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When someone living with dementia is distressed or violent, ‘de-escalation’ is vital

<p><em><a href="https://theconversation.com/profiles/steve-macfarlane-4722">Steve Macfarlane</a>, <a href="https://theconversation.com/institutions/monash-university-1065">Monash University</a></em></p> <p>Today’s <a href="https://www.abc.net.au/news/2023-05-18/cooma-aged-care-home-police-woman-in-hospital-taser/102361018">reporting</a> about the alleged tasering of a 95-year-old woman living at the Yallambee Lodge aged care home in New South Wales has brought the issue of behaviours and psychological symptoms of dementia into <a href="https://www.abc.net.au/news/2023-05-19/advocates-say-taser-clare-nowland-shows-aged-system-failure-/102365442">sharp focus</a>.</p> <p>Over half of those living in residential care <a href="https://www.aihw.gov.au/reports/dementia/dementia-in-aus/contents/aged-care-and-support-services-used-by-people-with-dementia/residential-aged-care">have a dementia diagnosis</a> and up to 95% of those living with dementia will <a href="https://www.ncbi.nlm.nih.gov/books/NBK551552/#:%7E:text=Behavioral%20and%20psychological%20symptoms%20of,%2C%20and%20caregiver%20well%2Dbeing.">experience such behaviours</a> at some point during their passage through the illness. Common behaviours that might be shown by those living with advanced dementia include agitation, anxiety, attempts to leave care, aggression, apathy, sleep disturbance, aimless pacing, psychosis and aggression.</p> <p>The full circumstances surrounding Wednesday’s events are unclear and they are subject to an <a href="https://www.abc.net.au/news/2023-05-19/advocates-say-taser-clare-nowland-shows-aged-system-failure-/102365442">investigation</a> by police. That may take some time. What is clear, however, is that there is much room for improvement in the way behaviours and psychological symptoms of dementia are managed in residential care. Situations that end with police involvement should be avoided.</p> <h2>Calling for help</h2> <p>In its final report in March 2021, the <a href="https://agedcare.royalcommission.gov.au/">Royal Commission into Aged Care Quality and Safety</a> <a href="https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-recommendations.pdf">recommended</a> “all workers engaged by providers who are involved in direct contact with people seeking or receiving services in the aged care system undertake regular training about dementia care and palliative care”.</p> <p>Currently, it is not infrequent for police to be called to respond to incidents in care homes. While programs have been implemented to better equip police to respond to the specific need of those <a href="https://www.nationaltribune.com.au/police-and-psos-better-equipped-to-support-people-living-with-dementia/">living with dementia</a> this work is still in its infancy.</p> <p>Aggression and agitation are two of the most common behavioural symptoms that lead to referral to specialist support services.</p> <p>Dementia Support Australia is a Commonwealth-funded service that has supported aged care homes and home-based carers in managing behaviours and psychological symptoms of dementia since 2016. There were <a href="https://www.aihw.gov.au/reports/dementia/dementia-in-aus/contents/aged-care-and-support-services-used-by-people-with-dementia/dementia-support-australia">8,702 referrals</a> to the service between January and June 2022. The number of referrals has increased in recent years.</p> <p>As an organisation at the frontline of dementia support, we extend our deepest sympathies to the 95-year-old aged care resident, her family, Yallambee Lodge staff and everyone else touched by this devastating incident.</p> <p>One of the advantages of having a national service such as this is that it has enabled the development of a national database that documents not only the nature and severity of the behaviours prompting the referral, but those factors that are most commonly identified as triggers for these behaviours.</p> <h2>3 leading causes</h2> <p>Aggression and agitation are not diagnoses in themselves, but symptoms. Symptoms have causes, and these must be identified in order to adequately address behaviour.</p> <p>The leading contributing factors we have identified in relation to behaviours are:</p> <p><strong>1. Unidentified or under-treated pain</strong></p> <p>This is relevant in over 50% of the cases we see. Earlier research on pain management in the setting of advanced dementia has shown those with a dementia diagnosis who are admitted to hospital with hip fractures tend to be prescribed only a fraction of the analgesia given to <a href="https://pubmed.ncbi.nlm.nih.gov/10799790/">those without dementia</a>.