"This is one of the most original works of geriatrics in a long time. It deserves a wide readership and much discussion." --D. O. Staats, MD, Doody's Book Review Service, Oct. 2010
Allen Power's new book, Dementia Beyond Drugs: Changing the Culture of Care, has just stripped you of your last excuse for not understanding what it takes to bring about real culture change within residential care settings while at the same time reducing the administration of psychotropic drugs. He has answers for questions you've had about assisting people living with dementia. Al's grasp of the subject is comprehensive and his style of communicating is informative, accessible, and inspiring. If you implement the information that Al suggests, you can be the person you've always wanted to be when assisting others living with dementia. He's one of the best guides out there on the pathway to understanding care that treats individuals with dementia with the personal attention, respect, and dignity they deserve. (Carol Ende, Executive Director Eden Alternative 2009-11-04)
“Allen Power is my kind of physician -- one who understands the research and who has a big heart. Drawing on years of experience, he presents a compelling case for eliminating the vast majority of antipsychotic medications used to treat unpleasant symptoms of dementia. Family members and caregivers will embrace his compassionate, relationship-based approach. Dementia Beyond Drugs should be required reading for every long-term care provider.” (Beth Baker Journalist & Author, Old Age in a New Age: The Promise of Transformative Nursing Homes 2009-11-11)
“This extremely important book directs our attention to the virtue and value of engaging individuals with dementia as people rather than as cases to be managed with drugs. Dr. Power's deep appreciation of how a humane environment can help persons with dementia to flourish rather than to wither should be required reading for all involved with residential care.” (Steven R. Sabat, Ph.D., Department of Psychology Georgetown University 2009-11-23)
"Dementia Beyond Drugs: Changing the Culture of Care is a totally engaging book that clearly illustrates the restorative effects of humane care in combination with advances in modern medicine. Dr. Al Power makes a compelling case for deep system change, where knowing the person is paramount in our approach to compassionate elder care." (Rose Marie Fagan, Co-Founder Pioneer Network 2009-12-01)
“This book is groundbreaking, courageous and awesome, representing a new milestone in dementia care. Dr G. Allen Power dares to challenge the current paradigm and urges readers to walk the walk of culture change, creating a better world for people with dementia. This thoroughly researched, practical and deeply compassionate book is a must for all working in the field of dementia.” (Hilary Lee, MSc, OTR, Chair The Society for the Arts in Dementia Care, Inc. 2009-11-25)
“Al Power has authored a book that fills an enormous gap in our understanding of how we, as individual caregivers and as a society, can improve the care for those with dementia. Written with his characteristic directness, warmth, and compassion, these pages are filled with new insights and clues as to how to avoid dangerous drug therapy and restore dignity and comfort to these individuals. This book will be a landmark in geriatrics and has something of value to family caregivers and seasoned physicians as well.” (William J. Hall, MD, Paul Fine Professor of Medicine and Director of the Center for Healthy Aging University of Rochester, School of Medicine 2009-11-23)
“Using story after powerful story to reveal the shortcomings of a biomedical approach to care, Dr. Power has helped us open our eyes to a new way of viewing those living with dementia. We have created worlds where our elders with dementia do not want to be, then medicated them to keep them there. Dr. Power's "Experiential Model" offers us a viable and humanistic alternative to caring for those with dementia. This model challenges care providers to not only open their eyes, but to also see the beauty and potential of the human spirit that remains. Our elders living with dementia are our greatest teachers and Dr. Power has been an exceptional student. He has learned their lessons well and, in this important book, now shares them with us. I hope we are ready and willing to learn.” (Nancy A. Fox, Chief Life Enhancement Officer Pinon Management 2009-11-23)
"This is a 'must have' book for your library if you care about persons with dementia. It is filled with practical, valuable information and insights that can transform practice. I highly recommend it." (Joanne Rader, RN, MN, PMHNP Nurse Specialist Consultant 2010-01-21)
