Before every shower, Jerry* would resist, kick, hit and yell. Staff at The Scarborough Hospital (TSH) couldn’t understand why bathing caused him such anxiety. A dementia patient on the hospital’s mental-health unit, his methods of communicating discomfort were limited to acting out due to the crippling mental effects of the disease. Staff considered using medication to calm him. Nurses tried coaxing him into the stall, to no avail. Members of the security team were often called because providers feared for Jerry’s safety and their own.
TSH psychogeriatric assessment RN Sarah Aiken says heavy workloads and busy shifts often mean nurses struggle to get to the bottom of their patients’ anxiety. In many instances, nurses have little time to explain the steps leading up to – and the pain that will accompany – an injection, for example. Surprised by the jab, many with dementia will lash out if they’re not properly warned. “We forget that patients with dementia (lose) their verbal and reasoning insight. They know there’s something wrong, but they can’t tell you what’s wrong,” says Aiken.
Plus, many nurses don’t recognize the signs and symptoms of dementia, and may become frustrated or impatient with patients’ loss of judgment and reasoning, and changes in mood and behavior that are common effects of the disease.
“If (patients) are able-bodied…you tend to (expect) them to respond normally,” Aiken explains.
Jerry’s team of health providers eventually learned he doesn’t like being cold. They assured him that, before every shower, they would run the water to ensure it was warm. And they brought extra towels to scrub him dry. “Understanding what patients are trying to communicate is the most important thing,” says Aiken. After this reminder, she decided to learn more about the disease by turning to the Alzheimer Society of Toronto (AST).
Aiken discovered the Dementia Care Training Program, which provides practical, theoretical and research-based education. She pushed for the four-class program at TSH, and signed up 10 providers from the psychogeriatric floor, including nurses (Aiken was one), occupational therapists and social workers.
“It’s about slowing down, and teaching people to see (things) through the eyes of the elderly,” says Aiken. Esther Atemo, public education co-ordinator with AST, says the focus is on non-pharmacological approaches. Participants, for example, wear glasses that blur their vision and have their fingers taped to mimic the effects of arthritis. Communication is also emphasized, because dementia patients have difficulty interpreting meaning, and words don’t come easily to them. Relaying care plans to providers during shift changes also ensures everyone is aware of mood patterns and preferences.
For psychogeriatric RN Vivian Rabinovitch, the course helped her to put herself in her patients’ shoes. “If you haven’t had this kind of training, you tend to act more from the gut,” she explains. The program “gives you a framework and language…and it removes some of the anxiety around caring for (patients with dementia).” Rabinovitch has worked with older adults for about a decade, and says the course was a good reminder that “all behaviour has meaning.”
“We need to step back and remember: whatever kind of angst we’re having, their angst is tenfold, their suffering is tenfold,” she says.
Rhonda Seidman-Carlson is VP of interprofessional practice and chief nursing executive at TSH. She is also immediate past president of the Registered Nurses’ Association of Ontario (RNAO). In an acute-care setting, nurses make up the bulk of the staffing pool, she says. They play a central role when it comes to providing safe, quality care to the elderly. This is especially important when you consider Alzheimer Society of Ontario statistics that suggest 181,000 seniors in the province are living with dementia. The organization’s national counterpart says 747,000 Canadians have the disease, a number that is expected to double to 1.4 million by 2031.
Nurses must understand the effects of this disease on patients, Seidman-Carlson says. That means using less psychotropic medications, which can be linked to falls and agitation, and decreasing reliance on restraints, which can increase anxiety, skin breakdown and incontinence. This will, in turn, help to reduce length of stay and help the client feel like “an individual, as someone with remaining abilities, and not just losses.”
“For those living with dementia, we want them to do exactly that: live with dementia,” Seidman-Carlson says. “We do not want it to be merely an existence, but rather a life enjoyed in all ways possible.”