Police officer competence in handling Alzheimer’s cases: The roles of AD knowledge,beliefs,and exposure

Abstract

This study seeks to understand the level of police officer competence for providing assistance during interactions with patients of Alzheimer’s disease (AD), and to reveal the roles their knowledge of AD, beliefs of AD, and previous exposure to patients with AD play in influencing these competence levels. Data were collected from police officers in two Phoenix metropolitan-area police departments through focus group discussions and survey. Four focus groups comprised of 27 police officers discussed their perceptions of AD and challenges of dealing with individuals with AD. Building on the findings from the focus groups, an online survey (n = 228) examined police officer AD knowledge, as well as their experience and competence in the handling of AD cases. Police participants had fair knowledge of AD with an average 71.8% accuracy rate. More AD knowledge (B = 0.29) and higher levels of education (B = 0.85) were associated with higher levels of competence of recognizing AD-related behaviors. Low levels of discomfort interacting with AD patients (B = −0.75) and having a family member of dementia (B = 1.32) were related to higher levels of competence of reacting appropriately to an AD patient. The findings suggest that information about the best practices for dealing with community residents with AD needs to be made available to police officers. To ensure a dementia-friendly environment, aging service providers need to reach out to local law enforcement departments and provide training that promotes AD knowledge, decreases AD-related stigma, and increases competence of handing dementia cases in a way that fits the policing culture.

Keywords

Alzheimer’s disease AD knowledge and beliefs AD exposure police officers Dementia-friendly environment

Alzheimer’s disease (AD), a neurological disorder associated with advanced age, has become a growing public concern as the older population in the US continues to grow. In 2015, among over 40 million Americans aged 65 years or older, 5.2 million had a diagnosis of AD. By 2050, the aging population is projected to double, reaching 89 million, of whom it is estimated that 13.8 million will have a diagnosis of AD (Alzheimer’s Association (AA), 2016; Jacobsen, Kent, Lee, & Mather, 2011).

Along with the increased prevalence, AD has become the fifth leading cause of death among those aged 65 and older (Alzheimer’s Association, 2016). Moreover, AD is ranked by a survey of 1200 Americans as the most fearful disease, ahead of heart disease and cancer, the top two leading causes of death (Home Instead Senior Care, 2012). AD is daunting partly because it is financially costly, potentially economically ruinous for seniors and their families. Kelley, McGarry, Gorges, and Skinner (2015) found that those who died of dementia spent at least $100,000 within their last five years, more than those whose death was due to heart disease or cancer. Another reason for this high level of fear is the limited knowledge about AD possessed by the general public, including service professional groups (Connell, Roberts, McLaughlin, & Akinleye, 2009). A recent MetLife Foundation survey (Harris Interactive, 2011) found that 62% of over 1000 Americans surveyed admitted they knew little or nothing about AD.

Understanding AD and its impact on individuals and families should be essential for service professionals if they are to address adequately this public concern. Likewise, police officers as first responders, often called on to assist AD residents in difficult situations, cannot be excluded in the effort to build a dementia-friendly community that provides an ideal combined physical and social environment for AD residents. This study aims to identify challenges and problems faced by police officers as they interact with and assist AD patients, and further discusses factors that influence officers’ perceptions of their home agencies’ and their own capacity to handle AD cases, and concludes with practical suggestions that would help police officers and other professionals better meet the needs of AD patients.

Given limited research on assistance with AD patients in policing, the present literature search examines first responders beyond the law enforcement community, including fire fighters, paramedics, and social workers. In the reviewed literature published from the 1970s to 2010s (e.g., Liederbach & Stelle, 2010; Shanley, Quirke, Shaw, & Sammut, 2004), we focused on those involving first responders and older people with memory problems, specifically AD and other kinds of dementia. Residents with AD in emergency situations are the most common scenarios that involve patrol officers. These situations include wandering, traffic violations, accidents, indecent exposure, shoplifting, and suicide (Bourns, 2000). Due to the neurological changes in the brain, individuals with AD may exhibit behavioral problems such as getting naked in public, wandering away from their home, ignoring traffic signs at an intersection, or becoming violent toward others (Bourns, 2000). Such behavioral problems have caused safety concerns for patients and other residents, thereby warranting the intervention of police officers.

Another situation that causes first responders to get involved is the abuse or other criminal victimization of the AD patients. When an individual with AD progresses to the advanced stage, 24 hour care is necessary, and caregivers (paid or unpaid) might not be able to endure the stress of caregiving, resulting in neglect or abuse of the AD patient (Beach et al., 2005; Cooper et al., 2009). Situations that involve abuse, if reported, require timely intervention by law enforcement officers, medical attention by paramedics, and a referral to local adult protective services that are often to the purview of social workers (Bourns, 2000). Little research has explored the possible approaches or strategies that first responders may use to improve their capacity to address the needs of AD patients. Dorfman and Walker (2007), for instance, found that the methods used by law enforcement officers varied widely across the many legal jurisdictions found in the United States. Bourns (2000) described a training curriculum approved for police officers in Illinois and Colorado to respond to older adults. The curriculum contained some themes that apply to AD patients, such as techniques for confronting individuals with AD, investigation of elder abuse in community and nursing homes, and policy advocacy for more stringent penalties against elder abuse perpetrators. Yet, the effectiveness or replicabilities of this curriculum remain inconclusive. In the community, the AA is a consistent champion promoting awareness, knowledge, and management of AD. More specifically, the AA has tried to assist the first respondent community. In 1997, the northern New Jersey chapter of AA partnered with 11 counties to institute a short-term AD training program. Safe Return, for example, is a program to help identify and recover AD residents (Lachenmayr, Goldman, & Brand, 2000). As a result, referrals to all AD-related service agencies increased in the region and police officers reported a higher competency in working with AD cases.

In 2009, the AA developed an online training module entitled “Approaching Alzheimer’s: Make your Response the Right Response” (www.alz.org), which targets first responders and covers appropriate responses to calls involving wandering, unsafe driving, shoplifting, abuse, and neglect. It is available online and offered through local chapters of AA to assist first responders. Yet, the level of awareness of this program within the policing community remains unknown.

To move these efforts forward, the present study examines self-perceived competence of police officers in dealing with residents with AD, identify factors that influence their perceived competence, and provide strategies to help address their challenges and training needs in relation to resources available to them. As Arizona is one of the destination states for older retirees, the population characteristics make Arizona an ideal locus for such a study. Among old Arizonans, about 130,000 currently live with AD or related dementia in 2016, and this number will increase by 66.7% in one decade, representing the third highest growth rate across the country (Alzheimer’s Association, 2016). The crime report of the police department of Tempe, one city of the Phoenix metropolitan area, indicates an annual average of 400 calls related to missing persons or welfare calls related to dementia since 2011.

Method

A two-phase sequential mixed-method design was used. Eight police departments in the Phoenix metropolitan areas were approached. Most departments were not able to participate because of concerns about strains on their resources, and one department was not eligible because they were participating in a similar project at that time. Two police departments in central Phoenix agreed to support this project. From February to March of 2013, four focus group interviews were conducted to gain insights of police officers’ attitudes and knowledge of AD, and as well to seek their input regarding appropriate survey format and contents. A follow-up online survey was then created to examine police officer knowledge of AD, AD beliefs and exposure, and self-perceived competence of handling AD cases. In April 2013, the survey was created using Qualtrics, and the survey link was sent to a designated police coordinator who forwarded to all eligible police officers within their respective department. The total eligible participants in these two departments were slightly over 700. Participants were given four weeks to complete the survey; one reminder message was sent two weeks after the link was initially sent.

Focus group interviews

Four focus groups were conducted with sworn police officers who at one point while on patrol interacted with individuals with AD. Each focus group had approximately five to six participants. The specific demographics of the 27 participants are detailed in Table 1. Each focus group was held at the main station for the respective law enforcement agencies. The groups began in a formal manner with the facilitation asking structured questions about AD, and then the groups became an open dialogue. The two principal investigators co-led the focus group discussion, and one graduate student assistant took notes. Major questions revolved around how Alzheimer’s disease is understood, situations in which police officers need to deal with AD cases, challenges associated with AD-related situations and perceived training needs.

Table 1.

Demographics of focus group participants (n = 27).

	Mean (SD)	Frequency	Percentage (%)
Age	43.37 (6.56)	–	–
Male	–	22	81.5
Ethnicity
Asian	–	1	3.7
African	–	1	3.7
Hispanic/Latino	–	3	11.1
Caucasian	–	22	81.5
Years in the PD	16.14 (6.17)	–	–
Rank
Assistant Chief	–	1	3.7
Commander	–	3	11.1
Sergeant	–	4	14.8
Lieutenant	–	6	22.2
Detective	–	5	18.5
Patrol Officer	–	8	29.6
Education
Some college	–	8	29.6
College graduate	–	15	55.6
Postgraduate	–	4	14.8

SD: standard deviation; PD: police department.

Online survey

Building on the focus group interviews, an online survey was created using Qualtrics to gain an overall picture of police officers’ understanding of AD and their competence in handling individuals with AD. A survey link was sent to all police officers in the two police departments. There were 241 who started the survey; 13 of them only completed partial of the survey; and 228 completed the survey. The average age of survey participants was 42.09 (SD = 8.08) with the primary ethnicities being Caucasian (86.3%). Latinos accounted for 7.5%, and African Americans accounted for 3.1%. About half of the participants had a college degree (51.3%); 20.6% had a master degree or higher. On average, participants have served in the respective police departments for 14.11 years (SD = 7.09). The participants were primarily patrol officers (42.6%) and detectives (30.4%) (see Table 2).

Table 2.

Demographics of online survey participants.

	Mean (SD)/(%)
Age	42.09 (8.09)
Male	80.8%
Ethnicity
Caucasian/White	86.3%
African	3.1%
Hispanic/Latino	7.5%
American Indian	0.4%
Asian	0.9%
Other	1.8%
Education
High school/GED certificate	1.8%
Some college	26.3%
College degree	51.3%
Master’s degree or higher	20.6%
Rank
Commander	2.2%
Lieutenant	3.9%
Sergeant	18.0%
Detective	27.2%
Patrol Officer	38.2%
Other	10.5%
Years in the PD	14.11 (7.09)

SD: standard deviation; PD: police department; GED: general educational development.

Measures

Competence of handling dementia cases

Participants were asked to rate their competence level on an eight-item Likert scale regarding their knowledge of interactions with Alzheimer’s patients and community resources for AD residents. Four questions asked how competent participants felt about recognizing AD-related behavior symptoms during their interaction with AD residents. Consider the following example: “When someone forgets what I just said and I have to ask them again and again, I can recognize this to be a behavioral health issue.” The Cronbach’s alpha of this subscale is 0.80. Four questions assessed their competence level of their training and knowledge of community resources in preparing them to handle AD-related cases. The Cronbach’s alpha of this second subscale is 0.82.

AD knowledge was measured by a scale consisting of six true or false statements about AD symptoms and treatment. The following is an example of one such statement: “People at the early stage of AD do best with simple instruction given one step at a time.” These statements captured the basic AD knowledge of police officers. These questions were selected in light of an existing scale of AD knowledge (see, e.g., Carpenter, Balsis, Otilingam, Hanson, & Gatz, 2009) and the recommendations from focus groups for brief and relevant items.

Discomfort with interacting with AD patients

This existing belief of police officers was assessed by one question: “I am not comfortable to interact with people with dementia.” This question was answered on a five-point scale that ranged from 1 = “completely disagree” to 5 = “completely agree.” AD exposure was measured by one question that asked whether participants had/have a family member with dementia (0 = “no”; 1 = “yes”).

Demographic factors included gender, ethnicity, age, years in the police department, and positions within the department (i.e., patrol officer, detective, sergeant, lieutenant, commander).