In a moving wake-up call to geriatrics professionals and caregivers, G. Allen Powers delivers a blueprint for the effective care of aging dementia patients in his book Dementia Beyond Drugs: Changing the Culture of Care. He calls for a sea change in the approach to dementia care, replacing the use of drugs with compassion, caring, and genuine efforts to treat patients with dignity and respect. Through case studies and personal accounts, Powers discards the pervasive model of dementia care utilizing antipsychotic medications that alter patients’ behavior and attempt to promote compliance. He encourages practitioners to embrace a cultural change in dementia care that focuses on the patient as an individual. He suggests that in many cases where communication and interaction can identify a source of confusion or agitation, drugs become unnecessary. Powers’ insider’s view of the need for sweeping changes in institutional care captivates readers through his vivid descriptions of experiential encounters and practical, humane solutions. Thought-provoking anecdotes prompt readers to evaluate situations and draw parallels to similar patient concerns. To effect the changes Powers proposes requires attitudinal modifications aimed at empowering caregivers to seek solutions that improve dementia patients’ quality of life and ability to navigate their environments without medication whenever possible. And Powers makes a powerful case for practitioners to ascertain that the possibility exists for the great majority of dementia patients. (Aging Well Magazine 2010-07-18)
For the past decade Dr Al Power, a specialist geriatrician, Associate Professor of Medicine at the University of Rochester, New York, Eden Alternative Educator and Mentor, has been taking every opportunity to discuss the use, or rather the overuse of medication in the management of dementia. This book brings together the essence of those talks in a lucid and easily understood manner. More importantly the book includes a minimum of ‘medical’ language making it accessible to most of the elder care workforce. The book is subtitled ‘Changing the Culture of Care’ and in many ways this is the primary purpose of the book. In discussing alternatives to drugs Dr Power delivers a ‘primer’ for a philosophy of care based on the development of relationships with the elder being cared for. It can be seen as a companion volume to the Eden Alternative Handbook. The book is divided into three sections. The first, Paradigms and Problems, includes a discussion of the shortcomings of most drug research associated with dementia and the relationship between many of the challenging behaviour associated with dementia and the institutional environment which provokes many of those behaviours. The second section, Shifts, describes a different approach, what Dr Power calls an experiential model. This model sees dementia, not as a burden on individuals and society in general but as a life experience, and emphasises the absolute need to see each person with dementia as an individual with individual needs. Our challenge is to understand the world from their perspective, rather than attempt to corral them into ours. The third section, Solutions, describes some specific examples of using the experiential model to understand some of the more common problems that arise with dementia. This book should be read by everybody who is disappointed by what they see as the current paradigm for residential care and who knows there must be a better way. (Eden Alternative UK & Ireland 2010-07-20)
**Description** This book gives the intellectual history of the Eden Alternative -- a restructuring of long-term care for demented persons. In shifting the attention from the institution to the person, different paradigms of care emerge. **Purpose** The purpose is to demonstrate a different way of caring for demented persons in long-term care. This is a large segment of long-term care and the author meets the objectives handsomely. **Audience** The audience is persons who care for demented person in long-term care. This covers a wide swath of individuals -- physicians, nurses, social workers, psychologists, administrators. The author is an expert in the area. **Features** The first of the book's three sections, on paradigms and problems, outlines the gaps in historical treatments of demented persons and lays the groundwork for discussing the Eden Alternative approach to care of these patients. The second part describes how changing to a more person-centered model of care brings better outcomes. The final section, on solutions, describes approaches to paranoid behavior, anxiety and agitation, communication, and "I want to go home." Throughout, well-articulated vignettes and clear descriptions of new approaches to care, linked to well-cited references, give the underpinnings for new approaches to care. Finally, an appendix lists resources. **Assessment** This is a most intriguing book. It broadens the traditional medical model, which, in its most classic form, gave medications to treat symptoms and therefore mitigate suffering. A deeper understanding of the psychological nature