Introduction
The age of the world population is increasing with life expectancy, and consequently, dementia is an increasingly important issue in all our society. Dementia became a real public health problem and various types of care are developed. Because dementia can induce a steep decline, patients need care and help for everyday life especially on the last years of their lives. We can see different ways to deal with dementia depending on different countries. In France, care homes are the more relevant type of care. They are facilities where some agents help people in their everyday life. The facilities are most of the time very big and can welcome a hundred of patients. These care homes are consequently less human than we can expect.
The stance of retirement homes in France
In France, an EPHAD (a residential establishment for dependent elderly people) is a medicalised structure, accommodating people suffering from a loss of physical or psychological autonomy and for which at-home care is no longer an option. Ethical issues are often at the heart of discussions when it comes to putting a family member in a specialized facility for the elderly. This decision-making is not easy, but when abuse scandals break out, the decision becomes even more difficult for families. Yet, nearly 600,000 people now live in one of the 7,200 EHPADs according to the Ministry of Health. Working conditions are precarious and denounced by the staff, while the budget is sometimes poorly distributed… Directors preferring to use the budget to renovate premises that are already new (instead of hiring staff), in order to show a more attractive look of their buildings, so that one family can choose their establishment over another. However, it affects the daily lives of residents, and staff denounce in particular showers and meals administered in a hurry and their inability to create appropriate links with residents because they are always in an emergency and understaffed situation: when the objective is one professional per resident, reality denotes one professional for more than six patients. In addition, although there are aids and subsidies calculated according to the senior’s level of resources, these structures are often very expensive and the family is regularly forced to contribute to the costs. While healthy elderly people will turn to foster families or independent residences, EHPADs will remain the institutions for highly dependent people with a high complexity of care.
What about patient care?
Since the 1999 reform, institutions have only been granted the EHPAD status on the only condition that it requires a well-defined and highly developed medicalization. This is where the main part of the care of residents in EHPAD resides. Psychological support is almost negligible, most of the time present one day a week or even every two weeks, the psychologist must provide psychological support to the residents, to their families but also to the medical or paramedical team. However, the animation is much more present but does not aim to maintain the autonomy, cognitive and psychological capacities of the residents. When they have the time and means, the psychologists can also set up individualized care and life projects according to the patient’s preserved and deficit capacities. Stimulation and rehabilitation workshops can also be set up, but always according to the place given to the psychologist in the institution. According to the “HAS” (High Authority for Health) 2008 recommendations, “cognitive stimulation is part of the non-drug management techniques for Alzheimer’s disease (AD) and related syndromes. It is a general pedagogical, cognitive, psychological and social approach. The proposed activities are ecological simulations, i.e. they allow benefits from them in daily life.”
As we said previously, France is not as modern as others countries in terms of therapeutic for dementia. In this part, we will present new strategies for fighting dementia which have been adopted throughout Europe.
- Simulation/Environment
In the Netherlands, instead of using traditional medication to treat their patients, some care homes give the spotlight to relaxation techniques with the help of simulation or specific environments. For example, patients (who are much more refered as residents) have access to simulation tools and artificial environment in order to relax and relieve their anxiety. They can enter a room with sands on the floor, listen to the sound of the sea while seeing it through a video screen. This kind of immersive environment thanks to simulation is not the only one strategy. Care homes rethink their own environment and re-create living places such as cafe or city bus stops in their living area. It allows residents to stay away from isolation and live in a place full of life. Their living environments are adapted too by creating a less stressful clinical setting. As Dr. Erik Scherder (neuropsychologist at Vrije University) said “If you can lower stress and discomfort, it has a direct physiological effect.
- Learning New Language
In Scotland, in the county of Ayrshire, residents from care home can attend French or Spanish classes. Indeed, according to psychologists and researchers, learning new language stimulates your brain by creating new connections which improve cognitive abilities in general. Besides this positive cognitive outcomes, people who suffers from dementia realize they are able to learn new things. It really increases their wellbeing and gives them more confidence in order to cope with their disease.
- Doll Therapy
People with an advanced stage of dementia can develop behavioral and psychological disorders such as aggressiveness or emotional problems. IPA (International Psychogeriatric Association) guidelines recommend the use, in combination with drugs, of non-pharmacological interventions that can take into account the person’s history, interests and capabilities.
A research paper (Pezzati et al, 2014) presented a interesting way of intervention : Doll therapy. Patients will build a specific bond and an attachment relationship with the doll and this can be very useful to prevent disruptive behaviors such as agitation, wandering, anxiety or fear. The benefits of this doll is multiple : increasing communication between patients and other people (they are more likely to talk about motherhood and caregiving so this is going to stimulates conversations), patients are smiling more and seems more active in a cognitive way. Moreover, doll therapy is less demanding in terms of costs and time of implementation in contrast to other non-pharmacological treatments. This kind of therapy highlight preserved abilities in people with dementia, they maintain their abilities to establish relationships with its past and present reality.
- Snoezelen room
Dementia can create confusion and isolation, often by cognitive decline on language that affects communication with others. Snoezelen room is a place where multi-sensory stimulation is provided to patient. We can use a range of different stimulation modalities such as visual, auditory, olfactory or tactile stimulation. This techniques relies on the preserve sensorimotor abilities from people with dementia and has fewer demands on intellectual abilities. The aim of Snoezelen rooms is to decrease the disoriented behaviour and also prepare patients to engage in meaningful activities of the day and gain awareness by stimulate the reticular activating system of the brain.
What are the questions raised by these treatments?
There is an urgent need to develop novel solutions beyond the limited successes of pharmacological that meet the needs of people with dementia and their carers. But it is important to keep in mind that some care should be handled with caution, especially when they refer to the subject’s past because we are never certain of the events that can be traced back. It is better to leave some traumas or bad experiences in the depths of memory.
In addition, some techniques have a real cost that is not accessible to everyone and therefore raises real ethical questions. Where is equality when two individuals with the same disease cannot access the same care because one has earned a better living than the other ?
Bibliography :
Pezzati, R., Molteni, V., Bani, M., Settanta, C., Villa, I., Poletti, B., Ardito, R. (2014). Can Doll therapy preserve or promote attachment in people with cognitive, behavioral, and emotional problems ? A pilot study in institutionalized patients with dementia. Frontiers in Psychology, 342 (5).
Words we have learned :
- Wandering : Déambulation
- Stimulation and rehabilitation workshops : Ateliers de stimulation cognitive
- A range of : Un panel de
- Granted : Accorder
- Handled with caution : A manipuler/traiter avec soin
Nahema Meyrignac & Barbara Daniel, M2 PPCECC