The experience of dementia: a review of the literature and implications for nursing practice

‘I try my best … I try to relieve the burden of my mum’: a narrative analysis of the everyday care-giving experiences for five intergenerational Singapore-Chinese families where one member has dementia

Singapore is experiencing a rapid growth in its ageing population with most of the islands’ inhabitants living in high-rise apartments due to the scarcity of land. The Chinese community living in Singapore comprises the largest ethnic group and they are more likely to live together under one roof in an intergenerational family grouping. Currently, there are gaps in understanding intergenerational Singapore-Chinese families and their approach to caring at home for a family member with dementia. The aim of this longitudinal qualitative study was to understand better this everyday care-giving experience. Using semi-structured biographical interviews and digital photographs to elicit family stories, five intergenerational Singapore-Chinese families were visited at home for a period of between six and 15 months. Each recruited intergenerational family was treated as a ‘case’. Narrative analysis of the data was applied within and between cases and resulted in the emergence of three themes that represented various dynamics in the data. The three themes were identified as: (1) family values, which is about the cultural context in which everyday care takes place, the religious beliefs and practices of the intergenerational Singapore-Chinese families, and the practice of filial piety; (2) family support, which is about everyday access to family and service networks, including the contribution of the live-in maid in caring for the family member with dementia; and (3) family bonds, which is about the maintenance of intergenerational family relations in the Chinese family kinship system.

Socio-Emotional Adaptation Theory: Charting the Emotional Process of Alzheimer's Disease

Purpose of the Study

The emotional reactions to the progression of Mild Cognitive Impairment and Alzheimer's disease (MCI/AD) oftentimes present as cognitive or behavioral changes, leading to misguided interventions by Formal Support (paid health care providers). Despite a rich body of literature identifying cognitive and behavioral staging of MCI/AD, the emotional changes that accompany these diagnoses have been largely ignored. The objective of this study was to develop a model of the emotional aspects of MCI/AD.

Design and Methods

One hour, semistructured interviews, with 14 patient-Informal Support Partner dyads (N = 28) interviewed concurrently; patients were in various stages of MCI/AD. An interdisciplinary team employed a grounded theory coding process to detect emotional characteristics of the participants with MCI/AD.

Results

Emotional reactions were categorized into depression/sadness, apathy, concern/fear, anger/frustration, and acceptance. The emotions did not present linearly along the course of the disease and were instead entwined within a set of complex (positive/negative) interactions including: relationship with the Informal Support Partner (i.e., teamwork vs infantilization), relationship with the Formal Support (i.e., patient vs disengaged), coping (i.e., adaptive vs nonadaptive), and perceived control (i.e., internal vs external locus-of-control). For example, a person with poor formal and informal support and external locus-of-control may become depressed, a condition that is known to negatively affect cognitive status.

Implications

Understanding the emotional reactions of individuals diagnosed with MCI/AD will provide clinicians with information needed to develop treatments suited to current needs of the patient and provide Informal Support Partners insight into cognitive and physical changes associated with MCI/AD.

Making the outside World Dementia-Friendly: Design Issues and Considerations

Design guidelines for dementia care homes have, in recent years, acknowledged the important role the internal environment plays in influencing the functional capabilities and emotional well-being of people with dementia. However, although the majority of people with dementia live in the community, similar guidance does not exist in relation to the outdoor environment. To identify aspects of design that should be considered in making the outside world dementia-friendly an analysis of the literature on the needs of older people with dementia and on current knowledge of best practice for internal environments was carried out. By drawing parallels with the outside environment this paper demonstrates that design solutions do potentially exist which would enable older people with dementia to continue to negotiate and use their local neighbourhoods. Familiarity, legibility, distinctiveness, accessibility, comfort, and safety all appear to have a major influence. Small street blocks with direct, connected routes and good visual access, varied urban form, and architectural features, and distinctive, unambiguous environmental cues could enhance successful orientation and wayfinding. Services and facilities within walking distance with adequate seating, lighting, shelter, and well-maintained, smooth, level, plain paving would ameliorate attending problems of physical frailty. The authors are now empirically testing these initial findings.

