lthough many churches now have all-age worship services, these are often in fact aimed at making the service accessible to the younger people present rather than ensuring that everyone can participate and benefit. All too often it is assumed that if concessions have to be made, these must be made by older people. The view seems to be that all other worship is designed for older people so they have no need of special attention. As a result older people may well feel that there is little in such worship to nurture and sustain them and some cease to attend. Trying to please everyone often results in pleasing no one.

In the words of a report from the Presbyterian Church of the USA, we need to remember in all our planning that ‘older adults are not a different category of persons but are simply persons who have travelled further along the journey’.

Dementia poses a whole range of challenges and opportunities 4 those who are tasked to lead worship. It requires a particular mindset and approach that is sensitive to the individual and what they bring into the worship space. Chris Crosskey offers 24 suggested outlines for worship with people living with memory change during the cycle of the Christian year. It is grounded, practical and theologically generative.

In this paper Kenneth Howse draws on a wide range of academic research to show that this is a contested area. There is a division between those who believe that the costs of supporting increasing numbers of older people threaten to become impossibly burdensome and those who believe that this threat has been massively exaggerated. Those who take the first view see the problem as primarily an economic one to be tackled by cost containment measures: pension reform, raising of the retirement age, tight control over health and social care expenditure. Those who take the second view tend to have a wider agenda: there is a ‘big enough pot’ but it needs to be shared more equitably. They advocate greater redistribution of wealth to correct persistent inequalities, the improvement of health and social care services which, by keeping more people healthier for longer, will actually reduce the overall burden, and the promotion of the participation of older people in society, seeing them as a resource rather than a problem.

Although the financial implications of demographic change cannot be ignored (and much of this paper offers detailed financial analysis) these cannot be seen ultimately as economic issues. The key questions are questions of justice. What can older people rightly expect from society? How far should their care fall upon members of their families? In broader terms, where should the balance lie between the generations in terms of paying taxes and receiving benefits? These questions take us beyond economics into ethics and political commitment. We are grateful to Kenneth Howse for presenting such a wide-ranging survey of both the relevant evidence and the divergent values which contribute to this complex debate.

This was an unusual lecture (given in 2006) in relation to those which have gone before in that it did not focus exclusively on the issues which older people face. While pensioner poverty was addressed, this was set within the wider context of the government’s total welfare reform programme over the past ten years. Some may feel that substantial parts of the lecture dealing with policies designed to help families from welfare into work or the need for a vastly improved child support system have little to do with older people, yet this would surely be a short-sighted view. The welfare of any section of the community is bound up with the welfare of society as a whole and it is perhaps right that we should be required to consider the problems which any government faces in trying to institute wide-reaching welfare reforms.

Much of the lecture makes bleak reading. In Frank Field’s view the Labour Government had unprecedented advantages when it came to power in terms of a strong economy, a huge parliamentary majority and a widespread willingness to embark on radical reform. Yet despite its best efforts, some of which have been successful, the overall impact of the reforms has been disappointing in spite of the huge sums spent and it is hard to see how current levels of expenditure can be maintained, let alone increased. Furthermore the scale of means-tested benefits is higher now than at any time since the 1930s and we have to ask questions about the way that affects public attitudes.

Philosopher and Theologian Helen Oppenheimer opens up her own experience of ageing. In this lecture she explores with honesty and tenderness some of the geography of old age. There is a useful and insightful response from Gordon Mursell inviting us into further theological reflection about what shape age might take in us.

The paper opens with a meditative consideration of suffering in all its universality and diversity, and in its many styles and degrees. We consider the virtues to be found in suffering, virtues which may indeed never surface in a particular life without the situation of suffering. So suffering can be the necessary occasion of good. We see this put, briefly, in the context of the Christian tradition (to which it is of course central), but mostly we have devout wisdom, meditatively presented. We turn to the specific trials, characteristics and opportunities of ageing and old age itself; and finally (and usefully) to the attitudes necessary for the effective care of the elderly. Here there is much imaginative and useful insight, highlighting best practice. It is a paper which pauses to express what is a way we all know but are rarely in a position to stop and explore.

Coleman’s critique of psychology and its dismissiveness of religion are acute and deserve further debate and reflection. It is ironic that many Christians draw heavily upon the discipline of psychology for their thinking and practice about pastoral care. Is it possible that, uneasy or insecure about theology and its discourses, too many have sought refuge in psychology? Coleman reminds his audience that in a world of fragmented knowledge and isolated disciplines we need to develop an approach to knowledge and learning which is interdisciplinary. This is especially important for those of us involved in thinking about and responding to older people and their care.

Coleman’s interest in and sympathy with institutions and communities of care is also to be commended. It reminds us, as Professor Malcolm Johnson noted, that religion is not just personal but corporate and communal. Religious affiliation and social care have often gone hand in hand throughout Europe and North America. One possible future for the church is to abandon some of the traditional structures of ministry and mission and through the provision of social care to recover the church’s engagement with people and their aspirations. Building and developing alternative communities of friendship might offer religion a possible creative way forward in a world so dominated by materialism and its values.

