Recreational activity ideas

Hello everyone,

With the holiday season upon us, we hope that many family and friends will be visiting their loved ones at your nursing homes. You and your staff may already be planning special holiday events for visitors to attend with the residents.

 But when there isn’t a specific event planned, visitors can sometimes feel unsure of what to do with their friend or family member, especially if their loved one has challenges with communication or mobility.

 A nursing home in Pennsylvania has a great solution for this! The Meadows developed a travel activity box, an open suitcase that sits in the foyer and is filled with activities for residents to do with friends and family. The box contains magazines, adult coloring pages with colored pencils and crayons, checkers, crossword puzzles, puzzles and decks of cards. Guests are encouraged to pick some activities, and then return the games and supplies to the box when they leave.

 Why not make one of these boxes for your facility in time for the holidays? Be creative with what you include in it! To encourage visitors to engage in more physical activity with residents, you might include resistance bands for exercise or balloons to blow up and toss back and forth. The grandkids will love it!

Have a great week!

 

Reducing inappropriate behaviors

Hello everyone,

Since we recently received a question from one of our study participants about how to deal with sexually inappropriate behaviors exhibited by some residents with dementia, we thought we would address this in a tidbit to give you all some strategies for how to respond when this happens at your nursing home.

This information comes from the Nursing Home Toolkit

Examples of sexually inappropriate behaviors include socially unacceptable behaviors toward self in public (such as disrobing, fondling and masturbating) and inappropriate behaviors directed at others (such as sexually explicit comments and inappropriate touching). Behaviors that are considered sexually inappropriate may be related to the human need for intimacy, although it may also be triggered by something in the environment such as suggestive television programs.

When a resident is exhibiting behaviors that are sexually inappropriate, remain calm and professional and gently—yet firmly—redirect the behavior by telling the person it is inappropriate and unacceptable.

When responding to these behaviors:

  • Let the person know how their behavior affects you and others. For example, “Mr. Jones, I don’t like it when you take your pants down. It makes the other nurses and me very uncomfortable.”
  • If the behavior persists, walk away and tell the resident, “I will come back once you stop exposing yourself so I can take care of you. Right now I am uncomfortable staying here.”

Some strategies to reduce sexually inappropriate behaviors include:

  • Redirect behavior through the use of food, drink or conversation.
  • Distract the person through activities that have meaning for the person and involve the use of the person’s hands, such as exercise or folding towels.
  • Provide stuffed animals to the person for grasping/fondling.
  • To help prevent disrobing and masturbation, choose clothing for the person to wear that opens in the back.
  • Identify and try to eliminate any triggers to the behavior.

As always, please feel free to share your experiences with us, and what has worked for you to help you deal with these challenges.

 Have a great week!

Respecting choices-Improving the lives of persons living with dementia

Hello everyone,

You are likely familiar with the idea of person-centered care. In the long term care setting, person centered care promotes residents’ choices, increases their sense of purpose, and provides a greater personal connection for those who need assistance from others with daily tasks.

An important part of providing person-centered care involves learning the preferences of the residents: What activities do they like to do? Who do they enjoy spending time with? What makes them happy? By respecting the preferences of residents and integrating those preferences into daily life, we can help increase their sense of wellbeing and provide an opportunity for them to thrive. And in addition to benefiting residents, person-centered care also helps increase the job satisfaction of staff, and meet current regulatory mandates.

We invite you to take a moment to watch this brief and fun “white board video” that discusses preference-based living in long term care, and illustrates why preferences of residents matter:

You can also access tools to use to help identify residents’ preferences by going to the Preference Based Living Website!

Give this a try with one or two of your residents this week, and let us know how it goes.

 

Have a great week!

Evidence-based strategies for pain reduction and a DICE suggestion from a community care partner

Hi everyone,

First off, thank you to Stella Maris of MD for sharing this great example of DICE with us:

 D- Resident urinating in a cup in the dining room and on the floor in the corner of his room.

I- Resident is a retired truck driver and would urinate in empty bottles/ cups in the cab of his truck while traveling long distances.

C- Staff have identified the resident’s cues when needing to go to the bathroom. He seeks out cups and heads toward any corner in the dining room.  Staff redirects resident to bathroom which has a bright colored sign on the door indicating it is the bathroom.

Staff also have placed a urinal next to his bed to cue him to use it when needing to urinate at night.

E- Resident has decreased episodes of public from daily occurrences to 1-2 times a week.

We invite you all to send us your examples too. You’ll win a gift for your residents if you do!

Next, since we discussed identifying and assessing pain in residents with dementia last week, this week we are focusing on some pain interventions. The following link is to a list of evidence-based nonpharmacologic interventions for pain that you may find helpful. It was prepared by Linda Keilman, DNP, GNP-BC of Michigan State University, College of Nursing:

https://www.nhqualitycampaign.org/files/Guide_to_Evidence-based_NonPharmacologic_Interventions_for_Pain.pdf

Dr. Keilman notes that we should address pain with the following outcomes in mind:

  • Improvement in quality of life
  • Maintaining function (physical, emotional, spiritual)
  • Maintaining cognition
  • Alleviating or reducing pain through a combination of medication and alternative interventions

Keilman, Linda (2015). Compendium of Evidence-Based Nonpharmacologic Interventions for Pain in Older Adults. Copyright 2015 by LJKeilman, East Lansing: Michigan State University, College of Nursing.

