Rookie Mistakes in Dementia Care:
Preventing Bad Habits©
Katherine E. Goethe, PhD
Martha E. Leatherman, MD
There are many caring and talented people working in long term care. Many of these people choose the difficult task of working with elders because of experience with caring for loved ones, a sense of compassion, or an interest in health care. Unfortunately, new caregivers are often unprepared for certain common resident behaviors, and so they will respond from instinct. Training in dementia is limited at most long term care facilities, and if it occurs, it is often long after the rookie caregiver has developed his or her own way of dealing with problems. We have described some of these common situations below and offer solutions that will help the novice avoid improper behavioral care of residents.
1. If the resident looks confused when you talk, just yell louder.
Because anyone being yelled at will likely make some attempt to appear engaged and will “play along” out of embarrassment, it will appear as if your raised voice was successful in making the resident understand. Soon however, it will become apparent that the resident never understood the words you were saying, and further attempts at talking louder will likely cause substantial agitation as the resident becomes increasingly frustrated. Worse, a resident with cognitive impairment will perceive a raised voice as a threat and may become irritated or even violent. The consequences over time are obvious—increasing isolation for the resident whom now the staff finds unpleasant, or medication for “agitation.”
There are multiple reasons that persons have difficulty comprehending what is said to them. Hearing loss is only one explanation. Other reasons include those problems associated with dementia, such as difficulty comprehending complex language, difficulty processing multiple messages, and language loss. It is critical to evaluate the resident for these and other causes of comprehension difficulties. Addressing these issues will greatly enhance quality of life for the resident as well as ease caregiver stress.
2. Get your work done and don't waste time conversing with the resident.
Faced with increasingly dependent and frail residents as well as a task-oriented work ethic that rewards completing the task list quickly and efficiently, it’s no wonder that staff have difficulty justifying seemingly non-productive activities such as just “visiting” with the resident. By focusing on the tasks to be done, it’s true that you might limit distractions and be quicker and more efficient at your job. At least this might be true in the short run.
In the long run, however, this single-minded focus on tasks carries multiple risks. In the first place, residents who don’t have meaningful personal interactions tend to become less functional, more depressed and more needy—all of which will paradoxically increase staff workload. In addition, by not spending time talking with residents, you miss the valuable opportunity to evaluate functioning, learn about new health problems that the resident might be waiting for the “right time” to disclose, or even learn about important ways in which the residence can improve. All of these benefits are subtle and more difficult to quantify than such things as numbers of tasks completed, but that fact doesn’t diminish their importance.
3. Don't tell the resident what you are about to do to them, because they might refuse.
True, a cognitively impaired resident might be fooled or surprised into participating in an unpleasant activity (like bathing) the first time or two. Those few times you might get the task done without a long argument. After that, though, invariably, the resident will begin to associate a particular caregiver with an unpleasant experience, so that every time the caregiver approaches, the resident will automatically begin to resist or refuse to work with the caregiver. The logical outcome of such avoidance will be behavioral outbursts—either at the time of day in which unpleasant activities occur or at the sight of the caregiver. Ultimately, managing an agitated resident will be much more time intensive (if it even succeeds) than spending up-front time announcing your intentions to the resident in the first place.
4. If the resident persists in unsafe behaviors, post signs near the bed, like "Mrs. Jones, be sure to call the nurse if you need to get up", or "Mrs. Jones, use the call button for help". Be sure the letters are large and easy to see.
This might be very effective in a cognitively intact resident. But, of course, a cognitively intact resident would not need such a reminder! Why won’t such reminders work? Remember that with dementia comes loss of insight and judgment. Not for one moment does the resident believe she needs help, so why should she use the call button? In her mind, she’s able bodied and perfectly capable of getting up to go to the bathroom without any help. Her cognitive dysfunction will also mean that reminders to her of her frailty will soon be forgotten. On the off chance that the resident does use the call button, if there is a delay between the time the resident calls and the time help arrives—no matter how good the reason—the resident is almost virtually guaranteed either to get out of bed anyway or to begin yelling for help. Fall documentation is very time-consuming and behavioral disturbances are some of the most staff-intensive issues caregivers face. Much better to invest time in developing a plan whereby the resident’s needs are anticipated.
5. Reprimand the resident when they get confused, forgetful, or emotional.
Similar to the situation in which yelling at the resident seems to get his attention in the short run, reprimands for forgetfulness or emotionality might briefly cause the resident to stop crying or to play along and pretend he is fully aware of what is going on around him. Over time, though, the resident will become more and more distressed over what he sees as the staff’s anger at him, and he will either react by withdrawal, aggressive behavior, or even appetite changes. In the long run, all of these reactions, elicited in part because the resident feels trapped and powerless, will generate substantially more work for staff. Obviously, increased staff workload is the least offensive outcome in this situation. The threat to a resident’s dignity and well-being engendered by such a policy is unconscionable.
