Effective Social Work with Older People

CHAPTER FOUR OLDER PEOPLE - THEIR NEEDS FOR SOCIAL WORK

Introduction

4.1 Old age is not of itself a 'problem', pathology or statement of need. In the words of the interim report of the 21 ^st Century Social Work Review (Scottish Executive 2005):

' Older people are not a homogenous group, and categorisation as a distinct service user group is, arguably, contentious. People do not receive social services by virtue of being 'older'. Rather they are in need of service, for example because of ill health, physical impairment, mental health difficulties (significantly dementia), addiction or offending.' (p16-17)

4.2 Under the heading 'the limitations of the client group approach', Statham et al (2005) write on the same theme:

"Many people in the adult groups have a range and variety of physical, sensory, mental health, substance misuse and/or learning difficulties, in different mixes, which interact with each other, and with acute and chronic health conditions, to produce a wide variety of obstacles to ordinary living, social inclusion and the exercise of their human and civil rights. The same conditions and combinations affect the lives of children and people over 60 or 65' (pp53/4.")

4.3 This chapter looks in more detail at the incidence and consequence of these conditions in people over 65, to consider whether and how the need for social work help may be heightened by the combination with age, i.e. whether care needs are significantly different or greater than if they had occurred in earlier adulthood. This will provide a basis upon which to discuss more fully the nature of effective social work with older people who have such conditions, or find themselves in these circumstances.

Demography

4.4 The results of the 2001 Census confirmed predictions about a large change in the demographic profile of Scotland over the next 23 years. The number of older people is predicted to rise by 46%, from 812,000 in 2002 to almost 1.2 million in 2027. Further analysis reveals even higher predicted rises in the very old population (aged 85 and over) from 88,000 to 174,000 over the same period (Audit Scotland 2004).

4.5 The overall increase in the older population has far reaching implications for future service provision, particularly an increase in demand for community care services. The anticipated growth in over 85s will place more pressure on these services. The rates of physical impairment and dementia are significantly higher among this group, leading to a need for more specialist care. As a percentage of the total population, the 65 and over age group will increase, while those most likely to care for them (aged 35-64 years) will decrease (Audit Scotland 2004).

4.6 We have included these figures and projections for two reasons: first, to underline the importance of defining clearly and carefully the need for social work support and help (as distinct from social care or social services) to older people with any of the needs described below, as social workers become an increasingly scarce resource. Secondly, it is important to define effective social work support as clearly as possible in order to ensure that social workers are not deployed on tasks where their particular blend of knowledge and skills are not needed, such deployment continuing only because it has always been so.

People with learning disabilities

4.7 Improvements in health and social care mean that people with learning disabilities can now expect to live considerably longer than before. Indeed, those with milder learning disabilities now have a life expectancy similar to that of the rest of the population (Hogg et al 2000).

4.8 As increasing numbers of people with learning disabilities live to an older age, they encounter age-related illness and conditions such as dementia (Watchman 2003). There are mixed messages from the research about how many people with learning disabilities are affected by dementia. Kerr and Wilkinson (2005) emphasise that 'people with learning difficulties for reasons other than Down's syndrome have a similar or only slightly increased risk of developing the condition'. They also quote figures showing that people with Down's syndrome have a much higher rate of Alzheimer's disease than the general population (36% of those over 50, 54% of those over 60).

4.9 Many adults with learning disabilities now living in the community are former residents of long stay hospitals, some having lived in institutions since childhood. Although they are believed to be, in the main, well settled and with a much improved quality of life, many may have little life history to draw on as they grow older. Some will have re-established broken relationships with parents or siblings, which may face new and different tensions as the family group age, and parents and older relatives die. Their ability to remain in the community even with support may become more limited, leading to readmission to institutional care which will present a very particular set of anxieties and challenges. Such older people are less likely to be able to draw on informal care and support in their communities (compared with their long-established 'local neighbours'). Indeed their position in the local community, and community attitudes towards them, may also change for the worse as they become older and their needs and impairments more pronounced. Just as social workers were heavily involved (as part of successful multi-agency teams)in the resettlement of patients prior to the closure of long stay hospitals, we should expect that social workers will be needed when some of these same people develop different needs, as they grow older.

4.10 The Same as You? (Scottish Executive 2000), the report of a comprehensive review of services to people with learning disabilities in Scotland, recommended that local authorities and health services make sure that older people with learning disabilities have the same access to health and social care support as older people generally. A range of professionals continue to be needed - including housing staff, learning disability nurses and psychologists. The Same as You? also identified a new role, that of Local Area Coordinator ( LAC) who should be responsible for co-ordinating services and support to individuals with learning disabilities, or families with a learning disabled member. The LACs must work with the whole person, in their whole environment, assessing and developing all the relationships that the client is part of, and that are changing. This role may be fulfilled by a social worker, although not necessarily.

