Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes - Alzheimer's Association Campaign for Quality Residential ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Alzheimer’s Association Campaign for Quality Residential Care Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes Building consensus on quality care for people living with dementia
Table of Contents
Campaign Overview 1
Phase 1 2
Dementia Care Fundamentals 5
Food and Fluid Consumption 9
Pain Management 11
Social Engagement 13
Phase 2 15
Resident Wandering 18
Resident Falls 22
Physical Restraint-Free Care 26
The Alzheimer’s Association is the leading donor- For more information, visit www.alz.org or contact:
supported, voluntary health organization in Alzheimer
research, care and support. Our mission is to eliminate Elizabeth Gould, M.S.W.
Alzheimer’s disease through the advancement of National Office
research; to provide and enhance care and support Alzheimer’s Association
for all affected; and to reduce the risk of dementia 225 N. Michigan Ave., Fl. 17
through the promotion of brain health. Chicago, IL 60601-7633
Phone: 312.335.5728
elizabeth.gould@alz.org
The Alzheimer’s Association offers quality care education
© 2009 Alzheimer's Association. All rights reserved.
This is an official publication of the Alzheimer’s Association but may be programs for direct care workers and other residential
distributed by unaffiliated organizations and individuals. Such distribution
care staff. For more information, call 1.866.727.1890 or
does not constitute an endorsement of these parties or their activities by
the Alzheimer’s Association. visit www.alz.org/qualitycare.
Dementia Care Practice Recommendations for
Assisted Living Residences and Nursing Homes –
Phases 1 and 2
Edited by Jane Tilly, Dr.P.H., and Peter Reed, Ph.D.
For more than 25 years, the Alzheimer’s STRATEGIES FOR QUALITY RESIDENTIAL CARE
Association has been committed to advancing All aspects of our Quality Care Campaign — from
Alzheimer research and enhancing the care, the selection of care practice areas to development
education and support for individuals affected of recommendations, educational programming
by the disease. Building on our tradition of and advocacy — are based on the best available
advocacy for improving the quality of life evidence on effective dementia care in residential
for people with dementia, we launched the settings. We are using four strategies:
Alzheimer’s Association Campaign for Quality • To encourage adoption of our recommended prac-
Residential Care in 2005. tices in assisted living residences and nursing
homes, we are advocating with direct care
More than 50 percent of residents in assisted
providers.
living and nursing homes have some form of
dementia or cognitive impairment, and that • To ensure incorporation of the practice recommen-
number is increasing every day. To better respond dations into quality assurance systems for nursing
to their needs, we have joined with leaders in homes and assisted living residences, we are
dementia care to develop the evidence-based working with federal and state policy-makers.
Dementia Care Practice Recommendations for • To encourage quality care among providers, we
Assisted Living Residences and Nursing Homes. are offering training and education programs to all
These recommendations are the foundation of levels of care staff in assisted living residences
our multiyear campaign. and nursing homes.
• To empower people with dementia and their
Each year we are focusing on a different set of
caregivers to make informed decisions, we
care recommendations that can make a significant
have developed the Alzheimer’s Association
difference in an individual’s quality of life. Phase 1
CareFinder™. This interactive online guide is
focuses on the basics of good dementia care
educating consumers on how to recognize quality
and three care areas: food and fluid consumption,
care, choose the best care options, and advocate
pain management and social engagement. Phase 2
for quality within a residence.
covers three additional care areas — wandering,
falls and physical restraints. In the next few
years, we will add recommendations in new
care areas, such as end-of-life care, and update
recommendations as new evidence on effective
care interventions becomes available.
To date, 26 leading organizations have expressed
their support and acceptance of the Phase 1
Dementia Care Practice Recommendations and
24 have stood with us to support the Phase 2
recommendations. We are grateful to these
organizations for their counsel during development
of the recommendations and for helping achieve
consensus in our priority care areas. September 2006
1
Phase 1 Introduction
Dementia Care Fundamentals
Food and Fluid Consumption
Pain Management
Social Engagement
Introduction to the Dementia
Care Practice Recommendations
Phase 1
The Dementia Care Practice Recommendations For the first year, the Alzheimer’s Association
are based on the latest evidence in dementia care chose three priority care areas where we believe
research and the experience of care experts. intervention can make a significant difference in
A three-year study, funded by the Alzheimer’s an individual’s quality of life. The dementia care
Association and conducted by researchers at the recommendations define goals for each care
University of North Carolina at Chapel Hill, explored area and present strategies for achieving them.
staff and facility characteristics associated with
quality of life for people with dementia in assisted Food and Fluid Consumption
living residences and nursing homes. Results from Inadequate consumption or inappropriate food
this study were published in The Gerontologist and fluid choices can contribute directly to a
(October 2005). decline in a resident’s health and well-being.
Recommendations are based on these goals:
The Association also conducted a comprehen-
• Provide good screening and preventive systems
sive literature review, Evidence on Interventions
for nutritional care.
to Improve Quality of Care for Residents with
Dementia in Assisted Living and Nursing Homes, • Assure proper nutrition and hydration, given
which critiques evidence on interventions resident preferences and life circumstances.
designed to improve dementia care. Dementia • Promote mealtimes as pleasant and enjoyable
care experts and professional staff from the entire activities where staff have an opportunity to
Alzheimer’s Association used this evidence observe and interact with residents.
and a consensus-building process to translate
the research into specific recommendations for Pain Management
dementia care practices. Pain is under-recognized and undertreated among
people with dementia, primarily because they can
Included in the initial set of recommendations
have difficulty communicating. Poorly managed
are the fundamentals for effective dementia care,
pain can result in behavioral symptoms and lead
which are based on person-centered care — care
to unnecessary use of psychotropic medications.
tailored to the abilities and changing needs of
Our care recommendations are based on the
each resident.
following goals:
Recommended practices for care include a • Ease the distress associated with pain and help
comprehensive assessment and care planning residents enjoy an improved quality of life.
as well as understanding behavior and effective • Treat pain as the “fifth vital sign” by routinely
communication. Strategies for implementing assessing and treating it in a formal, systematic
person-centered care rely on having effective way, as one would treat blood pressure, pulse,
staff approaches and an environment conducive respiration and temperature.
to carrying out recommended care practices.
• Tailor pain management techniques to each resi-
dent’s needs, circumstances, conditions and risks.
3
Social Engagement • Design interactions to do with — not to or for
— the resident.
Engagement in meaningful activities is one of the
critical elements of good dementia care. Activities • Respect resident preferences, even if the resident
help residents maintain their functional abilities and prefers solitude.
can enhance quality of life. Recommendations are
based on these goals: When nursing homes and assisted living
• Offer many opportunities each day for providing residences are considering changes to care or to
a context with personal meaning, a sense of the environment of the residence, they should
community, choices and fun. ensure that these changes comply with relevant
state and federal regulations.
Organizations Supporting the Dementia
Care Practice Recommendations, Phase 1
AARP Consumer Consortium on Assisted Living
American Assisted Living Nurses Association John A. Hartford Foundation Institute for
American Association of Homes and Services Geriatric Nursing, New York University
for the Aging College of Nursing
American College of Health Care Administrators National Association of Activity Professionals
American Dietetic Association National Association of Directors of Nursing
American Health Care Association Administration in Long Term Care
American Health Quality Association National Association of Social Workers
American Medical Directors Association National Center for Assisted Living
American Occupational Therapy Association National Citizens’ Coalition for Nursing
American Physical Therapy Association Home Reform
American Seniors Housing Association National Hospice and Palliative Care Organization
American Society of Consultant Pharmacists Paralyzed Veterans of America
American Therapeutic Recreation Association Service Employees International Union
Assisted Living Federation of America
The American Speech-Language-Hearing
Catholic Health Association
Association accepts the recommendations.
We are enlisting the support of these and other organizations, as well as consumers and policy-
makers, to help us reach the goal of our Quality Care Campaign — to enhance the quality of life of
people with dementia by improving the quality of dementia care in assisted living residences and
nursing homes.
4
Commitment to Dementia Care
Fundamentals for Effective Note : “Family members” can include people who
Dementia Care are related to a resident or are not related but play
a significant role in the resident’s life.
• People with dementia are able to experience joy,
• To have staff use a flexible, problem-solving
comfort, meaning and growth in their lives.
approach to care designed to prevent problems
• For people with dementia in assisted living and before they occur by shifting care strategies to
nursing homes, quality of life depends on the meet the changing conditions of people with
quality of the relationships they have with the direct dementia
care staff.
• Optimal care occurs within a social environment Recommended Practices for
that supports the development of healthy relation- Effective Dementia Care
ships between staff, family and residents.
Assessment
• Good dementia care involves assessment of a • A holistic assessment of the resident’s abilities
resident’s abilities; care planning and provision; and background is necessary to provide care and
strategies for addressing behavioral and communi- assistance that is tailored to the resident’s needs.
cation changes; appropriate staffing patterns; and
• A holistic assessment includes understanding
an assisted living or nursing home environment
a resident’s:
that fosters community.
• Each person with dementia is unique, having a
• Cognitive health
different constellation of abilities and need for • Physical health
support, which change over time as the disease • Physical functioning
progresses. • Behavioral status
• Staff can determine how best to serve each • Sensory capabilities
resident by knowing as much as possible about
• Decision-making capacity
each resident’s life story, preferences and abilities.
• Communication abilities
• Good dementia care involves using information
about a resident to develop “person-centered” • Personal background
strategies, which are designed to ensure that ser- • Cultural preferences
vices are tailored to each individual’s circumstances. • Spiritual needs and preferences
• Assessments should acknowledge that the
Goals for Effective Dementia Care
resident’s functioning might vary across different
• To ensure that staff provide person-centered staff shifts.
dementia care based on thorough knowledge of E x ample: Residents may become confused,
residents and their abilities and needs disoriented or more active as evening approaches
• To help staff and available family act as “care or during staff changes.
partners” with residents, working with residents
to achieve optimal resident functioning and a
high quality of life
5
• If assessment identifies problems requiring consul-
tation with health or other types of professionals,
making the appropriate referrals can help mitigate
these problems.
E x ample: Professionals such as physical or occupa-
tional therapists can help people with dementia regain
physical health and improve their performance of
daily activities.
• Obtaining the most current advance directive
information (e.g., durable health care power of
attorney or living will) as well as information about
a resident’s preferences regarding palliative care
• Thorough assessment includes obtaining verbal and funeral arrangements helps ensure that the
information directly from residents and from family resident’s wishes will be honored.
when possible. Note : While residents possess the capacity for
Ex ample : Staff can ask residents about their reactions decision making, they have the legal right to review
to care routines, and staff can provide feedback on and revise their advance directive.
successful techniques to the entire care team.
Ex ample : Family members can help develop a “life Care Planning and Provision
story” of the resident, offering detailed background • Effective care planning includes a resident and
information about a resident’s life experiences, family, when appropriate, as well as all staff
personal preferences and daily routines.
(including direct care staff) who regularly interact
• If obtaining information from a resident or family with the resident throughout the process.
is difficult, staff can still learn about the resident E x ample: By asking staff and family members
through other sources, such as medical records, who have the best relationship with the resident
and by observing the resident’s reaction to to describe how they elicit cooperation regarding
particular approaches to care. necessary care activities, those techniques can
become a routine part of care.
