FROM THE THIRD GENEVA CONFERENCE ON PERSON-CENTERED MEDICINE: PERSON-CENTERED
CLINICAL CARE ACTIVITIES
Person Centred Medicine for the Older Patient, with Specific
Reference to the Person with Dementia
Jon Snaedal MD
Associate Professor in Geriatric
Medicine, National University Hospital of Iceland, Iceland
Abstract
The concept of old age differs as
the pension age differs between countries and because there is no consensus of
the boundaries between middle age and old age, neither socially nor medically.
The old patient (i.e. the geriatric patient) constitutes a special challenge
for the health care providers because of the often complex presentation of
diseases, the frequency of cognitive impairment and specific social
circumstances. The old person with dementia requires special attention because
of his/her cognitive derangement and the need-driven dementia-compromised
behaviours. The person centred approach seems to be relevant to this age group
and several programs exist using this ideology, especially in the care of the
demented person.
Keywords
Old Age, Elderly, Geriatrics,
Dementia, Person Centred Medicine, Dementia Care Mapping
Correspondence Address
Prof. Jon Snaedal, Memory Clinic,
Geriatric Department, National University Hospital of Iceland, Landakot
v/Tungotu, IS 101 Reykjavik, Iceland. E-mail jsn@mmedia.is
Accepted for publication: 19 January
2011
Introduction
There is no general consensus on
what is meant by “the elderly”. Most often the age limit is the one that
constitutes the right to old age pension, which differs between countries. The
origin of the old age security system was in Prussia in 1889 on initiative of
the Prussian Chancellor, Otto von Bismark. In a letter to the German Parliament
it was stated: “those who are disabled from work by age and invalidity have
a well-grounded claim to care from the state." One persistent myth
about the Prussian program is that it adopted age 65 as the standard retirement
age because that was Bismarck's age. In fact the retirement age was set at age
70 and it was not until 1916 that the age was lowered to 65 [1]. It is of
interest to note that this age limit was set at a time when the life expectancy
in the Western world was much less than today and only a small portion of the
society could reach retirement age. The pension age differs between societies
generally and at the moment, there is no United
Nations standard numerical criterion, but the UN agreed cutoff is 60+ years to
refer to the older population [2]. In medical terms the confusion is no
less. The term “younger old” is often applied to the age span of 65 (or 70) to
85 years of age and the term “older old” for those older than 85 years. There
are however still many “home made” definitions such as seen by an example of
Canadian researchers that defined younger old as 57-74 years and older old as
75 years and older [3]. The confusion arises from the fact that persons
approaching or above the average life span of humans tend to be much more
medically and socially different from one another than any other age group.
From this fact comes the saying “When you have seen one geriaric patient, you
have seen one geriatric patient”.
The geriatric patient
Several studies on the value of
specific geriatric assessment during the eighties showed the risks of classical
medical diagnostic and therapeutic methods for the geriatric patient and on the
contrary, the benefits of individual holistic approach [4]. The risks for the
geriatric patients can be described by the concept of geriatric cascade
syndrome. When using the organ specified approach the complexity of the medical
situation is not taken into consideration and that leads to new medical
problems in the diagnostic and therapeutic process. When at the same time, a
due consideration is not taken to the need of the patient for mobilisation and
rehabilitation, the patient often ends up with seriously compromised abilities
for self care and is not able to be discharged to his own home. For successful
treatment of the geriatric patient, it is necessary for the carers to know the
person behind the disease(s). This is more important than in the treatment of
conventional internal medicine, most often of younger patients, as the success
of treatment may depend on factors related to the patient’s personality,
psychological health and social situation rather than to his physical health.