Service provision for people with dementia in rural Scotland

The provision of health and social care services to people with dementia and their carers living in remote and rural areas has been neglected globally. Meeting the needs of people with dementia poses many challenges for service providers. Such challenges may be compounded by the difficulties of providing and accessing services in rural areas.This article explores the views of Scottish service providers drawn from the voluntary, statutory and private sectors. Our findings highlight the difficulties relating to dementia and rurality faced by service providers in Scotland. We also consider innovative measures reported by service providers. Such measures indicate that not only can the distinct challenges of dementia service provision be overcome, but also challenges posed by providing services to people with dementia and their carers in rural and remote areas.These findings extend the literature on rural dementia service provision.The article concludes with a consideration of the practice and policy implications of providing dementia services in remote and rural Scotland.

Relationship Difficulties in Dementia Care

This article reports on a small-scale study where people giving and receiving care were invited to talk about their relationship. It draws on one care dyad of a woman (who has a diagnosis of dementia) and her daughter (who has provided care for her mother). A short series of interviews was conducted with both women, focusing on their biographies and current relationship. This article reports the account given by the mother and how this intersects with the account given by the daughter. The discursive analysis presented centralizes a concern with attending to the accounts of people with dementia. Analysis of the talk of people with dementia can make a valuable contribution to understanding care relationships. Such analysis has the potential for shedding light on difficulties in care relationships. The article ends by outlining some salient issues for professionals and family members involved in dementia care.

Processes and experiences of mutual support in professionally-led support groups for people with early-stage dementia

Participation in a support group is increasingly offered to those diagnosed with early-stage dementia; however, empirical data about such groups for this population remain scarce. This study aimed to investigate the mutual support processes that occur in dementia support groups and how members perceive the groups. Eleven individuals from two support groups participated; three sessions of each group were videotaped and semi-structured interviews were conducted with individual members. Quantitative analysis of the videotapes indicated that only a minority of responses were classified as helping behaviours, and that facilitators played a highly active role in the group interactions. The interview data were analysed qualitatively; the themes identified related to aspects of the group that participants found helpful and unhelpful, and their perceptions of how the group operated. The findings have theoretical implications regarding the role of support groups in creating and maintaining social identities, as well as practical implications for how professionals might facilitate these groups.

Illustrating the Importance of Including the Views and Experiences of Users and Carers in Evaluating the Effectiveness of Drug Treatments for Dementia

Undertaking a literature review revealed that when evaluating the effectiveness of the drug treatments for dementia few studies purposefully explore the views of users and carers. Their views are mainly derived from secondary analysis of conventional scientific evidence. Where the views of users and carers were explored it was discovered that they evaluate the effectiveness of the drug treatments in terms of quality of life. On its own, the conventional scientific approach of using outcome measures to evaluate the effectiveness of drugs is not sufficiently relevant or meaningful to users and carers. Findings from a study exploring the views of users and carers also demonstrate that professionals are willing to utilize the users’ and carers’ evaluations of the drug treatments for dementia. We suggest that reliable and valid measures are developed which explicitly explore the views of users and carers. This will go towards ensuring clinical trials are relevant and meaningful to the users and carers and not to professionals alone.

Investigating poor insight in Alzheimer’s disease

Persons with Alzheimer’s disease (AD) often seem to have a poor insight into the functional deficits brought about by the dementing process. There are many indications that preserved insight into deficits in dementia is of advantage to a person with AD. Various research approaches have been adopted to investigate poor insight related to AD. The purpose of this article was to present various research approaches for investigating poor insight into deficits in AD. The study is based on a literature survey. The findings show that concept of poor insight has been investigated in detail from different perspectives. Each one of the perspectives found, the neuropsychological, the psychological and the socio-psychological, has its merits, but none of them has yet led to study results that make us fully understand what poor insight implies and involves. We need integrated knowledge from the different perspectives, and in multidisciplinary research settings we believe that such knowledge could be developed.

Managing Changes in Everyday Occupations: The Experience of Persons with Alzheimer's Disease

The aim of this study was to uncover how people with dementia respond to the problems and changes they experience in everyday occupations. Seven participants with dementia were included. Data were collected by means of repeated interviews and observations that focused on the person's experiences of competence and management in everyday occupations. The analysis was carried out from within a phenomenological perspective and resulted in a structure describing management strategies. It was concluded that the participants used a wide variety of strategies. Some strategies were directed toward managing the altered conditions caused by the disease while others served the purpose of responding to the occupational problems of everyday life. The latter strategies were of three types based mainly on environment, habituation, and cognition. Overall, the implicit and explicit cognitive awareness underpinning many strategies seems to call for great caution when assuming that people with dementia soon lose their awareness of disability.

