Attachment Processes in Nursing Facilities that

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Attachment in Dementia Care
1







Attachment Processes in Nursing Facilities that

Provide Dementia Care to Older Adults

Julie B. Noble

Catholic University of America

SSS 653

Attachment Theory and Neurobiology:

Implications for Social Work Practice and Policy

April 30, 2010













Attachment in Dementia Care
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Attachment Behavior in the Dementia Unit

Modern attachment theory can be applied to the nursing assistant
-
resident relationship in
long term nursing care for older adults with dementia. Attachment concepts can inform nursing
and social worker
interventions, nursing assistant training, Medicare
-
Medicaid reimbursement
rules, psychosocial assessments and nationwide Minimum Data Set (MDS) documentation. The
result would be more effective residential care giving, lower costs, improved quality of lif
e for
residents and workers, federal expenditure for evidence
-
based approaches that deliver good
return on investment; faster and smoother resident adaptation upon admission; and an instantly
useful nationwide database that would include attachment
-
based
variables for more research
insights.


Evidence for an attachment
-
based geriatric social work practice and an attachment
-
based model of clinical intervention for LTC dementia residents is good. Research on caregivers
(Cicirelli, 1983); caregiver burden;
grief and bereavement; chronic illness; chronic pain
(Meredith, Ownsworth and Strong, 2007); fear of death; elder well being; emotion regulation in
late life; and religion clearly demonstrate that aging and disease are conditions of threat. Miesen
(1993
) created an experimental Standard Visiting Procedure (SVP) and theorized that the
experience of dementia erodes feelings of safety and security and activates attachment behaviors.

Attachment is a universal, continuous and motivational system activated whe
n an older adult is
admitted to a long term care residence. Separated from family caregivers, from their long
-
time
home and neighborhood and from all the Activities of Daily Living (ADLs) that formed a secure
and structured life abruptly disappear. Often

after the loss of a spouse, loss of a lifetime role, the
diagnosis of a serious illness, the loss of siblings or friends, the new resident is also rehabilitating
from a fall or suffering early cognitive and memory loss. Attachment behavior triggered in o
lder


Attachment in Dementia Care
3


adults with insecure attachment styles may be protective or adaptive to the task of adjusting to a
long term care facility. Emotions such as fear, shame, disbelief, denial and anger may
accompany the new resident after arrival.


Personality developme
nt up to this late
-
life threshold is non
-
linear, complex and
cumulative (Bennett & Nelson, in press). By age 80 and it has been formed, like a pearl, by
many influences other than early attachment. Placement in a nursing home can activate a return
to the

original trajectory because its “organizing core” is never lost (
Sroufe, Egeland, Carlson
and Collins,
2005).

Attachment theory has been applied to dementia care, with a focus on aggression and
other behavioral issues that demand costly special nursing
care. The 20 % of dementia residents
that display aggression are most impaired (Cheston & Bender, 1999) and often are consolidated
in “special care” units. There is a high negative correlation between aggression and the ability to
use language to express

oneself. Externalizing the cause of difficulties relieves the psychological
strain and serves the function of a form of communication (Cheston & Bender, 1999). To
understand the dementia patient’s emotional world is to understand this social behavior.
Emotional displays do not reflect neurological damage or cognitive deficits as much as
emotional behavior on a dimensional continuum. On one end is reflective functioning and the
ability to think through a response. On the other end is immediate, physica
l “parent fixation”
(Mieson, 1993) or cry for mother. In between, are behaviors shown by movement, as a function
of the social environment and its controls. Considerable social control discourages strong
emotions so the “hold and contain” goal is every n
ursing facility’s mission. Workers must be
open to the emotional content of reminiscence exercises and attachment behavior in the forms of
incontinence, wandering, hoarding and other nursing home norms. New attachment relationships


Attachment in Dementia Care
4


form to replace those
that are lost or released. This is not just dependency, a personality trait, but
attachment bonds that permit the resident to experience security and comfort. Any kind of long
-
lasting tie, even without elaborate content, qualifies to protect the resident

from harm and
maintain homeostasis with the nursing home environment (Bowlby, 1973).

Attachment Theory Informs a Person
-
Centered Model of Dementia

Instead of biomedical perspectives, which deny people with dementia an inner world,
there is now an increas
ing awareness that each person with dementia has a range of individual
characteristics and a lifetime of experiences, which can influence their response to the disease
(Cheston & Bender, 1999; Stokes, 2000). The usual organic model fails to see these older

adults
as emotional beings with an identity or sense of self. Care practices can interact with
neurological processes to weaken the patient’s sense of self or personhood. Identity is threatened
with the loss of skills and social roles and the unknown thr
eats of the future. The previously
stable self
-
view is now destabilized, in a restricted community where a sense of self is no longer
active or valued. Compliance becomes the only path to appease powerful forces of the
institution. The new emphasis on per
son
-
centered models described by the late Thomas Kitwood
(1997), invites social workers to address the subjective experience of the person with dementia.

