Identifying Dementia’s Complex Care Needs

Introduction

This summative assignment aims to develop an idea about the clinical experiences and nursing considerations that must be taken while providing holistic care to a patient in nursing practice. More specifically, the objective of this essay is to demonstrate the importance of identifying the complex care needs of a patient and providing him with necessary holistic care as per essentiality. To meet this objective, ‘dementia’ has been taken into consideration. The topic ‘complex care need’ is now becoming relevant in nursing practice due to a majority of the population is now living with chronic and multi-faceted health conditions which need early intervention.

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The term ‘complex care’ refers to the coordinated management of diseases or symptoms of an individual who is suffering from multi-faceted and interconnected physical and psychological complexities and which need intensive, and long-term medical intervention (Karam et al., 2021). For this proposed essay, the complex care needs of Dementia patients have been taken into consideration. Considering the complex care needs of dementia, it can be stated that the care approach of this specific psychological condition needs multidisciplinary approaches that encompass social, psychological, and medical intervention. According to medical research, Dementia is a progressive psychological disorder which can be characterised by constant decline of cognitive behaviour, loss of memory, and ability to manage daily activities, which can affect the patient as well as his family and caregivers (Cloak and Al Khalili, 2022). To address these complex needs, nursing intervention should include the approach to improving a patient’s quality of life by maintaining independence, valuing the dignity of the patient, and preventing the scope of further development of complexities and deterioration of health. In the UK, the National Dementia Strategy (2009) provided a structured framework for supporting people with complex care needs (Department of Health, 2009). On the other hand, the EKHUFT Dementia Care Strategy (2023-26) has been designed to place the patients living with dementia, their families and caregivers at the core of the care plan (East Kent Hospital University, 2022). Both these strategies of the UK prioritise early diagnosis, intervention, and provision of improved care coordination to meet the complex needs of dementia patients. Therefore, in this essay, the focus will be given to the complex care needs of dementia patients in relevance to policies and regulations set up by the government to meet the needs of patients in broader society. Additionally, this essay will discuss medical and nursing interventions along with a critical understanding of the complexities related to the provision of mental, cognitive, behavioural, and physical care services in integrated care settings to patients with dementia.

Discussion

Improvement of the quality of care for dementia in the UK has changed and evolved with the progress of time, driven by the advancement of technologies, medical knowledge, policy and regulation changes, and a shift towards a patient-centric and integrated care approach. By comparing historical dementia care with contemporary care practice, key changes and developments in how this complex care needs have been changed and managed can be evident, which ultimately proven as beneficial to improve the quality of life of both patients, their families, and caregivers. In 2009, the care of dementia was influenced by several perspectives and practices. For example, by 2009, dementia was recognised as a distinct disease rather than a normal disease which is related to ageing. However, the shift from this concept started in the early 20^th century with the work of German psychiatrists like Emil Kraepelin and Alois Alzheimer (Ciurea et al., 2023). Similarly, before 2000, dementia care in the UK largely followed the medical model, where the primary focus was given to the physical health aspect to meet the complex needs of such patients (Grasset et al., 2018). More specifically, during that period, the care was more task-oriented, with the priority on managing symptoms like loss of memory, episodes of care, and complexities that arise with the decline of cognitive approaches. Residential care homes were common in the UK to provide treatment to dementia patients, where the care was based on routine assistance and supervision (Grasset et al., 2018). Before 2009 the treatment approach of dementia in the UK was to mitigate the basic needs of the patient rather than providing them with holistic and integrated care by addressing the emotional, cognitive, and psychological needs of the patient. Afterwards, with the change of outlook, improvement in medical knowledge, and technological intervention, the care approach to meet the complex care needs of dementia patients started changing (alzheimers.org.uk, 2024). More specifically, this change began in the late 1990s and early 2000, when dementia started to be recognised as a medical condition as well as a social concern. In 2009, the UK Government set the National Dementia Strategy- a structured framework for providing care and treatment to people living with this cognitive illness. The National Dementia strategy, “Living well with Dementia” was published in February 2009 by the UK government, where the government has set goals for improving the awareness diagnosis process and service provision for dementia patients (Department of Health, 2009). In 2023, the UK government has set another Dementia Strategy in collaboration with NHS “EKHUFT Dementia Care Strategy, 2019”- a three-year plan to deliver high-quality, person-centred care to people who are living with formal or suspected dementia, along with the provision of support to their families, and caregivers (East Kent Hospital University, 2022). These approaches are evident that in comparison to 1990 or early 20^th century to 2009-2024, a comprehensive change has evolved in the treatment process of Dementia. Compared to the early days of medical intervention, in current times, care settings have become more person-centred, collaborative, and coordinated. Additionally, with time, the care plans for this disorder have become more individualised, where the primary focus used to give on the patient’s medical history, preferences for the treatment plan, remaining strengths and ability to design and administrate care, rather than idealising the patient’s deficits and disease symptoms. Another improvement in the quality of Dementia care in the UK can be defined by the establishment of memory clinics and dementia assessment services (Brown, Livingston and Mukadam, 2021). These clinics offer early screening and cognitive assessment to meet the diagnosis condition of dementia at an early stage, which is considered to be essential for providing on-time treatment and support and improving the overall quality of life of the patient with complex care needs. Memory clinics are comprised of staff neuropsychologists and special nurses who have the skill to conduct tests like CAT, MRI, and SPECT scans to assess memory function and cognitive function and provide detailed care to patients to support both patients with dementia and their family members (Arvanitakis, Shah and Bennett, 2019). However, despite this advancement, challenges remain in ensuring equitable access to dementia care by every individual across the country. Many researches suggest the variability in service provision for dementia care, specifically in rural areas, and discrepancies in dementia care provision (Giebel et al., 2021; Arsenault-Lapierre et al., 2023). Funding constraints within the NHS and social healthcare sector can also put pressure on the service delivery process, which as a whole impacts on quality of service and outcome of dementia care for the patient (Schlepper and Dodsworth, 2023).

