As of June 2, 2019, staff with direct access to clients with dementia shall receive 3hours of advanced training on caring for individuals with Alzheimer's disease and related dementias each year. The initial six hours of training required in subsection (c) shall satisfy the annual training requirement for the staff member's first year of employment.
The promotion of client dignity, independence, individuality, privacy and choice.
The concept of dignity is broad, but it encompasses the ability to maintain feelings of physical comfort, autonomy, meaning, interpersonal connectedness, hopefulness, and belonging. When looking at providing care, maintaining dignity requires meeting unique individual needs for each client.
It is particularly important to ensure that care is genuinely supportive of the individual and enhances that person's autonomy and well-being. The humanity with which assistance is offered, is crucial in helping the person retain their self-esteem and dignity. The manner and tone in which a person is addressed; the care taken to ensure that they participate as much as they can or wish in any decision about their day-to-day life; the trouble taken about appropriate and attractive food and environments; and access to meaningful activity all reinforce a client's dignity and ability to choose.
Client rights and principles of self-determination.
Self-Determination and Participation, also includes the concept of dignity by stating that the client has the right to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care. The client should be allowed to maintain interaction with members of the community both inside and outside of their home. The client can also make choices about their life in the facility that they feel are significant.
Self-Determination: All clients have the right to a dignified existence and self-determination. When looking specifically at self-determination, clients have the right to determine aspects of their own care. Self-determination is such an important aspect of dignity and respect that the Patient Self-Determination Act was passed in 1990 to allow patients or clients to make their own decisions about the types and extent of medical care they want to accept or refuse if they become unable to make decisions due to illness. It requires health care agencies to recognize the living will and durable power of attorney for health care
Right to Dignity: Clients also have the right to have communication with and access to people and services outside the agency. Dignity involves ensuring staff work to maintain or enhance the client's self-esteem and self-worth by maintaining the rights of the clients. These rights are protected under federal and state law. Within this understanding, clients should be informed about their rights, be encouraged to exercise their rights, participate in care planning, expect privacy and confidentiality, feel comfortable verbalizing concerns, be allowed to examine survey results, be allowed to work or not work, be allowed to visit or be visited by people outside their homes, be allowed to retain personal possessions, be allowed to self-administer medication when safe, and be allowed to refuse transfers. All of these conditions help encourage the maintenance of respect and dignity of clients.
Care of elderly persons with physical, cognitive, behavioral and social disabilities
Specific aspects of care that can lead to maintaining the dignity of elderly clients include grooming the client how they want to be groomed, assisting with dressing the client in appropriate clothing based on their preference and the time of day, facilitating the client in attending activities they choose, promoting the client's independence and dignity in dining, respecting the client's private space and property, respecting the client's social status, speaking to the client respectfully, listen carefully to the client and communicating effectively, treating the clients with respect, use the name the client prefers, including the client in conversation, and ensure the client feels that they are an individual.
Activities of daily living (ADLs) are the tasks we do during our daily lives. Because ADL skills decline as dementia progresses, caregiver involvement naturally changes over time. Caregivers often help more than is needed and research suggests that people with dementia even those with advanced dementia can do more than caregivers allow them to do.
Promoting independence requires good communication, patience, and the ability to understand and accept that dementia changes how a person approaches an activity. Many caregivers assume someone with dementia is no longer capable of understanding how to complete an activity and take over the task. This not only robs people of independence; it also affects their self-worth.
ADLs are generally divided into basic ADLs and instrumental or functional ADLs.
Basics ADLs are the skills needed to take care of personal needs such as:
Instrumental ADLs (IADLs) are the skills needed to function within society and within the community. As with basic ADLs, these skills decrease as dementia progresses. For example, when a person is no longer able to perform basic math calculations, a caregiver or financial advisor must oversee finances. When insight becomes limited and memory compromised, medical decision-making and medication management will also shift to the hands of a caregiver. IADLs include:
As with other activities of daily living, people with dementia often need time to dress and groom. The caregiver must assess the person they are caring for to determine the amount of help needed, must be patient, and must resist jumping in to help if no help is needed. Depending on the severity of the dementia and co-morbidities such as visual and perceptual changes, balance, and strength even the time of daycare givers must train themselves to encourage as much independence as possible.
For example, Alice has a severe visual impairment and fairly severe dementia. But she is very flexible and fairly strong. When she's sitting in a chair with proper back support she can easily bring her knee up to her chest. However, she can't see where to place her leg when she tries to put on her pants. It's tempting to do everything for her but this increases caregiver burden and fails to promote Alice's independence. In this case, the caregiver must be patient help Alice lay out her clothes and provide verbal and appropriate touch cues to direct the activity.
