Archive | Plymouth RSS feed for this section

How to communicate with someone who has a cognitive impairment

14 Jun

 

How to communicate with someone who has a cognitive impairment

 

Firstly I would like to thank Kate Smith from Memory Matters some of the information for this blog.

 

No two people with a cognitive impairment will communicate in the same way, but here are some ideas that might help.

 

Memory can be unpredictable, however in general short-term memory tends to be lost first and long-term memory stays with that person for a longer period of time.  However, if something emotional or very unpredictable happens during what is otherwise a mundane situation, such as a huge surprise happening during breakfast, then the details about what you ate and drank for breakfast will stay with you longer than other breakfasts.  This surprise / emotional memory works like long term memory and can be retained.  What is important or emotional to one person, won’t be the same for another, which is why it can therefore be unpredictable what will be remembered.

 

People with dementia can have difficulty focussing, which can relate to their inability to filter their environment.  People without this impairment can focus and concentrate on the thing that they consider important and may not even hear people close by talking to them, if their focus is so strongly fixed on the task in hand, but people with dementia don’t always have this high level of concentration, so if there are multiple things going on in their environment, they might struggle to concentrate on any one of them.  This can also be a useful thing, if they become agitated or anxious, as the carer can do something that will distract their attention from what / why they are anxious and change their mood really quickly, such as dropping keys on the floor to create a sudden noise.

 

The areas of the brain that are affected by dementia are different in each person and if the frontal lobe is damaged, this can lead to issues with both planning and impulse control.  The family members of people who have issues with impulse control will be surprised by comments or swear words that can be used, that were never used before.  The filter that ensured that their interactions were social appropriate and measured has disappeared and they will both act quickly and out of character for them as they were before.  They might become more angry or tearful for example, the display of their emotions is unpredictable.

 

Another aspect of the loss of impulse control is the loss of ability to plan or manage their lives.  If they are thirsty at 10.30am, they might not be able to wait until 11am for their morning coffee, or plan a loo visit etc, so when they realised that they need / want something, they want it now!  They might ask for what they want and will have difficulty concentrating until they get it or they might get up and walk off to get it, which could be mid conversation!

 

Unless the environment is very familiar, that they continue to see / use daily, they could be disorientated, including to parts of their own house they don’t go in regularly, such as the spare room or family members that they don’t see regularly because either they don’t visit or live a long way away.  As far as people are concerned, everyone has a name, relationship and visual look and it is possible that they can forget one or more of these aspects, so they might know you are familiar, but not your name or what relationship you are.  This can create issues of inappropriate behaviour if the person thinks you are someone else, particularly when sons are misunderstood for husbands or daughters for wives!

 

What is important is that they feel safe with you, not the information about you that they can remember or not!

Advertisements

Personal budgets and direct payments & personal health budgets

31 May

Personal budgets and direct payments & personal health budgets.

 

Firstly what is a personal budget?  It is a sum of money that is awarded by the Local Authority for that person to spend on their care to meet their assessed needs.  It can be spent however that person considers appropriate, however it should be spent on assessed needs and is not for what is considered a luxury of life to the detriment of paying for essential care.

 

The person in need of care and support can request a direct payment also known as a personal health budge of their personal budget, which means that the money is paid to the person or to the carer to be spent on behalf of that person as they see fit.

 

The care can also be commissioned by the Local Authority.  They will have undertaken an assessment of needs and in order to meet those assessed needs a sum of money will be allocated to that person, subject to means testing their ability to fund their own care.  Assuming that they do not have sufficient funds to meet the cost of their care, the Local Authority has a statutory duty to meet the cost of those assessed needs.  In doing so, it can take account of various factors, including their own budget, so they can choose a cheap option, as long as the cheap option does meet the needs of the person.

 

The personal budget should be sufficient to meet the cost of the assessed need and there should be transparency as to how that sum of money is calculated.  It should also reflect the cost to the Local Authority of meeting that need, so if the person wants to purchase care more expensive than the Local Authority can provide, then the cost will need to be topped up by a family member or from an unassessed asset.  The Local Authority must show that the care can be met for a lower cost than the enhanced rate, so as to pay a lower rate.  It is not sufficient to suggest that a particular provider can do a task at a certain rate, they have to show that the provider has capacity to meet the needs of that person and is willing to do so for a particular fee.

 

If the budget is to be taken as a personal health budget and the person in need of care is for example going to employ their carers directly rather than through an agency, then the Local Authority doesn’t need to pay the agency fee and can show that as they would commission care through an agency, that they can pay less as a personal health budget doesn’t need to meet the agency fee.  However they still need to pay sufficient to meet the needs, so it is not a reason to cut budget.  When directly employing a carer, the person may also need to make holiday payment and pension contributions, depending on the terms of the employment and these costs need to be taken into account in the budget.

 

If there is an issue about the budget, then a meeting with the social worker and finance team is appropriate, to go over the assessment of needs and then to use that assessment to calculate the cost of care and to devise a budget and then discuss what, if any, part of the budget can be made as a personal health budget.  The person can choose to have a mixed budget, with some care directly commissioned and others parts of their needs met by a personal health budget directly paid to them.

 

It is a tricky area of contention, if the person needing care believes that they have not been paid a sufficient amount to meet those assessed needs and with Local Authority budgets stretched, they closely scrutinize the money they pay to meet the cost of social care.

Dementia and walking

17 May

 

Dementia and walking

 

There are some people who have dementia who go out walking, can’t remember their way home and end up getting lost.  The purpose of dementia friendly communities is to support someone who might appear in distress, if they are seen in the community, to have compassion for someone with a dementia, but they might not appear in distress.

 

People walk because they always have or because they have a purpose, even if we don’t understand what that purpose is.  I’ve had clients that broke out of care home, breaking through doors to do so, because they had to go somewhere or be somewhere that was incredibly important to them, such as going to work, church or school. They might think that they are looking for something or someone.  Whatever their reason, however inexplicable to the people around them, it makes sense to them.

 

The person might get lost on their way to the place they are going or get lost on the way back.  This can generate a significant response for the authorities that are tasked with finding lost people, such as the Police or Search and Rescue, who do an outstanding job in difficult circumstances.  See the Police’s Herbert Protocol: https://www.met.police.uk/herbertprotocol

 

It can be challenging to communicate with people with a dementia, so it is difficult for them to explain what they are doing and why and it therefore becomes harder to help them by the people around them.  It is worthwhile taking some time to understand their reality, which might be being expressed in their facial expressions, or body language as well as through their verbal communication, which might be confused.

 

People with dementia are still people, they have human rights like everyone else and should not be treated as lacking their rights.  They might need support and care but this should be provided with their rights in mind, so as not to try to restrict them, but to enable them to walk as safely as possible.

 

They can have a GPS tracker placed on them, if it is in their best interests to wear one and they can be covert, again, if it is in their best interests to wear one.  There are some trackers that are insoles, so as long as the person is wearing their shoes, they will be wearing their tracker and can therefore easily and quickly be found, which is very relevant in extremes of weather, both hot and cold.  They should not be tracked oppressively, as they are still entitled to their freedom and only when their life is at risk, should they be tracked.

 

Walking is difficult for those around the person with dementia to manage, if they do it a lot, they will need to be appropriately supported, with everything that they might need, such as appropriate footwear and clothing, contact details in their pocket, snacks and water.  It is a tough role being a carer and they are amazing at it!

Dementia and domestic violence

3 May

 

Dementia and domestic violence

 

I have had a number of clients who have had issues with domestic violence, when there is a dementia involved.  It is a very difficult situation, as there is not the “usual victim and perpetrator”. It often arises because the person with dementia lacks insight into their condition and the carer doesn’t fully understand the condition or has carer burn out or it just isn’t what they thought would happen when they got together as a couple.

 

So what can be done?

 

Firstly, make sure that the person with dementia has had the appropriate referral to the GP to make sure that they have a formal diagnosis and access to any treatment that is available.  The dementia cannot be cured, but there are some treatments available for some types of dementia.  The diagnosis also gives that person access to certain activities, which may also help the situation.

 

The carer will also need support, as many carers are clinically depressed within a year of diagnosis, they live with an underlying level of stress, which can very easily escalate when an acute episode happens.  The person with dementia and their carer should ensure that they have had a referral to social services to ensure that they each have an assessment of their needs.

