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Fox Valley Senior Resource Network Coping with Challenging Behaviors in Dementia Care and Successful Staff Approaches Pres...
What is Dementia? <ul><li>Dementia is an illness that affects the brain and eventually causes a person to lose the ability...
What is Dementia? <ul><li>In the beginning of the disease, the person may be aware of some of the changes in memory and re...
Behaviors <ul><li>These behaviors ARE a form of communication that signifies the person’s emotional condition and  reactio...
The Key to Success – Keep Personhood in Mind <ul><li>All of us are unique and complex as our individual fingerprints. </li...
Example of Success and Keeping Personhood in Mind <ul><li>Behavior: Confusion </li></ul><ul><li>Parenting Approach –  Corr...
Enter their World & Validation Therapy <ul><li>Caregiver Approach </li></ul><ul><li>Reassure them.  Acknowledge what they ...
Caregiver Approach <ul><li>Using the Caregiver Approach versus Parenting Approach with Validation Therapy takes time, pati...
The Heartwood Name <ul><li>The Heartwood of a tree is the central core hardwood around which the annual concentric rings g...
Foundation of Person Centered Care <ul><li>A Comprehensive Life Story for each resident! </li></ul><ul><li>Not  just a Soc...
Key Points about ‘Who’ the Person Is… <ul><li>Preferred Name </li></ul><ul><li>Preferred Hand </li></ul><ul><li>Past livin...
Key Points - Continued <ul><li>Previous daily routines and schedules – when they like to do things? </li></ul><ul><li>Pers...
Special Care Environment <ul><li>Coordinator that is a specialist in dementia care issues and programming.  </li></ul><ul>...
Staff Knowledge and Training <ul><li>Staff value the  person fi rst, knows him/her as an individual, and sees the dementia...
Pacing of Activity:  Balancing “up” and “down” times <ul><li>People with dementia need a balance between: </li></ul><ul><l...
Balancing and Connecting Program (BAC) <ul><li>Research has shown that neither the “up” time nor the “down” time should la...
Q & A Time <ul><li>Disclaimer:  Although these answers are from some of our experts here today and efforts have been made ...
What tools are currently being used to assess a person’s level of dementia or cognition? <ul><li>MMSE </li></ul><ul><li>MI...
What are the best steps to go through when a person with impaired memory enters into a mutually consenting sexual relation...
What are the best steps to go through when a person with impaired memory enters into a mutually consenting sexual relation...
A “legally” competent person does not always allow HHC staff into the home.  She looks  out the window, does not remember ...
Is it necessary to treat all hallucinations & delusions?  What happens if the person is seeing or hearing people that are ...
When is it appropriate to involve Hospice for a person in end stage dementia? <ul><li>Medicare created a FAST Scale to ass...
When is 1:1 care appropriate or required? <ul><li>When a person chooses to have 24 hour companionship. </li></ul><ul><li>D...
What are the regulations for formally discharging a dementia resident from the different LOC facilities (RCAC/CBRF/SNF) <u...
Public Incontinence  <ul><li>Check for UTI or Constipation. </li></ul><ul><li>Scheduled toileting and documentation of res...
Public Incontinence Continued <ul><li>Take to restroom 1 hour after each meal – most likely for BM result. </li></ul><ul><...
Bathing Resistance <ul><li>Person may feel under attack?  May have been abused or raped in the past?  Promote participatio...
Bathing Resistance Continued <ul><li>Cover person with towel or hospital gown throughout shower.  Keeps warm and helps per...
Wandering / Exit Seeking <ul><li>Older adult is instinctually driven to expend energy, esp. when agitated. </li></ul><ul><...
Wandering / Exit Seeking <ul><li>Wandering may serve as a form of communication in response to many factors:  </li></ul><u...
Exit Seeking Tips <ul><li>#1 – Do a great PCC pre-admission assessment !!!!!! Know daily routines, social butterfly, intro...
Once out of the Home <ul><li>Please do not just redirect back in and say “it’s too cold” or “we are going to eat in 5 minu...
When a person with dementia is claiming abuse, how do you determine if it real or not? <ul><li>Step One:  Never Dismiss It...
When a person with dementia is claiming abuse, how do you determine if it real or not? <ul><li>Step Three:  Investigate th...
When a person with dementia is claiming abuse, how do you determine if it real or not? <ul><li>Step Four:  Conclude the In...
