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

 

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

TALKING ABOUT DEMENTIA – AND THE GIFT OF LISTENING

There they were cruising the Caribbean as she said they had done so many times before. They were Ben and Dahlia from Texas. They looked like so many of the other aging couples on that cruise ship. But after the brief introductions at the large dining room table, Dahlia found the need to tell the table that Ben has dementia.

What was so much more obvious than Ben’s confusion was Dahlia’s need to talk about it. Even to a table full of strangers, for one short meal on a seven day cruise, she felt the need to tell.

This information wasn’t needed for their table companions. Ben was impeccably dressed, even to the white sweater tied by it’s sleeves over his shoulders and sun glasses perched on top of his head. It wasn’t because of Ben’s table manners, although slow, Ben needed no assistance cutting his food or eating. Yes, Ben was very quite, but so are many older men who just sit back and let their wives do the talking.

No, Dahlia needed to tell for herself. She told of their 28 year marriage, the trips they had taken, how life had been before dementia robbed her of the life she once knew. You could see how she needed to tell, as she frequently repeated the same phrase “You should have seen him, he was something.” The listener could tell she has repeated this so many times over these last nine years since his diagnosis. Just saying it gave her a moment to remember, as she was still picturing him as he had been.

When they parted, you could see that people were trying to say something understanding, supportive, and comforting to Dahlia. So just as you do when you see that young mother who is struggling with a baby and toddlers in tow. You smile and say “wow, you have your hands full, and your children look so great and happy,” and you see that smile break out on her weary face. Someone has recognized, how hard her life is, and she is doing it well.

So now you tell Dahlia what an amazing job she is doing. Ben looks so content, and well taken care of, she is surly doing the hardest job there is, that of a caregiver. Dahlia gives you that same smile that you receive from the recognized mom. As you walk away you take one last look back, at this stranger with the big problem and the quiet husband.

7 QUESTIONS TO ASK ABOUT YOUR PATIENT FOR GOOD DEMENTIA CARE

Yes, John has dementia but that really doesn’t tell a lot about the person of John. In order to take really good care of John, you will need a lot of information.

  1. How alert and aware is John? Does he know his name, does he recognize his family, does he know their names, does he know the name of his caregiver? Can he find his way around inside his home? Can he perform a simple task by himself? Can he follow one or two step directions? How does John respond to people?
  2. How is John’s communication? What language would John most likely speak and understand? Is John’s speech usually clear and easy to understand? Does he get words mixed up, or does he make sense when he speaks?
  3. How well does he function? Does John walk, how much support does he need walking? Does John wash himself? Brush his own teeth? Can John comb his hair, or wash his face? How much assistance does he need with these daily tasks? How does John respond to help with these tasks?
  4. Can John eat by himself or does he need help?  How is his appetite, is this a problem? How much help does he need? Can he use a fork and knife safely or does he eat with a spoon? Does he have any swallowing problems, with liquids or with solid food? Does he need a special diet or soft ground up foods?
  5. Does John go to the bathroom by himself? The activity of being able to go to the bathroom independently involves several steps.  You need to know if John is able to wipe himself after a bowel movement. Is John incontinent of bowel or bladder? If John was on timed toileting would he be continent, does he just not make it there in time? Does John always go to the bathroom in the appropriate place? Does he give signs that he needs to use the bathroom?
  6. What are the usual or possibly problematic behaviors you might encounter with John? Is John’s disposition usually happy, sad, does he get angry often or easily? If John does get angry, what if anything does he do, yelling, striking out, hitting, or grabbing? If he is inclined to negative outbursts what usually calms him down? Does John have inappropriate sexual behaviors?
  7. Is John a safety hazard? If John walks does he leave, has he gotten lost? Why, has he gotten lost was he looking for someone, or did he think that there is some place he needs to be? Has he ever harmed himself or anyone else?

Whether you are a paid caregiver or a member of the family, in order to take care of someone with a dementia for a short time or consistently you need information. Important information.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

5 CRITICAL AREAS OF DEMENTIA CARE

Dementia care involves first and foremost, providing for the safety of the person with dementia. One of the major symptoms of dementia, is the loss of safety awareness. Hand in hand with that, is the loss of the ability to reason, or think your way out of a situation. A real problem, if the situation is dangerous.

Added to providing for safety, is having good dementia communication, knowing what a happy environment looks like for someone with dementia, providing for social and spiritual needs as well as addressing everything physical.

