Abstract
Learning disabilities in the elderly need interdisciplinary actions because the associated health and social problems are complicated and many. The changing trends of care from hospital based to community based makes learning disability nurses active members of the community based learning disability team. This essay discusses factors influencing the elderly with learning disabilities, nursing care for this client group and the Roper-Logan-Tierney Model of nursing as a suitable framework for this setting of nursing practice.
Introduction
Learning disabilities are neurological disorders of special importance as they need interdisciplinary caring actions. These disorders are constitutionally determined and manifest since childhood, thus, they carve the individual’s perception and interaction with surrounding social environment (Cratty and Goldman, 1997). The practice setting for learning disability nursing is intricate to define since it is within the scope of a complex background of service stipulations. Service provision may be through residential care homes, or people with learning disabilities may live with their families with or without supported living arrangement.
Further, there are larger service providers with specialist settings such as behaviour and cognitive and treatment and assessment units, hospices and homes for elderly may provide social and health settings. Thus, care planning and delivery of learning disability nurses’ services do not occur in traditional settings; instead, it occurs in a framework of multidisciplinary settings. Whether care is in the form of short nursing interventions or for long periods of care and support, nursing care plan should guide the provision of care, irrespective where people with learning disability live (Nursing and Midwifery Council, 2004).
This essay aims to review briefly problems of learning disabilities in the elderly client group and analyse a nursing framework used for caring of people with learning disabilities and to evaluate how effective it can be in nursing practice. The framework to discuss is the Roper-Logan-Tierney Model.
Factors influencing elderly people with learning disabilities
Defining growing older may look easy since it is a known experience met during life; however, a number of key questions need consideration. Growing old can be defined in the context of social backgrounds where the age of retirement is a general directive parameter (Ward, 2000). In terms physical and biological limitations accompany growing old; thus, in these terms, growing old is when these changes limit the individual’s capacity and activity, however, this is not always the case. Growing old can be a state of mind that is psychologically determined where some are living happily and others suffer grief reactions or feel under-evaluated (Ward, 2000).
Whatever definition of growing old is, the problem with elderly having learning disabilities is they do not belong to any definition. Socially, they are put aside as a society subculture with social restrictions and limited social networks. Although life expectancy has increased for this group of people because of better health and social care; yet, the biological characteristics of ageing differ in them than in normal individuals (Rice and Robb, 2004).
Further, little evidence exists on how older people with learning disabilities psychologically deal with growing old, possibly because of cognitive and behavioural inadequacy. Therefore, it may be more enlightening to discuss how ageing affects this group than to define ageing as it links to elderly people with learning disabilities (Thorpe and colleagues, 2000).
The influence of ageing on elderly with learning disabilities
It is understandable that ageing has an impact on all humans; however, for people with learning disabilities, there are noticeable differences related to age of onset besides problems specific to this client group related to their original condition or syndrome-specific problems (McCarron and colleagues, 2002). Teipel et al (2004. p. 812) pointed that all Down’s syndrome patients have neuropathological lesions similar to those of Alzheimer’s disease by the age of 40. Between 40-50 years, 5 to 10% of Down’s syndrome patients will manifest dementia similar to Alzheimer’s dementia.
McCarron and colleagues (2002, pp. 263-379) pointed that dementia (Alzheimer’s like) is a common problem in this client group, which results in carers taking more time in their care giving activity. Dementia necessitates the change of care into supervising the individual’s activities of living, responding to behavioural problems. Increased alertness to safety features, and paying enough attention to disturbances in normal daily activities imposed by the disorder as repeated night awakenings are other problems to attend (McCarron and colleagues, 2002).
In addition to syndrome specific manifestations of the elderly with learning disabilities, Janicki et al (2002, pp. 287-298) surveyed 1373 adults with learning disabilities and results suggest that 73% of the surveyed sample show sensory impairment before the age of 59. In other studies, the prevalence of mental health disorders in this client group is between 20-40%, and depression prevalence is around 11%. Behavioural changes are reported in elderly people with learning disabilities, most common in the form of dementia related behavioural changes, psychotic symptoms and aggression particularly in Down’s syndrome are also reported (Parry, 2002).
Family carers, social exclusion and policy issues
It is estimated that in the UK, 30000 family members (over 60 years) are performing the caring tasks for an adult relative with learning disability (90% of them are women, mothers or sisters). Of them only 9% considered an out of home placement of their cared relative, the word acceptance describes such commitment. However, this creates the problem of who to fulfil caring of the elder with learning disability upon loosing the primary family carer (Hubert and Hollins, 2000).
Research suggests that elderly people with learning disabilities as a client group receive less day care, respite care, attention from social workers, and have higher rates of untreated illnesses as they receive less input from health services (Hubert and Hollins, 2000). This makes social inclusion as a philosophy of health and social care to develop living environments responsive to the mental and physical needs of this client group and community learning disability nursing team practice two possible partnerships in the road map to care for the elderly people with learning disabilities (Thorpe and colleagues, 2000).
Nursing care for elderly people with learning disabilities
Theory and practice of nursing care
Nursing profession is not a single group it has many subspecialties with various subcultures as paediatric, intensive care, geriatric and psychiatric nursing. Each subspecialty developed a subculture and an individual identity because of differences in working areas, skills required and specific traditions followed. However, in all cases the public has high expectations of nurse caring. This makes defining nursing care a difficult task despite the many references on caring theories, however; the studies did not cross over the descriptive nature of nursing care.
A look to how nurses and patients look at care may provide a deeper understanding to care and can guide nurses to improve nursing care quality (Bassett, 2004). Bassett (2004, pp. 29-30) reviewed the literature on how nurses understand patient care, their role in the caring process and the studies that looked on how patients perceive nursing care. Bassett inferred the studies showed nurses attach high importance to the interpersonal side of caring or the humanistic facet of care.
Patients in many studies shared the same concept; however, in some studies, there were different perceptions that is patients may value higher levels of competency but not on the expense of the humanistic side of caring. Bassett (2004, pp. 29-30) also inferred the differences are context-dependent based on the patient’s circumstances in other words, what an acutely ill patient needs differs from what a chronically ill patient needs. This represents a challenge to nurses as the patient needs are dynamic and changing while they have to provide care mixed with skill at the right time with proper emphasis and in the right way (Bassett, 2004).
Learning disability nursing
The history of learning disability nursing relates to the history of learning disability previously based in large institutions. During the first half of the 20th Century, this nursing subspecialty was looked to as a part of mental nursing and named mental deficiency nursing. It is true they shared many traits and skills yet; the essential difference was the aim of (mental deficiency nursing) was primarily training to achieve long-term care rather than cure.
This was why these nurses were considered carers but not real nurses. During the last 35 years major social policy changes occurred, which affected the philosophy and practice of nursing people with learning disabilities. Four essential social policy changes occurred, first are the shifts from log-term stay hospitals to community settings, second is the mixed economy of care, third is introducing the concept of care planning and care management.
Finally is the developing role of the caring team in the framework of health and social care provision. Consequently, learning disability nursing developed to accommodate the changing philosophies and practices developing new skills and practices of working with this client group (Raghavan and Patel, 2005). Raghavan and Patel (2005, pp. 116-127) identified the role of learning disability nurse is to provide tailored individualized to people with learning disabilities and their families, integrating their work with other disciplines to create alternatives to hospital care.
To achieve this goal, a learning disability nurse has to have the following key tools, first is to develop partnership and reciprocal reaction in the nurse-patient relationship, and second is to provide caring and psychological comfort. Other tools include, handling the environment to create a therapeutic environment and to use evidence-based interventions (Raghavan and Patel, 2005).
