During the pandemic, lockdown and restricted movements were imposed on the general population in the name of slowing infection rates. This has provided us all with the opportunity to reflect on the implications of everyday restrictions which placed on people with dementia in the name of safety, and has put our approaches to risk in the spotlight. Even during ‘normal’ times individuals with dementia have many of their choices reduced and they may become confined either in a care home or other setting due to perceived safety risks. The practices within this setting may further restrict the freedoms and independence of the individual living there.
Unsurprisingly, these restrictions may cause increased distressed responses, perhaps even exacerbating depressive illness. Our own recent restrictions may help to empathise with individuals who, through no fault of their own, are no longer able to freely participate in activities or enjoy the outdoors as they may have done previously. Just as current events have caused the government to attempt to balance the correct level of restrictions with the well-being of the people, so we must look to balance our response to people living with dementia when taking risks.
When imposing risk management strategies upon an individual, they should always be least restrictive. However, is this what actually occurs? Are current means of confinement or risk management excessive as we become more risk averse? Is it easier to impose excessive restrictions when it comes to someone else’s freedom? When assessing risk do we tip the scales in favour of our organisational interests?
Research has bourne out that each of the parties involved in an assessment of risk will consider the risks from their own perspective which may skew the outcome of the assessment. Professionals tend to focus on the physical elements of risk, and sometimes struggle to view risk on an individual rather than an organisational level. This often leads to blanket approaches to “risky situations”, rather than person-centred approaches which best meet the need of the person with dementia. In large part this adverse approach stems from the potential for blame, or possibly litigation and frequently results in attempts to eliminate ALL risk.
A risk assessment process must take into account the many contributing factors which should impact on the level of restriction being put in place. It is vital when assessing risk to consider the impact on the individual’s mental health, behaviour and social connection as well as human rights infringements. One of the ways in which we can shift away from risk adversity is to involve the person with dementia whenever possible in the discussion around risk taking. Giving them an active voice in the risk assessment process reminds professionals and carers that their priorities in reducing risk rarely match the priorities of the individual with dementia seeking to take the risk, and can help them to consider all of the contributing factors when assessing the risk in a situation.
There are many ethical dilemmas and considerations when making the decision to move someone to a care home or in the imposition of restrictive measures. The document ‘Nothing Ventured, Nothing Gained’ is informative and gives some suggestions about risk management for people with dementia from a practical perspective. The Royal College of Nursing have also published guidance regarding utilising restrictive practice with a human rights based approach.
Restrictive measures are varied and may not always be recognised as a restriction. Examples of this would include leaving walking aids out of reach so an individual is less able to move about independently, segregation of individuals who exhibit distressed behaviour rather than investigating the reason and implementing a more effective, person-centred intervention. This question of risk also lies at the heart of family visits in the midst of a pandemic. So far, the approach taken has been a blanket approach, one rule applicable to all. Perhaps we could all benefit from a more person centred approach to risk.