The purpose of this program is to prepare the learner to effectively and safely work with cognitively impaired residents and to understand the importance of behavior management.
After completing this course, the learner will be able to:
Alzheimer's disease and related disorders are grouped by the general term "dementia" in this course. Alzheimer's is a progressive, devastating disease that starts slowly and progresses over time to interfere with activities of daily living. Alzheimer's is not a normal part of aging and the highest risk group is age 60 and up, and the occurrence doubles every five years after age 65 (Alzheimer's Foundation, 2009). This disease accounts for 50-80 percent of all dementia cases in the United States (Alzheimer's Organization, 2011). Dementia is the loss of cognitive functioning: thinking, remembering, and reasoning to such an extent that it interferes with every aspect of daily living. Although there are many different types of dementia, CNAs must learn to understand all aspects of dementia to better care for their residents.
Alzheimer's disease, discovered by Dr. Alois Alzheimer, in 1906, still has no real way to be diagnosed, except through autopsy.
Working with Alzheimer's residents takes a great deal of patience, understanding and compassion. It is not always easy to care for these special residents as they get agitated easily and may become angry and aggressive (Winston, 2010). Their moods change quickly, and caregivers need to adapt to each new situation. Knowing your residents and being able to anticipate their needs is so important. When you can anticipate, you will be able to diffuse a tense situation before it actually begins.
Behavior management begins with good communication skills. Good communication skills are the key to effective and safe practice. When a resident becomes agitated and starts to "act out," direct caregivers must learn to control the situation, keeping the environment safe for everyone in the area. Communication is difficult, at best. People with dementia have trouble with communication, and react with frustration and anger. The best way to manage agitation and anger is to prevent it. Learn to anticipate the residents' needs before they start to act out. Aggressive behavior is usually born from frustration. Alzheimer's residents are not able to verbalize their needs, hence the frustration.
Tips for good communication:
Because dementia affects every part of the brain, as the disease progresses, residents will need more intense assistance. No one progresses at the same rate, and the most likely scenario in long term care would be that there are 20 residents, all in a different degree of dementia. Each resident will do some things that others would never do (Alvare, Fuzy, & Rymer, 2009). Learn to be aware of the "triggers" that set off residents. If you know that one resident will act out in a noisy environment, try to place the resident in a quiet place. Identifying triggers and the emotions that follow is the basis of cognitive-behavioral therapy. It is a strategy that will give you a way to think through difficult scenarios and help to find solutions (Atkins, 2008).
Some triggers to look for:
Be sure to document everything you observe about the shouting, agitation and any other behaviors including the date, time and what is actually happening at the moment. Be sure to share the information with your co-workers at a staff meeting or at the change of shift. This is important because of continuity of care. You and your co-workers can then look for ways to remove the causes and solve the problem.
Validation therapy is letting the resident believe they live in the past or in imaginary circumstances (Alvare, Fuzy & Rhymer, 2009). Validating is giving value to what the resident is living at that time. Keep in mind that arguing with a dementia resident is like arguing with a small child. You will never win.
Safe approaches must be used when dealing with agitated or angry residents. Never approach a dementia resident from behind. If you try to touch a dementia resident, and they do not see you, they become startled and will try to hit you. Good eye contact, while standing right in front of the resident is important. Talk to the resident quietly and calmly. If you remain calm, so does the resident. Please remember that if the resident is angry, it most likely is not because of you. Do not take what they say personally because the resident is most likely unaware of his/her words on you.
A quiet environment is essential to help reduce agitation. This also helps the resident hear and understand what is being said. Turn off the television and radio during meals so the residents are better able to focus on the food. If the resident does become agitated, try to remove the resident to a quiet area.
Remember to watch your body language when dealing with Alzheimer's/dementia residents. If you appear to be angry or threatening to the residents, they will act in kind. Do not cross your arms, or put your hands on your hips. Sometimes dementia residents cannot understand spoken words and depend on body language to try to understand.
