Part A: Diagnosis and Interventions

Medical Diagnosis

Alice has been inflicted with a prolonged history of hypertension, symptoms pertaining to anxiety and depression, osteoarthritis particularly in her right knee along with suffering from an episode of myocardial infarction a decade ago. Myocardial infarction occurs due to the disruption in the circulation of oxygenated blood to the muscles of the heart which are concerned with its pumping action. The incident occurs commonly as a resultant of an artery blocked with oxidized lipids and plaque for prolonged periods leading to its hardening. Hence, a heart attack is a detrimental resultant of a damaged heart tissue, which is irreversible (Shah et al., 2015). A myocardial infarction results in severe long term chronic impacts, the most notable of which being hypertrophy, which is characterized by an enlargement of the functional, undamaged sections of the heart in an attempt to maintain its optimum activities. In Alice, her history of myocardial infarction will not only lead to hypertrophy, but a gradual loss of healthy cardiovascular functioning due to the heart’s difficulty to keep up with regular physiological functioning, further resulting in arrhythmia and compensatory heart failure (Prabhu & Frangogiannis, 2016). Alice’s condition of hypertension can lead to harmful impacts in Alice’s body such as damage and narrowing of the endothelial arterial lining, enlargement or bulging of blood vessels known as aneurysms and the resultant above mentioned complications of coronary artery diseases, hypertrophy and heart failure (Iadecola et al., 2016). Further lack of treatment of hypertension can detrimentally impact cognitive functioning through occurrences of cerebral stroke and a transient ischemic  attack as a resultant of disturbed blood flow to  the brain.  These long  term  impacts  can lead to mild cognitive impairment and dementia in Alice, as already observed in her reported loss of cognition, understanding, memory and appropriate speech (Perna, 2017). Alice also has a history of osteoarthritis,  characterized  by  joint pain  and  inflammation,  as a resultant  of  disrupted processes of bone modeling. The long term impact of Alice’s pain in her right knee will negatively affect her mobility and productivity, as evident in her requirement of assistance during performance of basic life functions (Glyn-Jones et al., 2015). Further impacts include disturbance of sleep due to her pain, along with a strong associated towards occurrences of psychological symptoms such as anxiety and depression, as already observed in Alice’s distress concerning her sister and loss of healthy mental functioning. Alice’s history of anxiety and depression can also lead to physiological symptoms such as muscle pains, arrhythmia, breathing difficulties, hypertension, prevalence of panic attacks and irritable behavior (Parmelee, Tighe & Dautovich, 2015).

The neuroendocrine hypothesis of ageing would be most the appropriate which highlights the complex interactions between  the central nervous system and the endocrinal glands, through  the  secretion of hormones. The primary  endocrinal gland involved in these activities is the hypothalamus, which directs the pituitary gland to further control the functioning of essential glands such as the thyroid, testes, ovaries and adrenal (Horowitz & Zunszain, 2015). Detrimental impacts of ageing reduces the efficiency  of this system, leading to a loss in cognitive  functioning,  lack  of  adequate  sleep,  disruption  in metabolism and the resultant comprises in blood pressure and cardiovascular functioning. Alice has exhibited prominent symptoms of impaired cardiovascular health, disrupted sleep patterns, prevalence of hypertension and loss of cognition in the form of Alzheimer’s Dementia (Schloesser et al., 2015). Hence this theory is suited best to explain ageing and Alice’s associated medical condition, since age-associated loss of hypothalamic-pituitary-adrenal functioning results in disruptions in the functioning of insulin-like growth factor, loss of cortisol, disturbances in the dehydroepiandrosterone (DHEA) circadian functioning and the resultant decrease in the ration of cortisol and DHEA resulting in appetite loss, shift from anabolic to catabolic metabolism, increased susceptibility to cardiovascular diseases such as atherosclerosis, loss of immune functioning and cognitive abilities (Gragnoli, 2014). This can be evident in Alice’s medical history and symptoms of myocardial infarction, anxiety, depression, Alzheimer’s dementia, lack of sleep and hypertension.

