Clinical epidemiology is a critical field of study in contemporary health care. It is a discipline of predicting the health outcomes of patients with a particular condition by considering the outcomes in groups of similar persons (Fletcher & Fletcher, 2021). Therefore, epidemiological studies directly impact the diagnosis, prognosis, and clinical treatment by presenting medical practitioners with relevant data on the course, presentation, and treatment of an illness.
Epidemiological studies can inform the prognosis or the predictions of how a disease will develop in an individual under different conditions. According to Fletcher and Fletcher (2021), prognosis accounts for the natural history of the disease, with no recorded medical intervention and its clinical course, with medical care being provided. Thus, studies on disease progress allow practitioners to make more informed clinical choices. For example, a Dutch study on the risk of pregnancy complications in women with Type I diabetes revealed that good blood sugar control is not sufficient in preventing the development of various issues (Fletcher & Fletcher, 2021). Therefore, additional treatment is needed to prevent associated developmental diseases and infant death. Similarly, data on how COVID-19 progresses in individuals can inform clinicians on how to address a novel disease in vulnerable populations (Liu et al., 2021). Thus, prognostic epidemiological studies identify prognostic and risk factors that allow measuring the clinical outcomes for individual patients.
Diagnosis is the method of identifying the disease by examining various clinical symptoms. It is a challenging process as many clinical presentations exhibited by patients and test results may indicate different illnesses. Epidemiological studies are crucial as they provide more in-depth data that help medical practitioners make the diagnosis. Thus, a study on vertebral disc abnormalities showed that they are common and may not cause discomfort in patients complaining of lower back pain (Fletcher & Fletcher, 2021). Meanwhile, a study conducted in India proposes a machine learning method that accurately diagnoses dementia in older adults (Bhagyashree et al., 2018). Furthermore, epidemiological studies offer data on treating the diagnosed conditions with the known clinical course. For example, research on cardiovascular disease in individuals diagnosed with insulin-dependent diabetes indicates that blood sugar control is ineffective in preventing various heart conditions from development (Fletcher & Fletcher, 2021). Therefore, other factors need to be addressed in groups of similar patients. In summary, epidemiological research is essential as it informs medical professionals and provides them with more data on the prognosis, diagnosis, and treatment procedures.
References
Bhagyashree, S. I. R., Nagaraj, K., Prince, M., Fall, C. H., & Krishna, M. (2018). Diagnosis of Dementia by Machine learning methods in Epidemiological studies: a pilot exploratory study from south India. Social psychiatry and psychiatric epidemiology, 53(1), 77–86.
Fletcher, G., & Fletcher, R. (2021). Clinical epidemiology: The essentials (6th ed.). Lippincott Williams & Wilkins.
Comparative analysis of the epigenetic impact of various environmental toxicants on the development of neurodegenerative diseases.
Background
Pollution causes serious concerns, and one of the reasons is its impact on the human body. Under the influence of toxins spreading in nature due to human activity, people’s epigenome changes (Li et al. 1). As a result, at the moment, the study of the influence of environmental particles on the development of diseases in humans is relevant. Although the etiology of neurodegenerative diseases such as Alzheimer’s or Parkinson’s disease is not fully established, the researchers are confident that toxicants’ impact is powerful (Antoniadou et al. 299). It is crucial to identify which of the environmental factors most contribute to the development of such diseases. Such a study draws attention to the problem of environmental pollution, which may contribute to increased environmental responsibility. Moreover, the study will help consider potential treatment options. From the evolutionary biology perspective, the topic reveals the features of the human epigenome’s reaction to environmental changes.
Previous Research, Hypothesis, and Research Plan
Several studies have already focused on various aspects of the problem, which provides the basis for the proposal of several hypotheses and a research plan. Li et al. describe nine works devoted to the environment’s influence on the genome and epigenome and the subsequent development of non-infectious diseases (1-2). Antoniadou et al. provide more focused research and offer a review of the effects of metals on the development of dementia (299-306). Mir et al. consider the environmental impact on the development of Alzheimer’s disease (44724-44742). Dunn et al. study the interaction of genes and external factors (73-80). One may hypothesize that toxicants negatively affect the human epigenome and contribute to the development of neurodegenerative diseases. The research plan will include an examination, review, and comparison of existing studies and evidence of the impact of toxicants through a literature overview to answer this question.
Works Cited
Antoniadou, Fevronia et al. “Toxic Environmental Factors and their Association with the Development of Dementia: A Mini Review on Heavy Metals and Ambient Particulate Matter.” Materia Socio-Medica, vol. 32, no. 4, 2020, pp. 299-306.
Dunn, Amy R. et al. “Gene-by-Environment Interactions in Alzheimer’s Disease and Parkinson’s Disease.” Neuroscience & Biobehavioral Reviews, vol. 103, 2019, pp. 73-80.
Li, Yanqiang, et al. “Environmental Genomics and Epigenomics: Response, Development and Disease.” Frontiers in Genetics, vol. 12, 2021, pp. 1-2.
Mir, Reyaz Hassan, et al. “Role of Environmental Pollutants in Alzheimer’s Disease: A Review.” Environmental Science and Pollution Research, vol. 27, no, 36, 2020, pp. 44724-44742.
Destructive diseases like dementia impose a considerable strain on individuals, their caregivers, and the public on a physiological, psychological, and economic level. Alzheimer’s disease is one of the most prevalent kinds of dementia and accounts for approximately 60–70% of dementia cases (Navia, R. O., & Constantine, 2022). In the world today, dementia is among the primary causes of impairment and vulnerability in older adults and the sixth largest cause of death among all diseases (Navia, R. O., & Constantine, 2022). According to estimates, 6.5 million Americans already have Alzheimer’s disease, and 13.8 million more instances are expected by 2055 (Ettinger, 2022).
Due to dementia diagnosis, patients frequently suffer from the negative impacts of stigma while not being able to receive the same treatment as others (Haapala et al., 2018). Moreover, a person’s self-esteem might be negatively impacted by their health, financial situation, work position, and connections with people around them (Haapala et al., 2018). Therefore, dementia is often not well-understood since, while being well-studied, the condition is frequently not recognized by the general public, which causes stigma and obstacles to diagnosis and treatment.
Research Questions
When studying such a condition as dementia, it is vital to pay attention not only to the final stage of the disease and its consequences but also to observe its development and prevention methods. As a result, the research questions for the topic of dementia are as follows:
How does the body deteriorate with dementia, and how strong can these changes be for the person diagnosed with dementia?
How can family members of the person with dementia promote a better lifestyle to prevent health conditions such as dementia in the future?
Answers to Research Questions
Regarding the first question, it is necessary to give an overview of dementia and its manifestations. A clinical condition known as dementia is a gradual deterioration in cognitive function that impairs one’s capacity to operate autonomously (Duong et al., 2017). Dementia symptoms develop gradually, persist, and intensify with time (Duong et al., 2017). Cognitive, functional, and behavioral impairments are common in dementia patients. The cognitive deficit dementia’s contributing factors can be strong and manifest as memory problems, communication functional limitations, agnosia (incapability to identify objects), apraxia (difficulty in performing previously learned activities), and impaired executive function (Duong et al., 2017). The damage to the cerebral cortex brought on by synapse malfunction, inflammation, and changes in the brain’s metabolism leads to cognitive decline (Duong et al., 2017). As a result, with dementia, the patient’s body deteriorates slowly.
As for the second question, immediate family, relatives, or friends can help individuals diagnosed with dementia reduce the quick progress of the condition. By leading a healthy lifestyle that includes frequent exercise, eating balanced food, not smoking, and moderate alcohol use, families may help lower a person’s risk of dementia (Livingston et al., 2020). Other ways a family can help a patient reduce the risks of further development of dementia is by keeping one’s mind occupied through reading, solving riddles, or acquiring new knowledge.
The Following Aspects of Interest
Finally, when it comes to the aspects of the topic that would be important to analyze, it is the dementia prevention methods from a young age. While there are numerous interventions used to prevent the quick process of cognitive function deterioration in people already diagnosed with dementia, it is vital to see what types of approaches can reduce the risk of Alzheimer’s disease occurrence. Therefore, prevention approaches from a young age must be analyzed.
Conclusion
In sum, dementia is among the most detrimental diseases, which not only causes immense malfunctions in cognitive abilities but leads to social stigmas, decreasing the self-esteem of the patients. As a result, it is necessary to increase awareness when it comes to Alzheimer’s disease and other related dementia conditions and provide individuals with approaches that will reduce the risk of condition development. For the given work, five academic sources were used to consult for the research, all of them being published within five years.
References
Duong, S., Patel, T., & Chang, F. (2017). Dementia: What pharmacists need to know. Canadian Pharmacists Journal, 150(2), 118–129. Web.
