living alone with dementia: assessing and managing the risk dr. c. a. cohen march 10, 2008
TRANSCRIPT
Living Alone with Dementia: Assessing and Managing the Risk Dr. C. A. Cohen March 10, 2008
Learning Objectives
• Describe important issues arising in caring for these clients
• Identify predictors of harm for these clients
• Outline strategies for assessing, monitoring & reducing risk
Facts and Figures
# seniors living alone # seniors with dementia
• CSHA: 50% of those with dementia live in the community
• 1/3 of seniors living with dementia in the community live alone
# living alone with dementia
What We Know
• Webber et al. ( 1994)
• 9 California dementia clinics
• 479/2505 (19%) patients living alone
• Compared individuals with AD living alone and those living with others
Living alone with AD
• Female• Older• Less impaired; with disease for shorter
time• Lower SES• Less likely to have primary caregiver• More likely to have friend/neighbour as
primary caregiver
Living Alone with AD
• More likely to have MOW’s, homemaking, case management
• Less likely to use MD’s, Day programs
Qualitative Research
• Gilmour et al. 2003
• 10 people living with dementia in rural Ireland
• 9/10 known to social services
• 8/10 family lived close, daily contact
• Interviewed families, family MD’s, RN’s, SW’s, paid carers
Identified Risks & Issues
• Families: heating, falling, $$, road safety, “getting lost”, cooking
• MD’s: wish to respect wishes, feel there are few alternatives
• RN’s: falls, nutrition
• SW’s: heating, falling, $$, “wandering”, cooking + who is responsible?
Identified Risks & Issues
• Paid carers: importance of local supports, own personal experience
• Person with dementia: no mention of risk, searching for meaningful activity & structure; 2/10 said services were “unwanted and unnecessary”
Outcome
• No incidents of harm
• 2 “preventative factors”– Importance of people in the community who
know the person & can put situation in context
– Level of contact with family, care staff, neighbours
Recommendations
• Establishment of partnerships between person with dementia, family and others
• Assessment of emotional/social aspects in addition to physical
• Staff need support from managers & colleagues
Living Alone + Issues
• Medical-legal issues
• Ethical issues/values
• Quality of life
• Safety
Medical-legal Issues
• Who is responsible?
• Client’s capacity/competency
• Substitute decision-maker issues
• Appropriate use of legislation
Ethical issues/Values
• From the perspective of:– Person with dementia– Family/ friends– Formal caregivers/health care providers– Society
• Autonomy (vs. Risk); Beneficence; Non-maleficence, Social Justice
Quality of Life
• Familiar & appropriate environment
• Relationships
• Mental & physical health (including dementia Rx)
• Day to day activities
• Hygiene
Safety
Continuum from:
Safe At Risk
Risk = Degree of Harm x Probability of Harm
Predictors of Harm
• Tierney et al. 2004/2007
• N=139 living alone with dementia
• 30/139 (22%) experienced harm
• 50% neglected food, hydration, hygiene
• 43% not adequately communicating with MD or following instructions from MD
Tierney et al.
• Follow-up over 18 months (or until incident of harm)
• 8% died
• 13% in hospital or “institution”
• 4% no longer living alone
Tierney et al.
• Predictors of harm: MMSE, COPD, Cerebrovascular
disease, perceived social isolation
• Poor performance in specific areas– Verbal recognition memory– Executive function– Conceptualization
Tierney et al.
• Implications for care– Reminders/cues are insufficient– Need more direct involvement; regular visits
by family, others
Safety: Financial Concerns
• Financial abuse & fraud
• Misuse of POA
Home Safety/Injury Model
• Hurley et al. 2004
• 1. Person with dementia + indicators of frailty
• 2. Safety Platform: physical environment + caregiver capabilities
• 3. Risky behaviours
Accidents/injuries
Strategies to Assess, Monitor & Reduce Risk
• 1. Clarify concerns
• 2. Person with Dementia
• 3. Physical Environment
• 4. Caregiver Capabilities
• 5. Risky Behaviours
• 6. Finding a balance
1.Clarify Concerns
• Nature of the concern(s)
• Information: source, reliability, gaps
• Who has the concern?
• Perceived consequences or outcomes
• What has been tried/ what happened?
2. Person With Dementia
3. Physical Environment
4. Caregiver Capabilities
5. Risky Behaviours
6. Finding a balance
• Assess risk of harm
• Consider client values/quality of life
• Consider family/friend/formal caregivers values, availability, partnerships
• Consider medical-legal issues
• Monitor, assess, plan for the future…
Conclusions
• Challenging situations
• Require creativity, patience & peer support
knowledge re risk of harm → better assessments & interventions
References
• Alzheimer Society of Canada, Ethical Guidelines (Living Alone) http://www.alzheimer.ca/english/care/ethics-alone.htm
References
• H. Gilmour, F. Gibson, J. Campbell (2003) Living alone with dementia. Dementia Vol.2 (3): 403-420.
• A. C. Hurley et al. (2004) Promoting safer home environments for persons with Alzheimer’s Disease: The home safety/injury model. Journal of Gerontological Nursing Vol.30:43-51.
References
• M. Tierney, G. Snow, J. Charles, R. Moineddin, A. Kiss. (2007) Neuropsychological predictors of self-neglect in cognitively impaired older people who live alone. American Journal of Geriatric Psychiatry Vol 15(2): 140-148.
References
• M.C.Tierney, J. Charles, G. Naglie, S. Jagal, A. Kiss, R.H. Fisher (2004) Risk factors for harm in cognitively impaired seniors who live alone: A prospective study. Journal of the American Geriatrics Society Vol 52: 1435-1441.