of persons with Alzheimer's disease permits a better understanding of what lies behind their behaviors. The book gives the beginnings of how to operationalize this understanding by changing the physical layout of long-term care facilities and by changing the agenda of these facilities. How to understand what demented persons mean in their language and actions and, in turn, how we can best respond are laid out in this timely book. It synthesizes a large body of new knowledge and presents it with very good vignettes. The gentle storytelling is done here to great effect. This is one of the most original works in geriatrics in a long time. It deserves a wide readership and much discussion. ----------------------------------------------------------- Weighted Numerical Score: 92 - 4 Stars! (David O. Staats, MD Doody's Review Service 2010-10-08)
"This is one of the most original works in geriatrics in a long time. It deserves a wide readership and much discussion." (Doody's Review Service 2010-10-08)
"This book should be read by everybody who is disappointed by what they see as the current paradigm for residential care and who knows there must be a better way." (Eden Alternative UK & Ireland 2010-07-20)
"In a moving wake-up call to geriatrics professionals and caregivers, G. Allen Powers [sic] delivers a blueprint for the effective care of aging dementia patients..." (Aging Well Magazine 2010-07-18)
Power (medicine, U. of Rochester), an internist, geriatrician, and nursing home practitioner, outlines ways to address the symptoms of dementia without using medication, for those involved in patient care, including nurses, social workers, occupational therapists, medical directors, and administrators, as well as family members and students. He describes the current view of dementia and its behavioral expressions, trends in medication use worldwide, and the research the prescribing patterns are based on; the problems with this model of care; a new experiential model of care for people with dementia to experience well-being and growth with little or no medication; and approaches to care based on his work with the Eden Alternative, a movement that is working to change elder care. (Book News, Inc. 2010-09-01)
With the demographic imperative of the world’s rapidly aging population, optimal care of older adults is a compelling concern. The prevalence of dementia is anticipated to increase as a consequence of these population trends. Current models of dementia care have limitations. In his book Dementia Beyond Drugs: Changing the Culture of Care, G. Allen Power proposes a transformative culture change from the conventional institutional model of dementia care to a person-centered model that is far more reliant on individualized interactions, communication, and cultivation of relationships than on pharmacotherapy, regimented schedules, and treatment plans. With a careful review and synthesis of the literature, Power’s book is sufficiently comprehensive and detailed to be useful for clinicians and anyone involved in patient care or administrative aspects of long-term care. It is also sufficiently accessible to be relevant for a lay audience. The text is infused with stories that emphasize the topics discussed and assist the reader in recognizing the compelling humanity of dementia care. The book has relevance to psychologists as it provides a context for the consideration of changes in the current modes of dementia care, presents evidence of the limitations of current therapeutic interventions, explains the various models of care that undergird the patient-centered model that the author proposes, and offers potential applications of the model. In addition, the model of care provided may be instructive for informal caregivers, friends, and family members. Power proposes what he describes as an “experiential approach to dementia” (p. 77). Although care partners understand the symptoms of dementia, for example, problems managing finances, geographic disorientation, or difficulty dressing, Power explains, “If we are to provide the best care for people with dementia, we need to spend a lot more time trying to understand what it feels like to live with dementia” (p. 5). Optimal dementia care requires moving from the biomedical context of symptoms to the experiential context of the individual with dementia. Increasing sensitivity to the experience of having dementia provides the opportunity to increase understanding of unmet needs. Power asserts that “transformation is the foundation of enlightened care. The institutional model will never succeed in this endeavor” (pp. 16–17). The first section of the book examines the current paradigm of dementia care. Power discusses the conventional care environment, which involves an institutional model that emphasizes pharmacotherapy. He presents a review of antipsychotics, including a discussion of potential adverse effects (Schneider et al., 2006), limited data demonstrating efficacy in management of challenging behaviors in dementia, and the question of whether the primary impact of antipsychotics and other medications used to treat challenging behaviors is sedation. Power explains that care partners may perceive that individuals treated with psychoactive medications appear calm. He asserts that the medications result in a less active and more sedated individual who is more accurately described as “calmatose.” Power further explains, When considering the use of any psychotropic drug for a behavioral expression, it is important to ask how the drug is going to solve the problem. Is there something about the way the drug lowers dopamine levels in the brain that makes a wandering person stop wanting to explore his or her environment, or that makes a person who hates being bathed suddenly find the experience more enjoyable? The challenge is to explain the mechanisms behind the drugs in use, particularly when a mismatch with the care environment is clearly triggering the distress. Other than in cases of true psychosis, it is difficult to reach any conclusion except that we are sedating the behavior, and therefore the person. (p. 30) Power provides a history of the modern nursing home. Long-term care was linked to the Medicare and Medicaid Act of 1965. Consequently, the aging process is conceptualized in the context of diseases and functional impairments. The emphasis on medical treatment means that nursing home residents’ “homes” are by definition an institutional setting. He explains that reimbursement and financial incentives built upon the disease model serve as a counterintuitive care model. Facilities receive greater reimbursement for illness than for health, and when health is restored, reimbursements are reduced. For example, a nursing home resident who develops a pressure sore will require daily wound care, with consequent high levels of reimbursement. When the wound heals successfully, reimbursement drops. Power also provides a comprehensive assessment of the impact of the institutional model. Residents sustain several losses with nursing home placement: material losses through the relinquishment of personal living space and belongings and separation from friends and loved ones; and nonmaterial losses including loss of privacy, dignity, control, and meaning. The same regimented schedule that provides efficient completion of tasks and cost savings for the facility staff may lead to loss of meaningful activities for residents. Power provides the example of a certified nursing assistant who was chastised for escorting a resident outside to enjoy the sunset. Power asserts that the implementation and persistence of the institutional model are a direct consequence of societal perceptions of aging. Consequently, any change in the infrastructure will require a massive paradigm shift. Society views aging as a loss: “To put the societal view simply, aging is decline. It is a slide from something good to something bad. The best we can do is try to manage this decline to whatever degree we can” (p. 58). Power goes on to explain William Thomas’s perspective on the stages of human development. Thomas (2004) conceptualized development as involving two states: doing and being. Doing involves activities that are observable and measurable; being often entails intangible acts. Society places high value on doing and thus on adulthood as the stage of development associated with high levels of doing. Power discusses the impact of the “cult of adulthood” on older adults. Societal messages emphasize concern for the burden of an aging society rather than conveying interest in the wisdom that may be provided. The primary impact of the cult of adulthood in long-term care is the reduction of a person with dementia to a problem list of impairments and abilities. The institutional environment is not limited to the spectrum of long-term care. People with dementia may have a similar experience in the community with the loss of purposeful social engagement. The second part of the book outlines a paradigm shift that emphasizes patient-centered experiential care. Power proposes a new model of dementia care that emphasizes the unique individuality of the people with dementia and highlights the importance of respecting autonomy and nurturing meaningful interactions rather than assessing cognitive and functional deficits. The biomedical model emphasizes objective performance at the expense of subjective data. However, psychometric batteries cannot provide insight into the person with dementia’s psychological experience (Sabat, 2001). Power proposes a fundamental change in the language and terminology used to describe dementia care. For example, rather than discussing behavioral problems, Power proposes the term behavioral expressions. The change in terminology takes the burden of responsibility for behaviors from the person with dementia to a