What did we do in this study?
In this SSHRC-funded study, we analyzed qualitative data from multiple sources and samples to explore how older adults, their family members and paid workers interpret the meaning of violence and aggression among older adults. We examined differences and similarities in these interpretations within differing settings (domestic home, congregate assisted living settings, residential care) and relationships (paid worker-client/tenant/resident; tenant-tenant; and family carer-older adult). We interviewed 19 diverse types of service workers from assisted living buildings throughout Winnipeg, Canada, and 13 older adults who lived in two specific buildings. We also collected interview and/or diary-based data from 11 family carers to persons living with dementia (residing in the Brandon or Winnipeg areas). With additional funding from MITACs, we explored how aggression among older adults was represented in Canadian mainstream news media (141 articles over the last decade). We also drew on secondary analyses of some of our other existing qualitative datasets.
What are our key findings?
First, we found that in general, family carers of persons living with dementia at home, whose partners had expressed aggression, coped with difficult emotions and fear by understanding their situations as ones in which they needed to change themselves. They spoke of needing to stay positive, minimize the situation, put the care recipient first, be calm and gentle, and avoid conflict or arguments. Guided in part by broader social norms of care, and by caregiver and dementia education materials, they tried to respond differently, and in so doing, to contain their emotions. This process was often a considerable struggle that, while helping manage the short-term threat of violence, did not eliminate it, and may have long-term implications.
Second, older assisted living tenants faced indirect forms of aggression and social exclusion in their interactions with other tenants. Interpretations of other tenants’ behaviours, particularly behaviours that threatened participants’ power or identities, were influenced by participants’ life histories and experiences of precarity in assisted living. Tenants’ interpretations of the meaning and causes of aggression were coloured by stigmatizing beliefs about age and dementia.
Third, tenants’ interpretations were similar to those expressed in a diverse group of service workers in assisted living – in that both groups tended to attribute aggression (and other problematic behaviours) to communal living, aging, and/or dementia. However, workers were also more likely to compare older adults to children in their explanations. Especially for workers, these types of interpretations helped them normalize or neutralize any potential personal experiences of victimization (and associated emotions) in situations where they lacked control. Again however, this raises concerns about how such interpretations can draw on and reproduce stigma.
Lastly, representations of aggression among older adults in mainstream news media focused primarily on nursing homes, and on incidents leading to the death of an older resident. Accounts tended to be fear-inducing, stigmatizing, and to rely on biomedical understandings of aggression as solely a symptom of dementia, with little consideration of the complexity of the issue or the relationships and contexts of violent interactions. Aggression tended to be presented as an almost natural part of the disease process, and as inevitable. Persons living with dementia who acted aggressively were characterized as lacking power, and as needing to be managed or segregated to protect others.
What needs to happen now?
We need to pay closer attention to how we understand, talk and write about aggression among older adults. Our dominant interpretations and explanations can contribute to a sense of fear and inevitability, reinforce stigma of age and dementia, dehumanize and erode the agency of older adults, and exacerbate powerlessness in paid and unpaid carers. Although we acknowledge that dominant interpretations often serve important short-term purposes for those working with and interacting with older adults, continued reliance on these perspectives hinders our ability to mobilize knowledge about the complexity of different forms of aggression, in different settings and relations of care, and to move beyond the limited solutions that currently exist.
What could change? For starters, education materials for family carers, and clinical conversations with carers could be more nuanced, such that carers know how to identify limits and boundaries to their own strategies to manage violence, and can access support for role exit, if needed. Practitioners can be encouraged to discuss and reflect on when family carers’ long-term well-being might also be at risk. Similar supports and education are needed for paid workers, and training in how to manage aggression in older clients should avoid reproducing stigmatizing ideas about persons living with dementia as helpless or incapable, and should attend to the power dynamics in settings of care. Tenants in assisted living, too, need to be engaged in a communal fashion not only to help generate solutions to aggression, but to critically reflect on the complex causes of aggression among older adults in these settings. Assisted living management can play an important role in challenging dominant understandings of aggression, but only if they themselves, too, are encouraged to reflect critically on their own assumptions in this regard. Lastly, journalists, but also those who seek to raise the profile of this issue within mainstream news media, and experts interviewed for these stories, are collectively responsible to advance nuanced coverage of aggression among older adults, to promote public awareness of differences between relationships, settings, and types of aggressive actions, and as such, the need for multi-faceted preventive policy responses.
In sum, this project addresses a relative gap in knowledge about violence and older adults in contrast to other age groups; in particular, a gap in inductive, constructivist research focused on the complexities of social and emotional dynamics and subjective interpretations. We critically explored, and deepened, social understandings of violence, facilitated open discussion within about violence and victimization related to older adults, and can inform organizational responses to prevent violent escalation. Findings are applicable to a variety of stakeholders and the public, who desire a greater insight into the dynamics and interactional complexities of violence, and who strive to understand and prevent the escalation of interpersonal violence. This includes organizations and institutions servicing older adults (non-profit, for-profit, governmental) and their families (caregiver associations), as well as networks of researchers, practitioners and decision makers (e.g., age-friendly communities and elder abuse networks). These findings can benefit older adults, their families, and the front-line workers whose support is crucial to their well-being.