary care, nuclear medicine, nursery, audiology, rehabilitation, social service, education, administration, and long-term care. Though detailed analysis of each specialty area is not pertinent to this study, it is impressive to note the diversification of staff members who demonstrate interest in working with the elderly, most of whom interface with elderly patients on a daily basis. Design The first hospital and nursing home selected for the study were designated as the Treatment Group and the other hospital and nursing home were the Control Group. The "treatment" was a one-hour continuing education lecture on "Nursing Management of Elderly Patients with Delirium and/or Dementia," derived from the information presented in the foregoing literature review. A second one-hour lecture on "Psychosocial Needs of the Elderly" was also prepared and, presented together, this two-hour program was accredited by the California State Board of Nursing for two contact hours of continuing education for nurses. The control group received the lecture on psycho social needs as the first hour of the program and received the lecture on delirium and dementia as the second hour. For the treatment group the order of presentation was reversed, with delirium and dementia comprising the first hour and psychosocial needs the second hour.______ ________ 30 A pretest/posttest was developed and subjects were tested at the beginning and end of the first one hour of presentation for both groups. Measurement Tool The pre/posttest consisted of 17 questions in a multiple-choice format. The posttest consisted of the same questions and answers as the pretest, though the order of the questions was slightly different. The test was labeled "Assessment" and may be seen in the Appendix. The first nine questions assessed the knowledge of the characteristics differentiating delrium and dementia, with a possible correct score of nine. The next eight questions assessed the appropriateness of interven- tions used by nursing personnel in the management of elderly patients with delirium and/or dementia, with a possible correct score of 13. These last eight questions were preceded by hypothetical situations describing an elderly person with delirium and/or dementia, and asking the respondent which intervention(s) they would choose. Statistical P rocedures The t test for paired comparisons was utilized to compare sample mean scores on the pretest and posttest in the areas of (1) knowledge and (2) interventions. The t test was chosen to determine whether or not the difference between the two sample means was significant. 31 A breakdown procedure was utilized to examine the mean scores of each subgroup of nursing personnel, includ ing RNs, LVNs, and NAs, in each area of knowledge and interventions. This procedure was chosen to examine whether or not mean scores were higher in hospitals than in nursing homes. 32 CHAPTER IV RESULTS The means and standard deviations on pre- and posttest data for each of the two control groups and two experimental groups may be seen in Table 2. Using = .05 for a one-tailed test, critical values were selected from the corresponding statistical table in Malec (1977, p. 218) . Comparison of the T value with the corresponding critical value indicates whether or not the T is sig nificant. As may be noted in Table 2, the T values are not significant for the Control Hospital, but are sig nificant in both knowledge and interventions for the Treatment Hospital. Thus, H^ is rejected for both knowledge and interventions for the Treatment Hospital and H^ is accepted. The T values for both the Control Nursing Home and the Treatment Nursing Home were not significant, except for knowledge in the control group which was in the opposite direction, with the posttest mean being lower than the prétest mean. Thus, H^ is accepted for both control and treatment nursing homes. 33 s- (O ( _ ) > CO o> o C\J o o en o T— 4 co en o 00 u r > o i r > co S Q CM CM r— H ( / ) +-> c CM CO CO O ce f O +-> i n o CM o e n CM o co co oO CM UO CM co Q to r— I co o co o L f) CM co o co o t —l CM L f) co L f) L f) r— I o 4-) • r - + J t/) +-> tn eu c eu +-> eu 4-> 4-J > eu (O +-> +j V ) Q. +-> ( O +-> ( / ) o eu ty) eu □ c a > eu 4-J X) + - > + - > +-> eu eu t/) u) C D e u + -> £ = e u 4 -J o To 4 -J + -> e u 4 -J 4 -J ■jz e u e u (O > e u « o I— s- o s- s- o r — s O- o_ e u o_ o_ o o + - > ^ CL. 