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  • Shortfall of Dementia Education in Radiation Therapy

    Kaitlin B. Fink, B.S., R.T.(R); Jason T. Snook, A.S., R.T.(R); Robert D. Adams, Ed.D., R.T.(R)(T), CMD, FAAMD

    Dementia is a decline in cognitive function or a loss in behavioral ability that can interfere with a person’s daily life and primarily affects older people.1 The World Health Organization (WHO) projects that the number of people who have dementia will triple by 2050, to approximately 115 million people worldwide.2 The United States Census Bureau also projects that the population of people aged 65 years and older will nearly double by 2060, to 98.2 million people.3 Add to these statistics the National Cancer Institute’s assessment that cancer occurs in 50% of individuals older than 66 years, and radiation therapists easily can deduce that older oncology patients who present for radiation treatment might exhibit symptoms of dementia.4

    To address the growing prevalence of dementia in the world’s older population, the WHO and the Alzheimer’s Association are increasing their efforts to encourage education about dementia as well as training for those health care professionals who treat this population. Along those same lines, the goal of this article is to increase awareness of dementia and the growing need to improve or increase the amount of required dementia education for radiation therapy students and professionals.

    Dementia Symptoms and Types

    The Alzheimer’s Association states that to be considered dementia, 2 of the following core mental functions should be impaired:

    • Memory.
    • Communication and language.
    • Ability to focus and pay attention.
    • Reasoning and judgment.
    • Visual perception.

    The severity of dementia ranges from mild, where a person is starting to lose his or her ability to perform daily functions, to severe, where a person depends on others to carry out daily functions.5 Dementia is caused when the communication in the brain is disrupted, whether short-term or long-term, which affects a patient’s mental functions.6 Short-term dementia can be temporary. Depression, adverse effects from medication, thyroid problems, vitamin deficiencies, and excess use of alcohol are possible causes; once the condition is treated, dementia can improve.6 Long-term dementia can worsen with time because of its damaging effect on brain cells and can be permanent. Common types of long-term dementia include6:

    • Alzheimer disease.
    • Vascular dementia.
    • Dementia with Lewy bodies.
    • Mixed dementia.
    • Parkinson disease.
    • Frontotemporal dementia.

    Of the 47.5 million people worldwide who have dementia, 60% to 70% of them also have Alzheimer disease, and the other 30% to 40% have another type of dementia.1

    Suggestions for reducing the risk of developing dementia include eating a heart-healthy diet, exercising regularly, and maintaining normal blood pressure and cholesterol levels.6 However, the 2 risk factors that cannot be controlled are genetics and age.

    World Health Organization

    The WHO coordinated the First Ministerial Conference on Global Action Against Dementia in March 2015 in Geneva, Switzerland, to increase awareness of the challenges of dementia. Conference attendees, which included ministers, clinical experts, research experts, and nongovernmental organizations, discussed how the world can unify to combat the disease, the government’s role, and future responses to the disease.7 WHO pledged to establish a Global Dementia Observatory to monitor the disease prevalence and dementia care resources in its member states and track the establishment of national dementia policies and plans. The plans will raise awareness of the condition, build the capacity for a timely diagnosis, and allow for training on dementia. The conference called for facilitating the delivery of health care and social care for people living with dementia.7 The WHO’s recommendations should alert the radiation therapy profession to the rising number of patients who have dementia and the greater need for therapists to receive training or education on dementia.

    National Alzheimer’s Association

    The Alzheimer’s Association put forth a call to action to health care facilities and the public to prepare themselves for the escalation in the number of dementia cases.8 In January 2011, the National Alzheimer’s Project Act was signed into law by President Barack Obama.9 The act proposed 5 goals aimed at improving the public’s education, research, prevention campaigns, treatment, and clinician training on Alzheimer disease and other dementia by 2025.9 The act encourages health care facilities and education programs to analyze their teachings and implement more robust dementia education to prepare its students and staff for the increase in patients 65 years and older who have dementia.8 Added education and training can enable health care providers to deliver improved patient-centered care, which might increase patient and caregiver satisfaction and increase their feelings of trust with staff, possibly improving each dementia patient’s hospital stay.

