Monday 22 February 2016

When concentration becomes difficult

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...
Beth x

You can follow me on Twitter: @bethyb1886

Monday 8 February 2016

GP's and care homes - A relationship under pressure

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...
Beth x

You can follow me on Twitter: @bethyb1886
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Please note: This blog was modified on 12 February 2016 due to information received.