Community care of elderly offenders with dementia
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《中华医药杂志》英文版
Community care of elderly offenders with dementia
[Abstract] As demographics and society’s needs change, so too do the roles and functions of the psychiatric nurse. In the last few years, forensic nurses continue to convey exactly what makes their place in the interdisciplinary team vital and unique. This paper describes how a forensic outpatient psychiatric nurse made significant differences in the life of an elderly offender with dementia living in the community.
[Key words] community;elderly offenders;dementia
Over the past few decades, a noticeable and steadily increasing elderly population has been the major focus of attention among health professionals in various countries. Increased attention to the needs of older persons is merited particularly in view of the aging or “graying” of the baby-boomer generation, i.e., those individuals born between 1945 to 1960. In Canada, it has been predicted that by 2021, the over-65 age group will account for 18% of the total population-a sum of 6.7 million people. This current change of demographics has resulted in an increased interest in the mental health needs of older adults (Canadian Coalition for Senior Mental Health, 2002)[2].
Similar trends are also apparent within the criminal justice system. Although there is a present dearth of literature specific to elderly offenders, there are emerging studies, which indicate the number of elderly offenders with mental illness and/or cognitive disorders, such as dementia however small in total number, has expanded steadily in recent years (Tomar,et al.2004)[15]. Curtice,et al.(2003)[3] study further confirms that the most common diagnosis among elderly offenders is dementia (19%) and the most common offence is often sexual in nature (56%).
In the past, treatment and care for elderly offenders with dementia (EOD) often involved admission to an institution, sometimes for life. Since the introduction of “deinstitutionalization”, there has been an increased shift toward community and family responsibility, with an expectation that family or community caregivers continue to provide care to mentally ill clients in their home environment. Such shift has been made possible by community-based facilities or services i.e. Forensic outpatient services designed to support patients, family caregiver(s) and/or loved ones in the community. Services provided may include on-going assessment and evaluation of the patient’s mental status, prescribing and monitoring medication, offering group, individual, family counseling, liaising and referral to other community agencies for additional services. Included are outreach services, such as home or residential and phone visits (Encinares,et al.2001; Jeon, 2003)[4,7].
Certainly, outpatient forensic nurses can make significant differences in the lives of elderly offenders with dementia (EOD) living in the community. This article describes how a forensic outpatient nurse’s integrated knowledge of gerontology, forensic, community psychiatric nursing and her critical thinking skills identified the unique care needs of an EOD. In addition, it talks about the noteworthy flexible, collaborative and coordinated efforts of the patient, family caregivers and the forensic outpatient interdisciplinary team in the development and implementation of an individualized
Correspondence to Maxima Encinares, 51 Windermere Avenue, Toronto, Ontario, Canada, M6S 3J3
Tel:416-762 5038
E-mail:Emma_Encinares@hotmail.com
treatment and care plan that preserved the dignity and maintained the patient’s quality of life.
Elderly Offenders with Dementia
Elderly offenders with dementia-as defined in this paper-are individuals 55 years old and above who were diagnosed with dementia and under the auspices of the criminal justice system. Typically, they are deemed not criminally responsible or unfit to stand trial because of their mental illnesses. In a more recent study, Lesser,et al.(2005)[10] found that elderly offenders with cognitive disorders, such as dementia were mostly charged with violent offense(s) i.e., sexually aggressive behavior. Further,this inappropriate behavior is frequently exacerbated as a result of inaccurate perceptions of stimuli, misinterpretations of the environment, effects and side-effects of medications and the presence of co-existing medical problems. Indeed, older adults with cognitive impairments, particularly with frontal and temporal cortical damage, have been associated with an increased risk of sexual misbehavior. Not surprisingly, these individuals do become involved with the criminal justice system.
Therapeutic Alliance
A therapeutic alliance with clients is based on trust. Once a trusting relationship is established, both the client and the nurse can generally successfully accomplish mutual goals (Encinares,et al.2005)[5].Of primary importance in working with individuals with dementia is developing a supportive relationship. This can be achieved successfully insofar as the nurse is able to: communicate that he or she understand what the patient is experiencing-even when the patient is most uncooperative, the nurse will be able to read cues from the patient, make certain deductions from the patient’s responses or lack of responses and from the nurse’s observation of the patient’s general behavior (Xakellis,et al.,2004)[16]; connect with the patient in an emotional level and bearing in mind that these individuals have current perceptions of the world through their senses; being non-judgemental; value the patient as a person by showing respect, acceptance and demonstrate affection, as well as being motivated and genuinely committed to maintain the patient’s quality of life (Wylie, 2003)[17].
Equally important in the relationship is the nurse’s awareness of his or her own emotion and limitations in working with this population. The commonly held notion that individuals with dementia does not remember events, once-familiar faces and require less social interaction as they deteriorate may affect the nurse’s attitude and his or her provision of care. Miesen (2004)[11] posits that there is a tendency for both caregivers (professionals, volunteers, family members and/or loved ones) and the dementia sufferer to project their own emotions, perceptions and past experiences onto current situation that may influence the care-giving relationship, and these terms are known as transference and counter transference.
Case Study
Mr. C. is a 58-year-old male, born in Milan, Italy, single living with his oldest sister, was found unfit to stand trial on charges of break and enter with intent, sexual and physical assault. He was allowed to live in the community with conditions stipulated in his disposition order, such as a specific place of residence, the place and frequency of reporting, to abstain from possession of any firearm or ammunitions.
Index Offence
The police reports indicate that in October of 2003, Mr. C. appeared at the condominium of a woman whose fiancée had worked with him in the past. After shoving the door open and entering the house, he grabbed and pulled her clothing, grabbed and squeezed her breast. He punched her about the body, before she managed to get away from him, opened the entrance door and yelled for help, at which point Mr. C. ran away. The victim suffered bruises all over her body and arms.
