DEMENTIA BEHAVIORS – WHAT IS THE FIRST QUESTION TO ASK

To know if this is really a dementia behavior, ask the question, “What if this person was 20 instead of 80 years old?” This is a question I frequently ask caregivers when they report a elder with dementia as having “behaviors.” Because if this activity or response wouldn’t be a behavior for someone 20 why should it be for someone 80.

“Mary keeps standing up.”  That is the behavior the caregiver reports about her patient Mary. Well, I asked the caregiver,  “do you keep standing up?”  “Of course I stand up, all day I am getting up and down,” the caregiver shared.  While it is more than normal to want to stand and walk. The caregiver being afraid the elder will fall if walking unattended, will often standing up to be a dementia behavior.

Just standing up, might mean the elder needs a meaningful activity and she is bored. It could be that the elder wants to get away from something such as; too much activity, too much talk, too much stimulation. It could be that all of a sudden the elder realizes she is hungry or thirsty, and just stands up to get something for herself. Or what is frequently true in Mary’s case, she just has to go to the bathroom.

Rose was over 100, and really looked good for her age. She was cared for by a live-in caregiver, and Rose always looked company ready. But once ready in the morning, Rose was seated on the couch in the TV room. The caregiver enjoyed spending her day watching daytime dramas and game shows.

Rose had vision and hearing problems, and couldn’t follow these shows. Rose wasn’t even a fan of such programming, she was too polite to say she didn’t like the caregiver’s programs.  So Rose would often just stand up to go do something else. The day was spent with Rose standing and the caregiver telling her to sit down.

For a behavior to be a dementia behavior, the question to ask is, is this activity trying to tell me something? Is there a need that is not being met? Is the elder trying to fulfill an emotional need? Is the elder trying to fulfill a physical need? What is being sought? And in the case of Rose, is the elder trying to get away from something?

Whatever the dementia behavior is, first stop and think of that question, would this be normal for a 20 year old?

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

8 QUESTIONS TO ASK WHEN CAREGIVING FOR THE PERSON WITH DEMENTIA AND DIFFICULT BEHAVIORS

The person with dementia no longer reacts the way they used to, many times resulting in problem behaviors. When you have identified a problem behavior, which can be anything from the elder spitting, to striking out at a caregiver, or even becoming sexually inappropriate, start with identifying exactly what is happening.

8 Steps to understanding difficult behaviors in the person with dementia:

  1. Identify the problem or behavior. Make sure you are clear as to what the problem is, and whose problem is it. In the case of the elder with dementia who spits; it is embarrassing, someone has to clean it up, and many times it is hard to find a caregiver for the elder.
  2. Identify when this behavior occurs. Does this behavior only happen during times of direct care? Such as the elder who strikes out during times of dressing, bathing, or brushing teeth.
  3. Identify how often this behavior happens. Does this behavior only happen occasionally, as during a large holiday get together? Does this behavior happen only later in the day when the elder is tired?
  4. Identify how long the behavior lasts. Is this behavior of short duration, and once the incident is over it is quickly forgotten by the elder?
  5. Identify what is going on in the environment when the behavior happens. Is the environment understandable to the elder? Remember the elder with dementia needs a time of transition between activities. He can no longer just switch from one conversation to another, or do several things at the same time such as eating and watching TV.
  6. Identify who is present when the behavior happens. Does someone present tend to startle or surprise the elder? Does someone seem to not know how to approach the elder? Is someone asking a lot of questions the elder is no longer able to understand? Does someone have expectations of the elder that they are no longer able to meet? Does someone present seem to be critical of the elder.
  7. Identify how intense the behavior is. Is this behavior of such intensity that is scares the elder as well as all who are present?
  8. Identify if there is more than one thing contributing to the problem. Especially if the elder has been having trouble sleeping and may be suffering from sleep deprivation. If the elder’s behavior becomes more difficult in the late afternoon, see if the elder has an problem with oxygen deprivation. Many elders who are more agitated later in the day may benefit from a sleep study.

Finding out what happened right before, or what is happening during the behavior, is of the most importance, when care giving for the person with dementia.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

5 REASONS THE PERSON WITH ALZHEIMER’S DISEASE CAN HAVE BAD BEHAVIORS

When life begins to be a mystery and the person with Alzheimer’s disease no longer understands what people say, the meaning of words, and he no longer understands the environment, he can react with anger. That anger can lead to his being restless or even combative. Sometimes striking out at caregivers, strangers and even those he loves.

