Emotions Linger Longer

Hello everyone,

Last month, DailyCaring.com had a great article by Dr. Elaine Eshbaugh about how the emotions of a person with dementia (whether positive or negative emotions) can remain with the individual long after the situation or event that caused the emotion to occur. For example, if you startle a person with dementia by coming up from behind them or speaking too loudly, that person may remain agitated for the whole afternoon. Out initial interactions with people with dementia, therefore, are critical.

Below is a link to the full article. We encourage you to take a look, and pay special attention to the tips she gives for smart ways to begin an interaction with someone who has dementia:

How Emotion Lasts Longer Than Cognition In and Out of Dementialand

Have a great week!

All Hands on Deck–Working with Champions to Reduce BPSD

Hello everyone,

To change how everyone in your settings manages behavioral and psychological symptoms associated with dementia, we need all hands on deck!  Your identified champions are your leaders and role models.  These individuals play a vital role in implementing the strategies we want all staff to use when working with residents with behavior and psychological symptoms of dementia.

Champions (along with other stakeholders such as administrators, nurses and social workers) not only act as role models, but also cheerleaders, teachers and observers. Encourage your champions to take a few minutes and watch the ways in which their co-workers interact with residents to make sure they are following the resident’s care plan and using person centered approaches during care interactions (e.g., having the individual participate in his or her bathing and dressing; walking the individuals to the bathroom regularly to avoid agitation; or singing the resident’s favorite song during an unpleasant care interaction).  Acknowledge, praise and reward the individual when an effective behavioral intervention is implemented.  Examples of such acknowledgments include:

  • A simple “Great job, keep up the good work!”
  • A write up in a newsletter recognizing their exemplary work
  • A Starbucks gift certificate (or an alternative treat!)

Conversely, when champions witness missteps by staff during resident interactions, they should turn these into opportunities to teach their colleagues a better way to handle those situations.  Role modeling a better way is one of the best ways to make new learning happen.  For example, when a caregiver tells a resident who is repeatedly getting up and down in an unsafe fashion to sit down they might fall…. And the resident persists and gets more agitated….it may be helpful to step in and show that taking the resident for a walk or having him or her stand and sing and dance for a minute or two may decrease the agitation.

Staying positive and persistent is key to changing the habits of staff and building a strong team of caregivers who help one another.

Lastly, please don’t forget to send us an example of how you used DICE to manage a challenging behavior in your community. You can win a free cordless push sweeper for residents to use!

Have a safe and Happy Fourth of July!!


End of the Fall Cycle

Hello everyone,

Now that we’ve finished discussing the DICE model for assessing and managing challenging behaviors, we’d like to hear from YOU! Please email us an example of how you and your staff have used DICE to address a challenging behavior of one of your residents. The communities that send us the best examples will cordless sweepers! These are great to use with residents who like to help clean, because they take away the risk of tripping and falling (no cord to worry about), and they are quiet—so no loud noises to bother others.

Speaking of fall risk…

Falling is an ever-present concern and challenge for care communities, and falls at home is often the reason why people move to a care community. Too often, however, staff and residents’ fear of falling can lead to a vicious cycle:

  • An ambulatory resident falls and gets hurt.
  • The resident recovers physically, but may now be afraid to walk for fear of falling.
  • The staff also fear that the resident will fall again, so they continually tell the resident to “sit down so you don’t fall,” reinforcing the resident’s fear.
  • The resident then sits more and walks less (if at all), and consequently becomes weak (which is just one of the many negative effects of immobility).
  • One day, the resident tries to walk or transfer without assistance (common among people with dementia who forget they need help) and falls because he/she is now so weak.

…And the cycle begins again.

How do we break this cycle?