Theory of Ageing

Ageing is associated with the physiological changes in the muscoskeletal system resulting in loss of muscular strength, elasticity and reduction in size. Ageing results in reduction in the ATP storage, myofibrils, myoglobin and glycogen reserves further resulting in loss of muscular movement and reduced mobility as observed in Alice’s inefficiency in performing daily activities (Van Beek et al., 2016). Ageing also results in physiological changes associated in the neurosensory system, associated with neuronal loss in the spinal cord as well as the brain. Age-associates loss of dendrites, leads to compromised synaptic transmission and associated inflammatory processes concerned with amyloid deposition in the brain, results in loss of sensory perception and cognitive abilities, as observed in Alice’s condition of Alzheimer’s dementia (Scott-Warren & Maguire,2017). The physiological changes of ageing also results in disrupted cardiovascular functioning resulting in increased susceptibility to hypertension, strokes and myocardial infarction, as clearly observed in Alice. Reduced cardiac response to cardiac glycosides and catecholamines and increased interstitial fibrosis, resulting in compromised cardiac outputs, arterial wall thickening and plaque formation are the underlying pathophysiological mechanisms (Flaatten, Skaar & Joynt, 2018). Detrimental changes to the neuronal system as mentioned above, results in compromised central nervous functioning and a loss of sensation in the bladder, resulting in increased incidences of urinary incontinence in elders, with a greater susceptibility in females as observed in Alice. Disturbance in the equilibrium between bone resorption and modeling results in an increased loss of bone mass and density further resulting in osteoporosis as observed in Alice (Curtis et al., 2015). Ageing is also associated with pathophysiological changes to the endocrinal system as mentioned in the prior paragraphs, resulting in loss of production and functioning of beta cells in the pancreas associated with insulin secretion, and the resultant compromises in glucose metabolism and associated susceptibility to metabolic disorders such as cardiovascular diseases and hypertension seen in Alice. Disturbed synaptic and neuronal functioning as mentioned above as also been associated with psychological disorders such as anxiety and depression as seen in Alice’s detrimental health condition (van den Beld et al., 2018).

The provision of primary health services are associated with mainly six types of services which include promotion of health, screening and prevention of the concerned disease condition, timely strategies for intervention, procedures for treatment and lastly, follow-up or sustained management of the patient’s medical status. For Alice, the primary health services should aim at screening, intervention, treatment and disease management (Banerjee, 2015). Cardiovascular screening and usage of dementia rating scales such as the Global Deterioration Scale will help in identifying the appropriate stages of Alice’s mental health condition as well as the current impact inflicted by her past cardiovascular medial history. Accurate screening and diagnosis will add direction to type of treatment required for Alice (Eichler et al., 2015). Alice also requires primary health services of treatment, for which a multidisciplinary approach will prove to be beneficial due to medical condition comprising of a number of disorders such as Alzheimer’s dementia, osteoarthritis, anxiety, depression and cardiovascular disorders. Hence, the primary service of multidisciplinary treatment will be required for Alice, and must consist of specialists such as orthopedics, neurologists, cardiac specialists, nurse practitioners and psychologists (Creavin et al., 2018).

Physiology of Ageing

It has been observed that Alice shows reluctance, forgetfulness and difficulties in eating. Hence, the caregiver must incorporate appropriate strategies such as gently assuring and communicating with Alice that she has not eaten and requires it for proper recovery, serving food at appropriate temperatures so that Alice can eat immediately along with serving the limited food choices in smaller utensils to prevent her from feeling overwhelmed (Hong & Gu, 2015). Alice also has complications of urinary incontinence along with her dementia, which needs management. Hence, strategies adopted by the caregiver must include usage of urinary incontinence pads in her underwear to prevent her from feeling distressed prior to toileting, implementation of night lights or commodes near the bedside to prevent Alice from waking unassisted to the toilet and further prevent falls, usage of signs and keeping the bathroom door open to aid Alice in seeing and guiding herself to the toilet and addition of support bars or a raised toilet sitting arrangement to aid in ease of toileting and urination without falls (Rose, Specht & Forch, 2015). An additional shortcoming in Alice requiring intervention  strategies is her difficulty in sleeping. For this, the caregiver can use strategies such as bright light therapy for alleviating her circadian rhythm disruption, maintenance of peaceful, dark surroundings to initiate her sleeping, incorporation of mild physical activities during the day and implementation of regularized fixed sleeping and waking schedules (Cipriani et al., 2015). Lastly, Alice’s condition of dementia has resulted in her difficulties to communicate effectively. For this, the caregiver must adopt compassionate, patient and empathetic communication strategies which includes usage of appropriate eye contact, communication of simple commands one at time in the absence of environmental disturbances such as noises or music, provision of limited choices in a question to avoid Alice’s confusion and display of encouragement and eagerness if Alice portrays desired behavior or prefers to share her stories (Kindell et al., 2017).

