Wayne State Dementia and Catastrophic Reactions

• A person with dementia may feel frightened or threatened when trying to perform basic activities. What can you as a nursing assistant do to assist the person? A.Do the activity for the person B.Break the task down into small steps C.Ask the family to assist D.Wait until the person is ready to assist

B. Break the task down into small steps •Allowing the person with dementia to do as much as possible on his or her own is very important; however, since they cannot remember how to do things, breaking the task down into small steps and assisting the individual is the best approach.

• The main difference between dementia and delirium is that dementia is temporary. A.True B.False

B. False •Delirium is a temporary state of confusion. It is a symptom of an underlying disorder, such as an infection or reaction to medication. Dementia is a chronic, permanent condition which results in loss of function.

Stages of Dementia

•Early stage - Begins to experience memory loss - Person is aware of memory changes, becomes fearful, anxious, or depressed - May become angry at other people •Middle stage - Difficulty communicating - Difficulty recognizing familiar people and things - Difficulty remembering steps necessary to complete familiar tasks - Personality changes; behaving differently - Incontinence •Late stage - Loses ability to walk and sit independently - Becomes bedridden - No longer able to speak, swallow, or smile - Totally incontinent of urine and feces - Death

Four Major Causes of Dementia

•Four of the most common types of dementia are: - Alzheimer's disease - Vascular (multi-infarct) dementia - Lewy body dementia - Frontotemporal dementia

More strategies

We can prevent distress by having a regular toileting schedule, and making sure their clothes are dry and comfortable. Sometimes a particular caregiver is able to connect with the person. Permanent assignments of these caregivers can decrease a person's distress. We can use the person's life story to develop a meaningful activity. A consistent, predictable routine and making sure the person is wearing their glasses and hearing aids can prevent vocalizations. We ask ourselves what need the person is expressing.

The Environment Catastrophic reactions

When a person is moved to a new setting, they lack familiar, comfortable cues in the environment. If a caregiver is new, or unrecognized, a person with dementia can resist care. The disruption of the normal routine will raise a person's anxiety level. When there is poor lighting or lack of contrast, the person has a hard time interpreting the environment.

Physical and Verbal Aggression

When a person with dementia becomes physically or verbally aggressive, they feel like they have lost control. The anger and anxiety takes over and caregivers need to respond in a way that is compassionate, and safe for all involved. We need to stay calm, and avoid angry body language (hands on hips, frowning, or pointing fingers at the person.) Respect their personal space. Some people feel much more comfortable if you stay a "handshake away" or arm's length. If you come too close, the person may feel threatened, become angry, and strike out. Assess the other residents to see if their behavior is making the person upset. Remove others if necessary if their safety is a concern. If you feel like you need to involve other caregivers, they can approach slowly. Do not overwhelm the angry or aggressive person by having too many caregivers involved. Sometimes we need to give the person some time to himself or herself. Acknowledge their feelings of anger and allow them some time to cool down before you approach them again. Has anyone been hit by a person when providing care? What emotions did the caregiver feel? How did the person cope with these feelings? What are the policies about communication combativeness in our own setting? When a person with dementia has a catastrophic reaction, staff are motivated not to have it happen again. We can structure a problem-solving model that can be used to map out the possible causes, potential solutions and develop an action plan.

The Environment

When a person with dementia becomes upset, we need to step back and look at the situation. Thinking carefully about what is going on around the person can give us clues to the need they are expressing. Sometimes it can be sensory overload. The number of people around, the noise level, sudden movements and startling noises all can be factors. They may not be able to recognize noises, or the people around them. All this can contribute to a person feeling vulnerable and insecure.

Why does a person have to move?

When a person with dementia moves to another setting, it is often because of some type of change in their independence. The inability to live alone, death or illness of a caregiver or spouse can be factors that make a move necessary. Many older adults have several chronic illnesses that affect their function and mobility. These include heart or lung problems, arthritis and osteoporosis. As a person ages, the incidence of dementia increases. A person over 85 has a 50% chance of getting dementia. Over half the people who live in nursing homes have dementia.

