GRANDMA CAN’T FIND THE BATHROOM – WHEN THE ELDER IS INCONTINENT

Grandma Lucy always has a big smile on her face. She is already in the late stage of Alzheimer’s disease. Grandma no longer talks or seems to understand what others are saying to her. She now needs total assistance bathing, dressing and eating.  Yet, Grandma Lucy can still walk and while she cannot go through the many steps of dressing. Once dressed she is able to pull down her slacks, as well as  incontinent brief, and then go to the bathroom.

The problem arises because Grandma no longer can identify the correct place to toilet. When she feels the urge to go to the bathroom, any flat surface she can sit on, will do. She no longer plans or anticipates that she will be needing a bathroom. In the moment when she feels the urge, she answers the call in a public place, secret place, anywhere she finds an opportunity to sit.

Missing the toilet, and using either another object such as a waste basket, or a flat surface such as a chair, sofa, or recliner is common, in a dementia unit, in a nursing home setting. Especially common, for those elderly who continue to be able to walk independently. Grandma Lucy always was a great walker, and has continued to be able to walk, even though now she walks without a destination. She just appears to be wandering as she keeps retracing her steps, all day long.

But contrary to the many who are no longer this active, she has no problems with constipation. On the contrary, Grandma is as regular as clock work. And this fact provides the solution for Grandma’s problem.

When a confused elder like Grandma Lucy can’t plan or anticipate needing to use a toilet, the caregiver needs to provide this service. Her caregiver knows that Grandma Lucy has a bowel movement everyday, about a half hour after breakfast.  As many people know, having a cup of hot coffee in the morning, and chewing breakfast, stimulates the colon and bowel.

Now the caregiver keeps a close eye on Grandma Lucy after breakfast, and right on time walks her to the bathroom. Grandma Lucy is now greeted with smiles and welcome during her wanderings instead of looks of suspicion.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

EARLY SIGN OF DEMENTIA – GRANDPA WEARS SWEAT SUIT TO HOLIDAY DINNER

Where is grand-pa? All the family were comparing notes, before dinner, on Thanksgiving. “Did you talk to Dad?” “Did he seem to understand where to go and what time?”  And so the conversation went, while the sisters were getting ready to put the dinner on the table. Then right before dinner time, there was the door bell, and the sound of Grandpa letting himself in.

There was Grandpa, smiling, joking and also sporting his old grey sweat suit. On closer inspection he hadn’t shaved, his hair looked greasy, and he was covered in dog hair. When asked by one of his son-in-laws why he was wearing a sweat suit for Thanksgiving, he gave his now customary response. “This is so comfortable,” “This is so warm,” and ” I am afraid of catching cold.”

When asked why he didn’t go to church that morning, it became clear that it was just too hard to get out of that sweat suit, too much trouble. Once again it is just too comfortable, and warm.

Once dressed the confused elder has a sense of security, feeling put together. And more mentally together as well, as the favorite outfit now becomes a security blanket. And what could be more secure than the feel of  fleece, the feel of a sweat suit. So the confused elder then begins to resist bathing, getting into pajamas or even changing that sweat suit for a clean one.

This chosen outfit is then worn everyday, to eat in, sleep in, work in, relax in, for every season, and on every occasion. Grand-pa doesn’t know that he is wearing his confusion out there, for everyone to see.

So for this family as well as for many families during the holidays, the private conversations turn to “how bad is Dad?” “Should we be doing something?” “Is it time for him to go to a nursing home?”

No, its not time yet. Grand-pa drove himself over, seems to only drive with-in a few miles of his home, and has had no accidents. He is able to monitor his gas, and maintain his very old car. He appears well fed, so he must still be able to get his own food.

What can be done now, is to keep in close touch with him. Get in the habit of calling frequently, asking what he has eaten, where he has gone, and what he is doing. Make sure that he is able to use his telephone and that it is user friendly. Go to his house and make sure he has an adequate amount of fire alarms, especially one in the kitchen and by the clothes drier. Get in a schedule of checking the batteries for those alarms. Look at his kitchen items for any signs of burning.

Look carefully around the house for tripping hazards and move furniture to create clear walk ways. If clutter is beginning to be a problem, ask for some of the things instead of suggesting throwing things away.

Get more people involved. Start having food delivered, especially grocery staples. Start having a cleaning service come in  on a regular schedule. The important thing is to start these services, so the confused elder gets used to having these people around. Then, over time, these services can be increased as needed.

