Maximising the potential of reablement
Supporting people living with dementia
There is a dearth of research evidence on supporting people living with dementia through reablement, not least because those individuals are generally excluded from reablement evaluations. Nevertheless, in practice, there is growing interest in supporting people living with dementia in this way and a general consensus that those people can benefit from a period of reablement. The recommendations presented in this section are therefore based on current knowledge from practice. They should not be read in isolation from the rest of this guide since all the other recommendations for good practice apply for people living with dementia as well as others.
- People should not be excluded from reablement on the basis of a dementia diagnosis. They should be assessed on the basis of their needs and strengths without prejudice about their potential to be ‘reabled’.
Where a person’s confidence or abilities have rapidly deteriorated following a bout of ill health or an accident, it is often possible to return them to their ‘baseline’ quality of life – although to a large extent this depends on family and friends being able to describe what that baseline was (e.g. what they were capable of doing before the precipitating event).
- It may be that a goal for most people living with dementia needs to be ‘preserving and encouraging a more functional state’ rather than achieving complete ‘independence’.
- Outcomes might more appropriately focus on reducing social isolation, building routine, supporting the carer and learning to live well with dementia as opposed to significant reductions in the amount of support required.
- The importance of working with the individual to develop person-centred goals, in line with the SMART principles, applies here as with any other person using reablement, although the time horizons within which to reach goals may need to be reduced.
- When planning support with people living with dementia (including goal-setting), it is particularly important to see past their diagnosis and gain an in-depth understanding of the person (e.g. their interests, past jobs or hobbies, their family context and the things that motivate them). Life story work may help to achieve an understanding of a person’s past experiences.
The Pool Activity Level (PAL) instrument is used by some teams for assessing the abilities of people living with dementia. The PAL instrument is designed for people with cognitive impairment, and is used to plan and deliver support in a ‘reabling’ way.
- An enabling care environment can help realise the potential abilities of people living with dementia. Attention should therefore be given to changes to the home or care environment, such as dementia design (e.g. adequate light levels, contrasting coloured floors, glass fronted fridges) and assistive technologies (e.g. medication reminders, voice recorders and memo minders).
Just as there is no single delivery model for reablement, there is no single model for organising a reablement service with the capacity to support people living with dementia. Several models, which are in operation around England and Scotland, are summarised here.
- Intake reablement services to which all new referrals (from hospital and the community) are made, including people living with dementia.
- Intake reablement services which accept referrals for people living with dementia on the condition that they can demonstrate they have ‘carry-over’ (meaning that the person can retain the memory of something they have learned, such as a technique for preparing a drink, from one day to the next).
- Reablement services dedicated exclusively to supporting people living with dementia – for instance, one that offers short-term intensive home care (including night care) to help people settle in at home following hospital discharge. The aim is to improve the rate of hospital discharge and prevent readmission.
- A pilot reablement project for people with dementia, which includes commissioning a local Alzheimer’s provider to deliver practical help and support (e.g. developing coping strategies).
- An enhanced reablement project, which is led by a psychiatric nurse and provides support to people with complex needs, including memory problems (almost 80 per cent of people referred to this service have a dementia diagnosis). The project provides three to five days of intensive assessment, monitoring and reablement, after which the person is most likely to be referred for a standard period of reablement with the borough’s main reablement service.
- Where reablement workers and therapists are supporting people living with dementia, specific training, in addition to reablement training, is crucial. There is no single accredited training programme for using reablement to support people living with dementia; however, the College of Occupational Therapists does provide a one-day workshop entitled ‘Challenging the myths: reablement for people with dementia’. Although it is primarily aimed at occupational therapists it is likely that they could tailor the workshop for others working in reablement. There are also many training and awareness programmes more generally targeted at working with people with dementia. Useful links are provided under Further resources below.
- Training on supporting people with dementia through reablement would usefully focus on:
- recognising the signs and symptoms of dementia
- tips for dealing with the potential complexities of helping someone with dementia to dress, wash and bathe safely – including ways of encouraging them when they are reluctant
- the importance of maintaining familiar routines and tips for encouraging independence
- ways of maintaining their everyday skills and an understanding of the importance of doing so
- offering help sensitively
- helping the person communicate
- dealing with challenging behaviour.
- Finally, It is crucial that local services are available to provide ongoing support, appropriate to people living with dementia.
Case study: enhanced reablement for people living with dementia
Mrs Yates was referred for enhanced reablement pending discharge from hospital. She suffered from dementia and had fallen in her kitchen at home on 11 January 2011 and sustained a fracture to her pelvis. Her daughter, with whom she lives, was at home at the time but Mrs Yates had attempted to walk without supervision. Mrs Yates’s husband also lives at home and also suffers from dementia. Mrs Yates had previously fallen a few weeks earlier and sustained the same injury to the opposite side of her pelvis. She has reduced safety awareness and often forgets to use her walking frame.
On 7 February 2011 Mrs Yates was assessed by the enhanced reablement nurse while still on the ward to establish her suitability for enhanced reablement when discharged. Her daughter was present at the time. Mrs Yates was medically fit for discharge and her daughter wanted her back home as soon as possible. Physiotherapy and occupational therapy reports suggested that she would benefit from continued rehabilitation. Mrs Yates was accepted for enhanced reablement with four home visits per day following discharge which was scheduled for the following day. Arrangements were made for the reablement physiotherapist to assess at home jointly with the enhanced reablement nurse on the day following discharge. Referral was made to telecare for assistive technology. Mrs Yates already had a link line pendant alarm but an additional bed and chair sensor with a carer alert pager, and a flood detector, were added to the system.
Mrs Yates was transferred to standard reablement with continued physiotherapy review on 12 February 2011. During the next five weeks she continued to require reablement support to wash and dress in the mornings and to get ready for bed at night. She needed prompting to use her walking frame at all times and supervision with mobility and transfers. Reablers were requested to support Mrs Yates to complete her physiotherapy exercises during visits. Mrs Yates also required supervision with toileting throughout the day. Visits remained at four times daily. To improve access at the front of the house a referral was made for wall-to-floor rails outside the front door and gate. Referral was also made for ongoing community physiotherapy, and ongoing support and review from the community social care team. The last day of reablement was 20 March 2011.
- 3-month follow-up: Mrs Yates continued to live at home. She completed her six-week period of reablement but her daughter declined any subsequent package of care, preferring to look after her parents herself.
- 6-month follow-up: Mrs Yates continued to live at home cared for by her daughter and without any formal package of care.
- 9-month follow-up: Mrs Yates continued to live at home cared for by her daughter and without any formal package of care.
- 12-month follow-up: Mrs Yates continued to live at home cared for by her daughter and without any formal package of care.
- A life story work toolkit can be accessed on the Dementia UK website.
- The PAL instrument can be accessed via the developer’s website.
- SCIE’s Dementia Gateway, featuring free training programmes. There is a specific section on suitable environmental design.
- The AT Dementia website provides information about assistive technology designed specifically to support people living with dementia.