Naughty or Nice?

Renee Kinder
Renee Kinder

If left up to me this holiday season, I vote let them be naughty.

While teaching a course recently to a group of caregivers on best practices for communicating with their residents, I asked them to share specific challenges they have during the course of their day.

“By challenges do you mean behaviors?” one nurse asked.

“Sure, behaviors,” I responded.

Their answers must TOP Santa's Naughty List:

•  Refusal during ADL care

•  Spitting food out at meals

•  Repetitive questioning

•  Wandering

•  Confusion, including wanting to leave, not understanding this is their home now

•  Touching, grabbing and holding onto caregivers when they are leaving the room

So my question is what do these not so nice behaviors mean? And what can we as caregivers do to better understand the individuals we serve?

As a mother of five in a busy household, I have had my fair share of experience with bad behavior.

Let's start with my eldest daughter and my first parent-teacher conference.

Mrs. Kinder, we need you to come in for a conference to discuss Kathryn's behavior.

Such was the email I received from my then 3-year-old's preschool teacher.

Within a couple of days, I was sitting in a preschooler chair at a tiny table in my daughter's classroom, anxious, worried and waiting to hear what the concern was.

Mrs. Kinder, we have noticed something interesting about Kathryn. She smiles when being reprimanded for bad behavior.

Internally, I am dying … Hold it in, Renee. Don't laugh Renee. The tone here is obviously very serious.

My response: I am so very sorry and have no idea where she has learned this (arghhh, that smirk from her father!). I will be sure to address this with her.

Lesson 1: Respect your elders

You see, the problem with my daughter's behavior wasn't the smile, per se. It was the perceived lack of respect with her response.

Similar to our day-to-day interactions serving elders in long-term care, respect is essential.

Respect your elders.

Respect their opinions, even when they appear to not understand.

Respect their freedom of movement, even if you feel it places them “at-risk.”

Respect their choices, even if they differ from your choices for them.

Lesson 2: Keep your hands, feet and hugs to yourself?

While teaching a course recently on patient-centered approaches for dementia patients, I had an attendee speak up: “We have learned that all they need is touch.”

Research in the field of therapeutic touch is undeniable, with touch said to be the most unappreciated of the five senses.

According to the National Institutes of Health, elder massage has been noted to offer physical rewards, mental and emotional rewards.

Touch triggers the hypothalamus to produce oxytocin, a hormone that performs a number of different physiological functions, including reducing stress levels, lowering blood pressure, increasing pain tolerance and boosting mood. There is even an evidenced link with accelerating wound healing.

Lesson 3: Let them eat cake

And pork chops, and watermelon, and thin black coffee.

I try to limit sweets in our home.

As a result, when my son Joseph was 3, he discovered his mom wouldn't buy ice cream but other mothers did.

One Saturday afternoon, he resolved to walk seven doors down, into the cul-de-sac, into the neighbor's house, open the freezer, leave the freezer open, leave the front door open (also releasing their cat) and walk home with a full tub of ice cream.

Food is important. Real food is important. And meal times are important.

I liken Joseph's behavior to so many individuals I have seen in long-term care:

•  You take away their thin water, so they find a water fountain or drink out of other residents' water pitchers.

•  We tell them they have to have pureed foods so the daughter now brings in KFC for supper so her dad doesn't “go hungry.”

•  We say, no more sugar or salt, but there is a secret stash of goodies in the resident's bedside table

In a previous article, I reviewed the importance of honoring dietary choices and navigating the informed consent process. However, realize that this is not an easy area for providers to resolve when there is conflict between what we feel an individual should have in regard to dietary restrictions or diet texture and what the individuals themselves decide what they want.

An extremely beneficial tool for navigating these situations has been published by the Rothschild Foundation. It is called Care Planning for Resident Choice.

Lesson 4: What Mom doesn't know won't hurt her

Families and caregivers for patients with advanced-stage dementia who are trying to navigate the need for reality orientation often struggle with this question.

For example, let's say one of your residents becomes extremely anxious daily at 2:30 p.m., stating that she has to leave to pick up her children from school.

As caregivers, we know that her children are now in their 50s and there is no one to pick up from school.

Do we tell her, “Now Mrs. Adams, you know that your kids are grown,” or do we enter Mrs. Adams' reality and find an alternative way to navigate this repetitive behavior by redirecting to another activity or task?

There is not a single to answer to use as a response to this question, and all cases do need to be dealt with individually. However, entering our residents' reality is key for understanding their world.

Doing so can reduce stress on the caregiver's part and anxiety on the part of the resident.

Lesson 5: Don't move, stay in my line of sight, Or NOT

The first question I remember asking myself when I stepped foot into a long-term care facility was, “Why is everyone in a wheelchair?”

Was this a standard of care?

You get your TB test, you get your bag of mini toiletries, and you get your very own wheelchair.

The impacts of sitting on health are staggering.

•  Up to 80% of residents in long-term care spend time sitting in a wheelchair every day.

•  Chronic sitting is actually an independent risk factor for poor health and early death.

•  Intermittent movement is critical for health and longevity with research showing that taking a five-minute walk for every hour you spend sitting in a chair can reduce heart disease risks associated with chronic sitting.

•  Sitting for long periods of time slows blood circulation, which causes fluid to pool in the legs and sluggish return of blood back to the heart, which causes increased risks for deep vein thrombosis.

•  Residents who are unable to walk have 6.6 times higher risk for development of pneumonia.

•  Studies have found that women who sit for more than seven hours per day have a 47% higher risk for depression than women who sit for four hours or less.

•  Adults who sit for more than 11 hours a day have 40% increased risks of dying within three years from any cause compared with those who sat for less than 4 hours per day.

•  Reducing sitting time to less than three hours a day may add two years to life expectancy.

Thankfully, this is a practice that we are seeing decrease significantly.

Many SNFs are working diligently to reduce alarms, become restraint-free, and allow for increased freedom of movement.

In closing, whether you consider your label naughty or nice, I wish you and all those you serve a happy, healthy holiday season!

Renee Kinder, MS, CCC-SLP, RAC-CT, is Director of Clinical Education for Encore Rehabilitation and the editor of Perspectives on Gerontology, a publication of the American Speech Language Hearing Association.

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Rehab Realities is written by Renee Kinder, MS, CCC-SLP, RAC-CT.  She currently serves as Director of Clinical Education for Encore Rehabilitation and acts as editor of Perspectives on Gerontology, a publication of the American Speech Language Hearing Association.

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