Dementia is a common disease in the geriatric population but can also be noticed in any stage of adulthood. In a study issued by European researchers, it is estimated that about 35 million people have dementia worldwide. It is called a syndrome because it involves a serious of signs and symptoms. It is a non-specific clinical syndrome caused by a wide variety of diseases or injuries that affect the brain. Due to alarming increase of number of dementia cases in elderly people, need for extensive research on appropriate care for the elderly dementia patients arises. Nursing home is considered as embodied institution mean to provide constant care.

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In order to study if the nursing home is the most appropriate care environment for older person diagnosed with dementia, an extensive literature search was performed in accordance to Oxford Brookes style. 10 articles were obtained as a result of extensive literature search after incorporating inclusion and exclusion criterion arising due to the personal need. The results are categorised in to four main themes which are as follows:
The facilities and care available at a nursing home. Is multidisciplinary approach essential?
Care received in nursing home vs. home care.
Impact of elderly people joining nursing home at an early stage.
Importance of nursing home in elderly patients in the early stage of dementia
After applying CASP tool to all the articles, Careful analysis was done to draw the discussion. Basing on the discussion, nursing home is considered as the most appropriate care environment for elderly patient diagnosed with dementia. Recommendations are proposed on the basis of conclusions and implications of my research in the future are mentioned.
INTRODUCTION:
Dementia:
Dementia is defined as a medical condition which is characterised by loss of cognitive ability which is caused either due to normal aging or any kind of sudden impairment (Berrios, 1987). It is also described as non specific illness causing set of symptoms affecting memory, language, attention and problem solving regions of the cognitive region of the brain (Calleo and Stanley, 2008).
Dementia could be either static, caused due to injury of the brain affecting the cognitive area or progressive (slowly progressive and rapidly progressive) resulting in damage of the brain. Although the disease is seen commonly in elderly patients, it occurs at every stage of adulthood (Berrios, 1987).During initial stages of dementia; all the higher mental functions are affected leading to confusion, forgetfulness leading to gradual progression (Gleason, 2003). In aged people, the experience of dementia is worse due to pain and ill health. These symptoms lead to problems associated with ambulation, mood swings, depression, disturbances in sleep pattern, decreased appetite and slowness in activity (Gleason, 2003).
Caring People suffering from dementia:
During the initial symptoms, the patient is taken care by the family members and relatives. They ensure the patient that the process is normal with aging which makes their lifestyle a bit easy (Algase, 1996). A person suffering from dementia is shifted to a nursing home due to unavoidable circumstances like absence of carers, hectic life schedule and excessive progression of disease, expensive treatment (Weinberger et al., 1993).
Nursing home is defined as a place of residence for patients needing continuous support. Nursing home is chosen in many circumstances as mentioned by Weinberger and coworkers. According to him, the need of skilled nursing care, physical intervention and close understanding of the patient play an important role. Along with continuous care, patients in countries like Ireland, United Kingdom and Wales also receive assistance from physical, occupational, speech therapists, social workers, psychiatrists, psychologists to look after the necessities (Kristine et al., 2002). Emergency management is also provided as an essential part of treatment which forms an added advantage. The most important responsibility of the nursing home is elderly care which provides the patients with all the basic services like assistance in living, day care and long term care (Kristine et al., 2002).
The Nursing home acts as a caring unit for many dementia patients at various stages of dementia. The quality of nursing home varies and is most important variable in determining efficiency (Kristine et al., 2002).The qualification, knowledge and responsibility of the carers or staff in charge and presence of physicians to monitor health condition of the patient play an important role (Kristine et al., 2002).
