Chosen case study: Cam Dao, a 68 year old woman who is being visited at home by the local Community Care Services for treatment of a lower leg ulcer.

Part A:

Healthy/Active Ageing:

The World Health Organisation (WHO) (2019) describes healthy ageing as the course of action for preserving and improving functional ability that supports well-being in older age. It is further described by Hunt (2017) as the taking on of activities to minimise the risk of illness and disease which leads to an improvement in physical, mental and emotional health. Hunt (2017) also states that these activities lessen the decline of functionality and improve quality of life for the ageing population. Not only does healthy active ageing support well-being, it reduces the risk of falls (Queensland Health, 2015). Physical activity and keeping active, helps older adults to stay independent (Queensland Health, 2015). If an incident such as a fall does occur, being more physically fit will reduce the damage (Queensland Health, 2015).

Functional capability consists of the intrinsic capacity of a person, the environment pertinent to the person and the relationship between these two aspects (World Health Organisation, 2019). Intrinsic capacity is made up of the mental and physical capacities of a person including their motor skills, their cognitive ability and their ability to hear and see (World Health Organisation, 2019). Intrinsic capacity can be affected by ageing, disease and injury (World Health Organisation, 2019). The environments pertinent to a person would include their home, their community and the society in which they live (World Health Organisation, 2019). It also includes people and their relationships, mind-sets and principles, policies about health, and the systems of support (World Health, 2019). Living in an environment that supports intrinsic capacity is the answer to healthy ageing (World Health Organisation, 2019).

Successful Ageing

In reality, researches have not yet reached an agreed definition of successful ageing (Sachdev, 2014). It is of importance to note that despite this, according to Sachdev (2014), their research shows that when elderly people were asked if they had aged successfully, their responses centred around the quality of their lives rather than placing concentrating on disease. Sachdev (2014) discusses an influential paper that was released in 1987 by Rowe and Kahn, who at the time summarised successful/positive ageing into three components: “freedom from disease and disability, high cognitive and physical functioning, and social and productive engagement.” Though it is seen that a lack of disease isn’t what is deemed most important by elderly people, what is deemed essential is their ability to adapt to illness, and upholding optimism and a feeling of purpose (Sachdev, 2014). In many surveys about successful ageing, psychological traits including optimism and resilience are perceived to be of great significance (Sachdev, 2014). Those reaching ages considered late elderly are seen to be people with more positive attitudes who do not focus on negative aspects of life such as regret (Sachdev, 2014). These people also tend to be well involved with society and have a large, close circle of friends and family (Sachdev, 2014). In one significant survey conducted, 90% if participants had rated themselves as having aged successfully despite the fact that only 15% reported nil diseases and 38% reporting nil disabilities (Sachdev, 2014). Once again more stress was put on good mental capacity, however even more than mental capacity, the importance of actively engaging with life, the ability to adapt to illness and ongoing growth were highlighted (Sachdev, 2014).

Support and Health Promotion

To maximise Cam’s quality of life and improve her participation in society/social interactions, as a nurse in this situation there a number of approaches that could be undertaken. Since Cam is currently receiving community care from the Community Registered Nurse, the nurse could make sure that when she comes to visit she is taking advantage of the fact she lives with her husband under their daughter’s house. Having family in the home and involving them in Cam’s care would be a way to make sure that the family is aware of the treatment plan so they can all assist and support Cam. It would also be useful because as stated in the situation Cam’s English can be hard to understand so having her family there to translate would greatly assist in the situation. It would be helpful for the nurse to explain to Cam and her family that these ulcers are more common than she would think and that she doesn’t need to be embarrassed by them. The nurse could also try and dress the wound more discretely so that it is more easily covered by long pants if this would help Cam’s self-confidence. She should also try and encourage Cam and her family to go out together more as having family present can increase a person’s confidence. It is important that the nurse does not try and rush Cam into anything and continue to reassure her to take small steps in becoming more social once again. Informing her that reconnecting with friends or even just spending some more time outside could greatly improve her mood and would also be beneficial to her mentality moving forward. She could also recommend even taking small walks, as to not increase pain too much, around the neighbourhood as a first small step and this would not only be socially beneficial but also a way to incorporate some physical activity into her daily routine.

