Environmental Engagement

It was so fun today to see a patient sitting outside greeting visitors.. waving and smiling... eating in the diningroom etc.  The same patient that used to stay in her room and scream at people when they entered the room and tried to help her with anything.  It's called environmental engagement and it's like turning on someone's life light switch.    You do this by spoiling the patient and very slowly helping them interact with his/her environment.  It usually involves a lot of sensory approaches.  Finding out which sensory things attract the patient and which things the patient avoids.  Helping him or her be able to tolerate those sensory items that cause him/her anxiety... and giving him/her the sensory stimuli that they crave...that's a skilled intervention and an art.  We'll be exploring more sensory interventions in future blog entries.  

Watch for Symptoms of Apnea

Apnea - a common problem for patients with dementia.  Apnea is defined as a sleep disorder involving abnormal pauses in the breathing pattern.  This causes a drop in oxygen levels and can damage critical organs such as the heart and brain.  Symptoms include sleepiness during the day, complaints of a dry mouth/throat, morning headache, difficulty staying asleep at night (insomnia), loud snoring, shortness of breath that wakes you from sleep, and general pain throughout body.  Putting a patient who has apnea on nighttime oxygen can make sleep apnea even worse.  Apnea can also progress dementia very quickly and also cause something of a temporary "delirium" on top of the dementia that can clear if the apnea is treated.  Ask your physician about testing for sleep apnea if you/loved one/patient have some or all of the above symptoms.  Also some behaviors may disappear once the apnea is treated - such as aggression, withdrawal, and/or lack of appetite.

"I'm not hungry"

This is a common statement among people with dementia.  They stop eating gradually until they reach a point where their body just isn't hungry anymore and just the sight/smell of food makes them sick.  This is a sensory problem and must be approached as such.  The last "taste" group that an individual eats prior to stopping eating completely are sweets.  So to stimulate the appetite - use sweets frequently throughout the day in small doses.  Sometimes I have to start with a little bit of soda in a tiny plastic med cup.  Encourage them to drink this little bit every hour or so.  Sometimes they eat a 1/2 tsp of ice cream frequently through the day.. sometimes it's graham crackers...sometimes it's chocolate...sometimes it's fruit or yogurt.  Start small and gradually build up the amount they eat/drink at a time and/or the frequency of their intake.  These items will "drive" the patient's appetite.  I use essential oil placed on cotton balls placed in the patient's pocket or near them...oils that stimulate appetite such as peppermint or citrus smells.  Also great is boiling apple cider in a small saucepan nearby.  Bake bread in a breadmaker..anything to use smell as an appetite stim.  Sometimes it's a visual processing problem - so I put a tablespoon of food in the center of an over-sized bright colored plate.  That's their meal.  The next meal (if they ate everything for the prior meal) I increase the amount in the center of the plate...gradually.  Until their mind's eye accepts a full plate as a meal.  Appetite re-stim is so easy and sooo rewarding to watch your patient become stronger and able to participate in his/her other therapies or activities of daily living.

Sleeping Beauty

I love it when I hear a nurse wake up a patient to give him/her their sleeping pill :)  Ironic isn't it?  Why do so many people have difficulty sleeping not only in the hospital, but especially in nursing homes, relative homes, and rehab centers.  How many of us like to sleep with a little bit of light?  How many have to have it completely dark?  Who likes to sleep under heavy blankets and who can't handle anything more than a sheet?  How many can't stand any "pilling" on their sheets?  How many need a certain material in their sheets?  Who among us must sleep with a TV, radio, or a fan?  So many variations not only with textures and sounds, but also with smells and the right kind of mattress.  And then we wonder why patients in our facilities are so tired and have difficulty sleeping.  Pay attention to these things from their home and try to re-create as many as possible in his/her new room.  This is a skilled therapy service and a necessary one.  Without sleep - risks involve everything from falls to malnutrition and skin breakdown.

Alert Systems

There are many times that we send patients home alone and we don't feel confident that they'll be safe.  There are alert systems on the market for instance from Life Alert that automatic alert devices.  The patient/person doesn't even have to push the alert button... the system senses when he/she falls and then a representative asks through the monitor if the patient is ok.  If the patient doesn't answer then assistance is sent to his/her home automatically.  The best support system is family/friends or hired caregivers to help supervise a person with dementia at home.  But when this support system is not available - these alert systems are very helpful to assist with a person's independence and safety.

"They Keep Taking My Things"

This is a common accusation from people with dementia - even though most of the time it stems from forgetfulness about where he/she put the item.  I like to help the patient establish a procedural ritual with those items.  That means that I want the habit of putting the item in it's "home" to become automatic for the patient.  I have to make the "home" colorful because people with dementia need 4x as much color contrast as the average person so neon colors work great.  Common items are dentures, glasses, hearing aides, canes, purses, wallets, and money.  Create this colorful home for the item and practice with the patient over and over placing the item in it's new "home' ...I like to tell him/her that we're going to "hide" the item (if they are really paranoid about theft).  It takes 3 weeks to establish a new habit with a patient so plan on spending a few weeks establishing this new ritual.  You can watch for progress as they need less and less help to find the "home", put their item away, and then retrieve it again.  Also watch the patient become less and less anxious about someone taking the item.

Rescue Strategy Continued

Had a patient today that was convinced that his walker wasn't "his" walker that he usually uses (and it was his walker).  So the therapist agreed with him and said "I can't believe someone would borrow your walker without asking!" and then took his walker away with her.  She came back about half an hour later and told him that she had located his walker and she even cleaned it up for him.  He was sooooo happy!  And it was the exact same walker.  That's all it took and he was happy/relaxed just moving on with his day.  Some things that can explode into huge issues... you can stop them before they become a real problem with a little bit of  behavioral intervention.

Rescue Version 3

Another form of the rescue strategy is to rescue the patient from his/her "perceived" situation.  For instance;  had a patient once that was convinced a man was in her room and she wouldn't return to her room for any reason.  Now we could've used reality orientation and told her that there was no-one there and she was hallucinating etc etc and it would only end in making the patient feel crazy and that she can't trust anyone because they don't believe her.  A better way is the rescue strategy - tell the patient you are going to clear her room for her and then do it.  Enter her room and then return to her and let her know that you cleared her room for her.  And if he comes back that she needs to let someone know immediately and we'll have him thrown out.  She'll feel confident that people believe her and this particular patient returned to her room for a good nights sleep.  I had another patient that was convinced the kitchen was trying to poison her.  So I had the kitchen pack up her lunch in a brown bag and told her I brought it just for her so I could make sure no-one tampered with it.  I could've told her that no-one was trying to poison her blah blah blah...and it wouldn't have helped her anxiety.  This way I gave her an "untampered with lunch" and she could eat with confidence.  Then I introduced her to someone in the kitchen that part of my "club" and she would supervise her food when I couldn't be there.  Then I introduced her to another person that would also keep a "look out".  And slowly we built her confidence for all of the kitchen workers.  She ate well and was able to complete her therapy because she had the food intake she needed to get stronger.

Aggression

We had a patient yesterday that was agitated and then escalated to the point that he required the police to intervene and rescue a nurse (patient had her in a choke hold).  This can be avoided if the agitation is identified and effectively dealt with before it escalates to the point of no return.  The first thing that happens when a patient starts yelling and showing his/her fists is a bunch of people like to gather around to help.  Unfortunately this is the worst scenario for the patient because it now looks like a mob (all against the patient) and makes the situation even worse.  It creates more noise and an over-stimulating event.  The patient feels more threatened then ever and the patient loses.  A better scenario is to try to re-direct the patient into a calm environment like his/her room with just a 1-on-1 conversation.  Speaking very calm and as little as possible.... using slow deliberate movements and avoid direct eye contact as this can also escalate anxiety/anger.  Try to touch the patient as little as possible until he/she calms down.  Music is often helpful (something calming) or certain scents like peppermint, cinnamon, lavender, or vanilla are also very effective for calming effects.  You can use a stimulation such as a taste like a peppermint candy or butterscotch.  Giving a heavy blanket or pillow for him/her to hold on to is also calming.  The key is to catch the behavior before it escalates to the point of yelling...watch the person for aggressive talk, aggressive singing, frantic eye movements, shakiness, crying, or aggressive wandering (seeking a way out).  Intervene at the first signs and you'll have much better luck with your calming activities.

Security

Feeling insecure, dizzy, etc is common among rehab patients especially those with dementia.  Something as simple as placing pillows around them in bed or having them hold on to a pillow and placing 2 more at their sides in the wheelchair can also help them feel more secure.  I often have the patient squeeze a pillow tight against their abdomen when beginning transfer training to help them feel safe..before we start training on pushing up and grabbing on to bars etc.  When the patient shows symptoms like fear when standing or avoids standing completely...  that's when these interventions work wonders.  Sometimes the goal is just to get the patient to stand without symptoms of dizziness or fear before you can work on other goals.

Rescue - Version 2

A neat example of another version of the rescue strategy was used today in our department and it works like a charm for Allen Level 4 patients.  The patient entered the therapy gym and had to wait for the therapist (who was finishing her note she was working on in an adjacent office).  When the therapist approached the patient (after a 10 minutes wait - the rehab tech had been entertaining her while she waited), the patient became angry and tried to hit the therapist.  What happened here?  A normally compliant patient became angry over something so trivial.  But this is an Allen Level 4 patient... a patient who has the cognitive level that wants to be the #1 priority regardless of your schedule.  If they find out you're going to treat another patient before him/her then they will stop cooperating with you because they sense that they are no longer your #1 priority.  So when this therapist asked me what she should do... I advised her to go to the patient (who was back in her room) and tell her "I just found out how long you were waiting for me in the therapy gym and I am so sorry... my staff knows how important you are and they are supposed to alert me the minute you enter the gym... again I apologize for your wait".  The therapist returned to the gym with the patient after having used this approach and the patient completed all therapy minutes.   I thought - what a great example of another version of the rescue strategy so thought I'd share it with you today.

Rescue Me

Allen Level 4 patients can be very tough customers.  Not believing anything is wrong with them and anything that is wrong is everyone else's fault...makes for a patient that likes to refuse therapy.  Establish rapport to treat a 4 :)  One technique that helps when you get refused by a Level 4 is the Rescue Technique.  The therapist who gets refused or told to "walk back out that door" needs to try to approach the patient again and while the patient is refusing...have a 2nd therapist walk in and say something like "I can't believe you're in here again, didn't you tell me she didn't want to exercise today?  Leave her alone; I'll bet you've never even been in a hospital before.. you don't know what she's been through"  The 2nd therapist now takes over the therapy and rapport will have already been established in that one little interaction.  Rescue strategy works almost everytime.  It's documented as Rescue approach initiated to elicit patient participation in therapy tasks.