Meanings and Motives for Engagement in Self-Chosen Daily Life Occupations among Individuals with Alzheimer's Disease

The aim of this study was to uncover and describe the meanings and motives for engagement in self-chosen daily life occupations for elderly individuals with Alzheimer's disease dwelling in the community. Six participants with Alzheimer's disease were included. Data were collected through repeated interviews and observations focusing on their motives for their self-chosen occupational engagement and the significance of the daily occupations. The analysis used a qualitative comparative and interpretative method. The findings show that the participants' occupations supported their ordinary pattern of everyday life and provided them with an opportunity to be in a coherent context. The occupations also allowed them to experience and communicate autonomy and certain characteristics of their identity and provided them with a private sphere. The findings revealed certain crucial but double-edged environmental keys to occupation. By identifying and supporting everyday occupations with personal meaning and value, therapists and caregivers may contribute to the well-being of individuals with Alzheimer's disease living in their own homes.

A literature review of spirituality in coping with early-stage Alzheimer's disease

AIMS

This paper presents a literature review focusing on the use of spirituality in coping by older persons with early-stage Alzheimer's disease from their perspectives. The purpose of this literature review is to examine the existing body of knowledge about spirituality in coping with Alzheimer's disease and to apply a spiritual framework of coping in organizing the literature to identify themes and gaps in knowledge.

BACKGROUND

Despite the abundance of Alzheimer's disease research, little is known about how older persons with this devastating disease cope with the consequential losses. Maintaining a sense of normalcy and preserving self-worth are coping strategies reported by older persons with early-stage Alzheimer's disease. As spirituality is an effective coping resource for older persons with numerous psychological and personal losses in their lives, it may be an important coping resource for person with Alzheimer's disease.

METHOD

A literature search was conducted to find research published between 1990-2006 aimed at understanding spirituality in coping with early-stage Alzheimer's disease.

CONCLUSIONS

Six research studies were reviewed. Findings suggest that persons with early-stage Alzheimer's disease draw from their spirituality and faith to find meaning and courage in facing the challenges of cognitive losses. Furthermore, they are able to provide rich information about their spirituality and the psychosocial aspects of living with Alzheimer's disease. Limited empirical knowledge compels the need for future research to explore how spirituality is utilized in coping with early-stage Alzheimer's disease.

RELEVANCE TO CLINICAL PRACTICE

Enhancing persons' abilities to cope effectively with their diseases is an important goal of nursing care. Understanding how older persons with Alzheimer's disease cope with their memory loss is critical to the development of evidence-based interventions to minimize the stress of living with this disease.

Measuring the quality of life and well-being of people with dementia: A review of observational measures

The dynamic nature of psychosocial interventions implies that trying to measure their effects using standardised clinical trial measures may not capture their full effects. Rich and valuable data during the sessions may be missed by using standard quality of life questionnaires. This paper compares observational measures in the context of recording the well-being of a person with dementia during and outside of a visual arts intervention. A literature search was conducted using systematic principles of searching, screening and retrieval to identify peer-reviewed English language evaluations of research projects using observational measures with people with dementia. Psychometric properties, strengths and weaknesses of 11 observational tools are reviewed in order to identify the most appropriate one for evaluating a visual art intervention for people with dementia. This review supports the Greater Cincinnati Chapter Well-Being Observation Tool as an appropriate measure to evaluate a visual art programme for people with dementia. The results of this review will help researchers plan projects to show the full range of effects for people with dementia for taking part in art sessions.

Dementia and the Deaf community: knowledge and service access

OBJECTIVES

This study concerns culturally Deaf people in the United Kingdom who use British Sign Language (BSL). Its objective was to explore how Deaf people's knowledge about dementia and access to services is mediated by their minoritised cultural-linguistic status.

METHODS

Twenty-six members of the Deaf community participated in one of three Deaf-led focus groups in BSL corresponding with the sample of: Deaf people over the age of 60 without dementia; Deaf people aged 18-60 working professional roles unconnected with dementia services; ordinary members of the Deaf community aged 18-60. Data were subjected to a thematic content analysis.

RESULTS

Participants' concerns about their poor levels of knowledge and understanding of dementia were augmented by their awareness that without sustained social contact in BSL opportunities for earlier recognition of dementia would be lost. Although primary care services were identified as the first port of call for dementia-related concerns, there was widespread mistrust of their effectiveness because of failures in communication and cultural competence. Confirmed diagnosis of dementia was not viewed as a gateway to services and support because Deaf organisations, dementia-related organisations and mainstream adult services were perceived to be ill-equipped to respond to the needs of Deaf people with dementia.

