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!

Share your ideas with our care community- Tidbit suggestions

Hello everyone,

Now that we’ve reviewed the four components of “DICE” for assessing and managing behavioral issues with residents who have BPSD, it’s your turn to show us how you have used this process in your own facility.

Please send us a brief example of how you or your staff have used DICE when addressing a specific behavioral issue of a resident. The best examples will win a prize for their facility, and we’ll share the examples in future tidbits so everyone can benefit! We look forward to hearing from you. Send suggestions to vigne1@verizon.net!

Have a great week!

Creating and evaluating the plan for managing behaviors- The DICE model in action

Hello everyone,

This week we’ll finish discussing the four steps of DICE. We hope you had a chance to discuss the “Describe” and “Investigate” parts with your staff, and are finding the process helpful as you work to assess and manage behaviors of your residents with dementia.

The “C” in DICE stands for “Create a Plan.” Once you have described the problem behavior and investigated and determined a probable cause of the behavior (see last week’s tidbit), then next step is to create a plan to address the behavior.

When creating a plan, keep in mind that interventions should be personalized and meaningful. An intervention for one resident may not work for another. In addition, an intervention that worked for a resident 3 months ago may no longer work for that same resident now.

Creating a plan takes in interdisciplinary team to ensure that all are on board with the plan, that it will be communicated to all necessary staff, and the team will work together to see it through.

Some tips when creating a plan of care to address a specific behavior:

  • Be innovative—brainstorm ideas with staff
  • Use what you know about the resident—causes/triggers of the behavior, resident abilities and preferences
  • Minimize environmental change—limit the number of caregivers and reward caregivers that work well with a resident; minimize room and roommate changes
  • Control the amount of stimulation—too little or too much can precipitate behaviors
  • Modify communication techniques—verbal cues, writing things down, communicating “face on”, repetition, role modeling, and providing a vicarious experience with the resident can all aid in communication
  • Enhance sensory experiences and the environment—music, dance, pleasing fragrances, favorite foods, tactile stimulation and supporting physical activity can all help with some challenging behaviors
  • Provide individualized care—be flexible when scheduling functional activities, anticipate challenges, distract, use creative explanations to prevent a catastrophic reaction and let the resident “do her own thing” when safe to do so

The final step—the “E”—is to “Evaluate the Plan.” Did the plan work?

  • Decide upon a time frame for re-evaluation.
  • Use objective instruments for target behaviors: Cohen Mansfield Agitation Inventory; Neuropsychiatric Inventory (short form or nursing home version); Cornell Scale for Depression in Dementia; Resistiveness to Care Scale
  • Review use of PRN medications
  • Listen to staff report

If the approach worked, continue with the plan of care. If not, go back to investigate other potential causes of the behavior and revise your plan.

Be on the lookout for another contest announcement in next week’s tidbit!

Have a great week!

Investigating behaviors- The second step in the DICE model

Hello everyone,

In last week’s tidbit we discussed the DICE process for assessing and managing behavioral issues in residents with BPSD. We focused on the “D”—describing a resident’s behavior with specific details that provide important clues about the cause of the behavior.

This week we focus in the “I”—Investigate. Once we have a detailed description of the behavior, we can investigate the influence of factors such as cognitive status, environment, caregiver approach, physical/medical disorders, and psychiatric symptoms on the resident’s behavior.

In many cases, a resident with dementia is having difficulty communicating something to us. She could be trying to tell us that she is in pain or depressed, that we are rushing her, that it’s too noisy in the room, or that she simply doesn’t understand what we are asking her to do. When we don’t get the message, the resident can become agitated, resistant to care, anxious or even aggressive.

Cognitive impairment includes amnesia (memory loss); aphasia (language impairment, receptive or expressive); apraxia (impairment of learned motor skills); and agnosia (perceptual impairment). Cognitive impairment can have a significant impact on behavior. It can lead to  behaviors such as a resident urinating in a trash can instead of the toilet, pushing caregivers away when they try to take her to the bathroom, or using a call button constantly to ask for someone to take her home and complaining that no one is helping her.

We should also consider the environment: temperature, noise level, over and under stimulation, too much or too little space, familiarity and routine. An alteration to an element of the environment can have an immediate impact on a person’s behavior. For example, construction work being done in a facility brings noise, new people and changes to a space. These can all lead to anxiety and stress for a resident with dementia. Under stimulation can lead to boredom, which can lead to behaviors such as wandering or disruptive vocalizations.

Caregiver approach can also influence a resident’s behavior. Older adults with moderate to severe dementia have difficulty understanding verbal directions. They can also misinterpret touch that occurs during care activities, perceiving it is a threat. When this happens, a resident can become fearful and either fight the caregiver (hitting, biting, etc.) or flee (resist care).

Physical/medical disorders in older adults with dementia can result in pain, constipation, infection and medication use (with a variety of side effects). Do any of these examples sound familiar?: “He’s so sleepy it’s hard to get him to eat. The food runs out of his mouth”; “He cries when we get him up to transfer to the chair”; “She’s up at night asking to go to the bathroom every 30 minutes.”

Psychiatric disorders obviously affect behavior. Some examples: “She has been tearful almost every evening and doesn’t want to get out of bed in the morning”; “She thinks someone took her children”; “He doesn’t sleep and is so irritable”; “She saw a snake outside her window.”

Now that you’ve read about describing a problem behavior and investigating possible causes of it, next week we’ll discuss…you guessed it—the “C” in DICE, which stands for Create a plan. We’ll review interventions you can use to address these challenging behaviors.

Have a great week!

Describing behaviors- The first part of DICE, a tool to assess and manage behaviors

First off, congratulations to Future Care Irvington, who sent in the winning tidbit for our contest!!! We asked you to send us tips for how you get your more challenging residents to bathe. A nursing assistant at Future Care Irvington said she gives verbal cues to her resident, one step at time, and talks to the resident about her interests while bathing. Great job, Natalie, and keep up the good work!

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.