Reflection on the Case of Bernard

While having a group discussion, as the team discussion supervisor I came up with a case study which gave us a platform to make a detailed conversation; which hence forms the background of this reflective essay based on the Graham Gibbs - Reflective Cycle (University of Bradford 2017). The issue at hand was the case scenario of one Bernard. Bernard is a 65 years old man, white British; Born in London. He is married with no children. He does not have a good childhood. He was brought up by a foster parent due to him losing his parent in a car accident when he was 4yrs old. He was neglected and verbally abused by his foster parent.  He has Dementia, Alzheimer to be precise, with a memory problem and COPD. He is very aggressive, abusive to staffs and self-harm. He attempted suicide twice taken an overdose of morphine. He said he always hear voices telling him to kill himself. He likes keeping to himself and only talk to you whenever is in the mood. He does not speak much if he is in the ward but outside the ward he speaks and communicates well. He lost his wife in 2016.He does not like the female staff, talks to them inappropriately with all sort of sexual insult. He dislikes anyone on the weight side and speaks ill of them. He is always negative in all conversation and his fond of swearing and using F words. Other than highlighting what my feelings were and emotional responses, it is equally critical to outline the position of the group members as well as offer the possible solutions for the challenges Bernard is facing.

What My Feelings Were and the Corresponding Emotional Responses

Why Bernard Does Not Communicate In the Ward; Hospital Setting

The experience of patients` remaining quiet and not developing an interest in talking is a typical encounter in almost all clinical settings. Nevertheless, the triggers to such antisocial behaviour are multiple and diverse. For the case of Bernard, I believe his childhood upbringing and the life he is leading apparently is a significant factor to consider. Childhood trauma when he lost his parents at barely four years of age, and the loss of his wife scarcely two years ago; without children and any close relative means Bernard is at best isolated, and most probably needs particular attention. On the contrary, nurses or medical attends are often understaffed or may be too busy to give specialised patient-centred care for every individual, a case that makes Bernard fall out of place.  Because of the mental illness, he is going through, a well-trained and specialised team of experts need to be attending to him consistently (Department of Health 2009). Nevertheless, any generalised appearance and less detailed medical examination or service delivery could at best compromise the personal willingness to enjoy a mutual relationship with the medical staff. While Bernard could resort to quietness as a sign of not wishing to bother the nurses, the medical team, on the other hand, could be too busy to realise the technical and specific needs Bernard requires, hence setting platform of a failed communication between the two.

Why Bernard Communicates Only Outside Of the Ward; Community Setting

Being inside the ward and outside of this facility is a big difference, not only to the medical staff but also to the individual patients. Indeed, it does not come as a surprise for introvert cases inside of the ward to appear all outgoing in the outside environment, as is the scenario in the case of Bernard. Because of the challenges he faces in the ward, and the probably hard times he has with the nursing staff, he finds a new environment to air out his feelings and find closure in the talking. The level of concern and the dignity medical staff have for the patients at an individual level are critical (Holmes 2012). If Bernard does not have a counselling system of service delivery which is better tailored to his emotional, physical, and physiological problems, then he has reason to discuss more with the outside world than the medical team. On the contrary, he could merely be paranoid, stigmatised, or even traumatised by the clinical surroundings. Indeed, the challenge is within the court of the nursing staff to demystify the myth, because if they establish why Bernard does not talk in the ward but communicates entirely while outside, it could be the debut for a better response to his medical regimen.

