Richard Cheston

An exploration into the relationships people with dementia have with physical objects: an ethnographic study.

In recent years there has been increasing interest in how different aspects of object relations theory might apply to dementia. While attachment theory in dementia has been well studied, there have been no systematic investigations of the way in which transitional objects are used by people with dementia. This study explores the relationship people with dementia have with physical objects using a focussed ethnographic method. Twenty-one residents and the staff of a care home for people with dementia were observed over a two-month period. Observations were recorded and analysed in light of Winnicott’s criteria for transitional objects and incorporated the work of other key theorists. The ethnography found evidence that people with dementia have varied relationships with objects and can employ objects in a transitional way. The paper then explores the implications of this research for understanding the function of transitional objects for people with dementia. The findings suggest that that Winnicott’s theory of transitional objects can provide a framework for understanding some of the processes of dementia.

A small-scale study comparing the impact of psycho-education and exploratory psychotherapy groups on newcomers to a group for people with dementia

Background: The importance of providing emotional support to people newly diagnosed as having dementia is now widely recognised. However, the evidence base for this work is limited, so that it is difficult to draw conclusions either about whether this form of work is effective or which form of intervention might be most suitable for people with dementia. Objectives: This study compared the effectiveness of exploratory psychotherapy and psycho-educational group interventions for new group members. Methodology: Participants had received a diagnosis of Dementia of the Alzheimers type or a similar form of dementia and had a mild level of cognitive impairment. Interventions occurred in ten, weekly sessions with participants attending either a psychotherapy or a psycho-educational group, each of which were facilitated by the same team of clinicians, and had the same amount of therapist contact. Data relating to levels of mood was collected at the start and at the end of the group intervention from eight participants in each arm of the study. Data collection occurred independently from the intervention by a researcher who was blind to the form of intervention. Results: There was a significant interaction between mode of therapy and levels of depression and a borderline significant interaction between therapy type and levels of anxiety. However, once the low affect level of participants in the psycho-educational groups was controlled for, differences between the interventions were non-significant. Discussion: Although the results that can be drawn from this study are limited, nevertheless it supports previous research indicating that a 10-week group psychotherapy intervention can be effective in reducing levels of depression for people with a mild level of dementia.

Simulated presence therapy, attachment and separation amongst people with dementia:

This article examines the impact of Simulated Presence Therapy (SPT) on the behaviour of six people with moderate or severe levels of dementia. Twenty-one sessions involving both SPT and a control condition (usual care) were carried out. SPT interventions were associated with lowered levels of both distressed behaviour and efforts to return home.

A pilot randomised controlled trial to compare changes in quality of life for participants with early diagnosis dementia who attend a ‘Living Well with Dementia’ group compared to waiting-list control

Objectives: The aim of this paper is to report a pilot study in which participants who had recently received a diagnosis of dementia were randomised to either a 10-week group intervention or a waiting-list control. Method: Memory clinic staff with limited previous experience of group therapy were trained to lead a 10-week group therapy intervention called ‘Living Well with Dementia’. Fifty-eight participants, all of whom had received a diagnosis of Alzheimers disease, vascular or Lewy body dementia within the previous 18 months, were randomised to receive either the intervention or treatment as usual (waiting-list control). Data collection occurred at baseline, within two weeks after the intervention finished and at 10-week follow-up. Results: The study met its recruitment targets, with a relatively low attrition rate for the intervention arm. The acceptability of the intervention and research methods was examined qualitatively and will be reported on elsewhere. For the primary outcome, measure of quality of life in Alzheimers disease (QoL-AD), and secondary outcome, self-esteem, there was some evidence of improvement in the intervention group compared to the control group. There was, also, evidence of a reduction in cognitive functioning in the treatment group compared to the control. Such reported differences should be treated with caution because they are obtained from a pilot and not a definitive study. Conclusion: This pilot study succeeded in collecting data to inform a future definitive cost effectiveness clinical trial of Living Well with Dementia group therapy.

An evaluation of primary care led dementia diagnostic services in Bristol.

