Smoking is a well-established health hazard that may exacerbate various conditions and reduce life expectancy. However, enforcing cessation measures on individuals with dementia (in the early stages) raises concerns about autonomy, quality of life, and ethical treatment. Navigating these conflicting interests requires a nuanced understanding of the ethical principles at play and a careful consideration of the practical implications including the body’s physiological responses to withdrawal.
The Association Between Smoking and Cognitive Decline
Smoking has long been associated with an increased risk of cognitive decline and dementia. Nicotine, the addictive component of cigarettes, can lead to vascular damage, inflammation, and oxidative stress in the brain, all of which contribute to cognitive impairment. Furthermore, smoking is a significant risk factor for vascular dementia, a form of dementia caused by reduced blood flow to the brain due to damaged blood vessels.
The Fact Sheet, “Dementia and Smoking” published by the US Department of Affairs, states that smoking can increase a person’s risk for Alzheimer’s disease and other types of dementia. They estimate that smoking accounts for “one out of every ten cases of Alzheimer’s disease in the world.” Tobacco usage directly influences the deterioration of cognitive functions and hampers the speed at which information is processed. Conversely, reducing tobacco intake or abstaining from it entirely can decelerate or even reverse this decline, bringing the risk level closer to that of non-smokers.
Understanding Smoking and Nicotine Addictions, Cessation and Withdrawal in Dementia Patients
Dementia patients with smoking or nicotine addictions may exhibit a range of behavioural symptoms, including agitation, irritability, restlessness, and cravings. These symptoms can escalate into aggression or agitation if the addiction is not addressed promptly and appropriately.
Additionally, smoking cessation can trigger acute withdrawal symptoms, which may exacerbate existing cognitive deficits and increase the risk of delirium—a state of acute confusion and agitation common in dementia patients. The abrupt removal of nicotine from the brain can disrupt neurotransmitter balance, leading to cognitive fluctuations and delirious episodes.
Care professionals who fail to recognize these symptoms risk misinterpreting them as typical manifestations of dementia, leading to inadequate management and exacerbation of the patient’s distress. Additionally, untreated withdrawal symptoms can increase the risk of falls, self-harm, and social isolation among patients.
It’s important to remember that dementia patients may struggle to adapt to lifestyle modifications, such as quitting smoking, due to cognitive impairments (such as poor judgment and poor memory) and entrenched habits, making cessation efforts challenging.
Ethical Considerations Surrounding Addictions and Smoking Cessation
At the heart of the dilemma lies the principle of autonomy—the right of individuals to make their own decisions about their health and lifestyle. For people living with symptoms of dementia, whose cognitive abilities may be compromised, autonomy can be challenging to ascertain. While some patients may still possess decision-making capacity, others may lack the ability to fully comprehend the consequences of their actions.
In such cases, the question arises: is it ethical to enforce smoking cessation against their will?
On the one hand, those who are “pro-smoking cessation” argue that the health risks associated with smoking outweigh the principle of autonomy in cases where patients are unable to make informed choices. However, those who oppose this view raise valid concerns about the potential infringement on individual rights and dignity.
Smoking may provide comfort and familiarity to people with dementia, serving as a source of solace amidst the confusion and uncertainty of their condition. Forcing cessation could disrupt established routines and coping mechanisms, leading to increased agitation and distress. Moreover, the loss of autonomy may undermine the patient’s sense of dignity and personhood, further compromising their well-being.
Without adequate support and counseling, attempts to enforce cessation may be futile or even counterproductive, causing unnecessary stress and conflict. Careful consideration must be given to the feasibility and impact of such interventions on the individual’s overall quality of life.
Person-Centred Care
Stereotypes about smokers, in general, as “irresponsible” or “self-destructive” may influence decisions regarding their care, leading to differential treatment based on smoking status. Moreover, in long-term care facilities, it is important for healthcare professionals to be aware of their own preferences and attitudes about smoking. Facilities must guard against stigmatization and ensure that smoking cessation policies are applied equitably and with sensitivity to individual needs and preferences.
In navigating these ethical dilemmas, a balanced approach is essential—one that prioritizes both the well-being and autonomy of dementia patients. This may involve offering a variety of smoking cessation support, and offering alternatives like e-cigarettes and other resources while respecting individual choices and preferences. Education and counseling should be tailored to the unique needs of dementia patients, taking into account their cognitive abilities and communication challenges.
This is where it is important to remember and put into practice the principles of person-centred care. It necessitates a thoughtful consideration of the person’s autonomy and desires alongside their cognitive capabilities. Caregivers’ perspectives, while valuable, must align with the person’s best interests and respect their autonomy.
Do Power of Attorneys (POA) and Healthcare Representatives Have the Right to Mandate Smoking Cessation?
While POAs are entrusted with making decisions on behalf of the incapacitated, the issue of smoking cessation involves complex dynamics.
First and foremost, it’s crucial to recognize the autonomy and dignity of the individual receiving care. Even if the individual has been granted authority over health decisions, their preferences and rights should be respected to the fullest extent possible. Smoking, despite its health risks, may hold significant personal meaning for the individual, providing comfort or a sense of familiarity, especially in the context of dementia or other cognitive impairments.
On the legal front, authority granted to POAs varies depending on the jurisdiction and the specific terms outlined in the legal documents. While POAs generally have the authority to make decisions in the best interests of the individual, the interpretation of “best interests” can be subjective and may require consideration of factors beyond just physical health.
Lastly, it’s important to consistently factor in the individual’s cognitive status. If they’re still cognitively sound and capable of making decisions autonomously, they should be empowered and supported in doing so. Preserving their independence and dignity is integral to their overall well-being.
Healthcare representatives must introspectively ask, “Am I truly prioritizing my loved one’s desires and autonomy in this decision, or am I projecting my own preferences?” It’s crucial to evaluate whether the decision aligns with their best interests and avoids causing inadvertent harm.
Making the Best Decision for the Patient
When considering smoking cessation for individuals living with symptoms of dementia, healthcare providers must weigh the potential benefits against the risks and tailor interventions to the individual’s unique circumstances. Factors to consider include the patient’s smoking history, cognitive status, presence of comorbidities, and caregiver support.
Shared decision-making involving the patient/resident, caregivers, and healthcare professionals is crucial in navigating the complexities of smoking cessation in dementia care.
At Dementia Solutions, we’ve made it our mission to demystify dementia behaviour and continue to explore person-centred, creative, non-pharmacological solutions to manage dementia-related behaviours. We believe that awareness creation and skill-building through education is the most effective and powerful tool we have to promote and maintain the well-being of both the person with dementia and their caregiver. You may find this Meaning Behind the Behaviour Story helpful.
If you need support in your caregiving experience or would like to learn more about our educational opportunities, please reach out to us at [email protected] and we would be more than happy to support you.
DISCLAIMER:
The contents of this blog are provided for information purposes only. They are not intended to replace clinical diagnosis or medical advice from a health professional.
