Theoretical basis of clinical social work in health care facilities with persons with Alzheimer's disease Aging and old age are a natural part of the life cycle, as well as an important stage of an individual's ontogenetic development. They are not only an individual but also a social phenomenon (Žiaková, 2005). Physiological factors, health problems, genetic predispositions, but also how a person psychologically accepts and experiences older age, can bring him a time of undisturbed, harmonious old age, but also psychological and physical decline, which is painful both for him and for those around him (Pribišová, 2007). So we can say that aging and old age is a fact that affects not only the person himself, but also affects his surroundings, especially the family. In the current postmodern era, we encounter situations where traditional family values ​​and attitudes are changing, especially in relation to grandparents and their care. In the past, it was common and natural for elderly parents to be cared for by their children. So they had the opportunity to spend the last moments of their lives in the circle of their closest ones. Currently, however, the mission and functions of the family are changing, and at the same time, the possibility of dependent seniors to live out their lives in the family circle is also changing (Gallová, 2011). Due to workload, financial situation, but also many times the children's reluctance and lack of interest, they stop taking responsibility for their dependent parent and place him in a social service facility.

It is practical social work that focuses its attention on the group of elderly people, which is especially important nowadays, when the average age of the population is increasing and more and more elderly people are dependent on the support and help of other fellow citizens. It is primarily about the support and development of such activities that enable seniors to live their old age with dignity, as old age brings many changes for them. Many times it seems as if by retirement, as well as by the gradual loss of their mental abilities and physical strength, seniors lose respect, respect and become a kind of burden on the part of other people and institutions. However, this attitude is too discriminatory and is not at all fair to the elderly. One of the ways to solve this situation is to improve their life and status in the environment they live in, which is known to them, i.e. in their own community (Hrozenská et al., 2008).

However, since the number of elderly people, including people with Alzheimer's disease, who are placed in institutional, medical facilities and are dependent on the help of others, is still increasing, it is absolutely necessary to create the position of a clinical social worker who can adequately approach the issue of caring for a given client-patient.

With increasing age, the risk of an aliquot wide spectrum of various mental disorders appears and increases. More than 10% of the population suffers from organic mental disorders, and of these mostly various types of dementia, and with increasing age there is also a sharp increase in incidence (Novotná, Magurová, Balková, 2008). At the same time, the incidence of dementia is increasing, with 3-7% of the population over 65 suffering from it, 15% of the population after 75, after 80 it occurs in 20-40% of individuals and the so-called senile dementia occurs in 10% of individuals who are younger than 65 years old (Németh, Hudáková, 2009).

Dementia is a chronic progressive disease of the central nervous system with a high disabling potential, but also a societal impact. In advanced stages, continuous help from another person is necessary, as well as institutional care. Dementia is a syndrome, not a separate nosological unit (Németh, Hudáková, 2009). In recent years, the dementia syndrome has become an important health and social phenomenon in industrialized countries, including Slovakia, which mainly affects seniors and seriously affects their family members, professional caregivers, as well as society as a whole (Fertaľová, 2012). M. Vojtěchovský (In Tavel, 2009) points to the fact that dementia is one of the four most common mental illnesses in old age. According to I. Stuart-Hamilton (1999), dementia means a complex loss of mental functions caused by atrophy of the central nervous system. The term dementia represents a certain set of symptoms that can be caused by numerous brain disorders. Among the characteristic disorders of intellectual functions, we can mainly include a violation of memory, the ability to learn new things, a violation of abstraction, orientation, spatial perception, as well as the ability to perform some practical activities that are important for normal human activity. Dementia and its diagnosis can only be determined if two or more cognitive functions of the brain are damaged, such as speech, memory, perception, etc. (Majerníková, Cmorejová, Klímová, 2012).

One of the most widespread forms of dementia, which changes the life of both the sufferer and his entire family, is Alzheimer's disease (Fertaľová, 2012). In the last fifteen years, its occurrence has a growing tendency, while the main cause of this condition is the aging of the population, and it currently affects at least five million people in Europe. Alzheimer's disease is associated with significant psychological, social and physical disability of clients-patients and is a serious economic problem. This disease represents 50-60% of all dementias, which are diagnosed in thousands of individuals worldwide (Majerníková, Cmorejová, Klímová, 2012).

Depending on the onset of this disease, we encounter two forms in clinical practice.

