Getting to know a resident's likes and dislikes allows for soothing interventions

By JULIE MINDA

Nursing home residents in cognitive decline can become aggressive or exhibit other challenging, potentially risky behaviors, according to Alfred Norwood, a behavior specialist on the faculty of the Avila Institute of Gerontology in Germantown, N.Y. He says that when residents become verbally or physically aggressive, frontline staff often are the target.

When staff lack the knowledge of how to head off an outburst or calm an agitated resident, their work becomes more stressful, and stress is associated with job dissatisfaction and staff turnover.

Sr. M. Peter Lillian DiMaria, O CARM, director of the Carmelite Sisters for the Aged and Infirm's Avila Institute, teaches techniques for managing or preventing aggressive behaviors in patients with dementia to students from the College of Saint Rose in Albany, N.Y.

That cycle is particularly problematic given the challenges of finding and keeping frontline eldercare staff.

Long-term care facilities connected with the Carmelite Sisters for the Aged and Infirm have found that when staff apply behavior management techniques, they can diffuse problematic situations and resolve the types of concerning behaviors that are common nationwide in long-term care sites caring for individuals with dementia.

The Carmelite Sisters' Avila Institute designed a daylong workshop to equip eldercare staff members who work directly with residents to intervene before behavioral issues escalate. It's generally taught in-person at long-term care facilities connected with the Carmelite Sisters. Avila Institute Director Sr. M. Peter Lillian DiMaria, O CARM, and Norwood teach the course.

Most participants work at facilities co-sponsored or sponsored by the Carmelite Sisters for the Aged and Infirm, or at affiliated facilities.

The behavior management course covers evidence-based approaches to get at the causes of aggressive or otherwise problematic behavior. The hope is that as staff become more alert to situations that trigger an individual's problematic behaviors they can make adaptations that will help the resident remain calm.

Medication risk
Sr. DiMaria says that when a resident is agitated, the course discourages the immediate administration of sedatives or anti-anxiety medication. She says that while such drugs can be useful under certain circumstances, they are relied on too frequently as a "fast and easy" fix.

Medication does not address environmental causes of behavior issues, and medications can lose their effectiveness over time, Norwood says. There also is a significant risk of dangerous drug interactions in a frail elderly population. For instance, antipsychotic drugs may interact in a harmful way with anti-arrhythmic drugs for heart disease and acetylcholinesterase inhibitors, which are drugs used to treat the cognitive symptoms of dementia.

"Recent research shows that early-stage dementia symptoms and concerning behaviors can be reduced to afford better quality of life for residents — and for their caregivers," says Norwood, adding that this outcome often may be achieved without psychotropic medication.

Once staff learn to use behavioral management techniques and avoid situations that agitate a resident, the quality of life should improve for the person, and for fellow residents, Norwood says.

Sr. DiMaria says of the course: "Our point and our cry is that we want people to be excited about all they can do through behavior management" to improve residents' well-being.

Advanced skills
Andrea Meyer is a social worker for St. Patrick's Residence Nursing and Rehabilitation, a Carmelite facility in Naperville, Ill. Meyer says symptoms and behaviors that can be common in long-term care facilities — and that usually are connected to cognitive impairment — include physical and verbal aggression. Sr. DiMaria says wandering is another behavior issue that is concerning in people with dementia.

Sr. DiMaria estimates that more than 500 people have taken the behavior management training course since it began about a decade ago. The course is meant to build on an in-person Avila foundational course that teaches the basic biology of dementia, how it might manifest in behaviors, and basic techniques to use in working with people with cognitive limitations. That course satisfies federal and state mandates for dementia training for long-term care staff.

The behavior management training provides more in-depth information on the brain changes that occur with dementia and the science behind behavior intervention and modification approaches. The course emphasizes the importance of getting to know residents' preferences, keeping residents physically and mentally active and engaged, and maintaining a routine that is consistent with the individual's patterns of daily life.

Sr. DiMaria explains how the approach worked in a situation in which one resident with dementia began yelling every day before meals, but couldn't verbalize what was wrong. The staff assessed the situation and concluded the resident was hungry. Getting the resident to the dining room earlier or providing snacks ended the outbursts.

Norwood says another resident with dementia spent much of the day in her room. She was verbally agitated. Staff concluded she was lonely and not getting enough human interaction. They began situating her in a well-traversed corridor and asked staff to talk with her whenever they passed by. This eliminated her distress.

Carmelite philosophy
Sr. DiMaria says it's important for staff "to come together and be prepared so you know all you can about the resident — who they are and where they came from, their routines." She says staff members' approach should acknowledge the dignity of each resident.

When staff get to know residents' idiosyncrasies, those idiosyncrasies become clues to how to address behaviors, she says. "The more you know them, the less problematic behaviors you will have."

Since pain can impact behavior, course participants are taught to thoroughly assess a resident's pain in five categories and to do so on a regular basis. These domains, as identified by Dr. Michael Brescia, executive medical director of Calvary Hospital in Bronx, N.Y., are: physical, emotional, psychiatric, spiritual and family-related pain.

Faculty and course participants talk through several actual case studies and potential interventions.

The course also addresses the issue of wandering by residents with dementia. As with other behaviors, it takes patience and tailored interventions, including increasing the residents' activity level to address their need to move; redirecting them to a quiet place they enjoy; playing their favorite music or finding another new focal point for their mind; providing a new stimulation, such as massage; and rewarding them when they sit safely, among other interventions.

Staff can keep a record of the wandering behavior to see if they can identify patterns or triggers. If the wandering does not create a safety hazard, staff do not necessarily have to intervene, says Sr. DiMaria.

Sr. DiMaria says she and Norwood are available to provide counsel about this and other problematic behavior if it continues after students have applied techniques learned in the class, but the goal is to get staff comfortable with independently using critical thinking, teamwork, problem-solving and innovation to solve resident behavior issues.

Natural approach
While Avila has not done research to gauge the effectiveness of the techniques, Norwood says informal surveys of course participants indicate they feel more comfortable working with residents with behavioral issues, and less burned out than before the course.

Meyer, the social worker, says the workshop gave her tools she regularly references during her unit's daily multidisciplinary morning meetings to discuss each resident's status. She says several people at her facility have taken the course and have shared the knowledge with colleagues.

Copyright © 2018 by the Catholic Health Association of the United States
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