A Report on Assessing Aged Patients With Dementia

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Table of Contents

Introduction
Abbey Pain Scale
The Cornell Scale for Depression in Dementia
Dysphagia Screening Tool
Article 1
Article 2
Article 3
Summary
Implications of the Research Findings and Recommendations
References

Introduction

Most aged persons suffer from dementia. A report by the Department of Health, Western Australia (2011) reveals that dementia affects 24% of persons aged 85 years. In Australia, dementia represents a noteworthy challenge due to the ageing population. Although the world is busy searching for ways to stop dementia, the present challenge is to exploit treatment and care opportunities.

Since assessment forms the main part of treatment and care of patients with dementia, this report gives several assessment tools that could be used in finding the degree of pain, depression and ability to feed in patients with dementia. The report first describes 3 assessment tools that could be used to assess a range of abilities of the person with dementia in scenario 3. These tools include the Abbey pain scale, Dysphagia screening tool and the Cornell Scale for Depression in Dementia (CSDD). The report then gives a critical review of three research articles on CSDD. Finally, the report summarizes findings and gives a recommendation for future practice.

Abbey Pain Scale

This is an observational scale that assesses pain in patients who have communication impairments. The scale measures five items including vocalization, facial expression, body language as well as behavioral, physiological and physical changes. All these items become rated on a scale of 0-3 (o-absent, 1-mild, 2-moderate, 3-severe) (Gruber-Baldini et al. 2005; Kallenbach & Rigler 2006). The sums of these items become calculated and interpreted on a scale of 0-14 (0-2-No pain, 3-7-mild, 8-13-moderate, 14-severe) (Eisses et al. 2005). Thus, this scale quantifies levels of pain in patients who have impaired verbal skills. In some cases, speech therapists aid in creating individual reports, and where need be pictorial rating scales become used.

Abbey’s pain scale is suitable for use in scenario 3 because dementia gets associated with pain and John refuses investigations. By using the Abbey pain scale, the assessor can assess the level of pain felt by John, through observation. Interpretation of these scales should describe the nature of pain experienced by John, in an effort to find a lasting solution to this problem.

The Cornell Scale for Depression in Dementia

The Cornell Scale for Depression in Dementia (CSDD) assesses signs and symptoms that become related to depression in dementia patients (Thakur & Blazer 2008). CSDD makes use of broad interviews to get information from patients as well as the informants since some patients tend to give false information (Baller et al. 2010; McAvay et al. 2004). Thus, CSDD uses two semi-structured interviews in data collection.

The interviewer determines scores through aligning preliminary scores, to scale items that are even, according to data collected from the informant. The assessor then asks the patient questions based on Cornell scale items (Lin & Wang 2008). The questions tend to find information about signs and symptoms that the patient might have experienced in the previous week (Kales et al. 2005). In case of any differences in ratings created after the two interviews, the assessor must interview the informant and the patient further, until differences disappear. Thus, the assessor influences final ratings obtained in CSDD.

Administration of CSDD takes only 20 minutes, and items become rated on a scale of 0-2 (0-absent, 1-mild, 2-severe) (Kroenke et al. 2001). The sums of all these scores become calculated. Scores that are less than six units show that the level of depression is insignificant. Scores cores that fall above 10 units show that depression is severe (Kroenke et al. 2001).

CSDD is suitable for use in scenario 3 because John appears depressed. As seen in the scenario, John lost his wife and since then, he has refused care and treatment. Besides, John is experiencing significant weight loss, which could be due to depression. Hence, the level of depression experienced by John should be assessed in efforts to manage his condition.

By using broad interviews in CSDD, an assessor can find reliable information from both John and his informants. In this case, caregivers or John’s brother can act as informants. Caregivers can give suitable information because John has been in the hospital for the past year. His brother can also act as an informant because we find that he expresses his wishes, on antibiotics use, to his brother and thus, they must be open with each other. CSDD is also suitable for use in John’s case as it takes little time to administer.

The implication of John’s depression can be determined using CSDD, which should be followed by proper measures such as prescription of antidepressant treatment.

Dysphagia Screening Tool

This tool assesses any difficulties in swallowing. The tool becomes administered in 6 steps (Callahan et al. 2006). First, the tool assesses whether a patient is attentive and conscious when feeding. In case the patient is not attentive when feeding, the assessor repeats the procedure after 24 hours. If there is still no response, the assessor should consult the services of a medical practitioner or a clinical nutritionist.

The second step assesses whether a patient can control oral secretions. If the patient cannot control drooping, the assessor should aid the patient to do dry swallowing, and if the patient cannot carry out this, a medical practitioner should become alerted.

The third step assesses the strengths of a patient’s voice or cough. If the voice or cough is unclear, a medical practitioner should become alerted.

The fourth step assesses the working of the laryngeal. The assessor gives the patient one teaspoonful of water. If no laryngeal elevation occurs, or the patient tries to swallow water, the assessor should seek the services of a medical practitioner.

