We hear so many stories on the news lately about the “violent resident” in long term care… “is your loved one safe?”, it may really concern you that your mom or dad is currently in danger where they are. People with dementia are not intentionally “aggressive or violent”. They do not have the ability to think through their actions and purposely cause harm to another human being. People living with dementia have broken brains and may perceive other residents as a threat to them. People living with dementia do not necessarily have a “thinking brain” to utilize but use their brain at an instinctual or emotional level.
It is helpful to remember that we all experience the world at these three levels; at the instinctual level, emotional level, and through the ‘thinking brain’; and in dementia, as the thinking brain becomes more and more impaired the person’s behaviour becomes more and more determined at the instinctual and emotional brain levels. To put this information in perspective, I will give you a normal day situation that you may be able to relate to. Imagine it is very late at night, and you are entering a dark parking lot to get to your car. You are alone and hear a noise. You turn around to see a man is walking towards you. How do you react? What happens to you instantly at that moment? Instinctually your body prepares for the ‘fight or flight’ response. This is a natural stress response the brain uses to keep you safe. Your heart starts to race; you feel panicked…you start to plan your escape or what you will do to protect yourself. Do you have any evidence that the person is going to hurt you? Do you know for sure harm is about to come your way? This is an example of the “stress response” and how the instinctual and emotional brain will overrule the thinking brain, until the thinking brain is given a clear and convincing message that you are not at threat. Now think of the person living with dementia and the fact that in their stage of the disease process they may not have the “thinking brain” to realize that staff and other residents of the home are not a threat to them. It is very important to remind your family members not to take matters into their own hands if another resident enters their room by mistake. Your family member may be quick to yell at these individuals or physically attempt to remove them as it is their room, and they do not want their possessions taken. Your family member instead needs to ring the call bell to alert staff and refrain from hollering at the person living with dementia. To shout at this individual will start the “stress response” and the person living with dementia may act instinctually and attempt to protect themselves because they do not have the “thinking brain” to realize it was them that intruded into someone else’s room. It is best if your family member attempts to smile and look non-threatening to the person with dementia. It is our own reaction to their innocent behaviour (they do not realize they have entered someone else’s room) that can cause a catastrophic reaction and possible harm to ourselves or to others. To intervene in this situation is best in a non-confrontational way, taking the path of least resistance. “Mr. Jones, I have been looking for you! I would love if you would come with me to have a cup of coffee!” An intervention such as this distracts the individual out of the room without using negative words or actions.
Behaviour is a way of communicating when an individual can no longer express themselves with words. Sometimes individuals living with dementia may have pain or an infection that may be causing what appears to be “aggressive behaviour”. Have you ever stubbed your toe? Sometimes when we are feeling pain, we may feel angry and say some words that may not normally come out of our mouths. People living with dementia may be experiencing pain from something physical and be unable to express this pain through words to the staff.
Have you ever seen a child with a high fever become “delirious” and say or do some bizarre things? Older people’s brains are the most vulnerable organ in their body. Their brain is the most likely thing to be affected by an infection or poor drug interaction. Young people may experience delirium caused by an infection or fever, but older people are much more susceptible to experiencing delirium due to their vulnerable brain. Older people’s systems are compromised therefore they may not even register a fever. Something as simple as a bladder infection can cause an extreme change in an older person’s usual mental state whether they have dementia or not. A delirious resident may appear to be an “aggressive resident”. Whenever there is a change in an older person’s usual mental state, whether it is that the individual appears frightened and confused or has become very quiet and hard to arouse, a delirium should be suspected and ruled out.
Depression in an older person can also cause what is called a “psychotic state” or “psychosis” characterized by delusions (fixed false beliefs) or hallucinations with impairment in reality. Depression can look like “dementia” in an older person. An older person with a psychosis due to depression could also misperceive their environment and appear “aggressive”.
Long term care homes are obligated to phone the police should an “aggressive incident” occur between 2 residents. If a resident inflicts harm on someone and they have a diagnosis of dementia they cannot legally be held responsible for their actions. The person with dementia does not have the cognitive ability to “intentionally cause harm”.
So, what is my intention of this newsletter article? To emphasize that long term care homes are not full of violent, mean people. We are keeping people alive for a lot longer due to advances in medicine and unfortunately sometimes the brains of these individuals have damage due to a progressive neurological disorder. With these damaged brains comes the misperception of the reality around us. Staff members in the Haldimand Norfolk Long Term care homes/hospitals do take a workshop called “Gentle Persuasive Approach” (GPA) which I facilitate. This workshop teaches the proper approach staff should take, should responsive behaviours occur when someone has dementia. These approaches and techniques can help the staff decrease catastrophic behaviours and the possible injuries that may occur as a result of these misperceptions.
Kathie Poitras, RPN
Psychogeriatric Resource Consultant
Alzheimer Society of Haldimand Norfolk
For more information on issues related to dementia, please call toll free
1-800-565-4614 or 519-428-7771 extension 520 or email at kpoitras@alzhn.ca