</p> <p><strong>2. Carer approach</strong></p> <p>Care staff receive only minimal levels of training in dementia care as part of their basic qualification and are often unfamiliar with communication strategies tailored towards those with cognitive impairment.</p> <p>Currently, the minimum qualification for a personal care worker involves no compulsory units in <a href="https://www.dementia.org.au/about-us/news-and-stories/news/are-aged-care-workers-required-have-dementia-training">dementia competency</a>. While we do not know the full circumstances from the events this week, the Royal Commission has made recommendations to improve care for those living with dementia. Carer approach is an issue in about a third of the cases we see.</p> <p><strong>3. Over- and under-stimulation</strong></p> <p>In about one quarter of Dementia Support Australia cases boredom and loneliness and/or an environment that does not take into account the specific needs of those living with dementia are an issue.</p> <p>Other common causes of changed behaviour include mood and anxiety disorders, communication difficulties, <a href="https://theconversation.com/what-is-delirium-194631">delirium</a>, sleep problems and poor carer knowledge of the specific likes/dislikes of the individuals they are caring for.</p> <figure><iframe src="https://www.youtube.com/embed/WE65yrnsrPk?wmode=transparent&amp;start=0" width="440" height="260" frameborder="0" allowfullscreen="allowfullscreen"></iframe><figcaption><span class="caption">People with dementia may react to uncertainty in unexpected ways.</span></figcaption></figure> <h2>Prevention and calming things down</h2> <p>The best way to manage most behavioural changes is to prevent the circumstances that lead to their development in the first place. Prevention is always better than cure.</p> <p>Once behaviours are occurring, there is no single correct way to <a href="https://www.dementia.org.au/national/support-and-services/carers/behaviour-changes/aggressive-behaviours">de-escalate</a> them. The appropriate de-escalation strategies will always be specific to what has caused the altered behaviour in the first place.</p> <p>Unfortunately, when behaviours have escalated to the point where police attendance is required, the responding officers are unlikely to be equipped with the necessary information about the person and their circumstances. That means they won’t be equipped to respond with effective and specific de-escalation strategies.</p> <p>One case in the United States from 2020 involved the arrest of a 73-year-old woman living with dementia, who had left a local store without paying for items <a href="https://edition.cnn.com/2021/04/27/us/loveland-police-officers-video-use-of-force/index.html">worth a small amount</a>. A <a href="https://edition.cnn.com/2021/04/16/us/loveland-lawsuit-use-of-force-arrest/index.html">lawsuit</a> filed following the arrest alleged it resulted in a fractured arm and a dislocated shoulder, and raised national concerns about the way first responders interact with those experiencing cognitive disabilities.</p> <p>Australia needs to learn from yesterday’s events and respond.</p> <p><em>If you are caring for someone with dementia there is help available. <a href="https://www.dementia.com.au/">Dementia Support Australia</a> is a free service, fully funded by the Australian government. Referrals can be made 24-hours a day by calling 1800 699 799.<!-- Below is The Conversation's page counter tag. Please DO NOT REMOVE. --><img style="border: none !important; box-shadow: none !important; margin: 0 !important; max-height: 1px !important; max-width: 1px !important; min-height: 1px !important; min-width: 1px !important; opacity: 0 !important; outline: none !important; padding: 0 !important;" src="https://counter.theconversation.com/content/205988/count.gif?distributor=republish-lightbox-basic" alt="The Conversation" width="1" height="1" /><!-- End of code. If you don't see any code above, please get new code from the Advanced tab after you click the republish button. The page counter does not collect any personal data. More info: https://theconversation.com/republishing-guidelines --></em></p> <p><em>Image credits: Shutterstock</em></p> <p><em><a href="https://theconversation.com/profiles/steve-macfarlane-4722">Steve Macfarlane</a>, Head of Clinical Services, dementia Support Australia, &amp; Associate Professor of Psychiatry, <a href="https://theconversation.com/institutions/monash-university-1065">Monash University</a></em></p> <p><em>This article is republished from <a href="https://theconversation.com">The Conversation</a> under a Creative Commons license. Read the <a href="https://theconversation.com/when-someone-living-with-dementia-is-distressed-or-violent-de-escalation-is-vital-205988">original article</a>.</em></p>

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Inside the hostile brawl between Erin Molan and the Daily Mail