Although efficiency of care is expected, there are many disadvantages associated with the nursing homes. The patient initially shows signs of disagreement to shift to a nursing home but may agree when explained. The chances of forgetfulness in these issues are also more which could cause agitation after joining (Algase, 1996). The initial adjustment of the patient towards the new atmosphere may create more confusion and deteriorate the health condition which is a major drawback (Steele et al, 1990). The cost of the nursing home and nursing staff is unaffordable by many of the patients which worsen the situation (Kristine et al., 2002). The extent of care and the support of family members play a vital part in influencing treatment. In particular situations like impaired mobility and disability or in cases where elder people are declared as mentally and physically incompetent, care in the nursing home remains as the best factor to increase longetivity of the patients (Steele et al, 1990).
The purpose of this paper is to review various national, International scientific journals and articles which seek to address on “Appropriate care of elderly patients diagnosed with early stage of dementia”. The intention of the present paper is to provide a suitable answer to the research question; “Is the nursing home an appropriate environment for an older adult diagnosed with early stage dementia”? To answer the question extensive study on literature search and study was performed. The literature review covered numerous journals, policies, and papers which examined the issues on care provided to the elderly patients in early stage of dementia. The reviews include thorough analysis of elderly dementia patients, forms of care available to them and to examine the best suitable care to improve the health condition of these patients. The present research will evaluate available data on nursing home as perfect environment for caring these kinds of patients. The review elaborates on the expectations of the patients and relatives towards care and the attempt of health professionals to live up to the expectations of them. The review also highlights the difference between care obtained in the home and a typical nursing home. It throws light on advantages and disadvantages of care given in nursing homes and these factors are considered later to draw conclusions on the most appropriate environment to care for elderly dementia patients.
OBJECTIVE:
The objective of the research paper is to investigate the literature on qualitative, quantitative and mixed experimental approaches on proper care of elderly patients. These inferences would form the basis for understanding if the nursing home is the most appropriate place for caring dementia patients.
METHODOLOGY:
In order to concentrate on the objectives of the study, extensive literature exploration was performed. A literature review is a body of text that aims to review the critical points of current knowledge including substantive findings as well as theoretical and methodological contributions to a particular topic (Aveyard, 2007). Literature review was considered as a best source of research methodology because of time constraint and lack of ethical considerations to perform primary research. Literature review focuses on primary research done in various clinical circumstances. The other advantage is possibility of comparative study among various qualitative, quantitative and mixed primary researches across the world (Aveyard, 2007).
During my study on the available literature, various situations experienced by dementia patients in nursing homes were studied. Ideas about circumstances experienced by the elderly patients in nursing homes were identified. Some of the papers focus on style of practice in nursing home and some of them focus on the attitude of patients towards nursing care. There were many controversies identified according to different perspectives of authors. Through these studies, an idea about the best suitable place of care for elderly patients at early stage of dementia could be conveyed.
Research process:
The process of research involved organized and vigilant consideration of literature suitable for my research work. The PICO model to formulate a question as suggested by Johnson and Fineout (2005) and by Stone 2002 cited in Gerrish and Lacey, 2010 is shown in the appendix 1 of the present research work. The model gives a simpler representation of the present research work.
The four main terms which were used as a part of my literature search included dementia, elderly patients, quality care and nursing home. While using these terms care was taken to use them in combination rather than using singularly which would widen the research area of expertise. The list of search terms and the keyword identification table as suggested by Aveyard and Sharp (2009) is given in the appendix 2a and 2b respectively of the present investigation report.
While considering the term dementia, early stage was emphasised in particular to refine my search. In addition to early stage, another term, elderly patients were also used to avoid searching among all the age groups. The term used for search looked like presented below:
Dementia OR Alzheimer* OR memory loss and early stage
The Boolean operator and was used in between these terms to ensure that research of literature included these three words in combination. In cases of excluding Boolean operator, the research resulted in articles including primary research of dementia at all stages among all age groups.