Bedside Manner “We Ask This of You Because We Cannot Do for Ourselves” <ul><li>When you come into our rooms, you are enter...
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Coping with Challenging Behaviors in Dementia Care and Successful Staff Approaches

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Coping with Challenging Behaviors in Dementia Care and Successful Staff Approaches

  1. 1. Fox Valley Senior Resource Network Coping with Challenging Behaviors in Dementia Care and Successful Staff Approaches Presented by Pat Hoogervorst, RN and Jason Schmitz, RN 6/8/2011
  2. 2. What is Dementia? <ul><li>Dementia is an illness that affects the brain and eventually causes a person to lose the ability to perform daily self care. All areas of daily living are effected over the course of the disease. Over time a person with dementia loses the ability to learn new information, make decisions, and plan the future. Communication with other people becomes difficult. People with dementia ultimately lose the ability to perform daily tasks and to recognize the world around them. </li></ul>
  3. 3. What is Dementia? <ul><li>In the beginning of the disease, the person may be aware of some of the changes in memory and rely more on others for reminders. As dementia worsens, the person may get lost easily and be unable to drive or manage finances. In advanced dementia, the person will lose the ability to eat, drink, bathe, dress, or use the toilet without assistance. Eventually, someone who is dying of dementia may not be able to swallow safely, talk, or get out of bed and will be totally dependent on others for help with every daily activity. Throughout the course of the disease, individuals may become sad, agitated, wander, or resist care. </li></ul>
  4. 4. Behaviors <ul><li>These behaviors ARE a form of communication that signifies the person’s emotional condition and reactions to care . </li></ul><ul><li>It has been said by many experts that 85% of resident behaviors are the result of staff’s actions and environment, NOT by psychosis, medical conditions, etc. </li></ul>
  5. 5. The Key to Success – Keep Personhood in Mind <ul><li>All of us are unique and complex as our individual fingerprints. </li></ul><ul><li>Although the disease process impairs a person’s ability to function normally in the present, the unique and complex person that she was is still there to be awakened and enjoyed. </li></ul><ul><li>The key to doing this is to shift from imposing “our reality” to understanding the reality of the person with dementia. </li></ul><ul><li>In order to do this we must catch our own habits of “parenting”, and consciously try new dementia care giving approaches. </li></ul>
  6. 6. Example of Success and Keeping Personhood in Mind <ul><li>Behavior: Confusion </li></ul><ul><li>Parenting Approach – Correction : Parents correct children who are confused in an effort to help them learn about the environment and what “reality” is. </li></ul><ul><li>Caregiving Approach – Enter their World : The key to solving confusion is to help people with dementia feel safe & listened to, and find something familiar for them to anchor to. </li></ul>
  7. 7. Enter their World & Validation Therapy <ul><li>Caregiver Approach </li></ul><ul><li>Reassure them. Acknowledge what they are expressing. Help them to name what they are feeling. Approach slow. Get to their level or below. </li></ul><ul><li>Validate their feelings with empathy. Look concerned. Copy expression/tones, repeat key words, move with the person. </li></ul><ul><li>Switch the person with dementia from asking about the people he is missing from the past, to reminiscing about the people he the way the person with dementia remembers them. (the needed connection the person is really asking or looking for). Listen – meet their needs! </li></ul><ul><li>After some time, gently switch the conversations to an important person in your life, with short story memories. </li></ul><ul><li>Or direct the person to something familiar to anchor them – a routine, a song, a touch, a favorite activity. (Try to trigger fond memories or positive holograms). </li></ul><ul><li>In over-stimulation, simplify the situation, eliminate distractions, commotion, # of staff, slow pace of environment. </li></ul><ul><li>Rationale </li></ul><ul><li>The person with dementia cannot always perceive our “reality” </li></ul><ul><li>What the person remembers from the past, has largely become his present. </li></ul><ul><li>Things from the past are familiar and comforting, remember, and do. </li></ul><ul><li>Connecting with the past is a way of reassuring safety and familiarity in a confusing world. </li></ul><ul><li>Honor the persons memory without correcting it. He will likely forget a correction in a few moments. </li></ul><ul><li>Risk of re-traumatizing the person by reminding him of his wife’s passing. </li></ul><ul><li>Confusion can also result from forgetting steps in doing a task, feeling overwhelmed by the # of things going on in the environment, or simply the inability to recognize anything familiar. </li></ul>