The UK model
In UK the changing nature of learning disability nursing has been influenced by five main factors, which are policy changes, specific legislations, nursing training and education, consequent changes in nursing practice and recruitment (Minto, 2001). O’Brien and Joyce (2000 pp. 22-24), pointed the main change of learning disability nursing in the UK is it passed to the post hospital (institutional) era with most learning disability individual cared for within the community. Besides, the experience gained overtime to understand and meet the psychological needs of this client group resulted in the development of a network of local integrated services.
The structure of these networks is specialist inpatient units working in coordination with community learning disability teams (O’Brien and Joyce, 2000). Barr (2004 p. 5) recognized the main role of learning disability nurses is facility dependent and not in specialist hospitals, Barr also identified three community-based settings where learning disability nurses can function. These are nursing and residential homes where the client group is usually adults with learning disabilities and inter-related complex physical and or mental needs, second is special education and day services where the client groups are children up to 16 years (Barr, 2004).
The third community-based facility is community learning disability nursing teams, which started in the UK in the mid 1970s as an outreach hospitals service to support people with learning disabilities and their caring families living in the near community. It developed into a large service and became an integral part of community-based services targeting people with learning disabilities (Hassiotis and colleagues, 2003).
Nurses usually work as members of interdisciplinary community learning disability teams providing services within a certain geographical area. They provide specialist nursing care different from day to day care provided by the district nursing. The main reasons for their involvement are challenging behaviour, mental illness, providing advice and support on physical care and management of epilepsy, besides advice about aging related problems and health screening and health promotion services (Barr, 2004).
The Roper-Logan-Tierney Model of nursing framework
The nursing process is a series of tasks or changes of actions aiming at a desired individual’s health result, during which a nurse takes systemic and dynamic actions to meet an objective and uses assessment and feedback to redirect actions targeting the objective. The nurses use the nursing process to tailor interventions and care to the individual’s needs. A nursing model is different from a nursing theory in that a model is a symbolic representation of a theory portrayed to demonstrate how to put a theory into practice. Nursing models are frameworks for nurses to base their patients’ assessment and determine suitable interventions; however, they have the inherent limitation of being as useful as the underlying theory (Evelyn and Melanie, 2002).
The basic concept of this model is life span approach (continuum) where individual pass from fully dependent on others during infancy to self-independent during adulthood then to dependent during old age until death. Roper, Logan and Tierney (2002) included foetus as a fully dependent phase of the course of life (Matousova-Done and Gates, 2006). The model identifies a set of twelve activities engaged in by all individuals whether sick or well during their life course.
These activities are maintaining a safe environment, breathing, communication, mobilizing, eating, drinking and eliminating (excretion), personal hygiene and clothing, keeping body temperature, working, playing (leisure), sleeping expressing sexuality and dying. Collectively these activities represent the model of living and each one is interpreted in the lights of life span continuum from dependence to independence, and in nursing practice, it is used in conjunction with the nursing process (Matousova-Done and Gates, 2006).
Several factors influence the model framework since they change the dependence-independence level of individual with learning disabilities, as sociocultural, biologic, environmental, psychological, and political-economic. Therefore, the model can be modified according to the nursing practice setting by adding pain for example when it is a significant activity in the individual model of living based on the individual’s need (Ruddy, 2007).
During the course of life, an individual may turn from independent to dependent (as with acutely ill patients) or become more dependent as is the case of the elderly with learning disabilities. This is when the truly valid role of community learning disability nursing team comes (Matousova-Done and Gates, 2006). The needs of elderly with mental disabilities as a client group are variable and differ from the need of older people; this makes a universal care in older people nursing homes or hospices not suitable for the client group of concern (Thompson, 2001).
This is another instance when community learning disability nursing team comes, being modifiable, the model can be tailored according to each individual’s needs (Matousova-Done and Gates, 2006). Some researcher argue this model is not suitable for learning disability nurses as it does not consider life activities like education, employment, or taking part in societal activities (Brittle, 2004 after Matousova-Done and Gates, 2006). However, being modifiable the model allows judging the traits of the individual in the lights of prior development, culture, and present level of development and therefore designing a model according to the individual’s specific needs (Ruddy, 2007).
