Perhaps the most difficult but necessary challenge for human service professionals is to question existing models of treatment. This is especially true when a more effective model is not yet available. Because of a conditioned passivity, individuals working in human services often exist professionally in an uneasy balance between what is right and what is, between what has been learned and the limits of one's imagination and vocational expectations.
As a clinical psychologist in my 42nd year of continuous work in western Minnesota, including regular consulting with several nursing homes, I without question accepted the existing treatment model for vascular dementia. There always had been one way of thinking, which defined dementia and/or Alzheimer's disease as a progressive, devastating organic disorder of uncertain cause, and for which there was little effective treatment. The psychologist's job always had been to help develop programs, usually with a behavior modification element, that attempted to lessen the frequency and severity of the disruptive behaviors exhibited by this group.
Two years ago, however, after reading that one rural nursing home typically admitted residents in their mid-80s but had admitted three individuals in a row in their early 60s, I began to experience a change in thinking about this monolithic medical model.
All three of the new admissions had a history of heavy drinking, nicotine addiction, and problems in the family and at work. Seeing this discrepancy in age, and because I had a teaching commitment at a branch of the University of Minnesota that encouraged research, I became involved in a study of three nursing homes comparing average age of admission between individuals with a history of alcohol and drug abuse and those with no history. This study, involving nearly 80 participants, generated an amazing statistic. The average age of individuals with an alcohol or drug abuse history who entered a nursing home for the first time was 69.3, compared with an average age of 81.5 for the nonabusing group entering a nursing home for the first time.
As often happens in research, the results of the first study inspired another. In the second study, 155 consumers from two rural Minnesota nursing homes (with one home having been part of the first study) were involved. This study looked at the relationship between behavior problems in consumers as rated by the nursing staff (who had no knowledge of the study's hypothesis) and a prior history of alcohol and drug abuse. Twenty-two individuals with behavior problems were identified in the two homes (14.2% of the total group studied). Of the 22, 13 (59.1%) had a history of prior alcohol and drug abuse. The probability that individuals with an abuse history would be rated as having behavior problems was four times what would be expected if only their frequency in the population was considered.
It was apparent, then, that at least at these nursing homes in rural Minnesota, those with a history of alcohol or drug abuse tended to be admitted to a nursing home at an earlier age and were more likely than the general population to be identified as having a behavior problem with a diagnosis of dementia. It became obvious at this time that two or more explanatory models were needed for those identified with vascular dementia. It also became important to think of these patients as having diverse psychosocial and therapy needs.
Differing personality traits
One possible cause of the difference in these two groups rests in preexisting personality. There is fairly good evidence that alcohol abuse is associated with specific personality traits that include explosiveness and other impulse control problems, immaturity, self-centeredness, and difficulty in connecting behavior choices with later consequences. All of these appear to be possible causative factors in the development of behavior problems associated with vascular dementia, even if later on in the person's life these traits may be present in diminished strength. From clinical observation of active alcoholics, it would also seem that such individuals would tend to get into more situations that could result in brain injury (fights, auto accidents, falls, etc.). Of course, the cumulative effects of both alcohol and nicotine abuse also are associated with brain deterioration.
The two studies seem to suggest, then, that there are at least two very different types of elderly individuals who develop dementia and are placed in behavior control units or programs. Those who enter the nursing home much later in life seem more likely to have a genetically triggered neurologic disorder that with aging inexorably compromises the capacity to think and behave rationally. This group conforms closely with the present model in both causation and treatment. The second group, much younger than the first when entering a nursing home for the first time, has a history of alcohol and drug abuse. What the average social history would not inform the worker is that members of this second group also would be much more likely to possess immature, impulsive, antisocial personalities as well as a past that would include family discord and vocational underachievement. Whether or not they have age-related, genetically triggered dementia, they would be much more likely to have experienced organic damage due to fighting, falls, and accidents as well as the cumulative effects of the substances themselves.
In preexisting personality and life experience, this second group would be coming from a much different place, both in terms of what has happened to them and in what motivates and directs their present behavior. Undoubtedly they would have vastly different therapeutic needs.