AC FFC Tidbit of the Week for May 2, 2021: Delirium Prevention Toolkit for Hospitalized Patients

A while back, we discussed the importance of preventing and recognizing signs of hypoactive delirium in your patients with dementia. This week we’d like to share a resource from the Hospital Elder Life Program that teaches more about delirium and includes “The Delirium Prevention Toolkit” to help hospitalized older adults maintain cognitive and physical functioning, especially during times of COVID-19 isolation:

We encourage you visit the link and look through the toolkit, which includes quick tips about hydration, nutrition, mobility, sleep, and activities and orientation. There are examples of relaxation exercises to help promote sleep and calm stress, range of motion exercises, and games for cognitive stimulation. Not only can these activities help reduce risk of delirium in patients, they can also help them maintain function during their hospital stay.

Have a great week!

AC FFC Tidbit of the Week for April 25, 2021: Create a Plan and Evaluate It – The Final Steps of DICE

This week we’ll finish discussing the four steps of DICE. We hope you had a chance to discuss the “Describe” and “Investigate” parts with your staff, and are finding the process helpful as you work to assess and manage behaviors of your patients with dementia.

The “C” in DICE stands for “Create a Plan.” Once you have described the problem behavior and investigated and determined a probable cause of the behavior (see last week’s tidbit), the next step is to create a plan to address the behavior.

When creating a plan, keep in mind that interventions should be personalized and meaningful. An intervention for one patient may not work for another. In addition, an intervention that worked for a patient initially or during a previous hospital stay may no longer work for that same patient now.

Creating a plan takes an interdisciplinary team to ensure that all are on board with the plan, that it will be communicated to all necessary staff, and the team will work together to see it through.

Some tips when creating a plan of care to address a specific behavior:

  • Be innovative—brainstorm ideas with staff
  • Use the “UMOVE” assessment (or other hospital-based assessment tool) to determine what a patient can physically do, then create an intervention plan that uses the patient’s abilities as much as possible (walking, stretching, participating in self-care activities, etc.)
  • Use what you know about the patient—causes/triggers of the behavior, resident abilities and preferences
  • Minimize environmental change—limit the number of caregivers and acknowledge caregivers that work well with a patient
  • Control the amount of stimulation—too little or too much can precipitate behaviors
  • Modify communication techniques—verbal cues, writing things down, communicating “face on”, repetition, role modeling, and providing a vicarious experience with the patient can all aid in communication
  • Enhance sensory experiences and the environment—music, dance, pleasing fragrances, favorite foods, tactile stimulation and supporting physical activity can all help with some challenging behaviors
  • Provide individualized care—be flexible when scheduling functional activities, anticipate challenges, distract, use creative explanations to prevent a catastrophic reaction and let the patient “do her own thing” when safe to do so

The final step—the “E”—is to “Evaluate the Plan.” Did the plan work?

  • Decide upon a time frame for re-evaluation.
  • Use objective instruments for target behaviors: Cohen Mansfield Agitation Inventory; Neuropsychiatric Inventory (short form or nursing home version); Cornell Scale for Depression in Dementia; Resistiveness to Care Scale
  • Review use of PRN medications
  • Listen to staff report

If the approach worked, continue with the plan of care. If not, go back to investigate other potential causes of the behavior and revise your plan.

If you have successfully used DICE with your staff to address a challenging behavior, please tell us about it! We’ll send you a prize for your efforts!

AC FFC Tidbit of the Week for April 18, 2021: Use your Sleuthing Skills for the Second Step of the DICE Model

In last week’s tidbit, we discussed the DICE process for assessing and managing behavioral issues in patients with dementia. We focused on the “D”—describing a resident’s behavior with specific details that provide important clues about the cause of the behavior.

This week we focus on the “I”Investigate. Once we have a detailed description of the behavior, we can investigate the influence of factors such as cognitive status, environment, caregiver approach, medical disorders, and psychiatric symptoms on the resident’s behavior. In many cases, a person with dementia is having difficulty communicating something to us. She could be trying to tell us that she is in pain or depressed, that we are rushing her, that it’s too noisy in the room, or that she simply doesn’t understand what we are asking her to do. When we don’t get the message, the person can become agitated, resistant to care, anxious or even aggressive.

