Living Alone with Dementia: Assessing and Managing the Risk

1. Living Alone with Dementia: Assessing and Managing the Risk Dr. C. A. Cohen March 10, 2008

2. 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

3. 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

4. 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

5. 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

6. Living Alone with AD • More likely to have MOW’s, homemaking, case management • Less likely to use MD’s, Day programs

7. 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

8. 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?

9. 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”

10. 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

11. 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

12. Living Alone + Issues • Medical-legal issues • Ethical issues/values • Quality of life • Safety

13. Medical-legal Issues • Who is responsible? • Client’s capacity/competency • Substitute decision-maker issues • Appropriate use of legislation

14. 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

15. Quality of Life • Familiar & appropriate environment • Relationships • Mental & physical health (including dementia Rx) • Day to day activities • Hygiene

16. Safety Continuum from: Safe  At Risk Risk = Degree of Harm x Probability of Harm

17. 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

18. 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

19. Tierney et al. • Predictors of harm: •  MMSE, COPD, Cerebrovascular disease, perceived social isolation • Poor performance in specific areas • Verbal recognition memory • Executive function • Conceptualization

20. Tierney et al. • Implications for care • Reminders/cues are insufficient • Need more direct involvement; regular visits by family, others

21. Safety: Financial Concerns • Financial abuse & fraud • Misuse of POA

22. 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

23. 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

24. 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?

25. 2. Person With Dementia

26. 3. Physical Environment

27. 4. Caregiver Capabilities

28. 5. Risky Behaviours

29. 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…

30. Conclusions • Challenging situations • Require creativity, patience & peer support •  knowledge re risk of harm → better assessments & interventions

31. References • Alzheimer Society of Canada, Ethical Guidelines (Living Alone) http://www.alzheimer.ca/english/care/ethics-alone.htm

32. 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.

33. 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.

34. 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.