Part B:

Biographical Approach to Assessment and Care Planning

According to Brown Wilson (2013), the elements needed to deliver a person-centred care plan and assessment are acknowledging the perspective of the elder person, finding out what matters to them, taking into account the important details of their life and cultivating conversational strategies to further involve the person in the decision-making process. In Australia, community care policies called for consumer-directed care so using this approach is fitting for the situation (Progomet et al., 2017).

In order to carry out person-centred assessments for Cam, the community nurse should begin with addressing Cam with her preferred name, asking her if she would like her family present while discussing care plans, what she knows about her condition and what she wants to achieve from community care. As Cam’s English is not easily understood it would be highly likely that Cam would have her husband and daughter present to assist with translating. Brown Wilson (2013) suggests to take into consideration the important details of her life. By using this the community nurse could endeavour to ask Cam questions about her hobbies and things she likes to do. By finding out these key elements it would allow for the nurse to recommend activities to Cam that would encourage her to leave the house more often. Cam has previously expressed feeling embarrassment about her ulcer. The nurse should take the opportunity to inform Cam that these ulcers are common and that she didn’t need to be embarrassed about them. It’s important that Cam not have a negative feeling towards the ulcer as shown in a studies that negative emotional response can affect healing time (Walburn et al., 2017).

As stated in the situation, Cam’s wound has become infected with a moderate amount of exudate. A moist wound provides the most ideal environment for wound healing, but finding a balance between a moist and dry wound is key (Brown, 2019). If there is an excessive amount of exudate, the nurse should consider using a superabsorbent dressing, while also making sure to clearly explain the situation to Cam (Brown, 2019). With the current condition of the wound it is paramount that the nurse monitor it closely as community care guidelines promote early intervention to prevent the wound from worsening (Littleford, 2010).

Stereotypes and Ageist Attitudes

Hunt (2017) defines ageism as the act of “stereotyping and discriminating against people because they are old (p. 397). There are many assumptions about older people including that they all are hard of hearing and/or cognitively slow, which leads to some nurses and other health professionals engaging in inappropriate behaviour.

It is clear that there are ageist attitudes present within the nursing community. One study reported that 87.5% of a first-year nursing cohort had engaged in negative behaviours, including talking slowly and loudly, to an elderly person (Frost, Ranse & Grealish, 2015). This is quite concerning considering studies show that elderly people experiencing ageism are shown to have poorer mental health (Lyons et al., 2017).

As a nurse it would be important to make sure that even when talking to a family member in a situation where they were acting as a translator, eye-contact should be established with the patient as well, friendly expressions should be used and ensuring there is no overcompensation on volume or slower talking pace as if you had assumed they were slower cognitively. This is important as it is seen that positive human contact can make a different to the lives of the elderly (Wilson, 2011).

References:

• Brown, A. (2019). Caring for chronic wounds in the community.
  
  Journal of Community Nursing
  
  ,
  
  33
  
  (4), 18-24,26,28. Retrieved from
  
  https://search-proquest-com.ezproxy.library.uq.edu.au/docview/2272758193?accountid=14723
  
• Brown Wilson, C. (2013).
  
  Caring for Older People: A Shared Approach
  
  (pp. 69-82).  London, Sage Publications.
• Frost, J., Ranse, K., & Grealish, L. (2015). Assessing ageist behavious in undergraduate nursing students using the Relating to Older People Evaluation (ROPE) survey.
  
  Australasian Journal on Ageing, 35
  
  (1), 58-61. doi:
  
  10.1111/ajag.12260
  
• Hunt, S. (2017). Working with older people. In Crisp, J., Douglas, C., Rebeiro, G., & Waters, D. (Ed.) Potter and Perry’s Fundamentals of Nursing – Australian version, (5th ed). (pp. 393-421) Sydney: Elsevier
• Littleford, A. (2010). Making a difference through intergrated community care for older people.
  
