ALIVE WITH ALZHEIMER'S

Cathy Stein Greenblat, a Professor Emerita of Rutgers University is both a sociologist and a documentary photographer whose preferred research methods are ethnography and visual sociology. The latter incorporates visual imagery into the research process as a means of presenting findings in more effective ways than conventional writing permits. This book represents the outcomes of many weeks of participant observation, conversations with residents, staff, and family members in Silverado, a senior living facility for people with dementia in Escondido, California. This is one of a group of twelve such facilities located in California, Texas and Utah.

In this optimistic beautiful book Greenblat uses her considerable literary and photographic talents to present a picture of people who are not just living with dementia but are actually alive, and mostly lively, despite their disabling condition. The book testifies to the intrinsic courage and resilience of the human spirit under threat. It also represents one woman's efforts to understand dementia and face her own inevitable aging, which given her family history, is likely to include dementia, for as she says: "My chances of avoiding this fate are not good. A field work project at Silverado, I felt might help me face my own fears" (p.3). The photographs are augmented by commentary obtained from photo elicitation interviews with staff and family members. This technique encourages people to talk about their thoughts and feelings as they view large numbers of photographs. Few of the residents were interviewed in the conventional sense because of their advanced dementia but many were capable of warm exchanges, vividly captured in speech and photographs.

The author identifies the key elements of the ethos and care created at Silverado which in many ways resembles another group of American residential care facilities using the Eden approach (Thomas, 1996). The major characteristics of both include: enriched sensory environments; respect and affection demonstrated in warm close staff-resident relationships; purposeful individual and group activities; imaginative recreation, stimulation, and occupation; music is widely used to provide stimulation, comfort, security and communication. Pets, plants, small children and close involvement with relatives, neighbours and local communities are also essential characteristics. Silverado includes hospice provision and aims to care for people throughout the entire course of their illness. Skilled nursing leadership and valuing and rewarding direct care staff is pivotal.

Generous resourcing is acknowledged and while residents represent an economically advantaged group the secret of their continuing engagement in life, though eased by money can only be adequately explained in ideological, not economic terms.

To resort to old-fashioned terminology it lies in the consistent application in practice of a horticultural rather than a warehousing model of care (Miller and Gwynne, 1972). While offering excellent medical attention, Silverado rejects the medical model as attested in an Afterword written by Enid Rockwell a geropsychiatrist who succinctly summarises current knowledge about the major dementias, the diagnosis, care and treatment of people who contract them and types of residential care facilities available in the US.

The images and text illustrate the outcomes of the Silverado ideology. Six chapters explore themes of change, engagement, outings, music, and involvement with staff and family. A short focused bibliography includes references on Alzheimer's, visual sociology and organizations and services.

This book reminds me of Openings, a book of poems and photographs by Killick and Cordonnier (2000). Greenblat's book is more cerebral, perhaps more optimistic, often joyful, and equally revealing. The photographs in both publications, however, give tantalising glimpses of people as they now are, captives to a condition not of their choosing, and in many ways beyond their control. Both illustrate the essence of person-centred care, which means person- in- relationship with another. These are people alive with dementia but people who are not alone. They are held in respectful, warm, affectionate, appreciative relationship with others, including for many, relationships with animals.

The Killick-Cordonnier book conveys more of the bleakness, dread and isolation of dementia yet also conveys humor, playfulness and peacefulness. The Greenblat book is restrained yet full of engagement - a day at the races, music making, parties, but it too illustrates the need to meet people where they are, not where we think they should be - or would like them to be. For it is in that oneness with each other that security is experienced, and life enhancing encounters which sustain both the person with dementia and the staff and family members who nurture them day by day, become possible.

Greenblat succeeds in fulfilling her hope that by documenting life at Silverado, the larger personal and policy issues, the universals in dementia care, might be illuminated. She shows that although some characteristics are lost, people can still respond to loving attention. And she demonstrates that such loving attention is possible within an institutional setting. The research reported in this book is far removed from the highly valued methodology of randomised controlled trials. Nevertheless, it presents a different kind of incontrovertible hopeful evidence of effective dementia care and as such demands attention from policy makers, managers of facilities, care staff, relatives and all concerned with dementia.

References

Killick J. and Cordonnier, C. (2000). Openings: Dementia poems and photographs. London, Journal of Dementia Care. Miller, E.J. and Gwynne, G.V (1972). A life apart. London, Routledge.

Thomas, W.H. (1996). Life worth living: How someone you love can still enjoy life in a nursing home: The Eden alternative in action. Acton, MA, Vander Wyk and Burnham.