Assessment of Dementia Patients and their Families: An Ecological-Family-Centered Approach

The involvement of social workers in the assessment and treatment of dementia patients and their families is expected to increase substantially by the end of this decade. Considering current estimates of some 4 million dementia patients, the potential demand for social work practice in health care is significant (Dobrof, 1986). Dementia is an irreversible, chronic, degenerative illness that destroys neural structures and often leaves its victims unable to communicate, bathe, dress, or otherwise care for themselves (Zarit, Orr, & Zarit, 1985). Dementia is characterized by intellectual, language, and motor impairments that lead to forgetfulness, confusion, and ultimately total functional disability and eventual death (Cole, Griffin, & Ruiz, 1986). The number of individuals with severe dementia is expected to increase 60 percent from current levels by the year 2000 (Light & Lebowitz, 1989). Patients and their families are seen by social workers and other health workers and other health professionals in every sector of the health care system, and this trend will continue into the 21st century. This article guides social work practice in the assessment of these patients and their families using an ecological-family-centered (EFC) framework. Social work practice with dementia patients and their families illustrates the necessity for an ecological-family-centered practice, which is based on the assumption that people can be understood and helped only in the context of the intimate and powerful systems of which they are a part (Hartman & Laird, 1983). It is difficult to accurately assess, diagnose, and treat dementia patients without input from their families. Patients with a suspected dementia often enter the medical system unable to recall the onset or nature of their memory loss. Family members provide useful supplementary data and contextual interpretation documenting the presence and degree of cognitive dysfunction. Their ability to provide this information places them in the center of the unit of attention or field of action, as typified by family-centered social work practice (Germain, 1984; Hartman & Laird, 1983). Moreover, ecological-family-centered practice engages families in an ongoing and complex relationship with their communities and, in particular, with the health care system. A diagnosis of dementia brings the family face-to-face with myriad health professionals who provide palliative rather than curative treatment. Patients and their families also often seek treatment for secondary symptoms of the illness, such as depression or delusions, as well as for family dysfunction that may arise through the effects of the dementing illness. In the treatment of these and other associated symptoms, the community, through its social services system, often becomes involved. Effective social work practice in this arena requires an understanding of the interrelatedness of all of these systems. FAMILIES OF DEMENTIA PATIENTS The emerging literature on families of dementia patients contains important findings for social work practice. First, life events are not independent: When one family member is confronted with adversity, others are affected (Cohler, 1983; Prunchno, Blow, & Smyer, 1984). Second, families often have the capacity to effect changes in their relatives that professionals can only guide (Gwyther, 1990). Third, dementia makes arduous demands on families as managers and advocates for the patient: Patients with dementia are typically involved in protracted and complex relations with hospitals, nursing homes, and other community institutions (Cohler, Groves, Borden, & Lazarus, 1989). Moreover, the significance of family involvement in this illness is of particular interest to social workers who are seeking information about the relationship of the family to other institutions across the life cycle. Cohler et al. (1989) suggested that understanding these relationships may lead to a better understanding of the demands of caregiving and processes of adult socialization to grief; others have compared the impact on the family to that of grieving and loss often associated with the death of a family member (Cohen & Eisdorfer, 1988). …