The Role of Nurses in Home Care in Alzheimer's Patients

It is aimed to reduce the negative effects of the disease and resulting problems with the most accurate medical and nursing approaches by ensuring that the patient is affected at least without changing the living conditions of the home care services, to increase the quality of life of patient as much as possible and to provide a comfortable death. Nursing services play an important role in establishing the connection between home and hospital within the scope of home care of Alzheimer's disease. Nurses can assist at home care by providing patient education family members in line with the needs of the patient, providing family participation in care, counseling and co-operation between the family and the hospital. As a result of these services, the quality of life the patient is increased and care burden of the caregivers is reduced. In this study, it was aimed to address the roles of nurses in Alzheimer's patients in the home care service in the home care of Alzheimer patients between the years 2009-2019. In this article, the studies were reviewed and an evaluation was made in the context of the roles/responsibilities of Alzheimer's patients and nurses.


Introduction
Thanks to medicine advancing in parallel with scientific discoveries in health and technology, the average life expectancy increases every year [1][2]. Average life expectancy rose from 47 in 1900 [3] are expressed in 2018 by the Turkey Statistical Institute data today 78 years [4]. With the increase in the elderly population, it brings with it common diseases in old age that were not noticed before [5][6]. One of these diseases, Alzheimer's disease, which has not been cured yet and affects the quality of life of individuals, has become an increasingly important health problem [7][8].
Alzheimer's disease is a progressive neurodegenerative disease that leads to memory loss, leading to forgetfulness, neuropsychiatric behavioral disorders, and impaired daily living activities [9][10]. As the disease stages progress, individuals with Alzheimer's disease become more limited in their daily activities and cognitive and behavioral disorders, and patients need the help of someone else to meet their physical, emotional, economic and social needs [10][11][12].
In Alzheimer's, the disease process is a process in which patients experience constant changes due to the progressive nature of the disease; it is a process that causes various dimensions of family members and caregivers' lives to be affected and challenged [13][14]. According to the results of qualitative and quantitative studies conducted with individuals who care for Alzheimer's patients, caregiving leads to an increase in the stress level of caregivers, psychological problems such as strain, anxiety, depression, social isolation and physical health deterioration due to the fact that most of the time is devoted to the patient [13][14][15][16].
Nurses, whose primary role is caring and having a key position among health workers, are expected to be sensitive to and support the caregiver's burden and difficulties. It is stated that this can improve the quality of life of both Alzheimer's patient and caregiver and other family members by increasing the caregiver's ability to adapt to changing conditions [17][18][19].
International literature includes studies to identify caregivers and determine their needs. However, there are not enough studies and home care services for caregivers in our country. Therefore, caregivers remain at home with the problems of their patients. It is thought that identifying the problems of caregivers can contribute to the studies and home care practices to be developed, and the quality of life of the patient and caregiver can be improved by addressing the caregivers.

Inclusion Criteria
The following criteria were taken into consideration in the selection of the articles to be included in the study; 1) The results of this study are the interventions performed by nurses in home care services related to patients diagnosed with alzeimer; 2) The language of publication is Turkish or English; 3) Published in the last decade (2008-2018); 4) Access to the full text. Randomized controlled trials (RCTs) and quasi-experimental studies (LDS) were included in the study.

Reasons Not to Include in Research
Researches and observations investigating home care interventions applied to patients who are not diagnosed with alzeimer have not been included in the systematic review. The studies conducted in the last ten years are taken into consideration for the evaluation of current information. There are no studies whose title or summary is not clear, the full texts cannot be reached and the publication language is not Turkish / English.

Sample Definition
Studies; In October 2017-March 2018 "OVID", "Medline", "Cochrane", "Pubmed", "Wiley Online Library" databases and "Google Scholar" and "YÖKSİS Theses" were selected. The following keywords were used; Researches in graduate and doctoral theses and nursing journals were also preferred. The titles and abstracts of all related articles identified by electronic search were independently reviewed by the researchers. The investigations of the researchers were then compared and 586 references were eliminated from the 598 studies included in the exclusion criteria, and the full texts of 12 studies were taken as the source for systematic review. Each of the selected articles includes relevant research on home care and nursing care associated with Alzheimer's disease.

Data Analysis
A standard data summary form was developed to summarize the data and the data was evaluated accordingly. The studies included independently by the researchers were summarized according to the data summarization form. Then the abstracts were compared and a consensus was established among the researchers.
In the content of data summarization form; 1) Authors and year of the study, 2) The name of the study and sample size, 3) Design of the study, 4) Dependent variables, 5) Method of study, 6) The findings of the study were included.
In the studies included in this systematic study, meta-analysis could not be performed because the characteristics of the participants, intervention and measurement methods applied were not the same.