Two domains are most important in this regard, the psychological health of the
patient including his cognitive abilities, and his social support. Dementia is
common in the oldest age groups and when present it can make all attempts to
treat the patient futile. Cognitive decline that is not severe enough to merit
the term dementia often goes undetected but is nevertheless important. Those
treating the patient need therefore to evaluate cognition and more precisely,
to what degree cognition has deteriorated and how. To evaluate the
psychological health of the patient is also of utmost importance. Older persons
often tend to explain their symptoms by their chronological age and that makes
their contribution to their own treatment sub-optimal. Depressive symptoms and
overt clinical depression are great obstacles to treatment success as well. The
time used to evaluate a person’s cognition and to communicate with him is
therefore time well spent. The social support is also of utmost importance for
his possibilities for independent living. For evaluation of social status and
support it is necessary to involve others such as family members and the
persons responsible for the social service in the community. Before doing that
the patients wishes must be respected. He knows best to whom he wants to turn
for help and he might trust some and mistrust others. According to human rights
charters such as the Declaration of Lisbon on the Rights of Patients [5], he
has the right to know everything regarding his illness, treatment and
prognosis, to decide to what extent he is treated and supported and whom to
consult in his family or community for his benefit. For this holistic approach,
the time-honoured method is to use teamwork for evaluation, caring and planning
[6]. The personal preferences of the patient must be respected; in other words,
the personal centred approach to treatment must guide the work. It can thus be
argued that the concept of person-centred medicine applies especially well for
the aged patients [7].
The person with dementia
The old person with dementia
constitutes a special challenge. Dementia is a frequent condition in old age
and in Europe, the age-standardized prevalence rate of dementia at age 65 and
over has been estimated to be 6.4% [8]. As the intellectual and psychological
health has deteriorated in the demented individual, the treatment and care is
classically based on information from others than the patient himself. The
staff turnover in residential care makes it difficult to maintain high
standards of professional care and lack of understanding of the patient’s
wishes and preferences can lead to neglect of psychosocial needs. This neglect
as well as pracites of physical restraint can exacerbate need-driven
dementia-compromised behaviours, leading to loss of self-care, decision making
and social engagement as well as increased social alienation [9], comprising
what Kitwood called malignant social psychology [10]. More than a decade
elapsed from the general consensus on the importance of the holistic,
personalized approach to the geriatric patient, to the arising concern of the
special needs of demented patient for a personalised approach in care. During
the last one and a half decade, more attention has been brought to the needs of
the demented patient and new programs have been developed and published. The
pioneer work of Tom Kitwood [11] where he put the person behind dementia to the
forefront has lead to extensive research in this field and promotion of several
programs intended to serve the demented patients. He founded the Bradford Dementia
Group in 1992 and his own program was called “Dementia Care Mapping” [12,13].
One program based on his idea comes from the CADRES study in Australia [14]. In
this study, urban residential sites were randomly assigned to person-centered
care, dementia care mapping or usual care. Agitation, a major symptom of
distress was significantly lower in the person-centred care than in the usual
care. The results confirmed the conclusion made in a comprehensive review of
non-pharmacologic interventions for the management of need-driven
dementia-compromised behaviours that the most promising treatments seem to be
individually tailored behvaioural interventions [15]. In another study focusing
on the person-centred care as an alternative to pharmacologic treatment, the
use of neuroleptics was almost halfed in the intervention homes as opposed to
the control homes without any increase in agitation or disruptive behaviour [16].
In the intervention homes, the staff received training in the delivery of
person-centred care and they were supervised weekly. This effect lasted for 12
months. In spite of this progress in care of demented individuals, an
astonishingly small number of studies on the demented persons own preferences
and wishes have been published. The reason seems obvious, in dementia; the very
ability to communicate with others in words is seriously compromised. However,
in times when the diagnosis of the diseases leading to progressive dementia is
made at early stages, when the person is still very able to communicate, the
focus should be shifted to the person with the disease. Most of these studies
have been done with qualitative methods and therefore including few individuals
but they have shown many interesting aspects such as the coping skills of
individuals with early Alzheimer´s disease [17]. There is a need for bigger
studies using quantitative measures as well.
Conclusion
It is in line with this development
in person centred approach in the care of the older patient and the demented
patient especially that the international initiative of person centred is
gaining momentum. This initiative started by a series of congresses, then to
establishing a network of interested parties and now by establishing an
International Journal for this topic.
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