Nursing Role-Risk Assessment
Risk assessment for offenders with dementia might differ significantly. It requires that the forensic outpatient nurse performing assessment to be sensitive, comfortable, flexible, able to adapt assessment to the client’s cognitive level and capable of independent actions, but also a good interdisciplinary team player (Encinares,et al.,2005;Lesser,et al., 2005)[5,10].
Persons with dementia may have limited ability to express their feelings and concerns. Involving family members and/or caregiver(s) who know the individual well may help to understand the patient better. Given that Mr. C. was not able to provide his past psychiatric, medical, criminal and sexual history-collateral information from his family and past treatment records were obtained. Records reveal a progressive decline in his cognitive functioning. Apparently, during the early stage of Mr. C.’s disease, he was noted to have mild memory lapses, had difficulty keeping his attention focused on one thing and unable to come up with the right words for some familiar objects. Gradually, he had difficulties remembering the names of his friends and recalling recent events in his life, constantly losing some of his personal belongings, and frequently missed appointments (forgetfulness). However, he was alert enough to cover up some of his difficulties to a degree that only his wife and son noticed the changes in his behavior (Marshall, 2004)[12].
Other cognitive problems soon developed. Mr. C.’s behavioral changes became more prominent with increasing social withdrawal, apathy and disinhibition. He became more forgetful, was unable to think logically, short attention span more pronounced, work skills progressively deteriorated. His wife also reported that he had a grand-mal seizure before his index offence. After some time, his cognitive and motor deficits became more apparent. For example-his activities of daily living needed to be supervised, such as bathing, eating, grooming and toileting. Problems with communication (frequently used inappropriate use of words and was repetitive) became more explicit. He wandered at night, and with periods of being uncooperative and physically aggressive (Marshall, 2004)[12].
The results of full physical examination, which included sensory testing, blood and urine tests helped exclude treatable conditions and established that Mr. C.’s dementia was not related to an underlying illness. His neuro-psychological examination suggested specific deficits often seen in dementia. An assessment of memory and intellectual functioning revealed loss of intellectual abilities of sufficient severity to interfere with abstract thought, judgement, impulse control, social relationships, occupational functioning and changes in personality and behavior. In addition, his electroencephalography and brain scan showed some neurological damage. The neurologist confirmed Mr. C.’s diagnosis of fronto-temporal dementia (Khouzman,et al.2005)[9].
His wife reported that there were instances that Mr. C. claimed seeing “soldiers.” The nurse being cognizant that for older clients exhibiting psychotic symptoms, it was important to determine if such symptoms were an extension of the elderly patient’s early life psychosis (Khouzam,et al.,2005)[9]. However, Mr. C. had no previous psychiatric history. Nevertheless, a positive family history for dementia served as an indicator of his risk. His wife confirmed that his father had exhibited the same symptoms before his death at the age of 50. A comprehensive review of medication ruled out the possibility of drug toxicity. Finally, the assessment and evaluation of his activities of daily living indicated memory loss and other deficits.
Value of Diagnosis
An appreciation of the underlying causes of cognitive impairment is necessary. Some impairment is reversible and responsive to medical intervention, while other forms cannot be reversed and, in fact, are progressive in nature, such as Alzheimer’s Dementia. Regardless of cause, the mental health professionals’ assistance with managing the client’s deficits is critical. The importance of knowing the diagnosis of dementia enabled Mr. C. and his family to gain insight of what was happening with him, the nature of his illness and its ramifications, developed realistic expectations, which lessened both his and his family’s anxieties and uncertainties. By talking about the challenges that having dementia brings, gave Mr. C. the feeling of control of some situations thus fostered independence and decision-making. An appropriate treatment and care program was formulated i.e., structures and routines. For his family, understanding the behavioral consequences of the disease prevented misinterpretations of Mr. C.’s inappropriate behavior i.e., sexual or physical aggression as intentional actions. In addition, both Mr.C. and his family were able to plan for the future. An example was his long-term care needs i.e., arranging admission to a nursing home in the last stage of his disease (Arendt, 2004; Prasher,et al.2003)[1,14].
Management and Care-giving in Elderly Offenders with Dementia
Currently, there is no effective treatment for dementia. However, some interventions are found to produce a treatment effect and can help elderly offenders with dementia to better manage their conditions (Prasher,et al.2003)[10,14].
The development of a comprehensive treatment and care plan for Mr. C. required collaborative and coordinated teamwork involving him, his family, the forensic outpatient nurse and other members of the interdisciplinary team. The crafted plan was flexible and individually tailored to his unique needs, designed to slow down the disease process, as well as managing his symptoms. It included monitoring and maintaining his physical health, managing his medication, modifying the immediate environment to provide safety and structure, providing reality orientation and reminiscence therapy and promoting optimum communication between him, his family and significant others. In addition, the treatment and care plan foci were not only on the physical status and on environmental factors of safety, but also toward preserving his dignity and integrity until the moment of his death (Lesser,et al.2005). Another important factor that contributed to the effectiveness of the plan was its frequent review and readjustment of both short and long-term goals to ensure that it was relevant to Mr. C.’s unique needs and functional status (Encinares,et al.2005).
Monitoring and Maintaining Physical Health
Nutritional Support
Getting individuals with dementia to eat can be a daunting task. Mr. C. was easily distracted that interfered with his eating. He frequently played with his food and/ or threw them on the floor. There were instances that he would demand for food even though he had just eaten his meals. The forensic outpatient nurse and the Occupational therapist, however, by teaching the patient and his family certain techniques enabled Mr. C. to focus on the activity of eating. The strategies included keeping a calm and pleasant environment during meal time, using plastic dishes, use of bowls instead of plates, adaptive devices, such as spoon with thicker and heavier handle which reminded him that he was eating, offering him one food at a time, reminding him to chew and swallow his food, and providing finger foods and nutritious snacks (Lesser,et al. 2005;Prasher,et al.2003).
