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Living Alone with Dementia: Assessing and Managing the Risk

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.

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Living Alone with Dementia: Assessing and Managing the Risk

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  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.

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