The Great Hall, 2 September 2010

Christine Duffield:
Thank you. I think we'll start and I'd like to thank you for all being here on a Thursday night when it's a little bit damp outside and welcome you to what is tonight the twelfth presentation in the 2010 UTSpeaks series.

Before we start, I should say I'm Christine Duffield. I'm the associate dean (research) for the Faculty of Nursing, Midwifery and Health. I would also like to acknowledge and pay respects to the Cadigal people of the Eora Nation on whose land UTS stands.

The other thing I need to just point out to you that I didn't read until this morning was that the lecture's being digitally recorded and it's also being videotaped and it may well be replayed later on ABC2s Big Ideas television program. So we might have all dressed differently I suppose if we'd known that and I would just think about that when you ask a question and say who you are. On that note, if you've got phones on could you please turn them off because anything that you have electronically might interfere with the reception? If you're heading out the door as an MC let me just say that the fire escape is out that door. So if you head out the door, please do so quietly 'cause it's probably going to be recorded.

My role is to really introduce Henry Brodaty and keep the procedures going and to finish on time. Any of you who know Lynn and Jane will know that that's actually not going to be an easy task. So I've got a code that I'm going to progressively ramp up if they don't get off the stage so we do finish on time 'cause we'll have some time at the end for questions and some discussion.

Tonight's topic of course, is timely given the growing debate about aged care and dementia and the services that we might need in the future. Particularly some of us as we're sort of getting to that period in time and also I suppose, with the debates currently about the Federal Government and whose going to be in government or not in government and what aged care or any sort of health policy will be.

So with no further introduction, I'm now going to pass this to Henry Brodaty. I'll just introduce him and let me just say that Brodaty means bearded but he doesn't have a beard. I've been practising all night how to say his name because I have a bit of an accent and I got it all wrong so it's, Brodaty.

Professor Henry Brodaty is the director of the Lead Dementia Collaborative Research Centre at the University of New South Wales and he's also head of Aged Care Psychiatry at the Prince of Wales Hospital. He's served on several New South Wales and Commonwealth committees related to ageing and dementia and currently leads the Dementia Policy Team which has drafted the NSW Dementia Services Plan for 2010-2015 which is when some of us might need these services of course.

He's also the past chairman of Alzheimer's Disease International which represents 77 national Alzheimer Associations and he's also past president of the Alzheimer's Australia and Alzheimer's Australia NSW. He's published over 300 papers and book chapters and is on the editorial board of several journals with a number of awards. So I pass it now to Henry Brodaty to introduce the other two speakers. Thank you and I'll be back.

Henry Brodaty:
Well Chris, you said my name perfectly so it really paid off all that rehearsal. Thank you very much for inviting me. It really is quite a prestigious event to be introducing Lynn and Jane and I think the title is really apt, The Human Touch because I think pretty well all of us have been touched by dementia; we either know people with it, we have had parents or grandparents with it, we're worried we might get it or we're looking after people with dementia.

We know the numbers are staggering; over a quarter of a million people with dementia in Australia now and that figure's set to pass a million by 2050. This is going to have enormous ramifications, particularly for workforce and it's within nursing that the real crisis will come. UTS is really blessed to have two leaders in the field who are really leading the research in dementia care, in Australia and internationally. They're well recognised, they're world recognised, they have garnered some very impressive research support. They've been putting out the publications in prestigious journals and they are really committed and passionate about improving dementia care in Australia.

I'll read the bits about it that you can read yourself but I just want to say a few more words after that. So Lynn has been working in this area for more than 40 years. As a registered - she must have started as a young child. She's worked as a registered nurse, a nurse unit manager, director of nursing, nurse educator and researcher and is now professor of Aged and Extended Care Nursing in the UTS Faculty of Nursing, Midwifery and Health.

She leads the nursing node for our - I lead a Dementia Collaborative Research Centre. We have a number of partners across Australia and our aim is to translate research into practice and one of our partners is in nursing and that's being lead by Lynn and leading it very well.

Jane Stein-Parbury is professor of Ageing and Mental Health - sorry, professor of Mental Health Nursing in the UTS Faculty of Nursing, Midwifery and Health. She's director of the area professor of Area Professorial Mental Health Nursing Unit for South Eastern Sydney & Illawarra Area Health Service.

I've now worked with Lynn and Jane for some years and I'm so impressed by the work that they're doing; the quality of it and the quantity of it but also how they seem to manage it. They're looking after students and they've been looking after their own parents with a lot of health problems themselves. In this area we talk about the sandwich generation or the women in the middle looking after children, looking after parents, looking after their own careers with partners and their own families to look after and Jane and Lynn really embody that.

So I don't think there could be any two people better first - better qualified to talk about the human touch. The work we've been doing has been looking about person-centred care, about putting the person at the centre of the care of people with dementia.

I'm a doctor I work in psychogeriatrics or old age psychiatry and it's too easy to just adopt a medical model and forget about the person and I've learnt a lot from Lynn and Jane over the years. So I welcome them both. I'm not sure who's going first in this tandem act - Jane? So Jane Stein-Parbury. Thank you.

Jane Stein-ParburyChristine just reminded me to turn on the mic. Welcome everybody. Thank you very much for joining us this evening for a topic that is very near and dear to a lot of people's hearts. I would like to acknowledge the Cadigal people of the Eora Nation who are the traditional custodians of the land on which our city campus now stands. I would also like to pay my respect to the elders, both past and present of the Eora Nation and extend that respect to other Aboriginal people who may be present here today.

It's a real pleasure to come and talk to you about this topic tonight. As Henry has said, a lot of us have been touched very deeply by dementia and the care of people with dementia. I'd first like to say thank you to Lynn Chenoweth who gave me a wonderful opportunity to be involved in this research a few years ago. I was able to bring the skills that I had acquired by being a mental health nurse and being somebody very interested in communication, interpersonal skills, how we make the human connection with people. It was a real opportunity to show how those skills had applicability in a setting other than a traditional mental health setting. So thank you, Lynn for inviting me and allowing me to be part of such wonderful research.

What we're going to talk about tonight - and that's just an outline of the presentation. I can't keep that in there - is the nature of dementia and the interpretation of behaviour and how we might see the behaviour of somebody who has dementia. We're going to look at what the often common response is to dementia and then look at the theory that Henry mentioned that we're working with which is the theory called person-centred care and we're putting that theory into practice and testing the effect that it has on people.