concept that connotes the fact that such behaviors likely represent the articulation of an unmet need. Thus, the care partner, a term to replace caregiver, is challenged to address the more complex task of assessing the pattern of behavioral expressions to determine the triggers. Do verbalizations increase when the resident needs to void? Does agitation resolve when the water temperature is adjusted? The final section of the book offers solutions to improve dementia care. The author emphasizes the importance of good communication and sustained interactions. He refers to Bell and Troxel’s (1997) concept of addressing the person with dementia as a close friend, as delineated in The Best Friends Approach to Alzheimer’s Care. This change in perspective alters the dynamic from a patient–health care provider interaction to a more positive and empowering encounter. Power offers methods to improve communication, reduce medication use, and provide dementia care with greater dignity, compassion, and respect for the individual. The concept of person-centered care is well supported by the medical literature (Cherry et al., 2008; Penrod et al., 2007; Specht, Taylor, & Bossen, 2009). Dementia Beyond Drugs: Changing the Culture of Care is an important addition to the field. Power characterizes the current state of long-term care and the limitations of the biomedical model, and he compels the reader to advocate for dementia care that is more compassionate, more humane, and more respectful. He provides a blueprint for a comprehensive culture change that requires society to recognize that while dementia affects cognition and function, dementia care must recognize that persons with dementia are not defined by their disease. Power calls for dementia care that embraces the ethical tenets of autonomy and respect. With the aging of the population, it is a compelling and timely message. References Bell, V., & Troxel, D. (1997). The best friends approach to Alzheimer’s care. Baltimore, MD: Health Professions Press. Cherry, B., Carpenter, K., McGrew, P., Satterwhite, L. J., Stepien, J., Ruppelt, W., & Herring, K. (2008). Social compatibility as a consideration in caring for nursing home residents with dementia. American Journal of Alzheimer's Disease and Other Dementias, 23, 430–438. doi:10.1177/1533317508326046 Penrod, J., Yu, F., Kolanowksi, A., Fick, D. M., Loeb, S. J., & Hupcey, J. E. (2007). Reframing person-centered nursing care for persons with dementia. Research and PsycCRITIQUES 1554-0138 Theory for Nursing Practice, 21, 57–72. doi:10.1891/rtnpij-v21i1a007 Sabat, S. R. (2001). The experience of Alzheimer’s disease: Life through a tangled veil. Malden, MA: Blackwell. Schneider, L. S., Tariot, P. N., Dagerman, K. S., Davis, S. M., Hsiao, J. K., Ismail, M. S., . . . Lieberman, J. A. (2006). Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. The New England Journal of Medicine, 355, 1525–1538. doi:10.1056/NEJMoa061240 Specht, J. K., Taylor, R., & Bossen, A. L. (2009). Partnering for care: The evidence and the expert. Journal of Gerontological Nursing, 35, 16–22. Retrieved from http://www.jognonline.com/default.asp Thomas, W. H. (2004). What are old people for? How elders will save the world. Acton, MA: VanderWyk & Burnham. (Monique M. Williams PsycCRITIQUES 2011-03-23)
Dementia Beyond Drugs: Changing the Culture of Care is an important addition to the field. Power characterizes the current state of long-term care and the limitations of the biomedical model, and he compels the reader to advocate for dementia care that is more compassionate, more humane, and more respectful. He provides a blueprint for a comprehensive culture change that requires society to recognize that while dementia affects cognition and function, dementia care must recognize that persons with dementia are not defined by their disease. Power calls for dementia care that embraces the ethical tenets of autonomy and respect. With the aging of the population, it is a compelling and timely message. (Monique M. Williams PsycCRITIQUES 2011-03-23)
In Dementia beyond drugs: Changing the culture of care, geriatrician G. Allen Power asks readers to rethink the way care is provided to older adults—in particular, to older adults with dementia. In fact, Power suggests that we ‘‘radically alter the way we look at the challenging behavioral expressions so commonly seen in people with dementia’’ (p. 2). Power focuses on what he calls an experiential approach to dementia, one where we ‘‘spend a lot more time trying to understand what it feels like to live with dementia’’ (p. 5). While Power’s call for change is not new, he does offer a unique perspective on how to apply culture change philosophies that move elder care out of the biomedical realm—including such approaches as the Eden Alternative, the Green House Model, and Person-Centered Care, among others. One of the strengths of Power’s work is his ability to synthesize the