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Ou (U n_ n_ eu 5 Ou CL. eu Ou û_ p o +j E o + - > &- c c +-> c E n3 ü C eu f t S o s- Li u 1 — 35 Table 3 shows a breakdown of nursing personnel into the subgroups of RNs, LVNs, and NAs on pretest data for both knowledge and interventions « As may be seen from this table, hospital RNs scored higher than hospital LVNs in both knowledge and interventions. In the nursing homes, RNs scored higher than LVNs who scored higher than NAs in knowledge, but in the area of interventions, the rank order is reversed to NAs, LVNs, and RNs, respectively, Comparing hospital staff to nursing home staff, we find that the nursing home RNs and LVNs scored higher in knowledge than the RNs and LVNs in the hospitals. On intervention scores, however, the hospital RNs and LVNs scored higher than the nursing home RNs and LVNs, respectively. Table 3 Pretest Means 36 Facility Knowledge Mean S. D, Interventions Mean S.D. Hospital ^(16) ^^(0) Nursing Home *K(4) 5.875 1,454 4.500 1,378 6.000 0.817 5.375 0.916 4.667 1.862 6.875 1.668 5.833 4.500 5. 000 5. 333 2. 041 1.915 0.926 3.327 37 CHAPTER V DISCUSSION The knowledge and intervention scores of nursing staff in the Treatment Hospital were significantly higher after treatment than those respective scores in the Control Hospital. The treatment was thus an effective means of educating nursing personnel in the hospital on the specialized needs of the elderly patient with delirium and/or dementia. In the Treatment Nursing Home, however, no significant improvement in scores was found. These results indicate that this particular continuing education program was not effective for improving the knowledge and intervention skills in nursing home staff who work with elderly patients. The question, then, is why was this treatment effective in the hospital setting, but not in the nursing home setting? A number of factors may have contributed to these results. The size of the class in the Treatment Nursing Home was markedly smaller than in the other three settings, and possibly other interested nursing personnel were unable to attend the program. Or, possibly, class size was indicative of the degree of interest in this 38 particular program- Second, fatigue may have been a factor as this program was presented in late afternoon where the other facilities received the program in late morning or early afternoon. Third, the setting provided for the program was a Physical Therapy room with dis tracting activity being performed in one side area. The setting provided in each of the other facilities was a more formal classroom without unnecessary distractions. Though all these factors may have contributed to the insignificant results in the nursing home setting, the major reason is thought to be due to the format of the treatment, that is, the lecture style of presenting the material. The passive participation of the audience in the lecture style of presentation may not have provided the incentive or stimulus necessary to learn the material, Rather, a presentation format which encourages a more active participation of the audience, such as role-playing or group discussion, may have resulted in greater learning. It would be valuable to educators to have additional studies on the degree of learning that takes place with various styles of presentation. Although not stated as a hypothesis, it was also predicted that hospital staff would score higher than nursing home staff on scores of knowledge and intervention skills already attained. This prediction was based on the rationale that the hospital is an acute care setting. 39 rapidly changing by definition, and traditionally privy to the most up-to-date technological advances in health care. Conversely, the nursing home specializes in long term care of elderly patients, many of whom have chronic illnesses that may exist relatively unchanged over a period of months or years. Nursing interventions in the acute care hospital tend to be focused on rehabilitation and cure. In the nursing home, however, the focus of intervention is geared more toward maintenance and, unfortunately, is too often custodial in nature. This prediction was not substantiated by the pretest scores and differences were insignificant. The results do, however, lend support to the importance of continuing education in gerontology for nursing personnel in both the acute care setting and the long-term care setting. Pretest scores demonstrate the need for such education in both settings, and alternative styles of instruction which encourage a more active learning approach may provide the catalyst necessary for such learning to take place. Through effective continuing education, knowledge and intervention skills of those who work with elderly patients may be increased, and the quality of care enhanced. 