With Australia’s Federal election to be held on July 2 this year, Bridget Howes considers how people living with dementia in residential aged care can be supported to exercise their right to vote.
The Australian Aged Care Quality Agency accreditation standards require that aged care residents are able to exercise civic legal and consumer rights and that aged care providers are required to assist them to do this. The Australian Electoral Commission (2015) states that the right to vote is fundamental for all Australian citizens.
However, an informal review of practice at BlueCross Community and Residential Services (BlueCross) in the lead-up to the 2014 Victorian State Government election indicated that staff and management held a number of incorrect assumptions about the rights of aged care residents with regard to voting in government elections. Some staff believed that it was no longer compulsory for people over the age of 75 years to vote, many believed that people living in residential aged care were exempt and there was a strongly held belief that anyone with a diagnosis of dementia or cognitive impairment would not have the capacity to vote.
This article explains the changes BlueCross has made since then to support our residents, including those with dementia, to take part in the electoral process. This fits with the aims of the BlueCross STARLife dementia practice model which promotes person-centered care, participation, engagement and community involvement for all residents including those living with dementia.
We decided to conduct the informal review after BlueCross residential homes were contacted by the Victorian Electoral Commission before the state election and asked to provide a list of people living in each place. This revealed that a significant number of BlueCross residents were listed on the electoral register at their pre-admission addresses. This then raised questions about where the responsibility lies for ensuring that the address is correctly recorded and for the processes that should be followed when a resident does not seem to have the capacity to vote.
Reviewing the literature
In response to these questions I reviewed the literature about voting and contacted the Victorian Electoral Commission to confirm statutory obligations in relation to voting. The commission confirmed that all citizens, regardless of age, are required to vote in state and federal elections unless they are medically exempt. (BlueCross uses the Australian Electoral Commission and Victorian Electoral Commission websites as references to ensure our guidelines around resident voting are in keeping with current legislation.)
Research suggests that voting is highly valued and that people of all ages consider voting as a fundamental right (Bonnie et al 2013; McEldowney et al 2009; Karlawish et al 2008). However, the literature review revealed that access to voting can be challenging in residential aged care settings. A need for research to support the development of guidelines for voting by residents in long-term care settings is acknowledged. Nurses, employers and organisational policymakers have a significant role in ensuring that older people can exercise their right to vote and policy development is mentioned as being of particular importance (Bonnie et al 2013; Regan et al 2011; Karlawish et al 2008).
Based on a US survey, Karlawish (2008) suggests that two-thirds of residential aged care homes indicated that they assessed voting capacity prior to elections. They report that methods differed and may have disenfranchised residents who were actually competent to vote.
It is often assumed that people with a diagnosis of dementia would not have the capacity to vote. Investigations into the capacity to vote in people living with dementia and the elderly suggest that the matter is more complicated than this.
Consideration of four decision making skills – understanding, choice, reasoning and appreciation – finds that the capacity to vote, although impacted by cognitive deterioration, is more related to understanding and appreciation than to choice and reasoning.
Voting by people living with dementia raises questions about assessing their decision-making capacity. In one study in which tests were completed to evaluate decision-making skills, the subjects performed poorly on understanding and reasoning items but scored well on making choices (Irastorza et al 2011; Tiraboschi et al 2011). Regan et al (2011) question the reliability of the mental capacity to vote being assessed by nurses who are not necessarily aware of voting rights and do not have access to organisational guidelines to equip them to undertake assessment of decision-making capacity.
Karlawish et al (2008) report on a court ruling in 2001 in favour of a mentally ill person with an appointed guardian. The ruling reasoned that a person who understands the process and consequences of voting and who can choose the candidate is capable of voting, irrespective of their guardianship status.
Supporting residents to vote
As Sue Nelmes, BlueCross Quality Risk Advisor and one of the BlueCross lifestyle team leaders, explains: “The conversations about voting need to start before a resident is admitted into residential care. Families and new residents are often unaware of the need to change addresses on the electoral register or that if a resident does not have the capacity to vote that an assessment is required to remove them from the electoral roll”.
At BlueCross it is usually the resident’s GP who completes the assessment if capacity to vote is in question. Sue is currently reviewing systems and policies at BlueCross to ensure that residents’ rights are acknowledged, and this includes the right to vote.
Our pre-admission paperwork has been amended from a previous question asking ‘do you want to vote?’, which suggested that voting is optional, to ‘are you listed on the electoral register?’ ”
If the resident still has the capacity to vote, they or their representative are prompted to change their address.
If the resident does not appear to be able to vote and is still on the electoral roll representatives are prompted to seek a medical assessment from the care home’s attending GP and are directed to the Victorian Electoral Commission website for more information about their responsibilities in the voting process.
I’ve recently presented education sessions to the leisure and lifestyle team explaining residents’ rights and responsibilities, our responsibilities as an aged care provider and those of the family around voting, how staff should support residents who are able to vote, and informing the team that a diagnosis of dementia does not necessarily mean that a resident is unable to vote.
The Australian Electoral Commission website (http://www.aec.gov.au/) provides information about support for people who require assistance to vote including the elderly, people with dementia, disabilities, visual impairment, non-literate people and people from culturally diverse backgrounds. The elector can choose a person to assist them and if they cannot sign they may make a mark that can then be verified. Postal voting and mobile voting stations provide access for people living in residential aged care and are supported by The Australian Electoral Commission. Mobile polling facilities can be set up in aged care homes, hospitals, prisons and remote areas of Australia prior to and on election day.
