A psychologist's view of best-practice dementia care
Mitchell Gelber, Ed.D, PC
In the more than 25 years I have worked with people living with the effects of dementia, I have found there are several best practices that are critical when caring for dementia patients in skilled nursing facilities.
Dementia, especially the most common type, has an overlapping presentation that causes neurocognitive, behavioral and personality changes. Yet, due to other interfacing medical and psychiatric factors — as well as the individual's age, nutrition, social history and educational background — no two presentations are exactly alike and the progress of the disease varies.
Furthermore, it can be difficult to determine a particular resident's limitations at any given phase of the disease due to increasing communication difficulties as the disease progresses. This leads to uncertainty regarding behavioral planning and medication use. Additionally, treating people with dementia, and working effectively with their families, requires patience and professionalism in the face of slow deterioration.
Given these complexities, it's no wonder that healthcare providers and staff often struggle to provide optimal care to this challenging population.
Based on my experience, I propose medical, nursing and other healthcare professionals consider the following guidelines in providing appropriate care of people who suffer from dementia. My recommendations begin with the most basic informational elements and then examine their application in the post-acute setting.
1. Gather as much information as possible during the initial evaluation. The greater the scope of information on a newly admitted resident, the greater the chance of correctly diagnosing and treating the person with the disease. In many cases, family members will prove excellent information regarding the onset of cognitive decline, strategies used by the family to manage behaviors, and other key historical data.
2. Carefully review the patient's H&P (History and Physical Examination) records. H&Ps from previous providers and facilities primarily provide information about the medical or psychiatric conditions which caused the initial hospitalization.
The medications, diagnoses, testing and observations described will generally alert you to recent events. But dementia is a slowly evolving disease that was probably evident prior to more recent medical events and treatments, and that is critical information. The current problems may have exacerbated an ongoing presentation.
Delirium, often caused by infections, adverse reactions and other medical causes, is often mistaken for dementia in post-acute settings. Once delirium and other medical issues have been ruled out, it is safer to consider a diagnosis of dementia.
3. Develop an interdisciplinary protocol for monitoring new patients. Consider daily functioning, cognition, comorbidities, mood disorders, agitation, medication management and family interaction. It could take a few weeks for a person with cognitive impairment to adjust to a new setting, settle into a new routine and attain maximum cognitive operation.
If they are dismissed as severely cognitively impaired with no expectation of improvement, they are much less likely to demonstrate their highest practical level of functioning.
4. Request an assessment by a psychologist in order to identify a historical timeline of cognitive decline and behavioral disturbance. Family members or others involved in the personal life of the resident can supply information regarding previous functionality. By searching for information from multiple sources, you can reduce denial, minimization or distortion of information.
5. Include all disciplines in your strategy for working with people who have dementia. Physical, occupational, and speech therapy can offer strengthening, simplification of routine and cognitive techniques to help with activities of daily living as well as regular social and family interactions.
6. Speak the language of the person with dementia. Use their words whenever possible and talk slowly — using simple language, enunciated carefully. Establish and maintain eye contact and direct attention while speaking. Whenever possible, sit down so that you are on the same level as the resident.
If you are going to do a physical examination, ask familiar staff members to join you in the room, and tell the resident what you are going to do BEFORE you commence any action. Use non-verbal signals like gestures and use verbal cueing as a way to determine word-finding capabilities.
7. Include the patient in decision-making whenever possible, based on his or her cognitive abilities. Unfortunately, once a diagnosis of dementia is made, both staff and families tend to categorize the patient and make assumptions based on their limited knowledge or observations. Role model techniques for giving the resident as much autonomy as possible, as opposed to automatically assuming that the resident is incapable of participating in any treatment planning or decision-making.
8. Wherever possible, it's essential that behavioral health specialists assist in monitoring changes in the resident's status. This will help ferret out what may be causing cognitive, behavioral or mood shifts. When these shifts occur, the provider will be adept at developing changes in the resident's care plan. My experience is that a highpercentage of acute change in the patient progressing with dementia is due to:
a. Changes in daily routine
b. Changes in staffing patterns (stable staffing assignments are an important key to dementia care).
c. Staff interactions and approaches to resident care (for example, when staff members speak too fast or move too quickly without properly preparing the resident for an activity).
d. Family contacts that can stir emotional changes and cause agitation, tears or anger.
e. Unwanted social intrusions from other patients.
9. Develop individualized behavior treatment plans. These plans should monitor problem behaviors and, most importantly, accentuate what strategies work with each patient, i.e. Individualized Treatment Plans.
On short-term rehabilitation units, medical staff define specific and concrete medical goals for each person's stay. Unfortunately, this can cause a lack of attention to cognitive and emotional deficits since these were not the reason for admission.
But facilities that ignore the cognitive and mood issues of subacute rehab patients are missing out on an important opportunity to improve their rehab outcomes. Attending carefully to these issues — including the resident's resistance to treatment, frequent denial or minimizing by the spouse and family, and other important cognitive and psychiatric factors that may impede a successful short-term stay — will provide important dividends in the success of any rehabilitation program.
This brief overview is intended to provide common sense approaches to working with people who have been correctly diagnosed with dementia. There are myriad varying situations that can occur with a dementia presentation, and I have discovered that focusing on the resident and utilizing basic intervention techniques works best. Thank you to everybody who works with this challenging population.
Mitchell Gelber, Ed.D, PC, is a licensed psychologist with TeamHealth who works with several skilled nursing facilities in Northern Arizona. He is the author of “Alzheimer's Shadow: Families Facing Critical Decisions.”