Mohammed T. Abou-Saleh

764 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY5. New coping skills(a) Communication (psychologist; 162 h). The first half of thiscomponent was theoretical. It focused on:. How to communicate with a dementing person.. The functions and expectations of communication.. How communication processes can be disrupted.. Information on language impairment that occurs indementia, such as receptive and expressive dysphasia.. Techniques for clear communication, e.g. the four Ss—keep it simple, slow, short and specific 9 .In the second half, techniques were practised by each patient–caregiver dyad while being videotaped and/or observed by thegroup through a one-way mirror. Caregivers were able toreview the videotape and analyse their performance andcommunication techniques.(b) Reality orientation (occupational therapist; 161 h). Thiswas based on a 24 h environmental reality orientation modelwith use of verbal techniques, signs, pictures, clocks, diariesand other strategies.(c) The therapeutic use of activities (occupational therapist;161 h). This introduced the concepts of activity as being goaldirecteduse of time, energy and attention. Activity analysiswas explained as breaking tasks into small steps, thenmodifying, eliminating or replacing steps that prevented thedementing person from completing the task (e.g. having abath, playing golf, cooking). There was also much discussionon appropriate leisure pursuits.(d) Reminiscence (occupational therapist; 161 h). Caregiverswere taught how to compile a ‘‘This Is Your Life’’ book,comprising mementos and photographs that described the pastlife of the patient. This proved to be a positive experience andsubsequently provided a good stimulus for conversation andreminiscing.(e) Coping with physical frailty (various; 361 h). First, aphysiotherapist discussed back care, walking and mobilityaids. Second, an occupational therapist discussed the use andabuse of aids to daily living; caregivers tried out many of theseaids in a modified kitchen, bathroom and bedroom in theoccupational therapy department. Third, a registered nurseoutlined the care of bed-bound, chair-bound and incontinentpersons.6. Fitness, diet, organizing the day and home (various; 361 h).(a) A physiotherapist encouraged fitness and flexibility incaregivers as well as patients. For example, a daily routine ofwalking after lunch was established.(b) A dietitian outlined the principles of a healthy,balanced diet and discussed time-saving kitchen techniquesas well as food fads and eating problems associated withdementia.(c) In a session on work simplification, and organization andsafety in the home, the occupational therapist exploredtechniques of how to prioritize and simplify tasks and howand when to recruit outside assistance. The aim was to helpcaregivers achieve a balance between work, leisure and rest intheir lives. Safety issues pertinent to the older person and thedementing process were discussed and a safety checklist for thehome and garden was provided.7. Medical aspects of dementia (psychiatrist; 261 h). Thesesessions provided medical information on dementia and itsdifferent types, principles of management, psychiatric complicationsand behavioural changes, use and abuse of medication,the interaction of dementia and other illnesses, and prognosis.As with all of these sessions, much time was given to answeringindividual concerns.8. Using community services (welfare officer; 161.5 h). Thisvery practical session included procedures and eligibility forsocial securities, provision of useful contact persons, andaccess to and availability of services. For some caregivers itwas a novelty to adopt the role of care manager, e.g.organizing other people, such as domiciliary nurses, to helpwith provision of care, rather than that of care provider,where the caregiver undertook tasks personally. Reinforcementwas given that use of services did not represent failureor dereliction of duty. Numerous pamphlets were providedon domiciliary nursing care benefits, pensions, methods ofassessing nursing homes and hostels and mechanisms forcomplaints about services.9. Planning for the future (psychiatrist; 161 h). The last formalsession was fairly open and considered how to plan foremergencies, e.g. should something happen to the caregiver.Other issues, such as driving, medications, safe use of alcohol,smoking, legal, medical and financial matters and otheremergency contingencies were discussed.10. Coping with problem behaviours. There was no time set todiscuss these specifically, although each session was structuredto allow discussion of current or potential problems, such asaggression or wandering. The aim was to give caregivers abroad education on the possible reasons for the emergence ofproblems and a repertoire of skills to prevent their occurrenceor to deal with them if they occurred.THE PATIENT PROGRAMFor caregivers to be able to learn in a relaxed setting, theyneeded to know that their partners were receiving satisfactorycare. Patients had their own program, which consisted of: (a)general ward activities, such as occupational therapy, outingsand relaxation classes; and (b) specific programs—groupdiscussion of their frustrations with their memory loss,reminiscence therapy and a memory retraining program.Given a forum for honest and open discussion, patientsestablished strong bonds with each other, were able to discusstheir feelings surprisingly frankly and often became protectiveof each other. Memory techniques included use of visualizationand one-tracking (focusing on one task to be remembered at atime). While we were unable to demonstrate any improvementin cognitive function 10 , our impression was that patient moraleimproved.ProcessThe course was residential and for a variety of (non-essential)reasons, as explained above, took place in the psychiatric ward ofa general teaching hospital, with caregiver and patient couplessharing individual rooms. An advantage of this setting was theavailability of facilities and staff. A disadvantage was theinappropriateness of some interactions with psychiatric patients,yet there was no attrition among the 96 participants who attendedthe program. The 10 day program began on a Tuesday andfinished on the Thursday of the following week (Table 1). Our5 day, Monday to Friday, pilot programs proved too congestedand caregivers requested that a weekend be included. This allowedcaregivers time to spend talking together, having fun, such as apicnic, and consolidating some of the knowledge previouslypresented.A major aim of the course was for participants to enjoythemselves. Sadly, fun and spontaneity are often lacking fromcaregivers’ lives. Leisure pursuits, such as walks, table games like‘‘Trivial Pursuit’’, carpet bowls, singalongs, dances and going outfor a drink, were included as part of the evening and weekendprogram. During these activities, caregivers would practise their