We're going to talk a little bit about our results of our research and then hopefully leave you with some handy tips and some concluding remarks.

So, dementia, we're here to bring a message of hope. How many people in the audience have had experience with somebody with dementia? How many people have that experience through their professional role? How many people have experience in their personal lives? So we see how much we all deal with this and a lot of us on the research team have also been professionally and personally touched by this particular condition.

Often when we hear the term dementia - when we think about dementia, we get a feeling of dread and a feeling of fear and often a feeling of hopelessness and what our research is showing, is there is hope. There's hope for people with dementia to have a quality of life and a sense of wellbeing. That's what's so exciting about what we're doing.

So you all probably know this is information that is familiar to you. Dementia is a variety of conditions with cognitive features and people have a decline in their mental ability, their ability to remember things, to learn new things, to retain information, to recall information and we lose our ability for learning, abstract thinking and judgment sometimes. There's often a loosening of emotional control as well and I'm going to talk to you a bit about emotions because emotional care is a lot of what we're doing in our work and difficulties in families and social functioning.

This has a devastating effect on the person. We were speaking out in the hallway before about - and we've all had the experience when you try to remember something. I wanted to send flowers to a good friend of mine today and I know where she lives, I've been there a million times and I couldn't remember the name of the street. I went to call the florist, I could see 27 but I couldn't remember the name of the street and I thought for a minute, that's how it feels all the time for people who have dementia. That inability to - we've all have that experience and then of course, you go out and do something and all of a sudden the street name pops into your head and that may never happen with somebody with dementia.

So there's a sense of disconnectedness. If you've ever felt a little confused or you didn't know what was going on, you often feel disconnected from your environment along with an altered self perception, awareness and response. This often leads to apprehension, anxiety, fear but that can be manifest outwardly but it can also be manifest by withdrawal from the social world. Things just get too hard and people with dementia will often say that this is all just too hard. They might not say it but they might think it.

These experiences and feelings are often expressed through behaviour and it's the behaviour that's often misinterpreted or misunderstood and that's what we're teaching people to reconsider, reinterpret, re-envisage what that behaviour might mean. The impact on carers and family is also profound. There's a sense of hopelessness, a sense of loss; I'm losing the person that I knew; this isn't my mother anymore; this isn't my father; who is this person here? Distress, burn out, irritation - you can get really angry and irritated with people when they're disorientated - confused, not behaving well; oh come on mum, you know that. You can do that. What's happening? It's really easy to feel a sense of agitation and irritation and then of course, carers are at risk of ill health especially if they themselves are ageing.

Now this is what we're working on with our research. We're looking at how people interpret the behaviour that they see with people that have dementia. How behaviour is interpreted will determine how we respond. We live in a relational world. Our sense of who we are is based on how we sit in a social environment. How other people respond to us will enable us to feel good, bad, indifferent, how we respond to them. So people live in a relational world and people with dementia, even though they're cognitively impaired, are still in this relational social world.

The responses of the other person with dementia will impact on their behaviour and this again is what we're teaching people. How you respond will often - could be a trigger for how the behaviour that you see back. Often this had gone unrecognised until a man by the name of Tom Kitwood - who Lynn's going to talk to you about - noticed how people treat people with dementia in residential care settings.

When behaviour is not understood as communication, then the quality of social interaction decreases. One of the things we teach people or we say to people - we're working in residential care facilities with care workers. So when I say one of the things we do with people, that's the people I mean. One of the things that we often start with in the training is, true or false? People with dementia lose the ability to communicate? True. So many people say true. Well they might lose the ability to verbally communicate but their behaviour is a form of communication.

So you start to envisage what we mean by communication. Maybe they can't retrieve words, maybe their thoughts are disorganised but their behaviour is telling us something. So they are still communicating and then people go, aha, yes, right. I get it. People do get it very quickly. By the way, working with people in the aged care industry I have to say, I have met some of the most dedicated, compassionate, caring people. So often the response isn't out of lack of caring or compassion, it's just a misinterpretation of what's going on.

So here's a good example and all of our examples come from our research. We're going to show you a few examples. So this is a man with dementia sitting in his room in a residential care facility and he's shouting. So one person sees it as verbal aggression, reaches for the medicine, gets a bit of silence for a period of time. You've masked it. You've covered it over. You've ignored it with the medication. Another sees that this man is bored. Sunday afternoon he used to like to go out and watch the Lions play. So they puts on a video of his favourite game, get his scarf, get him a meat pie, maybe not a beer but something to drink, and he now is content and happy. So he was bored. So the shouting behaviour was evidence of boredom.

Another example, a woman with dementia hits staff whenever they try to assist her with daily living like showering, toileting, the things that we often have to assist people with. One person sees aggression, the other sees unrelieved pain and often sometimes when you see aggressive behaviour and agitation - and a lot of you would know this - it can be because the person is actually physically in pain. You know yourself, when you're in pain. I get pretty cranky when I'm in pain. I don't know about you but I could be very cranky and if somebody was pulling me in a way that was hurting me, then I'd probably get pretty aggressive too.

A man touches the nurse's breast in the shower. One person sees it as sexually inappropriate and another sees that this man always showered with his wife and the cue was, here's another woman in the shower with me, so it's my wife. So you can see the response will depend on how we interpret it.

One of the activities that we do - one of the activities that's been very successful that we do is from the training resource that Tom Kitwood and his colleagues developed called Improving Dementia Care. This one is particularly moving for people. Just imagine, how would you feel if you were sick and lying in bed but no one is around to help you to get to the toilet, so you wet the bed? How would you feel? How would you feel if you're feeling really angry about something and nobody around you will take your grievance seriously and they keep telling you, oh, don't be upset? Everything will be fine. Come and have a cup of tea it will be better. How would you feel if that happened to you?

How would you feel if you were asleep in a chair at home and suddenly you're woken by a person you've never seen before and they're trying to take your clothes off and get you in the shower? How would you feel? How would you feel if you're feeling bored and restless at home so you decide to go for a walk? You go to your front door, it's locked and a stranger appears and tells you to go and sit down, you're not going anywhere. How would you feel?

These are experiences that people with dementia have, probably on a daily basis from their point of view. How would you feel under those circumstances? Tell me what were some of the things you thought when I said how did you feel?

Audience member:
Frustrated.

Jane Stein-Parbury:
Frustrated, angry, embarrassed, what else?

Audience member:
Ashamed.

Jane Stein Parbury:
Ashamed.

