The simplest way of managing dementia residents in any setting is through ‘management by medication’ and consequently sedation. This method allows those clients with dementia to be managed with reduced staff intervention so is generally favoured by professionals where budgets are under considerable strain. At Luxurycare, Aranlaw House in Poole and Seabourne House in Bournemouth, favour ‘behavioural management’ rather than management through medication which is viewed as an enhanced service.
The following examples illustrate how ‘behavioural management’ in preference to ‘management by medication’.
Case examples of how applying the Staged Behavioural Model of Care has benefited three of the residents we care for at Aranlaw House follow. The examples given do not include the persons name and certain details have been changed to protect the confidentiality of the individuals. In each case permission has been sought from the resident’s next of kin to use their relative as a case example in our Statement or Purpose. Examples have been chosen to try and illustrate the behaviours present at each stage and the responses we use to try and help the person to feel secure and comfortable.
Dementia Case Study 1
Mrs A is 78 years old and has dementia of the vascular type; she came to Aranlaw from hospital where she had been admitted when attempts to support her to remain in her own home were unsuccessful due to her failing memory, disorientation and lack of understanding of risks. These problems caused her to neglect herself and frequently leave her own home and get lost, often in the middle of the night. One of the things that made her particularly vulnerable was her tendency to talk to complete strangers, telling them that she lived alone and where her home was. When Mrs A arrived at Aranlaw she was very frightened and angry and did not understand why she was not able to remain in the flat that she had lived in for over 20 years, she was suspicious of everyone believing that we were all in some way to blame for what was happening to her. We started to gather as much information as we could about Mrs A’s life history and significant events. We were given useful information by neighbours, a friend of many years and Mrs A’s GP who had known her for over 20 years.
The Aranlaw team immediately adopted the helping techniques recommended for managing behaviours that are the result of the person feeling uncomfortable and fearful at this stage of the illness. These include ensuring that staff do not expose the person’s weaknesses, working with all feelings expressed including anger which can be frequent and sudden in onset, keeping our distance until invited to get closer, acknowledging and validating feelings rather than ignoring them or taking things personally. Most importantly we acknowledged Mrs A’s lifetime of experience as a senior nurse, asking her opinion on simple issues where we knew she would be able to feel that her input was valued and helpful. We gave her a key to her own room and encouraged her to choose what colour she would like it painted and where she would like to hang her pictures.
Within 4 weeks Mrs A behaviour started to change in a way that suggested our care strategy was having a positive impact on her and helping to make her feel more secure and comfortable; she started to confide in two staff she now trusted, she admitted that she was frightened of not being in control and of having memory difficulties. Mrs A became increasingly humorous, wanted to help staff and other residents as much as she could and was engaging and affectionate towards those staff she trusted. Mrs A no longer seemed uncomfortable when in the company of residents in Stages 2 and 3 of their illness instead she tried to help them as she was now feeling confident that she was respected for her professional skills and knowledge.
Mrs A has been with us for nearly a year now, she continues to live her life to the full despite her dementia; she likes to ‘work’ a full shift with the day staff only taking herself off to bed when the night staff have arrived and she feels that things are running smoothly, she goes out regularly for walks with carers and enjoys nothing more than accompanying Managers when they go to collect prescriptions etc from GP surgeries.
Dementia Case Study 2
Mr B also has dementia of the vascular type. Mr B is married and is 86 years of age; he came to Aranlaw from hospital where he was admitted following a fall in another care home. The home had been unable to manage his level of night time wakefulness and desire to walk about, sometimes for several hours at a time and so they had increased his night sedation hoping that this would help him to sleep. The sedation did make him very sleepy; however it increased his disorientation and did nothing to reduce Mr B’s determination to get out of bed and look for his wife.
Mr B’s wife was highly anxious about how we would cope with his wakefulness at night; she had arranged the previous admission to a care home when her own health problems forced her to reconsider her resolve to care for her husband at home. Mrs B was able to give us a full life history for her husband and we were immediately able to see that many of Mr B’s behaviours were the result of him believing that he was still working.
