Lippincott NursingCenter | Professional Development for Nurses · 2018-05-02 · vascular dementia, Lewy body dementia, and Parkinsonian dementia. Worldwide, nearly 44 million people

1

2

3

4

5

6

7

There is more than one type of dementia, including frontotemporal lobar degeneration,

vascular dementia, Lewy body dementia, and Parkinsonian dementia. Worldwide, nearly 44

million people have Alzheimer’s or a related dementia.

Alzheimer’s is the most common type of dementia. Between 60%-80% of dementia cases fall

under this category. Residents with dementia or brain injury often experience a deterioration

of cognitive function. These impairments adversely affect residents’ receptive and expressive

communication abilities. Receptive communication is the ability to decode and understand

information, such as following verbal instructions. Expressive communication is the ability put

thoughts into words and sentences, in a way that makes sense and is grammatically accurate.

This deterioration in ability to communicate can make engaging residents with dementia

difficult for even for experienced caregivers and often frustrating and emotionally

devastating for loved ones.

The effects of brain injuries make it difficult for caregivers to provide the necessary care to

residents. There are many strategies that tailor communication to each resident’s abilities.

For example, a resident may have difficulty creating a logical flow of ideas and expressing

themselves clearly. They might struggle to follow simple verbal instructions.

8

People with memory impairments live in various types of residential facilities: long term care

facilities (LTC), assisted living facilities (ALF), and skilled nursing facilities (SNF). There are

millions of people who transition from hospitals to acute care settings annually. Caregivers in

every type of facility both receive and initiate resident care.

Studies show that caregivers cite inadequacies of hospital discharge information, such as

residents’ psychological/functional history and medication orders, as well as information of

current health status, which can result in gaps in communication. The resulting

rehospitalization effect of a resident having to move from facility to hospital and then back to

the facility, has a negative impact on the overall health of the resident mentally and

physically.

Poor communication leads to family/caretaker stress, care delays, and increased risk of

patient rehospitalization. The resulting rehospitalization effect of a resident having to move

from facility to hospital and then back has a negative impact on the overall health of the

resident, both mentally and physically.

9

Living with memory impairment includes difficulties communicating about daily experiences,

which can lead to withdrawal, social isolation, and poor-quality care, which in turn leads to

poor quality of life. Residents with dementia or Alzheimer’s depend on caregivers to establish

and maintain relationships with those around them.

To create caring relationships, it is important that nurses communicate with residents with

Alzheimer’s verbally and nonverbally. With verbal communication, caregivers must assess a

resident’s ability to express ideas. When talking to a resident, “identify key concepts and

word associations in the conversation and ask for feedback.” Always try to “assist” the

resident in succeeding, rather than attempt to have a “quiz”.

Speak slowly, use simple language and make sure you are at eye level with them when

speaking to them. “Be patient, as residents may feel frustrated as they struggle to

communicate.” Residents may feel frightened, have anxiety which can cause more confusion,

language decline, and behavioral outbursts both physically and verbally. Remain calm and

reassuring while explaining what you plan to do. Residents may avoid verbalization all

together. According to best practices identified by the John A. Harford Institute for Geriatric

Nursing and the Alzheimer’s Association, caregivers must be able to interpret the meaning of

non-verbal behaviors, such as agitation, restlessness, and aggression. “These behaviors are

often an expression of unmet needs: pain, hunger, and/or toileting needs”3 as well as

fearfulness and frustration. Remember, these residents were once successful , thriving people

in the community, to now not be able to express themselves is an extreme level of frustration

that they are experiencing.

10

Generally, Alzheimer’s occurs in individuals age 65 and older. However, 5% of cases occur in

those younger than 65. There are two types of early-onset Alzheimer’s, genetic, which is

extremely rare, and the common type, frontotemporal lobar degeneration.

Signs and symptoms of early-onset Alzheimer’s appear between the ages of 30 to 65, and are

similar to those seen in other forms of the disease. Early symptoms include forgetfulness,

difficulty with conversations and concentrating. Late symptoms include severe mood swings,

severe memory loss, and incapacity for self-care.9 Other signs are loss of language skills and

gait changes.

The diagnosis can be devastating for family members who may now have to take on the role

of caregiver for a young parent or sibling. Caregivers must understand the special

circumstances of early-onset Alzheimer's in order to provide quality care to residents. Family

members can often become the least effective caregivers due to emotional distress and their

own anger, so it is essential that the family receive the proper guidance and education to

enable them to cope with the situation and become effective caregivers.

11

12

Complete and accurate written documentation is necessary to assure that residents receive

the appropriate care. Documentation supports the exchange of information with other staff

members.

Caregivers often obtain assessment information from loved ones who are familiar with the

residents’ communication abilities and can assist in interpreting residents’ communication

styles. According to Miller, an effective way to assess a resident’s ability to understand verbal

instructions is to “ask family members or other caregivers if a resident understands certain

words, and identify any specific expressions that they use in caring for the resident.” The

more information obtained, the better.