The same is true for grooming. For mouth care and other grooming tasks, go step-by-step, providing a safe and comfortable place for grooming. For men, encourage the use of an electric razor and for both men and women, encourage regular visits to the beauty or barber shop.
Interventions to support older people around eating and drinking vary: changing the color of a plate, increasing exercise, altering the environment or changing knowledge or attitudes. Some interventions alter food and drink directly via oral nutrition supplementation, food modification, dysphagia management, eating assistance or supporting the social element of eating and drinking. Other interventions such as altering the dining environment, providing education and training for people with dementia and their caregivers, behavioral interventions, and exercise programs affect food and drink intake or experience indirectly
Assistive or adaptive tableware have been a mainstay for many years. Unfortunately, most assistive tableware lacks aesthetic appeal. Since people have different needs and abilities, and assistive tableware stands out from standard items, users of assistive table settings may feel stigmatized.
A common strategy as dementia advances and feeding difficulties develop is to simplify eating by providing just a plate and spoon with pureed or diced food that can be eaten without needing to be cut up by the client. The plate should have a high lip that helps to push the food onto the spoon as a person tries to scoop it up.
Well-designed assistive tableware can be used by people of all abilities and should resemble standard domestic tableware. Color contrasts should feature prominently for example royal blue plates provide a contrast both with a white table covering and food on a plate. The same approach can be used with cups; for example, royal blue and white can be used to help those with low visual acuity or agnosia locate the handle and rim. The sides of the cup should be angled to reduce the need to tip the cup, a large handle will assure a good grip, and the top should be wide enough to allow a person's nose to fit inside the cup when tipped.
Interventions that have shown particular promise include eating meals with caregivers, family style meals, soothing mealtime music, constantly accessible snacks, longer mealtimes, education and support for formal and informal caregivers, facilitated breakfast clubs, and multisensory exercise. More research is needed to help understand what types of interventions are effective in supporting adults with dementia to eat and drink well, and to remain actively engaged with food and drink.
Throughout our lives, bathing is a private, independent, and personal experience. For someone with dementia, having another person help with bathing can be uncomfortable and even threatening. Success depends on a caregiver's ability to help the person they are caring for feel a sense of control and independence. This is accomplished by including the person is the bathing decision, encouraging independence, protecting the person's privacy and dignity, and practicing flexibility.
Prepare for bathing by making sure the environment is safe and comfortable. Bathing supplies should be within reach and the water pre-heated to the proper temperature. Grab bars should be available as well as non-skid mats.
During bathing, techniques that comfort and reassure a person with dementia include:
Incontinence is the involuntary leaking of urine or feces or both. For people with dementia living at home, incontinence can be embarrassing and stigmatizing. Incontinence adds to caregiver stress and depression and is a factor in the decision to admit a family member to a care home.
A number of issues are related to toileting and incontinence in people with dementia. Some are the result of the loss of cognition and memory, some from behavioral and psychological symptoms and some from the interplay of these with other comorbidities. Over-medicating with laxatives can be a problem. Toileting and incontinence issues can include:
Techniques and strategies used by caregivers to manage toileting and incontinence in a person with dementia typically start with reminders to go to the toilet on a regular basis. As dementia progresses, other techniques are needed such as adult diapers, bedside commodes, and direct help from the caregiver.
To make it easier for a person with dementia to find and use the toilet:
Keep in mind that incontinence can be related to a medical problem such as urinary tract infection, constipation or prostate problems. Incontinence is also associated with diabetes, stroke, Parkinson's disease and physical disabilities that prevent the person from reaching the bathroom in time. Medications and diuretics (drugs that increase urination) can also cause incontinence. This includes sleeping pills, anxiety-reducing drugs that may relax the bladder muscles, and drinks such as cola, coffee and tea.
Effectively communicating with individuals with dementia.
Good communication starts with patience and thoughtfulness. Good communication builds trust, encourages independence, and leads to better outcomes. Caregivers must learn and believe that consistently trying to understand the needs of the person they are caring for will make their job easier. Good communication takes into account a person's ability to comprehend, their sensory abilities, and their culture.
In the home setting, communication may be easier because the environment is familiar with fewer distractions although caregivers are often alone and cannot turn to a co-worker for help. No matter what setting, a calm tone, short direct sentences, a slow rate of speech, and patience encourages independence in people with dementia.
Communication can be hard for people with Alzheimer's and related dementias because they have trouble remembering things. They also can become agitated and anxious, even angry. In some forms of dementia, language abilities are affected such that people have trouble finding the right words or have difficulty speaking. You may feel frustrated or impatient, but it is important to understand that the disease is causing the change in communication skills. To help make communication easier, you can:
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