What causes bad behaviors in Alzheimer’s disease:

  1. His short term memory is affected, so no he doesn’t remember what he just had for lunch. And furthermore all of those questions, about things he can’t remember are getting on his nerves.
  2. He has poor judgement, so even though he has always been a cautious person he now is very impulsive. Even possibly having inappropriate social behavior, because he no longer exercises good judgement in actions or what he says.
  3.  He now is making poor decisions, due to Alzheimer’s disease and no longer understanding the environment. Spontaneously walking outside alone, to take a walk in winter without coat, hat gloves, etc.
  4. He now has an obvious short attention span, becoming impatient, fidgeting, having difficulty sitting still, becoming easily distracted or easily bored.
  5. He is losing verbal skills and having difficulty expressing wants and needs. So becomes angry when people do not meet those needs because of poor communication.

It turns out not to be such a mystery as to why the person with Alzheimer’s disease can have bad behaviors. The person with with Alzheimer’s disease is living in on ongoing mystery.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

WHEN THE PERSON WITH DEMENTIA HITS, PUSHES, OR GRABS

When a person with dementia strikes out, it is upsetting for all involved. Whether it is hitting, shoving, grabbing or whatever physically aggressive episode, finding out the cause is most important.

Start keeping a journal of these outbursts. Include the time the incident happened, the date and most important what was happening right before the outburst. Who was with the elder during the outburst, and what worked to change the situation.

Every caregiver needs to know the elder’s routine and realize how important it is to stay with the routine. Approach is all important. Always approach a person with dementia from the front, in a calm and caring manner. Quick movements or coming from behind the person can be perceived as a threat to the person due to his dementia.

Make direct eye contact with the elder, use his chosen name, and explain what you will be doing step by step. Do not overwhelm the elder with too much information too fast. When giving directions, make them easy to understand, one step at a time and wait at least 10 seconds for a response. Persons with dementia have slower reaction time and need more time to process directions.

When the elder attempts to hit, or act aggressively, step back, making direct eye contact assure him of his safety. Using his name, state his inappropriateness, and tell him that you are leaving the room. Return in 5-10 minutes acting as if nothing has happened and start fresh.  Do not turn your back on an angry confused person, and stay at least 2-3 feet away, out of arms reach.

If the elder is doing something dangerous to himself of others, in a very firm voice say “”No” or “Stop.” Once the outburst is over assure the elder that he is safe, this incident upset him as much as everyone else involved.

Keeping track of outbursts by writing them down will help in identifying triggers. Is the elder over stimulated, tired, hungry, thirsty, are there too many people and the environment too stimulating? Is the task you are doing with the elder too difficult?

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

HOW THE NURSING HOME PREVENTS FALLS

Every year the average nursing home will have between 100 to 200 patient falls. The people who fall the most often are men, and patients who are confused. Men fall almost twice as often as women because they are less likely to call for assistance, because it is more difficult for them to admit needing help. Patients with Alzheimer’s disease or another form of dementia fall frequently, because they no longer have safety awareness.  Statistics tell us that 35% of those patients who fall are unable to walk, yet they try.

Most patient falls happen in the patient’s room, when the person is attempting something without assistance. Few falls happen in places like a dining room or at a nurses station where many staff members are available to monitor for unsafe behaviors. The majority of those falls in patient rooms have to do with needing to go to the bathroom. Being incontinent of urine, having diarrhea, and having to urinate frequently at night all contribute to the high number of falls.

Added risk factors are poor vision, going bare foot, clutter on the floor, poor lighting and possible a slippery/wet floor from the patient becoming incontinent. As well as the patient forgetting to reach for their cane or walker in their rush to the bathroom.

A nursing home fall prevention program includes assessing each and every patient for their fall risk. All of the above mentioned problems are identified. A plan of care is developed and all staff members are informed of the plan. Safety devices are put in place, most of those devices are in the form of alarms. A good web site for safety devices is -www.Rehabmart.com. Their site is very user friendly and they have a large selection of safety alarms.

Looking at the environment, follows the assessment. Are the grab bars placed correctly? If the patinet is getting out of bed, is the bed in a low position, with an alarm? Is the lighting adequate, are there motion sensors in place? Is the patient on a regular toileting schedule before bed? How often does the staff check on them during the night?

A big deterrent for falls is a busy, engaged patient, a patient who has activities to go to that they enjoy. A patient who is really tired when it is time for bed, that they enjoy a good nights sleep.

Virginia Garberding RN

Certified in Restorative Nursing and Gerontology

SENIOR WITH ALZHEIMER’S DEMENTIA CHANGES TRYING TO COMMUNICATE

Of all of the changes the family sees in their loved one with Alzheimer’s dementia, the most frightening is personality and behavioral changes.  When the senior with dementia acts childish, irrational, stubborn, suspicious, paranoid, or becomes physically combative, the caregiver can be frightened.  The caregiver can feel that the relationship is over, this person is now a stranger.

These behaviors are not only frightening for the caregiver but even more so for the person with dementia.  Preventing behaviors is always the goal, and so much easier that dealing with a full burst of anger.