People with dementia

4.11 Parker and Penhale, noting that the incidence of dementia increases as people become older, nevertheless caution:

"Whilst the incidence of dementia is around 5% at age 60, 20% of those who are aged 80 and over can expect to develop dementia….Whilst this figure, and the increased risk of developing the disease with age is of concern to many, it needs to be kept in perspective: 80 percent of those aged 80 or over do not develop dementia." (p4)

4.12 MacDonald (2004), in a chapter devoted to dementia care, quotes Moriarty's summary of key findings from research:

• the prevalence of dementia is difficult to determine
• there is increased public awareness of dementia, as well as new drug therapies
• the need for access to counselling and support has been more clearly articulated as a result
• people from ethnic minority groups are becoming a growing proportion of people with dementia
• intensive domiciliary care, if reinforced by specialist care management, may enable people to remain in the community for longer
• people with dementia living in the community are especially likely to be reliant on the support of a single person, usually their spouse, or adult daughter
• carers' psychological health is likely to be poorer if they are caring for a person with dementia, and providing substantial amounts of care.

4.13 Later in the same chapter, MacDonald writes 'the confusion of dementia sufferers from minority ethnic groups has been found to be exacerbated by the lack of culturally aware services.' Bowes and Wilkinson (2003) draw attention to cultural differences in the way people perceive dementia. These authors argue that cultural variation is such that the 'only meaningful approach to meeting needs is to offer person centred mainstream services to all on an equal basis'. The reference to 'person centred' is a pointer to the need for social work skills in the provision of care and services to people with dementia and their carers.

4.14 The incidence of dementia, its various manifestations, the effects on behaviour, on quality of life, on relationships and on independence have been much better understood since publications such as Hunter (1997) and Marshall (1997) , as are the particular implications for social work practice. Tibbs (2001), for example, devotes a chapter of her book to the 'core tasks of social work' in relation to people with dementia, discussing assessment, including risk assessment, and care planning, noting the importance of involving 'multiple clients' (reflecting the varying and sometimes conflicting needs of carers) and the 'need for continuous adjustment to the care plan.' She adds:

"Experience teaches us, however, that in the case of the person with dementia, situations can change very quickly…One is the progressive nature of the dementia, which means that changes in the person's behaviour continue to occur. The other is that the carers also live in a situation of life change. Life for them becomes a long series of little losses, of change after change. The care plan needs to be a living, dynamic document." (Tibbs 2001)

She concludes her chapter with a plea for specialist social work expertise for people with dementia, a subject to which we will return in chapter 5.

People with other mental health needs

4.15 Although dementia is sometimes viewed as being synonymous with mental illness in older age, older people may have a range of mental health needs. In 2000, 10% people aged 60 to 74 living in private households in Great Britain had a common mental disorder, such as anxiety, depression or phobias. Women were more likely to have such a disorder (Office of National Statistics, 2003). However, there is a lack of theoretical or empirical studies about the impact of mental illness, other than dementia, on older service users and carers (Ferguson and Keady, 2001).

4.16 Depression is the most prevalent mental health problem in older age. The Mental Health Foundation (1999) suggests about 15% of older people experience depression. However, this figure is probably an underestimate, with high rates of undiagnosed and untreated depression known to exist in both residential and community settings (Audit Commission, 2000). The literature also suggests that older people are less likely than younger people to take up mental health services (Ashton and Keady, 1999). Factors that appear to contribute to depression include loss (e.g. of status or of an intimate relationship with a spouse) and social circumstances, such as poverty, poor housing and isolation (O'Neill, 1999).

4.17 Depression also tends to be associated with physical health problems, especially acute illness, and with being in pain (Livingstone et al., 2000). New findings from a study entitled 'Physical health and depressive symptoms in older Europeans', published in the British Journal of Psychiatry in July 2005, found that the link between poor physical health and depression in older people is stronger in the UK than any other country in Western Europe (Source: Care and Health website, July 2005).

4.18 There is a tendency for both professionals and older people themselves to treat late life depression as an inevitable consequence of aging (O'Neill, 1999). However, there is evidence of the effectiveness of a range of interventions, including environmental changes, psychotherapeutic and cognitive behavioural therapies, and anti-depressant medication (Snowdon, 1998:61).

