ANTIPSYCHOTICS AND DEMENTIA

Diana believes that the key to behavior management lies in the ability to determine the resident's motivation for their actions, i.e. striking out at staff.  Only when healthcare providers understand that motivation and then see their role as assisting the resident to reach their goal will success in reducing challenging behaviors, without the use of antipsychotics, be realized.

Diana offers many practical and immediately useable tips for behavior management of individuals with dementia.

Although each recommendation is priceless (just ask Diana!) here are a few that Diana would suggest that you commit to memory:

ALL BEHAVIOR IS MOTIVATED.  

1.  Freedom from the use of antipsychotic medications to manage a resident behavior will occur only when facility staff are empowered to look at the person's motivation for their actions. 

Unless and until the staff address the person's motivation for their actions, managing challenging behaviors will continue to be seen as a failure to staff members.  Although it is a well-known fact that antipsychotics are not indicated for use with individuals with dementia, lack of alternative interventions continues to plague long term care professionals. 

HOW WOULD YOU MANAGE THESE BEHAVIORS?

1.  The resident strikes out at caregivers.  This is one of the "reasons" we used to support the use of antipsychotics.   

Diana suggests often the behavior is motivated by the staff's approach and conversation.  Learning what the striking out behavior means coupled with appropriate communication techniques will lead to determining the root cause and providing vital information on how the staff can alter their approach. This results in a successful outcome for both the person and the staff member. 

2. A resident likes to sit on the floor instead of sitting in a chair. 

There is a faction at the facility that believes she should not sit on the floor and have instituted restraining shoulder harnesses to keep her sitting in a chair instead.

Diana suggests let her sit on the floor! Care plan it. Have a Physical Therapist perform an assessment on her ability to get on the floor and then get back up to determine where she will need help. Then outline a plan to help her to meet her goal successfully.

3. A resident gets very upset when we try to bath her. Currently we have quite a "battle" with her. Not only is it challenging for her, it is very challenging for staff.

Diana suggests several alternatives. Consider rinse-less soap; changing the words you use from "shower" to "bath"; reducing bathing from a total bath to washing body areas that cause odors such as hair and perineum; involving her is an activity where she gets "dirty" such as kneading bread or replanting a plant.

RESOURCES

1.  The five hundred pound gorilla in the room is the percentage of residents in a facility with Cognitive Loss. 

The national average is approximately 80%. There is no diagnosis, syndrome or symptom that affects any where near that many residents. Long term care staff members must become dementia experts if care is to meet the unique needs of this population.

2. Knowing a resident’s cognitive functional age is vital. 

Two standardized and validated tests are: ALLEN COGNITIVE LEVELS www.allen-cognitive-network.org and RCCT www.clocktestrcct.com. For more information on these tests, please visit these two websites.

Want to ask Diana a specific question? Visit her Contact Us page and ask away!

WHAT DO I SAY? - I’m good for nothing!

A family member recently asked me how in the world to respond to this comment made by her loved one with memory loss:  “I’M GOOD FOR NOTHING ANYMORE.”

Comments such as this are troublesome and very frustrating for both of you.  The initial, and normal, reaction is to disagree with them with a response such as “Oh no, that’s not true.  You’re still valuable to me.”

Unfortunately that doesn’t sit well!  It sounds like you are denying their feelings at best or arguing with them at worst.  The reaction often is increased frustration for all.

There IS a more successful approach.

Begin by meeting them where they are and showing you understand their feelings.  Remember with me a time in your life when you offered information to someone and they immediately told you that you were wrong.  Didn’t feel good I’ll bet.  Now add the dimension of memory loss.  The individual already feels a loss and a reply that doesn’t acknowledge that their information had value quickly heads the conversation south!


Sometimes your body language speaks louder than your words and will tell them you disagree with them.  Try using a caring, warm facial expression coupled with leaning toward them to demonstrate you heard them and do care what they are saying.


The next step is to make a comment such as “That must make you feel sad”; or “That’s got to frustrate you.”; or “Sounds like you are feeling really down.”  No need to rush, simply allow your concern to show.  Many times they will tell you more of what they are thinking.


I know you then want to say something.  Try a comment such as “I was thinking of the time you taught me to make perfect pie crust,” or “I was thinking how you held my hand when I was learning how to fish.”  Sit quietly and allow them to “feel” your support.

