Transcript Function Focused Care for the Cognitively

Elizabeth Galik, PhD, CRNP, FAANP
University of Maryland School of Nursing

25-50% of nursing home residents with
moderate to severe cognitive impairment
exhibit challenging behavioral symptoms
such as:
◦ Physical aggression
◦ Resistance to care
◦ Agitation

Behavioral symptoms most commonly during
care activities, such as:
◦
◦
◦
◦
◦
◦
Bathing
Oral care
Dressing
Transfers and mobility
Toileting
Mealtime



Communication challenges with spoken
language…can’t understand or express
Misinterpret/misperceive touch during care
as a threat or assault
Result is often “fight or flight”



Black box warning for antipsychotics due to
risk of death
CMS initiative to decrease antipsychotic use
Resistance to care often doesn’t respond well
to medications

Nursing home residents with moderate to
severe cognitive impairment
◦ Spend most of their time in bed or in a chair and
burn only 20-30 kilocalories a day beyond their
basal metabolic rate
◦ Spend less than 1 minute/day engaged moderate
physical activity
◦ Demonstrate significant decline in personal
hygiene, dressing, toileting, and eating within 6
months of admission




Contractures can begin to form after 8 hours
of immobility
Skin breakdown begins within 3 hours of
immobility
Older adults lose 1.3%-3% of their muscle
strength a day if they are immobile
Bed and chair rest leads to decreased
functioning of the heart and lungs





Pain
Infections
Potential for injury for resident and staff due
to resistance to care
Falls
Hospitalization




Encourages residents to participate in as
much of their own care as possible and
increases the time they spend in physical
activity
Minimizes behavioral symptoms
Doing care WITH rather than doing care FOR
Requires staff and families to work together
to motivate residents to do as much for
themselves as they are able







Basic personal care: bathing, dressing (can be
hand under hand)
Going for a walk or self-propelling in a
wheelchair
Feeding yourself as much as you are able
Brushing teeth
Stretching and range of motion
Getting up out of a chair
Exercise class








Use cueing, gesturing, pantomime
Resident washes one area and staff another
Hand under hand
Minimize verbal speech
Use deeper voice if resident is hard of
hearing
Remain calm
Limit the number of caregivers
Wait for the “best time” for the resident

Behavioral benefits

Physical Benefits
◦ Decreases resistive and combative behaviors
during care
◦ Less risk of depression
◦ Improves quality of life
◦
◦
◦
◦
◦
◦
Prevention of falls
Less functional dependence
Strengthens muscles and bones
Improves balance
Prevents contractures
Stimulates lung function and circulation.

Participating in physical activity is safe.
◦ Activities will be matched to the resident’s physical
and cognitive abilities
◦ There is something that everyone can do
◦ Staying seated and laying in bed causes weakened
muscles, bones, more confusion, pressure sores,
and infection
◦ Reduces risk of falls

What is the best way to identify what a
cognitively impaired resident can do?
Ask the resident?
Ask the family?
Ask other staff?
Assess physical and cognitive capability and get
them to try?
◦ Look in the chart and see what it says?
◦
◦
◦
◦





Range of Motion
Strength
Ability to follow a 1, 2, or 3 step instruction
Chair Rise/Balance
Walking?




Set goals based on physical and cognitive
capability and behavioral symptoms
Discuss goals with resident, family, and
review progress in care plans
Goals focus on function and physical
activity (performing ADLs, self-propelling in
wheelchair, walking, going to exercise
class) and minimizing behavioral
misinterpretations of touch during care
Make goals individualized

What are some ways that Function and
Behavior Focused Care can be incorporated
into the daily life of nursing home residents
with cognitive impairment?





Medication management-include the resident
in functional tasks (hold cup, self propel or
walk up to medication cart)
Walk or wheel self to the dining room
Have resident wash face or brush teeth with
cueing rather than you doing it for him
Set up meals for more independent eating
Hand under hand activities








Have the resident reach for an item in her
closet
Have the resident help you in the kitchen by
reaching for items in the cupboards
Sweep (also helps to build balance)
Fold and fly paper airplanes
Kick a ball
“Press down on the gas pedal”
Tap a balloon
Other ideas…





Incorporate supervision and cueing rather than
doing the task for the resident
Gesture, role modeling, demonstrate desired tasks
on yourself
Some residents are helped by self cueing in mirror
(may agitate others).
For resident who pull away as you come toward
them, stand to the side or behind them and use
hand under hand
Adaptive tools: washing mitts, extension sponges,
gait belts, etc.

