Rage and fear in nursing homes

The Norwegian newspaper Aftenposten published a rather unsettling article in its A-magazine this weekend about violence within elderly care centers/nursing homes in Norway. At first glance, I thought it would be about abuse of elderly residents by nursing home employees. This is not unheard of, and has been written about for a number of years now. No, this article was about abuse of elderly residents and nursing home caregivers by fellow elderly residents, and it is more widespread than one might think. The nurses and care workers do not report all of the incidents that occur, hence this type of violence is under-reported. Many of the violent residents have been diagnosed with dementia, and even though they are cognitively-challenged, they still retain their physical strength and their voices, both of which they use against their fellow residents and the caregivers. In some cases, the violence was directed against visitors, who ended up terrified. Most of the violence has to do with the rage some of these residents feel, most likely rage against their illness, their mental incapacity, the fact that they know they are in a nursing home and perhaps feel like prisoners, their sense of having lost their identity--the list is long. The point is that their dementia makes them angry, makes them rage, makes them act out, and when they do, much of it takes the form of physical violence, but also verbal abuse (yelling and swearing). Some of these residents throw glasses, cups, chairs; others hold others down, slap them, punch them, kick them, bite them, spit at them, and try to break the fingers of the care workers. Still others (men) were sexually abusive toward some of the elderly women living in the homes. In most cases, the care centers and nursing homes were understaffed, especially at night when some of the demented residents wandered through the halls and into and out of other residents' rooms. It is up to the residents to decide if they want to lock their doors or not; the nursing homes cannot make this decision for them without their permission unless violent situations such as described in the article arise. These situations cannot lead to any repercussions in terms of prison sentences either, since demented individuals cannot be prosecuted.

Any way you look at it, this is an impossible situation. If employees and non-violent residents end up terrorized by violent residents in nursing homes, it will not end well for anyone. I can envision a not-to-distant future where few to no young people will choose to work as nurses or aides in nursing homes. The number of elderly with dementia is predicted to double by 2050, thus need for round-the-clock care will only increase. I don't know what the future holds, but I do know that if something is not done to tackle the problem, it will not go away. I don't know what the policies are for tranquilizing such people, but it might be one way to proceed in order to keep them calm. I don't know how elderly with dementia are currently treated (with drugs), but at least if they are tranquilized they cannot be a danger to themselves or others. I know it sounds harsh, but the alternatives are harsher. If nursing homes end up being more understaffed than they are now, they will close, and then it will be up to individual families to take care of these violent demented individuals (most of whom were men in the Aftenposten article, but there were some few women). I feel sorry for them, but they cannot be allowed to destroy the peace that the non-violent elderly deserve after a long life. The latter deserve respect and the right to live out their lives in peace and without fear of being harassed or physically assaulted by fellow residents or anyone else. I applaud Aftenposten for raising this issue, which is most difficult to discuss and even more difficult to solve.

Apparently, this is a global problem, as I have seen online. In other countries, there are special nursing homes for elderly with severe (and aggressive) dementia. Anger is a part of dementia, and in other countries tranquilizers are often prescribed for such people. But they do not always take their medications. So it remains a problem--how to deal with these elderly, how to respect them but at the same time limit their aggression, and how to protect the non-violent residents and caregivers.

Remembering my mother on her birthday

Had my mother still been alive, today would have been her 94th birthday. Unfortunately, she passed away in 2001. The cause of death was sepsis, which is not a very uncommon cause of death among elderly people for reasons that are not well-known. My mother had been in very good health until she neared her 78^th year; I can recall only two times in her entire adult life when she was hospitalized, once for a viral infection in her middle ear, and the other for an operation to remove an inflamed appendix. When she was in her late seventies, she began to have problems with her back. She was eventually diagnosed with osteoarthritis of the spine, again, not an unexpected diagnosis for many of the elderly. Having been a great walker for most of her life, my guess is that she looked ahead and did not like what she saw—a future with limited opportunities for walking, perhaps the use of a wheelchair and/or walker—in short, a more restricted life than the one to which she was accustomed. She was independent and stubborn; when she was hospitalized initially for medical tests, she was in good spirits and was sure she would be able to return to her old life. Sadly, that was not the case. She ended up at a care center so that she could undergo physical therapy to get her back on her feet again. For some reason, she became quite stubborn (more so than usual) and refused that help. And that refusal was her undoing. Had she worked at her physical therapy, she might still be alive today. All these many years later, I understand that she simply could not accept the idea that she would be dependent upon anyone or anything, and the idea that she was suddenly infirm did not appeal to her. My mother had no patience for being old, for the various small irritations and physical limitations of old age. She was vehement about not giving in to old age. What is surprising is that she did not understand her role in her own recovery, even when it was explained to her; had she taken the reins and insisted upon therapy, had she done what it took to get better, she might still be alive. But she had no personal experience with chronic or long-term illness, even though she had taken care of my father, who had debilitating heart disease, until his death. Taking care of him had not prepared her for suddenly being afflicted herself. Her two brief hospital stays must have convinced her to get out of the hospital and back home as fast as possible. I understand her at the same time that I question her actions during the last few months of her life. But I accept what happened even though I don’t understand completely what happened.

In the intervening years, there have been other illnesses and deaths--family members and friends alike—and I have had a chance to witness first-hand how these people tackled the illnesses that preceded their deaths. Illness does some surprising things to people. Some of them simply accepted their diagnoses and the accompanying conditions, others fought against them. Those who fought were mostly younger or middle-aged people. I also know older people who have done what it takes to get well, who were assertive about getting back on their feet again; interestingly, they are still with us. I've also known older people who did what they had to do to get well, but death took them anyway. Along the way, I've learned that you simply cannot know how you would think or feel if faced with a similar situation. And until you step into the shoes of a person who is ill (with a terminal diagnosis or long-term illness) you have no real idea of what they’re going through. It’s best to be there for them, to help out, to listen, to advise when asked for advice, to offer hope, to be positive, even if we don't always understand their situation or their response to it. Not much more is asked of us.