Physical and Social Influences on People with Senile Dementia in Residential Care

Physical and Social Influences on People with Senile Dementia in Residential Care

Ann Netten

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9781138608405
• eBook ISBN: 9780429872556
• Edition: 1
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

Published in 1993. The Increasing numbers of very elderly people in the population and the decreased use of long-stay hospitals are leading to pressure for services in the community for people with dementia. Residential care plays an important role in the care of such people, and developing new, innovative services and monitoring the quality of care in existing institutions are important policy issues.

The book describes an investigation into the relationship between the residential care environment and the welfare of residents with senile dementia. Unlike many studies of residential care, the study included aspects of both the physical and social environment and examined the impact on residents over time. The study used some innovative approaches to assessing the impact of the environment of residents and the book describes a model using quantitative techniques to analyse outcomes for residents. The policy issues and provide pointers for specifying standards for the care of residents with senile dementia. The potential for innovative schemes building on the results of the study is discussed, and the concept of 'informal care homes' is introduced.

1 Issues in the residential care of people with senile dementia

Like the prevalence of the disease itself, interest in residential care of people with senile dementia is bound to grow. While the option of domiciliary care may be achievable for increasingly high levels of disability, for other groups of elderly and disabled people there is a limit to the endurance of relatives and friends of people with dementia. Their demands are such that support provided by community-based social services is necessarily limited, and institutional care of some form frequently becomes the only viable option. It is important, both for those in receipt of care and for those who can no longer cope with the burden of care, that these institutions should provide the most beneficial environment possible.

The Wagner review of residential care took as a point of principle that:

Living in a residential establishment should be a positive experience ensuring a better quality of life than the resident could enjoy in any other setting (Wagner, 1988, p.114).

But is it possible to determine if residents with senile dementia are having a positive experience? Is it possible to identify that they are enjoying a better quality of life than they could otherwise? Before such questions can be addressed there needs to be an understanding of the impact of different ‘settings’ or environments on elderly people with senile dementia. In particular there needs to be an understanding of the effect of the physical and social environment of the homes on the well-being of the ‘confused’ residents.

The focus of the investigation reported here is local authority residential care which caters for people of similar levels of disability to those cared for in both residential and nursing homes provided by the independent sector (Darton and Wright, 1989). The term ‘residential care’ is used throughout, but the discussion applies equally to nursing home accommodation. While the primary concern here is people with senile dementia, the problem to be addressed is the care of elderly people who have general orientation difficulties. Precise definitions are not of paramount importance. The category of resident with which this book is concerned is often termed ‘confused’. Throughout, therefore, the terms ‘confused’, ‘people with senile dementia’, ‘elderly mentally infirm people’ and ‘demented elderly people’ are interchangeable.

Characteristics of dementia

Senile dementia can be described from a number of perspectives: technical medical descriptions of changes in the brain, psychological measures of types of memory loss, and so on. An operational definition of dementia has been given by the Royal College of Physicians Working Party on Organic Mental Impairment in the Elderly:

Dementia is the global impairment of higher cortical functions including memory, the capacity to solve the problems of day-to-day living, the performance of learned perceptuo-motor skills, the correct use of social skills and control of emotional reactions in the absence of gross clouding of consciousness. The condition is often irreversible and progressive (Royal College of Physicians, 1981).

Dementia is defined, therefore, as symptoms and signs which may be the result of different pathological processes in the brain. Dementia can be described as pre-senile or senile depending on an arbitrary age limit (usually 65). Among senile dementias two conditions predominate:

•senile dementia of the Alzheimer type (SDAT), the commonest of all, is a primary degenerative disorder of the brain;

•multi-infarct dementia (MID) in which there is death of brain tissue (infarction) consequent upon a disorder of the cerebral circulation (haemorrhage, thrombosis or embolism).

An individual may suffer from either or both of these conditions. Unless there is a specific cause, such as a series of strokes, a firm diagnosis can be made only at autopsy. Diagnosis of dementia while the person is alive is a process of eliminating other possible causes such as the side-effects of drugs, alcoholism, urinary tract and chest infections, and other mental health problems (for example, depression).

Precise definitions and diagnoses of people suffering from senile dementia are desirable, but they are difficult to establish in the absence of clinical judgements. There are a number of diagnostic schemes such as the DSM III diagnostic criteria (American Psychiatric Association, 1980) which are used to determine the existence of dementia or Alzheimer’s disease. There has been a lack of consistency in methods of assessment, which has led the Medical Research Council (1987) to recommend a set of minimum data to be collected in studies funded by the Council to aid comparison between research studies.

The concern here is primarily functional: to describe the observed changes in the individual. Gray and Isaacs (1979) describe the manifestation of brain failure as the individual displaying:

•a tendency to commit errors;

•a failure to perceive errors; and

•a failure to comprehend the consequences of errors.

