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!

Delirium identification and reduction strategies

Hello everyone,

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 (

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 (, 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:


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:

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!