Cognitive impairment includes amnesia (memory loss); aphasia (language impairment–receptive or expressive); apraxia (impairment of learned motor skills); and agnosia (perceptual impairment). Cognitive impairment can have a significant impact on behavior. It can lead to  behaviors such as a person urinating in a trash can instead of the toilet, pushing caregivers away when they try to take her to the bathroom, or using a call button constantly to ask for someone to take her home and complaining that no one is helping her.

We should also consider the environment: temperature, noise level, over and under stimulation, too much or too little space, familiarity and routine. An alteration to an element of the environment (and being in a new environment like the hospital) can have an immediate impact on a person’s behavior, and can lead to anxiety and stress for a patient with dementia. Lack of stimulation can lead to boredom, which can result in behaviors such as wandering or disruptive vocalizations.

Caregiver approach can also influence a person’s behavior. Older adults with moderate to severe dementia have difficulty understanding verbal directions. They can also misinterpret touch that occurs during care activities, perceiving it as a threat. When this happens, a person can become fearful and either fight the caregiver (hitting, biting, etc.) or flee (resist care).

Medical disorders in older adults with dementia can result in pain, constipation, infection and medication use (with a variety of side effects). Do any of these examples sound familiar?: “He’s so sleepy it’s hard to get him to eat. The food runs out of his mouth”; “He cries when we get him up to transfer to the chair”; “She’s up at night asking to go to the bathroom every 30 minutes.” Reviewing a patient’s medical conditions and the possible side effects of their medications can help you identify possible causes of their behaviors.

Psychiatric disorders obviously affect behavior. Some examples: “She has been tearful almost every evening and doesn’t want to get out of bed in the morning”; “She thinks someone took her children”; “He doesn’t sleep and is so irritable”; “She saw a snake outside her window.”

Now that you’ve learned about describing a problem behavior and investigating possible causes of it, next week we’ll discuss…you guessed it—the “C” in DICE, which stands for Create a plan. We’ll review interventions you can use to address these challenging behaviors.

Have a great week!

AC FFC Tidbit of the Week: DICE–An Approach to Behavior Assessment & Management in Patients with Dementia

As you care for patients with dementia, learning what can trigger challenging behaviors such as aggression, agitation, and yelling out can go a long way towards helping to prevent them. This week we are introducing “DICE,” a tool you can use to assess and manage behavior change in people with dementia. DICE stands for:

  • Describe the behavior
  • Investigate the influence of things like cognitive status, environment, caregiver approach, physical/medical disorders, and psychiatric symptoms
  • Create a person-centered plan to address the behavior
  • Evaluate if the plan works

(Kales, Gitlin, Lyketsos, 2014, JAGS)

It helps to approach this process as a detective would approach an unsolved mystery.  Just like detectives, nurses and nursing assistants sometimes receive vague and incomplete information, they manage multiple responsibilities, they have developed a good intuition based on experience and familiarity, and may have to prove their case to others in order to move forward with an intervention.

The first step, effectively describing a person’s behavior, is critical as it sets the foundation for the investigation. A detailed description of a resident’s behavior should include:

  • Frequency (every week, day, hour, 10 minutes?)
  • Duration (Does the behavior go on for an afternoon? An hour? A few minutes? When does it stop?)
  • Setting (In common area? Shower room? Bedroom?)
  • Who is involved? (Specific caregivers? Other patients? Other staff?)
  • What was happening right before the behavior began?
  • Be specific…just saying someone is “impatient and often agitated” is not enough. Instead, “Patient repeatedly hits call bell before each meal every day, and when the nurse arrives, just mumbles and complains about the food” is far more helpful information. You can probably come up with a few theories of what the problem could be just based on those few details!

We’d like you to spend some time this week discussing with staff how they describe behaviors of patients that need to be addressed. How does being more specific offer additional clues as to the cause of the behavior? Next week we’ll focus on the second step of DICE, Investigation.

