Dementia, Drugs, Nursing by Degr[EE]s and Care Transitions

Of all the policy issues that government faces the care of an ageing population is irresistible in demanding attention. This one will keep tapping MPs, policy makers and families ... on the shoulder. It will constantly cycle through the government's gamut of official papers. In the UK this past week people suffering with dementia and the prescribing of anti-psychotic medication and deaths arising from the same has been highlighted and not for the first time.

Whilst my spare time web attention is also given to nursing IT and socio-technical matters, as an NHS community mental health nurse these vulnerable individuals are the primary focus of my work and that of my colleagues. There are three strands to the current role - in brief:

• Nursing home liaison - dedicated to specific homes;
• assessment, intervention and subsequent review;
• working with social services integration project duty desk.

Drugs are of course a day-to-night constant for all nurses, with the addition of debate across all the knowledge domains of Hodges' model - that is interpersonal, sciences, sociology and political domains of knowledge. We have witnessed this in the scientific evidence of substance misuse and the government misuse of drugs advisory group 'difficulties' and now this issue which is professionally closer to home: right on the doorstep in fact.

'Home' is the operative word as many of the people concerned reside in residential care and nursing home facilities. Let's scratch the surface of what we already know:

• These people can be very confused, vulnerable, they may be agitated and not easily reassured and placated without repeated skilled intervention.
• Facilities are subject to inspection and care standards.
  
• Many do not have an advocate in the sense of a family member who visits at least weekly and will challenge and question care and prescribing.
  
• Older people may already be on several drugs (polypharmacology) due to other chronic health problems.
• There is still a disconnect (holistic gap!) between the interdependence between mental - physical health problems.
  
• These facilities are that individual's home - they continue to live and hence age there.
• Homes get attached to their residents; in the best homes they (and their relatives and friends) become part of a greatly extended family.
• For confused people there is a potential community (albeit a closed one) that people can participate in or choose to stay in their room. This space, the freedom of movement it affords - toing-and-froing - should itself be subject to history taking and ongoing assessment.
  
• The quality of this community depends on the core staff and additional skills seen as essential by the organisation and care standards, e.g. activities coordinators, residents committees that also engage family, friends.
• NVQs and mandatory training in the sector is making a positive difference.
• There remains a high level of staff turnover.
  
• Some homes are dual-registered catering for nursing care with another floor for dementia care (does a 1st or 2nd floor provide secure access to a garden in the summer?).
  
• Homes rely greatly on the specialist services of local community mental health service, also given the placement of people in homes 'out of area' this involvement may be more remote and subject to varying degrees of engagement and hence quality.
• Homes are businesses and the movement of clients incurs changes in income.
• The quality and standards of architecture and design for residential accommodation has seen great strides in the past decade.
  

The bottom line (no pun intended) is the need for macro-management in terms of multidisciplinary team input; that is, primary care, modern matron, mental health and micro-management in terms of personalised care with regular review of physical and mental well-being and medication.

As government's of all persuasion utter the mantra of education! education! education! - this must be heard in the residential and nursing home care sector. The good news is that standards, competencies and the quality of care in the sector are improving; but to education we must add environment! environment! environment! As someone who appreciates aesthetics in design we should all be aware of the seductive properties of newly designed and furnished nursing homes (new carpets plus brand new flat screen LCD TVs does not automatically mean multi-dimensional care).

The counterpoint to this are the long stay, geriatric wards of old (c. 1977-1984) and the reaction of family friends when they first walked through the (three) doors.

They were distraught.

In time they came to appreciate the efforts of the staff and the importance of the knowledge, skills and attitude of the ward team. They could understand and see what staff were trying to achieve regards individualised care. Many responded to the open invitation to be part of the team, to get involved. Yes, the environment was far from 'right' (it was terrible), but it's the people on all sides of the care equation that count. It is the same today, but if the care environment is no longer appropriate then people should be moved to a place were their care needs can be met without recourse to anti-psychotic medication. That is why initial and ongoing person-centred assessment is very important.

It is very difficult to predict future needs and yet trying to anticipate them is the primary nursing challenge. If life is a book, then the turning of the page that ends one chapter and starts a-new is a non-trivial transition. That said and make no mistake, it is not for dramatic effect that we describe the behaviour of some individuals as challenging. Drugs are a tool and like all tools it is how they are used in assuring the highest standards of care, retaining personal dignity and maximising whatever quality of life an individual can achieve. Accounting for care interventions including medication is critical. If due diligence cannot be effectively applied in the financial sector then perhaps there is scope for due diligence in the care of older adults*?

*Some clients are under 65 years of age.

Additional links:
[17 Nov, 2009] Alzheimer's Society report: Poor dementia care in hospitals costing lives and hundreds of millions.

http://www.nhs.uk/news/2009/10October/Pages/Antipsychotic-use-in-dementia.aspx