Krishna Prasad Pathak Biography
Krishna Prasad Pathak, is a Gerontologist, researcher, editor and lecturer on Dementia issues. He has worked as a lecturer for General Medicine (HA), public health students BPH) and General medicine (HA). Currently he is appointed as a purple Angel Ambassador UK-Nepal, 2016, Alzheimers Association, USA committee member 2016-2017, and guest editor of Journal of Behavior Therapy and Mental Health. Further, conducting seminars and presenting scientific papers. His research interests are; Neurocognitive, neuropsychology, cognitive training and intervention, dementia risk; and management, prevention and care of late-life, Dementia and dementia related disease, Mental health, mental illness 3) Gerontology/aging, and health services.
The situation of Dementia & its issues. August 2, 2017
The word dementia comes from the Latin de meaning “apart” and means from the genitive mentis meaning, “mind”. Dementia is the progressive deterioration in cognitive function – the ability to process thought (intelligence). Dementia is significantly more common among elderly people &its syndrome found almost exclusively in the elderly (Hugh C.1997). However, it can affect adults of any age. Dementia is more than a mere memory problem. It is the gradual decline of mental functions and overall personality, including memory, without visible change in alertness. People with dementia gradually lose their previous skills, as well as other executive mental functions like planning, judgment; abstract thinking psychiatric disorders such as agitation delusions, depression are very common in patients with dementia etc. Dementia is therefore quite separate from the symptoms of normal aging. Wisconsin Medical journal finds that the dementia is being public health problem that is under recognized in primary care settings. It is pointed that the primary care physicians fail to recognize, findings & proper managements with the having demented disorders.
Similarly, the dementia illness & AD (Alzheimer disease) pose a significant public health & Since 1970s, the china’s population is being aging due to the life expectancy & drastic reductions in fertility. In china, the dementia problem is quickly increasing. It is estimated that about 5 percent of people (fewer than 65 years) suffer from dementia all over the world. Out of all types of dementia, more than half are due to Alzheimer’s disease, a condition in which the brain produces insufficient amounts of a neurotransmitter called acetylcholine. It is more a greater problematic only for those patients who are suffered by this dementia. After that dementia is problematic for care givers, family member, doctor & whole nation because it takes more time due to its vague sign & symptom. It is estimated that from 2005 the prevalence of dementia of 24.3 million with 4.6 million new cases of dementia every year. The number of people will affect double every 20 years to 81.1 million by 2040. The number of older people & their proportion of the population had been rapidly increasing between 1964-1982. The number of older peoples (0ver 65) doubled while the population under 14 grew by only 20 percent. Care givers & clinical persons found difficulties to diagnose the real problem of dementia in patients due to the high care of elderly people at home, nursing home & caring centers. In the case of patients with high care, the sign & symptoms of dementia is hide for general practionars. The rate of dementia will be double every years such that by 2050,more than 100 million people or nearly 1 in 85 persons will be affected worldwide.
Till now, there is no specific cause to lead dementia but following are the fundamental causes. The most common causes of dementia are:1) Alzheimer’s disease 2 ) stress 3) Dementia due to drugs and other substances alcohol,4) Brain tumor,5)Neurological disorders like Parkinson’s disease, Huntington’s disease 6)Head injury7)Mal-nutrition9)Endocrine abnormalities 7) Infection of the brain 8) Vascular Dementia (due to stroke 11) over excessive alcohol 13) Communicative difficulties.
Nepal is a developing country in a south Asia having such problem in Nepalese elderly people. There has been rare national survey done to estimate the number of dementia patients in Nepal Although dementia did exist in the past, it seems to have gotten worse in recent years due to two reasons—firstly, the increase in old age population with better life standards and health facilities; and secondly, the disintegration of the joint family, with younger family members migrating to foreign countries, which has put increased mental pressure on the elderly. Likewise, there are no specialized centers to dementia, not even in the nation’s top medical colleges. Which is concerning, because the burden of the care of old people with dementia is bound to increase in Nepali society for the same two reasons stated above—increased longevity and disintegration of joint families. The nursing care is the only practical solution at present.
The number of old age homes mushrooming in the private sector is the proof enough of the need of dementia care. There are some programs for old age people at present; unfortunately, these tend to be politically motivated. It is high time that stakeholders consider the integration of mental health services designed for the elderly, besides merely handing out old age allowances. But the problem is completely ignoring in Nepal. In Nepal generally elderly peoples are beyond the concern of family, caregiver centers, parents & society. Due to less concern of the patients & health works they are not able to improve their problems. In this way Nepalese elderly people are facing mental problems such as phobias, change in appetites, loss of interest in activities, loss of energy, helpless, fatigue, recurring thoughts of death or suicide, fatigue, low self-stem, depression anxiety, conduct disorder, deficit disorder etc. By this, the conclusion can be drawn that Nepalese elderly people are also the part of that numbers. But till date, no research can be found that were conducted in Nepalese elderly people.
To date, it is difficult to estimate (scientific data) the number of dementia patients. Although dementia did exist in the past, it seems to have gotten worse in recent years due to the increasing of old age population with better life standards and health facilities; the disintegration of the joint family, with younger family members migrating to foreign countries, which has been leading increased mental pressure on the elderly. And except these some other causes are leading causes like; confusion with other treatable conditions that causes are; depression, memory loss, urinary infection, vitamin deficiency and brain tumour.
In Nepal there is virtually no awareness of this dementia problem amongst public, professionals and policy makers. Even if it is not recognized as dementia, the illness places a heavy burden with the both elderly patient and their relatives. It can be estimated that currently about 135,000 people would be suffering from some kind of dementia in Nepal. This figure is likely to double every 20 years. No scientific published data are available on the number of dementia patients in Nepal. Similarly, there has been no national survey done (than this study) to understand the health professionals’ knowledge/attitudes, practices and obstacles to diagnose/management and care in Nepal.
In current situation of Nepal the nursing care in psychiatric/mental based hospitals are as practical solution spot. Nepalese physicians and nurses need more knowledge towards the diagnose dementia and to minimize the obstacles on caring process in hospital. It is demand to identify to solve the solution of dementia problem in patients by the general practitioners (GPs). Physicians and GPs should be encouraged and aided in developing local collaborative models that maximize available professional and agency resources. The need for educational programs and health-care policies that help to increase awareness of dementia in Nepalese HPs, nursing practice, management and care thereby improve the care provided to Nepalese people. General practitioners are failed to diagnose due to the over pressure of patients in clinical room, longer treatment process, patients less alertness to follow up, misunderstanding to dementia, access of health care services and caregiver’s less support etc. The majority of primary health care practitioners find that it is difficult to diagnose on health care intuitions in Nepal. To diagnose the dementia properly, it is important to have the trained health professionals, appropriate equipment and guidelines too.
Dementia is a burden issues for physicians, family members, caregivers and patients. General practitioners’/physicians’ knowledge and practices of dementia diagnosis and management is not satisfied due to the poor knowledge of epidemiology. The main difficulty for physicians is that the communication process with the patients is not one that allows for easy diagnosis of dementia. Likewise, another difficulties identified by the physicians are talking with patients about the diagnosis responding to behaviours problems and coordinating support services. The other factor is the lack of time and lack of social services support as the major obstacles to good quality care more often than they identified their own unfamiliarity with current management or with local resources. Some of general practitioners believed that dementia care responsibility goes to within a specialist’s- not only alone by the GPs.
The care of older age people with dementia is bound to increase in Nepali society for the same reasons stated above-increased longevity and disintegration of joint families etc. In Nepal, some programs for elderly people are setting up at present by the government; unfortunately, these tend to be politically motivated. It is time that stakeholders should consider the integration of mental health services designed for the elderly, besides merely handing out old age allowances. This is the emerging evidence that the dementia problem is gradually expanding as a future crisis and a national challenges in Nepal.
It is true that dementia care service in Nepal is not well prepared to provide in Nepalese hospitals and the policy level of Nepal’s is not excepting to overcome in the future also. At present, in Nepal, the nursing care, psychiatric/mental based hospitals are as practical solution spot. There are key role of mental health resources in the detection of cognitive impairment and diagnosis of dementia as well as there is less number of psychiatrists (0.13), 0.27 nurses and psychological providers (0.19) which does not meet WHO standardization .
Nepalese health professionals need more knowledge towards the diagnose dementia and to minimize the obstacles on caring process in hospital. It is demand to identify the dementia problem in patients by the physicians to solve the solution. Physicians should be encouraged and aided in developing local collaborative models that maximize available professional and agency resources. The need for educational programs and health-care policies that help to increase awareness of dementia in Nepalese nursing practice, management and care thereby improve the care provided to Nepalese people.
Demographic changes mean that dementia will represent a significant problem to manage in the hospital for nurse in future. To solve the problems and solutions with the Nepalese nurses’ community need to adopt to deal effectively with its diagnosis, care and management. As well as, the environment of working place, work schedule and technology/infrastructure may influence the likelihood of negative attitude towards people with dementia. There may be conflict between nurses’ cultural values and care practices in care settings. Therefore, there is a need for ongoing education of nurses, doctors in dementia care that may reduce the unnecessary conflicts regarding with management of dementia issues.