Some of the common behaviors are:
There is a difference in verbal and non-verbal communication. When talking to a resident, keep your voice calm and soothing. Always smile when talking to the resident. Tell the resident what you are going to do before you do it then proceed slowly. Use short sentences, call them by name and establish eye contact. Make the person feel important. Never argue with a dementia patient because you will not ever win. Arguing with these residents is like arguing with a toddler.
If the resident is pacing, try to figure out why he/she is pacing. Is the resident agitated or angry? Is the resident clenching his/her fists or grinding teeth? These are sure signs of agitation. If the area is noisy, try to assist the resident to a quiet place. If the resident refuses to move away, try to assist everyone else in the area away.
Wandering is done for a reason, even though we may not understand why. We must make sure that the person is safe while wandering. There are a few signs that wandering will begin: restlessness and disorientation (new). If you see these signs, redirect the resident if at all possible. Offer finger foods or an activity you know the resident likes. Know your resident, anticipate behaviors before they begin. If you are working in a home setting, be sure all doors are locked at night. If in a long-term care setting, frequent rounds must be made at night. Get rid of clutter in their rooms and turn on soothing music.
Rummaging or stealing is taking things that belong to someone else. The dementia resident may think the item belongs to him. Try to redirect the resident away from the area. If this is not possible, watch the resident carefully. Do not tell the family that the resident is "stealing" as this causes added stress (Alvare, Fuzy & Rhymer, 2009). Talk to the family about the behavior so they are prepared when they visit.
There are many reasons why a dementia patient gets agitated. First and foremost, we must keep the patient safe. Keep the noise level down, keep things a simple as possible and use soft music. Remember to get help if the agitation turns into violence.
The following are some reasons why agitation begins, and what you can do to help decrease the agitation:
The risk of violence is always an issue when taking care of dementia patients. They are not comfortable with new situations or routines. They like the same routine day in and day out. Whenever their routine is changes, no matter how small the change, the patient can become agitated. The patient may feel threatened or may feel he/she has no choice in the activity. You may not know their past histories, so if a patient gets upset, you may have triggered a bad memory. Never ask "why" because the patient may feel threatened because the answer may not be apparent. You may ask "What is bothering you?", but, again, he/she may not know the answer. You may need to give the resident an outlet for anger, but make sure he/she is in a safe place. Remember that anger can turn to violence. Stand near the door and do not block the exit in case the violence becomes too much for one person to handle.
Caregivers taking care of elderly people who may become violent or abusive should be advised:
It is important to use appropriate responses for effective behavior management. Not all of these responses can be used in every situation:
There are always warning signs before the violence erupts, so the caregiver must be attuned to every resident, and know what their triggers are. If you see any of the following signs you may be able to defuse the situation before the violence begins:
There are ways to prevent or decrease aggression in any setting. Dementia takes people out of the world of words, logic and reason and brings them into a landscape of feeling and sensing (Doraiswamy & Gwyther, 2008). So if we can remember this statement, it should make our intervention easier.
Let us review the rules of behavior management:
The basic activities of living (ADLs) that CNAs are concerned with include bathing, dressing, eating, continence, getting in and out of bed and walking. These are the personal tasks we all do on a daily basis. When we can no longer perform these necessary functions, we become dependent on someone else. The CNA is an integral part of these daily tasks.
In one study, it was observed that almost 50% of people who turn 65 in any given year in America, enter into an old age home because they are unable to carry out activities of daily living. What this means is that these people are unable to take care of themselves, and require assistance to do so (Thadani, 2010).
When assisting resident with ADLs, remember to go slowly and do not expect the resident to be complacent with all aspects of care. If the resident refuses care, do not argue, stop what you are doing, and come back later. Always be aware of the resident's anger and anxiety levels.
Nursing assistants provide care to Alzheimer's resident according to their own needs (Nursing Assistant Education, 2009). It is important to know which stage of dementia the resident is in at the time of care. As the resident progresses through each stage, your approach will change.
