This study was about how dementia which took place in Neatherlands on year 2007 and it showed the importance of beliefs and the knowledge deficit as well as the assessment that configures the nursing practice in terms of their deliverance of care among the elderly who suffers pain in such condition. As far as the study is concern, it would establish a more thorough practice that would facilitate the nursing field on how it would develop its system of care to this dealt issue that still needs to be run through by clinical experts for the betterment of care.


[quote]“ In a busy family practice, finding the time and energy necessary to care for older patients with dementia will be an ongoing challenge. Family physicians, and specialists, must be given the tools to manage these patients expertly and humanely. (1)

Caregivers should also be informed of the local home care program, since it may be able to provide information on available community resources, provide anticipatory guidance, assist with personal care when the need arises and look at the need for respite services. The pharmacotherapy of Alzheimer disease can decrease caregiver burden and the time required of caregivers to support the patient. Providing education, counselling, support and respite to caregivers can benefit both them and the patient.(2)

1.what can you contribute in the developement of nursing care among dementia patients who suffers in pain?
2.how will you consider assessment of pain among dementia patients?
3.What are some factors that will guide nursing practice in the development of assessment scale of pain among the elderly patient with dementia?

REFERENCES:

1.Allen M, Ferrier S, Sargeant J, et al. Alzheimer disease and other dementias: an organizational approach to identifying and addressing practices and learning needs of family physicians. Educ Gerontol 2005;31:521-39.
2.Pinquart M, Sörensen S. Helping caregivers of persons with dementia: Which interventions work and how large are their effects? Int Psychogeriatr 2006;18:577-95. [PubMed]

The topic with which this study touches is a very broad subject where no one has ever even dared to touch or study in more depth.
Nursing care, can only give much to a dementia patient but the palliative measures with which our profession is greatly known for. A study conducted by Hebert et al (2006) stated that “while it is important to note that caregivers are unique individuals with their own set of needs who are not mere extensions of the patient, we do believe that caregiver well-being is intricately related to their loved one's suffering. Although we suggest that caregiver well-being can be improved by interventions that relieve patient suffering, there remain unanswered questions.” [1] In my opinion, genuine empathy with which nurses are widely known for are the only genuine care we could offer to horribly suffering dementia patient. Doing the only thing we do at a higher standard and a consistent manner can never beat any other palliative intervention that science can offer. As was written in a study conducted by Sampson et al. (2008), “It could be argued that much of what comprises this intervention is just good quality care and should be part of routine clinical practice; it is too much like what professionals believe they "do already". Naturally, some elements of the intervention will occur in usual care, although all the evidence published to date suggests that it is rarely carried out in a consistent manner. Furthermore, this sort of concern hardly ever interferes with a careful, controlled evaluation. In addition to evaluating the intervention itself, we will also assess its implementation in terms of change management within a complex health system.” [2]
Pain assessment in dementia may be based on objective reports and subjective reports from significant others primarily because primary subjective reports may be distorted or otherwise highly unreliable considering the condition of the patients. It is also, in this light, that I believe the establishment of an assessment scale specifically designed to be based solely on answers dementia patients is a ridiculously insane idea. The more sane line of thought in my opinion would be a combination of objective assessment data and significant other’s (more accurate will be the primary caregiver) assessment data would provide a more accurate pain assessment data. Sampson et al’s (2008) statement will further shed light on the argument, “we do not know what constitutes a good outcome in these patients with advanced dementia who are generally unable to express their needs and wishes. We will use the views of proxies which may not accurately reflect patients' wishes when they last had capacity.” [2] Should someone develop a mixed assessment criteria it would be more helpful in learning more about the quality of their pain.