  Journal of Nursing and Healthcare of Chronic Illness, 2
  
  (3), 178-186. doi: 10.1111/j.1752-9824.2010.01061.x
• Lyons, A., Alba, B., Heywood, W., Fileborn, B., Minichiello, V., Barrett, C., Hinchliff, S., Malta, S., & Dow, B. (2018) Experiences of ageism and the mental health of older adults.
  
  Aging & Mental Health,
  
  
  
  
  22
  
  (11), 1456-1464. doi:
  
  10.1080/13607863.2017.1364347
  
• Prgomet, M., Douglas, H.E., Tariq, A., Georgiou, A., Armour, P., & Westbrook, J.I. (2017) The Work of Front Line Community Aged Care Staff and the Impact of a Changing Policy Landscape and Consumer-Directed Care,
  
  The British Journal of Social Work
  
  ,
  
  47
  
  (1), January 2017, 106–124. doi:
  
  10.1093/bjsw/bcw112
  
• Queensland Health. (2015).
  
  Healthy active ageing: How to get active.
  
  Retrieved from
• 
  
  https://www.health.qld.gov.au/stayonyourfeet/for-seniors/keep-active
  
  
• Sachdev, P. (2014).
  
  What is Successful Ageing?
  
  Retrieved from
  
  https://cheba.unsw.edu.au/blog/what-successful-ageing
  
• Walburn, J., Weinman, J., Norton, S., Hankins, M., Dawe, K., Banjoko, B., & Vedhara, K. (2017). Stress, Illness Perceptions, Behaviours, and Healing in Venous Leg Ulcers.
  
  Psychosomatic Medicine
  
  ,
  
  79
  
  (5), 585-592. doi: 10.1097/PSY.0000000000000436
• Wilson, A. (2011). Improving Life Satisfaction for the Elderly Living Independently in the Community: Care Recipients’ Perspective of Volunteers.
  
  Social Work in Health Care, 51
  
  (2), 125-139. doi: 10.1080/00981389.2011.602579
• World Health Organisation. (2019).
  
  Ageing and life-course: What is Healthy Ageing?
  
  Retrieved from
  
  
  https://www.who.int/ageing/healthy-ageing/en/
  
  

As the saying goes “health is wealth”, the provision of proper healthcare is extremely important as this implies well-being, happiness, and a good quality of life. A healthy population is essential for the growth and prosperity of a country. A nation’s health system should thus aim at providing quality healthcare to its population.

The Ministry of Health & Quality of Life, to whom an overall yearly budget of Rs 5 billion is allocated, provides public healthcare in Mauritius as a “welfare” service. (Source: Newsletter Ministry of Health & Quality of Life July 2009). As at the year ended 2008, health services were provided through 13 public hospitals including 5 specialised ones, 22 Area Health Centres and 108 Community Health Centres located throughout the country. (Source: Ministry of Health & Quality of Life).

Free healthcare provided by the Ministry of Health & Quality of Life has improved the health situation of the citizens of Mauritius. This is shown in table 1.2 below.

Table 1.2: Health Indicators in Mauritius for the years 1990 and 2008 (Source: Ministry of Health & Quality of Life)

The health indicators in Table 1.2 show favourable changes in the health situation of Mauritians in 2008 compared to 1990.

Apart from providing health services to the citizens of Mauritius through its hospitals and health centres, The Ministry of Health & Quality of Life being highly concerned about the well-being of the Mauritian population, tries to create awareness amongst them by carrying out several welfare activities. The latter include the launching of a Mobile Clinic which was done on 7 May 2009, public demonstration of physical activities such as yoga, aerobics, Tai Chi and physical exercise that are organised to encourage people to adopt a healthy lifestyle, tips given with regards to a healthy nutrition so as to fight obesity, organising empowerment programmes to sensitise the population on the adverse effects of tobacco and alcohol, talks on stress management and a National Cancer Control Programme has been developed to fight against cancer. (Source: Newsletter Ministry of Health & Quality of Life July 2009)