Know residents’ personal history and use this
information to engage them in functional
activities
◦ Example: Increase opportunities for physical
activity in the evening for “night owls”.

Establish a routine consistent with previous
life experience (home, work, leisure activities)
◦ Examples: A gardener might enjoy caring for
plants. A business man might enjoy packing his
briefcase or organizing a desk.







A windy day
A cup of coffee
Cleaning the house
to show tunes
Walking the dog
Christmas shopping
Coconut-lime hand
lotion
Her electric
toothbrush


How could we use our knowledge of Mrs.
Smith’s favorite things to motivate her to be
physically active and content?
Imagine one of your residents. How would
you use that resident’s past life
experiences/preferences to get him/her
physically and functionally active and
behaviorally stable?





Gradually increase time and intensity of
physical activity
Make sure the resident receives pain
medications to relieve discomfort.
Use relaxation and distraction techniques
Help them overcome anxiety and fear by
actually performing the activity.
Remind them “you can do it”




Cognitive decline is not the only predictor
of functional impairment. Residents can
often do more than we think they can!
Remind yourself and your peers of the
benefits of function and behavior focused
care.
Everyday, give residents the chance to do
something for themselves that you typically
did for them. (i.e. wash their face, put their
arm in a sweater sleeve)
Residents will take their lead from you!!
Believe in their abilities!!




Establish a trusting relationship with the
resident
Let the residents know that you really care
about them
Use humor
Get excited/use positive reinforcement with
residents when they participate in physical
activities (bathing, dressing, walking to the
dining room)





Pleasant destinations
Appropriate chair and bed height
Have equipment/tools that facilitates
physical activity (walkers, gait belts, washing
mitts, stretch bands) in accessible locations
Small group activities focused on function
and activity (Examples: movement groups,
walk to beauty shop with peers)
Be aware of the impact the environment
(light, noise, temperature, access to
outdoors)


Behavioral disturbance during care is most
likely to occur when the caregiver touches the
resident. So…..
Support more independent function during
ADLs by
◦ Use more cueing and modeling and less direct
hands on care
◦ Use fewer words
◦ Be patient and calm
◦ Reapproach if necessary



Motivation is strengthened when
caregivers believe that residents will
benefit from participating in function and
behavior focused care
Use other residents as role models to
motivate others
All residents can be motivated to
participate in at least a portion of their
own care. **Be positive and remind them
that they can do it!!** Be creative to find
out what makes each resident ENGAGE
and MOVE!





82 year old widowed, white man referred by staff
of the assisted living
Was involuntarily discharged from another AL
that couldn’t manage his care needs
“Restless, trying to walk, unsteady, gets verbally
angry with staff when they tell him to sit down so
he doesn’t fall, also argues with roommate.”
He dozes off during the day and awakens
frequently at night
No delusions, hallucinations and no physically
aggressive behaviors since admission 1 month
ago




2 years ago moved to Maryland from Kansas
when neighbors called family with concerns
related to his drinking and inability to care for
himself.
Following hospitalization and physical rehab stay,
did well in senior apartment until he developed
severe delirium in the context of a UTI.
Never returned to previous level of function and
moved to assisted living
Physically aggressive behavior and elopement
attempts and started on Risperdal 1 year ago.






HTN, hyperlipidemia,
Weight loss of 15 pounds in the last year; has
gained 3 pounds in the past month
Right nephrectomy
Bladder cancer with urostomy
L1 compression fracture
Medications: Risperdal, Trazodone,
Lorazepam, Tylenol, Senna


Awake but with poor attention and eye
contact, uncooperative with exam, speech
slowed, soft with long response latency,
anhedonia, no SI, no delusions,
hallucinations, MMSE=7
Festinating, shuffling gait, decreased arm
swing, mild resting tremor, masked facies,
bradykinesia, cogwheel rigidity






More alert
Sleeping at night
Improved cognition, MMSE 14, able to complete
serial 3s, give history
Still restless, wants to walk, and no improvement
in Parkinsonism (freezing at thresholds)
Staff giving him more opportunities to move with
assistance rather than telling him to sit down
5-6 year history of progressive motor symptoms,
never diagnosed with PD