Understanding Dementia and Managing Combative Residents In Long

Understanding Dementia and Managing Combative Residents In Long Term Care Burt Dirkse, ARM, RCFE-A Director, Risk Services BDirkse@MWIAInsurance. com

• Resident aggression causes physical and psychological trauma to both staff and other residents. • 88, 000 of the 1. 3 million nursing home residents (6. 8%) are physically aggressive each week. * • Residents may have underlying psychiatric conditions, cognitive impairment and dementia, which contribute to combativeness. *Potentially Modifiable Resident Characteristics That Are Associated With Physical or Verbal Aggression Among Nursing Home Residents With Dementia, 2006

• More than 5 million residents have Alz disease (2014) and other dementias, which will escalate rapidly as the baby boomer generation ages *Potentially Modifiable Resident Characteristics That Are Associated With Physical or Verbal Aggression Among Nursing Home Residents With Dementia, 2006

• Caregiver training can provide the knowledge to identify certain behaviors that can prevent an actual combative episode. • The outburst is not a personal attack on the caregiver; it is the resident’s way of communicating a need, want or desire.

Signs and symptoms of pain • Facial expressions – Frown, grimace, tension, muscle tightening, frightened appearance, eyes closed tightly, eyes wide open, rapid blinking • Body movements, body language – Changes in mobility or walking gait, guarding of self or part of body, rubbing a particular part of body, wringing hands, clenching fists, restlessness • Visualizations – Shouting, screaming, crying, noisy breathing, asking for help repeatedly, becoming verbally abusive • Watch for physical signs of pain during caregiving- bathing, toileting, dressing and dining.

Signs to look for. . • • • Pressure sores Redness/swelling 1 2 Arthritis/deformities in a joint Refusal to eat or loss of appetite Bruising Noisy breathing 3 4 Skin tears Sweating Unusual paleness

What to do… • If you observe any of these symptoms, report them to your supervisor or nurse immediately • They may be indicative of pain, but also symptoms of a more serious health condition, such as UTI, heart problems, pneumonia

Emotional Pain… • Sadness, fear, loneliness are examples, and can make residents more aware of their physical pain. • Non-medical interventions can decrease resident’s pain • Engaging residents to overcome emotional pain can include: – – – Offering food, beverage or toileting Walking, music, baking or fun conversation Spending time outdoors together on a sunny day Reassuring them and listening as they describe their concerns. Listening to soothing music or offering a gentle hand massage Repositioning to a more comfortable position or location, esp if in a wheelchair

More emotional pain interventions – Reminiscing about residents’ lives or talking about a favorite subject from their Life Story. – Exercising – Holding hands or giving a hug – Serving them their favorite snack – Playing with a visiting pet.

Watch for treatable issues • Dementia can be worsened by: – – – – Not wearing glasses or wearing the wrong glasses Excessive noise and confusion Missing hearing aids or battery failure Sudden health issues such as UTI Poor lighting in a room Glare from window or shadows Pain – physical or emotional Over-stimulation or fatigue

Resident-to-Resident Aggression • Resident-to-Resident aggression (RRA) most frequently happens in dining room and resident rooms. • RRA triggers: – Communication/language barriers – Entering the room of another resident – Territoriality (sharing common items) – Inability to communicate needs effectively • Room temp, TV volume, window shade, lighting

RRA, continued… • Other factors that contribute to RRA: – Roomate conflict – Responses to loud noises – Jealousy • Racial, ethnic and religious affiliation can trigger RRA • Psychological impairment=communication and negotiation skills are diminished, leading to conflict (verbal and physical)

RRA Prevention: • Perform a careful and comprehensive resident assessment before admission to identify individual triggers (physician report, care plan, chart, family interview, etc) • Observe resident in their current situation • Consider their background, acuity level (psych and physical), cultural norms and biases when placing them with roomates. Observe initial placement and comments/complaints.

