Alzheimer's and violence: One man's story
Alzheimer's and violence
Dwayne Walls had been a wanderer for most of his 76 years; most journalists have this vagabond gene. And on a stormy night last September, Walls wandered down a hallway in the Veterans' Victory House, a large nursing home near Walterboro.
In his fractured mind that night, Walls may have been pacing the newsroom, or heading to an interview, or driving to Charleston to coach his writing students. Maybe he was searching for his childhood home in North Carolina; it's difficult to say what really goes through a brain damaged by Alzheimer's.
Sometime after 9 p.m., Walls went into another patient's room and climbed in an empty bed. Moments later, another patient walked in.
Alzheimer's and violence
TODAY: The story of Dwayne Walls, his descent into Alzheimer's and how he was beaten in a local nursing home.
MONDAY: When Alzheimer's patients become combative, families have few options in South Carolina. Other states do better.
He was 88 years old and also had dementia. Neither he nor Walls would remember what happened next, but at some point, a nursing aide saw the man hitting Walls with his cane. Walls was on the floor, bleeding and unconscious.
Staffers at the nursing home called an ambulance to take Walls to the emergency room and phoned Walls' wife, Judy Hand. That night and over the next four days, they told her that Walls had merely fallen; they didn't mention the beating. Walls spent the next week in bed, and Hand was at his side when he died.
The nursing home's doctor later would write in Walls' file that his patient had contracted fatal pneumonia after becoming "immobile," but that the beating didn't account for this immobility.
Hand began to question what happened to her husband, and she knew that Walls would have had questions himself. As a reporter, his curiosity led him into the inner circles of the Ku Klux Klan, the homes of poor black farmers and courthouses where dirty politicians tried to steal people's votes. His best stories were about vulnerable people, and few are as vulnerable as those with Alzheimer's disease.
Had he investigated his own death, Walls would have uncovered documents raising questions about whether the home had enough people on duty to prevent such attacks. Other documents would cast a spotlight on his own behavior: As his Alzheimer's grew worse, he struck nurses and other residents.
His story would lead to a much deeper one, how nearly 80,000 people in South Carolina have Alzheimer's, enough to fill the University of South Carolina's Williams-Brice Stadium, and that memory loss isn't the disease's only troubling effect: More than two-thirds will exhibit some form of agitation or combative behavior.
He would hear from the area's experts who say that even though this aggressive behavior is a normal part of the brain's breakdown, nursing homes often don't hire enough people to meet the needs of these patients. Many blacklist Alzheimer's and dementia patients with histories of aggression, leaving already stressed families and loved ones with few options.
He would find that as baby boomers age, this problem will only grow worse.
He might begin his story by putting the puzzle back together, before Alzheimer's took a lifetime of thoughts and memories and scattered them about.
Provided by Judy Hand from a newspaper clipping
Dwayne Walls (right) pursues Klu Klux Klan members as a reporter for The Charlotte Observer. Walls also was an author and writing coach.
A storyteller's life
Walls was born in 1932 in Morganton, a small city in the foothills of western North Carolina. His father worked in textile mills and was a part-time traveling Baptist preacher. Walls grew to despise his father. Years later, he would tell stories of his father's abuse and infidelity, how he ran away in his early teens and took up with a family that owned a funeral home in Hickory. He stayed with the family for several years, digging graves during the day and working in the embalming room at night. He was sturdy, about 6-foot-2 and 200 pounds, and won a football scholarship to Lenoir-Rhyne University in Hickory. But he went into the Air Force instead and was dispatched to Korea.
"Dwayne said he was standing next to another man one day when the commander asked if either one could type," Hand recalled. "Dwayne said, 'I can type,' and he was put in charge of the base newspaper. He said he loved every minute of it. I think it was a turning point."
In the 1960s, he worked for The Charlotte Observer, and by his and others' accounts, he couldn't have picked a better time and paper to be a reporter. The South was in tumult, and his editors gave him and other young, bright writers months to investigate everything from voter fraud to the Ku Klux Klan. Years later, one of his colleagues would remark that Walls was the only journalist he knew who had a cross burned in his yard.
Perhaps because of his background, Walls gravitated to stories about the poor. After winning stacks of journalism awards, Walls left the Charlotte newspaper to write a book about black families migrating north to find better jobs, a pattern that had transformed Northern cities and the rural South. He called the book "The Chickenbone Special" because poor black families piled onto trains with bags of fried chicken and ended their trips in Northern cities with bags of bones. Later, he moved into teaching and consulting, preaching the virtues of depth and colorful anecdotes, flying to newspapers in his small plane to coach writers, including those at The Post and Courier.
Walls met Judy Hand at a party in December 1996. She was working at the Hollings Cancer Center in Charleston at the time, and they hit it off. "We could talk for hours," she said.
In 1999, they settled in a 10th-story apartment in the Ashley House off Lockwood Drive, with a spectacular sunrise view over downtown Charleston.
A few years later, though, Walls began to forget things. At first, he and Hand chalked it up to age. But it began to spill into his work; the writers he coached noticed his frustration as he went over their stories. When he tried to suggest the right word, one that might make a sentence sing, he pursed his lips, spat out a curse and shook his head as if to shake it loose. It was as if someone had put a wall around the word, and for a writer, few things are more frustrating.
Video
Alzheimer’s doesn’t just steal people’s memories. It also makes many violent. Like nearly 80,000 South Carolinians, Dwayne Walls had Alzheimer’s, and what happened to him reflects a growing problem: Under-staffed nursing homes may not be equipped to protect or treat the complex needs of these fragile people. Watch »
'Out of control'
There is no cure for Alzheimer's, but doctors are zeroing in on its causes. One leading theory involves proteins. Healthy people have stringlike proteins in their brain cells that normally curl like unfurled ribbons. These ribbons help nourish the cells. But in Alzheimer's patients, these ribbons get tangled, destroying the cells in the process, along with a person's memories and functions that control behavior.
In 2001, doctors told Walls he had Alzheimer's. By then, his consulting business was in disarray, and he had stopped working. In his spare time, he tried to write his memoirs, but the sentences he banged out on his vintage 1938 typewriter were little more than gibberish. He tried to watch television but couldn't follow the plots. He grew depressed and drank to cover up his frustration. By 2004, Hand said, "He was out of control."
She remembered hiring a caregiver. "On the first visit, he was typical Dwayne," charming her with one story after another. "But on the third visit, he got angry and ordered her out of his house. Then he ran down the hallway naked."
Hand had reached the breaking point, a place familiar to those who take care of Alzheimer's patients at home. She couldn't care for him herself, and he had become a danger to himself and other residents in the building. She decided to place him in a nursing home, C.M. Tucker Jr. Nursing Care in Columbia, which had a unit for veterans and was run by the state Department of Mental Health.
Walls quickly lost weight there, and Hand grew concerned. "I couldn't stand that place," she said.
One day, they moved Walls to another room and put a dangerously psychotic patient in his old one. Hand said she warned nurses that Walls would try to return to his old room. "They said they were going to really watch him. But at midnight, I got a call that he had gone to his room and gotten beaten to a pulp," she said.
In December 2006, investigators with the U.S. Department of Justice visited the facility and didn't like what they saw: Staff gave patients wrong foods and medications and too often used physical restraints to control behavior problems. They also found that the facility was poorly equipped to handle combative Alzheimer's patients. "There appears to be no formal behavior program for residents diagnosed with Alzheimer's disease, placing residents at heightened risk for the use of physical or chemical restraints to control behavior, and placing them at heightened risk of physical assault by other residents who may become frustrated at their repetitive speech or wandering," investigators concluded.
Hand didn't know about the Justice Department investigation at the time, but when she heard that a new nursing home for veterans was poised to open in Walterboro, she spent hours on the phone lobbying for his move. "I was so happy when they took him," she said.
Provided by Judy Hand
Dwayne Walls, with wife Judy Hand, was an Alzheimer's patient who died last September, one week after an attack by another patient in a Walterboro nursing home.
'We just loved him well'
Veterans' Victory House was completed in 2006 at a cost of $28 million in state and federal money. It has five pavilions, and each is named after a South Carolina veteran. It houses 220 residents, making it one of the larger nursing homes in the state. A sign outside says, "Home of the Greatest Generations."
The state Department of Mental Health owns the facility but has a contract with a private company called Advantage Veterans Services of Walterboro to run it. The company is affiliated with HMR Advantage Health Systems, which is based in Easley and operates 26 nursing homes in South Carolina and elsewhere in the Southeast.
