Dementia and Caregiver Abuse Dynamics

Introduction

Dementia is an umbrella term used for denoting progressive conditions developing due to degenerative changes in the individual’s brain. Dementia is found to be occurring mainly in older patients with characteristics of loss of social, behavioural and cognitive functions, interfering with the individual’s ability to speak, think, comprehend, remember, communicate and reason. With the progress of dementia, the functional and behavioural disabilities need a provision of daily assistance and support to the patient. In this regard, the care givers play a significant role in the lives of the patients at different stages (Brice 2016). According to Chalfont (2015), elder patient abuse of dementia has received considerable attention in policy reports, research and public discourses. It is an issue that has been studied and discussed for long, but no certain inference has been drawn yet. Patient abuses have been prevalent on the care givers part in care homes, health care settings and homes. The different dimensions of such abuse are largely dependent on the condition of the patient who suffers the abuses. Attempts have been made to understand the cause of the issue so as to eliminate them. Simultaneously, novice perspectives have come up from the traditional perspectives of dementia. New understandings have therefore emerged from the existing literature. Ascertaining the reasons underpinning patient abuse in dementia is necessary if the society is to be made free from such abuses (Jones and Miesen 2014). The overall aim of the present research project is to assemble, analyse and summarise available literature on the abuse of patients suffering from dementia for informing future research in this particular area. The objectives of the project were to identify the following:

• The risk factors for abuse and neglect of patients with dementia

• The characteristics of perpetrators who generally abuse patients with dementia

• The means of recognising the abuses of patients

• The need of strategies for managing and preventing cases of patient abuse of dementia

A comprehensive search of peer-reviewed journal articles and relevant books was conducted. The databases used for this purpose were PubMed, CINAHL, Medline, and Cochrane. This was supplemented by a search in the Google Scholar for identifying the pertaining grey literature relevant to the topic. The search terms used for a fast and accurate search were ‘patient’, ‘dementia’, ‘abuse’, ‘elder’, ‘mistreatment’, ‘neglect’, ‘care’, ‘carer’, ‘hospital’. The retrieved literature was thoroughly analysed for the key search terms in the titles. The focus of the undertaken literature review is the abuse of patients of dementia and search hits dealing with this topic were considered. Case histories, theses, dissertations and meeting abstracts were excluded. The published literature after the year 2006 was taken into consideration. The search was confined to publications in the English language. A number of ethical and anti-oppressive issues remain linked to dementia care due to the nature of the disease. Ethical issue arises in the association to the treatment of patients with mild cognitive impairment. The risks and benefits of long-term treatments are a topic of concern for care givers. In addition, ethical issues follow the genetic testing of autosomal and susceptibility dominant type. The diagnostic disclosure also raises many ethical issues. Cultural variations exist as to whether professionals believe it is ethical to make the patients aware of the prognosis and diagnosis of the disease. One significant issue, though not often discussed as a matter of ethics, is what kind of words is used when the diagnosis is being done. Maintaining patient confidentiality is a major concern while dealing with patients of dementia (Curran and Wattis 2016). Anti-oppressive practices in Dementia care requires the practitioners to undertake a critical examination of the power imbalance inherent in the structure of the organisation where care is given. This is in relation to a broader socio-cultural context for developing strategies to create an environment free from racism, oppression and discrimination. In social levels, dementia care demands practices that walk towards a better welfare of the society as a whole, free from ethical and legal challenges. Services are to be delivered in an inclusive manner, safe and secure for the patients (Toms, Lawrence and Clare 2015).

The project is divided into three main sections- literature review, application of theory to practice and lastly critical analysis and recommendations. The literature review covers the main aims and objectives of the project. The section on application of theory to practice identifies relevant strategies, policies and legislations handling the issues and identifies a case study of service delivery. The end section is a summary of the main points derived from the literature. The critical analysis is a reflection of undertaking the project work and evaluation of the experience. Recommendations are provided at the end for improving the care practices for dementia.