Wanting to go home

When a person with dementia says they want to go home, do they really want to go to a place? What need is the person expressing? The feeling evoked by home-comfort, security and acceptance are ones we can all relate to. A woman may be worried about making dinner for her children, or be anxious that her mother is looking for her. Recognizing her desire to be a responsible parent, or talking to her about her mother's cooking can invoke feeling from past memories. The more we know about the person's life story, the more we can offer comforting and familiar cues and meaningful distractions.

Screaming and Other Vocalizations

In the manual, Understanding difficult behaviors this definition is offered: "and vocal behavior which is disturbing to others for which a meaning or significance is unclear. This may include screaming, repetition of recognizable words, nonsensical verbal noises, talking incoherently, moaning or whistling."

Our Approach CR

It is important to know the life story of the person with dementia. This information may offer clues about why the person is expressing distress. We can provide soothing music, and talk to the person in a calm voice. We can assess the person for pain. Most of all we must be detectives, and try to determine if the person is in pain, upset by the environment, or needing some one on one attention. Do you have examples of when you or another caregiver was able to connect with a person who was screaming or making noise? What was special about their approach? Did you find out what need was being expressed?

Family issues

It is stressful for families to look at issues related to bringing in services or helping a person with dementia move to a new setting. Many times, they feel guilty for introducing new help or not keeping the person at home. They may feel that it is their duty to care for the person and that they have failed in their role as a caregiver, child or spouse. Sometimes it is admitting that the person is dependent and will not get better. Family members may have made a promise that the person would never go into a nursing home and they feel guilty. As caregivers, we have to be careful about making judgments about families. We may not be aware of all the dynamics and history surrounding their relationship.

Assessment When a person with dementia begins to receive services at home, or moves to another living situation, there is an assessment. The type and length of the assessment will depend on the setting. Parts of the assessment There are several factors that may be included in an assessment.

1. A medical history 2. A functional assessment to evaluate the person's abilities to perform their activities of daily living, such as bathing, dressing, and eating. This takes into account the person's vision and hearing abilities, chronic illnesses and physical mobility. 3. A mental health assessment will provide information about person's cognitive abilities. There may be a Mini Mental Status Exam. 4. A screening tool may be used for dementia or depression. There is a high incidence of depression in older adults, and often it is undiagnosed. Sometimes the person with dementia is depressed and medications can help. 5. The person's medications and their ability to take them reliably will be evaluated. The side effects and interactions from multiple medications may affect a person's ability to function. 6. A social history will provide personal information about the person with dementia. 7. The life story of a person can be explored, looking at past dreams, accomplishments, hobbies and preferences. Significant friends, family and pets can be identified. These provide cues about meaningful activities. 8. Things such as photos or a familiar quilt that can be used to make a new setting more homelike and provide cues in the environment. 9. Spiritual background 10. Financial assessment 11. Coping skills of a person with dementia and their family This information can be incorporated into the care of the person with dementia to provide meaningful activities and conversation topics. Each person, that will be providing care, should receive this information.

Definitions

1. Paranoia- unrealistic blaming beliefs, the inability to separate fact from fiction. 2. Delusions-beliefs that are contrary to facts, which remain fixed in spite of contrary evidence. 3. Hallucinations-sensory experiences that cannot be verified by anyone else, most common are visual or auditory.

Managing Difficult Behaviors Objectives

1. Recognize the needs and feeling associated with the experience of having dementia. 2. Identify the elements of person-centered care. 3. Describe the role of physical and social causes of dependence. 4. Identify important factors in assessment. 5. Identify common emotional reactions of families and the person with dementia to moving.

Why is moving hard?

A person with dementia depends on the environment for cues. Familiar surroundings and routines are very important. When a person with dementia moves to a new setting, there is a period of adjustment. Some common reactions people with dementia may experience may include: 1. Confusion and disorientation may be seen especially at first. If the person was ill before the move, they may have a hard time adjusting to their new surroundings. Familiar surroundings and predictable routines are very important for a person with dementia to function at their best. 2. They may be extremely anxious and become easily agitated because of the unfamiliar setting. 3. The person may deny that they have moved, and become angry if someone argues, or tries to use logic. 4. Some people become depressed or withdrawn because of the loss associated with the move and feeling of not belonging. 5. A person may feel extremely tired. Trying to figure out the new environment can be exhausting. 6. Sometimes a person with dementia feels relief when they move. This may occur when a person has been isolated, or the previous living situation has been stressful, or hard on the family. 7. If a person with dementia is allowed to visit the new setting and is able to give input, the adjustment may be easier. It may take months for the person with dementia to adjust to the new surroundings. A person may experience some of these same emotions when they begin to attend an Adult Day Services program. When caregivers are patient and reassuring, they can help the person feel like they belong.

