Neuropsychiatric Disease and Treatment Discussion

Assessing Needs – Dementia

Dementia is a mental health term referring to a condition in which an individual has impaired ability to make decisions, think or remember. The impairment interferes with everyday activities. One of the most common types of dementia is Alzheimer’s disease. Although mostly reported among older adults (65 years of age and older), dementia is not part of the normal aging. The normal aging process includes physical and cognitive declines to include forgetting recent events, forgetting names of acquaintances, struggling to find words and remembering them later, and occasionally misplacing keys. Even as an individual ages, the language and old memories built over years will stay intact. However, that is not the case for persons suffering from dementia who are likely to experience problems with visual perception beyond normal age decline, judgement, reasoning and problem solving, communication, attention, and memory. The main signs of dementia include inability to complete tasks independently, forgetting old memories, forgetting names of close friends and family members, using unusual words to refer to familiar objects, and getting lost in familiar locations (Bard et al., 2022, pp. 201-202). Neuropsychiatric Disease and Treatment Discussion

Dementia is a global challenge that causes great burden in families and health care institutions, while leading to significant costs that are expected to increase with time. While there are several risk factors associated with the occurrence of dementia, the main risk factor is age as it typically occurs among older adults 65 years of age and older. This means that with growing and aging populations, there is an expectation that dementia will become more prevalent. Consequently, it is important to have a specific and sensitive screening tool that would identify dementia in the early stages and facilitate early intervention to postpone its progression (Pollard & Jakubec, 2022, pp. 333-334).

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Diagnosis for dementia requires that the individual be subjected to tests on cognitive abilities, to include problem solving, memory and attention. Additional tests may be conducted to determine the underlying cause of the dementia, such as brain scans, blood tests and physical exams. As earlier indicated, dementia is a general term thus indicating that there are different types of dementia, depending on the cause. The most common types of dementia are Alzheimer’s disease, vascular dementia, lewy body dementia, fronto-temporal dementia, mixed dementia, and reversible causes dementia. The management and treatment of dementia depends in the underlying cause. In essence, determining the presence of dementia and its cause is an important step in managing the condition (Raz, Knoefel & Bhaskar, 2016, p. 172).

Mental health assessment for dementia patients is supported by the Health and Social Care Act that was passed by the National Assembly of Wales and received Royal Assent in 2020. The legislation places quality and safety above all concerns, thus insisting on the provision of high value evidence based care to patients (Welsh Government, 2020, p. 9). This essay discusses the use of Addenbrooke’s cognitive examination (ACE) III as an appropriate assessment tool for dementia. Neuropsychiatric Disease and Treatment Discussion

Discussion

Assessment

Mental health assessment refers to a controlled situation in which a mental health professional (such as psychiatrist or psychologist) makes use of a structured approach to check and see if an individual might have a mental health problem/issue. It is conducted over six stages, in no particular order. First, physical examination to determine if the symptoms mimic those of a mental illness and are, instead, caused by a physical illness. The physical exam also notes if the patient is taking medication and supplements, and how these may affect the symptoms reported. Second, laboratory tests conducted to rule out a physical condition, such as brain scan, urine test, or blood work. In addition, the tests look at the patient’s alcohol and drug use. Third, mental health history that looks at the duration of the symptoms, relevant family and personal history of mental health issues, and any other psychiatric treatment the patient may have received (Arvanitakis, Shah & Bennett, 2019, pp. 1593-1594).

Fourth, personal history that looks at lifestyle, age, marital status, work situation, and so on. This mainly looks at personal issues that may affect mental health, such as stressful work situation or other major traumas. Fifth, mental evaluation that requires the patient to answer questions about behaviour, feelings and thoughts. In addition, the evaluation collects more details about the symptoms in terms of who they affect day-to-day life, what makes the symptoms worse or better, and how the individual manages the symptoms. Besides that, the evaluation observes the patient’s behaviour and appearance, to determine whether the individual is aggressive, shy, or irritable, does the individual make eye contact, is he/she talkative, and how does the individual appear when compared to other person of the same age. Sixth, cognitive evaluation that gauges the patient’s ability to use mental reasoning, recall information and think clearly. It requires the patient to take test of basic tasks like solving simple math problems, recognising common objects and shapes, remembering short lists, and focusing attention. In addition, the patient may be required to answer questions about his/her ability to do daily responsibilities like going to work and caring for himself/herself (Arvanitakis, Shah & Bennett, 2019, pp. 1593-1594). Overall, mental health assessment involves a series of tests and observations by professionals. Neuropsychiatric Disease and Treatment Discussion

Therapeutic Relationship

It is important to note that accurate assessment is best conducted within a trusting therapeutic relationship in which the patient can be open and honest with the required information. The therapeutic nurse-patient relationship is presented as an interpersonal, professional alliance in which the nurse and patient join for a defined period to achieve the assessment goal. Each interaction between a nurse and a patient is unique because the two (nurse and patient) have distinctive personalities with the situation presenting different health circumstances and contexts. This allows the nurse to work with the patient towards achieving the set goals while ensuring that the patient receives safe competent care (Hartley et al., 2020). Regardless of the circumstance, the relationship between the nurse and patient is based on professional integrity, respect and trust. It requires the appropriate use of power and authority, with the nurse utilizing a caring attitude and behaviour to meet the needs of the patient (Crits-Christoph et al., 2019, p. 91).