The fifth step involves giving a patient one teaspoonful of water three times, and then the assessor asks the patients to say the words “aaahh” following every swallow. In cases of choking, coughing, gurgling, or breathlessness, the assessor should repeat this step with more thickened fluid in place of water. If these problems persist, the assessor should tell the medical practitioner.

The last step involves giving patients 50 mls of water in sips. If the patient experiences problems, services of a clinical nutritionist or a medical practitioner should become sought, since the client may require a Dysphagia diet. If there are no problems, patients should be given a normal diet.

The dysphagia screening tool is suitable for use in scenario 3 because John appears to have difficulties in swallowing. Also, the staff reported that he often gags on his food and later refuses diet and fluids. All these issues need investigation using the Dysphagia screening tool. Through using the Dysphagia screening tool, the staff can realize why John has difficulties in swallowing. For instance, they can find out whether John is attentive and conscious when feeding. In case John is not attentive when feeding, the assessor should repeat the procedure after 24 hours, and where need be the assessor should consult clinical nutritionists. This tool can also assess whether John’s swallowing problems are related to the inability to control oral secretions. The strength of John’s voice and cough should also face assessment in an effort to find out why John gags when taking food. Lastly, this tool should assess the working of John’s laryngeal to find out why John refuses fluids and diet. This may involve giving John water in bits and assessing evident behavior. Problems such as choking, coughing, gurgling, or breathlessness, should face assessment in efforts to find out the most proper diet and feeding methods for John in efforts to stop weight loss. Using this tool for assessment is also significant as it can help find areas that require specialized attention from medical practitioners.

Article 1

Brown, EL, Raue, P, Halpert, KD, Adams, S, & Titler, M 2009, ‘Evidence-based guideline detection of depression in older adults with dementia’, Journal of Gerontological Nursing, vol. 35, no.2, pp. 11–15.

Brown et al. (2009) explain that CSDD is efficient for screening dementia in aged adults. He explains that CSDD assesses signs and symptoms of depression in several areas of cognition. However, he also argues that a Mini-Mental State Exam (MMSE) must precede the assessment using CSDD. In his opinion, the administration of CSDD should occur when the patient scores less than 15 on the MMSE (Brown et al. 2009). However, he does not consider that MMSE could be erratic since some clients may give false information (Brown et al. 2009).

Brown et al. (2009) further argues that CSDD obtains information from both an informant and the patient. In his opinion, an informant should come from a close person or family member, who knows the patient well. Some persons who could be close to the patient, apart from relatives, not relatives may include social workers, nurses, home health aides (Brown et al. 2009).

Lastly, Brown et al. (2009) recommends that assessors who find scores of 11 or more in patients should immediately inform medical practitioners for more assessment, treatment, treatment and referral. Besides, patients who have scores below 11 should continue with assessments after treatment, and if the situation persists, patients should face screening after 6 months.

Article 2

Burns, A, Lawlor, B & Craig, S 2002, ‘Rating scales in old age psychiatry’, The British Journal of Psychiatry, vol. 180, pp.161-167.

Burns et al. (2002) explain that CSDD become used in assessing depression in patients with dementia. He also explains that the administration of CSDD should be done by clinicians, who should administer the tool both to the ‘carers’ and the patient. Thus, Burns et al. (2002) only considers care givers as informants and leaves out other people such as relatives, who could be having more information about the patient.

According to Burns et al (2002), the main difference between CSDD and other depression scales lies in the method of administration but not in finding symptoms. He also explains that the CSDD scale has 19 items, which become related on a three-point scale (absent, mild and severe) (Burns et al. 2002).

Lastly, Burns et al. (2002) reveal that a score of 8 and above is an indicator of depressive symptoms. In his perspective, CDD is the most suitable tool to assess depressive symptoms when there is cognitive impairment. However, Burns et al. (2002) does not give a clear insinuation of scores that are below 8. Also, his explanation that a score of 8 and above is an indicator of depressive symptoms is too general. Rather, he should show the level of these symptoms by using words like mild, moderate and severe.

Article 3

Phillips, L 2012, ‘Measuring symptoms of depression: comparing the Cornell scale for depression in dementia and the patient health questionnaire-9-observation version’, Research in Gerontolological Nursing, vol.5, no.1, pp.34-42.

Phillips (2012) reveals that CSDD is a measure of depressive symptoms in patients with dementia. However, he argues that the degree of depressive symptoms varies depending on the instruments used in the assessment. For instance, PHQ-9-OV and CSDD have comparable reliability to internal consistency but different cut-off points in scoring.

The cut-off point of CSDD is 8, while that of PHQ-9-OV is 5. This brings the difference in assessing depressive symptoms.

Phillips (2012) also reveals that CSDD accommodates low degrees of some mood symptoms that are dementia-specific such as “agitation, anxiety, multiple physicals complains, diurnal variation of mood, lack of response to the joyous occasion and mood-congruent delusions” (n.p.).

