M.A. Lyons : December 2011
REFLECTION ON THE USE OF INTERPERSONAL SKILLS FOR DE ESCALATING AGGRESSION WITH DEMENTIA PATIENTS
“Coz talking to them really does help you connect with them a bit better, if you understand them as a person”. Pp22 (Wheeler N I, 2010)[1].
The focus of this paper is on aggression in older people with dementia and the use of interpersonal skills and a person centred approach to de - escalate this behavior. It is important to understand the context of the‘whole person’ with dementia,[2] as the above quote implies.
According to the WHO 150 million people will have dementia by 2050 (Mathers, 2000) and in the UK the figure is estimated to be 1.7 million by then) rising from 0.75million currentlyAlzheimers (Society, 2011). It is a growing disease and must be understood so that people suffering from it can be nursed with knowledge and compassion.
Aggressive behavior tends to occur in the middle and end stages of dementia.(Langham, 2010).The Alzheimers society defines aggressive behavior in people with dementia as including “verbal abuse, physical abuse (kicks, pinches, punches) and overreactions to situations”.
I use Gibbs (Gibbs, 1988) cycle as a vehicle to reflect back on my learning. I give an honest account of my experience and the prejudices I carried to my first placement. I summarise the understanding I have gleaned so far, through my practice experience and reading.
Description of ‘Aggressive’ Events and Feelings aroused in me
I anticipated that working on a dementia ward would be a difficult placement for me. In particular I had heard from colleagues that older people could be aggressive and I felt nervous about working around this.There are 2 main examples which I observed at different times during the placement which I share and I experienced different feelings and attitudes with each.
On my first day at work on a ward of 11 male patients, I observed 2 patients whom I’ll call J & P[3] bare their teeth, swear loudly and hit out at staff who were getting them up. I thought – uh – oh I hope I don’t get to change them – as they look really scary. At this point I felt no empathy with them, just fear and a need to protect myself. I didn’t want to go near them.
The second event I observed (5th week into placement) was a colleague transferring ‘P’ to a chair, from a wheelchair. The colleague was rushing ‘P’ and was a bit rough and ‘P’ was sat down quite ‘hard’ and as the colleague concluded the task, ‘P’ hit him. I could see that ‘P’ was powerless to ‘object’ to how he was being treated in any other way.I was sitting on the other side of ‘P’ and he continued to show no animosity toward me. Here I felt angry on ‘P’s behalf. Kitwood might have called this intimidation, imposition and invalidation by the carer pp46/47. (Kitwood, 1997).
Below I explain how this change in myself and in my attitudes happened.
Evaluation
Firstly on reflection I note that my feelings went from fear and ignorance of ‘P’ to understanding and compassion in just a few weeks and I believe this came from both observing/discussing the (mainly) good practice of the ward nursing staff and working directly with patients myself over this period.
All kinds of factors can contribute to behavior becoming more aggressive. These include both organic(Page, 2011) and environmental factors. Dementia sufferers have an imbalance in neurotransmitters dopamine, serotonin or norepinephrine which affect the individual’s capability to ‘regulate’ their emotions. (Langham, 2010). Environmentally, loud or sudden noises, busy activity and changes in routines may contribute to confusion and increase aggression. Simply touching/intervening with patients may cause aggression. (Boyd, 2010)In 2010 Kunik found that pain and the declining quality of the caregiver relationship was linked with aggressive behavior in recent onset dementia. (Debakey, 2010)
People who suffer from frontal lobe dementia also tend to lose more of their personalities than those with vascular dementia and thus the aggressive behavior may be more shocking for caregivers in the former category or more sudden for caregivers in the latter category.
It has also been found that aggression is linked to depression in sufferers. (Lyketsos 1999). Indeed a general frustration and despair about one’s declining abilities is widely acknowledged as being a natural response to the disease.
The Alzheimers Society argues that aggressive behavior can be reduced and/or better managed through better understanding and positive interaction with patients. Alzheimers Society 2010In addition ward colleagues recommended reading Kitwood.He proposed 12 types of positive interaction including recognition, collaboration, negotiation, play, celebration, relaxation, holding, validation, creation and giving. (Kitwood, 1997). I make reference to just a few of these below.
