This assignment will look issues around older people’s mental health, in particular, dementia and abuse; this will include demographics of older people, statistics, the history, definitions and causes of dementia, and finally the lack of legislation to protect vulnerable people from harm and the implications for social work practice.
The population surge at the end of world war 2 has gave rise to an unprecedented population explosion and to what we now call the ‘baby boomers’, these people are now in their retirement years'(Summers Et al, 2006), and our population now contains larger percentage of older people that ever. In society today elder people are becoming the fastest increasing population in the UK, National Statistics (2009) states that ‘the population of the UK is ageing. Over the last 25 years the percentage of the population aged 65 and over increased from 15 per cent in 1983 to 16 per cent in 2008, an increase of 1.5 million people in this age group’. Due to the increase of the ageing population we are now seeing emerging health and social care issues in our society. Many older people will be active, involved within the community, and independent of others. However, as you get older it is natural to experience pain, a decline in mobility or mental awareness.
Mind (2010) states that ‘the most common mental health problems in older people are depression and dementia. There is a widespread belief that these problems are a natural part of the ageing process, but this not the case; it can start as early 40 but is more common in older people (Royal college of Psychiatrists, 2009), however, ‘there only 20 per cent of people over 85, and 5 per cent over 65, have dementia; 10-15 per cent of people over 65 have depression’ (Mind, 2010). It is important to remember that the majority of older people remain in good mental health. ‘Dementia mainly affects older people, although it can affect younger people; there are 15,000 people in the UK under the age of 65 who have dementia’ (Alzheimer’s society, 2010). However, ‘currently 700,000 – or one person in every 88 in the UK – have dementia, incurring a yearly cost of £17bn, and the London School of Economics and Institute of Psychiatry research calculated that more that 1.7 million people will have dementia by 2051’ reported by BBC news (2007).
‘The word dementia comes from the Latin ‘demens’ meaning ‘without a mind’. References to dementia can be found in Roman medical texts and in the philosophical works of Cicero. The term dementia came into common usage from the 18th Century when it had both clinical and legal connotations. Dementia implied a lack of competence and an inability to manage one’s own affairs. Medical use of the term dementia evolved throughout the 19th century and was used to describe people whose mental disabilities were secondary to acquired brain damage, usually degenerative and often associated with old age’ (Kennard 2006). From the 20th century onwards scientific knowledge was supplemented through the examination of the brain and brain tissue which was founded and performed by a physician Alois Alzheimer (Plontz, 2010). The National service framework (Department of Health, 2001, p96) now defines ‘dementia as a clinical syndrome characterised by a widespread loss of mental function’.
The term ‘dementia’ is used to describe the symptoms that occur in a group of diseases that affect the normal working functions of the brain. This can lead to a decline of mental ability, affecting memory, thinking, problem solving, concentration and perception, also problems with speech and understanding (Mind, 2010). ‘Dementia is progressive, which means the symptoms will gradually get worse. How fast dementia progresses will depend on the individual. Each person is unique and will experience dementia in their own way’ (Alzheimer’s society, 2010). Symptoms of dementia include: Loss of memory, Mood changes, and Communication problems. In the later stages of dementia, the person affected will have problems carrying out everyday tasks, and will become increasingly dependent on other people, two thirds of people with dementia live in the community while one third live in a care home (Alzheimer’s society, 2010). There are many types of dementia, and some of the causes of dementia are rarer than others, Alzheimer’s disease is the most common cause, damaged tissue builds up in the brain to form deposits called ‘plaques’ and ‘tangles’, these cause the brain cells around them to die (Royal college of Psychiatrists, 2009). Other most commonly known is vascular disease, Dementia with Lewy bodies, Fronto-temporal dementia. Mostly, patients themselves do not present to the clinician with dementia, owing to gradual onset and denial of the problem. There is no cure for dementia but there is medication that will help to slow down the progression of the disease. When finding help for dementia it is usually the primary carers, caregivers, supporters, partners or family members who initiate asking help and a diagnosis (Brodaty, 1990).
