3Spirit is excited to share that we are finalists in the following awards. The awards recognise exceptional contributions to social care. Our strong track record in social care, and our impact in the sector in the last 10 years, is the result of our dedication to developing our service delivery, training, resources and ensuring that the learners implement and commit to the learning post-training.
My name is Keith Oliver, and I was a primary school head teacher until diagnosed with Alzheimer’s Disease in 2010.
In my role within the 3 Nations Dementia Working Group, I was delighted to meet Caroline Bartle, and through Caroline to have the opportunity to support on line workshops providing dementia training. Amongst topics covered in these workshops are dementia and the environment, mental health and dementia and what life is like to live with dementia.
I always prepare and write my pieces bespoke specifically for 3 Spirit and sit in on introductions to enable delegates to meet me and for me to tweak my input to meet their needs. It is 100% apparent of the need to give delegates insight into the lived experience which I always do honestly and truthfully.
Dementia was the biggest issue facing our society and social care system prior to the pandemic and the past 18 months have made this even more so. The work 3 Spirit does with the help of folks like me is helping to address this. I have co-presented with Caroline and two of her colleagues, and all the team are great to work with they support and encourage me and it is evident they do this for delegates too. Sometimes delegates have limited technical experience of on line events and the patience of the 3 Spirit team is admirable in supporting them. Content of the courses is excellent and pitched at just the right level with differentiation incorporated in both planning and delivery.
Support from the admin team is always excellent and settling of invoices is prompt and efficient which makes life easier for me and my problems I have with Alzheimer’s. I really enjoy working with the 3 Spirit team and look forward, my health permitting to many more future collaborative ventures.
Many individuals do not receive the post diagnostic support that is needed. Finding affordable and sustainable post diagnostic support has been a challenge in the UK and waiting lists have been impacted negatively since COVID-19. Lack of funding and problems with integrated services are some of the many barriers to good post diagnostic support.
The research shows clearly that good quality post diagnostic support is required to provide people with the information, resources and support that they need to live as well as possible with their dementia.
So, what does good quality post diagnostic support look like?
As a basis, this should include how to manage symptoms but should also include how to maximise on strengths and abilities.
It should also include how to manage and maintain cognitive skills. This might include offering Cognitive Stimulation Therapy (CST).
It should also include how to keep connected with existing networks, people who are important but should also include information on new support networks. This might include peer networks where a person can share insights, experiences and strategies with others going through similar situations.
It should also include things like practical support, specifically where a person has care and support needs.
It should also include how to plan for the future, including making legal provisions.
Our ‘Still My Life’ framework attached is a great outline of the things a person can do following a diagnosis. We co-created this in collaboration with people living with dementia.
Over the last few years, we have had the opportunity to work in a more integrated way with health services in our course development. Supported by health and social care practitioners we have been considering how health and social care interact; the cause and effect, the impact and outcomes on a practice level within specific domains. This interlocking enables us to develop new insights and tools. Within this we have been considering:
What are the individual and collective benefits to services of receiving more support for exercise for people living in with dementia?
What are the potential barriers to providing exercise in care homes and/or community settings?
What priority is given to this and what training is available to facilitate this?
Health and Wellbeing is identified in the Dementia Care Skills Education and Training Framework (section 6), as a key area for education and development for staff working with people with dementia both at tier one and tier two. Section 6 includes health as well as psychosocial activities as expected, and exercise is explicitly mentioned in the first outcome. We have interpreted the outcomes to a more meaningful and measurable course outcome, with exercise linking to many other aspects identified within this section, including but not limited to falls and pain management. Alongside my health colleagues we have debated and developed the merits and outcomes of this course which is set to be a very practical and holistic look at front line integrated interventions.
Over the last few years there has been some exciting research emerging about the impact of exercise on dementia. Alongside which we have started to see exercise offered in front line services as part of prevention strategies. In addition, policy and legislation changes such as the Care Act 2014 have outlined their vision for prevention, of which exercise must feature. Organisations like Age UK have offered chair based exercise, and exercise has been targeted by some authorities as an intervention to reduce the risk of falls and other health outcomes.
