High Risk Admissions in Nursing Homes: Spotting the Red Flags and Taking Steps Toward Prevention

Skilled nursing facilities are frequently faced with admissions that, although initially are very appropriate, eventually turn into headaches for the administration. What characterizes the high-risk admission and what are some of the red flags that trigger us to the possibility that there could be difficulty down the road? First, families who present with conflicted decision making. In other words, they disagree with one another on the course of the care, and what is the most effective or the most appropriate care necessary. Or, there may be family members residing in different cities yet there has been no single person to assume a primary role or more care than the others, and suddenly the mother has to be placed in a nursing home. Here, we have what is called a diffusion of responsibility – no one and everyone wants to decide what’s best for the mother. Another red flag is when a family member who has been out of the picture and surfaces, taking control of all affairs, or attempting to take control, and now wants to make all health care decisions.

Another category of high risk admissions includes those families with very unrealistic positions on resident care. For example, when there are demands for very special schedules or personalized care. This is reflected in the case where the family member adamantly says that “my mother never bathed in the morning, she always took a shower at night – you’ll just have to accommodate her. This must be included in her schedule.” Another example is where there are very unrealistic expectations about the treatment that is required for a given condition, or the diagnosis that precipitated the admission. Families may disagree on how aggressive or non-aggressive the treatment should be. Is palliative care desired, or is aggressive treatment desired for the patient with a terminal condition. There may be very real differences of opinion in a given family context. Anytime we have these unrealistic expectations or mixed opinions we have the potential for caregiving conflicts. Conflicts among family members about "do not resuscitate orders" are frought with risk.

Families may disagree on how much care and how much cost they want to put into the long-term treatment of a loved one. When we have these disagreements, there is, again, a potential red flag. Similarly, another red flags comes up when the resident has clear desires about what type of care he or she wants, and the family refuses or vice versa, especially when the resident is alert and capable of his or her own health care decisions.

The third category of high-risk admissions includes those where there is a strong emotional component, or emotional overlay to placement. An example of this is when the family member, requiring placement, creates the guilt and overwhelming feelings of helplessness on the part of the family member, in turn creating more stress surrounding the admission. How often have we heard the phrase, “How could you do this to me after all I’ve done for you. You promised you’d never put me in a nursing home.” Such families may become very conflicted about what the best course of action should be. Again it just doesn’t necessarily mean there will be problems, but it is a potential cause for concern, especially if the resident makes hurtful comments to the family or makes them feel worse throughout the placement. The common refrain “After all I’ve done for you – how could you let me down like this” can be quite an emotional burden for some family members, and can cause families to be hyper-vigilant about the patient’s care.

Another common problem is when the placement is rushed and there has not been proper time to look for the most appropriate level of care that is needed. For example, a hip fracture or other acute development requiring placement in a facility when the family is unprepared, often leads to strong emotional reactions. Or, when the necessary admission actually accelerates the decision and confirms for the family that placement is needed can create conflict between patient and family. In other cases, there may be regrets about the costs of long term care, and fears about depleting the parent’s savings. Questions like “How can we spend all this money, doesn’t she qualify for Medicaid, doesn’t she qualify for Medicare. What do you mean we have to pay privately?” can easily generate dissention and conflicts about the placement, and may lead to serious caregiving complaints among the family members.

The last category of the high risk admission would include “hot buttons,” like the family that brings up their influential friends or a neighbor who happens to work for the District Attorney’s Office. Or, in another example, the family who stresses that they really want to be involved and want to be part of all the decision making, but they are unavailable by phone and they instruct that you only call between 7:00 and 8:00 p.m. on Monday nights. This mixed message – the expressed desire to be involved coupled with limited access – is a sign of potential difficulty, and the possibility that any untoward events will be perceived as lapses in good caregiving. Of course, the family member who complains on admission about the other facilities that Mom or Dad has been in, and recounts multiple placements over the past year, or certainly any resident with an outstanding law suit elsewhere definitely raise a red flag.