BackgroundTypically people who go to see their GP with a memory problem will be initially assessed and those patients who seem to be at risk will be referred onto a memory clinic. The demographic forces mean that memory services will need to expand to meet demand. An alternative may be to expand the role of primary care in dementia diagnosis and care. The aim of this study was to contrast patient, family member and professional experience of primary and secondary (usual) care led memory services.MethodsA qualitative, participatory study. A topic guide was developed by the peer and professional panels. Data were collected through peer led interviews of people with dementia, their family members and health professionals.ResultsEleven (21%) of the 53 GP practices in Bristol offered primary care led dementia services. Three professional panels were held and were attended by 9 professionals; nine carers but no patients were involved in the three peer panels. These panels identified four main themes: GPs rarely make independent dementia diagnosis; GPs and memory nurses work together; patients and carers generally experience a high quality diagnostic service; an absence of post diagnostic support. Evidence relating to these themes was collected through a total of 46 participants took part; 23 (50%) in primary care and 23 (50%) in the memory service.ConclusionsPatients and carers were generally satisfied with either primary or secondary care led approaches to dementia diagnosis. Their major concern, shared with many health care professionals, was a lack of post diagnostic support.

Attachment and coping of dementia care staff: The role of staff attachment style, geriatric nursing self-efficacy, and approaches to dementia in burnout

Past research suggests that dementia care staff are vulnerable to the development of burnout, which has implications for staff well-being and hence the quality of care for people with dementia. Studying personal vulnerability factors in burnout is important as it can guide staff training and support. Attachment theory suggests that adult attachment styles affect caregiving relationships and individuals’ responses to stress, providing a framework for understanding caregivers’ styles of coping. This cross-sectional survey study examined relationships between staff attachment styles, geriatric nursing self-efficacy, and approaches to dementia in burnout. Seventy-seven members of dementia care staff working on inpatient wards for older people completed self-report questionnaires. Insecure attachment, lower levels of self-efficacy, and more optimistic attitudes in staff were related to higher levels of burnout. Staff training on the role of attachment in dementia care is recommended. Further research is required to explore mediating factors between adult attachment styles and burnout.

A feasibility study comparing UK older adult mental health inpatient wards which use protected engagement time with other wards which do not: study protocol

BackgroundProtected engagement time (PET) is a concept of managing staff time on mental health inpatient wards with the aim of increasing staff and patient interaction. Despite apparent widespread use of PET, there remains a dearth of evidence as to how it is implemented and whether it carries benefits for staff or patients. This protocol describes a study which is being carried out on mental health wards caring for older adults (aged over 65) in England. The study shares a large proportion of the procedures, measures and study team membership of a recently completed investigation of the impact of PET in adult acute mental health wards. The study aims to identify prevalence and components of PET to construct a model for the intervention, in addition to testing the feasibility of the measures and procedures in preparation for a randomised trial.Methods/designThe study comprises four modules and uses a mixed methods approach. Module 1 involves mapping all inpatient wards in England which provide care for older adults, including those with dementia, ascertaining how many of these provide PET and in what way. Module 2 uses a prospective cohort method to compare five older adult mental health wards that use PET with five that do not across three National Health Service (NHS) Foundation Trust sites. The comparison comprises questionnaires, observation tools and routinely collected clinical service data and combines validated measures with questions developed specifically for the study. Module 3 entails an in-depth case study evaluation of three of the participating PET wards (one from each NHS Trust site) using semi-structured interviews with patients, carers and staff. Module 4 describes the development of a model and fidelity scale for PET using the information derived from the other modules with a working group of patients, carers and staff.DiscussionThis is a feasibility study to test the application of the measures and methods in inpatient wards for older adults and develop a draft model for the intervention. The next stage will prospectively involve testing of the model and fidelity scale in randomised conditions to provide evidence for the effectiveness of PET as an intervention.Trial registrationISRCTN31919196

A cross-sectional investigation of public attitudes toward dementia in Bristol and South Gloucestershire using the approaches to dementia questionnaire.

BACKGROUND To date, surveys of attitudes toward dementia have largely been conducted using unvalidated materials or have focused on healthcare professionals supporting people affected by dementia. The aim of this study was to carry out a survey of public attitudes toward people affected by dementia in Bristol and South Gloucestershire. METHODS A survey was carried out using a modified version of the Approaches to Dementia Questionnaire (ADQ). Data from people living outside the area, and people who were working with people affected by dementia were omitted from the analysis. Responses from the remaining 794 ADQ questionnaires were weighted to correct for under-represented age, gender, and ethnic groups. RESULTS Younger people held more positive attitudes toward dementia than older people. Individuals who identified themselves as White held more positive attitudes than non-White individuals. Individuals with personal experience of dementia held more positive attitudes than those with no experience of dementia. When considering age differences, gender played a role, with younger men having more positive scores than other groups. CONCLUSIONS This is one of the first surveys of public attitudes to dementia to use a validated questionnaire such as the ADQ. The study provides a baseline of attitudes toward dementia for the Bristol and South Gloucestershire areas, against which we will be able to compare changes over time. This is important due to the emphasis in public health campaigns on improving attitudes toward dementia.

