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: 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

 

Function focused care exemplars

As you continue to work with the “Champions” at your nursing homes, we encourage you to show them these brief videos from our website: http://www.functionfocusedcare.org/videocoaching

The six videos offer great tips on how to engage residents with cognitive impairment and help them perform activities of daily living such as dressing, oral care and toileting, and reinforce the information we presented during the training sessions. 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 from the video work with one of your more challenging residents?