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 (, 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. 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!


Short Videos Provide Practical Tips for Staff

Hello everyone,

As you continue to work with the “Champions” at your care communities, we encourage you to show them these brief videos from the Function Focused Care website:

The six videos offer practical tips on how to engage residents with cognitive impairment and help them perform activities of daily living, which is when challenging behaviors often occur in people with dementia. There is a video on each of the following topics:



Oral Care and grooming


Encouraging group activity

Motivating people to go outside

You can even show the videos on a mobile device to GNA’s and other busy staff, as each video is only about 3 minutes long! Consider showing a different video at each of your next staff meetings, and discussing the ideas presented. Could some of the approaches shown work with your more challenging residents? Let us know how you use them at your community.

Have a great week!

Never Give Up…EVERYONE Can Find Something They Enjoy

Hello everyone,

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 Spring is (sort of) 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 (you can find them at places like Five Below or WalMart and pools stores), cut them in half, and have residents hold one at each end and bend. The closer together their hands are, the harder it is to bend. 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, 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.

One final note–never give up! Never stop asking a resident to participate. You never know…maybe on the 50th try, they’ll say “yes!” Here’s a great example…at Future Care Sandtown in Baltimore, one of the residents is blind. Staff said he usually stayed in his room all day and listened to the television. With a little extra coaxing from the staff, he came out of his room and they played music for him and he danced! Now he does it all the time. Great job, Sandtown!! Keep up the good work.


Have a great week!

Are Your Policies Helping or Hindering?

Hello everyone,

Policies are certainly a necessity in community care environments, but sometimes they can have unintended consequences. 

For example, is it your community’s policy (either written or unwritten) to have all exercise and activity items locked away when not being used during a scheduled activity so they aren’t “misplaced” by residents? While safety and security are important, we should keep in mind that putting these items away can prohibit spontaneous activity when it is most needed, such as in the evenings or when someone is wandering or agitated and could benefit from an activity to distract or expend excess energy. Items like foam swim noodles and foam horseshoe games can safely be left out in common areas, and are inexpensive to replace if they go missing.

If leaving these items out in the open is still frowned upon, having them out of sight but centrally located and easily accessible can also work. Make sure that all staff know where the items are kept so they can be quickly retrieved when needed and not locked away.

Communities often encourage staff to clean exercise and activity items after each use. Consider having antibacterial/antiviral wipes nearby so they can be quickly wiped down and ready to be used by others.

Have a great week!

Small Steps Lead to Steady Success

Hello everyone, 

When we consider integrating changes to a philosophy of care it is important to remember that small, gradual changes can lead to more lasting success. Attempting to take on too much, too quickly can result in frustration or a feeling of being overwhelmed. 

When it comes to managing behavioral symptoms related to dementia, consider having nursing staff choose a few residents with less challenging behavioral symptoms to begin. Staff can hold weekly “huddles” to discuss ideas, challenges and successes they have had with individual residents. This can help them build confidence in their abilities and foster teamwork as well as trust in the approach to care that we are encouraging. 

Have a great week!


Focus on Families

Hello Everyone,

Educating family members of your residents about your efforts to reduce the behavioral and psychological symptoms of dementia through person centered behavioral approaches is critical. Family members can support staff and be a useful resource when exploring their loved ones’ preferences and determining what may motivate a resident to participate in his/her own care and engage in activity, which can lead to decreased agitation, apathy and resistiveness to care.

 One of the ways you can educate family members is by including information on your facility’s social media, in your newsletter or other regular mailings/emails your residents’ loved ones. Below is a pre-written piece to help get you started: 

Research repeatedly shows that older adults can improve their physical and mental health, slow cognitive decline, and increase their ability to participate in personal care needs like bathing and dressing by engaging in regular physical activity. Physical activity can also help decrease symptoms of dementia such as agitation, aggression, resistiveness to care and depression. Even short spurts of 10 minutes of activity can result in significant physical and emotional benefits. Being able to care for oneself as much as possible also helps preserve the dignity and independence that we all hope for as we age.

With this in mind, our staff will be working with your loved one to participate as much as possible in personal care activities and to engage in physical activities such as walking or self-propelling in their wheelchair to the dining room or doing some stretching and strengthening exercises while waiting for meals. You can help too. Go for a walk with your loved one when you visit, or ask a staff member to show you some exercises you can do with them while you visit. Ask their caregiver what activity goals they have for them and encourage your loved one as they try to reach their goals. Finally, support your family member’s caregivers as they use their knowledge and skills to involve your loved one in their care and other activities in order to transform expressions of distress into expression of well-being—a goal we all share.

Feel free to contact us if you have any questions about working with family as we move forward.

Have a great week and Happy Easter!