The primary purpose of this blog post is to raise awareness to this public health problem among cognitivel able residents, family members, care staff, interdisciplinary team members, physicians, administrators, care advocates, care providers’ associations, alzheimer’s association, regulatory agencies, policy makers, and legislators.Piaget cognitive learning theory the list can be used to encourage and inform advocacy efforts to address it and ensure that older residents with dementia (and staff members) will remain safe and free from psychological harm in their later years.Piaget cognitive learning theory

Staffing levels. Determine, fund, and require stafing levels that enable staff to supervise residents with dementia effectively (one pilot study by bharucha et al. (2008) has shown that close to 40% of episodes of resident-to-resident physical “aggression” on shared spaces of dementia units are not witnessed by staff members).Piaget cognitive learning theory the actual proportion of episodes is substnatially higher because many of these altercations take place inside residents’ bedrooms (such as between roommates and when residents with dementia enter other residents’ bedrooms).Piaget cognitive learning theory

Staff training. Develop and train care staff, interdisciplinary teams, and all managers in understaning, preventing, and de-escalating this form of behaviors.Piaget cognitive learning theory hire the right people and support and train them! (training includes 3 essential components: orientation training (prior to working with residents); ongoing in-service training; and “experiencial learning” i.E.Piaget cognitive learning theory hands-on guidance on the floor before, during, and after episodes of resident-to-resident altercations. Training in dementia care is and should be perceived as an endless journey (in general and in light of the high turn-over rate of direct care staff, nurses, social workers, recreation staff, and managers).Piaget cognitive learning theory there is alos an urgent need to train police officers and medical emergency personell in effectively addressing these behaviors (training on what it means to live with dementia, approaches, communication techniques, and psychosocial stratgies for prevention and de-escalation of these behaviors)

piaget cognitive learning theory

Meaningful activities. Require long-term care residences to provide adequate number of meaningful activites per day to residents with dementia throughout the day and evening hours.Piaget cognitive learning theory boredom often leads to various behavioral expressions in this population and frequently to episodes of resident-to-resident altercations. Some states still require one activity per day (such as in regulations of special care unist of assisted living residences in massachusetts), which is unacceptable and puts residents at risk.Piaget cognitive learning theory meaningful engagment in group and one-on-one activitives can substantially reduce the number of eposidoes of resident-to-resident “aggressiopn.”

piaget cognitive learning theory

Physical environment. Develop and provide dementia-friendly physical environments (certain environmental features contribute or directly cause these episodes, including large care units, crowdedness, shared/multiple occupancy bedrooms, excessive noise, overstimulation, inadequate lighting, and glare).Piaget cognitive learning theory design of dementia-friendly physical environments can help reduce significant portion of episodes of resident-to-resident altercations in dementia.Piaget cognitive learning theory

Early warning signs and situational triggers. Acknowledge the fact that in the majority of episodes of resident-to-resident altercations in dementia – when observing closely – it is possible to identify an early warning sign (e.G.Piaget cognitive learning theory body langauge and facial expressions) and situational triggers. This means that most of these behavioral expressions are potentially preventable.Piaget cognitive learning theory acknowledge the fact that in the majority of episodes of resident-to-resident altercations in dementia, residents’ unmet needs contribute or directly cause these behaviors (intersecting with residents’ cognitive impairment).Piaget cognitive learning theory

Documentation. There’s a massive and chronic underreporting of behavioral expressions in general and resident-to-resident “aggression” in dementia in particular in long-term care residences (both internally and externally).Piaget cognitive learning theory one study by prof. Jeanne teresi has shown a five fold increase in reporting of these episodes after staff training program. Create an organizational climate where reporting is seen by staff as a learning tool for improvement in prevention efforts versus a labeling tool where misperceptions of residents as “aggressive” and “violent” are perpetuated.Piaget cognitive learning theory avoid using behavioral documentation as a source for punitive/disciplinary measures against dedicated and caring care staff members. Require use of behavioral log (you can contact me to receive an example of such behavioral log) to identify behavioral patterns, which are the basis for developing individualized preventive interventions that work.Piaget cognitive learning theory

