“I want to go home”- Strategies for responding to this request

As we watch news coverage of the devastating effects of hurricanes Harvey and now Irma, we are reminded how important the idea of home—and feeling safe at home—can be. For most of us, thoughts of home evoke feelings of comfort, safety and familiar surroundings. It’s understandable then that when a resident with dementia says repeatedly that she wants to go home, what she may really be asking for is comfort and to feel safe. Understanding this can help staff and family members better respond to residents when they tell us they “just want to go home.”

DailyCaring.com has a helpful article on this topic, with three suggestions on how to respond when a residents tells you that he or she wants to go home: http://dailycaring.com/3-ways-to-respond-when-someone-with-alzheimers-says-i-want-to-go-home/

Lastly, this is a last call for tidbit contest entries! Please email us (vigne1@verizon.net) a brief “tidbit” of your own that describes how you or a staff member at you facility has been creative in getting residents to shower or bathe without a battle.

The facilities that email us the winning tidbit entries will each receive a gift card towards treating staff to lunch! We will also share your idea in a future weekly tidbit so your experience can help others too. We look forward to reading your great ideas….we know you have them to share!

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.