Here are some recommended steps to manage these high risk admissions:

o educate the patient and the family on the progression of their particular disease, and what level of care will be offered? What are the industry standards? Help to understand what the family’s expectations and how these fit with the facility’s routine care practices. Offer a detailed explanation about the progression of that particular disease or diagnosis precipitating the admission.

o clarify what expectations families have about nursing homes and placement, and try to uncover any misunderstandings about day-to-day issues they may have. What do they think is standard care regarding scheduling and what happens to laundry and personal items, how are the meals selected? When happens when there is a change of condition, what’s routine, what’s not routine.

o Help families to understand there is always a decision between balancing dependence and independence. How much care do we want to offer? How much ADL assistance, how much help with getting dressed? Is it better for the person to do it himself. Is it better for him to comb his own hair, to do his own grooming and hygiene? Or, is it better for the caregivers? What’s the trade-off? Yes the caregivers do it, the CNA’s do it, and yes, the job may get done quicker, it may be even better, but at what cost? If the patient does it and maintains some level of independent self-care it may not be the best, but it gives that person some level of dignity and purpose, rather than being so dependent on others.

o assign someone on the staff who will take on the role of being the designated risk manager, to do the trouble shooting, to handle the high-risk cases and to provide the role model for other staff so that they can develop these skills, especially those requiring good communication and problem solving.

The family that is part of these decisions and participate in care plans are really much more involved and are less likely to have an angry reaction or become dissatisfied, and less likely to threaten a lawsuit when something does go wrong. Primary prevention means keeping families involved in decision making, and not on the periphery as mere spectators of care.

If you are interested in this topic (the angry resident and avoiding litigation) or related subjects, visit the cohealth website (http://www.cohealth.org/) for a full array of programs on behavioral approaches to caring for older adults. CoHealth programs on end of life decision making, improving communication and safety in health facilities, ethical dilemmas, and motivational interviewing can enhance the work that we do as caregivers, and ultimately improve the welfare of our patients.

Dementia and Alzheimer’s Disease – Latest Report on Alzheimer’s Disease

Dementia is an age-associated condition, causing a reduction in mental or intellectual functioning.  The most common cause of dementia is Alzheimer’s disease. It accounts for 60 to 80% of all irreversible dementias, and is characterized chiefly by difficulty remembering names and recent events, and, very often, apathy and depression in the early stages. Later stages are marked with reduced judgment and reasoning, confusion and disorientation, behavior difficulties, and communication.

This month, the Alzheimer’s Association released its latest report on this disease, 2010 Alzheimer’s Disease Facts and Figures, the latest collection of statistics on its prevalence in different racial and ethnic groups, costs of care, and mortality. The full document can be found and downloaded from Alzheimer's report.

Some of the major highlights of this report include:

• Alzheimer’s disease was the 7th leading cause of death in the U.S. for 2006, across all ages, and the 5th leading cause of death for those over age 65. Deaths from this disease increased approximately 46% from 2000 thru 2006, in contrast with reductions in other diseases (stroke, down 18%, prostate cancer, down 8%, heart disease, down 11%, and HIV, down 16%).
• African-Americans and Hispanics are at greater risk than Caucasians, with the former group being about twice as likely, and the latter group being 1.5 times as likely as Caucasians to develop the condition. Though there is no known genetic factor that would account for these racial differences, other conditions, such as high blood pressure and diabetes are being studied as increased risk factors.
• Another significant finding is that African-Americans and Hispanics are less likely to be given the diagnosis, even though the rate of the disease is higher, reflecting that diagnoses will occur later in the course of the disease than for Caucasians.
• More women than men have dementia, because women live longer, and not due to any gender differences.
• Almost 11 million people in the U.S. provide care for a person with Alzheimer’s disease or related dementia.

The full report and other valuable information can be found on the website of the Alzheimer’s Association.

The CoHealth website endeavors to provide helpful educational programs for all caregivers working with older adults, from professionals, to home care providers, to family members. See the entire range of educational programs at http://www.cohealth.org/. Two especially useful programs are the CoHealth courses on differentiating among depression, dementia, and delirium, and understanding sensory losses that occur with aging. Continuing education credit is available for many health care disciplines.

Dementia and Behavior Problems – Why Do Difficult Behaviors Occur?

We know that an illness like dementia brings with it changes in normal or routine functioning. The deficits that occur in brain function with the onset of various dementias, such as Alzheimer’s disease, vascular dementia, fronto-temporal dementia, or dementia with lewy bodies also increase the possibility of abnormal behaviors. These abnormal behaviors only add to the challenges faced by caregivers, since the verbal or physical outbursts, the inappropriate sexual behaviors, the apathy and withdrawal, the resistance to care, among others, are not intentional or purposeful. Rather, they are the result of behavior controls that weaken and eventually break down with the atrophy of the brain tissue. And with these defective controls, the person with dementia is more vulnerable to minor upsets or frustrations than the average person can tolerate.

