WHY YOU DON’T ARGUE WITH A PERSON WITH DEMENTIA OR DELUSIONS

The elderly person with dementia, who has a persistent fixed incorrect idea or delusion, is literally unable to change their mind. The idea might be harmless, as in the case of the elderly woman who insisted she was always on a train. Or it might be dangerous as the person who is insisting he has to leave and go to work, when he hasn’t worked for many years. Harmless or not, these ideas frighten the family or caregiver because it demonstrates irrational thinking.  Using rational explanations or arguing doesn’t work when the person is unable to change their mind.

5 ways to address delusions without arguing:

  1. Let it go if at all possible. If the idea is not dangerous, doesn’t bother the person or others, let it go.
  2. If the idea or delusion is frightening, such as the woman who thought people were living on her patio, give reassuring , comforting words. “I am here and will stay with you,” while you use a distracting activity.
  3. A delusion might be an expression of some fear. Look to the environment. Are there shadows, do you need more light, are curtain or shades open at night creating reflections on a window?
  4. Support the feelings the person expresses, not the delusion.
  5. Ask the person to show you what they see. The shadow on a wall, when reality is distorted, may become a ghost to the confused.

Many delusions are just plain hurtful, as with the spouse who is no longer recognized and is accused of being an impostor. Some delusions are very embarrassing for the family, and require understanding and the education of others.  Well meaning friends and acquaintances may intercede and begin arguing the irrational  idea or delusion. Look at this as an opportunity to educate other people, so that they may support you, in creating your plan of care for this person.

When caring for the individual with irrational ideas, you never argue these thoughts away.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

THE NURSING CARE PLAN

The Nursing Care Plan is what directs all of the care of the patient. In a nursing community, when a new patient arrives the care plan is started immediately. At first it might only be a rough outline of the challenges the patient faces. Maybe the patient has had recent surgery and has a wound that needs to be tended to. Or the patient might have been admitted due to a recent fall or injury.  The staff needs to immediately know about safety precautions and the amount of assistance the patient needs on admission.

Within hours of admission that preliminary care plan is replaced with a complete plan created by all facility departments. These individual care plans are developed after extensive assessments. Now the patient who has fallen has had; a complete plan written by physical therapy, occupational therapy and if needed speech therapy, as well as:

  • nursing care plans for safety, how much assistance the patient needs to walk, stand up from a chair, even turn in bed, if the patient has safety risks due to dementia what does the confused person need to be safe, nursing care plans for every medication the patient is on from diuretics to psychiatric medications, nursing care plans for the nursing assistants for basic care – if the patient wears upper and lower dentures, does the patient go to the bathroom independently or does he wear incontinent products, how much assistance does the patient need to dress, bathe etc. nursing care plans for every disease process the patient has such as diabetes, congestive heart failure, arthritis etc.
  • social service care plans are where you would find out if the patient is a smoker or not, information about the family, especially if there is a problematic relationship, information about mood especially if the patient suffers from depression, information about the language the patient best communicates in and social services will track information from all departments to determine a discharge date
  • activity care plans will tell staff what specific interests the patient has, if he is religious to make sure he doesn’t miss any religious services, does he like animals, gardening, art, music, live entertainment, all of those activities available in a nursing community
  • dietary care plans these plans range from what the patient likes to dislikes, dietary restrictions and dietary needs  as well as how independent the patient is in eating or drinking

At first the care plan reflects the immediate problems, then after complete assessment it includes all the information necessary to take care of a person. Then the staff begin the real work of getting to know the patient, many times through family interview. Knowing the patient was a night worker and might still in old age like to be up at night, or that the patient was in the military and likes things as well as himself very neat.

This very personal information turns nursing care plans into person-centered care plans, by far the best kind of plan of care.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing 

STRANGE AND EMBARRASSING BEHAVIORS IN THE ELDERLY – FRONTOTEMPORAL DEMENTIA

Urinating in public, touching strangers, angry outbursts, running stop lights, driving on the wrong side of the road, shoplifting, indecent exposure, and so many more behaviors that those very elders would have found shockingly inappropriate in the past.

However for families the most troubling and strange behavior that is first noticed is the disregard for other people. Fran first noticed this in Charles when he traded in his sedan for a huge truck. A vehicle that she would never be able to get into. This purchase demonstrated a disregard for his wife’s arthritic condition which she had struggled with for the past 20 years. A disregard for her height, as she is a very petite woman. A disregard for her age, basically a disregard for Fran.

Now, whenever the couple went anywhere together, they had to use Fran’s car. This meant that now Charles was very involved every time Fran bought a new car. If Fran liked a car, no Charles needed more leg room, you can’t get that car. Instead of driving a car she liked, Fran now had to drive a large sedan, more to Charles’s liking.

Fran now was paying for a more expensive vehicle than she needed. Her up keep on the car was more expensive, as it always was a gas guzzler that Charles insisted upon. And no, Charles felt no need to contribute in any way, as he continually showed no regard for Fran.

With frontotemporal dementia, as these areas of the brain shrink, the person you once knew changes into another person. A person with increasingly strange and often embarrassing behaviors.

The frontal lobe of the brain is where reason, judgement, safety awareness, organization, planning, all of a person’s higher functions are located. Once this form of dementia, this disease progresses, those higher functioning abilities are diminished.

So now as Fran can see that Charles is showing little regard for societies norms, while he drives on the opposite side of the road because as he says “whats the problem, no one is coming!” She remember years ago when he started showing no regard for her, when buying his truck.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

MEMORIAL DAY – GREAT FOR REMEMBERING – HONORING AND TELLING STORIES

What I remember most was that they (my family’s military men) never talked about it, the war, “their” war. Every generation has what they consider their war. The war for my generation was the Vietnam war. For my uncles it was WW II. My great uncle Ray had served in the Army and I wish to this day that I knew where he had served, and what he saw. But he never spoke of it, not to me, not to my great-grandmother, grandmother or my mother. What we knew of the war was through news papers and later history books.

Uncle Harvey also served, in the Air Force and came back in one piece. There was that dent in the metal cover of the Bible he carried next to his heart, that he never explained. Like Uncle Ray, he had nothing to say, yet in every other way he was the consummate talker.

When Uncle Harvey returned he became a car salesman and was always known to drive the latest convertible. He was a good-looking, cigar smoking, and fun loving talker. But not about that, his war. I wonder if he just wanted to forget it, and get back his life. He went on to marry a widow of one of his buddies in the war. He raised her daughter as his own, and they had a very happy life.

Mom worked in a factory during those war years, she was a Rosie the riveter. In her later years she loved to reminisce about her years of high school. She most liked to talk about when we were kids and always said that was the best part of her life. But about those, war years that she was so very much a part of, she was unusually quiet.

Uncle Harvey’s picture in his uniform, is on the cover of my book, Please Get To Know Me – Aging with Dignity and Relevance.  My mother is sitting in front of a piano her parents had given her for her birthday. It is early 1943 and her brother is away in the war. And so his picture is on the piano and a star is in the front window.

Everyone knew these uncles had served but they never claimed a bigger share of the American dream. They never held forth in political conversations as though their opinion was any more valuable than anyone else’s, because they had served. They never got those uniforms out again, never marched in parades, and most of all never talked about it.

Like so many others just like them, all they wanted was just to fit in and pick up their lives. This is probably the biggest difference with the wars. These men came back physically whole, medicine wasn’t advanced enough to save the kinds of war injuries seen later. By Vietnam, the medical community could save so many more and we now had those severely damaged warriors.  Much more damaged in body and spirit, than seen before.

I never was able to hear my families stories, but thanks to nursing, I have been able to hear others stories, from those who need to tell.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

EARLY STAGE ALZHEIMER’S DISEASE AND CAREGIVING

Caregiving for the person in early stage of Alzheimer’s disease, is in some ways very different from the mid-stage and late stage caregiver role.

The early stage caregiver is in many ways a companion. A very alert and involved companion. A person who is proactive in preventing accidents. Looking at the confused person’s environment, while not changing the environment, (which would increase confusion) but modifying as needed for safety. Knowing the confused elder may no longer be that aware of tripping hazards, the danger of walking in busy parking lots, or handling hot food. So many areas in our, day to day lives, where our own personal safety awareness and good judgement keep us safe.

Helping the confused elder with communication difficulties. Giving the person that extra time they now need to get their thoughts in order. Not rushing the person as they are searching for words, and when providing those words, doing it in a way that is supportive not critical.

By offering frequent reminders of where the person is and what is going on. When the person has a concerned puzzled look on her face, the caregiver gently reminds her that she is at the mall, close to her home. Providing information to the date, time of year, temperature and most of all who people are in relation to the confused elder.

Keeping to a routine and familiar places gives the mildly confused person a sense of security. When that is not possible, as in the case of a change in residence. The caregiver needs to use less verbal directions and more walking a person through the new environment. Accessing that body memory through repetition, by doing something over and over, can re-create that routine and familiarity. Routine and familiarity bring comfort.

Taking time, while stepping back and trying to see what might increase confusion, and what the caregiver can provide to decrease that confusion.

The need that remains is always the same throughout the disease process, is for the the caregiver to be so very kind and understanding. Understanding of the struggles the person is facing to still be here. Support to still maintain their independence as much and as long as possible.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

DRUGS AND DELIRIUM

Anti-psychotic medications are routinely prescribed for delirium. However if the delirium is due to anesthesia, a drug, an electrolyte imbalance or infection and the effects will wear off relatively soon. It would be much wiser given the side effects, to just have someone stay with the individual. Non-drug support works much more effectively especially with the elderly than introducing yet another drug.

Side effects are far ranging such as; loss of balance, restlessness, trembling, difficulty urinating, weakness, dizziness, skin rash, and even unusual movements of the mouth, arms and legs. When these drugs are used, the family member should be given a complete list of the drugs side effects.

Delirium is a very frustrating condition for the patient. It causes misinterpretation of their environment. Keeping the patient informed of what day it is, what time of day it is, what has happened, where they are and what is going on right now is very important. Often if the patient is hallucinating they will tell you that they know what they are seeing, can’t be true, but they are seeing it anyway.

These drugs may be introduced just because it is difficult to care for someone who is delirious. However many elderly people being discharged from the hospital, are now leaving on powerful anti-psychotic medications due to delirium. The problem arises when the patient is no longer delirious due to the infection, surgery or medical condition that caused it in the first place. But now they are suffering from the side effects of the drug.

What does work for delirium? Studies now show that the quickest way to recover from delirium is to get moving. Having patients get out of bed and start walking it off, turns out to be the best and safest medicine yet. Make sure the patient is hydrated, there is a reason patients come out of surgery with IV solutions. Make sure the patient is exposed to sun light during the day and in a dark room at night so that they return to their normal sleep/awake cycle.

And most of all provide that one on one caregiver, who can explain the environment while reassuring the patient that all is well and they are safe.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing 

DEMENTIA AND DELIRIUM INCREASE CHANCE OF FALLS

Confusion due to dementia and delirium are known risk factors for falls in healthcare. Researches have noted that persons with confusion have a risk of falling 1.8 times that of the elderly without dementia. Falls in the elderly are predictable when the elder has; balance problems, problems with dizziness or fainting, cardiac problems, arthritis, osteoporosis, vision problems, is weak from immobility or a recent infection, is taking numerous medications or a medication for anxiety, or depression.

But the risk of a fall increases to almost double the risk when the elderly have dementia or delirium as well as the other known risk factors.

Behavioral problems – the person with dementia or delirium will have decreased safety awareness and make poor decisions. The person with dementia or delirium are more likely to forget to use assistive devices such as canes and walkers, or stop and put on good safe footwear. If the person also experiences angry outbursts of a physical nature, this also greatly increases their risk of falling.

Dietary deficiency –  the person with dementia or delirium can suffer from a poor nutritional status due to bad food choices. Adequate protein, essential vitamins, and water are needed for good health.  And especially vitamin D and calcium are necessary for strong bones.

Vision changes – a person with dementia can experience a decline in the ability to sense where they are in space. This often results in sitting down and missing a chair. Added to that a decrease in visual accommodation to light and dark, glare intolerance, altered depth perception and possibly physical changes in eyes due to aging, increase the risk of falls to an even greater degree.

Chronic illness – arthritis causing stiffening of joints, osteoporosis and bone deterioration increases risk of injury related to a fall, stroke and Parkinson’s disease increase the risk of falls. These are known issues with aging, and the elder with dementia who has painful swollen joints from arthritis is at even more risk.

Acute illness – has been shown to be a factor in 10% to 20% of falls in the elderly. An acute infection will cause weakness, fatigue, even dizziness. But the person with dementia or delirium will have an increase in their confusion.

Continuous monitoring of the elder with dementia or delirium is necessary as well as monitoring for these increased risk factors.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

HOW TO TALK TO SOMEONE WITH DEMENTIA

When a person with dementia has a difficult time understanding or following a long conversation. Breaking the conversation into small segments, with a repeat of important information will be more effective than a long talk. Help the person with dementia stay focused by making great eye contact, holding the person’s hand, any additional focused connection. Be very attuned to facial expressions. When one word doesn’t seem to be understood, use a simpler word. Adding gestures can not only demonstrate words, but can also bring more focus to the speaker.

