Positive Risk Taking in Dementia Promoting Excellence in Dementia

ENHANCED LEVEL Masterclass

Christine Steele AHP Dementia Consultant

Ruth Mantle Alzheimer Scotland Dementia Nurse Consultant

Aims: •Investigate the factors which influence our

approach to risk

•Review up-to-date research/ literature in

relation to positive risk taking & dementia

•Explore methods for integrating positive

risk taking within your current practice.

What do we mean by risk and what is our experience in the workplace of risk and dementia?

Case-studies

Definition of Risk

Originates from Italian word risicare means ‘to dare’.

Historically considered to be more about choice rather

than fate.

Today seen more as, ‘the possibility of incurring

misfortune or loss’ and to expose to danger or loss’ Collins, 1998

“The only thing we have to fear, is fear

itself”Franklin Roosevelt

‒ Society

‒ Cultures we work in

‒ Own personal narratives

‒ Values and life experience

‒ which in turn influences what we then consider being

risky or acceptable levels of risk and shapes the way we

respond’.

Douglas & Wildavsky, 1982

Our perceptions and understanding of risk are

shaped by:

‒ Professionals- focus on management strategies on

future and emphasize the physical domain of risk i.e.

falls

‒ Family/ carers- focus on present and emphasise

interpersonal domain of risk i.e. loss of partner role

‒ Person living with dementia- concerned with

biographical domain i.e. loss of self-identity

Risk Perspectives

‒ Hazard Manager- identify hazards and remove or

minimise threat to cause harm.

‒ Risk Facilitator- identifying and supporting activities

which add to the quality of life of someone.

‒ Dilemma Negotiator- identify and reconcile differing

views and seek consensus between person living with

dementia, family and practitioners.

Alaszewki et al 1998

Practitioner Role in Risk Management

Consider role we might play in discharge planning?

How might we influence decisions about discharge

destination and be a dilemma facilitator or risk

facilitator rather than a hazard manager?

‘Whilst physical safety remains key focus for healthcare,

the ability to maintain self-identity and key relationships

is of more importance to the person with dementia and

their family’ Gilmour et .al, 2003

‒ ‘probability of risk can be calculated as an objective

measurement of the likelihood of harm occuring

(Denney, 2005)

‒ Standardises and objectifies risk through use of risk

matrices

Physical Domain of Risk

Traditional risk discussions focus on downside risk

Risk that an event will turn out worse than expected

‒ If person goes outside, what are the chances he will get

lost, or walk into traffic?

‒ If he walks unassisted, what are the chances he will fall

and be injured?

‒ At a social event, what are the chances she will be

overwhelmed and distressed by the environment?

Thomas & Ronch

Upside risk

risk that an event will turn out better than expected.

‒ If person goes outside, what are the chances he will improve his conditioning and overall mood and sleep better at night?

‒ If he walks unassisted, could it improve his balance and lead to greater independence with other activities of daily living?

‒ If she goes to a social event, could it bring meaning, growth and forestall further cognitive decline?

‒ Tick-box mentality that replaces clinical judgement

‒ Tells you very little about person

‒ Format is often negative in focus with little room for

optimism or potential for working alongside risks or to

take risks

‒ Managing and avoiding risk

‒ Doesn’t always show reason for risk

Focusing on Physical Domain of Risk can lead

to:

‘often unintentional, that arise from emotional,

psychological or spiritual neglect’ Clarke et al, 2011

The psychological and emotional risks can remain hidden and in just

focusing on the physical domain of risk there is the danger that the

person is denied the opportunity to make meaningful choices and to

maintain a level of independence or autonomy.

Silent Harms

Not being given the opportunity to undertake such basic

activities as going to the toilet, leaving the ward/ home or

walking unaccompanied because others do not believe

the person to be capable of managing the potential risk

involved can further deprive the person of their sense of

identity and purpose.

Can lead to feelings of disempowerment and

hopelessness leading to deskilling and deterioration in

person’s physical and cognitive functioning.

Understanding that stress and distress in dementia might

in fact be the person communicating an unmet need or a

reaction to a silent harm........

Can help prevent it being as perceived as risky

behaviour but rather as a response to their reality at that

moment and staff to consider if there is anything that

can be done to meet that need.

Place at the centre of decision-making the person (who

happens to have dementia) rather than the dementia

(which happens to be part of the person)

‘Do not let someone’s past and future life be

overshadowed by dementia’

Sabat, 2011

Move from thinking just about person being vulnerable

(and so needing to manage their risks and harms) to

understanding that it is a situation which leads to

someone being vulnerable- so see the person as part of

the context of situation.

Negotiating Risk

Negotiating risk is neither the elimination of any activity

that might produce a downside nor an acceptance of all

activities without boundaries……

It is a conversation about who the person is and

asks:

‒ how they stand to benefit from engaging in an activity?

‒ what the downside risks are?

‒ can they be mitigated to an acceptable degree of

support?

Power, 2014

‘Think not so much about protecting someone and

avoiding risks, but getting to know what risks it is

reasonable to enable someone to take in order to

achieve a sense of achievement and purpose’.

Clarke, 2014

Supporting positive risk-taking‒ Bust the myths

‒ See the individual

‒ Identify and celebrate risk-takers

‒ Break down the stigma

‒ Provide a safety net

‒ Support decision making

- have I got accessible/ useful information I need?

- what are the risks associated with each available choice?

- what risk is being taken (and by whom)?

- what are the positive outcomes of taking the risk?

- what strengths can be identified?

- What steps need to be taken to manage the risk-taking?

- what could go wrong, and how can this be best managed?

- accept that some things can go wrong: who can help manage the fear or guilt?

Final thought

“People living with dementia must be allowed to take

risks, because if we don’t, we are in danger of relaxing

into the disease. At times we feel hopeless. At times the

hurt we feel is indescribable and we can let it be a barrier

to life. But there is a life for us, if we risk it.”

personal account of living with dementia Morgan,

2009