  8. 8. Caregiver Approach <ul><li>Using the Caregiver Approach versus Parenting Approach with Validation Therapy takes time, patience, research into the person’s past and willingness to try new things – in addition to a sense of humor! However, the rewards for both the caregiver and the resident can be abundant. It can allow them both to uncover and enjoy the rich person behind the illness. </li></ul>
  9. 9. The Heartwood Name <ul><li>The Heartwood of a tree is the central core hardwood around which the annual concentric rings grow. These annual rings symbolize the layers of memories formed over the years of our lives. Through dementia and Alzheimer’s’ some of these layers of memory break down and are lost. But the central core, or human essence, the “Heartwood” of a person remains. </li></ul>
  10. 10. Foundation of Person Centered Care <ul><li>A Comprehensive Life Story for each resident! </li></ul><ul><li>Not just a Social or Activity History Form and filed in chart. </li></ul><ul><li>More about life experiences and daily routines. Can be written in a narrative format. </li></ul><ul><li>Starts at assessment, and is required before admission. </li></ul><ul><li>Details incorporated into the initial care plan as many ways as possible. </li></ul><ul><li>Staff that work with the resident, should be familiar with the history and add to it. </li></ul><ul><li>Staff are aware of individuals’ trauma histories so that they can be sensitive to care issues that could trigger behavior, and so they can initiate effective calming techniques. </li></ul>
  11. 11. Key Points about ‘Who’ the Person Is… <ul><li>Preferred Name </li></ul><ul><li>Preferred Hand </li></ul><ul><li>Past living Hx (where are you from today & originally, who do you and did you live with, what type of places did you live in (house, apt., farm; was there a upstairs, basement?) </li></ul><ul><li>Marriage Hx and status. Past marriages? </li></ul><ul><li>Family members (feelings about various family members) </li></ul><ul><li>Introvert or Extrovert </li></ul><ul><li>A planner or doer </li></ul><ul><li>A leader or follower </li></ul><ul><li>A ‘detail’ or ‘big picture’ person </li></ul><ul><li>Work history – favorite and most hated jobs </li></ul><ul><li>Leisure background – favorite activities, what do for fun in your spare time? </li></ul>
  12. 12. Key Points - Continued <ul><li>Previous daily routines and schedules – when they like to do things? </li></ul><ul><li>Personal care habits and preferences (eating, sleeping, grooming, bathing habits) </li></ul><ul><li>Time use Hx – other schedules or routines? </li></ul><ul><li>Religious, spiritual, cultural needs and beliefs </li></ul><ul><li>Other values and interests </li></ul><ul><li>Favorite topics, food, places </li></ul><ul><li>Favorite music & songs. </li></ul><ul><li>Important life events or happened to you? </li></ul><ul><li>Hot buttons & stressors. What triggers re-living past life events? </li></ul><ul><li>Behavior under stress </li></ul><ul><li>What things help with stress? </li></ul><ul><li>Level of cognitive impairment </li></ul>
  13. 13. Special Care Environment <ul><li>Coordinator that is a specialist in dementia care issues and programming. </li></ul><ul><li>Strong understanding of different types of dementia. Knowledge of each person’s dementia and how their symptoms, changes in perception, etc. are experienced. </li></ul><ul><li>Manages the “big picture” coordinating program planning (training, policies, activities, environment, etc.) </li></ul><ul><li>Leads, mentors, models, and encourages the team to implement PCC. </li></ul><ul><li>Receives on-going education and stays up-to-date in the latest and innovative Alzheimer’s/dementia trends. </li></ul><ul><li>Practice tips posted as reminders </li></ul><ul><li>Clear, written criteria for admission & discharge. </li></ul><ul><li>People with early to moderate stage dementia grouped together to avoid duress. </li></ul><ul><li>Special Care Environment has it’s own QI Plan. Staff know it and participate. </li></ul>
