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There are various types of memory impairments that residents experience. Memory change, or

memory loss, is a partial or complete loss of memory caused by a physical or psychological

condition. The most common condition is dementia and traumatic brain injury.

Alzheimer’s is a type of Dementia and is the most common. There are other types of

Dementia as well which have different symptoms and behaviors associated with them. It is

important to know what kind of Dementia the resident you are caring for has. Engaging

residents with memory impairments can be difficult even for experienced caregivers and

often frustrating and emotionally devastating for loved ones. Alzheimer’s affects 47 million

people worldwide, and is expected to be tripled by 2050. There is no cure and the disease

cannot be prevented or slowed.

Residents with dementia, or brain injury often experience a deterioration of cognitive

function. These impairments adversely affect resident’s receptive and expressive

communication abilities. For example, a resident may have difficulty creating a logical flow

of ideas and expressing themselves clearly. They might struggle to follow simple verbal

instructions. These obstacles make it difficult for caretakers to provide the necessary care to

residents. There are many strategies which tailor communication to each resident’s abilities.

These will be discussed in the following slides.

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Living with memory impairment may include difficulty communicating daily experiences,

which can lead to withdrawal, social isolation, poor-quality care which in turn lead to poor

quality of life. Residents with dementia or Alzheimer’s depend on caretakers to establish

and maintain relationships with those around them.

To create caring relationships, it is important that caregivers can communicate with residents

with dementia or Alzheimer’s verbally and nonverbally. With verbal communication,

caretakers must assess a resident’s ability to express ideas. When talking to a resident,

identify key concepts and word associations in the conversation and ask for feedback. Speak

slowly, use simple language and make sure you are at eye level with them when speaking to

them. Be patient, as residents may feel frustrated struggling to communicate. They may

feel frightened, have anxiety which can cause more confusion, language decline, and

behavioral outbursts both physically and verbally. Remain calm and reassuring while

explaining what you plan to do.

Residents may avoid verbalization all together. Caretakers must be able to interpret the

meaning of non-verbal behaviors, such as agitation, restlessness, and aggression. These

behaviors are often an expression of unmet needs: pain, hunger, toiling needs, fearfulness,

and frustration.

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Generally, Alzheimer’s disease is seen in individuals age 65 or older. However, 5% of cases

occur in individuals younger than 65. The diagnosis can be devastating for family who may

have to take on the role of caregiver for a young parent.

Caregivers must understand the special circumstances of early-onset Alzheimer’s in order to

provide quality care to residents. There are two types of early-onset: common and genetic.

Common occurs in most cases, whereas the genetic form is extremely rare.

Signs and symptoms of early-onset Alzheimer’s appear between ages 30 to 65, and they are

similar with those seen in other forms of the disease. Early symptoms include forgetfulness,

difficulty with conversations and concentrating. Late symptoms include severe mood swings,

severe memory loss, and incapacity for self-care. Changes to gait and loss of language skills

are very common in early onset Dementia.

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Educating family members and caregivers about early-onset Alzheimer’s is crucial for quality

care. Children of individuals with early-onset Alzheimer’s may be concerned about the

possibility of developing early-onset Alzheimer’s themselves. Educate the children of

residents about genetic testing, but that it’s a choice which require special consideration.

With early-onset Alzheimer’s, it’s likely that family members will take on the caregiver role.

It is crucial to assess their coping strategies. It is also important to educate them about

available options for care and support groups. Support groups are often focused on

individuals over 65 so finding the “right” group is crucial for this population.

Additionally, it is important to educate the family about how to deal with the difficult

behaviors that early-onset Alzheimer’s poses. Caregivers must be prepared for paranoia,

hallucinations, anger, and resistance to care. With proper education, the quality of life for

both the residents and caregivers will improve. Family members can often become the least

effective caregivers due to emotional distress and their own anger, so it is essential that the

family receive the proper guidance and education to enable them to cope with the situation

and become effective caregivers.

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Alzheimer’s is a neurodegenerative disease with progressive cognitive, behavioral, cognitive,

and neuropathic changes. The disease is incurable and can be devastating for those affected.

As caregivers, it is imperative to understand Alzheimer’s disease progression in order to

inform legal medical considerations in healthcare facilities.

Studies show that deterioration in writing, or dysgraphia, highlights a specific deficit in

Alzheimer's patients and may identify other types of cognitive deterioration. One case study

tested a patient’s cognition over a period of 19 days and then repeated in 6 months.

As a result, the study presented a strong relationship between dysgraphia and other measures

of cognitive performance. Understanding cognitive ability in relation to reading, retention

and writing may be useful for gauging a resident’s legal capacity to make decisions.

