Enablement and support for people

living with dementia

Crisis intervention and rehabilitation 12th October 2017

Fiona Throp, Community Advanced Practitioner, RGN

Sophie Wilson, Mental Health Nurse Specialist, RMN

Airedale and Craven Collaborative Care Team.

Collaborative Care Teams Airedale Collaborative Care Team – based at Airedale Hospital Craven Collaborative Care Team – based at Skipton General Hospital The team provide rehabilitation and Intravenous therapy within peoples own homes to prevent hospital admission where possible or facilitate early supported discharge from hospital. This is called a wrap around service The team comprises of nurses, physiotherapists, occupational therapists, mental health nurse specialists, advanced clinical practitioners, health care support workers. Holmewood – 4-8 Intermediate Care Beds Providing specialist residential rehabilitation for people with dementia

Dementia Rehabilitation – A contradiction?

Dementia: May be defined as cognitive deterioration (medical model)

Rehabilitation: May be defined as restoring capabilities (functional rehab model)

The Enriched Model of Dementia

D B P NI H SP

(Kitwood 1997)

ENABLING STRUCTURING APPROACHES AND ENABLING STRATEGIES CAN BE ADAPTED TO ANY ACTIVITY OF DAILY LIVING THAT THE PERSON WITH DEMENTIA ENGAGES IN BOTH INSIDE AND OUTSIDE THE HOME ENVIRONMENT

Keeping people involved

Environmental Factors

• When considering the home environment there are many factors that can enable or hinder a person with dementia’s ability to engage in activities of daily living

• These environmental factors can also impact on a person’s safety for example risk of falls

• They can be internal or external for example: • Vision • Lighting • flooring

Sight Loss and Dementia Vision

• 1 in 5 people aged 75 and over, and 1 in 2 people aged 90 and over are living with sight loss

• Require twice as much light as lighting standards recommend

• Nearly four times as much as that of a 20 year old to see satisfactorily

Sight loss

• Age-related macular degeneration – loss of central vision

• Glaucoma – loss of peripheral vision

• Diabetic retinopathy – patchy vision

• Cataracts – loss of colour definition, problems with glare

Eye related conditions

• Colour perception

• Figure-background contrast

• Changes to visual field

• Recognising objects, faces, and colours

• Depth perception

Visuo-perceptual difficulties

Home Environment Lighting

• Avoid changes in lighting when going from room to room

• Avoid energy bulbs especially on stairs

• LED lights can give more light but also be energy efficient

• Poor lighting can increase anxiety and increase risk of trips or falls

Bulbs

• Natural light is free and offers excellent colour rendition

• Pull back curtains or blinds to let as much light in as possible

• Orientation of window

• Avoid glaring sunlight

• Health benefits from going outside

Natural light

• Having a combination of general, localised, and local lighting can be effective

• Avoid shadows – they can be confusing and sometimes be seen as steps

• Avoid glare from bulbs

Lights/lamps

Home Environment Contrast Colour, Signage, and Flooring

• A person may struggle to find toilet if all doors are same colour

• Likewise a coloured toilet seat can help with positioning

• Steps can be made safer by having a contrasting strip along the edge

• The outline of furniture can be seen more clearly

Contrast

• Having signs on doors can help orientate people around their homes

• Having signage on kitchen cupboards can reduce the effort of locating ingredients/utensils

Signage

• Avoid dark patterned carpets if possible

• Try keep flooring types/colour consistent

• Shiny surfaces can be misinterpreted as water or slippery

Flooring

Contrasting Colour and Flooring Other Examples

Inclusive Outdoor Environments Wayfinding

• The extent to which streets are recognised and understood

• Environments normally follow certain design patterns

• Hierarchy of street types

• Buildings that are familiar in design

• Street furniture that is easy to understand

Familiarity

• Understanding where they are and where they need to go

• The use of signage

• Landmarks and environmental features

• Street layout

Legibility

• Neighbourhoods have their own distinctive identity

• Helps a person understand where they are and feel at home in their surroundings

• Practical features such as post box - using wayfinding cues at decision points, such as road junctions

Distinctiveness

(Burton and Mitchell 2006)

Inclusive Outdoor Environments Wayfinding

• The ability to reach, enter, use and walk around places they need to visit

• Reaching destinations – local shops, health centre etc

• Wide footpaths, seating, bus stops, pedestrian crossings

Accessibility

• Enabling people to visit their place of choice, to enjoy being out of the house

• Comfort in knowing where they are can promote self-esteem and maintain independence

• Again seating – somewhere to rest, public toilets, bus stops with shelters

Comfort

• Accessing the outdoor environment without fear of falling, being knocked down, or being attacked

• Well-maintained and clear footpaths

• Signal-controlled pedestrian crossings

• Adequate street lighting

Safety

(Burton and Mitchell 2006)