Ettinger, S. (2022). Diet, gut microbiome, and cognitive decline. Current Nutrition Reports, 1-10. Web.
Livingston, G., Huntley, J., Sommerlad, A., Ames, D., Ballard, C., Banerjee, S., Brayne, C., Burns, A., Cohen-Mansfield, J., Cooper, C., Costafreda, S. G., Dias, A., Fox, N., Gitlin, L. N., Howard, R., Kales, H. C., Kivimäki, M., Larson, E. B., Ogunniyi, A., Orgeta, V., … Mukadam, N. (2020). Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet, 396(10248), 413–446. Web.
Navia, R. O., & Constantine, L. A. (2022). Palliative care for patients with advanced dementia. Nursing 2022, 52(3), 19-26. Web.
The frontal lobes are the biggest areas of the brain. As a result, they participate in multiple processes. At the same time, due to its size and anatomical location, frontal lobe damage is among the most common brain injuries recorded. When discussing the frontal lobe, it is essential to mention the prefrontal cortex, which is the front part of the frontal lobe. The prefrontal cortex correlates with a variety of essential functions associated with human existence and condition. In this paper, the frontal lobe will be analyzed from the perspective of its structure, function, and potential outcome correlating with its damage, namely, dementia.
Discussion
The frontal lobes, as mentioned prior, are responsible for some of the most important skills and activities a human can exemplify. According to researchers, the brain area that is directly placed behind the forehead is responsible not only for essential movement and language but a wide variety of cognitive abilities (Catani, 2019). For example, the frontal lobe is connected with one’s ability to organize, plan in advance, be insightful, and control certain verbal and physical responses. Without a doubt, the functions correlating with the frontal lobes are among the abilities that are uniquely human and extremely crucial when it comes to interactions with the outside world. Structure-wise, it is to be mentioned that different areas of the frontal lobe are responsible for the functions. For example, the prefrontal cortex is associated with high-level cognition skills, the premotor cortex is linked to movement planning and execution, the motor cortex correlates with movement initiation, and Broca’s area is responsible for language.
As it can be established, the frontal lobe is not only the biggest area of the brain but also one of the most important. Simultaneously, damage to the area is serious and can impact a person’s physical and mental well-being. Multiple outcomes have been linked to frontal lobe injuries, including paralysis, difficulties focusing on certain tasks, language impairments, movement issues, and other barriers. However, the specific condition that has been linked to the phenomenon and will be discussed is dementia. Dementia, while not a condition per se, is linked to symptoms such as cognitive issues, impaired decision-making skills, and memory loss and encompasses diagnoses including Alzheimer’s, vascular dementia, and frontotemporal dementia. Frontotemporal dementia is one of the diagnoses that has been linked to impaired frontal lobe activity, alongside dementia with Lewy bodies, Parkinson’s, and the aforementioned Alzheimer’s (Young et al., 2018). The condition occurs when the frontal and temporal lobes degenerate. Symptoms such as negative changes in social behavior, movement impairment, and language and speech problems are frequent in patients diagnosed with the condition (Battista et al., 2020). Similar to other diagnoses that are encompassed in the dementia category, frontotemporal dementia significantly affects an individual’s ability to think, remember, move, and express themselves. The negative connotations are major disruptors of the lives of people experiencing said symptoms, as well as their caretakers and the healthcare system as a whole.
Conclusion
The frontal lobe is the biggest area of the brain responsible for a multitude of objectives or skills primordial in day-to-day life. Namely, speech, language, motor skills, planning, organizing, and other high cognitive functions depend on the operations within the frontal lobe. On the other hand, damage to the area correlates with major behavioral and cognitive changes. One condition that has been linked to frontal lobe degeneration is Frontotemporal dementia, among others.
References
Battista, P., Griseta, C., Capozzo, R., Lozupone, M., Sardone, R., Panza, F., & Logroscino, G. (2020). Frontal lobe syndrome and dementias. Genetics, Neurology, Behavior, and Diet in Dementia, 617–632. Web.
Patients, caregivers, doctors, and healthcare organizations face particular difficulties as a result of Alzheimer’s disease. It is noteworthy that the deontological theory of ethics states that all clinical decisions must be made with respect to guidelines and what is right, regardless of the consequences. Still, there are issues, such as the issue of autonomy, where a medical professional might put restraints on a patient’s freedom, which will be in their best interest. Thus, honoring patient autonomy while recognizing their decision-making abilities that are gradually deteriorating and maintaining the provision of quality care in compliance with fundamental ethical standards are necessary while caring for people with dementia.
Ethical Issue: Deontology
The study of ethics, or ethical philosophy, entails organizing, justifying, and endorsing ideas of what constitutes appropriate and inappropriate conduct. The deontological theory basically promotes the fair treatment of patients and requires all medical professionals to comply with the rules, despite the outcome. According to this theory, whatever the outcome or any other considerations, the morality of a decision is exclusively determined by the form of the activity (Swartz, 2021). The decisions should, therefore, be made on the basis of what is most beneficial to the patient (Swartz, 2021). Without taking into account contextual factors, deontology regards behaviors as either good or bad. In these circumstances, one can think of the commandments from the Holy Scripture, which teach people not to kill, steal, or disrespect their parents (Swartz, 2021). It can be said that, similarly to commandments, Deontological principles separate right actions from wrong actions.
When speaking of the ethical issue of autonomy and restraints, it is vital to recognize how Deontology emphasizes respect and support of autonomy when it is the right decision to make. In this situation, when providing care for patients, limiting them in some kind of activities might be seen as a violation of their freedom and autonomy. However, if this is in the best interest of the patient and can prevent them from being harmed, it can be considered the appropriate choice in terms of Deontological logic.
Ethics of Dementia Care in Elderly Patients within Scholarly Literature
Dementia affects those in their elderly years, and the ones who frequently have additional co-morbid conditions and behaviors linked to dementia may be more dangerous. Following the issues of restricting freedom and controlling risk are those related to the application of both physical and pharmaceutical constraints. The physical constraint may take many different forms, ranging from the application of physical force to seemingly innocent activities like barring doors or placing a chair too low for the individual to get up from (Chien et al., 2022). In this case, a restriction in whatever manner must be roughly proportional to any possible damage to the individual. Obviously, there must be a compelling cause to apply constraint, and the methods employed should be based on the inadequacies of less invasive ones (Okuno et al., 2021). Healthcare providers can think it is ideal for a patient to remain at a hospital or clinic. It is a loss of liberty when a patient is unable to leave but is always under professional care and observation (Parker, 2020). Still, it must be demonstrated that this is appropriate and in the patient’s best interests before it may be authorized.
In the end, it is noteworthy that healthcare practitioners should keep in mind that risk is an unavoidable aspect of life and that decreasing risk in one domain might raise damage in another while doing this balancing exercise. Considering that autonomy and welfare both depend on freedom, risk management should carefully consider all potential hazards and benefits when evaluating the various elements (Parker, 2020). Therefore, decisions regarding autonomy require much consideration and still rely on the patient’s best interests.
Caring for Elderly Patients with Dementia: Guidance from RNAO
The Registered Nurses Association of Ontario (RNAO) emphasizes all practices and guidelines in their documents regarding proper patient care. RNAO (2018) provided and discussed guidelines for nurses providing care for patients living with dementia. The guidelines outline the responsibilities and roles of nurses in response to patient autonomy, privacy, and the provision of person-centered care. According to RNAO (2018), families of people living with dementia are direct partners that should be involved when providing care to people living with dementia. Registered Nurses are encouraged to provide continuous education and emotional support to families to cope with the emotional distress that accompanies the disease. During the education process, nurses are discouraged from influencing the patients or forcing them patients to choose to make decisions about the patient’s life.
RNAO is also an ardent supporter of person-centered care in caring for elderly patients with dementia. According to RNAO (2018), Registered nurses are encouraged to use evidence-based practices when treating and managing patients with dementia. RNs ought to create therapeutic relationships with patients and families, health promotion through creating awareness, and patient advocacy in the allocation of resources for better living standards (Lundberg, 2018). RNs are expected to be culturally sensitive and provide care to all patients regardless of age, gender, or social status.
The Media Coverage of the Autonomy Issue
Ethical issues in healthcare are often discussed in the media, focusing on the presumed negligence of medical personnel. For instance, Waterloo News discussed the practices of medical personnel when treating patients with dementia in one of the Canadian hospitals. The article emphasized how one study found that older hospital patients are more likely than their younger counterparts to receive restrictive treatments such as acute control drugs and medication in non-emergency scenarios (Waterloo News, 2022). Between 2005 and 2018, it was identified that there was a distinct trend of greater frequencies of these interventions being used in older persons in Ontario mental facilities (Waterloo News, 2022). In order to find out how frequently older hospital patients are constrained in non-emergency circumstances when compared to younger age brackets, researchers looked at 226,119 Ontario inpatient files over the course of these years (Waterloo News, 2022). Finally, it was accentuated that such control treatments have a number of detrimental health and psychological effects, especially in physically fragile older persons.
