Complex Dementias: An Engagement-focused Approach

Deidre has lived at Adderley Green neurological care centre, set in the heart of Bentilee in Stoke-on-Trent, for the past three years, having resided nearby in the local community for most of her life. For Deidre it’s 1985 and she’s spent the afternoon leafing through some classic novels at Webberley’s bookshop and now plans to enjoy a nice cup of tea at Tiko’s bakery and café. Deidre has dementia and today she’s been accompanied by a physiotherapist who’s been assessing her mobility and a healthcare assistant who engages her in conversation whilst helping her find some of her favourite books to enjoy.


Deidre is a resident at Gladstone House (within the care centre), a specialist custom-built, three-unit house that offers complex care packages for residents over the age of 65 with dementia and neuroprogressive conditions. Both Webberley’s and Tiko’s were well-known destinations in Stoke-on-Trent and have been recreated at Gladstone House along with a number of other popular landmarks, to provide a familiar and comforting setting for residents living with dementia.


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The physiotherapist and healthcare assistant accompanying Deidre are part of the multidisciplinary team (MDT), that provide person-centred care for complex dementias. This care is provided within a unique dementia-friendly environment that      also includes a sensory room and social spaces. Many of the residents at Gladstone House are in the latter stages of the disease, and so the MDT have the unique challenge of maintaining quality of life for each individual as their care needs progress. They may also have significant underlying health problems arising from acquired injuries or from a stroke.


Much of the guidance for care settings looking after residents with dementia focuses on those who are in the early stages of the disease. Very little covers complex or more developed dementia. So in order to bridge this gap, Gladstone House have developed a unique engagement-focused approach, accompanied by an award-winning dementia training programme, to ensure that each resident receives expert care focused on their individual needs.


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Inclusive, engagement-focused approach


Damien Humphreys is the Senior Physiotherapist at Adderley Green Care Centre and works closely with residents in Gladstone House. Specialising in neurological rehabilitation and management of musculoskeletal conditions, he also has a specialist interest in dementia.


Damien is passionate about improving quality of life for people living with the condition, and attributes the success of Gladstone House’s dementia care provision to their inclusive and engagement-focused approach. All team members support residents to stay active and engaged with daily life, even if they have complex care needs.


Damien says: “Our priority is to maintain a good quality of life for each person that we support. To do this, however, it means we must take a positive attitude to risk, we have a team of skilled therapists who can assess individuals and their specific needs. So that meaningful activities can be undertaken in the safest way possible. We encourage movement and participation in activities and daily tasks wherever possible, and try to maintain independence for residents by exploring what is possible for each person. As a team we adjust our way of working to suit the unique requirements of each individual.


“For example, sometimes residents arrive at Adderley Green and they have been bed-bound for a number of months. The first thing that we do is to ensure that they are given the opportunity to access social spaces so they can receive appropriate levels of stimulation and support. It’s important to remember that each individual with dementia responds differently to activities, so levels of engagement must be tailored to their specific needs.”


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The MDT at Gladstone House use the Pool Activity Level (PAL) dementia assessment tool to understand the appropriate level of stimulation for each person. PAL assesses the overall level of individual cognitive and functional ability, and focuses on the strengths of each person and what they are able to do, rather than what they are not. As Damien outlines, with this knowledge the MDT can work together to facilitate the correct physical and social environment required to sustain those abilities, maintaining quality of life wherever possible.


Damien says: “We’re determined that nobody should miss out, so we use the combined skills of our therapy and clinical team to give each person equal opportunity for interaction. As well as dementia, our residents frequently have complex medical conditions so the relevant assessments must have been completed by the clinical teams first. This is to ensure that any movement or activity we attempt is in line with the individual’s personal care plan.


“Where appropriate we’ll use assistive equipment – often individuals will experience weakness in their limbs if they have been bed bound for an extended period of time. With the use of hoists and slings, and with support from the therapy team, we’ll ensure the correct positioning and specialist seating is available for every person that needs them.


“Once the individual is seated or more comfortably positioned, and can be present for activities on the unit, we’re then able to explore appropriate levels of engagement. We use the Pool Activity Level (PAL) dementia assessment tool to tailor activities to their specific needs, and as a multi-disciplinary team, we all feed into the assessment.”


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Understanding the triggers for challenging behaviour


Activities at Gladstone House, Adderley Green are always intended to be enjoyable and meaningful for each resident who participates in them. However, if a resident has dementia, this will impair their cognition and reasoning which makes participation in activities more difficult. Sometimes residents can become distressed and present challenging behaviour. But as Damien explains, the triggers for challenging behaviour can be understood and reduced through a person-centred approach to care


Damien says: “When residents do display challenging behaviour, there are always reasons why this happens. Part of our work is to understand those reasons. For instance, some of the resident’s care needs may not have been addressed, and we have to consider the impact of their immediate environment. Individuals with dementia respond differently to stimulus and we need to ensure each resident is cared for within the most suitable environment for their needs.