Expressing a need

A person with dementia has an impaired ability to communicate and to be understood because of changes in the brain. This is one of the most challenging times for caregivers to be detectives and try to understand what need is being expressed. It could be hunger, fatigue, or the need to use the bathroom. Sometimes people sit in wheelchairs for a long time and need someone to change their position. The brain damage associated with dementia can affect person's vocalizations. Sometimes the person will say the same work over and over, or put together sentences that do not make sense.

• A person with dementia may exhibit some unacceptable behaviors. Some of these behaviors may be related to which of the following? A.Unable to communicate effectively B.Wanting to do their own thing C.Not understanding the policies of the facility D.Does not understand that the actions are not allowed

A. Unable to communicate effectively •An individual with dementia may act inappropriately not realizing that what he or she is doing is unacceptable due to the loss of understanding and inability to function normally. Their attempt to communicate is misunderstood and they will act out.

Hallucinations

Hallucinations can be one of the symptoms of some forms of dementia. Many of them are seeing people or animals. The person might not be upset by the hallucinations, but will be upset if you argue with them. Many hallucinations are harmless, and offering reassurance and a gentle touch is what the person needs. For example, if the person is afraid that someone is looking in the window, going to check outside and closing the drapes can relieve anxiety.

• Working with individuals with dementia can be very trying but also rewarding. If you find yourself become frustrated while caring for an individual with dementia, which of the following might you do? A.Ensure the individual is safe and walk away for a moment B.Talk to the nurse C.Ask for reassignment for a few days D.All of the above

D. All of the above •All the choices - ensuring the individual is safe and walking away; talking to your nurse; and asking for a short-term reassignment - are all acceptable ways of dealing with the frustration that can occur when assisting individuals with dementia. It must be remembered that they cannot control what is happening to them and if they could truly communicate with you, they would let you know that they are just as frustrated!

The old culture of dementia care

For many years, people who had dementia were called senile or diagnosed with organic brain syndrome. Dementia was seen as an incurable disease, and nothing could be done for the person. The medical model of care focused on the disease process to explain a person's behavior. A person could be labeled a feeder, a hitter, a wanderer, or a stage 7. A difficult behavior needed to be managed with skill. As the disease, progressed, only physical care was needed until the person died.

Strategies for Prevention

Make sure the person is wearing their glasses and hearing aids. Review all medications for side effects especially if they are new. Check to see if the person is comfortable. Tight clothing, pain or the need to use the bathroom can all contribute. Stick to the person's familiar routine. Plan activities for when the person is rested, and break tasks down into small manageable steps. Tell the person what you are doing and give cues to help him or her understand. Limit choices. Approach the person slowly from the front, and use their name. Introduce yourself and take a moment to set the mood and tone for what you are trying to do. Give the person plenty of time to respond to whatever you are doing and saying. Use their life story to give them familiar cues and offer distractions in distressful situations. Know their stressful time of day, and plan activities around it. If the person does become angry or agitated, speak to them in a calm, reassuring voice. We can acknowledge their feelings and offer a comforting touch. If you are able, try to gently guide them to another area that does not have a lot of stimulation. Medications for agitation are considered as a last resort after all other options have been tried. We can think like detectives and look at our approach, the environment, and what is happening to figure out what need the person is expressing.

Managing Difficult Behaviors Meeting the Challenges of Catastrophic Reactions

One of the most challenging aspects of care is maintaining control when a person with dementia becomes combative. This module will look at emotions expressed by the person with dementia and review strategies for preventing catastrophic reactions. We will recognize that a person with dementia that is angry or agitated is expressing a need. Objectives 1. Recognize why people with dementia become angry and agitated. 2. Describe strategies for staff to assist a person who is anxious. 3. Identify reasons for vocal behavior. 4. Describe strategies for dealing with physical or verbal aggression. 5. Identify steps in the problem solving process.