See the individual, not the task:
The following are examples of ADLS, and tips on how to perform them:
|Bathing||Warm shower room, calm environment, resident chooses time|
|Dressing||Task segmentation, resident choice of clothing, give verbal cues|
|Eating||Eye contact, distractions to a minimum, constant cueing to chew and swallow|
|Continence||Encourage fluids, offer "bathroom breaks", adjust the voiding schedule to resident's schedule, go to bathroom before/after meals|
|Walking||Ensure resident is safe, assist with cueing as needed|
Bathing dementia residents is a challenge. Prepare the resident before bathing, explaining what will be happening step by step. Respect the fact that bathing can be very scary. Be gentle and calm. Have all your supplies ready to go, and give a few of these supplies to the resident to carry (shampoo, soap, etc.). Make sure the bathroom is well lit and is at a comfortable temperature (Alvare, Fuzy, & Rymer, 2009). Be respectful of the resident's privacy. Bathing is not needed daily, so try a sponge bath if the resident is agitated or resistant to care.
Mealtime for dementia residents is a very important activity. Eating is a complicated ritual. It is demeaning to the resident to be fed. Every dementia resident is at risk for malnutrition. Ensure the resident has their dentures in. Ask families what the resident's favorite foods are. Finger foods are a good way to get Alzheimer's residents to eat. If they get agitated just hand them finger foods (food on the go). Keep the noise level down during meals. Do not have the television or radio on as these are distractions. Soft music helps keep the residents calm. If the resident must be fed, sit down, make eye contact, and talk to the resident even though he might not understand you. This is dignity and respect.
Assisting residents to dress can be time consuming and stressful. Show the resident the clothes and ask permission to help. Please make sure that the clothing is clean and in good repair. If you just lay the clothes on the bed or chair, the resident may not be able to accomplish the entire task without help. If the resident appears tired, give him a few minutes of rest.
Planning structured, individualized activities that involve and interest the person with Alzheimer's (AD) may reduce many of the more disturbing behavioral symptoms of AD, such as agitation, anger, frustration, depression, wandering or rummaging. Therapeutic activities should focus on the person's previous interests, cue the person to old and recent memories and take advantage of the person's remaining skills while minimizing the impact of skills that may be compromised (Fisher Center for Alzheimer Research foundation, 2010). If the activities are planned well, and are geared to this special population, dementia residents benefit greatly. Understand the resident's world, where they are right now, and the environment will be more pleasant for everyone.
One of the reasons Alzheimer's residents act out is due to boredom. With boredom comes pacing, agitation and anger; all the behaviors we try to prevent. Be compassionate, use soothing music of the resident's choice and have group activities that are comfortable for all. This means that residents in approximately the same stage of dementia should be together. This is not possible all the time, so, plan activities in advance. Know your residents' preferences so you can tailor the activities to their needs.
Getting to know your residents is the key to tailoring activities to meet their needs. You can ask the resident and/or family and friends:
Look for ways to connect with the resident to improve interactions. If the resident trusts you and feels that you have an interest in their world, activities are easier to accomplish.
Activities should be meaningful, hence you need to get to know and understand your residents. Activities should draw on their abilities and interest. Do not assume that a person can do an activity. Keep in mind that long-term memory is less affected in dementia, so, past abilities are most likely to be remembered (Florida Health Care Association, 2008). Try to avoid activities that are childish, but do not avoid this type if the resident asks. Here are a few examples of activities:
Exercise: Everyone benefits from exercise-never too old to start. Even moderate exercise can help elders. The following are a few examples of exercises. These can help improve balance, flexibility and endurance.
Music: Alzheimer's residents may not remember how to turn on the radio or recall how to dance. Bringing music back into their lives is meaningful and can bring smiles to their faces. Music activities can help reduce aggressive behaviors, withdrawal and help maintain physical functioning.