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When caring for a resident with memory impairments, there are occasions for potential

problems. Alzheimer’s and dementia sometimes make it difficult for residents to recognize

their surroundings. Feeling threatened or having anxiety and being frustrated can cause

residents to exhibit behaviors like shouting, pacing, wandering, and resistance to care.

There is a reason why behaviors are exhibited and usually it is because of an unmet need.

With education, caregivers should be prepared to respond effectively and with respect to

residents exhibiting these behaviors. When residents act “aggressive,” caregivers should

decipher the meaning behind the behavior and understand it as a form of communication.

Caregivers should also identify unmet needs that cause a resistance to care. An example of

unmet needs are: resident needs to use the bathroom but can’t express it, they are in pain or

hungry and can’t express it verbally. The caregiver must look for non-verbal cues. For

instance residents may touch themself indicating they need to use the bathroom, rubbing

their stomach, making facial expressions such as grimacing. How the caregiver identifies and

addresses the unmet need is crucial in terms of avoiding a behavioral outburst.

Individuals with memory impairment are sometimes infantilized in the way they are treated.

Give residents respect to achieve optimum care. Ask permission to enter an individual’s

personal space. Learn when to step away when aggressive behavior escalates.

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There are many educational materials for both residents coping with memory impairment and

their family members. The Alzheimer’s Association provides a written assessment guideline

which lists nine question techniques that will help family members and caregivers

communicate with residents.

There are online resources to help with assessing communication difficulties in adults with

memory impairment. It’s advisable that each organization have their own assessment tool

they use during the assessment phase. This information can be utilized by caregivers in terms

of communication. Some online resources include the Alzheimer’s Association Virtual Library,

Alzheimer’s Navigator, and the John A. Hartford Foundation. These sites provide information

on healthcare, housing, and communication techniques for people with dementia or

Alzheimer’s.

It’s crucial to document known patient characteristics. Caregivers should write down

resident’s likes, dislikes, preexisting personality, and behavior in current care. This written

information will enable caregivers to tailor their support to a resident’s specific needs.

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In order to provide necessary care to residents, written documentation needs to be utilized

and a care plan developed. It is important for health care workers to make sure they read

the care plan provided to them to understand the residents needs and status. In care

settings, caretakers need to use techniques that will help them exchange information with

and interpret communication by residents.

Caregivers often obtain written assessment information from loved ones who are familiar with

the patient’s communication abilities. To assess a resident’s ability to understand verbal

instructions, ask family members or other caregivers if a resident understands certain words,

and identify any specific expressions that they use in caring for the resident. The more

information obtained the better.

To assess a resident’s nonverbal communication, ask family members or other caregivers

about particular physical cues that the patient associates with daily activities. For example,

ask if a resident will get dressed more easily if clothing is set out on a chair.

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There are special techniques and strategies caregivers need to practice while caring for

residents. Residents with dementia have the impaired ability to communicate, which

complicates their nursing care. Caregivers must develop a positive rapport with residents to

provide them with the care they need.

It is important to recognize that residents who have difficulty communicating may feel

frustrated. The caregiver should acknowledge the resident’s feelings and offer support and

understanding, as well as enough time to answer any questions. The caregiver should allow

the resident to guide the conversation, never interrupting them or changing the topic.

Studies show that residents with dementia or Alzheimer’s will talk more in conversations

when they feel the caregiver is listening attentively to their expressed reality. A deep, mutual

rapport is valuable when assessing a resident’s specific needs. The caregiver must build trust

with the resident.

Music can be used as a means to communicate nonverbally. For example if a resident has

always enjoyed a certain type of music and does not like morning activities of daily living it

might help to play music they enjoy. This simple intervention communicates caring,

facilitates relationship building and distracts the resident from what they perceive as an

unpleasant activity. Other helpful techniques include, singing with the resident, remaining

calm and at eye level and discuss what you are doing prior to touching the resident.

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The strategy found in Communication Difficulties: Assessment and Interventions in

Hospitalized Older Adults with Dementia assesses receptive and expressive abilities of

individuals living with memory impairments. The strategy is nine questions that will help

caregivers gauge a resident’s abilities.

To assess receptive abilities ask questions like: “Can the resident understand a yes/no

choice?” or “Ask simple, direct questions that require only a yes or no response.” Observe

the resident’s ability to follow simple instructions.

To assess expressive abilities ask questions like: “Does the resident find the correct word?” or

“Does the resident have difficulty creating sentences or a logical flow of ideas?“ Observe the

resident for abusive or aggressive behaviors.

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When dealing with residents with memory impairments, caregivers should be aware of the

timing of different kinds of communication. Caregivers are responsible for a resident’s

transition of care and admission.

For instance, caregivers in skilled nursing facilities play a key role in the care for 5 million

patients who transition from hospitals to senior care facilities annually. Studies show that

inadequacies in hospital discharge information lead to repeated phone clarifications, care

delays, and time-consuming searches through medical records. This translates into the

caregiver not knowing what the resident truly needs and that is when accident and injury can

occur. Health care workers need to be equipped from the moment the resident walks in the

door. Information is vital to avoid legal risks.

Inadequate medical information can include inaccurate reports, especially in medication lists.

To improve transitions, studies suggest that hospitals need to communicate medical

information at least 24 hours prior to admission. Caregivers should also have access to a

prescribing provider with up-to-date knowledge of the patient. These improvements will

ensure that special requirements and medications are readily available to residents.

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One of the most challenging aspects of working with residents who have memory impairments

is monitoring and dispensing medication. In transitions of care, issues with medication can

cause conflict with admissions and emotional/physical safety of residents.

In a qualitative study, caregivers stated that a problematic care delay was the lack of signed,

hard copy opioid prescriptions, which are legally required to dispense controlled substances.

Delays in pain treatment can result in severe pain. Might want to add its a best practice to

make sure all medications are on hand before the patient arrives to the senior care facility to

avoid delays in pain management and medication administration. Review medication lists

with the team and understand what if any psychotropics are prescribed to ensure the team is

aware of any potential behavioral issues. Gather information prior to admit regarding patient

compliance with medication administration and if meds needs to be crushed or given in an

alternate form.

Another common challenge is conflicting medication orders upon patient arrival. Discharge

orders prior to admission may fail to communicate changes in medication, resulting in

medication not being readily available at on-site pharmacies. These medication errors can

lead to rehospitalization of patients and the dissatisfaction of their family members. This

does not apply to assisted living facilities because they do not have an onsite pharmacy. They

rely on scripts and get medications prior to move in. The direct care worker should look for

any tips or tricks provided before admit for the resident. If that is not gathered they may

need to be creative in dispensing medication and patient; meaning they may have to attempt

multiple times.

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The Gentle Persuasive Approaches in Dementia Care (GPA) is a person-centered approach to

supporting to residents with dementia or Alzheimer’s. This is a particularly effective method

for engaging residents with aggressive behaviors such as shouting, explosiveness, or resistance

to care.

The acute care environment can be perceived by residents as unfamiliar and threatening,

which may lead them to resist caregiver support. GPA is a standardized curriculum that helps

caregivers interpret and reframe resident behavior often viewed as “aggressive.”

The GPA curriculum discusses the impact of dementia on the brain, communication strategies,

as well as respectful self-protective physical techniques. A study that examined the

effectiveness of GPA showed that incidents of aggressive behavior declined by 50% three

months after GPA training was implemented.

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Living with dementia can pose difficulties with communicating in daily life. Due to problems

with communication, individuals with dementia can feel withdrawn and isolated which leads

to decreased psychosocial wellbeing that can cause a decline in cognition. The validation

method is designed to facilitate communication for people diagnosed with dementia.

The validation method accepts a person’s experience of reality and responds to their verbal

and non-verbal expressions. The validation method stresses the importance of trying to

understand the meaning behind communication in one-to-one conversations. Caregivers

should look for word associations. For example the word towel may be expressed as sheet.

Both items are material with a purpose but the specific word is verbalized incorrectly.

Using the validation method, it is also important not to interrupt residents with dementia, so

that they may speak more freely. Caregivers should not try to change the conversation to

something cheerful, but instead let residents discuss their feelings and disappointments. This

method is especially useful for persons with dementia around the age of 80 and without a

history of psychiatric illness.

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As Alzheimer’s becomes a growing epidemic, the burden on caregivers rises as well.

Individuals living with Alzheimer’s are likely to wander away from home. Exit seeking

behaviors are common for this population. Locked units with alarmed doors are common in

senior care facilities. Technology for devices like the Wander Guard are also helpful. Devices

like wander guard sound an alarm to assist with fall prevention forma bed or chair. They can

also be wireless systems that facilitate tracking the wandering person.

The innovation of the GPS shoe monitors the movement of individuals with memory

impairments, easing the anxiety of caregivers. The GPS shoe is wearable, inexpensive and

allows adults with memory impairment to maintain their independence while allowing for

easy tracking when they wander. Additionally, the GPS is extremely accurate, and can be

integrated with a phone app or call center. Locked units with alarms are common in senior

care facilities.