Combativeness with Caregivers • Contributing factors… – Activities: dressing, bathing, turning, transferring can be confusing to residents, who may lash out. Residents who can’t verbalize needs such as hunger, pain, thirst, toileting, body temp and sleep disruption may use combative gestures. – Environmental factors: light, noises, voices, traffic in room, roommate activity – Resident health: their health status and psych condition may impact their combativeness, and their perception of reality may be altered.

Strategies to Reduce Combativeness • Evaluate resident and the situation: – What are they trying to communicate ? 1 confused trying 2 to perform ADLs ? – Are they – What was happening prior to the episode ? – Are they oriented to the past and have trouble accepting present ? – Any loud noises ? 3 needs met 4(hunger, pain, thirst, toileting, – Are physical temp, sleep disruption) – Any new meds (side effects) – Any new routines, triggers or external factors ?

Strategies to Reduce Combativeness • Ask family about past behaviors or life experiences that may contribute to episiodes • Identify what causes problem behaviors (activity, condition or situation).

Activity: • Bathing: – Consider patient past experience (shower vs. bath vs sponge bath) – Modesty factors (cultural, ethnic, religious, gender pref. ) – Timing (time of day, when is resident most cooperative/least stressed ? ) – Temp of room and water. – Any pain with movement ? (pain meds prior to bath) – Explain the bathing process to each resident each time, including while undressing them. Don’t just pull them from their room, undress them and start touching them

Activity: • Mealtimes: seating preference ? Dining companions ? • Wandering: – Redirect pacing into productive activity – Reassure resident if they appear disoriented • Sleep Problem Mgt: – Address nightime restlessness with • • Improved sleep hygiene (incontinent ? ) Reduce noise and light, play soothing music Keep consistent sleep schedule Use night lights Provide favorite stuffed animal or blanket Increase activity during the day, monitor napping Limit caffeine

Activity: • Toileting – Is resident incontinent ? – Keep toileting schedule – Manage incontinence with pre-bed toileting, even if resident says they don’t have to go (they often will when on toilet). – Avoid constipation (inactivity and some meds contribute to constipation, which can cause pain and anger.

Condition: • Confusion & Agitation – – – Illness, UTI, pneumonia ? Prior drug/alc history ? Med changes or interactions ? Side effects ? Stroke/ CV accident ? May result in personality changes Psychological problems ? History of depression, mental illness ? • Are these being treated ? ? Side effects of psychotropic meds. – Pain: is res able to articulate pain ? Combative outbursts may be the result. – Changes in functional status ? • Hearing loss: able to understand commands vs. just nodding • Visual acuity: is vision declining ? This can result in frustration and fear

Situation • Environmental Adjustments: Modify the env’t to reduce agitation – Extrinsic factors: • minimize loud, distracting noises. Relocate resident is necessary • Flooring: minimize floor glare, choose flooring patterns/colors that are calming • Room temp: hot and cold affect resident comfort – Room placement: • Is resident compatible with roommate ? • Is resident territorial (chair, bed, clothes, TV) ?

Situation • Prevention & De-escalation – Maintain your composure (be aware of your emotions, tone, body language) – Approach resident calmly and express support, use positive/friendly facial expressions. Always approach resident from the front, not the back. – Active Listening: engage resident to determine needs, if possible – Effective verbal responding: reflect/paraphrase to clarify understanding. Use gentle, relaxed tone. – Redirection: provide options of other activities or places. – Stance: talk with them at eye level. Arms at sides, not crossed. Maintain appropriate distance if potential for hitting exists. – Do NOT initiate physical contact if the resident’s behavior is escalating. Touching can trigger violence in some. – Positioning: is res comfortable ? Repositioned regularly as needed ? – Jumping to conclusions: input from other team members is helpful, however, fully assess the resident/situation/environment. Never assume. – Resident stress management: exercise, walking, calming music, pet therapy, favorite doll or blanket.