Audience member:
Imprisoned.

Jane Stein-Parbury:
Imprisoned.

Audience member:
Belittled.

Jane Stein-Parbury:
Belittled.

Audience member:
Humiliated.

Jane Stein-Parbury:
Humiliated. So we can see that on a human feeling level, we would feel the same way and that's really what we're dealing with. Is we're dealing with connecting with people where we're all the same whether you're cognitively impaired or cognitively intact.

So feelings are universal although their expression can be cultural. People with dementia remain able to feel. If it's the one thing I've taken out of this experience and this research, is the power of human emotions and the fact that people with dementia, even though they're cognitively impaired, emotionally they're still there. Often they may not be able to remember your name but they'll remember you were the person who was really nice to me yesterday. They'll remember the feeling and this happened to us with our research.

There was a fellow on one of the units we went into and I walked onto the ward and we wear big badges that say we're there doing research and he came up to me for some reason or another and said, oh dear, I don't know where I should go. I don't know what I should do. What am I suppose to be doing next? So I walked over and said well let's see what's here. We've got the TV, there's some people watching TV, here's some magazines, maybe you'd like to have a look at one of the magazines? I picked up the magazine and he said, oh that looks good and he sat down.

The next day we came back - he'd only met me for that short period of time - walked on, he came right up to me and said, I'm so glad you're here. What am I suppose to do? [Laughter]

He didn't remember that I was Jane and I was doing research and I was there in that capacity but he did have - I think - an emotional memory and I think we don't know enough about emotional memory and how it's embodied and stays embodied in people. So while people's emotional reactions and responses may be exaggerated with dementia, they're often appropriate to the situation as the person is experiencing it. They're not what we call inappropriate, they match the situation even though it might be exaggerated or out of control it can get.

Engaging with somebody on an emotional level, recognising how they feel can be comforting in and of itself. You know we nurses, we care for people; we always want to do something; we're always doing something for somebody; we see a problem; solve a problem. Sometimes just being with somebody and engaging on that level is comfort in and of itself. So we don't always have to be doing something.

One view of dementia - the traditional construction of dementia -focused on neurodegenerative changes and we can still find this in the old text books. It focused on what was lost and the received view was the self goes away eventually but people like Oliver Sax have said years ago, I don't believe it. I can't imagine. How would you lose yourself? Tom Kitwood has a very similar view of it but this belief that the self is no longer there so it doesn't matter what we say; it doesn't matter what we do; they're not going to remember anyway; they're not really there. We can drag them into the shower kicking and screaming - I'm not saying that was in the text books - but it leads to what we could call a social death whereby people are treated as if they aren't there. They're talked over, they're talked around.

Our experience of common care practices and again I'm going to repeat, this isn't because people are malicious or they don't care about people but this is often what we observe, that distraction or ignoring the person, just ignore them they'll stop, like you would with a child. Well that's based on the fact that somebody's going to learn that you ignored them and remember that next time. They're not going to learn so behaviour modification won't work. It's learning, it's not happening anymore. Or ignoring the person, distracting, come on let's just go have a cup of tea. I'm upset. I want to talk about what I'm upset and you want me to come and have a cup of tea? Well I'm not ready to have a cup of tea. So what we're teaching people is how to engage first then go have the cup of tea but make the connection first.

A lot of people don't understand or believe that practices contribute to distress and problematic behaviour, little realisation that the care environment can lead to ill being. You mean what I'm doing? Isn't that just the illness? This is what I'm doing? No it's just the dementia doing that. Little attempt to draw the person's unique profile; everybody's treated the same. Everybody has to have a shower at the same time, that task orientation.

So this is just a diagram that depicts what we're saying. That first one is the traditional construction and we're trying to move it to this other way of constructing or thinking about it. So to think about the person rather than the dementia. Put the dementia in the background and bring the person into the foreground.

This is a typical scenario. Again it comes from our research and Lynn's going to show you how we helped people manage this. Con Soulos, he's just been moved into a residential care facility and he is having a bit of trouble. He's not letting people into his room. He attacks people that want to come in there. He says they're rude, especially those young people. You know, they've got no manners and they're bossy and they have no right to do it. So staff become very afraid of him. He's a big man, he's aggressive, he's yelling at them so they start to just leave him alone and his care actually suffers as a result.

How can we help him? Continue to keep others away? Get an expert in to help us come up with a behavioural solution? Develop policies and procedures? Ask his wife to come and help him and do it? Some of these approaches might help for awhile but none of them get to what's behind the behaviour. What's going on in Con's world? We haven't gone into his world. We're still standing in our own world calling him over to us. We need to walk into his world and walk with him.

Another one, Olive moves into an aged care home following a stroke. She becomes very withdrawn. She's very unhappy. She's critical of everybody. She's resistant. She doesn't want to cooperate. She's not being aggressive, just not cooperating. She's constantly talks about wanting to be left alone and she wants to die. What to do? Ask Olive - don't' talk about death. Don't talk like that. That's silly talk. You're not going to - come on let's go and have a cup of tea. Cup of tea solves everything. Ignore any mention of death? Well, she's how old, she's ready to die. She says she's ready to die. Why can't we talk about it? What's wrong with that?

Turn the subject into something more cheerful? Oh let's go out and look at the beautiful day out today and be happy. You know yourself when you're upset and somebody tries that and you just feel like this person doesn't understand. They don't understand. They're not going to help because they don't understand. Try to distract her? Distraction is a big, big one. Try to distract her. Try to get her mind off of it. If you're upset about something it's not that easy to distract somebody. So they might help but they're not going to take her situation seriously.

So what matters most to a person with dementia? The same things that matter to you and me; a sense of security, of continuity, of belonging, of purpose, of fulfilment and a sense of significant; to feel that you matter.

Now I'm going to leave it there and pass it over to Lynn who's going to explain to you the theory of person-centred care and what we've found in our research.

Lynn Chenoweth:
Thank you. Well what do we do for Con? First of all we discovered that Con was a CEO of a large multinational organisation. So once we'd met with his family we'd actually discussed what sort of life he'd lived, the experience he'd had in life and his responsibilities in his job, we realised that he was guarding his office and it was this problem that we were having with staff. Staff were completely ignoring the fact that he regarded this bedroom as his office. They were coming in, they were touching things, they were even trying to undress him and take him to the bathroom. So you can understand that in order to be able to change the way that the staff responded to Con and the way that Con responded to them, was to actually get them to rethink the situation.