Miller also suggests that to assess a resident’s nonverbal communication, “ask family members

or other caregivers about particular physical cues that the patient associates with daily

activities. For example, ask if a resident will get dressed more easily if clothing is set out on a

chair.” Another strategy is to ask family members if the patient is more receptive to taking

medications at a particular time of day, or if the resident will come to the location where

medication is given on his/her own.

13

There are many sources of educational materials suitable for both family members and

healthcare professionals. There are also online resources to help with assessing

communication difficulties in adults with memory impairment. One example is the

Alzheimer’s Association written assessment guide that includes nine techniques to help family

members and caregivers communicate with residents.

Each organization should develop an assessment tool and a policy and procedure for its use.

Managers should ensure that all staff receive training on the use of this tool. The information

that is obtained will assist all members of the team in their efforts to communicate

effectively with residents.

It is key to document known patient characteristics. Caregivers should write down resident’s

likes, dislikes, preexisting personality, and behavior in current care. This documentation will

enable caregivers to tailor their support to a resident’s specific needs.

14

15

16

One of the most challenging aspects of working with residents who have memory impairments

is monitoring and dispensing medication. In transitions of care, any issue with a resident’s

medication regimen (delay, lack of supply, incorrect dose, etc.) can result in an adverse

event affecting the emotional and physical safety of residents.

Another common challenge during transitions of care identified by researchers is conflicting

medication orders upon patient arrival. Discharge orders prior to admission may fail to

communicate changes in medication, resulting in a drug not being readily available at on-site

pharmacies. “These medication errors can lead to rehospitalization of residents and the

dissatisfaction of their family members.”

Communication between medical staff is a challenge, as well. It is essential that the entire

medical team be aware of the medication prescribed by each specialty and cognizant of all

possible drug interactions.

17

Care of memory impaired residents is complicated by their inability or difficulty

communicating. Caregivers must first develop a positive rapport with each resident.

Residents who have difficulty communicating may feel frustrated. The caregiver should

acknowledge this feeling, offer support, understanding and provide for sufficient time to

answer questions of both resident and family members. Studies have shown that resides with

dementia will engage in conversations when they believe the caregiver is listening attentively

to their expressed reality.

All team members should be provided with opportunities for training and education so that all

are better equipped to interact with residents and avoid injury and other adverse events.

What may sound like babble to the caregiver may be an attempt by the resident to

communicate.

18

According to Teepa Snow, creator of the GEMS Model and Positive Approach to Care

techniques, there are four categories of activity that make all human beings, including those

with dementia, feel valued, productive and purposeful. These are work, leisure, self-care,

and rest and restoration. 4

Snow emphasizes letting a resident’s behavior “go” instead of correcting an action because

the caregiver perceives it as wrong. For example, a resident who is eating with hands instead

of utensils. The behavior is one of self-care and is the resident’s response to hunger.

In this example, the resident’s action is fulfilling that need to eat, and should not be

corrected. Correcting such behavior may lead to agitation.5

19

The Montessori Method helps engage adults with dementia by stimulating the mind with

activities that use fine motor skills. The Montessori Method includes “the use of shapes, cards,

and objects to help develop the manual dexterity needed in daily life, like zipping clothes

and holding small objects.”

The acute care environment can be perceived by residents as unfamiliar and threatening,

which may lead them to resist caregiver support. Gentle Persuasive Approach is a

standardized curriculum that helps caregivers interpret and reframe resident behavior often

viewed as “aggressive” as, instead, being self-protective and related to unmet needs.

The Validation Method accepts residents’ experiences of reality and respond to their verbal

and non-verbal expressions. This method stresses the importance of understanding the

meaning behind communication in one-to-one conversations. One recommended strategy is

for caregivers to look for word associations.

20

There are times when there are disruptions in the necessary care being delivered to residents

with memory impairment. Dementia sometimes make it difficult for residents to recognize

their surroundings. If they feel threatened, anxious or frustrated, residents may exhibit

behaviors like shouting, pacing, wandering, and resistance to care.

Frequently, the reason behind these behaviors is an unmet need. Examples of unmet needs

include: resident needs to use the bathroom, is in pain, or hungry, but can’t express the need

verbally. The caregiver must look for non-verbal cues, such as a resident touching himself or

herself indicating they need to use the bathroom, rubbing their stomach, indicating hunger or

making facial expressions such as grimacing to show pain.

Caregivers must offer residents respect to achieve the goal of quality care. With appropriate

education, caregivers will be better able to respond effectively while showing respect to

residents exhibiting these behaviors. One way to show respect is to ask permission to enter

the resident’s personal space. In addition, caregivers need to know when to step away from

escalating aggressive behavior. Appropriate training and education in such strategies should

be provided to all staff. This is key to prevent resident and staff injury and ssociated claims.

21

Individuals with memory impairment are sometimes “infantilized” in the way they are

treated. Elders with dementia are more likely to resist care when caregivers use infantilizing

communication. Elders must be treated with dignity and respect regardless of their cognitive

level or diagnosis.

One way that caregivers infantilize residents it to use elderspeak in daily conversations.