4.19 Little research has considered the needs of older people with functional mental illness, such as schizophrenia and mood disorders, whether mental health problems have been present in younger adulthood or developed with increasing age. With the closure of long stay psychiatric hospitals, increasing numbers of older people with schizophrenia are living in the community. It has been suggested that the particular care needs of this group, including physical health and social needs, have not been well addressed (Royal College of Psychiatrists, 2002). Research in a rural area in England confirms that older individuals with schizophrenia experience high levels of social isolation (Rodriguez-Ferrara et al., 2004). McNulty et al. (2003) have also assessed the needs of older people with schizophrenia in Lanarkshire and found considerable unmet care needs in both hospital and community settings.

4.20 Long stay hospital wards for people with psychiatric disorders have been closing over the last 20 years. Many of the patients discharged were either over 65 on discharge, or are now over 65. Their background and current needs will be similar to those described above for people with learning disabilities. Again, the core tasks of assessment, planning, coordination and care management are likely to fall to a social worker, as 'lead professional'.

ADDICTION AND SUBSTANCE ABUSE

4.21 Some older adults will have abused alcohol or prescription medication when they were younger. Others may develop problems as they become older, sometimes triggered by traumatic events such as bereavement and illness. There is evidence of increasing numbers of older adults coming to the attention of services because their health, care, and sometimes safety are affected by alcohol consumption. Although generally alcohol consumption is known to decline with age, alcohol is a significant factor in self-neglect among older people, shortens life expectancy and is often associated with malnutrition (see Linnett 2001). Substance misuse among the older population is frequently overlooked but, once diagnosed, responds as least as well to treatment as abuse among younger people (McGrath et al., 2005). There are examples of older men and women appearing to have a serious alcohol dependency who have recovered a significant degree of control when they moved into a care home, with the companionship and support that brings. No 'effective' alternative may be available to them.

4.22 Service users who develop any of the range of alcohol related conditions, such as Korsakoff's syndrome, will demonstrate behaviours that may require specialist facilities beyond those available in the community (Kaplan and Hoffman, 1998). A literature review of service provision for people with alcohol-related brain damage found that most service users in the U.K are over 50 and that there is increasing prevalence of the syndrome. The need for integrated assessment and joint working, including social work intervention, to co-ordinate service provision is emphasized (MacRae and Cox, 2003).

PEOPLE WITH PHYSICAL ILLNESS, IMPAIRMENT OR FRAILTY

4.23 The majority of older people up to the age of 85 do not report having long-term illness or disability. Nevertheless, certain types of physical illness are strongly associated with old age. These include arthritis, and other muscular-skeletal conditions, heart and circulatory diseases and eye complaints (MacDonald 2004).

4.23 Many older people will be referred for the first time to social services as a result of

• a fall, or similar accident, resulting in a fracture and hospital admission
• stroke, heart attack or similar sudden onset, leading to admission for treatment or medical assessment
• the advance of a debilitating and disabling condition, such as arthritis, or Parkinson's, to the point where ability to maintain an independent lifestyle without significant support is seriously impaired
• similarly, deterioration and increase in sensory impairment.

Medical, technological and social developments mean there has also been a dramatic increase in the number of younger disabled adults who survive into old age (Priestley 2003).

4.24 The most common reason for social work referral is a decrease in the older person's capacity to carry out the activities of daily living. In some situations, treatment, including surgery, may well restore physical capacity, although significant rehabilitation, convalescence and 'intermediate care' may be required before that person's confidence and capacity are sufficiently restored to enable a return to a reasonable quality of life in their own home. Working in partnership with housing and health authorities, social services are able to support rehabilitation with equipment, adaptations, home support and care services. The process of assessment (to ensure that the services to be provided are tailored to meet individual needs) and of care management (to ensure that services remain in place so long as they are needed) is an essential part of supporting the older person.

4.25 It does not necessarily follow that social workers are always required to carry out those roles. Occupational therapists, community based nurses, or on occasion housing or hospital based nurses may be better placed, and have a more appropriate range of skills, not to mention a pre-existing relationship with the service user/patient. The location of the worker (i.e. if they are employed by the organisation which controls the resources the person needs) may be more important than the particular skill set. However, where recovery is incomplete and major change of home and loss of independence occur, social workers' particular skills in comprehensive assessment of psychosocial, spiritual and physical needs, and in managing and enabling change involving a range of factors and agencies, will be necessary.

OLDER CARERS

4.26 The term 'older people' can encompass two complete generations, as retirement takes place between 50 and 70 or more, and the numbers living into their 90s and beyond grow rapidly (Brand et al, 2005). As the Audit Commission (2004) notes 'most carers are of working age, but one in six are older people themselves. ' Indeed, the Census (2001) results show that people over the age of 65 are just as likely to be providing a very high level of care (50+ hours weekly) as they are to be providing less than 20 hours of care (MacDonald 2004). It follows that older carers are more likely to experience one or more of the disabling conditions described above as occurring in the older population. Twigg (1992) notes:

" A significant proportion of older carers report some form of disability. This can often add to the difficulties of their caring role, particularly if the cared for person requires physical tending."