The new view that “problem behaviors” should be viewed as attempts at communicating
(Stokes & Goudie,
1990; Kitwood, 1997) suggests that more empathic attitudes, if made a
priority, could validate a new, secure sense of who they are. By helping residents maintain
attachment bonds
---

whether with transitional objects, symbols, long
-
term memories, delusion
s,
ideas, places or relationships
---

workers could validate the competencies and capacities of the
resident in calm and reassuring ways.



Attachment in Dementia Care
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French healthcare protocols include psychotherapy with dementia residents (LeGoues,
1988; Maisondieu, 1995). Comment
s are reflected back and earlier answers are recalled to
prompt the resident to make links. Therapists work with residents during walks, cups of tea,
cigarette breaks or wherever possible. Sessions are exploratory or directive (Beck, 1976).
Meditation,
visual imagery and relaxation are used to help contain and hold resident emotions.
This comfort and reassurance helps the resident to tolerate their feelings or support their grieving
process. Validation therapy is most widely used for of psychotherapy f
or dementia (Feil, 1990,
1992, 1993). Often a dementia resident can return to the past to resolve unfinished conflicts by
expressing feelings that have been hidden. The focus is on emotion, not factual content.

For cost and quality purposes, attachment t
heory may contribute to understanding
outcomes of nursing home care. Residents who die or are moved to other nursing homes are
more likely to have been hostile, abusive, and disruptive or to wander away. Neither the amount
of visitors, nor their ability
to pay is a factor (Lewis, Kane, Cretin and Clark, 1985). The
variables that seem to matter are a high level of independence in ADLs and bladder continence;
these strongly associate with remaining alive in the nursing home. Elders at home had fewer
behav
ior problems. Dementia, incontinence and hip fractures were relevant variables too, but
only ADL scores predicted survival.

The number of older adults with mental disorders in nursing homes has grown
dramatically as mental health institutions have closed
. Nursing homes become inpatient
psychiatric units using psychotropic and neuroleptic medications. Even residents with no
premorbid history of mental illness develop a range of psychiatric, psychological, and behavioral
disorders in response to LTC placem
ent. Chemical restraints are restricted with the Omnibus
Budget Reconciliation Act of 1987, so psychological and behavioral interventions are now


Attachment in Dementia Care
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“essential in the LTC setting” (Goldberg & Devine, 2004).


Some 80 % of nursing home
residents with dementia
develop behavioral symptoms, so “nonpharmacologic interventions are
urgent” (Woods, Craven and Whitney, 2005).

Dismissive Attachment Styles and Use of Alternative, Symbolic Attachment Bonds

Securely
-
attached residents will show a realistic sense of self
-
ef
ficacy and trust in staff.
They will acknowledge, express and manage negative affect constructively (Magai & McFadden,
1995; Magai & Passman, 1998). They will leave their room and explore activities at the nursing
home such as concerts, Bingo, parties, le
ctures, exercise, art or cooking classes. Residents
with an anxiously
-
attachment style may see nurses or staff as unpredictable and themselves as
helpless (Magai & Passman, 1998). Avoidant residents will mistrust nurses, show reluctance to
display att
achment needs or feelings and display ‘compulsive self
-
reliance.’ This is evident in
residents who don’t want to burden nurses, try to handle ADLs on their own with frustration (and
falls) or stay in their rooms to be out of the way. This avoidant style i
s more prominent among
older adults than younger adults, especially among widows (
Magai, Cohen, Milburn, Thorpe,
McPherson, & Peralta, 2001).
(Magai, 2008; Zhang & Labouvie
-
Vief, 2004 and Cicirelli,
2010). D
ismissing scores are higher among older ind
ividuals and security scores lower
(Magai, 2001).

In one study of older adults
78% of the sample was dismissive

avoidant and only
22% secure (Magai et al. 2001) A longitudinal study that looked at individuals aged 15 to 87
found that both secure and dismis
sive attachme
nt increased over time (
Labouvie
-
Vief 2004).
Debate continues about why dismissive scores rise with age, whether it is a cohort effect; a
reaction to loss; normal maturation; a measurement problem; Watsonian child
-
rearing in the
early 20
th

cen
tury; or lack of support. Older adults with avoidant
-
dismissive styles display more
overt attachment behavior than the secure style (Browne & Shlosberg, 2005). This dismissive,


Attachment in Dementia Care
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self
-
reliant type is more common in Western cultures, especially among Afri
can
-
Americans
(
Bakermans
-
Kranenburg, van IJzendoorn, & Kroonenberg, 2004;
Consedine & Magaim 2003;
Montague, Magai, Consedine, and Gillespie, 2003).
Avoidant
-
dismissive individuals with
dementia experience more “activity disturbance” and score higher on
paranoia (
Magai & Cohen,
1998).

Dementia patients with avoidant styles show higher premorbid levels of contempt, anger
and inhibition (Bradley & Cafferty, 2001).


Fewer elders score with an anxious (ambivalent, preoccupied, “clingy”) style (Diehl et
al.,

1998; Magai & Cohen, 1998
). It’s more prominent in interdependent cultures such as those
from the East and M
iddle East (
Rothbaum, West, Pott, Miyake & Morelli, 2000)
; Takahashi
2005; van IJzendoorn & Kroonenberg 1988). Latinos tend to have a more inter
dependent
orientation (
Halgumseth, Ispa and Rudy

2006), which might explain the higher levels of
preoccupied attachment in these groups. Dementia patients who have this style show more
depression and anxiety (
Magai & Cohen, 1998).

Premorbid attachment
styles significantly
predict current dementia symptoms. (Bradley & Cafferty, 2001).



Just as the infant grows out of a pre
-
symbolic world, the elder may grow into a symbolic
world. As the infant received non
-
verbal cues from its mother in those earliest days, the old
-
old
adult may similarly revert to non
-
verbal cues. One type of symbol
ic attachment in elders is a
bond to a deceased attachment figure (Mikulincer & Shaver, 2008) where memories supply
comfort and security. Another type is an attachment to an all
-
knowing, all
-
caring God
(Granqvist, Mikulincer, & Shaver, 2010). This often i
nvolves viewing God as an attachment
figure (Cicirelli, 2004). Elopement, wandering, hoarding, fighting and touching other residents
are frequent “problem behaviors” that earn hundreds of studies and require many ineffective and


Attachment in Dementia Care
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costly interventions. One
might hypothesize that some of these behaviors are driven by
attachment behavior, e.g. leaving “to go home” or coveting objects that provide comfort. This
symbolic, even metaphoric, expression is frequently provoked with interventions such as those
using t
he expressive arts, mandala drawing, reminiscence groups, music and singing,
aromatherapy, poetry and life reviews. Symbolic or artificial attachment needs may also be met
using deathbed visions or hallucinations of loving, friendly visitors. In advance
d dementia, it’s
common to observe for the resident to manifest “parent fixation” where she speaks of her mother
and father as though they were still alive.

Secure Base Performance Depends on Nursing Assistants


As more individuals begin to be placed in nursing homes, the frontline workers, Certified
Nursing Assistants in the U.S., carry the greatest caregiver burden with the least amount of
training or wages. As the lowest
-
paid workers in a skilled nursing facil
ity but with bathing,
toileting, dressing and feeding duties, their intimate relationships with dementia residents take
center stage. As they carry out a resident’s ADLs, operating with attuned sensitivity or not, it’s
likely their importance as an attac
hment bond grows. When a resident must depart for the
hospital for an infection or surgery, the reunion upon his return will begin when one of these
long
-
lasting, nurturing caregivers greets them at the door.

It may instead be the Director of
Nursing or
a social worker or activities worker on staff, but the safe haven will be in the
proximity of nursing desk and the resident’s bedroom.

Income, Ethnic Background and Training

While most nursing staff who remain employed in a nursing home have considerabl
e
understanding of dementia care and empathic skill, there is little doubt their attachment style is
actively charged as they care for dementia residents. Resident behaviors trigger staff reactions


Attachment in Dementia Care
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of transference or counter transference. Some variables
will enrich and others will aggravate the
relationship. Language, dialect (timbre, rhythm, pace) and verbal and non
-
verbal
communication are important features for the attachment bond to thrive. The dominant
attachment style of the whole agency culture m
ay be predominantly from one ethnic group or
enshrined by long
-
time executive leadership. Time and money constraints encourage dismissive,
late or inconsistent responses to residents who push their beloved nurse call
-
button.

Lower income has been shown
to increase insecure attachment styles, such as fearful
avoidant (dismissing) behaviors and greater preoccupation (
Consedine & Magai, 2003).
Greater
income predicts greater security among English
-
speaking Caribbeans, Haitians, Dominicans, and
Puerto Rican
s. These are all typical ethnic groups in U.S. labor markets today. Can they create
the continuing and uninterrupted holding environment, Fonagy’s “background of safety,” for
residents to feel safe? Is their Internal Working Model (IWM) of caregiving cl
osely related to the
IWM of the attached resident? Can management expect them to arrive on the job with accepting,
nonjudgmental helping skills and the knowhow to gratify resident attachment needs?

Neurobiology of Dementia and Attachment
-
Based Intervent
ions

The neurobiology of dementia continues to unfold. The human brain is a social brain.
The mesocorticolimbic dopaminergic reward circuit is stimulated with interaction. “Relationship
leaps from one person to the other at the moment when emotion moves
between them” (Perlman,
1957). These affective interactions with others will consolidate deeply entrenched memories.
Semantic, episodic (autobiographical) memories may be reconstructed and altered after a lifetime
of neural pruning.

A study to learn wh
ether there is significant neuronal loss in dementia (
Mountjoy, Roth,
Evans and Evans, 2009).
determined that neuronal counts were significantly lower in dementia


Attachment in Dementia Care
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patients in the inferior frontal and superior temporal gyri (auditory, speech). Neuronal cou
nts
were significantly reduced in superior gyri (self
-
awareness, laughter) , middle and inferior
frontal gyri (go/no go and risk aversion processing), cingulate gyrus (limbic system; emotion
formation and processing, learning, memory and
executive function
) and superior and middle
temporal gyri (contemplating distance,

recognition of know
n faces
, and accessing word meaning
while reading). There was no significant difference in the parietal (spatial, navigation) or
occipital (visual) cortex. Corresponding glial counts show a significant increase in the demented
group only in the middle and

inferior temporal gyri (visual processing of complex object features
and face perception).

Critique of Early Attachment Research on Older Adults and Dementia


Important debates about why older adults become more dismissive or whether
psychotherapy is co
st
-
effective with dementia patients will not close until larger samples and
more studies validate results thus far. Many good hypotheses form based on studies on couples
or personality disorders or children, but measures and concepts from attachment rese
arch
focused on other developmental life stages or other attachment relationships may not be
equivalent. Similarly, indirect indicators of attachment are frequently used in studies with
samples that are too small to accommodate any assessment of the small
er categories, such as
disorganized or anxious.

There are no longtitudinal studies and no studies that focus on the reciprocal dynamics of
nurses and residents. There is confusion about attachment and dependency, which Bowlby
(1969, 1982) stated were di
fferent. However, Fraley & Shaver (1999) explain ‘secure
dependence’ as interdependence and ‘anxious dependence’ as uncertain availability. Can ‘felt
security’ exist in those conceptual terms? Many agree that as people age they expect losses and


Attachment in Dementia Care
11


‘diseng
agement’ or detachment are adaptive responses to loss. Others argue it is reorganization,
change, accommodation or a refocusing of the attachment model. Elder detachment may be loss
of hope or it may be the ‘coming to terms,’ which would be a positive re
organization of the
attachment representation. Bradley and Cafferty (2001) think that disengagement or detachment
might occur in certain domains or to certain objects, while at the same time the individual
strengthens a smaller number of close attachments
. Alternatively, older adults may be
contracting their attachment needs or transferring them to objects, ideas or illusions. There is
more to learn about the dismissing trend that accompanies age. Could it be a spiritual letting go
to prepare for death
? Grice’s 4 maxims may be inoperable with residents in moderate or late
dementia phases, but possibly a truly good listener can interpret the resident’s expressions and
answers along the scale. The Internal Working Model of residents may be expressed thr
ough
behavior rather than language but this is a challenge to interpret reliably. It’s also unknown
whether a dismissive or preoccupied resident can be re
-
oriented to be autonomous with the
interventions used today.

If attachment theory paints the
picture accurately, then the task of facing death could be
Main’s “fright
-
without
-
resolution” (1995). Indeed, some residents are going to go through a
disorganized death. Dementia patients could manifest their needs while appearing similar to
infant diso
rganization; interpersonal incompetence, emotional outbursts, aggression or appearing
dazed, frozen or bizarre are typical hospice behavior challenges. Validation therapy and
empathic listening sessions can help a dementia resident review her life and act
ivate long
-
term,
explicit memories. These are more easily reported


and often repeated


when the clinician
offers clues. In these ways, reflective functioning can be assessed for signs of coherence even in
the dementia resident.



Attachment in Dementia Care
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Recommendations


The sk
illed nursing facility is a superior locale for research. Marital status and family
relationships are by
-
and
-
large removed from the environment. Further, documentation is created
regarded shift
-
to
-
shift behavior, quarterly cognition and memory assessmen
ts and significant
changes captured in the Minimum Data Set (MDS). How rapidly the knowledge base would
swell if fields on the MDS forms correlated with attachment styles so that data for a million
residents could be sorted and studied.


Gerritsen, Achter
berg, Steverink, Pot, Frijters, and Ribbe (2008) attempted to construct
a reliable scale of challenging resident behaviors, using items already captured on the MDS.
They looked at 656 nursing home residents and had doctors and psychologists determine whi
ch
items from the MDS record are useful enough to belong to their Behavior Profile. There were
some internal inconsistencies but they emerged wth four internally consistent and valid subscales
measuring conflict behavior, withdrawn behavior, agitation and

attention seeking behavior. The
next step could be to inform this scale with attachment theory. If the behaviors could be sorted
into 3 or 4 attachment styles, one would not even have to modify the MDS. The behaviors they
selected are listed below:

1.

Conflict:
Repetitive persistent anger with self or others; verbally abusive behaviors;
physically abusive behaviors; resists care; and conflict with or repeated criticism of staff

2. Withdrawal:
Withdrawal from activities of interest

and reduced social
interaction

3. Agitation:
Periods of restlessness; repetitive physical movements; wandering; socially
inappropriate/disruptive behavior

4. Attention Seeking:
Negative statements; repetitive questions; repetitive
verbalizations; repetitive health complain
ts; and repetitive anxious complaints and/or concerns



Attachment in Dementia Care
13



Any future research into whether older adults with dementia can reorganize their
attachment representations will have to assess how to strengthen emotional bonds in this
restrictive environment. Resear
ch is needed to discover how attachment theory can enhance
interventions with dementia residents. Emotionally Focused Therapy (Johnson, 1996) may have
useful elements but may require a higher cognitive level. Dementia residents need cues from
caregivers a
nd clinicians, and nurses must learn to respond successfully to subtle, non
-
verbal
cues just as mothers do for infants (Bradley, ). Attachment behaviors such as touching, crying
and turning towards family members are seen in early dementia stages (Miesen
, 1992) and then
as the disease progresses attachment behavior declines but parent fixation increases dramatically.
This is an
internal

source of security, from within the person herself. This idea fits with Carl
Jung’s concept that a pair of opposites w
ere inborn in the self, the adversary (fear) and the
sustainer (safe base). Everyone needs a myth or belief framework (or IWM) or one collapses.
Attachment images (and belief frameworks) may fall away as we age as more of our unconscious
comes to the surf
ace. One redeems himself and falls again. Finally, one has to pick up his life
and carry it. This may require steady deactivation in order to achieve a state of wholeness or
completion, not perfection. “Symbols are the only way to express what cannot be

expressed,”
Jung wrote. Fonagy wrote that the influence of the unconscious effects the behavior of the
infant, yet there is resistance to accept that a similar dynamic occurs late in life. The nursing
facility as secure base is possible “almost regard
less of content” because quality of alliance is the
best predictor of intersubjectivity

and the self .

In
-
service training for CNAs would give them the competence and confidence that
residents need to feel from them. The reflective functioning burden is o
n the CNA. Fonagy


Attachment in Dementia Care
14


would tell them they need to be “supportive, respectful and empathic” to benefit residents. Teach
concepts such as proximity
-
seeking, availability, wiser and stronger and secure base. Exercises
could have students role play basics such a
s touch, gaze and sensitivity. Instruction should
explain the importance of not delaying response or if response is delayed, to come to the
resident, touch her and inform her of the delay. This could be called “Touch
-
and
-
Reply”
technique.

Finally, the Med
icare
-
Medicaid flat reimbursement rate must be challenged and the low
standards and goals for citizens with dementia needs to change. Nursing facilities are forced to
become task
-
driven, rushed and dismissive, the very response that aggravates insecure
at
tachment behavior, perpetuating the costly “special care” challenges. Non
-
verbal work with
residents needs greater respect and scholarly support. When an infant is oriented to the outside
world from the start but the dying is not allowed to be oriented
to his interior world because he’s
labeled “not all there” is a double standard. If we pronounced newborn babies such dismissive
labels, society would challenge it. Surely the aged deserve to meet death with less fear and
resistance, caused by this stig
ma.

The time for long term care leaders to embrace attachment theory is upon us. Behavioral,
bureaucratic
-
driven solutions, such as psychotropic drugs or electronic gates wired with alarms,
will never be as ethical or improve the quality of life of
nursing home residents. It will take
policy changes, a shift in how funds are invested and staff training but the path is clear and the
urgency is great.






Attachment in Dementia Care
15







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