Elderspeak is infantilizing communication, similar to the language people use when talking to

young children. “Features of elderspeak include diminutives and inappropriate intimate

names such as, ‘honey’ and ‘good girl’ and using shorter sentences. Elderspeak implies a

stereotypical view of elders being less competent than younger adults. The stereotypical,

implied message prompts negative self-esteem and withdrawal for an older person.”

All staff should receive education and training on how to avoid elderspeak and any other

infantilization of residents. Caregivers should talk to residents who have dementia with the

same respect they would give to anyone and would want for themselves. This will help

prevent or decrease the risk of resistance to care.

22

Medical negligence litigation has become an issue of worldwide concern. About 2% of nurse

practitioners have been named as defendants in a malpractice case in the United States. The

criminal prosecution of healthcare providers is a problem, and caregivers should know their

legal responsibilities.

Negligence cases are divided into three categories: minor, ordinary, and gross negligence. A

charge of negligence can arise from almost any action that damages a resident’s health, so

caregivers need to document everything thoroughly and be familiar with the legal aspects of

the healthcare industry.

Negligence has become practically synonymous with medical malpractice, because of the

number of malpractice suits in the United States. Caregivers must know how to practice

safely and lawfully. Always monitor for and report deterioration, administer medications

appropriately, know and follow polices. A rule of thumb and best practice is that if it is not

documented, it never happened, which leads to claims being litigated or settled.

Organizations should have clear and concise policies and procedures for reporting resident

injuries and how to address them. The middle manager should provide education and training

for all staff on these procedures.

23

As Alzheimer’s becomes a growing epidemic, the burden on caregivers rises as well.

Individuals living with Alzheimer’s are likely to wander away from home. Such exit seeking

behaviors are common for residents with dementia as well. Sundowning, a group of

symptoms that occur at specific times of the day, affects many with dementia and may result

in wandering.

If this type of behavior is exhibited, family caregivers and organizations may want to explore

the use of GPS trackers, such as the GPS shoe, as a way to keep their loved one or resident

safe. The GPS shoe is inexpensive and allows adults with memory impairment to maintain

their independence while allowing for easy tracking when they wander. Additionally, the GPS

is extremely accurate, and can be integrated with a phone app or call center. center. Other

interventions in facilities include various types of wander guard equipment and use of “locked

units”.

Although the GPS shoe is a helpful solution to concerned caregivers, it poses a few ethical and

legal quandaries. The ethical debate focuses on the relationship between safety and

autonomy. Some believe it is unethical to track individuals and stifle their freedom. However,

family caregivers tend to prioritize their loved ones’ safety over all other values. To avoid any

litigation, caregivers should use GPS tracking on residents only with the consent of family

members. Finally, it is neither advisable nor a best practice to let someone who has dementia

wander away with supervision even with a GPS shoe.

24

According to research, “Florida’s nursing homes are experiencing an increase in litigation

costs” and this provides an insight into the litigation culture within the rest of the U.S. In

addition, “Florida spends more money on nursing home regulation than on all other types of

health care facilities combined.”

“Changes in the way nursing homes are reimbursed under the Medicare system, increased

quality demands, and the high number of financially unstable nursing homes in Florida

contribute to a multifaceted environmental threat.”

Researchers proposed that increased oversight shed light on deeper, systemic problems in

Florida nursing homes and this has led to more legal cases. In addition the passage of the

Resident Bill of Rights in Florida (Florida Statutes §400.022–400.023) may also have

contributed to the culture of litigation. The intensity of litigation is not uniform across all

nursing homes, as will be discussed in the following case study that examines a low-risk

facility, a medium-risk facility, and a high-risk facility in Florida.

25

The following descriptions are from a study by Johnson and Bunderson study in which they

analyzed litigation patterns in Florida:17

The low-risk home was new fairly (1998) and well maintained. The facility had trouble

attracting qualified nursing assistants. However, there wasn’t a significant lawyer presence in

the area, and few claims were made.

The medium-risk facility was built in 1965, and needed exterior repairs. However, the facility

was clean. The administrator was a 20 year nursing home veteran. The facility was located in

a metropolitan area that had a small lawyer community that was actively seeking out lawsuit

opportunities.

The high-risk facility was built in 1995 and purchased by a for profit chain. Equipment and the

grounds were in disarray. The head administrator had been appointed for less than a year.

The home was in a large urban area with an active lawyer population who promoted suing

nursing homes through media.

26

Following their analysis of litigation brought in each type of facility, the authors identified

various factors that, if addressed in a proactive rather than reactive manner, could decrease

litigation. The first factor was staff perception. In the low-risk facility, none of the staff saw

litigation as a current challenge. This was unlike both the medium- and high-risk facilities’

staff which viewed litigation as a current challenge at 20% and 25% respectively.

The second factor was knowledge of the Resident Bill of Rights. In the low-risk site, the entire

clinical staff knew about the Resident Bill of Rights. Conversely, in the high-risk facility, only

84% of the clinical staff were familiar with the Resident Bill of Rights and 71% of the medium-

risk facility expressed familiarity.

Lastly, when asked why nursing homes are sued, the low-risk site identified internal factors

(quality of care and personnel neglect); the high-risk site identified external factors (TV ads);

and medium-risk sites identified both internal and external factors.

27

28

29

30

31

32