Make The Choice To React Differently To Behaviors

I am often asked to train nurses on how to deal with the aggressive behaviors of their patients.  I always say, “There is nothing you can do.”.   After I absorb the blank stare I am always sure to receive, I go on to explain that once a person has become aggressive, it is too late to apply techniques to keep aggression from occurring.  Our effort should then be placed on learning how to better communicate with those having cognitive problems, and thus increase our ability to assess mild levels of agitation and minimize escalation of aggressive behavior after it has already begun.

The following are my, “Top 10 Ways To React Differently To Behaviors”.  While the suggestions are often simple for caregivers to understand, the hard part is in getting the caregiver to make the choice to implement them into their routine.  After reviewing my suggestions, please leave a comment with any way you are able to incorporate the skills into your own caregiving.

1.  Patients cannot change their behavior.  Change your reaction to the behavior.

2.  Respect the patient while the patient is not respecting you.

3.  Allow the patient adequate time to speak and respond.

4.  Speak slowly and deliberately while aggression is occurring.

5.  Speak in a non-threatening tone of voice and don’t threaten patient.

6.  Expect disorientation and choose to orient patient during conversation.

7.  Expect delusional thinking and choose to agree with patients beliefs.

8.  Keep expectations realistic given the degree of impairment.

9.  Repeat questions using the same wording when you are not being understood.

10.  Convey love and affection through holding hands and providing praise.

“Ask an Expert” with Aging with Grace

I’ve been blessed with the opportunity of  serving Aging with Grace and their clientele within the new “Ask an Expert” program.  This exciting project incorporates the strengths of a diverse group of professionals in an effort to help you and your loved ones.

I am a Geriatric Clinician with over 10 years experience diagnosing and treating mental illness in the elderly population, in both outpatient and inpatient settings.   Learn more about me by clicking here>  BIO.   I look forward to exploring with you how my expertise may be of assistance to you during our free 15 minute consultation.

Email me with a date and time you would like to be reached along with your phone number and I will call.

jason.young99@yahoo.com

Thank you,

Mr. Jason Mark Young, MS

Beyond Coping: Mastering The Joyful Art Of Caregiving

I will soon be presenting within a virtual event entitled, “Beyond Coping:  Mastering The Joyful Art Of Caregiving”.

Ten informative teachers, including myself, have come together to provide you with education and advice and to share their collective wisdom and experience, with a focus on helping you to be more joyful in your care giving experience.

Attendance is FREE of charge. And you can listen from the comfort of your home or office and by using your telephone line or your computer.

Please learn more about the telesummit and sign up by clicking here:  “Beyond Coping:  Mastering The Joyful Art Of Caregiving”

Parent Diagnosed with Alzheimer’s – Where Do I Start?

On 7/22/09, I was interviewed by Dale Carter on BlogTalkRadio.  Please listen to the show:

The Stigma Of Geriatric Psychiatric Inpatient Treatment

On 7/6/09, I was interviewed by Patricia Grace, founder and CEO of Aging With Grace, on Blog Talk Radio.  Please listen to the show:

Dignity and Respect are Important Factors for Personal Caregiving

Most of the older people we care for retain a normal sense of modesty.  We can make efforts to provide as much privacy as possible while helping our aging loved ones with personal care.

Our loved ones may have cognitive problems, but they can still feel embarrassment. By adding some new knowledge to our toolboxes, we can greatly improve our skills with regard to personal care needs.

Consider keeping the number of people present to a minimum when undressing and bathing.  This is to avoid embarrassment and keep distractions to a minimum.  Your family member may be having problems hearing, as well as understanding the words you are saying.  With two or more conversations going on at once, it makes following your directions very difficult.  When your voice is the only one they hear, it is easier to focus on what you want them to do.

Keeping your loved one clothed for as long as possible before entering the bathtub is also very helpful.  This can be accomplished by leaving a robe on their shoulders until they are in the water.

Try to be mindful of the room temperature.  Often our elders like their environment much warmer or than we do.  This is something you can take care of before ever entering the bathroom.