40 CHAPTER VI SUMMARY This study examines the value of providing continuing education to nursing personnel who work with the elderly. Two hospitals and two nursing homes were selected in areas surrounding greater Los Angeles, California and a continuing education lecture entitled "Nursing Management of Elderly Patients with Delirium and/or Dementia" was presented to staff members. A pretest /posttest was developed and used to assess both knowledge and appropriateness of interventions used by nursing personnel in the management of elderly patients with these brain disorders. The results were significantly positive in the Treatment Hospital. The two hypotheses stating that both knowledge and intervention skills would increase following the treatment were thus accepted. In the Treatment Nursing Home, however, results were not significantly positive and these hypotheses were rejected. The lack of positive results following treatment in the nursing home may be due to the lecture style of presentation. It is suggested that alternative methods 41 of instruction, which provide a more active participation by the audience, would provide more stimulus and incentive for staff members to learn, thus enhancing the learning process. Findings on the level of knowledge in both settings underscore the importance of instruction in this area. 42 REFERENCES 43 REFERENCES American Psychiatrie Association, Task Force on Nomen clature and Statistics. Diagnostic and statistical manual of mental disorders (3rd éd.). Washington, D.C American Psychiatrie Association, 1980. Bergmann, K., Foster, E. M., Justice, A. W., & Mathews, V. Management of the demented elderly patient in the community. British Journal of Psychiatry, 1979, 132, 441-449. Birren, J. E., & Hirschfield, I. The emergence of gerontology in higher education in America. In H. L. Sterns, E. F., Ansello, B. M. Sprouse, and R. Layfield- Faux (Eds.), Gerontology in higher education: Developing institutional and community strength. Belmont, CA: Wadsworth Publishing Co., 1979. Birren, J. E., & Sloane, R. B. Manpower and training needs in mental health and illness of the aging. Los Angeles, CA: University of Southern California, Ethel Percy Andrus Gerontology Center, 1977. Blenkner, M. Environmental change and the aging individual. The Gerontolegist, 1967, 1 _ , 101-105. Brody, E. M., Kleban, M. M., Lawton, M. P., & Silverman, H. A. Excess disabilities of mentally impaired aged: Impact of individualized treatment. The Gerontologist, 1971, IJ^, 124-132. Burnside, I. M. (Ed.). Nursing and the aged. New York: McGraw-Hill Book Co. , 1976. Butler, R. N., & Lewis, M. Aging and mental health (2nd ed.). St. Louis: The C. V. Mosby Co., 1977. Campbell, M. E., & Browning, E. M. Nursing assistants : An untapped resource in providing quality care for the elderly ill. Journal of Gerontological Nursing, November-December 1978, 18-20« Eisdorfer, C., & Stotsky, B. A. Intervention, treatment and rehabilitation of psychiatric disorders. In J. E. Birren and K. W. Schaie (Eds.), Handbook of the psychology of aging. New York: Van Nostrand Reinhold, 1977. 44 Engel, G. L., & Romano, J. Delirium, A syndrome of cerebral insufficiency. Journal of Chronic Diseases, 1959, 9, 260-277. Godber, C. Dementia in the elderly. Don't overwhelm the family. (Part 2) Nursing Mirror , 1979, 149, 30-32. Gurland, B. J. The assessment of the mental status of older adults. In J. E. Birren and R. B. Sloane (Eds.), Handbook of mental health and aging. Englewood Cliffs, N.J.; Prentice-Hall, 1980. Hickey, T. In-service training in gerontology: Towards the design of an effective education process. No, V. Topical papers: Series I, educational programming and community research in gerontology. University Park, PA Pennsylvania State University Gerontology Center, June 1975. Isaacs, B. Don't bother— She won't notice! Nursing Mirror, 1979, 3^, 24-25. Jones, I. H. Senile dementia. Nursing Times, 1979, 75, 104-106. Karasu, T. B., & Katzman, R. Organic brain syndromes. In L. Beliak and T. B. Karasu (Eds.), Geriatric psychiatry. New York : Libow, L. S. Senile dementia and pseudosenility.: Clinical diagnosis. In C. Eisdorfer and R.. O'. Friedel (Eds.), * Cognitive and emotional disturbances in the elderly. Chicago : Year Book Medical Publishers, 1977. Malec, M. A. Essential statistics for social research. New York ; J. B. Lippincott Co., 1977. Plutzky, M. Principles of psychiatric management of chronic brain syndrome. Geriatrics, 1974, 29.' 