Obviously, in the given situation, the ethical issue of autonomy in decision-making is emphasized. Both scholarly and media materials emphasize that older patients with functional disabilities, aggressive behavior, mental retardation, and disorientation should receive treatment in accordance with their best interests. However, according to the media, before turning to such practices, person-centered and non-pharmacological management options should be considered (Waterloo News, 2022). However, the difference between scholarly material from the claim in the media is that medical personnel should make decisions in the best interest of the patients and the people surrounding them. Therefore, especially when aligned with scholarly material, such could pose a threat not only to themselves but others as well.
Social Justice and Patient Autonomy in Elderly People with Dementia
Whitehouse (2022) defined social justice as an approach that ensures that people living with dementia have access to resources and treatment that guarantee a life of dignity, regardless of one’s status. Social justice is all about ensuring equality and fairness in the distribution of resources and access to services. In a fair and just society, elderly patients diagnosed with dementia are allowed access to quality care regardless of social status, race, ethnic background, or gender. All people are allowed access to treatment and medications required to manage the symptoms of the condition, whether they are able to pay for the services or not. There is also a need for inclusive communities where individuals with dementia can lead comfortable lives without discrimination or stigmatization. Social justice can be attained through advocacy, where communities and physicians advocate for better programs and allocation of resources to cater for the unique needs of people that will develop dementia in the future to avoid straining the available resources.
Ethical Evidence-Based Actions for RNs to Promote Social Justice
Controversies surrounding caring for elderly patients can be addressed by Registered Nurses to promote social justice. When viewed from the perspective of social justice, care for elderly patients with dementia attracts ethical concerns that can be addressed by RNs. Bosisio and Barazzetti (2020) discussed the need for RNs to promote social justice through cultural sensitivity, bearing in mind that patients suffering from dementia can come from different races, ethnic backgrounds, and social classes. In addressing social justice, RNs are encouraged to address issues of discrimination, marginalization, and isolation of patients with dementia. Social justice can be pursued through fair and equal distribution of resources for the people in need. RNs can step in and train or educate families and caregivers on strategies that can be beneficial when living with elderly people with dementia. RNs can also advocate for the fair distribution of resources to meet the unique needs of affected individuals in society.
Conclusion
Dementia is increasingly becoming a healthcare concern in Canada and around the globe. The fact that more than a million Canadians are at risk of developing dementia calls for early preparation in tackling the impending problem. The condition impairs a person’s capacity to make independent and informed decisions, leading to a loss of autonomy. Loss of autonomy is an ethical concern due to the fact that every person has a right to freedom and the right to life. When other people, such as family members and physicians, make decisions on behalf of the patient, there are high chances of infringing on the patient’s rights, privacy, and freedom. RNs can advocate for patient autonomy by creating awareness, empowering families and communities, and providing psychosocial support to people living with dementia and their families. RNs should also be culturally sensitive and prepared to provide person-centered care to different populations of people suffering from dementia.
Mr. W was referred for an evaluation, and the current outcomes provide a few important details. Firstly, one should draw attention to the fact that the diagnosis of dementia was made in 2011, and the patient did not experience any evident symptoms of the condition for the next three years. Secondly, a decent medication list is also significant because drugs can significantly affect Mr. W’s cognitive functions. Thirdly, specific test results also indicate that dementia may not be an appropriate diagnosis for the patient. In particular, Mr. W was fully oriented and could provide specific details of his life. The patient’s speech was also fluent, while most tests of sustained attention showed normal results. However, the area of complex visuospatial processing was a weakness. This information demonstrates that dementia may not be the case for Mr. W, but it is reasonable to administer additional assessment instruments to ensure whether the patient has this condition.
Discussion
The Abbreviated Mental Test (AMT-4) is the first suggested instrument. According to Carpenter et al. (2019), it is an effective tool to diagnose dementia because its positive likelihood ratio was assessed as 7.69 at a 95% confidence interval. This data demonstrates that if a person has dementia, the selected instrument offers a high probability of identifying this diagnosis. It is possible to state that the tool is ethical because it does not subject individuals to harmful effects and is appropriate for professionals since it usually takes five minutes to administer the test (Carpenter et al., 2019). In addition to that, it is worth admitting that the instrument’s reliability was assessed as 0.90, while the validity was close to 0.75 (Tanglakmankhong et al., 2021). These figures demonstrate that AMT-4 can be applied to assess Mr. W’s conditions.
Simultaneously, the Brief Alzheimer’s Screen can be used to conclude that the patient does not have dementia. Carpenter et al. (2019) stipulate that this instrument has the lowest likelihood ratio of diagnosing a patient with this condition when it is absent. It is possible to claim that the given instrument offers high validity scores because its sensitivity is estimated at 95% (Carpenter et al., 2019). As for reliability, it is challenging to find the specific statistical value of this construct, but it is possible to expect good results. The rationale behind this statement is that the test only includes five activities that ask a patient to say the current data, remember words, spell a word backward, and others. It is possible to expect that the results can be reproduced under the same conditions. The description above also demonstrates that no ethical issues are present, and professionals can easily implement the instrument.
Conclusion
Finally, the Clock Drawing Test can be used to assess Mr. W’s conditions. This brief neuropsychological test is requested because it is an effective screening instrument to diagnose dementia on its own or as part of a test battery (Hwang et al., 2019). The given tool offers a few advantages since it is free of charge and easy to administer (Hwang et al., 2019). According to Emek-Savaş et al. (2018), the test reliability can be assessed as 0.72-0.98. Approximately the same figures describe the instrument’s validity, and Emek-Savaş et al. (2018) state that this phenomenon can be estimated at 0.72-0.92. Numerous articles confirm the fact that the selected tool is professional and ethical (Hwang et al., 2019; Emek-Savaş et al., 2018). Consequently, it is reasonable to use the three instruments to assess Mr. W and make a final diagnosis.
Over recent times, Dementia has been increasingly reported as a worrying health problem across the world. According to Hickman et al. (2007), approximately 24.3 million people in the world had dementia in 2005, and an estimated 4.6 million new cases are reported every year. This scholarly study by Hickman and his fellow researchers further reports that going by the current trends, by 2040, this number will rise to about 81.1 million people—which really is a perturbing figure, to say the least.
In another study by Wotton and Crannitch (2008), it is believed that Dementia will be experienced more in the developing countries which are already experiencing rapidly-growing life expectancy rates. In the UK alone, 700,000 out of 61 Million people are reported by Alzheimer’s Society (UK) to have dementia. By 2021, researchers are expecting this number to reach 940,000 people (International Longevity Center UK, 2009). These grim statistics have raised global concerns across the world with a good number of researchers coming up, slowly but surely, to try finding ways of curbing Dementia before it reaches unmanageable levels. But before delving into such intricacies, what really is Dementia?
Dementia is a health condition which is defined by Bidewell & Chang, (2011) as the progressive decline in cognitive function or, simply, the worsening of a person’s ability to process thought. Dementia is mostly prevalent in old people (Barnes et al., 2004). Nonetheless, Hickman et al. (2007) argue that it may affect adults of any age.
In Residential Aged Care Facilities (RACFs), Bidewell & Chang (2011) say that nurses tend to face various issues in the care of patients with dementia. In solving these challenges, many approaches have been proposed—as will be explicatively detailed later in this paper (Brown, 2002). A detailed analysis of these issues is embodied in the discussion given below.
Malnutrition and dehydration issues in patients with dementia in RACFs
In older adults, malnutrition is defined by Gaskill et al, (2009) as inadequate dietary intake that leads to the insufficient nutritional condition, weight loss and muscle wasting. According to Turner (2005), approximately 85% of nursing home residents suffer from malnutrition while 60% suffer from malnutrition.
In explaining the high percentages of dehydration and malnutrition in patients suffering from dementia, Barnes et al., (2004) support Reed et al., (2004) by saying that Dementia is a syndrome normally caused by a variety of diseases that produce disturbance of cortical functions with severe loss of cognitive ability and functional capacity. As a result, this leads to malnutrition and weight loss because of increased energy demand due to factors such as wandering, food refusal due to agitation, lack of appetite and declining capacity to chew, swallow (dysphasia) or feed independently (Reed et al., 2004).