Walls arrived there in May 2007 and was placed in the more secure Alzheimer's pavilion. Walls quickly regained weight and seemed calmer. Hand remembered a visit that winter when she found him sitting on a couch, shaved and smiling. She asked a nurse what they had done for him. A new diet? New medicine? "We just loved him well," the nurse replied.
Hand was so pleased she wrote Lt. Gov. Andre Bauer, who runs the state's Office on Aging, to thank the state for creating what she called the "Angel House."
Caregiver advice
What to do when an Alzheimer's patient becomes aggressive ... and what not to do:
Scientists know that many Alzheimer's patients go through periods of swearing, screaming, pilfering, wandering and other combative behaviors. Often this makes home care difficult. Here are steps experts say can help prevent such behavior:
-- Avoid violating a patient's space. This often leads to misinterpretation and aggression.
-- Check to see if the patient is in pain or hungry. Patients may become combative because they have no other way to express their needs.
-- Keep a written journal of events and triggers that lead to aggressive behavior, and communicate these triggers to other caregivers.
-- Maintain a regular routine.
-- Regular and gentle exercise on days when patients visit doctors may help reduce outbursts.
-- If an outburst occurs, talk to the patient in a low and soothing voice. If a TV or radio is on, turn it down or off.
-- Don't ask too many questions or make too many statements at once.
-- Focus on feelings, not the facts. Try not to concentrate on specific details; rather, consider the person's emotions. Look for the feelings behind the words.
-- Don't take the behavior personally. The person isn't necessarily angry with you.
-- Shift the focus to another activity. The immediate situation or activity may have unintentionally caused the aggressive response. Try something different.
-- Avoid using restraint or force. Unless the situation is serious, avoid physically holding or restraining the person. He or she may become more frustrated and cause personal harm.
Assaults common
As happens with about 70 percent of Alzheimer's patients, Walls grew more agitated as the disease marched through his brain, though he was by no means the only person in the wing suffering these effects.
In 2008, staff at the Veterans' Victory House documented in his medical records how another resident pushed him to the floor one month, and how a month later Walls hit another resident in the head with his fist. In June 2008, a resident hit another, who fell into Walls and knocked him to the floor. In July, a staff member found Walls in another resident's bed, his fists balled.
By August, a month before Walls' death, staff noted that he was "aggressive to others and himself," particularly when he was scared. But then the storm clouds cleared. Staff noted on the day Walls was beaten that he had no behavior problems and was moving around well.
Wife not told
Hand said she was in bed the night of Sept. 11, 2008, when her phone rang.
Walls had fallen and needed to go to the hospital for X-rays, a nurse said. She didn't mention the beating, or that a deputy had been called to investigate.
The next morning, a Friday, she called to see how he was doing. A nurse said he had no broken bones and was doing fine. Later that afternoon, a social worker called Hand and said she wanted to speak to her in person. Hand said she could make the one-hour drive later that night, but the social worker said she was leaving at 5 p.m. "I asked if everything was OK with Dwayne, and they said, 'yes' and that they would see me on Monday."
Hand drove to Walterboro the next Monday morning for a visit. "I walked into the room and gasped. He was black and blue all over, swollen and on oxygen. I ran out of the room and got a nurse. They came and I asked what had happened." Dwayne had fallen, they told her. Throughout the day, the home's employees stopped by to visit Walls to see how he was doing.
Later that afternoon, four days after the attack, she approached a staffer. "I said, 'He couldn't have possibly gotten that from a fall.' She looked at me and said, 'No one told you? He was beaten.' "
Staffing questions
Hand watched Walls grow weaker by the day. He didn't recognize Hand at this point, but she hoped that somewhere in his broken brain, he knew she was there. At 7:55 p.m. on Sept. 18, he took his last breath.
That night, Hand tried to call her son. Her cell phone didn't always work in that area of Walterboro, so she looked for a land line. As she wandered through the pavilion where Walls had lived, she noticed few people working. She asked a nurse how many nurses were on duty after 3 p.m.
"She said three. I could not believe that three nurses could care for 50 patients in an Alzheimer's locked wing."
What happened to Dwayne?