As annoying as the Thanksgiving sweat suit can be, it is really just a sign of things to come, and a sign it is time to plan.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

EXERCISE FOR PARKINSON’S DISEASE AND THE BRAIN – CROSSING THE MID-LINE

Boxing and Parkinson’s Disease

I recently saw a news show on television that highlighted the benefits of boxing, for persons with Parkinson’s disease. While everyone interviewed identified positive results, all the way from; moving better, to being motivated and at times being pushed to participate.  Those who strongly recommended boxing never really hit the nail on the head, and told us why this sport would work so well.

Boxing and Crossing the Mid-line

Picture an imaginary line from your head to your feet cutting your body in half. Every time you do something with your right hand and arm, swinging to your left and therefore crossing your mid-line you also increase the right-left connection in your brain. Watching the show and seeing the participants either hitting a punching bag, or in a ring hitting an instructor, you can easily see the therapy involved. When they punched with their right hand they frequently crossed over their body and hit the opponent on the right side of his body.

The brains two sides coordinate with their opposite side of the body. All of the connections happen in the middle of the brain called the limbic system. Exercises that cross the mid-line, reinforce and support  the connections in the limbic system. The limbic system is also the site of emotional intelligence, explaining why people feel happy after exercise.

Creating exercises that cross the mid-line

A simple balance exercise turned into a brain exercise can include swinging arms across the body. Kicking a leg across the mid-line while holding on to a chair is a simple brain movement. Bouncing a ball in front of you, with your right hand and then switching to your left hand, crosses the mid-line. Starting with a larger bouncing ball and then scaling down to a smaller and smaller ball also improves balance.

Great games with small children such as a bean bag toss when done crossing the mid-line, is a fun way to exercise the brain. Older children enjoy playing catch, and can start by just bouncing a large ball back and forth. Till they then can catch a ball in midair and switch up to a smaller ball.

Take that even further by hitting a tennis ball, volley ball, anything that provides that movement of crossing the body. Especially so for the confused elder who enjoys just throwing a beach ball around the family circle, or maybe a wild game of balloon toss. The easiest mid-line exercise for just about everyone, is to cross your arms and give yourself a big hug. The limbic system, is why that feels so good!

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

THE ANGRY AND AGGRESSIVE CONFUSED ELDER

Many an angry confused old man goes to live in a nursing facility because the caregiver can no longer manage the aggressive behaviors. And in many cases the caregiver might even be frightened and concerned that they may get hurt. The elder who becomes physically aggressive, hostile and combative puts everyone including himself in harms way.

Sometimes the behavior follows a pattern and you can see the anger building until there is an act of aggression.  But for some the aggressive act comes suddenly, almost from nowhere.

Ed, was the suddenly aggressive type. Ed married late in life and he and his wife never had children. Ed became the favorite uncle to his nieces and nephew.  He was the one who tirelessly pushed them around the block on their bikes until they got the hang of balance, and could take off on their own. Yes, Ed was known as a very kind, thoughtful, and quiet man. Well, respected in his community.

Now he was confused, diagnosed with mid-stage Alzheimer’s Disease and living in a nursing community. The first thing the family did when Ed moved into the community, was to inform the nursing staff that Ed could become physically aggressive. They realized that when Ed was asked to do something he no longer could do, he would quickly become frustrated and then angry.

They told the staff that what worked very well with Ed was to use courtesy, say “please” when giving directions. Words that were inclusive worked well, “Walk with me to the dining room,” “Lets get dressed, its almost time for breakfast.” Using specific, concrete, and positive words, while avoiding negative words like “No,” or “Don’t.”

When a confused elder shows signs of getting annoyed, uncomfortable and uneasy in a situation, the caregiver can use humor. If the elder, like Ed, looks like he is struggling with putting his shirt on, turn the focus to the caregiver. Blame yourself. “Oh no, what did I do now, did I give you that shirt inside out?” Then laughing say you don’t know what you are doing, it is a crazy day.

Give the elder that gift of preserving their dignity, by not pointing out mistakes. Ed knows he is making mistakes, his day is full of them. And when he is frustrated and angry, he is really angry at himself.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

DENTAL CARE FOR THE CONFUSED ELDERLY – THE KEY TO PREVENTING INFECTIONS

Once again the flu and cold season is rolling around. Not only at your local drug store will the pressure be on to get a flu shot, but all of those people in nursing homes will be vaccinated as well.  While try as they will, the pharmaceutical companies cannot get those significant numbers that prove that vaccines prevent flu. However the proof is easy to obtain that regular brushing of teeth, can prevent infections.

I was recently told by a speech therapist that a Japanese study proved that dental hygiene was twice as effective against pneumonia than medical intervention including antibiotics.

When teeth are not brushed regularly, a slime starts to develop on the teeth and gums. I have heard it compared to the slime that collects on the water in a vase, once the flowers have passed their prime. Poor dental care is one of the most upsetting situations for the family visiting in the nursing home. When Mom or Grandma is unkempt, smells of urine or has dirty teeth and nasty breath, she just doesn’t seem like Grandma.

