Person-Centered Care and Care Planning for Those with MNCD

Abstract

Assisting professionals to care for those with major neurocognitive disorders (MNCD), including the inevitable neuropsychiatric symptoms, using the person-centered philosophy is the goal of this text. After a review of the history of person-centered care planning, a model to assess/evaluate a person’s behavioral communications is presented. The viewpoint for all care starts with a strength-based assessment of the person living with dementia. The framework makes use of the supported decision-making paradigm. After assessment, there is a review about choosing and applying person-centered interventions using regular monitoring of outcomes.

Appendices

Appendix A: Sample Interdisciplinary Care Plan

Background Information

Date of report: January 12, 2019 Client’s name or initials: AM

Date of birth: 6/24/1934, although patient is unable to report

Reason for care plan update: Change in condition – reassessments completed by all members of the team, now working on interdisciplinary care plan for AM

Profile

AM is an 84-year-old woman who has lived in a memory care facility for the last 3 years and has severe MNCD. AM is able to answer to her name but has decreased verbal generative fluency. She smiles and nods her head in greeting, but does not engage in conversations. She follows the housekeeping staff around during the day. Her family believes that AM enjoys watching cleaning when it is done well. They report similar behavior in AM’s younger years; she liked keeping the house clean when her children were young. She also liked to cook, but hasn’t done any cooking for the last 20 years.

Change in Condition

AM’s behavior began to change about 3 weeks ago. She frequently becomes distressed, screaming at staff and chasing people who come into her room. These episodes occur on an almost daily basis, typically in the late afternoon. She takes several hours to calm down when she becomes upset. She has lost 17 pounds in the last 4 months. No precipitating factors or changes at the memory care unit have been identified. Her daughter’s visit frequency is about the same.

Life factors influencing current condition

• Per family, AM would not have described herself as a religious person.

• Homemaker, kept a spotless house, was an excellent cook.

• Liked getting her nails done, has not been able to sit for this in the past 6 months.

• Loved to travel.

• Husband was an artist.

• One daughter is married with a grown child of her own, lives near the Memory Care Unit, and visits most days.

Assessments

Neuropsychiatric Inventory-Q form: score – severity 14, caregiver distress 18.

Aggression 3/4, depression 3/5, anxiety 3/5, irritability 2/3, eating 3/2

MSSE: score of 7 – not calm 1, screams 1, malnutrition 1, eating problem 1, invasive actions (CBG) 1, suffering according to medical opinion 1, suffering according to family 1

Domain

Goals of care/end-of-life issues: Now in a palliative care, comfort care track

AM perspective: “No pain” was the last conversation about this, which occurred approximately 2 years ago. She has not been able to verbally provide additional input, although she has been communicating distress with her behavior.

Daughter: Family supports a focus on comfort. They are unsure what might be causing AM’s current outbursts.

Interdisciplinary team: Focus is on keeping AM comfortable and minimizing pain. Consideration is being given to current increase in distress and whether it is related to pain. Team is pondering if AM has started the transition to the end of life and estimates the trajectory over the next 1–2 months. MSSE suggests life expectancy of 6 months or less. Referral to hospice services is recommended to AM and her family.

Participant perspective	Issues	Plan	Discipline
“No pain” was the last conversation about this, 2 years ago	GOC/palliative care philosophy of comfort	Patient to be kept comfortable and pain-free; if that becomes difficult, refer to hospice for more wrap-around care – now will increase medications and refer to hospice	PCP, RN, SW
“I want to be cremated” stated 5 years ago	Funeral plan	AM and her family have arrangement with XYZ Funeral Home. Copies of paperwork in chart at memory care, with daughter, and at PCP office	SW, housing director, daughter, PCP
Daughter reports “My mom is suffering”	NPS: Mini-Suffering State Exam Score 7/10	Problem solve as needed to support stable placement Provide caregiver assistance with developing interventions Continue to track MSSE, NPI-Q	MSW, RN
Screaming and pushing	NPS: NPI-Q score 14/18	Psychiatry collaborative consultation: recommends having daughter come at 3pm and lay down with her mother to see if “modeling how to rest” helps. Move AM away from the noise before it starts to increase around 3pm. Continue dementia-specific medications. Trial pain meds (low-dose opiate+bowel medications) while beginning behavioral interventions as she appears to be suffering greatly	PCP, consult with psychiatry
AM able to walk, able to eat finger-food	Functional status	Continues as expected. Support by walking regularly with AM, and provide food in line with her preferences	Staff at MCU, daughter, activity dir
Appears upset when medications are handed to her and when her CBG is checked	Medical: HTN DM	Discontinue all medications that are not being given for NPS Discontinue CBGs. Encourage fluids as elevated CBG can lead to dehydration	PCP, RN
Daughter speaking for AM: MCU meets her mother’s needs	Living environment and safety	Continue MCU with added support from hospice staff	PCP, RN, MCU, hospice

After review of the care plan, all team members sign:

AM _________ Date ______ Dtr A ________ Date ______

SW_________ Date _____ RN __________ Date ______

Aide ________ Date ______ OT__________ Date ______

PCP ______ Date _____ Housekeeper_________ Date _____

MCU Dir ________ Date ____ Act Dir ________ Date _____

Outstanding actions:

SW and PCP will make hospice referral and send the first and current person-centered care plans. Hospice to consult with AM, Daughter, MCU staff, and rest of team.Date of referral:________Comments/Additions from AM or Dtr A:________________________________________________________________________________________________________

Appendix B: Sample Care Plan Chapter 9

Background Information

Date of report: September 21, 2019 Client’s name or initials: BN

Date of birth: April 10, 1940

Reason for care plan update: Regular reassessments completed by all members of the team, now working on interdisciplinary care plan for BN.