Games: Playing games bring people together, reinforcing social skills. Just remember that dementia residents may not remember the rules!
Arts and Crafts:
Reminiscing: Talking about the past can be comforting to dementia residents.
Celebrating birthdays, putting photos in albums, making memory boxes to place outside of their rooms and watching old movies or television shows can trigger memories. Ask the family to bring in items from home to help with these activities.
Use a room that is quiet, with the residents away from the general population, and encourage them to participate in activities. One of the busiest times on a unit is at change of shift. The sudden increase in people and noise makes it confusing (FHCA, 2008). Having an activity on the patio, or away from the noise and confusion, will keep the stress and anxiety levels of residents (and staff) to a minimum. Keep activities short. Never force a resident to attend activities, and please keep in mind that doing the activity is more important than the end result.
The benefits from meaningful activities include: nervous tension is reduced, decreased pacing and restlessness, reduced negative behaviors and decreased wandering. When dementia residents are happy, everyone involved is happy. Their feeling of self-worth is kept intact. Dementia residents like to go on outings, even if only for a ride in the car. Taking a wheelchair stroll through the neighborhood is usually relaxing.
Encouraging self-care can be deemed an activity. If the resident is easily distracted while performing ADLs, make it a fun time. Play music you know the resident enjoys, talk about "the good old days" as a form of reminiscing. Engage the resident in the conversation if at all possible. When you can set this precedent, the resident will begin to look forward to participating.
When working in a long term care facility, it is best to have some sort of quiet activity happening during the change of shifts. This is a confusing time not only for the staff, but for the residents too. There is a lot of noise, and people coming and going. Keeping the residents busy will decrease the stress and anxiety levels.
The Alzheimer's/dementia caregiver is often called the hidden or second victim of Alzheimer's/dementia (Alzheimer's Association, 2009). There is no doubt the caregiver role is stressful in any setting, but especially the home setting. Huge pressures are placed on caregivers (Alzheimer's Association, 2009). The caregiver will most likely have to reduce work hours, or perhaps even resign. Financial pressures are difficult at best. Having to deal with guilt, anger, loneliness, isolation, to name a few, have a great impact on caregivers.
Stress is the state of being frightened, excited, confused, in danger or irritated (Alvare, Fuzy & Rymer (2009). Not all stress is bad. Learning what your reaction to stress is, and how to manage stress is a vital part of the caregiver role. Taking care of yourself is important. Self-care is not selfish and it helps build self esteem. When you take care of yourself it enables you to take better care of your patients and even your co-workers. Your job is easier when you are healthy. When you are stressed so is the patient. The following chart is the stress warning signs and symptoms. If you feel that your stress level is getting too high, step back, take a deep breath, and try to calm down.
|Cognitive Symptoms||Emotional Symptoms|
|• Memory problems||• Moodiness|
|• Inability to concentrate||• Irritability or short temper|
|• Poor judgment||• Agitation, inability to relax|
|• Seeing only the negative||• Feeling overwhelmed|
|• Anxious or racing thoughts||• Sense of loneliness and isolation|
|• Constant worrying||• Depression or general unhappiness|
|Physical Symptoms||Behavioral Symptoms|
|• Aches and pains||• Eating more or less|
|• Diarrhea or constipation||• Sleeping too much or too little|
|• Nausea, dizziness||• Isolating yourself from others|
|• Chest pain, rapid heartbeat||• Procrastinating or neglecting responsibilities|
|• Loss of sex drive||• Using alcohol, cigarettes, or drugs to relax|
|• Frequent colds||• Nervous habits (e.g. nail biting, pacing)|
|(Help Guide, 2010)|
A stressor is something that causes stress. Stressors are situations that are experienced as a perceived threat to one's wellbeing or position in life (Mayo Clinic Staff, 2010). How we react to stressors defines our sense of well-being. Learning to recognize the stressors that may affect you is an important step in dealing with stress. There is good stress that everyone has in their lives. But, the stressors that cause harm are the ones that we need to be aware of. Have you recently lost a loved one? Have you been fired from your job? Are you going through a divorce? Have you been sick? These are all questions you may ask yourself. Then, when you have sorted out which stressors affect you the worst, you can begin to make a plan (Help Guide, 2010).