• Resident behaviors can be seen as a form of
communication and an expression of preference. • An effective care plan builds on the resident’s
abilities and incorporates strategies such as task
Ex ample : A resident repeatedly refusing a certain
food may simply not like that particular food. breakdown, fitness programs and physical or
occupational therapy to help residents complete
Ex ample : A resident who consistently resists entering
the shower room may need another method of their daily routines and maintain their functional
keeping clean. abilities as long as possible.
• Regular formal assessment, as required by federal • When all staff involved in a resident’s care are
or state regulation, is key to appropriate manage- familiar with the care plan, they will be better
ment of residents’ care. Equally important is equipped to provide appropriate care to the resident.
ongoing monitoring and assessment of residents, Note : Assessments, care plans and life stories will
particularly upon return from the hospital or upon be most beneficial if they are accessible to all staff.
a significant change in their conditions.
6
• Care plans will remain current and most useful • Information about a resident’s life prior to admis-
if they are regularly updated in conjunction with sion, such as his or her culture and role within
periodic assessments. the family, may provide clues about effective
• Care plans need to be flexible enough to adapt to approaches to care.
daily changes in a resident’s needs and wishes. E x ample: Knowing a resident’s morning rituals,
such as how they like coffee or tea and what time
Behavior and Communication they prefer to wake up, can provide insight into
how to care for a resident.
• Residents need opportunities and sufficient time
to express themselves. • If non-pharmacological treatment options fail
after they have been applied consistently, then
Ex ample : Speaking in simple, direct language to
residents, potentially accompanied by gestures, introducing new medications may be appropriate
pictures, written words or verbal cues, may help when residents have severe symptoms or have
staff communicate with residents when involved the potential to harm themselves or others.
in daily activities. Note : Medication and non-pharmacological
Ex ample :Residents may need to work with a approaches are not mutually exclusive. At times
speech-language pathologist to maximize their a combined approach might produce the greatest
communication skills. benefit for the resident.
• The behavior and emotional state of people • When considering new medications, consider
with dementia often are forms of communication the presence of any other potential problems,
because residents may lack the ability to such as depression.
communicate in other ways. Note : Continued need for pharmacological
• Staff need initial and ongoing training to identify treatment should be reassessed by a qualified health
potential triggers for a resident’s behavioral and professional according to the medication regimen
or upon a change in a resident’s condition.
emotional symptoms, such as agitation and
depression. • Staff communication with a resident’s family is
Note : Triggers may include visual or hearing
critical to helping the family understand the
impairments, hunger, thirst, pain, lack of social progression of the resident’s dementia, particularly
interaction or inappropriate strategies for care as he or she approaches the end of life.
activities by staff.
• When staff recognize these triggers, they can Staffing
use environmental and behavioral strategies to • Staffing patterns should ensure that residents
modify the triggers’ impact. with dementia have sufficient assistance to
• Staff actions can elicit positive behavioral complete their health and personal care routines
responses as well. and to participate in the daily life of the residence.
Ex ample : Positive staff actions include providing • Consistent staff assignments help to promote
relaxing physical contact like hand holding, the quality of the relationships between staff and
apologizing if a resident complains of pain during residents.
a care activity, listening to resident concerns and
providing reassurance.
7
• Direct care staff need education, support and • Staff need (1) recognition for their use of
supervision that empowers them to tailor their care problem-solving approaches to providing care and
to the needs of residents. (2) emotional support as they deal with their own
Ex ample : Direct care staff could learn when residents emotional reactions to the decline of residents
wish to get up and how they wish to be bathed. over time and eventual death.
Ex ample : Provide constructive feedback on staff • Staff should acknowledge and accept a resident’s
interactions with residents.
experience and should not ignore a resident’s
• Staff supervisors may need ongoing coaching to report of an event or his or her feelings and
help them empower and support the direct care thoughts.
staff to be decision makers. E x ample: When a resident is complaining of pain,
Note :Facility and staff managers serve an staff could tell the resident that they understand
important function as role models in providing it hurts and then report the pain to a staff member
good dementia care. who can address the resident’s pain experience.
• Administrators have the role of evaluating facility
Environment
policies and procedures to ensure that they support
direct care staff decision making during real-time • The physical environment can encourage and
interactions with residents. support independence while promoting safety.
E x ample: A positive environment has recognizable
• Staff who understand the prognosis and symptoms
dining, activity and toileting areas as well as cues to
of dementia and how this differs from normal help residents find their way around the residence.
aging and reversible forms of dementia are better
• The optimal environment feels comfortable and
prepared to care for people with dementia.
familiar, as a home would, rather than a hospital.
• Effective initial and ongoing staff training addresses: The environment should be less about physical
• Dementia, including the progression of the structures and more about the feeling inspired by
disease, memory loss, and psychiatric and the quality of the place.
behavioral symptoms E x ample: A home environment provides opportuni-
• Strategies for providing person-centered care ties for residents to have privacy, sufficient lighting,
pleasant music and multiple opportunities to eat and
• Communication issues drink, and also minimizes negative stimuli such as
• A variety of techniques for understanding loud overhead paging and glare.
and approaching behavioral symptoms, including E x ample: When appropriate, a home environment
alternatives to restraints might entail a private room and bathroom and the
opportunity for residents to have personal furnishings,
• An understanding of family dynamics
pictures and other items in their living area.
• Information on how to address specific
• Providing easy, safe and secure access to the out-
aspects of care (e.g., pain, food and fluid,
doors while maintaining control over unauthorized
social engagement)
exiting enhances the environment.