When there is no family

Sometimes a person with dementia come into our setting with no family or social history. This becomes a challenge when trying to provide person centered care. Some other sources of information can be explored: 1. Possible living relatives or friends may be located through the phone book or internet. 2. A distant contact may be able to provide information about significant individuals. 3. Old medical records may provide valuable information. 4. A visit to the person's former living environment may identify significant support systems. Sometimes they can facilitate a visit from an old friend who has been out of touch. 5. Hospital discharge planners may have information from previous admissions.

Reasons Why

Sometimes a person's poor vision or hearing can help to add to the confusion. Poor lighting can make a person feel disoriented. They may not be able to recognize people or interpret what is happening. Physical causes can be fever, infection, or having an impaction. Poor nutrition and lung disease may also contribute. Medications should always be evaluated especially if they are new.

Our Approach

Sometimes caregivers can feel under a great deal of pressure. They can become preoccupied with the task that they need to do, and forget about the needs of the person with dementia. Talking too fast and asking questions that require memory can be agitating. Repeating the person's name over and over can be agitating, also. Asking too many questions and not allowing the person time to respond can be frustrating. Approaching someone from behind or toughing them when they are not expecting it can frighten them and make them angry. People with dementia are very sensitive to body language and nonverbal communication. If we are impatient or under stress, they will pick up on it and respond. It is important to treat the person with respect, and never scold, confront, or try to argue with the person.

When something is lost

Sometimes the person with dementia will think that something is lost. They become anxious as they search for that purse, or other important possession. Taking the time to acknowledge the feeling that the person is expressing can be reassuring. Offering to help a person look or having a duplicate replacement can relieve their anxiety. We can also learn and alert caregivers about favorite hiding places. A gentle approach and recognition of the need expressed will validate their feelings of insecurity. If the thing that they are looking for is in storage, gently assure them that it is stored in a safe place. If we know the person's life story, we can offer a meaningful distraction such as ice cream or looking at favorite photographs. Insecurity and accusations are part of the disease. We do not take it personally when someone accuses us of something we did not do. Look for noises or things the person may be misinterpreting that may be causing anxiety. Make sure there is adequate light. Think about disruptions in the routine that have occurred. We can look for a history of phobias, past history of abuse or traumatic events.

Identify the problem

The first step is to identify the problem. Think about what is really happening. We can ask those familiar questions, who, what, when, where, why. Who Is there something from the person's life story that can give us a clue about their reaction? What feelings are being expressed? Is it a problem for the person with dementia or is a problem for the caregiver? What Were there triggers just before the situation? Was the task or activity too complicated? When Did the activity occur during the time of day when the person is fatigued? Was it just before or during a bath, a meal, or getting dressed? Were there warning signs that this would occur? Did the person show verbal or non-verbal signs of agitation, such as tapping hard on a table or frowning? Where Where did it occur? What was the noise level, or was lighting a factor? Why Above all, we must look at the feeling being expressed, and figure out what need is being expressed.

Stress and Dementia

The need for security is very strong for a person with dementia. Because of the brain changes associated with dementia, the world can be unpredictable and frightening. The fear and embarrassment felt by the person can lead to debilitating anxiety. When the person tries to regain some control over the situation, it can be a disaster. Sometimes they may be just going back to a familiar coping mechanism.

Person Centered Care

The new culture of dementia has several characteristics. Persons with dementia are viewed as being alive and responsive. They are able to relate to the people they interact with and need to have meaningful activities and experiences. In the new culture, caregivers are focused on empowering a person and creating an environment where there is respect for each person's unique characteristics. We understand the person with dementia has behavior changes. The behaviors we see are a result of brain damage. The focus of care is on the remaining strengths and abilities of the person with dementia. We recognize that ongoing assessment and brainstorming of solutions are important. Solutions to problem situations must be customized to the unique needs of each individual.

The environment CR

The person with dementia may be responding to the environment. The noise level in the room can lead to sensory overload. They may be responding to the behavior of others in the room. Sometimes there is not enough stimulation in the environment, and a person may be frustrated. Not having a feeling of meaning or purpose can promote fear, anxiety, and the need for vocalizations.