Literature review

Cooper et al. (2009) investigated the prevalence of abusive behaviours by family carers of patients suffering from dementia. The setting for the study was community mental health teams in Essex and London. The research was a representative cross-sectional survey. The sample population consisted of 220 family carers of patients with dementia who were newly referred to secondary psychiatric services. The primary outcome measure was physical and psychological abuse. The revised, modified conflict tactics scale was used for this purpose. 115 carers reported that they had done some abusive behaviour (52%, 95% confidence interval 46% to 59%). 74 carers reported that they had done significant levels of abuse (34%, 27% to 40%). The most commonly reported form of abuse was verbal abuse. Occasional physical abuse was reported by only three carers (1.4%). It was therefore concluded from the study that abusive behaviour demonstrated by family carers towards people having dementia is highly prevalent. Selwood and Cooper (2009) articulated that patients with dementia are more vulnerable to abuse. It may be essentially challenging to study broadly the patient abuse of dementia as is it often a hidden abuse, pulled off against some of the most defenceless and frail people of the society. Different factors, separately or in conjunction with one another, predispose to increased rate of abuse. The knowledge gained from different researches can be harnessed for trying to improve the scenario. A number of reliable and valid scales can also be used for detecting abuse and preventing them consequently. All care professionals uphold the responsibility of acting on any evidence of abuse for suitable strategies to be taken. Boye and Yan (2016) highlighted that in the context of the fast ageing population, a considerable amount of attention had been given to study dementia. Studies have mostly focused on the onset, prognosis and treatment of the disease. Though older patients having dementia are at an increased risk of physical and mental abuse, relatively less attention has been given to understand such abuse. Tronetti (2014) stated that for patients who are suffering from dementia, the range of abuse suffered by them varies from restrained scams to absolute physical violence. With the progression of dementia, all forms of abuse escalate. The stages of dementia- mild cognitive impairment, mild dementia, moderate dementia and severe dementia-lend themselves to different presentations of patient abuse. Knowing which form of abuse is most important and prominent at each stage helps the clinician to anticipate risks of abuse and the needs of the care givers as well as the patient. The victims are to be interviewed since the interviews are crucial for uncovering, documenting and intervening in a situation where abuse has taken place. A crucial factor in ending the victimisation is intervening by a clinician who is skilled in investigating facts while being is support of the victim. Cooney, Howard and Lawlor (2006) wanted to explore possible associations between dementia patients, features of carers and the caring situation and patient abuse that is acknowledged by care givers. The researchers interviewed eighty-twp care givers of dementia in their homes regarding here kinds of abuse, neglect, physical abuse and verbal abuse. A structured questionnaire was used for the purpose. 43 care givers admitted that they have carried out some form of abuse in their due course of practice. The most common form of abuse was verbal abuse that was 51%. 20% of care givers admitted that they had done physical abuse to dementia patient, while 4% caregivers admitted to neglect abuse. There was a significant association between psychological ill health in the care giver and verbal abuse and behavioural problems in the patient suffering from dementia. Physical abuse was associated with high degree of self-reported good health by the care giver. There was a high correlation of commonly expressed emotion with all the three types of abuse. From the study, it was concluded that there is the high possibility of identifying circumstances in which dementia patients face a high risk of abuse from the care givers. All possible intervention strategies are to address psychological health problems identified in the care givers. Behavioural problems in the patient are also to be addressed simultaneously. Management of high levels of expressed emotions is also necessary.