On arrival at Aranlaw it was immediately clear that Mr B did not understand where he was or why he was here; we used the life history information we had been given by his wife to try and engage him. Mr B’s mobility was quite poor and I was concerned that it might get worse if he was administered the night sedation he had been prescribed since being admitted to respite care. After consulting with Mrs B and Mr B’s GP and Community Mental Health Nurse I agreed we would not sedate him at night but would instead monitor him closely and use a pressure mat by his bed to alert staff when he got up; this was not so that we could prevent him getting up but so that we were aware of him being out of bed and could monitor him discreetly whilst he walked freely around the home.
Mr B has dementia at stage 2; at this stage the person’s factual memory is very poor and they rely heavily on emotional memories to make sense of their situation, the person with dementia at stage 2 is disorientated in time, often by several decades and in place, perhaps believing they are at work or in a hotel. When talking the person will often find it difficult to remember nouns and they will lose the thread of thoughts and sentences. The person no longer has the thinking ability to try and cover up their memory difficulties.
Initially Mr B showed many of the behaviours that are consistent with being fearful and feeling lost at stage 2; he was constantly looking for his wife, even if she left him for a few moments he would frantically search for her. He frequently got lost and was unable to find his own room. Mr B became very angry with staff if they tried to stop him following his wife when she left the building, he would repeatedly come to the office and ask how he was going to pay for his care worrying about having no money. When he left his room he would gather up personal items that he recognised like his glasses, comb and toothbrush and take them with him wherever he went, often putting them down and then becoming anxious that he could not find them.
Staff encouraged Mr B to sit down and talk to them, asking him to tell us more about what he does at work; when he mentioned people by name we asked about their role at work and made sure that we didn’t correct Mr B when he told us that he was late for a meeting or had a train to catch shortly. We asked his advice on financial matters as this was his area of expertise. When Mr B was worried about not being able to get in touch with his colleagues we offered to help him write to them. When he was angry we acknowledged this and gave him the opportunity to tell us what had upset him. We found that he was much more relaxed if he was given a daily newspaper. Mr B responded well to eye contact and to a gentle touch on his arm when he was upset.
Gradually Mr B could be seen to be much more settled and less fearful about what was happening to him, he was much happier to engage with routines within the home; he had favourite places to sit and was much happier to spend time with staff when his wife was not at Aranlaw. He would tease staff and was always there with a compliment for the ladies! We did not have to increase his sedation again as he slept well for the first part of the night only getting up if he was worried about something he believed needed doing at work; as he now trusted us we were able to talk to him about his concerns and together agree that we would deal with things first thing in the morning or if he was really worried he would dictate a letter to staff and we agreed to get it typed up the next day.
Mr B continues to live at Aranlaw, on some days he will tell us that he is thinking of retiring and taking things a bit more slowly and on other days he will seek out one of the managers for us to go over figures that he believes relate to mergers he is involved in. We schedule meeting times with him and then go to his room at the agreed time to take notes.
Dementia Case Study 3
Mrs C came to Aranlaw House when the care home she had been living in closed down. Mrs C had complex heath problems and these had been the focus of her care in her previous home; her dementia seemed to have been seen as part of her overall ‘frailty’ and no dementia specific care had been given to her. Mrs C was doubly incontinent and although she could weight bear she was unable to walk more than a step or two when being transferred with two staff. In the Home she had previously lived in Mrs C had been cared for in bed for most of the time as staff had felt she just wanted to sleep and was more comfortable in bed. Mrs C had lost a considerable amount of weight and was prescribed dietary supplements to drink to increase her calorie intake.