• Form with an early onset (up to 65 years) – its occurrence is less frequent, but it is characterized by a relatively quick onset as well as the progression of the disease. It is characterized by memory impairment, alexia, agraphia, acalculia, apraxia, sensory or amnestic aphasia. • Late-onset form (over 65 years) – its onset and progression is slow and gradual. Impairment of mnestic functions (memory abilities) and deterioration of intellect are typical (Pribišová, 2007).

According to the American Psychiatric Association, dementia of the Alzheimer's type involves the development of multiple cognitive disorders, which are manifested as disorders in the performance of activities (e.g. organizing, planning), memory disorders (this is a loss of the ability to learn new things or information or to recall information and things already learned), speech disorder (aphasia), movement disorder or loss of learned or acquired movements (apraxia) and cognitive impairment (agnosia). All these disorders cause problems in work and social life, but despite the fact that the person loses the abilities that helped him in his adult functioning, his awareness of himself does not change (Zgola, 2003).

Clinical picture of Alzheimer's disease

The development of Alzheimer's disease can take 8-20 years and depends on both social conditions and the individual's health (Callone, Kuclacek, Vasiloff et al., 2008). However, since this disease appears mainly at an older age, it often happens that it escapes attention and its symptoms are considered as a sign of natural human aging (Bartko, Čombor, Madarász, Luliak, 2008).

The clinical picture as well as the symptomatology of the health condition is individual for each client-patient, as the progression of the disease has its own pace and the deterioration does not appear in the same form in people and at the same time it does not have the same symptoms. Anyone who has encountered this type of dementia, whether it is the client-patient himself, a caregiver, a doctor or a relative, initially goes through a phase of denial. If a person is suspected of having Alzheimer's disease, they must undergo several tests to determine why the person is experiencing behavioral changes (Callone, Kuclacek, Vasiloff et al., 2008). Alzheimer's dementia is mainly characterized from the beginning by progressive dementia with a decline in memory, mental functions, speech disorders (Bartko, Čombor, Madarász, Luliak, 2008) and according to R.P. Callone, C. Kuclacek, B.C. Vasiloff et al. (2008) it can be divided into three stages.

  • Early stage (duration is 3-5 years) – the first area of ​​the brain in which brain cells die at this stage due to the disease is memory. However, if social skills, logical thinking, and judgment are in order, it is possible for a sick person to cope with memory loss by developing substitute ways. According to L. Etters, D. Goodall et al. (In Majerníková, Cmorejová, Klímová, 2012) at this stage, most individuals can still do several daily activities, but they may need help with their organization. This stage is characterized by getting lost even in familiar surroundings, feeling depressed, sad and anxious, problems with communication, problems with forgetting names, meetings, people and the like.
  • Mild stage (duration 2-10 years) – death of brain cells spreads throughout the brain and in this stage the individual has problems with dressing, orientation and often cannot remember how to use objects of daily use (Callone, Kuclacek, Vasiloff et al., 2008). In the early evening to evening, individuals have feelings of restlessness, are confused and also suffer from anger, mistrust and have difficulty understanding others and expressing themselves correctly (Majerníková, Cmorejová, Klímová, 2012).
  • Advanced or late stage (duration 1-3 years) – clients-patients are in this stage according to L. Etters, D. Goodall et al. (In Majerníková, Cmorejová, Klímová, 2012) dependent on the help of another person for their daily care, they sleep more often, communicate less and do not react in any way to the person who takes care of them. According to D. Bartek, I. Čombor, Š. Madarásza and M. Luliaka (2008) individuals exhibit delusions, hallucinations, are more emotionally unstable, aggressive, and neurological symptoms include stool and urinary incontinence, ataxia, and apraxia.

Clinical social work in healthcare facilities

Since the beginning of human history, social work has been considered a socially accepted form of helping an individual, a group, and the entire society (Levická, 2002). I. Tomeš et al. (In Mojtová, Sedlárová, Šrank, 2013, p. 15) states that: "social work is a specific professional activity that aims to improve mutual adaptation of individuals, families, groups and the social environment in which they live and to develop self-esteem and personal responsibility of individuals using the resources of people's abilities, interpersonal relationships and resources provided by society".

Clinical social work is a professional application of social work as well as methods in the diagnosis, treatment and prevention of psychosocial dysfunctions, disabilities, including emotional and psychological behavioral disorders (Barker, 2003). Today, clinical social work is an integral part of social work. In the system of general social work, its development went through a certain process within the development of both theoretical and practical and academic social work. The theory and practice of clinical social work was significantly developed in the 1990s in the Anglo-Saxon environment, and many authors point to the social demand of the time, which is precisely the formation of clinical social work (Balogová, 2012). It is a specific profession in the field of mental health and is carried out by educated social workers who must then participate in special training and practice under supervision. The basic goal of clinical social work is not only to evaluate, but above all to positively influence the bio-psycho-social-spiritual functioning of individuals, families, but also groups in their sociotopy (Ptáček, Pemová, 2012). According to M. Mojtová, K. Sedlárová and M. Šranka (2013), clinical social work is an area where social care is intertwined with health care and is an important part of the nursing and treatment process. Therefore, the given complexity of the treatment immediately includes help in solving the patient's social problems in cases where he is unable to do so independently with the help of his own resources or his family does not want or cannot provide this care on its own, or if the patient does not have a family. Clinical social work focuses on an individual approach to each client-patient, because just as each person is singular and inimitable, work with them is also unique. Since man is a holistic being, we cannot forget a single component of the bio-psycho-social-spiritual dimension. In his work, the clinical social worker is based on a holistic model that understands a person as a bio-psycho-social-spiritual being, and this model is based on a person's ability to adapt to new (changed) conditions. It can therefore be said that a holistic approach is a philosophy applied in the care of the client-patient, while this care is also oriented towards the family of the client-patient, their problems, needs, and mutual relations.

Currently, there is no legislation in Slovakia that would define the activity of a clinical social worker. On the other hand, in the Czech Republic, the law regulates the activities of social workers in the health sector, mainly in the framework of diagnostic, preventive, rehabilitation and nursing care, where they participate mainly in the area of ​​satisfying the needs of the client-patient (Mojtová, Sedlárová, Šrank, 2013). According to N. Špatenková (In Mojtová, Sedlárová, Šrank, 2013), a social worker works in the hospital in the department of social services, and his help is mostly in the nature of social and legal advice, social agenda and mediation. However, based on his education and further training in the hospital, the activity of a social worker does not have to be only administrative in nature. According to M. Mojtová, K. Sedlárová and M. Šranka (2013), a clinical social worker in health care facilities, such as hospices, hospitals, psychiatric hospitals, is an important member of a multidisciplinary team (psychologist, nurse, doctor) and his activity is directed towards both the client-patient and his social environment. His professional activity is oriented towards the world of a person who, as a result of an illness or injury, ended up in a health facility, where he requires the professional approach of health workers, but also of a clinical social worker. In healthcare facilities, we can meet different names of social worker, such as social worker, social nurse, clinical social worker or social service nurse.

Thus, the social worker gets his space also in health facilities, as he also contributes to the client-patient's recovery, but also to his early return to the family, by solving his social problems. It is clinical social work that requires a different approach to sick elderly individuals. Above all, it is necessary to show them understanding, decency, empathy, respect and to avoid unreasonable curiosity and even violence (Hrozenská et al., 2008). M. Šustrová (2012) states that social work in healthcare is a specific activity whose goal is to improve the overall health status of individuals, groups, as well as the entire population. It must be provided regardless of the sexual orientation, gender, age, nationality, health status, culture, race, religion and other socio-demographic differences of the individual, group or community. During the performance of social work in healthcare, a social diagnosis is established, and social therapy is also implemented, while part of it is the overall evaluation of the results of the care that is provided. He understands health as a state of complete physical, mental and social well-being, and its main goal is to solve a social problem, whether in the case of illness, disability or old age. Social work in healthcare also deals with the social consequences of the given disease and disability on the social situation of both the individual and his family.

The goal of social work in the health sector is to provide support and support, guidance and help for a person who is disadvantaged in some way due to his illness (Kovalčíková, 2005 In Mojtová, 2008). According to M. Mojtová (In Mojtová, Sedlárová, Šrank, 2013), work in medical facilities is also multidisciplinary, since the client-patient is also understood as a bio-psycho-social being. In the framework of the mutual connection of social and health care, the position of a social worker in a team of health professionals is very important and justified. According to the type of medical facility, according to the number of client-patients and the type of department, a social worker in the healthcare sector solves specific tasks. His work can be summarized in 5 basic stages:

  1. familiarization with the medical record,
  2. social diagnosis,
  3. proposal of solutions and social assistance plan,
  4. social therapy,
  5. verification of results (Hrozenská et al., 2008).

