Seminar 4: Caring for the older

person with dementia

Learning Outcomes
• This session aims for students to utilise knowledge gained in
practice and from module to enhance their practice
• Analyse some of the strategies and tools used when assessing
an older person with cognitive impairment in hospital and in
their own home
• Increase knowledge and understanding of delirium and
importance of assessment
• Analyse tools used to assess pain in people with cognitive
impairment and dementia
• Understand the importance of early diagnosis of dementia
• Gain an understanding of how cognitive assessment can be
assessed
• Understand the impact of dementia for carers and role of the
nurse in supporting carers
Barbara’s story continued…
Group activity 1
Watch DVD episode 3; please make notes in support of large
group discussion

• What issues have you identified?

• Provide examples of good practice identified

• Discuss the main points for practice (from your own personal
experiences and after watching the DVD)

• Discuss ideas for developing practice

• Prepare a summary of your main points to share with the rest

of the group
Group activity 2
Watch DVD episode 4; please make notes in support of large
group discussion

• What issues have you identified?

• Provide examples of good practice identified

• Discuss the main points for practice (from your own personal
experiences and after watching the DVD)

• Discuss ideas for developing practice

• Prepare a summary of your main points to share with the rest

of the group
Group activity 3
Watch DVD episode 5; please make notes in support of large
group discussion

• What issues have you identified?

• Provide examples of good practice identified

• Discuss the main points for practice (from your own personal
experiences and after watching the DVD)

• Discuss ideas for developing practice

• Prepare a summary of your main points to share with the rest

of the group
 VERA
Validate
Accept and empathise with what the person is saying

Emotion
Acknowledge their feelings, provide a kind and empathetic
understanding

Reassure
Simply stating that they are safe and that no harm real or
imagined will come to them

Activity
An activity that fits with the persons perceived view of the
situation
The use of This is Me could help
Delirium

“A syndrome of disturbance of consciousness accompanied by a

change of cognition that is not accounted for by pre-existing
dementia”
(Boker, Price & Smith 2006 p252)

“Delirium (sometimes called 'acute confusional state') is a common

clinical syndrome characterised by disturbed consciousness, cognitive
function or perception, which has an acute onset and fluctuating
course”
(NICE 2010 p5)
Delirium- Rapid onset, reversible! Commonly a consequence of
physical illness
Dementia
“Dementia is a progressive and largely irreversible clinical
syndrome that is characterised by a widespread impairment
of mental function”
(NICE 2006 p5)

People with dementia are at increased risk of developing

delirium at a greater incidence than people without
dementia

Delirium might highlight and underlying cognitive

impairment
 Delirium Superimposed on Dementia

“It can be difficult to distinguish between delirium and dementia and

some people may have both conditions.
If clinical uncertainty exists over the diagnosis, the person should be
managed initially for delirium”
National Institute for Health and Care Excellence (2010) p5

In people diagnosed with delirium or if it is suspected, identify

and manage the possible underlying cause

What about Barbara?

• Case Study.

• 85 year old male

• Diagnosed Dementia
• Resides in residential care home for several years
• Admitted to organic assessment unit with worsening “challenging behaviour” & risk to staff
• Deterioration in mood and behaviour for a few weeks
• Violent on intervention (esp on nurses trying to change leg dressings)
• Non concordant with all medication (inc antibiotics, pain killers, dementia meds and BP meds)
• Fluid and food intake worsening.
• Usually mobile with stick, now needing wheel chair but difficult to stand and transfer (aggresive
on intervention)
• Conversation rambling (new), ? Visual hallucinations, memory worsening recently
• New urinary incontinence noted.
 Its dementia….
Lets treat that……..

Dementia
deterioration Could it be
delirium?

Progressive
Worsening memory
Hallucinations
Mobility decrease
Meds concordance
worse
Known dementia
 Delirium Superimposed on Dementia
What else could be going on?
P:
IN:
C:
H:

M:
E:
 Lets Respect (2014)
? Another N?
 WHAT COULD WE DO? Nursing assessments and
MDT

P: PAIN- assessed and in severe pain!

IN:INFECTION- Leg swabs +
C:CONSTIPATION
H:HYDRATION- Dehydration-Encouraged high
liquid foods (Custard, ice cream, rice pudding, frozen lollies)

M:MEDICATION- Analgesic patch, liquid ABX

E:ENVIRONMENT- changed by admission, known
to make confusion worse in BOTH dementia and
delirium!

Additional N could be Nutrition:- Supplements

started
OUTCOME:
Patient much improved, pain controlled, legs
heeling, behaviours returned to pre admission
state.
Discharged to care home shortly after

https://www.youtube.com/watch?v=BPfZgBmcQB
8
Feedback and Summary
References and Resources

• Blackhall, A., Hawkes, D., Hingley, D. and Wood, S. (2011)

‘VERA framework: communicating with people who have
dementia’. Nursing Standard, 26 (10), pp.35-39
• Bower L. K,. Price J D,. Smith S C,. (2006) The Oxford
Handbook of Geriatric Medicine Oxford University Press.
Oxford
• Lets Respect (2014) Delirium available at:
http://letsrespect.co.uk/our-work/the-3-ds-depression-
dementia-and-delirium/delirium/ [accessed 23/09/2016]
• National Institute for Health and Care Excellence (2006) Dementia:
supporting people with dementia and their carers in health and
social care (CG 42) available at:
https://www.nice.org.uk/guidance/cg42/resources/dementia-
supporting-people-with-dementia-and-their-carers-in-health-and-
social-care-975443665093 [accessed 26/09/2016]
• National Institute for Health and Care Excellence (2010) Delirium:
Prevention, Diagnosis and Management (CG103) available at:
https://www.nice.org.uk/guidance/cg103/resources/delirium-
prevention-diagnosis-and-management-35109327290821 [accessed
22/09/2015]