Patients suffering from dementia  have been documented to present  greater susceptibility to compromised oral health due to their forgetfulness and ability to  adequately tend to personal grooming practices and brushing of teeth, resulting in decaying and destruction of teeth and gums (Foley et al., 2017). Further, the ingestion of specific medications may also induce dryness of mouth, as noted as a side effect in one of the medications given to Alice (atenolol). Hence, the caregiver must use simple instructions to remind, prompt, supervise and assist Alice in brushing her teeth.  Additional oral health maintenance strategies may  include, usage of long-handled toothbrushes, usage of water while brushing to prevent fluoride toothpaste swallowing, usage of holders or tiny brushes for flossing and addition of apple and avoidance of hard candy in Alice’s diet to aid in cleaning as well as chewing (Foltyn, 2015). Likewise, a dentist  may be involved as an additional  professional in the care plan team for Alice for monitoring her oral health effectively. Usage of specific mouthwashes may be incorporated which  will aid in prevention of drying of Alice’s mouth, but their implementation must be discussed by the caregiver with the dentist to monitor the incidence of swallowing (Zenthöfer et al., 2017). Alice also needs adequate care giving for the management of her dentures, where the concerned care giver must focus on daily removal, brushing and rinsing of dentures. Upon removal, the care giver must focus on cleaning her roof and gums with a toothbrush containing soft bristles. The concerned dentist regularly check Alice’s gums for signs of possible shrinkage since that can result in improper denture fitting, pain, susceptibility to infection and difficulty in food consumption (Zenthöfer et al., 2016).

Primary Health Services

The assessment of pain in dementia is often a major challenge due to inability of the patient to engage in effective communication. Likewise, patients with earlier stages of dementia have been found to understand at least one self reporting tool for assessment such as PQRST Assessment, Numerical Rating Scale, Visual Analog Scale and the Faces Pain Scale (Hadjistavropoulos et al., 2014). Hence, the caregiver can attempt to administer these tools on Alice to check if she can appropriately comprehend and communicate the nature of her pain. However, dementia  patients in their later stages exhibit detrimental communication abilities and hence, one cannot rely on self-reporting for pain assessment. In such a situation with  Alice, her primary caregiver who is aware of her behaviors may serve as a proxy rater in aiding with pain assessment. Further, in accordance to the guidelines presented by the American Geriatrics Society, pain can be assessed in dementia patients through observation of body part movements, facial expressions and gestures and vocalization (Burns & Mcllfatrick, 2015). The causative factor for pain in Alice is her osteoarthritis. For management of her pain, the concerned caregiver for Alice, can engage in strategies which will include incorporation of stretching of joints gently, which will aid in relaxation, loss of stiffness and reduction of pain. Likewise, implementation of mild exercises such as walking have been proven to be beneficial in arthritic pain management and hence, the caregiver may monitor and assist Alice in walking around the premises with supervision. Additionally, administration of oral medications such as corticosteroids, non-steroidal anti-inflammatory drugs, analgesics and hyaluronic acid have been found to yield beneficial health outcomes in pain management. The caregiver must administer these medications with appropriate supervision to prevent difficulties in swallowing (Petyaeva et al., 2018).

