AUTHOR Tony Bush, CertEd, RMN, DipN, is staff nurse, County Hospital, Pontypool, Gwent. ABSTRACT Bush, T. (2003) Communicating with patients who have dementia. Nursing Times; 99: 48, 42–45. It was not until the 1980s that significant research was carried out on brain disorders. Lack of understanding of dementia has perhaps been the reason for the overemphasis on physical care, and a failure to see these patients as people with feelings, beliefs and values. Three therapeutic techniques to help practitioners increase and improve communication with people who have dementia are described. It may be that communication is the key to understanding and resolving behaviour disturbances.
Recent research suggests that simply defining dementia in terms of organic brain disease and linking the process with ageing may not be as straightforward as was once thought. Stokes and Holden (1990) adopted the view that dementia was not a disease in its own right but, rather, a collection of signs and symptoms requiring further investigation.
There is confusion over what constitutes the disease process termed Alzheimer’s (Gilleard, 2000). Neurofibrilary tangles and senile plaques, initially thought to be the main neuropathological phenomena resulting in a diagnosis of Alzheimer’s disease, have now been found to occur independently of each other in the brains of older people with dementia as well as in those who do not have it.
Social, genetic and toxicological research has likewise proved inconclusive. Essentially, the true aetiology of the illness remains a mystery. Even the distinction between senile and pre-senile dementia is decidedly blurred, the same types of atrophy (shrinkage) and destruction of individual nerve cells in the brain occurring in both (Cheston and Bender, 2000).
Approaches to care
Delieu and Keady (1996) felt that understanding the physical biology of Alzheimer’s disease and other dementias was the bedrock from which all informed care should flow. However, it would seem that such theories, combined with an ensuing preoccupation with the biomedical aspects, might well have contributed to an overemphasis on the physical side of caring for people with dementia.
Nurses are perceived as being at the heart of the professional care response to the challenges set by the prevalence of dementia in our society. Yet Walsh (1998) raised the question: why, after so many years of using the nursing process and acknowledging the ethic of taking a holistic approach to care, were nurses apparently failing to assess and treat patients properly?
Psychological and social aspects of care are still found to be largely neglected, despite intrinsic physiological links in a holistic sense. The explanation for this neglect may lie in a failure to perceive the individual as anything more than a conglomeration of signs, symptoms and physical problems. It is also possible that nurses, universally restricted by time constraints, all too easily become entrenched in caring for individuals in purely physical terms. This is undeniably time-consuming and can often leave limited scope for considering other aspects of care.
The Alzheimer’s Disease Society (2002) estimates that there are over 700,000 people in the UK today with dementia, over 55 per cent of whom have been diagnosed with Alzheimer’s disease. In global terms, it is estimated that there are 18 million people in the world with dementia, a figure that could rise to around 34 million by 2025.
Cheston and Bender (2000) established that from the outset of the First World War until the 1970s, there was almost no research into Alzheimer’s disease. It was not until the 1980s, when the profile of the condition was raised sufficiently for funding for biomedical research into brain disorders to be granted, that it became more familiar in the public domain. Perhaps this long-term lack of prominence in the collective consciousness of the general public may go some way to explaining the apparent dearth of understanding of the condition and the often benign yet basic and functional approaches of caregivers, both lay and professional, towards the care and treatment of people with dementia.
Shifts in cultural emphasis have also been influential. The gradual erosion of the extended family, which began in the late 1950s and accelerated through the 1960s to the present day, combined with greater social mobility, has contributed to an increased burden of care upon professional services. Maintaining an elderly grandparent within the auspices of a close-knit and extended family unit has now become a practice of the past. The care in the community coda of Margaret Thatcher’s Conservative government (1979–1990) may have sought a return to this type of value but, ultimately, has resulted in underfunded community services being deluged with patients as a result of a serious underestimation of demand. In addition, the philosophy fostered the creation of an overcrowded private nursing home culture that replaced, to a large extent, long-term NHS care. Treating people in bulk with limited resources does little to nurture an enlightened and humanistic approach to care, to which the psychiatric institutions of the past are perhaps a telling historical testament.