Staff training needs related to dementia.

OBRA has created a new landscape for managing dementia in nursing homes, and staffs have to be brought up to speed

Over the years, the general nursing home population has become increasingly demented in its makeup. Some estimates indicate that 50% of all residents in nursing homes have Alzheimer's disease. Other studies show that Alzheimer's disease and related disorders represent two-thirds of the nursing home population. This trend is further complicated by the implementation of OBRA '87 and its mandated reforms of the nursing home industry.

OBRA represents a philosophical shift in orientation to working with residents who have a dementing disorder. In the past, problematic behavioral problems associated with dementia were managed through the use of physical and chemical restraints. OBRA is forcing facilities to develop alternative intervention strategies that are less intrusive and restrictive. All in all, these forces signal a need for facilities to reevaluate their orientation and in-service programs related to dementia care.

Past experience has shown that an appropriate training agenda for the future needs to incorporate the following components:

These modules need to be offered to staff on an ongoing basis as a way to refresh and re-enforce the philosophical orientation that OBRA represents.

Staff tend to have an inadequate and inconsistent understanding of dementing illnesses. In order to develop appropriate skills in caring for those with dementia, all staff need to be fairly knowledgeable about the various ways that dementia presents. Housekeeping, dietary, maintenance, laundry and administrative staff should be trained, since these individuals inevitably have contact with residents who have dementia. Staff need to recognize the various intellectual, thinking, behavioral, emotional and physical symptoms that accompany the disease process.

Staff need to develop an appreciation of the uniqueness of each resident who has been diagnosed with dementia so that an individualized plan of care can be developed. There is a tendency to see such residents as being "a typical Alzheimer's" which ignores the infinite ways that dementia presents. Since families of residents with dementia tend to be very knowledgeable about dementia and its effects, staff need to be equally conversant so that the family can feel a sense of confidence about staff's competence to provide care.

Perhaps the most crucial aspect of a comprehensive dementia training program is assisting staff in the development of appropriate ways of interacting with residents. Staff have a tendency to relate to residents in ways that tend to increase agitation or escalate problem behaviors. Consequently, staff need to be aware of the impact that their behavior has on the demented resident. Training should assist staff with understanding how their voice, body language and distance can be used to calm residents who are frightened. Staff also need to be trained to "read" residents' behavior so that a preventive, proactive approach can be developed.

Dementia interferes with communication abilities. Often, it may take up to 30 seconds for demented individuals to process information. If staff attempt to communicate as they would normally, the resident will tend to respond with resistance or combativeness. Staff need to be taught specific, concrete communication techniques that will increase the likelihood that the resident will feel safe and, therefore, free of the need for disruptive behavior.

Behavior management training is critical since psychotropic medications cannot be used as indiscriminately as in the past. All staff need to be extensively trained in this area. Training of certified nursing assistants in behavior management is a neglected area. If non-drug interventions are to be effective, CNAs must be intimately involved in the development and implementation of behavior management plans. Specifically, it is essential that they be informed of the need to track and count incidents of disruptive behavior so that needed data can be collected. Staff also need to receive information about the appropriate use of reality orientation, validation therapy, redirection, activities, etc. Indeed, the role of the nursing staff needs to be shifted more into functions that have been traditionally performed by social work and activity staff.

Nursing staff play a pivotal role in the decision to prescribe or withdraw psychotropic medications. Nurses need to receive additional training with respect to the appropriate use of these. Though there seems to be a dramatic shift away from prescribing psychotropic medications to demented residents, often resulting in dramatically improved quality of life, in the rush to implement drug titration programs, facilities have not always been able to determine who is appropriate for reduction and who is not. As a result, there are instances in which harm has been done to those needing medications because of underlying dementia-related psychosis.

Family care is a key training need for all staff due to the tendency for families of demented residents to be more intensely involved in care issues. This involvement stems from years of caregiving in a fashion that has been termed "the 36 hour day." Staff need to be sensitive to the family's need for support as they make the transition from being primary to secondary caregivers. Staff should be sensitive to the grief process that families undergo when a loved one has dementia. They need to be comfortable with addressing dysfunctional family response to the disease and the resulting decision to placed a loved one in a nursing home.

Finally, staff need regular training in self care. Caring for individuals with dementia is a physically, mentally and emotionally exhausting process. Unpredictable behavioral outbursts, continual decline of functioning and the demands of coping with repetitive behaviors all cause staff inordinate amounts of stress. Prolonged exposure to such stressors can result in caregiver burnout. All staff need assistance with recognizing signs of stress so that personal plans for stress management can be developed and maintained.

SIGNS, SYMPTOMS OF DEMENTIA, PROGRESSION

* types of dementia, i.e. Alzheimer's disease, multi-infarct dementia 

* causes

* research

* development of a therapeutic milieu

* treatment and management strategies

* conscious use of self

* communication techniques

* behavior management programs

* psychotropic medications

* physical environment

* working with families

* stress management

Mark Grimm is with the Geriatric Resource Organization, PC, an educational consulting firm in Denver, CO.