  14. 14. Staff Knowledge and Training <ul><li>Staff value the person fi rst, knows him/her as an individual, and sees the dementia as a disability of certain parts of the brain rather than thinking of the person in terms of their disease, symptoms & behaviors. </li></ul><ul><li>Staff focus more on the quality of their interaction with people with dementia, and know that this is more important than performing tasks (making beds, passing towels, etc.) </li></ul><ul><li>Staff behavior and language reflects respect and dignity for the personhood of all individuals. </li></ul><ul><li>Labels such as “feeder”, “wanderer”, “screamer”, “toileter”, “Hoyer”, “behavioral” are never used to describe individuals . </li></ul><ul><li>Staff believes this is so important that they remind each other when someone slips and uses negative labeling. </li></ul><ul><li>The attitudes that staff have towards behavior symptoms that the people in their care are displaying reflect, the knowledge that all behavior is communication , and they seek to learn what the person is saying through behavior. </li></ul><ul><li>Staff members seek to understand the unmet social and emotional needs, as well as physical needs, of people with dementia when working with behavioral symptoms. </li></ul>
  15. 15. Pacing of Activity: Balancing “up” and “down” times <ul><li>People with dementia need a balance between: </li></ul><ul><li>Sensory stimulating “up” time, and </li></ul><ul><li>Sensory calming “down” time </li></ul><ul><li>Any imbalance is likely to result in agitation. </li></ul><ul><li>Examples – spending 2-3 hours in a crowded activity/dining room in the high arousal state, “up” time results in stress. </li></ul><ul><li>Likewise, spending 4 hours alone with little external stimulation will also probably result in agitation. A long period of disengagement, or “down” time creates sensory deprivation – inadequate stimulation of the persons senses. </li></ul>
  16. 16. Balancing and Connecting Program (BAC) <ul><li>Research has shown that neither the “up” time nor the “down” time should last greater than 90 minutes. </li></ul><ul><li>Rather than introduce many new activities, it is often easiest and most beneficial to reorganize the day. </li></ul><ul><li>Spread out more evenly throughout day: ADL’s, activities, therapies, meals/snacks, TV/Music, nap times, etc.. </li></ul>
  17. 17. Q & A Time <ul><li>Disclaimer: Although these answers are from some of our experts here today and efforts have been made to assure accurate information, the actual content in this presentation is very brief by nature, intended to be used as only one tool or source of information, and is not intended as a directive to providers regarding care for patients or residents. </li></ul><ul><li>Each Question could be an entire presentation topic, or broken down into more sub-categories </li></ul>
  18. 18. What tools are currently being used to assess a person’s level of dementia or cognition? <ul><li>MMSE </li></ul><ul><li>MINICOG </li></ul><ul><li>Clock Draw </li></ul><ul><li>Animal Fluency </li></ul><ul><li>Word Fluency Test </li></ul><ul><li>Allen </li></ul><ul><li>Slum </li></ul><ul><li>Global Deterioration Scale for Assessment of Primary Degenerative Dementia </li></ul>
  19. 19. What are the best steps to go through when a person with impaired memory enters into a mutually consenting sexual relationship with another memory impaired person? <ul><li>Interview both residents (on more than one occasion) and assure the relationship is “consensual.” </li></ul><ul><li>Determine if they are able to understand “consent.” May be different from one person to the next. </li></ul><ul><li>4 steps to determine consent </li></ul><ul><li>Do they know what they are doing is a sexual act? </li></ul><ul><li>Do they know that they have a right to refuse, and know how to refuse? </li></ul><ul><li>Do they understand the health risks (STD’s)? </li></ul><ul><li>Do they understand that social fallout may occur (may be alienated from family, and other residents and staff may talk about them)? </li></ul><ul><li>Meet with POA / Guardian of each resident and explain relationship. Offer each family to meet and discuss. Educate family members on dementia and relationships. </li></ul>
  20. 20. What are the best steps to go through when a person with impaired memory enters into a mutually consenting sexual relationship with another memory impaired person? <ul><li>4 ) Provide phone # for Alz. Assoc. and State of Wisconsin Ombudsman. </li></ul><ul><li>Arrange in-service for staff, residents, and families by Amy Panosh, Ombudsman “Sexuality & Intimacy in LTC” </li></ul><ul><li>If POA and families do not want relationship to continue…. </li></ul><ul><li>Involve Ombudsman in the residents care plan . Staff may need to be more proactive and provide extra monitoring. </li></ul><ul><li>Understand that residents can have healthy (holding hands and kissing) relationships but not cross the line of a “sexual act.” </li></ul><ul><li>Ultimately, the decision is not made by the POA / Guardian / Family. It is made by the resident and through the process of “consent.” </li></ul><ul><li>7) Document, document, document. </li></ul><ul><li>It’s about balancing their rights AND protecting their rights. </li></ul>