5 Critical Areas of Dementia Care:

  1. Safety – walking alone across a busy highway, putting something on a hot burner and walking away forgetting about it, going outside in sub-zero temperatures without a coat, and more. Protecting the confused elder without having him feel he is being controlled, is good dementia care.
  2. Communication – just having the most beautiful home, with the best security system, won’t lead to great dementia care. Especially if the caregiver doesn’t know how to effectively communicate with a confused person. Good communication involves the speaker and the listener. When the confused elder is no longer able to communicate well, the burden is on the caregiver. The caregiver must know how to communicate through touch, gestures, smiles, patience and kindness.
  3. Environment – the environment needs constant review, and may change over time. Thinking of the environment as a way to make the elder with dementia know where they are and what is expected, is great dementia care. Clutter needs to be eliminated as it contributes to confusion. A kitchen needs to be used for preparing and eating meals. Having a TV running at all times in a kitchen reduces the environmental cues, that are telling the confused person, where he is. Creating a happy environment involves using music, activities, creating enjoyable smells, like the smell of cookies baking.
  4. Social and spiritual needs – whether this means continuing in church attendance, or participating in social groups, these connections remain important.  When the elder can no longer play that card game they won at for years, continuing the activity, while changing the level of the game is what is important. Getting together with familiar people, playing a game, laughing together, watching a movie together, these are important parts of dementia care.
  5. Physical – involves really knowing the person physically. What are the physical problems the person is challenged with other than dementia? Does this person have a vision or hearing deficit? Also good dementia care means knowing when the confused person has had a physical change in condition, when they cannot tell you. Physical also literally means engaging in physical activity to keep the body strong.

Many of these areas crossover to other areas. The person with a hearing deficit, will have an added burden of communication, increasing their confusion. The person who may be diabetic, will no longer be able to understand, how unsafe it is to not follow their diet restrictions.

To provide over all wellness, only 5 areas of dementia care turns, into a very big job.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

TEMPORARY DEMENTIA – REVERSIBLE DEMENTIA REALLY?

Really, there are some conditions that cause temporary dementia and are reversible. While there are many diseases or physical conditions that can cause dementia, some are reversible. Seeking medical assistance as soon as possible may make the difference in preventing any permanent brain damage.

Delirium often times resembles dementia so much so, that someone who knows the elder is very necessary to give a history, of the recent state of confusion. Dementia from a disease process develops slowly over time. However delirium may develop within hours, in the elderly. Knowing what is normal for the elder and the speed at which he became confused, is a significant part of the diagnosis. Many things can cause delirium, frequently in the elderly it is an infection. As well as the elder who becomes confused every time they are in the hospital, due to anesthesia.

Medications , when looking for the cause of sudden confusion, referencing the list of medications that can cause delirium is a good place to start. As the liver and kidneys age they are less able to remove medications from the body and the elder gets a build up of toxins. Added to this may be declining health and the number of medications our elders are now taking, can set the elder up for developing delirium, and a diagnosis of dementia.

Brain Tumor, the first symptom of slow growing brain tumors in the elderly, very much resembles dementia. Brain tumors are know to cause changes in cognition and even personality changes.

Depression, some people with depression may complain of forgetfulness, they looks sad or worried, have trouble concentrating, and look depressed. The important thing to notice is was the person depressed and then became confused? Or was the person experiencing mental decline, and that is what caused the depression. If in fact the depression came first, the symptoms that followed can be reversed when the depression is addressed.

Vitamin B12 deficiency, or pernicious anemia will cause confusion, slowness, irritability and the person appears to have lost their get up and go. Even though vitamin B12 is plentiful in the American diet, this deficiency develops because the elder can no longer absorb the vitamin and requires injections.

Water on the brain, hydrocephalus, an excess of spinal fluid around the brain. This can be caused by a head trauma, but usually begin without an obvious cause in the elderly. The elder literally slows down, walking as if their feet are stuck to the floor. They will lose bladder control as well as become confused. If the condition is caught early and a shunt is put in place to drain the fluid, the person can return to previous level of function.

As always, early identification of changes as well as quick intervention is the answer to mental recovery.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

BEST CARE FOR ELDERLY – PERSON CENTERED CARE

“I am feeling so bad, about how I have treated some of my patients,” the nurse told me. She went on to name patient after patient, that she said she has never taken the time, to get to know. This nurse works in an Alzheimer’s unit with 68 beds, that are always full. I was more than surprised at her statement. I have known her to be so involved and caring, that I couldn’t imagine she would see a problem.

“I just read your book, Please Get to Know Me” she said. She went on to explain that now she could see that while she knows her residents with behavioral problems, very well. And yes, those with very involved and sometimes needy family members she knows very well.  At times, almost too well.  But for those quiet, easy to care for patients, she said she didn’t feel she had really gotten to know them at all.

Nursing is a very fast paced job. No one watching a nurse would fault them for not really knowing each and every patient. After all their jobs are very hard, stressful and yes, fast paced. But as I said, this nurse is a very involved and caring person. I could see that this realization of what person centered care could and should look like, had hit her hard.

