National Assembly for Wales Health, Social Care and Sport Committee consultation on the use of anti-psychotic medication in care homes

 

Executive Summary The Royal College of Speech and Language Therapists (RCSLT) Wales welcomes the opportunity to respond to the Health, Social Care and Sport Committee’s consultation on the use of anti-psychotic medication in care homes. We believe this consultation is very timely given the concerns raised by the Alzheimer’s Society, Older People’s Commissioner for Wales, Royal Pharmaceutical Society and the Royal College of Psychiatrists about the inappropriate and overuse of anti-psychotic medication in care homes. Our response below focusses on two key elements within the terms of reference namely; • the provision of alternative (non-pharmacological) treatment options • training for health and care staff to support the provision of person-centred care for care home residents living with dementia. Key recommendations to the Health, Social Care and Sport Committee • There is a clear link between communication difficulties and behaviour that challenges. Non-pharmacological treatment options should include access to communication support provided by Speech and Language Therapists. • Staff in care homes should receive training on identifying communication difficulties in dementia and strategies to support and enhance communication. • We recommend the Welsh Government institute a cycle of national and local audits into anti-psychotic prescribing practices in Wales. The audit should also gather evidence on whether the patient received the anti-psychotic medication as the first option treatment and/ or whether there were alternative therapies available within their locality.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


About the Royal College of Speech and Language Therapists

 

1.   RCSLT is the professional body for speech and language therapists, SLT students and support workers working in the UK.  The RCSLT has 17,500 members in the UK (450 in Wales) representing approximately 95% of SLTs working in the UK (who are registered with the Health & Care Professions Council).  We promote excellence in practice and influence health, education, care and justice policies.

 

2.   Speech and Language Therapy manages the risk of harm and reduces functional impact for people with speech, language and communication support needs and/ or swallowing difficulties.

 

3.   Speech and Language Therapists (SLTs) provide life improving treatment, support and care for adults who have difficulties with communication, eating, drinking or swallowing.  Using specialist skills, SLTs work directly with clients, carers and other professionals to develop personalised strategies.   They also provide training and strategies to the wider workforce; such as care assistants so that they can identify the signs of speech, language and communication needs (SLCN) and eating, drinking and swallowing difficulties, improve communication environments and provide effective support.  

 

The provision of alternative (non-pharmacological) treatment options

 

4.   Communication helps us to cope with specific life events including transitions, illness, bereavements and stress. When communication is impaired it is much harder to adapt to challenging circumstances.  Communication problems occur in all forms of dementia & in the later stages these problems become increasingly challenging (Bourgeois 2010).   Communication difficulty can be exhausting for the person with dementia and affects their identity and relationships (Bryden, 2005).  Limited communication has significant social and psychological impact.  Frustration can lead to distressed behaviour and James (2011) argues that behaviour that challenges is an attempt to make sense of the environment or communicate an unmet need.  

 

5.   Loss of meaningful interaction and conversation also places increased pressure on caring relationships (O'Connor et al, 1990 Nolan et al, 2002).   Communication difficulty has been described as one of the most frequent and hardest to cope with experiences for family carers (Egan 2010 Braun 2010).  Orange (1991) found that a survey of family members of dementia patients around half of the respondents noted a change in their relationships as a result of communication difficulties.  In considering alternative options to pharmacological interventions, there is a clear need to ensure that the communication difficulties underlying distressed behaviour are identified and appropriate strategies put in place.  Staff and family carers who are trained to recognise how people in their care communicate distress, anxiety or pain through their behaviour (verbal and non-verbal) are better equipped to identify the triggers of behaviour that challenges in an individual, and address the potential for a person with dementia to harm themselves or others.

 

6.   SLTs have the specialist knowledge and skills to directly assess the contribution that unmet speech, language and communication support needs make to behaviour that challenges and provide advice on maintaining and maximising communication function to the person with dementia, their family and carers.  SLTs also have a clear role in training health, social care and voluntary sector staff, including care home workers in identifying communication difficulties in dementia and strategies to support and enhance communication.  Communication training for carers within the residential setting has been evaluated positively (Jordan et al, 2000) as effective and the role of SLTs as trainers outlined (Maxim et al, 2001).  This short case study provides an example of the difference SLTs are able to make within this environment.

 

David’s story David lived in a care home where he often argued with staff and residents making it difficult for everyone to live and work with him. Although, David’s speech was limited to a few words, staff thought David knew what he was doing and saying. • An SLT assessment showed David had significant difficulties understanding what was said to him so he became confused, he didn’t always know why people wanted him to do things and he made unintentional mistakes which of course frustrated him and others. • The SLT gave staff guidance on how best to interact with David to help his understanding. This greatly reduced his confusion and the arguments and stress which had been caused by it. Source: RCSLT/Alzheimer Scotland– Speech and Language Therapy Works for People with Dementia
 

 

 

 

 

 

 

 

 

 

 

 

 

 


7.   Despite a growing body of evidence to justify the impact of speech and language therapists within dementia care, provision of services in Wales is extremely patchy.  This is in sharp contrast to other nations, such as Scotland, where there have been significant developments with regard to speech and language therapy provision for people with dementia.  The recent audit of memory loss services by 1000 Lives (Public Health Wales, 2016) highlighted only 0.6 full time equivalent provision of speech and language therapy in specialist teams across Wales.  Similarly at a community level, despite evidence of the value of the inclusion of SLTs within multi-disciplinary community teams and the potential opportunities which exist, we are aware that too few teams across Wales stipulate inclusion of the role as part of a dedicated primary care integrated workforce.  In the current model, our services are often provided by small, flexible teams who must meet the competing demands of primary and secondary care.  Our members tell us that dementia services are not consistently delivered across Wales and resource pressures mean that dysphagia training often takes precedence over training to support management of communication difficulties. 

 

Training for health and care staff to support the provision of person-centred care for care home residents living with dementia

 

8.   RCSLT believes that central to the provision of person-centred care is the concept of preserved ability and wellbeing and the belief that all people with dementia, at all stages, have something to communicate.  As we have highlighted above, Speech and Language Therapists have a clear role to play in training health and care staff about communication difficulties and strategies to support and enhance communication. 

9.   In addition, we wish to highlight the importance of training for staff to identify difficulties eating, drinking and swallowing as a key element within the delivery of person-centred care.  Difficulties eating, drinking and swallowing can lead to a poorer quality of life for individuals with dementia leading to embarrassment and lack of enjoyment of food.  They can also have potentially life threatening consequences, resulting in choking, pneumonia, chest infections, dehydration, malnutrition and weight loss.  Dysphagia is a recognised challenge for people with dementia, particularly in the later stages of the disease.  68% of people in care homes with dementia have difficulties eating, drinking and swallowing (Steele et al, 1997).  Managing swallowing problems (dysphagia) in residential care reduces the risks of choking, chest infections, aspiration pneumonia, dehydration and malnutrition and decreases the need for crisis management that often results in unnecessary hospital admissions.  We believe that training is required to ensure staff, in addition to understanding the communication difficulties experienced by people with dementia, are able to identify the early signs of eating, drinking and swallowing difficulties to ensure people’s nutritional needs are met. 

10.                In a number of local health boards, SLTs provide telephone triage to care homes managing the communication and swallowing problems of those in their care, removing the need for a GP visit.  They also provide training to care home staff and others in the community to manage decline in swallowing performance from age and disease and communication difficulties.  For example, an SLT is employed on a part-time basis as part of the Care Home Liaison Team in Cardiff and Vale University Health Board and is an important part of the alternative support available to manage the behavioural and psychological symptoms of dementia.  However, as highlighted above, we are aware that these services are not consistently delivered across Wales and dysphagia training often takes precedence over training to support the management of communication difficulties. 

 

Further Information

 

11.                We would be happy to provide any additional information required to support the Committee’s decision making and scrutiny.  For further information, please contact:

 

Dr Alison Stroud

Head of Wales Office

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References

 

Bourgeois MS, Hickey EM (2009). Dementia: from diagnosis to management. A functional approach. Taylor and Francis: New York

Braun M et al (2010). Toward a better understanding of psychological well-being in dementia caregivers: the link between marital communication and depression. Family Process;49:2,185-203

Bryden C (2005). Dancing with Dementia. Jessica Kingsley Publishers: London

Egan M, et al (2010). Methods to enhance verbal communication between individuals with Alzheimer’s Disease and their formal and informal caregivers: a systematic review. International Journal of Alzheimer’s Disease;Article ID 906818,12 pages doi: 10.4061/2010/906818

James I A (2011). Understanding behaviour in dementia that challenges: a guide to assessment and treatment.  Bradford Dementia Group Good Practice Guides:Bradford

Jordan et al (2000).  Communicate: Evaluation of a Training Package for carers of older people with communication impairments.  Middlesex University/UCL Publication: London:

Maxin J et al (2001). Speech and Language Therapists as trainers: enabling care staff working with older people. International Journal of Language and Communication Disorders;36,supplement,194-199

Nolan M, Ingram P, Watson R (2002). Working with family carers of people with dementia.  Dementia;1:1,75-93

O Connor, DW et al (1990). Problems reported by relatives in a community study of dementia.  British Journal of psychiatry; 156, p.835-841

Orange JB, Ryan EB (2000). Alzheimer’s Disease and other dementias: implications for physician communication. Clinics in geriatric medicine;16, 153-173

Public Health Wales (2016). 1000 Lives Second Welsh National Audit Report. Memory Clinic and Memory Assessment Services.  Public Health Wales: Cardiff

Steele CM, et al. Mealtime difficulties in a home for aged. Dysphagia 1997;12:1,43-50