Furthermore, The Ministry of Health & Quality of Life aims at improving the quality of healthcare provided to the citizens of Mauritius. Recently, on 27 April 2009, it introduced the implementation of the ISO 9001: 2008 in health services so as to increase customer satisfaction and meet the needs of the Mauritian population. (Newsletter Ministry of Health & Quality of Life July 2009). The future plans of the Ministry include the setting up of Medical Schools where proper training will be given to healthcare providers and improving the hospitality and catering services provided in its hospitals. (Source: Newsletter Ministry of Health & Quality of Life March 2009)

From the above, it can be noted that The Ministry of Health & Quality of Life is highly concerned with the health of the citizens of Mauritius. However despite all the efforts of The Ministry of Health & Quality of Life, the Mauritian population does not seem to be fully satisfied with its healthcare services. Patients are increasingly filing medical malpractice cases which nowadays are repeatedly seen as being the headline of many newspapers. Media reporting has created an increased awareness of harm related to healthcare errors.

Additionally, despite the fact that industrialisation and economic growth during the last years have positively changed the lifestyle and the standard of living of the Mauritian population, the latter is highly exposed to diseases such as diabetes, hypertension, obesity, cancer, HIV/AIDS and so forth. Research has shown that 1 out of 5 Mauritians aged 30 and above has diabetes that is mostly caused due to obesity, unhealthy eating habits, lack of physical activity and alcohol abuse. (Source: Newsletter Ministry of Health & Quality of Life July 2009)

The HIV/AIDS status in Mauritius is quite high with 3792 cases registered from October 1987 to March 2009. This has resulted in 249 deaths as at March 2009. Prior to 2000, 20 to 30 new cases of HIV were being reported annually. However over the period of 2001 – 2005 the number had increased by almost twice annually: 55 in 2001, 98 in 2002, 225 in 2003, 525 in 2004 and 921 in 2005. The 538 new cases registered in 2008 showed that in spite of all the efforts of the Ministry of Health & Quality of Life, HIV in Mauritius is on a rising trend. (Source: Ministry of Health & Quality of Life: An analysis of Health Situation in Mauritius as at year ended 2008)

Furthermore each year more than 1400 new cases of cancer are registered in Mauritius. In 2008, 12% of all deaths were due to this disease. (Source: Newsletter Ministry of Health & Quality of Life July 2009)

Heart diseases and Diabetes mellitus were the first two main causes of mortality in 2008. Comparing the causes of death in 2008 with those of 1975:

Causes

1975

2008

All diseases related to the circulatory system including heart diseases

28.4%

35.0%

Diabetes Mellitus

2.7%

22.8%

Table 1.3: Causes of death in the years 1975 and 2008 (Source: Ministry of Health & Quality of Life: An analysis of Health Situation in Mauritius for the year ended 2008)

Table 1.3 shows a rapid increase in death due to heart diseases and diabetes mellitus over the last three decades. This can be explained by a change in the lifestyle and eating habits of the citizens of Mauritius which is making them become more prone to such non-communicable diseases.

Morbidity in Mauritius and the litigation/complaints concerning medical mal-practice therefore indicate that the Ministry of Health & Quality of Life is not meeting the needs of the Mauritian population.

The healthcare system in Mauritius is getting bigger and more complex as the expectations of the population are increasing. The citizens of Mauritius who are now better educated, have become highly demanding in terms of choice, access, quality of care and service. They furthermore feel that the system is deteriorating and becoming less responsive to their needs as the press only publicises the bad points. Such negative media comments definitely demoralise the health care providers.

The aim of this project is to investigate the problems faced by the public health care sector of Mauritius. This will be done through an empirical study at Flacq Hospital, one of the well-known general hospitals operated by the Ministry of Health & Quality of Life. Throughout this study, it is intended to assess the healthcare quality provided at Flacq Hospital and analyse the factors linked to service experience and patient satisfaction.

By evaluating patient experience important information can be obtained for identifying problems and taking appropriate measures for quality improvement in health-care facilities (Labarere and François, 1999; Batchelor et al., 1994). Improving the quality of service in hospitals will thus be beneficial to everybody namely patients, physicians, nursing staff, management and tax-payers. Such a “win-win” situation will be advantageous to the whole country.