Have a great week!

AC FFC Tidbit of the Week for April 4, 2021: The Language of Caring

As we celebrate the holy days of Easter and Passover, and Ramadan later this month, we are reminded of the diversity of faiths, cultures, and traditions that shape the life experiences of our patients. The more we know about these different cultures and traditions, the better we can understand and respond to our patients’ needs, especially patients with dementia. One common barrier to this understanding is language.

If you’ve ever traveled to a foreign country where you don’t speak the language, you know how difficult it can be to get directions to a museum or order a meal. Imagine how frightening and depressing it would be if everyone around you spoke a different language, but instead trying to order a meal, you needed to communicate more vital information, such as the fact that you were in pain or very confused.

Below are some tips on how to communicate with and engage patients who do not speak English:

  • If the patient has visitors or if there is a staff member who speaks the same language as the patient, they can be a valuable resource and can teach staff some basic phrases to use.
  • Create communication sheets or flashcards with simple phrases in the person’s language (Good morning, Please join us, Are you in pain?, etc.) and hang them in the patient’s room for staff to use.
  • Download a free translation application onto your phone to use when you or the patient have something important to communicate. There are apps that focus on medical terminology too.
  • Be mindful of body language. If a person cannot understand your words, they will rely on your body language and facial expression to help determine your intent. A smile and open stance can be a good start to help put the person at ease.
  • Take time to learn about the culture of the person, and invite family members to bring in food, music or simple activities from their culture to help your patient feel more at ease while in the hospital. If staff are involved, this can help build trust as well.

Have a great week!

AC FFC Tidbit of the Week for March 28, 2021: Antipsychotics and People with Dementia–When the Risks Outweigh the Benefits

People with dementia can sometimes become agitated, especially when they are in unfamiliar surroundings, with unfamiliar people, and feeling powerless…like when they’re in the hospital.

Sometimes, the first course of action to manage someone who is highly agitated in an acute care setting is to give them an antipsychotic medication. But giving antipsychotics to older adults with dementia carries significant risks, including an increased risk of death. There is a black box warning and risk of death associated with these medications when used with older adults with dementia.

Here are answers to three common questions about the use of antipsychotics:

For what conditions are antipsychotics approved for use by the Food and Drug Administration?

Bipolar disorder (not an exclusion from denominator), schizophrenia, adjunct to antidepressants for major depressive disorder (aripiprazole), Tourette’s syndrome (conventional antipsychotics only), and Huntington’s disease.

What risks are associated with taking an antipsychotic?

Falls and fracture; sedation; delirium; functional decline; extrapyramidal symptoms (Parkinsonism, dyskinesias); anticholinergic side effects (orthostatis, constipation, blurry vision, etc.); hyperglycemia; hyperlipidemia; drug interaction (40% chance); pneumonia; cardiovascular risks; and death (mortality is highest in first 30-40 days).

What are some non-pharmacological alternatives to antipsychotics?

Rule out medical cause (delirium screening, vigilant medical care); address unmet needs (Are they in pain? Thirsty? Need to use the toilet?); communication strategies; routine & constituency with activities and caregivers; environmental modifications; maximize sensory input (glasses, hearing aids, plenty of light); involve in functional & physical activities; incorporate personal preferences; supervision & safety; and specific therapies such as art, music, aromatherapy, etc.

These non-pharmacological approaches are things we’ve talked about in previous tidbits, and can often be effective. It requires critical thinking and teamwork, but when it works, it not only helps the patient avoid the adverse effects of medication, it’s fulfilling for the caregiving team too! By putting yourself in the patient’s shoes to understand and empathize with what they are feeling (and fearing!), you can often help calm a person who is agitated.

Finally, here’s a helpful overview developed by the American Geriatrics Society and Consumer Reports that you may also want to share with a patient’s family members:

Have a great week!

AC FFC Tidbit of the Week for March 14, 2021: One, two, three, four…Step those Patients out the Door!

