There is a greater focus on dementia care today than ever before. The Prime Minister’s Dementia Challenge1 sets out plans to go further and faster in improving dementia care, focusing on raising diagnosis rates and improving the skills and awareness needed to support people with dementia and their carers.
In terms of the challenges of delivering care; one of the key areas that is found to be overwhelmingly challenging, is how to provide quality care in care homes. The National Service Framework for older people2 stipulated that specialist mental health services should provide advice and outreach service for care homes. It was found that only 51% of teams provided any training and the pertinent issue was that community mental health teams (CMHT) cannot always stretch their limited resources to provide such services. There are about 250,000 people with dementia who live in care homes. Many of them experience behavioural and psychological symptoms (BPSD). There is a real need to improve the understanding and treatment so that people can ‘live well with dementia’, the goal of England’s National Dementia Strategy.3
Pharmacological management has focused on antipsychotics, even though from the total of 180,000 people with dementia who are treated, only 20% will derive some benefit4 and there is emerging evidence of detrimental outcomes.5 One reason that drugs are so heavily prescribed is that BPSD are frequently perceived as distressing and burdensome to both the person with dementia and their carers. However, research shows that only about a third of people with dementia are distressed by the symptoms and the effect on carers remains unclear.
How staff respond to patient behaviour has been found to vary due to factors such as how the staff are organised in the care home rather than the behaviour itself. Helping caregivers to understand why behavioural and psychological symptoms can develop for people with dementia can change how they feel about how challenging that person’s behaviour actually is.
There are two key challenges in improving quality of life of people with dementia in care homes:
1. Reducing over prescription of antipsychotic medications.
2. Improving management of behavioural and psychological symptoms of dementia using non-pharmacological techniques.
Over the last few years there has been a significant improvement in reducing usage of antipsychotics in dementia nationally. In 2012 the NHS Information Centre published the results of an audit of prescriptions of antipsychotic drugs by GP practices in England. Their report found that antipsychotic prescriptions for people with dementia reduced by 52% between 2008 and 2011.6 However there is only limited work done to address staff training using non-pharmacological techniques.
The All Party Parliamentary Group report7 found that the prescription of antipsychotic drugs to people with dementia was often the result of factors other than the symptoms of dementia. In particular, a lack of training in dementia care for staff means that professionals are often not aware that symptoms such as restlessness and shouting out can be the expression of unmet needs.
This could be because of unidentified pain or boredom due to a lack of social activity being available in the care home. The report found that antipsychotic drugs are often prescribed as a first resort, as a quick and accessible way of managing behaviour, when people with dementia often require different solutions such as person-
The APPG report also highlighted a lack of training for staff, and a lack of specialist advice and support as key issues. One third of care home managers surveyed for an Alzheimer’s Society report of care homes7 reported no support or very limited support from the local older people’s mental health service. In care homes, the National Audit Office (NAO) report on dementia care in England found one third of care homes with dedicated dementia provision reported having no specific dementia training
The key element to overcome the above challenges would be to provide quality training in dementia for staff. People with dementia have specialist needs and staff providing formal care must have the training and support if they are to provide good care. People with dementia may experience problems communicating and may struggle to express their preferences and needs. They may also display behavioural and psychological symptoms of dementia, which need to be understood if they are to be responded to appropriately.
Challenges in dementia training in care homes
As we know the care home sector can be some what scattered. There are number of independent care homes with limited resources for staff training. High staff turnover is another challenge and a huge disincentive to the employers to invest in expensive forms of training and development, yet lack of these opportunities further increase the turnover. There is also a high burn out rate among the staff and a considerable proportion of them may not have formal professional qualifications.
At present dementia training programmes available in care home settings are rather fragmented and not universally available. Local authorities and the commissioners have the responsibility for implementing dementia training in care home settings. However the biggest challenges are the cost and the quality of training and to identify suitable providers.
In order to bridge the gap between potential lack of training on BPSD in care homes and limited, often expensive options currently available, we need to consider a solution that is cost effective as well as sustainable. At present there are training programmes available through voluntary organisations, private providers as well as within community teams utilising junior trainees/community nurses on an ad hoc basis. Unfortunately, the quality of such training is often questionable due to the fact these are not appropriately valuated.