Preventing bad behaviors:

  • be alert and aware to what is going on in the environment – if the last time Grandpa became angry were there too many people, too much talking, too much noise, just too much stimulation?
  • arguing with a person with dementia never works, the person just doesn’t have the reasoning skills any longer to engage in finding solutions – divert attention and head off any confrontations
  • respect and protect the elder’s dignity , there is a real reason why bathing is such a hard task for someone with dementia – being undressed is a huge loss of control
  • make every task as simple as possible – breakdown the task into one step at a time – even though this slows progress – slow and happy is much better than fast and unhappy
  • reassure, and reassure again and again – the elder is very afraid of being abandoned – even the most demanding elder is basically afraid of abandonment

The elder with dementia doesn’t mean to be difficult. Difficult behaviors are a means of communication by the elder. The elder knows that they are missing something everyone else understands. The changes the elder feels they are no longer able to communicate with words. So the elder will try to gain control over their environment through – behaviors.

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

SUGAR CRAVINGS AND THE ELDER WITH DEMENTIA

Please, please can’t you open the ice cream parlor now?” the elderly woman begged the activity aide. Once again the young activity aide explained to Hannah, that it was 8 o’clock in the morning, and they don’t open the ice cream parlor till 2 in the afternoon.

The pain was easy to see in the elderly woman as she was turned away. Anyone who has experienced cravings can understand how she felt. Sugar craving is nothing new to millions of people with diabetes and pre-diabetes.

The craving for sugar is physical and so mental. For the elder with dementia and sugar cravings the time of day doesn’t matter. The fact that she had just had breakfast doesn’t matter. The fact that this tiny old lady just couldn’t be physically hungry doesn’t matter.

Hannah doesn’t remember that breakfast she just had. She will clearly tell you that no body feeds her at the nursing home. Because she believes it. Hannah knows what it feels like to be hungry and right now she is craving some ice cream and so she must be hungry.

For persons like Hannah it might have been the toast loaded with “sugar free” jam that triggered this craving. Or the large bowl of corn cereal she had with the toast. Maybe the 5 packets of sugar substitute she insists on putting in her morning coffee.

Loading up on a breakfast with empty carbs and sugar free products – served up by kind hearted nursing assistants, wanting to make all those Hannah’s happy is her problem.

Would she go back to her unit in the nursing home angry? Of course she did.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

THE CONFUSED ELDER AND MONEY

Is the real problem for Loraine financial, or her husband Ed’s impaired judgment? Studies tell us that by the year 2030, 20% 0f the nation’s population will be considered “the elderly”. There will be a dramatic increase in the need for mental health services for this older population. Right now there are many family members struggling to find supportive services for their elder.

What Loraine can do right now:

  • Take Ed to his health practitioner for an all-inclusive exam; medical history, and lab tests.Have the physician recommend a neuropsychologist to provide further testing. A diagnosis is going to be very important for their family. Many times family members who see changes are unable to see the whole picture until there is a diagnosis by a physician.
  • Loraine can contact the postal service and stop these unsolicited offers of new credit cards.
  • Loraine can then lay out the problem in writing for her sons. Seeing their parents’ financial situation on paper makes a bigger impact, then just saying Dad is running up charge account bills.
  • Loraine can then decide after the diagnosis (if the doctor finds that Ed is impaired) with her family, what course they will take.

There is a falsehood that many people believe, that if you don’t have “mental illness” that must mean that you have mental health. There is a vast divide between mental illness and mental health. Mental health in a person includes:

  • Being involved in productive activities
  • Having fulfilling relationships with other people
  • Having the ability to adapt to change
  • Having the ability to cope with daily challenges

 

 

Virginia Garberding RN
Certified in Gerontology and Restorative Nursing

THE CONFUSED ELDER AND MONEY

Ed had a stroke 15 years ago and has been on social security disability ever since. Ed is married to Loraine for 45 years. During those years Loraine has always worked two jobs and often three jobs as a nurse. She felt it was necessary to raise and educate their three boys, and she was glad to do it.

For many years after Ed had his stroke, Loraine planned their finances. She paid off loans; charge cards, their car and then the house. Loraine wanted to go into her retirement years debt free.
The problem is that as Loraine was paying off their debts, Ed was starting to apply for every charge card offer that came his way, and come they did. Ed now has an arsenal of credit cards and he isn’t at all afraid to use them. With this kind of spending, pretty soon Ed and Loraine found themselves getting a mortgage on their free and clear home, to pay off Ed’s credit cards.

So what is Loraine to do? She is retiring from her full-time job and going on social security. But she finds that she will have to continue to work part-time to make ends meet. Loraine might always have to work as Ed continues to spend.

Loraine is seriously considering divorcing Ed to get away from the financial hole he is digging. Yet, she is afraid that her sons will not support her in this move. She thinks they will not want any changes and probably feel that she should just go on taking care of Ed.

How can Loraine retire and start to take care of herself, without divorcing Ed?

 

 

Virginia Garberding RN
Certified in Gerontology and Restorative Nursing