Anger and Agitation

There are many reasons why a person may become angry or agitated. With the brain changes from dementia, a person may not be able to interpret what is being said or done to them. With some forms of dementia, visual hallucinations are one of the symptoms. They may have impaired vision or hearing. A person with dementia can become very fatigued and lose control more easily. The person may not be able to interpret the messages from their bodies and be able to tell you that they have pain. A urinary tract or other infection, and constipation are factors to consider. Medications may also be reviewed, and evaluated for side effects, especially if the person has just begun to take them. We must become detectives and think of the need the person is expressing. Some of these things would make us angry, or agitated, too. Like all of us sometimes the person with dementia is just having a bad day.

Developing a plan

Thinking of possible solutions requires brainstorming among all of the people who care for the person. It is essential that the caregiver has input in identifying the problem and offering solutions. We can think about what strategies have worked in the past and what has not been successful. The goal of what we want to accomplish is important. It is the person with dementia that is important. It is not the comfort or convenience of others, or getting the job done. Sometimes the goal is to have the problem occur less frequently. We may not be able to stop it completely. Not all proposed solutions will work. They may work for a time, and then another solution will have to be tried. The most important thing in the problem solving process is communication. Every person eon every shift has to be a part of the plan. If not, there will be no consistency, and the plan will fall apart. Remember that people with dementia do things for a reason. Often they are performing a role or reacting to a situation and the secret lies in their life story.

Helping Families

When we care for a person with dementia, we become partners with the family. It is helpful to let the family know how the person is adjusting. When family members come to visit a person in a new setting, they may feel uncomfortable. We want the families to feel like they were able to share a pleasant moment or memory with the person. Family and friends can be encouraged to share stories about the person. These can be incorporated into the person's care. Some families feel better having a structured activity with the person they are visiting. Caregivers can help identify meaningful activities such as looking at photos, sharing a snack, or reading the newspaper together. Sometimes the family stays too long or too many people visit at once. We can help the families to understand that a shorter visit may be easier for the person with dementia. Smaller groups may be less overwhelming. Because of the bring changes from dementia, the person may tire easily, or have a short attention span. All may enjoy shorter visits.

Anxiety and Paranoia

Why does the person with dementia become anxious or paranoid? Did you ever wake up in a hotel, and for a moment, could not remember where you were? A person with dementia wakes up in an unfamiliar environment every day. They depend on familiar cues to help them feel oriented. Did you ever reach into your purse, or pocket to find your wallet, and it was gone? Remember the feeling of panic that sweeps over you as you try to think where it might be? A person with dementia can have moments of debilitating anxiety. Sometimes it is because of paranoia, delusions or hallucinations.

Types of Behaviors: Pacing

•A person with dementia may pace back and forth - May have a physical need that is not being met (e.g., the person may be hungry or need to use the bathroom) - In response to a noisy, over-stimulating environment, or feeling scared or lost •Try to figure out what is causing the behavior, and take steps to relieve the cause of the behavior •Sometimes there is nothing to do but to let the person pace •Take the person to a safe place (e.g., a fenced-in garden) and walk alongside him or her until the behavior has run its course

Alzheimer's Disease

•Alzheimer's disease is the most common type of dementia, accounting for more than 60% of cases of dementia •More than 5 million people in the United States have Alzheimer's disease •If no cure is found, it is estimated that 11 to 16 million people will have the disease by the year 2050 •Alzheimer's disease usually occurs in people older than 65 years •However, people as young as 40 years may also get the disease •The risk for developing increases with age, people 85 years and older are at highest risk •Alzheimer's disease is a leading cause of death •Exact cause is unknown •Researchers have identified a number of risk factors - Age - Family history - Serious head trauma - Heart disease (hypertension, high blood cholesterol levels, diabetes)

The "4 As" of Dementia

•Amnesia - Difficulty remembering; memory loss - Short-term memory in early stages • Provide lots of reminders; introduce self each time; structured routine - Long-term memory in later stages • Living in pass; easy to embarrass and upset - Validation therapy •Aphasia - Difficulty speaking - Expressive - Receptive - Source of stress and frustration •Agnosia - Difficulty recognizing information obtained through the five senses - Unable to recognize objects - Unable to recognize danger - Unable to recognize people (family, friends, staff, self) •Apraxia - Difficulty coordinating steps needed to complete task • ADLs • Eating - Allow person to do what they can - Coaching - Hand-over-hand cueing - Never rush the person