The term ‘complex care need’ refers to the comprehensive health care support that an individual requires to overcome the complexities related to comorbidities or complex health challenges (Kuluski et al., 2017). According to divinehealthcaresolutions.co.uk, (2023), complex care needs refer to multifaceted and often chronic health conditions that need coordinated and continuous management, including multiple healthcare services and healthcare professionals. In the case of dementia, individuals experience a combination of complexities related to cognitive, psychological, physical and social challenges. These complexities increase the need for medical treatment, personal care, emotional support, and social engagement, which if unmet can lead the patient to further deterioration, and declined quality of life. According to Lewis et al. (2014), Dementia has a profound impact on individuals in the UK, which can affect various aspects of their lives. For example, according to research, people with dementia often experience episodes of psychological complexities regarding grief, anger, stigma, and fear, which with the progress of time can facilitate the development of anxiety, and depression. According to Alzheimers.org.uk, dementia primarily affects memory and thinking skills which leads the patient to the complexities of carrying out daily activities like cooking, managing finances, doing day-to-day work, difficulties with communication and so on (Alzheimer's society, 2019). These declines in cognitive abilities can also force people to develop a sense of insecurity, and self-isolation, and gradually lose confidence, and self-esteem which impact their sense of identity and social roles. Social effects of dementia include gradual withdrawal from social interaction due to a lack of self-worth, loss of self-identities, and episodes of confusion. As the disease progresses, individual tries to avoid social gatherings for the stigma of being negatively judged by people, and fear of embarrassment, which can exacerbate the sense of isolation, loneliness, and depression. The economic impact of dementia in the UK is also significant. According to the report, in 2021, the national cost of caring for individuals with dementia was estimated at £25 billion, which has increased to £34.7 billion in 2022, as per the estimation by the Alzheimer’s Society (Alzheimer's society, 2021). As of September 30, 2022-23, the total number of registered cases of dementia across the UK was 451,992 an increase of 1450 patient numbers from the prior year (NHS Digital, 2022). According to (NHS Digital, 2022), across the UK, Dementia and Alzheimer’s disease are considered as the leading causes of death accounting for 11,4% of all deaths. Considering this value, it can be estimated that the average annual cost of a person living with dementia in the UK is around £32,250. Therefore, it can be stated that people living with dementia used to face significant financial as well as social and psychological strain which has a direct impact on their families. According to research, dementia not only affects the individual but has also a profound impact on family members and caregivers. For example, the family members used to experience emotional toll, and stress from watching their loved one is losing cognitive abilities (Alzheimer's Society, 2022). On the other hand, care caregivers often experience a high level of anxiety and additional stress to maintain a balance between caregiving responsibilities, and their personal and professional livelihoods (Kayaalp, Page and Rospenda, 2020). Stringency to medical adherence declined cognitive abilities among dementia patients can lead to physical exhaustion among the caregivers, which negatively impacts their health and well-being.