The other important search term was concerned with the age of the patient which was mainly confined to elderly patients. The parameters used included Boolean operator ‘and’. The phrase was as follows:
Older person OR Elderly OR older adult
The other term used in conjugation in the research term included quality care. As quality care is considered as a wide term, a Boolean operator “or” and truncation symbol, star “*”was used to enable thorough research without exclusion of any important article or journal. The term entered was presented as below:
Quality care * or appropriate care* or concern or caring* or wellbeing or well-being
The use of Boolean operator and truncation symbol ensured non omission of important articles containing synonyms or differently presented words.
The final term used in literature search was “nursing home”. Since my research focuses to study the most appropriate care environment for elderly dementia patients at early stage, this final term was used separately. The terms used in comparison included:
Nursing home and care home* or residence*
In this particular context, nursing home and care home are considered in comparison with residence of the patient. To enable the results to be confined to single term, the Boolean operator, or was used. The operator and was used to search results including both, nursing homes and care homes. The truncation symbol star was used to include articles with words displayed in alternative formats.
The final research phrase for search looked as displayed below:
Dementia OR Alzheimer* OR memory loss and early stage
AND
Older person OR Elderly OR older adult
AND
Quality care * or appropriate care* or concern or caring* or wellbeing or well-being
AND
Nursing home and care home* or residence*
The immediate course of action was to use these terms in appropriate databases, I was guided by the university library manuals of the Oxford Brookes to consider CINAHL, BRITISH NURSING INDEX and MEDLINE as most relevant databases for search. CINAHL deals mainly in Nursing and health care in North America and Europe (Oxford Brookes University, 2009). British Nursing Index includes journals and articles based on care and community health pertaining to nursing and midwifery (Oxford Brookes University, 2009). Medline (Pubmed) is a collection of articles on medicine and nursing compiled by the intervention of National Library of Medicine ‘USA’ (Oxford Brookes University, 2009).
When the entire research phrase was posed in CINAHL, it retrieved 332 articles. When the same research phrase was typed in MEDLINE, it retrieved 75 articles. Further refinement was done in the search by using limiters 20000101-20101231 and retrieved 57 and 54 articles respectively. Inclusion and exclusion criteria were used in particular to include time constraint which enabled to select most recent articles in the present decade. This included articles beginning from 2000 to present. Another inclusion criterion was the place which restricted the search results to the investigation done in the UK. The inclusion and exclusion criteria yielded 55 and 29 articles in CINAHL and MEDLINE respectively (The database searches and hits are shown in the appendix as suggested by Oxford Brookes University, 2011).
To analyse the best suitable material to carry forward my research, four main principles as suggested by Aveyard (2007) were used, which included electronic searching, searching reference lists, hand searching of relevant journals and contacting authors directly. Out of all the suggested principles, the first three types were used as analytical tools in deciding best suitable literature. While choosing the primary research material, utmost care was taken to read through the abstract, findings and research methodology involved. This criterion was used for including or excluding the article for my research purpose. For some of the searches, hand searching was also used to obtain certain useful information on statistics in UK (shown in appendix 4). Due to time constraint in the research work, contacting health care professionals and conducting appropriate interviews could not be performed.
As a result of the research methodology, 10 articles were found relevant to the context being investigated. The findings of the papers were thoroughly studied in order to answer the research question. Nursing home was considered to be an ideal place to take care of an elderly dementia patient in initial stage of the disorder.
Critiquing my research methodology:
There were many criticisms noticed following my research methodology. The main criticisms observed included the following:
Inability to access all the journals in the databases as it required paid registration. Most of the websites which have excellent articles require a payment. I managed collect as many as articles I wanted to do answer this research question by login on Athens. It was beyond my finances to fund for all the articles.
Lack of time to contact primary health care professionals to incorporate their views as a part of my research work.
Lack of time to go through all the publications of a journal which resulted in referring to recent publications.
Lack of much information in the title which would enable me to take appropriate decision regarding the content of article which resulted in reading the abstract in order to include article for research.
Thus the major constraints of the present research article were identified to be cost and time. However, the freely available data obtained within the specified time were sufficient to draw conclusions to address the research question.
