Elizabeth Galik, PhD, CRNP, FAANP University of Maryland School of Nursing.

Elizabeth Galik, PhD, CRNP, FAANPUniversity of Maryland School of Nursing

25-50% of nursing home residents with moderate to severe cognitive impairment exhibit challenging behavioral symptoms such as:◦ Physical aggression◦ Resistance to care◦ Agitation

Behavioral symptoms most commonly during care activities, such as:◦ Bathing◦ Oral care◦ Dressing◦ Transfers and mobility◦ Toileting◦ Mealtime

Communication challenges with spoken language…can’t understand or express

Misinterpret/misperceive touch during care as a threat or assault

Result is often “fight or flight”

Black box warning for antipsychotics due to risk of death

CMS initiative to decrease antipsychotic use Resistance to care often doesn’t respond

well to medications

Nursing home residents with moderate to severe cognitive impairment◦ Spend most of their time in bed or in a chair and

burn only 20-30 kilocalories a day beyond their basal metabolic rate

◦ Spend less than 1 minute/day engaged moderate physical activity

◦ Demonstrate significant decline in personal hygiene, dressing, toileting, and eating within 6 months of admission

Contractures can begin to form after 8 hours of immobility

Skin breakdown begins within 3 hours of immobility

Older adults lose 1.3%-3% of their muscle strength a day if they are immobile

Bed and chair rest leads to decreased functioning of the heart and lungs

Pain Infections Potential for injury for resident and staff due

to resistance to care Falls Hospitalization

Encourages residents to participate in as much of their own care as possible and increases the time they spend in physical activity

Minimizes behavioral symptoms Doing care WITH rather than doing care

FOR Requires staff and families to work

together to motivate residents to do as much for themselves as they are able

Basic personal care: bathing, dressing (can be hand under hand)

Going for a walk or self-propelling in a wheelchair

Feeding yourself as much as you are able Brushing teeth Stretching and range of motion Getting up out of a chair Exercise class

Use cueing, gesturing, pantomime Resident washes one area and staff another Hand under hand Minimize verbal speech Use deeper voice if resident is hard of

hearing Remain calm Limit the number of caregivers Wait for the “best time” for the resident

Behavioral benefits◦ Decreases resistive and combative behaviors

during care◦ Less risk of depression ◦ Improves quality of life

Physical Benefits◦ Prevention of falls◦ Less functional dependence◦ Strengthens muscles and bones◦ Improves balance◦ Prevents contractures◦ Stimulates lung function and circulation.

Participating in physical activity is safe.◦ Activities will be matched to the resident’s

physical and cognitive abilities◦ There is something that everyone can do◦ Staying seated and laying in bed causes

weakened muscles, bones, more confusion, pressure sores, and infection

◦ Reduces risk of falls

What is the best way to identify what a cognitively impaired resident can do?◦ Ask the resident?◦ Ask the family?◦ Ask other staff?◦ Assess physical and cognitive capability and get

them to try?◦ Look in the chart and see what it says?

Range of Motion Strength Ability to follow a 1, 2, or 3 step instruction Chair Rise/Balance Walking?

Set goals based on physical and cognitive capability and behavioral symptoms

Discuss goals with resident, family, and review progress in care plans

Goals focus on function and physical activity (performing ADLs, self-propelling in wheelchair, walking, going to exercise class) and minimizing behavioral misinterpretations of touch during care

Make goals individualized

What are some ways that Function and Behavior Focused Care can be incorporated into the daily life of nursing home residents with cognitive impairment?

Medication management-include the resident in functional tasks (hold cup, self propel or walk up to medication cart)

Walk or wheel self to the dining room Have resident wash face or brush teeth with

cueing rather than you doing it for him Set up meals for more independent eating Hand under hand activities

Have the resident reach for an item in her closet

Have the resident help you in the kitchen by reaching for items in the cupboards

Sweep (also helps to build balance) Fold and fly paper airplanes Kick a ball “Press down on the gas pedal” Tap a balloon Other ideas…

Incorporate supervision and cueing rather than doing the task for the resident

Gesture, role modeling, demonstrate desired tasks on yourself

Some residents are helped by self cueing in mirror (may agitate others).

For resident who pull away as you come toward them, stand to the side or behind them and use hand under hand

Adaptive tools: washing mitts, extension sponges, gait belts, etc.

Know residents’ personal history and use this information to engage them in functional activities◦ Example: Increase opportunities for physical

activity in the evening for “night owls”. Establish a routine consistent with previous

life experience (home, work, leisure activities)◦ Examples: A gardener might enjoy caring for

plants. A business man might enjoy packing his briefcase or organizing a desk.

A windy day A cup of coffee Cleaning the house

to show tunes Walking the dog Christmas shopping Coconut-lime hand

lotion Her electric

toothbrush

How could we use our knowledge of Mrs. Smith’s favorite things to motivate her to be physically active and content?

Imagine one of your residents. How would you use that resident’s past life experiences/preferences to get him/her physically and functionally active and behaviorally stable?

Gradually increase time and intensity of physical activity

Make sure the resident receives pain medications to relieve discomfort.

Use relaxation and distraction techniques Help them overcome anxiety and fear by

actually performing the activity. Remind them “you can do it”

Cognitive decline is not the only predictor of functional impairment. Residents can often do more than we think they can!

Remind yourself and your peers of the benefits of function and behavior focused care.

Everyday, give residents the chance to do something for themselves that you typically did for them. (i.e. wash their face, put their arm in a sweater sleeve)

Residents will take their lead from you!! Believe in their abilities!!

Establish a trusting relationship with the resident

Let the residents know that you really care about them

Use humor Get excited/use positive reinforcement

with residents when they participate in physical activities (bathing, dressing, walking to the dining room)

Pleasant destinations Appropriate chair and bed height Have equipment/tools that facilitates

physical activity (walkers, gait belts, washing mitts, stretch bands) in accessible locations

Small group activities focused on function and activity (Examples: movement groups, walk to beauty shop with peers)

Be aware of the impact the environment (light, noise, temperature, access to outdoors)

Behavioral disturbance during care is most likely to occur when the caregiver touches the resident. So…..

Support more independent function during ADLs by◦ Use more cueing and modeling and less direct

hands on care◦ Use fewer words◦ Be patient and calm◦ Reapproach if necessary

Motivation is strengthened when caregivers believe that residents will benefit from participating in function and behavior focused care

Use other residents as role models to motivate others

All residents can be motivated to participate in at least a portion of their own care. **Be positive and remind them that they can do it!!** Be creative to find out what makes each resident ENGAGE and MOVE!

82 year old widowed, white man referred by staff of the assisted living

Was involuntarily discharged from another AL that couldn’t manage his care needs

“Restless, trying to walk, unsteady, gets verbally angry with staff when they tell him to sit down so he doesn’t fall, also argues with roommate.”

He dozes off during the day and awakens frequently at night

No delusions, hallucinations and no physically aggressive behaviors since admission 1 month ago

2 years ago moved to Maryland from Kansas when neighbors called family with concerns related to his drinking and inability to care for himself.

Following hospitalization and physical rehab stay, did well in senior apartment until he developed severe delirium in the context of a UTI.

Never returned to previous level of function and moved to assisted living

Physically aggressive behavior and elopement attempts and started on Risperdal 1 year ago.

HTN, hyperlipidemia, Weight loss of 15 pounds in the last year;

has gained 3 pounds in the past month Right nephrectomy Bladder cancer with urostomy L1 compression fracture Medications: Risperdal, Trazodone,

Lorazepam, Tylenol, Senna

Awake but with poor attention and eye contact, uncooperative with exam, speech slowed, soft with long response latency, anhedonia, no SI, no delusions, hallucinations, MMSE=7

Festinating, shuffling gait, decreased arm swing, mild resting tremor, masked facies, bradykinesia, cogwheel rigidity

More alert Sleeping at night Improved cognition, MMSE 14, able to complete

serial 3s, give history Still restless, wants to walk, and no improvement

in Parkinsonism (freezing at thresholds) Staff giving him more opportunities to move with

assistance rather than telling him to sit down 5-6 year history of progressive motor symptoms,

never diagnosed with PD