Mrs C spoke only a few words and would often sit for long periods humming to herself or singing the same line of a song over and over again as she pleated the hem of her skirt or repeatedly ran her hand over the table as if wiping it clean. As staff approached Mrs C to offer her help or bring her food or drinks she would often appear startled; not appearing to see them until they were right in front of her. Sometimes Mrs C could eat independently but more often than not she needed carers to assist her to eat and drink, she seemed to take no pleasure from eating and almost always declined to drink the supplements she had been prescribed.
We quickly realised that many of the needs that Mrs C had had been incorrectly attributed to her physical health problems. She was in fact exhibiting behaviours and visuo-perceptual and communication difficulties that indicated she had dementia at Stage 3. At this stage of the illness it is important to provide stimuli that is within the person’s visual field, which may be greatly reduced as the result of poor peripheral vision, loss of acuity and ability to see colour, as well as the person no longer being able to turn or raise their head easily to see in front of them or to look at what may be next to them. Social stimulation and activity at this stage is critical to prevent the person slipping prematurely into Stage 4.
Our staff now approached Mrs C more slowly; always from the front and gently spoke her name as they approached. When close to her staff crouched down to her level and used touch to confirm they were there and focusing on her. Gradually Mrs C stopped jumping as we approached and her eye contact with staff increased. We gave Mrs C a brightly coloured duster and she would often pick this up and wipe at the table as she had previously with her hand but she would attempt to fold the duster up and put it tidily on the table. Staff thanked Mrs C for helping to clear up and she would smile in response.
We started to try and offer Mrs C finger foods and it was now that we discovered her love of pizza, cocktail sausages and strawberries! Mrs C seemed to be much happier to eat when given the opportunity to feed herself with foods she could pick up and eat as she felt hungry. We found that a favourite drink for Mrs C was a strawberry smoothie and we added Complan and cream to increase the calories that Mrs C really needed. In her first month at Aranlaw Mrs C put on 2 kilos in weight and her enjoyment of food seemed to be returning.
Mrs C started to sing along to music we played when she recognised the tune and we noticed that she was now much more awake than when she had first arrived. Our Activity Co-ordinator spent time with Mrs C’s daughter obtaining a full life history and recording significant events so that we could all be aware of what was important to Mrs C and what she might enjoy reminiscing about or any activity we could include her in. We discovered that Mrs C had been a very proficient knitter; until about three years ago she had still managed to knit blankets for charity. We realised that Mrs C could no longer complete this task but we gave her some different textured and brightly coloured balls of wool and were amazed by how much enjoyment she got from just moving the balls around on the table or in stroking the wool against her face. Mrs C appeared to be very content at Aranlaw; over the next nine or ten months her physical health problems decreased and she gained weight and enjoyed her food. Mrs C’s daughter told us that she was able to enjoy the time she spent visiting her mother for the first time in several years.
Mrs C’s dementia did progress and for the last six months of her life she was in Stage 4 of her illness. At this stage the person is often very withdrawn with their eyes closed as if sleeping and they make little movement or attempts at vocalization. This was how Mrs C was for much of the time although we still had times when her personality was still very evident; when she might laugh out loud at something she saw or heard and have us all laughing with her, even though we might not know what had amused her so much!
Mrs C was now very withdrawn from everyday life at Aranlaw but we did not want her to miss out on the things we knew she had loved so when her daughter bought her a recliner chair we would wheel her into her usual position in the lounge for periods of the day and she could still be seen holding her balls of wool against her cheek or sometimes she would hum along to her favourite tunes. If we held her hand when the music played she would enjoy it if we tapped out the tune together. Mrs C really loved having her hands massaged; her whole body would visibly relax and she would smile and open her eyes when spoken to during her treat
Mrs C passed away at Aranlaw with her daughter and other family members present; our in-depth knowledge of Mrs C and all that mattered to her enabled us to provide her with the care she needed until the end of her life. Mrs C’s daughter continues to pop in and see staff and residents at Aranlaw; she tells us that she enjoys the opportunity to reminisce about her mother with people who knew her for the wonderful person she was.