The onset of dementia tends to be very gradual, with memory lapses often compensated for by writing notes or confabulation. To what extent compensatory mechanisms are related to the condition or to the personality of the individual has yet to be established (Woods and Britton, 1985). Referral usually occurs with the onset of more severe symptoms.

Holden and Woods point out that dementia is sometimes brought to the attention of professional care workers when an individual experiences a bereavement, change of house or other upheaval. Rather than being a causal factor:

Usually close examination reveals, for example, that the spouse who died was doing a great deal to compensate for the person’s deficits that were developing before bereavement; the change of house removes a number of environmental props that were helping to sustain the person’s failing functions, and so on (Holden and Woods, 1982, p. 11).

Gray and Isaacs suggest seven symptoms which, although not comprehensive, most patients will show if observed long enough:

•lapses in personal hygiene, such as refusal to bathe;

•lapses in feeding and dressing, such as objectionable feeding habits;

•impairment of domestic skills, such as gas appliances turned on and not lit;

•lack of judgement and prudence, such as irresponsible expenditure of money;

•cognitive errors, such as failure to recognise close relatives;

•personality and interpersonal relations, such as groundless accusations; and

•miscellaneous offensive behaviour, such as verbal sexual advances.

These symptoms reflect the consequences of cognitive difficulties rather than the difficulties themselves, but provide a picture of the types of problem likely to be encountered by those caring for people with senile dementia.

By definition senile dementia is a progressive condition, and cognitive and behavioural difficulties are likely to increase with age. However, the pattern, both of behavioural difficulties and mental deterioration, varies from person to person. Personality changes sometimes occur, with some people becoming disinhibited, although others manage to carry on social conversations in spite of severe deterioration in mental abilities. Holden and Woods (1982) suggest that the rate of deterioration often seems slower when onset occurs in people in their 80s rather than in their 60s.

The difficulties in caring for people who display such behaviour that they become a danger to themselves and create embarrassment for others are often compounded by the demented person’s failure to recognise the problem, as Sands and Suzuki point out:

Reifler et al. (1981) found that cognitively impaired persons living in the home saw themselves as suffering from no significant problems in activities of daily living, in personal health or in family relationships: professional persons and family care givers saw these same people as having problems in almost every area of life. For the person impaired this can lead to the feeling of being interfered with and manipulated; for the person giving care to feelings of being obstructed and unappreciated (Sands and Suzuki, 1983, p.2l).

However, many people respond to the symptoms of senile dementia with anxiety and fear (Newroth and Newroth, 1980; Schwab et al., 1985). Holden and Woods (1982) also point out that not all patients lack this insight and that many are aware of deterioration and may complain of loss of memory. They state that it is not unusual for such people to show signs of anxiety and depression, perhaps in response to the repeated failures they experience.

Life expectancy is considerably reduced for people with dementia. Kay et al. (1970) found the mean expectation of life in patients over 65 reduced from 10.9 years to 2.3 years for women with senile dementia. For men, average life expectancy reduced from 8.7 years to 2.6 years. Similarly, 74 per cent of a sample of patients with senile dementia had died within 2.4 years compared with 26 per cent of a sample of mentally alert patients (Kay et al., 1970). Moreover, Roth (1955) found 60 per cent of demented patients had died within six months of admission to mental hospital compared to 11 per cent of those with affective psychosis. It is important, therefore, to distinguish carefully between organic and affective mental disorders whose expected outcomes are very different.

Although there is largely a consensus that the condition of senile dementia reduces life expectancy – although Christie (1985) has expressed reservations about the evidence – life expectancy among elderly people generally is rising. There has been some discussion in the literature regarding the supposed increase in the life expectancy of demented people in recent years, largely because of variations in results between individual studies. Thompson and Eastwood (1981) concluded there was no increase in life expectancy but their study suffered from the same problem as the others: inconsistency of definitions, especially in defining the onset of the condition. Frequently the date of admission is taken as the starting point, but admission policies tend to vary with internal and external pressures on services. Increased life expectancy among demented people may simply reflect improved nutrition generally and the use of antibiotics (Bergmann and Jacoby, 1982; Henderson, 1986). Immediate cause of death is often from another condition, such as bronchial pneumonia (Woods, 1989) so while there is no direct treatment for Alzheimer’s disease itself, medical advances in other fields may affect the life expectancy of sufferers. Even if this is the case, however, it is not clear from the literature whether general increases in life expectancy will offset reductions due to dementia.

Incidence and prevalence

The problem of consistency of definitions also presents difficulties when discussing the incidence and prevalence of dementia. Mild, moderate and severe dementia are often distinguished but are rarely clearly defined other than in terms of instrumentation scores. Thus, ‘mild’ usually refers to people who are mildly confused or forgetful with no deterioration of personality or habits, ‘severe’ refers to considerable deterioration, and ‘moderate’ lies somewhere between the two.