For the entire 10 articles, critical appraisal skills programme, CASP (2006) tools were applied to draw the most relevant themes. The main themes identified are:
The facilities and care available at a nursing home. Is multidisciplinary approach essential?
Care received in nursing home vs. home care.
Impact of elderly people joining nursing home at an early stage.
Importance of nursing home in elderly patients in the early stage of dementia.
RESULTS:
The findings of the literature were categorized into main themes which made it easier to draw conclusions. The section depicts the investigation done in the 10 articles grouped together in accordance with the theme.
Theme 1: The facilities and care available at a nursing home. Is multidisciplinary approach essential?
Author, Year, Location
Title
Method/Study
Results
Comments
1. J. Cohen Mansfield and A.Parpura- Gill (2008). International Journal of Geriatric Psychiatry.
Practice Style in the nursing home: Dimensions for assessment and quality improvement
The investigation examined the operation style of the nursing home in terms of two main components which are the staff and institutional components.
The four domains which served as tool to test the staff conduct included knowledge, proficiency of practice style, flexibility and individual care and communication.
The three domains used to test the conduct of institution include support of staff, availability of resources and administration of policies.
As a result of the investigation, key features of institutional factors and staff were studied and monitored. Based upon the need and demand, the features requiring change and improvement were noted to ensure quality of care.
The investigation emphasises on the practice styles of the staff in a nursing home with respect to care provided. The research journal gives an insight of vivid styles of care provided within a nursing home which ensures quality of care. It focuses on the knowledge, communication, flexibility and understanding of the staff in taking appropriate care in elderly persons
It also gives a note on changing style of practice to cope up with increasing demand.
2. E.Finemma et al., 2005. International Journal of Geriatric Psychiatry.
The effect of integrated emotion-oriented care versus usual
care on elderly persons with dementia in the nursing home
and on nursing assistants: a randomized clinical trial
The investigation is based on randomised clinical trial of two groups of elderly dementia patients, measuring the effects at baseline after specific period of time. The study involved 146 numbers of elderly dementia patients and 99 numbers of nursing staff. The study was performed in 16 psycho geriatric wards located in 14 nursing homes located in the Netherlands.
The primary research studied the difference between the usual care and Integrated emotion-oriented care. The nursing assistants were tested on the basis of care given.
Positive effects were reportedly noticed in patients experiencing mild to moderate dementia in terms of portraying emotional balance and positive self image. Results also showed that training nursing staff resulted in less stress reactions increasing quality and patience.
The investigation revealed that emotion based care showed increase performance in early stage dementia patients when compared to normal usual care. However, It did not show any eye catching increase in quality with regard to people suffering from severe dementia. The study also focuses in reduction of stress in well trained nursing staff.
3. D. Challis et al., 2000.
Journal article from Age and Ageing.
Dependency in older people recently admitted to care homes.
The investigation was based on the study conducted among 308 elderly people aged over 65 in one of the nursing care home located in North west England. The study was conducted within two weeks of admission for people intending to continue treatment for long term. Barthel score and Crichton royal behaviour rating scale were used to analyse the dependency rates.
On the basis of Barthel rating scale and Crichton royal behaviour rating scale, 50% of the population were showed to be measured in the low dependency scale (13-20).Out of them, 31% in case of nursing home and 71% in case of residential care homes. On the whole, dementia patients are not assessed primarily before admission into the nursing home.
Studies revealed that there was lack of pre admission assessment and diagnosis before joining patients. This study throws light on lack of communication about the pre assessment and diagnostic information about the patients to the health care and nursing staff. Effective targeting of institutionalised resources is focussed with high importance.
4. Leontjevas et al., 2009.
American Journal of Alzheimer’s Disease & Other Dementias
Apathy and Depressive Mood Symptoms in Early onset dementia.
