Knowledge Center

Your elders each have a list of rights that you need to always respect as a caregiver. And note that this list is just plain common sense… it’s what all of us expect, actually. And just because they’re older does not mean that they have any less right than any of the rest of us.

Their basic list of rights includes the following.

1. The right to dignity and respect.
2. The right to freedom from abuse, neglect or exploitation.
3. The right to privacy.
4. The right to choose their personal preferences in activities of daily living.
5. The right to freedom from discrimination.
6. The right to adequate healthcare and basic necessities.
7. The right to participate in society, activities and cultural life.
8. The right to financial government assistance, if they need it.
9. The right to have control over their own property, financial affairs and personal effects, in accordance with the law.

They all make sense. We all want those rights, as human beings they’re what help make life pleasant and worth living.

But the problem is, in our society, elders are often treated as if they have fewer rights than the rest of us.

As caregivers, though, you should respect each and every one of those rights with all of your elders, all the time. So what does all this have to do with your specific, day- to- day care you should be giving your elders? To give you some specific ideas about how you should be conducting your care giving with respect to your elders’ rights, here’s what the Centers for Medicare and Medicaid Services (CMS) lists as required rights that you should be delivering to your elders… every day, all the time.

Your elders’ basic rights are a guide to how you should be delivering care

In our society, elders are often treated as if they have less rights than the
rest of us.

And note: These are CMS rules that caregivers are required to abide by... And this includes your Alzheimer’s elders. It’s a part of the CMS goal to have all caregivers “person-center” their care-giving. That means that you should center your care around the personal preferences of each of your elders.

Your elders have the right to choose their preferred hobbies, clothes to wear, type of bath and more.

According to CMS rules, you should treat your Alzheimer’s elders like anyone would want to be treated under those circumstances. It’s called the “reasonable person” concept.

-- To have available to them a variety of social opportunities and activities. And you should

consider their preferences when scheduling these events.

--Be free from abuse and neglect. This is an easy one to understand. It means your elders

should not be abused in any way: verbally, sexually, physically or mentally.

Violation of this right can result in huge fines and even prison time; and, also, anyone who witnesses or suspect’s abuse is required by law to report it quickly for further investigation by authorities.

It means doing all you can to keep them well, and a big one here is prevention of pressure ulcers.

--Have privacy in their rooms, and a homelike environment. This includes the right to keep and use personal belongings, and to have private visits. They’re also permitted to have private phone calls and emails.

--Be free from discrimination. In your care-giving, you must comply with civil rights laws that forbid discrimination based on race, color, national origin, disability, age, or religion.

--Be free from chemical or physical restraints.

It is against CMS regulations to use physical or chemical restraints (drugs) for discipline, or just for the convenience of staff.

And this includes restricting them to their bed with high bedsides.

For helping with behavioral problems, you should try other things before using restraints, including reminiscence, distraction, special activities, and so on.

--Make complaints without fear of retaliation.

Your elders have the right to make a complaint without fear of punishment. The agency is required to address their issue promptly.

-- To be involved in their own care plan.

You probably already know that, by law, you must develop a care plan for each client.

Your elders and family members also have a right to be involved in this process.

Plus... a CNA is now required to participate in developing each elder’s care plan.

--Have their family, doctor, guardians or representative notified immediately when their

health changes.

--To manage their own money and finances.

Treat your elders with respect!

Your elders should be:

• Allowed to choose their own clothing, activities, grooming and bathing times.
• Called by the name of their choice. Avoid baby names such as “sweetie”, “honey” and “baby.” You should not use baby talk with your elders.
• Warned by a knock on their door before someone comes in. That’s a matter of respect for their privacy.
• Provided privacy during care when the door is closed, privacy curtains pulled and window

shades drawn; and privacy for visiting with friends and family.

• Addressed with respect through positive body language and facial expressions.
• Able to enjoy their meals with help as necessary,
• Kept nicely groomed at all times. Treated as a very important person, always!

The Golden Rule

Treat your elders the way you’d want to be treated!

They can make their own choices

Your elders should be able to choose activities and socializing according to their own interests

and backgrounds, including:

• Allowing your elders as much choice as possible in dining.
• Allowing them to sleep on their own schedule.
• Making snacks available.
• Allowing them to choose which clothes to wear, and to be properly groomed.
• Letting them have friends and relatives to visit.
• Letting them continue to pursue their longstanding hobbies and interests. This includes

crafts, hobbies, listening to music or playing a music instrument, and so on.

• Allowing them to have their preferred type of bath.
• And so on!

How does the Privacy Rule affect you?

Basically, the HIPAA Privacy Rule boils down to this:

Caregivers who are not directly involved in the care of an elder cannot legally view,

discuss, or repeat any healthcare information about their elders, unless the elder has given them permission to do so.

However, there is one big exception to this rule: healthcare information can be disclosed to

other caregivers who are directly involved in the care and treatment of that elder’s health conditions.

In other words, doctors, nurses, and others can readily exchange health information with

each other about an elder who they are treating.

Others who can get detailed information about an elder are those who the elder has indicated approval for as personal caregivers. This can include immediate family members, certain friends, and those with healthcare powers of attorney.

These are the personal caregivers who can discuss the elder’s medical situation with staff, and who can be present in the room when medical staff visits?

What about those with Alzheimer’s?

According to CMS rules, providing high quality, meaningful, care applies to all of your elders, including those in the advanced stages of Alzheimer’s. You must treat those with Alzheimer’s disease with what the CMS calls the “reasonable person concept.” This means you must treat them like any “reasonable person” would want to be treated in any given situation.

It means you’ll cover them up when bathing, you won’t allow them to lie for long periods of time in wet sheets, that you give them privacy in their rooms when needed, and so on.

Person-centering

All of this might sound like a lot of difficult- to do requirements. But, when you boil it all down, it’s basically good common sense care-giving: Treating your elders the way they want to be treated... and not like objects.

It’s person-centering your care around each elder...which is the way you, or anyone else, would want to be treated.

At the core of your elders’ rights is person-centering; their right to make choices in their daily care-giving.

Medical privacy rights

Your elders also have the right to privacy relative to their confidential medical information.

And this is a big one, backed up by a very powerful set of government laws.

Violating them can result in jail time and huge financial penalties!

HIPAA

The federal law that protects your elders’ medical information is called The Health Insurance

Portability and Accountability Act (HIPAA.)

Basically, it’s a federal law which prohibits the use and disclosure of patient/client healthcare information, unless the person gives written consent allowing you to do so It does so through a set of regulations called the Privacy Rule, which came into effect on April 14, 2003.

Professional ethics are the building blocks that provide the foundation on which your care-giving career is based. Professional ethics provide a standard of conduct and code of behavior.

They are a set of principles which relate to what is morally right or wrong, and provide standards of behavior.

All professional ethics for all people are important, but professional ethics related to Care-giving and the caregiver are vital for the well-being of all.

In many cases they’re as important as your medical knowledge, for they can have a direct bearing on the quality of care that you deliver. As a caregiver, you are obligated to follow the standards of behavior and the rules that are guided by the professional ethics of your care-giving position.

As all caregivers know, the care-giving profession can often be difficult, or frustrating, with many challenging situations. The basic rule of thumb, no matter the situation, is to always be guided by your professional ethics and to do what you know to be right.

The professional ethics that should guide you, at all times, include the following principles:

• Always perform care to the best of your abilities, for all of your elders, all of the time. Giving the best care possible means doing what is supposed to be done, when it is supposed to be done, and in the manner that is supposed to be done… for all elders, always.

• Treat all your elders with respect… every day, all the time. Never mistreat them, or deny needed care… ever. This is one of the most important ethical considerations for caregivers, for it’s at the very core of your profession. Elders feel good if they are honored and respected in their daily life activities. Call them by name and not the generic “grandma” or “grandpa” or “hon.” Each elder has a name which is individual, and means something, and expresses a lifetime of work, hope, fear, loss, love and happiness. Treating them with respect, and giving them the best quality care possible, makes them feel that they are still important people, and that you believe they are important. This makes them feel good about themselves, and substantially improves their quality of life.
• Treat all elders equally. Give all your elders the best care possible, regardless of their gender, race, nationality, religion, personal beliefs or social or economic status. Take care of all of your elders with respect, and be considerate of all their feelings and beliefs. You may not agree or believe the same things, but your elders have the right to be and say what they wish.

• Provide care with kindness and patience. Some elders are easier to take care of than others, but kindness and patience is always required. In fact, they are major caregiver attributes, which all caregivers should strive to achieve. Kind, patient caregivers are the ones who have the most significant and positive impact on their elders... and the ones who are most fondly remembered.

• Be an advocate for your elders. This means you’re always supporting them, making sure they’re properly cared for and not neglected, that all care-giving requirements are being done adequately for each elder, making sure that your reports are always followed up, and so on. Remember… you may be the only advocate they have left in their lives… this is a very important responsibility in the care-giving profession.

• Provide privacy and maintain dignity. Put yourself in your elder’s place. Would you want the door or curtains open if you were using the bathroom or taking a bath? Would you want your visitor see you as you receive personal care? Privacy is essential in all daily care activities. Never shout down the hall with a temperature reading or a bowel movement occurrence. Protect your elders by providing the privacy you would want for you or for your family members. Providing your elders with privacy maintains their dignity. And also keep in mind that federal regulations require that you honor the privacy of those with Alzheimer’s, just as you would anyone.

• Respect confidentiality. This includes both oral and written. Each caregiver and elder has the right to expect that knowledge gained through the circumstance of illness or work will not be forwarded to others who do not need to know the information. Do not place medical records in any area where they can be seen by unauthorized individuals.

Professional Ethics in a nutshell:

• Always give the best care that you can, for all your elders, all the time.
• Respect your elders.
• Do what you know to be right.
• Perform job ethically and as required.
• Follow rules and regulations of your Agency, state and federal requirements.
• Be honest
• Be respectful
• Be kind

Repeat only information that has a direct bearing on the elder’s health situation, and only to those involved in the care of the resident, and do not let yourself be overheard.

Remember, also, that these confidentiality requirements are in the tough federal law called HIPAA.

• Don’t Gossip. What you see and hear on the job stays on the job. Never talk about one elder to another. Anything you do must be based on the knowledge that no one needs to know what you know unless it relates directly to the welfare of the elder. Also, don’t gossip about your fellow workers. The most respected caregivers don’t gossip, because it demeans them, and undermines the effectiveness of care at the facility.

• Practice good personal hygiene. Personal hygiene is the way you keep yourself clean and neat. The way you dress tells a lot about you. Professional and dedicated caregivers take pride in their appearance.
• Show loyalty. To be loyal does not mean to blindly follow the direction of others without question or discussion. Loyalty does mean being faithful to the administration, co-workers and elders of your Agency. Loyalty means not letting personal feelings interfere with your work. It means confining grievances or negative opinions within the agency itself, and following the standard procedures of the agency for airing those grievances or opinions.

• Maintain a positive attitude. Positive personal qualities are necessary for success as a person and as a caregiver. Your attitude is the way others see you through your behavior. Positive human relationships result from a positive attitude with elders as well as with other staff, family members and visitors.

• Be responsible and dependable. This means that you’re the type of caregiver who can be depended upon by everyone to always do your best, and to be there… always… when needed in every situation.
• Take care of yourself. The nature of your special profession requires that you need to be at your very best every day, all the time, in order to give the best possible care to your elders. In this profession, you need to be especially careful of things like substance abuse, lack of sleep, or other things that can cause you to have personal problems and not be at your best.

• Stay educated. You are in a profession that’s constantly changing… there’s always more to be learned. And you owe it to your elders to be the best-educated caregiver possible. Their quality of care depends on this knowledge. So take part in as many educational programs as you can, throughout your entire career... your elders are depending on this. Elders in healthcare facilities are people –people with the same concerns and worries as everyone else. They do face additional problems associated with disease and other changes related to different aspects of aging. Physical changes, memory loss, reactions to medications, financial dependency, death of a spouse and loved ones, and lack of close relationships make it difficult to be an elder in the world today. And they often depend upon their caregivers almost totally, to provide them the best possible quality of life.

• Be honest. Respect your elder’s possessions: Do not take things from elders that don’t belong to you. Don’t cheat, or provide misinformation, on your reports. Always tell the truth. Honesty is especially important in the care-giving profession, because your elders’ quality of care often highly depends upon their caregivers being honest.

Caregivers who diligently follow their professional ethics and who are kind, loving and

patient, are at the top of their profession, and are the ones remembered and talked enthusiastically about by their many appreciative elders.

Caregivers cannot disclose any healthcare information about the elders

in their care, unless the elder has given them permission to do so.

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law which prohibits the use and disclosure of patient/resident healthcare information, unless the person gives written consent allowing you to do so It does so through a set of regulations called the Privacy Rule, which came into effect on April  14, 2003.

How does the Privacy Rule affect you?

Basically, the HIPAA Privacy Rule boils down to this: caregivers cannot legally view, discuss, or repeat any healthcare information about the elders in their care, unless the elder has given them permission to do so.

However, there is one big exception to this rule: healthcare information can be disclosed to other caregivers who are involved in the care and treatment of that elders’ health conditions.

In other words, doctors, nurses, and others can readily exchange health information with each other about an elder who they are treating. However, an elder can give permission

for disclosure of their health information to anyone. And, according to the privacy law, healthcare institutions must give their patients details on how they intend to use their healthcare information. Elders are asked to sign a document that they did receive this notice.

At this point, your elders can also add whatever restrictions they want relative to disclosure of their health information.

According to the Privacy Rule, if a patient/resident discovers that information regarding their health – or other personal data – has been disclosed without their written permission, they have the right to demand both civil and criminal charges to be brought against healthcare providers.

This can lead to fines of up to $25,000, and even more, and jail terms of up to 10 years... and even higher civil penalties.

So, this is serious business. But, generally, it’s not that difficult to comply with, as long as you know the basic requirements of this law, which pretty much boil down to this:

You cannot give out any medical information about any of your elders without their permission.

It’s up to them: They can request that no information be given out about them to anyone, or that just certain persons should be given this information, or that certain friends and relatives can be told... but others not told. And so on.

What information should you protect?

The Privacy Rule covers all medical information – written, oral, or in electronic format – about our elders. It also covers things that you observe, as well. This information is called Protected Health Information (PHI), and refers to a person’s “past, present or future physical or mental health condition” according to the HIPAA law.

Examples of protected information include:

• diseases and conditions;
• medications and other treatments;
• tests results (e.g., blood tests);
• x-ray and MRI scans;
• dietary restrictions;
• and so on.

Here are some basic points to remember about the Privacy Rule:

• The law requires that someone in your institution inform your elders about how you intend to use information about them, and give them the opportunity to restrict the disclosure of their information, if they desire.

• You cannot inform others anything about a client’s medical condition... without permission from the elder...unless they are directly involved in the care of that elder.
• You should not leave personal medical information lying around so that others can see it. Medical information, and records, should be kept in folders or envelopes, out of sight of others. What this means, is that the days are long gone when you can run around town announcing that prominent local citizen Mrs. X. has been admitted to your facility with Alzheimer’s disease.

HIPAA law says that you cannot give out this information, unless the elder has specifically

given you permission to do so.