Conclusion
Better health care and social policies resulted in increasing the life span of individuals with learning disabilities. The changing polices to community base care puts learning disability nursing teams at a prime place in care and support of this client group. Health problems of this group of individuals are complicated and multifaceted. The Roper-Logan-Tierney Model of nursing is a suitable nursing framework for this particular setting, it modifiable and can be tailored to meet the needs of an individual and pays special attention to the level of dependency of this client group.
References
Barr, O., 2004. Nurses for People with Learning Disabilities within the United Kingdom: an Overview and some challenges for the future. IJNIDD, 1(1), 5-14.
Bassett, C., 2004. Nursing Care: From Theory to Practice. London and Philadelphia: Whurr Publishers.
Cratty, B., J., and Goldman, R., L. (1997). Learning Disabilities Contemporary Viewpoints. 2nd edition. Amsterdam: Harwood academic publishers.
Evelyn, W., M. and Melanie, McEwen, 2002. Theoretical Basis for Nursing. Philadelphia: Lippincott Williams and Wilkins.
Hassiotis, A., Tyrer, P., and Oliver, P., 2003. Psychiatric assertive outreach and learning disability services. Advances in Psychiatric Treatment, (9), 368-373.
Hubert, J. and Hollins, S, 2000. Working with elderly carers of people with learning disability and planning for the future. Advances in Psychiatric Treatment, 6, 41-48.
Janicki, M., P., Davidson, P., W., Henderson, C., M., MaCallion, P., Force, L., T. et al, (2002). Health characteristics and health services utilization in older adults with intellectual disability living in community residences. Journal of Intellectual Disability Research, 46(4), 287-298.
Matousova-Done, Z., and Gates, B., 2006. The nature of care planning and delivery in intellectual disability nursing. In Gates, B., ed. Care Planning and Delivery in Intellectual Disability Nursing. Malden, MA: Wiley-Blackwell, 2006. 1-20.
McCarron, M., Gill, M., Lawlor, B. and Begley, C. (2002). Time spent care for persons with the dual disability of Down’s syndrome and Alzheimer’s dementia. Journal of Learning Disabilities, 6(3), 263-279.
Minto, C., 2000. Contemporary Issues in Learning Disability Nursing-A UK Perspective. Hong Kong J Psychiatry, 11(1), 25-28.
Nursing and Midwifery Council (2004). The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics. London: Nursing and Midwifery Council.
O’Brien, G., and Joyce, R., J., 2000. Adult Learning Disability Psychiatry Services: Local Implementation of National Guidelines. Hong Kong J Psychiatry, 10(4), 22-24.
Parry, J. R., Editor, 2002. Overview of mental health problems in elderly persons with developmental disabilities. New York: National Association for the Dually Diagnosed (NADD).
Raghavan, R., and Patel, P, 2005. Learning Disabilities and Mental Health: A Nursing Perspective. Malden, MA: Blackwell Publishing Ltd.
Rice, J., and Robb, A. (2004). Learning to listen. Nursing Older People, 15(10), 10-13.
Ruddy, M., 2007. Models and theories of Nursing. Milwaukee: Cardinal Stritch University Library.
Teipel, S., J., Alexander, G., E., Schapiro, M., B., Moller, Hans-Jurgen, et al, 2004. Age-related cortical grey matter reductions in non-demented Down’s syndrome adults determined by MRI with voxel-based morphometry. Brain, 127, 811-824.
Thorpe, L., Davidson, P., and Janicki, M. P. (2000). Healthy Ageing – Adults with Intellectual Disabilities: Biobehavioural Issues. Geneva, Switzerland: World Health Organization.
Thompson, D., 2001. Meeting the needs of people with learning disabilities. Nursing and Residential Care, 3 (8), 364-366.
Ward, D. (2000). Adult Elderly Care Nursing, Ageism and the abuse of older people in health and social care. British Journal of Nursing, 9(9), 560-563.