Situation • Implement Resident Care Plan for interventions and communicate patient needs to staff to minimize behaviors. – Work with entire care team – Make goals realistic: you may not be able to stop all behavioral problems, but can reduce them. – Evaluate staff responses to the episode/outburst. • Consider manner of approach of resident, movement near resident, be at resident eye level, listen to resident, accept/acknowledge resident feelings, don’t correct them or argue with them, use calm tone of voice. – Implement education & training based on findings from episode. Look for themes, trends by resident.

Managing Challenging Behaviors • Behaviors are part of the disease process and are expected. They’re normal for the residents’ condition. • We must handle them creatively and compassionately • The resident is often trying to tell us something; it’s up to us to figure out what that is. • Learn how to turn a No into a Yes.

Behaviors can be a form of communication. As residents lose cognitive skills and vocabulary, their actions and emotions may be the only way they can express their wants and needs. • Someone who is sad and crying may be telling you they are frightened and need a hug and reassurance • Someone who is pacing may be telling you he needs to go to the bathroom • Someone who is tapping their foot or showing anxiousness may need something to eat or drink • Someone who wants to leave may be telling you that she needs more activity and engagement

Be a good detective… When a challenging behavior develops, you must figure out what need is not being met and then meet it.

Causes & triggers of behavior Resident’s physical or emotional state • pain, dehydration, UTI. They could be sad or depressed. These can contribute to challenging behaviors Problems in the environment • Noise, stimulation, clutter can cause stress for residents. Keep mood positive and happy (even if you’re not feeling it). Act. Fake it if you have to. Remain calm

Causes & triggers of behavior Tasks that are too demanding • Expecting too much or giving a resident an overly difficult task can cause push-back and result in challenging behaviors Communication difficulties • Challenging behaviors can happen when residents can’t understand or process what we’re asking them to do, or when they’re unable to understand what they need. They’ll probably not tell you that they don’t understand; they’ll just exhibit frustration

Managing Challenging Behaviors Remember • To offer residents food, drink and toileting. Sometimes, they don’t realize they need to use the bathroom or that they’re hungry or thirsty Reassure • Assure them that they are safe, secure and loved. Redirect • Distract the resident by assisting them to focus on something else. Change the subject. Move to a different location. Change of face.

Managing Challenging Behaviors Reconsider • Is the behavior actually a problem or is it just annoying to you ? Reapproach • If the resident doesn’t want to cooperate in a task or activity, leave them for a moment and come back to try again later. Repeat • State your question or request a second time if they don’t respond immediately.

Managing Challenging Behaviors Rephrase • State your comment or request in simple terms; break instructions in small steps. Reassess • Ask yourself if the behavior is abnormal Reaffirm • Validate the emotions that are being expressed. Don’t ignore what they are feeling. Get into their reality and ask questions. Tell then that you can see they are upset or sad and try giving them a big smile or hug.

Crisis-Level Outbursts When a resident is an imminent threat of harm to you, another resident or themselves: Remove yourself/others from immediate harm. Call for assistance Code Gray (need assistance with agitated resident) Code Silver (need immediate intervention to active violence or imminent threat) Code response team Follow up: re-eval resident admission. Can we adequately care for this resident’s needs ?

Managing Challenging Behaviors • Our residents are no different than us; they want to feel – Safe – Secure – Loved

Quiz Questions… Any warm body is a good admission when census is low. True or False ?

Quiz Questions… You can always believe family when they tell you that the resident never fell at home or had behavior issues. True or False ?

Quiz Questions… Residents with dementia will always be predictable and tell us what they need. True or False ?

Quiz Questions… If I’m having a bad day, that resident better not provoke me if she knows what’s good for her. True or False ?

Quiz Questions… My job is super easy and I’m probably over-paid for what I do. True or False ?

Summary • • Any questions ? Specific situations or challenges in your facility ? Any lessons learned on addressing combativeness ? Discussion of specific residents or outbursts ? – Solutions ? Combativeness in long term care may always be present, but we can reduce resident combativeness with staff education and training necessary to identify triggers which increase combativeness.