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!

Decreasing use of antipsychotic medications….

We thought you would find this recent article interesting as you and your staff work to improve the lives of your residents with dementia and decrease the use of antipsychotic medications as much as possible. The article discusses the results of several research trials and offers some approaches you may like to try:

http://www.npr.org/sections/health-shots/2017/07/19/537907127/for-dementia-patients-engagement-can-improve-mood-and-quality-of-life

In addition, one of the nursing homes participating in our study, St. Mary’s Villa in Pennsylvania, sent us this tidbit about their use of aromatherapy:

Aromatherapy & tactile stimulation can be used as an activity intervention by spraying lavender scent in the air by using a diffuser in the immediate environment.  It can have a calming effect on residents (and staff too!) and create a relaxed atmosphere.  In addition, one can also massage a simple lotion into a resident’s hands.  This provides the resident with a human touch experience. 

Engaging residents with apathy

A person who is withdrawn or apathetic is someone who is socially withdrawn and is experiencing a loss of interest and motivation. Behaviors that reflect being withdrawn or apathetic might include:

  • sitting alone in one’s room
  • avoiding contact with others
  • making limited eye contact with others.

It’s important to note that these behaviors are not often considered problematic because they don’t call attention to themselves like screaming does. They can, however, lead to rapid loss of cognitive and physical function.

How to approach the person who is withdrawn or apathetic:
  • Try to engage the person in creative activities.
  • Give instructions slowly and break tasks down into manageable portions for the person.
  • Remain positive and calm with the person.
  • Encourage the person to do what they can for themselves and provide praise often.
  • Avoid excess stimulation such as large crowds or loud noises.

Things to try:

  • Sensory stimulation may be helpful. Some ways to do this might include playing music, looking through visually stimulating thing such as pictures from old calendars or holiday cards, and touching or holding a stuffed animal.
  • Involving the person in cooking or baking activities can help stimulate the sense of smell and be a good time to talk and reminisce with the person as their memory allows.
  • Consider the persons’ preferences. For example, if the person is fond of animals, bring in a therapy dog as a way to spark interest and movement (reaching, petting).
  • A visit from young children can be a wonderful, heartwarming way to engage a withdrawn older adult.
  • For many, a short walk or simply sitting outdoors for a short period of time can offer valuable sensory stimulation.
  • Try to engage the person in a 1:1 or small group social activity.  Try to individualize social contact, which can include casual conversations or “small talk.” Adapt the conversation based on how advanced the person’s dementia is. For someone with very advance dementia try to focus mostly on questions involving “here and now” discussion such as comments about music playing, food being served or the weather. For an individual with mild to moderate dementia, small talk can be facilitated by asking the person simple questions, such as: “did you ever play football in school?” or “have you always lived in Wisconsin?”
  • Talk to family members to learn more about the person’s history and use this information to plan activities. For example, a painter could help make posters for events; a policeman could “walk the beat”; a homemaker could help knead dough, dust or sweep the floors.
  • Another simple strategy for facilitating social contact is to share information about your life or plans for the day and ask the person with dementia for their input about things you share using straightforward questions.

Best practice: Disruptive vocalizations

Disruptive vocalizations are any verbal noises (screaming, yelling, nonsense talking, cursing) which are generally considered unusual, inappropriate or are upsetting to others. Disruptive vocalizations may be the result of a person having unmet needs and not being able to express them to staff or may be due to too much or too little sensory stimulation.

So what should you do (or not do)  when a resident is making disruptive vocalizations?

Don’t  tell the person to “stop” or that their behavior is driving people to distraction.
Do listen to what the person is saying and see if you can identify any concrete need or request in the vocalization.

Some specific things you can try:

-Check for the presence of needed sensory aids (i.e. glasses, hearing aids) and provide them if missing.
Assess for too much (loud TV in room) or too little stimulation (resident is alone) in the environment and provide interventions based on the findings.
-Sing a favorite song with the resident (people are unable to sing and scream at the same time).