While the overuse of antipsychotic drugs remains a problem in care homes, one provider has pioneered a person-centred approach that has cut drug use and distress levels. Natalie Valios reports on how staff can gain a better insight into dementia
How would you feel if you had to wear a wet continence pad for a day, or had your glasses smeared with Vaseline? It’s unlikely Four Seasons Health Care staff feel comfortable as they undergo resident experience training. The idea is to challenge the attitudes of staff by showing them how some residents with dementia experience care.
Three years ago, 10 Four Seasons Health Care homes started piloting a model of specialised dementia care called Pearl, (Positively Enriching and Enhancing Residents’ Lives), which includes resident experience training. Part of the rationale was to review the use of antipsychotic medication. Caroline Baker, dementia care services director at Four Seasons, says: “Many residents come to us from hospital where they are put on antipsychotic medication because of their behaviour. When they are transferred to a home this often isn’t reviewed so it’s assumed they still need it.”
Antipsychotic use has fallen by 52% in the 10 pilot homes but the programme has also had wider effects, including reductions in depression levels, falls and hospital days.
Training is the key reason behind this. A two-day, person-centred care course for staff provides an understanding of the needs of people with dementia and how symptoms might affect them. “It looks at communication, signs of well-being and how we can reduce the negative impact we have on them by the things we say or do,” says Baker.
Significantly, the Pearl programme redefines “challenging behaviour’ as “distress reaction” – a response to a distressing situation, such as pain or fear. People with dementia often find it hard to communicate and resort to shouting or aggression. Staff are trained to recognise body language and verbal and non-verbal cues to establish the resident’s need. Consequently, there has been an increase in the use of analgesics and antidepressants.
Resident experience training is integral to the programme’s success. This involves asking staff for a small life history, for example details of their family, favourite food and how they like their tea or coffee. Then they are given the wet continence pad and smeared glasses. “At breakfast we give them tepid porridge and, if they like coffee with one sugar, we give them tea with no sugar so they can experience what it’s like to have no choice,” says Baker. “We feed them a bit too fast so it’s slightly uncomfortable. We don’t call them by their name, just say duck or love. They’re taken to a bedroom and left there with the door shut and the housekeeper comes in and vacuums round them without talking.
“At lunch it changes and we become very person-centred and use things from their life story. It ends with time for reflective discussion, which is almost the most important part, where they look at the two contrasting bits of the day. Some staff have been upset because they know they have done some of these things, even though they were without malice.”
Mishel Ingle, clinical manager of Four Seasons’ Granby Rose specialist dementia unit in Harrogate, says the resident experience training made staff more aware of their actions. “Although we don’t leave residents on their own, when staff were left in a bedroom for 20 minutes it made them realise just how alone people feel if no one pops in to say hello. We notice the small things now, so if a resident’s glasses are dirty, staff will clean them straightaway.”
About 500 staff have been trained in dementia care mapping, which is accredited by the University of Bradford. This is a specialist assessment, which evaluates the quality of care from the user’s perspective by observing them over a period of time, recording information and feeding it back to staff to make improvements.
Other key elements have included doll therapy, in which residents are introduced to a doll with which they can form an emotional attachment. Baker says one of the challenges was convincing staff this did not mean treating residents like children.
“The dolls help people who have a sense of loss when they come into a home so they hold the doll for comfort or speak through the doll,” she says.
Home design has also played a part in the Pearl programme and there is a big focus on orientation. Corridors are painted in different colours and have different themes to give residents two cues to remember where rooms are, including their bedroom. Bedroom doors have a picture that they associate with themselves, for example, a photo of them at an age they remember.
Martin Green, independent sector dementia champion, says the Pearl programme “is a great model” and challenges other providers to follow suit.
“They started from the premise of saying ‘let’s look at every aspect and not see people with dementia as the problem, but our services need to respond to their needs’,” he adds.
Four Seasons has 180 homes for people with dementia and each year about 50 go through Pearl training. The process takes up to a year and homes have to be validated before calling themselves a Pearl specialised dementia service. Currently, 25 are validated and this is expected to reach 60 by the end of 2010, with all 180 due to be covered by 2013.
“In any Pearl-validated home there is a real feeling of calm,” says Baker. “The noise has gone, residents are less distressed. This is mainly because care, communication and observations are better, and as a result of that you are then able to reduce antipsychotic medication.”
Action on antipsychotics
About 180,000 people with dementia are treated with antipsychotic medication across the country each year, an independent review for the Department of Health found last year.
Sube Banerjee, professor of mental health and ageing at London’s Institute of Psychiatry, said that just a fifth of those prescribed antipsychotic medication may benefit from the treatment, and that the drugs were directly responsible for an additional 1,800 deaths a year among patients.
The government accepted all 11 of his recommendations, which included the development of a curriculum for care home staff to learn skills in the non-pharmacological treatment of behavioural disorder in dementia; and for all primary care trusts to commission specialist in-reach services for care homes.
The DH appointed Alistair Burns as the national clinical director for dementia and tasked him with implementing the recommendations, including an audit of prescription levels.
An Alzheimer’s Society spokesperson says: “As soon as hotspots have been identified, we want action. We are yet to see the movement on antipsychotic drugs that we need.” She says the charity has no fears that the election result will change Burns’s role, adding: “All parties have said that dementia is a priority.”
How to reduce drug use
● Ensure good relationships with GPs and consultants so medication is reviewed within three months of admission as hospitals may have inappropriately prescribed antipsychotics.
● Thoroughly assess each resident to make sure nothing is being missed. They may be in pain or depressed and need analgesia or anti-depressants.
● Improve verbal and non-verbal communication with residents. Residents are sometimes put on antipsychotics because their frustration at being unable to communicate is misinterpreted.