I suspect that from time to time most of us lose our focus on a task, object, TV
programme, person or other aspect of our life that momentarily requires us to
put aside all other thoughts and images to ensure our full attention. This lack
of concentration is sometimes associated with a lack of interest in something
or someone who we are meant to be focusing on, or a need to ‘get something done’
that we perhaps really don’t want to do at that time.
In
the context of living with dementia, however, a lack of concentration can be
more than an occasional annoyance and become very pervasive into daily life,
both for the person themselves and those around them. A problem
concentrating is something that many people with dementia report as an early
symptom and it can come in many guises, from difficulty in concentrating when
reading and writing, to problems focusing in conversations, when driving, watching
TV, or completing routine tasks of daily living that previously held the person’s
attention.
I can
only imagine how frustrating these issues must be for a person with dementia,
and whilst they may act as an early warning sign to seek help, a diagnosis can
at best explain the problem rather than making it go away. As a person’s
dementia advances, problems around concentration can become much more acute and
affect an individual's ability to focus on eating a meal, drinking a drink, getting
dressed, washing themselves or participating in hobbies and activities.
For
those around the person with dementia, be they family, friends or
professionals, this lack of concentration from the person with dementia may also
pose problems. It can lead to frustration that the person isn’t focusing on
something that they need to focus on (like eating), and massive concerns about their wellbeing. These worries often set off a pattern of trying to persuade the person with dementia to concentrate on whatever it is they aren't concentrating on, and if that doesn't work the family member, friend or
professional exercising their power and bossing around the person with dementia.
First
and foremost, I am not a fan of trying to make people with dementia do things
that they either don’t want to do, or in the context of a lack of
concentration, are struggling to do. What I am a fan of is trying to find
alternative ways to support the person so that life can remain as familiar and comfortable
for them as possible.
So
for example, not everyone can concentrate for long enough to sit at a table and
eat or drink. That’s fine. They might prefer to sit in a comfortable chair with
a meal on their lap, or eat finger food on the go while they walk (my dad went through a phase of doing this). We can often
become very fixated on people doing things in an ordered way, or in the ‘usual’
way, or in the way they’ve always done them, and if the person with dementia responds
well to those options then great, but if they don’t it is important to be
flexible and modify the way we support them rather than expecting them to
conform to what we want or believe is necessary.
These
modifications often happen more readily when we think about the essential
aspects of life – like eating and drinking – but often happen less automatically
with the elements of daily living that might be seen as ‘optional’. Here I am
thinking about supporting a person’s hobbies or interests, or even just helping
them to do things that keep them physically active or mentally alert.
Lack
of concentration shouldn’t mean a person with dementia has to abandon things
they previously enjoyed, or indeed give up discovering new things. What is
needed is an understanding that the person may not approach a hobby, interest or task
in the same way that they used to – IE: sitting and reading a book, watching a
favourite film from start to finish, participating in a board game, doing
needlework, cooking, housework, gardening, painting/drawing etc – but that they
may still be able to do these things in a different way (change location/time
of day etc), in shorter bursts of activity, and/or with more intensive
assistance (helping the person, not doing it for them).
When
concentration wains some prompts may be helpful, like talking to the person
about what comes next, or inspiring them by reminiscing about aspects of their
early life that might relate to what they are trying to do. For example, if the
person is doing something creative like painting or drawing, but struggling to
start or continue with it, thinking about something they loved in early life
might just spark a thought that they can commit to paper.
If
the person struggles with conversation, some picture and word cards might
help. Make sure any glasses or hearing aids that are usually in place are
being used, and that distractions are minimal or non-existent (a blaring TV in
the background is rarely a good idea). Think too about balance - respect independence but don't leave a person with dementia struggling or disappointed because they can't complete something. For example,
if concentration is difficult when reading a book, see if the person would like
you to continue reading it to them when they have gone as far as they feel able
to that day.
Above
all, offer gentle encouragement, and try to back up the person’s fleeting
thought processes by helping to think for them in a completely person-centred
way,
sensitively anticipating, guiding and reassuring. This should always be
supportive, rather than in any way controlling, and it will inevitably involve
a lot of patience, time, calmness and perseverance.
Until next time...
