Promoting Positive Interactions

Hello Everyone,

In addition to the information we provided about inappropriate sexual behavior in last week’s tidbit, Dr. Elizabeth Galik, one of the investigators on our study, has written an article on this topic for Bottom Line Health. You can read it online here:

https://bottomlineinc.com/health/memory/dementia-and-inappropriate-sexual-behavior

This week, we’d like to discuss how to approach a resident with challenging behaviors in a way that can result in more positive interactions between the caregiver and resident. For example, if a resident scratches, swears or tries to hit a nursing assistant while she is helping the resident with morning care, how does that experience affect her? How will she approach her next encounter with the resident later in the day?

First, we as caregivers should be mindful that people with the dementia are exhibiting these challenging behaviors because of their disease. By not taking their angry words or actions towards us personally, we can objectively think about effective ways to react to their behavior that can result in increased expressions of wellbeing by the resident. Here are some ideas to help:

  • Before approaching a resident that you know can be challenging based on past experiences, take a deep breath and acknowledge your feelings. Are you angry? Anxious? Frustrated? If you enter the resident’s room while projecting these feelings, the resident will often pick up on them and respond accordingly. Try to “reset” yourself before you approach the resident and start with a clean emotional slate.
  • Put aside your expectations of what the resident will do. These expectations can turn into self-fulfilling prophecies.
  • Take a moment to put yourself in the shoes of the resident. Are they scared? Frustrated? Sad? In pain? If they aren’t able to articulate their feelings verbally, they will do this through their behavior. Try to figure out what they may be trying to communicate.
  • Remember the TMT-TMT rule: Too Much Talk and Too Much Touch by the caregiver can sometimes over-stimulate and agitate a resident. In these cases, a simple gesture and silent cuing may suffice. Also be aware of your body language. Standing over a resident can result in a “fight or flight” response. How would you feel if someone stood over you and tried to shove a toothbrush in your mouth?
  • Now, smile and take a few minutes to sit eye-to-eye with the resident (not standing over him), and talk about something you know the person enjoys….sports, upcoming holidays, weather, pets, etc. Starting with some brief moments of calm can have a positive impact on the rest of your visit and help establish trust.

You may have heard something similar to this before—while you cannot control the behavior of a person, you CAN control your response to it. Keep this in mind this week and see if this changes the way you interact with some of your residents.

Have a great week!

Care plan snapshots: Making care plans useful

Developing and updating care plans to ensure they include the required information takes a lot of staff time and attention. Unfortunately, they don’t usually live up to their potential for day to day usefulness and practicality.

To help address this, we’ve developed a Care Plan Snapshot…a “Readers Digest” version of a care plan that highlights the key information that a GNA or other caregiver would find most helpful day to day. It includes short and long terms goal(s), guidance on ADL care that helps residents maintain or improve function, behavioral issues with suggested approaches to care, and motivational ideas based on a resident’s interests. All in just a few pages!

Below is an example of a Care Plan Snapshot for “Mr. WXYZ”, along with an example of a completed capability test for him, which guided the development of the care plan’s goals and ADL care approaches. We invite you to take a look, share with staff, and discuss how this might be beneficial. Feel free to use and adapt as you’d like for your facility. For example, if family members are involved with a resident’s care, you may want to add a section on what family members can do during visits to help their loved one meet his/her goals.

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Capability Test for: Mr. WXYZ                                                     Date: July 19, 2017

Ask and encourage the resident to do each of the following:

  1. Range of Motion (ROM)
  • Full ROM to 180 degrees of abduction (hands over head) __1__ (1 point if yes, 0 if no.)
  • Full external rotation (hands behind head) _1____ (1 point if yes, 0 if no)
  • Full internal rotation and adduction (hands in small of back) __0__ (1 point if yes, 0 if no)
  1. Either lying or sitting, point and flex your toes, bend and straighten your knees, and/or if sitting, ask to march.
  • Able to flex ankle__1__ (1 point if yes, 0 if no)
  • Able to point toe__1___ (1 point if yes, 0 if no)
  • Able to bend and straighten knees ___1___ (1 point if yes, 0 if no)
  • Able to march ___1_(weak)_ (1 point if yes, 0 if no)
  1. Chair rise – observe to do this independently or how much help is needed (give up to 10 minutes to complete the task)
  • How many tries does it take? __0_ (Scoring: 1-3 tries= 1 point; > 3 tries = 0 points)
  • Do they use their arms? ___0___ (0 point if yes, 1 if no)
  • Can they make it to a full stand and stand independently for 1 minute? ___0__

(1 point if yes, 0 if no)

  1. Follow a one, two, or three step commands doing a functional task:

Ask the participant to take a towel, fold it in half, and put it on the table (bedside table or bed or whatever is available).