In essence, the dementia patient is more sensitive to internal and external stimuli. These stimuli can also be thought of as triggers or causes of the problem behaviors, and can be grouped into four categories:

i. Physical causes include sensory losses (e.g., vision, hearing), acute and chronic illnesses, dehydration, constipation, pain, adverse effects from medications, and anxiety and depression;

ii. Environmental causes include too much or too little stimulation, too little structure, unfamiliar routines, and caregivers who are unfamiliar;

iii. Task-related causes include activities that are too complicated or have too many steps, or rely on previously learned information;

iv. Communication causes include inability to communicate one’s needs, word-finding difficulty, inability to comprehend spoken language.

Many of these causes are outside the control of caregivers but many can be managed or modified. The more caregivers can address potential causes and eliminate or minimize them, the fewer chances there are to tax the person with dementia beyond his capacity. And of course, reducing these potential causes of behavior difficulties can also mean reducing the number and dosages of psychotropic medications needed to control the behaviors. Reducing the need for chemical restraints is always desirable.

See the entire range of educational programs on the CoHealth website, for health care professionals, health care workers, and family caregivers. Two especially useful programs are the courses on differentiating among depression, dementia, and delirium and behavioral approaches for sensory losses in older adults.

Two days left to register for Motivational Interviewing TeleConference

Two days left to register for Motivational Interviewing TeleConference

Understanding Dementia – Clinical Signs and Symptoms

Caregivers who work with older adults with dementia can benefit from understanding what toll the disease takes on a patient’s functioning. Earlier blogs have described many of the cognitive, behavioral and emotional changes that accompanying this dementing process. Today’s blog outlines the specific changes in mental ability that occurs, including the clinical signs of the disease.

Dementia is a syndrome or collection of symptoms that result in a global, or diffuse deterioration of intellectual abilities. It is important to recognize that the term dementia, in and of itself, does not say anything about the cause, or whether it is reversible. Of course, we are most familiar with primary degenerative dementias, which are caused by specific disease processes, such as Alzheimer’s disease, vascular conditions, Parkinson’s disease, and many others.

However, there are also secondary, or reversible (i.e., treatable) causes of dementia, including medications and dietary factors that can produce the same losses in intellectual functioning that we may see with a primary degenerative dementia. Pseudo-dementia (or false dementia) is the term for the dementia-like condition that is caused by severe depression. These treatable dementias are more common in community-dwelling elderly, especially those living alone, than in long term care settings, where treatable conditions have generally been ruled out.

One of the hallmarks of dementia is a loss of memory, especially memory for recent events (such as where an individual parked her car, or what she had for breakfast). More remote, or long term memory is generally intact. There is a loss of comprehension ability, which over time, limits how much the person understands what is being communicated. There is a loss of general information, that is, everyday facts and details that are commonly known by unimpaired individuals, such as the season, or major local or world events. We often see changes in attention and concentration ability, limiting the ability to stay on task for more than a few minutes. Judgment and common sense gradually decline with this condition, as do executive functions, such as reasoning ability and decision making.

There is a gradual loss of orientation, or what is also referred to as changes in sensorium. Cognitively-intact individuals are generally oriented in the temporal sphere (i.e., time), spatial sphere (i.e., place), and personal sphere (i.e., person). However, dementia results in a gradual loss of this orientation, first in the temporal, then spatial, and finally in the personal sphere. The remaining major cognitive changes we see in dementia are those related to verbal and language skills, first seen in word-finding difficulty and the ability to put ideas, thoughts, and needs into words. This progresses over time to severe deficits in the ability to communicate.

These changes occur insidiously, or cumulatively over time, and do not follow the same exact course for each individual affected. This makes it hard for caregivers to know what to expect, and how to adapt to the new losses in functioning. However, as we better understand these changes, and learn approaches that make up for or re-supply what is missing, there are fewer altercations and power struggles, and more time to focus on the individual’s residual strengths and capacities. These caregiving approaches will be discussed in coming weeks.

For more insights into these issues, see the CoHealth online programs on differentiating among depression, dementia, and delirium and on managing problem behaviors in dementia patients.  Useful, informative programs for families on facing Alzheimer's disease is also available on our website.  Visit the CoHealth website for more details about us, or mission, and our programs.

