Dementia is a syndrome in which progressive deterioration
in intellectual abilities is so severe that it interferes
with the person's usual social and occupational functioning.
An estimated 5 to 10 percent of the U.S. adult population
ages 65 and older is affected by a dementia disorder, and
the incidence doubles every 5 years among people in this age
group. Despite its prevalence, dementia often goes unrecognized
or is misdiagnosed in its early stages. Many health care professionals,
as well as patients and family members, mistakenly view the
early symptoms of dementia as inevitable consequences of aging.
Dementia symptoms include: anxiety, paranoia, personality
changes, lack of initiative and difficulty acquiring new skills.
Alzheimer/Dementia care requires a commitment to providing
quality care. It focuses on the person and always recognizes
the individual with respect and dignity.
The following dementia best practices focus on early recognition
of symptoms and what care providers, routines, activities
and environments must do, to change and not the resident who
is doing their best with diminished capacity.
Does the person have increased difficulty with any of the
activities listed below?
Knowledge of the resident's previous levels is invaluable
in assessing symptoms and interpreting results. Positive findings
in any of these areas generally indicate the need for further
assessment for the presence of dementia.
Report results to the attending physician.
Learning and retaining new information.
For example: Is more repetitive; has more trouble remembering
recent conversations, events, and appointments; more frequently
misplaces objects.
Handling complex tasks.
For example: Has more trouble following a complex train of
thought, performing tasks that require many steps such as
balancing a checkbook or cooking a meal.
Reasoning ability.
For example: Is unable to respond with a reasonable plan to
problems at work or home, such as knowing what to do if the
bathroom flooded; shows uncharacteristic disregard for rules
of social conduct.
Spatial ability and orientation.
For example: Has trouble driving, organizing objects around
the house, and finding his or her way around familiar places.
Language.
For example: Has increasing difficulty with finding the words
to express what he or she wants to say and with following
conversations.
Behavior.
For example: Appears more passive and less responsive; is
more irritable than usual; is more suspicious than usual;
misinterprets visual or auditory stimuli. In addition to failure
to arrive at the right time for appointments; the clinician
can look for difficulty discussing current events in an area
on interest and changes in behavior and dress. It might also
be helpful to follow up on areas of concern by asking the
patient or family members relevant questions.
Assessment is crucial to the development of a useful care
plan. The abilities and needs of the resident with dementia
change throughout the disorder at a rate and in a course that
is highly individual to that person. Families can provide
information regarding the resident's prior life, customary
routines, preferences, behavior triggers, and results of attempted
interventions. They can help interpret language, nonverbal
interactions and the meaning behind the behaviors affected
by major life events and traditions. Include caregivers in
the assessment process, as they are an integral part as they
notice subtle, individual cues they've come to understand.
Ask questions in a systematic way, write down the answers,
and observe. Also, describe a situation and then ask why the
situation exists.
Occasions For Assessment
Preadmission/Admission
? How long might this person stay at this level of need and
ability?
? What is this person's history and current status?
? What are this person's preferences, habits, and daily routines?
? How will this person fit in socially with other residents?
?I s this person and our program a good fit?
Care Plan Development
? What does this person need from us to meet his/her own life
goals?
? Who needs to help residents with efforts to meet those goals?
? How can we operationalize goals into concrete, measurable
objectives?
? How can we adapt our care and services to the resident's
schedules and needs rather than expecting that the resident
adapt to ours?
? How can staff caregivers be flexible and adapt care to the
changes this resident may go through?
? How can we compensate for deficits and build on the abilities
a resident has retained?
Ongoing Documentation
? What is the "baseline" level of ability, functioning,
and behavior for this resident?
? How can we measure the overt and subtle changes occurring
daily?
? As the resident's abilities and needs change, how should
our care plan change?
? What is the impact of the initiation of an intervention?
? What is working and what isn't?
? What differentiates good from bad days?
Problem Analysis and Resolution
? Why is this behavior occurring in this resident at this
time?
? Is this behavior consistent with the past?
? What needs or desires are evident in the behavior?
? What is occurring in the environment, in interactions with
this resident, and within this resident at the time of the
behavior?
? Does the behavior reflect changes in the resident's physical/medical
status or the effects of medications?
Situational Decision Making
? What is the most urgent at this time?
? Why is the resident doing this?
? What is triggering this in the environment, the interactions
with this resident, within this resident at this time?
? How is the resident experiencing this event right now?
? What are the response options?
Focus II. Ongoing Resident Care
Day to day care should be individualized based on the resident's
capabilities, physical health, behavioral status, and personal
preferences. Goals should include: maintaining maximum independence
in ADL's, safety and security, minimizing discomfort, special
attention to medical conditions, special attention to skin,
feet, teeth, gums, the perineal area and bowels; promotion
of nutrition and hydration, provision of physical conditioning
and fresh air; appropriate level of stimulation, achievement
and maintenance of a good mood, maintenance of dignity, family
involvement/satisfaction and promotion and support of functional
skills of bowel and bladder continence.