Many times for the elder in a nursing home, they have medications that impact on their dental hygiene. The medications may cause excessive saliva or dry mouth, either condition impacts the ability to keep teeth clean. There are several products available for dry mouth and dry lips, Biotin works well.

For the elder with excessive secretions using a suction machine with an adaptive tooth brush attachment prevents the build-up of secretions at the back of the throat. The brush can have a small smear of tooth paste or be dipped in mouth wash or Biotin. This works well with the elder who is no longer able to clear and spit secretions independently, or is unable to follow directions from the caregiver to do so.

For the confused elder I always recommend a children’s toothbrush. The smaller size is less invasive in the elder’s mouth. When the elder is no longer able to rinse and spit, the use of a children’s toothpaste is also recommended. These are made for someone who will most likely swallow the paste. By far the usual favorite is grape flavored toothpaste over the minty ones used by adults.

The most important thing is to just get started. Being accustomed to the feel of a toothbrush, as well as the feeling of clean teeth should never be allowed to be forgotten.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

DEMENTIA CARE – NORMAL DAY TO DAY ACTIVITIES FOR THE ELDER

Many people only think of activities in the large sense. Activities like; painting a great picture, a trip to the circus, working with clay, throwing a party or seeing live entertainment. All of these things are great, but day to day activities are just that, normal things you do every day. These activities are called “normalization activities,” and these are the activities of good dementia care.

Normalization activities help the confused elder with dementia feel that they are participating in daily life.  Participating in normal chores; dusting, setting the table, folding wash, gardening, washing dishes, raking, vacuuming, all of these are everyday activities. Activities that take the elder back in time are especially good. Instead of using the dish washer, let the elder wash dishes by hand. Polishing and shining shoes is a great activity for a man, especially if he served in the armed services.

Normalization activities give purpose to the elder’s life. Many years ago when the destitute elderly were housed in “poor houses” or “poor farms,” they were given jobs to “earn their keep.”  And as always seems to be the case, the pendulum swung much too far in fixing that issue. In today’s nursing home communities, it is very much frowned upon to “make residents work.” And so residents of nursing communities are to be cared for and occasionally entertained.

Normalization activities give the elder in the home, or the nursing home, an opportunity to have social interaction with others. They can have that special feeling of satisfaction doing a job together, and being part of something. Normalization activities provide a routine to the day, opportunities for pleasure, improved self-esteem and improved quality of life.

Some time ago I asked the activity staff of a nursing home, what gave them work related stress. One brave young woman said she felt that she wasn’t doing her job, if she wasn’t providing a three ring circus all the time. Three ring circuses aren’t the stuff of everyday life, washing dishes is, and washing dishes can also be, just great.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

 

 

 

 

 

 

 

THE CHANGING PERSONALITY AND THE ELDER WITH DEMENTIA

A person’s personality may change dramatically as they go through the stages of dementia. The once very dominant father may become the passive, cheerful confused old man that the nursing home staff just loves and the family hardly recognizes.

Just as the quiet, and always agreeable old aunt you remember might now be the most difficult and uncooperative person in the dementia unit. When the elder with dementia becomes difficult consider the following:

  • An inability to communicate. When the confused elder knows what they want, or more likely what they don’t want and the caregiver doesn’t understand. Or the caregiver didn’t take that crucial time before the activity to make a connection.
  • If the elder is asked to do something that is too difficult the stress could very well trigger an angry outburst.
  • PAIN can cause a change in personality. Some elderly act out from pain and some retreat. The pain may come from an acute condition such as a urinary infection, or a chronic condition such as arthritis.
  • A personality change can be a side effect of medication. The once active and engaged elder might now suffer from extreme fatigue due to a medication side effect.
  • An elder with dementia may have a problem with their emotional well-being due to changes in the environment. The environment is too noisy and over stimulating or just the opposite and too quiet with little to do. There may be a change in the direct caregiver causing the elder to feel anxious.

While the elder with dementia may display a personality quite different from their former self, he has the same needs as everyone else. The need to feel a sense of control, the need to feel included in whatever is going on, the need for positive self- esteem, the need to feel purposeful, the need to feel secure and the need to be loved.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

CREATING ENVIRONMENTS AS PART OF DEMENTIA CARE

Some elements in the environment can cause unwanted behaviors in persons with dementia. Unsettling noises, unpleasant people, being constantly directed or told “no,” all of these things can cause agitation in a person with dementia. Thinking about what is pleasant, and comfortable, this is when the term “homey” comes to mind. Everyone knows when a home feels homey.