    The Link Between Dementia and Cancer

    Although a plethora of data exist about patients who have cancer and about patients who have dementia, little data are available about the number of patients who have both dementia and cancer. However, what can be extrapolated from the available data is that:

    • Advancing age is the most important risk factor for cancer.
    • The median age for cancer is 66 years.
    • A quarter of new cancer cases are diagnosed in people aged 65 years to 74 years and a quarter in those older than 75 years.4
    • As a patient’s age increases, so too does the likelihood that he or she will receive a cancer diagnosis as well as a dementia diagnosis.

    The lack of data about patients who have both cancer and dementia might be due to this population’s caregivers choosing quality of life over quantity for their patients or loved ones and choosing not to have them undergo screenings and risk exposing them to the distress of an unknown environment.10 Nevertheless, because radiation therapy professionals are likely to come in contact with patients who have dementia at some point during their careers, it is important they have the knowledge and skills to care for these patients.

    Radiation Therapy Programs Survey

    To assess the general knowledge about dementia and the beliefs about the level of dementia education being taught at radiation therapy programs across the United States—which included 25 certificate programs, 18 associate degree programs, and 33 bachelor’s degree programs—this study’s researchers created and emailed a 6-question survey to all radiation therapy program directors (N = 76) in the United States (see Box).

    Nearly half (48%) of the directors of the certificate programs, 44% of the associate degree programs, and 24% of the bachelor’s degree programs responded, for a total of 28 responses. Of those, 57% believed that dementia was rising globally, and 28.6% believed dementia was rising among the population that typically presents for radiation oncology treatment. Fifty percent of directors believed that dementia should be included in the radiation therapy curriculum, but only 2 directors indicated that dementia education was part of their program curriculum. The other 26 programs touch on dementia and how it manifests in aging patients, but the education provided is very broad.

    Box

    One bachelor’s degree program offered dementia education within an Aging for Healthcare Providers course that covered:

    • The conditions that affect cognition.
    • Etiology.
    • Epidemiology.
    • Preventive lifestyle measures.
    • Impact.
    • Normal aging vs signs of dementia.
    • Cognitive assessments of dementia.

    One associate degree program taught the different stages of dementia and the precursors to Alzheimer disease in its Building Clinical Skills class. One program did not teach dementia in depth but was unique in its approach to teaching students about dementia by giving them an opportunity to take part in a training session that helped them understand what dementia patients go through physically and mentally on a daily basis.11 Students complete everyday tasks while wearing devices that alter their senses. Students found that eyesight, fine motor skills, hearing, and walking all were affected during the session.11 The training is meant to change how students perceive and empathize with patients who have dementia.

    Half of the program directors who completed the survey believed that dementia should be included in the radiation therapy curriculum. When asked where in their curriculum dementia care could be implemented, the directors identified these areas:

    • Patient care.
    • Pathology.
    • Special procedures.
    • Introduction to radiation therapy.
    • Cancer overview.
    • Patient interactions.
    • Nursing care.

    Although a quarter of the responding program directors believe dementia patient care–related questions should be included in the American Registry of Radiologic Technologists (ARRT) exam, 75% do not. For a tabulation of the responses, see the Table.

    Need for Robust Dementia Education

    The goal of this study is to bring awareness to program directors and students about the rising number of patients who have dementia and the certainty that students will see patients who have this type of condition in their careers. The goal is that this awareness will lead to strengthening the dementia education programs provide. The radiation therapy community needs to be educated about and prepared for the increase in the number of patients who have dementia they likely will be asked to treat, including learning to care for a patient who has deteriorated emotional control, social behavior, or motivation.1

    Dementia education should include instruction and training on types of dementia, symptoms of each type, factors that can calm a situation, and factors that can worsen a situation. Patients who have dementia with Lewy bodies, for example, might show symptoms of consistent hallucinations, falls, and fluctuating patterns of cognitive impairment.5 Awareness of this type of dementia will help health care professionals ensure their patients’ safety.

    Greater knowledge about dementia also might better help the radiation therapist to prevent harmful occurrences that might be common to patients who have dementia, such as falls from the treatment table, treatment errors due to patient movement, or missed treatments due to communication challenges.

