Wednesday, October 11, 2006

Perpetrators with Dementias

A couple years ago, a friend who runs a dementia care program asked me to talk to her staff following a tragedy involving a client, a man with Alzheimer’s disease, who'd killed his wife.

The staff was understandably upset. But what made matters worse was that some felt they’d seen it coming. They’d filed a report with APS, and a worker investigated. But since the violence was dementia-related and the client was already receiving dementia care services, the APS worker concluded there was nothing more he could do.

It was not my finest hour. The group wanted to know what they could or should have done differently; what would have happened if they’d gone directly to the police; what steps, if any, they could have taken to have guns removed from the client’s home (and those of other clients); and what the agency’s role should be when their clients are the ones abusing. I didn't have answers.

The case has haunted me. In retrospect, I doubt if these was anything they could have done differently, but it got me thinking about what we, as a profession, need to do. Clearly, we should be providing dementia care programs with guidance in what to do when they know clients have histories of domestic violence, how to assess future risk, and what to do to ensure caregivers’ safety. Not to mention working with law enforcement to ensure that violent elders with dementias are treated humanely.

The issue is particularly timely now as domestic violence theory and practice filters into elder abuse, and police are increasingly being instructed to use applicable domestic violence laws when responding to elder abuse cases. These developments are resulting in more elders with dementias getting entangled with law enforcement and ending up in prisons or institutions for the criminally insane. It's the prospect of these innappropriate responses, I believe, that has made some people in the dementia care field leery of the elder abuse, law enforcement, and adult protective services networks. Even when their clients are on the receiving end of violence, they may be subject to arrest as co-combatants.

There are no easy answers. Formerly peaceful, loving husbands who become violent with the onset of dementias shouldn't be forced to spend their final days in prisons. Yet, long-term batterers are also likely to become increasingly dangerous and unpredictable with the onset of dementia and shouldn't suddenly be absolved or excused. The fact that decline is usually gradual makes it even hairier to try to figure out the point at which people are no longer culpable for their actions.

These issues aren't going to be resolved by the dementia care community alone. Nor by the elder abuse/law enforcement/APS network. Coming up with fair and humane responses requires input from both sides. Nowhere does distrust and lack of communication between two fields threaten to have more heartwrenching results.

23 comments:

DawnJ said...

I am very interested in the affects of perpetrators with dementia on caregivers. I work with the elderly and I have one case that particularly sticks out in my mind. There was this couple and the wife had progressive dementia and was becoming abusive to the husband who was her primary caretaker. The problem was that to other people she was always appropriate and we even began to suspect that the husband was abusive to her. Eventually we were able to put them in a more monitored environment and we saw that the wife, due to her dementia, would fly of the handle for no real reason. One day this happened and a staff member was assaulted and we were forced to send her to a geriatric psych ward at a local hospital where she remained for about a month. The hospital played around with her meds while she was there and was able to get her dementia and mood under control. She returned home and there have been no signs of abusive actions since and she is back to her old appropriate self. I know that this is a rare case and not everyone has the resources this couple did, but I think that a way of helping perpetrators with dementia and their caregivers would to find a way to medicate the disease without changing the individual (which I know is nearly impossible), but it worked in this case. If not what else do we do about a victim of dementia who can not control their actions? Do we put them in prison or a straight jacket because they are a danger, there has to be a better way. Dawn J

Jessica Parent said...

This was a very interesting article and I find Dawn J's comments to be very helpful. As a DV advocate, I have had cases where a batterer got worse with the onset of dementia. I've also seen cases where we thought it was abuse but it was actually the onset of dementia.

I agree that people with dementia should be treated with dignity and respect...their condition is beyond their control. In addition, individuals on the receiving end of violence need to be protected. Whether it be a batterer who's violence has increased due to dementia or a person with dementia who is being violent, the conduct shouldn't be viewed as criminal if they cannot control their behavior. However, they need to be monitored quite closely and/or hospitalized. As the article pointed out, a woman lost her life because her husband killed her. That is a tragedy we should not forget.