“For example, a male resident, who had advanced dementia that affected his cognition, was struggling to settle in. He became quite agitated and physically aggressive when engaging with staff and frequently expressed a wish to leave the service. Unfortunately because of the complex nature of his care needs, he needed to remain at Adderley Green but he wasn’t initially able to understand or accept this.


“So our psychologist spent time with him each day, in order to understand what was triggering his behaviour and causing him distress. After talking and interacting together for a period of time they were able to take daily walks together. The resident was more relaxed and open with communication. Since then we have seen a significant reduction in his challenging behaviour.”


“In this instance we took a positive risk, to support this resident in accessing the local community. The MDT worked together to put a plan in place so that the safety of the resident, staff and people in the community was maintained, whilst meeting the resident’s needs and promoting a better quality of life. Our team has extensive training about dementia and have been provided with the knowledge and skills to be able to manage challenging situations. We mitigated the risks and were able to meet his needs, which of course was the underlying reason for the challenging behaviour.”


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A flexible approach to dementia care


In order for an MDT to meet the often complex and diverse needs of each resident, it is vital to adopt a flexible approach to care. As Damien explains, traditional approaches, particularly within physiotherapy, aren’t always successful with a complex patient group and are often unsuitable for their high level of care needs.


Damien says: “The ability to adapt normal ways of working so that we can provide person-centred care is essential. For example, group physiotherapy sessions, or even one-to-one sessions are not possible. Due to the cognitive impairments caused by dementia, it can be quite confusing for residents to take part in formal sessions. They can’t understand why they should participate and what the benefit is, so it can be unsettling for them.


“The last thing that we want to do is to cause additional distress for residents. Instead I’ve adapted my approach so that therapy sessions can be integrated within their daily routines. Residents participate in activities that mirror daily life so that includes elements of self-care such as getting washed and dressed, their daily meals, perhaps visiting a café and similar. I’m present whilst they go about these tasks and I’ve learnt to look for non-verbal clues as to how they are feeling and what additional support they may need.


“I can identify if they are in pain and I’m able to develop strategies for managing this pain so that they can continue to participate in meaningful activities and can maintain a positive quality of life.”


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Responsive therapy across the MDT


Each unit at Gladstone House has its own cinema and themed eating and seating areas, and each resident has access to the library, record shop and Murphy’s, the onsite public house. The corridors incorporate replicas of local community facilities including the village hall, Webberley’s bookshop and Tiko bakery and cafe. Such areas stimulate memories and enhance the quality of life for residents.


Elinor Jordan is an Occupational Therapist (OT) at Adderley Green and, as part of the OT team, she works with residents at Gladstone House to promote their quality of life whilst empowering each resident to be involved within their daily activities.


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Elinor and the other OTs at Adderley Green have also adopted a responsive therapeutic approach working with the unique environment at the service to both deliver therapy and enhance quality of life for residents.


Elinor says: “Our work is integrated throughout the resident’s daily routines and we try to make sure our assessments and therapies fit in with whatever they are doing. We try not to disrupt them.


“We always tailor our support to their appropriate engagement level, as determined by PAL. So perhaps we’ll provide sensory stimulation whilst they’re getting dressed with a particular soap or perfume where the smell triggers happy memories and creates a homely experience for them. This often prompts conversation or just


“The MDT approach enables us to provide safe and effective care but also incorporates a resident’s particular requirements at any given moment in the day. Our roles overlap so that we can support each other and our assessments and care planning are more thorough because of each team member’s input.”



Responding to changing care needs


A real benefit of this flexible therapeutic approach is that support is responsive to each resident’s current condition, rather than a historic assessment. As Damien explains, symptoms of individuals with complex care needs change frequently as their conditions progress and sometimes these can be missed without frequent interaction and monitoring.


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Damien says: “This approach ensures that I have regular contact with residents in their daily living environment. It provides me with much more knowledge and understanding of their situation than I would have if I was just running formal sessions off a previous assessment.


“Crucially it enables the identification of changing care needs as they happen, and we can create new assessments and provide appropriate therapeutic interventions within good time. The presentation of symptoms for individuals with complex dementia changes frequently, so my assessments are ongoing and I can see if additional support is needed.


“This applies to how our whole MDT operates. Due to our fluid approach to working, ensuring that everything we do is tailored to each resident’s individual needs and incorporated into their daily activities, we can provide a much more effective form of care. The benefit to the resident is greater as they experience a more positive quality of life and they can work towards outcomes that are most appropriate for them.”



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You can also visit each service’s profile page to find out more about what our EveryExpert approach to care looks like in practice:

The Bridge, Middlesbrough
Adderley Green, Staffordshire
Badby Park, Northamptonshire
Stanley House, Herefordshire
St Neots, Cambridgeshire
The Avalon Centre, Wiltshire


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