Results

Findings from focus groups

Two investigators read and coded interview notes independently. A third investigator, who reviewed interview notes, analytic codes, and themes, provided additional input. All three encoders achieved consensus about the themes developed in the transcripts.

Regarding knowledge of AD, it was found that police officers appeared to understand the association between memory loss and AD but knew little about the full impact of AD on an individual’s physical health and behaviors. Those who had a family member or personal relationship with an AD patient tended to have more knowledge of AD.

Participants reported challenging situations when police officers were involved with an AD patient. Police officers encountered AD cases often because a third party reported some unusual behavior or a family member reported a missing adult. The obvious challenge was regarding whom to transit the AD resident to because police officers were not aware of available resources. Another challenge was the tendency to relate an AD resident to a child because AD patients had difficulty articulating what was happening to them. Police officers had to resort to the protocol employed by police searching for a missing child when seeking for an AD resident who had wandered; there were no separate standard searching protocols available for AD patients.

Participants also reported that there was a lack of training on this subject. What officers knew about resources has been learned through necessity while on patrol except for those who attended the crisis team training, a training targeted officers often of higher ranking to improve their skills to deal with behavioral health issues among specific population. The type of training desired varies greatly from department to department and even from officer to officer within the same department. There are different needs between detectives and patrol officers. In general, participants suggested that training be short and highlight what is relevant to the officers while on patrol.

Survey findings

Figure 1 presents the distribution of participant self-perceived confidence scores. It appeared that police officers had more confidence recognizing AD-related behavioral problems (M = 14.48, SD = 2.84) than addressing the needs of a resident with AD (M = 12.2, SD = 3.91).

Figure 1.

Frequency of self-perceived competence.

Multiple regression analysis was conducted to examine the effects of AD exposure, AD knowledge, and beliefs on police competence of recognizing AD-related behaviors after controlling for demographics (see Table 2). Those with more AD knowledge of police officers were more likely to report confidence of recognizing AD-related behaviors. In addition, higher education was the only demographic factor that was related to more confidence of recognizing AD behavior problems.

Similarly, regression analysis was performed to identify factors that affect police confidence of reacting appropriately to dementia patients (see Table 3). Those who reported feeling discomfort interacting with dementia patients were less likely to react appropriately to AD patients. Those who had a family member with dementia reported more competence of reacting to AD patients.

Table 3.

Results of multiple regression analyses with confidence of recognizing AD-related behaviors and appropriate reaction to patients with AD as outcomes (n = 228).

Variables	Competence of recognizing AD-related behaviors		Competence of appropriate reaction to patients with AD
Variables	B	SE	B	SE
AD knowledge	0.29*	0.14	−0.14	0.20
Discomfort of interaction	−0.09	0.19	−0.75**	0.26
AD exposure	0.40	0.42	1.32*	0.57
Age	−0.06	0.04	−0.07	0.05
Female	0.27	0.54	0.52	0.73
Levels of education	0.85**	0.29	0.14	0.40
Years of service	0.01	0.04	0.03	0.06
Adjusted R²	5.0%		4.0%

AD: Alzheimer’s disease.

p < 0.05 (2-tailed); **p < 0.01 (2-tailed).

Discussion

This study found that police officers had some knowledge of AD and some confidence of handing dementia cases. However, their knowledge of AD appeared to be limited, and their self-rated capacity of addressing the needs of dementia patients has room for improvement.

We hypothesized that three major factors would influence police officer self-perceived competence. Knowledge of AD, feelings of comfort interacting with an AD individual, and AD exposure each had a differentiated role. More knowledge of AD was related to higher capacities of recognizing behavioral symptoms of residents with AD. Comfort with interacting with AD residents and pervious exposure to a family member with dementia were related to higher capacities of reacting to AD residents in an appropriate way. It interesting that the knowledge of AD does not entail confidence of appropriately reacting to AD residents. It implies that understanding the facts of AD does not necessarily transfer to communication skills needed to interact with AD residents, and that additional training promoting interactions with or exposures to AD patients may be needed to make police officers capable of approaching, engaging, and helping AD patients.