Assisting With Bathing

•Bath time can be a very frightening time •May not remember what a bath or shower is, or why needs to take one •The sound of running water, the bright lights, and the shiny surfaces in the tub room can be very upsetting •Being naked makes the person feel exposed and vulnerable •The person may be very afraid of falling •May become agitated when hears "time to take a bath." If this is the case, try to avoid the word "bath." •Instead, say "Let's go freshen up" or "It's time for an activity you will enjoy" •If the person seems very agitated, you might try singing to the person •Singing can have a very calming effect on people with dementia •Bath time will generally go more smoothly if prepare the tub room in advance •Make sure that the room is warm, fill the tub ahead of time so does not become frightened by the sound of the running water •Put a folded towel on the shower chair for comfort •Allow the person to wear robe as long as possible, consider draping a bath blanket or towel over shoulders while bathing •The bath blanket or towel will make the person feel less exposed and also provide some warmth •Hand the person a washcloth and let the person assist as much as possible

Assisting With Elimination

•Can present many problems for the person with dementia •May forget where the bathroom is, or fail to recognize the toilet •What should you do? - Sometimes, the person will have an accident because he is unable to move the necessary clothing out of the way fast enough - Taking the person to the bathroom on a regular schedule (e.g., every 2 hours) can help, as can helping the person to select clothing with fasteners that are easy to manage - If a person suddenly seems to be having a lot of accidents, report this to the nurse - The person may have a medical problem, such as a urinary tract infection, that needs to be addressed

Effects of Caring for the Person With Dementia on the Caregiver

•Caring for people with dementia is very important work •The difference you make in the lives of the person with dementia, as well as those of her family members, is significant •Can take its toll, physically and emotionally -Prone to outbursts of anger, become agitated very easily -On any given day, may be cursed at, spit on, slapped, hit, scratched, or pinched -Develop a fondness for the residents, can be very difficult when a resident has a "bad day" and that affection is not returned! -Behaviors can be very annoying, because they are repetitious -It is not always easy to figure out what you can do to make the behavior stop, and until a solution is found, the behavior can really try your patience •If feel yourself becoming overwhelmed, take a deep breath and remind yourself that a person with dementia cannot be held responsible for her actions •If you still feel angry, make sure that the person is safe and walk away •Ask a co-worker or the nurse for help with the person •Sometimes you may need to ask to be assigned to another resident for a while •If your frustration or anger moves you to the point of actually causing a resident physical harm - You will lose your job (as well as all chances of future employment in the health care field) - You may even be punished by a court of law for abuse •To provide the best care to your residents, you need to care for yourself

Vascular (Multi-Infarct) Dementia

•Damage to the blood vessels that supply the brain can affect the delivery of oxygen to the brain tissue •Mental functions are lost because multiple areas of the brain tissue die due to lack of adequate oxygen and nutrients •Thought to be the cause of dementia in approximately 20% to 25% of people with dementia, can coexist with other types of dementia •Most often affects people between the ages of 55 and 75 years, most commonly in 70 years old •It is more common in men than in women •Conditions that put a person at risk for developing vascular dementia include: - A history of myocardial infarction (heart attack) - Hypertension (high blood pressure) - Diabetes mellitus - Peripheral vascular disease - Transient ischemic attacks (TIAs) - Obesity - Smoking - High blood cholesterol levels •Symptoms may appear suddenly and they may vary from person to person, depending on which areas of the brain are affected •Like Alzheimer's disease, vascular dementia is irreversible and incurable •Keeping blood pressure, blood glucose, and blood cholesterol levels within normal limits can help to slow the progression

Types of Behaviors: Delusions and Hallucinations

•Delusions - A delusion is a false belief. For example, a person with dementia may think that she is someone she is not, such as the Queen of England. - Do not try to correct the person...this will only upset her...it would be like someone telling you that you are not who you think you are! - Try to redirect the conversation. For example, you might say, "Tell me about your day" or "Would you like to take a walk now?" •Hallucinations - A hallucination is seeing, hearing, tasting, or smelling something that is not really there - Common in people with dementia. For example, a person with dementia may tell you that there is a cat in the hallway or insects on the bed - If a person is hallucinating, reassure the person. For example, you might tell the person that you will ask the cat to leave, or go through the motion of sweeping the bugs off the bed - Then, gently redirect the person's attention

What is Dementia?