Additionally, malnutrition is caused by difficulties with eating due to loss of ability to recognize food, eating low amounts, refusal to get involved or cooperate during feeding time, or forgetfulness about food and (Hines et al., 2008).
Moreover, the shortage of staff to attend to each one of the patients is cited as a cause of poor health and malnutrition. Chewing and swallowing problems make it difficult for them to eat their meals well. These swallowing problems make them easily prone to aspiration of fluids into the lungs and consequently water restrictions are set in place for certain patients. This restriction on fluids leads to the risk of dehydration in patients with swallowing disorders suffering from dementia (Reed et al., 2005).
Recommended Solutions
According to Gaskill (2009), nurses should consider soft or vitamised meals as a solution to chewing and swallowing problems. Reed et al, (2005) further say that poor oral hygiene, lack of teeth, infections in the gums, teeth decays and poorly fitting dentures may prevent them from having enough food to make up a nutritional value. In these cases, oral nutritional supplementation may be a solution (Levi, 2005).
In a study conducted by Levi (2005) in aged care and assisted living facilities, it was remarkably revealed that food and fluid intake increases among residents if they are monitored by staff during meals, have their meals in public dining areas rather than in their bedroom, the facility provides an environment with no institutional features, free of environmental distractions and there is enough staff to provide assistance in the room. For this reason, it is advisable for nurses and the management in RACFs to inculcate such endeavors and programs into their facilities so as to orient these positive results.
On another note, Barrat (2004) outlines interventions such as fortified food, supplements and meal planning as other solutions to RACFs. In addressing malnutrition and dehydration, nurses and other staff education programs need to be designed on nutrition assessment procedures and early nutrition intervention methods (Manthorpe & Watson, 2002). This is, in order, to equip them in awareness, screening and assessing the residents’ nutritional status (Gaskill et a., 2009).
In solving the problem related to the aspiration of fluids caused by dysphagia, Hines et al., (2008) proposes increasing the viscosity (thickness) of drinking fluids. This idea is supported by Manthorpe & Watson (2002) who found out that thickened fluids were easily accepted by older people compared to dilute ones. Barrat, (2004) however, refutes this by saying that thickened fluids were not accepted by patients in his study since thickening agents were thought to suppress flavors of drinks. Debates on this issue are still ongoing and a decisive solution (through research) is yet to be found.
Other general solutions proposed to solve malnutrition include reducing noise in the RACFs (since patients consider it distractive), increasing light in the facilities (because patients love to see what they are eating), and providing meals on time. As for dehydration, nurses promoting fluid consumption in their daily meal routines is additionally encouraged.
Communication with aged care residents with dementia
Communication is very important in all human relationships and, in people with dementia, it is extremely critical to their well-being (Hickman et al., 2007). Patients with dementia are believed to experience numerous communication challenges. In most cases, they cannot express themselves coherently, and in worst cases, they may lose the communication function completely (Kohn & Surti, 2008).
As we all know, communication is a broad concept and can happen in a myriad of ways. The most common categories are verbal and non-verbal communication. Regardless of the category, caution and professionalism should be taken when communicating to these patients since they are normally very delicate and any wrong communication can be very detrimental to them. The fact that old people tend to slow to understanding complex issues, utmost professional discretion and patience—as was already mentioned—should be adherently observed.
Recommended Solutions
To have a quality life and receive the care they need, dementia patients just need to be consulted consistently, but in a loving and patient way. This might see seems difficult, but it is realistically achievable.
Moreover, intervention measures have been developed at individual and group levels to help the patients directly and indirectly with family members, friends and healthcare professionals (Borbasi et al., 2011). This is aimed at mainly improving the communication between the victims and those around them.
In order to improve communication for quality care, nurses should use communication that enhances decision making. Here, the nurse should show genuine interest and engagement of the patient in making everyday simple decisions such as what to wear, in bathing and even what to do (Tilly & Reed, 2004). This is supported by Harding, (2005) who says that cheeriness and warmth towards the patient as well as concern and seriousness display the same responses interest and engagement. This will make the patient to recognize familiar pattern around the facility for care without apprehension of the next activity.
Another way of encouraging communication with patients with dementia could be less focus on routine and obsession with time while intermittently giving them “monitored’ freedom to do things like walking and reading. When the nurses display a manner of communication that shows his/her focus on finishing with one resident so as to get to the next one or follow procedures, this is felt by the patient and may not be able to take care of the needs of the patient neither allow him/her to make decisions on the same (Hickman et al., 2007; Harding, 2005).
Dementia agitation in people with dementia living in RACFs
Agitation in dementia is recognized as a common and difficult issue among aged care residents. Nguyen et al. (2008) explicates this by estimating that 80% to 90% of patients with dementia develop at least one distressing behavioral problem at some point in the course of the disease.
Agitation is such a symptom and is characterized by inappropriate verbal, vocal or motor activities that result from unmet needs or confusion in the patient. Agitation can be displayed by several types of behavior as outlined by Nguyen & Paton, (2008). These include; verbal non-aggressive where the patient just complains, voices a lot of negativity, repeats questions or statements and regular uncalled for requests for help. Verbally aggressive behavior such as screaming, strange noises, cursing etc, physical non-aggressiveness characterized by doing inappropriate things and physical aggressiveness such as sexual advances, throwing things and grabbing among others (Levi, 2005).
Recommended Solutions
Agitation needs to be diagnosed properly in order to rule out delirium and appropriate intervention measures to be applied. Besides pharmacological interventions, non pharmacological measures should be administered first as (Detweiler et al., 2008). These could include providing an environment that is as close to a home environment as possible in the facility.
In addition to this, bright lighting could be used in the surroundings even during the day so as to avoid a misconception of stimuli (Neugroschi, 2002). Moreover, the environment should also be calm and with familiar things to soothe the patients (Bidewell & Chang, 2011).
A daily plan of activities, which the residents can engage in, will also help calm down and reduces stress. It is also important to provide adequate training to nurses on skills such as communication, managing behavior without confrontational manner and other support techniques and the planning and engaging the patients in activities in their care (Vink et al., 2003).
For patients with sleep disturbances, lack of enough sleep may cause agitation and intervention should involve addressing the underlying causes of sleeplessness (Hickman et al., 2007). First, there should be no excessive sleep expectations since, daily sleep requirements do not increase with age. This is echoed by Wilkes et al. (2005) who say that, daytime napping should be limited by engaging the patients in activities that are specially designed for dementia patients and physical exercises. In order to prevent agitation, Wilkes and his colleagues suggest a structured day should be provided so that a predictable routine is maintained. This should be done by providing orientation materials such as calendars, clocks and family pictures which should be kept in prominent places. Care should be taken when structuring a day so as to avoid rushing the patient because as it may result into agitation (Turner, 2005).
Pain in people with dementia
Research has shown that pain prevalence in elderly people is a common problem with 60 years and above adults experiencing twice as much pain as younger persons (Smith, 2007). Further, Smith says that 50% of institutionalized elderly people in the US have dementia and in European countries such as Austria and UK, 60% of institutionalized people have dementia. This is an indication of how pain assessment in RACFs is a challenge to the nurses.
Pain assessment in dementia patients is further complicated by unique barriers such memory loss, language problems, abstract thinking, loss of personality and judgment among others (Harding, 2005). Moreover, absence of behaviors associated with pain or difficulties in interpreting them make assessment even worse.
In pain assessment among patients with dementia, self reporting which is considered a ‘gold standard’ may not work since it will require the patient to understand the task and communicate about the patient (Brown, 2002).
Recommended Solutions
Primarily, agitation and other behaviors displayed by dementia patients may be an indication of pain (Maslow, 2004). Care should be taken though not to interpret these symptoms as pain indicators thereby complicating pain assessment even further (Harding, 2005).
In instances where the “gold standard” (mentioned above) does not work; other assessment tools will come in handy. This will require developing non-verbal assessment tools that will base their assessment on behavior observation (Maslow, 2004). One such tool nurses should use could be an observation chart for changes in the sleep patterns, appetite, physical activity, mobility and body/facial language of the patient at a given period of time (Harding, 2005).
Nurses or caregivers at the facility could also use physiological charts where the details of a patient’s especially those identified with problems in the first measure, such as heart rate, blood pressure will be recorded and monitored (Maslow, 2004). Though this has not been researched fully due to limitation validity and practicality, as reported by Fallon et al. (2006), with more research and a mixture of other interventions, it can significantly lessen pain.
Hygiene for people with dementia living in residential aged care facilities
Dementia often affects a person’s hygiene in that, they may loose interest or forget to wash or change their clothes and also bathing. This presents a different kind of a challenge to nurses in RACFs as the patients may require help toileting, getting dressed, brushing their teeth and general grooming (Kohn & Surti, 2008).
In addition to this, nurses face problems such as resistance or confrontations from patients to be assisted in caring for them due to the embarrassment of losing their privacy (Tilly & Reed, 2004). If at all the well-being of this patients is to be facilitated, these issues should be addressed as detailed below.
Proposed Solutions
In order to assist such patient, the nurse should exercise patience and avoid confrontations. The nurse should also try to maintain a level or a feeling of privacy by closing doors and pulling the blinds down. If the patient does not recognize himself/herself, cover the mirrors in the room and show a great deal of reassurance and patience while approaching the patient (Borbasi et al., 2011).
Another thing to address is the environment in which bathing or dressing is taking place. This can be bettered by making the room warm and attractive, providing adequate light and playing soft music in the background to get a calming and relaxing environment (Fallon, et al., 2006).
Conclusion
Dementia has become an increasingly common health problem that healthcare providers have to deal with in Residential Aged Care Facilities (RACFs). Patients of dementia have problems ranging from lack of attention, ability to tackle problems, language, ability to concentrate, ability to recall, think and behavior among others which become obstacles to living a normal social life. This is made worse by other medical and psychiatric conditions associated with dementia such schizophrenia, anxiety disorders, bipolar affective disorder and agitated depressive disorder.
However, by blending all the solutions discussed above, great improvements can be made not only by the dementia patients but the entire constitution of RACFs. In turn, the medical world will be monumentally bettered thus making the world a much better place than it is now.
Reference List
Barnes, L., Price, K., & Ramadge, J. (2004). Decision making tool: Responding to issues of restraint in aged care. Web.
Barrat, J. (2004). Editorial: Nutrition and Older People with Dementia. Clinical gerontology, 5(4), pp. 247-251.
Bidewell, J., & Chang, E. (2011). Managing Dementia Agitation in Residential Aged Care. International journal of generiatrics, 9, pp.299-315.
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Harding, S. (2005). Managing Delirium in Older People. Journal of the royal college of nursing,19, pp.46-51.
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Hines, S., McCrow, J., Gledhill, S., & Abbey, J. (2008). Thickened Fluids for People with Dementia in Residential Aged care Facilities: A Comprehensive Systematic Review. Australia: Queensland University of Technology.
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Manthorpe, J., & Watson, R. (2002). Pooly Served? Eating and Dementia. UK: University of Hull.
Maslow, K. (2004). Dementia and Serious Coexisting Medical Conditions: A Double Whammy. Nursing clinics of North America, 16(6), pp.113-119.
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Reed, P et al. (2005). Characteristics Associated With Low Food and Fluid Intake in Long-Term Care Residents With Dementia. The gerontologist, 17(2), pp.74-81.
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Suominen, M., Kivisto, S., & Pitkala, K. (2007). The Effects of Nutrition Education on Professionals’ Practice and on the Nutrition of Aged Residents in Dementia Wards. European journal of clinical nutrition, 25(13), pp.1226-1232.
Tilly, J., & Reed, P. (2004). Evidence on Interventions to Improve Quality of Care for Residents with Dementia in Nursing and Assisted Living Facilities. UK: The Alzheimer’s Association.
Turner, S. (2005). Behavioral Symptoms of Dementia in Residential Settings: A Selective Review of Non-Pharmacological Interventions. Aging and mental health, 11, pp.93-104.
Vink, A., Birks, J., Bruinsma, S., & Scholten, R. (2003). Music Therapy for People with Dementia. Cochrane database of systematic reviews, 12(3), pp.20-31.
Wilkes, L et al. (2005). Environmental Approach to Reducing Agitation in Older Persons with Dementia in a Nursing Home. Australasian journal on nursing older people, 11(3), pp.31-35.
Wotton, K., & Crannitch, K. (2008). Prevalence, Risk Factors and Strtegies to Prevent Dehydration in Older Adults. Contemporary nurse, 43(16), pp.214-217.
Care planning is a legal process that ensures the continuity of care (Chinn & Kramer 2008). According to Aggleton and Chalmers (2010), care planning portrays the care delivery pathway in a systematic and logical manner. This method facilitates collaboration among health professionals, patients and families during the decision-making processes (Ratheet et al. 2015). Patients assume an active role in the development of care plans based on the subjective identification of needs and preferences (Watson 2010). As such, personalised care is essential to meet the distinctive requirements of each patient.
The stages of the Care Planning Process
The process of developing a care plan follows a definitive cycle of four components: assessment, care planning, implementation and evaluation (Dwamena et al. 2012). According to Ratheet et al. (2015), each of the four steps mandates the health and social care professionals to provide holistic care. Although each stage requires the application of different skills, none of them supersedes the other (Fullbrook 2007). Dwamena et al. (2012) have argued that the four components provide unique contributions to the care planning procedure. According to Chinn and Kramer (2008), the failure to address the requirements of each phase undermines the quality of care.
The care planning process begins with the assessment of the client’s needs and preferences (Brotherton & Parker 2013). The use of various assessment tools is essential to generate an in-depth analysis of the care needs (McCormarck & McCance 2010). Efficient communication within the multidisciplinary team is of the essence during the assessment process. Ratheet et al. (2015) have also highlighted the significance of communicating adequately with the patients and their relations. The sources of information include non-verbal observations, written records and verbal communication (Dwamena et al. 2012).
The second phase entails setting short and long-term goals based on the findings from the initial evaluation (Aggleton & Chalmers 2010). McCormarck and McCance (2010) have indicated that practitioners should collaborate appropriately to formulate feasible goals. For example, a caregiver cannot design a care plan for a diabetic patient before conducting a rigorous assessment of needs (Brotherton & Parker 2013). In addition, the monitoring of vital signs requires the continuous collection of accurate baseline data. This information helps the health care provider to determine deteriorations in a timely manner (Chinn & Kramer 2008).
The third stage of the process entails the implementation of the interventions. This phase involves monitoring the patient’s progress to ascertain if the selected therapies are effectual (Dwamena et al. 2012). The assessment of needs is a critical aspect in each of the four stages. The appraisal of these phases provides feedback about the performance of the interventions (Brotherton & Parker 2013). Evaluation constitutes the final step of this procedure, and it determines whether the decisions taken during assessment, planning and implementation were practical (Aggleton & Chalmers 2010).
Nursing Care Models and Approaches
Patient-centred care (PCC) assumes a holistic approach, which views individuals as composed of the body, spirit and soul (Watson 2010). As such, PCC moves beyond meeting the patient’s immediate needs to addressing their social, spiritual, emotional and psychological needs (Watson 2008). The application of PCC in mental health care requires health professionals to value and respect individuals regardless of their limitations (Brotherton & Parker 2013). PCC also incorporates the patients’ family members and friends in the care planning process (Aggleton & Chalmers 2010).
Although PCC is crucial in the development of the care plan, a myriad of challenges undermines its implementation and promotion. First, it is difficult to implement the PCC in the absence of family members or advocates. This situation is particularly problematic when the client does not have a family (Dwamena et al. 2012). In addition, PCC emphasises the issue of quality but fails to provide evidence-based guidelines to realize this objective (Chinn & Kramer 2008). McCormack and McCance (2010) have indicated that the lack of conclusive evidence regarding the PCC philosophy is hindering the implementation of this model.
Secondly, the participation of patients and their families in the care planning process can be either non-existent or limited (Brotherton & Parker 2013). Aggleton and Chalmers (2010) have noted that the inferior position of family members or patients in care planning prevents them from participating actively in the care planning process. Other health and social care providers may perceive a debilitating condition as preclusion to meaningful participation (Dwamena et al 2012). On the other hand, Ratheet et al. (2015) have found out that most people are not aware of the need to take part in the care planning processes.
The Orem’s self-care model of nursing supports patient-centred care because it considers the biological, social and psychological needs of a patient during the treatment process (Simmons 2009). The Orem’s approach is similar to the Watson’s theory of caring, which mandates health professionals to provide holistic care (Watson 2010). The difference between these approaches is that the Watson’s perceptive focuses on therapeutic relationships between patients and their caregivers (Watson 2008).
By contrast, the Orem’s model mandates nurses to assist patients to meet their self-care needs (Simmons 2009). On the other hand, care providers use the Roper-Logan-Tierney model to assess the effect of an illness or hospital admission on a patient’s life. The primary goal of the Roper-Logan-Tierney model is to enable an individual to gain maximum independence (Aggleton & Chalmers 2010).
Legislation and Social Policy
The provision of patient-centred care brings to the fore ethical and legal implications. One of the principal issues in the care planning process is the concept of informed consent (Dimond 2007). The point of argument is that patients with severe mental disorders cannot take part in the development of care plans (Probst 2009). For instance, most patients suffering from dementia or other mental limitations lack the cognitive capacity to provide the consent (Kilbourne et al. 2008). On the contrary, case managers, caregivers or family members make unilateral decisions on the behalf of these individuals (Probst 2009).
