Success and limitations in supporting people with dementia, their families and staff in care homes with a dedicated Community Mental

Health Team

Carol Ainsworth, Dr. Suzanne Jeffries, Jane Preston, Debra Williams,

Dr David Jolley, Reagan Blyth,

Dr. Christine Brown Wilson

The Context

• 40% or more of people with dementia are resident within a Care Home

• 60% die in an institution.

• More than half of residents in care homes are experiencing dementia of some degree.

• Doctors are accused of prescribing antipsychotic medication to quell disturbed and distressed behaviour without considering

less toxic non-medicinal alternatives

Who are we?

• Nursing and residential home team (CMHT)• In operation for 10 years in Tameside and Glossop• Part of CMHT (OP)

• Across Tameside and Glossop- >65= 36,866(2006)

• RMNs• Assistant Practitioners• Consultants

What do we cover?

• 2,054 beds(2009) in the Tameside & Glossop area

• 5-6% (cf 4%) population in 24 hr care

• 49% residential (1,014)

• 24% nursing (493)

• 12% emi residential (243)

• 9% emi nursing (189)

• 6% others (115)

What do we do?

• Assessment- mental health, medication, challenging behaviour, complex capacity, mental health nursing needs, CHC assessments, cognitive function, response to treatments/interventions, placement, physical health

• Advice- telephone and face-face

• Support- client, staff, carers, primary care

What do we do?

• Education- carers, health and social care staff

• Advocacy

• Monitoring

• End of Life Care support

• Signposting

• Liaison

Challenging Behaviour?

• What does this mean?

• What kind of behaviours?

• Challenging to who?

Challenging behaviour

• Resistive behaviour (=/- “aggression”)

• Restless and agitated behaviour

• Poor food and fluid compliance

• Poor medication compliance

• Sexually inappropriate behaviour

• “Wandering” behaviour

• Continence issues

• Etc..........................

Assessment

• History

• Screening

• Observation and assessment

Assessment 1

Assessment 2

Assessment 3

Dementia Care MappingObservers spend sessions of three to six hours with a resident.

• They participate but observe during each five-minute period, andmake a judgement about the resident‟s well-being.

• They note any personal „detractions‟ that occur (such as the residentbeing ignored) and their severity.

• Five or six residents can be observed at a time (by an experiencedobserver).

• Managers receive detailed information about the actions of staff andthe interactions that take place in the home.

Management- biological

• Physical healthcare- treatment of infections, constipation, pain etc

• Appropriate mobilisation, physiotherapy, chiropody

• Appropriate food and fluid intake, dietician, SALT

• Medication- rationalisation, regular/prn, appropriate treatment of condition (later)

Management- social 2• Adequate and consistent staffing • Familiar environment with patient and calm carers. • Involve relatives if appropriate• Routine and structure• Appropriate lighting and allow sleep • Regularly orientate (clocks, calendars, papers)• Communicate at all times (glasses, hearing aids) on all

interventions (eye contact, speech, touch)• Provide reassurance at all times especially on self care

(be prepared)• Ensure good food & fluid intake • Engage and know the person. Spend time

Management- social 3• Safe, non critical accepting environment• Distract if agitated or distressed • Ensure activity plans within home, stimulation, walking,

reminiscence• Care plan 1-1 time if appropriate and beneficial • Assess and maximise autonomy with self care , re-

approach if necessary• Ensure continence care and comfort • Use sleep charts, & ABC charts• Alternative therapies eg massage, aromatherapy• Minimise risk • Think outside the box

Medication

• Beneficial effects V risks

• Side effects

• Monitoring

• Withdrawal

• Use of prn (as required)

Case study

• Female client age 76 diagnosed with Alz Type dementia recent discharge from hospital, subject to full ChC funding. Currently in EMI Nursing home.

• Team asked to provide support as client not eating or drinking adequately, staff also suspect that she is over sedated.

Case study continued:

• Observation of client at meal times

• Involved client in identifying preferences

• Discussed life history of client with staff

• Formulate care plan in partnership with staff, resident and family

• Medication review

• Make recommendations

Action

• Liaised with GP re pain relief.

• Spoke to family about increased dietary intake and also progression of the illness.

• Diet and fluid charts and weight charts commenced.

• Discussed with consultant

Themes

• Fresh pair of eyes‟

• Asking the question: WHY?

• Involving the person with dementia

• Life history approach to care plans

• Role of medication

• Working in partnership to identify solutions

References• National Dementia Strategy- Living Well with

Dementia 2009• The use of antipsychotic medication for people with

dementia: Time for action 2009• End of life care for people with dementia 2009• Always a last resort -Inquiry into the prescription of

antipsychotic drugs to people with dementia living in care homes 2008

• Healthier Horizons for the North West 2008• Best Interests at End of Life 2008• End of Life Care- Advance Care Planning 2008• Darzi review 2008

Contact information

Carol Ainsworth, Debra Williams, Jane Preston

Mental Health Services for Older People

Etherow Building

Tameside Hospital

Fountain Street

Aston Under Lyne

Lancashire

OL6 9RW

Tel: 0161 604 3474/3400