Normalization. Avoid normalization of these behaviors (e.G., “what do you expect? He has dementia; and "it happens all the time…there’s not much you can do abou it”; or “they are old.Piaget cognitive learning theory they can’t really harm each other.”) as it creates and reinforces a self-fulfilling profecy. Whould you allow these behaviors to occur towards your 3-year young child in day care?Piaget cognitive learning theory what is it that we apply different standards when it comes to older adults in general and those living with dementia? One answer has to do with agesim and the widely-held stigma towards people with dementia.Piaget cognitive learning theory

Serious mental illness. Acknowledge and address the fact by which a large number of people with serious mental illness (SMI) (such as schizophrenia) live in long-term care residences.Piaget cognitive learning theory most staff members in most long-term care residences are not trained to care for these individuals, let alone understand, prevent, and de-escalate their “aggressive” behaviors.Piaget cognitive learning theory fund, develop, and offer high-quality altervative housing solutions for those residents with SMI who, after careful interdisciplinary assessment, are determined not to be suitable for living with people with dementia.Piaget cognitive learning theory significant portion of people with SMI do not engage in “aggressive” behaviors towards others. Others do. Make sure to admit to your care settings only residents your staff members are capable of caring for and preventing their behaviors.Piaget cognitive learning theory the key is thorough pre-admission behabvioral assessment. Otehriwise, you may put your residents and staff at risk of injury (there are numerous reports in the media of “aggressive” behaviors by residents with SMI towards resident with dementia, including many that cause injuries and deaths subsequent to injuries).Piaget cognitive learning theory

Language. Use new culture of care and person-centered care language/wording and avoid any use of labeling language (such as “abusive” “violent” “out of control” “unpredictable”) in the context of people living with dementia.Piaget cognitive learning theory once labeled as “aggressive,” staff are much less likely to seek to identify the unmet needs that commonly underly these behavioral expressions.Piaget cognitive learning theory

Regulations. Review and modify federal and state regulations to ensure that the prevalent phenomeon of verbal, physical, and sexual resident-to-resident “aggression” is EXPLICITLY acknowledged and addressed.Piaget cognitive learning theory require all long-term care residences to address these forms of behaviors in their policies and procedures (including the measures taken to prevent and de-escalte them).Piaget cognitive learning theory require adequate number of hours of staff training specifically on prevention and de-escalation of this form of behaviors in dementia and serious mental illness.Piaget cognitive learning theory create incentives for long-term care residences to report various forms of behavioral expressions in general and episodes of resident-to-resident aggression in particular (internally and externally).Piaget cognitive learning theory make sure to include it as an integral part of regulatory agencies’ inspection visits and evaluations.

Psychotropic medications. Conduct careful and ongoing individualized assessment to determine which residents with dementia REALLY need psychotropic medications (usually a small portion) and who doesn’t need it (the majority) and may be even harmed by these medications due to adverse side effects including fatal ones (see FDA’s black box warning).Piaget cognitive learning theory reduction of psychotropic medications without timely provision of person-directed care, supports, meaningful engagement in one-on-one and group activties, and high-quality education/training to direct care staff members is iresponsible and could be outright dangerous to the resident and those around him/her.Piaget cognitive learning theory

Assistive technlogy. Develop assistive technology that would signal to staff in real time when an episode is about to take place and already taking place.Piaget cognitive learning theory one example is vigil dementia system which can alert staff in real time when a resident leaves his/her bedroom and enters another resident’s bedroom (a frequent trigger of altercations between residents with dementia).Piaget cognitive learning theory development of assistive technologies for prevention of altercations between roommates is SORELY needed (many altercations between roommates end up in injury and death subsequent to injury (as occured in several of the tragic incidents noted above on this blog post) .Piaget cognitive learning theory