The emergence of more collaborative working between health and social care has stimulated the growth of such initiatives; pooling funding to improve health outcomes with prevention. However, what is emerging from the research is that exercise potentially has much wider benefits than reducing the risk of falls, particularly in terms of its application to dementia. Mental health services and local primary care services have offered exercise on prescription for many years as a valid form of treatment for depression, so exercise may potentially offer a valid treatment for some of the neuropsychiatric disorders which often are associated to dementia for example; depression, apathy, hyperactivity and agitation. Exercise may also enable improvements in cognition, and some research seems to suggest that exercise may act directly on the pathology of dementia. What is very clear however is that exercise has far reaching impacts both for physical and mental wellbeing.
Exercise is planned, structured and repetitive movement which aims to improve or maintain physical health. Physical activity is any movement which contracts skeletal muscles and increases energy expenditure. The main types of exercise are aerobic, strength, flexibility and balance. Aerobic exercise increases breathing and heart rate. Strength exercises make your muscles stronger. Balance exercises can help prevent falls and flexibility exercises help you to remain limber and improve the range of movement.
However, accessing and maintaining activity where comorbidity is present can be a challenge. If a person is older when they develop dementia they may also experience barriers to accessing and maintaining exercise. For example, pain, fear of falling, arthritis, sensory loss, or respiratory problems. A person may also have restricted movement and some rigidity and quite possibly not be mobile. Good assessment, including pain assessment should be completed to develop a plan that is appropriate to that individual alongside advice from the GP. However not all people developing dementia are older, so this could exercise may be an excellent targeted intervention for younger people with dementia? A study in the Netherlands is currently researching the impacts of exercise in early on set dementia (EXERCISE-ON study) the authors (Hooghiemstra et al 2012) suggest that certain dementia characteristics such as apathy may lead to sedentary and socially impoverished lifestyles, and by targeting these interventions in a timely fashion they can have far reaching impacts.
Together with co-morbidity barriers, we need to consider the challenges dementia brings in potentially engaging in exercise. For example, difficulties with coordination, motor skills, visual perceptual challenge and memory difficulties. These difficulties will require us to have a considered approach to the support systems needed to overcome these challenges.
There is such a wide variety of exercise available to us therefore it is about identifying strengths, and identifying suitable exercises that engage these strengths. This might include walking, dancing and/ or using music. Music can powerfully evoke memories, impact on motivation as well as provide rhythm and structure to support difficulties with memory. It is therefore an excellent method of exercise.
Exercise may improve thinking skills. A Chinese study (Lam et al 2012) found that mind-body exercises such as Thai Chi could improve cognition as well as have additional impacts such as improving balance and strength. Exercise is targeted as a potential primary prevention strategy to delay / reduce onset of dementia once someone has been diagnosed with mild cognitive impairment. The wider impacts of exercise on health outcomes are well documented, despite this many services fail to see the importance of it, and more specifically their role in supporting and enabling exercise.
Some studies have been completed to look at how effective exercise is in care homes at reducing the incidence of depression. Depression impacts on quality of life and pharmacologic treatments are not without their side effects. Some studies have found no evidence that moderate exercise in a care home had an impact on depression (Conradsson et al 2010). In contrast Edris et al (2009) had more success in providing a three week exercise plan, as found that it reduced levels of agitation. Agitation and depression are not directly comparable, and clearly variables will differ within this context. However, reducing incidences of agitation could have a direct impact on staff costs associated to working with challenge. Researching the impact of exercise on depression within a care home is a complex task, as the social environment, beyond the time of the exercise will potentially impact. Separating these variables in research is bound to be a challenge.
Despite the barriers, both in research and in delivery opportunities for people living in care homes to exercise must continue to be a priority. Factors to be considered include: building design, access to outdoors, effective pain assessment and management, and education on the benefits of exercise. There may be a wider impact on these enablers, including improved mood, better sleep and potentially improved nutritional intake.
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Ahlskog, E.J., Geda, Y.E., Graff-Radford, N.R. and Petersen, R.C. (2011) ‘Physical exercise as a preventive or disease-modifying treatment of dementia and brain aging’, 86(9).
Aman, Edris et al.(2009) ‘Supervised Exercise to Reduce Agitation in Severely Cognitively Impaired Persons’, Journal of the American Medical Directors Association , Volume 10 , Issue 4 , 271 – 276
Baker, L.D., Frank, L.L., Foster-Schubert, K., Green, P.S., Wilkinson, C.W., McTiernan, A., Plymate, S.R., Fishel, M.A., Watson, S.G., Cholerton, B.A., Duncan, G.E., Mehta, P.D. and Craft, S. (2010) ‘Effects of aerobic exercise on mild cognitive ImpairmentA controlled trial’, Archives of Neurology, 67(1), pp. 71–79. doi:
Conradsson, M., Littbrand, H., Lindelöf, N., Gustafson, Y. and Rosendahl, E. (2010) ‘Effects of a high-intensity functional exercise programme on depressive symptoms and psychological well-being among older people living in residential care facilities: A cluster-randomized controlled trial’, Aging & Mental Health, 14(5), pp. 565–576
Duzel, E., van Praag, H. and Sendtner, M. (2016) ‘Can physical exercise in old age improve memory and hippocampal function?’, 139(3).
Hoffmann K, Frederiksen K, S, Sobol N, A, Beyer N, Vogel A, Simonsen A, H, Johannsen P, Lolk A, Terkelsen O, Cotman C, W, Hasselbalch S, G, Waldemar G, Preserving Cognition, Quality of Life, Physical Health and Functional Ability in Alzheimer’s Disease: The Effect of Physical Exercise (ADEX Trial): Rationale and Design. Neuroepidemiology 2013;41:198-207
Hooghiemstra, A.M., Eggermont, L.H., Scheltens, P., van der Flier, W.M., Bakker, J., de Greef, M.H., Koppe, P.A. and Scherder, E.J. (2012) ‘Study protocol: EXERcise and Cognition in sedentary adults with early-oNset dementia (EXERCISE-ON)’, BMC Neurology, 12(1), p. 75.
Littbrand, Hã., Lundin-Olsson, L., Gustafson, Y. and Rosendahl, E. (2009) ‘The effect of a high-intensity functional exercise program on activities of daily living: A Randomized controlled trial in residential care facilities’, Journal of the American Geriatrics Society, 57(10), pp. 1741–1749
Lam, Linda C.W. et al (2012) ‘A 1-Year Randomized Controlled Trial Comparing Mind Body Exercise (Tai Chi) With Stretching and Toning Exercise on Cognitive Function in Older Chinese Adults at Risk of Cognitive Decline’ Journal of the American Medical Directors Association , Volume 13 , Issue 6 , 568.e15 – 568.e20
Lowery, D., Cerga-Pashoja, A., Iliffe, S., Thuné-Boyle, I., Griffin, M., Lee, J., Bailey, A., Bhattacharya, R. and Warner, J. (2013) ‘The effect of exercise on behavioural and psychological symptoms of dementia: The EVIDEM-E randomised controlled clinical trial’, International Journal of Geriatric Psychiatry, 29(8), pp. 819–827.
Schwenk, M., Dutzi, I., Englert, S., Micol, W., Najafi, B., Mohler, J. and Hauer, K. (2014) ‘An intensive exercise program improves motor performances in patients with dementia: Translational model of geriatric rehabilitation’, Journal of Alzheimer’s Disease, 39(3), pp. 487–498Follow Us
Tier 2 (Subject 6) Dementia Health and Well-being Training Course
This course outlines the importance of maintaining physical and mental health in relation to someone living with dementia. This course provides information on how to tackle: nutrition, hydration, pain, continence care and sleep. Participants will develop a basic understanding of holistic approaches to health, but are provided with some practical information in supporting activities of daily living. The course is mapped to tier 2 – Dementia Core Skills Education Framework (subject 6). This course is delivered in an engaging way, and participants get the opportunity to engage in experiential learning activities.
Explain why it is important to maintain good physical and mental health.
Describe how to identify a person’s heath needs including malnutrition, pain, dehydration, falls and fatigue
List the signs of delirium and the signs of dementia, recognising delirium is a medical emergency
Describe the possible impact, including psychological and social impact, of incontinence.
Describe the potential causes of, and impact of loneliness and the importance of maintaining social engagement
Describe possible ways to support ADL’s in a person centred manner.
What a delight to offer this info graphic about dementia in nature, as the first for 2017. Inspired by the brilliant Garuth Chalfont, who has made an excellent contribution to the field. Being outdoors, and connected to nature bring many benefits, and particularly to those living with dementia.
Often overlooked, this simple accessible treatment may bring opportunities to manage symptoms, engage with others and improve quality life. Being outdoors may connect people and trigger memories in a powerful, and potentially more sustainable way. I attended the MIND project conference recently where I was reminded that being in nature may evoke mindfulness, an effective treatment in its own right.
Last year we did a scoping review of relevant research in exercise and dementia. Here I discovered the role of ‘green exercise’ and if combined with others, in a social situation, may bring additional benefits to the brain. As we walk and talk, our brains literally grow! At dementia congress one year I remember hearing about a CST project that was delivered completely outdoors, supported by the sensory trust. I am not sure what happened to this, but think it’s utterly brilliant. We need more projects and more research into social engagement outdoors.
However, the utopia is far from the reality. There are many barriers in the way to achieving optimum access to outdoors. There are practical challenges around building design, and/or accessibility in our communities. Many individuals in paid care still do not understand the therapeutic value, so do not support or provide access. Being outdoors can be too cold or too hot, and these practical challenges sometimes seem unsurmountable. There are physical barriers too such as mobility challenges, fear or falling and/or pain.
Whilst we work hard in our training sessions, and info graphics to raise awareness of the benefits of access to nature, what is needed is more funding, and more opportunities. We need to spend public money wisely, and engender community support where possible. I am constantly in awe of the excellent work of dementia adventure and all those other excellent projects big and small going on. We would love to hear about them.Follow Us
In our work on the Vanguard projects in reducing hospital admissions to care homes we have been considering the role of technology within the care homes setting. Areas that we have been looking at include but are not limited to telehealth, I Pad, and more modern, possibly contentious technologies, such as virtual reality headsets.
When planning this programme we considered:
How might technology increase social engagement in the care homes, without replacing human contact?
How might technology be used to proactively monitor health, to prevent/detect delirium and / or reduce unnecessary hospital admission?
How might technology be used to promote physical exercise in care homes?
The picture in other areas may well be different, but for here, and for now, at least we seem to be lagging as we found a fairly limited take up. This is also representative of the many care homes that we train. However, the potential use of technology in dementia care has been gathering pace, as new technologies emerge onto the market. A recent coping review that was carried out by GIbson et al (2016) identified 171 product types and 331 services. However, many of these are unregulated, and have not been rigorously tested in research conditions. Despite this there is a significant pull for these technologies. One of the driving factors (although not the only factor) is how these technologies increase efficiencies.
Assistive Technologies: ‘any device or system that allows an individual to perform a task that they would otherwise be unable to do, or increases the ease and safety with which the task can be performed’ (Royal Commission on Long Term Care, 1999)
Telecare: remote social care monitoring
Telehealth: Telehealth is the remote exchange of data between a person at home and their clinician(s) to assist in diagnosis and monitoring typically used to support people with Long Term Conditions. It comprises of fixed or mobile home units to measure and monitor temperatures, blood pressure, glucose levels and other vital signs parameters
The reasons to use technology are vast, and extend far beyond safety but might also include:
Increase engagement, support independence through multiple mechanisms (prompting memory, orientation, supporting motor skills etc), facilitate proactive and preventative health monitoring, improve wellbeing through multiple domains (including encouraging exercise) and relieve carers stress. Then there are the organisational benefits which might include better targeting of human resource, support communication across teams, support compliance and safeguarding through effective monitoring and reporting.
