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Improving communication skills in care of those with dementia

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The projected increase in the incidence of dementia highlights the importance of good communication skills and person-centred care for this group. Nerys Hairon reports

A new report published by the King’s Fund has predicted a massive increase in the incidence of dementia over the next 20 years (McCrone et al, 2008). Due to an ageing population, the report predicts numbers will rise by almost two-thirds – 61% – from an estimated 582,827 people in England in 2007 to 937,636 in 2026.

This prediction comes as a report from the Commission for Social Care Inspection found inadequacies in communication with people with dementia in some care homes (CSCI, 2008).

The projection from the King’s Fund illustrates the importance of high-quality care for patients with dementia, including skilled communication by healthcare professionals and person-centred care. NICE and Social Care Institute for Excellence (2006) guidance outlined principles of care, taking into account person-centred care and diversity and equality.

Incidence of dementia

The King’s Fund report, commissioned to estimate mental health expenditure in England up to 2026, found that prevalence rates for all mental disorders within all age groups are likely to remain broadly stable, with a slight fall in the overall proportion of people with a mental disorder.

However, the number of people with dementia is expected to increase substantially over the next 20 years, as a result of an increasingly ageing population. The service costs associated with dementia are far higher than all other conditions combined. Dementia currently accounts for two-thirds (66%) of all mental health service costs. By 2026 it is estimated it will account for nearly three-quarters (73%) of all service costs (at 2007 prices).

The report found the estimated prevalence of dementia in people aged 65 and over is 7.1%. For those aged 65–69, the estimated prevalence is 1.5% for men and 1% for women. Among people aged 95 and over, this rises to 30% for men and 34.4% for women.

The report estimates the total cost of dementia care in England in 2007 was £14.8bn, which is projected to rise to £34.8bn by 2026. This massive 135% increase is due to the ageing of the population plus increases in the real costs of care provision. Consequently, the report recommends establishing better systems of early detection and treatment of dementia.

Quality of care

These figures on the projected increase in the incidence of dementia have implications both for health service budgets and care services. The CSCI’s (2008) report indicates shortfalls in standards of communication with residents in some care homes.

This study, based on findings from 100 inspections of care homes, used the new Short Observational Framework for Inspection (SOFI) to examine the experiences of 424 people with moderate to advanced stages of dementia. The study involved a broad range of care homes, both specialist and non-specialist. Those seriously underperforming and subject to enforcement action were excluded.

Communication issues

More than one-third of the homes inspected by the CSCI did not meet statutory requirements in terms of quality of care planning and, in some homes, staff were detached from this process.

In 25 care homes, residents and their carers had been an integral part of the care planning process.

While the report recognises that offering the appropriate level of support to people with dementia can be a difficult balancing act, it found 22% of people spent time in a withdrawn mood state at a time of day when people were generally engaged in activities. Those least engaged were those with the most severe communication problems and disabilities.

The investigation did find excellent examples of care, offered with warmth, understanding and tolerance. The data in the investigation report shows a ‘significant relationship’ between people being in a happy and relaxed state and being engaged in the world around them.

Issues surrounding maintaining privacy and dignity were highlighted in 18 out of 100 care homes. The report argues that impersonal assistance and a task-oriented approach undermine people’s sense of dignity and can lead to them being passive and silent. It adds that the quality of communication – both verbal and non-verbal – has a great bearing on how people with dementia feel.

The CSCI emphasises that it is not just negative forms of communication that leave people feeling distressed; ‘neutral’ styles of communication can also have this effect. A neutral style of communication is defined as staff focusing on a task that needs to be completed, and lacking empathy and warmth.

The report also highlights the importance of promoting communication between people with dementia and family carers, the wider community and other residents.

Family carers should be made to feel welcome, and staff should strive to understand carers’ difficult feelings about their relative moving into the home. The report warns that if staff do not accept these feelings and carers are not made to feel welcome, relatives may become reluctant to visit. This can deny the person with dementia an important link with the past and their core identity.

In addition, it is important for homes to provide opportunities for people to engage with the wider community, such as enabling people to attend clubs or faith centres. Some care homes took positive steps to maintain relationships but the inspection found that this was not happening in every home.

Another issue highlighted was that nearly half the residents did not communicate with others living there. Detailed analysis found that 42% spent no time at all in contact with other residents during a time of day when higher levels of interaction might have been expected. Improved communication with other residents appeared to relate to well-being.

The report states that the quality of staff communication with people with dementia has a major impact on their quality of life. It concludes that a significant finding is the negative effect of neutral communication on the feelings of people with dementia, and stresses the importance of well trained and supported staff.

Person-centred care

Clearly these issues surrounding quality of communication with people with dementia demonstrate the importance of person-centred care. NICE and SCIE (2006) guidance outlined general principles of care, including person-centred care and diversity and equality.

The guidance stressed that good communication is essential, supported by evidence-based information, to allow people with dementia to reach informed decisions about their care. It emphasised that the views of people with dementia on who should and should not be involved in their care are important and should be respected. With the person’s permission, carers and relatives should normally have the opportunity to be involved in decisions about care and treatment.

Carers and relatives should be provided with the information and support they need, and carers should also be offered an assessment of their own needs. For recommendations on diversity and equality relevant to communicating with people with dementia, see box.

Diversity and equality in dementia care

To ensure equality in the provision of dementia care, NICE and SCIE recommended:

  • Always treat people with dementia and their carers with respect;

  • If there is a language barrier, offer:

  • Written information in the preferred language and/or in a format that can be easily accessed;

  • Independent interpreters;


  • Psychological interventions in the preferred language.

Identify specific needs arising from:

  • Diversity (such as sex, ethnicity, age, religion and personal care);

  • Ill health, physical and learning disabilities, sensory impairment, communication difficulties, problems with nutrition and poor oral health;

  • Identify and wherever possible accommodate preferences (such as diet, sexuality and religion), particularly in residential care.


Conclusion

The increasing incidence of dementia as a result of the ageing population means practitioners will need to develop and improve communication skills in caring for people with this condition. The CSCI (2008) report indicates areas where communication could be improved in order to have a positive effect on patients’ quality of life and well-being.


References

Commission for Social Care Inspection (2008) See Me, Not Just the Dementia: Understanding People’s Experiences of Living in a Care Home. Summary. www.csci.gov.uk

McCrone, P. et al (2008) Paying the Price: The Cost of Mental Health Care in England to 2026. www.kingsfund.org.uk

NICE, Social Care Institute for Excellence (2006) Dementia: Supporting People with Dementia and Their Carers in Health and Social Care. Quick Reference Guide. www.nice.org.uk

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