What I came to learn was that by taking the trouble to get to know ‘P’(recognition), offering reassurance (relaxation) and going at his pace (collaboration & negotiation), seemed to go a very long way to keeping him calm. A fellow student alerted me to the existence of mini biographies of the patients kept in their lockers for staff to refer to[4]. These helped give a little bit of depth to the person they were prior to dementia. Immediately reading these changed my view of the individuals.
Kitwood argued that a sense of relative wellbeing should be the aim when caring for a person with Dementia. He outlined core psychological needs which would need to be met in order to prevent a sense of ill being and named these as “Love, Attachment, Comfort, Inclusion, Occupation and Identity”. (Kitwood, 1997). As part of ‘getting to know him’ I noticed that ‘P’ liked to give and receive affection. He appreciated simple hand holding, smiling and soft vocal tone (timalation) by the nurse. I believe this is the love and comfort that Kitwood makes reference to. (Kitwood, 1997) I found that talking and listening to patients respectfully, perhaps about an interest they had eg gardening and fishing in one instance, made a difference. Talking with and getting to know their families was also enlightening and I believe gave their families comfort. It reminded me that ‘Nursing’ includes a partnership with families not just patients (RCN, 2003). I found that by telling ‘P’ slowly what we planned to do, could turn a sensitive activity into something more relaxed and comfortable. I even had a couple of patients ask me ‘how I was’ when I was a bit red from the physical activity involved ! I was very moved by this and it really made me see what a difference actively engaging in a relationship with a patient made. I found that by validating the patients, they responded in kind. This overall approach is very supported by Kitwood and Brooker who would argue that these conversations help to ‘recognise’ the patients socially and reinforce their confidence about the things that they ‘know’. (Brooker, 2007)
Kitwood contrasted the standard ‘biomedical model’ which he felt in general ‘objectified’ people, to a more person centred model which he advocated with a high emphasis on “intensive personal interactions with people”.(Flicker, 1999)
I observed that many nursing colleagues incorporated this attitude to the patients, both behaviourally and attitudinally, it really felt to me that they embodied key tenets of the NMC code (NMC, 2008) and the Kitwood philosophy. In changing in the morning, patients’ privacy was assiduously respected with use of the curtains. Patients were encouraged, touched carefully and warmly when appropriate and never bullied. From a dignity perspective I noticed that it was tempting (sometimes necessary in order to do the task eg hoisting) to have conversations ‘over’ the patient but it was clear to me that patients can understand a lot even if they no longer speak in coherent sentences, so reassurance was always necessary and I took care never to talk about a patient in these situations.(RCN, 2003)
Sense Making, Analysis & Debate
Reflecting back,I believe that the viewpoint I began with, on that first day,might be classified by Kitwood as containing elements ofmalignant social psychology. He defines this as meaning “the different ways in which the personhood of the individual is undermined” (pp4)I can see that I was objectifying ‘P’ ‘J’and failed to acknowledge them as people, I also wanted to ignore themfor as long as possible and I didn’t want to understand them because I was too scared and ignorant about them. Kitwood has stated that both fear and anonymity contributes to the ‘malignant’ attitude (Kitwood, 1997).
Yet for all the evidence in support of it, I observed that person centred care occasionally didn’t happen, perhaps because a colleague may be rushing, sometimes because they just didn’t want to engage with patients at that moment or sometimes it ‘didn’t appear to work’, no matter what anyone did, the patient could still be suspicious, tetchy or inconsolable. Here I might comment that depression or dysthymia is quite common, not unnaturally following a diagnosis of Alzheimers(Bazaire, 2003)and perhaps part of the nursing process is to accept that and ride the balance between not trying to make everything better – which is unrealistic – but still aiming for the achievement of ‘relative wellbeing’ overall.
Flicker, in his review of Kitwood’s book in 1999 points out a few flaws in the approach. Not least that it is time consuming and expensive of resource, he felt that the medical model was dismissed without a proper review and that the evidence for Kitwood’s approach was limited.(Flicker, 1999) Nevertheless, the Alzheimers Society wholeheartedly supported Kitwood’s holistic and compassionate approach.
Pharmacologic treatments are available to reduce aggression and agitation and these include anti psychotics, anti depressants and anti convulsants. These had variable results with our patients, with 4 patients being on risperidone (an anti psychotic which blocks the dopamine pathways of the brain) to treat their aggression(Bazaire, 2003). Only one of these patients was actively psychotic.It has been argued that drugsmay be over used to promote compliance in patients in nursing homes and other places (James, 2008).