While the transition from school into adulthood is daunting for any teenager, it is more complex for those with a learning disability such as Downs Syndrome. There is a lot of decisions to be made; where to live, where to work and meeting new people outside of school life for example. This means early planning is essential to make this transition easier.

During their time in school, Downs syndrome children have an Individualized Education Programme (IEP) which includes transition planning.

¹

The main aim of this is to think of the future and the skills and aims required for when they become adults. Making a solid plan for the future with help from teachers and healthcare providers such as doctors can make life less stressful.

As the end of school life approaches, this can cause teenagers with Downs syndrome to have mood swings or not preform as well in school. This is due to school being more than a place to learn, it is a place where they can regularly socialise with a good support system eg) IEP. Leaving this structured environment can be hard to accept and get used to. However, the school or GP can provide additional help and support to overcome this.

Living Arrangements:

Depending on their individual needs, adults with Downs syndrome have a variety of options of where they would like to live. These include;

• Living at home with family.
• Supported Living – on their own with the correct support.
• Residential Care – in a home with others with disabilities.
  
  ²
  

Jobs and Higher Education:

More adults with Downs syndrome are going onto further education such as college and university, while others are getting jobs. For those that decide to go straight into the workplace, there is three main type of jobs they can look for with the option of Volunteering. These are:

• Competitive – goals can be reached with limited job support.
• Supported – the same as competitive only with long-term or ongoing support to be successful. This is the most common type of job.
• Sheltered – a setting where people with disabilities can attend on a daily basis and carry out subcontract work eg) assembling packaged goods.
• Volunteer – for those who want to gain additional job training.
  
  ³
  

Relationships and Social Well – Being:

Quality of life is considered a crucial component to the well-being of patients with Downs syndrome.

⁴

The strength of quality care through stable social and psychological interactions has built a framework for a positive well-being for patients with Downs syndrome, improving their quality of life.

⁵

This means that although working is important, it is essential for people with Down syndrome to take part in sport, hobbies and other interests they may have.

People with Downs syndrome also like to date, form loving relationships and some even get married. However, they may need additional support when it comes to things like birth control and STD’s. Some couples may even consider starting a family although the fertility rate for men and woman with Downs syndrome tends to be lower. This doesn’t mean they can’t have children, but it does tend to make it more difficult. It is also worth noting that if one partner in a couple has Downs Syndrome, there is a 1 in 2 chance of their children having Downs syndrome too. There is also an increased risk of miscarriage and premature birth within women with Downs syndrome. In addition to this, becoming a new parent is hard for anyone, and even more so for people with Down syndrome, so extra help, support and specialist guidance will be usually be required in order to cope with the demands of a new baby.

⁶

Health Issues:

Adults with Down Syndrome are now living longer – the average life expectancy is now between 50 and 60 years old with some people even reaching their 70s. As they get older, people with Down syndrome are more likely to suffer from mental health issues, like depression. This can be triggered by a variety of reasons, most commonly loss, like the death of a parent. In other instances, there are medical reasons.

In comparison to the general population there is an increased risk with early ageing and age-related health problems at an earlier stage of life. This includes dementia, memory loss, and changes in personality that are similar traits of Alzheimer’s disease.

• 
  
  Depression
  
  

Depression is just as common in the general population in comparison to those with Down Syndrome and both are affected in exactly the same way. It is the most commonly diagnosed mental health issue for those with Down Syndrome. Depression is much more than feeling sad or low for a short while. Symptoms usually persist for at least two weeks, and often much longer. Dr Kerim Munir (Boston Children’s Hospital) has

written

that children and adults with Downs syndrome and symptoms of depression often lose the ability to enjoy many activities they used to love, they lose skills and they become very withdrawn. Depression may have appeared relatively quick or may have developed gradually over the course of many months.

⁷

When mental health doctors meet with a patient to provide a diagnosis and treatment plan, they rely on standard diagnostic criteria which has been developed by the American Psychiatric Association.

⁸

Many of these criteria are based on the patient being able to self- report subjective feelings eg) feelings of worthlessness. This means diagnosing depression in a person with Downs Syndrome is extremely complicated, due to limited verbal communication and conceptual thinking which affect the individual’s participation in the psychiatric interview.

