Currently, incidences of disruptive behavioural problems such as agitation, aggression, rest-activity pattern and sleep wake disturbance are reported to be high in people with dementia. The specific determinants of disruptive behaviour are still unclear but predisposing factors are considered to be associated with the external factors such as the negative staff attitudes and environment. Actually, disruptive behaviour is an umbrella that describes behaviours such as throwing objects, hoarding, resisting care, self abuse, wandering, repetitious verbalization, aggression and general agitation.Prevalence of aggressive behaviour has been considered as a subset of disruptive behaviour among individuals with dementia in long-term care facilities as 86. 3% has been reported. (Ryder et al. 1991). According to studies on cognitively intact residents and residents with dementia, shows a consistently higher prevalence of behaviours. This paper presents research literature to support the role of a positive environment including attitudes and staff interaction in the aggressive individuals with dementia.
Importance of a positive environment including staff interaction and attitudes towards the aggressive individuals with dementia Environment has been increasingly recognized as a significant therapeutic element in care of individuals with dementia. In the last decade, it has been realized that environment plays a significant role in reducing the disruptive behaviour, increasing the functional ability of the individuals with dementia, as well as improving their quality of life.
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Problem behaviour in dementia is associated with deficits in the executive control functions of the frontal lobe. However, complex behaviours seen in individuals with dementia are as a result of multiple, over-learned routines the environmental stimuli triggers. The executive control functions orchestrate the routines into coherent goal-directed behaviours which in turn contribute to the expression of the required habitual response while limiting the unrequited responses.
It therefore means that failure of executive control function leads to distractibility and overdependence on environmental factors or can even lead to apathy and environmental indifferences. However in any case modification of social and physical environment can reduce behaviours that are not required and can elicit the desired behaviours effectively. Moreover, environment is the major component in progressively lowered stress threshold model. (Sife, 1998).
Subject to the model, since the ability to adapt in individuals with dementia declines as the dementia progresses, the care givers should reduce the environmental demands to ensure that the level of the environmental demands is congruent with the abilities of individuals with dementia. Basically, disruptive behaviours are more often when the stress threshold of an individual is exceeded. Most of the intervention strategies given in the literature engage manipulation of physical and social environments to meet the unique needs and personalities of individuals with dementia.
Following the recognition of the important role of environment to individuals with dementia, many long-term care facilities have come up with special care units that give a total supportive milieu for them. Following the increase of such special care units design guidelines such as recommendation for both social and physical environments have been developed to ensure that the environment provided by the facilities enhanced the well-being and personhood of individuals with dementia.
(Morgan & Stewart1997). However, since there is no empirical data, the special care unit design manuals are based on extrapolations and clinical experience. Predictability and structure are the important aspects of the environment in which individuals with dementia live. The daily routines that reflect the rhythm of the society are predictable, and with a chance to rest and opportunity for activity, individuals are kept in touch, thus promoting their well being.
Patient-centred dementia care is the recommended approach in caring individuals with dementia as it focuses on independence, it is value-driven, and it is concerned with the empowerment and well being of individuals with dementia and their families. Moreover the patient-centred care makes the individuals to feel socially confident, valued and supported thus creating personhood which is described by Kitwood (1997a) as a status that is bestowed in individuals by others within the society in the context of social being and relationship.
Care for the individuals with dementia should focus on maintaining the personhood in the face of the individuals whose mental powers is failing. (Kitwood, 1996). Paying attention to personhood involves recognizing the centrality of the relationship and the uniqueness of the individuals as well as the fact of the embodiment. It therefore means that dementia care that is only involved with the dementia as the disease and its treatment has nothing to do with the patient’s personhood, damages the patient, and treats as a passive object rather than a human being.
Patient-centred dementia care is recommended as it is based on the ethic that regardless of disabilities, all human beings have absolute value and need to be respected, and on the convictions that just like all other human beings, people with dementia are capable of living a fulfilling live. (Kitwood, 1999). The principle central to patient-centred dementia care is that the life experience of the individuals, their network relationships and unique personalities should be valued and considered with constant attention by the staff giving the care.
This is based on the observation that once dementia is presentation it can never be reduced to the neuropathological damage effects, instead, it is a combination of factors such as social psychology, neurological impairment, physical health, biography and personality. Focusing on the losses or deterioration of the patients with dementia reinforces negative perceptions, progression of dementia and its treatment. Based on several studies, self-esteem is considered as a necessity for the well being of individuals with dementia. (Thorngate, 1999).
Patient-centred dementia care is concerned with establishment and maintenance of positive and supportive social environment for individuals with dementia. In the context of this care, the personhood of the individuals is established through strengthening of the individuals positive feelings, promoting the healing of psychic wound and nurturing the individuals skills or abilities. Generation and sustenance of positive interaction used singly or together, secure and stable relations, replenishes the personhood of individuals with dementia constantly.