120-127. Powter, S. A symposium on care of the elderly. Senile dementia. Nursing Mirror, 1977, 145, 31-32. Proctor, S. In-service training: Role and structure in long-term care facilities. Denton, TX; North Texas State University, Center for Studies in Aging, 1975. Snyder, B. S., & Harris, S. Treatable aspects of the dementia syndrome. Journal of the American Geriatrics society, 1976, 24, 179-184. 45 Verwoerdt, A. Clinical geropsychiatry. Baltimore, Md: The Williams & Wilkins Co., 1976. Zarit, S. H. Aging and mental disorders. New York: The Free Press, 1980. Zarit, S. H., Reever, K. E., & Bach, J. Relatives of the impaired elderly: Correlates of feelings of burden. The Gerontologist, 1980, 20, 649-655. 46 APPENDIX 47 ASSESSMENT I For the following, indicate on your answer sheet whether this is a characteristic of (a) delirium or (b) dementia. 1. Memory impairment 2. Rapid onset 3. Fluctuating symptoms 4. Reversible if treated 5. Impairment of judgment and impulse control 6. Sensory misperceptions, including misinterpretations, illusions, and hallucinations 7. Changes in personality 8. The use of symbolic language (such as, "I am in Huntington Hotel" rather than "Huntington Hospital") 9. A reversal of the customary sleep-wake cycle (awake at night and sleeping during the day) Case 1 Mr. Johnson is a 67 year old man who was admitted to a nursing home because Mrs. Johnson states that she can no longer take care of him at home. Mrs. Johnson states that her husband * s condition began about 8 years ago with forgetfulness of "little things" like returning telephone calls and finishing tasks that he had started. Little reminders were sufficient to help Mr. Johnson get through the day. The forgetfulness has increased to the point where now Mr. Johnson does not remember the names of friends, relatives, and sometimes, even his wife. Mrs. Johnson states that her husband has been "getting lost" whenever he wanders out of the house, and that neighbors have been calling to ask Mrs. Johnson to pick up her husband. Mrs. Johnson states that Mr. Johnson's personal ity has changed, too. When he used to get angry, he never swore or used obscene language. Now, little things "set him off" and he uses terrible language. Mrs. Johnson states that her husband's behaviors are about the same as a year ago, but a little worse. Last week, Mr. Johnson left the gas stove partially turned on with no flame. Mrs. Johnson states that if she had not been awake and smelled the odor of gas, she can only guess what would have happened. 10. You would recommend that social and milieu therapy for Mr. Johnson consist of: 48 a. rigid, daily routines with new activities for variety b. rigid, daily routines with little or no variation c. restriction from activities because he is too confused d. repeating the same, pre-selected activities to help retrain his memory 11. The main goal of family thereapy, here will be a. to reconcile any differences betweeen Mr. and Mrs. Johnson b. to teach Mrs. Johnson that this disorder can be reversed with proper treatment c. to encourage Mrs. Johnson to take her husband home again d- to assist Mrs. Johnson in exploring all possibilities available to her and Mr. Johnson Case 2 Mrs. Thompson is a 76 year old women who was admitted to Community Nursing Home last month with a diagnosis of Organic Brain Syndrome. She is a pleasant women who is alert and spends most of the day wandering the hall and greeting patients, staff, and visitors who enter the Home. She asks them how they are feeling, where they live, and what type of work they do. Five minutes later, however, Mrs. Thompson does not remember ever « having met these people. Mrs. Thompson recognizes her children when they come to visit, but after they leave, she does not remember that they came to visit. Mrs. Thompson usually cannot fine, her room, but when taken there, she recognizes her clothes and belongings and agrees, "Yes, this