I don't think that Dawn J's case has to be a rare case. This type of treatment should be available. For individuals who work with dementia patients, there needs to be some "duty to warn" or "duty to protect" others. If a person with dementia is escalating in behavior, caretakers need to be protected. We can't just throw up our hands and say, "Oops!"

Domestic violence theory should not be applied to medical conditions. If we are so concerned about the elderly population and the shortcomings of current interventions, why isn't anyone purposing something different instead of blaming the DV theory or the women's movement for not being all encompassing?

Jessica Parent

Lisa Nerenberg, Consultant, Speaker, Trainer said...

Dawn and Jessica, I really appreciate both of your comments. I think dealing with abusers who have dementias is one of the unmet needs in our field. Distinguishing DV from the effects of dementia can be extremely difficult, particularly when the onset of dementia is gradual. We especially need assessment tools, safety plans when risk is high and advocacy for elders with dementias who come into the criminal justice system.

Dawn, you mentioned a case where there was a positive outcome. What kind of agency was it you worked in?

Jessica, I'm curious to know how the two scenarios you described were handled by the DV program you work for and what the outcomes were.

Abbey said...

Abbey P.

In response to Dawn's comment, this is very eye opening for me to read and learn about. I work with children who are abused and always feel that they have hope for the future. Elder abuse and dementia is a totally different playing field. It is almost scary to know that we have lived past our childhood and for most of us we survived with just a few cuts and scraps.
What I don’t always realize is that I still have my future to look at. You can have the perfect marriage, but as stated by Dawn, this woman developed dementia. Due to her dementia her marriage changed. She became abusive to her husband, which it seems like would not be the case if she never developed this. This couple is truly lucky to have found the resources that they needed and had such caring workers that helped them stay together in a healthy way.
I feel that as social workers these kinds of stories are the ones that make us want to work harder. Thank you Dawn for sharing.

Abbey said...

In response to Dawn's comment, this is very eye opening for me to read and learn about. I work with children who are abused and always feel that they have hope for the future. Elder abuse and dementia is a totally different playing field. It is almost scary to know that we have lived past our childhood and for most of us we survived with just a few cuts and scraps.
What I don’t always realize is that I still have my future to look at. You can have the perfect marriage, but as stated by Dawn, this woman developed dementia. Due to her dementia her marriage changed. She became abusive to her husband, which it seems like would not be the case if she never developed this. This couple is truly lucky to have found the resources that they needed and had such caring workers that helped them stay together in a healthy way.
I feel that as social workers these kinds of stories are the ones that make us want to work harder. Thank you Dawn for sharing.

Anonymous said...

This post brought up some tough emotions for me. i have had three grandparents who have suffered from either dementia or alzheimers. It is very sad because the person you have always loved and known does not always act like the person you knew them to be. alzheimers and dementia changes a persons behaviors often. a person who was loving and giving could actually end up being an abuser. that is what happened to my grandfather. he was a man who was so gentle and loving and after being diagnosed and living with dementia he began to go downhill and become angry. he became violent and would hit us because we put him in the nursing home. i felt scared and terrified. i felt that the staff did not respond to him respectfully, just keeping him in his room because they were afraid he would hurt them. i was angry because he was upset because they would not let him have his physical freedom to move around. i agree with dawn completely there has to be a better way. my grandfather was not a criminal he didnt deserve to be locked up for the way a disease was affecting his brain and making him respond. i do feel however family members and caretakers should feel safe and not have to live with violence. i am grateful that my grandfather was never sent to jail or treated as a criminal, but i felt that the issue was not dealt with he was unsafe for his caregivers and his family. it is such a sad issue because these individuals are not who they have always been and dont act the same as they did. meredith w.

Anonymous said...

When working with persons with dementia and their friends, family members, and caretakers, I whole- heartedly agree with J. P. that we, as professionals, have a "duty to warn" others that dementia may turn this normally loving and harmless individual into someone who becomes upset, angry, and violent. We must not blame the victim, but point out that it is the disease (dementia) making the patient (I do not like using the word "perpetrator")violent.