Probable Kind of Stories Staff are talking about Him Especially the Female

On the one hand, the female staff could be talking negatively about Bernard, and that is why his reaction is very adverse to the female gender. On the contrary, Bernard could be paranoid at best, because of his mental condition. The case scenario of Bernard brings on board a patient who has many cases that need critical care, and all of them are extreme (Strategy 2009). For instance, losing parents to a grisly accident at a tender age, being tormented by foster parents, and eventually entering marriage but without children years later is a significant social and psychological challenge. Moreover, the demise of his wife means he has not a close relative to attend to his issues. The mental sickness he has apparently has messed up his emotional and personal containment.  Well, all the elements above do compromise the personality of Bernard, and predisposes him to paranoia, so that he is unwilling to communicate to the female staff and despise them because of his situation. Furthermore, his relationship with the female gender could be a cause of hatred, and this needs guidance and counselling other than the medical treatments (Bang et al. 2015). There could also be room for backbiting and eaves throbbing by the female staff on Bernard, but this position cannot be supported adequately because Bernard is at based an emotionally distressed individual.

What Medical Staff Do Differently In the Ward?

The litmus test that challenges me to imagine that the medical staff are the ones judged with the responsibility to rectify the fall out with Bernard and not himself is the fact that he talks while outside the ward and not inside. In addition to his compromising childhood and adulthood social backgrounds, the nurses must rise above the cloud of confusion and offer patient-centred care to Bernard so as to improve the situation.  One of the factors the nursing staff should correct is perhaps not leaving Bernard on his own in the ward, and shortening the time of attendance, in that a consistent and continuous quality service delivery framework is established (Choices 2015). In fact, a form of specialised care ought to be put in place, so that       Bernard can access a suitable environment that allows him the freedom to talk and interact with the environment inside of the ward. On the other hand, guidance and counselling are critical, to make him believe that the female nurses do not mean to hurt or mistreat him, preferably, they are part of the team that is willing and able to make him recuperate.

What Was Good/ Bad About the Situation (Subjective Judgment?)

How the Group Responded To the Topic

On reflection of the discussion about Bernard, much information came in handy from the members of the team. In fact, a lot of contributions were given on the issues of risk management issues about Bernard as well as his problems with the female gender. Moreover, the elements of abusive language and the effects of the status of the mental illness about Bernard served to give a better background in understanding his social and clinical life.

Risk management about him

The question of risk management is often critical and controversial when it comes to combined cases of Dementia and Alzheimer, as is the case with Bernard. In the discussion, I preferred that taking into consideration the awareness of physical risk management for him is essential. On the other hand, most researchers are of the contrary opinion, as expertise insight indicates that too much physical attention to bear can easily compromise the social life and interactions skills of the affected individual (Loy et al. 2014). However, in other cases, close attention paid and intimacy created offers a platform for a positive medical response (WHO 2016). Consequently, I found it indispensable that medical staff in the judge of Bernard, who has a mental health condition, ought to have a versed exposure to as far as the mental challenges are concerned, to settle the issue at hand suitably. By offering patient-centred and individualised care, as well as taking the necessary risk factors, a better approach is inevitable.

I preferred that the clinical staff get to understand the person of Bernard in detail before culminating in critical decision making on risk management. First, Bernard is a paranoid patient, considering his challenging upbringing, the lousy taste of adult life, the virtue of his age apparently as well as the Alzheimer condition. Paranoid persons frequently experience a condition termed attribution bias (Holmes & Amin 2016). They cannot differentiate reality from appearance. For instance, Bernard finds it challenging to distinguish intentional behaviour from what happens inadvertently in the ward environment. I think when he feels insecure; Bernard develops hostility toward the female gender, the rest of the staff, and can only find solace in the external world. Frequent paranoia in the word made me believe firmly that Bernard is depressed, feels powerless, and often experience both relinquishing habits as well as isolating himself to make sense of the clinical condition he suffers from. In fact, by being abused and using the F-word, as well as abusing female staff frequently is an indicator of litigious, persecutory, exalted, and erotic paranoia (National Health Service 2015).

Indeed, putting in consideration the risk factors to counter any dire outcomes is critical, because I insisted that people, who are paranoid like Bernard would typically harbour troublesome personalities, would find it difficult to uphold interpersonal relationships. Fear and anxiety, together with other affiliated disturbing behaviour are communion manifestations of paranoid people. With Bernard, I thought a specialised in the area of psychology; guidance and counselling would be suitable to help manage the situation (World Health Organization 2012).