  • Follows a one-step verbal command __0____ (1point if yes, 0 if no)
  • Follows a two-step verbal command ___0____(1point if yes, 0 if no)
  • Follows a three-step verbal command ___0___ (1point if yes, 0 if no)
  • Follows a one-step visual/cueing command ___1___ (1 point if yes, 0 if no)
  • Follows a two-step visual/cueing command ___0___ (1point if yes, 0 if no)
  • Follows a three-step visual/cueing command ___0___ (1 point if yes, 0 if no)

Total Score:  7 (max = 16)

HIGHER SCORES ARE BETTER CAPABILITY

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Care Plan Snapshot

Resident Name: Mr. WXYZ
Room number:  0A

 

Care Goals

Short term goal #1: Resident will attend at least one preferred activity each day to decrease boredom and restlessness
Short term goal #2: Resident will perform sit-to-stand exercises at least once daily with assistance from staff to increase strength, maintain ability to transfer, and decrease risk of falls
Short term goal #3: Resident will go outside at least once per day, weather permitting, with assistance from staff
Long-term goal: Resident will show an increase in expressions of wellbeing (smiling, laughing, engaging in activities) and a decrease in expressions of distress (agitation, restlessness, wandering and apathy).
Care Area Resident Responsibilities Staff Responsibilities
Physical

Activity/

Ambulation

Resident will self-propel in WC, perform sit-to-stand exercises with assistance daily, participate in at least one scheduled activity daily, visit outdoor courtyard once daily, and transfer out of WC and into chair for all meals with assistance

 

 

Staff will encourage resident to self-propel in WC, assist with sit-to-stand exercises after lunch daily, encourage and assist resident to attend at least one daily activity with staff; visit outdoor patio with assistance from staff once daily, and assist with transfer out of WC for all meals
Bathing/Grooming Resident will wash/dry face and upper body with visual cuing from staff

 

 

Staff will provide 1-step visual cuing and encouragement for resident to wash/dry face and upper body
Dressing Resident will dress upper body with visual cuing from staff and engage in AROM while getting dressed

e.g., wave to friend in the hallway, march knees up to hit GNA’s hands, swim strokes

 

Staff will provide 1-step visual cuing to assist resident in dressing upper body; assist resident to perform AROM while dressing using 1-step visual cuing; ask resident to lift legs to help dress lower body
Eating Resident will eat finger foods and use utensils as needed with visual cuing from staff

 

 

Staff will place one food on plate/in bowl at a time, cut foods as needed and provide finger foods to encourage independence; use visual cuing with utensils
Oral Care Resident will brush teeth twice each day with 1-step visual cuing from staff as needed

 

Staff will have supplies ready and provide 1-step visual cueing and encouragement
Toileting

 

Resident will assist with transfer to toilet

 

Staff will encourage toileting after meals or at designated intervals; use 1-step cues during transfers; monitor for skin breakdown
Behavioral Issues:  Restlessness, agitation; occasionally engages in disruptive vocalizations, apathetic
Related to: Schizophrenia; Alzheimer’s disease; difficulty adjusting to new surroundings
Approaches by staff:

  • Assess for boredom, pain or other behavioral and psychological symptoms of dementia
  • Engage resident in sit-to-stand exercises, visits outside and other physical activities regularly
  • Provide consistency in care using same caregivers when possible; communicate successful strategies with other caregivers
  • When resident shows signs of boredom or agitation, attempt to engage him in one of his favorite activities, e.g., a game of horseshoes, going outside to courtyard, visit with receptionist
  • Respond calmly to resident during times of agitation, allow resident to vent feelings, and provide ample time for resident to respond to simple questions and direction from staff
  • Model behavior for resident
  • Offer choices to resident when available
 

Motivational ideas/Rewards:

 

(What are his interests, likes/dislikes, strengths? Who are his favorite caregivers?)

Mr. WXYZ loves to go outside and visit with his buddies. They like to talk about their time in the war. He also enjoys listening to jazz music, and it calms him down when he is agitated. His favorite GNA is Mary. He does not like eating in bed or playing games like BINGO, because they are for “old” people.

 

Combating combative behavior

Here’s a short and sweet—and very practical—tidbit that one of our intervention nurses shared:

In the past when staff have exhausted all approaches/interventions to stop or decrease a resident with combative behavior, I have cut a pool noodle in half or thirds and had the resident hold it in each hand.  I’ve also given the resident gum to chew in order prevent biting the staff.

This beats the alternative of heavily medicating.

Best practice: Fall risk reduction

Falling is an ever-present concern and challenge for nursing homes, and falls at home is often the reason why family members decide to move their loved one to a nursing facility. 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/ a quick stand up for a moment or two / a hug and a dance…..
  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!
  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!

Going outside: Residents need fresh air and sunshine

We hope you all had a chance to spend at least a little time outside over the July 4th holiday. Did your residents?

Fresh air and sunshine can do wonders for people’s spirits, especially for people with dementia. Research has shown that when people can freely use outdoor areas, agitation and aggression reduce, independence is promoted, and memory recall is more likely to occur. An outdoor space or garden gives people the chance to be physically active, feel unrestrained, be more in touch with nature, socialize, and do meaningful activities (like plant flowers) that make them feel at home. It can also help maximize sleep duration for residents who have trouble sleeping through the night.

Find more information at:

https://www2.health.vic.gov.au/ageing-and-aged-care/dementia-friendly-environments/gardens-outdoors

And while indoor household tasks like folding laundry and sweeping floors can help engage residents in meaningful activity, this can work outside too! Have residents help sweep leaves and dirt off the deck or patio, pick up sticks, fill the bird feeder, and plant or water the flowers. There are lots of outdoor games too…horseshoes, beanbag toss, walking races, and beach ball volleyball to name a few.

What can you do this week to get more residents outside?

Engaging residents with apathy

A person who is withdrawn or apathetic is someone who is socially withdrawn and is experiencing a loss of interest and motivation. Behaviors that reflect being withdrawn or apathetic might include:

  • sitting alone in one’s room
  • avoiding contact with others
  • making limited eye contact with others.

It’s important to note that these behaviors are not often considered problematic because they don’t call attention to themselves like screaming does. They can, however, lead to rapid loss of cognitive and physical function.

How to approach the person who is withdrawn or apathetic:
  • Try to engage the person in creative activities.
  • Give instructions slowly and break tasks down into manageable portions for the person.
  • Remain positive and calm with the person.
  • Encourage the person to do what they can for themselves and provide praise often.
  • Avoid excess stimulation such as large crowds or loud noises.

Things to try:

  • Sensory stimulation may be helpful. Some ways to do this might include playing music, looking through visually stimulating thing such as pictures from old calendars or holiday cards, and touching or holding a stuffed animal.
  • Involving the person in cooking or baking activities can help stimulate the sense of smell and be a good time to talk and reminisce with the person as their memory allows.
  • Consider the persons’ preferences. For example, if the person is fond of animals, bring in a therapy dog as a way to spark interest and movement (reaching, petting).
  • A visit from young children can be a wonderful, heartwarming way to engage a withdrawn older adult.
  • For many, a short walk or simply sitting outdoors for a short period of time can offer valuable sensory stimulation.
  • Try to engage the person in a 1:1 or small group social activity.  Try to individualize social contact, which can include casual conversations or “small talk.” Adapt the conversation based on how advanced the person’s dementia is. For someone with very advance dementia try to focus mostly on questions involving “here and now” discussion such as comments about music playing, food being served or the weather. For an individual with mild to moderate dementia, small talk can be facilitated by asking the person simple questions, such as: “did you ever play football in school?” or “have you always lived in Wisconsin?”
  • Talk to family members to learn more about the person’s history and use this information to plan activities. For example, a painter could help make posters for events; a policeman could “walk the beat”; a homemaker could help knead dough, dust or sweep the floors.
  • Another simple strategy for facilitating social contact is to share information about your life or plans for the day and ask the person with dementia for their input about things you share using straightforward questions.

Reducing resistance to care

Resisting care, sometimes called combative with care, is a common behavior that is different from agitation or aggression. A person who is resisting care may pull away, attempt to leave or become agitated or aggressive during care activities. An example of a person resisting care may be saying “stop that, leave me alone!” and pulling away from staff during a specific care activity such as bathing. It is thought that resistance occurs because the person does not understand the care activity and sees this as an invasion of their personal space or a threat to their safety.

How to approach the resident:

  • Assume a non-threatening posture: smile and speak in a pleasant tone of voice, keep arms open (not crossed), conduct care at the resident’s eye level and from the side.
  • Don’t stand over the resident
  • Slow down care and ensure you are communicating clearly and explaining the task in a step-by-step process.
  • Do not use “baby talk” (elder speak) when delivering care.

General strategies to reduce care resistance:

Encourage the person with dementia to do as much for themselves as they can. Put objects necessary for the task within their field of vision so they are more easily located and remove objects that are unnecessary or distracting.

  • Identify long-standing habits and adjust routines accordingly. For example, if the resident is used to doing oral care at the sink, take them to the bathroom to complete this part of their care.
  • Consider whether the activity may be uncomfortable or painful and consider pain treatment before the activity.