Perhaps hospitals, nursing homes, rehabilitation facilities, and other types of social service agencies should start including "family meetings" (this may include the patient's friends, partner, and any others who are part of the patient's care) as part of the client's care regime. In these family meetings, educating all individuals present on the stages of dementia and the side effects that it inflicts upon the individual (such as angry outburts and violent behaviors)would be a wonderful learning opportunity and would also instruct all others who care about this individual, on how to stay safe in the client's (or patient's) presence, i.e. keep guns locked up in the home, make sure knives and other potentially harmful objects are out of the patient's sight and reach, etc.

Meetings like this do not have to just take place with family members in these types of agencies. In focusing on community outreach in preventing elder abuse and mistreatment, safety meetings like these could also be held in churches, town halls, and Senior Centers across the country. Educating law enforcement on the behaviors of individual's battling dementia could also make the police officers more understanding and tolerant when they come in contact with someone with dementia. It is our duty as professionals to not stand idle and just watch. We need to help through actions and educating.

Adrianna C.

Rebecca P said...

Prior to the course, cases regarding perpetrators with dementia did not cross my mind. After reading this article along with Dawn and Jessica’s comments, it has opened my eyes to a new aspect of elder abuse and domestic violence. It feels heartbreaking to read about such cases and at the same time seems so challenging as to how to move forward regarding issues as such. I do agree that jail does not seem appropriate for an aging perpetrator with dementia, but seems like there is a fine line, especially with the safety of others at risk.

I do not work with clients with dementia and must confess, I am not sure how I would handle cases like the ones posted here. My grandfather suffered from dementia, and I now feel lucky that he was not violent, as it was something I had not even considered before. Thank you for opening my eyes to this aspect of elder abuse.
Rebecca P

MindyD said...

Yikes. A better way must exist, but where is it? When completely befuddled by something, I usually start looking around on the Web for some guidance/background information. I found what looks like a great site – Dementia and Aggressive/Abusive Behavior Summit: Summary of Proceedings . The URL is http://dhfs.wisconsin.gov/aging/dementia/proceedings.pdf.
There is a huge amount of information here, what stands out to me so far is the contrast drawn between the Dementia Approach and the DV Approach -- so thought-provoking. Using several case studies, the report made some important points for practitioners who work with folks with dementia. The report contrasted the Dementia Approach vs. DV Approach, which made a huge difference in what next steps would be taken. It pointed out the importance of finding out what else was going on in the situation, what has been the pattern in the family, and who else is involved. It addressed what the most important value was to address (safety or autonomy). It asks who the client is and who is the victim, reminding me of class discussion in which Dr. Bergeron pointed out that sometimes there are actually 2 victims. SO many considerations. I would think that a multi-system team approach could be the most effective in cases of perpetrator dementia; however, the report recommends using care and caution to avoid intervention conflicts, since different disciplines may have different perspectives, which lead to recommending different, sometimes opposite, interventions. One suggestion made is focusing on empowering the abuse victim as much or more so than teaching ways to manage the behavior of the person with dementia. Like Dr. Bergeron, I’m still processing this… (There is much much more information on this site, just as an FYI.)

DawnJ said...

To answer Lisa question I work in a continuing care retirement community. This is basically a long term care nursing home but does not feel like a nursing home at all. In response to Adrianna’s comments the facility I work in does have routine family meetings which I believe are very important for educating everyone involved. However sometimes it is very hard for family members to accept that their parents or spouses have dementia and may be changing and despite all the education you can supply some people will never accept it. In the case I gave things worked out wonderfully but that is not always the case and social workers need to be ready to deal with the good and bad results that are inevitable when working with dementia. Dawn J

Stephanie said...

It is interesting and a bit scary that a person with dementia can become abusive towards their caregiver. I can see the general publics response being that they "don't know what they're doing and thus cannot be accountable for their actions". There are various levels of dementia and at what point to we hold an abusive person responsible for their actions, even if they have dementia? Are there laws that address this issue? I am assuming not since there are not really any elder abuse laws to begin with.