Principles of Behavior Management with Dementia – Don’t Take it Personally – Principle No. 9

It is easy to misunderstand or misinterpret the actions of someone with dementia, to wonder why he is saying hurtful things, or to feel offended when his interpersonal behavior and communications are so uncharacteristic for him. Whether in a residential setting or a nursing home, the effects of dementia can produce unpredictable and often offensive emotions, behaviors, and attitudes. Regardless of how long we may have known, loved, and cared for someone, there will be occasions when a coarse, crude comment, a striking out with a clenched fist, or a distasteful act like spitting is directed at the caregiver.

The damaging effects of the dementing illness can present an even greater burden if we take these unpleasant or aggressive behaviors personally. How could the patient be so unkind and ungrateful, after all I have done for him? Why would he try to hurt me, when I’m only trying to get him to finish his meal? Where did that foul language come from – I never heard him say things like that before! Questions like these reflect our disbelief and puzzlement about the sudden changes. But, we have to remember that the loss of emotional and emotional controls that accompany this illness is usually not intentional or purposeful. Yes, these outbursts can be provoked or triggered, as discussed in previous articles, but we can’t expect the outburst to be tamed just because we care so much.

The controls are gone, or at least weakened and erratic. As a result, our interpretation or explanation of the event should be more realistic and objective. To interpret the event as intentional is to perceive the person as capable of controlling his own behaviors. Generally, this is not the case.

Yes, it does bother or hurt us, as caregivers, that the patient has lost these emotional and behavioral controls. There is even some sadness as we see the real person slipping away from our grasp. Someone once described Alzheimer’s disease as a funeral that never ends. Being an effective caregiver means to never lose that sense of caring and empathy for the patient. But, it also means understanding that the threats and problem behaviors are not intended to hurt us, but rather they surface simply because we are there.

For more insights into these issues, see the CoHealth online courses on differentiating among depression, dementia, and delirium and on managing problem behaviors in dementia patients.  Nurses and other health care providers may be interested in leaning more about S-BAR as an effective tool when communicating with other caregivers. Visit our website at http://www.cohealth.org/.

Principles of Behavior Management and Reality Orientation with Dementia – Principle 8

The information in this blog series is intended to help paid and unpaid caregivers manage problem behaviors caused by dementia. The slow insidious decline that we see in dementia is characterized by losses in mental, emotional, behavioral, and self-care capacities. The recommended interventions offered are considered milieu-based, or environmentally-based because they help to create an environment that is structured and anxiety-reducing, settings that reinforce appropriate behaviors while avoiding interactions that trigger unwanted behaviors.

This blog describes the need for extraordinary structure, explanation, and cues to make up for what is missing due to the loss of general awareness and information that accompanies dementia. This loss is manifested in little or no awareness of everyday events, like holidays, important facts, seasons, local or world events, anything that you and I may take for granted. Because the person with dementia is unaware of these facts, it is essential to communicate these to the patient, and repeating as often as necessary. This is referred to as reality orientation, and should take place whenever interacting with the person. We want to communicate what’s happening to the individual: explain what is going to happen, what just happened, what the daily schedule is, what the day and date and seasons and upcoming holidays are, when the next meal is, even what we’re having for the next meal or had for the last meal, and so on. We see this on the activity boards in the nursing home, though the verbal interaction between caregiver and patient is much more effective.

We take this information all around us for granted, but for the confused, disoriented person, it is necessary to replace this missing information. And, the need for this information sharing is not short term or temporary, but permanent. The term “prosthetic environment” is used to describe the permanent, extraordinary atmosphere that we want to create: multiple cues and reminders, continually offering explanations, facts, everyday information, in short, anything and everything that helps to orient the person, and helps her feel safe and secure. This is called a prosthetic environment for good reason: a prosthesis is a device used to replace a missing part of the body, such as a leg. And, just as a prosthetic leg is needed permanently, a prosthetic environment is also needed permanently for those with brain impairment to minimize confusion, disorientation, anxiety, and distress. Whatever structure, communication, and reality orientation we can provide, the better. In the absence of this, the person gets more anxious because she cannot tolerate uncertainty, ambiguity, or the unknown. The more the anxiety level escalates, the more likely she is to engage in problem behaviors.

As we learn the many ways that dementia impairs a person’s functioning, we can be better prepared to anticipate, make up for, or replace some of the losses that the patient experiences. This means better management of potential behavior problems, and helping the person function at her highest possible level.

Many of these concepts can be found in the caregiver educational programs on our website, http://www.cohealth.org/. Some of the titles include behavior management, understanding Alzheimer’s disease, nursing home placement, and end of life decision making.