The days are long gone when you can run around town announcing that prominent local citizen Mrs. X. has been admitted to your agency with Alzheimer’s disease.

And note this: the US Department of Health and Human Services (HHS) has a very active enforcement division that investigates these complaints.

It is being taken very seriously by federal officials. Under these rules, you cannot tell anyone about your elders, including postings on the Internet, without their permission.

If you do this without her permission, they can file a complaint with federal officials, and fines and civil penalties can be issued against you and your institution.

But, generally, it’s not that difficult to comply with, as long as you know the basic requirements of this law, which pretty much boil down to this:

You cannot give out any medical information about any of your elders without their permission.

Basic points Be careful about what you post on Facebook or other Internet sites about your elders. You cannot post any information about them without their permission, or you’re in violation of HIPAA.

“The kind of commitment I find among the best performers across virtually every field is a single minded passion for what they do, an unwavering desire for excellence in the way they think and the way they work.” —Jim Collins

What about family and friends?

One of the most frequent questions among caregivers is this: “What can I tell the elder’s family and friends?”

That’s an interesting question, because family and friends... once they learn that a loved one is in a nursing home or hospital... are quick to get on the telephone or visit, to try and find out how the elder is. They are justifiably very concerned, and want to be available to lend friendship and support. This is an area where you’ll want to double-check your own institution’s privacy regulations, because they may be different than the HIPAA regulations.

Plus, different state regulations may also apply. “Even when the patient is incapacitated, a provider can share appropriate information for these purposes if he believes that doing so is in the best interest of the patient,” according to the HIPAA law.

It’s recommended that you only give out basic information about the elder’s condition, and

avoid the medical details, except to those involved in the elder’s medical care. After an elder is in your institution for awhile, and medical personnel have discussed the disclosure of information in more detail, the elder may well give permission for more disclosures of information about them to friends and relatives. But, until they have done this, the basics of the Privacy Rule apply.

What can you tell visitors?

HIPAA officials state that you can tell visitors basic information about your elders if they ask about the elder by name… and if the elder has okayed the release of this basic “directory information.”

But, HIPAA officials state that that it is generally okay to inform family members, and personal friends, about the general condition of the elder, as long as the elder does not object to this.

Here’s what HIPAA says about this: “HIPAA does not cut off all communications between providers and the families and friends of patients:

“Doctors and other providers covered by HIPAA can share needed information with family, friends - or even with anyone else a patient identifies as involved in his or her care - as long as the patient does not object.”

This means that, before giving out this information, you need to be sure that an elder has not requested that it not be disclosed. And those who want their privacy may well request that no information about their condition be given out to friends.

Visitors can be given the elder’s phone, and general health condition such as “good,”  serious”, “critical”… but not specifics… unless the elder has denied permission to give out this

information.

Religious affiliations may also be given to clergy only, and clergy only do not have to ask about your elders by name in order to get this information. Note that your state may have stricter regulations, which you’ll need to be familiar with.

What if your client is unable to give you permission?

Sometimes, a client may be incapacitated in such a way that they cannot give you permission

to disclose any information. In this situation, HIPAA regulators state that, if it is determined

to be in the best interests of the client, medical information can be disclosed to relatives or close personal friends… but only the basics, and in minimal amounts.

It is generally okay to inform family members, and personal friends, about the general condition of the elder... if the elder does not object “Doctors and other providers can share

needed information with family, friends - or even with anyone else a patient identifies as

involved in his or her care - as long as the patient does not object.” Before giving out any

information, you need to be sure that an elder has not requested that it not be disclosed.

As a nursing assistant it is very important that you have the skills to deliver person-centered care. This article tells you what these skills are and how you can develop and practice them.

Caring for elders is challenging work. But there is something special about it. Unlike many other professions, it gives you the chance to make a real, positive, difference in other people’s lives.

As you work closely with your elders, you become that special person they look to for help, comfort, reassurance, or just to talk. You become the family they left at home.

So, your work is not just about keeping your elders clean and well dressed, or ensuring that they eat and drink and take their medications. It is much more.

It’s about giving them something to look forward to, every day; a reason to live inspite of mental and physical illness.

This means giving them the best possible quality of life while they’re in your care.

What is person-centered care?

At the heart of all this is your ability to deliver person-centered care. It’s providing care that respects an elder’s wishes, preferences and needs.

Person-centered care means providing care that respects your elders’ wishes, preferences and individual needs Person-centered care-giving requires you to develop and master four important skills.

You should be able to:

• treat the elders in your care as individuals;
• look at life from their perspective;
• provide them with their preferred activities and ways of doing things;
• communicate frequently, and effectively, with them.

Regulations require it

Federal regulations now require that elders receive person-centered care; that is care organized around the needs of the individual, rather than those of the nursing home, hospital or other setting.

Why? Because evidence shows that person-centered care is key to wellbeing, for both elders and caregivers; and it improves staff satisfaction; and reduces turnover as well.

Each of your elders has their own unique background, history, interests, skills, likes, dislikes, hobbies, careers and more. You need to get to know them, and use that information to help you design person-centered care-giving for each one, individually. Not only is this the best possible care you can give for your elders’ best quality of life, but it’s also required by CMS guidelines and regulations.

In fact, person-centeredness is the concept guiding several projects for the improvement of quality of life in nursing homes promoted by the US Department of Health and Human Services (DHHS), and the Centers for Medicare and Medicaid Services (CMS).

The CMS specifically says that person-centered care-giving “refers to the idea that each resident has a personal identity and history that involves more than just their medical illnesses or functional impairments.”

Research shows that person centered care has a real positive effect on both elders and caregivers. It can improve quality of life and wellbeing; contribute to job satisfaction; and reduce caregiver burnout and turnover.

The American Journal of Alzheimer’s disease and Other Disorders, reports that elders with dementia, who receive person-centered care, are more likely to engage in activities.

And, according to research conducted at Western Reserve University, Ohio, if they don’t receive this type of care, their cognitive skills deteriorate more rapidly.

These findings are of particular significance, if we consider that up to 70 percent of nursing home residents have Alzheimer’s disease or other forms of dementia.

According to the CMS, as a core part of person-centered care, elders should be enabled, as much as possible, to choose what to do during the day, when, and how.

When you person-center the elders in your care, you let them have as many personal preferences as possible in things like food, clothing, and activities. Research shows this substantially improves their quality of life, and their health and cognition.

They should also be able to decide:

• when to get up from, and go to, bed;
• what to wear;
• when, where, and with whom to have their meals;
• what to eat and drink;
• when and how to be bathed;
• when to receive visitors; and
• which leisure activities they want to be engaged with.

And, it works!

Also, individualized bathing dramatically reduced aggressive behavior in residents with dementia, while having control over waking and bedtimes improved morale among clients and staff alike.

Treating your elders as individuals

People are all different, and this doesn’t change with age. Older people still have their own personality and history, which makes them unique. So you need to treat them each as unique, special, individuals in order to deliver effective person-centered care.

How do you put this into practice?

First off, you need to get to know your elders well, because knowing them well is the only way that you can meet their likes and needs.

There are several very effective things you can do to get to know your elders, and provide person-centered care.

• Show a genuine interest in their past experiences. (“I’d love to know more about the time in which you worked at the farm.”)

According to researchers, this is particularly effective with elders with dementia, since most retain their long-term memory until the late stages of the illness.

 Ask them for advice. (“I have been told you are a great cook! What spice should I use in casseroles?”)

• Give them opportunities to be helpful. (“Shall we water the flowers together? I’d really appreciate your help.”)
• Answer their questions and, whenever possible, take the time to have a chat with them.
• Listen to what they say. Remember to look them in the eyes and smile, and to nod, occasionally, to show that you are following them.
• Be polite and friendly.
• Offer genuine compliments.
• Never treat them like a child.

These strategies will make the elder feel wanted, and their life worth living.

This involves being aware of preferences, interests, habits, daily routine, and life history,

particularly key stories about special achievements, such as anniversaries, birthdays, promotions, and so on.

Regular use of this information will help you in many ways. It will give you ideas for:

• activities that bring your elders real joy;
• conversational topics that are important to them;
• objects, events or situations that can trigger positive memories, improve their mood and, in doing so, make them feel better. If you work with elders with dementia, knowledge of their past jobs may be particularly helpful to understand their often confused behavior, says professor of dementia care practice, Dawn Brooker, of Bedford University, in the UK.

“For example, people who have held managerial positions during their working life may find it confusing to be told what to do by a care worker who, in their eyes, is just a junior employee.

“Likewise, if a person with dementia thinks she is a care workers’ mother and the care worker is attempting to help take her to the toilet, she is likely to get irritated.”

Looking at life from their perspective

Try and put yourself in your elders’ position. These are vulnerable people living away from home, at a time in life when they most need their loved ones. Understand this and you will be able to understand their experience in the facility; what they are going through, what they think and feel, and what they long for.

The goal is that, by putting yourself in the place of your elders, you become conscious of what is best for them. Then, doing the right thing will come natural.

More person-centered care tips

• Ask your elders their opinion on things. “Should we take a walk together, or would you like to watch the television?”
• Don’t dismiss their fears and concerns. Instead, show that you understand them, and their fears will disappear more quickly.
• Give due attention to their health needs. Check them frequently for pain, sight and hearing problems, and so on.
• Help them do things they like. Research shows that older people who are encouraged to follow their wishes are more likely to engage in activities, are happier, and feel physically better.

• Let them have their own personal clothing and possessions.
• Help them choose what and when to eat and drink, where they want to sit, when they want to sleep and wake up, whether they want a bath or a shower, and when.

Try and put yourself in your elders’ position.

Get to know your elders!

Have frequent conversations with them. Find out about their past history, and what they like to do. They’ll love the conversation time with you, plus these conversations will give you valuable information on how to personalize your care for each of your elders.

Your elders are depending upon you to help make their remaining years as joyful and productive as possible.

Notice: We attempt to be as accurate as possible, but the information contained here should not be implemented without checking current guidelines from your own medical and supervisory personnel.

Have you taken much time to really think about what the care-giving profession is all about?

Sure, we all know that it involves a lot of routine jobs: taking blood pressure and temperature, toileting, bathing, dressing, that sort of thing.

But there's more to it than that: you're responsible for delivering a good quality-of life to your elders, in addition to basic care. Think about it: your elders are depending upon you to help make their remaining years as joyful and productive as possible .

And that's something you should think about all the time, every day, in your ongoing care-giving activities.

This is a very important, responsibility. As front-line caregivers, you may well be the person who many of our elders see the most, by far and away. How you relate to them, all day long, every day, will be a major factor in determining their happiness, feelings of well-being, and quality of life.

This requires a major skill that all caregivers should have as a core part of their care-giving personality: Compassion. A smiling, joyful attitude is one of the most effective things you can do to provide compassionate care-giving.

Four important factors in effective, compassionate care-giving:

• Communications
• Respect
• Understanding
• Kindness

A good starting point in attempting to pinpoint what is meant by compassionate care-giving,

Characteristics

• Communicate sensitively with the elder and the eider's loved ones, listening carefully, showing empathy and instilling a sense of hope.
• Respect the eider's values, culture, choices and decisions.
• Understand the significance of the eider's family and community

And here's a basic, dictionary type definition of compassion:

"A deep awareness of, and sympathy for, another's suffering."

For the care-giving profession, perhaps this line should be added to that definition:

"Doing all you can to alleviate that suffering, and giving your elders as much hope and

joy in their lives as possible, all day long, every day."

Elders with Alzheimer's Disease are suffering.

They are suffering every day because they are losing their ability to do things that they always used to be able to do. They can't think as well and can't take care of themselves, they can't remember, they get lost, they use poor judgment and reasoning, they can't physically move around as well, and they do things they would never normally do.

Compassionate conversation: Do it frequently, look them in the eye, talk about things

they're interested in, be cheerful and optimistic. Get to know each of your elders.

The challenges of Alzheimer's

All Alzheimer elders do not do the same things. There are three distinct stages the Alzheimer elder progresses through as the disease continues, but no two elders are exactly alike.

That's one of the reasons why caring for elders with Alzheimer's can be so frustrating and stressful.

First off, it's a good idea for you to mentally prepare yourself for the realities, challenges, and opportunities in caring for those with Alzheimer's disease.

Here are some professional tips for general care-giving skills to get you started down the right path:

• Get a thorough understanding of the disease, and the progression it takes, as the elder lives longer. Get training, ask your supervisor for help, read books about Alzheimer's. Individualize the training you receive in your care for each of your elders.

• Because of different elder behaviors and changes that can occur on a daily basis, it is important for you to think of ways to prevent personal frustration and related stress that can affect your care, and your every day life. Develop some things that can relieve your stress, and use them often.

• You must take care of yourself if you are going to be an effective caregiver. Eat well, exercise, get enough rest and take care of any medical concerns. If you are sick, stay home and get well. Seek outside help if you need a different point of view or personal advice.
• Plan for and take "me time." Not always easy, but it can be done. Schedule a manicure, a walk along a trail, lunch with a friend, or a long, leisurely bath with no interruptions. Or simply listen to your favorite music. Your family always gets "me time," so make sure you get some for our self. "Me time" allows for reflection, a chance to relax and have fun. Relaxing and having fun is important for your elders and it is important for you as well.

Compassion tips

Now that you have some tips to help orient your professional attitude and skills to help you with Azheimer's caregiving, what can you do to apply them toward being a compassionate caregiver.

Caring for elders with Alzheimer’s disease has its own unique challenges, which… in order for you to be a successful caregiver… you need to prepare yourself for, and be able to professionally deal with as they arise.

Overall, when caring for those with Alzheimer’s, you should keep in mind the following… each of which will have an impact on your care-giving, and how successful it is:

Some important traits for successful, and effective, care-giving of elders with Alzheimer’s disease include:

A whole lot of compassion and understanding; plenty of patience; having a versatile, bounce-back personality; and being alert and highly observational.

You cannot expect the elder to improve. They will have their ups and downs, but their decline will be ongoing. You can expect a steady reduction in your elders’ abilities to remember things, think, and act.

This means that you will have to be a very versatile caregiver, ready to change your  care-giving practices quickly and easily, accepting it as a normal part of your care-giving.

• Each elder will have their own, unique, set of problems and challenges as their disease progresses. A technique that worked well for one elder, may not work at all for another. This means you have to “learn and as you go,” make necessary changes in your approach, as you learn about the individuality of each of your elders.

• You cannot expect your elders with Alzheimer’s to learn effectively, if at all. What this means, is that you’ll need to repeat your actions over and over again in response to their various problems, needs, and behaviors. This can be frustrating to caregivers, but it is a reality of Alzheimer’s disease that you need to accept, and effectively deal with.

• There is no way to predict how their individual disease will progress You will not know, much ahead of time, what type of pattern their disease will follow, or what types of symptoms will be presented. Again, this is where your versatility becomes one of your best care-giving assets.

• Some Alzheimer’s elders will be easy to care for as they decline, others much more difficult. For those who are difficult, there are often no proven care-giving techniques that work all the time with these problems. You can only do the best that you can do, and not always expect that everything will work properly, all the time. This means you’ll need to be a very versatile and resilient caregiver.

• Remember that your elders’ problems are due to damage in their brains, which is beyond your control. So do not take their actions personally. Their actions are the result of their disease.
• Your compassionate attitude is key. You need to always keep in mind that your compassionate care-giving is extremely important to the welfare of these elders.