On another note, I found Dawn's case study very interesting because I had a grandparent with dementia and his behaviors were the complete opposite. He was an abuse father/husband and an alcoholic but when he began to be affected by Alzheimer's he forgot to drink and actually became a very nice man. His abusive behaviors stopped. I cannot imagine what it must have been like for my grandmother to be in an abusive relationship for years and then to have it stop and to have to care for her husband, who became completely dependent.

Stephanie S.

Marti B. said...

I feel that this is a very important topic, and I am glad it was made a topic up for discussion. I interned at a hospital this past year, and spend some time in the geriatric psych unit, working with patients with dementia and their families. I agree with Adrianna that it is extremely important to educate caregivers and family members on the effects dementia can have on their loved one's behavior. Many family members are so shocked by the violent behaviors of their loved one because they were not aware that this may happen. Also, family members may be less likely to report the violence to the appropriate person (doctor, social worker, APS etc.) out of fear that they will get their loved one in trouble with the law. Therefore, it is extremely important that this conversation is initiated by professionals. The patient is not only putting their family in harm, but they are at risk of harming themselves as well. Therefore, safety needs to be discussed with family members and caregivers.

This is such a hard topic, because I, like everyone else, am having a very difficult time seeing a positive solution. One must consider the safety of both the individual and their family/caretaker. However, individuals who are victims of dementia cannot control their behavior, and it is not right to isolate them or put them behind bars. This is a very discouraging topic to me, and thank you Dawn for showing us an example of a solution with a positive outcome.

Noel said...

I would like to thank everyone above for sharing their personal experiences with us. I know how difficult it is to share these stories. Watching a family member suffer with Alzheimer's or dementia can be devastating. Meredith and Stephanie both pointed out ways that disease can completely change a loved one's personality. Imagine, a person that you have known and loved for many years is suddenly changing so that their personality and behaviors are completely opposite of how he or she has always been. Perhaps even forgetting who you are. When violence and aggression are coupled with these changes, it can be very overwhelming. As social workers, I think it is so important that we do not forget who the dementia patient was and treat them wholly rather than only focusing on the violence. Maintaing safety is our number one priority. However, we simply cannot ignore or justify violent behavior because of declining brain health. It is very puzzling, and I wish I knew the answer so that Lisa's story does not happen again.
I feel very strongly that research and prevention of Alzheimer's and dementia should be priorities for our society. There is no known cause or cure, but researchers see a genetic connection. While Alzheimer's does not run in my family, it may someday affect me because it does exist in the family of someone I love. I try to be very aware of things that we can do to ensure his brain health for our future.

Anonymous said...

Until recently elder abuse seemed simplistic. However, since reading and learning about the various forms of abuse that the elderly endure, elder abuse I realized, is diverse and complicated. Perpetrators with Dementias is one of the many types of abuse that I have never thought much about. Ruth

Dementia is a sad and debilitating disease that can have a huge impact on the person with the disease and everyone around them. As I hear my grandmother speak of her friends who have been diagnosed with some form of dementia and the impact it has on them and their friends and family, the consequences of such a disease seem insurmountable. In the case of some of my grandmother's friends, they have left their homes and moved into assisted living environments. Their family members were able to afford care for their parents or sibliings but unfortunately for millions of elders are not able to afford around the clock care. Instead many elders with dementia remain with family members who have very little support and resources.

As the case history stated, if the women who was shot and killed by her husband was able to receive support services she still might be alive. As my grandmother and parents become older, the realities of what can occur become more apparent. So often in our society we do not face reality until it is too late.

It is so important that discussions like these here on this blog occur. As we become better educated on the effects of this disease we will be able to have a positive impact on the lives of the elderly. As many of my collegues have pointed out dementia is not an easy illness to deal with but I don't believe that people should be jailed because of it. Dawn gave one of many positive ways of helping a couple deal with the effects of such a debilitating disease. I think elders with dementia should be closely monitored by physicians, social workers, and all others involved in providing care. This will ensure the proper care and protection of both the perpetrator and the caregiver.

Cindy W said...

Well, here I go again. I already posted a comment to this site, but I seem to have lost it in "cyberspace" somewhere :=(
I believe that a team approach with community collaboration could be added to a list of possible solutions.
As Lisa states, there are no easy answers, but it certainly would be a crime to see a Alzheimer's or dementia patient or care-giver, end up in the criminal justice system due to unhealthy responses caused by frustration and anger to a situation that may have been avoidable with some preplanning.
Service providers working with APS workers, family members, law enforcement, and dementia care field specialists could team up and work together to help the care-giver and care-recipients that are dealing with this unpredictable and sometimes dangerous issue of dementia.
It would be nice if this team approach of community collaboration could be formed as an early intervention technique, when the patient is first diagnosed, being proactive, rather than waiting as the dementia patient gets worse and all parties seem to be reacting to unfamiliar and unpredictable circumstances.
Creating family genograms with DV histories, substance abuse issues, and other pertinent information would be helpful to the service providers helping the care-giver and care-recipient in establishing target areas to be aware of.
This is a type of self-report, but it can be substantiated by family and perhaps the medical community from past records, lending more credibility to the life history of the dementia patient and care-giver.
Humane care with safety ensured for all parties is an important aspect of this population and I feel having law enforcement involved without collaboration with the mental and medical health fields would be a disservice to this population.
I have never worked with dementia or Alzheimer patients/care-givers, so maybe this collaboration is already a part of the process?

Sarah M said...

In reading over the responses, I liked Cindy and Adrianna's answers regarding the important of early intervention and family knowledge of the disease. When you hear of such cases as the one Lisa relates, the automatic reaction seems to be one of horror and then a 'What went wrong?' response. On some level, it must be a failure of the system in some way, shape, or form. Did the social worker ask about weapons in the home? Was the dementia diagnosis clearly explained to caregivers? Like Dawn mentions, did they understand or seem to not want to believe? Was there a fear of action by the police that prevented reporting of abuse?

I also liked Jessica's point about domestic violence theory not being applied to medical conditions. I agree with this, but at the same time, issues like this seem twice as hard because by default, we need to deal with both sides of the coin in order to fully do our job. We're assessing the effects of the medical condition on the violence and vice versa, looking at trying to protect the family while also trying not to incriminate the person's violence because of their dementia, and all the while protecting their right to self-determination...it's not a surprise that bits of the entire process tend to fall through the cracks, and unfortunately end in situations like the one Lisa blogs about.

Dementia care programs that address possible aspects of the illness, such as domestic violence and the need to assess risk, are imperative for both families of patients and practitioners. It is also important to develop guidelines for proper solutions to violence by perpetrators with dementia that do not include intervention by law enforcement. If we can take away that fear, perhaps more family members or victims of violence by perpetrators with dementia will be willing to report the abuse. As the situation is now, the topic is not being addressed aggressively enough, even though practitioners and family members often 'see it coming,' as Lisa's blog entry illustrates.

Anonymous said...

After reading the article by Bergeron in the journal of Gerontological Social Work (2001) it is clear to me how important domestic violence theory is to elder abuse in terms of spousal abuse. Just as the information in this blog points out, without gathering information about the history of a couple, it is viewing the incident with in a vacuum. As social workers we are trained to view what social influences affect the client and their reaction to those influences.

Although I agree with Jessica about "duty to warn" when incidents come up concerning elder abuse, I feel that family and responsibility ties an elder might feel could over ride or cloud an individuals judgment to leave or get help. Since the Bureau of Elderly and Adult Services (BEAS) appears to work from the caregiver stress theory, it might be difficult to find the assistance couples need in these situations. This gap in service would be great to explore as it is not as cut and dried as first glance. It is my belief that protection for all members of the family is what the system is striving for and therefore thinking outside of traditional explanation can only benefit those we are trying to protect.

Mandy G

Cathy O said...

