The focus of this study is to discuss key contributions that reablement approach can make to enhance the health of people living with dementia.
The aging population is projected to lead to a rise in the occurrence of cognitive impairment and dementia, with a number of people living with a diagnosis of dementia in the community. This change will evidently affect health care services meant to keep older adults living independently in the community for longer. Reablement will play an important role in maintaining physical function in older adults (Hunter et al, 2016).
Literature searching was carried out in MEDLINE (PubMed) and CINAHL (EBSCO). Using standard methods for reviewing literature, it considered scientific papers and those published by voluntary and public sector organisations. Several search terms were used, including homecare, reablement, restorative, rehabilitative and dementia. Articles were excluded if they did not pertain to people older than 65 years old. Literature had to be published between 2000 to 2018. Due to the nature of the narrative review, the approach primarily focused on developing insights into the reablement /rehabilitative approach focusing on people with dementia.The search strategy is available in Appendix 1.
Dementia is one of the most significant conditions of aging. It is estimated that more that 46 million people are currently living with the disease worldwide, with that number expected to triple by 2050 (Poulos et al. 2017).
There are approximately 850,000 people with dementia in the UK. By 2040, the number of people with the disease is expected to double. (Parkin and Baker, 2018). It is estimated that there are currently 20,000 people living with a dementia in Northern Ireland of whom almost 13,000 have a confirmed diagnosis (HSC, 2016). This is recognised as a major social, economic and health care challenge.
Dementia stands to be an example of cost effective care and support that enhances quality of life whilst delivering value for money. A strong body of research shows that early assessment and intervention, effective community support and reducing the need for institutional care all have great potential to improve quality of life and deliver cost efficiencies. (Alzheimer’s Society ,2010) Reablement has the potential not only in managing the costs of an ageing population, but as an initiative which truly represents the concept of personalisation and improving quality of life. (Ebrahimi and Phillips,2018).
Reablement fits in with policy perspectives of the ration to enable people to live well with dementia, and offers a practical approach that contributes to continuing well-being and the potential to live independently in the community.
More recently, however, people with long-term conditions report a lack of involvement in their own care needs (NHS England 2015). This is astounding, considering the emphasis by the (Health and social care board,2016) and Department of Health ,2011) for services as well as health professionals, to be people-centred. Given the choice, most older adults would prefer to continue living at home over a residential or nursing home facility. (Ebrahimi and Phillips,2018). Aspinal et.al (2016) also recognises the overwhelming majority of elderly population prefer to remain in their own homes and reablement aims to help older people regain skills so they can manage as independently as possible.
Reablement is an immediate and time-limited home-based intervention with emphasis on rigorous, goal-orientated rehabilitation for older adults at risk of functional deterioration. (Hjelle, et al. 2016).
‘Reablement improves outcomes, restores people’s ability to perform usual activities and improves their perceived quality of life. On evidence to date, there is a high probability that reablement is cost-effective’. (Social Care Institute for Excellence ,2013 pg1)
Reablement in the context of dementia
Occupational therapists within reablement services empower those living with dementia to optimise independence and choose activities of their choice (Ryder and Jones 2016). This can often involve changes in support mechanism and adaptions of environments. The reablement approach should be goal orientated, to include psychosocial, environmental factors and discussed with the dementia client, care giver or family. Goal setting should be assessed of the person’s abilities, ensuring they are achievable and meaningful. For the client with dementia the approach focuses on regaining lost function when there is potential or adapting to loss of function that cannot be regained (Poulos et al,2017).
Wwhen using a reablement approach with clients with dementia, the goals are likely to be around ‘preserving and promoting a more functional state rather than attaining independence’. It is also suggested that reablement may concentrate on reducing social isolation, establishing routines and supporting the carers (SCIE, 2013).
Outcomes might focus on reducing social isolation, establishing routine, supporting the carer and learning to live well with the condition as opposed to significant reductions in the amount of support required (SCIE, 2013).
Using SMART principles to develop person-centred goals or The Pool Activity Level (PAL) instrument is used by some teams for assessing the abilities of people living with dementia, and is used to plan and deliver support with a ‘reabling’ approach. The time frames to reach each goal will depend on the individual and may need to be reduced.
There is growing research that within reablement programmes exercise interventions for people with dementia can be beneficial. Exercise has been reported to improve ADL performance, balance and mobility, and reduce falls risk. Exercise has the potential to enhance cognitive performance in both Alzheimer’s disease and cognitive impairment (Laver et al, 2016).
It is clear that disease management should be an element of the reablement approach for clients with dementia. Effective control of the dementia should commence with an initial comprehensive medical assessment followed by pharmacologic/non-pharmacologic interventions, with the main objective of maximising quality of life. Classifying the type of dementia and the presence of comorbidities can often be the best way to guide management (Poulos et al,2017).
The different types of dementia, such as Alzheimer’s disease can account for over half of the population, followed by vascular dementia, Lewy bodies, frontal lobe dementia and alcohol related dementia. Each dementia has various cognitive and behavioural characteristics that can affect functional deficits and the person’s ability to follow their reablement program (Poulos et al,2017).
Environment and assistive technology to aid function.