Profile

BN is a 79-year-old woman who has lived in assisted living facility for the last 3 years and has mild MNCD. BN is able to have conversations. She enjoys talking, reading, and playing cards. She loses track of conversations at times and has limited recall. Notes don’t seem to help much.

• Roman Catholic background. Attends mass on Sundays.

• Librarian, loves to read, is in a book club at ALF.

• Likes getting her hair done.

• Loved to travel.

• Husband was a civil servant.

• No children. Niece lives in a distant state but calls BN once per month.

Neuropsychiatric Inventory-Q form: severity 2, caregiver distress 2

Anxiety 1/1, irritability 1/1

MSSE: 1/10 dialysis

BN’s perceptions: Things seem good right now. Lots of minor medical issues, but living here has been good for me. I have a whole new group of friends. The food is pretty good too.

Domain: End-of-life issues – now in a palliative care, functional focus track

BN perspective: “As long as I can keep going and enjoy time with friends, life is good.”

Other interdisciplinary team members – continue to support optimal quality of life. Life expectancy is less than 5 years. DNR is in place. If benefits of an intervention are less than risk over next 5 years, advise against them.

Participant perspective	Issues	Plan	Discipline
I don’t want CPR; I saw that happen to my best friend, and it was awful	GOC: Focus on daily functioning palliative care philosophy	Encourage BN to be as active as possible; her “use it or lose it” attitude is lifelong	RN, ALF act dir, aides
“I want to be cremated” stated 5 years ago	Funeral plan	Copies of paperwork in chart, with daughter and at PCP office	Housing director, PCP
Denies suffering	Mini-Suffering State Exam Score 1/ 10	Problem solve as needed to support functioning Provide caregiver education regarding end of life as needed	MSW, RN
Some anxiety during dialysis	NPI-Q score 1/2	Encourage listening to music and watching distracting movies during dialysis. Discuss when it may be time to stop due to not supporting a good quality of life, and document those discussions	Kidney team, PCP

Domain: Cognition/functioning

BN perspective: “I lose track of some things, I need the staff help, life is good.”

Other interdisciplinary team members – Allen cognitive level 4.6 mild-moderate functional impairment. Strengths are ability to scan the environment and utilize objects if they are visible.

Participant perspective	Issues	Plan	Discipline
I need reminders	Does not track dialysis days any longer, benefits from invitation to activities	Staff to come and get her for medical and dialysis appointments, invite to all activities, and keep track of her schedule for her	Aides, ALF RN, and manager to monitor

Domain: Emotional/neuropsychiatric symptoms

BN perspective: I get nervous sometimes. I am not depressed. I enjoy being as active as I can.

Other interdisciplinary team members – the emotional impact of dialysis is emerging as an area to attend to closely. At some point, if it causes too much distress, will need to discuss stopping dialysis.

Domain: Medical

BN perspective: I can tolerate dialysis for now. Maybe not for too much longer. Otherwise, I don’t think I have medical problems.

Other interdisciplinary team members – continue much of current care. Frank conversation now with BN and her niece and the PCP about the future of stopping dialysis. Begin to plan for that. Send documentation of care plan to nephrologist and offer to have joint meeting with PCP, BN, and niece by phone with nephrologist.

Participant perspective	Issues	Plan	Discipline
7 years ago, completed	Advanced directive	Participant named niece her primary healthcare power of attorney, she does not have an alternate	PCP
“I get tired a lot”	End-stage renal disease on hemodialysis – secondary hyperparathyroidism and anemia CPAP at night History of low protein levels	Continue Sensipar and sevelamer Check labs prn Increase daily water intake Renal follow-up per schedule Lab draws/blood pressure checks left arm only Draw labs as ordered Hemodialysis three times a week Communicate with XXX Kidney Center to reschedule run when participant has missed run Make sure settings are correct every night and put away every morning Encourage compliance Replace respiratory care supplies per replacement schedule Renal diet: participant has been educated on renal diet guidelines Small portions of meals as she desires Nutrition supplement Weigh at ALF once a month, and send to PCP and nephrologist	PCP RN Care aide RN

Domain: Living environment/safety

BN perspective: I really like living here. I have friends and enjoy activities.

Other interdisciplinary team members – At the current time, BN’s needs are being met well here. Continue to focus on maximizing ability to be as independent as possible.

Participant perspective	Issues	Plan	Discipline
I love to read	Active in book club	Continue to encourage to read, especially well-loved books BN is familiar with	Activity director
My eyes get tired when I read	Decreased visual acuity	Provide large print books and magnification device	Occupational therapist
I sometimes forget when book club is; I would hate to miss it	Decreased short-term memory	Provide environmental cues to remind BN of schedule; large digit clock with alarm Reminds 10 minutes before group starts	Occupational therapist; activity director

After review of the care plan, all team members sign:

BN _________ Date _______ Niece ________ Date _______

SW_________ Date _______RN __________ Date _______

Aide ________ Date ______ OT__________ Date ______

PCP _________ Date _____ Act Dir ________ Date _____

Housing Coordinator____________ Date _______Outstanding actions:Send copy of Person Centered Care Plan to Nephrologist officeDr. _____________ Date_________Comments/Additions from BN or Niece:________________________________________________________________________________________________________