Complementary therapies aim to improve and enhance, the quality of life of  a patient, through supplementation of the existing procedures (Wahner-Roedler et al., 2014). For Alice, the complementary therapy which can be used is massage therapy. Alice has recurrent condition of osteoarthritis, characterized by debilitating pain in her right knee. Massage therapy has been documented to yield beneficial results in arthritic patients, as it leads to joint relaxation, reduction of joint stiffening resulting in increased motion and stability (Field et al., 2016). Alice’s condition of dementia has been associated with additional behavioral symptoms of anxiety, depression and forgetfulness. The complementary therapy which can be utilized here is music therapy, which has been documented to induce calmness and composure in dementia patients inflicted with behavioral issues like agitation along with aiding in the recollection of memories. Further, improved cognitive and emotional functioning have been associated in dementia patients receiving music therapy, resulting in improved patient-nurse relationships (Melhuish, Beuzeboc & Guzmán, 2017).

Identify problem  /issue	Establish Goal(with Time Frame)	Take Action	Evaluate Outcomes	Reflect on process
Actual Problem/ Issue: Urine Incontinence	To improve bladder control within the next 2 months followed by maintenance of positive toileting habits throughout her aged-care facility stay.	Some of the key intervention strategies include (Carnahan & Johnson 2017): · Incorporation of protective underwear for absorption of spillages. · Installation of absorptive pads in chairs, beds or seats made of disposable materials. · Availability of extra set of clothes or underwear for mitigation of excessive wetting. · Application of topical vaginal patches, rings or creams for rejuvenation and toning of urethra muscles. · Implementation of pelvic floor exercises, double voiding or behavioural techniques to improve bladder control. · Administration of medications like Mirabegron for urge incontinence management.	Usage of tools such as (Manley et al., 2016): · The Incontinence Severity Index (ISI) · The Urogenital Distress Inventory Syndrome (UDI-6) · Wexner Continence Grading Scale	· Alice may display  considerable reluctance and resistance to the wearing of protective underwear. For this, I must carefully incorporate the pants while during her, making it a part of her natural outfit. However, in severe cases, I must reassure her bysaying that wearing protective clothing will allow me to take care of her effectively and she will be efficient in urinating on her own and will not have to suffer from a fall. · I must reassure and gently console Alice during times when she may feel embarrassed due to her condition. · To improve her bowel control and ensure safety, I  must engage in constant monitoring and supervision. However. The process will take time due to her forgetfulness.
Actual Problem/Issue: Increased pain in right knee	· To reduce and eradicate the pain in Alice’s right knee within the next 2 months followed by maintenance of appropriate mobility throughout her aged care facility stay. · To improve Alice’s recognition and perception of her pain within the next 2 months for improved pain management.	Some of the key intervention strategies include (Husebo & Corbett, 2014): · Incorporation of joint relaxation technique such as stretching to aid in improvement of flexibility, reduction of joint stiffness and the resultant decrease in pain. · Incorporation of supervised mild physical activities such as walking to aid in improvement of joint flexibility, enhancement of stamina and energy and decrease in pain. · Administration of medications such as opiods, corticosteroids, non-steroidal anti-inflammatory drugs, analgesics and hyaluronic acid. · Administration of additional alternative therapies such as massages for reduction in pain and associated anxiety and distress.	In situations of improved self-reporting, usage of pain assessment tools such as (Lichtner et al., 2014): · PQRST assessment · Visual Analog Scale · Numerical Rating Scale · Faces Pain Scale During situations of compromised communication abilities, tools to be used include proxy rating by caregiver through observation of vocalization, body movements and facial expressions (van Dalen-Kok et al., 2018).	· During the incorporation of physical activity in Alice, I will be required to engage in adequate monitoring and supervision, since unsupervised movement may put her at a risk for falls. · As can be evident in the case study, Alice is finding it difficult to engage in effective conversation which is required for appropriate pain assessment. Hence being her primary caregiver, I must be highly receptive to her non-verbal gestures and ask her simple questions concerning her pain, which she will be able to answer effectively for future pain assessment.
Potential Problem/Issue: Falls due to unmonitored wandering	To prevent further occurrences of falls in Alice and the associated negative health outcomes throughout her stay in the aged care facility.	Some of the key intervention strategies include (Booth et al., 2015): · Implementation of a caregiver team where each member will engage in timely monitoring and supervision of Alice, to check for any signs of unsupervised wandering. · Engage in monitoring and supervision if Alice is caught wandering alone. · Usage of effective and empathetic communication strategies to assist her into her room or enquire about her unmet needs. · Arrangement of adequate lighting in the surroundings to prevent misinterpretation of objects and the resultant falls. · Clearing of paths meant for walking to prevent falls due to tripping over clutter or unwanted objects. · Installation of sign boards containing direction and safety instructions to aid in safe movement. · Installation of necessary products such as water, phone, tissues or glasses to prevent confusion and restlessness. · Reduction in distractions such as noise and provision of peaceful surroundings to prevent agitation, restlessness and the resultant wandering. · Removal of loose fitted shoes and replacement with well-fitted containing fasteners to prevent tripping.	Timely monitoring by the primary caregivers and constantly engaging in conversations with Alice will help evaluate her safety, the presence of any unfulfilled needs along with presence of any agitation or restlessness which may lead to unsupervised (Keall et al., 2015).	· According to MacAndrew et al., (2017), patients with dementia engage in frequent wandering majorly due to the presence of some need which is not being met, as evident in Alice looking for her sister and believing that it is time for lunch and she needs to go shopping. In such situations, if I observe Alice wandering, I must engage in calm, patient and empathetic conversation with her in order to identify her requirements. · During situations of aggression or resistance, I must engage in affectionate conversation with Alice and explain her calmly how she may get hurt by falling.
Potential Problem/Issue: Poor nutrition/Weight loss due to forgetfulness during food consumption	To improve Alice’s food consumption and resultant nutritional status, and hence restore her weight to optimum levels within 2 months followed by maintenance of the same throughout her stay in the aged-care facility.	Some of the key intervention strategies include (Jansen et al., 2015): · To involve a nutritionist in the development of an appropriate diet plan for Alice. · Engagement in adequate communication strategies to remind Alice to eat. · Implementation of a fixed eating schedule. · Incorporation of easy to ingest, calorie dense food to combat Alice weight loss.	Weekly evaluation of Alice’s weight through weighing scales. Daily observation, monitoring and recording of Alice’s eating practices (Watson et al., 2017).	Alice may forget to eat in the presence of distractions. Hence, I must provide a noise-free, peaceful environment while feeding her. To prevent Alice from feeling confused and overwhelmed and the resultant avoidance of eating, I must provide her meals with limited food choices, in smaller plates and in the form of finger foods for simple ingestion. To mitigate Alice’s problem of weight loss, I must incorporate energy dense food items like sugars and whole grains in her diet. I must make sure that the aged care facility is providing meals in accordance to the diet plan given by the dietician.