So what we first of all did was to ask the staff to acknowledge his title, to recognise that he's Mr Soulos. He's not Con, they have no right to speak to him in that way. So first of all everybody agreed we'd call him Mr Soulos. We'd actually ask permission to come into his end of the corridor. We would certainly knock on the door and wait for permission to enter his room; we would actually ask permission to do anything for him. The other thing we did was to ask his wife to come at times when we felt that we would like to provide personal care and she was there so he felt quite safe. One was around this when she wasn't there was to explain to him that his wife was coming to visit to go to lunch with him. So what would he like to do was to help him get prepared for her meeting and he was quite happy to agree to that. So that was one way around getting toileting and care done when she wasn't there.

We also recognised the fact that he needed to maintain his role. So in order to recognise his responsibilities as CEO, he would normally have meetings every day. So what we did with some of the other people in the facility, who also had fairly senior positions in their previous life, was to set up a daily business meeting. So we actually had a separate little private room, we had tables and chairs set up as if for a meeting. We had a minute taker who was one of the staff members and that person recorded the minutes. The minutes were recorded and produced and given to each of the people to start the business each day.

Con sometimes was invited to chair that meeting, other times he let other people chair the meeting. We also wanted to increase his socialisation so we encouraged his wife to come at lunch time and we had a small room set up. So we had a table and chairs for Con and his wife to have lunch with flowers on the table, knife and fork and tablecloth and we also invited one other resident and his wife and they had a small group gathering. So this extended to a few other couples over time. So therefore we actually solved quite a few problems by actually recognising that we were going into his world rather than forcing him to come into our world. We recognised where he was at and actually encouraged the staff to treat him with respect. To honour and respect his past and his history and to actually provide him with all the opportunities that he needed to be able to feel good about who he was.

So what did we do to help Olive? What we did was to understand that Olive was in a state of distress. She was grieving the loss of many things. Her physical state, her home, her pet, her family, she'd lost function and she was isolated in this place amidst of strangers. So what we did was to ask Olive why she was feeling so upset. Why was she constantly saying she wanted to die? What could we do to help her before she died to satisfy some of her life needs? Olive said, well look, what I'd really like to do before I die is to get my poetry typed up and bound and so I can actually have them all together.

We had no idea she was a poet so actually what we did, we had a meeting with staff, we got the staff together with Olive to work out how we're going to get these poems down. So staff took turns to sit with her and to hand write as she actually spoke her poems. They were then typed up by staff, staff worked together to buy a lovely folder. They put them into this lovely folder, they decorated with pictures, cut out cards which Olive helped to put together. Once this had happened, we had a morning tea with lovely food and we invited all the residents and their families with formal invitation and the staff and we had a poetry reading morning.

She was celebrated and from that time on, we encouraged Olive to work with other residents who wish to write poetry or stories and this became an ongoing activity that happened to meet her needs. So therefore, by getting to know who Olive was and to acknowledging who she was and her history and what she had to contribute, we were able to bring her out of her depression.

So basically central to person-centred care, is to look beyond the brain damage and to acknowledge and value the uniqueness of each person, what they bring to their life.

So when we teach our staff how to consider the needs of people with dementia, we talk about the environment, the social environment within which they're living and working and the care processes that occur. So we actually have this combination of a total environment that we need to pay attention to in order to produce wellbeing rather than ill-being in the person. So we always look for this type of happy face in our settings.

Now what I'm going to do if to briefly talk to you about one study in a program of research that we've been conducting for about six years now. We started out with some seeding funding from UTS and an ARC incentive grant to do some pilot work around this type of model and then we were lucky enough to get an ARC grant and then we've got an NHMRC grant and it's sort of gone on from there.

So the study I'm going to talk about now is the CADRES study. This study was funded by the Australian Government and we got in-kind support from UTS and University of New South Wales and South East and Sydney Area Health Service and of course the facilities where we did the work. Our project manager was Yun-Hee Jeon from University of Sydney and we greatly acknowledge the work that she's done to lead this work and this is the research team here.

Now this was a randomised control trial. It was not a very big control trial. It was only in 15 dementia care units across the greater Sydney region but what we decided to do was to actually compare person-centred care compared with usual care and there was another model that we used to actually test person-centred care again and that is called dementia care mapping. What we wanted to do was to look at whether this model of dementia care mapping which is a way of putting person-centred care into place - whether or not we needed that model or whether we could just rely on the person-centred care model directly and we compared that with usual care.

These were the things we were hoping to improve. We wanted to reduce the incident and severity of behavioural symptoms in people with dementia; we wanted to reduce accidents and injuries and hospitalisations and medications related to behaviour; we wanted to improve wellbeing and quality of life in the person; and we wanted to improve quality of care. We also did work to see if we could improve the outcomes for staff but I'm not reporting on that today.

So in terms of the measurement, we had a whole range of validated measures; resident measures; we had care quality measures; we had demographics and other clinical information that we used; we looked at care quality through a number of measures; and we also did an economic analysis to see if in fact, person-centred care was cost effective compared with usual care and compared with the dementia care mapping process of implementing person-centred care.

So in order to put in place these two different interventions, we relied on the Bradford University improving dementia care resources. These resources were developed by Tom Kitwood and colleagues from Bradford University in the UK and we followed this precisely because we wanted to make sure that we put the person-centred care theory into practice, absolutely the way that Tom Kitwood said we ought to do it.

So with the person-centred care intervention, Jane took responsibility for that. What she did was to use the training modules from Kitwood, two day intensive training. She then went out on site with the staff in the facilities and she worked with them one on one. First of all starting with care planning to make sure that care planning was from a person-centred perspective and then to implement that care planning into practice in a person-centred way and she went out twice to each of the homes working intensively with those staff and provided follow up support through telephone contact.

Yun-Hee and I undertook the dementia care mapping process because we had been trained in that process. We did five day training of the staff from the five facilities. We actually did intensive observation of residents and documented all of that evidence over an eight hour period for each resident. We then used that information to work with the staff at the facilities to do person-centred care planning and person-centred care implementation and then we also did the follow up with telephone support at the time.

So with that training for the person-centred care training and the dementia care mapping training, we did exactly the same technique which was to pay attention to the person's feelings. We taught the staff to stop what they were doing and to listen to what the person was telling them whether it was a verbal expression or a bodily function - a function of the way that the person behaved. To pay attention to that and to actually try to work out what they could do to meet that person's needs.

