“The squeaky wheel gets the oil” is a well-known proverb. In terms of challenging behaviors, the man running down the hall naked or the woman crying loudly at lunch generally get our attention more quickly than the quiet lady in room 101 who likes to keep to herself and “isn’t any trouble.”
In fact, all of these behaviors are in need of our attention, including the lady in room 101. Apathy is one of the most common and persistent of the behavioral and psychologic symptoms of dementia, and has profound consequences for morbidity and mortality. While research shows that apathy is associated with changes in brain function in people with neurodegenerative disease, it also shows that individual, caregiver and environmental factors also precipitate apathy.
Non-pharmacologic approaches to apathy have shown to be more effective (pharmacologic approaches have shown modest results), with tailored activities based on the person’s history, preferences and retained abilities. These person-centered activities can supply intrinsic motivation by capturing the interest of the person and providing them with a reward. Music therapy, multi-sensory behavioral therapy, art therapy, cognitive stimulation, and therapeutic conversation are some interventions to try.
We invite you (CONTEST ALERT!) to send us a tidbit about how you manage residents with apathy at your community. Did something specific you did work for a resident? What are some of your creative ideas for how to approach apathy? The communities that send us the best tidbits will win prizes! Please email them to firstname.lastname@example.org.
Have a great week!
Here are a few more tidbits from your fellow nurses and nursing assistants working in Pennsylvania nursing homes. Thanks for sharing your ideas and approaches to care! We all benefit from everyone’s experiences and successes.
Joyce Sebring, who works at St. Mary’s Villa in Pennsylvania, shared her approach for dealing with restless residents. She likes to give them something to do pertaining to their hobby/job, such as paperwork for a former secretary, an old lamp to fix for an electrician, and building blocks (PVC piping is good too!) for a carpenter. Joyce also uses memory games she finds in stores that address sight, smell and touch. Looking at memory books made by family members can also help calm a person who is restless.
We liked that this idea tailors staff response to the behavior through recognition of the residents’ past work and hobby preferences.
Janice Sparrow (pictured below) is an RN at Linwood. When a resident is calling out for a family member, she gives him/her a picture album of the resident’s family for the resident to look through. We like the clear and direct link between behavior and positive response by the staff.
What about aggression? At the Meadows, Jennifer Merthew (pictured below) talks with residents to calm them and allows the residents to talk about what is upsetting them. Her advice is to never ignore the emotions of the resident, but rather encourage expression of feelings in a safe location such as their room or another quiet spot. We like the honoring of a resident’s voice in this response, specifically listening to the resident and “never ignoring” that they are communicating an emotional need to us.
Melissa Neishell, RN (pictured below) has had residents who scratch and pick at their skin. She recommends changing their detergent and/or hygiene products and creating a cooler environment. We like the consideration of physical causes here, and that you are not overlooking the obvious. This is the “I” in DICE. Nice job everyone and have a great week!
Here’s a sweet story from down under. This couple has been married for 38 years, and the husband has Alzheimer’s disease. He had forgotten that he was already married to his wife, so he proposed to her again. She lovingly said “yes”, and thought he would let it go. He didn’t—he wanted a wedding, so their friends pitched in to throw them a wedding ceremony! See the heartwarming video here:
Sometimes with dementia, the best thing to do is go with the flow and let the patient guide you instead of the other way around. It will give you a window into what they are thinking and feeling, and you may be pleasantly surprised.
Have a great week!
Our friends at nursing home facilities in Pennsylvania have sent us some wonderful tidbits for our tidbit contest. We’ll share a few with you each week.
To start, Kacie Szczech, a CNA at St. Mary’s Villa, has a great idea for residents who wander and like to take other people’s things. She suggests leaving a “treasure box” of miscellaneous items placed in frequented areas for the resident to go through and take some things, such as: towels for folding, empty containers, stuffed animals, and large costume jewelry (if safe). Our research team likes this approach because it does not try to restrict or change the resident’s behavior, but rather supports wandering as an unmet need. Nicely done Kacie!
Janet, another staff member at St. Mary’s Villa, shares her approach to caring for residents with insomnia. She creates and keeps a bedtime routine to signal the resident that it is time to settle down: remove glasses, turn off lights in the room, draw the shades, turn off TV, offer snack prior to lying down, check and change brief. Our team liked this tidbit because it focuses on a common issue for the evening shift staff, and is a simple suggestion that does not require any additional resources to implement.
Have a great week!
A study published in the Journal of Nursing Scholarship posed the question, “Is an Engaging or Soothing Environment Associated With the Psychological Well-Being of People with Dementia in Long-Term Care?” (https://www.ncbi.nlm.nih.gov/pubmed/27802364)
Well…what do you think the researchers learned? They found that an engaging environment was associated with more positive emotional expressions, and that a soothing environment was associated with neither positive nor negative emotional expressions.
In terms of resident-focused care, this is important to consider as we plan care and activities for those residents with dementia. While a soothing environment may be beneficial during times of agitation, the default should be an engaging environment, which can result in more positive emotions overall.
Have a great week!
Dementia and old age are the strongest risk factors for delirium, a condition of acute confusion and rapid changes in brain function. It is important to distinguish delirium from behavioral and psychological symptoms of dementia, as delirium is a medical emergency that should be addressed immediately by the healthcare team. Delirium typically involves a vulnerable patient and often occurs after surgery, infection (such as a urinary tract infection), or due to adverse medication effects.