If your family member starts to have trouble with something they have always been able to do on their own, don’t get discouraged.  Sometimes you may have to “show” them how to wash themselves if they don’t understand what you are asking them to do.  Move the washrag along your body and see if they can mimic you.  This can help them to remember what you want them to do and reduce their frustration greatly.

When you stop and think about it, these are ways that we want others to treat us. We all want privacy, we don’t want a bunch of people in the bathroom with us, and we don’t want to be too hot or too cold!  By keeping these factors in mind, you will probably see a big difference in the cooperation you get from the person you care for.

The Road Less Travelled; The Inpatient Psychiatric Option

Making the decision to admit a loved one to a geriatric psychiatric unit can be extremely difficult and emotionally devastating for families.  Unfortunately, those who never choose to make the difficult decision to do so can never feel the ecstatic relief and happiness from improvements that can come as a result of making such a commitment for change.

Caregivers often recognize the need of such treatment, though avoid admitting to themselves just how bad things have gotten.  This avoidance often leads to worsening of problems that can be more easily resolved if the family follows their intuition as to what needs to occur.  By learning more about common treatment scenarios at psych units, one can be more prepared to make an informed decision if faced with needing such assistance.

When a geriatric patient begins to experience a substantial decrease in appetite and sleep, this can quickly become a life threatening situation.  For example, someone diagnosed with Major Depression showing a sudden decrease in appetite may benefit greatly from an evaluation of their antidepressant medications.  Often, specialists are able to prescribe medications that have strong appetite stimulating properties in addition to their psychotropic effects.

The person diagnosed with Alzheimer’s Disease doing fairly well for a few years may begin to become more agitated and uncooperative with care, sometimes refusing medications.  If the complete refusal of medications continues for long, numerous complications can occur.  Many times, adjustments can be made to memory enhancing meds and anti-psychotics that can be of great help.  Other times there is untreated depression and / or anxiety that can be addressed accordingly.

The aforementioned examples certainly do not encompass the hundreds of differing treatment scenarios that occur.  Though by considering the positive results that can be reached in a short amount of time within an intensive psychiatric program, one can conceptualize how such an approach may be able to help their loved one.  Acute intensive psychiatric treatment should be thought of as the option to take when ones primary physician and / or psychiatrist has been unable to stabilize the patient on an outpatient basis.  The only reason to seek treatment at an inpatient unit is to allow a specialist the opportunity to evaluate the patient for needed changes to their medications.  This is certainly not the only advantage of entering such a facility, though it is the primary goal that should never be lost sight of.  Great things happen in these facilities.  All caregivers of elderly persons with cognitive problems should become more knowledgeable on where their loved one could obtain such help should it ever be needed.

Aphasia: Facts & Tips For Better Communication

Most people have not heard about aphasia, nor do they know the term until someone in their family or a friend acquires aphasia.  Aphasia is an impairment of language, affecting the production or comprehension of speech and the ability to read or write.  Effective communication is crucial to comprehensive assessment of mental problems occurring in seniors.  Learning more about aphasia can be an excellent way to improve ones skills in providing care.

Aphasia is always due to injury to the brain.  It occurs most commonly from a stroke and particularly in older individuals. But brain injuries resulting in aphasia may also arise from head trauma, from brain tumors, or from infections.

The condition can be so severe as to make communication with the patient almost impossible, or it can be very mild. It may affect mainly a single aspect of language use, such as the ability to retrieve the names of objects, or the ability to put words together into sentences, or the ability to read. More commonly, however, multiple aspects of communication are impaired, while some channels remain accessible for a limited exchange of information. It is the job of the professional to determine the amount of function available in each of the channels for the comprehension of language, and to assess the possibility that treatment might enhance the use of the channels that are available.

Important for caregivers to keep in mind is the wide range of severity that aphasia can encompass.  Some people are able to understand others with almost no problems while their speaking is most affected.  Others experience the reverse scenario of interpreting speech being difficult while verbalization comes very easily.

First and foremost we must exercise patience in allowing the processing time needed by those affected with aphasia when communicating.  We are often compelled to “fill in the blank” for the person who is having trouble completing a thought.  Many times a greater amount of time must be dedicated to completing what would normally be a short discussion.  We must also not be quick to “reword” what we are saying when the aphasic person is having trouble understanding us.  Often times changing the wording only complicates things further.  Restating your questions / statements rather than rewording them will often produce better results in communication.

Should my loved one be placed on an antidepressant as has been recommended by their physician?

There are so many things that can be discussed in reference to psychotropic medications.  I am going to focus on questions that you, as family members, can ask yourself in deciding if antidepressant medication therapy is the right choice for your loved one.  Hopefully after reading this article, you will have the information available to assist that doctor and / or facility in making the best determination.

First we must define what types of scenarios necessitate the consideration of antidepressants to be prescribed in the first place.  Essentially, the presence of a Major Depressive Episode needs to have occurred and / or be presently occurring to even consider the necessity of psychotropic medication use.  The following is a list of the types of symptoms that must be present in order to justify a Major Depressive Episode: (keep in mind that at least five must be present during the same two week period)

1. depressed mood most of day, nearly every day
2. marked diminished interest or pleasure in all, or almost all, activities most of day, nearly every day
3. significant weight loss when not dieting or weight gain
4. insomnia or hypersomnia nearly every day
5. psychomotor agitation or retardation nearly every day
6. fatigue or loss of energy nearly every day
7. feelings of worthlessness or excessive or inappropriate guilt
8. diminished ability to think or concentrate, or indecisiveness, nearly every day
9. recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

Now let’s take a look at many scenarios where antidepressants may not be appropriate.

Could symptoms be happening as a result of a medical condition?  Considering the many medications being used to address medical conditions, the person may, for example, be losing or gaining weight in response to side effects of a medication already prescribed.  Many narcotic pain medications can cause sleep difficulties.  Physiological effects of medications cannot be underestimated as possible causes.

Has your family member recently experienced the loss of a loved one?  Bereavement causes a depressive state that is natural and expected.  We should be more concerned if our family is NOT affected by such events!  I cannot tell you how many times I have been consulted within nursing homes where a staff member has approached me and said, “Mrs. Smith has been so depressed over the past few weeks after her son passed away.  She really needs an antidepressant.  Which one do you suggest?”  I have so many times had to explain that depression following a death of a loved one is not a scenario where medications are appropriate.  Love, support, understanding, and most importantly patience are the best prescriptions in this case.  We must wait at least two months to see if symptoms decrease to assess if medications may be helpful.  It is not as if we can tie a specific timeframe to how long it takes a person to “get over” a loss.  We can though wait 2 months to see if someone is still experiencing five or more depressive symptoms at once.  In most cases, the number of symptoms decreases and even though Mrs. Smith may never completely “get over” the loss of her son, she may very well get through the initial adjustment period where we must allow her to greave without bringing medications into the picture.

While we are speaking of the adjustment periods, it is an excellent time to talk about the correlation between adjustment to nursing home placement and medications to address associated depressive symptoms.  Often people have a very difficult time adjusting to living in the nursing home.  Many times I have worked with people who lived in their homes for 40 or 50 years in the same house and now suddenly and unexpectedly find themselves living in a nursing facility.  I cannot even imagine that feeling.  So why so many times do people feel that an antidepressant is necessary in this case?  It is understandable that one be depressed.  As was applied in the aforementioned subject of grief, we should wait a couple of months to see how a person adjusts before exploring use of medications to address symptoms. Information about a person’s personality should be conveyed to social services staff at facilities upon admission as to avoid such confusion from occurring.

Anxiety should always be considered as a cause of depression.  Depression can cause anxiety and anxiety can cause depression.  As a clinician I am always keeping a close eye on person’s symptoms because both conditions are so closely related.  The key thing to keep in mind is that if the primary problem is anxiety, than treat the anxiety and see if the depressive symptoms cease.  If the problem is depression, treat the depression and see if the anxiety ceases.  Too often medications are given for both conditions at the same time and all the medications were not needed.

