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New approaches to dementia care involve care mapping and using activities to help people with dementia to maintain their emotional lives and improve their well-being, writes Henrietta Bond.

Ten years ago a person with dementia might have been physically well cared for - but little more. Today much greater attention is paid to the overall quality of life of clients with dementia, such is the progress that has been made on several fronts with social and health care.

A range of new approaches has been developed in the past few years and new ideas are emerging all the time at the cutting edge of dementia practice. Dementia is caused by illnesses - such as Alzheimer's disease - which destroy nerve cells in the brain, producing an irreversible deterioration in cognitive capacities. No method of prevention or cure is known, though some drugs are proving helpful in slowing down cognitive deterioration in the early stages. Donepezil (trade name Aricept) is the only such drug currently marketed in the UK but others are being tested. Such treatments are expensive and, in an increasingly rationed health service, hard to come by.

But innovation has fortunately not been confined to the drugs field. Person-centred approaches to dementia care have been pioneered by individuals such as Tom Kitwood, psychologist, author and leader of the Bradford Dementia Group at the University of Bradford. With colleagues, he has developed dementia care mapping, in which people with dementia in care settings are observed over periods of time and their responses recorded.

By observing a number of individuals in the same setting, a picture of the quality of care can be established. The Bradford Dementia Group runs training courses in dementia care mapping, which is being taken up by organisations and care providers as a quality assurance tool.

'The key is to see dementia not as a specific illness but as a progressive disability,' says Kitwood. 'So it's important to find ways to enable someone to remain a functioning person. A person can still have a rich emotional life even when their cognitive functions are seriously impaired. A positive approach to care involves a serious commitment to addressing a person's psychological needs.'

Kitwood says a care setting must aim to meet five elements of need: comfort, attachment, inclusion, occupation and identity. A person with dementia needs to experience tenderness, closeness and the soothing of pain and distress. They may need the reassurance of new attachments to care staff or residents in order to function well, to feel an active part of the shared life of a group and to enjoy activities through which they can express themselves.

It is important for staff to gather as much of each person's history as possible in order to understand what interests them and what would cause them anxiety.

Mary Marshall, director of the dementia services development centre at the University of Stirling, says one of the challenges is to find ways to ensure that other aspects of a person's life compensate for those aspects that are not functioning correctly. By learning how to interpret people's challenging behaviour, the stress on them and those caring for them can be minimised.

'Wandering used to be considered the result of neurological damage. But we now understand that it's often a person's attempt to communicate a need - such as being too hot, too cold, or maybe that their drugs are making them restless,' says Marshall. 'We may well be able to address that need - and if nothing else we can ensure that they have better environments to wander in.'

Westminster Health Care has 35 purpose-built mental health units around the country. These buildings are designed to allow easy access to the outside world - within a safe environment such as an enclosed courtyard. There are also 'therapeutic gardens' and other features to stimulate residents' senses.

Inside the homes an effort is made to assist orientation and reminiscence. Each resident has a scrapbook about their home and family. Photographs and ornaments in communal areas reflect the local area. Personalised door plates reflecting each individual's interests help residents who are losing their ability to read to identify their bedrooms.

The homes also use the services of John Killick, a writer with exceptional communication skills who listens to a resident's reminiscences, creates a story from them and reads it back to the resident. 'It really helps the person to realise that someone has understood them,' says Jim Marr, director of nursing.

'It also gives hope to families to realise that the person is aware of what is going on around them and being able to understand more about the person helps staff to tailor their care.'

Tessa Perrin is an occupational therapist employed by Essex social services department to provide mental health services to elderly people. She has recently completed a research project at Bradford Dementia Group, looking at how occupations of various kinds can provide therapy for people in the later stages of dementia.

'My most controversial finding is that dementia can be viewed as the beginning of a return to childhood,' Perrin says. 'Just as a child gains skills, so a person with dementia is bereaved of skills. This allows us to move away from cognitive approaches to focus on sensory stimulation for people in the later stages of dementia, while all the time treating the person with the courtesy and respect we give to adults.'

Perrin has considered a range of activities including music, handling animals, simple cooking, looking at brightly coloured picture books, using a doll and playing with a balloon. She has observed that people's well-being increases when pursuing these activities.

Perrin also believes that severely impaired people can benefit from 'mothering' - the same closeness and physical affection that young children find so important. She would like to see more training to help people understand the importance of spending time with someone who cannot communicate verbally, responding to body language, eye contact and facial expressions.

There has been a notable move towards person-centred dementia care during the past five to ten years, Perrin observes. She says: 'It's really important that we are debating the many new ideas around because the potential rewards are very rich.'

Terry Philpot, 'In their own write', Community Care, 15-21 May 1997

Creative focus

Central & Cecil Housing Trust, which provides care and accommodation in London, and Building Community Through Arts, a community development charity also based in the capital, collaborated in a project looking at creative activities for people with dementia.

Sushma Mangal, a care assistant at Central & Cecil's Homemead residential care home, took part in a clay workshop as part of this project. Among those attending was Rose Brown, a resident who has dementia that particularly affects her short-term memory.

Brown was not keen on the feel of the clay - she said it reminded her of school. But after playing with it she started to talk about baking at home and she made a 'tart' from the clay. Brown, who is on a diet for health reasons, then began to talk about how much she misses sweet foods.

Staff noticed that Brown benefited from the creative activity and from being able to talk about her frustration. The practical activity enabled her to focus on the present and to recall specific memories. This is important as dwelling too much on the past can be confusing for Brown because of her short-term memory loss.

Mangal, who had initially been apprehensive about the clay workshop, was inspired by the positive response from the group to try the technique with other residents.

New ball game

Darnall Dementia Group is a voluntary organisation in Sheffield committed to providing constructive person-centred support to people with dementia and their carers. Its day centre is run by two staff and a team of volunteers.

Tilly Barnes (not her real name) was living alone in a wheelchair-adapted bungalow after being discharged from hospital, where she had received treatment for depression. She was described as having 'mild to moderate' dementia.

Barnes, who was sad and withdrawn, initially rejected the place offered at the Darnall day centre - to the dismay of her daughter. The centre offered the daughter information and support and invited her to the carers' support group. Armed with a greater understanding of her mother's perspective, she encouraged her to consider the centre's renewed offer of a place.

When Barnes first began to attend the centre she would not join in activities and spoke little - apart from swearing at people who passed her. However, she showed great aptitude for ball games, despite her physical disabilities. She began to join in football, indoor bowls and skittles and to take part in singing. Her pleasure in strong colours soon became apparent when she was asked to select a birthday card for another group member. She was also asked to help with choosing, colouring and writing for a range of craft activities.

Although her disabilities have increased, Barnes now shows clear signs of belonging. She swears much less and is able to seek reassurance when anxious.

She receives support and encouragement from others in the group and responds cheerfully when she is greeted.