The therapeutic relationship between a nurse and a patient is best explained by Peplau’s theory of nurse-patient relationship that describes the interaction between nurses and patients as going through four phases, each phase characterized by specific tasks and interpersonal skills. The four phases overlap and serve to broaden and deepen the emotional connection between the nurse and patient. First, pre-interaction phase in which the nurse prepares to engage the patient. During this phase, the nurse prepares the assessment tools, collects relevant information on the patient, and anticipates any concerns that the patient may present (Kumar, 2020, p. 78). Neuropsychiatric Disease and Treatment Discussion

Second, orientation phase in which the nurse defines the purpose, roles and rules of the interactions, and provides a framework for assessing the needs of the patient. The nurse builds a sense of trust by exchanging basic information with the client (presenting nurse name, professional status and any other information relevant to the nature of the relationship), making introductions and using nonverbal supportive communication to reinforce the spoken words. Good preparation can help in setting the context of the care and building trust (Hagerty et al., 2017, p. 162).

Third, working phase in which the nurse applies the problem solving strategies by subjecting the patient to the assessment tool. The patient is engaged as an active participant with the relevant goals established and applied to guide the assessment. The conversation between the nurse and patient turns to active problem solving related to the assessment being applied with a focus on getting the patient to more deeply open up and disclose the required information. This phase is targeted at self-direction and self-management to whatever extent possible in promoting the wellbeing and health of the patient. The nurse can apply limited self-exposure to get the patient to open up (Hagerty et al., 2017, p. 162). Neuropsychiatric Disease and Treatment Discussion

Fourth, termination phase in which the nurse is no longer required for the context of care since the assessment is at an end. The nurse and patient assess the results of the assessment, exploring the meaning of the nurse-patient relationship, and determining the goals that have been achieved and those that are yet to be achieved. It requires that they discuss the achievements, their feelings concerning concluding the relationship, and plans for the future, such as need for additional assessment or how to proceed with treatment. Termination of the meaningful relationship between the nurse and patient is final in the setting as any hint that the assessment would continue when it has ended would be unethical, unprofessional and inappropriate (Hagerty et al., 2017, p. 162).

ACE III

ACE (Addenbrooke’s cognitive examination) is an extended cognitive screening tool designing for assessing dementia and differentiating between fronto-temporal dementia from Alzheimer dementia. It is composed of tests of visuospatial skills, visual perception, language, memory, orientation, and attention. Prior to ACE, Mini Mental State Examination (MMSE) was applied. However, MMSE was noted to have neuropsychological omissions, with ACE being developed to overcome this shortcoming. The development of ACE was as a screening technique for evaluating cognitive functions. In this way, ACE was developed as a freely available, brief cognitive tool for detecting dementia syndromes (Beishon et al., 2019). Neuropsychiatric Disease and Treatment Discussion

ACE included MMSE elements. However, MMSE was no longer open access in 2001. This implied that any elements of MMSE included in ACE had to be removed because of copyright issue, thus resulting in the development of ACE-III that had alternatives to MMSE elements. With this development and the substitutions, ACE-III administration made MMSE scoring void (Takenoshita et al., 2019, p. 123). Similar to the previous versions of the assessments, ACE-III assesses five cognitive domains: attention, memory, language, verbal fluency, and visuospatial abilities. First, attention cognitive domain asks about date, to include current location and season, repeats back three simple words, and serial subtraction. It has a subtotal score of 18 points. Second, memory cognitive domain asks the patient to recall the three simple words presented in attention cognitive domain. In addition, it requires the patient to memorize and recall a fictional address and name, and recall widely known historical facts. It has a subtotal score of 26 points (Calderón et al., 2021).