Note : Residents who have elopement behaviors need
opportunities for safe wandering.
8Adequate Food and
1 Fluid Consumption
Dementia Issues Recommended Practices
• Insufficient consumption or inappropriate food Assessment
and fluid choices can contribute directly to a decline • Nutrition screening and thorough assessment are
in a resident’s health and well-being. the foundation for providing optimal nutrition care.
• Adequate assistance, preventive screening and • Assessments need to address nutritional problems
intervention for nutritional problems will help to and resident characteristics such as poor dental
assure the overall health of residents suffering health, swallowing difficulties or distractibility during
from dementia and will prevent unnecessary meals that may affect food and fluid consumption.
complications.
E x ample: Set up referrals to a registered dietitian
• Dementia may lead to reduced food and fluid for residents who are at high risk for nutritional
intake, due in part to decreased recognition of problems, in compliance with regulatory requirements.
hunger and thirst, declining perceptions of smell Registered dietitians can prioritize nutritional prob-
lems and interventions by verification, evaluation and
and taste, dysphagia (swallowing difficulty), inability
interpretation of physical, chemical and behavioral
to recognize dining utensils, loss of physical information.
control, such as the ability to feed oneself, apraxia
E x ample: Those who have swallowing difficulties
(impairment of ability to move) and depression. may need assessment by a qualified professional
• Residents with dementia may lose the ability to familiar with dysphagia.
communicate hunger and thirst. • Difficulty with eating may also be the result of
• Residents may refuse to eat because of physiologi- residents having impairments of balance, coordina-
cal or behavioral conditions, or they may do so tion, strength or endurance.
because they are at the end of life. Note : Ensure that seating adequately compensates
• Addressing dementia-associated problems and for these impairments.
helping to ensure adequate intake of food and fluid • Ongoing monitoring of residents is necessary to
requires a concerted staff effort. discover changes in food and fluid intake, functional
ability or behaviors during meals. Any changes should
Care Goals be reported to dietetic staff and care planners.
• To have good screening and preventive systems • Adequate assessment to minimize mealtime
for nutritional care to avoid problems such as difficulties includes observing residents for warning
weight loss, malnutrition, pressure ulcers, infection signs such as:
and poor wound healing • Difficulty chewing and swallowing, or changes
• To assure proper nutrition and hydration so that in swallowing ability
residents maintain their nutritional health and avoid • Poor utensil use
unnecessary health complications, given resident
• Refusing substitutions
preferences and life circumstances
• Low attentiveness to a meal or wandering
• To promote mealtimes as pleasant and enjoyable
away during the meal
activities. Mealtime provides an opportunity for
staff to observe and interact with residents, helping • More than 25 percent of food uneaten during
to ensure health, well-being and quality of life. a meal
9• Regular monitoring and recording of a resident’s • Weight loss is often expected at the end of life,
weight helps ensure that staff recognize and but should still be assessed.
address the cause of any changes. Note : Residents should not be forced to eat beyond
what they desire.
Staff Approaches
• When considering tube feeding as an option, one
• Various activities can engage residents in the should be aware of the potential consequences.
mealtime experience and stimulate appetite. Tube feeding could have many serious side effects
Ex ample : Create opportunities for residents to help for residents with dementia, including aspiration,
plan the menu and set the table; stimulate olfactory infections and resident removal of tubes.
senses by baking bread or a pie prior to the meal.
Ex ample : Create a “happy hour” to encourage Environment
increased fluid intake.
• Residents should have a pleasant, familiar dining
• When practical, residents can choose the time environment free of distractions to maximize their
when the meal is served. Mealtimes may need to ability to eat and drink.
be rescheduled for a different time of day if a E x ample: Distractions during meals should be
resident exhibits time- or light-dependent agitation, limited by avoiding mealtime interruptions and by
distraction or disorientation. reducing unnecessary noise and the number of
items on the table.
• During the meal, residents often require assistance
E x ample: Serving residents with dementia in smaller
to maximize their own ability to eat and drink.
dining rooms can minimize distractions.
Encouraging residents to function independently
E x ample: A resident’s attention to food can increase
whenever possible can help prevent learned
through visual cues, such as ensuring visual contrast
dependency.
between plate, food and place setting.
Ex ample : If assessment shows that a resident can
E x ample: Present a variety of foods in attractive ways.
eat independently, but does so slowly, the resident
can eat at his or her own pace, perhaps with verbal • A positive social environment can promote the
reminders to eat and drink. Mealtimes can be ability of residents to eat and drink.
extended for slower-eating residents. E x ample: Consider where residents are seated to
Ex ample : Adaptive utensils and lipped plates or construct the most appropriate arrangements given
finger foods may help individuals maintain their relative need and personalities.
ability to eat. E x ample:Provide small tables that encourage
Ex ample : For those residents who manage better conversation among tablemates.
if they face fewer choices, serving one food item at
a time is preferable. Food and Fluid
Ex ample : If residents need hand feeding, guide the • Residents need opportunities to drink fluids
resident’s hand using the “hand-over-hand” technique.
throughout the day.
• It is ideal for staff to sit, make eye contact and E x ample: Incorporate fluids into activities and have
speak with residents when assisting with meals. popsicles, sherbet, fruit slushes, gelatin desserts
• Fortified foods and supplements may become or other forms of fluid always available to residents.
necessary, but first try other food approaches • Nutritional requirements need to be met in the
such as favorite foods and food higher in nutrient context of food and cultural preferences.
density, calories and protein. • As a resident’s functional ability declines,
• Residents with severe and irreversible dementias food should be prepared to maximize the food’s
may no longer be able to eat at the end of life and acceptance.
may need only comfort care. E x ample: If a resident cannot handle utensils, try
Note :Residents at the end of life need their mouths modifying the shape of food so it can be picked up
moistened and good oral care. with the fingers.