She began to have other questions. Colleton County Coroner Richard Harvey told her over the phone that the beating contributed to Walls' death, but she was surprised when the death certificate listed the cause as natural and didn't mention the altercation. In an interview, Harvey said he did an autopsy but the results showed that Walls died of pneumonia, not from any other injuries.
Related story
Veteran's home investigated in Alabama, published 05/17/09
Meanwhile, in summarizing Walls' death, the nursing home's doctor wrote that Walls developed pneumonia after spending more time in bed. He noted that Walls had been attacked but that the autopsy didn't find any "significant trauma" that would have caused Walls' "immobility." That finding, however, conflicts with other notes in Walls' medical file showing that he was walking around fine during the days before the attack.
The doctor wrote the summary in November, two months after Walls' death, and after an ombudsman hired by the lieutenant governor's Office on Aging visited the home. The agency had received a complaint about "residents that beat other residents," low staffing levels and "residents sitting in soiled diapers."
Hand said neither she nor anyone on her behalf made that complaint.
After the visit, the ombudsman noted the altercation involving Walls but said the agency doesn't investigate resident-to-resident abuse.
The ombudsman nonetheless concluded, "There is a shortage of staff," after looking at the facility's staffing logs. The reports showed the Alzheimer's unit had just one licensed nurse on duty for 52 patients on morning shifts before and after Walls' attack. On one night shift, the wing had no licensed nurse at all. The ombudsman asked the nursing home to follow state regulations, which requires at least two licensed nurses during the morning shift and one on the night shift.
More recently, an investigator with the state Department of Health and Environmental Control made an unannounced visit to the home and found it hadn't properly reported the incident involving Walls and the 88-year-old man who beat him. State law requires nursing homes to report "serious incidents" involving residents who assault others.
Officials with Veterans' Victory House and its parent company, HMR Advantage, said, "The safety and health of our residents is our primary concern," but declined to comment about Walls' death or complaints about conditions in the home.
Hand said she knew that Alzheimer's would take her husband, and she doesn't blame the 88-year-old man who beat him. "He didn't know what he was doing," she said. Alzheimer's patients "need to be watched. They need to be understood. It's the way Dwayne died that bothers me. He was such a gentle man, and he always took care of the underdog."
More information
DHEC report from April 2009 investigator’s visit to Veterans Victory House. The investigator found the home hadn’t properly notified the agency about Walls’ beating.
Colleton County Sheriff’s Office incident report on the Sept. 11, 2008 beating of Dwayne Walls.
Doctor's summary of Walls' death 11/25/08
Findings from Lt. Governor’s Office on Aging ombudsman’s visit to Veterans' Victory House.
State report showing not enough is being done to help Alzheimer’s patients and their families (58 page PDF)
Department of Justice reporton veterans nursing home in Alabama operated by HMR Advantage
Department of Justice reporton C.M. Tucker Nursing Care Center in Columbia, detailing numbers problems after a 2006 inspection
She recently hired a local attorney, Matt Yelverton, who specializes in nursing home cases. Walls' death reflects a larger failure, a focus on profits over people, Yelverton said.
"We all have aging family members, and we all, at some point, will depend on a long-term care facility to properly care for someone we love," he said. "Dwayne and people like him are being left behind every day."
State falls short
Walls often urged his students to give readers details — "show" what happened, don't just "tell." Walls' struggle with Alzheimer's during his final days would prove to be a vivid example of how such patients need extraordinary care to protect them from themselves and others.
Some South Carolina leaders know this. Earlier this year, a task force of psychiatrists, nursing home executives and experts on aging concluded that the state doesn't do enough to train nursing home staffs to handle aggressive Alzheimer's patients, and that families have few options when their loved ones are removed from homes because of combative behavior.
The report, which received little media attention, cited a government-owned treatment facility in North Carolina as a model, a place where patients are allowed to wander freely throughout the facility because staff ratios are low; one certified nursing aide for every five patients. Because of this intense supervision, patients can climb into each other's beds and staffers can quickly take action to prevent conflicts.
Ironically, Hand sometimes had a gut feeling that when Walls wandered the halls at Veterans' Victory House, he was searching for a way to get back home to North Carolina, a place where in his final days he might have found more peace.
Reach Tony Bartelme at tbartelme@postandcourier.com or 937-5554.
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