CONCLUSIONS

Locating problems of late diagnosis within the Deaf community's poor awareness and knowledge of dementia fails to recognise the structural barriers Deaf people face in timely access to services and accurate recognition of dementia-related changes.

Articulating the strategies for maximising the inclusion of people with dementia in qualitative research studies

It is essential to understand the experience of living with dementia from the perspective of the person with dementia so that services can be appropriately constructed. This review paper, drawing on prior work, identifies key strategies for the meaningful inclusion of persons with dementia within qualitative research studies, it examines the articulation of these strategies and shares how these strategies were operationalised within one national research study in Ireland. Strategies within the literature were categorised and then synthesized into a guide consisting of four main areas; gaining COnsent, maximizing Responses, Telling the story, and Ending on a high (CORTE). The CORTE guideline was used to as a tool for analysing relevant research reports. CORTE is a synthesized account of grouped strategies that could be used to maximize the meaningful involvement of persons with dementia and can also provide a guide for reporting the strategies used so that researchers can learn from each other.

The experience of people with dementia in a social care group: Case study

In Germany hourly care for people with dementia and relief for family caregivers are often delivered through social care groups. The existing literature describes these groups from the perspective of professionals or family caregivers, with little involvement of people with dementia. This qualitative study is the first step in exploring the experiences of people with dementia in social care groups. Five persons suffering from dementia in one group were interviewed and additionally observed with DCM in three group sessions. The interview transcripts were coded open and axial according to Grounded Theory. The DCM data was analysed descriptive. The main phenomena in the interviews are ‘familiar community’ and ‘personal meaning’. The DCM results show that people with lower cognitive function are excluded from most activities, whereas more staff attention causes better well-being. To create a ‘familiar community’ in a social care group, staff skills and knowledge are required.

The 'demented other' or simply 'a person'? Extending the philosophical discourse of Naue and Kroll through the situated self

This article presents a critique of an article previously featured in Nursing Philosophy (10: 26-33) by Ursula Naue and Thilo Kroll, who suggested that people living with dementia are assigned a negative status upon receipt of a diagnosis, holding the identity of the 'demented other'. Specifically, in this critique, we suggest that unwitting use of the adjective 'demented' to define a person living with the condition is ill-informed and runs a risk of defining people through negative (self-)attributes, which has a deleterious impact upon that person's social and relational personae. Moreover, use of the locution 'demented' reinforces a divide between the 'demented' (them) and the 'healthy others' (us). Social constructionist theory, malignant positioning and viewing people with dementia as semiotic subjects are the philosophical pillars through which we construct the main arguments of the critique. The article concludes with the voice of one of the authors, a younger person with dementia, asking for language in dementia care to be carefully reconsidered and reframed and for the recognition of the diagnosed person's agency in the conduct of their day-to-day lives.

A Bio-Psycho-Social model enhances young adults’ understanding of and beliefs about people with Alzheimer's disease: A case study

The incidence of Alzheimer's disease (AD) is predicted to grow by multiples in the coming decades, and today's young adults will be formal and/or informal caregivers in unprecedented numbers. Their ability to support the independence and well-being of people with AD will depend on their ability to identify intact social and cognitive abilities, selfhood, and needs of people with AD. This case study, conducted in an undergraduate seminar, provides preliminary, suggestive evidence for the educational advantages of a Bio-Psycho-Social approach to understanding these aspects of people with AD. Findings revealed a striking increase in students’ accurate understanding of: (1) the losses due to AD; (2) intact positive qualities in and inaccurate negative stereotypes about people with AD; and (3) important needs of people with AD. These are discussed in light of extant theory. The application of this approach in the case of one student and her family is explored.

‘That’s me, the Goother’: Evaluation of a program for individuals with early-onset dementia

We conducted face-to-face, semi-structured interviews with six white men with early-onset dementia (EOD) and supplemented the interviews with a focus group with six wives of the men to document perceptions of a weekly, supervised volunteer program for the men at the local zoo. The program, ‘Get Out of the House,’ is designed to provide individuals with EOD a weekly opportunity to participate in meaningful, supervised volunteer work in the community. Interviews with participants revealed that they strongly identify with the program and are eager to share their experiences, about which they show some depth of insight. The focus group revealed that the program represents a break in the day-to-day routine for spouses and families, as well as participants, and has benefits that extend beyond the program time itself. Challenges with the development and implementation of such programs and implications for research and practice are discussed.