Note : When residents are near the end of life,
artificial nutrition and hydration may be withheld, in
accordance with their wishes.
102 Pain Management
Dementia Issues
• Pain is defined as an individual’s unpleasant
sensory or emotional experience.
Note : Acute pain occurs abruptly and escalates
quickly, whereas chronic pain is persistent or recurrent.
• Pain is a highly subjective personal experience for
which there are no consistent, objective biological
markers.
Note : Because of a lack of objective markers, pain can
be easily under-recognized and undertreated among
people with dementia.
• Poorly managed pain can result in behavioral symp-
toms and lead to unnecessary use of psychotropic
medications.
• One of the challenges in managing pain for people
with dementia is assessing and communicating
with them about their pain experiences and about
the side effects of medications. Recommended Practices
Note : An individual’s cognitive functioning, commu-
nication abilities, cultural background or emotional Assessment
status may affect these experiences. • Pain assessment should occur routinely, including
when residents have conditions likely to result in
Care Goals pain and if residents indicate in any manner that
• To ease the distress associated with pain and help they have pain.
a resident enjoy an improved quality of life • Effective pain assessment addresses:
• To treat pain as the “fifth vital sign” by routinely • Site of pain
assessing and treating it in a formal, systematic
• Type of pain
way, as one would treat blood pressure, pulse,
respiration and temperature
• Effect of pain on the person
• To tailor pain management techniques to each
• Pain triggers
resident’s needs, circumstances, conditions • Whether pain is acute or chronic
and risks • Positive and negative consequences of treatment
• For those residents who cannot verbally com-
municate, direct observation by staff consistently
working with them can help identify pain and
pain behaviors.
E x ample: Observing residents when they move
may uncover problems that may not occur when they
are at rest. The problems may require referrals to
occupational or physical therapists.
11Ex ample : Observation may uncover behavioral • Pain can be prevented through the regular use of
symptoms, such as agitation and mood changes, medications. Offering medications PRN, that is,
or verbal and physical expressions of pain, such as
only when the resident reports pain, may not be
sighing, grimacing, moaning, slow movement, rigid
sufficient treatment for many residents.
posture and withdrawing extremities during care.
• There may occasionally be valid clinical reasons
• When pain occurs and the cause is not known,
for not wanting to mask acute pain with analgesics
conduct a thorough assessment of the resident’s
until a cause for the pain can be identified or
condition and contact family, if available, to collect
ruled out.
background information on the resident’s past
E x ample: It may be necessary to monitor acute
pain experiences.
abdominal pain to identify a surgical emergency.
• When residents are in pain, appropriate referrals
• When chronic pain occurs, non-pharmacological
to a qualified health care professional can lead to
approaches are often helpful.
effective treatment.
E x ample: Useful strategies to ease pain and promote
Ex ample : Pharmacists could be contacted when there
well-being include relaxation, physical activities,
are questions about the positive and negative aspects
superficial heat and repositioning.
of employed pharmacological treatments.
• Analgesics or narcotic pain medications may be
• All staff, including direct care staff, should be
necessary if non-pharmacological therapies are not
involved in pain assessment by being trained to
sufficient.
record their observations and report signs of pain
Note : Licensed practitioners should determine
in residents to licensed nursing staff.
the type and amount of medication based on the
Note : Use of assessment tools. severity of the resident’s pain and his or her past
• There are many pain scales and tools available, experience with analgesics. When deciding on
and staff may want to try various types to pharmacological treatments, consider all medication
side effects, including those affecting dementia and
determine which ones work most effectively
cognitive functioning.
for any given resident with dementia.
• Residents and their families should receive
• If an appropriate pain scale is determined, staff
information about palliative care options, including
should be trained to use the same pain scale
hospice, when residents appear to have entered
consistently with a resident.
the final stages of dementia.
• Periodic reassessment of a resident’s pain
• When appropriate, work with a resident’s physician
experience should use the same assessment
to enroll a resident who is in the final stages of
tool over time as long as necessary.
dementia in hospice.
Note : Signs that a resident may be in the final stages
Staff Approaches
include a resident’s inability to walk without assistance
• Prevention of pain is the first defense against it. and to sit up without support, inability to smile,
Ex ample : Avoid conditions that cause pain, such unrecognizable speech and swallowing problems.
as infections, fractures, pressure ulcers and skin Note : Entry into end-of-life care programs can help
tears, through use of appropriate caution when promote effective use of pain medication and ease
caring for residents. the end of life process.
12Social Engagement and Involvement
3 in Meaningful Activities
Dementia Issues Care Goals
• Residents have the opportunity to maintain and • To offer many opportunities each day for providing
enhance their sense of dignity and self-esteem a context with personal meaning, a sense of com-
by engaging in meaningful social interactions munity, choices and fun
throughout the day, every day. • To design interactions to do with — not to or for
• Staff require training and support to understand — the resident
how to help residents achieve this goal. • To respect resident preferences, even if the resi-
• Both formal and informal activities provide the dent prefers solitude
resident and the caregiver a sense of security
and enjoyment. Recommended Practices
Note : Formal activities are those typically found Assessment
on the community activity calendar (classes,
• A formal initial assessment that involves family,
parties, discussions); informal activities are everyday
interactions (a chat with a friend, a walk down when available, and ongoing interaction with a
the hall, a soothing bath). resident promotes understanding of the activities
• Meaningful activities are the foundation of demen- that would be meaningful to the resident.
tia care because they help residents maintain their • Assessments will help determine various resident
functional abilities and can enhance quality of life. characteristics relevant to social engagement and
• Every event, encounter or exchange between activity participation. To involve residents in the
residents and staff is a potential activity. most meaningful activities, assess a resident’s:
Ex ample : Dining is a meaningful opportunity • Capacity for physical movement
for socialization, enjoyment, satisfaction and self- • Capacity for mental stimulation
fulfillment.
