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!

Respecting choices-Improving the lives of persons living with dementia

Hello everyone,

You are likely familiar with the idea of person-centered care. In the long term care setting, person centered care promotes residents’ choices, increases their sense of purpose, and provides a greater personal connection for those who need assistance from others with daily tasks.

An important part of providing person-centered care involves learning the preferences of the residents: What activities do they like to do? Who do they enjoy spending time with? What makes them happy? By respecting the preferences of residents and integrating those preferences into daily life, we can help increase their sense of wellbeing and provide an opportunity for them to thrive. And in addition to benefiting residents, person-centered care also helps increase the job satisfaction of staff, and meet current regulatory mandates.

We invite you to take a moment to watch this brief and fun “white board video” that discusses preference-based living in long term care, and illustrates why preferences of residents matter:

You can also access tools to use to help identify residents’ preferences by going to the Preference Based Living Website!

Give this a try with one or two of your residents this week, and let us know how it goes.

 

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!

Aligning patient-centered activities with CMS guidelines

Most have you have probably been paying attention to the new CMS guidelines for 2017. One of the new guidelines (f-tag F679) relates to activities: “The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.”

This is a challenge for most staff working with nursing home residents, and is far more challenging when those residents are experiencing BPSD.  It can seem an overwhelming task when dealing with so many different people with a variety of needs, so we hope this week’s tidbit will help guide you and provide ideas for ways create activities and practical plans for your residents that will meet the CMS guideline.

When choosing an activity for a resident with BPSD, keep in mind that the intervention should match the functional skills of the person to promote movement and an opportunity for success. In Neurodevelopmental Sequencing Program (NDSP), individuals are placed in a program level based on an assessment of their level of functioning. You can read the full paper by Linda Buettner, CTRS, PhD and Ann Kolanowski, PhD, RN, about this at:  http://www.gnjournal.com/article/S0197-4572(02)09019-5/abstract

See the table below from the paper to help determine functional levels and appropriate activities for each:

Level I: Strengths: Ambulatory but with overhead movements more difficult; decreased endurance level; able to change positions independently; usually continent; assists with personal hygiene

Challenges: At risk for falls; slower gross motor movements; balance problem; needs reminders to maintain posture; strength and endurance may be decreasing; may have muscle tension or loss of hand control (weaker grasp)

Interventions:

  • Active sports and games of choice
  • Fall prevention
  • Cognitive stimulation programs with motor component
  • Geriatric exercise
  • Walking group
  • Air mat therapy (balance and strength or relaxation)
  • Kitchen activities
  • Assisting with special events: decorating, food preparation, pushing wheelchairs, greeting and assisting
  • Leisure lounge and leisure education

Level II: Strengths: May have trunk control and head-neck control; able to use upper extremities; fair range of motion and strength; may be able to independently move wheelchair; can roll over segmentally

Challenges: Unable to ambulate without maximal assistance; may have poor posture habits; decreasing visual acuity; may use palmar grasp; reduced fine motor control; incontinence; needs assistance for bathing, dressing, toileting

Interventions:

  • Geriatric exercise to music
  • Adapted sports/games
  • Food preparation activities
  • Air mat therapy (balance and strength or relaxation)
  • Prepare for special sensory events
  • Stimulation box and simple pleasures activities

Level III: Strengths: Conscious; able to respond to familiar stimulation; may be able to make eye contact

Challenges: Non-ambulatory; poor trunk control; poor head and neck control; poor range of motion; poor strength, e.g. head lag; head or knee contracture; poor vision and hearing; may be able to roll (or may log roll); incontinent

Interventions:

  • Passive and active range of motion
  • Massage
  • Positioning (e.g. air mat, bean bag chair)
  • Reaching activities
  • Air mat therapy
  • Sensory integration, special sensory events, and tactile simple pleasure items

In another paper, Recreational Activities to Reduce Behavioral Symptoms in Dementia,   (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780321/) the authors emphasize that activity interventions are most effective in the prevention of behavioral symptoms and less so during a behavioral crisis. Second, they need to be provided on a routine basis to prevent the behavioral symptoms from recurring. Third, interventions are most successful when they are matched to a person’s interests (remember that family members are a rich source of information about the activity preferences their loved ones) and functional abilities and balance throughout the day with periods of rest. Finally, these interventions require a partnership between nurses, nursing assistants, activity directors, recreational therapists and physicians to be successful.

If you are looking for some new ideas for activities to do with your residents, Table 2 from the paper lists recreational activities commonly enjoyed by people with early and moderate dementia. A few from the list include:

  • Table games
  • Chair volleyball
  • Horse shoes
  • Music lessons
  • Cooking
  • Construction crafts
  • Dancing
  • Gardening
  • Putting green/adapted golf
  • Relaxation session

We hope this helps you think about the activities that are most appropriate for each individual resident at your facility, and starts a dialogue between your staff members about ways to address BPSD through activity interventions. Please share your thoughts and ideas with us on this important topic.