Lastly, Phillips (2012) reveals that CSDD is an efficient tool for assessing depressive symptoms among patients with dementia.

Summary

In summary, assessing patients with dementia involves the use of different tools. In assessing scenario 3, we found the most suitable tools for use as Abbey pain scale, Dysphagia screening tool and CSDD. Abbey’s pain scale is suitable for use in scenario 3 because dementia gets associated with pain and John has refused investigations. By using the Abbey’s pain scale, the assessor can assess the level of pain felt by John, through observational scales.

The Dysphagia screening tool is also suitable for use in scenario 3 because John appears to have difficulties in swallowing. Through using the Dysphagia screening tool, the staff can realize why John has difficulties in swallowing.

CSDD could be as well used in scenario 3 because John appears depressed. As seen in the scenario, John lost his wife and since then, he has refused care and treatment. Besides, John is experiencing significant weight loss, which could be due to depression.

We also reviewed several articles on the development and use of CSDD. These articles revealed that CSDD is a measure of depressive symptoms in patients with dementia, and it uses broad interviews to get information from patients, as well as the informants. While other authors included both family members and caregivers in the interview process, Burns et al. (2002) only included caregivers. Also, Brown et al. (2009) recommended that a Mini-Mental State Exam (MMSE) must precede the use of CSDD, while other authors did not mention this issue. Lastly, all authors explained that the administration of CSDD should be done by clinicians.

Implications of the Research Findings and Recommendations

The findings of this report are essential as they can act as guidelines for administering assessment tools when handling patients with dementia. I would recommend any medical practitioner, or caregiver, use these tools to follow proper ways during administration to get the best results for use in the treatment and care of these patients. Also, any caregiver or nurse assessing patients with dementia should integrate different tools to assess different disabilities. This will make sure that different difficulties or patients’ needs become addressed.

References

Baller, M, Boorsma, M, Frijters, DH, Marwijk, HW, Nijpels, G, & Hout, HP 2010, ‘Depression in Dutch homes for the elderly: underdiagnosis in demented residents’, International Journal of Geriatric Psychiatry, vol. 25, pp.712–718.

Brown, EL, Raue, P, Halpert, KD, Adams, S, & Titler, M 2009, ‘Evidence-based guideline detection of depression in older adults with dementia’, Journal of Gerontological Nursing vol. 35, no.2, p. 11–15.

Burns, A, Lawlor, B & Craig, S 2002, ‘Rating scales in old age psychiatry’, The British Journal of Psychiatry, vol. 180, pp.161-167.

Callahan, C, Boustani, M, Unverzagt, F, Austrom, M, Damush, T, Perkins, A, Fultz, B, Hui, S, Counsell, S, & Hendrie, H 2006, ‘ Effectiveness of collaborative care for older adults with AD in primary care’, Journal of the American Medical Association, vol. 295, no. 18, pp. 2148–2157.

Department of Health, Western Australia 2011, Dementia model of care, Aged Care Network, Perth.

Eisses, AM, Kluiter, H, Jongenelis, K, Pot, AM, Beekman, AT, & Ormel, J 2005, ‘Care staff training in detection of depression in residential homes for the elderly’, The British Journal of Psychiatry, vol. 186, pp. 404–409.

Gruber-Baldini, AL, Zimmerman, S, Boustani, M, Watson, LC, Williams, CS, & Reed, PS 2005, ‘Characteristics associated with depression in long-term care residents with dementia’, The Gerontologist, vol. 45, pp.50–55.

Kales, H, Chen, P, Blow, F, Welsh, D, & Mellow, A 2005, ‘Rates of clinical depression diagnosis, functional impairment and nursing home placement in coexisting dementia and depression’, American Journal of Geriatric Psychiatry, vol. 13, no. 5, pp.441–449.

Kallenbach, LE & Rigler, SK 2006, ‘Identification and management of depression in a nursing facility residents’, Journal of the American Medical Directors Association, vol. 7, pp. 448–455.

Kroenke, K, Spitzer, R L & Williams, JB., 2001, ‘Validity of a brief depression severity measure’, Journal of General Internal Medicine, vol.16, pp. 606–613.

Lin, JN & Wang, J, 2008, ‘Psychometric evaluation of the Chinese version of the Cornell scale for depression in dementia’, Journal of Nursing Research, vol. 16, pp. 202–210.

McAvay, GJ, Bruce, ML, Raue, PJ, & Brown, EL 2004, ‘Depression in elderly homecare patients: patient versus informant reports’, Psychological Medicine, vol. 34, pp.1507–1516.

Phillips, L 2012, ‘Measuring symptoms of depression: comparing the Cornell scale for depression in dementia and the patient health questionnaire-9-observation version’, Research in Gerontolological Nursing, vol.5, no.1, pp.34-42.

Thakur, M & Blazer, D G 2008, ‘Depression in long-term care’, Journal of the American Medical Directors Association, vol. 9, pp. 82–87.

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