How to evaluate quality of care from the perspective of people with dementia: An overview of the literature

This article reviews the literature on the inclusion of the perspective of people with dementia when evaluating quality of care. The few identified relevant studies suggest that there is consensus that people with mild to moderate dementia are able to talk about their experiences with care with clarity and insight. A minimum level of orientation to place, attention and language skills in the person with dementia are important for a successful subjective evaluation. On the basis of the relevant literature, we additionally formulated practical guidelines useful when one aims to collect information with interviewing, self-administered questionnaires, or focus groups from people with dementia to assess quality of care. In people with mild to moderate dementia, assessment of quality of care can best be done by individual interviewing and focus groups. Further research is needed to ascertain what people with dementia find important in relation to quality of care.

How can we get access to the experiences of people with dementia?

This paper suggests and discusses a methodological approach that aims to facilitate the inclusion of people with dementia in research where the ambition is to better understand their experiences. People with dementia have commonly not been included as informants in research as their cognitive deficits have been regarded as a hindrance. Moreover, in the qualitative research tradition, most inquiries rely on data obtained from interviews, thereby requiring communication and verbal skills, which are skills that are affected early in the cause of dementia. Consequently, the considerably under-researched area of how dementia is experienced and managed from the perspective of those afflicted has long been put aside. This paper suggests that a combination of qualitative observations and adapted interviews may make it possible for people with dementia to participate as research informants. Issues concerned with creating a relationship with informants with dementia and helping them to elicit their experiences are elaborated and discussed. Some suggestions are made concerning how the context can be used for this intent, and how the observations and interviews can be adapted to the informants with dementia.

Admiral nursing and the family care of a parent with dementia: using autobiographical narrative as grounding for negotiated clinical practice and decision-making

BACKGROUND

Providing family care at home for a person with a long-established diagnosis of dementia has been recognized for some time as a multifaceted and complex phenomenon where care roles alter during the course of the condition. Presently, the nursing response to meeting such need is currently poorly defined and documented in the literature and depends more upon descriptive illustrations of practice efficacy rather than any evaluated system of knowledge and skills transfer or framework utilization.

AIM

The aim of the study was to capture an autobiographical account of a family carer's (Kath, co-author) journey through the experience of her mother's dementia and the reflexive dialogue and shared care planning that ensued with the Admiral Nurse (Susan, co-author).

DESIGN

Kath's narrative was captured using practitioner-research principles and 10 interview contacts; the autobiography was then used as the basis for therapeutic and clinical work, as reported and jointly negotiated between Kath and Susan.

RESULTS

The findings demonstrate the importance of constructing care from an autobiographical perspective and integrating lay knowledge within an overall professional response to family/carer need in dementia caregiving situations. The negotiated clinical response to Kath's grief process (the death of Kath's father, the main carer support to her mother with dementia) and Kath's subsequent adaptation process is illustrated through a shared sessional plan and agreed measures of effective care.

CONCLUSION

Integrating narrative approaches into care practice demonstrates important new ways of working alongside families of people with dementia to help develop negotiated, transparent and shared systems of care.

Conducting qualitative interview research with people with expressive language difficulties

Despite the increasing application of qualitative interviewing and analysis approaches, individuals with expressive language difficulties are still frequently excluded from such research. In this article, the authors seek to clarify the role for and importance of conducting qualitative interviews with respondents with impaired expressive language. They review current research with reference to studies conducted with individuals with intellectual disabilities or dementia, or those who have experienced stroke or traumatic brain injury, and identify deficits within existing research. They consider the challenges and difficulties that contribute to the limited inclusion of individuals with impaired expressive communication in qualitative interviews and discuss the way forward with suggestions of possible means of overcoming these obstacles. They argue that a willingness to adapt methods appropriately and to modify expectations is an important factor in ensuring that researchers hear the voice of respondents with expressive language deficits.