Now that we have listed the scenarios where antidepressants are often unnecessary, let’s take a look at when they can be a great alternative to improving quality of life for the ones we love.

Anytime where a person is experiencing suicidal ideation, either with a specific plan or without, it is my feeling that antidepressants be strongly considered.  Close assessment of these situations should be completed just as in all cases though.  Suicidal statements can sometimes be made during attention seeking type behavior and other times may be expression of going through a time in life of dealing with feelings about death and dying.  The person that is 93 years old and states, “I just wish god would just go on and take me home” is not necessarily in need of antidepressant therapy.  But the person that states, “If I could get my hands on my shotgun that hangs over my bed at home, I would kill myself”, should be seriously considered for assistance through medications.

When plenty of adjustment time has been given in either a scenario where someone is grieving a loss or is having trouble adjusting to placement, this is a time to consider if medications can help.  The underlined issue here is that if someone experiences five or more symptoms of a Major Depressive Episode for longer than two weeks and it continues for a long period, they will more likely become physically ill as a result.  If the depression can be treated successfully, then other problems may be less likely to arise.

Many antidepressants have appetite stimulating properties to them.  If someone is depressed and this is thought to be the cause of their weight loss, then antidepressants have the capacity to be highly effective in activating appetite, both in alleviating depressive symptoms, and stimulating appetite through mechanisms within the medication.

Those diagnosed with dementia are great candidates for antidepressants.  Especially those persons who have just been diagnosed with the disease are often appropriate.  People in the mild stages of dementia are often much more emotionally affected by the disease during the early stages rather than at the moderate or severe stages because of the fact that later in the disease progression they may not even recognize that they are affected by the disease at all.  In early stages one must deal with acceptance of the disease and they are aware of their many faculties deteriorating.  During this time in their lives they can benefit greatly from medications not only to help cope with the situation, but in the fact that depression actually causes dementia to progress faster.

The dominating theme throughout consideration of the appropriateness of antidepressants is to assess the situation thoroughly.  We must consider all the factors that may be contributing to depression in order to best address the root of the problem.  The root of the problem is not always clinical depression, though when it is found to be, antidepressants can be a great way to improve the quality if life for your loved ones.

-  Here are some thoughts from fellow Twitter users when asked, “Do you feel that antidepressant medications are under-prescribed or over-prescribed within the geriatric population?”…

@wayneguerra -  ER MD working on iTriage, an iPhone App that gives users medical information, transparency around price and quality, and access to healthcare.

“My subjective opinion is antidepressants are overprescribed.  Many of the elderly we see in the emergency departments come from living situations where they are disenfrachised and lonely.  Not surprisingly they are depressed, and it is easier to prescribe medication rather then work on the social issues behind their depression.  Many times it is more situational than true organic disease.” – Wayne Guerra

@ElderCareRN - Registered Nurse, writer, caregiver for my father, offering Encouragement, Education, Empathy & Effective strategies to Enrich the lives of eldercare giver.

“My official position is that anti-pressants are under prescribed & anti-psychotics are over-prescribed. This generation of elders come from the depression era and don’t often seek help for such things as ‘feeling down today’ “. – Shelley Webb

@MrMedSaver – Founder and president of MrMedSaver.com, an online consulting company that helps people save money on their medications.

“Way overprescribed…I think many doctors prescribe antidepressants at the drop of a hat.   The problem’s even worse with antipsychotics.”  – Jake Milbradt PharmD

@drkathyjohnson – CEO and founder of Home Care Assistance. PhD and CMC.

“The problem with all medication use in the elderly is that adverse effects of medication are often misinterpreted as a new medical condition.  It takes a Geriatric MD or Senior Care Pharmacist to identify and prevent medication-related problems.  In terms of anti-depressant medication, the potential for interactions with other drugs is of concern, and vertain antidepressants have been shown to worsen anxiety in some seniors.  So prior to starting any antidepressant medication, potential medical, medication and environmental precipitants must be thoroughly investigated.” – Dr. Kathy Johnson

@caregiving - Certified ElderCare Coach, Author, Speaker.  Founder, Caregiving.com.  Interested in Social Media, Biking, Sports, Travel. Glad to connect!