Tricks of the trade:

  1. Review with staff why people with cognitive decline (who may not be able to communicate their needs verbally) want to get up and walk on their own. Are they bored? Do they hurt from sitting for a long period of time? Do they need to use the bathroom? Do they forget they need help to walk?
  2. A supervised 5-minute walk could be enough to satisfy their need to move for a while, and may help decrease negative behaviors later on due to boredom or discomfort.
  3. Instead of saying, “Sit down, you might fall!”, try to get in the habit of saying something like, “I see you want to walk. Please wait and someone will help you very soon.” Then take the individual for a short walk down the hall, to a common area, or outside to a patio or courtyard. Spending those 5 to 10 minutes walking with a resident will end up saving lots of time in the long run. Have staff take turns doing supervised walks.
  4. Perform fun “sit to stand” exercises throughout the day with residents….put on some music, have them grab the rails along the hallway and do 5 minutes of sit to stands with them. They help keep leg muscles strong and use up excess energy too.
  5. Spread the love and encourage physical function…..ask the resident, “Could you stand up and give me a hug?” –The reward back is a big hug from you!

Have a great week!

Create a Plan and Evaluate It–The final steps of DICE

Hello everyone,

This week we’ll finish discussing the four steps of DICE. We hope you had a chance to discuss the “Describe” and “Investigate” parts with your staff, and are finding the process helpful as you work to assess and manage behaviors of your residents with dementia.

The “C” in DICE stands for “Create a Plan.” Once you have described the problem behavior and investigated and determined a probable cause of the behavior (see last week’s tidbit), then next step is to create a plan to address the behavior.

When creating a plan, keep in mind that interventions should be personalized and meaningful. An intervention for one resident may not work for another. In addition, an intervention that worked for a resident 3 months ago may no longer work for that same resident now.

Creating a plan takes in interdisciplinary team to ensure that all are on board with the plan, that it will be communicated to all necessary staff, and the team will work together to see it through.

Some tips when creating a plan of care to address a specific behavior:

  • Be innovative—brainstorm ideas with staff
  • Use what you know about the resident—causes/triggers of the behavior, resident abilities and preferences
  • Minimize environmental change—limit the number of caregivers and reward caregivers that work well with a resident; minimize room and roommate changes
  • Control the amount of stimulation—too little or too much can precipitate behaviors
  • Modify communication techniques—verbal cues, writing things down, communicating “face on”, repetition, role modeling, and providing a vicarious experience with the resident can all aid in communication
  • Enhance sensory experiences and the environment—music, dance, pleasing fragrances, favorite foods, tactile stimulation and supporting physical activity can all help with some challenging behaviors
  • Provide individualized care—be flexible when scheduling functional activities, anticipate challenges, distract, use creative explanations to prevent a catastrophic reaction and let the resident “do her own thing” when safe to do so

The final step—the “E”—is to “Evaluate the Plan.” Did the plan work?

  • Decide upon a time frame for re-evaluation.
  • Use objective instruments for target behaviors: Cohen Mansfield Agitation Inventory; Neuropsychiatric Inventory (short form or nursing home version); Cornell Scale for Depression in Dementia; Resistiveness to Care Scale
  • Review use of PRN medications
  • Listen to staff report

If the approach worked, continue with the plan of care. If not, go back to investigate other potential causes of the behavior and revise your plan.

Have a great week!

Investigating Behaviors: The Second Step in the DICE Model

Hello everyone,

In last week’s tidbit, we discussed the DICE process for assessing and managing behavioral issues in residents with BPSD. We focused on the “D”—describing a resident’s behavior with specific details that provide important clues about the cause of the behavior.


This week we focus on the “I”Investigate. Once we have a detailed description of the behavior, we can investigate the influence of factors such as cognitive status, environment, caregiver approach, physical/medical disorders, and psychiatric symptoms on the resident’s behavior. In many cases, a resident with dementia is having difficulty communicating something to us. She could be trying to tell us that she is in pain or depressed, that we are rushing her, that it’s too noisy in the room, or that she simply doesn’t understand what we are asking her to do. When we don’t get the message, the resident can become agitated, resistant to care, anxious or even aggressive.

Cognitive impairment includes amnesia (memory loss); aphasia (language impairment–receptive or expressive); apraxia (impairment of learned motor skills); and agnosia (perceptual impairment). Cognitive impairment can have a significant impact on behavior. It can lead to  behaviors such as a resident urinating in a trash can instead of the toilet, pushing caregivers away when they try to take her to the bathroom, or using a call button constantly to ask for someone to take her home and complaining that no one is helping her.

We should also consider the environment: temperature, noise level, over and under stimulation, too much or too little space, familiarity and routine. An alteration to an element of the environment can have an immediate impact on a person’s behavior. For example, construction work being done in a facility brings noise, new people and changes to a space. These can all lead to anxiety and stress for a resident with dementia. Lack of stimulation can lead to boredom, which can result in behaviors such as wandering or disruptive vocalizations.

Caregiver approach can also influence a resident’s behavior. Older adults with moderate to severe dementia have difficulty understanding verbal directions. They can also misinterpret touch that occurs during care activities, perceiving it is a threat. When this happens, a resident can become fearful and either fight the caregiver (hitting, biting, etc.) or flee (resist care).

Physical/medical disorders in older adults with dementia can result in pain, constipation, infection and medication use (with a variety of side effects). Do any of these examples sound familiar?: “He’s so sleepy it’s hard to get him to eat. The food runs out of his mouth”; “He cries when we get him up to transfer to the chair”; “She’s up at night asking to go to the bathroom every 30 minutes.”

Psychiatric disorders obviously affect behavior. Some examples: “She has been tearful almost every evening and doesn’t want to get out of bed in the morning”; “She thinks someone took her children”; “He doesn’t sleep and is so irritable”; “She saw a snake outside her window.”

Now that you’ve learned about describing a problem behavior and investigating possible causes of it, next week we’ll discuss…you guessed it—the “C” in DICE, which stands for Create a plan. We’ll review interventions you can use to address these challenging behaviors.

Have a great week!

Using “DICE” to Assess and Manage Behaviors…Let’s Start with “D”

Hello everyone,

Today we are going tackle the first part of DICE, a tool you can use to assess and manage behavior change in people with dementia. DICE stands for:

  • Describe the behavior
  • Investigate the influence of things like cognitive status, environment, caregiver approach, physical/medical disorders, and psychiatric symptoms
  • Create a plan
  • Evaluate if it works (Kales, Gitlin, Lyketsos, 2014, JAGS)

It helps to approach this process as a detective would approach an unsolved mystery. Just like detectives, GNAs and nurses often receive vague and incomplete information, they manage multiple responsibilities, they have developed a good intuition based on experience and familiarity, and may have to prove their case to others in order to move forward with an intervention.

The first step, effectively describing a person’s behavior, is critical as it sets the foundation for the investigation. A detailed description of a resident’s behavior should include:

  • Frequency (every week, day, hour, 10 minutes?)
  • Duration (Does the behavior go on for an afternoon? An hour? A few minutes? When does it stop?)
  • Setting (In common area? Shower room? Bedroom?)
  • Who is involved? (Specific caregivers? Other residents? Other staff?)
  • What was happening right before the behavior began?

Be specific…just saying someone is “often agitated” is not enough. Instead, “Resident repeatedly hits call bell before each meal every day, and when GNA arrives, just mumbles and complains about the food” is far more helpful information. You can probably come up with a few theories of what the problem could be just based on those few details!


We’d like you to spend some time this week discussing with staff how they describe behaviors of residents that need to be addressed. How does being more specific offer additional clues as to the cause of the behavior?

Next week we’ll focus on the second step of DICE, Investigation. Have a great week!

Delayed onset PTSD

Hello everyone,

This weekend, as we honor the sacrifices of the thousands of soldiers killed in wars fought on behalf of our country, we are also reminded of the living soldiers who must still deal with the aftermath of battle, many of whom suffer from post-traumatic stress disorder, or PTSD.