Telephone use among noninstitutionalized persons with dementia living alone: mapping out difficulties and response strategies

The aim of this study was to map out and describe difficulties and response strategies in telephone use among elderly, noninstitutionalized persons with dementia living alone. To obtain explorative data, interviews and observations in the homes were undertaken with 10 participants diagnosed with dementia. The participants were observed when showing their telephones, calling a well-known number, responding to a request previously sent by letter to make a telephone call, and finding a number in the telephone directories. The data were analysed using a comparative approach, and resulted in descriptive categories. The participants' difficulties were categorized as difficulty in 'knowing what', 'knowing where', 'knowing how' and overcoming motor, perceptual, verbal and environmental obstacles. In responding to these, they used a variety of environmentally related strategies such as using perception or habits and habitual places, verbalizing aloud, seeking help from others, and adjusting the physical environment. They also used a few cognitively related strategies such as repeating and stopping and reflecting. Overall, difficulties were frequent and common, and the effectiveness of the strategies was questionable. The results indicate that it might be unrealistic to assume that elderly persons with symptoms of dementia who live alone are able to satisfactorily use the telephone for safety, communication and participation in society.

Wives giving care to husbands with Alzheimer's disease: a process of interpretive caring

Wives giving care to spouses with dementia are a particularly vulnerable segment of the caregiving population. In this article a grounded theory study of 20 such wives is described, with their experiences explained as a process of interpretive caring. Wives began the process by either seeing changes in their husbands or recognizing changes in their work. Following this, the wives moved on to a phase of drawing inferences about what they observed and then took over their husbands' roles and responsibilities. These changes prompted the wives to rewrite identities for their husbands that incorporated the dementia and to rewrite identities for themselves to reflect their new roles, abilities, and strengths. Finally, the wives set about constructing a new daily life to sustain both partners. This process is neutral and allows for positive aspects of caring to be considered along with grief and frustration.

Assessment by nurses of mood, general behaviour and functional ability in patients with dementia receiving nursing home care

The aim of this study was to investigate the reliability of the Patient Mood Assessment Scale (PMAS), the General Behaviour Assessment Scale (GBAS) and the Gottfries Bråne Steen scale and to investigate mood, general behaviour, degree of dementia and symptoms for patients with dementia living permanently in nursing home care (n = 75). Interviews were conducted with the contact nurses, focussing on their view of the patients during the preceding week, based on the above-mentioned assessment scales. In 29 cases a second interview was conducted with another nurse in order to investigate the inter-rater reliability. The inter-rater reliability was high for items associated with ADL and intellectual functions, but low for items associated with emotional aspects. The nurses' difficulties in assessing the patients' emotional state could arise because these matters are not regularly discussed among the staff or could reflect the nurse's inner state rather than that of the patient. The varying understanding that the nurses had of the patients raises the question of whether the care provided is based on the nurses' opinions rather than on the patients' needs. There is a need for continuous and reflective discussions in the staff group, focusing on the patients' physical as well as emotional needs.

Caring for a relative with dementia: The perceptions of carers and CPNs

Older people with dementia living in the community are most likely to be cared for by other older people, predominantly spouses, who will be at increased risk of stress‐related health problems themselves. Appropriate support of such carers is crucial if carer breakdown and consequent care‐receiver admission to residential homes is to be avoided. This paper examines the experience of older carers of frail older people with dementia and examines the kind of support that is provided to such carers. In practice, the sole source of professional support received by older people in this study was from community psychiatric nurses (CPNs). CPNs' role did not comprise hands‐on care‐giving and family carers carried out most personal/physical and healthcare tasks themselves, aided in some cases by care workers. The paper concludes by suggesting that lack of support for carers in these activities requires redress.

What are the principles and processes of inspiring hope in cognitively impaired older adults within a continuing care environment?

This study focuses on the principles and processes that psychiatric/mental health (P/MH) nurses use to inspire hope in cognitively impaired older adults within a National Health Service (NHS) continuing care environment. Using a grounded theory method, the data were coded and analysed, in an attempt to produce an integrated conceptual framework of hope inspiration. This comprised four core variables: applied humanistic code, pragmatic knowledge, interpersonal relations and nurse as utilizer. The authors postulate a relationship between the function of caring, the activity of helping and the practice of instilling hope, as a basis for suggesting that inspiring hope to clients is one of the primary acts of P/MH nursing. The authors conclude that the four core variables are intertwined and inseparable from one another, and bound up with P/MH nursing practice. From this position, it is suggested that the processes of inspiring and instilling hope cannot be separated from the qualities of being a P/MH nurse. However, a more detailed and complete understanding of the concept of hope can increase the nurse's effectiveness as a carer.

How do we facilitate carers' involvement in decision making?