AT are used by different people in different ways. GIbson et al (2016) usefully categorised the AT into 3 camps: ones that are used by people with dementia, ones that are used on people with dementia and ones that are used with people with dementia. For each of these there is a different set of ethical questions, and differing drivers in design. Who is making the decisions about the purchase and use of these technologies? For informal carer’s the quest may be driven by questions like, how can this technology reduce the caring stress levels? Where these technologies are being used to unobtrusively reduce risks, such as monitoring technologies. How much of this is creating a false sense of security? (Nygard et al 2005).
There has been significant investment in the community to respond to demographic challenges. Policy has stimulated investment in the Assistive Technologies (AT), with the Technology Strategy Board investing £25 million of matched funding between 2008 and 2011. However, whilst these technologies are more widely available in the community, at a practice level, there continues to be real challenges in the uptake, both in the community as well as in care homes. Yet the conversations continue about the evolving possibilities of technology. The Dementia Congress in Brighton this year, as well as the Alzheimer Europe conference in Denmark, featured presentations on ‘robots’. The conversations that ensued included ethics, as well as how these could be used in cashed strapped times.
Greenhalgh et al (2012) suggest that there are several conversations going on around the use of AT, of which ethics is only one. The ‘ethics’ conversation is mainly driven by the professionals working in the sector. Developers and ‘modernists’ are concerned with the benefits and use of AT in saving time, and creating efficiencies. There is also the ‘political’ conversation stating the economic benefits of the telehealth, and telecare markets and the role of industry in influencing, or managing vested interests. Then finally there is the ‘change management’ conversation which argues that there is a mismatch between the system, and actual work practices, and work needed to be completed to address this. These conversations create tensions in the development and uptake of AT, and there is boundless interconnectedness between these.
Nauha et al (2016) looked at the use of AT for people at home with a memory disorder. In this study they also explored how the use of these technologies can facilitate, and support the work of the care staff, together with how the technology is effective in supporting the person with dementia. An important consideration, if we are to address the concerns of the ‘change management’ conversations we need to be thinking unilaterally about the benefits of AT. This means looking at the benefits not only to the individual but also for the service.
So as stakeholders continue to battle it out in different forum, on a practice level there is more concern about where and how do I source these technologies? Are they affordable? Will they work? How can they enable? How do they support carers both formal and informal? And finally, and possibly most importantly, how can they be used ethically?
Assistive technologies (AT) might include low tech, to high tech. These might include clocks and signage to support orientation. Devices which prompt and remind, such as medication dispenses, recorded devices or iPad technologies. Alerts and alarms, communication aids or technologies that support recreation and engagement.
Local authority social care support has traditionally been the largest supplier of AT, most of which are tele care, services like just checking can monitor movements / or lack of movements, and successfully identify issues, hopefully before they develop. In addition to telecare, telehealth is having an increasing role. In Croyden a pilot project was undertaken, which successful reduced the admissions to hospitals
Therefore, on a strategic level technologies are being introduced to enable us to work more effectively, to reduce impact on an overburdened NHS. However, many of these technologies are being introduced much later on post diagnosis, often where there are already significant challenges to an individual’s health and wellbeing. As local authority eligibility increases, often individuals are at crisis point before accessing these services, and along with that accessing information about suitable AT. To compensate for this many individuals are now looking in other places for up to date information on the range, and suitability of technologies. Sometimes unsuccessfully sourcing the right technology at the right price. Whilst there are some great websites, like www.atdementia.org which was set up some years ago, brilliant and comprehensive these ‘of the shelf’ products are being purchased without any proper assessment. As the major risk factor for dementia is age, many individuals are living with co-morbidity, including, but not limited to sensory problems, impact significantly on the application, and use of these technologies. In addition, individuals are often have cognitive challenges: memory problems, impaired judgement and visual perceptual challenges.
Cahill et al (2007) found for the AT to be utilised effectively, informal and care staff need to be available to support, show and encourage individuals to use the products. Therefore, what training is being provided to front line staff, and informal carer, on how to maximise the use of these technologies, and how many staff are reluctant because of unanswered ethical concerns?