When assessing people who have dementia it is important to highlight the impact of the environment and how it can be adapted to enable individuals to function. Housing can be made ‘dementia-friendly’ when components such as lighting, acoustics, colour contrast and technology are incorporated (Dementia Services Development Centre, 2017).
Throughout a reablement programme, the occupational therapist may wish to consider ways to assist the person with dementia in navigating around their home. This would include labelling cupboards and drawers to prompt the person of their content. The labels may be words, symbols or photographs depending on what helps the individual. Transparent doors on cupboards are often used so contents can be made visible.
Technology can be important in supporting a person with dementia to function within the home environment, where items such as pill dispensers which contains the required medication and is set to alarm at times when the medication is required, electronic diaries, automatic telephone reminders and flood detector. Just Checking is an activity monitoring system that helps people live in their own homes for longer by showing family and professionals their day-to-day capabilities. These technologies could all be used to reduce risk, maximize and prolong independence.
Various technology-based solutions aimed at supporting people with dementia are in development stage. One area currently under development is that of the smart kitchen. (Lindsay 2013). People with dementia may struggle to prepare meals, or food may spoil and be forgotten about but the smart kitchens aims to reduce the amount of time spent on care and promote independence. (Wharton and Monk 2008). The kitchen environment incorporates cameras, object-mounted accelerometers and under-floor pressure sensing using a combination of wired and wireless networks (Oliver et al. n.d.). The objective is that the kitchen is able to detect the activities which occur within it and provide relevant guidance. This innovation should assist those with poor memory, sequencing or planning skills to be able to create a meal independently and therefore has a clear application within reablement.
“An enabling care environment can help realize 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 colored floors, glass fronted fridges) and assistive technologies (e.g. medication reminders, voice recorders and memo minders”. (SCIE,2013pg1).
One of the most common concerns about assistive technology is based around ethical issues. Use of these technologies must be informed by indication of their efficiency, particularly as new technologies develop. Careful assessment of their applicability is needed, balancing the rights of the person with dementia with the intrusive nature of some technologies. People who are being requested to use assistive technologies need to be trained in using them to get the best outcome (Department of Health 2011).
Supporting families and caregivers
Supporting families and caregivers can be enabling for both the carer and person with dementia. The availability of caregiver provides the opportunity for the person to remain living in their own home and also having the potential to be more functionally independent through reablement programmes. The experiences of caring for a loved one can also be associated with caregiver burden, stress, social isolation and financial hardship (Brodaty and Donkin,2009). It is therefore important to assess and address the needs of both the caregiver and care recipient.
A range of interventions to assist the care giver has been identified (Broadly and Donkin,2009). Strategies may include care plans that incorporates the needs of both care giver and care recipient, providing education and training to improve the caregivers’ ability to manage the symptoms of dementia, respite or utilising technology to enhance independence in the care recipient and to assist the caregiver.
The ways in which carers, both formal and informal, are trained is crucial in the effectiveness of achieving in reablement. Equally, staff need to be sensitive to small changes in the service user’s condition, if they are to maximise effectiveness.(Parsons et al 2012).
Summary and conclusions
The reablement approach has great potential to contribute to the possibility of living well with dementia. The adoption of this approach is long awaited and urgently needed for people with dementia. Reablement programmes with dementia clients, can be person-centred, practical, relatively inexpensive, and readily understandable, can help maintain functioning at an optimal level, prevent crises, and enable interventions to take place in a planned and effective way. Linda Clare
There is also potential to contribute to encouraging healthy lifestyle choices that can help maintain function for as long as possible. It can be argued that changes in attitudes and resource allocation will be required in order to implement this approach effectively with dementia clients.
The voices of people with dementia can now be heard in research on the experience of dementia (Wilkinson 2002, Bryden 2005)., in terms of their experience of health and social care (Barnett,2000 and Lorentzon and Bryan 2007). People with dementia are acting together to have an influence on the world around them through local, regional, and national user involvement initiatives such as the Open-Door Network (Howorth et al.2011). Currently, there is still a long way to go in making service user initiatives truly representative of the population with dementia at large. (Lither land and Capstick,2013).
Ryder-Jones and Bailey (2016) research highlights that partnership working with people living with dementia, local business, health and social care the voluntary sector and charities has enabled the establishment of a dementia friendly community in Hartlepool. Use of dementia friends and design principles have supported engagement to raise awareness and improve the experience of the person with dementia and their family. This contact with dementia friendly community has enabled occupational therapists to provide new opportunities in the community setting promoting social inclusion and also reflecting core values of the profession.
To conclude there is growing evidence to support a reablement approach for people living with dementia. To date there have been an increasing number of trials that have demonstrated the effects of occupational therapy led reablement approaches that have been adapted with environmental modifications to provide support for people with dementia and their carers. The Care of Persons with Dementia in their Environments (COPE) program (Gitlin et al.,2010) and the Tailored Activities Program (TAP) (Gitlin et al., 2008)
It is acknowledged the availability of research still remains limited in terms of providing care for people with moderate to mild dementia, with co-morbidities and also in the actual cost effectiveness of reablement models of community care delivery specifically for people with dementia. However, in practice there are increasing numbers of professionals who believe that reablement can be valuable with this client group.
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’. (SCIE, 2013 pg1)