Core features of delirium include acute onset and fluctuating course, inattention, disorganized thinking and a change in level of consciousness (hyper-alert or drowsy). Other possible symptoms include hallucinations, delusions, restlessness, sleep disorder, inappropriate behavior, poor postural control, and a decline or low performance of self-care activities. Keep in mind that while hyperactive delirium is more obvious due to hallucinations or striking out, hypoactive delirium is more subtle, and the person may just seem very sleepy (https://acphospitalist.org/archives/2016/03/delirium-screening.htm).
When you suspect delirium, assess the resident as least once per shift using a brief assessment tool, such as the days of the week backward or months of the year backward. Keep in mind that for a person with dementia, this assessment would not be effective if the person could not do this task anyway. Instead it can be better to determine–sometimes with help of family members–what a person’s baseline cognitive function is and use this to help assess delirium, along with a more complete assessment by medical staff.
The resident with delirium may have poor judgement and difficulty focusing, switching and sustaining attention, so be sure to keep the resident safe from falls and other adverse events, and do not use physical restraints and bed alarms.
According to the Nursing Home Toolkit (http://www.nursinghometoolkit.com/delirium.html), some ways to reduce risk of delirium in nursing home residents include:
- Keep residents mobile, hydrated and engaged in activities they enjoy
- Keep eyeglasses and hearing aides in working condition and available to resident at all times to promote sensory input and communication
- Encourage use of dentures to help ensure adequate nutrition
- Use consistent assignment of staff and avoid room changes
- Treat pain with appropriate non-pharmacological and pharmacological interventions
- Encourage family involvement for re-orientation; use companions as needed
- Provide non-pharmacological sleep protocol (back rub; decaffeinated tea) and quiet room at night with low level lighting
- Don’t administer prn (as needed) sedative, antipsychotic, or hypnotic medications to prevent and/or treat delirium without first assessing for, removing and treating the underlying cause of delirium and using nonpharmacologic delirium prevention and treatment approaches.
- Don’t discharge patients with delirium form post-acute care without and appropriate delirium treatment, care management, and communication plan for transitioning care and ensuring ongoing follow-up
Find more information on this topic at: http://www.nursinghometoolkit.com/delirium.html
Have a great week!
Dailycaring.com named its number one article from 2017, showing that sometimes even the simplest ideas can have a significant impact. The article is about giving weighted blankets and lap pads to people with dementia to help reduce their anxiety and improve sleep.
According to the article, a 2008 study showed that weighted blankets were a safe and effective non-drug therapy for decreasing anxiety, and the results were confirmed in a 2012 study. How does it work? The heaviness of the blanket provides “deep pressure therapy”. When the body feels the gentle pressure of the blanket, it produces serotonin which improves mood and promotes calm. A typical weighted blanket for adults is about 15 to 30 pounds, but will depend on the person’s weight and physical condition. The standard guideline is that a blanket should be about 10% of the person’s body weight, plus 1 or 2 pounds (but lower if the person is frail). A lap pad is typically 2 to 5 pounds.
The article advises readers to ask a doctor before using a weighted blanket, since people with respiratory, circulatory, or temperature regulation problems, or people recovering from surgery, may not be able to safely use one.
To find out how to make your own weighted lap pad or blanket, or where to buy one, click on the link to the full article:
Please let us know if you’ve tried this with any of your residents, and have a great week!
It’s usually a lot simpler to prevent a problem than it is to deal with an issue once it’s already occurring. Unfortunately, nursing home staff is often so accustomed to “putting out fires” that they feel like they don’t have the time to prevent them from starting in the first place.
Much of what we’ve talked about these past few months is really this…prevention! Engaging residents in activities to keep them from feeling bored, agitated or useless; taking a closer look at the environment and habits of staff to see how it may result in negative behaviors; keeping residents active and taking them outside so they can enjoy the many benefits of physical activity and sunshine…all can lead to reduced negative behaviors related to dementia.
Take a moment to discuss with some staff or think about an incident that occurred recently that could have been prevented had it been handled differently. We’d love to hear some examples from you.
Have a great week!
Many nursing homes have dedicated “activity personnel” who coordinate activity programs for residents, which include events such as bingo, trivia hour, musical entertainment and holiday crafts. Formal activities are important because they help residents socialize, get them out of their rooms, and sometimes (though we’d love to see more) encourage physical activity.
Often though, scheduled activities occur at the same times each day and for some residents, these times don’t work well with their daily routines. Their sleep and energy patterns don’t always sync with what’s planned on the weekly calendar. Or they may not have the cognitive ability to participate in what’s planned. What then? Do they miss out on their only opportunity for activity, meaningful interaction and fun?
Encourage all staff to lead spontaneous activities throughout the day as their time permits and reward them when they do. Just 10 minutes here and there can make a big difference and prevent boredom and agitation in residents with dementia. Look around your environment…are there foam noodles, art supplies, and other things kept nearby that a GNA, nurse or even a family member can grab quickly? Have some music CD’s handy with a CD player in the common areas or near dining rooms. You’d be surprised at how quickly a dance party can start just by turning on some tunes! By providing GNA’s and other staff with these tools, they will have options to turn to when a resident could benefit from distraction and activity.
Have a great week, don’t forget to send us your short tidbits for our tidbit contest, and Happy New Year!
Happy New Year Everyone!!! Send us pictures from your holiday celebrations with residents for our photo contest…including your New Year’s Eve Fun!
Here’s some inspiration from the Today show…a volunteer Santa dancing with a nursing home resident:
Have a safe, happy and healthy New Year!!!