Gender issue

Because of the compromised mental estate of Bernard, I made a hypothesis that he is affected by misogyny, which is the intense hatred and deliberate dislike for the female gender. While in the ward, Bernard is reported to have sexual objectification, sex discrimination, social exclusion, male privilege, patriarchy, as well as violence against women. Experts have shown that when parents die and a child is left in the hands of foster parents at a tender age, it is a delicate situation which could make that child or break him/her permanently (Prince et al. 2015). Indeed, the psychological approach on the case scenario of Bernard informed me better, based on the scientific backing hitherto, to conclude that the fear and anxiety he exhibits is a complete manifestation of what his childhood was like. The imagined threats, conspiracy and persecutory behaviour resonate with the absence of family and social fulfilment. Distrust, false accusations, and irrational phobias are what made me conclude that the hatred Bernard has for female gender is not self-emanated. Instead, the environment is such an essential derivative of the character. Nevertheless, group members were of the understanding that psychiatric diagnosis is a central symptom of the manifestations of gender issues in the life of Bernard.

Abusive to staff

The group of members was of the strong understanding that the clinical estate of Bernard and how he behaved was the definite pressure that caused the abusive and contemptuous character toward the staff. The social distress of the recently deceased wife, lack of children in his marriage, and mental disease all have contributed to his accelerated memory loss, confusion, predisposition to needing specialised care and exclusive attention, as well as the perpetual social relations trouble (Kingston & Ellett 2014). Members of the group deliberated that Bernard needs a more personalised space than being cared for in a conventional ward. Private position when being dressed, bathed, as well as critical care to avoid getting lost and hence attracting public ridicule is essential (Kingston & Ellett 2014).  The sleep disturbances, psychological distress, hallucinations and paranoia together with changes in personality ought to be understood beforehand, and this would give a transparent background of which kind of person the staff would be dealing with. Moreover, group members suggested that the language skills could be lost, as is the case with severe dementia; hence Bernard becomes abusive and vulgar in his communication. Indeed, the abusive nature of Bernard to the staff needs higher clinical and psychological insight on the part of the staff, to handle in not as an offensive patient, but rather as one who needs specialised care.

His mental illness

Bernard has a psychological condition; which presents with the symptoms of dementia as well as Alzheimer. Among other manifestations, agitation, memory loss, disorientation, delusions, and paranoia are common. Typically, abnormal depositions at the nerve cells as well as the shrinkage of the human brain are the triggers of Alzheimer (Kingston & Ellett 2014). Nevertheless, since dementia is no one specific clinical condition, it could as well be a manifestation of the many mental instabilities Bernard is suffering from. For instance, vascular dementia, Alzheimer`s disease, frontotemporal dementia and affiliated ailments (Thewissen et al. 2008). The daily operations, as we discussed, are the common elements that characterise dementia and the presentation of Alzheimer. Impair reasoning, rude behaviour, and being a social misfit without intention is such manifestation.  Professional treatment and specialised care are needed for Bernard, maybe before he advances to senile dementia, a more serious condition that comes in with the advanced age and mental decline due to Alzheimer. It emerged that Bernard could be most probably suffering from cortical dementia, because of the loss of skills to master and use language appropriately, as well as the lack of ability to perceive his environment and relate appropriately..

What Sense I made of the Situation

Environmental Influence on Him

The environment is one central factor that makes every living organism. Hence the upbringing and the later life of every human person is the most affected by the environment. While a young boy, Bernard lost his parents to a grisly road accident. Psychological, emotionally, mentally, and socially, Bernard must have been distracted significantly. In fact, guidance and counselling coupled with consistent moral support seemed inevitable at such a moment in life (Huang & Mucke 2012). Nevertheless, I found it worrying that the foster parents who took over as guardians could not help but torture Bernard. Such a precarious moment predisposed him to a future uncertain, problematic, and full of fear and anxiety at best. The stigma that leaves s a permanent sequel has been reported to occur among minors, whose hope in childhood life is considerably parent sourced. 