Wiglesworth et al. (2010) in their article reported screening for abuse and neglect of dementia patients. The aim of the study was to investigate the features of dementia patients and caregivers and situations that lead to mistreatment of these patients. The purpose was to inform clinicians regarding the screening of patient mistreatment. A suitable sample of care giver and care recipient dyads were assessed for factors associated with any form of mistreatment. These factors were literature supported. The evidence was considered by an expert panel, and the criteria for data collection were decided as physical abuse, neglect and psychological abuse. The study was conducted at the homes of the participants. One hundred twenty-nine patients with dementia and their respective care givers took part in the study. Health, demographic and psychological variables and relationship characteristics were the measurement instruments. Mistreatment was found in 47.3% population. The variables linked with varied types and combinations of mistreatment forms encompassed anxiety of care giver, social contacts, depressive symptoms, emotional status, role limitations and perceived burden as well as the psychological aggression of the care recipient. The combination of psychological aggression and physical assault of the care recipient showed the highest sensitivity (75.4%) and specificity (70.6%) for mistreatment. The findings from the study indicate distinct features of older patients with dementia and the care givers. They can be used in clinical screening tool for patient mistreatment. Paveza, Estefan and Corvin (2014) stated that elder mistreatment is a growing concern of modern health care sector and almost 800000 older patients are found to be suffering from such poor behavioural issues. Elder mistreatments lead to serious consequences like feelings of self-contempt, inadequacy and depression. People with Alzheimer’s disease have high chances of elder mistreatment. However, it was not clear whether the high risk for abuse represented life-long patterns of abuse between individuals or whether they were a representation of the change in conflict style due to changes related with dementia. The investigators aimed to research on this context. Data collection was done as part of the Aggression and Violence in Community Based Alzheimer’s Study [AV-CAD]. Data represented patient care giver dyads. In-person interviews were conducted, and mailed survey was also done. Changes in conflict resolution style (verbal aggression, reasoning and violence) post and pre-dementia were measured. The Conflict Tactic Scale (CTS) was used for measurement and analysis was done with the help of McNemar’s Test. Reasoning was the conflict resolution style in 89.3% of elders and 91.4% of caregivers before the onset of dementia and 45.3% of elders and 66.3% of caregivers in the post-diagnosis period of dementia. Use of violence and verbal aggression as a conflict resolution style after detection of dementia was found to be higher for both caregivers and elders. However, it was not related to behaviours in the period before the onset of dementia. The study leads to the inference that elder abuse in a large number of patients with dementia may be a result of the aetiology of the disease itself. The care givers find it difficult to cope up with secondary symptoms of dementia, like violence, aggression and combativeness. Although the study was conducted in the USA, the findings from the study held implications for other countries as well who are finding challenges imposed by increasing number of patients with dementia. Paveza, Estefan and Corvin (2014) conducted a review of elder abuse and dementia. According to the researchers, older patients suffering from dementia are at high risk of abuse; however, this topic has not been given the required attention. The researchers conducted a literature review for examining the relationships between dementia and elder abuse. It was found that psychological abuse was most prevalent among dementia patients. Moreover, physical abuse affected around 3.5–23.1 percent of older patients. The data also indicated that the risk of mortality as result of self-neglect and abuse was higher in such patients. No major steps have been taken to curb such ill practices as challenges lie in funding, knowledge of clinicians and motivation. There is an immediate need of adequate funding for implementing state as well federal programs that can address this issue. Stronger programs that target the well-being of the patients suffering from neglect and abuse would help to solve the problem.