Then what we did was to actually focus on wellbeing. So everything that the staff were meant to do was about wellbeing so if they were providing personal care or toileting or they were walking somebody or providing a meal for them or engaging in an activity, everything they did was to focus on the wellbeing of the person rather than getting the task done.

We also wanted to make sure that the person was able to maintain meaningful function so that whatever they did was something that was meaningful for them. So if they were going for a walk, it was meaningful in the sense that they were going to do something. They were going for a walk for the purpose of looking at something or feeling something or just sitting and enjoying the weather.

We wanted to make sure that the environment was enriched and when we talk about an enriched environment we're talking about an environment that is not over stimulating. We want an environment that has pleasant stimulation but not noxious stimulation. So we reduced loud noises, bright lights, too much heat, too much cold, we actually stopped breezes coming onto people, we made sure people were warm, we made sure people had interesting activities to do, that they could recognise where they were, we made sure there was visual cues that they could recognise where the bathroom was, where the dining room, where their bedroom was, these are the sorts of things that you do when you want to make sure the environment supports the wellbeing of the person.

Now some results. In order to do this study we did a pre-post test design and a follow up. The pre-post - so we did a pre test of collecting all the data on the residents, we did the intervention for three months, we come back four months later and did the post-test data collection on all the residents and then came back four months later and did a follow up data collection.

At the end of the follow up period, we actually looked at all of the data and compared it with the pre-test and what we found was that in terms of agitation, that there was a significant reduction in agitation of residents with dementia in our study with the PCC - the person-centred care. The dementia care mapping also had a reduction but not as high as the person-centred care training and the usual care you can see there the orange bars - you can see that there was a rise in agitation which was sustained at follow up.

So that was a very exciting finding. It was the first time that I think anyone had ever found that through these techniques. We also looked at the psychiatric symptoms using the neuropsychiatric inventory. Now this particular tool is a validated measure which looks at the hallucinations, delusions, paranoia, violent aggressive, things like that as well as some of the agitated behaviours. We found that in fact there was an initial improvement and then a reduction.

So what we found was that we did actually have some reduction in those behaviours but they weren't significant. However, if we break down that particular tool and when we look at the components of it, we can see that there were some significant findings for a few things: improved appetite and eating; improved sleep; and less disinhibition. So that was really important because those things mean a lot to the person with dementia.

There were border line improvements in these other areas. We did see that with usual care it's an interesting thing, there was an improvement over time with apathy and indifference and of course, that would be a Hawthorne effect. There was no effect for the psychiatric symptoms, so we cannot say that person-centred care from our study and the other studies we've done, actually affects these types of very, very severe behaviours. So person-centred care is okay and it works well for a person with a mild to moderate dementia but not necessarily for somebody with a very severe dementia with very severe behaviours.

Now if we look at care quality we can see here that at base line we had very different things. So in the five person-centred care groups you can see that the quality of care at base line was much higher but once we adjusted for the base line differences. We found that over time, person-centred care improved care quality significantly. If we look at the positive care here the other one was about social interaction, this one is about the actual way that the care's delivered and we found that with person-centred care again, there was a great improvement in the way that care was delivered over time.

So if we look at the summary findings - and there were lots of other findings but I haven't reported on them - we found that there were significant findings for a few things. Now quality of life was one of the things we measured. We didn't see an overall improvement in quality of life according to the QUALID scale which is the Quality of Life in Late-Stage Dementia however, when we use the dementia care mapping wellbeing scores, we found that there was a significant improvement in wellbeing. Wellbeing is one component of quality of life, there are many other components. One of the things we've discovered is that we've used a number of quality of life instruments now in all of our studies, so far not one of those validation measures has actually shown a significant improvement in quality of life. However, the DCM measure does. So therefore, we need to do much more work on developing more sensitive measures.

We did find that there was an improvement in care quality particularly social interaction and this is one of the things that we really like to see is how staff communicate with a person with dementia.

Now there are lots of implications then for health care services. At the service level, what we need to remember is that the whole focus of services ought to be on the person and I've noticed in New South Wales Health and in fact the Government now has actually recognised that this should be the focus of all services but the person who is at the basis of the service, ought to come first. Whatever we do, ought to be for the wellbeing and the care of that person. The managers need to provide staff with an opportunity for ongoing education and support and this includes good supervision.

So you can't just educate someone and expect them to be able to implement these approaches in practice without good supervision, mentoring and encouragement. For staff we need them to make - to pay attention to understanding what the person with dementia is trying to tell them through their behaviour. Pay attention to the feelings. Value and recognise the unique characteristics of each person that just because I've got dementia doesn't mean to say I'm like the person next door. I'm unique and I have unique needs and unique values and I have unique beliefs so therefore these need to be addressed if I'm going to be in a state of wellbeing.

The other thing that they need to do is to reinforce the person's strengths. So whatever the person is still able to do, we need to maintain that rather than focus on the weaknesses or the things they're no longer able to do and this gives the person a sense of integrity. We need to allow and encourage as much choice as possible in small decisions of everyday life.

So this is what we felt when we got this study published in The Lancet. All very excited, that's Jane and I in very old age.

Jane Stein-Parbury:
That's Lynn dancing [inaudible] [laughter]. They said they would publish the paper.

Lynn Chenoweth:
Yes, so we're very happy about that. That's given us a lot of invitation now from scientists all around the world to actually talk about this, to raise it as an issue, to do further research so that's been a great outcome. What we'd like to do now is to actually give you a few tips on how you might implement this process. So Jane, would you like to come up?

Jane Stein-Parbury:
Okay. Thanks Lynn. We've got a picture of a flower because I couldn't really draw it with the thing very well but this really indicates - the petals indicate the areas in which you need to focus if you're going to do person-centred care and in the centre of the flower is the idea of love. To show people that they're cared for, that they're loved, that people do honour them, care about them, praise them, acknowledge them and it really does go a very long way. So this is really work of the heart as much as anything.

Attachment okay, Lynn?

Lynn Chenoweth:
Well all of us need to feel that we belong. We all need to feel that there are people in our lives who care about us. We all need to want to give care, to give love and to receive love. So the way that we can actually encourage this is to strongly encourage families, friends, volunteers, neighbours to come and be part of the person's world to maintain those long attachments. To have attachments with staff and others, to have attachments with other residents so one of the roles of staff is to encourage those attachments and to maintain that sense of continuity with the past, the present and a future I hope that I will feel as if I have attachment.