As behavioral disorders occur in old age at the same time as disorders of cognitive processes or with disorders of the intellect, in a naturally aging individual the diagnosis may indicate the presence of primary degenerative dementia (dementia with the presence of Lewy bodies, Alzheimer's disease, frontotemporal dementia or Pick's disease, Parkinson's disease, Huntington's disease, etc.) or secondary dementia in seniors with an unhealthy lifestyle, or in younger people (Multi-infarct dementia, vascular dementia, alcoholic dementia, post-traumatic dementia and others). From the point of view of these starting points, the clinical social worker is faced with the question of what abilities he must possess and at the same time what competences he has towards the disabled senior and his loved ones from the performance of his work (Balogová, 2012). M. Mojtová, K. Sedlárová and M. Šrank (2013) state that the competence, focus and professional activity of a clinical social worker results from the basic understanding of health as a state of complete mental and physical well-being of a person, in our understanding of the patient. Each of these components of health affects the family, work and personal environment of the individual. The basic competence in the practice of a clinical social worker is to determine the social anamnesis of an outpatient (hospitalized) client-patient, while focusing on the analysis of his health and social situation during and before hospitalization, or during his outpatient visit to a medical facility:

  • based on an interview (with the client-patient, with his relatives, acquaintances) evaluates his life situation,
  • observes how the client-patient's hospitalization in a medical facility develops and how the disease affects his needs, while helping the client-patient to solve problems resulting from poor health,
  • provides basic but also specialized social counseling and can also provide professional advice, guidelines, social intervention and the like to clients-patients and relatives,
  • prepares a proposal for social assistance in cooperation with the client-patient himself, family members and in connection with other medical facilities (Mojtová, Sedlárová, Šrank, 2013).

A clinical social worker is responsible for his clients-patients and, since he has access to medical records, he must be trustworthy at all times and must protect confidentially all the information he has obtained about the client-patients. In addition to professional competences, he must also have a complex personality, which depends on his education, character traits, communication and other skills and abilities, on his willingness to work on himself and on his recognized values ​​(Mojtová, 2008).

Clinical social work with seniors

Clinical social work in healthcare is oriented towards a comprehensive social approach to all its clients-patients, regardless of age. It is only in extraordinary situations caused primarily by health and social factors that the need for social work with seniors appears and focuses its attention on the care of such seniors whose health condition is associated with reduced functional abilities and independence (Janečková, 2005). In everyday practice, according to V. Pidrman (In Balogová, 2012), a clinical social worker meets a clinical client-patient suffering from severe dementia, while 75% of clients-patients are suspicious of their surroundings, 40% or more of clients-patients suffer from delusions that someone is robbing them, 25% of clients-patients suffer from hallucinations, 80% of clients-patients have shows a high level of morbid restlessness and aggression, 50% of these client-patients suffer from sleep disorders and 40% from depression.

Seniors are important clients-patients of social work. The helping profession must approach these clients-patients very attentively and humanely. Seniors are perceived by clinical social workers on two basic levels:

  • health level – seniors with dementia, after injuries, with mental illnesses, physically ill, immobile, dying, disabled,
  • social – economic level – lonely elderly clients-patients, disabled and institutionalized clients-patients (in medical facilities, in social service facilities).

Social work with seniors also brings with it certain critical moments and problems when it is impossible to determine a sharp boundary between social work and health care. Their penetration should take place both in social services and in medical facilities, as the deterioration of health brings with it the need for social services. Both of these types of services must be provided simultaneously, that is, the clinical social worker must work in a team with medical personnel. However, there is also the opposite relationship, when from the point of view of health, social changes represent a certain burden and risk for the senior, and it is the clinical social worker who must help the client-patient adapt to the change, work with the client-patient's life story and support his quality of life and health. Clinical social work with the elderly must be carried out with quality even in the case of client-patient communication problems due to dementia. The clinical social worker must therefore have the skills necessary to establish contact and recognize their needs, he must also work with trust and relationship, create a feeling of security and safety, and at the same time work with the client-patient family (Janečková, 2005). From the point of view of relationship and communication problems, it can be said, as stated by M. Hrozenská et al. (2008) that communication is the first condition for the implementation and functioning of interpersonal relationships. In practice, we often encounter the fact that clients-patients, especially older ones, react maladaptively to hospitalization. According to E. Žiaková (2005), the so-called "geriatric maladaptation syndrome", which is caused by factors that condition the adaptive reaction in an elderly individual. However, in order for a senior, i.e. a client-patient with Alzheimer's disease, to cooperate, according to M. Hrozenská et al. (2008), communication must not only be effective, but also positive and active. One of the conditions for providing quality care is precisely effective communication with people with Alzheimer's disease. knowledge, as well as a huge amount of empathy, patience and the ability to listen not only with hearing, but also with sight (observation of non-verbal communication) and heart (showing empathy).