What is Risk

Risk is the possibility that an event will occur with harmful outcomes for a particular person or others

with whom they come into contact Dix and Smith (2009)

Risk is frequently defined in relation to ideas of danger, loss, threat, damage or injury

Morgan (2004)

case study Grace’s Journey

Grace was admitted to hospital following a fall and long lie which led to further physical complications. Admitted to Holmewood for a period of rehabilitation and assessment as she was assessed as not being safe to return home at point of discharge from hospital. Transfer, mobility, and stair practice was completed and Grace progressed well from mobilising with a wheeled zimmer frame to one stick while at Holmewood. Cognitive and capacity assessment (around finances) completed, and DVLA contacted at her request as was still driving prior to hospital admission. Grace’s neighbours were involved in care planning at Grace’s choice and empowered to offer the support that they felt able to offer rather than obliged to The team liaised with distant family members to support Grace’s wish for them to have power of attorney Environmental and home visits were completed. Followed by joint visits home with Grace to support and enable her to prepare her home environment ready for discharge (cleaning etc). Grace was supported home on discharge once her home environmental organised and support systems in place to support her. This included input from social services for daily support, and attendance at day centre at Holmewood, and support with shopping and cleaning by neighbours Completed following discharge to ensure that support systems provided the right care for Grace in her home. Almost three years on Grace still lives at home, in the right place with the right care, and is clearly thriving. We still have the pleasure of seeing her regularly at Holmewood where she attends the day centre which provides opportunities to engage in chosen leisure activities for example art and trips out on minibus with her friends

Safety

Safety

Nutritional issues in dementia Behavioural changes

• Difficulty shopping, cooking, storing food

• Forgetting to eat or forgetting about eating

• Eating spoiled foods

• Changes in food choices

• Changes in ways of eating

• Using cutlery

Initial stages

• Difficulty opening mouth and chewing

• Pouching

• Unable to eat independently

• Eating non-foods

• Food refusal

• Unable to express pain (eg dental) or ask for food/fluids

• Swallow difficulties

• Depression

Advancing dementia

• Inadequate nutritional intake

• Weight loss

• Malnutrition

• Sarcopenia (muscle loss)

• Infections, falls, pressure ulcers

• Reduced independence

• Low mood

• More admissions, more complications, longer length of stay

Leading to

Improving fluid intake

All drinks count

Prompt and encourage

Make access easy

Familiar or coloured glass/beaker?

Tremors? Try mug with easy grip handle filled half way?

2 handled cup?

Thicker drinks easier to control

Encourage “wet foods”:

• Yogurts, milky puddings, custard, ice cream, jellies, soups, casseroles, gravy, fruit, ice lollies

Care home achieved 50% decrease in falls by: • making water more

accessible and visible • Reminding residents to drink

Nutritional issues in dementia Dehydration

Urine infections

Falls Constipation

Kidney stones

Pressure sores

Confusion

Reduced appetite

Drowsiness Forgetting or refusing to

drink

Possible hospital

admission

Case Study

Keith was referred to ACCT following a fall. He required assessment on his ability to manage the stairs safely. Keith had a diagnosis of dementia and had previously been known to the team.

During this assessment it was reported by the carers that Keith had lost weight recently and was continuing to do so.

When visiting Keith it was observed that his fridge had a small variety off foods available to him.

Keith would request similar foods at each meal time. These were often foods which provided few calories such as a salad with a slice of ham.

Keith was active around his home he would spend much of his day cleaning.

Keith had his routines and a shopping list he was reluctant to change.

A referral to a dietician was made this resulted in advice for home care to offer / provide more calorie dense foods. Keith continued to decline and it was noted he would refuse to eat these food items.

During the assessment it became evident that Keith was lonely and isolated due to his reduced mobility as a result of knee pain but also a lack of confidence to access the local community independently.

Keith agreed to a trial at a day centre. On this day he had not eaten his breakfast again. He declined to eat it before leaving the house. When collecting him from day care hat afternoon it was reported that Keith had eaten a substantial mid morning snack and a hot meal at lunch time whilst in the dinning room with others.

A medication review was also requested and the Paracetamol prescription was changed from ‘as required’ to x4 daily in order to reach a therapeutic dose which was prompted by home care.

Family were now reassured that Keith was getting a hot meal x2 / week and it highlighted the need for the social stimulation and the impact this has on appetite.

Keith’s mood lifted and his weight increased a little. Keith was more content at home. He continues to require much encouragement to eat but home care have increased the time they spend with Keith at meal times and family make extra effort to eat the occasional meal with Keith as and when they can.

Nutrition: information for patients/carers

http://sharepoint-srv2/C4/C6/Dietary%20Information%20Leaflets/default.aspx

Questions? What next?

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