Often, more than any others, these elders depend upon their caregivers for support, help with activities of daily living, and help with maintaining a good quality of life.

Much research shows that, even though they may not show it, compassionate care-giving does have an extremely positive impact on these elders, often up until the very end of their lives.

Your care-giving is very important to these elders, so do it the best that you possibly can.

Research shows that, even though they may not show it, compassionate care-giving has an extremely positive impact on your elders.

Some quick tips that can help Learn to be very patient.

Patience is a necessity for caregivers working with elders who have Alzheimer’s.

Be very understanding.

You’d need to be very understanding of their disease, and their individual needs.

Be compassionate.

Being compassionate is what care-giving is all about, and your elders

with Alzheimer’s have a great need for your compassion, every day… all the time.

Be a diligent observer.

Being a good observer, and recording and reporting changes, behavior situations, and so on, can be one of the best things you can do to make your care-giving job easier and more effective. It’s these observations that will allow you to learn about your elders, what they need, and what type of care-giving response works best.

In addition, your observations and reporting of changes can be of great assistance in getting the elders the proper medical care that they need.

Especially for those elders in the advanced stages of the disease, who often cannot tell you what is wrong and what they need… your diligent observations are the most important factors of all, in getting them proper care.

Don’t be afraid to ask for help and advice.

Everyone caregiving for elders with Alzheimer’s needs help, and often lots of it, many times. Always ask for help whenever you need it, for whatever reasons. Learn as you go. Because Alzheimer’s disease results in many unexpected changes in behaviors, and with each elder be different in how the disease progresses and the response to it, your learning is never over.

The more you learn, the better your care-giving will be, and the better you’ll be able to cope effectively with this disease.

Keep your elders in a dependable, regular routine.

Change can be very disturbing to Alzheimer’s elders, as they get used to a routine, and depend on it to keep stability and understanding in their lives. It can be one of your best care-giving tools in preventing problem behaviors.

Always respond with kindness… always. No matter what the situation, or how disturbing it is, responding with kindness is always the best way to go, by far away. Remember

that these elders cannot help the way they are, and need your kindness more than ever during troublesome episodes.

Break down activities with your elders into small steps.

Alzheimer’s elders cannot process and comprehend large amounts of information, and too much can make them very frustrated. All activities should be done in small steps, with lots of encouragement and suggestions at each step.

This includes things like eating, bathing, oral care, dressing, and scheduled activities.

This is a very important care-giving tool, that can help keep a lot of problem behaviors and

frustrations from developing.

Keep the environment as calm as possible, according to each elder’s needs. Many problem behaviors can be attributed to undue noise and activities… shift changes, TVs that are too loud, unexpected visitors, and so on.

Some elders are bothered more by these things than others, which you will learn as you go. But quietness and calm can sometimes work to resolve problem behaviors, when all else fails. Being able to use distractions effectively... choosing those that each of your elders are most interested in... is one of the most valuable tools you can use to resolve

Be ready to use favorite problem behaviors.  distractions at a moment’s notice. Researchers recommend this as one of the most effective tools you have to help resolve problem behaviors.

To use these effectively, you need to learn all you can about your individual elders: their likes, dislikes, hobbies, professional interests, children, grandchildren, and so

on.

And, then, have these areas of interest ready to go in case of any types of problems.

This “distraction chest” will include things like photo albums of them and their family, pictures in books in areas of their hobby and other interests, favorite objects that they like to hold, favorite music, favorite exercises, and so on. (Note that researchers have found that favorite music is one of the most powerful tools of all, so have CDs ready ahead of time.)

Give them something to hold, such as a favorite stuffed toy. This can often work with many types of problem behaviors, and is quick and easy to do.

Use “Comfort Touch.” This can be something as simple as holding their hand, or putting an arm around their shoulders. Falls are one of the biggest problems, plus there’s potential injury with objects, food, medicines, and so on. Frontline caregivers are the best protection these elders

have against serious injury.

So make yourself aware of the procedures you need to follow in order to prevent falls, and keep them from other injurious situations.

Many elders respond very quickly and favorably to this type of care-giving touch. Use it

often.

(One precautionary note: a few of your elders may react badly to being touched, especially

when they’re in a state of agitation… so you’ll want to avoid it with them until they have calmed down.)

Always think of safety. As the disease progresses, safety becomes an extremely important concern. Elders in the advancing stages of this disease can get themselves in trouble, and cause themselves serious injury in a hurry.

Some specific behavioral problems, and recommended solutions; Aggressive, agitated behavior

Aggression and violence-type behavioral disturbances are one of the most difficult and frustrating things that Alzheimer’s caregivers have to face. One of the problems with this behavior, is that caregivers may not always know which elders may become aggressive, and when. Not only that, but it can often be a difficult situation to resolve, with no care-giving technique working well with some elders all the time.

For those difficult cases, medication can help. In these situations, you need to inform medical personnel about the elder’s problems.

Researchers report that aggressive behavior is apparently more common in the middle stages of the disease, when thought processes, and judgment are starting to fail.

Some tips on coping with aggressive behavior:

When facing an aggressive elder, here are some immediate tips for getting the situation under control:

• Remain calm. Your calm demeanor and soft reassuring voice may well be all that’s needed to calm down the elder.
• Do not argue with the elder.
• Talk in a low, soothing voice.
• Give reassurances that everything is ok.
• Turn off the TV or remove other loud noises.
• Try and distract the elder to a favorite activity.
• Be a careful observer, and see if you can determine a cause.

These observations may help you avoid similar situations in the future.

Check for medical problems. Their aggression may be due to pain, for example.

Try limiting choices. Some aggressive behaviors are due to frustrations on the part of the elder, who may be having a difficult time making up their mind on such things as what to eat, what to wear, which games to play, and so on. If you can limit the number of choices, that can help. Or, try simply giving them direct orders on what to wear or what to eat.

Maintain a regular routine.

Often, disruptions in daily routine can trigger aggressive behaviors and frustrations in elders.

Schedule regular exercise.

As with many problem behaviors, a regular program of exercise has been proven to help significantly…even if it’s in small amounts.

Think safety. You’ll need to do all you can to prevent injury to the elder. Get help immediately,if needed for this.

Use distraction. This is where your knowledge of your individual elders can help you considerably, by using the technique of distraction. Often, you can distract them with a favorite activity, such as looking at picture books, albums, taking a walk, or listening to their favorite music.

If a shower is preferred, use a shower nozzle holder to keep water from spraying over them.

Let them have privacy. Play their favorite music.

Be gentle, reassuring. Always use a very gentle, reassuring tone of voice, always assuring

your elders that you are there to help, and that everything will be okay.

Protect yourself, and others. If the violence is extreme, stay out of range until the elder calms down, so that you or others do not get injured. Get help immediately, if needed.

Wandering and restlessness.

Wandering is a common problem in those with Alzheimer’s. It can take many forms, including efforts to get outside and go home, or simply be expressed in excess activity and restlessness inside the facility. Also, in other cases, this type of activity may simply be a reflection of things they did in their previous lives… such as taking walks, jogging in the evenings, being very active at their jobs, and that sort of thing… and they are just attempting to return to that type of activity.

In many cases, researchers advise that wondering is not necessarily a bad thing; that it’s okay to let your elders do it, as long as they are not endangering themselves or others. Try regular exercise. Research has shown that regular exercise can be of significant help in reducing wandering, restlessness, and sleeplessness in your elders. (Plus, there is some evidence that exercise may improve cognitive behaviors, as well.)

Also helpful: giving the elder work assignments within the facility during the day.

These can include things like dusting, sweeping, carrying trash, and that sort of thing. Not only does this supply valuable exercise, but it can make the elder feel valuable… just like they did in years past.

If possible, take walks with the elder during the day, especially if walking is one of the elder’s

preferred activities. These walks can be inside the facility, or outside if you have assistance, if you have concerns about getting the elder to return to the home.

Following are some suggestions that may help prevent aggressive episodes:

In some cases, researchers believe this is caused by excess energy that builds up in the elders, or can be due to frustrations and other problems related to the disease.

Use preferred bathing methods. Bathing often triggers aggressive outbursts. Much research as shown, however, that these can be reduced if you allow the elder to wash up in the same manner that they did in their younger years, such as preferring a shower instead of a bathtub.

Limit the number of naps :

in the daytime, so they sleep better at night.

Serve their major meal at midday, with only lighter meals in the evening. This can help sleep.

Limit the amount of drinks that the person has in the evening, to help reduce nighttime wakenings to empty their bladder. And, make sure the elder uses the toilet before going to bed. Also, try limiting the amount of caffeine consumed later in the day, from things like coffee, tea and colas.

Make sure the temperature is satisfactory in the elder’s room.

Check for pain. Elders with Alzheimer’s often don’t understand what pain is, and wander around in an attempt to walk away from it.

Try music. Much research has shown that playing the elder’s favorite music can help resolve many types of behavioral problems.

Do they need the bathroom?

Mayo Clinic researchers report that many cases of wondering are elders looking for a bathroom.

Provide a safe place to wander. Mayo Clinic researchers suggest providing a safe place for your elders to wander, such as a circular trail through your facility, or a room, and so on.

This can allow them to wander around, get valuable exercise, and satisfy some of their frustrations. Just make sure their path is safe.

Keep the elder safe. Make sure they cannot get outside. Consider having your wondering elders wear medical alert bracelets.

Wandering outside can be a very dangerous activity in cold weather… several elders die each year in these situations.

Camouflage doors that you don’t want them to go through with wallpaper or curtains.

Child-proof doorknobs and locks. Use an alarm system.

Sexual behavior problems

Sexual behavior problems can take several forms, and lead to public embarrassment and other problem situations. This type of problem may be brief, or last for a long time, or it may come and go. Researchers say that this type of behavior, however, is relatively rare in Alzheimer’s elders, but when it occurs, it can be a major challenge for caregivers. There is no consistently effective treatment available for inappropriate sexual behaviors, that works for all elders, all the time. However, you should report such behaviors to medical personnel, as there are medications that may help the situation with some elders.

Some tips:

Get advice from others who have had this experience with elders in the past. They may well have some suggestions that can be of help to you.

Develop a plan ahead of time, for how you will handle the various behaviors, if they occur in an inappropriate place. This will keep you always-prepared.

Stay calm. Many researchers recommend dealing with these types of behaviors in a calm,  matter-of-fact way. And, if it’s not in a public place, and no one is being harmed, simply letting them proceed.

And remember, this is caused by severe brain damage and loss of thought processes. The elders are not doing it on purpose, and it may well be a regression back to a time when they were children.

Distraction can work well, especially if you can begin the distraction ahead of the inappropriate behavior. This is where your alert observations may become very valuable… if you can learn when such behaviors will occur, and get the elder distracted ahead of time, you may be able to avoid many of them. Again, these can include exercise, walking, music, looking at picture albums or books, reading stories, and so on.

Evidence-based research has found that playing and elder’s favorite music is one of the best tools caregivers can use to resolve a wide variety of problem behaviors.

Gently ask them to stop.

In some cases, this may work with some elders… but not always.

Special clothing. Use clothing with no fly opening in the front, and that is difficult to remove.

Or, put their clothing on backwards.

Be compassionate and reassuring.

Do not scold the elder, or make them feel ashamed.

Do not be confrontational, as it may only make the situation worse. React with patience and compassionate understanding.

Get help immediately, if necessary. Sometimes, in rare instances, the sexual behavior may manifest itself in aggression toward a caregiver, or other person. This can be a dangerous situation that needs resolving immediately with extra help, as necessary.

Need bathroom? Researchers report that frequently these behaviors are caused by elders simply looking for a bathroom.

Hallucinations and delusions

Hallucinations are when an elder sees, hears, smells, tastes, or feels something that is not there. Delusions are false beliefs from which the elder cannot be persuaded otherwise. They can be related to wandering and aggressive behavior, in some instances.

Some tips:

Do not argue with the elder about what they think is happening. To them, there situation looks like it is really happening; they actually think they are seeing or feeling their delusion or hallucination.

Give them lots of gentle reassurance that everything is okay, and that they are safe.

You can say things like “Yes, I know it must be frightening, but I’m here with you and you are safe.” Or: “It is sad that your mother has just died. Let me hold your hand, and maybe that will help.”

Turn off the TV. Sometimes, loud or violent TV programs can trigger delusions and hallucinations in your elders. Also, you should check for other loud noises or other distractions, as well.

Use distractions. Again, distractions to their favorite activities can often help this situation considerably. Playing their favorite music has also shown to be very effective in some of these cases.

Be very compassionate, kind, and understanding at all times.

Hallucinations and delusions can be very frightening for the elder. To them, the situation is real, so do not argue with them and attempt to convince them that it is not real. This can make the situation worse.

Researchers recommend a compassionate, reassuring approach, where you gently assure the elder that everything will be okay, that they are safe, and that you are there to help.

Remember that your elder may be very frightened, as their situation looks very real and frightening to them. Also, always remember that a major part of your care-giving job is to provide compassionate, understanding, care. That’s why you became a caregiver in the first place.

You cannot convince them otherwise, and attempting to do so may make the situation much worse.

Always react with calmness, patience and compassionate understanding

Remembering the past is highly recommended, and proven, to enhance the wellbeing of your elders.

Here is evidence-based information and step-by-step instructions for properly organized

and conducted reminiscence therapy programs, according to the research.

Bringing back fond memories of their lives-well-lived is an enjoyable, and effective

therapeutic technique, for your elders. With some situations, it’s more effective than drugs, according to Experts define reminiscence therapy as encouraging older people to share pleasant memories of the past to improve their well-being.

And, in fact, reminiscence has been associated with many important benefits in old age.

Decades of studies have demonstrated that it is an effective way for stimulating memory and cognition, increasing happiness, and reducing depression.

It also helps adjust to life in nursing homes, by enhancing residents’ social interaction with one another. And it provides that all-important sense of pride and accomplishment that makes elders feel still worthy of other people’s respect, love, and appreciation.

As effective as medications

The benefits of reminiscence extend to all elders, regardless of age, gender, education, or health status. And they are all but mild. Take, for example, the effect of reminiscence on depression.

Dutch researchers, who reviewed the results from past studies conducted on this topic, found that reminiscence produces improvements similar to those of medications.

The finding is particularly important, for medications can have serious side effects, including a three-fold increased risk of stroke.

Besides, they are expensive, and simply don’t work in some people.

The researchers conclude, in the International Journal of Geriatric Psychiatry, that, whenever appropriate, reminiscence should be considered as an effective and safer alternative to medications for the treatment of depression in later life. Other research has found that reminiscence and music can also be more effective than drugs for aggression and improper behaviors.

“Reminiscence should be considered as an effective and safer alternative to medications for the treatment of depression in later life.” Structured or unstructured

Reminiscence can be used with individuals or groups, and can be structured or unstructured.

In structured reminiscence, sessions specific themes (e.g., childhood, holidays, jobs, etc.) and topics are discussed in a certain order.

Questions are, of course, important to trigger memories, and should be very specific.

For example: “Tell me about your first job. When did you start? Was your family happy about it? Did you feel proud? Who was your best friend at work? Why did you leave?”

