Day In The Life Of A Dementia Nurse Consultant

Meet Amanda Crombie, a Nurse Practitioner Candidate and Dementia Nurse Consultant. We chat with Amanda about what her area of nursing is all about, discuss in-depth different aspects of dementia, the impact of losing her husband to dementia and her visions for the future of aged care and dementia nursing.

Introduction

I trained at the Alfred Hospital from 1982 to 1984 and as you can see from the picture this required me to wear a long dress, starched apron, collar and cuffs, a silly hat and sensible brown shoes! After finishing my training I worked for about 30 years in reproductive medicine.

I am currently a Nurse Practitioner Candidate working as a Dementia Nurse Consultant in a community health setting in East Gippsland, Victoria. The region I cover is 21,000 square is kilometres so I do a lot of driving.

I have two golden retrievers called Bob and Bonnie who have big hearts and no brains, 18 chooks, a beehive, and two goats. I have no children but I live next door to my brother who was good enough to marry my best friend and I am very close to their children. I have a lovely garden and a view to die for.

What inspired your move from reproductive medicine into aged care nursing in 2011?

Having spent around 30 years working in reproductive medicine, firstly in an IVF program in Melbourne and later as the sole provider of services in ovulation induction and artificial insemination program I ran in East Gippsland I was at a bit of a loose end when my boss retired. After several months of pottering around my garden and driving my chooks, dogs, and horse nuts I came to the realisation that I wanted to find a nursing job that afforded continuity of care because this was one of the most satisfying parts of working in infertility.

This led me to a job in an aged care facility, which is about as far from IVF as you could possibly get!
The last time I had anything to do with a patient over 45 was during my training working in a medical ward where people used to languish awaiting a bed in an aged care facility, which in those days were few and far between. Thanks to the internet I was able to do a crash refresher in geriatric nursing. One of the greatest surprises to me was the proliferation of drugs. When I last pushed a drug trolley around in the early 80s the MIMS annual was one thin volume, ACE inhibitors were being trialled at the Alfred, and polypharmacy wasn’t a big issue!

This is one of the many beauties of the nursing profession. Once you have the fundamental components of the profession under your belt you can refine your skills in any direction you wish, and everything you have done before contributes to your skillset.
It wasn’t long before I appreciated that many of the people living in residential aged care had some degree of cognitive impairment and this seemed to be on the increase.

Realising that I knew nothing about dementia I took some time one weekend to look into it. This led to a snap decision to commence a Bachelor of Dementia Care through the University of Tasmania. My last experience with tertiary study was in the late 70s so this could have been a stupid idea.

At the outset, while I was properly learning how to use a computer for more than just data entry and refreshing my skills at academic writing, I really did question my decision. However, five years later, at age 60 and with a newly acquired Seniors Card I graduated as valedictorian so my decision was vindicated, and it was the best thing I’ve done for my career, hands down.

Talk us through your role as a Dementia Clinical Nurse Consultant in a community health centre. What does your average day entail?

My average day sees me on the road to a client’s home where I conduct a holistic assessment. Before I begin my assessment, I take time to put cognition in an age-appropriate context, given that as we age the function of our prefrontal cortex changes, so we have more difficulty both focusing and dividing attention, our cognitive processing speed slows down somewhat, and we have more trouble than we used to come up with names for people and things.

It is reassuring for people to appreciate this, and it sets them up to be more relaxed about the testing to come. It is also important for me to eliminate any potential organic causes for cognitive problems (such as a deficiency in B12, poor thyroid function, or the presence of depression). Likewise, it is important to know the person’s education history because this will influence how they perform in testing, as will any sensory loss they have.

Critical to forming a diagnosis is an understanding of the impact that cognitive problems are having on the person’s ability to function independently. It is also important to understand the quality of social supports that are in place to assess how well the person might manage to stay safe if they are living on their own. In essence, my visit provides a window to all this.

The outcome of my assessment is a report I formulate and send to the patient’s GP and add to our in-house patient record system for other health professionals in my organisation who share my client. Contained in my report are the details of performance in the screening tests, but I have to be careful to describe this in a way that is meaningful to the reader as many health professionals have a limited understanding of what the tests are actually measuring and what the results mean.

Therefore, I write the report in a way that makes it clear why the person might be having difficulty with particular aspects of their daily life which allows the reader to appreciate how the person needs support. It is outside my scope of practice to make a diagnosis, and though I know what I see when I’m looking at it, I have to be careful how I frame my report so that it is not interpreted as a diagnosis by the reader, and this is one of the challenges I face as a practitioner.

Tell us about some of the common challenges you face?

One of the challenges I come up against often is assessing people who completely lack insight into the cognitive problems they are having. These are the people who generally fare worst, as they shun the support they so desperately need. Those who live alone and aren’t aware of their cognitive problems are the cohort who are the most likely to end up at the hospital with accidental poisoning from taking too many tablets in one day or after having a fall because they are confused by being dehydrated from forgetting to drink.

Recognising this pattern and identifying the factors that suggest potential cognitive problems I developed a Red Flag tool for use by our district nurses and home care workers which enables them to identify someone whose cognition needs assessment. It would be good to secure some funding to roll this out more widely.

What aspect do you find most rewarding about dementia nursing?

Most people are very appreciative of the opportunity to have a cognitive assessment as they have been either overtly or covertly worried about their cognition for some time. The opportunity to have a discussion with the person and their loved ones about the situation they find themselves in and a chance to offer some strategies to address the issues they have is much appreciated by almost everyone, and they relish being able to verbalise what has been unsaid for a long time.

People fear dementia and worry that they are developing it and it is very satisfying to either allay their fears when they prove to have not a lot to worry about (yet) or to reassure those who have problems and be able to steer them towards the appropriate referrals for further investigation. Given that we are yet to find a cure for dementia I feel it is important for me to provide clients with ways to support their brain health (eat a Mediterranean style diet, sleep well, exercise regularly, address hearing loss, do interesting things, and stay socially connected) because reducing risk factors is the only option we have at present. Being able to offer support in these ways is very rewarding.

What keeps you motivated in your role as a Clinical Nurse Consultant?

It’s not hard to motivate me. I’m a bit like the Duracell Bunny! Nursing has been a gift that keeps on giving to me and I feel very grateful that I went down the path I did all those years ago that led me to where I am today. How lucky we are as nurses that we can do something every day to make life better for another person and get paid for it! I feel a responsibility to share what I know with others, and I enjoy the opportunities I have in my work to share my knowledge with new graduates. This motivates me too.

What do you want other health professionals (ie: nurses) to know about dementia?

For anyone who works in a setting that involves care of older people a fundamental understanding of what dementia is and how to support someone with dementia is essential to the delivery of best-practice care. There is certainly a lack of dementia-specific knowledge amongst health care professionals which urgently needs to be addressed so that the increasing number of people living with dementia in our community are cared for by people who have at least a rudimentary understanding of dementia and dementia care.

It is quite shameful, for example, that people with dementia who have responsive behaviour associated with an unmet need continue to be prescribed dangerous and ineffective antipsychotics at an alarming rate, and it has been shown that the driving force behind this is nurses. Better knowledge of dementia and better support of our aged care nurses would go a long way towards remedying this.

What are some common misconceptions?

That dementia is just about memory loss. This is certainly true for people who have the beginnings of Alzheimer’s disease where the first symptom is problems with short-term memory. However, people with cognitive changes associated with vascular problems are more likely to have problems with their executive function, such as planning and organising rather than problems with their memory so they slip under the radar.

This is a problem because we need planning and organising skills to carry out the higher-order functions such as cooking, paying bills, taking medications correctly and driving. You can probably see where this might end!

Another misconception that I’d like to dispel, seeing as I have the platform to do so, is that working in aged care is all about making cups of tea. My time working in aged care was an enlightening experience, to say the least. I gained a true appreciation of the skills required to care for frail elderly people and their families in a setting that to staff is a place of work but to the residents is a home.

This is quite a balancing act, and the Covid-19 pandemic has shown how just how hard it is to make a home-like environment fit for purpose when it comes to things like infection control. The other balancing act in aged care is dividing time between important clinical work and the endless paperwork that accompanies the job.

In many facilities the registered nurse works as the lone clinical practitioner, bearing a big weight of responsibility and an impossible task every day.

What are some key skills required when supporting a patient and their family through a diagnosis of dementia or cognitive impairment?

Listening and not interrupting would have to be the most important skill. I also feel it is important to reassure people upfront that I am not planning to take their driving licence off them or put them in a nursing home as a result of my visit. Once they are told this they tend to be far more relaxed and accepting of what I am there to do. It is also important to realise the limitations of screening tools and not use them as a weapon!

Given that 80% of the diagnosis of dementia is made on the collateral information gained through history taking and an understanding of the impact of the cognitive impairment on function over time it is a skill to make people comfortable enough to give you an honest response to your questions so that your history taking is accurate. To be honest, sometimes it is a skill to get one foot inside the door!

Do you find it challenging to work as the sole practitioner in your region?

Although I am the only Dementia Nurse Consultant in the very large region I cover I am fortunate to have had experience working as a sole practitioner for many years so nothing phases me. I am also grateful to be surrounded by a group of fantastic multidisciplinary colleagues and I have a Nurse Practitioner colleague who works in Palliative Care close by to consult with when I feel the need. In 2021 thanks to the Internet we are never far away from someone or some information to guide us.

Which other health professionals are involved in the multidisciplinary team within your work?

Where I work there are speech pathologists, physiotherapists, podiatrists, occupational therapists, a dietitian, a diabetes educator, chronic disease nurses, district nurses, and GPs.

You have personal experience with dementia, with your husband being diagnosed during your studies?

Ironically, while I was studying dementia at UTAS my partner began showing signs of dementia and in 2018 he was diagnosed with this condition. When he died in April this year it caused me a great deal of sadness for the years lost together but also some relief for the end of his suffering. This experience has certainly given me great empathy and a deep understanding of the effects of dementia. I feel that having had the experience myself has made me able to anticipate what is behind some of the questions I am asked by people and this has allowed me to answer authentically.

Do you think having an indepth understanding of the disease made it easier for you to accept your husband’s diagnosis?

One thing that I often reflect on, having lived this experience alongside my partner, is that although I was taught to refer to people with dementia as people living with dementia and not suffering from dementia, I do not agree. While people can live with dementia they really do suffer with it too, and I feel we do them a disservice to not acknowledge this.

What is one patient interaction you will remember forever?

Truly, after 41 years of nursing, you are asking me to pick one!!! I fondly remember a woman I went to see when I was working as a district nurse and doing health assessments. She was a 99yo ex-nurse. One of the components of the assessment is a test called an up-and-go test which forms part of a frailty index. It requires you to time how long a person takes to get out of the chair, walk a short distance and return. I told my patient this was what I intended to do but before I could turn on my stopwatch she had already been up and gone!

We then discussed balance and I made the comment that it gets harder as we get older to stand on one leg. She agreed this might be a problem but that she hadn’t considered it and then stood up and proved that it wasn’t a problem for her because she could stand as well on one leg as she could on two. A remarkable woman who made me appreciate that we are not defined by our chronological age.

How do you propose healthcare can be adapted to better meet the needs of patients with dementia or cognitive impairments?

We currently have over 472,000 people in Australia living with dementia, and this number is predicted to increase to 1,076,000 by 2058 so we need to be prepared. We need to lobby our governments hard to ensure that the Royal Commission findings do not gather dust on a shelf. We need to hold them to account because we are all heading in the direction of old age and when we get there, I’m sure we all want to find that the services we require are fit for purpose and are delivered by people with appropriate skills.

I have just read a recently published article which discussed the Covid-19 pandemic in the context of the social determinants of health which suggested that an important measure in the provision of a just and sustainable post-Covid-19 world is the strengthening of public sector provision of health care and the stopping of further privatisation, commercialisation, and outsourcing.

The authors suggest that governments should dedicate 5% of GDP to achieve this. This makes perfect sense to me, and I believe it would allow for better regulation and governance of the aged care sector and more investment in the human resources we so greatly need to care for our ageing population.

As a stark example of the differences between private and public sector aged care one only needs to consider the huge difference in the numbers of people who sadly lost their lives from Covid-19 in private aged care in Victoria (around 900), compared to the 5 who lost their lives in public aged care. We also need to pay our aged care nurses better and provide a nurse to patient ratios that are manageable. If the conditions for nurses working in aged care were made better we have a fighting chance to make it an attractive career prospect. If we don’t them our aged care system is doomed to remain as it is and this has been shown by the commission to be not fit for purpose.

Where would you suggest health professionals go (resources/courses) for more information about dementia?

We are lucky in Australia to have some fantastic free online education available through both Dementia Australia and Dementia Training Australia. I have sampled many of their courses and highly commend them to anyone who is keen to improve their knowledge of dementia. A particularly good that I can recommend is one is called The View from Here, designed for nurses working in the acute care sector. UTAS also has some fantastic MOOCs which only go for a few weeks (Understanding Dementia, Preventing Dementia, and a new one I have just completed called Understanding Traumatic Brain Injury).

You are beginning a Masters of Nurse Practitioner soon. What do you hope to achieve once you have completed this qualification?

Nurse Practitioners have been identified by the Aged Care Royal Commissioners as part of the solution to the many problems they identified during the Royal Commission, and I have a vision of creating a cohesive aged care team within my organisation that can collectively provide high quality, streamlined, and holistic service to our ageing population.

What is your key takeaway message to readers of this article?

My advice is to never stop learning and don’t use your age as a reason not to. Look at CPD as an opportunity to get better rather than a chore to be tolerated, and please, please, please make some of it about dementia. My parting words and my mantra is the advice given to me by a wise charge nurse when I was having a meltdown over some minor disaster – “Unless the person has died you can fix it!”