  21. 21. A “legally” competent person does not always allow HHC staff into the home. She looks out the window, does not remember who they are, and does not open the door. She also becomes paranoid of the caregivers once they are in the home and needs frequent reminders of who they are and what they are doing there. She relies on HHC for noon cooking, meal prep, cleaning, and activities. If she does not allow HHC staff in home, she does not eat most of the day or just eats a cookie. <ul><li>If possible, assign same staff. </li></ul><ul><li>Have daughter introduce staff as friends of hers. </li></ul><ul><li>Place large colored prints of staff faces near door or window so person can compare, when confused or paranoid. </li></ul><ul><li>Have pictures of staff with daughter, and resident near her chair for regular viewing. </li></ul><ul><li>Staff need daughter’s work telephone #. </li></ul><ul><li>Daughter can call mother and tell her to let them in - they are friends of hers, there to help. Or daughter can call everyday on schedule. </li></ul><ul><li>HHC must have set criteria for discharge AND when to notify emergency services for elder self neglect. </li></ul><ul><li>County may need initiate a protective placement, if family cannot provide on a daily basis. </li></ul>
  22. 22. Is it necessary to treat all hallucinations & delusions? What happens if the person is seeing or hearing people that are not there? <ul><li>Research has shown that the use of antipsychotics in people with dementia should only use these drugs when their behavioral symptoms are due to: </li></ul><ul><li>mania or psychosis, </li></ul><ul><li>present a danger to the person or others, </li></ul><ul><li>or cause the person to experience extreme distress, </li></ul><ul><li>a significant decline in function, </li></ul><ul><li>or substantial difficulty receiving needed care, which may be life threatening. </li></ul><ul><li>So the answer is to the question is “NO”. </li></ul><ul><li>“ Black Box” Warning - NO drugs are specifically approved by the U.S. FDA to treat behavioral and psychiatric dementia symptoms, and there are some severe risks associated with their use, including death. </li></ul>
  23. 23. When is it appropriate to involve Hospice for a person in end stage dementia? <ul><li>Medicare created a FAST Scale to assess Hospice eligibility. </li></ul><ul><li>All Hospice companies use the FAST Scale to determine eligibility. </li></ul><ul><li>Fast Scale of 1-7. 7 on the more dependent side. </li></ul><ul><li>For a person with dementia to be eligible for Hospice under the dementia diagnosis , they must score a 7. </li></ul><ul><li>Not ambulatory, not able to sit up independently, not able to smile or hold head up, dependent on all ADL’s. </li></ul><ul><li>Most always a person with dementia qualifies for Hospice much earlier than the above scenario, under a different diagnosis other than dementia. </li></ul><ul><li>Examples include: frequent UTI’s, weight loss, frequent ER visits, or hospitalizations, cardiac, edema, weight gain not related to increase food/fluid intake, and failure to thrive. </li></ul>
  24. 24. When is 1:1 care appropriate or required? <ul><li>When a person chooses to have 24 hour companionship. </li></ul><ul><li>DHS 83 “ to prevent, control, or improve the resident’s constant or intermittent mental or physical condition that may occur or may become critical at any time including residents who are at risk of elopement , who have dementia , who are self−abusive , who become agitated or emotionally upset or who have changing or unstable health conditions that require close monitoring.” </li></ul><ul><li>  </li></ul><ul><li>Most common reasons to have 1:1 care in a facility setting : </li></ul><ul><li>Frequent Falls </li></ul><ul><li>Exit Seeking / Elopement </li></ul><ul><li>Self Abuse </li></ul><ul><li>Abuse to other Residents </li></ul>
