​Dementia manifests in psychological and behavioral symptoms that alter nursing home residents’ behavior. For example, a resident may communicate an unmet need by becoming physically aggressive. Such manifestations can make it challenging for long term and post-acute care providers to uphold residents’ autonomy while also providing a safe environment. Providers may try to balance these needs by prescribing psychotropic medications to manage these behavioral symptoms. How­ ever, this approach isn’t always the best option for the resident or the facility.

For residents, the benefits of psychotropic medication may not outweigh the higher risk for injury or ailment. Residents’ age and frailty elevate their risk for these medications’ many side effects. Additionally, although psychotropic medication may decrease a resident’s behaviors, this may be due to the medication’s sedative quality, which can cause other issues such as an increased risk for falls.

The Centers for Medicare & Medicaid Services (CMS) is currently auditing facilities’ use of psychotropic drugs, particularly antipsychotics. This process will examine whether facilities have documented appropriate diagnosis and indications for use of these medications. When CMS identifies coding errors during this audit, it will adjust facilities’ quality measure ratings.

Whenever possible, facilities should strive to use non-pharmacologic interventions rather than medications. To reduce psychotropic medication use and enhance care for residents with dementia, directors of nursing services (DNSs) can take the following steps.

1. Review the Facility Assessment. The Facility Assessment can identify care and service areas in place and gaps to fill regarding dementia care. Ask questions such as: Do staff know how to communicate with residents who have dementia? Is programming in place to bolster residents’ abilities and provide meaningful engagement?

2. Screen and assess residents. A pre-admission screening helps to ensure the facility can meet a potential resident’s needs. If the facility does not have necessary resources in-house, the DNS should discuss with other leadership whether collaborating with consultants in the community can meet the resident’s needs during his or her stay. Once the resident has been admitted to the facility, staff should complete a thorough assessment in a timely manner. Ask questions such as:

a. When does the resident wake up?

b. What upsets the resident?

c. What works best to calm the resident if he or she becomes anxious or upset?

d. What activities does the resident like to do at home?

3. Develop a person-centered care plan. After the assessment, caregivers should then implement individualized, person-centered interventions that will help meet the resident’s needs and goals. Person-centered care planning is essential to quality care. Avoid general interventions; assist staff to develop interventions specific to that particular resident. Also, ensure that goals are achievable and interventions are appropriate. For example, when a resident with dementia has short-term memory loss, reminding the resident to ask for help before transferring to reduce the risk for falls is not an appropriate intervention. Once the care plan has been developed, ensure there is a process to communicate interventions to direct care staff so they know the best way to care for the resident.

4. Involve the family as soon as possible. Residents with dementia can’t always speak for themselves. To understand their wishes, family caregivers are an invaluable source of insight into the resident’s personal story. Residents and their families who are involved can work as partners to improve the quality of care and safety for all. They are valuable members of the health care team who offer a unique perspective on the care provided in a facility. It is essential that family members know and understand what interventions are in place and why. It is also important that they feel they can voice concerns or share ideas with staff regarding their loved one’s care. Understanding the resident’s needs and preferences, as well as the family’s, is an important part of the relationship.

5. Communicate. Communicating clearly with residents and family members is essential to ensure that interventions are appropriate, and effective communication begins with listening. Staff and leadership can do this by:

• Using open-ended questions.
• Acting on what the resident and family members say.
• Helping residents articulate concerns.
• Getting a translator if needed to support the communication.
• Sharing resident preferences with everyone on the care team.

If there is a problem regarding the behavior of the resident, be honest with the family and work with them to provide the best way to resolve the issue. If an issue cannot be resolved, discuss that with the family as well and work with them to find another facility that will take in the resident that will be a better fit.

6. Choose the right staff. Caring for residents with dementia takes a special person, and not everyone is cut out for it. Everyone has their strengths; the DNS must utilize those strengths for the greatest good for both residents and staff. Look for those who are team players with skills and talents such as patience, compassion, flexibility, and the ability to problem solve.

7. Knowledge of dementia and related disease processes. Clinical leadership and staff should understand the impact dementia has on the resident’s physical, psychosocial, and psychological well-being. Focus interventions on upholding residents’ abilities while reducing the risks as much as possible.

Train Staff to Care for Residents with Dementia

Providing care to residents with dementia requires specialized training. Staff need to understand how to provide care while maintaining resident dignity and safety for both residents and staff. Training also improves assessment skills, choices of interventions, and the ability to de-escalate a fraught situation. Utilize resources such as a psychiatrist, psychologist, and/or nurse practitioner to provide this training. CMS also offers a training program called CMS Hand in Hand: A Training Series for Nursing Homes that emphasizes person-centered care for residents with dementia through short, on-demand webinars and videos.

Regardless of how a resident’s symptoms of dementia manifest, patience and respect are essential in caregiving. Do not rush. Rather, meet the resident where he or she is and respect what the resident is feeling. Remember to look beyond the diagnosis and see the person.

Some suggestions for how staff should interact with residents with dementia include:

• Recognize the resident as a whole and unique individual.
• Build on the resident’s strengths.
• Support the resident to do as much as possible.
• Connect through laughter and touch.
• Just be with the resident and listen to them.
• Be cognizant of one’s own tone and body language.

Providing quality of care to all residents is the ultimate goal. Using the above tips will assist the DNS to create an environment that enhances care with non-pharmacologic interventions.

Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT, is a curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN).