Dementia-Related Behaviors in Nursing Homes

Dementia-related behaviors are often termed “problem behaviors” by staff in the nursing home. They are a major cause of admission to the nursing home because families believe that nursing home staff is equipped to deal with them – some are and some are not.

Nursing homes that do not effectively manage problem behaviors cause elders to suffer great discomfort, malnutrition, pressure sores, dehydration, infections, and a reduced quality of life. State guidelines require that staff are educated yearly on the management of dementia. Some nursing homes fail to provide proper dementia care due to a lack of staff, a lack of education for staff, and a lack of administrative commitment to providing quality care.

Dementia-related behaviors are caused by a variety of factors. Elders with dementia may feel frustrated and embarrassed accepting assistance with bathing and toileting. The perception of excessive demands, frustration caused by misinterpreted messages, changes in routine, boredom, distress, and underlying illness are other reasons that such behaviors occur. Each person with dementia is an individual and will react to circumstances in his/her own particular manner. Every behavior has a purpose. The goal is to find that purpose for the demented elder.

How should nursing homes be preventing and treating such behaviors?

Many tactics can be used to prevent and treat behaviors. Prevention is much easier than treatment and all staff should learn interventions. The following are some ways in which behaviors can be prevented and treated without the use of physical and chemical (medication) restraints to promote optimum quality of life for residents. These are things you should look for in the nursing home environment and staff as they interact with residents. These tactics may also help you to interact with your loved one if they have problem dementia behaviors.

• A calm and uncluttered environment and familiar routine. Elders with dementia often become extremely upset in a strange situation or among unfamiliar people. Consistency of staff is important. Nursing homes with high staff turnover and constantly changing staff will have more dementia-related behavior problems.
• Pictures or labels on objects in their rooms may help elders locate them.
• Place one item on the table at a time to eat and only essential silverware.
• Approach the person slowly and calmly from the front. Do not initiate physical contact or try to restrain.
• Focus on familiar skills during activities and break tasks into simple steps.
• Encourage independence even if it takes longer. Try to do difficult and frustrating tasks when the person is at his/her “best.” Nursing home staff should be flexible with schedules.
• Distraction can help. A simple suggestion such as having a cup of coffee may defuse the situation.
• Tell yourself you are dealing with the illness, not the person.
• If the confused person suffers nighttime agitation, a night light may reduce this.
• Use short, simple sentences. Avoid negative sentences. Instead of saying, “Don’t go outside,” say, “Stay inside.” This will defuse arguments.
• Gestures and pictures can help explain what you are saying along with words. Elders with dementia have a difficult time interpreting verbal communication as the disease progresses.
• Speak clearly in an adult manner. Words like “honey” and “sweetie” are inappropriate.
• Encourage talk about familiar places and past experiences.
• Be aware that the person may not recognize staff members or family members. Staff and family members need to tell the elder who they are as the disease progresses (this is emotionally very difficult for family members).
• Speak clearly, allowing time for response.
• Ask questions that require only a “yes” or “no” response.
• Focus on a word that makes sense, or responds to the feeling being expressed in those with word-finding difficulties.
• If hallucinating, give a truthful explanation of the noise, but avoid arguing or trying to convince the person. A distraction may be useful.

Are there specific behaviors that require the nursing home staff to use unique behavior management techniques?

Yes, the following are examples.

• Wandering
  • A “stop” sign or “do not enter” sign in unsafe areas.
  • Allow for regular exercise to minimize restlessness and allow wandering in safe areas.
  • Put away the person’s coat and purse. Some individuals will not leave without them.

• Angry/Agitated Behavior
  • Reduce caffeine intake.
  • A private room may help, if possible.
  • Try gentle touch, music, reading, or walks.
  • Limit choices to minimize confusion. Instead of asking, “What would you like for lunch?” say, “Here is some soup.”
  • Acknowledge anger over the loss of control.
  • Distract with a snack or an activity.

• Repetitive Speech/Actions
  • Reassure or distract the person. Avoid reminding the person that he/she just asked the same question.
  • Do not discuss plans with a confused person until immediately before an event.
  • Place a sign near the dining area stating “Lunch is at 11:30” or “Lisa will visit at 7:00.”
  • Learn to recognize behaviors. Pulling at clothing could indicate a need to use the bathroom.

• Paranoia “Someone is stealing from me”
  • Assist the person in looking for a missing object. Avoid arguing, and then try to distract.
  • Try to learn where the confused person’s favorite hiding places are for storing objects.

• Personal Care Issues
  • If bathing is a problem, realize a day can be skipped, just not multiple days.
  • The person may not remember just having eaten. Keep food out of sight during non-meal times. Serve food pre-cut if using utensils becomes difficult.
  • Dressing is difficult for most dementia patients. Choose loose-fitting, comfortable clothes that have zippers or snaps instead of buttons. Reduce choices by removing seldom-worn clothes from the closet. To facilitate dressing, lay out one article of clothing at a time, in the order it is to be worn. Remove soiled clothes from the room.

What else should nursing home staff be doing to manage behaviors?

• There should be a thorough assessment and a care plan to address behaviors.
• Staff should involve you in the behavior management plan so that staff as well as family members are managing behaviors in the same way, and a consistent approach is used.
• Social service staff should be highly involved with behavior management.
• Staff should immediately notify the physician of any acute changes in behavior that might signify illness. The family should also be notified.
• Consult with a psychiatrist to help manage problem behaviors with medicine if needed.
• Use a team effort to manage behaviors.

Resource

Greenwalk, S. C. Whose Problem is IT? ? Westhaven Services and Social work policies, Procedures and Guidelines for Long-Term Care.