<p>The Daily Mail has not taken Erin Molan’s defamation lawsuit lying down, revealing they have been raking through several years of rugby league podcasts in an attempt to prove that the Channel nine presenter is objectively racist.</p> <p>DM has reportedly collected a number of quotes from <em>2GB’s Continuous Call Team</em> archive and have on record saying “You like raw feesh?”, “Pick up your chopsticks” and “I wuv you wery long time”.</p> <p>The 61-page defence alleges the <em>Continuous Call Team</em> frequently spewed out “racist content” on the show by mocking Pacific Islander and Maori names along with emulating Chinese, Indian and other accents.</p> <p>Molan’s lawyer told NCA <em>NewsWire</em> in a statement: “Ms Molan has commenced proceedings in the Federal Court of Australia for defamatory allegations made about her by the Daily Mail.</p> <p>“Those allegations, now repeated by the Daily Mail in its defence, are denied. It would be inappropriate to comment further as the matter is before the court.”</p> <p>Molan claimed that the Daily Mail painted her as a racist and an “arrogant white woman of privilege” in a story about her saying “hooka looka mooka hooka fooka” on air back in June.</p> <p>She has repeatedly defended herself by saying she was not mocking Polynesian names and was actually referencing to a past <em>Continuous Call Team</em> story about Chris and Ray Warren.</p> <p>The Daily Mail’s defence was filed on Monday and contains transcripts of 24 conversations on<em> Continuous Call Team</em> dating back to March 2017.</p> <p>It involves Molan and past and present co-hosts Ray Hadley, Bob Fulton, Darryl Brohman and others.</p> <p>One excerpt dating back to April 1, 2017, hears Hadley saying, “And now, why don’t we have a conversation with Darryl doing his Chinese and Erin doing her Chinese?”</p> <p>“Herro, I wery goo lookin,” Molan said, according to the defence.</p> <p>“Just do one for me, ‘I love you long time’, just do that for me,” Hadley said.</p> <p>“I wuv you wery long tiyme, wery handsome man, ohhh, you like to walk with me in a cercle,” Ms Molan said.</p> <p>In another clip given by the defence on March 17, 2018, Hadley tells a story about women in Japan giving birth.</p> <p>“You like raw feesh,” Molan said. “Sorry, was that racist?”</p> <p>“Yeah … it wasn’t good,” Fulton said.</p> <p>“Was it really? No it wasn’t, ’cause they do,” Molan said.</p> <p>According to the defence, Molan sometimes participated in the conversations.</p> <p>The defence also said that at times she laughed along, stayed silent, or asked “in a humorous fashion” whether what had been said was racist.</p> <p>In another excerpt from August 24, 2019, Brohman states he is going to release a Chinese cookbook.</p> <p>“Gonna put a big nappy on so I look like a sumo and say, ‘Come and get it! Big Marn’s Chinese Cookbook!’,” he allegedly said.</p> <p>“Herro! That’s gonna be the name of the book,” Brohman said later.</p> <p>“I just don’t know if this is OK now in this day and age,” Molan said.</p> <p>“Oh, who cares,” Fulton responded.</p> <p>Later in the conversation, the defence claims Molan said “Now we’re all talking like ohhh … you no … bad boy … you naughty … dwop your pen … pick up your chopstick” in an accent.</p> <p>“Can I just throw something in here? Do we like working here? I don’t think we’re gonna have a big chance of being here next year,” Fulton said.</p> <p>“I know we like to toe the line but this might be like a whole heel over the line,” Molan said.</p> <p>“No, no, we’re right,” Mark Levy said.</p> <p>The defence also included another transcript from March 18, 2017, in which Brohman put on several accents, including Irish, American, Chinese, Japanese, and Indian.</p> <p>Molan said: “Someone will write in now and say we’re being racist. I think it’s hilarious.”</p> <p>The defence also includes transcripts of Brohman who recounted the story about Chris and Ray Warren.</p> <p>It is the story that Molan said she was referencing with her original comment.</p> <p>“It was last year at a Manly game and they had a reserve that I hadn’t seen before, but he had a name with about 30 letters in it, and I had trouble pronouncing it, and I said to Chris, ‘Mate, how do you pronounce this bloke’s name?’” Brohman said on April 5, 2020.</p> <p>“He said, ‘Well, Dad thought his name was Chooka-lucka-loo-loo, but I said no, no, no, Dad, I think it’s Chooka-lucka-loo-loo-loo-loo.’”</p> <p>Audio of the conversations remain publicly available online.</p> <p>In the defence, the Daily Mail claims these conversations prove Molan is racist.</p> <p>Molan also accused the Daily Mail of falsely stating she refused to apologise when she says she had in fact apologised on air.</p> <p>In the defence, the media outlet said it was not “a true apology” and she had “simply stated that if people ‘in the current climate’ had been offended or hurt by her that she was sorry”.</p>

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