It would later manifest that Bernard gets married but without children in the whole of his adult life. Social life is critical and typical for all people. A lack of children may be because of infertility, or other reasons is at most stigmatising in the society. In fact, depending on the mode of culture and traditions of a given community, one could become a reference to failure, shame, and prejudice among folks (Huang & Mucke 2012). I considered that Bernard must have gone through this experience, because of his behaviour and desperate character in his adulthood. Thinking that he had no parents, and the foster parents had created fear in him to develop friendship and intimacy with non-relatives, his wife must have been the only friend and source of hope in Bernard’s life.  Now that the wife passed on barely two years ago, Bernard is probably a messed up and poorly destabilised character, whose emotional stability is compromised adversely. In essence, the environment from childhood to adulthood has influenced the current sorry state of Bernard (Reitz et al. 2011).

Why Is He Aggressive

As opposed to physical aggression, Bernard manifests more of verbal aggression than the former. In fact, the mental situation of this patient is the cause of aggression, because the behaviour is sudden, and happens without cause to warrant the reaction. Indeed, handling an aggressive person is very challenging (Reitz et al. 2011). However, a clear understanding background that Bernard has Dementia and has been diagnosed with Alzheimer is helpful, in the quest to handling the situation efficiently.

As I examined keenly the aggression exhibited by Bernard, it was evidenced to me that poor communication, the physical and environmental factors are the core triggers of that character in the patient.  In fact, I was of the opinion that what was contributing more to that character needed to be scrutinised the more (Reitz et al. 2011). Elements like pain can result in aggressive behaviour in this case. Moreover, the continued deterioration of the brain cells in dementia and Alzheimer only adds to the worsening of the situation.

I also concluded while doing the discussion that Bernard had lots of physical discomforts.  Even though he could not mention it to the medical attendants, it is critical and helpful to understand that it is never uncommon that patients of Alzheimer have consistent urinary infections and related genital pain (Reitz et al. 2011). Because of the emotional and mental instability, patients of Alzheimer would typically resort to aggression because at best they do not know what causes the discomfort. Thirst, hunger, and tiredness because of lack of comfortable sleeping make a person aggressive.  On the other hand, because Bernard is on medical intervention, the side effects of the respective regimen could be the trigger of such behaviour. Proper treatment should be delivered, and suitable medication dispensed, I thought. This is because an expert insight is indispensable when it comes to such critical cases, presenting with both advanced age and emotional instability. In the discussion, we had a synonymous agreement that a suitable behavioural symptom treatment would entail the determination of possible causes and the exact behaviours manifested in the daily life of the patient.

On the other hand, the environmental factors could be a trigger for the aggressive behaviour that Bernard manifests. A good example I came up with, based on the literature review in urinary tract infections (Reitz et al. 2011). In Alzheimer, such hidden ailments could be terrible and hence substantial triggers of behaviour change.  A few questions I asked before concluding the environmental contribution to behaviour change for Bernard includes; is he customarily overstimulated by the high pitched noise around him? Does he react badly to physical disorganisation and such clutter? Or whether he does not like strange people around him, other than choosing his friends but not to be chosen as one by others.  I recommended together with the group members that the clinical staff needed to understand the moods of Bernard. In fact, people suffering from similar conditions tend to respond better during morning hours, hence the need for the clinical staff to approach him furthermore, Bernard should be understood when he is most stable. By so doing, irritability and emotional distress could not be his chosen way of life as the case scenario presents him.