As a part of epidemiological study, patients were studied for symptoms of apathy and depressive mood in early onset of dementia. Studies were performed in 63 nursing homes. MADRS, NPI and MMSE scales were used to detect rate of depression and MDS-RAI and GDS were used to detect severity of dementia.
Studies revealed that depressive mood disorders and apathy are not observed severely in cases of patients suffering from early onset dementia .The results noted were accounted as 14% in ADL, 13% in GDS and 9% in MMSE.
The investigation reveals that the symptoms of mood depression and apathy are seen extensively in patients suffering with early onset of dementia when compared to elderly patients revealing the severity of aggression.
Theme 2: Quality of care received in nursing home vs. home care.
Author, Year, Location
Title
Method/Study
Results
COMMENTS
1. Ehrlich et al., 2006.
Home health care management and practice
Caring for the Frail Elderly in the Home: A Multidisciplinary Approach
The study depends upon short portable mental status questionnaire proposed by Pfeiffer in 1975 to identify dementia in geriatric population.
The test confines to recall and memory of short term and long term orientation.
Additionally, evidence based practice is applied to screen patients with the disease.
The screening methodology enabled identification of patients suffering with dementia. Interdisciplinary approach is applied to propose a model for caring elderly people in home atmosphere.
The primary research article focussed on the major disorders affecting the elderly person which forms the basis of joining a nursing home for care. The interdisciplinary approach gives an idea about caring older patient from the most necessary syndromes to enable ease of treatment in the house without intervention of nursing home.
2. Milke et al., 2006.
Journal of Applied Gerontology
Meeting the Needs in Continuing
Care of Facility-Based Residents
Diagnosed With Dementia:
Comparison of Ratings by Families,
Direct Care Staff, and Other Staff
The data was collected by sampling method in five different places including Edmonton, Alberta, Canada, Pennsylvania and New York. A total of 184 elderly residents diagnosed with dementia and 197 nursing staff participated in the study. Suitably tailored questionnaires were distributed across the five sites among non direct care staff, family group, direct care group, licensed practical nurses.
The results of the investigation provided the comparison of care between families, direct caregivers, and other staff and volunteers. It also gave an idea about extent of care needed by the residents by each class. The results provide comparison of care in nursing home and the care in the patients own house.
The research work emphasizes on individual care provided by various groups like families, friends, licensed medical nurses, volunteers and other professional care givers. It gives a relation of trust and cooperation between the patient and care givers. It focuses on various negative aspects of care in the patient’s house created due to stress, pressure and miscommunication.
The article gives insight on the advantages of care provided by professional care givers over the family members in terms of knowledge, patience and quality.
Theme 3: Impact of elderly people joining nursing home at an early stage.
Author, Year, Location
Title
Method/Study
Results
COMMENTS
Connor et al., 1991.
Papers from British Medical Journal
Does early intervention reduce the number of elderly people with
Dementia admitted to institutions for long term care?
The investigation utilised seven general practice areas located in Cambridge in the form of controlled clinical trials. 2885 subjects aged over 75 diagnosed with dementia were involved. 159 subjects in the group were diagnosed with initial stage dementia, 86 of them required extra support and 73 of the subjects had access to usual services and acted as control.
The research revealed that there was no direct contribution of early intervention to long term admission of patients in the nursing home. 9 out of 14 subjects who were living at home without support joined nursing home due to the extended facilities available.
The investigation focussed on screening procedures of dementia to identify level of severity of the disorder in the patients. In certain patients, the severity is high requiring instant admission into nursing home and in some cases, support by family members would be sufficient. Evidences also record that early intervention of dementia would decrease the risk of severity in the disease.
Theme 4: Importance of nursing home in elderly patients in the early stage of dementia.
Author, Year, Location
Title
Method/Study
Results
COMMENTS
1. Voyer et al., 2005
Clinical effectiveness in nursing
2. Dettmore et al., 2009
Geriatric nursing
Characteristics of institutionalized older
patients with delirium newly admitted to an
acute care hospital
Aggression in Persons with Dementia:
Use of Nursing Theory to Guide
Clinical Practice
The investigation involves cross sectional secondary analysis study of old patients in nursing homes and other health care units. Confusion assessment method was used to test patients with delirium upon their admission.