⁹

In addition to this, diagnosis may be further complicated by medical conditions such as hypothyroidism, vitamin B12 deficiency and Alzheimer’s dementia, all of which have symptoms that can mimic depression.

¹⁰

Treatment for depression includes;

• Counselling
• Medication
• Treatment of any underlying associated medical conditions
• Encouraging exercise and getting involved in activities that help build self-esteem

• 
  
  Dementia
  
  

Chromosome 21 carries the APP gene, which produces a specific protein called Amyloid Precursor Protein (APP). An excess amount of this protein causes a buildup of protein clumps (beta-amyloid plaques) in the brain.

¹¹

As someone with Down Syndrome has an extra copy of chromosome 21, by the age of 40 they will have these plaques, and as a result, there is increased problems with how the brain cells function and therefore an increased risk of dementia.

It is important to note that not everyone with Down Syndrome will develop Alzheimer’s. However, for those that do, the signs and symptoms usual start to show around 40 – 50 years old. The most common early signs are changes in overall function, personality and behaviour compared to the usual symptoms of memory loss and forgetfulness. Examples of these signs include;

• Reduced interest in being sociable, conversing or expressing thoughts.

• Decreased enthusiasm for usual activities.
• Decline in ability to pay attention.
• Sadness, fearfulness or anxiety.
• Irritability, uncooperativeness or aggression.
  
  ¹²
  

Diagnosis of dementia is difficult in a person with down syndrome due to the challenges associated with an intellectual learning disability. Diagnosis usually takes a long time and can only be confirmed after consideration of a number of factors, including; detailed history, performance on assessments over an extended period of time and exclusion of all other possible reasons for change.

¹³

Although there is no cure for Alzheimer’s dementia, drugs such as donepezil (an anti-cholinesterase inhibitors) have been shown to be effective in alleviating symptoms and slowing progression.

Other health issues adults with Down syndrome tend to face include:

• Being
  
  overweight
  
• 
  Diabetes
  
• 
  Cataracts
  
  and other problems seeing
• Early
  
  menopause
  
• 
  High cholesterol
  

To help someone with Down syndrome remain healthy as they grow older, it is vital ensure they get regular check-ups and stay on top of any medical issues they have.

¹⁴

1. 
   https://www.webmd.com/a-to-z-guides/tips-adults-down-syndrome#1
   
2. 
   https://www.downs-syndrome.org.uk/for-families-and-carers/supported-living-2/
   

3. Employment and Volunteer Work

4. Goodman MJ, Brixner DI. New therapies for treating Down syndrome require quality of life measurements. Am J Med Genet A. 2013 Apr;161A(4):639-41
5. Felce D, Perry J. Quality of life: the scope of the term and its breadth of measurement. In: Brown RI, editor. Quality of life for people with disabilities: models, research and practice. Cheltenham (UK): Stanley Thornes; 1997. p. 56-71.
6. 
   https://www.nhs.uk/conditions/downs-syndrome/living-with/
   
7. 
   https://www.downs-syndrome.org.uk/for-families-and-carers/health-and-well-being/getting-older/alzheimers-disease/
   
8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association, 1995.
9. 
   https://www.advocatehealth.com/assets/documents/subsites/luth/downsyndrome/mcguir.pdf
   
10. Szymanski LS. Diagnosis of mental disorders in retarded persons. In Stark JA, Menolascino FJ, Albarelli MH, Grey VC (eds), Mental Retardation and Mental Health: Classification, Diagnosis, Treatment Services. New York: Springer Verlag, 1988.
11. 
    https://www.nia.nih.gov/health/alzheimers-disease-people-down-syndrome
    
12. 
    https://www.alz.org/alzheimers-dementia/what-is-dementia/types-of-dementia/down-syndrome
    
13. 
    https://www.downs-syndrome.org.uk/for-families-and-carers/health-and-well-being/getting-older/alzheimers-disease/
    
14. 
    https://www.webmd.com/a-to-z-guides/tips-adults-down-syndrome#3