The feeling of homey can mean pleasant smells. Smells like bread baking, apple or pumpkin pie, roast beef, cookies baking, all of these words can trigger memories of those comforting smells. Having certain smells over the course of a day can help cue a confused person as to what is happening. Greeting an elder in the morning with “good morning” while the smells of bacon frying and fresh brewed coffee are coming from the kitchen helps the elder know it is morning.

Create a homey room with furniture in limited patterns and choosing colors that are warm. Select seating that is comfortable and looks like an invitation to sit and spend some time. Many colors and patterns can make a room look “busy.” Use basic solid color carpet that is a contrasting color from the furniture so the elder can see where the furniture ends and the carpet begins. Reduce clutter on all surfaces, but include familiar items for the comfort they bring.

Throw rugs will become tripping hazards as are small glass tables. Anything that causes a glare or is difficult to see the edges of, are potential safety hazards. This includes shiny dark flooring. Lighting that is too low or creates especially dark areas of the room, can cause paranoia as well as be unsafe.

A safe secure outdoor space that is accessible to the confused elder to use independently is a very positive activity, as well as good dementia care. Giving the elder the chance of more options by choosing to be inside or outside maintains self-esteem and independence. The elder can enjoy safe interaction with nature while rocking in that homey old rocker, and maybe another one of those cookies.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

ALZHEIMER’S DISEASE TAKES AWAY THE PERSON YOU WERE

In 1985 Phyllis Yingling wrote this to her mother’s caregivers.
One day while walking on the beach, I found a fragment of what must have been a magnificent conch shell…a remnant of a masterpiece, an exquisite shard. I tried to imagine the part as a whole when it was at its best, before it was broken by the churning sea…and Time. The shell must have been an elegant exoskeleton, a prime example of its species. Now, all that remained was a chunk of pink and white shell, its scalloped edge chipped and scratched. Its complex shape, intricate design and brilliant colors had vanished as the crashing surf took its toll.

I thought of my mother, a victim of Alzheimer’s disease for the past five years. At 78, wheelchair bound, unable to walk or speak coherently, she resides in the nursing wing of a retirement home. In recent years she has become an exquisite shard of the magnificent person she once was, before she was broken by degenerative disease….and Time. She is the remnant of a masterpiece.

Those who knew and loved her in her prime still see her as the loving mother, warm hearted wife, and fun loving sister she used to be. We know her as the gifted teacher, the outstanding church and community leader, the confidante and friend, the lover of laughter and music, the wearer of beautiful hats, hats that she wore for most of her years. We love her all the more for the change in herself that she has had to endure.

Those of you who know her now see only the shell of a once vital person, a lovely fragment of a magnificent individual. As caregivers for the elderly, it must be difficult to imagine the elderly people you work with as the young people they once were. As you feed them, walk with them, change their clothes, endure angry outbursts, bathe them, and tuck them in at night.

Please know that families and friends…and the individuals themselves…are grateful when you show respect and kindness, and handle them as gently as a once exquisite shell.

 

 

Virginia Garberding RN
Certified in Gerontology and Restorative Nursing

CONFUSED ELDER ADMITTED TO NURSING HOME BECAUSE OF AGGRESSION AND AGITATION

Aggression and agitation are reactions, usually triggered by a small unimportant incident. Aggression on the part of a confused elder is:

  • Not planned
  • Not premeditated
  • Doesn’t have a long-term goal
  • Will be explosive with no obvious buildup
  • Is periodic
  • Is part of a brief outburst between long periods of calm behavior
  • The more confused the elder becomes the more likely to have a outburst of agitation
  • Most aggression is seen in a married man taken care of by spouse
  • Agitation is more likely in a confused elder with few social contacts
  • The aggressive behavior is most likely to occur during times of direct hands-on care -bathing, toileting, dressing, shaving, eating
  • We are told that 70-90% of the elderly with Alzheimer’s disease have some behavioral problem. Who wouldn’t? If you don’t understand what is going on around you, what people are saying to you, what’s happening to you, why wouldn’t you become agitated or aggressive.

Leading cause of Agitation and Aggression – loss of physical function
When the confused elderly person wants is to take care of themselves but is unable to, he becomes agitated An increase in the decline of physical function will lead to aggressive behavior faster than a decline in cognitive function. The caregiver doesn’t even know what the elder wants or why they are getting angry.

Aggressive and agitated behavior is one of the leading reasons a confused elder is admitted to a Nursing Home. The family is able to handle the forgetfulness and confusion but the aggression, especially on the part of a elderly man who is still very strong, becomes just too much for the family.

Virginia Garberding, R.N.
Certified in Gerontology and Restorative Nursing