The research work utilizes Need-driven Dementia- compromised Behavior (NDB) model to explain aggression in the individuals undergoing constant core in a nursing home.
In the total of 104 patients suffering from cognitive impairment, 68% people were recorded to possess delirium. The MMSE scale was used to screen patients to test the presence of delirium. The major symptoms which were observed in all the patients were bowel incontinence, illness. The most uncommon symptom observed was hearing impairment which occurred rarely.
Clinical management algorithm was framed in accordance with the NDB model to study the behavior of aggressive patients and frame a theory to take care of the patients in aggressive moods and to avoid repetition of the syndrome.
The research emphasizes on the importance of nursing homes in providing care and offer screening of the disorder. The severity of cognitive impairment doesn’t influence the preventive nursing interventions. Independent of the level of impairment, nursing care portrays important feature in improving the quality of patients requiring close care.
The patients suffering with dementia undergo frequent episodes of aggressive beahvior making care by professional care givers difficult. The paper focusses on the proposal of clinical management algorithm which is based on ndb model to manage certain aggressive episodes of the patient.
3. Holliday-Welsch et al., 2009
Geriatric nursing
Massage in the Management of Agitation in
Nursing Home Residents with Cognitive
Impairment
The study was performed using subjects who are susceptible to agitation and aggrieve mood by nursing staff. The susceptible patients were selected by the use of minimum data set (MDS) report. The data collection was done during 3 days considered as base line, then the intervention followed up to another 6 days continued by follow up for the next few days.
it was observed that Subjects’ agitation was lower during the intervention of massage
Than at baseline and remains still low at follow-up. Wandering, verbally agitated, physically agitated and care resistance were proved to be decreased upon intervention of massage.
In this study, the five aspects of agitation which are wandering, verbal agitation, physical agitation, abusiveness, socially inappropriate agitation, disruptive aggressiveness. At each of the observation, agitation was scored for five times. Massage is one of the non pharmacological interventions in these patients suffering from agitation. This could be used as an effective tool by nursing staff in eliciting quality care
DISCUSSION:
All the themes identified in the research play a suitable role in delivering the conclusion to provide a suitable answer for my research question. The themes are arranged sequentially to ultimately conclude upon appropriate care for elderly dementia patients at early stage of the disorder. Each of the 10 articles selected, carries an important examination which forms the basis for future implications in the nursing staff.
The first theme based in my results is facilities and care available in nursing homes using a multidisciplinary approach. This particular theme identifies the importance of nursing home as an institutionalised care centre to exhibit support and care to all kinds of dementia patients. The study proposed by J. Cohen Mansfield and A.Parpura- Gill (2008) suggests the nomenclature involved in nursing homes including the care provided by the nursing staff. The paper focuses on the improvement of these facilities to improvise style of nursing home which ultimately determines the quality. He regards flexibility, knowledge, communication as an essential factor for influencing care by nursing professionals. Along with characteristics of the staff, he also focuses on certain institutional factors which serve as tool of improvement (Beck et al., 1999). The most important institutional factors include timing of care, alternatives of care, resident and family involvement (Porras, 1987; Kanter, 1993). The frame work which is important for a nursing home is changed regularly on the basis of organizational and staffs needs to ensure implementing better system for staff especially in case of dementia, where there is a need of care specialist to monitor a group of care providers (Noelker and Harel, 2001). The investigation based by on the study of e. Finnema et al., 2005 portrays the role of emotion oriented care in the patients suffering from mild to moderate dementia in nursing homes. He describes the role of emotional oriented care in influencing body adaptation and balance of the dementia patient seen in early stages (Finnema et al., 2000). General health condition was also proved to improve especially in c