A recent article in the Nursing Times explored how the nationwide dementia strategy was being implemented in practice(DoH, 2009). The authors looked at 9 homes and assessed that 4 of them had moved to a ‘Biopsychosocial’ approach, whilst 2 were in transition and 3 in the older medical model. It appeared that higher levels of drug use were used in the latter homes whereas medication was seen as a last resort in the former.
Conclusions
Overall the authors concluded that “Our findings suggest optimum dementia care relies on staff having confidence, competence and special qualities such as a lot of patience and understanding which enable them to interact positively with residents. This ensures they are seen as PEOPLE with dementia and that their individual needs are met by empowering both carers and residents” pp22 (Wheeler N I, 2010)
On the one hand this discussion could imply progress in the specialist treatment of dementia and yet on the other the recentNational Audit of Dementia, indicated that staff in the general hospital system are not confident in dealing with people with dementia. The report found that “half of staff had not received sufficient training in communication with people with dementia, whilst 54 per cent had not had enough training in dealing with challenging behaviour”.(HQIP, 2011). There is clearly a need for more training and understanding in this area –amongst (generic) professionals.
I believe that building a relationship with the patient will go a long way toward defusing aggression – other treatments may help but I believe this is the most powerful.I believe I can now work more knowledgeably with aggressive behavior in other health contexts.
I am consciousthat every patient is an individual and I must remain in touch with this. I must go to each placement making few assumptions.
As a student I had the luxury of time and of not being hurried. It is a paradox sometimes that the slower you go, the easier it is and ultimately things get more efficient. In contrast, rushing can lead to a more negative response. Always go at the patient’s pace.
It seems that no matter howmentally ill, kindness and tenderness can go a long way to sootheand comfort the patient. As a professional I must not take it personally if what I do ‘doesn’t appear to work’– sometimes nothing works and it really is that bad (for the patient) but being with them may make a difference, we cannot always know.
M. A Lyons December 2011
Word Count
2194
REFERENCES
ABHB 2007. Guidance for the management of Confused Older Adult Patients in General Hospital Settings. Newport: Aneurin Bevan Health Board.
ALZHEIMERS SOCIETY. 2010. Dealing With Aggressive Behaviour. Alzheimers Society. London: .
ALZHEIMERS SOCIETY. 2011. The progression of Alzheimer's disease and other dementias. London: .
BAZAIRE, S. 2003. GP Psychotropic Handbook : the Professionals Aide Memoire, Bath, Fivepin Ltd.
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DOH 2009. Living Well with Dementia : A National Dementia Strategy. In: HEALTH, D. O. (ed.). London: Department of Health.
FLICKER, L. 1999. Review of Dementia Reconsidered. BMJ, 318, 880.
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JAMES, A. 2008. Myth of the Antipsychotic. Guardian.co.uk, 2nd March.
KITWOOD, T. M. 1997. Dementia Reconsidered : the Person Comes First, Buckingham, Open University.
LANGHAM, R. 2010. What are the Causes of Aggression in Dementia patients [Online]. US: Lance Armstrong Foundation. [Accessed 5th January 2012].
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summary of methods and data sources. In: ORGANISATION, W. H. (ed.). Geneva: World Health Organisation.
NMC 2008. The code: Standards of conduct, performance and ethics for nurses and midwives. London: Nursing and Midwifery Council.
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RCN 2003. Defining Nursing. London: RCN.
SOCIETY, A. 2011. The progression of Alzheimer's disease and other dementias. In: SOCIETY, A. (ed.). London: Alzheimers Society.
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1
[1]Quote from a carer working in a nursing home talking about working with older people and challenging behavior.
[2] “Dementia is a syndrome caused by a range of illnesses. Most are currently incurable, and cause progressive, irreversible brain damage. They include Alzheimer's disease (the most common cause), vascular disease, frontal lobe dementia and Lewy Body disease. Symptoms of dementia can include memory loss, difficulties with language, judgement, and insight, failure to recognise people, disorientation, mood changes, hallucinations, delusions, and the gradual loss of ability to perform all tasks of daily living”. Mathers & Leonardi.
[3]Anonymised to protect patients confidentiality NMC 2008
[4]“This is me”. A small 6 page leaflet/Bio, sometimes containing photos, shedding light on their likes, dislikes, previous work, hobbies, family etc