The goal is to help participants remember the details of particular events of their past life.

Questions are important to trigger memories, and should be very specific.

Decades of studies have demonstrated that reminiscence is an effective way to stimulate memory and cognition, increase happiness, and reduce depression.

In unstructured reminiscence, although sessions may have different themes, questions tend to be general, such as: “Tell me about anything you want to about your first holiday.”

This allows participants to recall freely whatever they wish, and often results in topics being discussed at random. Research shows that structured and unstructured reminiscence are similarly effective. However, in one study by Canadian scientists at the University of Calgary, which directly compared the two approaches in elders with depression, structured reminiscence produced greater improvements.

Planning

Good planning is crucial to properly organized and conducted reminiscence therapy programs.

Typically, these consist of one or two one-hour weekly sessions, of up to 15 elders, repeated for six weeks or more. First off, find out as much as you can about each of your elders, such as things they like or are proud of, hobbies, past jobs, favorite places, and so on.

Also check for potential problems, such as speech, vision, hearing, or cognitive impairments You should help them overcome these problems.

Here is what reminiscence experts recommend:

• Speech difficulties. Make a chart of words that are likely to come up during the sessions, so that your elders can express themselves by pointing at them.
  
  
• Poor vision. Find volunteers to describe photographs and other items that will be used at the sessions. Ensure prescription glasses are worn, clean and unscratched. Provide low vision aids (e.g., magnifiers).
  
  
• Hearing problems. Write down important information (e.g., discussion topics, instructions, Songs’ lyrics, etc.) on large sheets of paper or on a blackboard. Make sure close captioning is available for TV programs and movies. Check that hearing aids are in good working order, have their batteries charged, and have their volume set properly. Mild cognitive loss doesn’t require much adaptation, for the ability to remember the distant past and talk are unaffected. But moderate and severe cognitive loss, however, require you to:

• shorten the sessions to 30 minutes;
• keep groups smaller than six elders;
• speak in short sentences of simple words;
• ask questions with yes/no answers;
• allow more time to respond to questions.

If the ability to remember and talk are completely lost, use your knowledge of the elder to describe to them photos and other objects associated with happy memories of their past.

And keep in mind that research shows that reminiscence can benefit your elders with Alzheimer’s... even those in the more advanced stages.

So they should be a part of your program.

Alzheimer’s elders Helping with problems Choosing themes

Dr. Cynthia Stinson, of Lamar University School of Nursing, Texas, says: “The majority of

studies recommend reminiscence focusing on positive memories.”

One study, in particular, “showed that the most popular theme among older women was ‘favorite holiday.’ “This was followed by what the participants called ‘firsts’, such as the first pet, job, day of school, date, toy, playmate, and memory.”
Tips Allow your elders to choose themes for the sessions, if they wish. Make sure everybody has enough time to talk, and don’t interrupt them. Some memories can upset your elders. Be ready to provide comfort and reassurance.

• Offer refreshments during the sessions. (Check, first, for any dietary restriction your elders may have.)
• Give certificates at the end of the program.

Make sure eyeglasses are adequate and clean. Also check hearing aids, and help with other problems.

Other themes popular among elders are:

• cars owned,
• childhood,
• church activities,
• family life,
• friends,
• food preparation,
• life accomplishments,
• life turning points,
• leisure activities,
• marriage,
• music of the 1920s, 1930s, and 1940s,
• places where they once lived,
• volunteering experiences.

Bringing up the memories

Consider that it’s easier for elders to recall events and people if they have something to look at, and hold…. family photos, scrapbooks, and old gifts are just a few examples, and all work

very well. Other useful items include:

• Badges.
• Military memorabilia.
• Past magazines and newspapers.
• Postcards.
• Old kitchen utensils and recipes.
• Scents.
• Traditional food.
• Television and radio programs of the elders’ youth.
• Vintage recordings, toys and car models.

Let your elders know they can bring along any of the above at the sessions.

They’ll probably need help to find some of the items. See what you can do, and encourage

their families to look at home for objects that relate to their loved one’s past.

Conducting the sessions

To obtain the best results, you should start each session by creating a positive and pleasant atmosphere. Researchers recommend, for example, to begin with five minutes of gentle music.

Next, introduce yourself and welcome the participants. Explain the theme of the day and, when everybody is ready, invite them to share favorite memories with one another.

Listen with interest to what they say. And, get involved! Be prepared to share a few memories yourself.

Remember, the most important tools you have at your fingertips are the objects you and your elders have brought along. Refer to them often to facilitate the reminiscing. But, don’t force anyone to remember something, if they can’t or don’t want to.

You should ensure a warm atmosphere of acceptance and joy throughout.

So, give your elders individual attention. Say something nice to each one of them.

And be kind... and smile all the time.

Keeping up the motivation

You may find that, occasionally, some of your elders lose interest in the sessions.

Evidence shows this is a common problem for any activity program.

It can easily be resolved, in most cases, by giving sessions a purpose, such entertaining visitors, for example.

Older people just love sharing their stories with others, so it may be well worth inviting their family to come along. Not only will this keep your elders motivated throughout the program, it will also be an enjoyable way for relatives (and you!) to know more about their loved one.

Grandchildren, in particular, will be fascinated by how different life was in the past.

Some elders simply forget to attend the sessions. So, you may want to give frequent

reminders of the times and locations of the reminiscence sessions.

It also helps your elders remember, if you hold the sessions always in the same place, at the same time, and on the same day of the week.

It’s easier for elders to recall events and people if they have something to look at, and hold.

The most important tools you have are the objects you and your elders have brought along.

Following is an example of structured reminiscence session for use by nurses and activity directors working with elders, as reported by Stinson in The Journal of Continuing Education in Nursing. The session’s theme is remembering the past through music.

Note: Research shows that elders’ favorite music is a particularly effective, and therapeutic, reminiscence tool. What you need

• Songs from the 1920s to 1960s.
• Audio equipment.

What to do

Play the songs in chronological order and encourage your elders to sing and clap their hands to the rhythm of the music. At the end of each song, ask if they can recognize the song’s title and singer. Next, invite them to talk about special memories they associate with it.

Note: As explained earlier, in structured reminiscence, the facilitator asks specific questions about people, objects and events.

Structured reminiscence example

So, in this case, you may want to ask things like:

• When was the first time you listened to this song?
• How old were you?
• Where you with someone?
• Do you remember his/her name?
• What feelings did you experience at the time?
• Do you experience the same feelings today?
• Did you buy the recording or was it a present?

When you have played all the songs, ask each elder to pick up one that means something special to them and to explain why. Again, you may want to jog your elders’ memory by asking a few relevant questions. This session is one of the 12 included in a program developed by Stinson and colleagues, which, in a recent study published in the Journal of Psychiatric and Mental Health Nursing, significantly reduced depression in older people.

And here is an example of unstructured reminiscence session. This is an adaptation of a session developed by Dr. Perm Fry and his team, of Calgary University, in Canada.

Like the one described above, Fry’s session was part of a program that reduced depression in elders, according to the journal Clinical Gerontologist. The session focuses on life review.

What you need

Your goal is to bring back memories of important life events. So, you may want to use photographs, songs and other items that relate to the elders’ past, to facilitate the reminiscence.

What to do

Unlike the structured reminiscence example, you should start the session with a general question, letting your elders free to recall whatever they wish and in the order they prefer.

Unstructured reminiscence example

For example, you may want to invite them to listen to a certain song, or look at some photographs. Then, say something like: “Tell me about the memories this brings to you.”

You should refrain from asking specific questions about people and objects, unless, of course,

your elders mention them spontaneously. A simple: “Tell me more,” will work, if you want to encourage them to continue to share their memories.

Music is therapeutic

And note that considerable research shows that playing music for your elders has been found to be therapeutic in several research studies. It improves problem behaviors, helps with cognition, improves depression and feelings of wellbeing, and more.

Research shows that a key to getting success with your music is to offer tunes that the elders like.

Much research clearly shows that most all of your elders should have regular exercise...

including those who are frail and those who have Alzheimer’s

The incredible benefits of exercise!

Researchers know that physical fitness is perhaps the single most important thing an older person can do to remain healthy.

So it’s clear that one of the most important activities for the health and well-being of your residents is getting them involved in an exercise program, or simply keep them up and moving around as much as possible.

In fact, the scientific evidence about the beneficial impact of exercise in the elderly is overwhelming.

Moderate, regular physical activity has been associated with

• lower risk of cardiovascular disease and diabetes;
• improved depression and cognition;
• reduced risk of falling;
• reduced bone loss and fractures in osteoporosis patients;
• reduced mortality.

Exercise prevents falls

Falls are devastating, life changing events and a leading cause of death in elders.

• only one in four elders with a hip fracture make a fully recovery;
• one in two lose forever the ability to walk independently;
• one in five die within 12 months, as a result of complications.

Get them up and out of those wheelchairs as much as possible... don’t let them sit in them all day long, or use keep them in wheelchairs just for caregiver convenience!

Most important:

Keep them moving Exercise is a key factor in falls prevention. Many research studies conclusively show that elders who get regular exercise have less falls.

And this includes your frail elders, who may only able to do a small amount of exercise, such as short walks.

You should encourage your elders to stay active in whichever way they like, and suits their conditions; consider, for example, walking, gardening, cycling, dancing….. and so on.

This will help them maintain strong muscles and bones, as well as good balance and flexibility, in turn reducing their risk of falls.

Tai Chi

Tai chi, a gentle form of exercise originated from an ancient Chinese martial art, seems to work particularly well for elders.

The journal Age reports, for example, that practicing tai chi daily for 30 minutes, or more, improves the ability of an older person to maintain their balance when they trip.

But the key is to get them to exercise regularly, and not let them sit around doing nothing day after day.

Even regular 15-minute walks are valuable.

The key is to get them to exercise regularly, and not let them sit around doing nothing day after day.

The Elders Dance Project

One interest exercise program is called Elders Dance Project and was specifically designed to encourage older people in nursing homes, day care centers, and other settings become more physically active through dance.

Why dance? Because dance is not just about movement and exercise.

It is also a fun and enjoyable way for older people to get together and widen their social networks; and has research proven benefits on mood, balance, co-ordination, and overall wellbeing.

Even something as simple as regular walks are valuable for your elders. Help them do it, as often as they can! Visibly happier

The Elders Dance Project ran for eight weeks, during which 18 elders met once a week, for 1.5 hours, in groups of about ten individuals.

Music plus exercise

Music was a key factor in the dance project.

And note that many of the elders did not “dance” per se, but did arm movements and other exercises to the rhythm of the music.

Said researchers “The music we used during the session was recorded, and participants had the freedom of requesting the types of music they wished to dance to.”

The types of “dances” used included exercise movements like gentle stretches and loosening of joints and limbs.

Although there was always music playing in the background, the participants would often sing along, as well. Poetry or stories were also used during the sessions.

Researchers said there were several participants with Alzheimer’s Disease, who joined in the groups.

Some did it unexpectedly, partway through sessions; others would come and watch the first week and, then, join in later.

Those who were very frail remained seated and joined in the dances by moving their arms and hands.

“We would also ask them to help,” said researchers, “by holding a prop or choosing a song, for example, as this would make them feel very much part of the group.”

Analyses of interview and direct observation data showed that, by the end of the study period, the program had not only helped the elders stay physically active in a fun and enjoyable way, it had also brought many other important benefits as well:

• an improved sense of self confidence,
• increased levels of engagement and socialization,
• more eye contact,
• sense of freedom of expression,
• a greater sense of belonging.

In other words, the elders were visibly happier, talked a lot more, looked at each other more, and laughed together.

Dancing had clearly lifted their mood, resulting in greater enjoyment and sense of fulfillment.

Exercise benefits for Alzheimer’s elders

In a trial funded by the American Therapeutic Recreation Association, researchers found that patients with dementia who attended a three-month program of recreation therapy significantly reduced their incidences of falling. The program consisted of:

• A daily morning walk.
• Strength, flexibility, and balance music-based exercises, held three times a week in the mid afternoon.
• Air mat therapy (i.e., relaxation and gentle exercise on a vinyl air mat attached to an air compressor), held twice a week in the evening. Importantly, the activities were scheduled for the times of the day when falls tended to be more frequent. Regular exercise has the additional advantage of reducing behavioral problems in your elders with Alzheimer’s, such as aggression, which can also lead to falls.

Furthermore, exercise helps reduce depression, improve appetite, and maintain good physical

health.

Exercise also improves cognition

Exercise is perhaps the most studied intervention for the improvement of cognition in older people.

More than forty years of research suggests that it can improve memory and thinking abilities, as well as lower the risk of dementia or delay its onset.

And the more varied the exercise, the greater the benefits. Several elders with Alzheimer’s disease joined the groups.

Adaptations for dementia elders

Persons with dementia require the following precautions and adaptations:

• Schedule the same exercises every day at the same time.
• Have the elder exercise next to a sturdy table they can hold on to if they lose balance. (Elders with severe dementia need one-to-one assistance.)
• Explain and demonstrate all movements of an exercise.
• Help the person visualize the movements. Say, for example, “Touch the ceiling!” if you want them to raise their arm.
• Saying “left” and “right” generates confusion in the person with dementia. Say, “This arm, the other arm.”
• Be watchful for any signs of distress or frustration. Tactfully lead the person by the arm away from the group, in a quiet corner or other room, and provide comfort and reassurance.

Get them up and out of those wheelchairs!

A huge 80 percent of nursing home residents spend time in a wheelchair every day. Yet, many of them don’t need to sit in wheelchairs nearly as much as they do.

Wheelchairs are too-often used just because they are convenient, because they allow caregivers to move residents faster and to avoid the risk of falling.

But here’s the problem with that: Spending even a few hours in a wheelchair can lead to all sorts of medical conditions that have the potential to severely compromise the quality of a resident’s remaining life. Spending too much time in a wheelchair can be a disaster. It causes the elder’s muscles to deteriorate so that when they do walk, they may fall; plus it can cause pressure ulcers and other medical problems.

For one thing, bones and muscles start wasting away. So wheelchairs, in fact, actually increase

the risk of falls. They also increase the likelihood of pressure ulcers, contractures, backache, shoulder pain, constipation, and lung and heart deterioration.

Engaging in conversation, or other socializing activities, is also difficult, leading to isolation, loneliness, low self-esteem, and depression.

The good news is all this can be prevented by making sure wheelchairs are used only if necessary, and by encouraging more walking.

Tip: To get your elders in wheelchairs to do more walking, help and encourage them to walk to activities, meals, bathroom, etc., as much as they can. You may need to help them, especially at first if they’ve been sitting too much in a wheelchair, but it’s well worth your effort in the health benefits that they’ll gain.

Don’t just always take the easy way out and wheel them from place to place!

Works for the very old and frail

Participation in appropriate forms of physical activity should be considered for all your elders, regardless of their age and frailty.

Research shows that exercise has substantial benefits even for your most frail elders, and can actually help reverse sarcopenia… the loss of weight and muscle mass as they age.

Of course, before starting exercising, your frail elders should have a physical and medical examination to ensure that they can participate safely in the activities...and you should follow the instructions of medical personnel, relative to they type of exercises they can safely p participate in.

(Actually, you need to do this for all your elders.)