It is not advisable or best practice to let someone with memory impairments “wander” away

without supervision even with the GPS shoe tracker. Activity involvement is key to decrease

wandering tendencies and can help with sundowning. Sundowning is a term used to refer to

behavioral changes that often occur in the late afternoon or evening for people living with

Alzheimer’s disease.

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The rise of new technology poses privacy challenges in the legal system. The United States

legal system directly addresses the use of GPS shoes, though it has primarily risen in the

criminal context. The Supreme Court cases examine whether the GPS shoe data is a collation

of fourth amendment rights.

In a 2012 decision, the Supreme Court unanimously maintained that attaching a GPS unit to a

suspect’s vehicle and using it to track another individual’s movement for a long period time

constituted a search. Five of the Justices claimed it was an invasion of property, while four

Justices argued it was a violation of privacy.

Criminal monitoring differs significantly from health uses of GPS tracking. However, in order

to avoid any litigation, caregivers should use GPS tracking on residents only with the consent

of families. There are other means of technology such as APPS on smart phones, wander guard

usage in senior care facilities, and locked units.

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For older individuals living with dementia, resistance to care is common. Caregivers often

resort to elderspeak in daily conversations with older adults with dementia. Elderspeak is

infantilizing communication, similar to the language people use when talking to young

children.

Features of elderspeak include diminutives and inappropriate intimate names such as,

“honey” and “good girl.” Elderspeak implies a stereotypical view of elders being less

competent than younger adults. The stereotypical, implicit message prompts negative self-

esteem and withdrawal for an older person. Elders must be treated with dignity and respect

regardless of cognitive level of diagnosis.

Studies show that cognitively intact older adults have a negative view towards elderspeak.

Elders with dementia are more likely to resist care when caregivers use infantilizing

communication. Caregivers should talk to residents with dementia with the respect they

would give to younger adults. This will decrease the risk of resistance to care.

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In care facilities, there are many ethical dilemmas that exist for residents who have memory

impairments such as dementia. The most significant ethical issues are decision making in end

of life care, use of restraints on residents, and a lack of resources.

In a study on nursing homes, 91% of the nursing home staff experienced ethical problems in

their daily work. When a resident is in a long-term care facility, caregivers are often forced to

make decisions about nutrition and covert medication.

There is a demand for a framework of ethics in care facilities. The inclusion of ethics in

everyday meetings has to be a main focus in care facilities. It is also important that managers

and policy makers participate when lack of resources is discussed. The current best practice is

for residents to have no invasive physical restraints or chemical restraints.

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Litigation is the process of taking legal action against in this case the organization.

Malpractice is improper, illegal, or negligent professional activity or treatment, especially by

a medical practitioner.

Remember to report immediately any injury or accident.

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A case study of litigation in Florida nursing homes examines a low-risk facility, a medium-risk

facility, and a high-risk facility. According to the study, the low-risk home was a new and well

maintained. The facility had trouble attracting qualified nursing assistants. However, there

wasn’t a significant lawyer presence in the area, and few claims were made.

The medium-risk facility was built in 1965, and needed exterior repairs. However, the facility

was clean. The administrator was a 20 year nursing home veteran. The site was located in a

metropolitan area that had a small lawyer community that was actively seeking out lawsuit

opportunities.

The high-risk facility was built in 1995 and purchased by a for profit chain with a bad

reputation for lawsuits. Equipment was out of place and the grounds were poorly kept. The

head administrator had been appointed for less than a year. The home was in a large urban

area with an active lawyer population who promoted suing nursing homes through media

outlets.

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After assessing the different facilities, the study drew conclusions about litigation in nursing

homes. The first factor was staff perception. In the low-risk facility, none of the staff saw

litigation as a current challenge. Conversely, 25% of staff in the high-risk facility saw litigation

as a current challenge. Potential for lawsuits exists in all facilities.

The second factor was whether the administrative staff knew about the Resident Bill of

Rights. In the low-risk site, the entire clinical staff knew about the Resident Bill of Rights.

Conversely, in the high-risk facility, only 84% of the clinical staff were familiar with the

Resident Bill of Rights and 17% believed it had an effect on their facility. Education about

resident rights can help prevent malpractice.

Lastly, when asked why nursing homes are sued, the low-risk site identified internal factors

like quality of care and personnel neglect. Conversely, the high-risk site identified external

factors like TV ads and perceived poor care. This study contributes an understanding of health

care facilities by suggesting legal environments do not exist independently, but rather are

enacted based on administrative perceptions. A guiding principle to avoid malpractice is to

make decisions based on the policies and procedures in the workplace.

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