The Whitworths of Arizona, bringing science to you in everyday language.

Friday, January 4, 2013

Just Telling Isn't Enough

“Don’t rush into a room with little more than a greeting and start working with a dementia patient,” the CNA (Certified Nursing Assistant) trainer told Janie’s class. “They function at a slow pace. Too much speed and not enough information confuses them, which slows down their thought processes even more. This adds stress, which increases symptoms like delusions. So walk in the room and, with a pleasantly calm voice, let your patient know what you want to do. Ask their permission. Include them in the task. Otherwise, someone who is already delusional may feel attacked and that’s when you are likely to get hit.”

Janie remembered what her instructor said. She was late—as usual, but she walked into Ed’s room instead of rushing in the way she wanted to. She took the time to ask him if he would like to have a shower instead of just telling him it was time for a shower while getting him ready. “OK,” Ed responded with a smile. Janie smiled back, glad that her instructor’s advice was working. Ed was being more agreeable than he usually was.
Information given and permission received, Janie bent over to take Ed’s shirt off—and he slugged her in the jaw. To Janie, “have a shower” meant a whole string of events, from removing Ed’s clothing to toweling him dry. To Ed, whose LBD type of dementia made sequential thinking difficult if not impossible, “shower” had nothing to do with taking his clothes off. He perceived Janie’s bending down into his personal space as an attack.

For the overworked and rushed CNA, or for that matter, the stressed out family caregiver, taking time to explain every little thing can seem like a burden. But in the long run, it saves time, because their patients will be much more cooperative—and less combative. But as Janie learned, it’s not enough to simply explain the concept—the big picture. They need to explain each step as they go along. Let’s replay the above scene:

“Hi Ed, would you like to have a shower?” Janie says as she enters the room. With a smile on her face she waits for Ed to think a minute before he nods and says, “OK.”

After Ed answers (giving him time to process), Janie continues, “Well then, we need to get your shirt off.” (Telling him the first step of what she wants to do.) Janie waits until she is sure Ed understands what she said. (Letting him know about the shirt is a 'step.') Then she continues, “Which arm do you want to take out first?” (Including him in the task.)

Now that Ed knows why Janie is reaching for his shirt, he cooperates, holding out his left arm. As they go along, Janie tells Ed each step before she does it and includes him when she can. She never moves to the next step until she can see that Ed is with her—that his processing is “up-to-date.” Ed is less confused because he isn’t being rushed. He has a better idea of what Janie wants this time, and so instead of fighting her, he helps. Ed gets his shower and enjoys the experience. Janie is done in record time and moves on to her next patient with a feeling of success.

The first scenario is most likely to happen in a care facility where staff members are less familiar to their patients than family caregivers are and therefore can more likely be seen as attackers. However, if you are a family caregiver, you need to use these skills too. It may also fall upon you to be the “instructor” who explains these skills and the reasons for them to the well-intentioned, but not always Lewy-savvy Janies in your loved one’s care facility.

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