But just because they’re very frail should not be a reason to not exercise, as those elders can get substantial benefits from even a simple exercise program.

They can do exercises from a sitting position, if necessary, including chair rises using their arms, knee extensions, biceps curls, and so on.

(Have your AD or Therapist set up programs for your frail elders, then to all you can to encourage them to participate...!) Motivate them

Some elders are reluctant to exercise, because they fear of falling or experiencing pain, or

because they simply don’t feel “up to the challenge.” It is the caregiver’s responsibility to provide encouragement, by explaining that exercising will make them feel better and enjoy life more. A warm, friendly smile and words of praise during the activity will do the rest.

One of the most important activities for the health and well-being of your residents is getting them involved in an exercise program, or simply keeping them up and moving around as much as possible.

Note: Any exercise program should be conducted under the supervision of your activity director or therapist, and always with approval of medical personnel. And if any elder seems to experience problems during exercise, such as pain or shortness of breath, be sure and report immediately.

Music-based exercise program reduces falls

A study in the Archives of Internal Medicine found that a six month program of exercise performed to the rhythm of music halved the number of falls in elders, as a result of improved balance and walking ability. The program is an adaptation of the Jaques-Dalcroze eurhythmics

method. The study’s lead researcher, Dr. Andrea Trombetti, of Geneva University, in witzerland, tells Current Nursing about its benefits and how it can be implemented to achieve long-lasting benefits for your elders.

Dalcroze eurhythmics

Dalcroze eurhythmics (DE) was developed in the early 20th century, in Geneva, as a method for teaching music through movement.

It has been associated with therapeutic benefits, such as improved balance, co-ordination and concentration.

And, for this reason, it is now practiced worldwide in a wide variety of settings and by people of all ages.

The original version of Dalcroze eurhythmics consists of body movements performed to the rhythm of improvised piano music.

Simplified versions have also been developed that can be performed specifically by older people. Trombetti’s program is one of these.

Music: person centered

The program consists of 25 one-hour weekly classes of walking and arm movements performed in time to music. “Each class is for 20 to 30 elders,” Trombetti explains. “And uses live music performed by a piano player.”

There is one important requirement for the class to be effective: the music must be chosen to suit the preferences of the group.

“So, the choice of tunes is essentially dictated by the elders,” Trombetti says, “and it varies considerably, ranging from Edith Piaf and Jazz standards to classical music, like Mozart’s minuets.”

Balance-challenging exercises

A typical class involves the facilitator asking the elders to walk while moving their arms in time to the music. Trombetti says: “The elders are invited to listen to a certain music piece and express what they hear through movement.” But, unlike in other, similar interventions, they need to maintain high levels of attention and concentration while doing so. That’s because they are also instructed to be ready to suddenly change their movements whenever the music changes. This challenges their balance and walking abilities, and is the key element of the Dalcroze method.

“The exercises are performed with or without accessories, such as balls, hoops, and skipping ropes,” Trombetti adds. “And their difficulty is gradually increased over time.”

Suitable for dementia patients

Although most study participants were cognitively healthy, some had early dementia.

These elders, who also are at great risk for falls, successfully attended the program, regardless of their cognitive impairment. Long-lasting benefits

Its benefits were maintained for six months after the end of the program. And no injuries or

other adverse events occurred during the sessions. This indicates that the program is not only effective but also safe.

A fall is one of the worst things that can happen to one of your elders. Fact is, they’re a leading cause of death and disability in elders. A fall can completely destroy an elder’s quality of life, and many never recover from a fall.

Here are some facts about falls:

• only one in four elders with a hip fracture make a fully recovery;
• one in two lose forever the ability to walk independently;
• one in five die within 12 months, as a result of complications.

The good news is that many falls are preventable. And one of the major reasons for this, say researchers, is highly informed caregivers, who know exactly how to keep their elders on their feet.

Regular exercise is a key factor in falls prevention Most important:

Keep them moving

Regular exercise is a key factor in falls prevention.

Many research studies conclusively show that elders who get regular exercise have significantly less falls.

And this includes frail elders, who are only able to do a small amount of exercise, such as short walks.

You should encourage your elders to stay active in whichever way they like and suits their conditions; consider, for example, walking, gardening, cycling, dancing…..and so on.

This will help them maintain strong muscles and bones, as well as good balance and flexibility, in turn reducing their risk of falls. Tai chi, a gentle form of exercise originated from an ancient Chinese martial art, seems to work particularly well for elders.

The journal Age reports, for example, that practicing tai chi daily for 30 minutes, or more, improves the ability of an older person to maintain their balance when they trip.

Note: If your elders have not done any exercise for a while, make sure they get physician

approval before starting any type of physical activity.

Get them out of their wheelchairs

A major problem that causes lack of exercise, muscle weakness and falls is spending too much time in wheelchairs. If they’re able, you should get your elders up and out of those wheelchairs for regular exercise, as much as possible. And you should never keep them in wheelchairs just for the convenience of caregivers.

What happens when they spend too much time in wheelchairs, is that their muscles become weak, and they lose their abilities to balance.

So, when they do attempt to walk, they can easily fall. In fact, this is a major cause of falls in elders.

Some things your elders should avoid doing to prevent falls include:

• Getting up at night with the lights out.
• Rushing around.
• Standing up too quickly, especially after eating.
• Sitting on too-low chairs.
• Carrying bulky items that prevent them from seeing their feet while walking.
• Not holding onto grab bars.
• Dragging their feet while walking, instead of picking them up.
• Wearing slippers or socks, instead of shoes.
• Wearing clothes that drag on the floor.
• Attempting to sit in a walker without locking it, first. (According to recent estimates, this behavior alone causes falls in approximately 50,000 elders, each year.)

Make the environment safe

You may also want to make the environment as fall proof as possible. Here are some things

you can do:

• Check that the carpets have not loose edges.
• Keep the floor dry and free from clutter and telephone/ electrical cords.
• Place rubber mats in the bathroom.
• Make sure chairs, coffee tables and other furniture are near the wall, not in the middle of the rooms.
• Have night-lights installed in the bedroom of each elder.
• Adjust the height of the beds in such a way that, when the elders sit on it, their feet stay flat on the floor.

Make sure everything is well-lit, and that night lights are used But they key is to get them

to exercise regularly, and not let them sit around doing nothing day after day.

Even regular 15-minute walks are valuable.

Educate them

Another important thing you can do is to educate your elders about the importance of avoiding behaviors that may result in a fall. Some of them simply don’t know that they can help themselves in this way.

So, make sure you sit down together, say, once a week, and go through the things they should and should not be doing to prevent falling.

You should do all you can to get your elders, who are able, out of their wheelchairs for regular exercise. This will help prevent muscle weakness and gait problems... a major source of falls. Even short walks can be effective.

Falls and vision

Vision problems are one of the major reasons for falls. So, you need to ensure that all your elders undergo regular eye checks and have the proper glasses. And, also, that their glasses are clean and not overly scratched. More visual recommendations:

• Make sure that sunglasses, if used, are not too dark or too light.
• Cover shiny surfaces with cloths or mats, as glare increases the risk of falling.
• Have your elders stop at the door for a few moments, when going from indoors to outdoors, and vice versa, so that their eyes can adjust to the light change.
• Ensure that rooms are well lit, and provide lamps that illuminate directly the object your elders need to see.

Advice for your elders 

Why elders fall

There are a number of reasons (called risk factors) that make older people more likely to fall

than younger ones. According to authors writing in American Family Physician the most significant reasons for elders falling include

• Lower extremity muscle weakness
• A history of falls related to gait balance problems
• Improper use of an assistive device
• Visual impairments
• Depression
• Cognitive impairment

Also, the authors said that use of certain medications was “strongly associated” with increased falling, including psychotropic medicines, cardiac drugs, diuretics, and anticonvulsants.

In fact, they stated that “starting a new antipsychotic medication was associated with a very high risk of falling.”

So watch those elders who have those new meds very carefully.

The initial assessment

Researchers agree that a successful falls prevention program starts with your falls assessment program.

American Family Physician authors report that a “multifactorial risk assessment” is the most consistently effective strategy to prevent falls.”

This assessment involves

• your elders undergoing a full medical evaluation
• nursing staff taking the elders’ history of medications, diseases, previous falls, etc.,
• completing a fall risk assessment tool.

Fall risk assessment tools are, generally, preferred to history taking because their validity has been tested in studies.

Remember, though, that your assessment is of very little use if you don’t follow up and use the information you’ve gained for each of your elders.

Using the results of your assessment, your elders who are identified to be at risk of a fall should then be evaluated by your falls team.

• Vital signs (temperature, pulse, respiration, blood pressure, orthostatic pulse and blood pressure — lying, sitting and standing)

• Current medications (were all medications given, was a medication given twice?)
• Patient assessment
  
  

1. Injury
2. Probable cause of fall
3. Comorbid conditions (e.g., dementia, heart disease, neuropathy, etc.)
4. Risk factors (e.g., gait/balance disorders, weakness)
5. Morse/Hendrich Risk Assessment

• Other factors:

1. Resident using a mobility aid? If so, what was it?
2. Wearing correct footwear?
3. Clothing dragging on floor?
4. Sensory aids (glasses, hearing aids, was veteran using at the time?)
5. Environment

—Bed in high or low position?

— Bed wheels locked?

— Wheelchair locked?

— Floor wet?

— Lighting appropriate?

— Call light within reach?

— Bedside table within reach?

— Area clear of clutter and other items?

— Siderails in use? If so, how many?

1. Was the treatment intervention plan being followed? If not, why not?
2. Were the falls team and other nurses notified?

The post-fall assessment

Also, each time an elder falls, you should conduct a post fall assessment. Here are some of the items that the National Center for Patient Safety (NCPS) recommends should be in this assessment:

1. Date/time of fall
2. Elder’s description of fall (if possible)
3. What was resident was trying to accomplish at the time of the fall?
4. Where was the resident at the time of the fall (patient room, bathroom, common room, hallway etc.)?
5. Family/guardian and provider notification

Of the several available, the most widely used in nursing homes and hospitals, and also the most reliable, according to recent findings published in the Journal of Gerontological Nursing, is the Morse Fall Scale (MFS). MFS is available at https://www.mdapp.co/morse-fall-calecalculator-248/

It includes six items, is easy to use, and takes less than three minutes to complete.

It’s important that you use each elders’ assessment results. Remember that your initial assessment is of no help to your elders, if you don’t use the information in it to help protect each elder from falling.

The main causes of falls

The Centers for Disease Control and Prevention (CDC) report that muscle weakness and gait problems are the most common causes of falls in nursing homes… 24% all falls in these facilities. But the CDC also says that environmental hazards are also a major cause of falls in nursing homes… causing 16-27% of nursing home falls.

The CDC lists the following as proven falls-prevention techniques for nursing homes:

• Starting off with a thorough initial assessment.
• Maintaining an ongoing staff education program about falls risk factors and prevention strategies.
• Making changes in the nursing home environment to make it easier for elders to get around safely. Changes the CDC recommends include:
• Installing grab bars
• Adding raised toilet seats
• Lowering bed heights
• Installing handrails in the hallways
• Providing hip pads
• Using alarm devices that go off when elders try to get out of bed or move around without help.

What about restraints?

Contrary to what some may think, research shows that restraints do not prevent falls.

In fact, research shows that they actually increase the rate of falling, because an elder who is restrained much of the time develops weak muscles and balance problems, that make a fall more likely when the elder is up and about.

Specific advice

The VA, based on their studies of falls and their prevention, has these specific recommendations for falls prevention:

In their rooms:

• Set up elder’s room so they can exit the bed from their strongest side
• Make sure everything’s within easy reach: call button, light switches, and so on.
• The room should be well-lit.
• The room should be free of clutter and tripping hazards.
• Bathroom and exit doors should be clearly marked.
• Fall prevention posters should be posted in the elder’s room.
• Use non-slip floor mats.
• Have available proper footwear, either treaded slipper socks or hard soled shoes.

(Also make sure their clothing does not drag on floor.)

Note: The VA advises that treaded socks should NOT be worn if there are rugs in the environment, as this could increase their chances of falling.

• Do not use full side rails, unless medically required, as they are considered restraints and increase likelihood of death due to entrapment, and can cause the

In the bathroom:

Since many falls occur in bathrooms and showers, VA caregivers recommend the following interventions:

• Use slip resistant strips on the floor and in the tub, or a cleanser that increases floor traction even when wet.
• Make sure shower grab bars are installed, and covered with a traction-increasing material.
• Install transfer bars on toilets that are the proper height.
• Showers should have a stool, so the elder can sit while showering.
• Use raised toilets.

Hallways and common rooms

• Free of clutter and tripping hazards, such as equipment, electrical cords and spills.
• Well lit at all times.
• Accessible, sturdy handrails available.
• Provide chairs as “rest stops” down the hall.
• Provide chairs that are sturdy and easy to get out of. elder to fall further when attempting to climb over rails.

• Give each elder extensive training in the use of their assistive devices.

Be sure and get all the training you can in falls prevention. It will pay off for your elders!

Recommendations for falls prevention for those with Alzheimer’s disease

Elders with Alzheimer’s disease are much more prone to falling that your other residents.

But there are things you can do to help prevent these falls.

Veterans Administration caregivers recommend the following interventions for those with Alzheimer’s disease, which are proven to reduce falls in this group of elders:

This includes residents who forget their limitations

1. Use Bed & Chair Alarms

These alarms can be used to alert the staff when a resident is attempting to transfer on their own. There are two types of alarms:

1. Pressure sensor alarms. When the weight of the patient is removed from the sensor the alarm sounds.
2. Tab alarms. When the patient moves beyond the length of the string attached to them the alarm is sounded.

Both of these alarms can be hooked up to the nurse call system and can sound at

the nursing station.

2. Bed Placement

The bed can be placed along the wall so that the patient exits towards their stronger side. This eliminates the need for side rails along the side of the bed, reducing the likelihood of bed entrapment.

3. Hip Protectors

Hip protectors are a good intervention for residents with dementia and other cognitive

deficits. They allow the patient to be active while helping to prevent hip fractures if they fall.

4. Frequent Checks on the elder

The elder should be checked on frequently if in their room. If the elder is prone to wandering,

a safe place should be provided that is supervised and set up with comfortable chairs and handrails.

5. Mobility Aids

When elders with cognitive impairments use mobility aids, several things should be done

to ensure the patient knows how and remembers to use the aid.

1. Mobility aids should be placed directly next to the patient’s bed on the side that the patient exits.
2. Residents should use the mobility aid frequently to increase the likelihood that they will remember how to use it.

Generally, residents should wear them all the time; however, some elders may find them uncomfortable at night. But keep in mind the hip protectors only work if they’re being worn when a fall occurs.

This will work in the same way that elders with cognitive disorders still know how to

tie their shoes.

1. To assess a resident’s knowledge of how to use their mobility aid, ask them to use it, not just explain how to use it. But, even if an elder can’t explain how to use their mobility aid they may be able to use it.

Since muscle weakness is one of the main causes of falls, all of your elders, who are able, should get regular exercise.

And... this includes your frail elders, too, as research shows that they can benefit significantly from even a very simple exercise program, such as short daily walks.

Just be sure that your exercise programs are approved for each elder by medical personnel.

Do not let your elders sit around doing nothing all day long!