Are you helping your patients take steps in the right direction? A study published last month in JAMDA, the Journal of Post-Acute and Long-Term Care Medicine, offers more evidence of something we already suspected: hospital patients can be walking more than they currently do, and more walking while in the hospital may result in better physical activity levels and function once they leave the hospital.

The authors of the study, Factors Associated with Step Numbers in Acutely Hospitalized Older Adults: The Hospital-Activities of Daily Living Study, concluded: “Among acutely hospitalized older adults, step numbers double 1 day post-discharge, indicating that their capacity is underutilized during hospitalization. Physical performance and physical activity during hospitalization are key to increasing the number of steps post-discharge. The number of steps 1 week after discharge is a promising indicator of functional decline 1 month after discharge.”

Read the full article here:

So, do you and your team have a plan to get patients walking more? How about a walking contest? Pedometers for staff—and steps only count if you’re walking with a patient? For patients with dementia, try motivating them to ambulate by walking to a window down the hall to look outside, getting a piece of candy from the nurse’s station, or telling them they can listen to music after their walk. Ask family members to encourage them to walk too, and be sure to offer praise once they start walking, especially if they were reluctant to do so. Share with us via email how you get your patients taking steps in the right direction. We’d love to hear from you and can share your ideas in a future tidbit!

Have a great week!

AC FFC Tidbit of the Week for March 3, 2021: Key Strategies for Communicating with a Person with Dementia

It’s not rocket science. Anyone who’s been in a relationship, worked on a team, or played a game of telephone knows that communication is key. With great communication, people feel heard, things get accomplished. Without it, feelings are hurt, tasks fall through the cracks, and in some cases, chaos can ensue. Communication is sometimes easier said than done, however. And when we’re talking about communicating with a person who has dementia, this can bring additional challenges. For example, body language—theirs and yours—can play a bigger role than usual when someone has cognitive impairment.

As you work with your patients who have dementia, keep these 12 key strategies in mind to help you more effectively get your message across to your patients, and in turn, better understand what they are trying to tell you:

  1. Put yourself in the person’s shoes—are they scared? Frustrated? Sad? In pain? If they cannot articulate verbally, they will do this through their behavior. Try to determine what they may be trying to communicate.
  2. TMT-TMT Rule: Too much talk and too much touch can overstimulate and agitate a person with dementia. Sometimes a simple gesture and silent curing is better than talking.
  3. Be aware of body language. Standing over a resident can cause a “fight or flight” response.
  4. Smile and take a few minutes to sit eye-to-eye with person, and talk about something you know the person enjoys, such as sports, upcoming holidays, grandchildren, pets, etc. before beginning hands-on care. This can help build trust.
  5. Be patient, calm, and consistent. Routine is good.
  6. Keep voice, face and body relaxed & positive. A smile and open arms says a lot!
  7. Make eye contact, communicate “face on” and respect personal space.
  8. Use gentle touch to reassure when appropriate.
  9. Observe their nonverbal reactions & respond accordingly.
  10. Write things down for them if they have trouble hearing or understanding you.
  11. If you have to repeat something, use the same words. Using different words the second or third time may confuse them.
  12. Create a vicarious experience for the patient. Role model the activity you’d like them to do so they can observe and copy what you’re doing. If they see you doing the activity successfully, they will be more likely to believe they can do it too!

Next time you are working with a patient who has dementia, be mindful of these tips and strategies for communicating more effectively with them. Talk with your co-workers about strategies that have worked for you, and discuss communication challenges and ideas for addressing those too.

Have a great week!

