Challenges & Solutions, Toward better care

dementia not the cause in majority of harmful resident-on-resident interactions

 “Senior with dementia guilty in death of nursing home resident,” the headline reads.

The incidence of these kinds of tragedies seems to be on the rise, and they will continue to occur with increasing frequency if we don’t address the causes and find solutions. Unfortunately, by blaming dementia for behaviour that could be averted if the real causes of the behaviour were identified and resolved, we are “barking up the wrong tree.”

The 2016 story headlined as above goes on to describe the sequence of events that led to the deadly incident. It says that a damning critical-incident report about the episode was not shown to the jury, and that the report found the nursing home failed “through a pattern of inaction and or inappropriate and insufficient action” to protect residents.

As is the case in most such incidents, there’s a lot more going on than dementia. These kind of headlines, and the labeling used by medical professionals as well as researchers, perpetuate and reinforce the stigma and misconceptions associated with people who live with dementia. The result is we’re no closer to addressing the issues that lie behind violent resident-on-resident interactions in long-term care facilities.

Dementia behaviour consultant Eilon Caspi explains on his archival blog documenting hundreds of such cases:

“It is important to emphasize that the vast majority of harmful resident-to-resident interactions that involve people who live with dementia in long-term care homes are the result of negative and distressing factors in the social (i.e. other people) and physical environment. In most situations, unmet human needs, situational frustrations, and perceived and real threats contribute or directly cause these behavioral expressions.

These social and physical environmental factors and unmet needs intersect with the person’s cognitive disability to generate the episodes. Most elders with dementia are not inherently aggressive. Like us, they react, respond, defend, and protect themselves when they experience distress, and when they sense that their dignity, privacy, identity, and personhood are threatened.

Those who believe that most people with dementia are inherently “aggressive,” “violent,” and “abusive” are mistaken. These common misconceptions run the risk of further labeling and stigmatizing this already stigmatized vulnerable and frail population.

It is easy to forget that people living with dementia have a profound brain disease because their cognitive impairments may not be immediately and physically obvious. In most situations, when people with dementia engage in these episodes, they are actually fighting with each other to preserve their dignity. They “Fight for their Dignity.” The definition of dignity is the quality or state of being worthy, honored, and esteemed.

The widely-held misconception that most people with dementia engage in aggressive and dangerous behavior towards other residents reflects a “blame the victim approach.” This approach, in turn, often leads to a slippery slope in which psychotropic medications are used inappropriately and excessively. These medications are largely ineffective for most individuals with dementia, and frequently cause a series of side effects some of which are dangerous and can be deadly (some have a Black Box warning by the U.S. FDA).

Once the person with dementia is sedated, it becomes harder to identify the unmet human needs that caused the behavioral expressions to begin with, and there is little hope of then arriving at a humane, practical, and life-affirming solution for the person. Instead, other serious problems such as physical discomfort, disorientation, heightened anxiety, and falls ensue.”

All of that said, there must surely be cases in which the character of the person plays a significant role and may predispose her or him to aggressive and/or violent behaviour. Someone who has been difficult and aggressive their entire life may remain difficult and aggressive or get even more so when he or she lives with dementia. But again, this is not, in my opinion, a result of dementia; rather is is a function of the individual’s personality. Furthermore, assaults and other crimes are committed in our communities at large; it’s naive to expect that long-term care facilities will be crime free. The key is to do all we can to prevent crime and violence from occurring anywhere and everywhere, including in long-term care facilities.

Thanks to Eilon Caspi for the good work he does in this important area of dementia care. Read more about him below and get access to his 90-minute pay-to-play training seminar Fighting for Dignity: Prevention of Distressing and Harmful Resident-to-Resident Interactions in Dementia in Long-Term Care Homes.”

Eilon Caspi is a Gerontologist and Dementia Behavior Specialist. He has worked his entire adult life in the aging field. He started his career as a nurse’s aide in 1994 in a nursing home where his grandfather resided. Both of his grandmothers had dementia in the final years of their lives.

During the last 15 years, Caspi has worked with, or on behalf of, people living with dementia and their family care partners, as well with care staff and other professionals who provide support and care to these individuals in the community and in long-term care facilities (such as nursing homes and assisted living residences). He can be reached here.

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