In this article, you will learn how to help elders with Alzheimer’s disease eat enough and regularly, while making the mealtime experience safer, more enjoyable, and less stressful.

Having a pleasurable mealtime experience is an important CMS “Culture Change” guideline

Helping elders with eating is not just for safety, according to the Centers for Medicare and Medicaid Services (CMS.) The CMS points out that trained help at mealtime is crucial to ensure that elders receive adequate food intake, so that they don’t become dehydrated or lose  weight…. And also to provide eating experiences that are pleasurable and family-like.

In fact, a pleasurable eating experience is one of the most important recommendations in the CMS’ Culture Change Initiative. Why? Because an increasing number of studies show that this is important for the physical and psychological wellbeing of an elder, especially if they have dementia.

Research clearly shows that negative eating experiences can cause significant emotional distress, and also lead to malnutrition and dehydration, which, according to research  in the Journal of Gerontological Nursing, are major causes of death among cognitively impaired older adults.

On the other hand, positive mealtime experiences are less stressful for residents, and for

caregivers, too, for that matter. Helping elders who have Alzheimer’s disease with eating can be very challenging, and requires different skills for each component of the meal.

You need to know, for example, how to effectively set up the meal, present and offer the food to your elders, and communicate with them in a caring and loving way.

You also need to know what to do after the meal, and learn important skills to avoid the most common problems, and ensure that meals are safe.

First: Position the elder correctly

An effective, and safe, mealtime experience begins with the proper positioning of the elder, who should be up straight, if physical conditions allow.

This may seem obvious, but studies demonstrate that the incorrect positioning of the elder is one of the most common errors among CNAs, who tend to encourage the person to tilt their trunk forward.

Also, don’t stand during the meal. Sit opposite the elder, and at eye level to the person.

This is important with all elders, to avoid giving the impression of being in a hurry, and because it makes it easier for you to help and interact with them. But it’s particularly important with those with Alzheimer’s, as some feel threatened when someone stands close to them, Or over them, and can become aggressive.

Address disabilities

Encouraging your elders’ independence at mealtimes is one of your priorities. This means you need to do all you can to allow them to do as
much of the eating process as possible.

This means that you should help them with physical problems that may affect your elder’s ability to eat and drink independently. For example, the elder may be unable to bring the food from the plate to the mouth because they can’t see well, they have hand tremor, or can’t move

their fingers without experiencing pain as a result of arthritis.

In this regard, the CMS’ revised F325 Nutritional Status Guidance for surveyors of long term care facilities states that staff can “optimize the resident’s’ ability to feed him/herself by addressing factors that impair functional ability or by providing the appropriate food texture and necessary assistance, supervision and dining environment.”

Encourage your elders’ independence at mealtimes by helping with their disabilities

• Don’t use childish language.
• Don’t make remarks about the elders, even if in a joking tone (e.g., “You just don’t want to eat today, don’t you?”).

• Don’t talk with colleagues about your own personal topics, ignoring the elder, during the meal.
• Don’t hurry the elder. Allow all the time they need to taste, chew and swallow the food.
• Don’t lie the elder down immediately after eating.

Don’t

Here are a few practical examples of ways to address health problems most frequently found among older adults, which may impair independence at mealtimes:

• Arthritis and osteoporosis.

Both conditions cause hand weakness and joints pain.

If the elder suffers from them, their already limited ability of holding and manipulating food and cutlery due to Alzheimer’s disease will be further impaired.

One easy way to help them is to provide lighter than normal cutlery and cups. Also, spoons, forks, and knives with bamboo or birch... rather than metal... handles are recommended,

as wood is warm and, therefore, more comfortable to use, especially for arthritic residents.

Hand tremor.  Use weighted cutlery and cups, with body larger than normal. This will greatly help the elder, as they will be able to keep their hand steadier when eating and drinking.

Place trays and plates on a rubber matt (a thick damp cloth will also work), which will stop them from sliding when the person cuts or picks up their food. If the elder is one handed, tape the plate firmly to the table.

• Poor eyesight/blindness.

Make sure the elder wears their prescription glasses – clean and unscratched. Explain which foods are on the tray, and where, especially if they cannot be recognized, because mashed or liquefied. Always arrange the various items in the tray in the same way.

Engraved cutlery may help the person distinguish forks from knives and spoons, while plates in contrasting colors with the tray makes it easier to find the food in the tray.

Remember, if your elder has glaucoma, to place the food right in front of them, because their peripheral vision is extremely poor. The opposite is true, if they have macular degeneration.

“Working hard is only the first part of success. Making good choices is the second part, and it truly takes both to achieve success at whatever you do.” —Ivan R. Misner

Warmth and affection are important caregiver attributes Adapt the environment

You also need to adjust the environment to meet the specific needs of a person with dementia.

So, make sure:

• distractions in the room are kept to a minimum, such as noise, unpleasant odors, or too many people;
• it’s neither too cold nor too hot; and
• there is enough light, but no glare.

And don’t forget those small, but all-important, things that will help your elder feel more at home – a fresh flower on the tray, their favorite cup, or the napkin received as a gift, for example.

Food presentation is important

This refers to the way food is presented and offered to the elder.

• Use plates and cups in contrasting colors, as they are easier for the elder to see.
• Check the food’s temperature before serving.
• Open lids, cartons, and so on.
• Ask the elder what they want to eat first. Limit the choice to two items (e.g., “Would you like

to eat mashed potatoes or broccoli, first?”), and point at the food when asking. This makes it easier for a person with mild to moderate AD to understand, and respond.

However, if your elder is more severely impaired, you will need to use simple yes/no questions (e.g., “Would you like to eat the soup, first?’).

• If the elder hesitates to start eating, and appears confused, show them what to do. Consider using the handon-hand technique. Place your hand on the elder’s hand and guide it from the food to their mouth, and vice versa. You may, at some point, leave their hand and see whether the elder can continue independently.
• Offer the various food items (one at the time) in the elder’s preferred order.

Give choices

As part of the CMS’ efforts to make the eating experience more home like, elders should be given more of what they like to eat; not only does this make a meal more enjoyable, it also,

generally, results in increased food consumption and reduced cases of weight loss, especially

among elders in care homes. Ask your residents about their favorite foods. Research shows that they are able to provide useful information, even if they have dementia. Also, ask family, friends, staff, and fellow residents.

Note: Many of the elders in your care are likely to have dietary restrictions due to various

diseases and conditions, or may have food allergies and/or intolerance. So, you should check that their meals don’t include any of the foods they shouldn’t eat.

If your elder can’t eat independently

You should always encourage independence, by providing verbal and physical prompts, offering

finger foods, if needed, and by stepping in only when necessary. However, for the more severely impaired of your AD elders, this may not be possible. You need to help them eat.

In fact, this is true for most nursing home residents, says the CMS:

“Residents may need assistance with feeding if they have, for example, impaired swallowing due to muscular weakness or paralysis, a tendency to aspirate or choking, poor teeth, ill fitting dentures or partial plates, or poor muscular or neurological control of their arms or hands, as with Parkinson’s disease.”

Encourage your elders’ independence at mealtimes

“Whenever you have a doubting inner voice in your head: one that says ‘You’re not good enough,’ ‘It’s already been done,’ ‘You’re too old,’ ‘You’re too unfocused,’ ‘Your idea will be a waste of time,’ ‘There’s not enough time,’ or anything like that . . . reply back by saying, ‘SO WHAT, I’LL DO IT ANYWAY!’”—Creativity Coach Jill Badonsky Consider softly playing the elders’ favorite music. Scientists at the University of Sheffield, in the UK, have analyzed the results of 67 studies on strategies to improve food intake in older people with dementia, and found that music is among the most effective in this respect.

Playing the elder’s favorite music is one of the best methods of improving food intake Playing

Favorite music is very effective

Here are some important points for you to consider:

• Make sure, before offering food, that the elder is alert.
• Offer small bites or sips.
• Ensure that the elder’s mouth is empty before offering another bite or sip.
• Use soft foods if the elder is unable to chew, or cannot remember how to do it; for example, cream soups, mashed potatoes, or stew.

These are not recommended if the person has also difficult swallowing (i.e., dysphagia), as they might cause choking.

Use plenty of verbal prompts

Remember, verbal prompts, that is, simple sentences that gently and kindly encourage the person to perform the various tasks, are particularly important, at all disease stages.

Things like: “Please, Mr. Lens, take the spoon,” “Well done! Now, open your mouth,” and so on. This strategy has been found effective in several studies.

Communication: warmth and affection are key

The best communication technique is one that focuses on caring manners and giving attention to the elder, and involves both words and gestures.

You are an all-important source of human contact and comfort for your elders. And much of this is provided through the mealtime experience.

Therefore, you should make the best of each, and every, meal, so that it is a pleasant social experience for your elders.

• Make eye contact with the elder.
• Talk and smile. Remember, the conversation shouldn’t focus on the meal, but on topics that are of interest to the person (e.g., “How was your day, today?” “Did your children visit yesterday?” “Oh, you are lovely in this picture! When was it taken?”).

Keep it light and pleasant, just like you would do with family and friends.

• Depending on the disease stage, you may want to encourage your elder to share with you their stories about food-related events of the past, favorite foods during childhood, and so on.

This will make the meal more enjoyable, and will also be an excellent opportunity for the elder to practice their memory and thinking skills.

• Talk even if the elder can’t talk. In fact, with those in the more advanced stages of dementia you will need to do all the talking. So, be prepared!
• Make them feel accepted and loved. Offer a hug, or give a gentle stroke on their hand, as appropriate.

Dealing with difficult behaviors

Compared to other elders, those with AD present three major additional challenges:

wandering, aggressive behavior, and hyperorality.

Overall, difficult behaviors affect up to 90 percent of people with Alzheimer’s, and may disrupt the mealtime routine. Hyperorality is a tendency to put everything in the mouth.

So, you need to pay particular attention to non-edible, or too small, items.

Those who wander are often unable to sit during the meal.

One way you can deal with this problem is offering something interesting for the person to look at or hold. For example, a basket with familiar items, such as pictures, or other mementos.

This may help them stay at the table, at least for a while. If nothing works, simply walk with the person offering them finger foods. Elders with aggressive behavior may scream, throw objects and food, bang on the table or even spit.

It’s important that you avoid being confrontational. Stay calm and continue to use a gentle tone of voice. Offer reassurance. Say something like: “I am here for you. I will help you, don’t worry.” If you feel you can’t control the situation, ask for help, before things escalate out of control.

You are an all-important source of human contact and comfort for your elders

More tips

• Offer snacks between meals. this strategy led to a big 44 percent increase in food intake.

This is particularly important in residents with a greater risk for malnutrition;

for example, elders with an increased need for calories and proteins as a result of illnesses like chronic obstructive pulmonary disease (COPD), cancer, pneumonia, fever, and pressure ulcers.

• Encourage the elder’s family to share meals with their loved ones at the facility.

In addition, consider that elders in the early stages of Alzheimer’s may still be able to prepare a simple meal.

What if the elder doesn’t eat?

You may find that, no matter your efforts, the elder simply refuses to eat. This is a relatively common problem in dementia. Don’t force them, as this will only make things worse. Rather, try one of the following:

• Offer them something sweet, like ice cream, honey, or puddings.
• If the person doesn’t open their mouth, gently squeeze their upper and lower lips together, and release.
• If they have difficult swallowing, also called dysphagia, gently massage their throat, from the base of the neck upward.

Watch out for swallowing problems

Dysphagia... difficulty with swallowing... is a common safety concern in people with dementia.

Dysphagia can be very serious... it may cause your elder to choke or develop potentially fatal illnesses, like aspiration pneumonia. So, it is important that you know whether the elder suffers

from it. Observe them carefully while they eat. Do they:

• Swallow very slowly, or not swallow at all?
• Chew their food for too long, or too little?
• Drip food and liquids from the mouth?
• Spit or vomit?
• Cough, or have throat clearing or ‘wet’ voice?

The presence of one, or more, of the above, might indicate dysphagia, and you should inform the nurse supervisor, immediately.

People with swallowing problems should be given pureed foods. Avoid soft foods, because they may cause the elder to choke. It’s also important that you

• always use a spoon, half full or less;
• place only the tip of the spoon into the elder’s mouth;
• add thickeners to liquids;
• offer small sips of drink

every two or three spoonfuls of food; and ask the person to swallow a second time before living more food, so as to make sure their mouth is empty. Make sure you know the Heimlich maneuver in case of a choking emergency. This is easy to learn, and can save the life of your elders should a choking accident occur.

Allow them to do so; for example, when their loved ones come to visit. The recently developed Artifacts of Culture Change Tool, by the CMS, states:

“Elders experience joy when able to prepare a favorite recipe for friends and once again share meals with families.”

• Watch out for any change in your elder’s behavior at mealtimes, and report promptly to your supervisor.

Stand behind the elder. Wrap your arms around their waist.

Make a fist with one hand, and place its thumb side toward the elder, just above the belly button. With the other hand, grab your fist and push upwards and into the person’s belly.

Each upward thrust should be quick and done with your hands. Don’t squeeze the ribcage. Continue until the object is expelled.

The Heimlich Maneuver Your help is crucial: observe and report

Careful observation of your elders, while assisting them with eating, can help avoid a whole

range of other problems. For example, inappropriate dosage of drugs and supplements may cause loss of appetite, sense of taste, and/or smell.

Poor appetite is also associated with constipation – which may be a symptom of diabetes or disorders of the gastrointestinal tract, including cancer Other things you should be on the lookout for are poor fluid intake, as this may rapidly lead to dehydration, and whether the elder is not eating specific foods.

Report any problems you observe to your supervisor.

As one of the most common and serious medical conditions among elders, delirium poses a major health problem, particularly for older adults who suffer from dementia, where it may easily go undetected with often dramatic consequences.

Nevertheless, rapid recognition of symptoms and a non-drug approaches aimed at restoring and maintaining awareness of the environment can help prevent complications and ensure recovery.

Delirium is a common, sometimes life-threatening, condition occurring in up to 50 percent of all hospitalized and community elders aged 65 or older, and in up to 60 percent of nursing home residents over the age of 75.

Delirium is an acute stage of confusion that comes and goes over the course of the day. Its symptoms can include such things as:

• altered level of consciousness
• inattention
• disorganized thought and speech
• disorientation
• behavioral disturbances

Delirium is particularly common among older people with dementia, where it has a prevalence of up to 89 percent.

“Delirium in a patient with preexisting dementia is a common problem that may have serious complications,” says Donna Fick, RN, PhD, of the Medical College of Georgia.

“It may worsen the outlook of their dementia… and may be associated with substantially worse long-term outcomes than in people without delirium, including prolonged hospitalization, decline in cognitive and physical functioning, re-hospitalization, nursing home placement, and death.”

In one study, involving patients with and without dementia, nurses and physicians failed to recognize delirium in those elders with dementia in 88 percent of the cases, says the researcher.

In contrast, all of the cases of delirium in those without dementia were detected. “Delirium in those elders with dementia should not be regarded as unimportant, and labeled as an exacerbation of dementia that will resolve when the patient returns home,” says Fick.

In other words, delirium needs prompt diagnosis and treatment for the well-being of the elder.

This is where front-line caregivers can be very important, for they are often the first ones to notice subtle changes in their elders, which may be signs that delirium is developing.

Since delirium has some of the same symptoms as dementia– such as anxiety, agitation, hallucinations, confusion, and aggression– it often goes undetected in the cognitive impaired elderly, and can be mistakenly diagnosed as worsening dementia.

And when it is not properly diagnosed, or overlooked as dementia, that can be a serious problem for the elder. For if left unresolved, ongoing delirium can make the elder’s medical situation much worse.

If you notice any of these signs or changes, you should report them immediately. Delirium needs special treatment, and it can often be resolved when properly diagnosed.

What is delirium?

On the whole, the main characteristics of an episode of delirium can be summarized as follows:

• Deterioration in cognitive functions, like memory, orientation, and language.
• Disturbance of consciousness, including reduced attention, inability to concentrate, and improper awareness and responsiveness to the environment.

• Sudden onset of symptoms, which may develop over a short period of time, usually hours.
• Tendency of symptoms to fluctuate considerably during the course of a day.
• Delirium can last from several hours to several days.

Underlying causes

Diseases such as diabetes, hyper- or hypo-thyroidism, hypoglycemia, kidney disease, and pulmonary disease, are all important causes of delirium.

Other potential causes include

• fever;
• infections;
• dehydration;
• immobility;
• sleep deprivation;
• visual and hearing impairments;
• head trauma;
• cancer.

In addition, studies have shown that certain medications–benzodiazepines, sedatives, antipsychotics, antihistamines, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen –may also induce delirium.

Recognizing delirium in dementia

Although the sudden onset and the fluctuating nature of delirium remain the key features for the prompt identification of this condition in the cognitive impaired elder, other important clinical features allow caregivers to distinguish delirium from dementia.

Frontline caregivers...who have close contact  with their elders... are often the first to recognize these early mental and behavioral changes characteristic of delirium.

Anyone caring for someone with dementia should therefore be on the outlook for the following symptoms:

• Increased mental confusion.
• Increased irritability, anxiety, and agitation.
• Visual and auditory hallucinations, and delusions.
• Shifts in mood.
• Excessive sensitivity to light and sounds.
• Apathy and depression.
• Wandering and rambling speech.
• Tremor.

Typically, the elder will suddenly appear more confused than usual and, depending on their speech ability, will ask for things to be repeated several times.

They will start to slip in and out of consciousness, and, in the periods of lucidity, they will be either unusually quiet and withdrawn or more active than normal.

Some elders may become aggressive against nursing staff, and attempt to climb over bedrails, or to remove catheters, drains, and tubes. Others may have suicidal thoughts

Avoid the use of drugs

Once delirium has been recognized, attempts to diagnose the underlying cause should be made without delay.

An elder with delirium is at increased risk of falls, pressure sores, and incontinence, so

quick diagnosis and treatment is strongly advised.

Symptoms need to be treated promptly and adequately. But, for this, most experts recommend

that drugs be used only when everything else has failed, since medications like benzodiazepines and antipsychotics may actually worsen delirium.

Furthermore, several studies indicate that, although cognitively impaired persons are more vulnerable to delirium, they are also more likely to benefit from appropriate nondrug interventions. Experts advise that you keep the elder who has delerium as active as possible.

In elders with dementia, the recommended intervention is a non-drug approach that maximizes caregiver support… minimizing medication use, ensuring adequate hydration, and attending to sensory needs, such as vision and hearing impairment, explains Fick.

In particular, “environmental interventions such as providing a regular routine, orientation objects (clocks, calendars, photos), adjusting lighting, providing familiar caregivers, reducing restraints use, and simplifying the environment, may decrease delirium in person with dementia.”

Non-drug interventions are recommended, including:

• Provide good lighting, day and night
• Eliminate excessive and sudden noise
• Provide exercise
• Conduct cognitive stimulation activities

Help with reorientation

In fact, providing constant visual and verbal clues to keep the elder in touch with reality– an approach known as Reality Orientation (RO)– is now considered by experts worldwide as the preferred alternative to drugs for an effective management of the symptoms of delirium.

The following suggestions from Dr. David Meagher, from the Department of Clinical Research of Crichton Hospital, Scotland, can help family caregivers, and hospital or nursing home staff, to orientate the cognitively impaired elderly with delirium:

• Place clocks and calendars within the person’s view.
• Give frequent reminders of the time of the day, day of the week, month, and year.
• Remind the elder of the names of staff and relatives, and of the name of the hospital or nursing home.
• Provide the person with familiar objects from homes, including family pictures.
• If possible, ensure that care is provided by the same member of staff.

For the orientation approach to be successful, it’s essential to communicate clearly with the elder–using short, simple sentences and repeating things whenever necessary–and provide reassurance, affection, and comfort.

Importantly, the person’s sight and hearing should be checked and corrected with glasses and hearing aids. Sleep patterns should be maintained or restored.

Other caregiver interventions, that research has shown to be effective in treating delirium, include:

• A daily exercise program.
• Reducing noise from things like beepers and telephones, in order to help them with sleeping.
• Daily cognitive stimulation activities for those elders with Alzheimer’s.
• For those elders who have sensory impairments, providing devices such as visual aids, larger size push button phones, and sound amplifiers.

Provide a good therapeutic environment

According to guidelines from the English National Health Service (NHS), good management of delirium should also be directed at improving and simplifying the environment. This can be achieved by:

• Providing adequate lighting during the day.
• Leaving the night-light on during the night.
• Ensuring exposure to natural light, even if only through a window.
• Eliminating excessive, or sudden, noise.
• Removing potentially harmful objects.
• Ensuring that the room is adequately warm.

Research shows that it’s also essential that, whenever possible, the elder with delirium remains active. In particular, “ambulatory patients should walk three times each day,” says Meagher, while “non-ambulatory patients should undergo a full range of movements for 15 minutes three times each day.”

Restraints should always be avoided since they may cause harm and injuries, and have not been proved to be effective in improving the symptoms of delirium.

Note: you should always be very compassionate and understanding for those elders who have delirium. This can be an extremely difficult, often frightening, time for them, and may indicate that other serious diseases are present, as well.

So they need all the compassionate, friendly, understanding caregiving that you can give them.

Great them each day with a smile and kind words. That can help them a lot.

“If he has a bedsore, it’s generally not the fault of the disease, but of the nursing.”

In most cases they usually are completely preventable... and a sign of caregiver negligence.

What to do

Although some of your elders may have conditions that make pressure ulcer prevention a big challenge... for most of them, preventing pressure ulcers is not difficult. Any knowledgeable caregiver can do it.

... Florence Nightingale Pressure ulcers, also called bedsores, are one of the worst things that can happen to one of your elders. They lead to pain, infection, death.

They can have a devastating impact on an elder’s participation in activities, feelings of wellbeing, and quality of life.

And they often cause the death of the elder.

A huge 60,000 Americans die each year from complications from pressure ulcers

Unfortunately, they’re a too frequent problem in long term care, and a major reason for reports of lack of care quality...and signs of caregiver neglect. No. 1 reported harm

Fact is, in most states, pressure ulcers are the No. 1 reported patient safety harm.

And, the bad news is: although there are situations with some elders that make their prevention difficult...

in most cases they usually are completely preventable...and a sign of caregiver negligence.

And the simple reason for this is that most pressure ulcers can be prevented with diligent care giving.

Florence Nightingale, the founder of modern nursing, in 1859 wrote: “If he has a bedsore, it’s generally not the fault of the disease, but of the nursing” Many research studies show that the incidence of pressure

ulcers in all healthcare settings can be nearly eliminated with a program of diligent care.

And it’s not complicated... it’s relatively easy to do.

Diligent caregiving is the answer. Much of it simply involves watchful, alert nurse assistants!

An since CNAs often see their elders more than anyone, they are one of the most important factors in  preventing pressure ulcers.

Preventing pressure ulcers is, in fact, one of your most important jobs as a frontline caregiver!

Simple caregiving skills

All that’s involved are a few very simple… and commonsense…caregiving skills that most anyone can quickly learn. That’s the good news. The bad news is that, all-too often, caregivers fail to provide this type of diligent care.

And too many pressure ulcers is often a sign of poor, unprofessional caregiving. If you just follow a set of relatively simple procedures, most pressure ulcers will be prevented under your watch:

• Perform an initial pressure ulcer assessment of each of your elders, and develop a specific care plan for each based on these results.

And diligently follow that care plan for each elder... every day!

• Make sure your immobile elders sitting in a chair are re-positioned at least once every hour... in some cases every 15 minutes!
• Make sure your other elders are re-positioned at least every 2-4 hours in most cases.
• Set up a reminder system so that you’re always notified when an elder needs repositioning.
• Never let an elder be wet and soiled… always keep them dry and clean. Always.
• Do a daily skin check of your at-risk elders: those who are immobile, and those who have diabetes or other conditions that make them vulnerable. And if you see any signs of red skin, or sores, report immediately!
• Never drag your elders across sheets… dragging can cause tears in their delicate skin, and cause a pressure ulcer.
• Use recommended supports to keep their bony areas up off the mattresses.

Locations of pressure ulcers

In elders who must stay in bed, most pressure ulcers form on the lower back below the waist, at the hip bone, and on the heels.

For elders in chairs or wheelchairs, the exact spot where pressure ulcers form depends on the sitting position.

Pressure ulcers can also form on the knees, ankles, shoulder blades, back of the head, and spine.

One hour!

You need to be constantly watchful for pressure ulcer development.

Reason: Elders who are unable to move, may get pressure ulcers after as little as 1-2 hours if left in the same position.

Elders who sit in chairs, and who cannot move, can get pressure ulcers in even less time... sometimes as quickly as 15 minutes!...

because the force on their skin is greater…and especially if they become wet or soiled.

But here’s the problem: An hour goes by very fast in the hustle of caregiving. So it’s easy to forget that an elder needs to be moved.

The solution: Develop an alarm/reminder system in your facility that ensures that you’re informed each and every time an elder needs to be re-positioned.

An efficient and dependable reminder system is an absolute requirement for proper pressure ulcer prevention.

Facilities who establish reminder systems often report a substantial decrease in pressure ulcers.

Using a reminder system is a must! An hour goes by fast in busy nursing homes, and it’s easy to forget.

An elder can get a pressure ulcer in less than an hour if not moved! Watch your diabetic elders closely. Be extra watchful of your elders with diabetes.

Because diabetes causes problems with blood flow, these elders are more susceptible to getting a pressure ulcer.

Not only that, but pressure ulcers in these elders can be very difficult... sometimes almost impossible... to heal.

And, because of that, pressure ulcers in these elders are a leading cause of amputation, and death.

So check their skin often, and report any red patches, skin tears, and so in immediately.

Their feet especially need frequent checking, as pressure ulcers can easily develop there in these elders, and lead to amputation if not caught early!

An initial examination using a tool that predicts the potential for pressure ulcers, is a must. The Braden Scale is a popular one.

Watch your diabetic elders closely. Pressure ulcers in these elders can result in amputation and death!

• Identify those elders at risk of developing pressure ulcers, the level and nature of risk(s); and
• Identify the presence of pressure ulcers. “This information allows the facility to develop and implement a comprehensive care plan that reflects each resident’s identified needs. “The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate.”

Develop a plan... and follow it! You then need to develop a specific pressure ulcer prevention plan, based on the initial assessment.

And, to make it effective, you need to check this plan each day, and make modifications as necessary.

Facilities who use their elders’ assessments and care plans on a daily basis report significant success

in substantially lowering pressure ulcers in their facilities.

The value of good nutrition

Do not overlook the value of nutrition for the elder. Good nutrition has been proven to help prevent and heal pressure ulcers.

So do all you can to make sure your elders are eating properly and not getting too thin.

If you think proper eating and nutrition may be a problem, report immediately. And don’t forget water.

“Water is essential to maintain adequate body functions,” says the CMS in its guidelines.

“It is critical that each resident at risk for hydration deficit or imbalance, be identified and that hydration needs be addressed.” Inadequate water intake has been identified as making elders more at risk for developing a pressure ulcer.

Watchful care-giving is the key

The key to preventing pressure ulcers in your elders is watchful care-giving. For those elders who are vulnerable to developing pressure ulcers, you need to watch them carefully.

--Check their skin daily... especially the key pressure points.

--Make sure they change position frequently.

--Never let them remain wet or soiled.

--Follow their care plan.

Care facilities who follow these simple rules have seen their incidence of pressure ulcers drop to near-zero!

It works! And the key to making it work is simple: Make sure you do your part during your care-giving by following through on each part of “watchful care-giving” for your elders... all the time, each and every day!

Report!

And remember that it’s very important that you report any problems you see on your elders’ skin immediately... including even simple patches of redness.

Early prevention and treatment is a must if a serious, life-threatening pressure ulcer is to be avoided.

Complete an assessment

CMS requires assessments... and they work!

So, the fi rst thing you need to do with a new elder is to complete an assessment, to determine the risk for pressure ulcers.

Not only are these assessments required by CMS guidelines, but they work... if used in an ongoing and diligent manner.

Here’s what CMS guidelines in their State Operations Manual say:

“A complete assessment is essential to an effective pressure ulcer prevention and treatment program. A comprehensive individual evaluation helps the facility to:

For those elders who can do it themselves, educate them to reposition

their key body points every 15 minutes. Vulnerable elders who sit in chairs, and who cannot move, can get the start of pressure ulcers sometimes as quickly as 15 minutes! Your elders who sit in chairs, and cannot move themselves, can get a pressure ulcer in less than an hour. So you need to reposition them frequently!

Much research has recently been conducted on how to prevent pressure ulcers in elders. Following are the key recommendations, based on the latest findings.

• Check the elder’s skin daily, head to toe. Look for reddened skin, bruises, blisters and cuts, particularly over bony areas.
• Report reddened skin right away, even if there is no other skin damage. This is crucial to detecting problems, before they turn into pressure ulcers.

• Pay special attention to your diabetic elders. They are not just at risk of foot ulcers in general, due the diabetes.

They are also highly likely to develop heel pressure ulcers, Heel ulcers are the most common type of pressure ulcers a􀅌 er those that can develop in the buttocks…. So it’s really important to keep the heels off the bed, so that there is no pressure on them.

You can do this by placing a pillow or folded blanket under the elder’s calves. Also, make sure you check the elder’s heels daily. Tell the nurse if you notice:

– Reddened or broken skin.

– Calluses (these typically form as a result of pressure or friction).

– Loss of sensation, including pain sensation.

• Use an assessment tool to identify elders at greater risk for pressure ulcers. Many facilities have the Braden Scale, which is easy to use. It involves giving a score to assess:

– the elder’s ability to feel and communicate pain;

– their ability to walk and move around;

– their skin’s moisture level;

– their intake or food and drinks; and

– the level of assistance they need for moving in bed or chair.

Note: Effectively using the information obtained in assessment tools... all the  time, every day, with each at-risk elder... has been found to be very effective in substantially lowering the numbers of pressure ulcers.

You can fi nd the Braden Scale at: h_ p://www.bradenscale.com/images/bradenscale.pdf

• Consider using the ‘SAFER’ protocol. Developed by researchers at the North Memorial Medical Center in Minneapolis, Minnesota, SAFER is short for the following care-giving techniques:

– Skin emollients twice a day.