Patients with dementia may be subjected to mistreatment as well as abuse in care homes, hospitals or community. The abuses can be emotional, financial, psychological, physical, and sexual, including the unsuitable prescription of anti-psychotic drugs. Dementia patients are more vulnerable to such kind of abuse as they struggle to discuss openly their feelings and emotions, moreover, they have difficulty in remembering things. Dementia also makes it harder to detect abuse. Common reactions to abuse, like a sudden withdrawal from communication, can also be a symptom of dementia (Brooker and Latham 2015). Kovac (2013) threw light on the fact that abuse for dementia patients is common in healthcare settings. Patients are especially vulnerable since the disease prevents them from making an appropriate reporting of the incidences and recognising such incidences. They also often fall prey to strangers wrongly taking advantage of the cognitive impairment of such patients. Abuse of dementia patients may be physical, neglect, emotional, sexual and deprivation. Signs of abuse include pressure marks, bruises, abrasions, fractured bones, unexplained withdrawal from activities, reduced communication. It has been reported that the health care professionals responsible of taking care of the patients contribute largely to the abuses. The social contacts, depressive symptoms and emotional status are the contributing factors. Health care professionals often suffer high levels of stress while handling patients of dementia of all stages. A majority of the professionals do not resort to abuse at times of stress. Abusers may be using stress as an excuse for justifying the inappropriate behaviour. They can be finding it difficult to provide care for patients who have different and demanding needs. Patients with the disease become frustrated and confused and tend to show even more aggressive behaviour towards the care givers. Care providers must understand the nature of the disease and learn methods of de-escalating violent behaviour without responding improperly. The high prevalence rate of abuse among older patients having dementia indicates that the disease itself is an important risk factor for elder abuse. As per reports of several studies, fewer dementia symptoms work as a protective factor against the risk of verbal abuse. This, therefore, suggests that more severe impairment in cognitive function exposes the patient to a higher risk of abuse. Reports indicate that in early stages of the disorder, undiagnosed cognitive impairment has a chance of being a significant source of tension arising between the patient and the caregiver. In addition, behavioural disturbances of the patients, such as aggression, pose a challenge for the care givers to act appropriately. Verbal abuse is, therefore, common for such patients. On this note, it is to be highlighted that there is a mixed pool of evidence on patient abuse and level of functional impairment. Some studies have proved that care givers have less chance of abusing patients who have the greater functional impairment. There are some aspects on the patient’s part that contribute to patient abuse, the most important being socio-demographic characteristics. Of such characteristics, lower income, age and gender have a considerable level of association with risk of abuse. A number of studies have indicated that male patients are more vulnerable to abuse in comparison to female patients (Downs and Bowers 2014). Callaghan and Ritchie (2017) discuss that caregiver risk factors for dementia abuse include poor psychological health. Low self-esteem, mental health issues like depression, anxiety and alcohol abuse are predictive of violent feelings. The quality of the relationship between the caregiver and the patient before the onset of the disease is a potential risk factor for patient abuse. Many studies have reported that abuse has an association with a poor pre-morbid relationship as well as the poor current relationship. Caregiver abuse of the patient is associated with abuse of the carer by the patient. As per the authors, the dynamics of patient abuse in dementia can be best understood in the context in which they are given care services. Environmental and contextualised risk factors include high carer burden, more involved caring, in terms of duration, the volume of care giving tasks and the use of coping strategies for the dysfunctions. These factors also vary depending on the stage of dementia. Boltz (2016) in this regard state that less use of services also increases the chances of patient abuse. If the carers have a perceived lack of feelings and support of social isolation, then this also increases the risk of abuse. Network communications with care giving experience and the stipulation of emotional and instrumental help from network contacts decrease the possibility of violent feelings of carers. Peer groups that provide familiarity are successful in providing a platform for carers where they can share their valuable skills and experiences pertaining to care giving. These profit them with increased competence and confidence for better managing the challenges of daily practices. The likelihood of abuse is hence reduced.

Yan and Kwok (2011) examined the risk factors and prevalence of elder abuse in older dementia patients of Chinese origin by the family caregivers in Hong Kong. 122 family care givers were included as participants. Recruitment was done from local community centres for the elderly. Participants gave information on the care recipients' physical functioning, demographic characteristics, the agitated behaviour of care recipients, caregiver burden, and whether they had directed any abusive behaviour in the previous month. Sixty-two caregivers reported to have verbally abused or physically abused the patients in the past month. It was concluded from the study that physical and verbal abuse are prevalent among Chinese patients with dementia. Care givers who did not have any form of support and assistance from other sources had more agitated behaviours. The most contributing factor towards patient abuse was caregiver stress. Extreme stress in caregivers gives rise to undesirable abuse. Spending more amount of time with the patients was a reason for stress and more abuse. The results of hierarchical regression analysis indicated that the amount of time spent with the patients was a significant predictor of verbal abuse. In summary, the main factors that are most common for contributing to the high risk of patient abuse for dementia include aggression or abuse towards the care giver, psychopathology of the care giver, caregiver burden, and quality of the relationship. Evidence that relates to the extent of cognitive impairment in a patient with dementia and absence of social support are mixed. Subsequently, ostensible prompting risk factors for abuse of patients with dementia, for instance, functional impairment, are not well supported by a rich pool of literature.