AC FFC Tidbit of the Week for February 28, 2021: 10 Tips to Reduce Resistance to Care

As you integrate Function Focused Care with your patients with dementia, sometimes you will encounter resistance to care, especially during more intimate activities like bathing, dressing and oral care. This week we’re sharing 10 tips to help you decrease this resistance while encouraging your patient to participate in their own care:

  1. Approach is key! Assume a non-threatening posture: smile & speak in a pleasant tone of voice, keep arms open (not crossed), conduct care at patient’s eye level and from the side. Do not stand over the patient, as they can perceive this as a threat.
  2. Slow down care and ensure you are communicating clearly and explaining the task in a step-by-step process. (We’ll talk more about communicating with people with dementia in a future tidbit!)
  3. Encourage the person to do as much for themselves as they are able. Use role modeling, cueing, and tell them “great job” when they do it.
  4. Put objects needed for the task (e.g. comb, toothbrush, etc.) within their field of vision so they can find them easily.
  5. Remove objects that are unnecessary or distracting (like a TV remote that they can confuse with a hairbrush).
  6. Use your knowledge of a patient’s interests to invoke pleasant thoughts for the resident and build trust with them. Remember that “Get to Know Me” board we talked about a few weeks ago? This is where that comes in handy! The information about a person’s family, career, and hobbies can be nuggets of gold when you need to build trust and decrease resistance to care.
  7. Identify long-standing habits and adjust routines as needed. For example, if the patient does not like going into the bathroom to brush her teeth, bring a basin of water and toothbrush to her bedside instead.
  8. Have they had their pain medication yet? If you think the activity may be uncomfortable or painful, wait until they have had their pain medication before attempting the activity.
  9. Pay attention to the environment. Is it too noisy? Playing calming music of a favorite song of the resident may help. Is the room too dark or too bright? You may need to close the blinds or turn on lights. Is the room cold, especially for bathing? Grab an extra blanket or towels.
  10. Finally…Don’t forget the music! Music can reduce resistance to care behaviors during bath/shower time and meal time, as well as during other activities of daily living.

For a 10-minute overview on strategies to help reduce resistance to care, check out our quick Power Point video using the link below. You’ll be asked for your name and an email address to access the video:

AC FFC Tidbit of the Week for February 21, 2021: Don’t D/C Without FFC!

Your patient is ready to be discharged from the hospital and her family members are relieved to finally be getting their loved one back home to a familiar setting, since she has dementia and the hospital stay has been confusing for her. You’ve got the list of medications and follow-up appointments to review with them, but are you missing something?

Your unit has been working on integrating Function Focused Care (FFC) with patients who have dementia, and the nursing staff has done a great job getting this patient walking and encouraging her to participate in her own care, like washing her face, brushing her teeth and even getting dressed. While family members may be focused on other issues like new medications during a discharge meeting, remember that including the need for physical activity and providing function focused care through role modeling and cuing is just as important for the wellbeing of their loved one. If you, as the trusted healthcare provider, take the time to discuss the importance of physical activity and function focused care during your discharge teaching, then caregivers may better perceive this to be a priority and follow through with it. Be specific and use examples in your teaching, and ask family members what activities they feel they can do with their loved one at home.

We’ve attached a simple template for a FFC Care Plan after a hospital stay that you can use during discharge teaching and help family members develop a daily schedule. It includes an example of a daily schedule with activity ideas. Review this with family members during the discharge meeting, and encourage them to add their own thoughts and ideas to the plan with you, addressing concerns they may raise as you go.

There are many other resources you can share with caregivers to help them integrate physical activity and FFC into daily life with their loved one. For example, the National Institute on Aging has just released a new booklet on exercise: “Get Fit for Life: Exercise & Physical Activity for Healthy Aging.”  This resource is easy to read and full of information about why exercise is important, what kinds of exercises improve health, overcoming barriers to exercise and tips for getting started after an illness or other break. The booklet is free and you can order up to 25 printed copies or download it as a pdf file, which includes links to many other resources and videos too.  Below is a page from the booklet that includes simple tips for helping a person with dementia stay active, which can help them maintain function, a regular sleep and toileting pattern, and improve mood. Remind caregivers that exercise has many benefits for them too, including helping to reduce stress!

Another great resource are the free, short videos on the Function Focused Care website. While these were developed to help show staff at long term care communities how to incorporate FFC into daily care and deal with challenges, the tips and strategies can be used by caregivers at home too.

So, think about your discharge teaching and how you can consistently add physical activity and function focused care to your normal list of items to discuss and review, especially for patients with dementia, as caregivers may not realize the critical role these play in the health and wellbeing of their loved one.