Culture change. Incentives and ongoing commitment to culture change journey and person-directed care for people with dementia (as outlined by the pioneer network and demonstrated by the green houses of the eden alternative (dr bill thomas), judy berry (founder and former CEO of lakeview ranch, minnesota (currently president of dementia specialist consulting), english rose suites, minnesota (jayne clairmont) and arcare, austraila (daniella greewood) will automatically reduce most of these behaviors.Piaget cognitive learning theory when the human needs of people with dementia are proactively met in livable environments, you will see substantial reduction in these behavioral expressions.Piaget cognitive learning theory

An critical component of person-directed care is the recognition that close trusting relationships with residents with dementia is the single most important assest we can have when working with and caring for people living with dementia.Piaget cognitive learning theory one of the keys for developing these relationships is knowing the life-histories of residents with dementia in as much detail as possible. When staff are successful in building and maintaining these close trusting relationships with residents, they are in a good position to understand, prevent, and de-escalate various behavioral expressions of unmet needs including episodes of resident-to-resident altercations.Piaget cognitive learning theory another seceret of culture change is that close trusting relationships must take place in all directions within the care organization and beyobd (such as with residents’ family members and all involved external egencies).Piaget cognitive learning theory

To ensure that these and many other measures will be implemented on a large scale in all long-term care residences (including, among others, nursing homes and assisted living resdiences) there is an urgent need to develop and establish the national center for prevention of resident-to-resident altercations in dementia.Piaget cognitive learning theory for detail, see my letter to the editor of JAMDA:

Welcome to the international center for prevention of distressing and harmful resident-to-resident interactions in dementia in long-term care homes.Piaget cognitive learning theory the center aims to build a community of people and organizations who are interested in addressing the prevalent, concerning but under-recognized public health problem of distressing and harmful resident-to-resident interactions (verbal, psychological, physical, material, and sexual) in dementia in long-term care homes (such as nursing homes and assisted living residences) and between participants of adult day health centers.Piaget cognitive learning theory

It is important to emphasize that the vast majoity of these episodes are the result of negative and distressing factors in the social (other people) and physical environment.Piaget cognitive learning theory in most situations, unmet human needs, situational frustrations, and perceived and real threats contribute or directly cause these behavioral expressions.Piaget cognitive learning theory these social and physical environmental factors and unmet needs intersect with the person's cognitive disability to generate these episodes.Piaget cognitive learning theory the vast majority of elders with dementia are not inherently aggressive. Like us, they react, respond, defend, and protect themselves when they experience distress and when they sense that their dignity, privacy, identify, and personhood are threatened or violated.Piaget cognitive learning theory

It is easy to forget that people living with dementia have a profound brain disease because their cognitive impairments may not be immediately and physically visible.Piaget cognitive learning theory when looking closely, in most situations, when people with dementia engage in these episodes, they are actually fighting with each other to preserve their dignity.Piaget cognitive learning theory they "fight for their dignity." the definition of dignity is the quality or state of being worthy, honored, and esteemed (webster dictionary).Piaget cognitive learning theory the widely-held misconception that most people with dementia engage in aggressive and dangerous behaviors towards other residents reflects a "blame the victim approach." this approach, in turn, often leads to a slippery slope in which psychotropic medications are used inappropriately and excessively.Piaget cognitive learning theory these medications are mostly ineffective for most individuals with dementia and frequently cause a series of side effects some of which are dangerous and can be deadly (some have a black box warning by the U.S.Piaget cognitive learning theory FDA). Once the person with dementia is sedated, it becomes harder to identify their unmet human needs that caused the behavioral expressions to begin with and there is little hope of then arriving at a humane, practical, and life-affirming solution for the person.Piaget cognitive learning theory instead, other serious problems such as physical discomfort, disorientation, heightened anxiety, and falls ensue.

Protecting the confidentiality of residents, staff members, managers, and family members is critical so please submit only de-identified information i.E.Piaget cognitive learning theory reports that do not include any information that could potentially reveal the identify of people involved in those episodes or the name of the long-term care home in which the episode occurred (unless the information was already published and available to the general public such as newspaper articles).Piaget cognitive learning theory