6. Use baby talk or terms of endearment, like "granny" or "gramps", instead of the resident's name.
Staff and residents become like family to each other. We know that residents become invested in staff’s personal lives and staff grieves loss of function or death of residents. It is not surprising that such daily intimacy generates the use of such terms of endearment as “honey,” “sweetie,” “mama,” or “baby.” Unfortunately, treating residents in such a way can cause already powerless residents to utilize immature tactics in interactions with staff. Someone who needs help toileting, eating, and bathing needs to feel dignified and respected, rather than feeling like a child.
An equally dangerous outcome of this practice of using pet names for residents is the danger that some frontal-lobe-impaired residents might misinterpret the use of pet names as sexual advances. To the resident with frontal lobe impairment (common in many forms of dementia) being called “sweetie” by an attractive young caregiver is an invitation to sexual overture. Allowing such an situation to develop is cruel to the bewildered resident who is then “investigated” for “inappropriate sexual advances” and harmful for the ongoing caregiver-resident relationship.
7. Use logic and reason to get them to do things, especially when they are confused.
One of the hallmarks of dementia is the inability to reason and use logic. Additionally, as we pointed out earlier, persons with dementia do not believe they have any problems to begin with, so they are likely to argue with someone who tries to tell them what to do. Long explanations and logical reasoning are actually more confusing, because the resident cannot process the information, hold it in memory, and apply it to their situation. So, the more you try to explain things, the more confused the resident may become. At that point, staff will have to spend a lot of time managing the resulting irritability or anxiety, when it would have been easier to use validation and redirection to begin with. For instance, a common scenario is the resident who wants to know where a deceased spouse is. Attempts by staff to “center the resident in reality” result in the already confused resident’s mistrusting staff even more. This can result in sometimes ferocious adherence to her contention that the spouse is alive and leads the resident to having to come up with explanations—the spouse has been hurt, is having an affair, or has abandoned the family. This is why validation techniques work – you do not disagree with the resident, but you acknowledge feelings driving insistent questions. Then the resident can be redirected into the “here and now” much more easily.
8. Leave them alone unless they start to yell or cause a problem.
At first it may seem that the most efficient use of staff’s time is to take care of problems, rather than spend time with residents who seem not to be in need of anything. However, even persons with dementia can learn over time that they can receive personal attention if they yell or call out to you. Also, just because a resident is quiet does not necessarily mean that he does not need anything. Due to the speech problems and lack of initiative, residents with dementia may not be able to indicate their needs or concerns unless they are asked.
As noted earlier, residents who do not have social interaction become isolated and depressed. When alone, residents can also become nervous and confused, because there is no one to reassure them about their surroundings. By engaging the resident when they are quiet and alone, you can prevent many behavior problems and use the experience to assess the resident’s current condition. Waiting until a resident is yelling or already behaving unsafely will cause you to use up valuable time trying to manage the disturbance, taking attention away from other residents.
9. If you are with another caregiver, be sure to have a conversation with them and pay as little attention as possible to the resident nearby.
In the short run, you need to communicate with other staff, and social interactions with co-workers are important to morale. Besides, as noted above, the resident may not seem to need anything. However, if you have ever been in a group and others were conversing and not including you, you know how uncomfortable and awkward the situation can be. Imagine how confused the resident may become, because they do not understand the conversation topic or cannot understand your body language. The resident may want to ask a question or express a need, and you may miss the signals. After a while, residents may become irritable, afraid, or even agitated by the situation. Your time will be much better spent if you include the resident in conversations, or use the interaction to direct them to an activity elsewhere.
10. If the resident refuses a request or does not answer you, simply walk away. Remember, you are not supposed to force them to do things.
It seems efficient to simply ask the resident if they want to do something or ask them a question, then go to the next resident if you do not get the response you want. Your time is valuable. Besides, resident’s rights are the most important thing to remember, right? Unfortunately, in the long run, the resident will miss out on social opportunities, important treatments, daily care, and even medications if you do not take the time to set the stage for them. Many people with dementia will automatically refuse a request, because they cannot process the information very quickly or they don’t understand that they need any care. Allowing the resident time to think about and process your question will increase the likelihood that you can engage them. Brief conversation before you make requests can help prepare the resident and reduce the feeling that they are being pressured to do something.
Understanding the basic principles outlined above can save caregivers time, facilities money, and residents discomfort or improper care. The main thing to remember is to spend time with residents when they do not need your help. Talk to them, have brief conversations, smile, and take your time. In the long run, they will trust you more, and they will be more cooperative when you really need them to be. Spending a few minutes with a resident today can save you hours of time later.
© 2007 Dignity First, Inc.
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