 Some of the many pain interventions to consider in addition to traditional pain medications such as NSAIDS and acetaminophens include:

  • environment modifications such as adjusting room temperature, lighting and sounds
  • cold or heat therapy (icy-hot lotions, like those with Lidoderm, can be helpful and applied often)
  • exercise
  • controlled breathing
  • music therapy
  • art therapy
  • pet visits
  • distraction or diversion

 Effective interventions will vary by person, so you may need to try several different things before finding an intervention that works for a resident. Considering the many negative physical and emotional consequences for a person in pain, we can all agree that these interventions are well worth the effort.

Have a great week!

Holler if it hurts? Strategies for identifying & assessing pain in people with dementia

Hello everyone,

Much research has shown that people with dementia are at an increased risk for having their pain under-assessed and under-treated, leading to serious physical and psychosocial consequences including:

  • Gait impairment (leading to increased fall risk)
  • Decreased appetite
  • Sleep disturbances
  • Agitation
  • Physical combativeness
  • Wandering
  • Decrease in daily activities
  • Impaired cognition
  • Verbal aggression
  • Depression
  • Social isolation
  • Learned helplessness

(Shega J., Emanuel L., Vargish L., Levine S.K., Bursch H., Herr K., Karp J.F. & Weiner D.K.  (2007) Pain in persons with dementia: complex, common, and challenging. The Journal of Pain 8, 373-387.)

 If you and/or staff observe some of these behaviors in a resident with dementia, do not assume it is part of the disease. Rather, take some time to assess the person for pain.

While self-reporting pain-rating scales such as Verbal Rating Scales and Facial Pain Scales remain the ‘gold standard’ when assessing pain in older adults, people experiencing moderate to severe stages of dementia may be unable to communicate the existence and severity of their pain.

 A widely used tool called “PAINAD” (Pain Assessment in Advanced Dementia, developed by Victoria Warden, Ann C. Hurley, and Ladislav Volicer) can be used to identify and assess pain in older adults who are unable to verbally communicate. Click here for the tool: http://www.mghpcs.org/eed_portal/Documents/Pain/Critical_Care/Dementia_Pain_Tool.pdf

To use the tool, caregivers observe the patient during periods of activity and record behavioral indicators of pain:

  • breathing (normal, labored, noisy?)
  • negative vocalization (none, groaning, crying?)
  • facial expression (smiling, sad, grimacing?)
  • body language (relaxed, tense, pacing, rigid?), and
  • consolability (no need to console, distracted by voice/touch, unable to console?)

 Once you’ve identified and assessed the pain in a patient, you’ll need to plan an intervention. Some behaviors, such as verbal agitation, pacing and restlessness, improve most with pain treatment. Other behaviors such as hitting, kicking, scratching respond less to treatment.

We’ll discuss some pain interventions next week. In the meantime, don’t forget to send us your DICE examples to win a prize for your facility!!!

Have great week!

Share your ideas with our care community- Tidbit suggestions

Hello everyone,

Now that we’ve reviewed the four components of “DICE” for assessing and managing behavioral issues with residents who have BPSD, it’s your turn to show us how you have used this process in your own facility.

Please send us a brief example of how you or your staff have used DICE when addressing a specific behavioral issue of a resident. The best examples will win a prize for their facility, and we’ll share the examples in future tidbits so everyone can benefit! We look forward to hearing from you. Send suggestions to vigne1@verizon.net!

Have a great week!

Creating and evaluating the plan for managing behaviors- The DICE model in action

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.

Be on the lookout for another contest announcement in next week’s tidbit!

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 in 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. Under stimulation can lead to boredom, which can lead to 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 read 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!

Describing behaviors- The first part of DICE, a tool to assess and manage behaviors

First off, congratulations to Future Care Irvington, who sent in the winning tidbit for our contest!!! We asked you to send us tips for how you get your more challenging residents to bathe. A nursing assistant at Future Care Irvington said she gives verbal cues to her resident, one step at time, and talks to the resident about her interests while bathing. Great job, Natalie, and keep up the good work!

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.

“I want to go home”- Strategies for responding to this request

As we watch news coverage of the devastating effects of hurricanes Harvey and now Irma, we are reminded how important the idea of home—and feeling safe at home—can be. For most of us, thoughts of home evoke feelings of comfort, safety and familiar surroundings. It’s understandable then that when a resident with dementia says repeatedly that she wants to go home, what she may really be asking for is comfort and to feel safe. Understanding this can help staff and family members better respond to residents when they tell us they “just want to go home.”

DailyCaring.com has a helpful article on this topic, with three suggestions on how to respond when a residents tells you that he or she wants to go home: http://dailycaring.com/3-ways-to-respond-when-someone-with-alzheimers-says-i-want-to-go-home/

Lastly, this is a last call for tidbit contest entries! Please email us (vigne1@verizon.net) a brief “tidbit” of your own that describes how you or a staff member at you facility has been creative in getting residents to shower or bathe without a battle.

The facilities that email us the winning tidbit entries will each receive a gift card towards treating staff to lunch! We will also share your idea in a future weekly tidbit so your experience can help others too. We look forward to reading your great ideas….we know you have them to share!