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Geriatric Medicine – July 2012 “Achieving better care for dementia patients”

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The SPECAL (Specialised Early Care for Alzheimer’s) method aims to give patients with dementia a feeling of being in control and being able to make decisions which are carried out. It incorporates a number of core tools and best practice techniques including validation therapy, life history work, distraction techniques, orientation strategies, communication skills and reminiscence therapy.

The agitated and confused patient with dementia who is bewildered in the unfamiliar surroundings of hospital is a scenario often seen, and demographic changes dictate that it will become increasingly common.

Frontline healthcare staff who encounter a person with dementia displaying unusual or challenging behaviour may feel they are out of their depth and are not sure where to start in caring for and treating the individual. Valuable time may be wasted if communication with a patient is ineffective but this is not always readily recognised in a busy healthcare setting. Working practices and procedures must be adjusted for the special needs of individuals with dementia. When these needs are not taken into account, the patients will not receive optimum care.

While clinicians and some nursing personnel have an appreciation of dementia at a neuronal level, there is an urgent need to widen the understanding of how the patient with dementia can be comprehensively cared for as an individual so that treatment plans for conditions unrelated to dementia are assisted.

The Good Care Group, which applies the SPECAL (Specialised Early Care for Alzheimer’s) method in caring for patients with dementia in their own homes, believes the method can be used to great effect by those working in both primary care and secondary care. The group’s views mirror an evaluation by the Royal College of Nursing Institute, which underlined the value of the SPECAL approach, showing how it enabled people with dementia to be cared for at home longer.

The SPECAL method acknowledges that the person with dementia naturally utilises intact memories, often about events from many years ago, to assist in making sense of their current situation. The SPECAL Photograph Album is an analogy likening the individual’s normal memory system with a compilation of photographs which helps people to understand the way normal memory works, what happens as we age, and a single highly significant change which occurs at the onset of dementia. The person’s likes and dislikes, and what motivates him or her, are sensitively and systematically investigated using a monitoring tool called SPECAL Observational Tracking (SPOT).

Listening to a person being cared for, and identifying actions, gestures, frowns and smiles, assists in building a clear picture of the individual’s personality, strengths, weaknesses, and needs. When cognitive decline is advancing, it is important to recognise that feelings are paramount. There is a distinct, ongoing need to protect the emotional state of the person for whom care is provided. This significantly contributes to optimising the quality of life of the individual, enabling him or her to live well with dementia.

The SPECAL method is still sometimes wrongly associated with “make believe”. The reality is that those working with the method are in tune with cherished memories held by those for whom care is provided, and are able to “recycle” these memories so that, for people living with advanced dementia and short-term memory loss, the present has meaning and is a comfortable place in which to be.

Facilitated by the method is a constructive conversational flow without imposing different ideas on the individual. The SPECAL method requires much organisation, training and time but will save time for professionals in the long run. The use of basic elements of the approach can reap immediate and major benefits across the healthcare spectrum, making patients more contented, co-operative and receptive to treatment, and making staff more relaxed and efficient.

When the SPECAL method is applied, increased brightness and positivity in the individual can be seen quite quickly. Patients with dementia who are in an advanced state of unattended emotional distress will need time and effort to bring about a profound change but it is never too late to improve their situation.

A system in which a personal information sheet is created for each person with dementia is very useful. The Good Care Group has found that a one-page information briefing for each individual with dementia allows doctors, nurses, carers and other healthcare professionals to obtain a rapid understanding of what will help the communication process with the individual. Once an effective communication bridge has been achieved, the person is much more likely to remain calm and anxiety free, and dialogue with healthcare professionals is significantly improved.

The briefing sheet has notes on themes which can bridge the gap between the intact memories of the past and what needs to be done today, whether it be in the hospital, the primary care centre, the specialised community clinic or the person’s home. When an individual encounters unfamiliar surroundings, some questioning is highly likely, and then the information briefing sheet can prove invaluable if it outlines the types of question that the individual is most likely to ask, together with answers which the individual will most readily accept.

Healthcare professionals are likely to create smoother care paths, and improve the implementation and efficiency of treatment for patients with dementia if some basic ground rules utilised in the SPECAL method are followed. These rules are aligned to what is suggested in notes for a Royal College of Nursing’s Advanced Nurse Practitioner Forum, which was titled “Promoting positive approaches in dementia care”.

It is suggested that information is continuously drawn from the patient with dementia. Healthcare professionals should look for behavioural clues as to what generates positive and negative reactions. It may not take long to identify certain phrases that gain a positive response and can be used to further develop a communication bridge.

The patient with dementia is likely to repeat stories, details of fond memories, and snippets of information which makes him or her feel good. Such repetition may be seen as unproductive and a nuisance. However, the repetition has a positive side for the healthcare professional because elements of what is being repeated can be fed back to the individual, helping to win trust and co-operation.

If the patient causes a problem, for example in the process of implementing a specific treatment, protection of the patient’s self-esteem must be foremost. The healthcare professional should act as if he or she is the incompetent one, not the patient. Blaming a patient with dementia for a minor difficulty might see innocuous—but it could be damaging. The patient is likely to lose self-esteem and may become withdrawn. Through apparently taking blame, the healthcare professional attracts the focus of negativity and uses his or her “failing” to boost the patient’s feeling of wellbeing by imparting to the patient a sense of competence and control. The patient’s emotional safety is retained.

Top tips for improving dementia patient care

When caring for or treating a patient with dementia:

Allocate some time, even if it is brief, to talk to the patient and to understand more about his or her feelings and needs
When cherished memories are mentioned by the patient, respond positively
Aim to continuously draw information from the patient, and look for behavioural clues as to what generates positive and negative reactions
Never contradict the patient as this is pointless and unproductive
Never ask the patient direct questions. Such questions can significantly raise the patient’s level of stress
Be ready to pretend to have made a mistake or to not have properly understood something if a difficulty arises. Say to the patient “silly me” not “silly you”.
Ideally, prepare and use an information sheet for the patient to assist in creating an effective communication bridge.
More information about SPECAL is available at www.specal.co.uk and details of The Good Care Group can be found at www.thegoodcaregroup.com

References

1. Pritchard EJ, Dewing J. (1999) A multi-method evaluation of a service for people with dementia. RCNI Report No 19. Oxford. Royal College of Nursing Institute.

2. Garner P. (2008 3rd edition). The SPECAL Photograph Album. Windrush Hill Books. Hawling.

3. Thompson R. Promoting positive approaches in dementia care. Royal College of Nursing Advanced

Nurse Practitioner Forum, 2010. http://www.rcn.org.uk/__data/assets/pdf_file/0011/359318/Rachel_Thompson.pdf

Independent Practitioner – July/August 2012 “Take risks and work hard to realise them” Practice Nursing – June 2012 “An improved experience for dementia patients”
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