• Interest in social interaction
• Access to personal space and opportunities for free
time to relax are essential elements for enhancing
• Desire for spiritual participation and fulfillment
quality of life. • Cultural values and appreciation
• Various specific recreational interests and
preferences
• At the time of admission, families and residents
should be invited to provide staff with “a life story”
that summarizes the resident’s past experiences,
personal preferences and current capabilities.
Staff Approaches
• Social engagement of residents is not the sole
responsibility of the activities staff. Every staff
member has the responsibility and the opportunity
to interact with each resident in a manner that
meets the resident’s needs and desires.
• A plan for social engagement and meaningful
activity is a critical part of the care plan.
13• Staff can achieve both brief and extended interac- Activities
tions with residents throughout the day. Brief but • Residents should be encouraged to use their
meaningful encounters may greatly enhance a remaining skills in their daily activities. Use
resident’s life. techniques that encourage residents to be as
Ex ample : It takes very little time to share something independent as possible.
personal with a resident, such as family photographs,
• Frequent, meaningful activities are preferable to
or to approach a resident in a hallway and compliment
a few, isolated programs.
her on her dress.
• Activities should proactively engage residents.
• Lack of verbal communication skills does not
prevent residents with dementia from being socially E x ample: Having residents watch staff make
decorations for a party is not as meaningful as
engaged. On the contrary, staff may play an even
asking residents to help make the decorations.
more important role by initiating an engagement.
• The outcome of an activity or social interaction
Ex ample : If a resident’s life story indicates that the
resident enjoys music, play music or sing a song. is not as important as the process of engaging
the residents.
• Activities need to acknowledge that some residents
E x ample:A gardening activity can be pleasant
with dementia experience increased confusion,
whether or not a plant grows.
agitation and movement at the end of the day.
• Offering activities that accommodate the
• Appropriately trained staff and volunteers can
resident’s level of functioning can promote
facilitate group activities.
participation in them.
Note : Staff training can include methods of
E x ample: Word games may be highly successful for
adapting activities for the needs of each resident with residents at one cognitive level and highly frustrating
dementia to maximize participation and engagement. for residents at another.
Environment
• When an activity includes multiple participants,
consider the group dynamic and the overall mood
• Elements in the structure or layout of assisted
of the group, and be flexible in adapting the focus
living residences or nursing homes can create
and purpose of the activity.
opportunities for meaningful activity.
Ex ample :Develop walking paths that encourage
• Opportunities for involvement in the community
exploration and strolling when the home’s facility are important for the sake of feeling part of the
layout permits. greater society.
Ex ample : Develop interest points such as a fish E x ample: Consider attending a concert at a local
tank or a colorful tapestry that encourage visual or theater, participating in a community service project
tactile stimulation. or playing with local children through an intergenera-
tional program.
• Activity materials can be available at all times for
use by non-activity staff and visitors. • Staff can offer opportunities for families to be
involved in activities.
Note : These materials may include such things
as baskets of fabric swatches, greeting cards, • Group sizes and lengths of time for the activity
calendars with attractive photos and tactile items need to be tailored to the functional level of
such as aprons, hats and fishing gear. residents.
• Resident functioning can improve when the E x ample: Ideal group sizes range from four to 10,
environment minimizes distractions that can depending on the activity and abilities of the residents.
frighten or confuse residents, while maximizing E x ample: Thirty minutes or less of one specific
environmental factors that promote independence. activity or task is appropriate for most individuals
with dementia before transitioning to another task.
Ex ample : Hold an activity in a quiet room free of
distractions or noise. E x ample: Residents who are not ambulatory can
be meaningfully engaged and stimulated by such
Ex ample : Ensure appropriate lighting, temperature
activities as massages, music and storytelling.
and comfort for residents.
14Phase 2 Introduction
Resident Wandering
Resident Falls
Physical Restraint-Free CareIntroduction to the Dementia
Care Practice Recommendations
Phase 2
The second phase of the Dementia Care Practice For the second year of the Quality Care Campaign,
Recommendations are again based on the latest the Alzheimer’s Association chose three priority
evidence in dementia care research and the care areas where we believe intervention can
experience of care experts. In addition to the make a significant difference in an individual’s
evidence used to inform Phase1, The Association quality of life — wandering, falls and use of physical
conducted a comprehensive literature review, Falls, restraints. The dementia care recommendations
Wandering and Physical Restraints: Interventions define goals for each care area and present strate-
for Residents with Dementia in Assisted Living gies for achieving them.
and Nursing Homes, which critiques evidence on
interventions designed to improve dementia care. Resident Wandering
Dementia care experts and professional staff Wandering may be a behavioral expression of
from the entire Alzheimer’s Association used a basic human need such as the need for social
this evidence and a consensus-building process contact, or a response to environmental irritants,
to translate the research into specific recommen- physical discomforts or psychological distress.
dations for dementia care practices. Recommendations are based on these goals:
Underlying the practice recommendations are • Encourage, support, and maintain a resident’s
person-centered approaches to dementia care, mobility and choice, enabling him or her to move
which involve tailoring care to the abilities and about safely and independently.
changing needs of each resident. Recommended • Ensure that causes of wandering are assessed
practices for care include comprehensive assess- and addressed, with particular attention to unmet
ment and care planning as well as understanding needs.
behavior and effective communication. Strategies • Prevent unsafe wandering and successful exit
for implementing person-centered services rely seeking.
on having effective staff approaches and an environ-
ment conducive to carrying out recommended Resident Falls
care practices.
People with dementia are at risk of falls because
The recommendations emphasize the importance of their neurological impairments. The environ-
of consistency in care approaches, development ment may also contribute to risk conditions.
of relationships between staff and residents and Recommendations are based on these goals:
increasing staff knowledge of individual resident • Promote safety and preserve mobility by reducing
needs, abilities and preferences. Successful risk of falls and fall-related injuries.
implementation of the recommendations depends • Minimize injuries by avoiding physical restraints.
on having a sufficient number of appropriately
trained staff.
16Physical Restraint-Free Care • Provide staff with techniques they can use to
prevent, reduce and eliminate use of restraints.
Physical restraints may be used in the mistaken
belief that they help ensure safety, but they
generally harm residents. Recommendations When nursing homes and assisted living
are based on these goals: residences are considering changes to care or to
the environment of the residence, they should
• Foster a restraint-free community in the nursing
ensure that these changes comply with relevant
home or assisted living residence.
state and federal regulations.
• Identify the underlying problems or needs that
prompt the use of restraints, and address them
using restraint-free methods.
Organizations Supporting the Dementia
Care Practice Recommendations, Phase 2
AARP Consumer Consortium on Assisted Living
American Assisted Living Nurses Association John A. Hartford Foundation Institute for
American Association of Homes and Services Geriatric Nursing, New York University
for the Aging College of Nursing
American College of Health Care Administrators National Association of Activity Professionals
American Health Care Association National Association of Directors of Nursing
American Health Quality Association Administration in Long Term Care
American Medical Directors Association National Association of Social Workers
American Occupational Therapy Association National Center for Assisted Living
American Physical Therapy Association National Citizens’ Coalition for Nursing
American Seniors Housing Association Home Reform
American Society of Consultant Pharmacists National Hospice and Palliative Care Organization
American Therapeutic Recreation Association Paralyzed Veterans of America
Assisted Living Federation of America Service Employees International Union
Catholic Health Association
We are enlisting the support of these and other organizations, as well as consumers and policy-
makers, to help us reach the goal of our Quality Care Campaign — to enhance the quality of life of
people with dementia by improving the quality of dementia care in assisted living residences and
nursing homes.
174 Resident Wandering
Dementia Issues E x ample: Changes in routines or caregivers
• Wandering is a term many use to describe the • Distressing medical or emotional conditions
behavior of people with dementia who move about E x ample: Pain, urinary urgency, constipation,
in ways that may appear aimless, but which are infection or medication effects
often purposeful. Wandering, like all behavioral E x ample: Depression, anxiety, delusions or
hallucinations, boredom or isolation
symptoms of dementia, occurs for understandable
reasons. It may be a behavioral expression of a • Desire for more physical stimulation
basic human need, or a response to environmental E x ample: Desire for fresh air, to see and
irritants, physical discomforts or psychological touch plants, to feel sunlight or simply the
distress (see examples below). desire to move
• To many people, use of the term “wandering” • Exit seeking is a form of wandering in which a
suggests that the activity should be stopped when, resident attempts to leave the premises. It can
in fact, it is often better to support a resident’s result from the resident’s desire to return to a
movement. Without agreement about an accept- secure, familiar home or former workplace. The
able replacement, these recommendations use resident may be trying to reconnect with family
the term wandering, while also emphasizing members or may be following old habits, such as
the potential beneficial effects of moving about leaving for work in the afternoon. The resident
and exploring. may be drawn outside by a sunny day or have a
desire for fresh air or a daily walk.
• Wandering is helpful when it provides stimulation
Note : Some residents may not actually be trying
or social contact, or helps maintain mobility.
to leave, but may simply see a door and decide
The beneficial effects of this activity can include to go through it, thus, they exit their residence
resident conditioning and strength preservation, unintentionally.
prevention of skin breakdown and constipation,
• A resident may wander when in a new environ-
and enhancement of mood.
ment. The unfamiliarity of the new environment
• Wandering may be detrimental when it results may make persons with dementia more confused
in a resident leaving the premises, or entering and increase their risk for wandering.
unsafe areas or another resident’s space. Physical
• Successful exiting (commonly referred to as
problems can occur, such as injuries, dehydration,
elopement in the clinical setting) occurs when
weight loss, excessive fatigue or agitation, or death.
a resident who needs supervision leaves the
• Wandering may serve as a form of communication residence without staff awareness or supervision.
occurring in response to many factors or situations, Note : People who wander persistently are the source
including: of 80 percent of successful exiting. About 45 percent
• Physical or psychological needs of these incidents occur within the first 48 hours of
admission to a new residence.
Ex ample : A need for food, fluids, toileting or
exercise • Potential consequences of successful exiting
Ex ample : A need for security or companionship include injury and death.
Note : Physical restraints have not been demonstrated
• Environmental irritants
to reduce the incidence of successful exit seeking
Ex ample : Excessive sound, confusing visual stimuli or to enhance safety in residents who wander. Rather,
or unfamiliar surroundings restraint use is associated with an increased risk
of injury.