What the OT Is Doing About It

Occupational therapy is a crucial segment of clinical service delivery that is handy in managing both dementia and Alzheimer disease.  By promoting safety, response to medication, maximising social engagement, and optimising life makes it easier for both the patients and the clinical attendants.  Consequently, much is expected from these professionals to help Bernard cope (Reitz et al. 2011). Much must be happening with Bernard at the facility because occupational therapy entails skilled service delivery in healthcare. Educational services and rehabilitation are core practices to consider to make Bernard respond better.

What I Can Conclude From the Experience

Medication Reaction

Medication is essential in Dementia, as well as Alzheimer cases. Bernard is in the ward, and like this on constant medication and monitoring. Nevertheless, some of the drugs have side effects, which range from mild to extreme. In the case of Bernard, I deliberated that diarrhoea; nausea, weight loss, and vomiting are inevitable, as they are typical presentations among patients with similar clinical conditions (Huang & Mucke 2012). Nevertheless, literature review indicates that Dementia cases can be managed without necessarily using drugs. Because high blood pressure, Transient Ischemic Attack and high cholesterol levels are triggered by Alzheimer medication, such are likely side effects that should be catered for in clinical care.

Mood Swing

Research data indicates that people suffering from Dementia and combinations of Alzheimer often experience mood swings. Typically, the change in mood, which often appears aggressive and suddenly, is a severe challenge to caregivers (Huang & Mucke 2012). It is from this philosophical point of view that I concluded that the unbecoming behaviour exhibited by the character of Bernard is triggered by mood swings.  The best approach I thought could help manage Bernard entails multiple actions. Some of the deliberations include knowing when he is approachable in the day, his best meals, music, when he feels social and when he dislikes people around him, the pain he feels and the triggers of his fury; for instance hunger, lack of sleep among other elements.  If the causes of a mood swing, like say pain, are realised, the clinical attendants ought to find better ways to contain the situation and bring the patient back to the moods.

Attitude of the Staff toward Bernard That Depresses and Isolates Him

The world health organisation indicates that most people suffering from dementia and Alzheimer are often emotionally and mentally depressed by how the society relates to and describe the disease, hence making them fell treated differently and with contempt. Misinformation and stereotypic address are what made me deliberate during the discussion that Bernard has been compelled to stay in his room and isolate himself from the medical attendants. Medical terms, series of ward references, symptoms, and medication is what people are reduced into, plus the old age, hence making them appear as lesser beings than others (Huang & Mucke 2012). Indeed, the group concluded that the professional, social, and environmental references are what to the most part have made Bernard brace up himself for social exclusion.

Stigma

Stigma is a serious issue affecting people with dementia. Furthermore, the increasing number of the ageing population in the US, for instance, means the probability for developing dementia has escalated, and hence the statistics serve to create anxiety and fear among the ageing population (Bang et al. 2015). Therefore, the stigma that emanates from the disease is such a significant toll on healthcare, and Bernard is no exception for the same. His actions and behaviour are an accurate reflection of someone under psychological pressure, emotionally cornered and at best socially compromised. In fact, graceful ageing from Bernard calls for combined management of anxiety and stigma, to make robust the clinical management of other conditions.

What Will I Do Differently in Future/ My Plan of Action Now

Solutions

A detailed forensic examination should be done limited to the psychological and clinical expertise, to realise whether and to what extent the childhood problems affect Bernard in his late adulthood. The loss of parents to the accident, torture at the care of foster parents, and related social injustices are such a severe sequel to the life of an individual. Guidance and counselling plus psychological management could help Bernard cope (Loy et al. 2014). Memory loss, Dementia, Alzheimer, and OCPD means the ageing Bernard is not doing so gracefully. There is need to address the issues in a multifaceted approach. Medical treatment and management are essential. In fact, OCPD impairs sufficient flow of oxygen into the brain, hence worsening the brain performance, which ought to be management. Moodiness, suicidal feelings, isolation, and such antisocial behaviour, as well as misogyny; means Bernard needs close monitoring and patient-centred care for a faster response (World Health Organization 2012). Handling Dementia patients are often tricky, and hence the unbecoming character of Bernard who hates females uses F-words and is verbally violent. If his condition is understood, it would be easier to handle him, because such character is an express manifestation of the nature of sickness Bernard suffers from.