    Radiation Therapy Program Assessment

    The radiation therapy curriculum does not contain a substantial amount of education on dementia, including the types of neurological deficits that can affect patients or how radiation therapists can transform their communication style and treatment techniques to perform safer radiation therapy treatments based on each dementia type. In addition, the American Society of Radiologic Technologists (ASRT) Scope of Practice and Practice Standards for Radiation Therapists, the ASRT professional curriculum for radiation therapy, and the ARRT radiation therapy exam content specifications do not mention dementia or caring for patients who have dementia.12

    Table

    Scope of Practice

    Radiation therapists strive to adhere to the recommended scope of practice, but with expanded education regarding dementia, the following responsibilities would more likely be successfully upheld:

    • Performing optimal patient care.
    • Assuming responsibility for patients during procedures.
    • Preparing patients for procedures.
    • Identifying and responding to emergency situations.
    • Applying principles of patient safety during all aspects of patient care.

    Practice Standards

    The ASRT Radiation Therapy Practice Standards, which serve as a guide for appropriate practice, might be challenging to uphold while treating a patient who has dementia12:

    • Radiation Therapy Clinical Performance Standards; Standard One, Assessment – the professional should be able to collect pertinent data about the patient and the procedure. Within this standard, criteria 7 specifically states that the worker must be able to monitor the patient’s status during procedures, treatment, and follow-up care. Therefore, one must be able to assess factors that could affect the procedure negatively. Having the ability to assess the signs of dementia could prevent a detrimental occurrence and secure the patient’s safety.
    • Radiation Therapy Professional Performance Standards; Standard One, Quality – the radiation therapist anticipates and responds to the needs of a diverse population. The key is to provide the most efficient care for all patients, no matter their condition.
    • Radiation Therapy Clinical Performance Standards; Standard Two, Analysis and Determination – the professional should be able to analyze information needed to review the patient’s ability and be able to set up a plan to use immobilization techniques and perform treatment. There likely is a strong need for immobilization techniques when delivering radiation treatments to patients who have dementia. With better education on dementia, the radiation therapist will be able to address questions (repeated, additional, or more specific) from patients exhibiting dementia.
    • Radiation Therapy Clinical Performance Standards; Standard Three, Education – the radiation therapist should address the questions and concerns of the patient or caretaker to educate them on the treatment to follow.
    • Radiation Therapy Professional Performance Standards; Standard Four, Collaboration and Collegiality – the professional should be able to evaluate his or her own performance and recognize the need for educational growth, and to then share the learned expertise with others in the profession. In addition, it states that the radiation therapist pursues lifelong learning. Receiving education on dementia would help radiation therapists to handle communicating and promoting safety while performing radiation treatments.
    • Radiation Therapy Clinical Performance Standards; Standard Five, Evaluation – the radiation therapist should take action and revise a plan based on the patient’s condition to reach the expected outcome. If that plan does not give the outcome the professional initially wanted, a revised plan should be made.
    • Radiation Therapy Clinical Performance Standards; Standard Eight, Documentation – the radiation therapist provides pertinent information to authorized individuals involved in the patient care, if necessary.
    • Challenges of communicating with patients in the geriatric population or patients who have impaired mental function.
    • Challenges of communicating in stressful situations with families.

    Although the ASRT professional curriculum does not mention dementia specifically, ASRT has provided 2 Directed Readings and 1 module on caring for patients with dementia and Alzheimer disease. “The Many Faces of Dementia”, published in the November/December 2009 issue of Radiologic Technology (Vol. 81, No. 2), describes several forms of dementia and the role medical imaging plays in diagnosing the condition. “Alzheimer Disease: Focus on Computed Tomography”, published in the November/December 2013 issue of Radiologic Technology (Vol. 85, No. 2), covers brain anatomy, pathology, and computed tomography (CT) and magnetic resonance (MR) imaging of Alzheimer disease. Module 2 of Patient-centered Care for Diverse Populations has a section on dementia and Alzheimer disease.

    The Registry Exam

    Patient care is a large part of a radiation therapist’s training; specifically, 47 out of 200 questions on the Registry certification exam were noted on the exam’s content specifications.14 However, the ARRT radiation therapy exam does not require exam takers to know the specifics of dementia to obtain certification; therefore, questions about patients who have dementia are not included on the exam. Because students tend to focus only on the material that will be presented in the exam, it is unlikely they will study subject matter that is not being tested. However, if students were tested on dementia content, it might better prepare them to care for this patient population when it presents for treatment.