is my room. Thank you, dear." 12. Which one or more of the following might be helpful to reduce Mrs. Thompson's wandering? a. a sign with Mrs. Thompson's name on her bedroom door, above her bed, and on her closet b. a glass of warm milk and a snack c. a warm bath d. a backrub 13. Shortly after admission, Mrs. Thompson began attempt ing to leave the ward with visitors and became very agitated when staff prevented her from doing so. She began receiving Haldol 5mg Q.I.D. (a major tranquil izer, 4 times per day), which was effective in 49 relieving Mrs. Thompson's agitation. Additionally, she receives Haldol 5 mg on a PEN basis. Now 4 weeks later, Mrs. Thompson is frequently combative with staff when they attempt to help her, and strikes out at patients who get near her. When Mrs. Thompson is taken to her room, she denies that the room or belongings are hers, and begins rummaging through her roomate's closet. You would recommend which one of the following? a. give Mrs. Thompson a PRN Haldol to relieve her agitation b. increase the routine dosage of Haldol for Mrs. Thompson because her behavior suggests that she requires a higher dosage to relieve her agitation c. reduce or eliminate the routine dosage of Haldol for Mrs. Thompson because her behavior suggests that she has become toxic from the drug d. both a and b 14. Mrs. Thompson keeps repeating the same question, "When can I go home?" even though you just answered her five minutes ago. Which two of the following sould you recommend? a. answer Mrs. Thompson patiently and consistently each time b. orient Mrs. Thompson to reality each time c. attempt to distract Mrs. Thompson so you will not have to get into an argument with her d. let Mrs. Thompson's behavior determine the answer most appropriate for her e. answer Mrs. Thompson any way you want to because she will not remember anyway Case 3 Mrs. Taylor, an 80 year old woman, was admitted to the orthopedic ward of Community Hospital with a fractured hip. Surgery was performed to repair the hip and Mrs. Taylor is now able to sit in a wheelchair. Mrs. Taylor will listen to directions about the transfer from bed to wheelchair for only a few seconds and then her mind wanders to other sound or activity in the hallway. When Mrs. Taylor is left alone sitting in the hallway in her wheelchair, she is smiling and pleasant, laughing and talking to herself, but her speech doesn't make any sense. She picks at her clothing and attempts to reach for things on the brightly colored tile floor (though nothing is there). Arrangements are being made for the placement of Mrs. Taylor in a nursing home next week. 50 15. Mrs. Taylor has great difficulty dressing herself in the mornings and feeding herself at mealtimes. Staff complain that Mrs. Taylor "plays with her clothes and food and doesn't follow directions." You would recommend which one of the following to make sure that Mrs. Taylor is dressed for the day and eats at mealtime? a. give Mrs. Taylor explicit directions then leave her alone for as long as it takes her to complete the task b- stay with Mrs. Taylor, give frequent directions and minimal assistance c. dress Mrs. Taylor in the morning and feed her at meals 16. Mrs. Taylor has been incontinent of urine several times a day now for the past week. You would recommend which one or more of the following? a. a consistent toileting program for Mrs. Taylor b. assessment for possible urinary tract infection c. a foley catheter for Mrs. Taylor d. the use of diapers and plastic pants for Mrs. Taylor e. decrease Mrs. Taylor's fluid intake 17. A young female patient in her 20s is about to be admitted to the orthopedic ward of Community Hospital, Mrs. Taylor shares her room with a woman in her 30s and is being considered for a room change. The only other bed available is in a room with a 70 year old female patient. You would recommend which of the following as being the best choice for Mrs. Taylor? a. admit the new patient to Mrs. Taylor's bed and move Mrs, Taylor into the room with the 70 year old woman b, admit the new patient to the room with the 70 year old woman

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Creator Behl, Gary A. (author)

Core Title Nursing management of elderly patients with delirium and/or dementia

Degree Master of Science

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

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