In Practice: Reflections from NPs and PAs

Charity Maniates, MSPA, MPH, PA-C practices geriatric medicine in Maine.

 

It’s 3:00 pm in the nursing home — a pivotal moment each day when residents are jolted out of their daytime routine into the regimen of the evening. For the staff at the facility, it’s simply the daily change of shift.

The elders sit in the communal living space, dotted with mismatched chairs, a small table scattered with newspapers, and the constant haze of fluorescent lighting. The nurses’ station, like a miniature watchtower, sprawls in the living space. CNAs cluster near the nurses’ station; their laughter is intermingled with the reporting of the day’s events and tasks to be completed. Nurses sit at the computers, focused on rapidly finishing their charting, or rushing to process orders and completing care plans. The medication carts stand like dreary beacons in the midst of the community room, staff opening the drawers exposing the stacks of pill packets for the shift medication count. Adding to the pulsing of noise is the high-pitched ringing of the unit telephone that no one has time to pick up. The unit doors are flung open, welcoming the constant flow of traffic from visitors, kitchen staff, providers, and others walking purposely through the residents’ living space. The elders sit watching, uncertain how to respond to the actions, sounds, and influx of new people.

The atmosphere crescendos and intensifies, washing over the residents sitting in rocking chairs or self-propelling aimlessly on the unit. One resident, a vocal and ambulatory individual, stands up, grabs her walker, and angrily storms over to another resident telling her to keep quiet and attempts to strike her. This elicits reactions from residents from tears to yelling — in particular, a commanding order from a feisty, lovable woman with dementia to “LEAVE HER ALONE!” that reverberates above the others. A few staff intervene and attempt to redirect the agitated woman to another chair. Another woman approaches the nurses’ station and anxiously asks,” I’m not sure what I do? Where do I go next?”

A man with advanced dementia sitting quietly in his wheelchair, who only communicates in unintelligible sounds, starts singing loudly at the top of his lungs. A 101-year-old resident approaches the nurses’ station, adeptly maneuvering her electric wheelchair around the tangle of people, demanding repeatedly to the nurse, “I want you to call my daughter, tell her to come pick me up and bring me to camp!” Her request seems quite reasonable. Why wouldn’t she want to escape the chaotic environment and head to her camp on a lake in northern Maine? I certainly would if my home were invaded daily by unfamiliar faces surrounding me.

At numerous moments throughout the day, including change of shift, nursing home residents are bombarded with stimuli, unfamiliar faces and schedules. Layer on hearing and visual impairments, and the ability to process simple daily interactions through language and body cues becomes quite complex. Because dementia blunts the ability to vocalize needs, simple reactions are perceived as “agitation.” Often the solution is a black-label antipsychotic that quells agitation by causing oversedation. Understanding the individuality of each patient helps to identify triggers of irritation, pleasure, or soothing. Contrary to current perceptions, this approach doesn’t take extra time or intensive training.

Nursing homes, federal systems and the outdated policies overseeing those systems haven’t changed much in the past 50 years. Organizational change and research efforts are excruciatingly slow. So, what can we do now?

Recently, I had the opportunity to hear the insights of Dr. Allen Power, a physician and internationally known advocate of the Eden Alternative, an approach to addressing dementia behaviors through changing nursing home culture towards person-to person approaches and away from medications. This model features seven foundational tenets of caring for elders with dementia that, if addressed, reduce perceived “negative behaviors:”

IDENTITY—being well-known; having personhood; individuality; having a history
GROWTH—development; enrichment; expanding; evolving
AUTONOMY—liberty; self-determination; choice; freedom
SECURITY—freedom from doubt, anxiety, or fear; safety; privacy; dignity; respect
CONNECTEDNESS—belonging; engaged; involved; connected to time, place, and nature
MEANING—significance; heart; hope; value; purpose; sacredness
JOY—happiness; pleasure; delight; contentment; enjoyment

Ultimately, focus is diverted to the individual and their well-being, rather than to the specific task at hand. The result? A more meaningful interaction and role for both the elder and those providing daily care.

For more on these seven domains of well-being in dementia care, below is a short video clip of Dr. Power: