Depression In An Elderly Patient

Case Study

Mr. H of age 76 years, lived with his wife, who is also 75 years of age, they do not have children. Mrs. H visited the clinic along with Mr. H and she was extremely worried because Mr. H often forget his name and identity, he could not recognize his wife as well and sometimes he left his house and could not recall his address so the neighbours use to return him back. This problem was increasing day by day. From past two years he was an Alzheimer’s patient and were treated with medicine for a long time to assure his cure (Jack, et al, 2013; Kumar, et al, 2015). One month back the things got worse when Mrs. H found he can see some ghostly appearance of his old family and friends around him, most of them are not even alive. Sometimes he is also feeling horrified and screaming as if somebody is trying to captivate him. As Alzheimer’s disease is a form of dementia eventually it grows to be delirium (Fong, et al, 2012; Murray, et al, 2014). He was eventually going down with a major depression as he could not understand what is happening (O'Sullivan, et al, 2014). The case was critical so he got admitted immediately to the hospital. Being a mental health nurse, I was quiet sure at that time he needs proper psychological interventions apart from his regular treatment of Alzheimer’s disease.

Psychological intervention required for this case and role of collaboration among nurse and patient: In this case study scenario Mr. H was thoroughly needed psychological interventions (PSI), as this is a case of pure mental health recovery. The term psychological interventions are a number of therapeutic interventions, non-pharmacological in nature and deals with social, personal, occupational, relationship and psychological problems (McHugh, et al, 2012). These treatments deal with both primary and secondary reasons of problems related to mental health and at the same time they encompass different kinds of rehabilitation therapies within the same domain. These therapeutic models are cognitive behavioural therapy (CBT) (Sheldon, 2011) dialectical behavioural therapy (DBT) (Wolk, et al, 2013), supports from the pears and many others. PSI is required for those cases where the patients face problem related to comprehensive need. For a person who is psychosis like hallucination, delusions, disorganisation and negative symptoms should thoroughly treated with PSI and during PSI the reason behind the psychosis is needed to be figured out. The patients those who are suffering from long term depression due to certain health conditions not directly related to mental health but making them depressed or feeling in state of never ending illness sometime undergo psychological trauma. Some patients even cannot understand their psychological distress and come with complaints related to other imaginary health problem. They needed to be checked thoroughly and sometimes through some robust psychological intervention methods. In the current scenario the patient has complicated problems. The pathophysiological problem is Alzheimer’s disease and its inevitable outcome is dementia and long term dementia has led him to delirium. Therefore, it needs to be treated under the roof of psychological interventions.


The role of nurse in psychological interventions is a most importance issue and needs prime emphasise. The patients spend most of the time with nursing stuffs and workable relationship is necessary between them. Good nurse-patient alliance has positive outcome in psychological interventions and this bond pushes the whole process of treatment and in other words the caring nurses indulge the patients’ participation in treatment. To make this happening the nurse should grow a synchronous, reciprocal and mutual sense of belongings with the patient. He/she must fill the void inside the mind of patient by companionate behaviours and high level of communicational skills.

Psychological intervention in mental Case Study: The patient is suffering from dementia and associated delirium and before his psychological intervention, evidence based analysis is necessary. Kolanawsky et al. have argued about the using of the cognitive training by using stimulating activity can enhance the cognitive process and also facilitate the neural plasticity in dementia (Kolanawsky, et al, 2010). Dementia and overlapping dementia and delirium is sometime a common problem of mental health but it is always important to disentangle if delirium and dementia both are present. This is also a part of cognitive therapy. Downing et al. have discussed the similarities and dissimilarities between the symptoms of delirium and dementia and they have argued that after diagnosis and confirmation of dementia the patient should be treated carefully to increase their safety, mobility and quality of life’s value .At the first level the initiative should be taken for educating the patient and the caregiver about the disease. Secondly a few safety measures should be taken, like protection of the patient from physical injury, side rails of bed, furniture with restrictive support etc). In current case treatment should also include behavioural therapies. However, for dementia definitely some more care is needed and here cognitive therapy is very important (Downing, et al, 2013. As in the present case the patient is suffering with both delirium and dementia, therefore both cognitive and behavioural therapy is needed. Whittamore et al, in a cohort based case study based on the prevalence of delirium in old age were found that, 41% of patients suffering from dementia have comorbidity for delirium and dementia. It was observed that delirium is common in older people those are suffering from pre-existed dementia and they have 6% to 10% higher risk to grow delirium. The symptoms of delirium for these pre exposed dementia patients were disordered emotional pattern, delusion, excessive hallucinations, anxiety and irritation (Whittamore, et al, 2014). Amanda Griffiths and the co-workers found that two third patient of age 70 in hospital have dementia/delirium or both. Most of them lack the proper knowledge regarding their ailment as they do not know the diagnostic feature for such mental health problems. These make the nurses agitated to handle them, thus training is needed to make them aware and also it needs multi-disciplinary approach to make the training of these patients possible. This training is needed not only for the patient but also for the health sector professionals (Griffiths, et al, 2014). Partridge et al, work and evidentiary supports suggested that better understanding is needed for psychological support of the delirium patients because sometimes patient recall the delirium and that will be stressful for the mental health nurse. Proper therapeutic skill must be needed to circumvent the situation (Partridge, et al, 2013). As the PSI given for a person having the mental health problem are different for different cases, as they are coming from the different directions, so specialist intervention is needed. Special training should be given to the nurses dealing with mental health problem. Most of them at first found that this is difficult to handle the situation, but eventually handling the case studies make them specialist for giving proper therapy to mental patient. The expert training is needed to know which mental health problem can be treated with which PSI. In this scenario as the patient Mr. H is suffering from dementia and also over one month he is also suffering with the delirium condition, so being a trained mental health nurse I thought to take approach of giving early intervention for PSI first, like to memorise his name and other things properly I suggested his wife to give him a notebook where he could maintain his usual work routine as well as his name and address to be written inside. As well as me and my team were tried to give him a short psychoeducation like giving him a knowledge about his health condition, specially the effect of Alzheimer’s disease on mental health. This was not only done by me but an expert multidisciplinary team was there. Firstly the doctor told him about the pathophysiology of this disease like, giving him some knowledge of neurofibrillary tangles and amyloid beta peptide aggregation in Alzheimer’s and the knowledge and evidence that it would ultimately cause dementia in older age. Mr. H then understood that he is not an exceptional case but this occurred with many other like him. Also physiotherapy team is needed for treating Mr. H, as he is suffering from early onset of delirium. The evidence based supports shows that delirium cases need physiotherapist as during hypoactive delirium the lack of movement observed and sometimes the speeches becomes impaired. Rains et al. observes that physiotherapy is one of the best practice to delirium patient intensive care. Approaches those are multi-interventional helps to reduce the days of delirium and also reduction of hospital stays observed. These approaches includes speech trial, mobilization practice as well as the training for pain relief self- management (Rains, et al, 2017).

As mentioned earlier that there are different psychological intervention technique, for addressing the case of Mr. H and given him proper care Cognitive Behavioural Therapy (CBT) was introduced. This therapy mainly give the understanding power and also explain the situation properly for a mental healthcare patient. This along with the evidence based supports provides the particular framework to change the behaviour of the patient which is treated as unhelpful of the care of patient. Aaron Beck in 1960s’ develop this psychological therapy. It basically correlate among the thinking of the patient which is unhelpful and altered the structure of knowledge also the state of feeling which is sort out to be unpleasant can be altered. There are some core principles that are followed during the CBT practice in patient. These are like, formulation of care which evolves rapidly, sound knowledge in therapeutic interventions are needed. Collaborative team work and actively participated mind is necessary, the basic structure follows the specific goal and a problem which has a particular focus, the education base on this therapy is needed for nurses of mental healthcare, and new discovery can be a guided one known as Socratic process. Third wave cognitive therapies are those Therapies based on CBT is a third wave technique related to cognition and this is not the technique which enforce a new thought and try to challenge the thought of patient but it teaches hoe to learn to accept the thoughts which are making trouble. There are some misconceptions are present regarding CBT, some people thought that only the patient’s having high level of intelligence are get benefited from this technique, it does not consider the patient’s feeling, it is not at all a technique but simply teach to think positively and it does not deal with patient’s past. Mr. H is suffering from the psychosis due to the onset of delirium, when he was hallucinating and delusion occurred, the best practice for this condition will be cognitive therapy. In this case study scenario one-to-one care based therapy took the main focus. First generation therapy based of CBT for such cases shows moderate efficiency but the new approach towards the individual psychosis understanding was more efficient. The depression that arise due to the dementia that not having the memory of current situation or name of his relatives can as well be treated by this theory (Kramer, et al, 2014). Huguet, et al. suggested that depression induced due to different disease condition or syndrome can be cures by the use of CBT (Huguet, et al, 2016). The case was considered to be very critical for mental health nurses as the depression and dementia are interlinked. The dementia condition may arise for him due to his depression or the depression is due to the dementia, as he was suffering from the impaired cognition due to dementia. Gould et al. suggested that this therapy shows extreme efficacy for the treatment of depression in older people as well (Gould, et al, 2012). In the systemic review by Sector, et al. reviewed that the cognitive behavioural treatment based therapy can be efficiently treat the dementia cases (Sector, et al, 2012).

NICE guidelines for the delivery of psychological intervention in legal framework: National Institute of Health and Care Excellence (NICE) made a guideline for the introduction of PSI in patient by nurse. The guide is for the healthcare members, line managers of healthcare unit and the professional attached with the healthcare system. This also helps the people who are using the healthcare support and the family members or the carer of the patient. Registered nurse those are doing the work for impatient healthcare patients and the assistance of healthcare practitioner working with the mental health patient. Apart from the nurse these guidelines are employed for the ward manager, nurses of advance practice the matron and the nurses dealing with the condition of transition among the paediatric and adult. Members from the multiple discipline and the staff those are giving support to the mental health nurse are also meant to follow the guidelines. The series of settings for this practice covers the following things like the setup of care unit for psychiatric care for intensive practice, 136 units that are for safety for mental health patient, one unit for rehabilitation and also few secure units. The settings those are not under this guidelines are treatments in home, house for supporting the patient, day care unit, care giver in voluntary manner and also the intervention of local authorities like school. The settings that are covered under this guidelines for giving the psychological interventions to the patient are outcome of the user of the service and the indicators of the service with the safe structure of staff those are giving the setting necessary for mental healthcare. The safety of this service care delivery depends upon the maintainace of ration for nursing staff and the service users. Other factors affecting the mental health staff’s specially nurses are the factors of service user, like the illness intensity of the patient, type of treatment, the factors of comorbidity, self-harm nature and the full dependency on the care given by the nurse. The factors related to the environment like the size of the unit and ward, the availability of specialist for intervention and the working efficiency of the other team are to be considered. The staffs factors like the balance among the number of registered nurse and the assistant staffs in an unit, the skill needed for handling case and the accession of the multi-disciplinary team. This case study shows that the care was given by strictly following all the guideline in the mental health practice. The book for ‘psychiatry and mental health nursing’ gives the specific values for mental health nursing, that how a nurse could manage to identify the particular case study and categorise it into different types, like whether the case is due to anxiety, depression, loss of mobility, delusion, hallucination etc. and then started the treatment. In this case scenario being a mental health nurse at first it was necessary to categorise the scenario, and it was assessed that this case is the delirium that induced due to dementia and the depression for it. So by following the above mentioned guidelines the cognitive behavioural treatment (CBT) was used for successive treatment. Ethics should be considered while taking the informal consent from the patient’s family and if possible patient’s consent should be taken for giving the patient CBT treatment. The patient should not be forced to take the treatment without prior consent (NMC code, 2018).

Knowledge and skill for individual and team: To maintain the efficiency of critical mental case care, the staff nurse and the supporting multi-disciplinary team must have to be well knowledgeable and have excellent skill. Blythe et al. demonstrate that how important is the skill regarding the physical health care of mental health nurse and the importance of this practice. Mental health patients are often suffers from the poor physical health and have been diagnosed with this, then the mental health nurse are having the skill of giving care treatment of physical health comes to account. So the mental health care nurses are trained by the education to give the physical treatment and only a well skilled nurse can do that. (Blythe, et al, 2012). Townsend et al, showed that the skilled mental health nurse must practice the physiology and anatomy behind the reason of the mental illness, like in this case study to treat Mr. H for the delirium induced by dementia knowing the basic physiology of Alzheimer’s disease is necessary and its related pathophysiology should be known to the nurse. Griffiths, et al. observed that the proper skill and professional attitude of nurse will give confidence to the patient and their families and therefore reduces the chance of improper or forced treatments (Griffiths, et al, 2012). Elder, et al. stated in his book excellent skills and enormous knowledge required for taking the challenge related to the patient’s care. The knowledge acquired by the nurse during the practice will be implemented to the future case study, this evidence based practice will enhance chance to get cure (Elder,et al, 2011).

The efficiency of proper team work from the staffs of multi-disciplinary field is always needed. Here in the case study of Mr. H the doctor’s medicine for Alzheimer’s disease and its effect on dementia, should be discussed with the trained nurse for mental healthcare. As he is suffering from the delirium and that would cause the impairment of movement, so it was necessary to consult with the physiotherapy. By following all the ethics of mental nurse I took the help of these multi-disciplinary team to deliver the best care for Mr. H.

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In the above case study of Mr. H the complexity of mental healthcare has been discussed in the light of mental health nurse’s practice. The problem was three fold as the patient was suffering from the dementia and gradually developed delirium that lead to the overall depression of the patient. So by following the CBT technique and the necessary evidence-based practice, I and the multi-disciplinary team were tried to circumvent the situation by following all the ethics and the guidelines of NICE.


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