Thus, now a day, it is compulsory to identify the dementia problems and its disorders. Therefore, to find the prevalence of dementia problem in elderly people in Nepal a large scale of study is needed.
Dr. Krishna Prasad Pathak.
There is universal question that who is dementia specialist? Who has the pivotal role on dementia diagnosis, management and care? Also, is there essential to have multi-disciplinary team’s combination to diagnose, management and care? Is this fact that due to the gap of appropriate knowledge the misdiagnosing rate is increasing? Therefore, we were hurried to find the above mentioned, myths and facts and to give a message on this issue.
It is already known that a key person is General practitioners (GPs) for dementia diagnose- GP is a first focal point of contact-usually begins with a GP. General practitioners (GPs) and the primary care team are uniquely situated to play a central role both in the diagnosis and ongoing care of dementia. GPs face several challenges in fulfilling this role owns  (Downs, 1996).
Moreover, the GP can refer a person to a psychiatrist of later life or a Geriatrician to obtain specialist support during the course of the condition. Where a person is under 65, a neurologist may be the consultant referred to geriatrician. A GP can diagnose the type of dementia, cognitive impairment, changes that emerge and manage symptoms and medication, blood pressure, cholesterol and general health screening. However, GPs need to visit more time to declare. People with dementia who need to go five-six- even-eight or nine times, and then referrer to a memory clinic. There might be another false probability to be referred by GPs for memory clinics. With dementia, there is factual reason why primary care can’t give its right contribution on diagnosis and care on right time, that is why dementia diagnosis is being overburden to the patients each time to visit the GPs- only 45% formal diagnosed [56,57] (Alzheimer disease international, 2011; Alzheimer Society Ireland, 2015).
Likewise, a nurse does play a crucial role on earlier diagnosis and appropriate management and care (Bryans M., 2001). A health nurse works with people in their homes, in care center and hospital to help them, to manage their health condition early identification of dementia and the formulation of management strategies for patients and their carers. The goals of nursing care person with dementia in hospital and community settings include: develop the dementia friendly relationship like empathy and trusty, supports for patients for self-care and their loved ones for effective communication, maintain the safe environment for patients, promote the persons’ social engagement. Therefore, those nursing staffs working close to the other staff and residents assess their observations that can prevent unsuitable elucidation and lack of information  (Furaker, et al, 2013).
Thus, the questions remain that who is dementia specialists? This is a complicated disease to diagnose dementia by the only one experts so multi-experts team is necessary for accurate diagnose. The referring process to the neuropsychiatric, geriatric and neurology in dementia might have an important element for the further assessment  (Beck, Cody, Souder, Zhang, & Small, 2000). According to Alzheimer society Ireland (2015) has recommended visiting, below health professionals . For example: General practitioners: who can measure and evaluate cognitively, or ‘thinking’, functions such as memory, concentration, visual-spatial awareness, problem-solving, counting, and language skills If a further more detailed test is required they can refer to a neuropsychologist- a psychologist specialising in the assessment and measurement of cognitive function. Neurologist: who specializes in conditions which affect the brain -is neurologist. When a person is under 65 and has dementia they will often work with a neurologist who can help them to cope with the diagnosis and manage symptoms as they emerge. Geriatrician: The geriatric assessment covers a multidimensional, multidisciplinary domains such as functional ability, physical health(hearing, urinary continence, daily living activities, fecal, abdomen, tremer, rigidity, heart, blood, glucose, balance and cognition), cognition and mental health, and socio-environmental circumstances of elderly  (Elsawy and Higgins, 2010). A geriatrician is often involved in working with people with dementia to help to manage symptoms and talk about medications. Psychiatrist of Older Age or Later Life: who specializes in the mental health of people over 65 is called Psychiatrist of Older Age or Later Life. He works with people with dementia who experience depression or who experience symptoms that affect their personality and behavior. Also, can help you to manage symptoms and work with you to develop strategies to cope with your diagnosis. Furthermore, some others health professionals is called “Support of Mobility professionals in care”: these have been given below in flow figure.
Except these, there are some others treatment approaches like; Cognitive stimulative therapist, Environmental modification, Memory training programs, Montessori based training, Reminiscences training (Harris, 1997), Simulated person therapy (Bayles et al., 2006), Validation therapy  (Naomi Feil, 1982), Diet modification approach.. Downs, M.D. (1996). The role of general practice and the primary care team in dementia diagnosis and management. International journal of geriatric psychiatry, vol.11:937-942.. Alzheimer’s Disease International (2010). The Global Economic Impact of Dementia, UK; Alzheimer’s disease International (ADI) 21 September 2010 Reprinted June 2011, www.alz.co.uk.. Alzheimer Society Ireland (2015). Who is who in dementia care? http://www.alzheimer.ie. Bryans & Wilcock, 2001). Issues for nurses in dementia diagnosis and management. Vol:97. Issue:44. pages no;30. Furaker, C., & Agneta, N., (2013). Registered nurses’ views on nursing competence at residential facilities. Leadership in Health Services. Vol. 26 No. 2, pp. 135-147.. Beck, C., Cody, M., Souder, E., Zhang, M., & Small, G. W. (2000). Dementia diagnostic guidelines: Methodologies, results, and implementation costs. Journal of the American Geriatrics Society, 48, 1195-1203.. Elsawy, B., Andhiggins, K. E. (2011). The geriatric assessment. American family Physicians. Volume 83, Number 1. Pages 47-57.. Harris, J. L. (1997). Reminiscence: A culturally and developmentally appropriate language intervention for older adults. American Journal of Speech-Language Pathology, 6(3), 19-26.. Bayles, K. A., Kim, E., Chapman, S. B., Zientz, J., Rackley, A., Mahendra, N., … Cleary, S. J. (2006). Evidence-based practice recommendations for working with individuals with dementia: Simulated presence therapy. Journal of Medical Speech Language Pathology, 14(3), xiii.. Neal M, Barton Wright P. 2003.Validation therapy for dementia. Cochrane Database Syst Rev. (3):CD001394.
White-Coated Doctors’ Art of Hospital Discharge.
As we know, currently a very numbness news that dozens of white- coated doctors have found fake qualification. We believe life is given by God and life save by Doctor. Therefore, the medical profession is accepted as a noble profession because it helps in saving life of patients- “doctors are always making their best predictions. A patient generally approaches a doctor/hospital based on his/her reputation and the patients do the expectation in two folds: first, both, doctors and hospitals are able to provide medical treatment with all the knowledge and second, they will not do nothing harm to patient in any ways because of their carelessness, financial affordance, negligence, or reckless attitude of their staff- it is not debatable questions. Though a doctor might not be a life saver position of patient’s at all times, he/she is expected to use his/her expertise in the most appropriate way keeping in mind the interest of the patient who has entrusted his life to him. Furthermore, it is expected that a doctor carry out a very essential diagnosis, management and care from the patients unless the patients do not leave hospitals.
These days we are more concern about the doctors’ qualification and reliable hospitals but we never think of art of hospital discharge and its significant effect-it is hiding factors in public- a very important hidden issue. The term of Hospital Discharge is used when a patients leaves hospital once they are sufficiently recovered.
During the civilization the staying in hospital was longer, for example: in Northern America the duration of maturity patients used to stay about 7 days but today they stay 1-2 days, likewise in 60s the heart disease patients were spent 13-16 days. Now days even bypass surgery will take 3-5 days in hospital- Cleveland Clinic said. Patients of abdominal hysterectomy patients in 1960s were occupying approximately 11 days and 52 days of total convalescence! Today, the average hospital staying duration for vaginal hysterectomy is 2 days. The rate of lengthy staying at acute care hospitals significantly is decreasing from the 1960s due to the advancement of medical technology, financial pressure, civilization of community and knowledge of public and modern medical practice. The journal of medicine further added accordingly: stabilizing the patient, minimizing length of hospitalization, postponing complete diagnosis and treatment for the outpatient setting, booting that patient out the front door of the hospital as quickly as humanly possible.
If we talk about dementia the people with dementia usually need further long-term care after leaving hospital, and some may move into a care home. Others need support in their own home or in the home of a relative or community care institutions. The Royal College of Nursing, 2013, reports that around a quarter of hospital beds are occupied by dementia patients because it is not wise to discharge soon. At the end of their life older people with dementia (two thirds) spend their final years in a hospital. Dementia patients have a higher mortality rate during hospital admission compared to similar people without dementia. Likewise, people with dementia receive less palliative care compared with similar individuals without dementia. Health Professionals need to be more aware of palliative care frameworks that have relevance for dementia patients. More than 13% of people require long term care and it is estimated that somewhere between 101 to 277 million dementia patients will need care between 2010-2050. Again, in the UK, if dementia specialist nurses could reduce even for one day the hospital occupancy rate of older people, the amount to be saved almost £11,000,000 nationally. On the other hand- “if dementia care were a country, it would be the world’s 18th largest economy.”
The above mentioned fact arises the questions that is early hospital discharge beneficial for doctors, patients and hospitals? Or raising risks readmission rates? Or is sooner always better, the hospital discharge?
Hochman pointed out the basic four points on regarding for discharge: 1. why the patient is hospitalized? 2. What has to happen for patient to leave safely and early? 3. Where is “home” for this patient? 4. Why patient is still hospitalized-not discharged?
There are many studies those showed the importance of effective discharge planning and care, and have focused the actual advantages in improving patients’ outcomes and rehospitalisation rates. Several studies have illustrated benefits, however, until healthcare financing systems are changed to support such innovations in care, they will remain unavailable to many people. hospitals, caregivers, patients and their family and others are continuing their efforts to alter our healthcare system to make discharge planning a priority. With our dramatically increasing population, these changes are ever more necessary.
Thus what should have the discharge planning? In general we understand that discharge process used to decide what a patient needs to move from one level of care to upper level care.” but the doctor can define /decide a patient’s release from the hospital, or needs more time but the medical conditions, a team approach, a social worker, nurse, case manager or other person might be actual process of discharge planning completion. The basics of a discharge plan are: Planning for homecoming or transfer to another care institution, Evaluation of the patient, Discussion with the patient, Determining if caregiver training or other support is needed, Referrals to home care or care organizations, Arranging for follow-up appointments or tests.
Furthermore, the discussion on physical condition of family member before and after hospitalization; medications and diet , details of the types of care; and discharge facility or care home, information on patient’s condition; what activities is needed to help with the patients; including extra equipment; such as wheelchair, oxygen, commode, handle meal preparation tools/equipment, chores and transportation extra care services.
Benefit of discharge planning
Sonner or appropriate discharge planning can minimise the chances on the following aspects: readmission to the hospital, fast in recovery, to be ensure medications are prescribed correctly, and to care properly. However, very least hospitals are successful in this. The AMA and JCAHO points for discharge planning, there is no globally accepted guideline system in US hospitals. Additionally, patients are released from hospitals “quicker and sicker” than in the past, making it even more critical to arrange for good care after release. Some studies have resulted that 40 % of patients over 65 had medication errors after discharging the hospital, and 18 % of medicare patients discharged from a hospital are readmitted within 30 days. This result does not show a good neither for the patient, nor for the hospital. Also, not for the financing agency eg; medicare, private insurance, and own funds and it helps planning and good follow-up of patients’ decrease the readmissions rate and healthcare costs.
Role of doctors in the discharge process
It is true that the health professionals/ staff will not be well familiar with all aspects of situation and his/her history but as doctors, certainly may know a lot information of the patient and abilities to provide care and a safety care home. The doctors can discuss patients/family’s willingness and ability to provide care for example; physical, financial or other limitations and impact. Some complicated patients need some essential training of special care, techniques, ie; procedures for a ventilator, or transferring someone from bed to chair, wound, feeding tube or catheter care, Alzheimer’s dementia, stroke, or other neurological disorder, impaired memory, older people often have hearing or vision problems, language problem etc. All they need especial care and only docotrs can provide an appropriate discharge process in hospital and after the hospital. Usually, most people looks like in a hurry to leave the hospital and forget what to ask essential care at home. Doctors can teach on Personal care; bathing, eating, dressing, toileting; Household care: cooking, cleaning, shopping; Healthcare: medication management, doctor’s appointments, therapy, wound treatment, injections, medical equipment and techniques; Emotional care: laughing, crying, meaningful activities, social conversation, and community care: rehabilitation, transportation facility, language and cultural.
Typically not to send patients home at 2 a.m. because night hours aren’t generally preferred to discharge. Sunny brook Health Sciences says -Early hospital discharge is a seemingly unstoppable trend that is increasingly associated with risks – as evidenced by rising hospital readmission rates. Therefore, the medical community should discuss on -does the early discharge leads the dangerous? Is it unstoppable trend of readmission? Is it true that “hospital is not exactly the safest place? Most patients would much rather sleep in their own beds and not be exposed to infections in a hospital? Do the doctors do monitoring their patients in hospital?
What should be considered before hospital discharge?
Mainly the following areas must be addressed before to discharge. 1] Medication reconciliation: to do sure that no chronic medications were stopped and safety of new prescriptions. 2] Structured discharge communication: Information on medication changes, pending tests, and follow-up needs must be accurately and promptly communicated to outpatient physicians. 3] Patient education: Patients, family member must understand their diagnosis, their follow-up needs, and whom to contact with questions or problems after discharge.4] Post-discharge tool for patients 5] How to care at home 6] Warning signs and symptoms of complications 7] Medications and all medications as prescribed detailed. 8] Activity restrictions: for how long others misconception of meals personal contamination 9] Surgical site infections and risks. 10] Schedule of follow-up or appointments.