Valuing the whole person – The Enriched Model

Last June I wrote a blog post about changing the world through my PhD. I still believe my research is an important step to making change to wider practice, and to getting a job in which I can influence positive change.

But changing the world doesn’t have to be such large scale! We can change another person’s world just by treating them as a person!

So how can we treat our patients more like people? We start by looking beyond the task we’re performing to the person we are with.

Personhood

Tom Kitwood understood this idea well, calling it Personhood; “it implies recognition, respect and trust” (Kitwood, 1997).

Personhood can be massively undermined when people are not considered according to their individual needs. By treating the people in our care as patients and tasks, we can easily lose the recognition, respect and trust we all deserve.

The real challenge is how we put this into practice. Kitwood came up with a model to help us think outside the “task” and the “patient” and give more positive experiences to the people we are caring for .

The Enriched Model

1. Neurological Impairment

This includes the decline of cognitive abilities that comes with dementia – memory loss, slower processing, language difficulties, loss of abstract thinking, reduced planning and sequencing, behaviour, and more!

2. Health and Physical Well-being

A person with dementia may also have other illness, temporary or long standing, which will impact their functional ability and how they are experiencing their time in our care. These may include pain, sensory impairments, chest infections, UTIs, wounds or trauma, pressure ulcers, long term conditions (diabetes/blood pressure or heart conditions), and mental state.

It’s so important to know if the person you are caring for has more than a dementia diagnosis – how else will you be able to understand how they may be feeling?

3 & 4. Life History and Personality

A key way in which we make sense of the ‘here and now’ is through reference to past experience. This doesn’t change for somebody with dementia.

It’s so important to learn about their past relationships, occupation, hobbies and experiences for 2 main reasons:

  1. It builds our respect for them, enhancing their personhood, and,
  2. It gives us an idea of how they might perceive a current situation.

Talk to them, talk to their family, use the “This is Me” or “Life History” documents to try and find out about the person under your care.

5. Social Psychology

People and their experiences are moulded by their sense of self, relationships, interactions and the environment. Our relationship and interactions with the people we are caring for have the potential to be extremely positive or extremely damaging.

Considering the whole picture and knowing the person will make all the difference to our relationships and the way we interact with them.

“Personhood implies recognition, respect and trust”

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So, how do we treat our patients more like people? In the same ways we do with other people! We get to know them, respect them, recognise them as a person and we trust them. We do all we can to enable the abilities they hold, and we interact in positive ways when assisting them with the abilities they have lost.

A person is more than their dementia diagnosis. Lets keep hold of who they are and ensure their care is the best we can provide!

A person is more than their dementia diagnosis.

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Tissue viability - Dementia Care Research

Nutrition and skin health – learning from ANTS training day

A great opportunity came up for me when I was invited to present at the Agents for Nutrition and Tissue Viability Study day (ANTS) at the Royal Bournemouth Hospital last Tuesday. If you read my previous blog post Understanding Eating in Dementia – more than just memory loss, you will get a brief overview of what I talked about!

Aside from my own presentation, however, it was the rest of the day that I particularly enjoyed. I loved hearing how nutrition is so relevant to such a range of topics – Acute Kidney Injury, Diabetes, Stroke, Tissue Viability – and developing my knowledge about PEG feeding and Nasogastric tubes!

Care of older people is complex and I would challenge anyone who claims they don’t want to work in older person’s medicine for fear that it would be boring!

My favourite sessions were from the tissue viability nurse; skin integrity is such a complex issue and nutrition plays such an important part!

Tissue viability

For the non health/medic people out there, this is basically skin health. It’s sadly common for older people especially (though not exclusively) to have skin damage through not having healthy skin.

The damage can develop from pressure on a particular area, from friction/shearing on movement or because of prolonged moisture exposure. Often older people, especially those who are unwell in hospital, are at a high risk of skin breaking down and developing sores, which can lead to complex health issues.

“Wounds can heal without dressings” – TV Nurse Specialist

There are various ways of keeping skin healthy – changing position regularly, good personal hygiene, correct moving and handling… and nutrition! Keeping the skin nourished and hydrated is a massive part of wound prevention, but what about healing?

Nutrition and wound healing

The best bit of the talk, for me, was when the tissue viability nurse made the controversial claim (from a nurses perspective anyway!) that wounds can heal without dressings.

