Table 5

CMO configurations with supporting evidence for transitioning to the fourth age

Context (C)-Mechanism (M)-Outcome(O)Example of supporting evidence from the literature
CMO: Where there is a public failure of self-management (C), a person enters the fourth age (O) via mechanisms including institutionalisation (M), ignominy (M) routinisation of care (M). Public failure of self-management: reflections from a paid carer, ‘Not being able to take responsibility, not knowing that things (food) are mouldy or at the expiration date. Not knowing when you need to clean up (the house) and also not knowing how to perform certain actions.’ 69
Ignominy and routinisation : ‘this condition was devastating to watch, to(wife’s name)who was always rather coy, shy about the activities of bodily functions, to have her more or less on a timeslot and put into a machine, ‘cos they’d had lunch, lifted up and wheeled into the toilet – that was very devastating… I didn’t like to see her suffering these sorts of indignities.’ 58
She passes stool and handles the faecal matter. Makes a mess and this then cannot be cleaned. The whole household stinks. There is smell of faeces always. Nobody will help. Even my husband, that is her own brother, does not want to be at home. He cannot stand the bad smell.’ 103
CMO: Where communities of identity exist (C), people with dementia are seen to go about their business, their growth and development is then visually acknowledged so people develop an understanding of their needs and daily challenges. Through compassion (M) this may aid community development (O). Communities of identity : ‘…where people living with dementia are normalized not only in terms of their day care activity—by not being treated as passive consumers of ‘treatments’ or ‘services’ but as active agents of their own preferences and activities—but also as people to be publicly seen going about their usual business. Furthermore, people not directly involved with care for people living with dementia are encouraged to participate in that care and to obtain basic understandings of both the challenges of living with dementia and also the challenges in its daily care. Thus the levels of public education about living with dementia and its care are significantly raised….’54