18Care Goals • History of recent falls or near falls
• To encourage, support, and maintain a resident’s • The resident’s footwear and clothing
mobility and choice, enabling him or her to move • The resident’s access and response to safe-
about safely and independently guards (e.g., video monitors, sensors, door
• To ensure that causes of wandering are assessed alarms, access to handrails and places to rest)
and addressed, with particular attention to • Determine if unsupervised wandering presents
unmet needs a risk or benefit to the resident and others in
• To prevent unsafe wandering or successful exit the residence.
seeking • Assess the residence to determine if it can meet
the needs of a resident who wanders. An adequate
Recommended Practices environment involves:
Assessment • Physical and social environments that provide
• Before admission, collect information from activities appropriate for a resident’s cognitive
family, friends or the transferring facility about the functioning and interests, as well as opportunities
resident’s history and patterns of wandering and for walking, exploring and social interaction
strategies the family used to prevent unsafe • Communication and search plans in the event
wandering or successful exiting. of successful exiting
• Assess each resident’s desire and ability to move
Staff Approac hes
about, and associated risks, such as becoming
lost, entering unsafe areas or intruding on another • Develop a care plan, based on resident assess-
resident’s private space. While evaluating the ment, which promotes resident choice, mobility and
triggers of wandering and a resident’s wandering safety. Update the plan as the resident’s wandering
patterns, it is essential to determine: patterns change with the progression of dementia.
Involving family or other caregivers in planning
• Whether wandering is a new occurrence
will help them understand the resident’s condition
• Wandering patterns
as it changes.
• Medical conditions that may contribute to
• Assign staff to work with residents in ways that
wandering, such as urinary tract infections,
support consistent relationships so that each
pain and constipation
resident develops a sense of safety and familiarity
• Cognitive functioning, especially safety aware- with staff.
ness and being impulsive
• Ensure that staff understand whether a resident
• Vision and hearing has a propensity to wander and the conditions
• Functional mobility status: balance, gait and under which this occurs.
transfer abilities • Staff need to understand and recognize the
• Sleep patterns consequences of limited mobility.
• Resident life history, including past occupation, • Ensure that residents are able to move about freely,
daily routines and leisure interests are monitored and remain safe.
• The resident’s own toileting routines • Residents who have just moved into a new area
or home may need additional staff assistance until
• Emotional or psychological conditions that
may be related to wandering, such as depression they are comfortable in their new environment.
and anxiety or need for companionship E x ample: Have specific welcome activities for
new residents to help them feel comfortable and
• Social considerations, such as interest in part of the community. These activities should avoid
involvement with others overwhelming the residents with new situations
• Environmental hazards (e.g., poor lighting and and people. Involve family members or previous
caregivers to ease the transition.
uneven floors)
19• Communicate regularly with families of residents DO: Begin by offering to help the resident.
who wander regarding their need for movement. Ask about her daughter, or ask what kind of
Describe resident behaviors and discuss measures snack she would like to prepare and offer to help
to support their continued mobility, while protecting her with the preparation. The goal is for the
them and other residents with whom they may resident to perceive the staff person as a friend
have contact. and advocate.
• Help residents who do not have cognitive impair- DON’T: Begin by telling her that she can’t go out
ment understand wandering as a symptom of or that her daughter is now grown up. The goal
dementia. is to avoid having the resident perceive staff as
• Ensure that residents who wander have adequate an adversary.
nutrition and hydration, which may include offering DO: Develop a longer-term approach to avoid-
food and drinks while they are “on the go.” ing exit-seeking behavior. For example, involve
Note : This is particularly important for residents who the resident in a 2:30 p.m. activity in a location
are unable to remain seated during mealtime. where she doesn’t see the staff preparing to
• Staff may use various approaches to minimize leave when shifts change.
unsafe wandering. These approaches include: • If an alarm system is used to alert the staff when
• Identifying resident needs and wishes, and then a wandering resident is attempting to leave the
offering to help the resident engage in related, facility, choose the system that is least intrusive
suitable activities and burdensome.
Note : For some residents, chair and personal alarm
• Using a preventive approach to unsafe wandering
systems are a burden (as evidenced by the resident’s
Ex ample : For those who wander when needing to protests or attempts at removal) and in some cases
use the toilet, schedule toileting according to the may lead to an increase in agitated behavior.
resident’s patterns and use cues to help the resident
Note : Chair, bed, and personal alarms that are
find the bathroom quickly.
audible to the resident may discourage all movement,
Ex ample : Engage the wandering resident with not just unsafe attempts to stand or walk unassisted.
food, drink or activities that promote social
engagement and purposeful tasks, such as sorting, • Train all staff on the consequences of unsafe
building or folding. wandering, the protocols to follow to minimize
Ex ample : Provide regular exercise and stimulation successful exiting and the procedures to follow
for residents through programs tailored to a when a resident is lost.
resident’s level of cognitive and physical function-
• Promote identification of residents who are at risk
ing. Balance physical activities with regular quiet
of successful exiting:
time to allow for rest. Consider involving family
or friends in these activities on a voluntary basis. • Keep photographs of residents who wander
Ex ample : Take residents outside regularly, in a central, secure location and ensure that
preferably daily except during adverse weather. receptionists, security staff and others in a
Ex ample : For residents who are awake during position to help can prevent successful exiting
the night, make activities available with an adequate by recognizing these residents.
level of staffing to provide encouragement and Note : Care should be taken to ensure confidential-
supervision. ity and compliance with any relevant federal and
• Accompany wandering residents on their journeys state requirements.
when supervision is required to ensure safety or • Provide opportunities for everyone to get to know
encourage a meaningful alternate activity. these residents.
Companionship is an added benefit.
• Have a “lost person” plan to:
R esident E xample : A resident heads for an exit door
at 3:00 p.m. when she sees nursing staff leaving the • Account for each resident on a regular basis, such
facility. She states that she must get home to meet her as during mealtimes, and when shifts change.
daughter after school. • Establish a sign-in and sign-out policy for
families and visitors when taking residents out
of the residence.
20You can also read
