LOWLINELowry M., Linguard G. and Neal M. (2016)

A Strategy to Facilitate the Management of Anger in Individuals

living with dementia

Martin Neal

What’s the Need

• Anger is often a situation that carer’s and relatives perceive to be problematic and a challenge to themselves

• Carers and relatives report that the management of anger is challenging

• Reframing how we consider anger can expand the repertoire of interventions available to the carer and relative

The need to rethink anger • The “Management” of anger is a problem that

has been reported to occur by newly qualified nurses (Thomas, 2010)

• Anger is frequently reported to be problematic for those living with and caring for people with dementia.

• Anger can be perceived as a “problem” to be managed and subdued rather than an opportunity to engage with people and gain greater understanding

So What is LOWLINE

• An approach based upon established principles in communication and empathetic listening to help resolve difficult situations.

• Takes the position that :

• Anger may not be bad

• Anger can be an indication of an unmet need

• Anger is a natural part of the grieving process

• Anger can be a manifestation of fear

What it is not

• A means to avoid having to manage angry individuals

• A way of keeping people calm

• An advanced high level intervention requiring lots of training

• Not just for professional staff and carers –might be helpful for families and relatives.

The components • Listen – Active listening and reading the non verbal

messages

• Offer -reflective comments, which should be brief and use the words spoken by the angry patient

• Wait – Avoid jumping in, filling the gaps

• Look - The use of eye contact

• Incline your head indicating interest

• Nod – occasionally

• Express – a desire to understand and demonstrate empathy

So where does it fit in the world of people living with dementia ?

• There is a substantial body of literature written about the importance effective communication with people living with dementia - Kitwood, Feil and De Klerk Rubin, Hubbard et al, Brooker, and Blackall et al

• Some approaches explicitly identify anger as a feature of living with dementia that requires specific intervention Feil - validation.

Feil

• Feil’s concept of validation, based upon a set of core values and interventions, reinforces the position that behaviour has meaning. It is the responsibility of the person interacting with the individual to try to identify these meanings. Anger is a natural response to many of the circumstances that arise from having dementia, the deprivation of liberty, loss of self and infantilisation to name but a few.

Kitwood

• Person Centred Care and the promotion of “personhood”. This approach has at it’s core the premise that the uniqueness of the individual should be acknowledged

• The failure to acknowledge the individual not only negates the person but can also lead to a harmful state where malignant social psychology can occur.

Brooker

• The VIPS model • V A Value base that asserts the absolute value of all human

lives regardless of age or cognitive ability

• I An Individualised approach, recognising uniqueness

• P Understanding the world from the Perspective of the person living with dementia

• S Positive Social psychology in which the person living with dementia can experience relative well-being.

The concept of acknowledging anger directly aligns to the Perspective domain of the model

Blackall et Al

• VERA

• V = validation.

• E = emotion.

• R = reassure.

• A = activity.

LOWLINE aligns itself specifically to the concept of paying attention to the individual’s emotional content

To Conclude

• LOWLINE provides a simple framework for those interacting with individuals living with dementia

• It encourages carers to reframe the way they consider anger; viewing it as an opportunity rather than a challenge.

• It aligns itself well to several established approaches that are acknowledged to promote person centred care.

• LOWLINE provides a framework by which to train individuals to reconsider how they manage and perceive anger.

References Blackhall A., et al (2011) VERA framework communicating with people who have dementia Nursing Standard November 9-5

Brooker D. (2006) Person - Centred Dementia Care making services better. Jessica Kingsley publishers.

Feil N. and de Klerk – Rubin (2012) The Validation Breakthrough Simple Techniques for Communicating with People with Alzheimer's and Other Dementias/ Health Professions Press, Baltimore

Hubbard G., Tester S. and G. and Downs M. (2003) Meaningful social interactions between older people in institutional care settings Ageing & Society 23, 2003, 99–114.

Kitwood T. (1997) Dementia Reconsidered. The Person Comes First. Open University Press, Milton Keynes

Lakey L. (2009) Counting the Cost: Caring for People with Dementia on Hospital Wards.

Lowry M., Linguard G. and Neal M. (2016) De-escalating Anger: a new model for practice. Nursing Times. Vol. 112 issue 4, 4-7:

Thomas CM. (2010) Teaching nursing students and newly qualified registered nurses strategies to deal with violent behaviour in the professional practice environment. Journal of Continuing Education in Nursing 41:7 299- 308