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.