Chapter 9: Caring for People With Dementia

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

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)

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 frustratio

• 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.

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: 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

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

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: 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

• 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.

• 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!

Reality Orientation Approach Versus Validation Therapy Approach

Example Reality Orientation Approach Validation Therapy Approach Mrs. Rivera is trying to leave the facility. She is very agitated. She keeps repeating that she needs to go home to take care of her mother. Nursing assistant: "Don't you remember? Your mother died 20 years ago. You are staying here with us." Mrs. Rivera's agitation increases. She may continue to insist on going home, or begin to grieve her mother's death. Nursing assistant: "You want to go home to see your mother. Aren't mothers wonderful? Here, sit down and tell me about your mother." Mrs. Rivera is diverted from wanting to go home. She happily sits down with the nursing assistant to discuss mothers. Dr. Carroll, a retired family doctor, believes that he needs to leave the facility and go to the hospital to deliver babies and make rounds on his patients. Nursing assistant: "I'm sorry. Don't you remember that you are retired? You live here in the nursing home with us now. We can't let you leave because you might get lost or hurt." Dr. Carroll becomes agitated because what the nursing assistant is saying does not match his current reality. Nursing assistant (leading Dr. Carroll to the nurse's station): "I bet we can find you a nurse who would love to have you make rounds with her and see the patients here." Dr. Carroll is diverted while still thinking that he has some value as a doctor.

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 • Aphasia • Agnosia • Apraxia

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)

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

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 "off-limits" 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

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