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February 01, 2018

Many people have referred to the unprecedented shift in global population aging as a Silver Tsunami, figuratively referring to the tidal wave of those reaching the age of 60 or older—a group that will expand by 1.2 billion people over the next 40 years.

Increasingly this group is living longer, and with that comes a corresponding increase in the number of seniors living with dementia.

In long-term care homes, the prevalence of dementia, of which Alzheimer’s disease is the most common cause, is nearly 60% of the resident population. Behavioural symptoms such as verbal outbursts, physical aggression, resistance to care, depression, anxiety and paranoia occur in up to 80% of long-term care residents with dementia. Occasionally, these behaviours lead to physical assaults of family members, staff and other vulnerable residents. Rarely, these assaults lead to significant injury and even rarer still, death. Some of these assaults are predictable in certain limited circumstances where the triggers of the behaviour are apparent. But, they are still very difficult to prevent. Also, many are seemingly impulsive assaultive behaviours that cannot be readily predicted or prevented without significantly limiting the autonomy of at-risk patients by some form of environmental, physical or drug-induced restraint.

Unfortunately, there are serious limitations to the effectiveness of the drugs used to prevent and treat these behaviours in dementia. The only way these drugs might fully prevent all undesirable behaviours is to so heavily tranquilize the person that they are no longer able to engage in all the other activities that support quality of life (socializing, engaging in recreation, communicating with family and staff).

The use of environmental and physical restraints (residents confined to their rooms, beds or chairs) has been appropriately condemned in the long-term care field as an unethical restriction on freedom of movement and activity. Short of incarcerating patients with dementia to prevent these challenging behaviours, we must try to rely on other approaches.

Many well-intentioned advocates believe that more staff will reduce the chances of assaultive behaviour occurring. But, how many more staff would be enough and what is the ultimate goal—to completely eradicate the chances of any assaultive behaviour? If this is what we are trying to achieve, then the best guesstimate is that we would require one staff member for every dementia resident at risk for these challenging behaviours on all work shifts. And even if this staffing solution did fully eliminate the risk of assaultive behaviour, is this not an absurdly expensive solution that few communities would be willing to financially support?

Baycrest has taken a leadership role in building skills capacity in Ontario long-term care homes and in the community so that those caring for adults with challenging behaviours have knowledge of those best practices that will lessen the risk of assaultive behaviour.

Our philosophy at Baycrest is to try to find the right balance between respecting the rights of autonomy and a life worth living while preventing patients with dementia from harming themselves or other people. We practice a holistic model of care which includes a variety of strategies for preventing and managing challenging behaviours related to dementia, rather than overly relying on just medications or using physical restraints.

Most times, this approach works well, and our model has led to Baycrest being appointed the health services lead for the Behavioural Support for Seniors Program by The Toronto Central Local Health Integration Network.

But, given the present limited state of knowledge, our care model is not perfect. Sometimes, altercations between behaviourally disturbed dementia residents and between these residents and caretakers take place. Unless we as a society are willing to severely limit the personal freedom of patients afflicted with dementia, we must accept the consequences. We must not treat our long-term care residents as prisoners, their rooms should not be prison cells and our devoted staff cannot be expected to serve as prison guards.

I am advocating for a healthy debate about these difficult issues among community members, policy makers and healthcare providers. What risks for potentially assaultive behaviour are we willing to accept as a trade-off to protect an individual’s right to autonomy and freedom of movement? Is it ethically acceptable to prevent assaultive behaviour in dementia patients by restricting their ability to also express healthy behaviour? What resources are we as a society willing to allocate to the care of older adults with dementia? These long-term care residents with dementia are our parents, they were our teachers, and they will someday comprise a sizeable number of us.

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