Bernie  KeenanBy Bernie Keenan Senior Lecturer Birmingham City University, Co-Chair West Midlands Institute for Ageing & Health

Monday night’s Panorama programme on poor practice in a nursing home offered a harrowing account of inadequate and even abusive care of an older person with dementia. The poor feeding and manual handling techniques and the failures in terms of dignity, respect, and communication are all too commonly reported , and are reflected in the findings of a number of recent reports, including the Health Service Ombudsman Report ‘Care and compassion?’( 2011). In a response to such ‘scandals’ Age UK (2012) have called for the Government to establish a Care Quality Forum to look at all aspects of care home staffing.

The issues involved are of course complex, and include the stigmatised societal views of older people and those with dementia as ‘diminished’ or ‘lesser ‘ human beings, which are internalised by the carers and indeed the older people themselves, (Goffman 1963 , Kitwood 1997). However, I would suggest that there is a fundamental need to address the training and support of staff in these settings. Caring for older people with dementia is demanding, complex and highly skilled. Without the knowledge base to meet these challenges untrained staff often revert to the mother/ child relationship which is the only model of care available to them, with the result that they infantilise the person they are caring for (Miller & Gwynne 1972, Kitwood 1997). The lack of appropriate orientation or training also often results in a task orientated approach, reducing care to a series of physical tasks ‘ getting through the work’ (Clarke 1978), or ‘minimal warehousing’ (Evers 1981).This epitomises the care seen in the Panorama programme where the older person is washed, fed, and repositioned with minimal personal interaction, stimulation or communication, there is a comment during the programme that she is treated like “a piece of meat”.

The National Institute for Clinical Excellence- Social Care Institute for Excellence guidelines for Dementia (2011) call upon us to provide services that address the specific personal, social, mental and physical needs of people, what the  recent ‘Prime Minister’s challenge on dementia’ calls making areas dementia friendly (Department of Health 2012). A holistic, person centred and evidence based approach is more humane, more effective and can be cheaper. For example, poor practices, such as the overuse of psychotic medication to sedate older people with dementia (Banerjee 2010), are more costly than behavioural interventions such as cognitive stimulation (NHS Institute for Innovation & Improvement 2011).

Objective 11 of the National Dementia Strategy (2009) discusses the improvement of care home care and advises the commissioning of specialist in-reach services from older peoples community health teams to work in care homes, a successful example of this is a Birmingham initiative where a team of 3 Doctors and 4 Community Psychiatric Nurses provided specialist education and support regarding caring for older people with dementia to 4 care homes in the area (Khan & Curtice 2011). Following the intervention the care home staff recorded improved levels of knowledge and confidence in caring for older people with dementia.

The number of older people with dementia will treble over the next 40 years (Alzheimer’s Disease International 2011), and have huge implications in terms of residential care. Last night’s Panorama programme was a painful reminder of how urgently we need to address the shortcomings in that care for the frailest and most vulnerable members of our society, many of whom, like the elderly lady featured in the programme, are unable to speak out for themselves about the inhumane and dehumanised environments in which they are expected to live out the remainder of their lives.

Alzheimer’s Disease International (2011) World Alzheimer Report 2011: the Benefits of Early Diagnosis and Intervention, Alzheimer’s Disease International, London
Banerjee S. (2010). The use of antipsychotic medication for people with dementia; a call for action. Department of Health
Clarke M. (1978) ‘Getting Through the Work’. 9in) Dingwall R & McIntosh J (eds). Readings on the Sociology of Nursing. Churchill Livingstone, Edinburgh
Department of Health (2009). Living Well with Dementia: A National Dementia Strategy. DH, London.
Department of Health (2011). Health Service Ombudsman Report: ‘Care and compassion?’ DH, London
Department of Health (2012). Prime Minister’s challenge on dementia: Delivering major improvements in dementia care and research by 2015. DH, London
Evers H.(1981). ‘Tender Loving Care?. Patients and Nurses in Geriatric Wards’ (in) Copp L.A 9ed) Care of the Ageing. Churchill Livingstone Edinburgh
Goffman E. (1963) Stigma: Notes on the Management of  Spoiled Identity. Englewood Cliffs, NY; Prentice Hall
Khan F, Curtice M. (2011) Non-pharmacological management of behavioural symptoms of dementia. British Journal Of Community Nursing Vol 16 no 9; 441-449
Kitwood T (1997). Dementia Reconsidered: the person comes first. Buckingham. OUP
Miller E.J, & Gwynne G.V.(1972) A Life Apart-A Pilot Study of residential Institutions for the Physically Handicapped and the Young Chronic Sick. Tavistock Publications, J.B. Lippincott Company
National Institute for Health and Clinical Excellence – Social Care Institute for Excellence 2011 update of 2007 Standard number 42. Dementia. The NICE-SCIE guideline on supporting people with dementia and their carers in health and social care. . national Collaborating Centre for Mental Health. The British Psychological Society and Gaskell.
NHS Institute for Innovation and Improvement, (2011). An economic evaluation of alternatives to antipsychotic drugs for individuals living with dementia. NHS Institute for Innovation and Improvement, Coventry House, University of Warwick Campus, Coventry.

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Bernie Keenan

Bernie Keenan

Senior Lecturer Birmingham City University, Co-Chair West Midlands Institute for Ageing & Health