Riverlea is a 75-bed BlueCross aged care residence in the western suburbs of Melbourne. Over the past 12 months Riverlea has actively worked to improve the experiences of people living with dementia using the BlueCross STARLife model to promote ‘Living, Independence, Fulfilment and Engagement’.
Faye Audino, the residence manager, estimates that at least 50% of Riverlea residents have some cognitive impairment and recognises that supporting all residents to vote is essential.
“Our residents that attend the STARLife Club have reached a stage in their dementia where they would be unable to vote, but there are a number of residents with some cognitive impairment that we can support to exercise their voting rights,” Faye said.
Riverlea is currently participating in a Shaping Montessori Communities workplace program run by Alzheimer’s Australia Victoria and supported by BlueCross.
Seeking the views of the residents and families is a key principle of the Shaping Montessori Communities approach and, in keeping with this, when it comes time to vote in the Federal election eligible residents will be offered the choice of lodging a postal vote, going to a polling station or using the mobile voting stations which will be set up at the home.
Lifestyle coordinator Corinne Dowsett says the Riverlea staff are more prepared this year to support residents to vote, compared with the 2014 Victorian state election.
“We didn’t get it right last time. A number of residents were still on the electoral roll although they did not appear to have the capacity to make decisions and choices. Some were adamant that they wanted to vote and staff attempted to support them but this led to a confusing and negative experience in some cases. However, other residents who were able to vote despite having some cognitive impairment were supported to vote and with guidance about the process of using the mobile polling stations these residents were able to make decisions and choices.”
“This year we are more prepared and hope we are able to support those who are able to vote and that any residents who do not have the capacity to vote do not participate in a negative experience. We are talking to residents and relatives and hope that we are able to support their choices whenever possible.”
Riverlea resident Joan Senior (who does not have dementia) says it’s important to ensure that all Australians are listened to: “We must have a say in what happens in our country”. When Joan first came to Riverlea she was unwell and did not really think very much about voting. However, at election time when she realised she was listed on the electoral roll at her previous address her daughter drove her to a polling station so she could vote. She then changed her address on the register to Riverlea. In the last Victorian State election Joan voted at the mobile polling station arranged by the team at Riverlea and described this as a positive experience.
Jean Nunn, another Riverlea resident, does not have dementia but acknowledged there were others living there who may need extra support to vote, as “every vote makes a difference”. She and her daughter Diane Niblock agreed that the mobile voting station provided at Riverlea during the Victorian state election gave residents the opportunity to vote without having to travel to the polling station.
The experience at Riverlea reflects the views contained in the literature that voting is important to citizens of all ages, with the home’s residents, families and staff valuing the support given to residents to exercise their right to vote.
While responsibility for voting lies with residents and their representatives, there are many things that BlueCross has done to assist our residents and their families with this. There have been significant improvements in the knowledge of the leisure and lifestyle teams and residence managers around residents’ right to vote and how to support this.
The leisure and lifestyle teams and senior managers have taken a proactive approach to supporting the process and are well prepared for the July Federal election.This year staff are confident that residents’ medical assessments are up to date and the majority of resident addresses on the electoral register have been updated.
Across the organisation the leadership team and I are continuing to review consumer rights for people living with dementia, and supporting our residents to exercise their right to vote in elections is an important part of that process.
Bridget Howes is the BlueCross STARLife Dementia Specialist (BlueCross Community and Residential Services). Contact her at: firstname.lastname@example.org.
Aged Care Quality Agency (1997) Aged Care Accreditation Standards, fact sheet. Accessed 30/04/15. Available at: www.aacqa.gov.au/.
Alzheimer’s Australia (2015) Intergenerational report highlights need to act on dementia. Media release, 5 March. Accessed: 31/03/15. Available at:
Australian Electoral Commission (2015) Change of address webpage. Accessed: 30/04/15. Available at: www.aec.gov.au/enrol/change-address.htm.
Bonnie R, Freedman P, Guterbock T (2013) Voting by senior citizens in long-term care facilities. Election Law Journal 12(3) 293-304.
Irastorza L, Corujo P, Banuelos P (2011) Capacity to vote in persons with dementia and the elderly. International Journal of Alzheimer’s Disease 2011 1-6.
Karlawish J, Bonnie R, Appelbaum P, Knopman D (2008) Identifying the barriers and challenges to voting by residents in nursing homes and assisted living. Journal of Ageing and Social Policy 20(1) 65-79.
McEldowney R, Teaster P (2009) Land of the free, home of the brave: voting accommodations for older adults. Journal of Ageing and Social Policy 21(2) 159-171.
Regan P (2011) Patient participation in public elections: a literature review. Nursing Management 17(10) 32-36.
Tiraboschi P, Chito E, Sacco L, Sala M, Stfanini S, Defanti C (2011) Evaluating voting competence in persons with Alzheimer Disease. International Journal of Alzheimer’s Disease 10 1-6.
Victorian Electoral Commission (2015) How to vote webpage. Accessed: 30/04/15. Available at: www.vec.vic.gov.au/voting/howToVote.html.