  25. 25. What are the regulations for formally discharging a dementia resident from the different LOC facilities (RCAC/CBRF/SNF) <ul><li>RCAC – 30 Day notice, except in emergencies - health or safety of self or others is imminent . </li></ul><ul><li>CBRF’s and SNF’s are generally under the same regulations when it comes to dementia and Notice to Discharge. 30 days written advance notice. May take 45, 60, or more if can’t find a suitable placement to meet the needs of the resident. </li></ul><ul><li>Despite having criteria in our regulations, DHS has a Ombudsman AND departmental review process. There recent decisions have been in favor of the residents to stay in their current living arrangements. Their theory is based on the fact that if a facility decided to admit a person with a dementia diagnosis (with no or some behavioral concerns), it should be expected that at some point the person will have hallucinations/delusions, start to wander or exit seeking, refuse care & medication, or other sexual or dangerous behaviors. </li></ul><ul><li>Facilities must have criteria for admission & discharge and are realistic for persons with dementia, and there are polices and procedures for EACH behavioral trait. </li></ul><ul><li>SNF Story – Many elopement attempts. 30 day notice. Ombudsman review / not approve D/C. Resident was a bus driver for Valley Transit. Ombudsman required that facility take her on the bus 2 X Day to fulfill her need. 2 Staff X 2 Hours a Day. ** This could be the same for a CBRF as well. </li></ul><ul><li>Even though this is a little over excessive, EXPECT more of this PCC . </li></ul>
  26. 26. Public Incontinence <ul><li>Check for UTI or Constipation. </li></ul><ul><li>Scheduled toileting and documentation of results (small, large, loose, hard, etc.) </li></ul><ul><li>Label Door as TOILET. 50 years ago, the signs on the door were TOILET, not Restroom. </li></ul><ul><li>May also put image of Toilet on a picture. </li></ul><ul><li>Remove closet door – unable to distinguish between the doors. Remove bathroom door off - easy view of Toilet. May not be able to find the room in time, so goes on floor, basket, sink, or planter. </li></ul><ul><li>If frequent UTI’s – give 100% cranberry juice, and maybe cranberry vitamin. </li></ul><ul><li>Good pericare -2-3 times a day. </li></ul><ul><li>Review patterns / frequency of BM’s. Educate staff on how many days is the normal pattern to increase monitoring and toileting. </li></ul><ul><li>Could try to control the persons BM schedule by providing prune juice / MOM on certain days to get results. </li></ul>
  27. 27. Public Incontinence Continued <ul><li>Take to restroom 1 hour after each meal – most likely for BM result. </li></ul><ul><li>90 second rule – takes about 90 seconds before the process to start. Most caregivers give up to 45 seconds. * This was discovered by transferring into shower chairs, then gathering supplies, and then….. </li></ul><ul><li>Make the toilet in sharp contrast to the floor or wall behind it with paint or poster board. </li></ul><ul><li>Assure good lighting. Have night light in bathroom or leave light on. </li></ul><ul><li>Assure easy manageable clothes – snaps, waste bands. Avoid buttons. Mistake – families buy new clothing when move into a new home that are unfamiliar and a new set of difficulties. </li></ul>
  28. 28. Bathing Resistance <ul><li>Person may feel under attack? May have been abused or raped in the past? Promote participation in undressing. </li></ul><ul><li>Assess pain – treat as 5 th vital sign. Minimize movements or give pain pill before cares. </li></ul><ul><li>Give person view of the shower or tub, starting the water, and keeping the bathroom warm! </li></ul><ul><li>FULLY prepare the bathroom in advance by gathering all required supplies. </li></ul><ul><li>Hi my name is Jason and I am your Caregiver. Scrubs or white coat “syndrome” helps to not confuse from the lay person. Watch low cut scrubs – HRF sexual inappropriateness. Many CBRF’s allow staff to wear regular street clothes. May cause person to have a misconception of who the caregiver is, and not a professional? </li></ul><ul><li>Find out before admission how they used to bathe? Tub or shower? Person could be accustomed to a bath and be afraid of showers and water on the head. </li></ul><ul><li>Know what time of day they preferred bathing. Follow their previous routines. Be Flexible in staff schedule. Educate staff to not force a shower. Skip and do later in day when person is more clear and calm. </li></ul>
  29. 29. Bathing Resistance Continued <ul><li>Cover person with towel or hospital gown throughout shower. Keeps warm and helps person feel less vulnerable. </li></ul><ul><li>Keep persons glasses on during shower – person may have a depth perception impairment that may make entering a bathtub or shower frightening. </li></ul><ul><li>Be gentle. A elder person skin is very sensitive. Avoid scrubbing, and pat dry instead of rubbing. </li></ul><ul><li>Wash the most sensitive areas last, including the head, face, and perineal area. </li></ul><ul><li>If aggression occurs and you are hit, pause and take a deep breath. </li></ul><ul><li>Remind yourself it is not personal and that there may be a reason why they are hitting. Realize they may just be confused about the process. </li></ul><ul><li>If you cannot calm yourself, BEST to change caregivers. Walk away, take 5. Re-center yourself – so you can continue the rest of your day providing PCC. </li></ul>