I’m not a nurse and don’t know a lot about wounds, so here’s my number one piece of learning of the day! Nutrition is essential in the healing process!

What nutrients does the body need for each stage of wound healing?

  1. Haemostasis (blood clotting)
    – energy
    – protein
    – vitamin K
  2. Inflammation (blood vessels dilate to allow nutrients to reach the wound)
    – vitamins A, C and E
    – selenium
    – antioxidants
    – energy
    – protein
  3. Proliferation (granulating tissue)
    – energy
    – protein
    – copper
    – iron
    – vitamins A, B6 and C
    – zinc
  4. Remodelling/maturation
    – energy
    – protein
    – zinc
    – vitamin C
    – iron

I hope that is useful information for all you health professionals or people looking after loved ones with skin sores. Isn’t the body a fascinating thing!?

And remember – when people with dementia are on hospital wards they especially need our help to stay nourished!

 

Understanding Eating in Dementia – more than just memory loss

Long ago… back in the year 2015… I completed the University of Tasmania’s ‘Understanding Dementia Massive Open Online Course (MOOC)’ – something I would highly recommend to anyone from any walk of life who has an interest in dementia or dementia care.

Particularly impressed by Dr Jane Tolman’s presentation on the different domains of dementia, I felt it was something everyone should be familiar with!

I immediately started to apply her teaching to why people with dementia may have difficulty eating and drinking. Also inspired by Hilda Hayo (Chief Admiral Nurse), here are a few key ideas:

The 5 domains:

  • Cognition
  • Psychiatric
  • Physical
  • Behaviour
  • Function

This may come as a shock for some – dementia is just a memory problem, right? Wrong! Dementia is a neurodegenerative disease of the brain; sadly when your nervous system is under attack, more than your memory will be effected.

So why is eating a problem?

Cognition

I’ve said it before – eating is a complex cognitive activity. Yes, to eat you need memory! Memory and awareness of the time, such as when you last ate etc. However, you also need initiation, planning, object recognition, environment recognition, judgement, concentration, attention, understanding and much more.

People with dementia often lose these abilities, meaning: they may not start eating a meal when it is put in front of them; they may forget what they are doing half way through; they may leave the table during the meal; they may not recognise you are giving them food or even that they are hungry; they may not know how to use the cutlery or bring the food to their mouth.

Psychiatric

This is an interesting one; mental health is not always associated with dementia, but people living with it can experience hallucinations, delusions and depression.

One possible outworking of this – if food is believed to have been poisoned, it probably won’t be eaten.

Hallucinations can include olfactory (smell), visual and tactile (feeling). Imagine if your food had a strange smell or tasted vile, imagine if you could see something unpleasant on it.
It’s unlikely it would be eaten.

Have any of you ever felt depressed and lost your appetite? Enough said.

To eat you don’t just use your brain, you need your body

Physical

Probably the most common physical problem in eating and drinking for people with dementia is swallowing difficulties – it’s certainly a good job we have fantastic Speech and Language Therapists, Nurses and Dietitians to help tackle that one!

Also, losing the physical ability to pick up food with cutlery can be a major issue – thanks again are due for the brilliant multi-disciplinary teams we have working on solutions!

The physical environment can also impact eating and drinking – it may be over-stimulating – causing distraction – or under-stimulating – enhancing depression or reducing the chance of the act of eating being initiated.

Function and Behaviour

I think by now we’re getting the idea – dementia is more than just memory loss.

Loss of cognitive and physical capacity will undoubtedly impact the ability to function.

People may think people with dementia are being “naughty” or “manipulative” but the truth is very different.

Confusion, fear and the psychiatric effects of dementia can have understandable impacts on behaviour. After all, if you were in an unknown environment feeling alone, depressed, confused, and suspicious, how would you behave? Especially if somebody tried putting food in your mouth and you didn’t know what it was or how to say ‘no’!

Another point highlighted by Dr Jane Tolman is the loss of social understanding in dementia – losing the ability to know what is socially acceptable and the lack of judgement or ability to reason will also understandably lead to certain behaviours.

Dementia is more than just memory loss

I hope this little insight has been useful in helping you understand more about dementia and why people with dementia may not eat as much as they need.

I’m excited about seeing how all this applies in acute hospital wards and what more I may find out through my study… keep connected with me to find out!