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!

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!

Best practice: Fall risk reduction

Falling is an ever-present concern and challenge for nursing homes, and falls at home is often the reason why family members decide to move their loved one to a nursing facility. Too often, however, staff and residents’ fear of falling can lead to a vicious cycle:

  • An ambulatory resident falls and gets hurt.
  • The resident recovers physically, but may now be afraid to walk for fear of falling.
  • The staff also fear that the resident will fall again, so they continually tell the resident to “sit down so you don’t fall,” reinforcing the resident’s fear.
  • The resident then sits more and walks less (if at all), and consequently becomes weak (which is just one of the many negative effects of immobility).
  • One day, the resident tries to walk or transfer without assistance (common among people with dementia who forget they need help) and falls because he/she is now so weak.

…And the cycle begins again.

How do we break this cycle?

Tricks of the trade:

  1. Review with staff why people with cognitive decline (who may not be able to communicate their needs verbally) want to get up and walk on their own. Are they bored? Do they hurt from sitting for a long period of time? Do they need to use the bathroom? Do they forget they need help to walk?
  2. A supervised 5-minute walk could be enough to satisfy their need to move for a while, and may help decrease negative behaviors later on due to boredom or discomfort.
  3. Instead of saying, “Sit down, you might fall!”, try to get in the habit of saying something like, “I see you want to walk. Please wait and someone will help you very soon.” …then take the individual for a short walk/ a quick stand up for a moment or two / a hug and a dance…..
  4. Perform fun “sit to stand” exercises throughout the day with residents….put on some music, have them grab the rails along the hallway and do 5 minutes of sit to stands with them!
  5. Spread the love and encourage physical function…..ask the resident, “Could you stand up and give me a hug?” –The reward back is a big hug from you!

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.

Environmental influence on resident behavior

As promised, here is the first of the “Weekly Tidbits” we’ll be sending every Sunday to provide ideas and motivation to you and your staff as you work to address behavioral and psychological symptoms of dementia (BPSD) with your residents. If you’d like additional members of your staff to receive the tidbits, please email Erin Vigne (vigne1@verizon.net), and she will add their email addresses to our list. Please feel free to forward these tidbits to staff, print and post on bulletin boards, or even publish in your facility’s newsletter or on your Facebook page!

This week, we’d like you to think about the environment in your facility and how it may influence behavior and/or encourage or discourage physical activity among your residents. Remember, if we can help residents stay engaged in pleasant ways, then they may be less likely to become anxious, depressed or agitated. They may also feel better if moving a bit more with less pain and generalized achiness.

Look around your common areas. Are there cues that would prompt a staff member to lead residents in physical activity, or do you just see a television? When family members are visiting, do they always sit in the resident’s room and talk, or are they encouraged by staff to take their loved ones for a walk outside where there are benches to rest? Does your activity director have custody of all the fun items that could encourage movement?

Start with common areas, where many residents spend the majority of their day. Consider placing a basket there with foam swim noodles (when cut in half, they are great for resistance exercise!), small weights or elastic bands, and movement scarves to throw and catch. Having these items out in the open can prompt nursing assistants and other staff to start some spontaneous exercise with residents when they are bored or need distraction. Is there a way to play music in common areas? Turn off those TV’s for a while each day and get staff and residents to dance! Staff can bring in their iPods or phones to plug in to speakers and take turns playing their favorite dance tunes.

Next, are your halls dull? Look at your main corridors. Residents use corridors for walking to a destination, exercise, and social interaction. Are there places to rest if it is a long hall? Is the hall cluttered with items that could cause a trip, or limit access to the handrails? Are there pleasant things to look at during a walk? Consider changing artwork periodically and adding art created by residents. Or choose a new theme each month and hang posters down the hall that correlate with the theme. The hall can then become a destination itself, and family members may be more likely to take their loved ones for a stroll. You could host a contest to see who can decorate the best resident door around a certain theme (summer, holidays, sports, etc). Involve staff and family members too, and offer prizes.

We look forward to discussing your ideas at our next meeting. Have a great week!