A person with dementia may lose their train of thought during a conversation. Helping the person with dementia with a word, or forgotten idea depends on the relationship. If the confused person feels that they are being controlled, this form of “help” may be viewed as an intrusion. If it can be done in a lighthearted way, it can guide the person back to their train of thought.

A person with dementia can be very distracted in a noisy environment. One of the first things Sara noticed about her husband was that he seemed rattled when out in a restaurant. She started requesting a table far from the kitchen, where the slightest clang of utensils, would make her husband turn to the sound. He frequently complained about the noise, even though it seemed very normal to everyone else. As time went on it became apparent that in order to even conduct the simplest of table conversation, they would need to go dining at off hours, when the restaurants were almost empty.

A person with dementia may begin to avoid crowded events, or become anxious in crowds. Not only dining out can become a problem, but going to a theater, sporting event, church service, or any event where there are large amounts of people, can be an opportunity for the confused person to become anxious. Very good pre-planning for any event becomes so important. If the caregiver doesn’t plan well, and is running late to an event, the confused person will take on the anxiety as well.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

HOW TO GET THE MOST OUT OF THERAPY FOR THE ELDERLY

What kind of therapy can a person get?

Therapy is determined by two things. The benefits that are available from Medicare A, and B as well as the individuals insurance co-pay, is always the first consideration. The amount of time actually used for therapy is as important as the payer source, and is determined by the individual’s progress in therapy. Medicare and private insurance do not pay for maintaining function or ability, they only pay for improvement. Once it has been determined that the patient has reached their full potential they are discharged.

How often do you get therapy?

Many family members think that the more therapy a person receives, the faster they will recover. However the person who tires easily, and also may be receiving more than one form of therapy, will have to be scheduled according to their energy levels. Their energy may depend on what time of the day it is, as well as how long a therapy session they can tolerate. This is why therapy is scheduled in minutes, and charged to Medicare in that way. Making good use of the their therapy time, results in better use of therapy funds.

Types of therapy:

  • Geriatric therapy – for the elder who is fragile due to age. Therapy can provide strengthening exercises working closely with the a dietitian to provide increased nutrition.
  • Therapy following stroke, head injury, nerve injury – the therapies work through the re-educating of muscle groups. The patient is provided services in physical therapy, occupational therapy and speech therapy. Most of the time these patients requires all three therapies.
  • Pain management – for the patient with stiff joints resulting from disease processes as well as soft tissue injuries physical and occupational therapies will help. As well as for pain that is associated with other physical and chronic disorders.
  • Edema therapy – the therapy department monitors excessive fluid in extremities and provides therapy to conservatively control this fluid imbalance.
  • Orthopedic rehab – whether it is a hip replacement or a fracture the therapy department through assessment and evaluation develops a personalized program reflecting the patients’s strengths and needs. So if the patient is returning to work therapists would want to know what kind of work, so that the program could reflect what the person previously did.

In order to create that personalized therapy program, the patient or family, will have to think about what is their goal for this person. The goal may be that the elderly person with dementia can once again eat independently. Or, that the person with a debilitating stroke will once again be able to use a toilet.

When the therapy team knows the patient’s goal they can begin to develop that very personal, therapy plan of care.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

VA NURSE RETIRES AT THE AGE OF 87

Molly McLaughlin just retired at the age of 87, from the VA. Her 67 years of service to nursing started taking care of solders from the Spanish-American war. Yes, solders who served in the 1898 conflict, when William McKinley was president.

She began her career right when WWII was ending in 1945. Nursing at that time was an entirely different set of challenges than today. Yet, Molly is no stranger to today’s world of healthcare from taking care of wounded warriors, to victims of HIV/AIDS.

Thanks to Yahoo News, we have this very touching and inspiring story of a dedicated professional, a nurse. A true life story that could inspire young girls looking for a rewarding career. Yet, at the same time we see published yet another story involving the size of Taylor Swift’s thighs. It seems the news media can at times recognize real news, and real heroes. Yet the culture continues to pull us back, to the worst in all of us, encouraging the same in our youth.

We can only hope that after her life of service, Molly spends some time doing what nurses do so well, documenting. Documenting all of those memories, all of those patients, all of those solders, all of those experiences that will never come again.

Molly’s story on Yahoo News? Every time we click on the trivial we encourage the media to print more of the same. So for today, what will it be Molly or Taylor?

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing