National Assembly for Wales Health, Social Care and Sport Committee’s consultation on the use of anti-psychotic medication in care homes
This submission is made on behalf of the Royal College of Occupational Therapists (RCOT), the professional body for occupational therapists across the UK.
The submission is made in response to the Health, Social Care and Sports Committee’s consultation on the use of anti-psychotic medication in care homes. Further information on any aspect of this response can be gained by contacting the RCOT.
Executive Summary
1. This response outlines the importance of specialist dementia services providing support to care homes and the role occupational therapists can play in supporting care homes to deliver on person centred care and non-pharmacological interventions to address behavioural and psychological symptoms associated with dementia.
2. The Royal College of Occupational Therapists is currently gathering further data on best practice examples as part of its Occupational Therapy: Improving Lives, Saving Money campaign.
Submission
Establishing a person centred ethos:
3. Older people living in care homes historically have not had equality of access to multidisciplinary services, although they arguably have the greatest health and social care needs. Within the UK multidisciplinary liaison services are providing in-reach support to care homes. In these teams, occupational therapists can promote person-centred care through training, on-site role modelling and working directly with care home staff. This would include:
Ø using dementia-specific assessment tools to ensure person-centred activity planning and establishing accessible one-page profiles of residents with staff members. Supporting meaningful activity is dependent on having insight into the person’s life experience, roles and interests. The Pool Activity Level (Pool, 2006) is often cited as an assessment tool as it provides a life history and it describes the different levels at which an individual may engage.
Ø Reviewing needs of residents, suggesting ways of breaking activity down and delegating different roles/steps of activity.
4. A person centred approach would primarily focus on identifying and understanding who and what is important to the person so that they can be supported to maintain a relationship/involvement with these as their illness progresses. This focus on living life would allow an enablement rather than a management ethos. For example: in consideration of risk the value of the activity to the person and their previous approach/attitude to risk would be a key deciding factor within support plans. The focus on enablement would encourage a more positive approach – working with the person’s strengths and skills and existing support. This will lead to a less risk adverse culture, minimising restrictions on people living their lives and engaging in the occupations that matter to them.
5. Supporting people with dementia to be active, engaged and to have outlets for communicating thoughts and emotions through activity reduces the build-up of frustration. It allows staff to be alongside the person and offers insight into who they are beyond the diagnosis and symptoms of dementia.
6. The Royal College has produced a toolkit to establish an enabling ethos within care homes and addresses dementia within the guides.
College of Occupational Therapists (2013). Living well through activity in care homes - the toolkit. London: COT. Available at:.https://www.cot.co.uk/living-well-through-activity-care-homes-toolkit-0
7. There are existing examples of high quality training delivered by occupational therapists. For example:
Ø Abertawe Bro Morgannwg University Health Board Dementia Care Training Team picked up two awards for their specialist training. The jointly funded team, based at Glanrhyd Hospital, were awarded Stage 1 Practice Innovation Unit by the Welsh Centre for Practice Innovation (WCPI) acknowledging continuing work to improve standards in dementia care. Plus, they’ve been Highly Commended in the National Social Care Accolades which are awarded by the Care Council for Wales.
Ø Helen Lambert and Alison Turner, both Occupational Therapists, and Mental Health Nurse Karyn Davies developed and delivered training to ABM and Bridgend County Borough Council staff to improve the support people with dementia received, and ensure everyone receives the same care across the area. Helen Lambert, went onto lead on the development and delivery of a Dementia Reablement Training Package for Cardiff City Council and the Social Service Improvement Agency. http://www.ssiacymru.org.uk/home.php?page_id=8644. This led to the development of a Dementia Reablement toolkit and service model: http://www.ssiacymru.org.uk/resource/english--lr.pdf. These can be translated to span care homes and the training of care home staff.
Training for Care Home Staff in non- pharmacological interventions:
8. The majority of care homes have not specifically been designed to provide care for people with the complex needs of those with severe/later stages of dementia. This means that residents with dementia often have multiple unmet needs such as: involvement in everyday activities, isolation and anxiety and depression. These unmet needs can lead to decreased quality of life and increased costs of care due to managing the resulting symptoms of behavioural and psychological symptoms of dementia. (Orrell et al. 2007.)
9. Occupational therapists can directly work with residents to address behavioural and psychological symptoms of dementia. Through:
Ø Assessing patterns of distressed behaviour and identifying potential reasons, such as pain, anxiety, the approach of staff and the environment.
Ø Providing help and training to staff to support the person with dementia to undertake daily living activities such as bathing, dressing, eating, and participating in social activities, thereby minimising frustration. This may involve adopting assessment tools, adapting communication, the environment and activities. (Gitlin et al 2001, Padilla, 2011).
Ø Evaluating communal spaces in care homes and improve the environmental design to help compensate for impaired memory, learning and reasoning skills. This helps reduce the levels of stress experienced by people with dementia and their carers and improves the quality of individuals’ daily lives. (Barber-Miller 2010, Morgan-Brown et al 2011).
Ø Providing appropriate exercise or other activities that are graded to an individual’s capabilities to increase their quality of life, preserve their identity and provide them with a positive emotional outlet.(NICE 2008)
10. Within the Royal College’s next report Living, not Existing: Putting prevention at the heart of care for older people in Wales there is a call for equality of access to be the guiding principle for older people who, due to their age and health, are unable to care for themselves and keep themselves from harm. If equality of access to occupational therapy is to be achieved, the design of services must enable occupational therapists to widen their approach in order to meet the varying needs within their local communities; this includes providing in-reach support to care homes.
References:
Barber-Miller, C (2010) An evaluation of service provision. Occupational Therapy News, 18(5), 26.
Gitlin LN, Corcoran M, Winter L, Boyce A, Hauck WW (2001) A randomized, controlled trial of a home environmental intervention: effect on efficacy and upset in caregivers and on daily function of persons with dementia. The Gerontologist, 41(1), 4–14.
Morgan Brown M, Ormerod M, Newton R, Manley D (2011) An exploration of occupation in nursing home residents with dementia British Journal of Occupational Therapy 74(5) 217-225
National Institute for Health and Clinical Excellence (2008) Occupational therapy interventions and physical activity interventions to promote the mental wellbeing of older people in primary care and residential care. London: NICE. Available from: http://www.nice.org.uk/nicemedia/pdf/PH16Guidance.pdf
Orrell M, Hancock G, Hoe J, Woods B,Livingston G and Challis D (2007) A cluster randomised controlled trial to reduce the unmet needs of people with dementia living in residential care. International Journal of Geriatric Psychiatry. 22(11)1127–1134
Padilla R (2011) Effectiveness of interventions designed to modify the activity demands of the occupations of self-care and leisure for people with Alzheimer's disease and related dementias. American Journal of Occupational Therapy, 65(5): 523-531.
Pool J, (2012) The Pool Activity Level (PAL) Instrument for occupational profiling (4th ed). London: Jessica Kingsley Publishers.
About the Royal College
The Royal College of Occupational Therapists is the UK Professional Body and Trade Union for over 31,000 occupational therapists, support workers, managers and students. Occupational therapy enables people of all ages to participate in daily life to improve health and wellbeing. They are the only Allied Health Profession trained at a pre-registration level to work within both physical and mental health.
Contact
For further information on this submission, please contact:
Karin Orman
Professional Practice Manager
Royal College of Occupational Therapists