    Selected Educational Assessments

    The medical imaging and respiratory therapy professions also do not require dementia education of their professionals, but the occupational therapy profession has shown an increased interest in providing education about working with patients who have dementia. The nursing profession has the most extensive curriculum related to dementia—the American Association of Colleges of Nursing set competencies for students related to treatment for patients who exhibit symptoms of dementia.8,15-17 The radiation therapy profession could better prepare its students for the increase in the number of patients who have dementia by learning from these programs about how to compensate for a patient’s diminished mental, behavioral, or cognitive skills.17

    Medical Imaging

    Medical imaging was found to be similar to radiation therapy regarding its educational standards on dementia, and its scope of practice was nearly identical to that of radiation therapy but included additional responsibilities such as technical exposure factors and specialized radiologic procedures.15 The radiography curriculum similarly included communication with the geriatric and mentally impaired, volume and speed of speech, and interacting with patients’ families. These areas were the only dementia-related topics found within the curriculum. On the medical imaging Registry exam, 33 out of 200 questions were content specifications on patient care treatment and management.18 The comparison between medical imaging and radiation therapy did not reveal an unbalanced amount of dementia education.

    Respiratory Therapy

    The Commission on Accreditation for Respiratory Care, which accredits respiratory therapy schools, does not mandate dementia-related education for respiratory therapy students in its Accreditation Standards for Entry Into Respiratory Care Professional Practice of 2015.16 If a respiratory therapist wants to become credentialed, a clinical simulation test and a multiple choice exam are required. The National Board for Respiratory Care credentials respiratory therapists, and its Clinical Simulation Examination Detailed Content Outline states that respiratory therapists must be able to solve problems that patients who have neurological and neuromuscular issues might present.19

    The Therapist Multiple-Choice Examination Detailed Content Outline states that respiratory therapists will be asked questions based on various patient conditions.20 Three of these patient conditions include neurologic, geriatric, and psychiatric conditions.20 Respiratory therapists are tested on their knowledge of various patient conditions that might mimic dementia, but the curriculum proposed by the Commission on Accreditation for Respiratory Care does not require that dementia education be taught. Whether the programs teach the subject of dementia is up to the individual program.

    Occupational Therapy

    The Accreditation Council for Occupational Therapy Education, which sets the standards for the occupational therapy and occupational therapy assistant programs, does not mandate curricula on dementia types, but its standards do mention the evaluation and care of cognitively declined patients, from the pediatric to the geriatric. The curricula must prepare students to work with patients of all ages who are in various stages of physical and mental health.17 The following dementia-related subjects are included within their curricula17:

    • Effects of genetic conditions and injury on the physical and mental health performance of the patient.
    • Intervention strategies to fix or compensate for cognitive deficits.
    • Remediation and compensation for mental, cognitive, perceptual, neuromuscular, behavioral skills, and sensory functions.
    • Human development through the lifespan.
    • Developmental psychology.

    These programs focus on working with cognitively declined patients of any age but also provide therapeutic benefits, just as radiation therapy does.

    Nursing

    The American Association of Colleges of Nursing, the national voice for baccalaureate and higher nursing degrees, has a standard curriculum that requires students to learn how to communicate with and take care of patients who have dementia. This association set standards for students to learn academically and experientially with this patient population, and it calls for faculty to be experienced in the areas in which they teach.8 The faculty also is expected to be able to teach its students about situations that might occur while caring for a patient who has dementia.

    The 2010 American Association of Colleges of Nursing’s The Essentials of Baccalaureate Education for Professional Nursing Practice requires that competency statements be included in nursing programs regarding the following competencies21:

    • Implementing and monitoring strategies to prevent risk and promote quality and safety.
    • Using noncoercive decision making for older adults to promote restraint-free care (chemical/ physical restraints).
    • Assessing barriers for older adults.
    • Facilitating safe and effective transitions across health care.
    • Identifying actual or potential mistreatment of older adults, including physical, mental or financial abuse, and self-neglect.
    • Integrating leadership and communication techniques that foster discussion and reflection.
    • Recognizing complex interaction of acute and chronic comorbid physical and mental conditions and associated treatments common in older adults.
    • Planning patient-centered care with consideration for mental and physical health of informal and formal caregivers of older adults.