Promoting Sleep and Rest
Mr. C. experienced difficulty sleeping and frequently wet of urine through the night. On-going health education and advice, such as keeping Mr. C. occupied and active during the day, not allowing him to take naps in the afternoon, short exercises late in the afternoon or early evening, limit fluid intake before bed time, asking him to void before going to bed so he will not be awakened at night with a full bladder promoted his sleep. Using waterproof mattress, incontinent pads and the use of plastic urinal prevented bedwetting and helped addressed his physiological needs.
Maintain Self-care
Although, Mr. C.’s functional loss was progressive, it was necessary that his self-care capacity was assessed and supported at every stage of his illness. An aspect of Mr. C.’s treatment and care plan was encouraging him to do things for himself independently or with minimal help as much as possible, such as washing, dressing, and feeding (Khouzam,et al.2005; Prasher,et al.2003)[9,14]. This strategy can be time-consuming, and at times, frustrating endeavor, however, it was noted that the more Mr. C. effectively managed his daily routine, his anxiety lessened. To encourage him to attend to his personal hygiene needs: bathing and toileting routines were established, frequent reminders about his daily grooming and personal hygiene were provided, prompts or “lead” helped him to finish his routines i.e., laid his clothes in order. Graded program of specific task that was simple, practical, concrete and attainable, which required active participation of his family was crafted to help him follow directions. For example, if Mr. C. resisted to his oral hygiene, mouth swabs were used, and if he continued to resists, he was given an apple to eat, which helped clean his mouth (Khouzam,et al.2005;Prasher,et al.2003)[9,14].
Adapting the Environment
Supportive environmental settings can positively affect disease symptoms and the patient’s quality of life (Khouzam,et al.2005; Lesser,et al.2005)[9,10]. In order to appropriately serve and maintain Mr. C. in the community, it was necessary to modify his environment, such as: keeping living areas with acceptable smells, comfortable temperature and well lit without shadows or glare particularly his room, lessened his misperceptions; playing soft music provided stimulation; blaring noise was avoided to prevent sensory overload; furniture were kept in a consistent place, used prompts and appropriate clues, such as colored arrows on the floor pointing to his room, labeling his room, kitchen and bathroom with identifying symbols i.e., picture of a toilet in the washroom reduced his disorientation and confusion. Recommendations and instructions were provided on the use of adaptive devices to support independence on activities of daily living, such as safety in the kitchen, climbing stairs and during bath time i.e., toilet seat was elevated and safety bar near the toilet and bath tub were installed. These approaches helped Mr. C. regained the needed skills that made his life more organized and comfortable.
Beyond maintaining a pleasant milieu (and because of the forensic or legal issues involved), keeping Mr. C. and the community safe were the two major proactive goals. Hence, door alarms were installed and fences were built around the house backyard with safety gates to prevent Mr. C. from wandering and/or leaving his residence (Lesser,et al.2005)[10].
Enhancing Communication
Providing opportunities to enhance communication with his family and significant others was also of high priority. Such opportunities provided a supportive and instructive relationship in the context of which Mr. C. regained social skills. For example, it was found useful to: approach him in full view; get his attention before speaking to him; call his name, use touch to get his attention, but not until he is aware of the presence of the person speaking; allow more time for him to respond to statements or questions-Mr. C. required more time to process what have said to him and for him to formulate a response. These strategies avoided and reduced his angry outbursts and striking out. By speaking in a slow, simple, short, firm and clear sentences and using emphatic tone helped to express understanding of his feelings particularly when he was hallucinating. Selecting topic on shared knowledge or background information on his personal history promoted and assisted in carrying on a meaningful conversation.
Further, the forensic outpatient nurse recognized that when working with individuals with dementia and/or with families, one must be sensitive to readiness to change. Therefore, all personal and environmental changes for Mr. C. were paced accordingly and gradually.
Medication Management
In general, physiological changes related to aging are usually marked by decline, such as decreased functioning of the circulatory, urinary, and digestive and nervous systems. From a pharmacological perspective, these factors result in increased susceptibility of older adults to adverse drug reactions (Jeon, 2003)[7].
In our case, a small dose of anti-psychotic and anti-convulsant medication served to reduce Mr. C.’s disordered thinking and alleviated his distressing symptoms i.e., restlessness, agitation and seizures (Khouzam,et al.2005; Lesser,et al.2005)[9,10].Due to Mr.C.’s experienced difficulties in swallowing tablets and capsules, liquid preparations were prescribed, and/or crushing and mixing his medication with food promoted his compliance with medication. In addition, he was closely monitored for the effects and side-effects of medication.
Reality Orientation and Reminiscence Therapy
While psychopharmacological intervention is an extremely important part of the treatment and care plan, psychotherapeutic interventions particularly in the early stage of the disease process are often equally valuable (Prasher,et al.2003)[14].
Reality orientation i.e. easily read clocks, calendars proved very useful in helping Mr. C. re-established ties with reality i.e., date and time, orientation board helped Mr. C. to remember task he had to accomplish thus helped him regain a feeling of independence and an amount of self-confidence. Verbal orientation was also used. For example, in responding to Mr. C.’s hallucinations, confrontations were avoided. Instead, his emotional feelings were acknowledged and reassurances were provided that he was in safe place. In many instances, thoughts were redirected to help blocked out the hallucinatory experiences and supported reality.