•Dementia is the permanent and progressive loss of the ability to think and remember, caused by damage to the brain tissue •A person with dementia experiences: -Problems with memory, especially short-term memory -Difficulty putting thoughts together and understanding concepts -Problems with judgment (the person is not able to make good decisions) -Disorientation (the person is not oriented to person, place, or time) -An inability to manage activities of daily living (ADLs)

Dementia Versus Delirium

•Dementia must not be confused with delirium, which is a temporary state of confusion •Delirium is a symptom of an underlying disorder, such as an infection, or a side effect of a medication -Once the underlying disorder is treated or the medication is stopped, the delirium goes away -In some cases, the person may die if the underlying cause of the delirium is not identified and treated

Types of Behaviors: Repetition (Perseveration)

•Doing the same thing over and over •For example - The person might repeat the same phrase or question constantly - She might constantly move a piece of cloth around on a coffee table, as if dusting •Behaviors are usually not physically harmful, may be a sign the person is bored •Very annoying to caregivers and other residents •Distract the person by going for a walk, or get involved in an activity such as looking through a magazine, may help to break the cycle

Types of Behaviors: Rummaging

•Go through drawers or closets, searching for an item that he is never able to find •Ask the person what he is trying to find, and offer help in finding it •Rummage through other residents' belongings or every single drawer in his own dresser, it may be necessary to make certain areas "offlimits" by locking them •Special drawer or a box filled with small personal items that he can rummage through

Assisting With Dressing

•Have trouble selecting an outfit to wear •Often want to wear the same clothes every day •What should you do? -Limiting the number of outfits to choose from; asking family to purchase several identical outfits can help to solve these problems -To help make dressing less frustrating for the person, select articles of clothing that are simple, rather than complex

Assisting With Eating

•It may be difficult to get a person with dementia to focus on eating at meal times •May forget why she is at the table, or become distracted by others at the table •A quiet setting and limited food choices can help, will not recognize eating utensils or forget how to use them •Remind the person how to eat by placing your hand over the person's hand - Together, you bring the fork or spoon with the bite of food to the person's mouth •If the person cannot focus long enough to eat a proper meal, try offering the person "finger foods" such as sandwiches, cut-up vegetables or fruits, or a stuffed baked potato •A plastic cup with a lid and a straw or a spout can help to ensure that the person drinks enough fluids •Advanced stages of dementia eventually lose the ability to eat independently •Most of the food placed in the mouth just comes right back out again •Tongue-thrust motions are common in the late stages •A special syringe with a nozzle-shaped tip is used for feeding instead of a spoon •The syringe is used to place the semi-liquid food further back in the mouth so can swallow it more easily •The food is given slowly in small amounts to prevent choking •Using a feeding syringe may allow the person with advanced Alzheimer's disease to continue taking food by mouth for a longer period of time, instead of through a feeding tube

Reality Orientation

•Many years ago, caregivers used a technique called reality orientation with people with dementia •Based on the idea that it is important to bring the person back to the "here and now" by constantly orienting the person to time, place, people, and things •If the person was given enough information to stay on track, then he could be brought back to the present •Is useful for people who are experiencing temporary confusion that is reversible and treatable (i.e., delirium), it is not an effective technique with dementia

Types of Behaviors: Inappropriate Sexual Behaviors

•May attempt to get into bed with a resident who is not her spouse •Masturbate or undress in a public area, such as the dining room •Must take measures to stop inappropriate sexual behaviors, especially if making unwelcome sexual advances toward another person -Gently, but firmly, lead the person back to room and redirect attention by introducing another activity •Although OBRA specifically says that a resident of a long-term care facility must be allowed to fulfill her sexual needs with another consenting resident, another resident with dementia is not able to give that consent •You have a responsibility to protect all of the residents of the facility from unwelcome sexual advances

Meeting the Emotional Needs of a Person With Dementia: Activity Therapy

•Need to exercise their minds •Still can become bored •Activities may be planned for a group of residents, or just for one resident •There are many different types of activities that a person with dementia can enjoy: - Creative activities (flower arranging, painting, baking) - Intellectual activities (looking at a book of photographs, reading the newspaper aloud together, attending a play) - Social activities (hosting a tea party, going on a picnic) - Physical activities (taking a walk, participating in a group exercise class) •When planning an activity, take care to choose one that relates to the former interests and abilities of the person or people who will be participating in it

