532 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERS
Evaluation
Treatment outcomes change constantly as the dis-
ease progresses. For example in the early stage of de-
mentia, maintaining independence may mean that
the client dresses with minimal assistance. Later the
same client may keep some independence by select-
ing what foods to eat. In the late stage, the client may
maintain independence by wearing his or her own
clothing rather than an institutional nightgown or
pajamas.
The nurse must assess clients for changes as
they occur and revise outcomes and interventions as
needed. When a client is cared for at home, this in-
cludes providing ongoing education to family mem-
bers and caregivers while supporting them as the
client’s condition worsens. See the sections below on
the role of the caregiver and community-based care.
COMMUNITY-BASED CARE
At least half of all nursing home residents have
Alzheimer’s disease or some other illness that causes
dementia. In addition, for every person with demen-
tia in a nursing home, two or three with similar im-
pairments are receiving care in the community by
some combination of family members, friends, and
paid caregivers.
Programs and services for clients with dementia
and their families have increased with the growing
awareness of Alzheimer’s disease, the increasing
numbers of older adults in the United States, and the
fund-raising efforts for education by noted figures
(e.g., the family of former president Ronald Reagan).
Home care is available through home health agen-
cies, public health, and visiting nurses. These ser-
vices offer assistance with bathing, food preparation,
and transportation, and other support. Periodic nurs-
ing assessment ensures that the level of care pro-
vided is appropriate to the client’s current needs.
Adult day care centers provide supervision,
meals, support, and recreational activities in a group
setting. Clients may attend the center a few hours a
week or full-time on weekdays if needed. Respite care
offers in-home supervision for clients so that family
members or caregivers can run errands or have social
time of their own.
Residential facilities are available for clients
who do not have in-home caregivers or whose needs
have progressed beyond the care that could be pro-
vided at home. These clients usually require assis-
tance with ADLs, such as eating and taking med-
ications. Clients in a residential facility are often
referred for skilled nursing home placement as de-
mentia progresses.
The physician, nurse, or family can initiate re-
ferrals for community-based services. Families can
contact the local public health department or the de-
partment of human or social services listed in the
phone book. If the client has been admitted to the
hospital, social services also can assist in making an
appropriate referral.MENTAL HEALTH PROMOTION
Research continues to identify risk factors for demen-
tia. Sheshadri et al. (2002) have found that people
with elevated levels of plasma homocysteine are at
increased risk for dementia. Their study showed that
as levels of plasma homocysteine increased, so did
the risk for dementia. Because folate, vitamin B 12 ,
and betaine are known to reduce plasma homocys-
teine levels, potential therapeutic strategies using
these substances may modify or diminish the risk
for dementia (Loscalzo, 2002). Clinical trials currently
are in progress to see if lowering homocysteine levels
actually decreases the risk for dementia and whether
or not high supplemental doses of B vitamins will
slow the progression of Alzheimer’s disease.
Seshadri et al. also found that people who regu-
larly participate in brain-stimulating activities, such
as reading books and newspapers or doing crossword
puzzles, were 47% less likely to develop Alzheimer’s
disease than those who did not. The study also re-
ports that physical activity was not found to be as-
sociated with reduced risk.ROLE OF THE CAREGIVER
Most family caregivers are women (72%) who are
eitheradult daughters (29%) or wives (23%) of clients
with cognitive disorders. Husbands account for 13%
of all caregivers. The trend toward caring for family
members with dementia at home is largely the result
of the high costs of institutional care, dissatisfaction
with institutional care, and difficulty locating suit-
able placements for clients with behaviors that are
sometimes disruptive and difficult to manage (Small,
2000). Family members identify many other reasons
for becoming primary caregivers including the desire
to reciprocate for past assistance, to provide love and
affection, to uphold family values or loyalty, to meet
duty or obligation, and to avoid feelings of guilt.
Caregivers need to know about dementia and
the required client care as well as how client care will
change as the disease progresses. Caregivers also
may be dealing with other family members who may
or may not be supportive or who may have differing
expectations. Many caregivers have other demands
on their time such as their own families, careers, and
personal lives. Caregivers must deal with their feel-
ings of loss and grief as the health of their loved ones
continually declines (Lo & Brown, 2000).