Nursing in Practice Autumn 2022 issue | Page 28

28 | Nursing in Practice | Autumn 2022

Symptom management and comfort care planning The following points outline some specific ways in which nurses can adopt more of a palliative approach to care for people at different stages of their dementia , including towards the end of life .

Help the person and their family carers understand delirium . Delirium can be a frightening experience for people with dementia and their families . Helping them to understand the symptoms and what is happening can help to alleviate some of the distress , alongside using delirium assessment and management strategies . Hypoactive delirium can often be missed in dementia because it can be assumed the person is fine since they are quiet and appear ‘ settled ’.

Consider using the mnemonic ‘ PINCH ME ’. To improve symptom management and reduce the risk of delirium , assess and treat any underlying problems , which may include : Pain , Infection , Nutrition , Constipation , Hydration , Medication and the Environment .

Explore pain . Establishing how the person responded to pain before developing dementia can be helpful . For example , did they go quiet , or become irritable ? They may no longer have the ability to verbally communicate how they are feeling or where the pain is . They may use different words or say ‘ no ’ in response to an offer of analgesia or when asked if they are in pain , possibly because they misunderstand the question .

Think about a pain tool , which is best used as part of an overall pain management plan . There are several such tools but among the more commonly used observation scales for verbal communication difficulties are :

• Abbey Pain Scale .

• Pain Assessment in Advanced Dementia ( PAINAD ).

• Doloplus-2 Scale . It can also be helpful for families to know what to look out for , such as body bracing or calling out .

Consider comfort care . Work with the person and their family to establish what keeps them pain free , relaxed and happy , what brings emotional and physical comfort and which environments make them feel safe and at ease . Review the potential of sensory-type interventions , such as Namaste care , which may help bring comfort towards end of life .

Focus on person-centred care . How can the person with dementia maintain a sense of attachment , inclusion , love , occupation and identity ?

Consider communication strategies . People with dementia , even in the advanced stages , can often communicate their needs well but doing so can involve a lot of effort , with time needed to process and articulate thoughts . They may have a short attention span , have difficulty handling several pieces of information with competing thoughts or memories , or have problems finding the right words . Consider the use of visual aids , pictures or cards to facilitate conversation .

References 1 London School of Economics and Political Science . Projections of older people with dementia and costs of dementia care in the United Kingdom , 2019-2040 . London : LSE , 2019 . bit . ly / 3AKGuyU . 2 Office for National Statistics . Deaths registered in England and Wales : 2021 . ONS , 2022 . bit . ly / 3wTxeaD . 3 Brayne C et al . Dementia before Death in Ageing Societies- The Promise of Prevention and the Reality . PLoS Med 2006 3 ( 10 ): e397 . bit . ly / 3Re4fGM . 4 NICE . Dementia : assessment , management and support for people living with dementia and their carers . London : NICE , 2018 . nice . org . uk / ng97 . 5 van der Steen J et al . White paper defining optimal palliative care in older people with dementia : a Delphi study and recommendations from the European Association for Palliative Care . Palliat Med 2014 ; 28 ( 3 ): 197-209 . bit . ly / 3TSFEsT . 6 Brown J et al . Association of comorbidity and health service usage among patients with dementia in the UK : A population-based study . BMJ Open 2017 ; 7 : e012546 . bit . ly / 3wTwjag . 7 Browne B et al . Defining end of life in dementia : A systematic review . Palliat Med 2021 ; 35 ( 10 ): 1733-1746 . bit . ly / 3eijzDy . 8 World Alzheimer ’ s report 2016 : Improving Healthcare for people living with dementia . Coverage , quality and costs now and in the future . London : Alzheimer ’ s Disease International , 2016 . bit . ly / 3TCW2gO . 9 Medical Protection . Mental Capacity Act 2005 – Lasting Powers of Attorney – England and Wales . London : Medical Protection , 2015 . bit . ly / 3q74J5u .

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