clinical focus
look like if you take advantage of the timetable that comes with
it. Right down to getting a park at the gym because you’re going
there at a different time of day.
The course also works through some of the sleep and night-
time experiences of people with dementia in residential aged
care. What are some things people might not think about when
it comes to this aspect of care?
Have you ever had the experience of waking up in a different room
and for a few moments been disoriented as to time and place? It
can happen to those of us who are lucky enough to travel through
time zones and get jet-lagged. And you’re in a hotel somewhere
and you wake up and you have no idea what time it is, and you
don’t really know where you are – even the bathrobe hanging on
the back of the door looks like Darth Vader. And it’s a tremendous
surge of relief when you suddenly comprehend where you
are, what the time is, where the city is, and the world becomes
coherent again.
Well, imagine this scenario. A person with dementia is living in
residential aged care and they haven’t been there for long – it’s
still in the first few months where they’re getting oriented to the
place. They wake at two in the morning, perhaps it’s an internal
trigger related to toilet needs, though they may not be aware that
it’s related to the toilet, but something’s caused them to wake.
They’re over 70 and usually wear glasses and a hearing aid. But the
glasses are off, the hearing aid is out, and the world is muffled and
dim. They have a sense of hearing some noise but can’t pinpoint
the source. They might have a sense of some patchy light but
can’t recognise it. They’re glancing around the room but it doesn’t
look familiar – the shadows look like animals and strangers. It’s
very similar to what I just described of waking up in a hotel room
that’s not yours and you’re jet-lagged. And in a matter of seconds,
the person with dementia might feel highly anxious, completely
disoriented and not quite sure what to do.
Now the whole scenario could have even built an emotional
bridge to another part of early life for that person. Maybe as a
child they spent time in boarding school and there was staff
that patrolled the dorms. Chances are there are lots of trigger
factors in this sort of scenario that the night care staff might not
realise can affect the person with dementia – keys jangling on a
belt, footsteps in the corridor, a trolley being pushed up the hall,
even the conversations staff are having with each other outside
residents’ doors.
Now, all these noises can be measured. You can even get free
smartphone apps to figure out just how noisy we are when doing
our jobs. So we can actually get a sense of these sorts of things,
and people may not realise how much those noises and lights
and funny sounds actually travel and impact on care, and how a
person with dementia is feeling.
Let’s assume now that staff have become aware that this person
is awake, they’ve even perhaps entered the room. There’s a whole
range of other triggers. What if the person who’s come in to check
on the resident is wearing day clothes? Smells of coffee breath?
And yet is telling you it’s time for sleep, to get back into bed? So,
there’s a whole bunch of cues here that are helping night care staff
be aware of them. Even turning up and checking on somebody
while wearing a dressing gown over your uniform might provide
those cues to people with dementia that say, hey, it’s sleep time
now. Or help them settle and deal with the anxiety of orienting
them to the time and place with appropriate lighting, maybe some
smooth music, those sorts of things.
And the course focuses on the idea of salutogenic person-
centred care. How does the night-time context play into that?
The word ‘salutogenic’ is not owned by Dementia Training
Australia. Let me explain it by, first, saying that sleep has a
tendency to be talked about in the language of problems. So, we
focus on being awake for too long, insomnia. And when we are
not sleeping, we worry it’s going to be a symptom of something
dreadful and sinister or cause something worse, even death. I
remember as a teenager worrying when I didn’t get enough sleep
that it was going to cause me to die at the age of 17.
Now that ‘language of problems’ applied to something like
sleep is part of the mindset we would call a traditional pathogenic
approach. In other words, what’s the pathogen, what’s the cause
of the problem? What’s the cause of the disease or what’s the
source of ill-being? And what can we do to make the problem
go away? And for sleep, a sleeping pill is a good example of that
approach. Sometimes it’s valid, but it’s not always going to be the
right response all the time.
A salutogenic approach to sleep is the flip side of pathogenic,
because salutogenic literally means sources of wellbeing. So
instead of focusing on being awake, as a problem in itself, we’re
going to start looking at the factors which, firstly, contribute to
restful sleep as a positive, and planning ahead.
For example, we know that in person-centred care for
dementia, we might be aware the person is incontinent, but
checking behaviours at night to wake a person up to replace their
incontinence pad is not a useful way of keeping them asleep. So
we’re going to have to make a decision there between keeping
the person comfortable and rested versus keeping them dry and
awake. And that’s a care plan decision.
But also with the salutogenic approach, we can allow ourselves
to challenge the assumption that being awake at night is a
problem in the first place. We have all sorts of assumptions about
what we’re supposed to do at night. And person-centred care, at
night for a person with dementia, might actually commit them to
be awake and have it as a meaningful moment on their terms. It
probably is okay to be able to have a snack o r a chat, to watch the
telly, or even do a bit more on a favoured hobby. It has to be better
than being disoriented in the dark.
So, salutogenic person-centred care will look at night-time and
sleep needs from the perspective and preferences of the person
with dementia, rather than the routine or timetable of the facility
delivering care. It’s easier said than done, but for the person with
dementia, what goes on at nights in a salutogenic framework will
hopefully be comprehensible to them, manageable for them and
ultimately meaningful on their own terms. These are the three
ingredients of salutogenesis.
What do you hope shiftworkers take away from the course?
I’m hoping that the fact that there’s a course for them, specifically
looking at their world, is a key message that says, hey, you’re a key
part of the action here in making the best life possible for people
with dementia, but also for yourselves.
Shiftworkers are among the unsung heroes in the aged care
sector. We need this part of our workforce to be as happy, healthy
and satisfied with their careers as possible. And hopefully this
course will contribute to these aspirations. We have about 400
folk already signed up for the first rollout of the course, and we’re
looking forward to their feedback as to whether it tackles the
issues from their perspective and what we can do to improve the
course as we continue to develop it. ■
agedcareinsite.com.au 23