Behavioral and psychological symptoms of dementia (BPSDs) are prevalent in our long term care facilities and cause great stress for the person with dementia (PWD) and the corresponding caregiver (family or professional). To control these BPSDs, the person is often given an antipsychotic to lessen the psychotic symptoms that may be accompanied by severe agitation. This process often carries with it a high risk of morbidity and mortality and thus, CMS has instituted an initiative to reduce antipsychotic use in the long term care environment.

Once we remove this customary practice (antipsychotic utilization), we must have an urgent priority to develop and institute comprehensive strategies to reduce antipsychotics. These non-pharmacologic interventions can often address the agitation adequately and prevent the need for pharmacy.

One key aspect of prevention of BPSDs is to “meet the person at their point of need” – often quoted by Dianne Timmering (VP of Spirituality). The seeds for psychotic symptoms, indeed, agitation is often sown before the PWD ever enters the long term care environment. Therefore, once a person with dementia enters into our facility, we must take every effort to get to know the new resident as much as possible.  In Serenity, we do that by completing the “Bridge To Memories Past” and the “My Way”. Getting to know the person takes time and every encounter by the staff and family can serve as a method to increase our knowledge about that person, including their strengths and little idiosyncrasies.

Dementia often creates a shield that we cannot see behind and hides the expressions of personhood. Thus, we must help to remove that shield so that we can connect with the PWD and establish a meaningful connection with that person.

How do we meet that person at their point of need?  One way is to meet their spiritual needs.  Spiritual needs is defined as:  belonging, feeling connected, affirmed as a valued human being, and to experience meaning [sense of purpose]. Faith communities in our facilities through the utilization of our Chaplains, has great potential to reduce or prevent BPSDs. Through conversations with Chaplains, the PWD has potential to gain a sense of meaning from helping others and feel valued.  The Chaplain can help to promote ways the PWD can give back to the facility so that they feel useful (despite their condition of dementia).

Meeting the needs of a person with dementia will be very difficult unless we address organizational barriers (facility barriers). For example, rigid facility routines and policies, inadequate dementia training for all staff, excessive psycho-pharmacology, and inadequate staffing levels.

The CMS Initiative gives us the ability to go back to the basics of care as outlined in OBRA 87′ and re-double our efforts to meet the psychological and spiritual needs of all persons, especially those with dementia.

A team from Université Laval, CHU de Québec, and pharmaceutical firm GlaxoSmithKline discovered that the molecule monophosphoryl lipid A (MPL) stimulates immune cells in the brain, leading to the breakdown of the senile plaques associated with Alzheimer’s, according to a Tuesday statement. The researchers observed an 80% reduction of senile plaques in mice injected once a week for 12 weeks with MPL.

MPL’s safety has already been established, leading the researchers to believe it can be used in a vaccine to stimulate the immunity of both diagnosed Alzheimer’s patients and those at risk.

What does this actually mean?

Alzheimer’s disease (AD) is a neurodegenerative pathology characterized by the accumulation of amyloid beta (A-beta) and neurofibrilary tangles in the brain. As part of this accumulation of A-beta, there occurs a parallel inflammation (through the release of cytokines [immune system agent]) as the disease progresses. These cytokines can be neurotoxic to neurons if elevated levels are achieved.

The beauty of this presented study is that the microglial cells are triggered with the vaccine (MPL [monophosphoryl lipid A]) which clears A-beta and is neuro-protective (meaning other neurons are not damaged by clearance of the plaque). Also, MPL has been used as a previous vaccine in humans (Cervarix) and shown to be safe. MPL may have the ability to cross the blood-brain barrier and clear A-beta via phagocytosis (meaning – “to devour”) harmful particles and excrete them from the body.

Finally, although MPL treatment has not been confirmed in humans in relation to A-beta, the compound has been used successfully as a human vaccine (Cervarix) and based on this recent study may hold great promise as a safe and effective treatment of AD.

Have you ever experienced this?  A resident suffering from dementia becoming impossible to manage from about 5pm to Midnight.  The resident screams if confined to a geri-chair or relentlessly paces up and down the hall tearing at her clothes, mumbling some kind of gibberish.  She may go into her room, pack up all of her stuff and relate to you that she is going home.

Why is this happening and what do I do to help the resident?

Sometimes residents with acute or chronic confusion become more confused, restless and insecure late in the day and especially after dark.  The resident may be demanding,
restless, upset, suspicious, disoriented and may even see, hear or believe things aren’t really real.  Their attention span and concentration become more and more limited as well.

We are not really sure what causes sundowning, however, it is more prevalent in those with brain diseases, whether acute or chronic. Elders with dementia tire more easily even from minimal demands on their cognitive ability.  Therefore, all stimuli becomes problematic for them because all of their “cognitive energy” has been depleted.

Quiet Time As An Intervention

In each Serenity facility, we offer Quiet Time as an intervention to sundowning. This program will offer a time for rest, relaxation, or reflection to allow each resident an opportunity to refresh their mind and body in an environment with decreased stimulation. This period of relaxation will decrease their level of anxiety, frustration, or agitation which is created by tiredness and or overstimulation.

The benefit of this activity is to promote a balance between activity and rest.

Finally, remember a sundowning resident may also be hungry, uncomfortable, in pain or need to use the bathroom, all of which they may only be able to express through their restlessness and agitation.

“Imagine that you have absolutely no short-term memory. You have no idea where you are or why you are there. You don’t know how you got to this place, and you have no concept of what you’ll be doing later. You look around but don’t recognize anybody. Now a perfect stranger comes up and, after mumbling something, attempts to take your clothes off.”

How would you respond? Would you try to get away? Would you scream? Would you fight?

For elders with impaired cognition, the above scenario and many others like it, happen almost daily in a long term care facility. The elder does not know where they are or what is going to be done to them. Their behavior expresses the confusion, fear or anger they may be feeling.

Through our failure to understand and attend to who the elder is and address the unmet physical, mental, or emotional needs, we escalate many behaviors. The effort to look for the conditions that give rise to the behaviors, rather than try to control or eliminate them, is the hallmark of behavior management and the Serenity Model.

Finally, there is a trend in long term care facilities today of violence and aggression that poses serious threats to our elders, staff, property and the overall care we administer. A deeper understanding of the possible causes and potential effects of physical altercations is a crucial step in designing prevention and appropriate treatment plans for the protection of the elder and staff. The ultimate goal is safety and improved quality of life for the elder!

We will share glimpses into our programming, our findings and discoveries.  We are continuously evolving and changing in an effort to better serve our residents and clients.  Serenity is not interested in just doing what everyone else is doing but rather want to move into new areas of opportunity.  We desire to not just warehouse and care for residents, but to truly enhance their lives, while at the same time enhancing the lives of the caregivers, because they have more and better tools with which to serve.

We are excited to host this blog space and do not plan to limit the blogging to ourselves, but rather to have as many different experts blogging here and to share their insights into what is happening all around the globe.  We hope you will find these blogs useful and helpful and we want your feedback.  Please share your thoughts, comments and questions. Thank you and we hope you will visit our site often.