You can follow me on Twitter: @bethyb1886
When
I first read that GP's were proposing to alter their current arrangements for visiting care homes, I wasn't surprised. Back
when my dad was living in care homes, GP's were already under considerable
pressure. I know that one of my dad's care providers had to pay for GP visits,
and even then some of the younger GP's in the practice were reluctant to visit
the home when residents were quite poorly.
By contrast, the senior GP in the
practice visited regularly, had a lovely bedside manner (he was a tall man and
would kneel on the floor so that he was at dad's eye level to chat to him), and
even attended one of our relatives meetings to discuss providing healthcare for
the residents and long-term planning.
I
recall arguing with one particular young female GP about whether dad had any
'quality of life' and whether or not he should be given antibiotics for a chest
infection (in my view he had quality of life, and he got the antibiotics in the
end, which cleared his infection). I also remember possibly the worst
experience I'd ever had with a doctor, when an out-of-hours GP visited late one
Saturday evening and refused to even touch dad to examine him.
That
experience with the out-of-hours GP is perhaps a glimpse into the future
whereby the services of the local GP practice could, potentially, be replaced with privately
contracted GP's who may not provide the same level of continuity or personalisation.
It is not a scenario I welcome or look forward to in any shape or form.
It is
my view that a regularly visiting, local GP is absolutely vital to the provision
of high quality care in care homes. A good local GP will get to know their
patients, pick up on illnesses and conditions quickly, keep medication under
review, and provide a useful external oversight role in relation to how well the
care home are caring for their residents.
I
appreciate that general practice is under severe, unprecedented pressure and
needs additional funding, but there is no suggestion that care for other sectors of society needs a separate contractual arrangement with the government and for that reason this feels like victimisation.
The argument from GP representatives is that care homes are
becoming extensions of hospital wards, and the needs of the people living in
them are increasingly unmanageable for local GP's within the current
structure and funding of general practice.
It is
undoubtedly true that care homes have changed from what they were.
Traditionally a residential home accommodated people of relative ability who
just needed a bit of assistance with personal care, low level health needs and
some companionship, while nursing homes offered the same but with a registered
nurse on duty to support people with more extensive health needs, medications
etc.
However
as people live longer, have more complex long-term conditions, and the NHS is
under pressure to discharge people back into the community, it's fair to say
that a lot of residential homes have become more like the traditional nursing
home model, and the nursing homes of today have morphed into mock hospital
wards. But that isn't the fault of the people living there. They aren't in
hospital, so don't have access to hospital doctors - the only way they can have
care from a doctor is from a GP practice.
By
all means GP's need to raise their concerns with the government and seek
additional support to continue to provide the care that people in care homes need,
but if the government don't agree to a separate contractual agreement to cover GP care in care homes, it would be wholly wrong for care for this sector of society to be withdrawn. People in care homes rarely ask to be living
there, and they are as entitled to care from their local family doctor as
anyone else. For these individuals, their care home is their home - they
shouldn't be penalised for living in a care home by losing their local GP
service.
I
appreciate that GP practices work best when patients visit them rather than
when GP's have to conduct home visits, but if the patient can't get to the
surgery then the GP needs to go to them, regardless of where they live. Yes,
care homes may have the option of buying in private GP care (if indeed they
could afford it, which is highly questionable for many), but from the perspective of residents that isn't the
same as having your own local GP who gets to know you and your needs.
If
new contractual arrangements with GP's aren't forthcoming, I fear that
individuals with dementia may be hit the hardest. For this group of people
continuity of care is vital. A good local GP who understands the person - and
understands dementia - can make a huge difference to the life of an individual
with dementia, as we saw first hand with that senior GP whose interactions with
dad were a real joy to see.
Families
also rely on good local GP's to help and advise them on the different
conditions their loved one has, the various medications they are (or could) be
taking, and when discussions need to be had in relation to long-term planning
and end-of-life care. Keeping people in their care home for end-of-life care is
infinitely preferable to being in hospital, but good local GP support is vital
to facilitate that.
I hope
that GP's and the government
will manage to find a mutually agreeable compromise, and that this issue doesn't escalate in the way the junior doctors contract has. Without such a compromise the
people who suffer most will, yet again, be some of the most vulnerable in
society, a fact that shames us all.
Until next time...
You can follow me on Twitter: @bethyb1886