wealth of care literature and techniques, and, using examples from his experiences working in long-term care and his training as an Eden Alternative Educator, place them in a practical context for working with persons with dementia. Also noteworthy is Power’s understanding that change requires many components, and that change in one area (e.g., physical environment) is not enough to effect culture change overall. Written in language that is accessible to a wide audience—from students and family members to care staff and other medical professionals, Dementia beyond drugs: Changing the culture of care lays the groundwork for not only why culture change must occur but also what must happen for it to occur. The book begins with a prologue that Power characterizes as ‘‘a story of failure’’ (p. xv). The story looks both at one woman’s unfortunate experience with dementia care and Power’s own development and insight into the shortcomings of the traditional nursing home model. The 14 chapters that follow are organized into three sections that take readers on a journey, looking first at what Power sees as the problems of the current model of care, then at the specific changes that are needed, and finally at the ways of achieving those changes. Interspersed in each of the chapters are illustrative vignettes and personal accounts. While Power’s focus is primarily on long-term care institutions, he addresses the similar challenges found in community care as well. In Part 1, ‘‘Paradigms and Problems,’’ Power first takes a broad approach describing our problematic societal perspective on aging in general as well as the flaws of our current understanding of the experience of dementia. While Power is careful to criticize the system rather than the people working in the system, he does point out numerous ways the system is broken. Some of these ways, to name just a few, include the use (or misuse) medication to try to control dementia ‘‘behaviors’’; the routinization, medicalization, and depersonalization of daily life for persons with dementia; and the misguided funding system that reimburses more for medical care and less for care successes achieved through nonmedical means. Part 2, ‘‘Shifts,’’ offers chapters that explore the way in which the system could be changed—first by comparing and contrasting the biomedical model that ‘‘sees dementia mostly as a neuropathology’’ (p. 77) and an experiential approach where it is the person with dementia’s perception of the world that needs to be understood. In this section, Power provides numerous examples for how to gain such understanding. He also examines ways in which care environments (both in long-term care and in the community) can be deinstitutionalized and how meaning can be reintroduced into older people’s daily lives. Finally, in Part 3, ‘‘Solutions,’’ Power offers some practical strategies and examples of how to deal with care challenges (e.g., communication, anxiety, agitation, paranoia) that might otherwise be ‘‘treated’’ with medication. While it is unlikely that these solutions will provide a cure-all for every situation, they are likely to give readers at all levels pause—enough to consider that there might be another way of doing things. Indeed, Dementia beyond drugs: Changing the culture of care is all about asking us to rethink how we ‘‘do’’ care for persons with dementia. (Rona J. Karasik, Professor & Director, Gerontology Saint Cloud State University, Saint Cloud, MN Educational Gerontology 2011-12-21)
"Power has the ability to synthesize the wealth of care literature, examples from his work in long-term care, and his training as an Eden Alternative Educator---placing them all in a practical context for working with persons with dementia...Dementia Beyond Drugs is all about asking us to rethink how we "do" care for persons with dementia." (Rona J. Karasik, Professor & Director, Gerontology Saint Cloud State University, Saint Cloud, MN Educational Gerontology 2011-12-21)
About the Author
As a Certified Eden Alternative Educator, Dr. Power serves as an Eden Mentor at St. John s Home in Rochester, New York, where he has worked since 2000.
Dr. Power has lectured on geriatric and culture change topics both nationally and internationally. He has been interviewed for print and broadcast media including BBC Television, The Washington Post, The Singapore Straits Times, The Wall Street Journal, and WHYY radio among many others. Dr. Power is also quoted in the book Old Age in a New Age: The Promise of Transformative Nursing Homes by Beth Baker (2007, Vanderbilt University Press).
An accomplished musician and songwriter, Dr. Power s music has been performed on three continents. His song of elder autonomy, If You Don t Mind, was performed by Peter, Paul and Mary, and Walter Cronkite used his song I ll Love You Forever in a 1995 Discovery Channel documentary on American families.
Find more at alpower.net and allenpower.wordpress.com.