 

There should be a conversation with each of the parties to try to alleviate some or all of the fundamental issues that give rise to the domestic violence and to try to get each party to understand their situation, as far as is possible.  This can involve a very careful and sometimes skilled conversation with the person with dementia to try to interpret and understand their situation and their understanding of their situation.

 

Both parties need a plan for safety and it is likely that the carer will be the person responsible for the instigation of both plans, which continues to put a lot of pressure on the carer.  The clients I have are concerned for their safety and that of their loved one, so want a prompt response in the safety plan.  This puts pressure on local services, which need a process to respond to this situation, which is different from a “usual process”.

 

This is a safeguarding issue, which is the responsibility of the Local Authority, to ensure that the person or people are kept safe.  The plan could include lots of different strategies, which include diversion for one or both parties, medical input or in a serious case of harm, could include sectioning a person.  And in some circumstances, for married couples it might include divorce, which might not be what they had intended in regards to their caring role, but if one of both parties continues to be in serious danger, it might be the least worst outcome!

 

The most important thing is to ask for help and not suffer alone in the home, as there is help that can be provided by all the services that are there to support people to live as successfully as they can in the community.

Adjusting to life as a carer

19 Apr

 

Adjusting to life as a carer

 

When you are a carer for a loved one, either spouse or parent, there is a period of time to adjust to the new role.  If you are caring for a parent, it appears to be a switch in roles, they cared for you and now you care for them.  Your life is now changed.

 

This takes time to mentally adjust to the new situation and there is a grieving in doing so, as you have lost what you have before.  However this grieving is very challenging, as it seems strange to grieve for someone who is still alive!  Many carers are clinically depressed with the struggle of the change, the new role and the thanklessness of the situation, particularly if it is a deteriorating situation.

 

It takes time to adjust, to make changes in your life, to find the time that you used to do something else, to then use as a carer.  And everyone in your immediate family has to adjust to that as well.

 

If you are working, then you can discuss any changes you might need to make with your employer.  If you don’t want them to know, there is no requirement for your to tell them, but you will have to if you want them to make adjustments for you.

 

It takes a huge amount of mental energy to be a carer, which is disproportionate to the amount of time it takes to provide the hands on support of visiting and dealing with whatever needs sorting out.

 

It might also mean that you have to give up something that you did before, at least for a while or change it.  When I was a carer, I made the decision not to go on long haul flights, it was just too far to get back, if there was a problem.  And I didn’t go away short haul very much!

 

I hear a lot of comments about how stressful it is to be a carer and about how people are able to cope.  People find ways to cope and it is useful to be mindful of your stress levels and find something that will allow you to deal with your stress, be kind to yourself.  Having good mental health is one of the most important attributes of being a carer.

 

There is a lot of pressure on you, as a huge amount of the cost of care is undertaken by unpaid carers, so the health and social care systems are set up to take account of the support that people are given.  It become something that appears expected, rather than treated with gratitude, as the generous gift of time and energy that it is.

 

The truth is, people get ill, people die, it’s not something families like to face, but nevertheless, it is true.   If as a carer, you have turned up and done your best, then that is all you can do.  You have done a good job and should be congratulated.

Going to hospital with a loved one

5 Apr

 

Going to hospital with a loved one

 

There is that horrible phone call, from the police or paramedics that lets you know that something terrible has happened.  It’s almost always at an inconvenient time and they want you to drop what you’re doing and head off to the hospital or come to where they are, if you are near enough.

 

If the matter is a life and death emergency, then you will be advised to meet them there and they will be blue lighted to the hospital or possibly even by helicopter.  If not the ambulance will make its way to the hospital and you can meet them there.

 

Depending on where you are in relation to your relative and the hospital, if you arrive before them, then the emergency department administrators will know they are on the way and will be able to give you an approximate time of arrival.

 

There is a four hour target of arriving at A&E and being discharged from there, either home or into the hospital, possible to a medical assessment ward (MAU).  This four hours does not start to run, until the paramedics have handed them over and there can be a queue for that, which can take up to an hour or even more.  Therefore the expectation that this will be done within 4 hours of the ambulance pulling up at the hospital doesn’t necessarily take this extra time into account.  So when you get to the hospital and pass by a place that sells food and drink, buy some, you could be waiting a long time and might need sustenance.  Make sure that you have a book or your phone is fully charged, as the waiting may be boring and you might need something to occupy you.