4.27 This will be additional to the stress of caring, perhaps for a parent, uncle or aunt, or partner. MacDonald (2004) quotes figures showing the extent to which this care may be needed away from the carer's home. Spouses over pension age provide most support with personal care tasks (Stalker 2003).

4.28 In the event of breakdown or deterioration, not only will assessment and services be required both for carer and cared-for person, but there will be additional dimensions of relationship stress, grief and loss. These factors may require the involvement of a social worker, as distinct from a health professional.

PALLIATIVE CARE - THE NEED FOR A HOLISTIC APPROACH

4.29 In chapter five, we look in greater detail at the social work role with people who are dying. Here we note simply that social work with older people is, inevitably, much more likely to involve work with people at the end of their lives. We shall see how this requires key social work skills - working with loss and dependency, engaging with families affected by death, practical tasks, attending to emotional and spiritual struggles and to the support needs of colleagues in the multidisciplinary team.

4.30 We refer to death and dying here partly as an example of direct social work with older people, but also as a further illustration of the ways in which needs and circumstances combine to present a set of challenges which social work is uniquely placed to face. Here we draw an example from Marshall (1997) concerning a social worker called Mary Dixon, described as an exceptionally skilled and experienced practitioner with older people. Dixon writes about a family with whom she worked for a number of months, describing the initial situation thus:

"Mr and Mrs Mair were referred to the community care team I work in by their daughter Marjory. Mrs Mair was experiencing problems due to her poor short term memory. She could easily be upset by changes to her routine, and was sometimes agitated with those around her. Her frail 90 year old husband was struggling to provide the care she needed. However, his own health was poor; he suffered from respiratory problems and was quite arthritic."

4.31 Dixon goes on to describe her efforts over the next few months to meet the range and combination of needs in this one case - completing a comprehensive assessment, enabling an application for attendance allowance, arranging day care and 'cajoling' the GP to refer for a formal diagnosis of Mrs Mair's condition. These 'care management' tasks were well received by all the family, who became confident in the social work intervention. However:

"Suddenly, at the turn of the year, Mr Mair became ill, and died within three days. The close knit family were shocked and soon torn apart by their grief. Central to their distress was the reaction of Mrs Mair to losing her partner of sixty two years. She had visited him in hospital, been with him when he died, attended his funeral, but all with no reaction, no obvious grief. At the graveside her only action was to nudge her daughter, and ask what time they would be going home to dinner." (p222)

4.32 Dixon then explains the work needed to enable the family, Mrs Mair and other care staff come to terms with these 'massive' changes, including of course whether, and how, to help Mrs Mair, in her dementia, to understand or even believe and remember that her partner had died. We will look at this again more fully later. Here we emphasis the importance of examining effective social work in the context of combinations of multiple needs - in this instance, dementia, physical impairment, grief and loss, in the client as well as the family. Complex scenarios of this kind are a particular feature of social work with older people: like all social work, it is about the whole person within their family, community and circumstance, not simply their presenting need of mental illness, learning disability or whatever. Social workers must understand the range of needs and what research tells us about incidence, changing patterns and trends. For the social worker, the task is to face the impact of those, singly or in combination, on the person, their family, and the other services which support them.

4.33 In our experience, this case example is not exceptional: rather, it is representative of the complex challenges that regularly face social workers who work with older people.

4.34 We conclude this chapter with a reference to another paper prepared for the 21 ^st Century Social Work Review (Statham et al 2005):

" Various terms and subdivisions are in use, such as 3 ^rd Age, and 4 ^th Age, 'sundowners', and 'frail elderly people' to distinguish the relatively active, unimpaired, and independent, from those with often multiple physical, sensory, mental health and psychological problems, who require treatment and support from a variety of agencies and other sources. In reality the line between relative independence and complete dependency is a spectrum with a multitude of stages, and people move along it in different and highly individual patterns. Many older people are contributing to the community in various ways as carers and minding grandchildren, in paid employment, as volunteers and in voluntary organisations, as councillors in different levels of local government. The loss of a spouse, onset or discovery of severe illness, a fall and loss of confidence, or being victim of a burglary, can all produce an abrupt shift to greater dependency."

4.35 In short, older people do not need social workers just because they are old. It is when the sudden 'shift', recurrence or gradual change occurs that social work comes into its own. The skills and role of the effective social worker, in the event of such severe traumas, change or loss for an older person, are explored in more detail in the following chapter.

Conclusions