Discussion
In Alzheimer's, the disease process is a process in which patients experience constant changes due to the progressive nature of the disease; it is a process that causes various dimensions of family members and caregivers' lives to be affected and challenged [20][21]. According to the results of the study conducted with individuals who care for Alzheimer's patients, caregiving leads to an increase in the stress level of caregivers, psychological problems such as difficulty, anxiety, depression, social isolation and physical health deterioration due to the fact that he spends most of his time on his patients [13][14][15].
Akyar and Akdemir in his study; 64% of the caregivers experience difficulties in the family due to caregiving, 40.6% of the caregivers are unable to receive support in care, 34.4% are experiencing psychological difficulties, 18.8% are experiencing economic difficulties, 90% are affected by daily life, 83.3% of caregivers had problems in care and caregivers should be supported and monitored by nurses who are experts in care [22].
Because of the nature of the disease, Alzheimer's disease poses some difficulties in the life of both the sick individual and the caregiver. In Alzheimer's disease, which is one of the progressive aging diseases that limit the mental and physical abilities of individuals, individuals cannot perform their selfcare functions and they need the help of another because they cannot continue their daily life activities. In this case, it brings responsibility and care burden to caregivers [2,14,16]. In the study conducted by Altay et al. On the subject, the care burden of caregivers increases as the caregiving time increases. Therefore, it is very important to ensure that the burden of caregivers is shared in the family and that individuals develop coping methods. Nurses have important roles in informing patients and their families about coping methods [23].
In the study, Altin and Aydin Avci examined complementary and alternative treatment methods used for patient care by Alzheimer's caregivers at home. It was found that 53.0% were afraid of not taking it seriously, 28.8% were afraid of being rebuked and did not consult with nurses about the use of coping methods for patient care because they did not think it was a relevant issue [24]. Nurses should be sensitive and take care of the patient. Caregivers should be encouraged to apply for home care services if they do not consider themselves sufficient in patient care. The caregivers of Alzheimer's patients should be encouraged to continue their communication with nurses regarding the use of coping methods for patient care and ask the caregivers about coping methods and their questions should be answered clearly.
Caregiving can be described as a material and physically exhausting task that consumes time and energy [25]. "The care is not limited to a single type of aid, but also health care (medication, treatment, monitoring, etc.), personal care (washing, feeding, toileting, dressing, etc.), coordinating the social services of the patient, shopping and small home management. it includes financial assistance and sharing the same house" [26]. In a study conducted by Altın and Aydın Avcı [24], 37.9% of the caregivers were the bride of the patient, 33.9% were the children, 10.7% were the spouses, 10.2% were the siblings, and 7.3% were the caregivers. and son-in-law.
In the studies in which caregivers were examined, it was concluded that caregivers were generally women. For example; In a study conducted by Akyar and Akdemir [22], 86% of the caregivers were women and 67.6% were found to be women in the study by Bostancı [27]. The reason for this is the gender perspective that is influenced and shaped by the current culture. As a result of the patriarchal structure, the women who are believed to be born as "mother düşünül are thought to be more sensitive, compassionate and therefore more suitable for caregiving than men [22,27].
It is inevitable that the caregiving family members who have to devote a significant part of their day to their patients will be adversely affected in this process and have psychosocial, financial and health problems; These problems experienced by the caregivers also negatively affect the care process and increase the burden of care. Uygun and Taylan examined the factors that affect the care burden of family members who give primary care to Alzheimer's patients. The majority of the caregivers were female (74.1%), married (81.5), 45-64 age group (64.8%) and the daughter of the patient (43.5%). care, 67.6% ‚need help with companionship, 49.1% had health problems due to care, 43.5% of those who said they had a health problem were found to have psychiatric disease [2]. Based on this study, the majority of caregivers stated that they needed support in the care of patients. In addition, as the period of care (years) and the average daily hours of care increases, the burden of care increases. In order to reduce the burden of caregivers, caregivers should be supported by developing voluntary and / or hourly care services during the day [22][23].
For the caregivers of Alzheimer's patients, the type of care the patient needs increases the burden of care. The fact that patients require serious supervision due to their inability to perform life activities increases the burden of caregivers. In the study of Yacı and Kulaksızoğlu, 27.8% of the patients continued their basic life activities without help, 24.4% were able to see their own food, toilet and bathing needs themselves, but 33.3% received remote assistance where remote surveillance was required. reported that they received moderate help with food, toilet, bathing needs and instrumental daily living activities, while 14.4% received all care in bed [28].

Conclusion
Caring for an Alzheimer's patient is a very tiring, demanding and long process. In order not to be affected much by this process, first of all it is necessary to accept the disease, obtain information about the disease and get help. Nurses come into play at this point. Nurses are a profession that advocates that people should improve their quality of life, make conditions suitable for them, guarantee human rights, make fair use of resources and have a say in their own lives. They work in collaboration with other professions and take part in the geriatric team to ensure coordination and communication among the professionals. In addition, the patient and his family make it easier for them to accept the disease and remove them from their fears and worries. It shows the options to the patient and his / her family in determining the paths to be followed and removes the obstacles in accessing the resources they need. In the light of the studies examined, nurses, whose primary role is caring and having a key position among health workers, should carry out due diligence studies for the caregivers and take care of continuous and high quality care in line with these determinations. constructive interventions. It is necessary to establish institutions where caregivers can leave their patients as needed and / or continuously, to extend consultancy and training services to caregivers, and to initiate and develop institutional practices in order to minimize the problems experienced by caregivers due to care.