Despite the previous challenges, every individual has the right to make autonomous decisions. The Mental Capacity Act (MCA) contains provisions that protect people with mental limitations (Alonzi, Shear & Bateman 2009). The Mental Capacity Act (MCA) allows patients to make specific decisions even if they suffer from dementia, stroke, brain injury, learning disabilities and any other debilitating conditions (Bisson et al. 2009). According to Boyle (2008), it is essential to conduct a mental capacity assessment before judging the ability of these individuals to make independent decisions.
Patients with mental limitations may require third parties to provide informed consent (Dimond 2007). The Mental Capacity Act allows people to appoint the people who will act as their representatives when they become incapacitated in the future (Donnelly 2009). On the other hand, MCA necessitates the appointment of independent advocates with no affiliation with the NHS or social services (Bisson et al. 2009). The Human Rights Act is another UK legislation that requires health and social care workers to provide treatment while at the same time protecting the patients’ human rights (Alonzi, Sheard & Bateman 2009).
The persisting inequalities in the health and social care services are undermining the delivery of patient-centred care (Hoffman 2011). The main problem is that people from ethnic and racial minority groups do not receive optimal care because of language barriers and cultural differences (Saha, Beach & Cooper 2008). The Equality Act has mandated the NHS to reduce inequalities and eliminate discrimination by providing culturally sensitive care. The Equality Act supports these efforts by protecting individuals against discrimination because of their age, sex, race, disability or gender and other attributes (Bisson et al. 2009).
Care Planning and Dementia Flow Chart
The care pathway for patients with dementia begins when the patient arrives at the emergency department. The first step entails assessing the needs of the patient by communicating with them and their caregivers (Probst 2009). Probst has argued that all patients should have an equal access to the assessment procedure. The staff should use translation and interpreting services when handling patients from diverse cultures.
The knowledge about the Mental Health Act, the Mental Capacity Act and the human Rights Act is vital to facilitate decision-making processes. The involvement of other professionals is also essential during the assessment process to produce conclusive results (Mughal 2014).
The assessment process continues after the admission of the patient to the ward. The purpose of these activities is to prevent the exacerbation of symptoms. According to Dwamena et al. (2012), effective communication and collaboration with other professionals, caregivers, family members and friends improve clinical outcomes.
The development of the nursing plan during admission should emphasize patient comfort and safety (Ratheet et al. 2015). The most critical issues to consider include nutrition, physical activity and personal hygiene (Kilbourne et al., 2008). Communication and feedback are also fundamental aspects that professionals should incorporate into the assessment of needs and interventions (Probst 2009).
The final step of the care pathway involves the development of a discharge plan. This plan should include the patient’s preferences and needs, as well as procure community-based services (Bisson et al. 2009). The practitioner should also assess the emotional, psychological or social needs to facilitate the rehabilitation process. The evaluation of these needs helps the health and social care providers to refer the patient to appropriate services within the community. Community-based care facilitates the delivery of referral care, evaluation and assessment (Chinn & Kramer 2008).
Another crucial component of the discharge plan involves the formulation of strategies that will support the patient to live independently (Kilbourne et al. 2008). The majority of people suffering from dementia and other mental disorders often live in communities (Bisson et al. 2009). Probst (2009) has indicated that the multidisciplinary team provides support to patients and their caregivers.
Collaboration is particularly crucial since the Community Care Act requires the provision of mental and physical health services within the community (Boyle 2008). These services include social work and nursing interventions, supported accommodation, day centres and home care (Donnelly 2009). The goal of these strategies is to empower caregivers and families members (Bisson et al. 2009).
Conclusion
Care planning has increasingly become an integral component in the delivery of health and social care. The care planning process entails four aspects: assessment, planning, implementation and evaluation. One of the fundamental issues in care planning is the patient-centred care (PCC). The essence of PCC is to involve patients, as well as their caregivers and families in the decision-making processes.
Another aspect of PCC is the inclusion of the multidisciplinary team in the care process. The combination of these factors is essential in dementia care because of the debilitating symptoms of this condition. Thus, the development of patient-centred care will continue to assume a forefront position in health and social care.
References
Aggleton, P & Chalmers, H 2010, Nursing models and nursing practice, Macmillan: New York.
Alonzi, A, Sheard, J & Bateman, M 2009, ‘Assessing staff needs for guidance on the Mental Capacity Act 2005’, Nursing Times, vol. 105, pp. 24-27.
Bisson, JI, Hampton, V, Rosser, A & Holm, S 2009, ‘Developing a care pathway for advance decisions and powers of attorney: qualitative study’, British Journal of Psychiatry, vol. 194, pp. 55-61.
Boyle, G 2008, ‘The Mental Capacity Act 2005: promoting the citizenship of people with dementia’? Health and Social Care in the Community, vol. 16, no. 5, pp. 529-537.
Brotherton G & Parker S 2013, Your foundation in health and social care, 2nd edn, Sage: London.
Chinn, P & Kramer, M 2008, Integrated theory and knowledge development in nursing, Mosby-Elsevier: St. Louis.
Dimond, B 2007, ‘Mental capacity and decision-making: defining capacity’, British Journal of Nursing, vol. 16, no. 18, pp. 1138-1139.
Donnelly, M 2009, ‘Best interests, patient participation and the Mental Capacity Act 2005’, Medical Law Review, vol. 17, pp. 1-29.
Dwamena, F, Holmes-Rovner, M, Gaulden, CM, Jorgenson, S, Sadigh, G, Sikorskii, A, Lewin, S, Smith, RC, Coffey, J & Olumu, A 2012, ‘Interventions for providers to promote a patient-centred approach in clinical consultations’, Cochrane Database System Review, vol. 12, no, 12, CD003267.
Fullbrook, S 2007, ‘Best interests, a holistic approach: part 2(b)’, British Journal of Nursing, vol. 16, no. 12, pp. 746-747.
Hoffman, NA 2011, ‘The requirements for culturally and linguistically appropriate services in health care’, Journal of Nursing Law, vol. 14, no. 2, pp. 49-57.
Kilbourne, A M, Post, EP, Nossek, A, Drill, L, Cooley, S & Bauer, MS 2008, ‘Improving medical and psychiatric outcomes among individuals with bipolar disorder: a randomized controlled trial’, Psychiatric Services, vol. 59, no. 7, pp. 760–768.
McCormack, B & McCance, T 2010, Person-centred nursing: theory, models and methods, Blackwell Publishing: Oxford, UK.
Mughal AF 2014, ‘Understanding and using the Mental Capacity Act’, Nursing Times, vol. 110, no. 21, pp. 16-18.
Probst, B 2009, ‘Contextual meanings of the strengths perspective for social work practice in mental health’, Families in Society, vol. 90, no. 2, pp. 162-166.
Ratheet, C, Williams, ES, McCaughey, D & Ishqaidef G 2015, ‘Patient perceptions of patient-centred care: empirical test of a theoretical model’, Health Expectations, vol. 18, no. 2, pp. 199-209.
Saha, S, Beach, MC & Cooper, LA 2008, ‘Patient centeredness, cultural competence and healthcare quality’, Journal of National Medical Association, vol. 100, no. 11, pp. 1275-1285.
Simmons, L 2009, ‘Dorthea Orem’s self care theory as related to nursing practice in hemodialysis’, Nephrology Nursing Journal, vol. 36, no. 4, pp. 419-421.
Watson, J 2008, ‘Social justice and human caring: a model of caring sciences as a hopeful paradigm for moral justice for humanity’, Creative Nursing, vol.14, no. 2, pp. 54-61.
Watson, J 2010, ‘Caring science and the next decade of holistic healing: transforming self and system from the inside out’, Beginnings, vol. 30, no. 2, pp. 14-16.
Dementia, one of the fastest-growing mental health-related diseases around the globe, has been increasing in the UAE for the last fifteen years, which has influenced the business idea of dementia bracelets for elderly people. People with dementia suffer from memory loss and require close attention since they also tend to have multiple bodily sicknesses complicating the dementia situation. Considering all the facts, it can be said that close monitoring of such patients will help them improve their physical health, secure their nutrition, and reduce the risks of contamination and restlessness. The actual problem lies within the monitoring system of the patient, as it would be impossible to perform monitoring all the time. Another challenging task is to keep people with dementia under control. Additionally, hospitalisation of the patient has significant adverse effects on the individual. Thus, the best way is to ensure appropriate health care for the patient at home (Phelan et al., 2012). The research of the situation has opened an opportunity to think about a product that could improve the quality of life of people with dementia in the UAE.