Types of Behaviors: Agitation

•Often become very upset and excited •May pace, shout, or strike out at caregivers or other residents •Unable communicate effectively with others, so they express themselves through behavior •Many things can cause agitation, including pain or an infection, an unmet physical need (e.g., hunger, a full bladder, or lack of sleep), or a noisy environment

Types of Behaviors: Catastrophic Reactions

•Over-react to something that would cause a healthy person minimal or no stress •For example, may become very agitated or begin to scream or sob loudly when you try to give him a bath •Often occur when the person feels threatened •For example, the person may feel that his privacy is being threatened when you attempt to give him a bath •Feeling overwhelmed •For example, a ringing telephone in a room where the television is on and people are talking might be too much for a person with dementia to handle

Types of Behaviors: Wandering

•People with dementia may stray away from home •It is very dangerous because the person is confused and disoriented - Might get lost, walk into the path of an oncoming car, or drown in a body of water, such as a lake or river - May not be dressed appropriately to be outside •Wandering cannot be stopped, many long-term care facilities have developed ways to allow residents to wander safely -Outside courtyards with high fencing, allow the resident to wander outside within the safe environment of the facility - May also wear a bracelet or an anklet that will set off an alarm if tries to leave through a doorway that leads to an unsafe area - Alarm sounds, staff members are alerted and can guide the person back to safety

Frontotemporal Dementia

•Result of damage to frontal and temporal lobes of the brain •Affects personality, behavior, language, and memory •Onset seen between the ages of 40 and 65 years

Meeting the Emotional Needs of a Person With Dementia

•Several approaches are taken to help meet the emotional needs of a person with dementia - Reminiscence therapy - Activity therapy

Validation Therapy

•Stresses the importance of acknowledging the person's reality •Rather than correcting the person, attempt to distract and redirect the conversation whenever possible •For example, change the course of the conversation by encouraging the person to talk about things from her past •Pay special attention to the words, phrases, and body language that the person uses, better understand what the person is trying to communicate •What the person is saying may seem like nonsense to you, but there may be important meaning behind the words •Validation therapy protects the feelings of the person with dementia •Helps the caregiver to understand what the person with dementia is experiencing

Lewy Body Dementia

•Symptoms are a result of the abnormal buildup of protein bodies in the brain •Affects thinking, movement, and memory •Develop problems controlling body movements •Tend to experience visual hallucinations •May be alert and capable one day and confused and in need of help with ADL the next day

Meeting the Emotional Needs of a Person With Dementia: Reminiscence Therapy

•To reminisce means to remember •In reminiscence therapy, the person with dementia is encouraged to remember and share experiences from his past with others •For example -If a person with dementia insists that she needs to go see her mother (who has been dead for years), you might say, "What does your mother look like?" or "Tell me about a favorite food that your mother used to make when you were growing up"

Caring for the Person With Late-Stage Dementia

•Unable to walk - Risks: pressure ulcers, contractures, pneumonia •Unable to swallow - Feeding tubes; depends on advance directives •Comfort care -Oxygen therapy •Care for someone who is dying •Care of the family

Managing Difficult Behaviors

•When caring for a person with dementia who is demonstrating a particular behavior, you must use your observation skills to try and answer the following questions: - What is the behavior? - Whom is the behavior associated with? - When does the behavior occur? - Where does the behavior occur? - Why is the behavior occurring?

Meeting the Physical Needs

•When helping a person with ADLs, there are several general things to do to make the task at hand go more smoothly: - Speak clearly, in a calm tone of voice - Remind the person at each step what she needs to do next - Use hand gestures in addition to spoken instructions - Plan for the procedure in advance - Keep to a regular schedule

Types of Behaviors: Sundowning

•Worsening of a person's behavioral symptoms in the late afternoon and evening, as the sun goes down •For example, the person may become more agitated, restless, and confused in the evening hours, and may have trouble getting to sleep •Exact cause unknown -Might be brought on by fatigue, especially if the person frequently wanders, paces, or engages in other repetitious behavior of a physical nature -Occurs because the person cannot see as well in the evening hours, when the sun starts to go down •Not being able to see well can increase the person's confusion and agitation •Turning on lights earlier in the evening may help to prevent or reduce sundowning behavior