Despite the problems of definition, a number of authors have drawn on individual studies of the prevalence of senile dementia to derive overall expected prevalence rates and future growth in this subpopulation. Preston (1986) used the data from seven studies and, adjusting for age differences, estimated that 6 per cent of those aged over 65 were likely to be moderately or severely demented. Ineichen (1987) also re-assessed a number of estimates of the incidence of dementia, including the Newcastle studies (Kay et al., 1964, 1970), examining assumptions and definitions. He concluded that 1 per cent of the 65-74 age group and 10 per cent of those over 75 suffer from dementia. Although these figures are lower than those of Kay et al. (1970) and Bergmann et al. (1978), they predict a larger rise in numbers given the expected population changes, so that between 1983 and 2001 there will be 17 per cent more people with senile dementia in England and Wales. In areas with high populations of elderly people, the increase will be much larger: during the same period the population of demented elderly people in the area served by Bath Health Authority is estimated to rise by 34 per cent. Other estimates put the increase in the numbers of people with senile dementia even higher. Using figures from Henwood and Wicks (1984), Sinclair (1988) predicted an increase of 52 per cent between 1971 and 2001 in Great Britain. This would mean an estimated 450,000 people had senile dementia in 1971 and this would rise to 684,000 by the year 2001. Similarly, using European-based age and gender prevalence rates estimated by Hofman et al. (1991), Schneider et al. (1992) used population projections to estimate that there were 540,000 people with dementia in England in 1991.

Such estimates, however, may be unduly pessimistic. A number of studies have identified a much lower prevalence than expected (Pattie et al., 1979; Clarke et al., 1986). O’Connor et al. (1989) report a rate of 5.3 per cent for moderate and severe dementia in a population aged 75 years and over. Using estimates by Jorm et al. (1987) these authors would have expected a prevalence of 11 per cent in this population. The authors suggest that the differences arise from using a more sensitive screening method (Cambridge Mental Disorders of the Elderly Examination, CAMDEX), rather than representing part of an overall cohort effect as has been proposed (Hagnell et al., 1981). Pattie (1988), in a discussion of similar results using Clifton Assessment Procedures for the Elderly (CAPE), suggests differences may be due to assumptions in earlier studies that ‘mild’ impairment would lead to severe dementia. Fries (1989) suggests that improved health and nutrition have resulted in the delay of onset of chronic illness so morbidity will be ‘compressed’ into a shorter period. He notes that there is insufficient evidence to say whether this is likely to be true of Alzheimer’s disease. Henderson (1986) has called for longitudinal studies using sensitive screening instruments to clarify prevalence rates.

It has been argued (Opit, 1988; Robertson, 1990) that much of the confusion about prevalence of mild dementia is to do with changing definitions. The separation of dementia from normal ageing processes is a social construct, culturally defined, and such definitions will shift with changes in the concerns of society. As mild confusional behaviour does not necessarily lead to severe senile dementia, the problem is not so much one of diagnosis as of boundary-setting.

Despite such debates there is little disagreement that the predominant risk factor of severe dementia is age. Kay et al. (1970) found that prevalence varied from 2.3 per cent in persons aged 60-69 to 22 per cent in those aged over 80. O’Connor et al. (1989) found 4.1 per cent of all grades of dementia in those aged 75 to 79, 11.3 per cent of those aged 80-84, 19.1 per cent of those aged 85 to 89, and 32.6 per cent in those aged 90 years or over. Even if the prevalence in the population as a whole is lower than thought, therefore, the ageing population ensures that severe senile dementia will continue to ‘confront the world as a major challenge to public health’ (Henderson, 1986, p.3).

The need for residential care

Independent living in the community and permanent hospitalisation represent the extreme ends of the spectrum in the ‘continuum of care’ (Knapp, 1984). In the policy world the emphasis is increasingly upon caring for people with physical and mental difficulties in the community. The aim is to shift care as far as possible towards the community end of the ‘caring continuum’ (Department of Health and Social Security, 1981; Griffiths, 1988).

A major consequence of the policy of shifting care of demented elderly people from institutions to the community will be an increased dependence upon carers and community-based services. Where carers are absent, community services may be able to provide adequate care for people who are physically dependent, but these services are unlikely to be able to fulfil the needs of otherwise unsupported elderly mentally infirm people. This is largely because of the constant level of monitoring which is required when caring for people whose judgement is poor and whose behaviour can be dangerous (Gray and Isaacs, 1979).

Even where carers are present, the stress of coping with senile dementia can ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication Page
• Table of Contents
• Preface
• 1 Issues in the Residential Care of People with Senile Dementia
• 2 The Research Questions and Study Design
• 3 The Social Environment: Caring Regimes
• 4 The Social Environment: Social Climate and Regime Classification
• 5 The Physical Environment
• 6 The Effect of the Environment of Residential Homes on Demented Residents
• 7 Policy Implications and Future Research
• References
• Subject index
• Author Index