Some of the psychotherapeutic techniques that promote these relationships include: facilitation which involves providing the missing parts of action to enable the individuals to do what they would not have done, holding which involve providing physical and psychological space for the individuals to expose vulnerability and tension, and validation which involves the accepting reality - the fact that they have dementia- and the feeling of being connected, alive and real.
Actually, caring for individuals with dementia possess challenges to the care giver in all environments probably because the condition is characterized by progressive brain damage making creating difficulties in their communication, remembering things and to think clearly. Because dementia is associated with swing s in moods, and changes in behaviour and personality, the staff and other care providers should develop positive attitudes when dealing with the troubling behaviour such as aggressiveness and communication difficulties encountered while providing the care.
Aggressive behaviour among individuals with dementia continues to burden and challenge the caregivers in special care units and nursing homes. It therefore means that working in such facilities increases the risks of experiencing aggression. Actually, aggression is associated with older people with cognitive impairment than individuals with no cognitive behaviour. The staffs in long-term care facility and nursing home are required to set a positive mood for interaction. The body language and attitude communicates the thought and feeling of an individual better than words.
The positive mood is set by speaking to the individuals in a respectful and pleasant way. To show affection and to convey message, the staff should use tone of voice and facial expression. Studies show both positive and negative attitude of staff towards the aggressive behaviour of individuals with dementia. These two domains are consistent with the theory of planned behaviour which suggests that attitudes follow from the beliefs held by individuals about the attitude’s object just as actions and intentions follow from attitudes.
(Ajzen, 1998, p. 32). Although the personality traits and attitudes are similar in a way, attitudes are more malleable and they can change unlike the personality traits. This means that although most of the caregivers’ attitudes toward aggressive individuals with dementia are negative, they can be changed through appropriate training. Negative and positive attitudes are associated with various forms of care used to prevent the aggressive behaviour from continuing.
Acknowledging the relationship between care for individuals with dementia and attitudes, and indication of the effectiveness the positive needs-based approach in reducing aggression can prompt change in the attitudes of the staff. According to the findings of the study carried out by Nakahira et al. (2008, pp. 13 on attitudes towards dementia-related aggression among staff, staff characteristics such as level of education, years of experience, position, occupation and age are related to their attitudes. Staffs with higher position, more clinical experience and the older ones have positive attitudes towards patients’ aggression.
It is therefore believed that education factors, and clinical experience influences the attitudes of the staff towards patient’s aggression hence appropriate education can be used to influence the negative attitudes of the staff towards aggressive individuals with dementia Based on the findings of the study carried out by Middleton et al. (1999) carried out to compare the staff’s attitude towards aggressive behaviour of patients with dementia in traditional unit and in special care unit, the staffs from the special care unit have sympathetic towards aggressive individuals with dementia than the staff in traditional unit.
Although aggressive behaviour is more in special care unit than in traditional unit, the staff at the special care unit understands that the behaviours are part of the dementia disease thus they do not feel that the patients intentionally directs the aggressiveness towards them as is it believed by staffs in traditional unit. Furthermore, the staffs’ attitudes and decision-making can be influenced by organisational factors. Staffs working in dementia units of gerontological and mental hospitals within acute hospitals have negative attitudes towards aggressive patients.
By measuring the attitudes of staff towards aggressive individual s with dementia, areas requiring skill improvement or education can be identified and it can be used over time to monitors changes in attitudes. Staff education to change the negative attitudes should advocate that there are possibilities of unmet needs among individuals with dementia, and that aggressive behaviour is a form of communication used by the patient and that efforts to understand the message conveyed by the patient, and attempts to meet the possibly unmet needs lowers the aggression incidences.
Conclusion Incidences of disruptive behavioural problems such as agitation, aggression, rest-activity pattern and sleep wake disturbance are reported to be high in people with dementia. The specific determinants of disruptive behaviour are still unclear but predisposing factors are considered to be associated with the external factors such as the negative staff attitudes and environment. Environment has been increasingly recognized as a significant therapeutic element in care of individuals with dementia.
Moreover, it is the major component in progressively lowered stress threshold model which states that the ability to adapt in individuals with dementia declines as the dementia progresses, the care givers should reduce the environmental demands to ensure that the level of the environmental demands is congruent with the abilities of individuals with dementia. Basically, disruptive behaviours are more often when the stress threshold of an individual is exceeded.
Most of the intervention strategies given in the literature engage manipulation of physical and social environments to meet the unique needs and personalities of individuals with dementia. Patient-centred dementia care is recommended as it is based on the ethic that regardless of disabilities, all human beings have absolute value and need to be respected, and on the convictions that just like all other human beings, people with dementia are capable of living a fulfilling live.
The principle central to patient-centred dementia care is that the life experience of the individuals, their network relationships and unique personalities should be valued and considered with constant attention by the staff giving the care. Staff education to change the negative attitudes should advocate that there are possibilities of unmet needs among individuals with dementia, and that aggressive behaviours are forms of communication used by the patient and that efforts to understand the message conveyed by the patient, and attempts to meet the possibly unmet needs lowers the aggression incidences.
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