Part 8 in our series on Dementia. Check out Part 1, Part 2, Part 3, Part 4, Part 5, Part 6, and Part 7.
Dementia is such a hard disease because it mentally and physically robs us of the person we love and leaves us with only a glimpse of the person we once knew. If dealing with the temperamental and physical changes aren’t hard enough, throwing the safety factor into the mix makes this disease that much more challenging for the caregiver.
The frontal lobe is responsible for our ability to react safely in any given situation. However, when the frontal lobe begins to deteriorate with the progression of dementia, a person begins to lose much of that self-control and ability to recognize and to react to a potentially dangerous situation.
Safety is such a huge concern in a resident with dementia due to:
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Loss of impulse control
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Inappropriate behavior
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Personality changes
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Memory issues
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Problem solving difficulties
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Poor judgment
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Decreased response to painful stimuli
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Paranoia
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Hallucinations
With seating and positioning, safety can be a huge challenge because the resident may not understand or remember:
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How to identify or use the safety features of a wheelchair, increasing the fall risk.
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The fact that they can no longer walk and that they need a wheelchair increases the number of times trying to get out of the wheelchair system.
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They cannot safely get up out of the wheelchair unassisted, increasing fall risk and the risk of injury.
Part of the caregiver’s role is to be a constant reminder to the resident that they need a wheelchair and that the resident is safe in it. Caregiver burnout is something very real, and we, as therapists, need to do what we can to make their job less overwhelming and manageable.
Here are some ideas to help decrease caregiver burnout:
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Provide extensive education to the caregiver on how to approach the resident, learn about the features of the wheelchair and how they work. Teach them about the unique properties of the resident’s cushion, back, and accessories so they can fully understand the goal with each individual seating system to promote maximum safety and quality of life.
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Provide visual cues for the resident to be able to recognize his wheelchair. I have made signs with a photograph of their wheelchair and hung them on the resident’s wall. Label the sign with a catchy title–“Mr. X’s Wheels” for example–or something similar that will serve as a daily visual reminder of the fact that they have a wheelchair and what it looks like.
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Hang an easily recognized personal item from the chair so the resident can feel an attachment to the chair.
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Put bright tape on brake extenders or any other features of the chair to act as a visual cue to remember to utilize those features.
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Place a seat alarm on a resident that continuously attempts to get up unattended, and/or place them in a highly trafficked area to be able to “catch” them in the act and assist immediately.
Remember, the resident has the right to get up out of the chair and the right to fall! Our goal is to give the caregiver time to assist them before the resident can harm himself.
In addition, consider that the resident:
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May not be able to control the impulse to get up out of the chair whenever they desire
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May be paranoid that someone is trying to harm them by placing them in the chair
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May be seeing or hearing things that makes them want to get up out of the chair to flee a situation they perceive as dangerous
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May be in such an irritated state that they fidget, wiggle, and cry to get up out of the chair multiple times a day
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May not be able to react to painful stimuli verbally and react through unsafe movements in the chair to demonstrate discomfort
These issues are very difficult for a therapist because there is NO cookbook solution. Facilities get anxious with a “difficult” resident and refer them to therapy to “fix” the issue. There is a fine line between making changes to the wheelchair system to make a resident safe and restraining a resident. Our job is a very difficult one for sure!
We must take time to know the residents and their patterns. Study their behaviors and learn what sets them off. Every resident is different, and it may be trial and error until you find the right combination.
Suggestions I can make that have worked for me in the past are:
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Change the location of the resident multiple times a day to simulate “taking walks,” or, if the resident is still mobile, place them on a walking schedule. This may help the restless resident stay engaged and experience different sights and sounds that might catch their attention and deter them from constantly trying to get out of the wheelchair.
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With other more anxious residents, look for a calming room, and try soft music or nature sounds to soothe them and decrease their desire to get up multiple times. Avoid overstimulating areas of the nursing home that would increase their anxiety and stress level.
When dealing with a resident that may continually try to get up out of a chair due to discomfort, paranoia, hallucinations, or irritability, remember we cannot physically stop them from getting up. What we CAN do is make it “safer” for them when they attempt to get up, which will decrease the risk of injury or falls.
Here are some ideas to consider:
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Use wheelchair models with built in adjustability to fit the resident’s dimensions. A correctly sized chair will eliminate the need to perform any unsafe or excessive movement when trying to get up from the chair. This may decrease the risk of the chair tipping or injury to a LE when trying to get up.
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Use of anti-tippers and an anti-roll back mechanism assist in decreasing fall risk with a resident that continually tries to get up unassisted.
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If the resident does not have any serious contractures to the LEs or need leg rests for alignment issues, lower STFH to allow the feet to make contact with the ground. Sometimes not feeling trapped in decreases anxiety and decreases the number of times attempted to get out of a chair.
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On the other hand, some residents love tactile input, and the feeling of being “snug” calms their system. With this kind of resident, look for immersion style cushions, and back supports that envelop the spine. Use of leg rests are better in this situation. Make it your goal to really capture the resident’s shape and make him or her feel safe in the chair to decrease the desire to get out of it.
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Often residents can feel pushed out by the back support if it is too taut and upright. Change the back support to one that has the ability to create back angle, and position the resident in a posture that makes sitting in the chair inviting.
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With some residents a cushion that has more contour and locks the resident’s pelvis and LEs in better alignment may make it more difficult for them to get up. This could give a family member or CNA more time to stop a resident before it is too late.
Just remember that the resident has lost the capacity to know what is safe. Through trialing various seating systems, we can find and position them in a system that reduces the incidence of unsafe behavior. We may not stop unsafe behavior completely, but we will have reduced caregiver burden by giving them the tools to prevent falls and harm happening to their loved one!
Ana Endsjo, MOTR/L, CLT
Clinical Education Manager LTC Division
Ana Endsjo has worked as an occupational therapist since 2001 in a variety of treatment settings. She has mainly worked with the geriatric population, dedicated to the betterment of the treatment of the elderly in LTC centers. Her focus has been on seating and positioning and contracture management of the nursing home resident. With this experience, her hope is to guide other therapists, rehab directors, nurses, and administrators through educational guides, blogs, webinars, and live courses in her role as Clinical Education Manager for the long term care division.