Family conflict in dementia: prodigal sons and black sheep

To describe family conflict in cases of dementia referred to the Guardianship Tribunal of New South Wales, Australia.

The file notes of 50 cases of family and systems conflict in cases of dementia presented to the Guardianship Tribunal were examined. Demographics, MMSE score, and type and severity of dementia were recorded. The documents and evidence presented to the Tribunal were coded and subjected to thematic analysis to identify the themes of the conflict, the protagonists and the position of the person with dementia with respect to the conflict.

Family conflict was most commonly seen in mild to moderate dementia. Conflict occurred most frequently between siblings (with a group of siblings allied against a 'black sheep' member) and involved other systems such as service providers in 25% of cases. The person with dementia was usually involved in the conflict or in alliance with one or other of the family members in conflict, especially when paranoid ideation was fuelled by family members. Common themes included accusations of neglect, exploitation, lack of communication or sequestration of the person with dementia. No family had received family therapy prior to the application; conciliation during the hearing was successful in 30% of cases. Legal transactions such as Powers of Attorney were frequently made and frequently revoked by persons with dementia involved in family conflict.

Dementia may be a great family divider, particularly when there are cracks in family solidarity. The understanding of family conflict in dementia has ramifications for both clinical and medico-legal practice. These findings may encourage family-centered interventions which address family dynamics and interpersonal conflict. They may also assist in capacity assessments of persons with dementia who change legal documents because of family conflict.