Third, fluency cognitive domain asks the patient to say as many words as possible starting with a specific letter within one minute, and naming as many animals as possible within one minute. It has a subtotal score of 14 points. Fourth, language cognitive domain asks the patient to complete sequenced physical commands using a pencil and paper. It involves the patient writing grammatically complete sentences, naming objects shown in drawings, answering contextual questions, and reading words with irregular spelling-sound correspondence. It has a subtotal score of 26 points. Fifth, visuospatial cognitive domain asks the patient to copy diagrams, draw a clock face showing a specified time, count sets of dots, and recognise fragmented letters. It has a subtotal score of 16 points. The assessment takes approximately 20 minutes to complete, and has a maximum score of 100 points with a high score indicating better cognitive functioning (Calderón et al., 2021). Neuropsychiatric Disease and Treatment Discussion

An index study conducted on ACE-III reveals that it has high specificity (0.96 for frontotemporal dementia and 1.0 for Alzheimer’s disease) and sensitivity (0.93 for Alzheimer’s disease and 1.0 for frontotemporal dementia). In addition, the assessment tool has significant correlations with other neuropsychological tests for the five domains, thus showing that ACE-III can act as a screening tool for providing a patient’s quick psychological profile. Besides that, the study reveals that ACE-III is capable of differentiating between patients with and without cognitive impairment and mild-cognitive impairment. Additionally, ACE-III performance has broader clinical implications by informing on the patient’s functional impairment (Bruno & Vignaga, 2019, pp. 44-45).

An evaluation of ACE-III ability to differentiate between healthy persons and those with dementia reveals that it is reliable. Like other assessment tools, ACE-III provides a brief and quick tools for conducting a cognitive screening and evaluating the five cognitive domains. In this way, ACE III acts as a comprehensive tool for developing a cognitive profile of the patients, and helping with differential diagnosis for dementia. Furthermore, it includes scores of the different cognitive domains, and this is helpful for tracking the dementia over time (Potts et al., 2022). In essence, it is clear that ACE III is a sensitive and specific screening tool for identifying patients with dementia through assessing their impairments in five cognitive domains.Neuropsychiatric Disease and Treatment Discussion

Conclusion

This essay concedes that dementia is a growing mental health concern among aging populations that causes great burden in families and health care institutions. Reported among older adults 65 years of age and older, there is an expectation that dementia will become more prevalent, thus creating a need for specific and sensitive screening tool that would identify the specific type of dementia in the early stages and facilitate early intervention to postpone its progression. Health and Social Care Act presents legislative support for sensitive and specific dementia assessment as a measure providing high value evidence based care to patients. Mental health assessment typically involves physical examination, laboratory tests, mental health history, personal history, mental evaluation, and cognitive evaluation. The assessment is best conducted within a trusting therapeutic relationship between the nurse and patient, a relationship described in Peplau’s theory of nurse-patient relationships with four phases: pre-interaction phase, orientation phase, working phase, and termination phase. A review of ACE-III determines that it is a freely available, brief cognitive tool for detecting dementia syndromes by assessing five cognitive domains: attention, memory, language, verbal fluency, and visuospatial abilities. An evaluation of ACE III reveals that it is specific, sensitive, reliable, provides a quick psychological profile, differentiates between patients with and without cognitive impairment and mild-cognitive impairment, and informs on functional impairment. In essence, it is clear that ACE III is a sensitive and specific screening tool for identifying patients with dementia through assessing their impairments in five cognitive domains. Neuropsychiatric Disease and Treatment Discussion

References

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Calderón, C., Beyle, C., Véliz-García, O., & Bekios-Calfa, J. (2021). Psychometric properties of Addenbrooke’s Cognitive Examination III (ACE-III): An item response theory approach. PLoS ONE, 16(5), e0251137. https://doi.org/10.1371/journal.pone.0251137

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Hartley, S., Raphael, J., Lovell, K., & Berry, K. (2020). Effective nurse-patient relationships in mental health care: A systematic review of interventions to improve the therapeutic alliance. International journal of nursing studies, 102, 103490. https://doi.org/10.1016/j.ijnurstu.2019.103490

Kumar, R. (2020). Essentials of Psychiatry and Mental Health Nursing. Elsevier.

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Potts, C., Richardson, J., Bond, R. B., Price, R. K., Mulvenna, M. D., Zvolsky, P., … & Duffy, F. (2022). Reliability of Addenbrooke’s Cognitive Examination III in differentiating between dementia, mild cognitive impairment and older adults who have not reported cognitive problems. European Journal of Ageing, 19, 495–507. https://doi.org/10.1007/s10433-021-00652-4

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Takenoshita, S., Terada, S., Yoshida, H., Yamaguchi, M., Yabe, M., Imai, N., Horiuchi, M., Miki, T., Yokota, O., & Yamada, N. (2019). Validation of Addenbrooke’s cognitive examination III for detecting mild cognitive impairment and dementia in Japan. BMC geriatrics, 19(1), 123. https://doi.org/10.1186/s12877-019-1120-4

Welsh Government (2020, June). Health and Social Care (Quality and Engagement) (Wales) Act: Explanatory Memorandum incorporating the Regulatory Impact Assessment and Explanatory Notes. https://gov.wales/sites/default/files/publications/2020-06/health-and-social-care-quality-and-engagement-wales-act-explanatory-memorandum.pdf Neuropsychiatric Disease and Treatment Discussion