Case study 4: South London and Maudsley NHS Foundation Trust (Older Persons Mental Health Unit)

Background

case4Mr J has been admitted to an acute older persons’ mental health unit for assessment of non cognitive symptoms of dementia. He is finding it difficult to get used to the unit and cannot remember why he is here. At busy times of the day, Mr J will attempt to leave the unit, which will affect his well being and safety. At times he can become verbally aggressive and there have been a few occasions when he has pushed staff out of the way in order to leave the ward. Mr J verbalises repeatedly: “Why are you keeping me prisoner? Who are you?”

Personalised interventions

Mr J’s primary nurse spent time with him and the family to obtain a life story at the time of admission. The primary nurse used the “This is me” tool to obtain Mr J’s likes and dislikes, activities he enjoys, his role in society and the values he finds most important. This tool enabled staff to be clear about Mr J’s preferred names, what he likes to eat, his favourite clothes and what is helpful at times of distress. Mr J. really enjoys a clean shave and his wife demonstrated how he likes this done. All this information was used to inform his care plan.

Based on the information received and what has been observed since he has been on the ward, at the times when Mr J is distressed the following has been helpful:

    • Speaking clearly, slowly, using his preferred name and ensuring he has time to respond in every interaction
    • Answering any of Mr J’s question honestly and as succinctly as possible
    • In any interaction, ensuring that Mr J is orientated to the environment
    • Increasing staff one-to-one time at these times
    • Showing Mr J familiar objects that he likes
    • Providing an activity that he enjoys at the times he is likely to be distressed. This could include listening to music, reading a newspaper to him, walking in the garden, looking through his family photo album with him, talking about past positive memories, use of therapeutic touch and offering drinks that he likes
    • It has been observed that Mr J is less distressed at busy times when his wife visits – flexible visiting for his wife and family to attend have been implemented
    • Helping Mr J to speak with his wife on the phone
    • Involving Mr J in helping staff with tasks so that he feels useful and significant.

Outcomes

    • Overall reduction in Mr J’s distress; as a result of a team approach that delivers responsive care, incidents are resolved quickly
    • Staff feel supported and enabled to provide responsive care
    • The family state that they feel involved in Mr J’s care and feel that he is safe in hospital
    • Mr J is spending less time at the door and has made no attempts to leave
    • Mr J appears to recognise staff and positively interacts with them.

Key messages for practice

    • The critical dimension of ALL care is to be kind, compassionate, respectful and to treat the person how you would like to be treated.
    • Always look behind the behaviour that the person is presenting with and try to understand it.
    • Challenging behaviour in dementia is the person communicating something and it is our role to know the person so we have a better understanding of what they are trying to say.
    • Staff must always see the PERSON with dementia rather than the person with DEMENTIA[1].
    • Family and informal carers are crucial to understand the needs of the person and their full involvement in care will lead to better outcomes.
Source: Vanessa Smith Assistant Director of Nursing and Quality: Mental Health of Older Adults and Dementia Clinical Academic Group, South London and Maudsley NHS Foundation Trust 

[1] Kitwood, T.M (1997) Dementia Reconsidered: The Person Comes First. Buckingham: Open University Press