When an elderly person has dementia, and is no longer able to share who they are with their caregivers, the family is the bridge between the patient and caregiver. Now this nurse understood, that there is more to taking care of a confused person, than knowing their diagnosis and medications. Knowing who has a skin ulcer, who is diabetic and needs to have their blood sugar monitored is very important of course.

But isn’t it just as important to know who was a kindergarten teacher? Who did some missionary work in their 2o’s and lived in Japan? Who raised 5 children, and now has 13 grandchildren and 10 great grandchildren? Knowing just this can prompt the nurse to remember that every time there is an activity that involves children in the nursing community, this patient needs to be there. Because, she loves children.

Please Get to Know Me – Aging with Dignity and Relevance, is a guide for a family member to help their loved ones receive the best care through caregivers who know them. It is a guide for the caregiver, to help them see that for the patient, the best care is to be taken care of by someone who knows you.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

READING BETWEEN THE LINES, IS THE REAL STORY OF ALZHEIMER’S DISEASE

“Harvey died just before Thanksgiving,” his widow wrote, this is his story.

“Harvey showed signs of memory loss three or four years ago. Then after Christmas last year it got worse. In April he fell off our front step and all tests were negative, then it seemed to escalate. Through the summer the nights were really bad. Pills were not working. The month of August after what seemed like hundreds of phone calls we found a care center. Harvey had two good months there. Then one night he wanted to get up to go to the bathroom. Afterwards, the staff took him back to bed and he died in his sleep. What a blessing!”

One brief paragraph, nine short sentences, not really enough to tell the story of Harvey. But maybe it is, his story is like so many others.

Just a few years when the family identifies his memory loss?  We know he was struggling for longer than that. The time of mild cognitive impairment, when the person is mildly confused, yet functioning, can be many years. Years when the person doesn’t need any help dressing, bathing, eating, but might be having trouble remembering a word or an event. He could remember how to drive the car, and as long as his wife was giving him directions, they didn’t get lost. By having a routine to life and sticking to the routine, it makes it harder to see the changes, they just creep up on you.

The 3-4 years of memory problems she remembers, was most likely when his struggles were becoming more obvious. Especially if other people now noticed. Having a fall, any injury, infection, anything to change the normal routine tends to escalate the symptoms. And the person no longer bounces back to their previous level of function.

Pills were not working. No, medications for Alzheimer’s disease tend to only help for a period of time.

Nights were really bad. So many people caregiving for someone with Alzheimer’s disease come to that place where they are looking for a care center because the nights are bad.

But it wasn’t all bad. Between these few lines you know there were holidays and birthday celebrations. Grandchildren were born and many family get togethers were enjoyed by Harvey. The elderly couple enjoyed going to a movie, or out to eat. They were faithful members of their church, where Harvey was well known. He died at the age of 85, and only lived those last two months in a nursing home.  What a blessing!

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

MILD COGNITIVE IMPAIRMENT AND REASONING

Dorothy is 80 years old and anyone would say she looks just great. Today she is volunteering at her local nursing home, as she has done for the last 15 years. Her hair looks perfect, her clothes always matching and becoming. She has her usual great smile and good humor for all of the residents.

However there had been a particularly bad snow and ice storm the night before. A nurse seeing Dorothy remarked that she was surprised to see her out on such a bad day. Dorothy seemed unfazed by the weather. “Aren’t you afraid of falling?” the nurse asked. Oh no, Dorothy assured her she never falls. Looking down at Dorothy’s feet the nurse commented on the dress shoes with 2 inch heels,  Dorothy was wearing. Pointing to all of the snow and ice patches still on the driveway, the nurse asked why she was going out in those shoes. As the conversation continued it was clear that Dorothy was not connecting the dots between safety, caution, weather, common sense and those very pretty and impractical shoes. In fact, Dorothy showed signs of losing her good humor, if pressed on the subject.

Mild cognitive impairment is considered a condition that might indicate that the diagnosis of Alzheimer’s disease will be next. It is considered a condition that really doesn’t interfere with normal life or activities. Mild cognitive impairment may improve, stay the same or progress. Mild cognitive impairment involves issues like searching for words, losing your train of thought in a conversation, mild forgetfulness, feeling sad or overwhelmed. Many things can account for these such as poor diet, anxiety, depression and especially loss of sleep can cause many of these problems in the elderly.

But the decline in reasoning and judgement are particularly worrisome. Reason involves thinking through a problem and coming up with a solution. It involves higher thinking abilities such as applying logic, verifying facts and making sense of a situation. When the loss of judgement or reasoning skills is lost, this now does interfere with normal life and activities. The loss of reason can have consequences, like Dorothy in her pretty shoes sliding around on ice.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing