Jef Smith discusses the progress made with dementia care and how effective current opinions, practices and treatment are for tackling this devastating disease.
Overview of care
Dementia is now such a frequently discussed issue in social care circles that it is difficult to remember a time, not so long ago, when the stigma and misery attached to the disease made it an almost taboo subject. For sufferers, none of the misery and little of the stigma has disappeared, but at least the relative openness with which professionals now tackle dementia makes for a healthier dialogue and creates a climate in which good practice can be shared and disseminated.
For this progress, politicians may take some of the credit since, although resources remain scandalously limited compared with other areas of the health service, dementia has recently been given a high priority in both Whitehall and Westminster. David Cameron’s personal commitment in launching the Prime Minister’s Dementia Challenge and choosing the disease as the central topic for a British-hosted gathering of the G8 nations, both of which took place in 2013, were two of the more significant undertakings.
Regarding social care practice, the Care Quality Commission has been in the forefront of raising dementia’ s profile. Its thematic review of dementia service (published in October 2014) focused on collaboration between organisations, particularly care homes and hospitals. This series of inspections, covering around 150 providers, resulted in a composite report with the telling title Cracks in the Pathway. Its major conclusion was that there are indeed serious gaps between services, marring the type of seamless collaboration that is a prerequisite of good care.
Failures of co-ordination certainly contribute to memory loss and confusion in those who suffer them, and thus may be identified as an aggravating factor, if not exactly a cause, of dementia. One of the major criticisms of hospitals in relation to the older people who form an increasingly large part of the patient group is that the practice of moving people between departments severely adds to their disorientation — a fact any care worker who has visited one of their clients while in hospital will readily confirm.
It is not clear that this sort of reactive confusion leads to a permanent worsening in a dementia sufferer’s condition. Nevertheless, even if the distress is only temporary, it would surely be worth seeking a change in the way hospitals operate. This would enable specialist treatments to be brought to patients at a single location rather than the current practice of shifting already anxious people around for the convenience of the professionals.
Such issues, however, are at the periphery of the question many ageing people ask: “Can dementia be prevented?” The answer is by no means simple, but the central consideration is that of risk factors.
A risk factor for dementia is something that increases a person’s likelihood of developing the disease, so minimising such risks provides at least partial protection. Of course, some risk factors are effectively out of our control, the obvious examples being genetics and age, both of which have been clearly shown to be relevant. The role of genetic inheritance is being very actively explored by researchers and seems likely in due course to be a major area of fresh understanding, possibly even leading to a cure.
By contrast, it is clearly impossible to prevent ageing, though its damaging effects are under continuous review. Although there are some types of dementia that can affect people early in life, the disease remains one predominately experienced by people over 65, the age by which about 7% of the population have become sufferers (increasing to 1 in 6 for those over 80). It is not clear which, if any, of the factors associated with ageing (eg high blood pressure and the increased likelihood of strokes and heart disease) contribute to this situation, and whether developments in those areas might make a difference to the growth of dementia numbers.
At present, the growing numbers of older people in the population sentences our society to a steady increase in the incidence of dementia. The fact that women are slightly more at risk than men — again for no clear reason — accelerates that growth, since women live longer than men.
For care workers, there is rather more point in considering the factors over which some control can be exercised, though here the picture remains somewhat speculative. Regarding food, for example, there is little guidance other than that a healthy, balanced diet (eg low levels of saturated fat, plenty of fresh fruit and vegetables, and regular intake of the fatty acids found in oily fish) is best — a point about which most care home kitchens hardly need reminding.
The extent to which any or all of these actually lower the risk to dementia itself or simply lessen the likelihood of other illnesses associated with dementia is disputable. Much the same can be said about regular exercise — it promotes healthy heart activity and people with healthy hearts tend not to get dementia, or get it later in life. However, whether this protects against dementia itself is unknown.
A similar caution needs to be expressed over habits known to be detrimental to health in general, particularly smoking and excessive drinking. Heavy alcohol consumption over a period can lead directly to some types of dementia, such as Korsakoff’s syndrome, but generally the link of both smoking and heavy drinking to dementia is again via other conditions. The position regarding alcohol is complicated by the fact that some research has suggested that light or moderate drinking may even act to protect the brain. As the regularity with which conflicting reports appear indicates, medical opinion is still in some disarray about the value or the danger of drinking, even in modest quantities, and it will be a while before fully authoritative advice can be issued.
Opinion has also shifted significantly within the last few decades on the role of aluminium in causing dementia. Once a widely favoured explanation, aluminium “poisoning” has fallen out of fashion lately, and although investigation of the issue continues, it is now a case study of the danger of putting faith in attractively simple solutions. How easy indeed it would be if merely banishing one metal from our daily lives — much like stripping asbestos out of our buildings — could procure a major public health benefit. Real life, alas, is much more complicated.
Most of the above are factors about which care workers are pretty powerless. We may try to persuade our clients to drink or smoke less or to eat more healthily, but many elderly people are fixed in their ways and not inclined to accept advice, except from those they regard as established experts (and not always even then). The promotions of mental activities and social engagement, however, may be more within a care home’s range of influence, and here the evidence, though far from decisive, begins to present a clearer picture.
Interaction and stimulation
The benefits to older people of frequent social interaction (as opposed to the sort of isolation that tends towards loneliness) appears obvious, and the company and stimulation that a residential care home can provide is, in this respect, a very positive element that a relatively communal way of life offers. By its very nature, a home provides its residents numerous opportunities to meet and make new friends, and many homes can testify to the satisfying relationships they have seen develop and the therapeutic effects on people newly admitted who had been living alone.
Most of the discussion about social contact in homes has focused on interactions involving staff. There would be benefits from paying more attention to the ways in which residents help each other, and consequentially to what care workers can do to foster such positive relationships. Discrete introductions of people known to share interests or memories can lay the basis for friendships that may be mutually helpful; not all service users have retained the social skills or confidence to make such contacts for themselves. Activities such as outings, events in the home and group exercises or games clearly help to keep residents engaged, which can possibly help to stave off dementia.
Experts seem on surer ground in recommending mental activity as prevention since there is growing evidence that reading, learning a fresh skill (eg a new language or a musical instrument) and exercising the brain with puzzles goes some way to compensate for the damage associated with dementia, perhaps by increasing a person’s tolerance of that damage before the symptoms of the disease seriously kick in. Research into more systematic “brain training” is at an early stage but the indications are looking positive.
The message for care home staff is much the same as for diet and physical exercise; helping residents to stay mentally and socially active has benefits of a similar order to eating well and exercising sensibly.
So, the answer to the question “Can dementia be prevented?” remains uncertain, but this should not deter care workers and their managers from using every available piece of current knowledge to help their service users at least stave off the effects of the disease’s progression. The impact of dementia on individuals’ lifestyles is so devastating that almost anything that can be done, however temporary its value, is still worth trying. Perhaps the most useful message, trite as it may seem, is that protecting residents from the onset of dementia involves little more than what is involved in providing good care generally.
Last reviewed 5 March 2015