Ongoing treatment and management of behavioral symptoms is
a major element of the care and in the effective treatment
of the disease. Five general modalities are available for
the treatment of behaviors are:
Address difficult behaviors analytically. Assess the resident
in the situation in which the behaviors are occurring. Analysis
of the behavior and its causes should precede any consideration
of the use of medication or physical restraints to control
the behavior.
Problem Solving Outline For Challenging Behavior
Assess The Behavior To Discern Why The Resident Is Engaging
In The Behavior
1. Describe in detail the behavior
? Include what occurs, when it occurs, how often it occurs,
and who else tends to be involved in the situation in order
to discern the pattern of the behavior. Be very specific and
use objective terms (e.g., "Mrs. S struck caregiver's
shoulder with open hand when the caregiver was leaning over
to tie Mrs. S's shoe," rather than "Mrs. S was combative
during her care").
? Describe conditions regarding the behavior. Identify what
preceded and what resulted from the behavior.
? Document the occurrence and conditions of the behavior for
a period of time to establish a baseline.
2. Examine the extent to which the behavior is a problem
? Identify who is raising the concern about the behavior (family
member, caregiving staff, the person with dementia, or other
residents).
? Who experiences the behavior as a problem? Is anyone in
physical or other danger as a result of the behavior?
? Can the problem be solved by reducing others' exposure to
the behavior rather than changing the behavior itself or by
changing others' tolerance level for the behavior (such as
staff perceptions and tolerance for sexual invitations or
swearing)?
3. Try to discern why the resident is engaging in the behavior,
by examining 1& 2 above
? To what extent can the behavior be explained by understanding
the way the individual with cognitive deficits experiences
and reacts to the situation? For example, does hitting or
screaming during undressing occur because the resident feels
threatened?
? Did something in the environment trigger or cause the behavior?
For example, is there too much, too little, or an inappropriate
type of stimulation? Is there a change in the environment?
? Is the task too difficult? Are there too many task steps
to keep in order?
? Is there something about the resident's preferences, habits
or expectations that has been affected? For example, is the
resident used to eating breakfast before taking a bath? To
what extent is the resident's health or emotional status playing
a role?
4. Identify the interventions attempted to date that have
and those that haven't worked. Examine the conditions under
which interventions are more likely to be effective.
Modalities For Treatment Of Behaviors
1. Prevention of the problem through caregiving staff education
(especially about recognizing what happens before a behavioral
crisis erupts) and the provision of meaningful activities.
2. Behavioral management through changing the environment,
i.e., identification and removal of triggers of disruptive
and replacement with more pleasant stimuli. For example: unpleasant
stimuli (noise, commotion, or sun glare).
3 Behavior modification directed at discouraging unwanted
behavior and/or rewarding desired behavior, but this may not
be a useful approach in the late stage of the disease.
4. Distraction (e.g., preventing biting by giving food) or
engagement in meaningful activities.
5. Medication
Focus III. Programs
The challenge of designing a program that meets the needs
of residents with dementia and fits the interests, habits,
values and abilities of these individuals is the responsibility
of the caregiving staff. The purpose of programming is to
help a resident express herself as the person he/she knows
themselves to be in a way that accommodates their disability
and honors their abilities, values, habits and familiar roles.
There are activities that help one feel safe, in charge,
a part of a group, loved, and loving come from the day-to-day,
moment-by-moment events and encounters of life.
A full balanced life depends on successfully performing activities
from the following three domains:
? Productive Activities (work) - That make us feel useful
and needed
? Leisure Activities - Relaxation and entertainment that
are fun
? Self Care Activities - Personal and instrumental activities
of daily living through which we express our independence
and the intimate personal aspects of our personality.
The amount of satisfaction one gets from doing things that
make each day goes a long way to determining our overall satisfaction
with life.
To be meaningful, an activity will meet the following criteria:
Activity Programming
1. Have a purpose that the resident can appreciate and endorse.
Does the resident know what he is doing and why?
2. Be done voluntarily. Does the resident really want to do
this or is she being coerced?
3. Respect the resident's age and social status. Avoid activities
that feel or look childish or socially inconsistent with resident's
status. The product of any activity must also be appropriate
to adults. For example, instead of making figurines with plasticine,
use gingerbread dough and bake them into cookies.
4. Take advantage of the resident's retained abilities. Security
depends on being in control and control depends on being able.
5. Ensure an opportunity for success.
6. Feel good. When the resident is unable to remember or anticipate,
there is no place for "present pain for future gain."
The actual activities that will meet the above criteria differ
from individual to individual. Each individual needs and deserves
individualized program planning based on the best possible
evaluation of his abilities, interest, habits and needs.
When presenting an activity don't ask; direct and inform
and phrase it politely. Give strong, concrete cues. Point
to the thing or demonstrate the action. Initiate the activity
with the resident watching so he/she can see what is expected.
Trigger an automatic reaction. For example, it is easier to
respond when one is simply handed an article instead of being
told to find it and pick it up. Be sure that the activity
is within the resident's ability to understand and perform.
If the person is truly refusing to participate, respect his/her
right to refuse. Minimize distractions, turn off TV's and
radios, and avoid "crossfire" conversation, in which
staff members are talking to one another over the resident's
head.
