Dementia: Quality of Care 2016

1. LOWLINE
Lowry M., Linguard G. and Neal M. (2016)
A Strategy to Facilitate the
Management of Anger in Individuals
living with dementia
Martin Neal

2. What’s the Need
• Anger is often a situation that carer’s and
relatives perceive to be problematic and a
challenge to themselves
• Carers and relatives report that the
management of anger is challenging
• Reframing how we consider anger can expand
the repertoire of interventions available to the
carer and relative

3. The need to rethink anger
• The “Management” of anger is a problem that
has been reported to occur by newly qualified
nurses (Thomas, 2010)
• Anger is frequently reported to be problematic
for those living with and caring for people with
dementia.
• Anger can be perceived as a “problem” to be
managed and subdued rather than an
opportunity to engage with people and gain
greater understanding

4. So What is LOWLINE
• An approach based upon established
principles in communication and empathetic
listening to help resolve difficult situations.
• Takes the position that :
• Anger may not be bad
• Anger can be an indication of an unmet need
• Anger is a natural part of the grieving process
• Anger can be a manifestation of fear

5. What it is not
• A means to avoid having to manage angry
individuals
• A way of keeping people calm
• An advanced high level intervention requiring
lots of training
• Not just for professional staff and carers –
might be helpful for families and relatives.

6. The components
• Listen – Active listening and reading the non verbal
messages
• Offer -reflective comments, which should be brief
and use the words spoken by the angry patient
• Wait – Avoid jumping in, filling the gaps
• Look - The use of eye contact
• Incline your head indicating interest
• Nod – occasionally
• Express – a desire to understand and demonstrate empathy

7. So where does it fit in the world of
people living with dementia ?
• There is a substantial body of literature
written about the importance effective
communication with people living with
dementia - Kitwood, Feil and De Klerk Rubin,
Hubbard et al, Brooker, and Blackall et al
• Some approaches explicitly identify anger as a
feature of living with dementia that requires
specific intervention Feil - validation.

8. Feil
• Feil’s concept of validation, based upon a set
of core values and interventions, reinforces
the position that behaviour has meaning. It is
the responsibility of the person interacting
with the individual to try to identify these
meanings. Anger is a natural response to
many of the circumstances that arise from
having dementia, the deprivation of liberty,
loss of self and infantilisation to name but a
few.

9. Kitwood
• Person Centred Care and the promotion of
“personhood”. This approach has at it’s core
the premise that the uniqueness of the
individual should be acknowledged
• The failure to acknowledge the individual not
only negates the person but can also lead to a
harmful state where malignant social
psychology can occur.

10. Brooker
• The VIPS model
• V A Value base that asserts the absolute value of all human
lives regardless of age or cognitive ability
• I An Individualised approach, recognising uniqueness
• P Understanding the world from the Perspective of the
person living with dementia
• S Positive Social psychology in which the person living with
dementia can experience relative well-being.
The concept of acknowledging anger directly
aligns to the Perspective domain of the model

11. Blackall et Al
• VERA
• V = validation.
• E = emotion.
• R = reassure.
• A = activity.
LOWLINE aligns itself specifically to the concept
of paying attention to the individual’s emotional
content

12. To Conclude
• LOWLINE provides a simple framework for those
interacting with individuals living with dementia
• It encourages carers to reframe the way they
consider anger; viewing it as an opportunity
rather than a challenge.
• It aligns itself well to several established
approaches that are acknowledged to promote
person centred care.
• LOWLINE provides a framework by which to train
individuals to reconsider how they manage and
perceive anger.

13. References
Blackhall A., et al (2011) VERA framework communicating with people who have dementia
Nursing Standard November 9-5
Brooker D. (2006) Person - Centred Dementia Care making services better. Jessica Kingsley
publishers.
Feil N. and de Klerk – Rubin (2012) The Validation Breakthrough Simple Techniques for
Communicating with People with Alzheimer's and Other Dementias/ Health Professions Press,
Baltimore
Hubbard G., Tester S. and G. and Downs M. (2003) Meaningful social interactions between
older people in institutional care settings Ageing & Society 23, 2003, 99–114.
Kitwood T. (1997) Dementia Reconsidered. The Person Comes First. Open University Press,
Milton Keynes
Lakey L. (2009) Counting the Cost: Caring for People with Dementia on Hospital Wards.
Lowry M., Linguard G. and Neal M. (2016) De-escalating Anger: a new model for practice.
Nursing Times. Vol. 112 issue 4, 4-7:
Thomas CM. (2010) Teaching nursing students and newly qualified registered nurses strategies
to deal with violent behaviour in the professional practice environment. Journal of Continuing
Education in Nursing 41:7 299- 308