So there are many ways you can do that to encourage small group work with one other person to actually have private spaces where family and friends, neighbours and other residents can meet and do fun things together to actually identify what the person enjoys doing and to maintain those particular activities with people that they care about. These are absolutely fundamental and very easy to achieve.

Inclusion, people don't like to feel that they're the other. When somebody has dementia it's very often the case that they become socially isolated because they might be embarrassing, they might be sexually disinhibited, they might say the wrong thing, they might spill their food, they might forget where they are and people's families sometimes get embarrassed by this behaviour. The perpetual perseveration of wanting to know who I am, where I'm going, where things are.

So these sorts of things can socially isolate people. It can also happen in the residential setting, it can happen in the hospital, it can happen at community service. So what we need to do is to make people feel that they're still important and still be included so wherever possible we try to draw on the person's strengths to maintain inclusion in all activities of their choosing and not to isolate them at the back of the room because they're disruptive. What we need to do is to encourage people to take a full part in everything that's going on and to support and help them to do that through prompting and encouragement.

Jane Stein-Parbury:
Comfort is a really big area and we often comfort people by reassuring them and a lot of what we taught people is how to reassure them and we don't mean to say, there, there it will be okay. That's really not reassuring that's just fobbing me off. So what we teach people is how to reassure people in a very concrete way to reassure them that they're safe; I'm here; I'm here to help you; I won't let anybody hurt you; I'm here to make sure you feel better; that's what I'm here for. That's very reassuring for people to hear that rather than to here that you'll be alright. Can you hear the difference? There's a real difference in how that's presented to provide comfort in a physical sense we've talked a bit about the pain that somebody might be in so when we do see some of these behaviours to see if somebody is in a state of physical discomfort and to consider that because often their behaviours are a result of this.

To comfort with company, to comfort with - and these things all go together like all the petals form the beautiful flower - to comfort and to reassure that people aren't alone. To comfort them they can stay where they are, they don't have to pay for the food or pay for the room and you can stay here we're not going to send you away. To comfort them sometime that their family is safe. Everything's okay or let's go check on it. So the comforting activities are really quite - they're very specific. They're not a global; everything's going to be okay. It's a very specific thing to that particular person.

Lynn Chenoweth:
Yes, one of the things that residents sometimes will say and patients in hospital, who's going to pay for this? They may for example, be suffering in pain or nausea or whatever and they're afraid that if they ask for help they need to pay for a tablet or pay for a doctor to come and see them so they hang on to it. They're very stoic. So what we have to constantly reassure them that they don't have to pay for services our job is here to help you. This is why we're here, we want to help you that you're safe and as Jane said, we're not going to let anybody harm you. So this is a really important concept here that any of us can implement.

Jane Stein-Parbury:
Occupation, we all need to have something meaningful to do and a sense of occupation a sense of meaning and of course this will be variable. People have different senses of what gives them some meaning and purpose in life. On one of our - one of the site visits that I made there was a lady who got quite agitated after lunch. It was always after lunch she would start pacing around and mumbling under her breath and whatever. It was at that same time that the care workers were doing the laundry and when we looked at her life and looked at her background, what we realised is that she wanted to help with the laundry.

What she wanted to do was help fold the clothes and when she was told to just go away and sit down, we're doing our work here but when we invited her in to help to fold the laundry, that agitation and that distress really went away. So whatever sense of activity or occupation has to be something that's meaningful for that person and we do in our training a lot of activity planning, a lot of thinking through what's the most appropriate type of activity rather than a one size fits all approach because all of these approaches have to be individualised. It was lovely to see the lady fold the clothes and she really enjoyed doing that.

Lynn Chenoweth:
We have another…

Jane Stein-Parbury:
I don't know that I would. [Laughs]

Lynn Chenoweth:
There's another - I think it's Alzheimer's Australia - put out a fabulous video. There are lots of resources that you can get from some very good organisations that support staff and families of people with dementia. One of these stories is about a lady who actually would never sit down to eat and she was perpetually going around the table when the other residents were sitting and fiddling with their meal, taking their plates, putting things down, tasting their food, no one could understand what was going on. When her family came and they said, why on earth are you trying to get her to stop doing this? She always did this at home. She never sat down to eat. She had a big family, she'd always be getting the children to eat, tasting their food to make sure it was okay, serving people. She always stood at the kitchen to eat. She never ate with her family because her job was to actually look after the family.

So once the staff recognised that, they allowed her to stand at the serving bench and to eat her food at the serving bench near the kitchen - where the kitchen was serving and then they allowed her to go and help with the other residents by putting the plates, taking the plates, she was completely happy no longer was she getting other residents hitting her, pushing her away when she was trying to take their plates away because the staff explained to the other residents, that her job was to help with serving. So you can see it's a very simple approach.

Identity, all of us have a personal identity. If you think about yourself, there's something about you, there are many things about you that are quite unique that perhaps nobody else has. Things that you appreciate, that you value, the way that you behave, the way you interact with others. All people with dementia have exactly the same qualities as - unique qualities - that we have. They might be similar, they might be different. So what we have to recognise is that they do not lose those unique qualities and they do not lose the sense of those unique qualities with dementia, nobody does.

So they may not be able to express them in the same way, our job is to encourage and help them. Find out from the families, friends, neighbours, what these unique qualities and talents are and try to encourage and support those in everything that you do. To reminisce with the person, to talk about the qualities and the wonderful things that they did. About their pets, about their family, about going to school, their favourite teacher, and all those unique things so that we can actually maintain their unique identity. Which Tom Kitwood calls personhood.

Of course, all of this takes place in an enriched environment, if we don't have the air and the sun and the soil and the water, how can we grow and how can we maintain health and wellbeing? So this environment, this total environment which is about the care quality, its' about the interactions, the relationships, the physical environment, all of this matters and of course, this is all pouched within a service which has policies and procedures which have to be supportive of meeting the needs of the person and also meeting the needs of the staff who provide this care.

Jane Stein-Parbury:
One of the things that we've found in that environment is that a lot of organisations that are involved in especially residential care, are very much focused on getting tasks completed and you really do need to release and managers need to release that everything has to be done by 10 o'clock or the walls will fall down. Everybody is cleaned and showered and neat and tidy. So a release of the task orientation really has to happen in order for this kind of care to occur and we could probably say that in other health care settings as well.

Lynn Chenoweth:
We'll just finish up by just mentioning that there are some really good studies that have taken place and produced very good outcomes for people with dementia and for staff and care quality and these are just a few of them listed. So I suggest you go and have a look at the literature and see how that these particular approaches can be applied for very specific situations. Thank you.

Jane Stein-Parbury:
Thank you.

Christine Duffield:
Thank you to Jane and Lynn. I was in Canada in May and a friend of mine said there's three things - given we're about the same age you know? - There's three things we have to wake up every morning and ask ourselves and the first of these is who am I? The second is and who are you? The third is where am I? So I hope that when I wake up one morning and there's one of those questions I can't answer, I find myself in an institution where there's this…

Lynn Chenoweth:
You mean a safe place? [Laughter]

Christine Duffield:
That's right. That I'm in a safe place and they'll answer the questions for me and because they've been so good, we now have time for questions so if there are questions - and I'm sure there are - we have our two panel members up here. We've got a few moments.

Mark:
Hello, my name's Mark a registered nurse in the community. I was wondering in terms of your research, whether there was any aspects in terms of a holistic perspective, of looking at a person's spiritual dimension and how we as health care providers, engage with that dimension and in terms of both fostering this person's spiritual wellbeing and also providing an environment which encourages a level of spiritual health?

Lynn Chenoweth:
Now Tom Kitwood's theory - psychosocial theory of personhood in dementia - includes the dimension of spirituality. We didn't pull apart that theory in any detail tonight but I would suggest that you actually have a look at that theory and look at the dimensions and the way that spirituality unfolds within this concept of personhood, or that unique identify, cultural values, social values all of those things and it's certainly a very important part if we understand spirituality to be that integrity, that sense of who I am and why am I here question.

Barbara Latin:
My name is Barbara Latin; I have a mother in care. How long do you think it's going to take before we can have person-centred care? There is just not the time, there's not the staff in the current facilities that we have and it's just heartbreaking to see the numbers are rising, I've had an incident where my mother's been in hospital just recently and it was heartbreaking because they are facilitated through the emergency, through the GRACE teams and what have you but they are on their own. The hospitals are filled with frail, aged care people. Where are these places going to be? There are so many old aged care facilities, can you help us?

Jane Stein-Parbury:
It's a very tough one. Everybody heard the question? I guess there's two things. There certainly is residential aged care facilities that are designed for that and that's obviously where we've been working. What we've found is that a person-centred approach does not take more time. In fact you often save yourself a lot of time. So there's always the perception that because it's person-centred, I have to sit down and have a deep and meaningful conversation with somebody for half an hour. It doesn't need to be it can be - and that sense of wellbeing can happen in five second so it doesn't take more time.

That's the first thing and that's a good thing but having said that, you still need enough staff. You certainly need to be adequately staffed with the right kind of staffing and your staffing have to work together. It's a whole systems approach. If there's somebody over there going, you haven't done it. You didn't get it done, that doesn't work. It has to be the whole system has to cooperate with it and if things don't get done, there'll be somebody else to do it and that's okay. So this really does require what they call a real culture shift in care.

The acute care situation when people are hospitalised who have dementia, I can say is a real challenge and a real problem. Right, Lynn? I mean, Lynn has had a lot of experience with this. I've had personal experience with it myself as well.

Lynn Chenoweth:
We do of course have acute care units where they have tried to create a person-centred environment. They've tried to actually educate their staff and to get people thinking differently and there are successes. For example, at Sutherland Hospital we have an acute care unit which works very well. One of the ways that they've been able to support a person-Centred approach is to change the physical environment. So that it's on the ground people have a space they can wander outside, sit in the shade, look at the trees, they come in, they can move through, it's not exactly the same as a normal acute care unit. So therefore, people are safer, they're not falling as much, they're not as disoriented, they feel more settled, you have less staff because you don't need as many staff when residents or patients are not as agitated.

So it does happen but unfortunately, until we get a whole as it were health system approach to this and agreement on it, it's not going to change easily. There are moves towards the Government taking this initiative. They have certainly put money into wanting to educate staff through the Department of Health and Ageing, trying to get education in all of the residential settings. The New South Wales Health at least has tried to pick this up and they're trying their best. It basically, needs a whole re-shift of thinking in all of the services for it to work.

Jane Stein-Parbury:
The one thing we do know about culture change, you can't put the nice signs up on the wall and say we're person-centred; you've got to change what people do. You have to change your behaviour to change your culture. You can't just come up with a feel good statement.

Audience member:
So how can you [inaudible]. Sorry - [unclear] RN and I just feel it so exasperated when I go into nursing homes sometimes. I've stopped nursing for awhile and I've gone around to look after family members in different areas and it's really hard to take my nurse's hat off, to go in and see the changes. It doesn't happen with the nursing staff. I'm sorry. They're so busy and you have many people working this area and how do you implement this personal-care and time so that these people can be feeling this way, cared for and protected. Because it's all task orientated having to get everything done and if I ask any of the nurses anything about any of the residents, they haven't a clue. They don't know what they ever did with their life or whatever.

Jane Stein-Parbury:
The release of task orientation is one of our biggest challengers in this I can you that and everybody has to come on board with it.

Audience member:
Then you have different cultures on top of that so this is a big issue.

[Aside discussion]

Trisha Fox:
Hi, my name is Trisha Fox. Just to clarify one or two of the slides, on one slide it might have said something like - or you might have said there was no effect - person-centred care had no effect on agitation or aggressive and then later I thought that meant there was no effect for those who had severe agitation and aggressive…

Lynn Chenoweth:
Can I - I can clarify if you like. Yes we had two measures. One was the Cohen-Mansfield Agitation Inventory which focuses on all of the agitated behaviors: verbal, nonverbal and so forth, a whole string of them. On that measure, which is a validated measure used widely around the world, - we had significant improvement. The Neuropsychiatric Inventory measure which measure the more severe psychiatric symptoms plus some agitated behaviors, we didn't see in some psychiatric symptoms like hallucinations, delusions, paranoia, we didn't see a significant improvement there but we did on the agitated behaviors.

Trisha Fox:
Thank you. One other thing that has just come to mind, in terms of different cultures there's an issue of sexuality now that has come out in aged care so I just want everyone to maybe think about that too that there are gay and lesbian and possibility transgender residents in aged care that need to be thought about as well.

Lynn Chenoweth:
Yes and of course, Tom Kitwood's theory would certainly - and his approach - wouldn't discriminate anybody, anyone - whoever the person is their unique identify has to be supported. That's what the whole aim is of this whole approach.