 According to (Alzheimer's society, 2021), Dementia is a complex and progressive neurological condition that affects cognitive functions including memory, thinking ability, and behavioural approach of an individual. In the UK, currently, more than 900,000 people are living with this condition, and as per estimation, by 2025, the prevalence rate of dementia across the country might rise to one million, and by 2040, it could reach 1.6 million (Wittenberg et al., 2019). The biopsychosocial model of Dementia suggests that cognition cannot be determined only by biological, and physical health factors, rather, social, and psychological factors can have a significant impact on cognitive health and dementia-related risks. Abundant evidence exists to link health and biological factors with a higher risk of cognitive decline including genetic factors, loss of sensory ability, age, physical inactivity, and hypertension. According to a report from the Lancet Commission on dementia prevention, (Livingston et al., 2020) have identified modifiable risk factors for dementia which include physical health factors like hearing loss, hypertension, obesity and diabetes, as well as psychosocial factors including education, social isolation, and depression. According to the biopsychosocial model, the social needs of dementia refer that this disease can lead to isolation and withdrawal of individual from social activities. In this disease, patients often struggle to manage relationships, causing a loss of social identity. The stigma surrounding dementia often exacerbates this isolation as individuals are judged negatively or forced to be disconnected from the community (Brandt et al., 2022). On the other hand, the psychological needs of this model regarding dementia have significant psychological impacts, as the majority of the patients experience depression, anxiety, and apathy. The loss of cognitive ability can lead to irritability and emotional distress. Lastly, biological needs refer to the biological factors related to cognitive decline. As a whole, the biopsychosocial effects of dementia refer to the complexities of this disease care, which necessitate the intervention of a multidisciplinary approach to addressing the complex needs of a dementia patient.

Considering the complex care needs of dementia patients, it can be stated that to meet those needs a patient-centred nursing intervention is essential. In the UK, several policy frameworks provide guidelines for nursing strategies for dementia care. For example, one of the key policy principles that directly address dementia care in the UK is the Prime Minister’s Challenge on Dementia, 2020. This policy aims to improve the diagnosis process, care and support for the people living with these complex care needs while fostering the development of a dementia-friendly community (Department of Health, 2016). This policy also focuses on enhancing the quality of care by increasing awareness, promoting early detection and on-time diagnosis, and ensuring the provision of well-coordinated health and social care services for dementia. The Care Act 2014 in the UK also provides guidelines to promote the well-being and dignity of the individual who needs care and support to overcome the complexities related to dementia (Department of Health and Social Care, 2023). On the other hand, the Mental Capacity Act, of 2005 also provides a framework for people with the dimension for making an informed decision on behalf of those who lack the capacity to decide for themselves. This act covers the financial affairs, personal welfare, and property protection of the people living with declined cognition (Department of Health and Social Care, 2005). In the UK, NICE or National Institute for Health and Care Excellence provides a policy framework for nursing intervention for dementia with the recommendation of supporting people living with dementia and their families and caregivers. According to the NICE guideline (NG97) (2018), healthcare professionals should be liable for ensuring dignity, independence, and quality of care while providing medical support to patients with dementia (National Institute for Health and Care Excellence, 2018). The key recommendation of this policy includes the diagnosis of dementia on time, creating a patient-centric and integrated care plan by keeping the patient’s preferences, and needs at the centre of the plan, and ensuring regular assessment of the progression. NICE also stresses non-pharmacological intervention including cognitive stimulation therapy, by highlighting the importance of coordinated care for treatment the of dementia patients. On the other hand, the guidelines set up by the NMC or Nursing and Midwifery Council stress on the roles and responsibilities of nurses while delivering person-centred care to the dementia patient. The NMC code (2015) mandated that nurses should be legally bound to maintain compassion, professionalism, and a code of conduct while dealing with patients with declined cognitive behaviour, and should work within a multidisciplinary team while delivering holistic care (Nursing and Midwifery Council, 2018). This guideline can be aligned with the NHS Long Term Plan which focuses on improving the cognitive behavioural approaches of dementia patients through continuous professional development and providing coordinated care. The aim of the NHS Long Term Plan for dementia care is to reduce unnecessary hospital admissions, expand the community-based care approach, and improve the support for families and caregivers of dementia patients. Therefore, it can be stated that the important nursing strategy for dementia care would be person-centred care, where the nurses will prioritise the provision of individualised care by understanding the patient’s medical condition, preferences, and remaining cognitive abilities. This should be aligned with the Care Act, of 2014, and the NHS Long-term Plan for Dementia which advocate for patient-centric, and holistic approaches to dementia care (Rees et al., 2023). Additionally, Early detection and Intervention will be another key nursing strategy, where nurses will play the role of identifying early signs and symptoms of dementia and provide early diagnosis on time. The support for caregivers and interdisciplinary collaboration are two important nursing strategies through which the nurse must work collaboratively with multidisciplinary team families and caregivers of dementia patients to provide education, respite services and emotional support to both dementia patient and their families.