Application of theory to practice

Identification of relevant policies/ strategies/ legislation tackling the health issue (patient abuse in dementia)

There are a number of different pieces of legislation that health care professionals in the United Kingdom abide by while working in the field of elder abuse in the country. These legislations, polices and strategies encompass handling of patient abuse for dementia. The framework for protection includes social care staff, social workers and allied professionals from a range of healthcare settings. Attaining the basic knowledge of relevant legislations is necessary for the practitioners in such kind of work where they constantly handle patients who are fragile and vulnerable. The adequate knowledge of set regulations and legislations is a part of the qualifying training for a major section of the population. It is often the case that health care professionals are predominantly and primarily involved in the application of such laws, though the application may be reliant on the nature of the circumstances. Care workers are to protect individuals from harm and injury and within the UK context the common approach is to protect the adults, concerning abuse of vulnerable adults in general. Such approaches cover the needs of the older dementia patients suffering abuse and neglect (Penhale 2008). Older patients with impairments, cognitive or physical, may be more prone to abuse and may be more vulnerable. It is significant to note that no single piece of legislation is there that is concerned about the protection of vulnerable adults in the UK though it is hoped that in future such laws would be made. Instead, a number of different legislations work together to eliminate the incidences of elder patient abuse in the country. The legislation designed for the protection of patients with mental is Mental Health Act 1983. A new Act regarding mental capacity covers those elder patients who lack the capacity to take up their decisions. In accordance with the existing legislation, adults with varied needs are to a large extent protected from difficulties of life within the National Health Service and Community Care Act 1990. The Sexual Offence Act 1957 protects the individuals from unwanted sexual advances and sexual abuse. Part IV of the Family Law Act 1996 offers protection to individuals from violence occurring within the domestic setting. This encompasses an assortment of measures that are to be used in cases of molestations and other abuses (Buckland 2014). The major safeguarding policies undertaken by the government aim to stop abuse wherever possible, prevent harm and reduce risk of abuse, safeguard adults in a manner that supports their choices and does not control their way of living, concentrate on improving the quality of life and raise public awareness so that professionals and communities work in collaboration. There are three particular legal duties in relation to safeguarding in the Care Act 2014. Firstly, the local authority has a duty to enquire whether there is a strong cause to suspect that the individual has been abused or is at risk of abuse. All local authorities are to set up a Safeguarding Adults Board that would be a body for protection of the adults. The Safeguarding Adults Board has the responsibility of arranging for case reviews of serious safeguarding incidents. Once an individual from the community notifies the local authority of any concern regarding patient abuse, it is the duty of the local authority to respond appropriately (Reese 2010).

Guidance from the government with regards to adult protection does not appear to be a priority domain of concern until relatively recently. Yet this is likely that it forms an integral aspect of prevention of abuse against the vulnerable individuals. The Social Services Inspectorate began working in the year 1998 for rectifying the lack of guidance concerning vulnerable adults. Many local authorities have started working in this area and do not wait for national initiatives to be improved. Within the sensitive, complex and difficult situations arising from situations of elder abuse, there needs to be a successful collaboration between agencies. Multi-disciplinary approaches in case conferences are vital while dealing with abusive situations. Safety, network and strategy planning meetings are constantly held for improving the effect of adult protection. The involvement of the police has been of major importance in many cases of patient abuses. A number of Domestic Violence Units (DVUs) within the different police forces are presently widening their scope and are more concerned about the exploitation, violence and abuse of the elderly members of the society. Contact with the respective authorities at an early stage is crucial for active involvement and investigation in situations. Having said this, getting clear legal advice is also needed in many situations. In the United Kingdom it is a good option to access the local authority legal sections or through independent legal advisor of the victim (Khalifeh et al. 2013). Good practice issues refer to the development of appropriate responses to situations of adult patient abuse. There are investigations of situations that are abusive, and the agreement is that the Councils of Social Services Responsibilities need to play a key role in this area. Assessments are holistic and in accordance with the community care for adults, Department of Health 1991. Good practice includes elements such as subsequent investigations and initial referral. Careful coordination is done for investigating the situations. Sensitive, suitable and separate investigations are carried out, and necessary steps are taken. A balance between the needs of the victims and the need for treatment is maintained. The protection plan includes attention to the needs of the victim for support, safety and service provision together with concerns of risk management. The contemporary agenda for Social Services outlined in the care provisions of different organisations relate to more service and institutional settings and draw the attention of service-users. Research is being undertaken constantly to investigate the degree of partnership working. Effective inter-agency working is required in many settings, and this can be achieved through development and sustenance of defined inter-agency shared protocols and working arrangements (McGarry Simpson and Hinsliff-Smith 2014).