– Assessment of skin head to toe.

– Floating of heels off the bed.

– Early detection of sources of pressure, and use of pressure relieving devices (e.g., foam wedges, pillows, special mattresses).

– Repositioning frequently.

The journal Wound Care reports that, in one study of older adults, implemented together these techniques helped reduce pressure ulcers from 15.5% to 2.1% in just over six months!

Pain is such a serious problem in elders that the centers for Medicare and Medicaid Services (CMS) now has pain control as one of their major quality initiatives in their quest for nursing home improvement. And the Joint Commission now calls pain control the “5th vital sign” and requires all hospital caregivers to frequently check for pain in their patients, just as they do for fever and high blood pressure.

Research studies in elder pain control clearly show that this extra effort toward identifying and treating pain in elders definitely pays off.

Big improvements in pain are possible

In case you have doubts that pain can be improved in your elders, huge improvements in elder pain have been shown in studies in the CMS Nursing Home Quality Initiative.

Studies were made of those nursing homes that established pain diagnosis and treatment programs, and results showed that you can attain huge improvements in pain in your elders.

Specifically, the results showed that

1. You can get big reductions in pain being suffered in your elders, by using a few simple tools and procedures to identify those in pain. They work!
2. Up to half, sometimes more, of elders in a facility are in unnecessary pain. This is pain that could be improved with more alert care-giving.
3. In many facilities, caregivers need to do a much better job of diagnosing and treating pain in their elders.
4. Suffering in elders can be significantly reduced just by initiating a few simple steps in a knowledgeable pain reduction program.
5. Frontline caregivers are a very significant part of the quality of life of their elders.

Discovering it is important

Much of your pain program needs to center around identifying it in the first place. And it isn’t always easy to spot pain in your elders, which is why the alertness of CNAs is so  critical.

This is because research continually shows that many elders do not want to report their   pain, sometimes even if they’re in very serious pain.

Studies in nursing homes show that you can attain major improvements in pain in   your elders Specific recommendations

• Be sure you regularly ask your elders about pain.
• Use available pain assessment tools regularly, to determine if your elders might be in pain.
• You should take it seriously when your elders, or their family members, report to you that the elder is in pain, and find out more about it.
• Be willing to discuss pain, and its management, with your elders, and their families... or have medical personnel do it. The more they know about successful pain management, the more likely they are to tell you about their pain.
• Encourage them to be active participants in their pain management, and report to you when things are working, and when they are not.
• Reassure elders who are reluctant to report pain, that there are many safe and e effective ways to relieve their pain.
• For elders who have Alzheimer’s, you will need to be alert for signs of pain, as they may not be able to tell you that they are in pain... or even know that they are in pain.

These signs can include groaning, grimacing, areas that seem to be sore to the touch, lack of sleep, and that sort of thing. In these elders, you’ll have to be very observant...remembering that you may be their main hope for discovering their pain, and getting help for them. A simple pain scale assessment tool is highly recommended.

• Be sure to report all instances of suspected pain to medical personnel.

And be an advocate for your elders... and follow-up to do all you can to make sure they get treatment for their pain. The secret to helping your elders who are in pain is very watchful care-giving... and reporting what you observe. Your pain program needs to center around identifying elders who are in pain, and one way you do this is by frequently asking your elders about their pain Be an advocate for your elders... and follow-up to do all you can to make sure they get treatment for their pain specific questions to ask

Here’s some additional advice from the VA, on questions you can ask your elders in what’s called a “Comprehensive Pain Assessment Interview.”

• Are you having pain now?
• Where is your pain?
• What does it feel like?
• Is the pain always there?
• Does the pain come and go?
• How long have you had the pain?
• What makes the pain better?
• What makes the pain worse?
• Are you experiencing any other symptoms?
• How does the pain affect your activity, sleep, appetite, mood, social functioning and relationships, energy, and overall quality of life?
• On a scale of 0 to 10, what number represents how much pain you can tolerate? (At this point, you may want to show them the pain rating scale.)

Tips on discovering pain in your dementia elders

For elders with dementia, assessing pain becomes a more difficult challenge. They may not be able to tell you about their pain, or may not even recognize that they are in pain.

In this case, pain assessment most often depends upon the observations of skilled caregivers.

Here’s what you can watch for in your elders with dementia:

• facial expressions.
• groaning or other verbal clues.
• body movements.
• changes in interpersonal interactions.
• changes in activity patterns or routines.
• mental changes.

Specifically, some of the things you may observe, that can indicate pain in elders with dementia (and others, too) include:

• tightening eyes;
• limping;
• whimpering;
• leaning on wall;
• awkward sitting positions;
• swollen joints; and
• trembling.

A National Institute on Aging study led by the University of Washington recently found that falls are nearly three times more likely in residents with pain than in those without.

The important implication of this finding is that fall prevention is a crucial part of caring for mobile residents who are in pain.

Check on these residents often; discourage behaviors that can lead to falls, such as getting

up at night with the lights out or without help; and eliminate environmental hazards like cluttered floors, spills and poor lighting, immediately as you notice them.

Caring for the resident in pain

While medications are essential for alleviating pain, you play a crucial role in providing residents with emotional support and helping them maintain a good life quality.

You can do this in two relatively easy, but very important, ways:

3. Show empathy towards the elder’s pain. Let them know through kind words of reassurance and caring touch that you understand how they feel.

4. Provide person-centered ‘comfort care.’ Nurse educators at the Hartford Institute for Geriatric Nursing, New York University College of Nursing, recommend respecting residents’ individual preferences for coping with pain. For example, some elders prefer to be alone in their room; others find it helpful to have some kind of distraction, such as talking with someone, praying or watching TV.

Pain Assessment Questionnaire

Source: VA Medical Center, Providence, RI

 How would you rate the intensity of your pain?

0 1 2 3 4 5 6 7 8 9 10 or: No Pain; Mild Pain; Moderate Pain; Severe Pain

• Where is your pain located?
• What is the nature of your pain? Constant? On and off?
• Does the pain travel to another part of your body? Where?
• Are there any particular times of the day when it is worse?
• Can you describe your pain? Aching? Burning? Shooting? Stabbing? Other?
• Does your pain interfere with your daily activities? Sleep? Appetite? Work? relationships?
• What makes your pain worse? What relieves your pain?
• Do your medicines help?
• Are you having any side effects from these medicines? If so what are they?

If you feel stressed out in your job at times, you’re not alone. Care-giving is a stressful job, and many frontline caregivers experience stress at work at some point.

However, nursing staff caring for elders have a particularly elevated risk of becoming stressed.

Staff working with geriatric patients face many sources of stress on an ongoing basis:

• Taking care of dying elders.
• Lack of knowledge in dementia care.
• Conflicts in the workplace.
• Heavy workload.
• Inadequate pay.
• Job dissatisfaction.

Since repeated exposure to stress inevitably leads to burnout, CNAs working with older people are also the most vulnerable to burnout. We all experience a certain degree of stress in our workplace, and most of us cope with it. However, if we are constantly under pressure, stress builds up, coping becomes more and more difficult and, eventually, burnout sets in.

What is job burnout?

Burnout is characterized by mental, emotional and physical exhaustion.

It’s serious, because it can cause problems with much of your entire life... not only the job, but its effects can spill over into your personal life, as well...

and even lead to depression, if it goes on long enough and is severe enough.

Symptoms of burnout include:

• Loss of interest in work.
• Loss of interest in life.
• Decrease in productivity at work.
• Withdrawing from social contacts.
• Difficulty sleeping.
• Difficult relationships with family, friends and colleagues.
• Disillusionment with career or family.
• Short temperedness.
• Constant tiredness, lack of energy, and frustration.
• Negative self-image.
• Low sense of self-achievement.
• Negative job attitude.
• Increasing thoughts of death.

You may tend to arrive late. And, once you arrive, you may have difficulty getting started, or focusing on your tasks for more than a few minutes.

You may seem to have lost all your enthusiasm for the job. And you may feel annoyed if your collegues show concern for you, and hardly take part in conversation and jokes. You may be contemplating the idea of leaving your job. Prevention remains the best approach to burnout. And because burnout is the result of chronic exposure to stressful situations, the most effective way to avoid it is to learn how to prevent stress.

Warning signs

Usually, there are warning signs if you are developing job burnout.

For example, you may start feeling anxious before going to work, or you may even dread the prospect of going there.

From stress to burnout

Although closely related, stress and burnout are two different things: Stress occurs when we face a situation that we perceive as too difficult, or impossible, to deal with.

Burnout is the result of too much accumulated stress, and is defined as a feeling of physical and emotional exhaustion.

When we experience stress, we feel under pressure and become tense, anxious and irritable.

In the study, the most commonly used strategies were exercise, eating healthy, massage, relaxation, and prayer. Burnout prevention plan

In a study by researchers of the University of Minnesota School of Nursing, in Minneapolis, 96.4 percent of a sample of 726 nurses said it is essential to cope successfully with stress.

What causes burnout?

Healthcare workers, especially frontline caregivers and those involved with care-giving Alzheimer’s elders, are particularly vulnerable to burnout because continually exposed to many stressors. For example:

• Frustrations in working with elders in the advanced stages of Alzheimer’s.
• Emotionally demanding tasks, such as assisting their elders dying or experiencing pain difficult to control; handling blood and body fluids; and cleaning open sores.
• Unresolved feelings of grief following the death of a patient/resident.
• Being unable to provide effective care due to insufficient training or lack of time. This is particularly true for newly enrolled and dementia staff.
• Distress over mandatory overtime and unpaid vacation time.
• Excessive workload and working night shifts.
• Difficult relationships with colleagues, residents/patients, or residents’/patients’ families.

What to do Eliminate negative thoughts

Ongoing negative thoughts are a major cause of stress.

This is because they further increase your anxiety and aggravate the pressure you feel under.

In addition, negative thinking can make you perceive as stressful something which, in fact, is not.

But, with a little practice, you can eliminate these negative thoughts.

One of the UK’s most prominent experts in stress management, Professor Steven Palmer, of City University, London, has the following advice for developing a positive attitude and avoiding negative thoughts:

• When presented with a difficult task, consider it as a challenge and a learning opportunity. Avoid thinking: “I will never be able to do it.”

• Don’t blow things out of proportion; see them in the right perspective.
• If you do something wrong, focus on doing better next time. Avoid thinking “I am a failure.”
• Never assume that other people have negative thoughts about you – that you are not up to the job, for example.

Humor can also help you get through your workday with a positive attitude, and has a direct beneficial effect on your health, as well, since it helps release anxiety and pressure.

In fact, healthcare experts now encourage the use of humor as an effective method for coping with stress, and preventing burnout.

Use humor Establish a balance between work and personal life

Finding and maintaining a healthy work-life balance may be difficult for a number of reasons.

First, a nursing job involves being away long hours from home, which reduces the amount of time available for family, friends and leisure.

Second, some staff also need to stay connected to work during non-working hours, by email, telephone and pager. This, according to new evidence published in the Journal of Nursing Management, makes it even more challenging to maintain a balance.

Third, family commitments, such as caring for school-aged children and older family members, may make it hard to concentrate on job tasks and, therefore, contribute to work life conflict.

Here are a few tips to help ensure a healthy balance between your work and personal

life:

• Cut out unnecessary activities.

Make a list of things in life that really matter to you – family, work, health, etc. – in order of importance. Then, see if you are spending too much time on activities that are not a priority. If

so, eliminate them.

• Learn to ‘disconnect.’

Don’t bring work home unless necessary; avoid answering work-related emails or making work related calls as much as possible. Keep your work and home life separated as much as you can... although in healthcare professions that can be difficult.

• Plan for leisure time.

Enjoy other activities other than work. Plan for fun and socializing opportunities; cultivate old interests and hobbies or develop new ones. Enjoy each one of these leisure activities at least once a week.

• Take advantage of any help your facility offers.

This may include self scheduling shifts, on-site childcare, flexible working hours, four-day  weeks.

• Learn to delegate.

Accept help, for errands and house chores for example, when this is available.

Take care of your health

Caring for others requires continuous physical and psychological effort. This commonly leads

caregivers to neglect their own health. And since poor health reduces the ability of coping with stress, by doing so, they unwittingly increase their risk of burnout.

 More suggestions:

• Eat a healthy and balanced diet.
• Maintain a healthy body weight.
• Cut down on on caffeine.
• Control alchohol consumption.

Keeping a log of what you drink can help you realize whether you are drinking too much.

• Exercise regularly. Aim for at least 20 to 30 minutes on most days. Exersise, if done regularly, is an especially effective stress reduction tool.
• Don’t smoke. Smoking is one of the most damaging habits of all... both to you, and those around you who are breathing your second hand smoke.

More tips

In addition to the interventions above, stress experts recommend:

Use your right to say ‘no.’ If you feel overwhelmed or have been asked to perform tasks you are not skilled for, or things that are not in your priority list, just say ‘no’ and don’t be afraid to ask for help, if you feel you need it.

Use relaxation techniques.

These can include deep breathing exercises, massage, yoga, and progressive muscle relaxation.

They can also be activities you simply enjoying doing, such as listening to music, reading,

and gardening. Or something as simple as a warm bath or contemplating a view.

Aromatherapy massage combined with music appears to be particularly effective at reducing stress-related anxiety, according to scientists at Griffith University, Australia, who tested this intervention on nursing staff for three months.

Stay in control of your anger.

It is common to become angry when under pressure. But this further increases stress, and compromises health and relationships.

Learn to manage your time.

This involves making a list of your tasks at the beginning of each day... both at home and at work. Be realistic when allocating time to each task, and allow for contingency time. Leave non-urgent ones for later in the day.

Make to-do lists... they can help you stay organized, and under control.

Making to-do lists can also help a great deal with eliminating procrastination, which is a common stress-producing problem for those who have it.

Look for career enhancement opportunities.

Since job dissatisfaction due to lack of skills has been reported in studies, to be associated with burnout, opportunities for learning and career development are also important part of an effective burnout prevention plan.

Talk to your supervisors

Finally, if you try different things, and just cannot get your burnout situation resolved... that’s the time to ask for help. Go to your supervisor and tell them that are having problems with too much stress and burnout.

It may well be that your supervisor can make a few changes in your schedule, and work environment, that can be of considerable help in resolving the situation for you.

You can discuss with your supervisor areas that you think are particularly troublesome and where you’re having the most stress and difficulty. Perhaps something as simple as more training may be needed...

if you think so, tell them this.

• Do you wake up exhausted?
• Do you get angry when you are stuck in traffic?
• Do you lose your temper easily?
• Do you dread holidays that should be enjoyable?
• Do you often forget things?
• Do you have little or no time for daily chores?
• Do you feel depressed at the end of the day?
• Do you have frequent headaches, fatigue, muscle aches, and/or digestive problems?

You can assess if you are experiencing stress by answering these questions:

Twelve Stress Management

Tips

1. Create a “to do” list for the next day
2. Leave work problems at work
3. Leave home problems at home
4. Take a relaxing walk
5. Listen to relaxing music
6. Read a chapter from a good book
7. Make and keep schedules
8. Get organized and clear out the clutter
9. Prioritize projects
10. Delegate when appropriate
11. Don’t procrastinate
12. Motivate and be good to yourself