Holiday tidbit contest

Hello everyone,

In order to get everyone into the holiday spirit, we are excited to announce our Holiday Tidbit Contest! As you celebrate the holidays with residents at your facility, consider person-centered approaches to help decrease behavioral and psychological symptoms of dementia.

 For example, music is a big part of the holidays, so try playing classic holiday songs during care activities or while writing out Christmas cards with residents. Ask visitors to take residents for walks around the facility to look at the holiday decorations. Do you have residents who liked to bake? Host a cookie decorating party for residents and their guests. You can supply the pre-baked cookies, and residents can add the icing and sprinkles. Messy, but fun! Keep in mind that for some residents, the extra “hustle and bustle” around the holidays can be too much stimulation for them, and they may need extra breaks throughout the day for quiet time and rest.

 This article from Daily Caring.com has some great tips and ideas too:

http://dailycaring.com/5-best-alzheimers-holiday-tips-for-an-enjoyable-season/?utm_source=DailyCaring&utm_campaign=e65bccd561-DC_Email_2017-12-11&utm_medium=email&utm_term=0_57c250b62e-e65bccd561-123152321

 Email your tidbit (it only has to be a paragraph!) to Erin Vigne (vigne1@verizon.net) by January 7th. Those who send in the winning tidbits will win a prize for their facility!

Have a great week, and we can’t wait to read YOUR tidbits!

Non-verbal communication techniques

Hello everyone,

DailyCaring.com has a great piece this week about non-verbal communication with people with dementia. Sometimes our words are misunderstood, and body language can say far more. Take a moment to read more (link to article is below) about the 6 nonverbal communication techniques that can make caregiving easier with your residents:

  • Be patient and calm
  • Keep voice, face and body relaxed and positive
  • Be consistent
  • Make eye contact and respect personal space
  • Use gentle touch to reassure
  • Observe their nonverbal reactions

Have a great week! 

 

Non-pharmacological approaches to BPSD

Hello everyone,

Last week we discussed some of the negative side effects of psychotropic drugs commonly used to treat behavioral and psychological symptoms of dementia (BPSD) and a 5-step approach to reduce their use. The next step is to explore alternatives to pharmacologic treatment to decrease these challenging behaviors. Educating staff and loved ones of residents about these alternatives is critical to successfully addressing BPSD for the long term.

 According to the IPA Complete Guides to BPSD , a large body of evidence supports the use of psychosocial interventions for BPSD and these approaches are indicated as first-line management. These interventions work best when they are tailored to people’s backgrounds, interests and capacity. See the PELI Tools. 

 Treatment Principles for BPSD (from the IPA Complete Guides to BPSD, Module 5):

  • Address one symptom at a time
  • Follow the ABC approach: Specify the Antecedent of Behaviors (circumstances that spark them) and their Consequences (what makes them better or worse)
  • Measure the symptom before an after making an intervention to confirm that it is effective
  • Start with a small achievable goal and proceed step by step
  • Apply the intervention consistently. Do not expect immediate change; improvement takes time
  • Continually evaluate and modify plans. Decide in advance what “success” means for this person
  • Think in advance of an alternative strategy if this one fails

 Researchers continue to conduct a variety of studies to determine the effectiveness of non-pharm treatments including:  activity and recreation, aromatherapy, family tape-recordings, music and sound, one-to-one interaction and physical activity. 

Attached is a pdf file with Module 5 of the IPA Guide to BPSD, which includes much more information on non-pharmacological treatments. Since these approaches need to be feasible in addition to being effective, the Nursing Home Toolkit includes practical guidance for nursing home providers who are trying to integrate non-pharmacological approaches to address BPSD.

 Have a great week!

IPA complete guide to BPSD: Non-Pharmacological treatments

Antipsychotic medication reduction and appropriate use

Hello everyone,

 The use of psychotropic drugs for people with dementia living in long term care facilities is common, but research continues to show that their risks often far outweigh their benefits, and they are effective for a limited number of symptoms. The Centers for Medicare and Medicaid Services’ national initiative to improve behavioral health and decrease antipsychotic use among nursing home residents with dementia has prompted the education of interdisciplinary healthcare teams, patients and their families about the use of psychotropic drugs and effective alternatives to them. Attached is a helpful tool developed by the American Medical Directors Association that you and your team can use to assess a dementia patient’s antipsychotic use.

 While research has shown short-term effectiveness of psychotropic drugs in the treatment of those with psychotic symptoms (hallucinations, delusions) and significant physical aggression, there is little evidence of efficacy of these drugs with restlessness, verbal outbursts and resistance to care. Rather, these issues can be better addressed through behavioral interventions, which we will discuss in next week’s tidbit.

 Risks of antipsychotic medications include:

  • Falls & fractures
  • Sedation, delirium, functional decline
  • Extrapyramidal symptoms
  • Anticholinergic side effects, e.g. orthostasis, constipation, blurry vision
  • Hyperglycemia
  • Hyperlipidemia
  • Drug interaction potential
  • Pneumonia
  • Cardiovascular risks
  • Death—morbidity is highest in first 30 to 40 days

 Psychotropic drugs, especially antipsychotic drugs, are often prescribed too often and for too long. Evidence has shown that psychotropic drugs can be safely discontinued in many cases. Consider this 5-step approach when determining the appropriateness of a psychotropic drug for a patient, and when it is time to reduce dosage.

 A Five-Step Approach to Antipsychotic Reduction & Appropriate Use

  1. Assess facility policies, environment and culture, and baseline data: what are your beliefs about antipsychotics? Is there adequate staff to support non-pharmacologic approaches? Are current activities appropriate and effective? Can the environment be altered to decrease symptoms? What is rewarded…i.e. is quiet and sleeping rewarded more than functional and moving?
  2. Staff and family education: Do family and staff understand the limits of the efficacy of the drugs, along with their risks? Are they aware of non-pharmacologic interventions and their benefits?
  3. Interdisciplinary team of champions: Partner with consultants; not just about filling out tracking forms; staff should communicate regularly with drug prescribers to help determine when it’s time for a gradual dose reduction
  4. Start with “low hanging fruit”: Start with a patient whose medication is not effective, or has negative side effects, or who is already on a low dose of a medication or PRN, with no clear history of aggressive behavior or psychosis, and no GDR in 6 months. Go slow, develop strategies with clinician prescribers, reassess, be mindful that this may not be successful, involve family and put a non-pharmacological plan in place.
  5. Ongoing motivation and mentoring: Assess for change in target symptom, evidence of adverse effects or functional decline; gradual dosage reduction should be considered in 3-6 months once symptoms have been effectively treated OR if adverse effects outweigh benefits.

 Next week, we’ll discuss non-pharmacological approaches to use in place of psychotropic medications to address behavioral and psychological symptoms of dementia.

Link to this document to assess antipsychotic medication use in persons with dementia- Multidisciplinary_Medication_Management

Have a great week!

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!

 

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!

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!