Marshall (2004)[12] contends that reminiscence or life review can be a source of pleasure; helps resolve present and past conflicts and enhances patient’s self-esteem. In addition, sharing stories about personal relevant events and topics can be useful in creating an identity for an individual. However, it is important to recognize that while this approach can be useful, sensitivity and care must be exercised in using this method as for some individuals the past can be a reminder of their painful experiences and/or losses.
Photographs of Mr. C.’s parents, his family, his country of origin and his favorite pet were placed on his bedside table, family videos and his favorite and familiar music were played to relive his past. These techniques helped him remained stimulated and adjusted to various changes in his life.
Legal Issues
Expectedly, specific legal issues may arise as consequence of an individual with dementia being involved with the legal systems, especially consent and capacity issues, working with the Ontario Review Board, and access to services. Thus, knowledge and support to patients and families in terms of information, consultation and advice i.e., legal aid lawyers are vital. In many instances, nurses advocate for the patient and family caregivers (Encinares,et al.2001)[4].
In the early stage of the disease, offenders with dementia may have the capacity to make an array of responsible decisions about their own finances and treatment and care. However, it is also important to realize that this may change overtime depending on the progression of the disease process. Thus, capacity for financial and treatment decisions must be considered in each circumstances, and assessed if needed.
The task of the forensic outpatient nurse in the case of individuals found unfit to stand trial is to restore competency through psycho-education designed to increase knowledge of courtroom procedures, charges and possible consequences, and communication skill to cooperate with lawyer. However, due to the debilitating progressive cognitive impairment, offenders suffering from dementia, fitness to stand trial may never be achieved (Curtice,et al.2003)[3].
Vital Role of the Family
Having an older family member who perhaps is dementing and who subsequently becomes involved with the criminal justice system creates immense pressures in the family. Frequently, family caregivers experience a range of emotions and concerns in responding to the complexity of needs of elderly offenders with dementia. In most cases, family caregivers become confused, angry, and at the same time may have feelings of guilt, shame, bitterness, unrealistic hope, sadness and depression, which could manifest in over protectiveness of the patient and hostility towards others and service providers (Jeon, 2003)[7].
The recognition that providing care to individuals with dementia involves dealing with family members and/or loved ones and their roles within the care-giving relationship creates conditions that make it possible to continue to care for the patient in the community. Establishing and maintaining a collaborative relationship with the family could have positive effects from a risk management perspective and achieving a desired therapeutic patient outcome-both as a primary caregiver and a source of information (Jeon, 2003)[7].
To assist Mr. C.’s family and to maintain him within the family context, his family was viewed as an active member of the caring relationship. Providing Mr. C.’s family the opportunity to express their feelings by listening to their story by simply offering a sympathetic ear was an important step in helping his family to cope with his illness. By jointly establishing a set of goals, his family felt valued, and an agreement was reached with the family on realistic expectations from Mr. C. Providing health education to ensure high quality care that included information to: better understand his illness, about services and mental health treatment available especially after-hour services, access to specialists who have experience working with this population, the role his family might play in his care and ways how to better manage care-giving tasks including safety issues and using a sense of humour in difficult and frustrating situations helped prevented Mr. C.’s long-term care admission.
Caring for an individual with dementia can be disruptive to a family’s integrity, goals and lifestyle. Thus, the issue of respite from caretaking responsibilities should be addressed. Linking his family to appropriate resources and support in the community lessened the burden and pressures on his family as a primary caregiver. For example: respite care, such as home health care three times a week, adult day care services (being transported by a special bus) twice a week, helped alleviated Mr. C.’s family’s care-giving stress
Epilogue
Mr. C. continued to deteriorate mentally and physically, which prompted the forensic outpatient nurse, collaborating with his family, to refer Mr. C. to a long term-care facility. Mrs. C. continued to provide quality care in their home environment until he was admitted to a nursing home. Family caregivers were able to visit him regularly in the nursing home. Concerning Mr. C.’s legal situation, his charges were dropped. He was subsequently discharged from the Ontario Review Board and from the Outpatient forensic clinic.
REFERENCES
1. Arendt, T.Metasynthesis of neurobiology of Alzheimer’s disease. In Gemma M. M. Jones & Bere M.L. Miesen Care-giving in Dementia; Research and Applications, Brunner-Routledge, New York. Volume,2004,3,3-21.
2. Canadian Coalition for Seniors Mental Health (2002). Retrieved March 12, 2005 from http/www.ccsmh.ca
3. Curtice, M, Parker, J., Wismayer, F. S. & Tomison, A. (2003) The elderly offender: an 11-year survey of referrals to a regional forensic psychiatric service. The Journal of Forensic Psychiatry & Psychology, 14(2):253-265.
4. Encinares, M. & Lorbergs, K. (2001). Framing nursing practice within a forensic setting. Journal of Psychososcial Nursing and Mental Health Services, 39 (9):35-41.
5. Encinares, M., McMaster, J. & McNamee, J. Risk Assessment of forensic outpatients:Nurses’ Role. Journal of Psychososcial Nursing and Mental Health Services,2005,39(9):35-41.
6. Holston, E. C. & Schutte, D. L.The clinical utility of genetic information in the care ofpersons with Alszheimer’s disease. Medsurg Nursing, 2004,3(6):415-419.
7. Jeon, Y.H.Mental health nurses work with family caregivers of older people withdepression: Review of the literature. Issues of Mental Health Nursing,2003,24:813-828.
8. Kanapaux, W. (2204). Many needs but few Psychiatric services for seniors in long-term care. Psychiatric times, November 2004,XXI (13):3-7.
9. Khouzman, H.R.; Battista, M.A.; Emes, R. & Ahles, S. (2005). Psychoses in late life. Evaluation and management of disorders seen in primary care. Geriatrics,60(3):26-33.
10. Lesser, J.M.; Hughes, S. V.; Jemelka, J. R. & Griffith, G. (2005). Sexually inappropriate behaviors: Assessment necessitates careful medical and psychological evaluation and sensitivity.The Psychiatric Consultant,60(1):34-37.
11. Miesen, B.Care-giving in dementia: An emancipatory challenge. In G. M.M. Jones and B.M.L. Miesen (eds.) Care-Giving in Dementia, Research and Applications. Brunner-Routledge, New York,. Vol,20043,404-414.
12. Marshall, A.Coping in early dementia: Finding a new type of support group. In G. M.M.Jones and B.M.L. Miesen (eds.) Care-Giving in Dementia, Research and Applications, Brunner-Routledge, New York. Vol,2004,3,240-260.
13. Papadementriou, V.Hypertension and cognitive function; Blood pressure regulation and cognitive function: A review of literature. Geriatrics,2005,60(1):20-24.
14. Prasher, V. & Percy, M.Alzheimer Disease. In I. Brown & M. Percy (eds), Developmental Disabilities in Ontario, 2nd. Ed. Ontario Association on Developmental Disabilities, Canada,2003,794-804.
15. Tomar, R., Treasaden, I. H. & Shah, A. K.Is there a case for a specialist forensic Psychiatry service for the elderly. International Journal of Geriatric Psychiatry,2005,20: 51-56.
16. Xakellis, G., Brngman, S. A., Ladson Hinton,W., Jones, V. Y., Masterman, D., Pan, C. X., Rivero, J., Walhagen, M. & Yeo, G.Journal of American Geriatric Society,2004,52:137-142.
17. Wylie, K.Enriching the environment. In R. Hudson Dementia Nursing; A guide to practice, Ausmed Publications Pty Ltd,2003,33-43.
(Editor Emilia)(Maxima Encinares)
[Abstract] As demographics and society’s needs change, so too do the roles and functions of the psychiatric nurse. In the last few years, forensic nurses continue to convey exactly what makes their place in the interdisciplinary team vital and unique. This paper describes how a forensic outpatient psychiatric nurse made significant differences in the life of an elderly offender with dementia living in the community.
[Key words] community;elderly offenders;dementia
Over the past few decades, a noticeable and steadily increasing elderly population has been the major focus of attention among health professionals in various countries. Increased attention to the needs of older persons is merited particularly in view of the aging or “graying” of the baby-boomer generation, i.e., those individuals born between 1945 to 1960. In Canada, it has been predicted that by 2021, the over-65 age group will account for 18% of the total population-a sum of 6.7 million people. This current change of demographics has resulted in an increased interest in the mental health needs of older adults (Canadian Coalition for Senior Mental Health, 2002)[2].
Similar trends are also apparent within the criminal justice system. Although there is a present dearth of literature specific to elderly offenders, there are emerging studies, which indicate the number of elderly offenders with mental illness and/or cognitive disorders, such as dementia however small in total number, has expanded steadily in recent years (Tomar,et al.2004)[15]. Curtice,et al.(2003)[3] study further confirms that the most common diagnosis among elderly offenders is dementia (19%) and the most common offence is often sexual in nature (56%).
In the past, treatment and care for elderly offenders with dementia (EOD) often involved admission to an institution, sometimes for life. Since the introduction of “deinstitutionalization”, there has been an increased shift toward community and family responsibility, with an expectation that family or community caregivers continue to provide care to mentally ill clients in their home environment. Such shift has been made possible by community-based facilities or services i.e. Forensic outpatient services designed to support patients, family caregiver(s) and/or loved ones in the community. Services provided may include on-going assessment and evaluation of the patient’s mental status, prescribing and monitoring medication, offering group, individual, family counseling, liaising and referral to other community agencies for additional services. Included are outreach services, such as home or residential and phone visits (Encinares,et al.2001; Jeon, 2003)[4,7].
Certainly, outpatient forensic nurses can make significant differences in the lives of elderly offenders with dementia (EOD) living in the community. This article describes how a forensic outpatient nurse’s integrated knowledge of gerontology, forensic, community psychiatric nursing and her critical thinking skills identified the unique care needs of an EOD. In addition, it talks about the noteworthy flexible, collaborative and coordinated efforts of the patient, family caregivers and the forensic outpatient interdisciplinary team in the development and implementation of an individualized
Correspondence to Maxima Encinares, 51 Windermere Avenue, Toronto, Ontario, Canada, M6S 3J3
Tel:416-762 5038
E-mail:Emma_Encinares@hotmail.com
treatment and care plan that preserved the dignity and maintained the patient’s quality of life.
Elderly Offenders with Dementia
Elderly offenders with dementia-as defined in this paper-are individuals 55 years old and above who were diagnosed with dementia and under the auspices of the criminal justice system. Typically, they are deemed not criminally responsible or unfit to stand trial because of their mental illnesses. In a more recent study, Lesser,et al.(2005)[10] found that elderly offenders with cognitive disorders, such as dementia were mostly charged with violent offense(s) i.e., sexually aggressive behavior. Further,this inappropriate behavior is frequently exacerbated as a result of inaccurate perceptions of stimuli, misinterpretations of the environment, effects and side-effects of medications and the presence of co-existing medical problems. Indeed, older adults with cognitive impairments, particularly with frontal and temporal cortical damage, have been associated with an increased risk of sexual misbehavior. Not surprisingly, these individuals do become involved with the criminal justice system.
Therapeutic Alliance
A therapeutic alliance with clients is based on trust. Once a trusting relationship is established, both the client and the nurse can generally successfully accomplish mutual goals (Encinares,et al.2005)[5].Of primary importance in working with individuals with dementia is developing a supportive relationship. This can be achieved successfully insofar as the nurse is able to: communicate that he or she understand what the patient is experiencing-even when the patient is most uncooperative, the nurse will be able to read cues from the patient, make certain deductions from the patient’s responses or lack of responses and from the nurse’s observation of the patient’s general behavior (Xakellis,et al.,2004)[16]; connect with the patient in an emotional level and bearing in mind that these individuals have current perceptions of the world through their senses; being non-judgemental; value the patient as a person by showing respect, acceptance and demonstrate affection, as well as being motivated and genuinely committed to maintain the patient’s quality of life (Wylie, 2003)[17].
Equally important in the relationship is the nurse’s awareness of his or her own emotion and limitations in working with this population. The commonly held notion that individuals with dementia does not remember events, once-familiar faces and require less social interaction as they deteriorate may affect the nurse’s attitude and his or her provision of care. Miesen (2004)[11] posits that there is a tendency for both caregivers (professionals, volunteers, family members and/or loved ones) and the dementia sufferer to project their own emotions, perceptions and past experiences onto current situation that may influence the care-giving relationship, and these terms are known as transference and counter transference.
Case Study
Mr. C. is a 58-year-old male, born in Milan, Italy, single living with his oldest sister, was found unfit to stand trial on charges of break and enter with intent, sexual and physical assault. He was allowed to live in the community with conditions stipulated in his disposition order, such as a specific place of residence, the place and frequency of reporting, to abstain from possession of any firearm or ammunitions.
Index Offence
The police reports indicate that in October of 2003, Mr. C. appeared at the condominium of a woman whose fiancée had worked with him in the past. After shoving the door open and entering the house, he grabbed and pulled her clothing, grabbed and squeezed her breast. He punched her about the body, before she managed to get away from him, opened the entrance door and yelled for help, at which point Mr. C. ran away. The victim suffered bruises all over her body and arms.
Nursing Role-Risk Assessment
Risk assessment for offenders with dementia might differ significantly. It requires that the forensic outpatient nurse performing assessment to be sensitive, comfortable, flexible, able to adapt assessment to the client’s cognitive level and capable of independent actions, but also a good interdisciplinary team player (Encinares,et al.,2005;Lesser,et al., 2005)[5,10].
Persons with dementia may have limited ability to express their feelings and concerns. Involving family members and/or caregiver(s) who know the individual well may help to understand the patient better. Given that Mr. C. was not able to provide his past psychiatric, medical, criminal and sexual history-collateral information from his family and past treatment records were obtained. Records reveal a progressive decline in his cognitive functioning. Apparently, during the early stage of Mr. C.’s disease, he was noted to have mild memory lapses, had difficulty keeping his attention focused on one thing and unable to come up with the right words for some familiar objects. Gradually, he had difficulties remembering the names of his friends and recalling recent events in his life, constantly losing some of his personal belongings, and frequently missed appointments (forgetfulness). However, he was alert enough to cover up some of his difficulties to a degree that only his wife and son noticed the changes in his behavior (Marshall, 2004)[12].
Other cognitive problems soon developed. Mr. C.’s behavioral changes became more prominent with increasing social withdrawal, apathy and disinhibition. He became more forgetful, was unable to think logically, short attention span more pronounced, work skills progressively deteriorated. His wife also reported that he had a grand-mal seizure before his index offence. After some time, his cognitive and motor deficits became more apparent. For example-his activities of daily living needed to be supervised, such as bathing, eating, grooming and toileting. Problems with communication (frequently used inappropriate use of words and was repetitive) became more explicit. He wandered at night, and with periods of being uncooperative and physically aggressive (Marshall, 2004)[12].
The results of full physical examination, which included sensory testing, blood and urine tests helped exclude treatable conditions and established that Mr. C.’s dementia was not related to an underlying illness. His neuro-psychological examination suggested specific deficits often seen in dementia. An assessment of memory and intellectual functioning revealed loss of intellectual abilities of sufficient severity to interfere with abstract thought, judgement, impulse control, social relationships, occupational functioning and changes in personality and behavior. In addition, his electroencephalography and brain scan showed some neurological damage. The neurologist confirmed Mr. C.’s diagnosis of fronto-temporal dementia (Khouzman,et al.2005)[9].
His wife reported that there were instances that Mr. C. claimed seeing “soldiers.” The nurse being cognizant that for older clients exhibiting psychotic symptoms, it was important to determine if such symptoms were an extension of the elderly patient’s early life psychosis (Khouzam,et al.,2005)[9]. However, Mr. C. had no previous psychiatric history. Nevertheless, a positive family history for dementia served as an indicator of his risk. His wife confirmed that his father had exhibited the same symptoms before his death at the age of 50. A comprehensive review of medication ruled out the possibility of drug toxicity. Finally, the assessment and evaluation of his activities of daily living indicated memory loss and other deficits.
Value of Diagnosis
An appreciation of the underlying causes of cognitive impairment is necessary. Some impairment is reversible and responsive to medical intervention, while other forms cannot be reversed and, in fact, are progressive in nature, such as Alzheimer’s Dementia. Regardless of cause, the mental health professionals’ assistance with managing the client’s deficits is critical. The importance of knowing the diagnosis of dementia enabled Mr. C. and his family to gain insight of what was happening with him, the nature of his illness and its ramifications, developed realistic expectations, which lessened both his and his family’s anxieties and uncertainties. By talking about the challenges that having dementia brings, gave Mr. C. the feeling of control of some situations thus fostered independence and decision-making. An appropriate treatment and care program was formulated i.e., structures and routines. For his family, understanding the behavioral consequences of the disease prevented misinterpretations of Mr. C.’s inappropriate behavior i.e., sexual or physical aggression as intentional actions. In addition, both Mr.C. and his family were able to plan for the future. An example was his long-term care needs i.e., arranging admission to a nursing home in the last stage of his disease (Arendt, 2004; Prasher,et al.2003)[1,14].
Management and Care-giving in Elderly Offenders with Dementia
Currently, there is no effective treatment for dementia. However, some interventions are found to produce a treatment effect and can help elderly offenders with dementia to better manage their conditions (Prasher,et al.2003)[10,14].
The development of a comprehensive treatment and care plan for Mr. C. required collaborative and coordinated teamwork involving him, his family, the forensic outpatient nurse and other members of the interdisciplinary team. The crafted plan was flexible and individually tailored to his unique needs, designed to slow down the disease process, as well as managing his symptoms. It included monitoring and maintaining his physical health, managing his medication, modifying the immediate environment to provide safety and structure, providing reality orientation and reminiscence therapy and promoting optimum communication between him, his family and significant others. In addition, the treatment and care plan foci were not only on the physical status and on environmental factors of safety, but also toward preserving his dignity and integrity until the moment of his death (Lesser,et al.2005). Another important factor that contributed to the effectiveness of the plan was its frequent review and readjustment of both short and long-term goals to ensure that it was relevant to Mr. C.’s unique needs and functional status (Encinares,et al.2005).
Monitoring and Maintaining Physical Health
Nutritional Support
Getting individuals with dementia to eat can be a daunting task. Mr. C. was easily distracted that interfered with his eating. He frequently played with his food and/ or threw them on the floor. There were instances that he would demand for food even though he had just eaten his meals. The forensic outpatient nurse and the Occupational therapist, however, by teaching the patient and his family certain techniques enabled Mr. C. to focus on the activity of eating. The strategies included keeping a calm and pleasant environment during meal time, using plastic dishes, use of bowls instead of plates, adaptive devices, such as spoon with thicker and heavier handle which reminded him that he was eating, offering him one food at a time, reminding him to chew and swallow his food, and providing finger foods and nutritious snacks (Lesser,et al. 2005;Prasher,et al.2003).
Promoting Sleep and Rest
Mr. C. experienced difficulty sleeping and frequently wet of urine through the night. On-going health education and advice, such as keeping Mr. C. occupied and active during the day, not allowing him to take naps in the afternoon, short exercises late in the afternoon or early evening, limit fluid intake before bed time, asking him to void before going to bed so he will not be awakened at night with a full bladder promoted his sleep. Using waterproof mattress, incontinent pads and the use of plastic urinal prevented bedwetting and helped addressed his physiological needs.
Maintain Self-care
Although, Mr. C.’s functional loss was progressive, it was necessary that his self-care capacity was assessed and supported at every stage of his illness. An aspect of Mr. C.’s treatment and care plan was encouraging him to do things for himself independently or with minimal help as much as possible, such as washing, dressing, and feeding (Khouzam,et al.2005; Prasher,et al.2003)[9,14]. This strategy can be time-consuming, and at times, frustrating endeavor, however, it was noted that the more Mr. C. effectively managed his daily routine, his anxiety lessened. To encourage him to attend to his personal hygiene needs: bathing and toileting routines were established, frequent reminders about his daily grooming and personal hygiene were provided, prompts or “lead” helped him to finish his routines i.e., laid his clothes in order. Graded program of specific task that was simple, practical, concrete and attainable, which required active participation of his family was crafted to help him follow directions. For example, if Mr. C. resisted to his oral hygiene, mouth swabs were used, and if he continued to resists, he was given an apple to eat, which helped clean his mouth (Khouzam,et al.2005;Prasher,et al.2003)[9,14].
Adapting the Environment
Supportive environmental settings can positively affect disease symptoms and the patient’s quality of life (Khouzam,et al.2005; Lesser,et al.2005)[9,10]. In order to appropriately serve and maintain Mr. C. in the community, it was necessary to modify his environment, such as: keeping living areas with acceptable smells, comfortable temperature and well lit without shadows or glare particularly his room, lessened his misperceptions; playing soft music provided stimulation; blaring noise was avoided to prevent sensory overload; furniture were kept in a consistent place, used prompts and appropriate clues, such as colored arrows on the floor pointing to his room, labeling his room, kitchen and bathroom with identifying symbols i.e., picture of a toilet in the washroom reduced his disorientation and confusion. Recommendations and instructions were provided on the use of adaptive devices to support independence on activities of daily living, such as safety in the kitchen, climbing stairs and during bath time i.e., toilet seat was elevated and safety bar near the toilet and bath tub were installed. These approaches helped Mr. C. regained the needed skills that made his life more organized and comfortable.
Beyond maintaining a pleasant milieu (and because of the forensic or legal issues involved), keeping Mr. C. and the community safe were the two major proactive goals. Hence, door alarms were installed and fences were built around the house backyard with safety gates to prevent Mr. C. from wandering and/or leaving his residence (Lesser,et al.2005)[10].
Enhancing Communication
Providing opportunities to enhance communication with his family and significant others was also of high priority. Such opportunities provided a supportive and instructive relationship in the context of which Mr. C. regained social skills. For example, it was found useful to: approach him in full view; get his attention before speaking to him; call his name, use touch to get his attention, but not until he is aware of the presence of the person speaking; allow more time for him to respond to statements or questions-Mr. C. required more time to process what have said to him and for him to formulate a response. These strategies avoided and reduced his angry outbursts and striking out. By speaking in a slow, simple, short, firm and clear sentences and using emphatic tone helped to express understanding of his feelings particularly when he was hallucinating. Selecting topic on shared knowledge or background information on his personal history promoted and assisted in carrying on a meaningful conversation.
Further, the forensic outpatient nurse recognized that when working with individuals with dementia and/or with families, one must be sensitive to readiness to change. Therefore, all personal and environmental changes for Mr. C. were paced accordingly and gradually.
Medication Management
In general, physiological changes related to aging are usually marked by decline, such as decreased functioning of the circulatory, urinary, and digestive and nervous systems. From a pharmacological perspective, these factors result in increased susceptibility of older adults to adverse drug reactions (Jeon, 2003)[7].
In our case, a small dose of anti-psychotic and anti-convulsant medication served to reduce Mr. C.’s disordered thinking and alleviated his distressing symptoms i.e., restlessness, agitation and seizures (Khouzam,et al.2005; Lesser,et al.2005)[9,10].Due to Mr.C.’s experienced difficulties in swallowing tablets and capsules, liquid preparations were prescribed, and/or crushing and mixing his medication with food promoted his compliance with medication. In addition, he was closely monitored for the effects and side-effects of medication.
Reality Orientation and Reminiscence Therapy
While psychopharmacological intervention is an extremely important part of the treatment and care plan, psychotherapeutic interventions particularly in the early stage of the disease process are often equally valuable (Prasher,et al.2003)[14].
Reality orientation i.e. easily read clocks, calendars proved very useful in helping Mr. C. re-established ties with reality i.e., date and time, orientation board helped Mr. C. to remember task he had to accomplish thus helped him regain a feeling of independence and an amount of self-confidence. Verbal orientation was also used. For example, in responding to Mr. C.’s hallucinations, confrontations were avoided. Instead, his emotional feelings were acknowledged and reassurances were provided that he was in safe place. In many instances, thoughts were redirected to help blocked out the hallucinatory experiences and supported reality.
Marshall (2004)[12] contends that reminiscence or life review can be a source of pleasure; helps resolve present and past conflicts and enhances patient’s self-esteem. In addition, sharing stories about personal relevant events and topics can be useful in creating an identity for an individual. However, it is important to recognize that while this approach can be useful, sensitivity and care must be exercised in using this method as for some individuals the past can be a reminder of their painful experiences and/or losses.
Photographs of Mr. C.’s parents, his family, his country of origin and his favorite pet were placed on his bedside table, family videos and his favorite and familiar music were played to relive his past. These techniques helped him remained stimulated and adjusted to various changes in his life.
Legal Issues
Expectedly, specific legal issues may arise as consequence of an individual with dementia being involved with the legal systems, especially consent and capacity issues, working with the Ontario Review Board, and access to services. Thus, knowledge and support to patients and families in terms of information, consultation and advice i.e., legal aid lawyers are vital. In many instances, nurses advocate for the patient and family caregivers (Encinares,et al.2001)[4].
In the early stage of the disease, offenders with dementia may have the capacity to make an array of responsible decisions about their own finances and treatment and care. However, it is also important to realize that this may change overtime depending on the progression of the disease process. Thus, capacity for financial and treatment decisions must be considered in each circumstances, and assessed if needed.
The task of the forensic outpatient nurse in the case of individuals found unfit to stand trial is to restore competency through psycho-education designed to increase knowledge of courtroom procedures, charges and possible consequences, and communication skill to cooperate with lawyer. However, due to the debilitating progressive cognitive impairment, offenders suffering from dementia, fitness to stand trial may never be achieved (Curtice,et al.2003)[3].
Vital Role of the Family
Having an older family member who perhaps is dementing and who subsequently becomes involved with the criminal justice system creates immense pressures in the family. Frequently, family caregivers experience a range of emotions and concerns in responding to the complexity of needs of elderly offenders with dementia. In most cases, family caregivers become confused, angry, and at the same time may have feelings of guilt, shame, bitterness, unrealistic hope, sadness and depression, which could manifest in over protectiveness of the patient and hostility towards others and service providers (Jeon, 2003)[7].
The recognition that providing care to individuals with dementia involves dealing with family members and/or loved ones and their roles within the care-giving relationship creates conditions that make it possible to continue to care for the patient in the community. Establishing and maintaining a collaborative relationship with the family could have positive effects from a risk management perspective and achieving a desired therapeutic patient outcome-both as a primary caregiver and a source of information (Jeon, 2003)[7].
To assist Mr. C.’s family and to maintain him within the family context, his family was viewed as an active member of the caring relationship. Providing Mr. C.’s family the opportunity to express their feelings by listening to their story by simply offering a sympathetic ear was an important step in helping his family to cope with his illness. By jointly establishing a set of goals, his family felt valued, and an agreement was reached with the family on realistic expectations from Mr. C. Providing health education to ensure high quality care that included information to: better understand his illness, about services and mental health treatment available especially after-hour services, access to specialists who have experience working with this population, the role his family might play in his care and ways how to better manage care-giving tasks including safety issues and using a sense of humour in difficult and frustrating situations helped prevented Mr. C.’s long-term care admission.
Caring for an individual with dementia can be disruptive to a family’s integrity, goals and lifestyle. Thus, the issue of respite from caretaking responsibilities should be addressed. Linking his family to appropriate resources and support in the community lessened the burden and pressures on his family as a primary caregiver. For example: respite care, such as home health care three times a week, adult day care services (being transported by a special bus) twice a week, helped alleviated Mr. C.’s family’s care-giving stress
Epilogue
Mr. C. continued to deteriorate mentally and physically, which prompted the forensic outpatient nurse, collaborating with his family, to refer Mr. C. to a long term-care facility. Mrs. C. continued to provide quality care in their home environment until he was admitted to a nursing home. Family caregivers were able to visit him regularly in the nursing home. Concerning Mr. C.’s legal situation, his charges were dropped. He was subsequently discharged from the Ontario Review Board and from the Outpatient forensic clinic.
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(Editor Emilia)(Maxima Encinares)