Initial  Assessments:
Get More Information...Not Less

As part of the Nursing Home Reform Act and as part of the
Reconciliation Act (OBRA) of 1987 it is required that residents receive assessments
and a comprehensive care plan. Most departments are participating and completing
initial assessments and reassessments. Every company is different in what forms they
use. Some create their own while others use forms from catalogues. In many cases,
the staff uses automated systems that include the assessments.

What are of concern regarding the initial assessments are the questions not being
asked.

We are now faced with the majority of our residents who are being admitted to long
term care with a diagnosis of dementia, either as a primary or secondary diagnosis.  
Communication is a huge component of the dementia diagnosis. One big area that is
not addressed in the initial assessments is basic communication questions. What
words, gestures, facial expressions and sounds does the resident know and what do
they mean? In most cases the responsible party who knows the resident best should
be able to provide a lot of important information.

Either, the Speech Therapist, Social Worker, Nurse or Recreation Therapist / Activity
Professional must be asking the responsible party basic communication questions.
What words does the resident know and what do the words mean? What do their
gestures and facial expressions mean? What do the sounds mean?  How did the
family calm the resident down when trying to figure out what the resident wanted? Staff
should ask more detailed questions about their daily routine and leisure pursuits. Get
the details not generalizations. The more details you know the better. Staff should ask
these questions, “How did the resident spend their morning, their afternoon, their
evening and their weekends? Ask what time they get up, what time they took naps, etc.
Ask the family, what behaviors did they observe in the home? Ask the family, what were
their interventions and did they work? Ask more details about their leisure pursuits?

This information than must be added to the chart and relayed to all staff who work on
the unit.

New York State Department of Health has a fantastic program called EDGE Electronic
Dementia Guide for Excellence. See this link.
http://www.nccdp.org/wandering.htm They
have developed excellent tools for interviewing family as well as other fantastic
resources. See their person centered forms
http://www.health.state.ny.
us/diseases/conditions/dementia/edge/forms/index.htm

These are complete strangers coming into your facility. It is important to have this
information. Think how frustrating it is for the staff to not understand what the resident
wants. Think about how much time would be saved, if only someone had asked these
questions. Equally, it is frustrating for the resident as we are strangers to them as well.
Some basic agitation issues and behaviors could be avoided if the staff were provided
this basic information.

Equally important is to relay this information to all staff that this resident may come in
contact with.  Every day there should be a brief stand up meeting and all new
admissions discussed with all staff who work on this unit. This includes dietary aides,
housekeeping, maintenance, activity professionals, social workers, nurses, nurse’s
aides, etc.

Have you met residents who know only one word? But how they say the word may
explain what they want. With Dementia, some residents may say opposite of what they
mean to when trying to convey something. Staff has to learn to be detectives. They have
to watch the body movements, facial expressions, gestures, tone in their voice as well
as the words to figure out quickly what someone is trying to convey.

The resident is also watching the staff gestures, body movements, facial expressions
and tone in their voice to figure out what staffs mean. Staffs need to use adult gestures
to also convey what they want. The resident needs all kinds of clues to assist with
communication and gestures are a part of that. But be careful not to use baby gestures
and baby talk as these are not children. On some level they will understand that you are
talking down to them through gestures or baby talk.  

Having this information is part of basic communication approaches. It’s a part of culture
change and knowing your resident and providing individualized care. How can you
provide individualized care and individualized approaches if you do not have this
information?

Long term care staff has observed all kinds of resident behaviors when basic
communication techniques are not taught to your staff and this in turns affects the
resident. Such behaviors as striking out, yelling, biting, wandering, agitation, repetitive
questions and spitting can be avoided if the staff had the information available for each
resident and understood the unique and individualized approaches.

When the staff’s do not use good communication techniques, the resident may isolate
themselves, and then that leads to depression and fatalism. Now the team is care
planning for behaviors that could have been avoided if good communication techniques
and approaches were taught and implemented from the moment the resident arrived in
your home.
 
Utilize your Speech Therapist. The Speech Therapist is a fantastic resource to utilize
who   can suggest communication techniques and tools. The Speech Therapist should
be providing in-services throughout the year because there is so much information on
communication to provide to your staff that it could never be covered in one session.  

One other area of communication that is not receiving enough attention is how to
respond to repetitive questions. Staffs need continued training and resources in this
specific area.  There is a great book called “Creating Moments of Joy” available through
www.activitytherapy.com. This fantastic book and resource should be available at every
nurse’s station, activity desk, clergy office, volunteer office, dietary department, rehab
department and social services office. Often times our staff have no idea what to say
when a resident states, “I want to go to work, I need to pick up my child from day care, I
need to see my husband.” What is the correct response when a female resident
requests to see her deceased husband? Unfortunately, many staff are trained to use
reality orientation and it is often times the only form of therapeutic intervention they have
been taught.

Reality orientation is not the most effective communication tool, technique or approach
for our Dementia residents. At times this may work in the early stages of Alzheimer’s
disease.  Rather, there is another more humane way and that is “entering their reality
and living their truth.”

Creating Moments of Joy book provides excellent suggestions on what to say and how
to respond to repetitive questions, or what to say when they see themselves as young
and wanting to go to work. As staff, we know when we clock in for the day that we are
paid to repeat our selves over and over again. As we answer the question, “what time is
lunch” for the 50th time, we know we need to answer with a sincere smile. We know
this but we need to remind ourselves, that if they “remembered” what time lunch was,
they would not be asking over and over again. Remember, they lack the ability to retain
new memories.

We have to teach our staff, that it is not lying but rather giving a resident an answer that
is believable. “Enter their reality and live their truth”. My grandmother as she watched the
horrors of 911 unfold in front of her, she watched the Pentagon in anguish. Her
husband was an officer in the Navy and deceased many years. She leaned over to the
wonderful home health aide and asked, “Was my husband in there?” The wonderful
home health aide replied, “Oh, no, your husband has been dead for years!”  For which
my grandmother replied, “Why, than didn’t anyone tell me?” And her grief at that
moment was as intense as it was the day he passed away. The home health aide
could have responded, “He is at work, he is at the barber, he is out grocery shopping.”
Any of those answers would be believable and kind. In turn, it is also important that the
staff know the history of the resident. Had the home health stated, he is out tending to
the farm, would be an answer that my grandmother would not believe, because her
husband was not a farmer.

There were many options the home health aide could have replied with but because
she had not been taught any other way, and was trained to use reality orientation, my
grandmother was experiencing raw grief over and over again.

During in-services, provide the staff with different scenarios and allow the staff to come
up with solutions to communication challenges. The in-service director should consider
the use of role playing and unique situations as another tool when teaching
communication.  

Provide plenty of resources to your staff from magazines, videos and books on standard
approaches and new communication techniques. Utilize Alzheimer’s and dementia
web sites that have resources on communication and download the fact sheets.

One administrator shared a great idea. He kept the dementia resources in the
employee break room. This administrator found the staff really took the time to read
magazines, books and resources that were left out. Often times, these resources are
just sitting piled in the DON, Department Heads and Administrator’s office. Share these
materials with the staff that need to read the resources the most. Additionally, make a
resource library available to family and visitors as well.

Review your current Initial Assessments. These can be modified and should be
changed to reflect the new detailed questions that health care professionals must be
asking the family and the resident if we are to provide individualized and competent
care. Provide ongoing communication in-services to your staff and make available
resources pertaining to communication.

If you want to build mutual trust with your resident, avoid catastrophic reactions,
depression, fatalism and loss of staff work time, the staff must be taught the tools to
communicate effectively with your patients who have dementia.      
-END
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Sandra Stimson has
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