References

Banerjee, S. (2015). Multimorbidity—older adults need health care that can count past one. The Lancet, 385(9968), 587-589.

Booth, V., Logan, P., Harwood, R., & Hood, V. (2015). Falls prevention interventions in older adults with cognitive impairment: a systematic review of reviews. International Journal of Therapy and Rehabilitation, 22(6), 289-296.

Burns, M., & McIlfatrick, S. (2015). Palliative care in dementia: literature review of nurses’ knowledge and attitudes towards pain assessment. International journal of palliative nursing, 21(8), 400-407.

Strategies and Interventions for Dementia/Challenging Behaviours

Carnahan, R., & Johnson, T. (2017). Making a Bad Diagnosis Worse? Suspect Drug Management of Urinary Incontinence in Persons with Dementia. Journal of the American Geriatrics Society, 65(2), 238-240.

Cipriani, G., Lucetti, C., Danti, S., & Nuti, A. (2015). Sleep disturbances and dementia. Psychogeriatrics, 15(1), 65-74.

Creavin, S., Wisniewski, S., Noel-Storr, A., & Cullum, S. (2018). Cognitive tests to help diagnose dementia in symptomatic people in primary care and the community. Br J Gen Pract, 68(668), 149-150.

Curtis, E., Litwic, A., Cooper, C., & Dennison, E. (2015). Determinants of muscle and bone aging. Journal of cellular physiology, 230(11), 2618-2625.