The paradox of dementia: Changes in assimilation after receiving a diagnosis of dementia

This qualitative study used semi-structured interviews to explore how six people talked about their difficulties before and after a dementia diagnosis. Participants’ accounts of their memory problems were analysed in terms of the verbal Markers of Assimilation of Problematic Voices Scale. This analysis indicated that after diagnosis some participants were able to integrate aspects of their illness that had previously been too painful, and which had been warded off. The process by which individuals were able to integrate a dementia diagnosis into their sense of self-involved stepping in and out of awareness, with both acceptance and denial featuring in their accounts as they approached and then retreated from addressing the diagnosis. In contrast, other participants resisted moving towards explicitly acknowledging their dementia but were instead able to express concerns about what this movement would entail, for instance voicing their fears that it would mean that they had surrendered. Social support seems to have been crucial in enabling participants to sustain a positive sense of self in the face of this adjustment.

Dementia as an Existential Threat: The Importance of Self-Esteem, Social Connectedness and Meaning in Life

Dementia is an umbrella term for a large number of illnesses, all of which involve neurodegenerative changes in the brain. The most common forms of dementia are Alzheimers disease and vascular dementia, but there are over 100 other, rarer conditions. All of these different illnesses involve a progressive decline of cognitive functions in which symptoms gradually spread, so that eventually almost all areas of cognitive functioning are affected. Over time, these cognitive changes compromise the persons practical ability to manage everyday activities, leading to increasing levels of dependency on those around them. At present there is no cure for any form of dementia. If we are to achieve an understanding of the psychological impact of dementia, then we also need to understand the way in which dementia acts as an existential threat. Dementia can compromise identity, challenge independence, prompt social isolation and threaten our ability to find meaning and purpose in life. Thus, a 2014 YouGov poll commissioned by Channel Five news in the UK found that fear of dementia was greater than fear of cancer, particularly amongst older people (1). Managing existential threat Over the last 20 years, an established body of literature has emerged that has detailed the way in which people respond to threats. To date, this body of work has been largely conducted from a social psychology perspective. However, we believe that the insights that have steadily accumulated may help us to develop a much better understanding of how people respond to dementia. This, in turn, may help us to improve a number of different areas of dementia care. This work clearly points to three, linked factors that play a crucial role in helping to prevent anxiety when people are confronted by threats including reminders of their own mortality: self-esteem, social connectedness and meaning in life. People who score highly on all three of these factors seem to be more able to think about the nature of the threat that they face without becoming overwhelmed with anxiety. In other words people who feel good about themselves and who feel more connected to the world around them are also better able to find meaning and purpose in life even when they are reminded that life can be short, brutal and nasty. Given the importance of self-esteem, social connectedness and meaning in life in enabling people to tolerate threats to their identity, it follows that it is important within dementia care both to understand the consequences of low self-esteem and to identify methods of increasing this. Forgetting is a psychological defence as well as a neurological symptom As humans we are good at putting up mental barriers that help to prevent us from being disturbed by threats to our self-esteem. Research suggests that there is a pattern of selective forgetting in which memories that enhance our self-esteem are better recalled--a phenomena that has been termed mnemic neglect. For instance, if we are asked to remember two types of feedback, some of which is positive and enhances self-esteem and some of which is negative, then we are more likely to remember the negative information if it relates to another person than to ourselves. Memory, then, seems to act in a self-protective fashion. If mnemic neglect occurs in the same way for people affected by dementia as it does amongst the general population, then this may help to explain why some people who are affected by dementia struggle to recall information about their illness. In addition, research also indicates that under certain circumstances mnemic neglect disappears. This is the case, for instance, when information is provided by a close friend (2), when the information is about traits that are changeable (3), or which are not highly negative (4). Understanding more about how mnemic neglect operates with people affected by dementia may help us to go on to develop more effective ways of talking to people with dementia about their illness. …