    These competencies are covered in any of the adult care or gerontology classes a nurse will take. The Essentials document also suggests additional content, rationale, teaching strategies, resources, and a glossary of terms based on each essential for instructors to follow.21 Liberal education covering the sociology and psychology background of aging also is recommended. Evidence-based practice also is used in nursing because students can interact with older adults who have dementia to see how the disease manifests. The need to maintain professionalism when caring for the patient also is discussed.21 This framework provides numerous suggestions for teaching. The Essentials document also proposes many methods to educate students21:

    • Role playing.
    • Interviewing or meeting with an older adult.
    • Online simulations.
    • Interprofessional education scenarios.
    • Assessments on paper.
    • Modules online.

    Meeting with an older adult to ask about his or her daily life, for example, can make a student more empathetic and less frustrated while working with an older adult who might take a while to understand and perform tasks. The student also learns how to put this knowledge into practice in the clinical setting, whether through a psychiatric rotation, retirement home rotation, or general hospital rotation.

    Conclusion

    The findings of this study suggest that although there is support for inclusion of dementia education in radiation therapy programs, it is unlikely to happen unless a greater emphasis is placed on education and training on the topic of dementia. In their current forms, these radiation therapy documents do not address knowledge of and care for patients who have dementia.

    Because the number of patients who have dementia is rising, radiation therapy professionals need to be prepared and able to work with cancer patients who show signs of dementia. Considering that the radiation therapy scope of practice, practice standards, curricula, and certification exam require no education regarding dementia, radiation therapy professionals might not have sufficient training to adhere to these standards and provide optimum care for these patients. To address this growing and urgent need, educational standards should be improved to include information about the specialized care required for these patients.

    A survey of program directors in the United States found that only 2 programs out of the responding 28 provide training on dementia causes and types. This demonstrates room for improvement in the curriculum and in the advancement of education within each program. Other health care professions, which have a curriculum similar to radiation therapy, have more robust curricula regarding dementia.

    The results of this study indicate that radiation therapy program staff has the potential to learn from the actions of other programs and share dementia resources. Learning about 1 radiation therapy program’s dementia education and resources could encourage another program to implement similar education within its curriculum. Radiation therapy programs could adopt the teaching strategies and competencies from other professions as well—specifically the nursing profession, which has a robust dementia education component—and use them as a model to educate students in class and in the clinical setting about working with patients who have dementia. The methods of learning about dementia in the nursing profession, for example, are similar to what radiation therapy programs already use to educate students about other subjects; therefore, implementing dementia education in radiation therapy could be manageable.


    Kaitlin B. Fink, B.S., R.T.(R), is a University of North Carolina Chapel Hill radiation therapy student. She earned her bachelor of science degree in medical imaging at Misericordia University in Dallas, Pennsylvania.

    Jason T. Snook, A.S., R.T.(R), is a University of North Carolina Chapel Hill radiation therapy student. He earned his associate of science degree in radiologic sciences at Gannon University in Erie, Pennsylvania.

    Robert D. Adams, Ed.D., R.T.(R)(T), CMD, FAAMD, is assistant professor for the University of North Carolina Department of Radiation Oncology and the University of North Carolina Division of Human Factors Engineering. He has served on the Editorial Review Boards of
    Radiation Therapist and The Canadian Journal of Medical Imaging in Radiologic Sciences.