To solve this complex problem, my company (proposed) has developed an innovative product idea. The firm plans to produce an elderly kit bracelet that should be worn on the patient’s hand. The bracelet will be connected to a cloud system which will do the task of monitoring. With the help of a specialised application (mobile and PC), caregivers (family members, nurses, and healthcare service providing organisations) will be able to monitor the patient effectively. The bracelet will send emergency signals when the patient is at risk to caregivers who are supposed to look after the patient. It is believed that the product will help ensure better care for people with dementia in the UAE.
Business overview
The proposed business has the potential to ease the suffering of thousands of elderly in the UAE. Additionally, rapid technological development around the world is making life easier than before, and as an outcome of this trend, people rely more on electronic devices. The idea involves clever integration of information technology and a physical product; however, a proper strategy is required for the success of the business.
Vision: The vision of the company is attaining superiority in providing technical support to people with dementia across the globe.
Mission: The mission of the firm is to produce a superior-quality dementia kit bracelet for assisting in the monitoring of people with dementia and sell them in the UAE market.
In order to achieve the mission successfully, the company must ensure effective integration of the following policies:
an efficient production system;
well-organised marketing plans;
proper financial plan;
logistics management.
Production system
The dementia kit bracelet will require an automated production facility where physical bracelets will be produced. Moulded plastics, bonded materials, and copper will be the main raw materials for manufacturing the bracelet kit; a network device and GPS trackers will be outsourced from a third party mobile IC producer in South Korea. A risk sensor will be produced by a group of software engineers who will work in the technical team of the firm. For product development, prototyping, and testing, a dedicated research and development facility will be installed.
Marketing plan
Although the product will have countless advantages for people with dementia and their caregivers (family members and nurses), it is currently unknown to its potential buyers. There are 9 million people in the UAE; it is assumed that around 2% of the population are suffering from the disease, which means the number of potential customers for the product will be around 180,000 (The official portal of the UAE Government 2017). Moreover, the number of patients is increasing at a significant rate, which is positive for the business. To sell the bracelet to all those people, it is required to convince patients’ families. Since the product is made for people with dementia, the niche marketing strategy would be the most appropriate. It is found that product awareness is one of the most important tools of marketing, generating purchase intention among customers. Business managers should put their effort not only in enhancing the product quality but also in increasing brand awareness among the target customers as a strong positive relationship is found between awareness and buying intention of people (Malik et al. 2013).
Employing this idea can be the most effective way of generating sales of the specific dementia bracelet. In order to increase awareness of family members of people with dementia about the benefits of the kit bracelet, a clear demonstration will be required. The first step to the marketing approach will be collecting the information concerning family members of people with dementia from different hospitals and healthcare providing institutions in the UAE. The second task will be to inform all these potential buyers about the advantages of the product. Simultaneously, a digital marketing campaign (video, email, and healthcare blog) will be initiated. After that, a telemarketing campaign will be needed to push the sales of the bracelets. Another important tool of the marketing program will be CSR activities: the company will take initiatives to donate bracelets to some people with dementia. It is found that CSR is a cost-effective and influential form of marketing, which increases the profitability of a firm and acts as a signal of product quality (Servaes and Tamayo 2013). Furthermore, a B2B marketing approach will be considered to establish a profitable venture with different healthcare centres in the country.
The implementation of the marketing plan is likely to have a significant impact on the sales of the bracelet during the first year of operation. The company is expected to capture around 25% market share in the first year, another 35% will be covered in the next year, and 25% – in the third year of operation. In the third year, the company plans to come up with a new marketable healthcare device for people with dementia in the UAE and to expand the bracelet business internationally. The international expansion will increase the sales by 35000 additional units of bracelets approximately during that year.
Finance
The financing of the firm will follow a leveraged approach. It is estimated that the initial facility establishment will cost around $13 million. To finance the amount, $8 million will be collected from the shareholders, and the rest of the $5 million will be funded with long-term debt. The expected cost of equity is 15%; the cost will be 10% for the long-term debt. Therefore, it can be estimated that the cost of capital for the company will be 13%. Further analysis of the project’s expected financial situation is shown in the financial section of this report that explains how the project will add value to the assets of investors.
Logistics Management
Management of product distribution and raw materials will be problematic and costly for the company. To avoid the problems, the collection of raw materials and distribution of products will be managed through a third-party logistics support provider (3PL) company. Using 3PL will reduce the logistics cost substantially, making the delivery system efficient and secure.
Market Opportunity
The market is completely new for the intended products, which will create a first-mover advantage and offer some lucrative opportunities to grab. The actual market size of the product is expected to be around 40 million annually in the UAE. A survey was conducted to see the marketability of the product, which was conveying a green signal. A significant number (86.9%) of respondents showed a positive attitude towards the product. A positive perception of health care professionals is also observed from the study. In contrast to that, a significant number of the medical organisations didn’t show their interest in the product, which probably happened due to their lack of knowledge. This threat can be turned into an opportunity through a product awareness campaign. In their study, Torres and Kunc (2016) found that direct marketing approaches help CEO’s comprehend the best marketing practices and recognise the best supply channel. Another important opportunity revealed by the research is the market growth potential. It is found that the number of patients with dementia in the UAE is increasing at a notable rate. Also, the customers are realising the need of having a quality technical product to solve the monitoring problem of people with dementia due to the high cost of employing a nurse to do the same task. Satisfying this acute need for a mechanical monitoring device for people with dementia at a lower cost than nursing care appears to be a real option with substantial economic worth.
Industry Analysis
Analysis of the industry involves both the external and the internal analysis. Without assessing the macro-environmental factors related to a bracelet business, it would become quite impossible to manage the business efficiently. To illustrate the significance of the external environment, especially in the context of innovation, Baranenko et al. (2014) concluded that the external environment governs the development of innovative capabilities of modern production-based firms. They also mentioned that needs, possibilities, and alternatives are the key variables that regulate the external environment of a business. The proposed business idea is developed considering the needs of an alternative product for people with dementia as well as the future possibilities of the industry. Therefore, the external environment of the business will be crucial to the success of the firm.
External Analysis
The external factors that have a significant impact on the business operation are political, economic, environmental, social, technological, and legal issues. The political condition of the UAE is stable and supportive of establishing a technical products manufacturing firm. Furthermore, there will be governmental support in establishing this type of production facility. It implies that obtaining a license for the business would be relatively easy. The economic condition of the country is a perfect match for establishing an innovation-based manufacturing firm. The economy is favourable for introducing a new health care product.
Similarly, the social condition is suggesting growth in the number of elderly people, which is exhibiting a possibility that can be explored to create new business opportunities. Technological aspects of the UAE are quite intriguing; the people like using innovative and technical products. In other words, anything made with advanced technology will be purchased and used by the majority of the population in the UAE. The proposed device and the production facilities do not pose any threat to the environment of the country, which implies that the environmental issues should not affect the business. Finally, the laws and regulations of the country do not create any barriers to starting a business. Therefore, it can be stated that the external environment of the UAE will be assisting the proposed business idea to succeed in the market.
Internal Analysis
A short summary of Porter’s Five Forces Analysis:
Barriers to Entry. There are no acts as a deterrent against new competitors. There are no high capital requirements, no limited access to the channels of distribution. High costs of licensing on products and getting patents on technology must be considered.
Supplier Power. The suppliers will not affect business performance influencing the quality and price of the final product since the variety of suppliers is big enough to change a supplier if necessary.
The Threat of Substitutes. There can be substitutes such as computerised small medical stations and robots or other types of remote control systems.
Buyer Power. The power of buyers is high enough to allow such purchases of home health care products. The goal is to set a comfortable price for the product. However, buyers can demand lower prices, higher quality, or additional services, or search for substitutes available for the product.
The Degree of Rivalry. The degree of competition among existing firms is low now but will constantly get higher; the company will minimise the competitors’ influence in 5 years.
Value Chain
A system of inter-reliant actions often generates trade-offs that must be settled with an appropriate strategy to gain a competitive advantage (Porter and Millar 1985). A strong value chain system would make the firm capable of offering the best value propositions to its customers. The value chain is a conventional framework to plan the value-creating activities within a firm (Johnson et al., 2014). The company plans to create value through efficient management of inbound logistics, operations, outbound logistics, marketing and sales, and after-sales support. Also, the firm will continuously improve its infrastructure, human resources, and procurement policy to ensure an efficient value chain.