Most people ignore their emotional health until there's a problem. But just as it requires time and energy to build or maintain your physical health, so it is with your emotional well-being. The more you put in to it, the stronger it will be. People with good emotional health have an ability to bounce back from stress and adversity. This ability is called resilience. They remain focused, flexible, and positive in bad times as well as good (Help Guide, 2010).
Your ability to tolerate stress depends on many factors, including the quality of your relationships, your general outlook on life, your emotional intelligence, and genetics (Help Guide, 2010). Sometimes just talking to someone about your stress level helps. Talk to your co-workers that you trust or your supervisor. To develop a plan, think about the nice things you can do for yourself, what the sources of stress are, what you can do to change your life to reduce stress, and learning to cope with the stress (Alvare, S., Fuzy, J., & Rymer, S., 2009). When you realize what your stressors are, you can then begin to better manage your stress levels. When your stress is under control, your residents will behave better because they will not feel as stressed themselves.
Alzheimer's/dementia affect everyone around the patient. It affects the nursing staff as well as the family. Working with dementia patients every day takes its toll on the caregiver, whether it is nursing staff or family. Frustration levels run high. Sometimes the family must cope with feelings of embarrassment. Their loved one may "act out" in public, say things they should not say and may hurt themselves or others.
Family members respond to the role changes, especially when the child becomes the parent. It is the same for CNAs. You begin to feel like you are the parent, and this can stir up many negative as well as positive emotions. Learning to cope with the stress is the best possible way to help your families and patients. It does not matter if you work in a facility or in the home setting; working with families in distress is always difficult.
Family members can also be a good resource. They can help you learn more about the resident (Alvare, Fuzy, & Rymer, 2009). Make sure you have a good relationship with the family. It is good for you and the resident. The more you know about the resident, likes and dislikes, the stress level becomes lower.
Always respect the families' differences. They may be a different culture or religion than you, and have different values. If you are unsure of what to do or say, check with your supervisor. Let the family know that you understand their anxieties. Just verbalizing your understanding helps the family.
Financial burdens usually increase partly because there are more medical expenses, and expenses for home care. One of the family members may have to give up working outside the home which adds to the stress levels of everyone involved. As the dementia increases, the caregiver responsibilities increase, and the family will lose the freedom they are used to having. The family will have to make incredibly difficult decisions as the disease progresses including whether or not to place the patient in a long term care facility. After the family makes the decision to place the person in long term care, they may begin to feel all their "power" will be taken away, and that they will have no say in their loved one's care. Anger and stress levels are extremely high during this time. Learning to communicate with family members is important. Explaining what you are doing with the patient is important. Asking the family for ideas helps keep them "in the loop."
If the environment is not right, the resident reacts in a negative manner. Bright lights may improve the symptoms. Keep noise to a minimum. Provide a safe area for agitated residents, keeping clutter down. Always keep the furniture arranged in a consistent manner. Remember, dementia residents need routine.
Sundowning is a difficult behavior to cope with. Sundowning is when the resident becomes confused at the end of the day. There are many theories, but no one is certain about the cause. Fatigue may play a part in Sundowning. If the resident gets tired during the day, allow time for a short nap (30 minutes). Play soothing music, keep the lights on and have familiar items in the residents' rooms to reduce the effects of Sundowning.
Dining is an important part of the dementia residents' day. The dining room should be calm and uncluttered. Low, soothing music should be played and noise should be kept at a minimum. Serve foods with reduced sugar and with no caffeine to lower the risk for agitation and Sundowning.