    References

    1. Dementia. World Health Organization website. http://www.who.int/mediacentre/factsheets/fs362/en/. Updated April 2016. Accessed October 23, 2016.
    2. Dementia cases set to triple by 2050 but still largely ignored. World Health Organization website. http://www.who.int/mediacentre/news/releases/2012/dementia_20120411/en/. Published April 2012. Accessed October 23, 2016.
    3. Newsroom. United States Census Bureau website. https://www.census.gov/newsroom/facts-for-features/2017/cb17ff08.html. Updated April 10, 2017. Accessed April 11, 2017.
    4. Age. National Cancer Institute website. https://www.cancer.gov/about-cancer/causes-prevention/risk/age. Published April 29, 2015. Accessed April 18, 2017.
    5. Solomons L, Solomons J, Gosney MA. Dementia and cancer: a review of the literature and current practice. Aging Health. 2013;9(3):307-319. doi:10.2217/ahe.13.27.
    6. What is dementia? Alzheimer’s Association website. http://www.alz.org/what-is-dementia.asp. Accessed April 18, 2017.
    7. Governments commit to advancements in dementia research and care. World Health Organization website. http://www.who.int/mediacentre/news/releases/2015/action-on-dementia/en/. Updated March 2015. Accessed May 15, 2017.
    8. Batchelor-Aselage M, DiMeglio B, Aaron CS, Dugger BR. Infusing geropsychiatric nursing content into curricula: challenges and solutions. J Nurs Educ. 2014;53(7):387-394. doi:10.3928/01484834-20140619-09.
    9. Obama administration presents national plan to fight Alzheimer’s disease. National Institute on Aging website. https://www.nia.nih.gov/newsroom/2012/05/obama-administration-presents-national-plan-fight-alzheimers-disease. Published May 15, 2012. Accessed April 25, 2017.
    10. Torke AM, Schwartz PH, Holtz LR, Montz K, Sachs GA. Caregiver perspectives on cancer screening for persons with dementia: “why put them through it?” J Am Geriatr Soc. 2013;61(8):1309-1314. doi:10.1111/jgs.12359.
    11. Tour VD. Second Wind Dreams website. http://www.secondwind.org/virtual-dementia-tour/. Published 2017. Accessed May 4, 2017
    12. The practice standards for medical imaging and radiation therapy. American Society of Radiologic Technologists website. https://www.asrt.org/docs/default-source/practice-standards-published/ps_rt.pdf?sfvrsn=2. Published June 26, 2016. Accessed October 23, 2016.
    13. Radiation therapy professional curriculum. American Society of Radiologic Technologists website. https://www.asrt.org/docs/default-source/educators/ED_Curr_RTTAdptd2014_20160606.pdf?sfvrsn=8. Published 2014. Accessed October 23, 2016.
    14. Radiation therapy examination. American Registry of Radiologic Technologists website. https://www.arrt.org/docs/default-source/discipline-documents/radiation-therapy/thr-content-specifications.pdf?sfvrsn=14. Published January 2016. Accessed April 30, 2017.
    15. Radiography curriculum. American Society of Radiologic Technologists website. https://www.asrt.org/docs/defaultsource/educators/curriculum/radiography/acad_curr_radcurrfinal2017_20170206.pdf?sfvrsn=2. Published 2017. Accessed April 30, 2017.
    16. Accreditation standards for entry into respiratory care professional practice. Commission on Accreditation for Respiratory Care website. http://www.coarc.com/29.html. Published June 1, 2015. Accessed May 5, 2017.
    17. 2011 Accreditation Council for Occupational Therapy Education (ACOTE) standards and interpretive guide. American Occupational Therapy Association website. https://www.aota.org/~/media/Corporate/Files/EducationCareers/Accredit/Standards/2011-Standards-and-Interpretive-Guide.pdf. Published 2011. Accessed April 30, 2017.
    18. Radiography examination. American Registry of Radiologic Technologists website. https://www.arrt.org/docs/default-source/discipline-documents/radiography/rad-content-specifications.pdf?sfvrsn=22. Published 2016. Accessed April 30, 2017.
    19. National Board for Respiratory Care. Clinical simulation examination detailed content outline. https://www.nbrc.org/Documents/CSE%20Detailed%20Content%20 Outline.pdf. Published January 2015. Accessed May 5, 2017.
    20. National Board for Respiratory Care. Therapist multiple choice examination detailed content outline. https://www.nbrc.org/Documents/TMC%20Detailed%20Content%20Outline.pdf. Effective January 2015. Accessed May 5, 2017.
    21. American Association of Colleges of Nursing. Recommended baccalaureate competencies and curricular guidelines for the nursing care of older adults. http://www.aacn.nche.edu/geriatric-nursing/AACN_Gerocompetencies.pdf. Published September 2010. Accessed December 13, 2016.

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