Therefore, working with a multi-disciplinary team is important in dementia care in the UK due to the complex and multifaceted nature of the condition. According to (Social Care Institute for Excellence, 2022), a common approach to the development of community-based multidisciplinary teams is they will be comprised of health and care professionals from different disciplines, and they will come together and coordinate to provide care to the patient. According to the biopsychosocial model, the importance of collaborative work within a multidisciplinary team is important for dementia care as in this condition, the biological, psychological, and social needs of the patient should be met. Therefore, in a multidisciplinary team, the key roles of general practitioners towards meeting the complex needs of dementia patients will be to carry out early diagnosis, determine the severity of cognitive decline, prescribe medical intervention and monitor the overall health progress of the patient. On the other hand, the role and responsibilities of nurses in MDT will be to provide daily care, and direct support to the patient by helping them manage their medication, and day-to-day activities, assisting with personal care and monitoring the symptoms, and overall progress of the patient (Mardani, Griffiths and Vaismoradi, 2020). Another role of the nurse in MDT is to educate the patient, families and caregivers about managing the declined cognitive ability and ensure the needs of the patient are being met through the provision of person-centred care principles advocated by NICE guidelines (National Institute for Health and Care Excellence, 2018). Additionally, to provide person-centred care for the cognitive decline of dementia patients, the multidisciplinary team will comprise with occupational therapists, who can help the dementia patient to maintain their independence by developing the ability to do regular activities and modifying their livelihood. Additionally, this team will include social workers, psychologists, and dietitians, whose major role or responsibility will be to work in collaboration with the patient, and families, understand the needs of the patient, and offer personalised care and therapeutic opportunities to the patient to improve cognitive behaviour, to meet dietary needs by addressing dehydration and malnutrition, and medication that can promote overall health outcome of the patient (Galvin, Valois and Zweig, 2014).

As a whole, it can be stated that nursing and healthcare staff in multi-disciplinary teams play an important role in meeting the complex needs of dementia patients, through providing individualised action, specialist referrals, community support, mental health care and specific interventions like nutritional and hydration management. Cognitive behavioural therapy is an important intervention or strategy to meet the complex needs of dementia patients. According to Kwon et al. (2017), CBT or cognitive behavioural therapy is specifically used to meet the complex psychological needs of dementia patients. According to the Royal College of Psychiatrists (2023), while traditional CBT focuses on altering the negative thinking pattern, the new cognitive behavioural therapy tries to emphasise improving the emotional well-being of the patient by reducing the tendency of depression, and anxiety and managing behavioural symptoms including aggression. This therapy includes the use of reality orientation, memory aids, and structured routines as tools to help patients cope with their cognitive deterioration (Stott, 2018). With this CBT, the healthcare professionals try to empower the dementia patient with skills and the ability to deal with cognitive decline and emotional regulation.

On the other hand, referrals to specialist services can also be considered as another intervention, where the healthcare worker can make timely referrals to specialists like neurologists, geriatricians, and psychiatrists when it comes to managing the symptoms and coexisting conditions of dementia patients (Aynur Özge et al., 2023). For example, to meet the complex needs of a dementia patient, an occupational therapist can be consulted as he can help the patient to maintain their independence by developing the ability to do regular activities, whereas a speech therapist will help the patient to overcome communication issues. Early referral to specialists like psychologists can be important for dementia patients as it can help the patient to manage their cognitive decline and behavioural changes at a very early stage which can expand the scope of quick recovery and regain the improved cognitive behaviour for the patient. Additionally, treatment and support within a community can be considered as another intervention strategy for meeting the complex needs of dementia patients. In such a strategy or intervention plan, nurses can collaborate with community care teams to offer home-based care to dementia patients, so that they can live in a familial environment and overcome the stigma of being judged negatively by others. Community services like memory clinic respite care can provide ongoing support and reduce the stress on caregivers and family members of dementia patients (Maayan, Soares-Weiser and Lee, 2014). Special interventions like mental health nutrition, and hydration management are also important to meet the complex needs of dementia patients. According to Mole et al. (2018), hydration and nutritional care are important as dementia patients are prone to malnutrition and dehydration due to a decreased rate of appetite and memory loss. In such a scenario, the nurses will ensure the regular and on-time feeding schedules and hydration routine for the patient in collaboration with the dietitian so that the specific hydration and nutritional needs of the patient can be met along with physical and psychological health and well-being.

The combination of individualised action, referrals to specialists, cognitive behavioural therapy, community support, and nutritional intervention work synergistically to meet the complex needs of dementia patients. According to Karam et al., (2021), by offering personalised, and coordinated care, healthcare professionals and nurses can ensure that each of the patients is receiving person-centred care and intervention that can improve the patient’s cognitive behaviour and psychological, and physical well-being. CBT can help patients to manage declined cognition and behavioural symptoms like depression, aggression, and anxiety, whereas timely referral can ensure the comorbidities of the patient are managed on time (Kwon et al., 2017). Involving community-based services in care for dementia patients can provide a familial environment, where the patient can develop self-worth, and self-esteem and can be accustomed to medical intervention which ultimately helps them to overcome from the sense of self-isolation and develop behavioural outcomes (Yates et al., 2019). Lastly, nutritional and hydration management can prevent physical deterioration, ultimately improving the patient's overall quality of life. To provide patient-centric care to meet the complex needs of dementia patients, the SMART goal can be developed in healthcare practice. The purpose of the care goal will be to improve the overall health and outcome of the patient. For example, for a dementia patient, the SMART goal will include the implementation of a personalised care plan by involving nursing intervention, CBT, and other management strategies (specific). The measurable goal for the care plan will be to acquire a maximum reduction of anxiety, aggression, and depression levels which can be measured by the Generalised Anxiety Disorder Scale (GAD-7) (Rutter and Brown, 2016). The achievable goal in the care plan will include the use of interdisciplinary collaboration between healthcare professionals., community teams, patients, and family to deliver individualised and evidence-based care, whereas the relevance of this care plan can be measured by comparing the KPIs with the guideline set up by NICE and NHS Long-Term Plan. On the other hand, after the discharge of the patient, a post-discharge care plan has to be developed by caregivers to ensure community support and regular follow-ups to maintain the continuous progress of such patients.

Conclusion

To conclude this assessment, it can be stated that dementia is becoming a social concern across the world as well as in the UK. This is because, dementia can be defined as a neurological disorder which impacts on livelihood of any individual with several complexities, including cognitive decline, development of aggressive behaviour, difficulties with communication, loss of memory and so on. In such a scenario, a person-centred nursing care approach is considered to be essential to address the complex care needs of dementia patients. In the UK, the quality of dementia care has changed and evolved over time. Nowadays, as per the biopsychosocial model, dementia care addresses the interconnectedness of the biological, psychological and social needs of the patient. In this assessment, the complex needs of dementia patients have been discussed thoroughly with different nursing interventions, policy frameworks, and the role of multidisciplinary teams in care, through which the overall health and well-being of dementia patients can be ensured.

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