In this lecture she explores the place of humour in old age, the humour that sharpens the mind and lifts the spirit, the humour that acts as a wry defence against melancholy or despair, but also the humour that can be cruel and that needs to be challenged. Along the way she also points to some of the needs of older people and how younger carers and family members may be able to help meet them. Her lecture amply demonstrates the value of listening to what older people have to say about themselves on their own behalf.

Most of the papers collected here were presented at a Leveson Centre in 2003.   In the first paper Kate Read, Director of Dementia Plus, gives an overview of the nature of dementia, the ways it manifests itself and looks at how an understanding of the person can make a difference to the quality of care. Jill Phillips who until recently was home manager of one of MHA Care Group’s specialist home for people living with dementia then provides practical hands-on examples of this approach. A substantive paper by Margaret Anne Tibbs is based on the research she carried out at MHA Care Group as part of a Bradford Dementia Group team which resulted in the report A Special Kind of Care. In it she considers the important issue of communication with people with dementia and explores ways in which faith survives or fails to survive under this assault on the self.

The collection concludes with a previously unpublished paper by Alison Johnson which was originally presented at a Journal of Dementia conference in Warwick in 2000. Based on her Winston Churchill Fellowship in Australia, where she looked at good practice in dementia care, she paints a picture of living and working together in care homes where residents, staff, relatives and members of the wider community together live life to the full and come to the beginning of each day with eager anticipation and to the end of the day with a sense of achievement and satisfaction. The publication concludes with a bibliography suggesting further reading in the field of dementia and spirituality.

The papers published here are all based on presentations given at a seminar held at the Leveson Centre in March 2004. The aim of this event was to consider how those involved with people living with dementia could continue to see the person rather than the disease and thus be able to respond to his or her spiritual needs.

In the first paper, John Killick draws on his work at the Stirling Dementia Services Development Centre to show how it is possible to establish and maintain meaningful relationships with people living with dementia. He suggests that this is not merely possible but actually rewarding and that we may even be able to learn from people with dementia because they have a particular kind of consciousness which is largely denied to the rest of us. He illustrates this with moving poems from people with the condition whom he has interviewed.

Gaynor Hammond then looks at the role of reminiscence in helping older people with dementia retain their personhood. As we go through life we all build up a personal history with a mixture of joys and pleasures which help to make us the people we are. Gaynor describes how Faith in Elderly People Leeds developed the idea of the Memory Box which contains people’s personal mementos which can then be used as memory cues to open up ‘windows of recognition’ and help them to retain their identity.

Finally Sally Knocker examines the needs of older people with dementia suggesting that time, attention, human contact, conversation, a friendly smile are some of the most important gifts we can offer. She looks at the work of Tom Kitwood in this area and concludes that this should be an important ministry for churches.

This publication brings together four papers based on presentations at a Leveson Seminar on palliative care for people with dementia. This is a neglected field. It is widely accepted that those suffering from cancer, and other conditions where physical deterioration is to be expected and its course is to some extent predictable, receive palliative care. The same kind of care is not routinely offered to those living with dementia. Four contributors address this issue from different perspectives.

Katherine Froggatt explores the difficulties involved in applying the concept of palliative care or end-of-life care to people living with dementia, who may have limited awareness of what is happening and for whom the dying process may extend over several years. These difficulties affect family and carers as well as the person with dementia. Part of the problem is the inability of those living with dementia to articulate what the experience is like for them. It is therefore desirable to address end-of-life issues soon after the onset of the condition but this needs to be done sensitively so that confronting the dying does not detract from the living that is still to be done.

Adrian Treloar, a consultant in old age psychiatry, considers the option of continuing to care for a person with dementia at home until the end. He does not suggest that this is possible for everyone but offers case studies where it has been done successfully and explores the conditions which are required to make it possible. These include a willingness to ‘take on’ the professionals who may require some convincing that this is the best option.

Margaret Goodall considers ‘the long goodbye’ of people in the last stages of dementia in the context of the care home. She draws on the work of psychologists who have investigated how people find meaning in life and discusses three ‘therapies’ in relation to this: Reminiscence Therapy, Reality Orientation and Validation Therapy. Her key assertion is that the search for meaning is the overriding spiritual need of people living with dementia as they approach the end of life and that there are techniques which can assist in this.

Leslie Dinning offers the view of a hospital chaplain. He sees his role as going on a journey with the person living with dementia, with the family and with the staff, all of whom need support. It is a journey in which the light is fading but it was not always like this. Light from the past can be brought to illuminate the present. As he says in one of his concluding key points, ‘the chaplain is there to help to bring to mind all that the person was and still is in the context of family and community’.

None of these authors would claim to provide us with an ‘answer’ (let alone ‘the’ answer) to caring for those in the final stages of dementia. They do however offer us a wealth of insights from their differing perspectives and professional expertise to enable us to begin grappling with the issues. We are pleased to be able to bring their thoughts to a wider audience than those who were able to attend the seminar.