It is very sad to think of one’s loved one declining into the dark abyss of dementia, to transform from a loving parent/spouse, into someone unrecognizable, and unable to recognize or continue to share in historical family transmission. When dementia turns violent, it is especially devastating. Families may not want to let go, or they are fearful and let go too soon. The author is right: who knows, in the insidious decline, at what time one must succumb and make a decision on appropriate after-care in an effort to forestall potential dangers.

My neighbor came over one day to tell me that her grandfather had shot his wife and then himself in another state. Perhaps if someone had picked up on the signs at some point, she would still have her grandparents.

lindsey mogren said...

I also find this topic extremely interesting and thank everyone for their thoughtful input. Knowing personally a older person who became violent towards his wife as his dementia progressed towards the end of his life, prior to this class, I had never considered involvement with APS or the CJS in their situation. I simply thought that the violent outbursts were symptomatic of the disease, however unfortunate. I found myself feeling bad for both of them, as well as their children. I often found myself questioning the wife's fierce loyalty to her husband, despite the repeated abuse. In the same way the public often asks of an abused wife "why doesn't she just leave?" I often thought, why doesn't she place him in an elder care facility? (My thought process has certainly changed!)

I'm not sure if there was a history of domestic abuse in their case, but I think that this factor is an extremely important one to consider when providing either caregiver support, or as a worker with the client with dementia. The criminal justice response is often quick to label the victim as the vulnerable one, in this case, the partner with the dementia. Consequently, the care provider becomes the abuser or perpetrator. We have seen that this is not always the case, and can have detrimental, sometimes lethal consequences, as in the case where the man with dementia killed his wife.

I agree with Jessica when she states that there is a "duty to warn" caregivers of the potential affects that dementia can have. I also think that Cindy brought up an excellent point in really looking at the entire picture by not just looking at what is happening at that one moment in time, but looking at what has happened over time: a family history. If the abuse that is being perpetrated by the elder with dementia is a continuation of a relationship that has been plagued with abuse for years, then this should be identified. I think that Lisa makes a excellent point when she says that long-term batterers should not be excused their battering with the onset of dementia.

As for those who were formerly "peaceful and loving" who are now abusive, Dawn's approach of medication should certainly be considered. I also like Cindy's approach of taking a wraparound approach of all services and looking at what is best for the elder and partner as a duo. We need to consider that many of these couples have been together for years, and like victims of domestic violence, they too want the violence to stop, but perhaps not the relationship.

Lindsey M.
7/17/07

kimc said...

As I was reading Lisa's article on the man with Alzheimer's who ended up killing his wife...I couldn't help but think about how hard it is to work in the social work field sometimes...things are not always "black and white" and there is often a lot of "gray"...(no pun intended) Nevertheless, seeing the "gray" (the special circumstances, the exceptions, the subtleties) is, often, the greatest thing we can bring to other professionals, as well as to the families we work with...Sometimes seeing the "gray" means we are approaching a situation is a non-judgemental way...sometimes we are the only ones with the "fresh" perspective...So, though it's really hard when we don't see something coming (or we do and we don't have mechanisms in place yet to provide solutions or answers,as in the case with the man with Alzheimer's) and the staff have to go through so many "What Ifs?"...we should remember that there are many situations in which seeing the "gray" and expanding other's views of a person or a situation has really helpd someone...

Plus, I think when we see the "gray" we can better "fine tune" our tools for assessment, our interventions and our research...We know better what to ask...

Anonymous said...

Amanda C: I agree that we need to do more in terms of demantia care and assessing cases in terms if history. I know a family where an elderly wife suffered from dementia and attaked her own husband periodically in the middle of the night because she thought he was an intruder in her home. She should probably not have been prosecuted for this, but maybe steps could have been taken to remove her from her home where her elderly husband would have been safer and she would have been spared from attacking others in her state of mind. I agree that there are no easy answers, and without resources, money and programs we will continue to not have many answers for this issue. I know it would have been devastating to this husband to have his wife prosecuted or remover from their home due to her actions, but for his safety and hers maybe a residential facility should have been looked into. She passed away shortly after she began to attack her husband. I am sure there are cases much worse than this.

