A salutogenic approach, which focuses on factors for health and wellbeing rather than disease, has enormous relevance in aged care, and particularly dementia care, writes Professor Richard Fleming.

The Royal Children’s Hospital in Melbourne was designed with a clear intent: to create a physical environment that can assist with recovery and good health.

Richard Fleming

A giant fish tank is used as a central point and way finder. Meerkats live on site. Murals, inspired by nature and animals, are used to help visitors navigate floors and wards, with different colours on each floor and different animals representing each wing of a ward.

Research into the effects of design on medical outcomes was key to redefining this space; moving away from a traditional clinical environment towards one that is child-friendly, providing context and promoting wellbeing in a place where sick children are cared for.

This is salutogenesis in action. And the ‘salutogenic approach’ has enormous relevance in aged care, particularly in the care of people with dementia.

If we look at aged care generally, and the care of people with dementia specifically, there is a visible shift towards the rights of people to pursue a full life, away from excessive focus on risk and problems.

This is a shift from a pathogenic to salutogenic approach.

The pathogenic model of health is based on factors such as disease, accidents, risk and injury. The salutogenic approach is quite different.

Salutogenesis means ‘sources of health’ from the Latin word ‘salus’ (meaning health) and the Greek word ‘genesis’ (meaning source).

The Royal Children’s Hospital in Melbourne was designed to create an environment that assists with recovery and good health.

The salutogenic approach focuses on factors that support health and wellbeing, rather than pathogenic factors that cause disease and ill-health. The salutogenic approach takes us beyond problems and symptoms towards joy, happiness, enthusiasm, hope, and even excitement.

These are concepts not often associated with the experience of living with dementia and, we should ask, why not? This is not to glamorise the experience of living with dementia, or to be relentlessly positive about it; but rather to adopt a balanced perspective, promoting positive experiences as an essential part of the overall experience of living, even when dementia is a part of living too.

American-Israeli medical sociologist Aaron Antonovsky coined the term salutogenesis in 1968 to capture an answer to the question: why do some people manage to avoid illness and do well even when they are subjected to extreme stress?

He looked back at the experience of holocaust survivors as the primary source of his inspiration. He was able to show that within this group, relatively unstressed people had much more resistance to illness and were more likely to survive. He argued that a sense of coherence was needed to protect the person from stress.

A sense of coherence, he said, is established when the world is understandable, manageable, and has meaning. With these three factors in play, people are able to make the best of their lives, even when under extreme stress or illness and even when their circumstances are awful.

Antonovsky’s first point – the world is understandable – is about a person’s ability to make sense of their life story, their context and current circumstances. Without this fundamental understanding, people have little capacity to make the most of circumstances or negotiate life’s challenges.

A residential aged care facility that is designed to incorporate way-finding features, such as colour-coded walls, helps make the context more understandable for a person with dementia.

Activities like painting and music, that may link people to their early life, can do the same.

The second point – the world is manageable – is about a person’s ability to manage day-to-day physical realities; staying warm, dry, clean, rested and nourished, and other maintenance of their physical lives. Residential aged care facilities have traditionally operated in this space, often by managing the world for the person with dementia. Accreditation of facilities typically benchmarks on these ‘world-managing’ factors.

The third point – the world has meaning – is about the foundation of the desire to live. It is meaningfulness that gives life forward thrust, strengthens the will to live, and as such it is possibly the most important of the three.

Meaningfulness is also the most elusive because meaning is difficult to define and is highly personal. But we know that meaningfulness is found in personal connections, responsibilities and the sense of making a contribution.

And this is where the work we can do with people with dementia can be most profound.

However, understandability, manageability and meaningfulness are not only relevant to the lives of people with dementia, surely, they are also important to the people who care for them.

Aged care resource

Dementia Training Australia is a new education and training organisation with aspirations to contribute on a national scale to making the experience of dementia understandable, manageable and meaningful for all.

We are funded by the Australian Government to provide education and training across Australia to health and aged care staff who deliver care to people with dementia.

Our goal is to ensure that the resources and courses we develop address all three aspects of this approach, not just manageability.

This is an aspirational goal. We have many current resources that do focus on manageability (mainly from the point of view of the person who is trying to manage the world for the person with dementia) and some that include understandability. But few that address meaningfulness.

Our task is to provide resources and services that genuinely contribute to the wellbeing of people with dementia and the people who care for them.

Not to be satisfied with taking away symptoms, important though this is, but to address the tougher problems of helping staff and people with dementia have the sense of coherence that protects them from stress.

We provide access to a wide variety of resources and courses as well as specific support for environmental design, medication management and reducing responsive behaviours.

Salutogenesis is not a term that is widely understood in the dementia care community, but DTA wants to make it so. We want to be known as an organisation with a clear commitment to the salutogenic approach, an organisation that is developing services and resources to help people with dementia, and the staff who care for them, experience understandability, manageability and meaningfulness in their lives.

Professor Richard Fleming is executive director of Dementia Training Australia. DTA is a consortium led by the University of Wollongong and consisting of Alzheimer’s Australia, La Trobe University, Queensland University of Technology, Wicking Dementia Research and Education Centre (University of Tasmania) and the University of Western Australia.

September is dementia awareness month.

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