1 - Randy S. Hebert, MD, MPH, Robert M. Arnold, MD, and Richard Schulz, PhD (2006), Improving Well-Being in Caregivers of Terminally Ill Patients: Making the Case for Patient Suffering as a Focus for Intervention Research, lifted from the National Institutes of Health Author Manuscripts, accessed June 22, 2009 retrieved from www.pubmedcentral.nih.gov
2 - Elizabeth L Sampson, Ingela Thuné-Boyle, Riitta Kukkastenvehmas, Louise Jones, Adrian Tookman, Michael King, and Martin R Blanchard (2008), Palliative care in advanced dementia; A mixed methods approach for the development of a complex intervention, lifted from the Bio Med Central Palliative Care, accessed June 22, 2009 retrieved from www.pubmedcentral.nih.gov

Milieu management can be use as an intervention to client suffering from cognitive disorder such as in dementia. Decreasing the stimulus around the client’s environment such as temperature regulation and lighting is a great help in alleviating their sufferings. Together with milieu therapy, Pharmacotherapy could also be utilized.

Given the fact that the client is suffering from cognitive and perceptual problems, it would be very difficult for the nurse to assess the level of pain experienced by the client. In any case, the care provider can use the process of observation so as to obtain data.
Reference:
Norman L. Keltner, Lee Hilyard Schwecke, Carol E. Bostrom, Psychiatric Nursing, (5th ed.) p.463,Singapore, Elsevier Inc.

Pain in a patient with dementia may be expressed by a change in behavior. The patient with a cognitive impairment may not be conscious of the sensation of pain which is actually causing a problem. This group of patients is a risk for under treatment for pain because of the lack of articulation ability.

The health care providers should the reporters of the non-cognitively intact resident. A health care provider would often notice increased agitation, restlessness, grimacing, crying, withdrawal from normal activities, loss of appetite, moaning, repeated verbalization, or other signs. The patient with dementia may not be capable of reporting the pain sensation, so family members who are taking care of the patient are key-persons to know if there is a change in behavior of the patient.

REFERENCE: Tabloski, P. (2006). Essentials of Gerontological Nursing. New York, Pearson Education Inc.

As dementia usually affect older people and as the number of older people is climbing, the possible conclusion is more dementia care seen in the future.
Pain management should be effective considering that a large percentage of older people, either in the community or care facilities, are affected by pain. It is a challenge to nurses and caregivers to identify subtle clues their clients may exhibit, especially if their clients can barely communicate verbally.


Stephen D.M. Smith.(2007). Assessing pain in people with dementia 1: The challenges. Retrieved June 23, 2009 from http://www.nursingtimes.net/nursing-practice-clinical-research/assessing-pain-in-people-with-dementia-1-the-challenges/197743.article

Older adults with dementia are frequently hospitalized, and a substantial minority present with pain during hospitalization. Although general pain management guidelines are available, care can prove challenging in the setting of dementia.

Chronic pain can lead to further cognitive impairment, accidents and behavioral problems which can be minimized if the pain is properly assessed and managed. Patients with dementia receive fewer analgesics than any other patient group, but the likelihood of pain in this group is as high as in other older people.

The facial expression of pain has emerged as an important pain indicator in demented patients, who have difficulties in providing self-report ratings.Moreover, facial responses were closely related to the intensity of stimulation, especially in demented patients.

References:

1.Kelley, Amy S (AS); Siegler, Eugenia L (EL); Reid, M Carrington (MC); (2008). “Pitfalls and recommendations regarding the management of acute pain among hospitalized patients with dementia.”. Retrieved June 23,2009 from http://www.find-health-articles.com/rec_pub_18565001-pitfalls-recommendations-regarding-management-acute-pain-hospitalized.htm

2.Kunz, Miriam (M); Scharmann, Siegfried (S); Hemmeter, Uli (U); Schepelmann, Karsten (K); Lautenbacher, Stefan (S); (2007). “The facial expression of pain in patients with dementia”. Retrieved June 23,2009 from http://www.find-health-articles.com/rec_pub_17949906-the-facial-expression-pain-patients-dementia.htm.

3. Cunningham, Colm (C); (2007). “Managing pain in patients with dementia in hospital”. Retrieved June 23, 2009 from http://www.find-health-articles.com/rec_pub_16898198-managing-pain-patients-dementia-hospital.htm