Case study of service delivery

Care UK Care Homes aim to help older people live happily in a healthier and fulfilling state. The organisation has been providing high quality care for older individuals for the past three decades. They are leading the way in social care for decades. There are about 100 residential care homes in the country with around 7000 people continuing to live independently and actively in comfortable, safe and warm surroundings. Personalised care remains at the heart of the services provided by the organisation and the care homes provide a range of comprehensive care services under one roof. These include dementia care and respite care. The organisation appreciates that no two patients are the same and the experienced carers and nurses provide compassionate care to each individual. All residents receive care that is tailored to the unique needs, wishes and personalities of the individuals. The organisation is more of a family of likeminded people, sharing the commitment to deliver the optimal quality of care for older patients (Gordon et al. 2013). Care UK care homes have a long track in good dementia care, and there are little complaints regarding the care services provided. The organisation is constantly looking for different ways to bring improvements in the care quality. The care homes for dementia, spread across different cities in the country, have been designed to make provision for the unsurpassed promising environment for individuals dealing with the complications of dementia, for preserving the sense of identity and giving them choices to continue with a normal life. The approach to dementia care is flexible, and it is made sure that all the needs of the patients are catered. Immense support is provided to the patients and their family members so that they can cope up with the distress. Resources are offered along with support for these people who face difficult experiences. The professionals working in the organisation form a dedicated, outright and forward thinking dementia team with knowledge and adequate training. Care UK care homes work with “Action on Elder Abuse” that aim to prevent the outright abuse of older patients. The organisation works to protect and prevent the abuse of older adults who are vulnerable apart from protecting those who are at an increased risk of abuse. They organisation works as a charity for addressing the issues and is the only charity in the country that works exclusively on the issue of older adult abuse at the present time. The work is primarily to challenge elder abuse. Care UK care homes recognise the need of having health care staffs who abides by the rules and regulations required to be maintained in relation to abuse of patients. Care givers are therefore recruited who can exhibit a proper professional attitude, show dedication and have a caring nature, together with a commitment to consider continued professional education and development. Patients are considered as valuable assets in the care homes, and high standards of care are given, making foundations for an environment that are safe for the patient. Staffs that are motivated and are able to are selected specifically for the care homes. An extra mile is reached for building strong informal relationships with the residents.

With the support of the senior authorities in the organisation, the care homes have developed a forward thinking and robust dementia strategy. A dedicated dementia team has been made who can adequately address all issues. The contribution of the team to the dementia strategy is immense and invaluable, bringing out the best in individuals. The team is committed to providing dementia training to all the individuals who work at the care homes in order to incorporate within them the realisation of avoiding patient abuse. The carers gradually come to terms with how it feels to live with dementia. They are made aware of the visuals, hearing and physical challenges that dementia poses. The specialist dementia training includes intensive empathy training, training on communication and CA DOLS which provides the carers with sufficient knowledge of the Mental Capacity Act. The training helps the many care staffs to put themselves in the shoes of a dementia patient. The training provides them with a more deep understanding of how a patient of dementia acts in a certain way thereby reducing the chances of abuse of any form. They develop increased patience and work harder to avoid any potential chances of abuse to any patient under any circumstances (careuk.com 2017).