Best practice: Disruptive vocalizations

Disruptive vocalizations are any verbal noises (screaming, yelling, nonsense talking, cursing) which are generally considered unusual, inappropriate or are upsetting to others. Disruptive vocalizations may be the result of a person having unmet needs and not being able to express them to staff or may be due to too much or too little sensory stimulation.

So what should you do (or not do)  when a resident is making disruptive vocalizations?

Don’t  tell the person to “stop” or that their behavior is driving people to distraction.
Do listen to what the person is saying and see if you can identify any concrete need or request in the vocalization.

Some specific things you can try:

-Check for the presence of needed sensory aids (i.e. glasses, hearing aids) and provide them if missing.
Assess for too much (loud TV in room) or too little stimulation (resident is alone) in the environment and provide interventions based on the findings.
-Sing a favorite song with the resident (people are unable to sing and scream at the same time).

Best practice: Oral care

Oral care is extremely important for everyone, and older adults are no exception. Yet sometimes, after we help a behaviorally challenging resident get bathed and dressed, proper oral care can become an afterthought. It can also be one of the most difficult personal care activities to have a resident perform. Here are some tips to help you work with a resident with BPSD who needs assistance with oral care:

  • If a resident is reluctant to brush her teeth or refuses when you initially ask, try to distract her with another brief enjoyable activity or conversation and then try again.
  • Have supplies ready before you begin: toothbrush, toothpaste, cup, and mouthwash if using.
  • If a resident will not open her mouth, ask her to say “eeeee” as this will naturally get her to open her mouth enough to sneak in a toothbrush. Or you can try singing together and sneak in the toothbrush then.
  • Since teeth brushing can feel invasive and even threatening when done by a caregiver, encourage independence in this task. By role modeling in front of a mirror, while you stand beside the resident, you can cue the resident to engage in the task without having to touch him/her.
  • If a resident is physically unable to brush his/her teeth independently, use the hand-under-hand technique so the resident is still participating in the activity with you and can maintain a sense of control. If the resident can’t hold the brush or resists, shake hands with him, turn your hand palm up so they only see their hand, use your skill fingers (thumb and first two fingers to hold the toothbrush and you can guide it in.  Those with significant dementia think they are doing it rather than you.  If a resident is able to hold the toothbrush and just needs some guidance, you can simply place your hand over their hand and help guide them.
  • Some people don’t do well in the bathroom. Considering having residents brush their teeth while sitting on their bed.
  • Lastly, keep in mind that the toothpaste is the least important factor. The friction from a damp toothbrush is the most important, and every brush helps!

This 3-minute video illustrates these tricks of the trade in action: http://www.functionfocusedcare.org/oral-care

 

Increasing resident engagement in activities

We’ve talked about how encouraging residents to participate as much as possible in their own care can help maintain or even increase function and decrease negative behaviors. Let’s remember that residents with moderate to severe dementia can have fun too!

How often do we see a group of residents participating in a recreational activity, but notice that at least a few of them are left out? Sitting in the corner looking on? Often, these more “challenging” residents are the people who most need to be active and engaged in activity so they avoid feelings of frustration, agitation, and boredom.

To help with this, here are some activity ideas that your nurses, nursing assistants and recreation staff can use to get residents with cognitive decline in on the fun:

  • Flyswatter volleyball: Give residents plastic flyswatters have them hit a balloon back and forth to each other
  • Dance, dance, dance! Turn off those televisions and turn on some music and dance. Have staff members take turns playing music from their iPods through a speaker. Fast or slow, old or new, music has the power to move everyone.
  • Horseshoes: Now that summer is here, horseshoe games are everywhere. Look for the foam kind and play inside or outside on a patio. Residents can play while standing or sitting.
  • Foam swim noodles: Get a bunch of these, cut them in half, and start bending. These make for great resistance exercises! Leave them out in common areas for a safe, easy way to start spontaneous exercise.
  • Movement scarves: These can be found on enasco.com, or you can make your own with a lightweight material. Toss these colorful scarves in the air and have residents try to catch them. These scarves can be better than throwing a ball back and forth since people with slower reflexes and limited hand flexibility can catch them more easily.
  • Chores! Yes, chores. Your kids might not agree, but for older adults with dementia, doing familiar household chores can be calming and comforting. Grab a basket of cloth napkins and ask them to help you by folding them. Give them a broom and ask them to help you sweep the floor since company will be coming. Get some pillowcases or old clothes, hang a clothesline between a few walls, and give them some clothespins. They can hang the laundry.
  • Don’t forget to go outside! Warmer days are here now, so in the morning or early evenings when it’s a bit cooler, go outside. The sunshine, change of scenery and fresh air is something we all need. Look at the flowers, look for birds, and have some lemonade.