“Under-prescribed.  I think depression in the elderly is an over-looked problem.  I wish we did more to help w their depression.” – Denise M. Brown

@onerusty – Be the change you wish to see in the world.  Fan of theseniorlist.com.  Empowering seniors and those who love them.  Let’s live, love & learn!

“Antidepressant’s underprescribed in general population, over in nursing homes.” – Frank Clark

@daccarte – Interested in all things that enhance the quality of life in the elderly

“As a daughter of an elderly mother and from what I’ve read, I think anti-depressants are probably under-prescribed.  Although I don’t think depression is inevitable in the aging process, I do think there are a number of factors that make the elderly more susceptible.  Health problems, disabilities, hospitalizations, isolation in their homes, major transitions.  I imagine many elderly are like my mother.  They try to cope in silence. While I don’t believe drugs are a quick fix, I do believe the drugs play a role in the treatment of depression, especially in the elderly.” – Dale Carter

What can make the most positive impact toward more effective communication with the cognitively impaired senior?

The title of this post triggered immediate requests for me to be more specific.  Most often I was asked if I was referring to caregivers at home or long term care facility professionals.  I was focused on neither.

Posing the question, “What can make the most positive impact toward more effective communication with the cognitively impaired senior?”, within the Twitter format was an excellent way to see what people think is most crucial.  It was my goal to induce a bit of “soul searching” as people tried to answer within 140 characters or less.

The following are the answers I received…

@joemd - Husband, Father, Physician, Educator, Writer, and Life Coach for Doctors, Guiding them to More Free Time, More Income, and More Fun.

“A smile, eye contact and a hand to hold.”

@caregiving – Certified ElderCare Coach, Author, Speaker. Founder, Caregiving.com. Interested in Social Media, Biking, Sports, Travel. Glad to connect!

“Helping family caregivers better understand the perspective and abilities of someone w/ a cognitive impairment.”

@gerohelper – GeroHelper on LinkedIN, B.A. Gerontology, Geriatric Web 2.0 and Assisted Living Reform are my interests, enjoy geriatric freelance writing

“Finding out where they are in time, who they think they are, & connecting in their reality – b/c their reality is all that exists anymore.”

@MrElderCare – Expert in elder care financia planning & bridging the communication gap between boomers and their parents.

“Begins w/ understanding that the cognitively impaired communicate differently and the caregiver must adapt to the care recipients ability to duplicate. Approach with patience, simplicity and tenderness.”

@Liononstage – Author, speaker, speech coach, trainer, and communication consultant, Dilip’s passion is to help you unleash your communication & performance potential.

“Cognitively impaired seniors are like children w/ life experiences.  To communicate with them – stimulate memories, be kind, patient.”

@daccarte – Interested in all things that enhance the quality of life in the elderly.  Creator of website assisting families with transition of aging parents.

“Keep noise level down, stay calm and respectful, offer simple choices.”

@AnneSadler – Owner of Smart Senior Services, a geriatric care management company. She has 23 years experience in nursing home administration.

“Listening with your heart.  They have so much to tell us if we would only listen.”

@procarenurse - I am a Nurse Life Care Planner, Care Manager and Nurse Consultant.

“Find out what motivates them and take advantage of that and get help from people they trust.”

@ElderCareRN - Registered Nurse,writer, caregiver 4 my father, offering Encouragement, Education, Empathy & Effective strategies to Enrich the lives of eldercare givers.

“Touch is the most effective communication;  gentle, non-threatening, loving, accepting touch does wonders.”

We all have different areas of expertise and experiences that lend toward our playing a part in caring for others.  Some of us do so in within our profession, and some through taking care of our families.  (and some do both!)  We need only pay attention to the many wonderful keywords used throughout these answers to reflect on what is truly important in continually making our best effort to communicate with the cognitively impaired, regardless of in what capacity.

Understanding, Connection, Adaptability, Patience, Simplicity, Tenderness, Experience, Kindness, Quiet, Calm, Respect, Listening, Motivation, Trust, Gentleness…

and Love.