Dementia residents pose a challenge during meals. Dementia is a progressive disease that eventually robs one of their memories, including how to eat, chew and swallow. Food may not interest a dementia resident, or they may forget what food is for. Residents with Alzheimer's disease require a higher intake of energy (Calories) to maintain body weight (Spindler, Renvall, Nicholas, Ramsdell, 1996). Because of this special need, caregivers must pay attention during meals. Meals should be offered at consistent times every day. Sit down when assisting with meals, and make eye contact. Minimize distractions while in the dining room. Talk to the resident, keep the task of eating simple (Alvare, Fuzy & Rymer, 2009). Use adaptive equipment as needed, including large spoons and small bowls for the food. Keep the table clear of all extra items because Alzheimer's residents forget what certain items are for. They may put salt and pepper in their milk or catsup in their coffee. Finger foods are helpful especially when the resident cannot sit for periods of time. When they begin to fidget it is best to let them get up and wander before getting too agitated. Giving finger foods allows them to continue to eat while wandering. Do not serve food that is too hot. Use contrasting colors on the table such as colorful plates and table cloths. If a resident needs to be fed, take your time. Do not hurry a dementia resident.
When eating becomes a problem, sit with the resident and cue often. Tell the resident to "pick up the fork, put the food in your mouth, chew and swallow." It takes patience and understanding to feed dementia residents. Feeding tubes are not usually recommended for dementia residents. Because dementia is progressive, with no hope of a cure, the idea of prolonging life should not be an option. The quality of life rather than the quantity of life must be examined. Feeding tubes do not prevent malnutrition or extend life (Li, 2002).
There are many situations that do not work when trying to feed Alzheimer's residents. Do not treat the residents like a child or talk down to them. Do not mix foods together as this adds to the confusion. Never allow a resident to eat alone at the bedside.
Ethics is the knowledge of right and wrong (Alvare, S., Fuzy, J., &Rymer, S., 2009). All residents and patients have the right to:
All residents and patients have the right to be respected and treated with dignity (Winston, 2010). Dementia residents should be afforded the same kind respect and dignity as all other residents.
Ethical issues require us to know the difference between right and wrong. The issues for caregivers include:
Patient autonomy vs. Physician responsibility:
It is very important to make these decisions while you are still healthy. Once a person is deemed incompetent, it is too late. If the resident has no living will or health care surrogate, extreme measures must be taken at the end of life. Once a living will is made, it must be followed by the health care team.
Alzheimer's/dementia disease affects a family's emotional, physical and financial well-being. There are times the family becomes overwhelmed and does not know how to find help. Caregivers are obligated to assist the family as well as the patient. Knowing where to turn for help is important.
There are local Alzheimer's Associations that families can reference for help. Joining a support group is helpful also. If you are working in the home care setting, knowing where to find help is imperative. The family can call the local Alzheimer's Association or at the national level. Find out where the Alzheimer's care units are in your community. Perhaps there are adult day care centers available. There even may be a respite center, where the patient can stay for 1-2 weeks while the family rests or takes a vacation. All states have a council on aging that will assist families. There are also Ombudsman programs to ask for help. Asking the family physician for help is an option. The following are resources to suggest to the families.
The Alzheimer's Association
1-800-272-3900 (24/7 help line)
Provides information about Alzheimer's disease and other dementias, organizes family support groups, sponsors educational forums, supports research.
A national program created by the Alzheimer's Association to identify wanderers and help them return home.
National Council on Aging
Online resource offers a searchable list of programs that can help with health care costs.
Alzheimer's disease and related dementias are devastating, not only to the patient but to the family as well. Alzheimer's starts slowly and progresses over the years to affect every aspect of the patient's life. Caregivers are subjected to extremely stressful situations. Behavior management is the key to safe care giving. Learning to confront and deal with aggressive or abusive behaviors helps the caregiver take good care of the patient and well as herself. Learning to anticipate the residents' needs affords the caregiver a better relationship with the resident.
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