We therefore formulated a training model/pilot project involving a higher trainee in old age psychiatry (ST4 and above) and a trainee psychologist who is experienced in the non-pharmacological management of behavioural and psychological symptoms of dementia. We selected eight care homes in the London Borough of Ealing based on the frequency of referrals we had received during previous year. The training was conducted once a month in each care home with prior agreement with the care home management at no cost. With the guidance of the consultant psychiatrist and psychologist of our team, we created a framework for our workshop as documented below.
• The Communication Games (30 minutes)
• Behavioural and psychological symptoms of dementia (60 minutes)
• Working with behaviours that present challenges to services (60 minutes)
• Scenarios, discussion and feedback (45 minutes).
During the communication games we focused on different scenarios where patients with dementia struggle to communicate their needs. Each carer had the opportunity to take part in the role-play. This was a useful technique to gain insight into patients’ needs rather than labelling them as being challenging. Based on the communication games we set the scene for topics on BPSD that focused on early identification of such signs and symptoms and strategies to minimise further worsening. The psychologists focused mainly on monitoring the patterns of BPSD using the ABC behavioural chart.
We consciously limited didactic teaching and created it to be more interactive with the staff. Every effort was made to discuss individual experiences and our approach was more of clinical discussions rather than theory. (A detailed description of the programme is beyond the scope of this article however it can be accessed via the lead author).
Our project was evaluated by incorporating a training effectiveness questionnaire (completed on the same day) and a training follow up questionnaire (completed in four weeks. A total of 108 carers attended during the course of training and also completed training effectiveness questionnaires. We received 60 completed training follow up questionnaires after six weeks.
Our quest was to develop a cost effective yet sustainable training model for care home staff involving a senior trainee and a trainee psychologist. Our pilot project confirmed that within available resources it is possible to deliver such training at no cost. Trainees need to dedicate one session per month and to be effective training should be conducted every 3–6 months (depending on the availability of trainees) in each care home within the CMHT catchment area.
Care home employers are more likely to accommodate and support such training due to the cost effective nature. If you manage to deliver a high quality training programme utilising both psychiatrists and psychologists it is very likely to improve the quality and care provided by the carers.
We believe that such training should be incorporated as one of the core training objectives for the old age specialist registrar curriculum. Since it is conducted once a month, trainees can utilise one of their special interest sessions as these also do focus on their own personal development.
Not only could the trainees improve their teaching and communication skills but also these sessions can be used as part of workplace based assessments where the consultants will have an obligation to get involved.
Higher trainee posts can be limited in some trusts and they also regularly rotate. Therefore, there is some uncertainty of continuity. In addition depending on the post, higher trainees may have other commitments. More over, there is also an issue regarding flexibility in selecting what trainees would like to do during their special interest session.
We are not suggesting our project is the total solution but we believe it to be a viable model that is cost effective and sustainable, which could be a part of a solution to dementia training in care homes.
Conflict of interest: none declared
1. Older People & Dementia (DH). Prime Minister’s challenge on dementia Delivering major improvements in dementia care and research by 2015: www.dh.gov.uk/dementia
2. Tucker S, Baldwin R, Hughes J, Benbow S, et al. (2007). Old age mental health services in England: Implementing the National Service Framework for Older People. International Journal of Geriatric Psychiatry 22(3):211-217.
3. Department of Health. Living well with dementia: A National Dementia Strategy. Feb 3, 2009
4. Department of Health. The use of antipsychotic medication for people with dementia: Time for action. A report for the Minister of State for Care Services by Professor Sube Banerjee. October 2009:
5. Ballard C et al (2009a). 'Reflections on quality of life for people with dementia living in residential and nursing home care: the impact of performance on activities of daily living, behavioral and psychological symptoms, language skills, and psychotropic drugs', International Psychogeriatrics 21:1026-1030.
6. NHS Information Centre, 2012, An audit of antipsychotic prescriptions for people with dementia
07. All Party Parliamentary Group on Dementia (2008) Always a last resort: inquiry into the prescription of antipsychotic drugs to people with dementia living in care homes.
08. National Audit Office (2007). Improving services and support for people with dementia.