In this context, it can be said that the work of a clinical social worker is broad-spectrum, while in the process of social work he follows the latest methods and when solving the client-patient problem situation, including access to it, he also uses the latest work approaches. When performing his work, a clinical social worker must observe basic ethical principles, he is also obliged to respect general binding legal norms, basic human rights, and must be clearly consistent with respect for these basic human rights and freedoms (Mojtová, Sedlárová, Šrank, 2013). He is therefore obliged to perform his work in accordance with the ethical principles that apply to all roles performed by a clinical social worker. The main ethical principles of clinical social work can be considered:

  • autonomy - it is necessary to approach each client-patient and participating persons as equal partners and respect their free decision,
  • advocacy – an effort to emphasize the requirement of ethical correctness of sensitivity and the sought-after solution for those starting points that can be relied on in the proposed solutions,
  • awareness of purpose - the ability to find, evaluate and continuously follow goals that are not at hand,
  • confidentiality – this is the relationship between the client-patient and the clinical social worker,
  • dignity – it is about recognizing human rights in society, emphasizing their importance and protecting them from such treatment that would reduce their dignity,
  • confidentiality – in order to strengthen the trust between the professional and the client-patient, it is necessary to maintain confidentiality,
  • benefit - act for the benefit of others, for their maximum good,
  • do no harm – this principle prevents harm in the interest of the client-patient and prevents risks that could lead to harm,
  • justice – respect for client-patients, not making any distinctions between clients-patients and providing health and social care to everyone who needs it (Mojtová, Sedlárová and Šrank, 2013).

M. Mojtová (2008) claims that even in direct social work, a social worker as a professional who possesses professional knowledge and a general overview of the goings-on of society must meet personal prerequisites, while he should adopt the following ethical principles in the performance of his profession:

  • beneficiencia (beneficiality) – means doing maximum good for a specific individual,
  • non-maleficence (harmlessness) – requires excluding any intentional or unintentional harm or damage, while the social worker must follow the rule – never harm,
  • independence (autonomy) – respect the client-patient's decision based on his own conviction,
  • justice – treat everyone equally fairly, make no distinctions between clients-patients,
  • veracy (truthfulness) – do not lie to others and always tell them the truth,
  • trustworthiness – respect the confidential information and actions of the client-patient,
  • tolerance/understanding – understand and accept the opinions of others,
  • respecting the client – to appreciate the rights and responsibilities of others, because respecting others means that we do not treat them as a means to fulfill our purpose,
  • transparency – act in accordance with ethical standards that are respected by all involved,
  • finality-definiteness (finality) – to act in such a way that may have priority over the requirements of religion, law and social customs.

At the same time, it is necessary to point out the ethical requirements for social workers in healthcare facilities:

  • physically and mentally healthy,
  • personally and professionally capable: a.) conscience, b.) self-confidence, c.) professional level, d.) communicativeness, e.) solidarity, f.) prosociality, g.) empathy, h.) status virtues a i.) sympathy (Mojtová, 2008).

Every clinical social worker must be aware of his/her competences, and with the help of awareness of his/her own abilities and introspection, he/she is able not only to better plan, but also to carry out work with other people. Thus, helping professions are responsible for activities in satisfying their own needs, as well as the needs of clients-patients (Kutnohorská, Cichá, Goldman, 2011).

Conclusion

Aging and old age is a natural stage of life and cannot be prevented. The population is aging and more and more seniors find themselves in situations where they are dependent on the help of others. In such cases, they end up in one of the social services facilities, where they are provided with help and care by professionals. Until now, in the professional literature, we could meet their names as social workers, social nurses, nurses of social services. Today, however, we also encounter the name clinical social worker and we consider it necessary to point out in society the necessity of its professionalization as well as the application of clinical social work in practice. Clinical social work is a very current and interesting topic in the world, but currently also in Slovakia, despite the fact that this type of scientific field is not yet studied in Slovakia. However, the current problem of the postmodern era is the care of older persons, and therefore the integration of health and social care is necessary. It is in this context, as we pointed out in the post, that there is a need for clinical social work and the care of clinical social workers for seniors, including people with Alzheimer's disease. Above all, in healthcare facilities, the clinical social worker has an irreplaceable place, who helps the client-patient to adapt to the new environment and provides him with both social and medical care, taking into account his health and age.

Authors: Mgr. Zuzana Šoltésová, doc. JUDr. Mgr. Dušan Šlosár List of bibliographic references

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