Reflection and recommendation

Dementia has significant social, medical and economic implications for both the patient and his care giver. Older patients suffering from dementia are especially vulnerable to the increased risk of neglect and abuse. The statistics of patient abuse for dementia is supported by the willingness of the caregivers to disclose abusive behaviour. But the discreet nature of patient abuse increases the chance that such statistics are underestimations of the actual scenario pertaining to the issue. Since the abuse is markedly more in elder patients in comparison to the common population, means of preventing the abuse must be developed. Research on dementia abuse tends to give special attention to physical and psychological abuse and to some extent on neglect. This largely overlooks other abuse subtypes out of which financial abuse is most common. The reasons for abuse are multi-faceted and mostly involve the behaviour of the patients and the burnout and stress faced by the care givers. It is their inability to cope with the extreme nature of the dementia disease that prevents them from delivering an abuse-free range of services. In conclusion, the existing pool of literature on abuse of patients of dementia is sparse. Though some studies have contributed to highlight the knowledge of abuse in patients with dementia, there is still a considerable amount of gap in knowledge and research related to patient abuse of dementia. It is limited by insights into the topic that precludes abuse and self-neglect in health care settings. Nonetheless, the present project paper highlights the further need of strong research, especially for ascertaining the preventive measures in combination with interventions are can be on the whole successful in systematically addressing the abuse of patients with dementia. The following are the strategies recommended to bring improvements in the process of dementia care for the elder patient. By adopting the strategies, it is expected that optimal care delivery would be achieved without any incidences of patient abuse, physical, verbal or psychological. Adequate Dementia training for healthcare professionals in hospitals and care homes- From the existing literature, it has been indicated that lack of sufficient training is a vital cause of poor quality care. Staffs are unable to undertake effective communication with patients suffering dementia, especially older patients. They are not able to involve the patients in a proper decision-making process following the principles of Mental Capacity Act and therefore are not capable of caring for the psychological and behavioural symptoms. This implies that patients are often left behind from receiving appropriate person-received care and are deprived of the legal rights. Inappropriate interventions like anti-psychotic drugs and physical restraints are also provided, that severely exacerbate symptoms of dementia. Health care professionals must be given adequate training so that they are able to deliver person-centred, high quality care for improving the dignity of the patients and their quality of life. Training is to be provided on a regular basis, focusing mainly on management of unfavourable behaviour of dementia patients. Evaluation of the training is required in order to understand the areas of improvement that need immediate attention. Health care settings must allocate sufficient funds for this purpose and exercise leadership in fulfilling the purpose of rigorous training (Huges et al. 2014).

Robust and effective enforcement- Mistreatment and abuse are a serious concern and are to be considered having a relation with general complaint procedure. The regulators of the health care settings are to get involved in this matter for taking strict actions against those who are found guilty of such acts. Legal actions are to be taken against the care givers to resort to abuse of patients, and the heavy penalty is to be implied. This would prevent other carers from abusing patients in future (Knapp Iemmi and Romeo 2013). Support for care givers- people having dementia experience a range of psychological and behavioural symptoms and therefore behave aggressively. Such behaviour is stressful for care givers. It has been found the care givers lack adequate support for managing the behaviour. Though abuse is unintentional in most cases, it is unacceptable as intentional abuse. To present such form of unintentional but undesirable abuse, carers are to be given emotional support to ease their situations and bring relief. Psychological counselling for the carers would be beneficial (Edvardsson, Sandman and Borell, 2014). Action on financial abuse- Financial abuse is the illegal and unauthorised use, or theft, of a patient’s valuables, money or property. This is often perpetrated by third parties and care givers. Patients with dementia are at a greater risk of such abuse. For curbing financial abuse, all health care settings must call for improved financial information, guidance and advice for people with dementia as well as care givers. The role of trading standards is to be strengthened. All care settings must undertake financial assessments on a regular basis. Safeguarding teams are to be build up for working together in investigating cases of suspected financial abuse. Improved data sharing between different agencies would also be advantageous. All financial services sectors must sign-up for dementia-friendly financial services (Beerens et al. 2014). Full-bodied examination of abuses of power of attorney- As per the Mental Capacity Act, another person may take responsibility of taking up decisions on behalf of a dementia patient who is not able to do so. However, the powers conferred by a power of attorney can be abused. Individuals with dementia lacking capacity are predominantly open to such abuse. It is, therefore, indispensable that suspected cases of abuse of power of attorney are considered for thorough investigation for safeguarding individuals with dementia (Stephan et al. 2015). It would be now a good opportunity to reflect on the project work undertaken. The project has given me valuable insight into the topic of dementia care and patient care. While conducting the project I have gained rich information on the different aspects of care of elder patients and how such issues can be addressed. I believe caring for dementia patients means a delicate interpretative work required by all care provisions. This principle would be applied by me in practice, culminating in mutual respect between me and the patients. Providing optimal care signifies that my skills and knowledge would be best used for the purpose of serving the patients of dementia. This project gave a good opportunity to understand the requirements of dementia care and how they can be improved. My contribution towards bringing changes in the current situation would be through my nursing professional practice.

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