Eichler, T., Thyrian, J. R., Hertel, J., Michalowsky, B., Wucherer, D., Dreier, A., … & Hoffmann, W. (2015). Rates of formal diagnosis of dementia in primary care: The effect of screening. Alzheimer’s & Dementia: Diagnosis, Assessment & Disease Monitoring, 1(1), 87-93.

Field, T. (2016). Knee osteoarthritis pain in the elderly can be reduced by massage therapy, yoga and tai chi: a review. Complementary therapies in clinical practice, 22, 87-92.

Flaatten, H., Skaar, E., & Joynt, G. M. (2018). Understanding cardiovascular physiology of ageing. Intensive care medicine, 1-4.

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Foltyn, P. (2015). Ageing, dementia and oral health. Australian dental journal, 60, 86-94.

Glyn-Jones, S., Palmer, A. J. R., Agricola, R., Price, A. J., Vincent, T. L., Weinans, H., & Carr, A. J. (2015). Osteoarthritis. The Lancet, 386(9991), 376-387.

Gragnoli, C. (2014). Hypothesis of the neuroendocrine cortisol pathway gene role in the comorbidity of depression, type 2 diabetes, and metabolic syndrome. The application of clinical genetics, 7, 43.

Hadjistavropoulos, T., Herr, K., Prkachin, K. M., Craig, K. D., Gibson, S. J., Lukas, A., & Smith, J. H. (2014). Pain assessment in elderly adults with dementia. The Lancet Neurology, 13(12), 1216-1227.

Hong, H. H., & Gu, M. O. (2015). Feeding difficulty and its influencing factors of elders with dementia in long-term care facilities. Journal of the Korea Academia-Industrial cooperation Society, 16(2), 1240-1252.

Horowitz, M. A., & Zunszain, P. A. (2015). Neuroimmune and neuroendocrine abnormalities in depression: two sides of the same coin. Annals of the New York Academy of Sciences, 1351(1), 68-79.

Husebo, B. S., & Corbett, A. (2014). Dementia: pain management in dementia—the value of proxy measures. Nature Reviews Neurology, 10(6), 313.

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Oral Hygiene

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MacAndrew, M., Fielding, E., Kolanowski, A., O’Reilly, M., & Beattie, E. (2017). Observing wandering-related boundary transgression in people with severe dementia. Aging & mental health, 21(11), 1197-1205.

Manley, L., Gibson, L., Papa, N., Beharry, B. K., Johnson, L., Lawrentschuk, N., & Bolton, D. M. (2016). Evaluation of pelvic floor muscle strength before and after robotic-assisted radical prostatectomy and early outcomes on urinary continence. Journal of robotic surgery, 10(4), 331-335.

Melhuish, R., Beuzeboc, C., & Guzmán, A. (2017). Developing relationships between care staff and people with dementia through Music Therapy and Dance Movement Therapy: A preliminary phenomenological study. Dementia, 16(3), 282-296.

Parmelee, P. A., Tighe, C. A., & Dautovich, N. D. (2015). Sleep disturbance in osteoarthritis: linkages with pain, disability, and depressive symptoms. Arthritis care & research, 67(3), 358-365.

Perna, R. (2017). Hypertension and its effects on brain functioning and cognition. Prevention, 17, 191-200.

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Scott-Warren, V., & Maguire, S. (2017). Physiology of ageing. Anaesthesia & Intensive Care Medicine, 18(1), 52-54.

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van Dalen-Kok, A. H., Achterberg, W. P., Rijkmans, W. E., Tukker-van Vuuren, S. A., Delwel, S., de Vet, H. C., … & de Waal, M. W. (2018). Pain Assessment in Impaired Cognition (PAIC): content validity of the Dutch version of a new and universal tool to measure pain in dementia. Clinical interventions in aging, 13, 25.

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Zenthöfer, A., Baumgart, D., Cabrera, T., Rammelsberg, P., Schröder, J., Corcodel, N., & Hassel, A. J. (2017). Poor dental hygiene and periodontal health in nursing home residents with dementia: an observational study. Odontology, 105(2), 208-213.

Zenthöfer, A., Cabrera, T., Rammelsberg, P., & Hassel, A. J. (2016). Improving oral health of institutionalized older people with diagnosed dementia. Aging & mental health, 20(3), 303-308.