In a review published last July by Progress in Neurology and Psychiatry (http://www.progressnp.com/article/delayed-onset-post-traumatic-stress-disorder-symptoms-dementia/), authors Clara Martinez-Clavera, Sarah James, Eva Bowditch and Tarun Kuruvilla discuss delayed onset PTSD in older adults, and how the symptoms can be mistaken for behavioral and psychological symptoms of dementia (BPSD) commonly seen in people living with dementia. According to the review, “published cases of WWII veterans in the early stages dementia describe the onset of PTSD after decades of living without symptoms.” War experiences are not the only cause of PTSD. The International Classification of Diseases, 10th Revision, defines PTSD as a condition that follows exposure to a stressful event or situation of exceptionally threatening or catastrophic nature, which may cause pervasive distress.

Dr. Kuruvilla says is important to recognize PTSD in people with dementia so that caregivers and family can understand better the origin of their distress and manage it most effectively. Getting a person’s detailed trauma history during the memory assessment can help caregivers identify residents who may be at risk for delayed onset PTSD, though the authors note that this can be challenging due to lack of valid assessment tools and a reluctance to upset those involved by asking for details of a past trauma. However, the authors stress that it is essential to obtain this information before significant cognitive decline occurs.

According to the article, non-pharmacological management for some cases of PTSD could include avoiding noisy environments, one-on-one support with caregivers, reassurance at times of distress, reminiscence therapy and emphasis on positive life events. More research is needed on this. First-line pharmacological management of PTSD symptoms include SSRI’s and SNRI’s, and may include these in combination with anti-dementia medication. There is little evidence supporting the use of antipsychotics or hypnotics for delayed-onset PTSD.

 Have a safe holiday weekend!

Aggression….or something else?

Hello everyone,

Aggression is a common behavioral symptom of distress in people with dementia. As you try to determine what may be causing aggression, take note of the context of the aggressive behavior. In some cases, the aggression may actually be resistance to care.

For example, is the person trying to hit or scratch a caregiver during morning care? This may due to the inability of the person to communicate his/her desires to the caregiver, or a feeling of being threatened during a vulnerable interaction such as dressing or bathing. Try to include the person in caregiving activities as much as possible. Hand the person a washcloth and ask her to wash her face (or use visual cuing/gesturing) while you wash feet or gather clothing. If needed, use hand-over-hand technique while brushing teeth, bathing and combing hair. This promotes range of motion activity, helps preserve dignity, and gives a sense of control back to the person with dementia.

Have a great week!

How to Respond to What’s NOT There…

Hello everyone,

Many people with dementia (Lewy Body, Parkinson’s dementia and sometimes Alzheimer’s disease & other dementias) experience hallucinations, usually in the middle to later stages of the disease.

DailyCaring.com has a great article this week with 10 ways to respond when someone is experiencing dementia hallucinations. We encourage you to follow the link below and look through them, and discuss them with your staff. This is also helpful information to share with family and friends who are visiting their loved ones at your care center.


Have a great week!

Breaking Down Language Barriers

Hello everyone,

If you’ve ever traveled to a foreign country where you don’t speak the language, you know how difficult it can be to get directions to a museum or order a meal.  Imagine how frightening and depressing it would if everyone around you spoke a different language, but instead of being on vacation, you were in your own home and needed to communicate more vital information, such as the fact that you were in pain or very confused.

Some of you have asked for tips on how staff can more effectively communicate with and engage residents who do not speak English. This can be challenging, especially with residents who have dementia. With some investment of time and extra effort, however, both staff and residents can benefit.

Here are some things to try:

If the resident has family or friends nearby, or if there is a staff member from the same culture who speaks the same language as the resident, they can be a valuable resource and can teach staff (and even other residents!) some basic phrases to use.

  • Create communication sheets or flashcards with simple phrases in the person’s language (Good morning, Please join us, Are you in pain?, etc.) and hang them in the resident’s room for staff to use.
  • Download a free translation application onto your phone to use when you or the resident have something important to communicate. There are apps that focus on medical terminology too.
  • Be mindful of body language. If a person cannot understand your words, they will rely on your body language and facial expression to help determine your intent. A smile and open stance can be a good start to help put the person at ease.
  • Take time to learn about the culture of the person, and invite family members to bring in food, music or activities from their culture to help entice the resident out of his/her room and get others—including staff and residents–involved.

Let us know if any of these suggestions help you, and have a great week!