The bracelet will be produced in the established production facilities, where most of the production functions will be automated. The only thing that the production process will require is the proper input of required raw materials, which will be managed with a hybrid operations management strategy. A certain amount of raw materials will be held in a warehouse facility to avoid production inconsistency, while the suppliers will replenish the stock through an electronic reordering system. Once the bracelet is made, it shall be carried to the IT facility where the network device will be installed. Simultaneously, a group of software engineers will work on the development of the application that will keep track of the device and report data to the person who is monitoring it. Once the device is ready to get connected to the network, it will be sent for testing and quality checking. Each product will be tested before packing for the final delivery. The packaged product will be delivered to the customers through a predetermined third-party logistics provider. In addition to that, a dedicated support team will help the customers with after sales support services to ensure superior utility from the product.
Value Proposition
The package of utilities that are offered to the customers and can include but are not limited to performance, design, customisation, handiness, and price is considered as the value proposition of a firm (Osterwalder and Pigneur 2010.). The customer’s psychology about the received value in return for their payment for the particular product is the perceived value (Zeithaml 1988). The value proposition is the core source of competitive advantage for this business project as it will offer a unique value for people with dementia – the primary user of the product. Among the utilisable apparatuses of a marketer, the value proposition is considered to be the best (Hudadoff 2009). The business will focus on establishing a proper value chain system that would help it to offer such a value proposition to its customer, which attains maximum customer satisfaction. The following bundle would be offered to the customer of the dementia kit bracelet to create a competitive advantage in the market:
Improved life for people with dementia through active tracking.
A permanent solution to the tension for the caregivers of patients.
The kit is inconspicuous and indispensable.
Technology for the health of people with dementia.
Superior and error-free after-sales services.
Financial Plan
The initial production facility will require a good amount of investment to initiate the production process of the bracelet. According to the marketing plan, the company should have a capacity of 100,000 finished bracelets in a year to meet the demands generated by the promotional teams. To ensure such productivity, the company must produce 300 finished bracelets per day, which would be a challenging task for the firm. The production facility will require four sets of machinery which will cost around $800,000 per set. Each set of machinery will have a capacity to produce 100 finished bracelets every day. In order to reduce the investment risk, the firm will purchase 10,000 square feet of land in the business bay at the rate of $603 per square foot. The land will be used as collateral to generate $5 million in debt financing from the bank. The development of factories and buildings will require around $3 million. The working capital requirement for the project is estimated at 10% of the expected annual sales, which will be around $2.3 million. To sum it up, the initial layout for the project will be around $12.5 million.
Particulars
Amount
Machinery
3,200,000
Lands
6,030,000
Working Capital
3,000,000
Licenses and Patents
300,000
Total Outflow
12,530,000
Table 3: Initial Outflow.
The following balance sheet will provide a clear view of the financial position of the firm at the beginning of the operation. Approximately 80,000 shares of $100 will be offered to private investors. The debt amount will reduce the financing cost as well as the risk of loss. The loan will increase the value of the share to $162.5 even before the firm’s operation start. Although the debt will reduce the earnings, it would provide the firm with a leveraged benefit for boosting the shareholders’ earnings.
Assets
Amount
Liabilities and Owners equity
Amount
Machinery
3,200,000
Stockholders’ equity
8,000,000
Lands
6,030,000
Long term loans
5,000,000
Working Capital
3,000,000
Licenses and Patents
300,000
Bank Balance
470,000
13,000,000
13,000,000
Table 5: Balance Sheet.
The expected cash inflows of the business are calculated under a set of assumptions. The cost of the bracelet is assumed to be $225 with a direct maintenance cost of $25 (DM $75, DL $110, MOH $45). The sales revenue of the bracelet will be $500 in the first year, $450 in the second year, and $420 in the third year. Also, the buyer is required to pay a $100 subscription fee for the cloud-based monitoring service, which will generate more revenue for the firm. The machinery will be depreciated in 8 years with no salvage value; the firm will follow the straight-line depreciation method. The firm will pay a flat 25% tax on its income from the second year; interest payment will be 10% per year on the book value of the loan.
The company will pay a yearly wage of $1 million and a salary of $2.2 million to its software engineers and technical teams. Another $500,000 will be the management salaries. Fuel and other overhead expenses will be around $25 and $20 per unit subsequently. According to the marketing plan, there will be around 180000 total people with dementia; the company will sell the products to these patients’ families. The selling quantity will be 45000 in year 1, 63000 in year 2, and 80000 in the third year. The selling and marketing budget will be $8 per unit of product. Under the above-mentioned assumption, the projected financial scenarios are presented in the following Table 6.
Particulars
Year 1
Year 2
Year 3
Sales Revenue
$22,500,000
$28,350,000
$33,600,000
Subscription revenue
$4,500,000
$10,800,000
Gross Revenue
$22,500,000
$32,850,000
$44,400,000
COGS
$11,250,000
$15,750,000
$20,000,000
Service cost
$1,125,000
$2,700,000
Gross Profit
$11,250,000
$15,975,000
$21,700,000
Selling & Administrative Expenses
Fuel cost
$1,125,000
$1,575,000
$2,000,000
Other overhead
$900,000
$1,260,000
$1,600,000
Salaries & Wages
$3,700,000
$3,700,000
$3,700,000
Selling & Marketing Expense
$360,000
$504,000
$640,000
Depreciation
$400,000
$400,000
$400,000
Total Selling & Admin Expense
$6,485,000
$7,439,000
$8,340,000
Earningsbefore interest and taxes (EBIT)
$4,765,000
$8,536,000
$13,360,000
Interest Expense
$500,000
$500,000
$500,000
Earning before tax (EBT)
$4,265,000
$8,036,000
$12,860,000
Tax (25%)
$1,066,250
$2,009,000
$3,215,000
Earning after tax
$3,198,750
$6,027,000
$9,645,000
EPS
$59.56
$106.70
$167.00
Table 6: Forecasted Income Statement.
Using the projected free cash flow, we can calculate the net present value of the project. We will get a positive NPV of $1,385,942; the internal rate of return will be 21.14%, which is more than the financing cost of 15%. In other words, the project will add significant value to the shareholder’s investments.
Risk Management
Management of the project risk involves finding the threats associated with the investment, examining the probable impact of the threats, and planning to minimise the risks. The strategic plan of a firm must incorporate a dynamic risk management policy (Di Serio et al., 2011). Start-up companies are usually exposed to a high level of uncertainty, which cannot be measured beforehand (Sommer et al., 2009). The future performance of a business depends on the efficient utilisation of uncertainty supervision tools. The bracelet producing company can face a number of threats raised from its internal and external environment.
Risk factors
The proposed firm can expect to experience a number of threats due to the inconsistency in its core functions, namely, operations, marketing, financial, and logistics management. Risks from operations may evolve from ineffective management of human resources, unplanned production schedule, inefficient hiring of IT personnel, poor quality control tools, and unsystematic monitoring of functions. These operational threats can have a seriously bad impact on the product quality, which will plunge the sales, and therefore, the value of the firm. Also, a proper contingency plan is to be developed for avoiding emergency situations, i.e. an increase in the price of raw materials, fuel, and others.
Similarly, an improper marketing strategy can create an opportunity for new entrants in the market, which will increase the market competition. As a result, the firm will lose market shares and will fail to meet the projected sales of the bracelets. Hence, the marketing plan should create a barrier to entry for its forthcoming rivals.
Financial risks are the most significant type of threat for an organisation, which is puffed up in the case of a start-up company. The company can face the threat of liquidation from weak working capital management. Also, inefficient use of the firm’s financial assets will result in a plunge in profitability, and unplanned financing will bring a lower value of the investment. Therefore, a proper capital and financial management policy will be applied to the business.
The logistics system can either create a threat of delayed production or delay the delivery of products; both will result in a poor customer experience which is a heavy threat to the brand value of a start-up firm. To avoid this particular threat, a warehouse will be used to store a contingent amount of raw material. Also, stock of finished products shall be kept to meet emergency situations.
SWOT Analysis
Understanding all the aspects that could either enhance the performance of a business or pose a threat to the success of the business is substantial. Both the internal and external elements of a business can have positive or negative impacts on its performance. The most widely used tool for identifying the external and internal elements that have an impact is the SWOT analysis.
Table 7: The SWOT analysis of the business.
SWOT analysis not only helps to identify different elements but also assists with strategic planning and managing the associated risks resourcefully. Overall, the value creation process is the strongest internal asset that enables the firm to offer a set of unique value propositions to its customers. Although some external threats seem to be uncontrollable, they can be managed sufficiently by exercising different opportunities and managerial options.
The Project Plan and Implementation
Most of the academic authors accentuate the implementation of the project’s implementation planning. A unique business idea with adequate resources has often failed to monetise the market opportunity due to poorly designed business structures. The proposed business plan is a well-structured business idea that has been modified in different stages of the project until it reached its best version.
Figure 3: Gantt chart.Table 8: Milestones.
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