Gina J. said...

I agree with what Jessica said regarding the fact that individuals with dementia who cannot control their behavior should be closely monitored, and in some cases, hospitalized. Perhaps if these individuals were more closely monitored, issues such as needing to increase or change medication could be dealt with before the point where there is potential for dangerous situations to arise.
One issue that seems to be reoccuring with all aspects of domestic violence (including elder abuse) is the way some law enforcers handle domestic violence incidents and the individuals who are involved. It is my opinion that anyone who is going to be interacting with issues of domestic violence, (whether it is with elders, their younger counterparts or individuals with dementia) should be required to recieve an education about how to do the work in the most appropriate manner. These situations are already complex and difficult enough; the last thing that is needed in such situations is more chaos. I think it would be highly advantageous to require all levels of law enforcement (police, lawyers, and judges, etc.) to receive an education of this manner.

A Bergeron student said...

I’ve had some experience with people with dementia, both personally and professionally. My widowed mother had vascular dementia as a result of a series of minor strokes in her seventies, which led to a gradual decline in her cognitive function over a period of years. My two brothers and I, along with our spouses, developed a plan with our mother to assist her in remaining independent in her home. Despite the diagnosis of dementia, my brothers often attributed my mother’s memory impairment to “not trying hard enough” at a task. They didn’t understand that our mother’s ability to function, sometimes at a higher than normal level, and sometimes at a lower than normal level, was a result of her brain function, and not the degree of effort she applied to a task.

My professional experience with dementia came from an internship this past academic year at an assisted living facility, in which appr. 80% of the residents had dementia. One of the residents with whom I worked was the cognitively-intact, elderly wife of a cognitively-impaired, elderly man with Alzheimer’s, who had cared for him at home for many years before moving to the assisted living facility. He had gradually become more and more physically aggressive, including toward her, and she could no longer manage him alone. He was a tall, well-built man who was still physically strong. She had chosen this particular facility because it would allow them to live together, and for her to continue to provide as much care to him as she wished, while having the additional support of the facility’s direct care staff. Although she understood that his increasingly aggressive behavior toward her was due to his disease, she nevertheless personalized it, and saw it as a reflection of his feelings toward her.

As I observed in both of these cases, some individuals’ responses to their loved ones with dementia, specifically the tendency to discount the effect of the disease on a person’s change in behavior, and instead view the behavior as intentional or controllable, could prevent them from seeking the help they need. Particularly for elderly spouses who do not attribute the source of the aggressive or abusive behaviors by their spouses with dementia as symptoms of the disease, there may be great reluctance to admit their mistreatment or abuse to anyone because of shame or embarrassment. I therefore agree that education, both public and targeted (e.g. toward specific groups, like physicians, or elders in senior centers), and through forums such as caregiver support groups, are important to help victims of abuse obtain help.

At the assisted living facility where I interned, I, like Dawn, saw firsthand the very positive effects that medication changes can have in reducing aggressive behaviors. A dementia patient’s evaluation at an in-patient hospital’s gero-psych unit, and accompanying medication adjustment, could greatly reduce aggressive behaviors and improve his/her sense of well-being (it is important to note that none of the residents I observed were in advanced stages of Alzheimer’s, so I don’t know how applicable this would be to later stage Alzheimer’s patients). I must caution, however, that many residents with dementia who first moved to the assisted living facility had been prescribed medications by their family physicians that were not appropriate for their particular form of dementia. Dementia is a term that describes a group of symptoms caused by a number of disease processes or conditions (e.g. diseases such as Alzheimer’s, or vascular dementia), so there is not a one-size-fits-all treatment for all people with dementia. In our role as social workers, we need to refer clients to professionals to assess the type of dementia they have before medication is prescribed, and to make sure that the professional prescribing the medication is knowledgeable about various types of dementia treatments.

Mindy, thanks for your reference to the Dementia and Aggressive/Abusive Behavior Summit: Summary of Proceedings site.