  30. 30. Wandering / Exit Seeking <ul><li>Older adult is instinctually driven to expend energy, esp. when agitated. </li></ul><ul><li>Movement is calming and the person is seeking familiar objects or places to cling to. </li></ul><ul><li>Walking is familiar, repetitive task. Fear arises when the brain fails to recognize the environment as familiar, then panic, and agitation can take over. </li></ul><ul><li>Can be helpful: conditioning and strength preservation, prevention of skin breakdown and constipation, and enhancement of mood. </li></ul><ul><li>Can be detrimental: entering into unsafe areas or another residents room, injuries, dehydration, weight loss, excessive fatigue or agitation, or a successful elopement from the Home. </li></ul>
  31. 31. Wandering / Exit Seeking <ul><li>Wandering may serve as a form of communication in response to many factors: </li></ul><ul><li>Need for food, fluids, toileting, or exercise. </li></ul><ul><li>Need for security or companionship. </li></ul><ul><li>Excessive sound, phones, alarms. </li></ul><ul><li>Change of shift/caregivers </li></ul><ul><li>Pain, urinary urgency, constipation, infection or medication effects. </li></ul><ul><li>Depression, anxiety, boredom / isolation, hallucinations or delusions – see deceased husband outside, or need to get back home from school because mom/dad will be angry. </li></ul><ul><li>Desire to return to most recent home or former workplace. </li></ul><ul><li>Following old habits: walk on a sunny day, check the mail box, gardening. </li></ul>
  32. 32. Exit Seeking Tips <ul><li>#1 – Do a great PCC pre-admission assessment !!!!!! Know daily routines, social butterfly, introvert / extrovert, etc… </li></ul><ul><li>If went to work every day at 3. Get person to help you at 2:45 with tasks away from favorite exit doors. </li></ul><ul><li>Put away coats, hats, purse, boots – anything that resembles outside. </li></ul><ul><li>Watch for precursors – packing up room, wearing purse. Temp. 1:1 staff. </li></ul><ul><li>STOP signs on doors. Door poster murals to disguise doors. </li></ul><ul><li>Yellow striped tape in front of door – depth perception – may not cross. </li></ul><ul><li>Place items of interest/food at locations of interests = rest time/stop exiting </li></ul><ul><li>Label rooms with easy words or pictures. </li></ul><ul><li>BAC Program – balance daily life to avoid boredom or over stimulation. </li></ul><ul><li>Take outside 1-2 times a day to fulfill need. </li></ul><ul><li>Assure all staff and family members know who is at risk for elopement. </li></ul><ul><li>Tape recorded messages from family to play over and over . “Hi George, this is your wife LuLu. I am running late. I am at work or the grocery store. I will see you in a little while. Stay inside and color me a picture of a bird.” </li></ul>
  33. 33. Once out of the Home <ul><li>Please do not just redirect back in and say “it’s too cold” or “we are going to eat in 5 minutes.” Once a person elopes – it is a 80-90 % chance they will re-attempt in less than 1 hour. Temp. 1:1 staff and engage or calm. </li></ul><ul><li>Know your resident. Know where they are going. ASK! </li></ul><ul><li>Search what they are need of? Maybe just someone provide a sense of emotional bond, trust, and security. Use validation therapy. </li></ul><ul><li>Have a list of methods for staff to use to communicate and redirect the person back indoors. Most methods may be resident specific. </li></ul><ul><li>Have Activity Boxes ready. Will also help with general anxiety. Quick for staff. </li></ul><ul><li>Good Guy / Bad Guy. Be perceived as the understanding and supportive person. </li></ul><ul><li>Walk until exhausted. Carry a walkie talkie or cell phone with you. Be prepared to sit down on grass, or bring W/C along. Have staff come get later. </li></ul><ul><li>Understand person may need to be under a protective placement. </li></ul><ul><li>Safe Return - Alz. Association. Mark clothing. </li></ul><ul><li>Have a Missing Person policy and procedure. Run Missing Person Drills!!!! </li></ul><ul><li>Fun and big learning experience . </li></ul>