Conclusion

The case of Bernard has been a crucial learning platform not only as far as Alzheimer and dementia are concerned, but also for an all-around clinical setting and the patient environment, and patient-medical staff relationships. Stigma, mental and emotional instability, as well as antisocial behaviour because of lack of mood stability are evidenced manifestations for such cases as Bernard. Indeed, the group members dwelled more on the effects of historical encounters as a core element of the influence of the adulthood life of Bernard. The loss of parents to an accident, torture and verbal abuse by foster parents, lack of children, and the untimely demise of the wife compromised the social standing and hence the entire personality of Bernard.  A critical medical approach, as well as non-medicinal management, would form a reliable clinical framework to address better the challenges Bernard is facing apparently. Moreover, understanding that his phenomenal behaviour; prejudice for women, F-word, and moodiness are elements inseparable from mental sickens would be the background of offering proper patient-centred care for Bernard.

References

Bang, J., Spina, S. & Miller, B.L., 2015. Frontotemporal dementia. The Lancet, 386(10004), pp.1672–1682.

Choices, N., 2015. What causes dementia? - Dementia guide - NHS Choices. NHS UK. Available at: http://www.nhs.uk/Conditions/dementia-guide/Pages/causes-of-dementia.aspx%5Cnhttp://www.nhs.uk/conditions/dementia-guide/pages/causes-of-dementia.aspx.

Department of Health, 2009. Living well with dementia : National Dementia Strategy, Available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/168220/dh_094051.pdf.

Holmes, C., 2012. Dementia. Medicine, 40(11), pp.628–631. Available at: http://linkinghub.elsevier.com/retrieve/pii/S1357303912001879.

Holmes, C. & Amin, J., 2016. Dementia. Medicine, 44(11), pp.687–690. Available at: http://linkinghub.elsevier.com/retrieve/pii/S1357303916301670.

Huang, Y. & Mucke, L., 2012. Alzheimer mechanisms and therapeutic strategies. Cell, 148(6), pp.1204–1222.

Kingston, J. & Ellett, L., 2014. Self-affirmation and nonclinical paranoia. Journal of Behavior Therapy and Experimental Psychiatry, 45(4), pp.502–505.

Loy, C.T. et al., 2014. Genetics of dementia. The Lancet, 383(9919), pp.828–840.

National Health Service, 2015. About dementia - Dementia guide. NHS Choices: Your health, your. Available at: http://www.nhs.uk/conditions/dementia-guide/pages/about-dementia.aspx.

Prince, M. et al., 2015. World Alzheimer Report 2015: The Global Impact of Dementia - An analysis of prevalence, incidence, cost and trends. Alzheimer’s Disease International, p.84.

Reitz, C., Brayne, C. & Mayeux, R., 2011. Epidemiology of Alzheimer disease. Nature Reviews Neurology, 7(3), pp.137–152.

Strategy, N.D., 2009. Living well with dementia : Dementia, Available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/168220/dh_094051.pdf.

Thewissen, V. et al., 2008. Fluctuations in Self-Esteem and Paranoia in the Context of Daily Life. Journal of Abnormal Psychology, 117(1), pp.143–153.

University of Bradford, 2017. Reflection models and frameworks.Graham Gibbs - Reflective Cycle. , pp.1–9. Available at: http://www.bradford.ac.uk/wimba-files/skill-space/Reflective_Writing_HTML/page_04.htm.

WHO, 2016. WHO | Dementia. WHO. Available at: http://www.who.int/mediacentre/factsheets/fs362/en/.

World Health Organization, 2012. Dementia: a public health priority. Dementia, p.112. Available at: http://whqlibdoc.who.int/publications/2012/9789241564458_eng.pdf.