 

There are periods of activity and a lot of waiting as the staff undertake their investigations, they undertake a lot of their work with you nearby, but not there for reasons of access and dignity.

 

The area can be very busy, depending on what time of day and what day of the week, late on a Saturday night is not a great time for an elderly relative to have a fall!  The staff are busy and are trying hard to do their jobs effectively in a challenging environment and many retain great empathy skills even when under immense pressure.

 

If you have a power of attorney for health and welfare and your relatives has issues with their mental capacity, then it is worthwhile ensuring that you have a copy of it available, if possible.  If you’re loved one lacks capacity to make a decision, then you make it for them, so you will need to let the staff know that you have it, to ensure that any decisions that need to be made are done so, having discussed them with you and asked for your final decision.

 

If there is no power of attorney for health and welfare, then they should still discuss the situation with you and ask what your loved one would want, however the final decision as to what to do is the healthcare professionals and they are required to make a decision in that person’s best interests.

 

When someone you love is poorly, it is always a distressing time, watching them ill and/or in pain.  You are there and you are trying your best, that’s all you can do, so be kind to yourself about how stressful this situation is.

 

My key suggestions therefore are:

Be prepared for a long wait.

Get some food and something to drink during that wait.

Bring your health and welfare lasting power of attorney.

Be patient and respectful to the staff.

Be kind to yourself with how upset you might feel.

 

 

Legal Fees

15 Mar

 

Legal Fees

 

People can find paying a lawyer hard to understand, as there can be a number of fee options.  With the new businesses entering into the legal market, the option on fees is likely to increase.

 

Traditionally we work on an “hourly rate” basis, whereby the solicitor will have a specific set hourly rate, usually based on their skill and experience.  Then for each hour or part of the hour that they work, they charge their hourly rate.  Most commonly they charge 10 units per hour, so for every 6 minutes or part thereof.

 

We can then work on a “fixed fee” basis, so before we start we agree a fee and unless something that we have excluded takes place, then the fee is known and agreed beforehand.  There is commonly a small element built into the fee to take account of any contingency, so that if a big contingency takes place, the likelihood is that the solicitor will lose, but if no contingency takes place, then the client will lose. And if a small contingency takes place, then the fees are probably about right.  The margins built in are small, so there are never usually significant winners or losers.

 

We can then work on a “conditional fee agreement” or CFA, otherwise known as a “no win no fee” basis.  This kind of agreement is relevant when the matter is being litigated and on litigation, the general rule is that the loser pays the winners costs.  A long time ago one of my undergraduate lecturers said that if you know the answer to the question, you don’t litigate it and I’ve always remembered that.  Litigation is therefore an arena to deal with an issue where the answer is not clear and therefore each party runs the risk of losing and having to pay the others costs.  The answer to this is usually insurance; the price of the policy can be passed onto the loser or sometimes the claimant will have to pay a small premium.  The concept of conditional fee agreements is that if your client loses, the lawyer gets no fees, but if your client wins, then you get a percentage uplift on your fees up to 100%, but it is based on the hourly rate system.  So effectively for every hour that you work, you can be paid for up to 2 hours work.  It is very profitable for the cases you win, but the firms want to be reasonably certain that they will win, so will access the likelihood of success very carefully before they agree to the conditional fee agreement.

 

The other kind of no win no fee agreement is the “contingency fee agreement”, also known in the industry as a CFA!!  This is based on the US model of a share of the amount recovered, that we are familiar with from TV and film.  From TV and film, we are comfortable with the idea.  This is used in an administrative process and not where the matter is being litigated, so there is no risk of adverse costs (the loser paying the winner) and therefore no need for an insurance policy to protect from adverse costs.  The fees are often far higher, but the firm again takes the risk that they may get paid nothing, clients are usually happy to have a share of something, rather than all of the nothing they had without the help of the solicitor.

 

There are also things like legal fees as part of your house insurance, but this can sometimes come with restrictions, because the insurer usually wants to know that either the fees are nominal or can be recovered via adverse fees.

 

There is no right and wrong answer on fees, some people like certainty with fixed fees, some people don’t want the risk of fees, so opt for a no win no fee and some just don’t want the uplift, so will pay an hourly rate.  As long as the fee structure is understood, the choice of how to pay for fees is the clients.