  34. 34. When a person with dementia is claiming abuse, how do you determine if it real or not? <ul><li>Step One: Never Dismiss It. Protect the Resident </li></ul><ul><li>1) First person on scene immediately assesses resident’s personal safety and potential of harm to other residents. </li></ul><ul><li>2) If a caregiver is named, the on-site supervisor or Lead Caregiver immediately removes the accused caregiver from the patient care area. </li></ul><ul><li>Step Two: Assess the Effect on the Resident </li></ul><ul><li>  </li></ul><ul><li>1) Lead investigator / nursing supervisor immediately completes a body assessment and documents findings. </li></ul><ul><li>2) Lead investigator / nursing supervisor must assess for psychological changes and document findings. </li></ul><ul><li>3) Provide appropriate medical / psychosocial treatment and support to resident. </li></ul><ul><li>4) Contact family members, if resident wishes and is able to make his/her own decisions by being legally competent. </li></ul>
  35. 35. When a person with dementia is claiming abuse, how do you determine if it real or not? <ul><li>Step Three: Investigate the Allegation </li></ul><ul><li>1) You must notify local law enforcement authorities of any situation where there is a potential criminal offense (physical or sexual abuse, theft of resident’s property, missing narcotics, etc.). </li></ul><ul><li>2) When deemed necessary by the interdisciplinary team, involve other regulatory authorities who can assist (i.e. local law enforcement, elder abuse agency, adult protective service agency, and coroner). </li></ul><ul><li>3) Determine whether accused caregiver may continue working the remaining of shift, the next day; whether in that particular facility or another owned by entity. </li></ul><ul><li>4) Collect and protect evidence. </li></ul><ul><li>5) Obtain written, signed statements from all witnesses or persons with information. </li></ul><ul><li>7) When possible, obtain a detailed account of the incident from the resident including feelings, pain, or discomfort. </li></ul><ul><li>8) Obtain a written, dated, and signed statement from the accused caregiver. </li></ul><ul><li>9) Document, document, document!!!!! </li></ul>
  36. 36. When a person with dementia is claiming abuse, how do you determine if it real or not? <ul><li>Step Four: Conclude the Investigation / Reporting Requirements </li></ul><ul><li>1) Review all components of the investigation </li></ul><ul><li>Definition: “Reasonable Cause” means that the greater weight of evidence provides a reasonable ground for belief that the individual committed the act as alleged. </li></ul><ul><li>Incidents must be reported to BQA when: </li></ul><ul><li>A. You have reasonable cause to believe you have sufficient information or evidence OR another agency could obtain the evidence, to show the alleged incident occurred AND </li></ul><ul><li>B. You have reasonable cause to believe the incident meets, or could meet, the definition of abuse, neglect, or misappropriation. </li></ul><ul><li>2) Inform accused caregiver that a report to another agency has been submitted. </li></ul><ul><li>3) Notify Resident, POA, or Guardian of the state report. </li></ul>
  37. 37. Bedside Manner “We Ask This of You Because We Cannot Do for Ourselves” <ul><li>When you come into our rooms, you are entering our homes.  Please, knock on the door. </li></ul><ul><li>Remind us of your name and position. Some of us are quite forgetful and we may be embarrassed to ask. </li></ul><ul><li>Please, tell us what you are going to do - even if you think we may not understand. </li></ul><ul><li>Please, let us know that you care. </li></ul><ul><li>Please, listen to us.  Ask us how we would like to be helped.  Then try to do it our way.  </li></ul><ul><li>Just like nurses are all different, so are we. </li></ul><ul><li>Please, try to give each of us at least three hugs a day.  People need hugs in order to </li></ul><ul><li>live. It'll be good for you too.   </li></ul><ul><li>Please, touch us gently.  We're fragile. If we express pain or discomfort, slow down and </li></ul><ul><li>Try another way.  Ask us for our cooperation. </li></ul><ul><li>Please, speak kindly to us. </li></ul><ul><li>Please, try to give us choices.   Let us pick out the clothes we wear today.  Ask us if want </li></ul><ul><li>make-up, or want to go to community meeting.  If we don't answer, do what you think is </li></ul><ul><li>right.  If we do answer, try to do what we want. </li></ul><ul><li>Please, try to understand what is wrong with us.  </li></ul><ul><li>Please, try to be patient.  We know that some of us are pretty difficult.  Try to be forgiving. </li></ul><ul><li>For our part, we know all this is a two-way street.  We need to speak nicely to you and to </li></ul><ul><li>Be cooperative. </li></ul><ul><li>Lastly, always remember that we do appreciate you and love you, as you do us.  </li></ul>

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