Interventions to improve competence in police officers should provide education about AD, reduce stigma associated with AD, and offer ways to engage police officers in the dementia community. Doty and Carnasos (1990) suggest that training covering AD knowledge and community resources specifically tailored to the needs of law enforcement officers would lead to improved officer understanding of AD and agency capacities when dealing with AD-afflicted residents. Reducing stereotyped images of AD patients can be done through promoting personal interactions with AD patients and their families in community outreach activities that most police departments offer.

In addition, police departments need to collaborate with community service agencies, such as the AA, which already has an online training module targeted for first responders as mentioned earlier. The online training module adopts an interactive interface with real-life videos embedded and appears user friendly. Yet, its applicability to the policing community can be improved in that it largely relies on self-study and the length of up to 2 hours to complete the quiz and learn about all the information can be inconvenient for police officers. Police officers might be better trained through have these contents incorporated in their existing training programs. For example, the City of Phoenix police department provides crisis intervention training to police officers across several metropolitan areas. Contents about dementia can be included in this type of training. Those who have attended this training can be considered as experts of contact in the police department. They can serve as entry points for their colleagues who encounter a dementia-related situation. Another strategy is to make dementia-related information more accessible to the police population. Police officers will find it handy to have information through tablets or small cards that can be put in their pockets.

Local police departments need to expand their search for resources dealing with specific challenge such as the one mentioned in the focus group discussion, to locate a missing person with AD. There are some resources that local police departments can utilize. The Department of Justice’s Bureau of Justice Assistance released a series of training videos in 2013 to help law enforcement aid and find missing AD patients (Justice Department, 2013). These training videos, created through collaboration with the International Association of Chief of Police and the AA, depict three different public safety scenarios with AD patients and a video that goes over policies for law enforcement (Justice Department, 2013). It appears that these training programs have not been implemented in this study’s police departments, and the positive or negative effects on law enforcement remain to be seen. These training contents can be reviewed and applied to see whether it improves police officer’s capacity to address AD cases.

In 2015, the city of Tempe in Arizona was selected as one of the six cities nationwide to launch the initiative to build an Alzheimer’s friendly city (DaRonco, 2015). Part of the initiative is to develop programs to inform the public, train police and firefighters to recognize and respond to this issue. Findings of this study provide evidence that resonates the community need for such an initiative and suggest specific areas (e.g., engaging policing community through promoting AD literacy) that this initiative can target for the next step.

Several limitations of this study need to be noted. We noticed that the effect size of the two regression models was small, suggesting other factors that might explain the competence of police officers in assisting community residents with AD. The small sample size of the survey could be another limitation. In order to reach out to the maximum number of qualified participants, we had with each department one high-rank officer designated to send out survey links. Other effective and efficient ways need to be explored to do research on this population.

This study represents a preventative approach to examine a community mental health concern. Law enforcement officers as well as other professionals should work together to build a community that is dementia-friendly. With continued research in this regard, the first responder community can continue to develop efficient ways to address needs of residents with dementia and their family members (Shanley et al., 2004). Through identifying the needs of law enforcement officers, we can further direct our effort to alleviate their stress and enhance their capacity to address this community and societal challenge.

Footnotes

Acknowledgements

The authors thank the two police departments in Central Phoenix region for their assistance with data collection and their general willingness to participate in the research.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by the funding from the College of Public Service and Community Solutions at Arizona State University.

Fei Sun is an associate professor of the School of Social Work at Michigan State University. His research interest focuses on identifying and developing psychosocial interventions to reduce the impact of Alzheimer's disease on individuals, families and communities.

Xiang Gao is an assistant professor of the Department of Sociology at Huazhong University of Science and Technology.

Hillary Brown was a graduate student of the School of Social Work at Arizona State University.

L Thomas Winfree Jr was a visiting professor at Arizona State University's School of Criminology and Criminal Justice during the active research phase of this study. He is a professor emeritus in New Mexico State University's department of Criminal Justice. The author of over 100 refereed journals and book chapters, as well as seven textbooks on crime and justice topics, Winfree continues to research youth gangs in the international context.

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