BACKGROUND

Government health care policy urges service providers to involve service users in the decision-making process. Research studies have recommended changes to current health care practice to facilitate this involvement. However, carers' organizations continue to highlight a gap between policy and practice in relation to involvement.

AIM

The aim of the study reported on in this paper was to investigate involvement in a specific health care context with a view to identifying both opportunities for change and practical, realistic ways of bringing about that change. This was a qualitative case study using a case study design. The field site selected was a respite and assessment (23 bedded) ward within the Psychiatric Unit of a hospital specializing in the care of older people. Informal carers (n=20) and members of the multidisciplinary team (n=29) were interviewed about their views and experiences. The interviews were audiorecorded and transcribed. Family meetings, multidisciplinary team meetings and ward routines were the focus of non-participant observation. Field notes from these observations, together with the interview data were analysed using constant comparative method.

RESULTS AND CONCLUSIONS

The reported experiences of carers in this study highlighted four markers of satisfactory involvement: feeling that information is shared; feeling included in decision making; feeling that there is someone you can contact when you need to; and feeling that the service is responsive to your needs. The majority of carers felt dissatisfied with the level of involvement. The situation we found echoed that found in other studies, i.e. the majority of informal carers (henceforth 'carers') interviewed were dissatisfied with the level of their involvement. However, our investigation, in which the views of health care professionals as well as those of carers were sought, provided invaluable insight into why this might be the case. Two main sources of difficulty were found: hospital systems and processes, and the relationship between nursing staff and carers. The argument made is that practitioners themselves must notice and challenge these barriers if carer involvement is to be facilitated.

The social consequences for families with Alzheimer's disease patients: potential impact of new drug treatment

The social consequences of Alzheimer's disease are highlighted in this review with regard to impact on family situation, a changing treatment context caused by demographic changes, reorganization of long-term care, a financial crisis in the public health systems and the introduction of antidementia drugs. In the early phase of dementia there may be significant consequences for the patients and the family members which are largely unrecognized by the healthcare system. As the disease progresses, the impact on caregivers in terms of physical and emotional burden, financial and employment status may be enormous. The current care provision in Sweden, the UK and The Netherlands is described. Innovative care alternatives and strategies may improve the situation. The introduction of antidementia drugs such as the acetylcholine esterase inhibitors may also contribute to improved circumstances for patients and caregivers. There is still a great need for further research in this field.

Eliciting user perspectives on what works

Social care research has moved gradually in recent years to include the subjective perspective. Dementia care, which in many ways is still in its infancy, has lagged behind in this development, and much research has been informed by the carer rather than the person with dementia. As a young subject area, it is right that dementia care should look around for lessons that can be learned from other disciplines. This paper will consider how research with people with learning difficulties has developed a culture for hearing the views of service users. It will outline various methodologies, with considerations of their strengths and weaknesses. The paper will then review research in dementia care which features the subjective experience, and will finally draw out lessons and identify possible ways forward.

The role of a CNS in a memory clinic

The advent of medications to treat the symptoms associated with mild to moderate Alzheimer's disease has added to the critical need for early diagnosis of dementia. Yet diagnosis and treatment of Alzheimer's disease require specialized assessment and knowledge. To address the needs of patients and families coping with Alzheimer's disease, an ambulatory care memory clinic was established in Fredericton, New Brunswick, Canada. This article describes the four components of the clinical nurse specialist role in this clinic that reflect the essential characteristics of advanced nursing practice.

The discursive construction of dementia care: implications for mental health nursing

This paper sets out a new approach to dementia that may be used to underpin mental health nursing practice. The paper begins by examining the development of community care. Various models of service provision to people with dementia are then critically examined. As an alternative to these approaches a new model of dementia is developed which highlights the position of various family members in the provision of dementia care including the person with dementia and also the importance of linguistic devices such as narrative and discourse. Finally the implications of this approach upon the mental health nursing practice are examined together with various suggestions for the development of research.

The link between Down's syndrome and Alzheimer's disease: 2

In this article, the second of two parts, the needs of family and professional carers of people with Down's syndrome and Alzheimer's disease are examined. Substantial numbers of people with Down's syndrome survive to the age of 50 and beyond and so work still needs to be done on finding solutions to the problems faced by this client group and its carers. As well as the difficulties faced by any family carer of a person with dementia, those caring for someone with Down's syndrome and Alzheimer's disease may also have to deal with additional worries and problems. Consideration is given to service provision and the implications for nursing. A case study will illustrate some of the points made.