Sue Reynoldson:
Hi, Sue Reynoldson from Sydney University. Thank you very much Lynn and Jane. Excellent presentation. Just listening to your presentation, I'm very much reminded of the work of Naomi Feil's validation therapy and a group of us very much tried to promote that in nursing homes around Australia in the '90s and got Naomi out here. I would be very much interested in your feedback on how you see person-centred care relating to validation.

Lynn Chenoweth:
The validation of who I am, what matters to me, what is going on for me in my reality is absolutely essential. Reality orientation itself doesn't work that well because we have to know when it is that we come into the person's reality and when we need to gently draw them into ours. So for example, if somebody is seeing flies all over them - they're covered in flies and they're distressed and they're agitated and screaming, we don't come in immediately and say, no there are no flies. It's okay. There are no flies. That won't work because they believe and see and feel them. So what we do is we say, oh my goodness. Yes they are terrible - there are flies everywhere. Quick. Let's get them out. Let's get something. We'll get the fly spray. We'll spray the room. We'll get them out of the room. We'll brush them off you. We'll put them in a bag and we'll throw them out the window.

Then we'll take them into our reality by bringing them into a pleasant experience outside of that room. In the meantime, we assure them that we're going to fumigate the room. We're going to clean it and get rid of every fly. So this type of approach is what Tom Kitwood recommends we use rather than the pure theoretical validation approach. But nevertheless, elements of that are used in this process.

Jane Stein-Parbury:
It certainly resonates with it but as Lynn said, sometimes you enter and sometimes you bring them out and that's one of the things we teach. When is it appropriate to go in to the person's world and when is it appropriate to try to bring them into our world.

Christine Duffield:
We've probably got time for a couple of more questions. So we have Henry in the front row.

Henry Brodaty:
Henry Brodaty, thanks for a wonderful presentation and the passion is just palpable, it's wonderful. A lot of the questions revolved around, how do we get this into business as usual in nursing homes and it's far worse in hospitals where I work where there's virtually no person-centred care. I guess one of the biggest ways of getting it in would be economic arguments. You didn't present the economic data, Lynn…

Lynn Chenoweth:
No I didn't.

Jane Stein-Parbury:
Oh, thank you. Yes Henry.

Henry Brodaty:
If it takes two days of training from Jane or Jane clones and to get such wonderful results, that's not much and it's something we need to be advocating for at a Commonwealth - particularly at a Commonwealth level - to achieve that. So I just wondered if you'd like to explain that.

Lynn Chenoweth:
Thank you for raising that because we did do an economic - we didn't. Our colleagues with that background did that analysis who were part of the team and we did find that it was a cost effective - Person-centred care cost effective approach in terms of all of the outcomes. It was very inexpensive, it didn't take a lot of staff training, we definitely saw enormous changes in staff's attitudes, behaviours, application of that knowledge. We were training up people without much formal education, people from non English speaking backgrounds who could barely speak English.

It was the approach. The way that we train and the way Jane implements this type of training is so successful and I strongly recommend that we actually adopt this as a national approach because it works. The lights go on straight away as soon as you get the person to recognise that we have to recognise people's feelings. Go with the feelings and then work out strategies to help that person feel good about themselves. That is the fundamental basis of this training and it does work.

Christine Duffield:Our final question over there and then they'll be time to talk to them after we've closed the session. Thank you.

Julie Campbell:
I'm Julie Campbell from the ACAT at Prince of Wales. I was just wondering, at what level were the personnel or the staff that you were training? Were they…

Jane Stein-Parbury:
The people that we trained were care workers and the staff. They weren't managers. They were selected because they were people seen to be leaders and remember there's leaders throughout an organisation. I don't have to have a title to be a leader. So they were selected as people who could influence other people. It was a variety. Some were registered nurses, some were activities coordinators, some were AINs. So we had a whole host of people and the important thing is that they could influence other people and they had support from their management 'cause that was another thing we looked at.

Julie Muir:
Can I just ask onto that because we work together. I'm Julie Muir from the Randwick/Botany ACAT team as well in dementia and now I've lost my train of thought. I've got been reading about…

Lynn Chenoweth:
Have a cup of tea. It will probably pass. [Laughter]

Julie Muir:
…person-centred framework. So would you acknowledge within your research findings that you probably need for ongoing facilitation of person-centred care an organisational approach and enabling of that plus an environment that helps with that?

Jane Stein-Parbury:
One of the things that we haven't reported here tonight were staff outcomes because we measured things like burn out in staff and we looked at staff as well. One of the things we have found is that initially with the Person-centred care, the emotional exhaustion scale on our burn out inventory actually went out. So that tells you in an organisation - I mean, it actually came down but initially it did and it actually makes sense to me. Once you're engaging with people about how they feel, you're going to maybe get emotionally exhausted yourself.

So what it needs is good clinical supervision mechanisms built around it and there's been a really nice work done on introducing this and introducing a system so people have to be supported in their thinking through and their reflection on their practice as a way of sustaining themselves. So I hope that answers your question.

Christine Duffield:
Thank you for that. I think we'll draw it to a close but they will be around for a little while longer if you want to have a chat to them. I would like to thank Henry for his generous introduction to Jane and Lynn.

I think it's really nice when we see a multidisciplinary team working together and obviously they've got a lot of respect and regard for each other.

I would also like to thank Jane and Lynn who I've known for a long, long time. I don't remember how long actually [laughter]. A long time but it's nice to see colleagues who grow and develop and their research interests grow and develop and them start to merge and I'm really glad they're working where they're working because I might need their services in the not too distant future because I probably don't remember who they are. So if you could just join me in…

Jane Stein-Parbury:
You'll feel it.

Christine Duffield:
I'll feel it. Jane taught me everything I need to know about mental health. I just have to ask people, how do you feel? It doesn't matter what the answer is, how do you feel? So if you could just join me in thanking Henry and Lynn and Jane that would be great.

[Applause]

I've got a little note I forgot to read…

Jane Stein-Parbury:
Thanks for coming along.

Christine Duffield:
…which is could you just leave your glasses in the empty boxes outside. I think that means the drinks are off. [Laughter] Does it? But I think that the speakers get a glass of red wine and I was told that red actually stops dementia so I've lived with that piece of research. Lynn tells me it's wrong but I don't believe it. Thank you very much for coming.

Lynn Chenoweth:
Thank you.