Your goal of course is calm, enjoyable conversations and going where they are is often the key.

THE PERFECT GIFT

We all want the time we spend with our loved ones to be fun and rewarding.  With just a few alterations we can make the time spent with a person with memory loss truly fun for all.

Consider smaller get togethers of 1-4 people at a time
Individuals with memory loss are often overwhelmed by large crowds.  Often it is difficult if not impossible for them to interact with large numbers of people at the same time and they simply shut down and withdraw from the activity.   We often see them sitting on the sidelines looking lost.  When these feelings persist they often ask to leave shortly after have arrived.

Consider short visits of 30 minutes at a time
It takes a lot of energy for the person with memory loss to “stay in the moment”.   They will get tired very quickly as they strain to understand and be a part of the conversation.  Again, the unwanted result is often their insistence on leaving.

Be prepared with topics from their past for conversation starters
Conversations about current events often leave the person with memory loss “out of the loop”.  Their short term memory loss makes it difficult if not impossible for them to understand and stay with a conversation that is focused on recent topics.   Prepare prior to the visit by thinking of old stories or events from their past.  Manage the conversation by bringing up a story that has potential meaning for them.  If they remember the story they can join in.  If they don’t remember the story, it was your story not theirs.  The approach doesn’t frustrate them and allows them to  maintain their dignity.

Refrain from the use of the words “No” and “Do you remember?”
Often the person with memory loss will offer information that isn’t accurate.  Telling them “No, that isn’t right” or correcting them will only make them feel inadequate and frustrate everyone.  Learning to go with the flow will make the conversation much more pleasant.   

Saying “Do You Remember”, when they are challenged by memory loss, often increases their feelings of inadequacy.  You can bring up the same topic with a simple “I was thinking..." followed by the topic you want to address allows them to join in if they remember and keeps the pressure to remember off of their shoulders.

The gift of a rewarding conversation is indeed priceless!

DEMENTIA CARE - A TEAM APPROACH

I asked a colleague of mine if occupational therapy could be utilized to improve the lives of residents with dementia, she quickly and loudly answered “YES!”  Lynn Dennie, COTA, was kind enough to provide the following description of the vital role therapy can play in managing the care of dementia clients at the same time addressing the potential of increased revenue through therapy.  Following are her thoughts....

How many times has it been heard: “John is being treated...but he has dementia.”?  What is being said when this statement is made?  When a statement is made is there limitations made in client care and the revenue that can be generated as well?  As the awareness of dementia grows, so does the cost in caring for clients with dementias, but are we leaving health care dollars on the table?

The Risk Factors involved with dementia care are falls, skin integrity, dehydration/malnutrition and decreased socialization/interaction with others just to mention a few.  These risk factors can all add up to added health care costs for all involved whether in nursing facilities, assisted living environment, or in a client’s home.

The costs related to care for the client with dementia can become a burden for all involved, causing us to work “harder instead of smarter”.  With increased risk factors, the cost of care for dementia clients also increases.  For example, risk factors lead to increased risk documentation (incident reports), increased need for safety equipment, increased use of medications (as warranted through documentation), and can ultimately increase the need for more staff to monitor the dementia clients safety, producing a feeling at times of “chasing the tail”.  Not only do cost accelerate, but slowly the approach of staff/care givers become reactionary instead of proactive.  This can lead to loss of staff retention due to “burn out”, and costs associated with proper replacement of staff.

So the question remains, what can be done?  It begins with accurate assessment of the individual with dementia.  Therapy can be utilized to assist in decreasing associated risk factors, such as falls; thereby strengthening the components associated with therapeutic interventions with set protocols, and staff/family education. Decreasing risk factors has the potential, then, to decrease healthcare costs.

What is the result of Instituting Dementia Interventions?  Through consistent dementia assessment and programming, there can be a decrease in cost factors, a staff focused on being proactive, increased client/family satisfaction which will lead to increased in overall reputation and as an end result enhances census development.  Finally, a facility’s financial performance is enhanced by revenues obtained by therapy. 

So are we leaving those health care dollars on the table?  We are when we do not meet the needs of the dementia client.  However, when therapeutic interventions address risk factors as well as when specialized dementia programming is implemented, a facility’s revenues can be enhanced and in turn operational costs reduced.