Maintaining quality Alzheimer's care. (Assisted Living Review).

In the 1970s, only 500,000 people suffered from Alzheimer's disease in America. Today, that number is greater than four million. And in the year 2050 it's estimated that more than 14 million people in this nation will have Alzheimer's. This projected increase in Alzheimer's cases will create an enormous demand for dementia care, more and more so in assisted living facilities. In addition to building enough facilities to meet future bed capacity needs, the biggest challenge for the future of dementia care will be ensuring quality care for all residents in all settings.

Training caregivers to understand and implement the fundamentals of dementia care is the only way to establish a foundation for quality care. It takes an administrator with extensive expertise in the environmental and clinical management of dementia residents to ensure that those caregivers are properly supervised and trained. The focus of the fundamental training must encompass how to reduce confusion, while enhancing residents' ability to communicate, residents' safety needs and staff capabilities in managing behavioral changes.

Administrators must emphasize to caregivers the importance of being patient and calm with confused residents. Caregivers must learn to explain care procedures to residents and encourage them to be as independent as possible. Caregivers should also know how to reassure residents during all interactions and make them feel as safe and comfortable as possible.

Avoiding discussion of complex themes and concepts is essential to maintaining the residents' attention and comprehension. The caregiver should use simple words and short, uncomplicated sentences, which include nouns and proper names. Pronouns such as hers, his and those cause speculation and can lead to erroneous interpretation. Ask residents questions that require merely yes/no answers. Avoid instructions that require many tasks in a short period of time. Always complete tasks one step at a time.

Residents respond most positively when they are treated with respect; therefore, a caregiver must not argue with, contradict or speak to them in a negative manner. Caregivers who don't understand what a resident said should gently ask the resident to repeat; the caregiver can even anticipate and offer a guess at what the resident is trying to say. They can keep residents focused by maintaining eye contact with them, speaking and reassuring in a calm manner.

Many residents with dementia have a heightened awareness of nonverbal cues; consequently, staff must take care to avoid negative body language such as rolling eyes, finger pointing and standing with their arms crossed in front of them.

For caregivers to consistently communicate better with residents, they must be repeatedly trained. Residents in environments where effective communication is a priority will show greater independence, have less agitation and be more comfortable; this will allow residual strengths to surface and improve residents' effort, ability and desire to communicate.

Dementia care providers who insist on quality care go above and beyond fundamentals when it comes to resident safety. Visitors are usually the most overlooked aspect of the safety issues. Administrators must not only ensure that staff consistently respond to residents' safety needs, but that visitors respect the safety of residents, too. Ideally, first-time visitors should view a brief safety video before entering resident care areas. If that's not possible, the facility should at least provide brochures or handouts specifying essential precautions that must be taken to ensure the residents' safety. The following examples should make it absolutely clear why this is important:

* A repairman working at a facility left his tools out when he went to lunch. A resident picked up the hammer and started a demolition job on the wall, even swinging it at staff when they intervened.

* As a visitor walked through a lobby, a resident politely asked for a glass of water. The visitor gladly went to the drinking fountain and returned with a cup of water. The resident gulped the water down before staff intervened-the resident, who was on swallowing restrictions, had aspirated the water into her lungs and developed pneumonia.

A resident on a patio asked a visitor for a cigarette. The visitor obliged, even lighting it for her. She took a few puffs and then put the cigarette in her pocket and went back inside. A few minutes later she started to scream and, when staff responded, they found her clothes on fire.

Efficient behavior management is another important component of any facility's quality Alzheimer's care program. "Sundown syndrome" is a malady common in people with dementia, occurring as night falls. Throughout the day, confusion, environmental and sensory stimulations, and frustrations build up, and residents become increasingly confused. This causes growing anxiety and agitation, which could lead to pacing, wandering and even combativeness. It is important that caregivers are taught that keeping residents involved, within their cognitive capability, in a structured daily program will help prevent anxiety and agitation from escalating throughout the day.

As their memory and judgment progressively fails, it becomes more difficult for dementia residents to express their needs; often, feelings and concerns are expressed physically. To keep residents comfortable and content, caregivers must know to routinely assess agitated residents for pain, constipation, infection, hunger or thirst and the simple need to go to the bathroom. Aggression in residents will increase when their basic needs aren't met--a normal, human nature reaction, even for those who have no form of dementia.

Handling aggressive behavior in Alzheimer's residents is one of the most difficult aspects of dementia care. Caregivers should avoid startling agitated residents or approaching them suddenly. They should approach residents from the front and stay at a safe distance to respect their immediate need for personal space. Residents with dementia can also be hypersensitive to disruptions or to the emotional climate prevailing within their surroundings. Therefore, maintaining a calm and soothing environment is essential in the effort to reduce confusion and agitation. Removing residents from areas that create overwhelming feelings often calms them immediately. Again, caregivers should always simplify instructions and use distractions by redirecting the resident to another topic or activity.

The most important aspect of dementia care is having quality caregivers. Finding such caregivers has always been difficult in the healthcare industry, and many managers simply settle for whomever fills out an application. But, because dementia residents have such diverse needs, it's essential that administrators never compromise high standards and only hire caregivers with experience and who are dedicated to excellent care for the frail elderly and are respectful of them. Once the facility is full of quality staff, it's much easier to cultivate quality care.

Good dementia care programs must invite caregivers to family conferences and individual care planning. This allows them to better understand the medical, social, emotional and physical needs of their residents. Another important indicator of quality dementia care is a commitment to continuity of care by having the same compassionate and kind caregivers work with the same residents daily.

Companies offering dementia care must avoid hiring administrators only for their sales and marketing expertise. A top-of-the-line administrator will not only have dementia care expertise, but will also be committed to settling for nothing but the best care for all residents. To achieve that goal, the administrator must insist on proper training for the facility's caregivers--and a consistent, loving, appropriate follow-through on their part. Caring for the frail elderly should never be about just amenities; rather, as administrators must remind themselves every day, it's about humanity.

Jaime Todd is a long-term care turnaround consultant based in Claremont, California. He has worked as a social worker and administrator in the field for 12 years, specializing in Alzheimer's care. For further information, call [phone] or e-mail [e-mail].