Depression may be misdiagnosed as dementia the difference being that people who have depression are more likely to be aware of their issues therefore are able to discuss them, whereas someone with dementia may not be able to do this due to their symptoms. Nonetheless, the Mental Capacity Act (2005) states that every person has the right to make their own decisions and must be assumed to have capacity unless otherwise proven and people should be supported to make any decisions. Under the MCA, you are required to make an assessment of capacity before carrying out any care or treatment (Office of the public guardian, 2009). The Mental capacity act is an act that protects individual rights and ensures that the person’s liberty is not taken. ‘It is based on best practice and creates a single, coherent framework for dealing with mental capacity issues and an improved system for settling disputes, dealing with personal welfare issues and the property and affairs of people who lack capacity. It puts the individual who lacks capacity at the heart of decision making and places a strong emphasis on supporting and enabling the individual to make their own decisions’ (Office of the public guardian, 2009). However, even with a structure in place to protect individual’s rights and liberties many people who have dementia are more vulnerable to abuse due to their lack of capacity. The University College London research revealed that a third of carers admitted “significant abuse”, in total 115 carers reported at least some abusive behaviour, and 74 reported more serious levels of mistreatment (Cooper et al, 2009). Caregivers can also be on the receiving end of verbal or physical abuse directed at them by parents or spouses who are confused and angry over declining mental capacities due to stroke and Alzheimer’s disease. In some cases, Alzheimer’s disease or other forms of dementia may cause the patient to be uncharacteristically aggressive (Coyne, 1996).
It is only in recent years that abuse of the elderly has become more apparent, Crawford Et al (2008, p122) argues that over time it has very slowly come to the attention of people in the last 50 years that abuse does actually exist behind closed doors; in the 1950’s older people lived in large families where issues were hidden, and in the 60’s to 70’s older people started living alone or in residential homes and it was not until the early 80’s that abuse had started to be recognised and defined. Penhale and Kingston(1997) argue that over the years it has been difficult to emphasise the issues of abuse due to not finding a sound theoretical base to which an agreement of a standard definition can be made and applied. Action on elder abuse (2006) defines elder abuse as ‘A single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person’. Abuse comes in not just physical abuse it comes also in sexual, psychological, neglect, discrimination and financial as well. ‘Older people may be abused by a wide range of people including family members, friends, professional staff, care workers, volunteers or other service users, abuse can also be perpetrated as a result of deliberate, negligence or ignorance’ (Royal pharmaceutical society (RCA), 2007). Abuse can occur in a variety of circumstances and places such as, in own home, in a residential or day care setting or hospital and can by more than one person or organisation. Pritchard (2005) asserts that we will never have a true picture of the prevalence of elder abuse due to the unreported cases, and can only count ones that are known to organisations and services.
Most abuse is still unreported due to victims being frightened, ashamed and embarrassed to report the abuse, not realising their rights or not being able to due to tier mental health. Summers et al (2006, p7) points out that ‘those statutes that make abuse criminal are often ineffective due to them not being utilised by the victim’, and this means that this will be the biggest challenge and barrier for change in getting people to recognise the scale of the problem and raising awareness so that the government agree to change the legislation to protect older people. Abuse of any kind should not be ignored and there should be legislation to protect adults from abuse like there is in child protection, people who recognise the extent of elder abuse argue why should adults be treated as second class to children, is their suffering and deaths any less important? The Alzheimer’s Society (2010) states that ‘abuse of people with dementia should be considered in the same way as child abuse’.
Crawford and Walker (2008, p12) state that ‘prejudice refers to an inflexibility of the mind and thought, to values and attitudes that stand in the way of fair and non judgmental practice’. Thompson (2006, p13) defines discrimination as the process in which difference is identified and that difference is used as the basis of unfair treatment. A barrier to recognising the abuse of people with dementia and older people is that of social stigma, negative perceptions and connotations of words for mental health, such as confused or senile. ‘Confused is something that we all experience at some time in our lives, whereas senile is a more complex word and the first recording of its usage was neutral meaning pertaining to old age, but now has negative connotations linked to mental decline due to age (Crawford and Walker, 2008). Therefore, challenging people’s perceptions needs to done to change these social constructs to enable a change in legislation and protection of vulnerable adults. In March 2010 the department of health ran a series of campaigns to address poor public understanding of dementia which included TV, radio, press and online advertising featuring real-people with dementia (Department of health, 2009).
In 2009 the first ever dementia strategy was launched that hopes to ‘transform the quality of dementia care, It sets out initiatives designed to make the lives of people with dementia, their carer’s and families better and more fulfilled It will increase awareness of dementia, ensure early diagnosis and intervention and radically improve the quality of care that people with the condition receive. Proposals include the introduction of a dementia specialist into every general hospital and care home and for mental health teams to assess people with dementia’ (Department of health, 2009). However, this is not legislation it is just a strategy for dealing with people with dementia. The government are recognising that there is little protection for vulnerable adults and that further legislation need to be put in place and stating that dementia care is a priority (BBC news, 2007). At present, there is no one specific legislation which directly protects vulnerable adults, instead the applicable duties and powers to assess and intervene are contained within a range of legislation and frameworks, such as the Mental Capacity Act 2005 and Mental Health Act 2007 and the national service framework for older people. ‘One of the themes for national service framework (NSF) is respecting the individual which was triggered by a concern about widespread infringement of dignity and unfair discrimination in older peoples access to care. The NSF therefore leads plans to tackle age discrimination and to ensure that older people are treated with respect, according to their individual needs, specifically in standard 2 it relates to person centred care ‘ (Crawford and Walker, 2008, p8).
And expectation of NSF is that there must be systems and processes put in place to enable multi agency working. In 2000 the government published ‘No secrets which is guidance that requires local authorities to set up a multi agency framework which includes health and the police with a lead person (adult social care) to carry out procedures into the allegations of abuse whilst balancing confidentiality and information sharing’ (Samuel, 2008). No Secrets is only ‘guidance and does not carry the same status as legislation, the LA’s compliance is assessed through an inspection process, therefore the LA can with good reason choose to ignore the guidance’ (Action on elder abuse, 2006). This has concerned agencies who want to see the protection of adults given the same equivalent priorities as child protection and think that legislation is the only way to accomplish this.
A review of No Secrets guidance has been carried out in 2008 and consulted with over 12000 people (Department of Health, 2009), the report found that over half (68%) of the respondents were in agreement to new safeguarding legislation and 92% wanted local safeguarding boards to be placed on a statutory footing and still there is no legislation to protect vulnerable adults (Ahmed, 2009). A recent article in community care told the failure of the government to commit to making a policy has only strengthened campaigners fight and given rise to criticism (Ahmed, 2009).
The need to protect vulnerable people brought about the protection of vulnerable adults scheme (POVA) which is run by the Department of Health to regulate and monitor the employment of staff in the social care workforce, through this scheme a list of people who are unsuitable to work with vulnerable people is kept. More recently, the Safeguarding of Vulnerable Groups Act 2006 which was launched in 2008 replaced POVA with the Independent Safeguarding Authority (IDeA, 2009). The problem with this is that abusers of dementia sufferers are usually family member or informal carer that are under considerable stress and may not receiving help from within the health and social care system, therefore, an abusive situation can carry on for some time until the situation is found by an outsider. This situation may only be found when a informal carer starts asking for help, and when informed of the situation it is good practice and essential to make sure that carers are getting the help they need which can prevent the abusive situations. Under the 1995 Carers (Recognition and Services) Act carers are entitled their own assessment of need and by doing so this may allow for respite or payments to be made for their services (Parker Et al, 2003). University College London researchers who interviewed people caring for relatives with dementia in their own homes stated within their research that ‘Giving carers access to respite, psychological support and financial security could help end mistreatment’ (Cooper et al,2009). When working with relatives who are carers it is important to remember who is the service user, although it is important to ascertain the wishes of the relative it should not override the wishes of the service user, this is especially true when there is a break down in the care of the service user and the carer wishes the service user to be placed in care.
Many older people with dementia receive care in a residential home; this may be due to family member no longer being able to cope with the care of the person. The local authority has a duty to assess the needs of a person with dementia ensuring that their wishes are heard and adequate care is put in place. ‘Assessment is an ongoing process, in which the client participates, the purpose of which is to understand people in relation to their environment; it is a basis for planning what needs to be done to maintain, improve or bring about change in the person, the environment or both’ (Anderson Et al, 2005).
The trouble with placing people with dementia in care homes is there are not enough care homes specifically for people with dementia and people end up in a home that do not have trained staff to cope with individual needs of someone with dementia, therefore, people s wishes may not be heard. As part of the joint assessment process it is the social workers role to ascertain the wishes of the individual, this is done by assessing their needs in an holistic way which includes and medical and social aspects of the person. If there is doubt as to the mental capacity of the person then a mental capacity assessment will need to be acquired by asking to joint assess with community psychiatric nurses (CPN). Priestley (1998) states that ‘the community care reforms established the principle of joint working between health and social services authorities as a priority for effective care assessment and management with social services taking the ‘lead role’.
In conclusion there seem to have been many shifts in the direction of how policy and procedures framework and guidance care for people with dementia, although there is still no firm legislation to protect them. However, there seems to be more recognition of the issues that surround dementia and future goals are towards the training of people to understand those issues so that professionals are able to deal with the complex needs of a person with dementia.
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