Potential barriers to the use of technology:
Accessing timely and suitable information
Sourcing technology that works with comorbidity
Accessing suitable assessment
stigma associated to use
costs and relative funding for technology
as much of the technology needs to be supported by others, training is needed
Another major factor, which is often overlooked and not evident in the research papers I have read is the impact of the cuts on the uptake and use of technologies. On the one hand, you might consider that having technologies in place will create efficiencies, however introducing new technology requires change. As we have seen with the introduction of the Home Spirit Tool home care services are simply too stretched to even entertain the idea of piloting new ways of working.
In addition to the potential barriers we have the ethical considerations to make. One of the principle concerns is how can technology be used to address loneliness, but without replacing human contact? How might we manage effectively the tensions between surveillance for safety and privacy. As technology evolves it pushes the boundaries around ethical concerns. For example, we have seen the introduction of Virtual Reality, augmented reality for the individual to simulate experiences. Supporters believe that this can support the recall of memories and positive emotion. However, is this a form of treachery (Malignant Social Psychology – Tom Kitwood)?
Despite these ethical challenges, we will continue to explore the benefits and application of AT in our work both in the development of the Home Spirit Tool www.homespirit.org, and in the development of our training. We aim to give our learners the confidence to explore the ethical dilemmas openly as well as engage the people that they support in these conversations. Particularly, how might AT enable us to positively risk take.
Gibson, G., Newton, L., Pritchard, G., Finch, T., Brittain, K. and Robinson, L. (2014) ‘The provision of assistive technology products and services for people with dementia in the United Kingdom’, Dementia, .
Gibson, G., Dickinson, C., Brittain, K. and Robinson, L. (2015) ‘The everyday use of assistive technology by people with dementia and their family carers: A qualitative study’, BMC Geriatrics, 15(1).
Greenhalgh, T., Procter, R., Wherton, J., Sugarhood, P. and Shaw, S. (2012) ‘The organising vision for telehealth and telecare: Discourse analysis’, BMJ Open, 2(4), pp. e001574–e001574.
Hagen I; Cahill S; Begley E; Faulkner JP (2007) ‘It gives me a sense of independence’ – findings from Ireland on the use and usefulness of assistive technology for people with dementia. Technology and Disability 19 (2007) 133–142
Nauha, L., Kera nen, N.S., Kangas, M., Ja msa , T. and Reponen, J. (2016) ‘Assistive technologies at home for people with a memory disorder’, Dementia,
Nygård, L. and Starkhammar, S. (2007) ‘The use of everyday technology by people with dementia living alone: Mapping out the difficulties’, Aging & Mental Health, 11(2), pp. 144–155
Rosenberg, L. and Nygard, L. (2013) ‘Learning and using technology in intertwined processes: A study of people with mild cognitive impairment or Alzheimer’s disease’, Dementia, 13(5), pp. 662–677.
Sugihara, T., Fujinami, T., Phaal, R. and Ikawa, Y. (2013) ‘A technology roadmap of assistive technologies for dementia care in Japan’, Dementia, 14(1), pp. 80–103.
There is an estimated 1.2 million Lesbian, gay, bisexual transgender (LGBT) older people in the UK, many of which will have dementia with services often failing to meet the specific needs.
The public sector equality duties require organisations to eliminate discrimination, advance equal opportunity and foster good relationships for all those using services. However so often the opportunity for older people to even ‘mention’ their sexuality is supressed. It is the role of all social care organisations and leaders of services to raise hidden issues that silently trample on human rights. It is essential to push boundaries and to enable the people we work with to honestly reflect on their practice.
The subject of sex is too often ignored when thinking of people in their 60’s, 70’s and 80’s plus. Many practitioners lack the confidence and skills to know how to raise the subject. Whether we were born in the UK or moved here in our lifetime, we are still terribly ‘British’ when it comes to the subject.
Some people from the LGBT community have already struggled with higher risk of mental ill health, suicidal thoughts, self-harm and substance misuse and a lifetime of waiting for law to catch up with common sense in order for their rights to be upheld. It was only in 1973 homosexuality was removed as a mental disorder from DSM and 2013 before same sex marriage was recognised in law.
It is estimated that only 53% of people from the LGBT community have ‘come out’ to a health professional – the remainder may include those that feel their lifestyle choices are nobody else’s business, but it is possible that many may fear discrimination and keep their mouths and closets firmly shut. How can we ever tailor services to meet the specific needs and preferences of people from the LGBT community, if they do not feel safe to become visible?
For individuals living with dementia memory problems mean that often individuals have to experience ‘coming out’ twice, into services which are often not prepared, willing or skilled enough to support these needs. The vital work in reminiscence can bring a persons’ history to the fore, often resulting in the person finding themselves as well as others understanding them better. However what if, by bringing a person back to a childhood when they were a different gender results in difficult memories?
The rise in HIV in men over 50 continues, with a much later presentation for health care, and a higher mortality rate than their younger counterparts. Older men reporting that unsafe sex is still common place. From this we can presume that unsafe sex is as prevalent across all over 50’s and may have an effect on STI’s in the whole community. It feels necessary to raise this issue as specific health and social care needs arise from this information and not to only associate HIV to the LGBT community, but also to consider safe sex in our older population. More specifically what role do older people services play, or should play in supporting safe sex?
Older people from the LGBT community remain more likely than both heterosexual peers & younger generations and to be single & live alone. They are also less likely to have children, which means they are more likely to have a greater need of formal care & support. It would also suggest that where a person with children may be less likely to need residential care, and those without may have a greater need and sooner. So this would mean that out of the estimated figure of 1.2 million of LGBT older people, many may be living invisibly in our care homes. In data collected by CSCI (now CQC) in 2008 only 7% of care homes and 8% of domiciliary care providers reported carrying out specific work around equality for LGBT, with less than 1% of care homes who had done any specific work around sexual orientation & assessment or care planning. With no preparedness or any provision to acknowledge LGBT, it seems living in a care home is similar to living in their closet. Clearly much work is needed to advance this practice.
We need more LGBT friendly care homes, or specific care homes that understand what a gender neutral pronoun is. These flag ship services will embrace all people, regardless of their sexual orientation. More broadly much work is needed around older people and sexuality. Challenges faced with being older; ageism, physical and mental frailty pose problems for meeting sexuality and intimacy needs. A basic and fundamental human need for all regardless of age or sexual orientation. This is essentially about coming back to our core social care roots; promoting person centred care, dignity and inclusion.
Include sexuality & gender identity in assessment.
Consider marketing strategies: use same sex couple’s photos in marketing.
Consider using appropriate language such as gender neutral pronouns.
Carry out training in sexuality and older people as standard practice
Consider culturally sensitive reminiscence: Trans gender is different in childhood
Appreciate not everyone has conventional model of ‘family’
Consider physical building constraints to privacy
Put pressure on stakeholders to make LGBT and dementia a research and commissioning priority
Further resources: NATIONAL CARE FORUM, VOLUNTARY ORGANISATIONS DISABILITY GROUP –Dementia Care and LGBT Communities a Good Practice Paper (2016)
As health and social care trainers we straddle the medical and social model, and believe whole heartedly, holistic, and integrated practice is required to enable positive outcomes, and well-being within our communities. Within each realm of medical and social perspective, many factors which may be viewed in isolation maybe interdependently linked: manipulating one factor, may impact upon others. We need to take a balanced approach, informed by consent, and at times, pharmacological strategies are warranted, and at others times we should consider non-pharmacological approaches.
It is our responsibility, within training sessions, to encourage staff to reflect upon their clients and the complex nature of the conditions, to equip them with skills to observe, report and signpost. One subject raised within sessions is polypharmacy. Many of the services we train are commonly working with comorbidity, and complexities around fluctuating sates, often resulting in competing care and treatment strategies. To support discussions relating to polypharmacy, we developed some resources with the aim to get people to think and reflect more broadly about the topic.
Inappropriate polypharmacy is a very real and present threat, as many prescribing practitioners face tensions between treating common conditions and the risks associated with polypharmacy.
Many people with dementia, together with older population are affected by polypharmacy. Older people generally will have multiple health conditions which require medication. However, given the potential communication difficulties presented with dementia, particularly around problematic pain management, it is possible that there is a higher prevalence of polypharmacy in this group.
There is no clear definition for Polypharmacy: Sometimes numerical: for example greater than 6. Accepting a numerical definition of polypharmacy has the disadvantage: does not recognise that in some cases the combination use of certain medications is beneficial to the older person. Inappropriate polypharmacy is when the person takes more drugs than are clinically indicated.
Polypharmacy is a concern in this group because there are age-related physiological changes that alter the ways in which drugs are handled by the body. This may include:
• Reduced renal function
• Reduced liver function
• Reduced ratio of body fat to water
• Delayed stomach emptying
There are substantial risks of polypharmacy: for example, there may be severe side effects, some of which further compound cognitive challenges. There may also be drug-drug interactions and drug-disease interactions. The impact can be far reaching; Side effects may cause drowsiness leading to an increased risk of falls. There may be impacts on appetite and poor nutrition leading to multiple problems, not least a compromised immune system. Further than a physiological level, for example certain medications may impact on changes to sexual drive, impacting on identity and ultimately self-esteem. Changes in mood caused by the medication, coupled with cognitive difficulties may lead to emotional distress and challenging communication. In some instances the inappropriate use of medication can create the very problem that it is trying to solve.
There are many possible causes of inappropriate polypharmacy:
• Multiple physicians
• Over the counter medicines including herbal preparations
• Medicine dependent culture
• Medication administration errors
• Treating medication side effects with other medications: e.g. a medication may cause constipation, may then be prescribed a laxative. Alternatively maybe appropriate to consider non drug approach: diet.
When the side effects of medication are misdiagnosed as symptoms of another condition. Further medication is prescribed (Cascade prescribing), further side effects and unanticipated drug interactions may present. Older people with dementia who take a cholinesterase inhibitor and who experience urinary incontinence are more likely to receive an anticholinergic medicine to manage their symptoms
Drugs including some antidepressants, muscle relaxants, antispasmodics, and antihistamines may have anticholinergic effects and, therefore, may cause confusion, blurred vision, dry mouth, light-headedness, constipation, and difficulty with urination and/or loss of bladder control causing additional difficulties for a PWD.
Some examples from research:
In a prospective cohort study of 294 older people 22% percent of patients taking 5 or less medications were found to have impaired cognition as opposed to 33% of patients taking 6-9 medications and 54% in patients taking 10 or more medications.
Also in this paper: Polypharmacy affected patient’s nutritional status. A prospective cohort study found that 50% of those taking 10 or more medications were found to be malnourished or at risk of malnourishment
Jyrkka J, Enlund H, Lavikainen P, et al. Association of polypharmacy with nutritional status, functional ability and cognitive capacity over a three-year period in an elderly population. Pharmacoepidemiol Drug Saf. 2010;20:514–522. [PubMed]
A study in elderly patients with dementia reported that those patients who reported a fall had an increased prevalence of polypharmacy
Lee CY, Chen LK, Lo YK, et al. Urinary incontinence: an under-recognized risk factor for falls among elderly dementia patients. Neurourol Urodyn. 2011;30:1286–90. [PubMed]
Two-thirds of hospitalisations for adverse events involved four medicines or classes — warfarin, insulins, oral antiplatelet agents or oral hypoglycaemic agents — taken alone or in combination
Budnitz DS, Lovegrove MC, Shehab N, et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 2011;365:2002–12. [PubMed]
All Party Parliamentary Group on Dementia (2008) Always a last resort: inquiry into the prescription of antipsychotic drugs to people with dementia living in care homes. Alzheimer’s Society. London.
Kleijer BC, van Marum RJ, Egberts AC, Jansen PA, Knol W, Heerdink ER. (2009). Risk of cerebrovascular events in elderly users of antipsychotics. J Psychopharmacol. Nov;23(8):909-14. Epub 2008 Jul 17.
NHS Information Centre (2012) National Dementia and Antipsychotic Prescribing Audit.
Gill SS, Mamdani M, Naglie G, et al. A prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs. Archives of internal medicine 2005;165:808–13. [PubMed]