For clinical and staff professionals in senior living communities, improving the quality of life for long-term care residents with dementia is part of the everyday mission of care. Over 50 percent of assisted living and nursing home residents have some form of cognitive impairment (Alzheimer’s Association, 2007). The rapid growth of the 85+ population means this will only increase.
These higher acuity residents present specific and increased challenges for nursing and non-nursing staff in achieving good quality of life and preventing avoidable medical situations. To meet this need, over 70 percent of assisted living (AL) communities offer dementia assistance, usually in memory care units (McKnight’s Senior Living 5/3/17).
The need of AL residents with dementia for correct, considerate supervision, engagement, and clinical oversight is greater than for others in AL communities. Like other residents, they are at risk for falls, functional decline, and polypharmacy issues, according to Sandra Simmons, Ph.D., of Vanderbilt University’s Center for Quality Aging. Most communities recognize that case management from the start is necessary, using assessment tools such as the Functional Assessment Staging Test (FAST) to determine the resident’s Allen Cognitive Level and progression. Unlike other residents, the person with dementia, even at early stages, is often unable to accurately communicate or explain their needs and feelings to the staff. That puts the responsbility on staff to carefully observe the dementia resident’s activities, behaviors and physical status every day to assess their continued well-being.
Anne Ellett, NP, MSN of Silverado Senior Living, identified 9 physical and behavioral areas to watch in assisted living residents with dementia:
- Weight changes. Both increases and decreases in weight can be significant in indicating cognitive decline, a physical condition such as CHF, or medication side effects. Positively, it can indicate improved diet management and nutrition. Eating disturbances, such as difficulty swallowing, appetite change, changes in food and beverage preferences, and dining habits, are key indicators of dementia progression (Relationship between Eating Disturbance and Dementia Severity in Patients with Alzheimer’s Disease)
- Infections. The person with dementia may not be able to express that they do not feel well. Frequent infection can be a sign of increased frailty.
- Falls and injuries. Changes in gait may be the first sign of infection, medication side effects, or other health problems, and can lead to falls and injury.
- Doctor and Emergency Room (Department) usage. Facilitating regular medical care and monitoring in the care plan can mitigate the latter to only necessary admissions.
- Pain assessment. Pain is often called the ‘fifth vital sign’. Recognition that the resident is in pain may be difficult, as the person may be unable to express when asked how and what they feel, as well as where. Staff who know the resident well are best able to monitor behavior changes and signs of general distress, as well as non-verbal and behavioral cues.
- Activities of Daily Living (ADLs). This includes monitoring and measuring ADL patterns and changes in such areas as activity, agitation, frequented locations, grooming, dress, hygiene, bathroom usage, waking times, sleep quality, nighttime activity, wandering, and elopement.
- Social engagement. Is the resident leaving the apartment for formal and informal social activities? Activity meaningful to them, short or long in duration, enhances the resident’s quality of life, lowering stress and anxiety. A lack of socialization may indicate a lack of interest in activities offered or mark a cognitive/physical decline.
- Behavior change. Highly significant as an indicator of infection or pain, behavioral and psychological symptoms of dementia (BPSD) may also serve as a form of communication to others to express unmet needs, confusion, distress, or anxiety. In a 2015 study of behavioral training approaches for AL caregivers, “Available evidence supports non-pharmacologic behavioral interventions as a best practice approach to BPSD management. A behavioral approach to BPSD involves identification of behaviors and the underlying causes, which are the essential elements in the proper management of BPSD.”
- “Disappearing into the wallpaper”. While some residents with dementia can be loud or agitated, others become quiet, passive, and undemanding. These residents are at risk because they are easy to overlook and according to Ms. Ellett, may not have received a thorough medical assessment and a comprehensive diagnosis. They need proactive care to stabilize their health.
The Alzheimer’s Association’s Campaign for Quality Residential Care influenced the development of effective, person-centered approaches to dementia care. It began in 2005 with the release of Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes, which established guidelines and context, with the objective of establishing a partnership between the resident and caregivers. The AA identified two phases of care strategies: Phase 1--dementia care fundamentals, food and fluid consumption, pain management and social engagement; Phase 2-- approaches to resident wandering, falls, and physical caring without the use of restraints.
Putting these strategies into action—and a glimpse into a better future—are new community and care models such as Abe’s Garden, which is built around an evidence-based lifestyle model to elevate resident care. It resides on a purpose-built campus in Nashville, and is organized around three ‘households’ with kitchen areas, common and outdoor areas, and residential suites. Not overlooked are stress reduction in furnishings and even the detail of natural and supplementary lighting to help regulate circadian rhythms. Abe’s Garden partners with Vanderbilt’s Center for Quality Aging for continuing research and community improvements. In the Netherlands, the Hogeweyk community near Amsterdam is organized around seven lifestyle ‘houses’ with individual residential themes (e.g. upper class, urban, homey) built around a central open courtyard and with village-type facilities such as a supermarket. This gives their residents understandable surroundings with appropriate stimulation and most importantly, socialization to work within their limitations.
Additional reading: Dementia Care in Assisted Living: Needs and Challenges (Issues in Mental Health Nursing), Managing Person-Centered Dementia Care in an Assisted Living Facility: Staffing and Time Considerations (The Gerontologist), Improving Assisted Living for Residents With Dementia: Two Solutions (CrisisPrevention.com)