Recibir gozosamente el misterio de Dios Amor

Process also matters in the care of people with dementia in residential care settings. That is why there should be more experimentation with different models of care for people with dementia in long-stay care. We need to explore and evaluate different psychological care strategies which highlight and nurture the resourcefulness of people with dementia in both residential and community

care settings (Chapman et al, 1994). The evidence with respect to the

effectiveness of various strategies available is sparse, but there are an increasing number of therapies and activities which challenge what Downs (1994) calls 'the therapeutic nihilism commonly found in the care of people with dementia'. Reality orientation was the first attempt to recognise the personhood of people with dementia and to deal with the orientation problems associated with

dementia (Holden and Woods, 1995). This was followed by validation therapy (Feil, 1982) and resolution therapy, both of which seek to highlight the feelings and emotions of people with dementia, including their ability to communicate with other people. Reminiscence therapy for people with dementia is very popular in day and residential settings (Woods et al, 1992). While there is no evidence that reminiscence therapy improves cognitive function, it can, and does, bring a lot of pleasure to people with dementia and facilitates

communication within groups (Gibson, 1994). Religion is an area which retains meaning for many people with dementia, and for these people old hymns,

prayers and devotional rituals (of their own denomination) may be a very important element of reminiscence therapy. The spiritual needs of people with dementia are, of course, important in their own right and opportunities must be available for continued participation in religious observance.

There are also many different types of expressive therapies that seek to provide stimulation for some, or all, of the senses, as a way of addressing impoverished communication and interaction among people with dementia. There is good evidence of the positive affect on music on some categories of people with dementia (Holden and Woods, 1995; Kneafsey, 1997). The Sonas aPc approach provides stimulation for all the senses, using music and the sense of touch to create a relaxed and safe environment for participants, to encourage and activate the potential for communication in people with dementia. The feedback from residents, relatives and staff in the residential units where the programme has been run is unambiguously positive (Linehan and Birkbeck, 1996). There are positive affects for patients and staff during the administration of the

programme and improvements in general spatial orientation, independent functioning, and the use of initiative were also identified in the three months following the programme.

To facilitate a greater emphasis on the social and emotional needs of patients in residential facilities, and to provide scope for the individualised provision of care to people with dementia, management and organisational structures will have to become more flexible (Gilloran and Downs 1997). A person-centred approach to care for people with dementia is a critical ingredient for good quality care provision. Good management practice is a necessary pre-requisite for a person-centred approach to care. So is a comprehensive training strategy

for all staff working with people with dementia. In-service training has been identified by Gilloran et al (1995) as contributing to overall high levels of staff morale which can only be good for patient care. The lack of suitably trained staff in both public and private residential care settings was reported many times during the consultation process. There was unanimous agreement among the people we spoke with that training for people providing care in residential settings should be a priority. New training programmes are needed which would focus on the attitudes and technical competence of staff, and on ways of promoting person-centred models of care delivery to people with dementia. The Sonas programme should become an essential component of new training

programmes for people working in residential care. Recent advances in technology should also be examined for their usefulness in supporting

habilitation, social and intellectual stimulation, care, security and surveillance. The existing regulation of long-stay provision for elderly people, including people with dementia, is too concerned with technical issues, mainly related to infrastructure and finance, and not concerned enough about models of care provision within both the public and private systems of care. The individual needs of demented patients as people are often overlooked by care providers when the prevailing approach to care is based on a routine model (Downs and Marshall, 1997), or worse still, a rejective model of care (Liuokkonen, 1992). Kitwood, (1993) talks about the concept of the person in dementia care, and the need to move towards an interpersonal, genuinely communicative, and moral psychology of care. To achieve this objective we need to know much more about existing care relationships among health professionals, family carers and patients. We need better information systems for the routine generation and collection of data on process in both community and residential care facilities. Information about people with dementia learned while the person attended community care services, such as day care, should be transferred to residential care settings should that person have to enter long-stay care. This information will be very useful for staff in residential care settings in their efforts to treat the new patient as a unique person (Berenbaum, 1997). Finally, we need a more active role for patients and their families in the assessment and planning of services.

20. We recommend that social, psychological, artistic and

sensory/communication needs be given equal weighting to physical needs in residential care settings, and that management structures support a holistic and person-centred approach to care.

21. We recommend the development of effective training programmes for staff working in all types of residential care facilities. These training

programmes should be designed to facilitate a person-centred approach to care and service delivery.

8.4 Conclusion

Residential care for people with dementia should be provided in small-scale homely environments. This has not been the case in Ireland in the past. New investment is required if we are to follow the international trend towards small, safe, domestic-style accommodation for people with dementia. There is also an urgent need to invest in design features in long-stay accommodation, given the accumulating evidence on the affect of design on the functioning of people with dementia. Design features have largely been ignored in the provision of long- stay facilities in this country. The process of care in residential care is equally important. More attention should be focused on the social and sensory needs of people with dementia through the support of various psychosocial interventions such as reminiscence therapy, validation therapy and reality orientation in the early stages of dementia. Expressive therapies, including music and touch, should also receive more attention as therapeutic approaches to care for people with dementia. Training for staff will be an important aspect of more effective residential care for people with dementia. So also will the ongoing monitoring and dissemination of models of best practice leading to the eventual elimination of sub-standard accommodation and poor quality care.