Chapter 4: Providing a Therapeutic Environment
What follows is Chapter Four of Meet Me Where I Am: An Alzheimer’s Care Guide, by Mary Ann Drummond. Drummond, an Alzheimer’s care expert and licensed nurse, is Vice President of Operations at Carillon Assisted Living.
Each chapter of Drummond’s book will be released in serialized installments. Chapter Five, Managing Difficult Behaviors, will be released on March 26.
Chapter 4:
Providing a Therapeutic Environment
“Oh, the comfort, the inexpressible comfort of feeling safe with a person: Having neither to weigh thought nor measure words, but to pour them out, just as they are, chaff and grain together, certain that a faithful hand will take and sift them, keep what is worth keeping, and with a breath of kindness blow the rest away.”
-George Elliot
What do you think of when you hear the phrase, home sweet home? Is it where you presently live or is it a special place from your childhood? When you close your eyes can you still see, smell and visit this place with warm feelings and happy memories? For most of us, there is one place that stands out above all others as home. Just saying the word evokes a shadow of magic moments and treasures lost in time.
Imagine sitting in your favorite room, snuggled up beside the one you love, watching a roaring fire and listening to the gentle hiss and crisp crackle of the logs as they succumb to the flames. It’s cold outside but all you feel is warmth and contentment. Feels nice, right? Now picture yourself in a place you have never been before, sitting in a room that feels cold and uninviting. You have no idea why you are there and you find yourself wanting to go home. You begin searching for doors, opening all that you find, searching for a way out. Only, instead of leading you to your home, each door you cross through only brings you to yet another strange place. Safe, warm and comfortable are feelings far from your reach.
Unfortunately, for people with Alzheimer’s, it is not uncommon to feel lost in your own home. The home that is remembered can be so far in the past that it may not exist anymore. There is often a powerful drive to return to home and what is familiar, which leads to a behavior known as “wandering” or “exit seeking.” Many will experience events where they actually leave their current home to find the “home” they remember. This is not a safe behavior, and can have serious consequences such as becoming lost or injured while on foot. It is important for caregivers to recognize the onset of wandering and exit seeking behaviors and to make interventions that will prevent the patient from leaving the safety of their environment.
The following activities represent cause for alarm as they signal wandering or exit seeking behavior is likely to occur:
- Staging clothing for packing, or keeping a bag packed and “ready.” They may tell you they are waiting on a family member to pick them up, or that they are going to go for a visit soon and want to be ready. They may even be seen carrying their purse and a few personal items with them when simply walking around the house, clutching to them for no apparent reason, but reluctant to let the items go or put them away when requested.
- They are observed carefully watching doorways and exit areas, and often get up and go toward the door to the outside whenever it is opened.
- They begin to get up in the middle of the night and can be found pacing around the house, sitting in the living room, or rummaging through the pantry “looking for breakfast.”
- They begin to pace nervously as though they are searching for something that cannot be found, going in and out of various rooms in the house and plundering through drawers and closets.
- They begin to talk about having to go to work, meet a child at the bus stop, go and pick up a spouse, or some other “trip” that needs to be made to care for some family member or perform an act that was once a routine part of their daily life.
- They begin to have difficulty finding their own bedroom, or begins to ask questions such as, “When are we going home?” even though they are at home.
- When asked, “Where are you?” they respond that they are some place other than their current location.
When any of these warning signs are present, the caregiver of the Alzheimer’s patient should be aware that the safety of their loved one is in danger. This is the point wherein continuous supervision becomes necessary, and can be one of the most difficult crossroads of the journey. Sometimes families are blessed in that there may be multiple siblings to help share the load. However, caution should be exercised to maintain consistency in the patient’s physical environment.
For example, four sisters decided to take shifts each day to ensure their mother was in direct supervision of someone at all times. While this sounded like a good plan on the surface, it involved moving their mother around every few days from house to house. Within a few weeks, their mother began to exhibit signs that her disease was progressing and she was no longer able to do for herself what she was able to do a short time prior. Passing their mother from house to house created instability and removed predictability from their mother’s care routine.
Without the predictability of a consistent environment, the patient can become overwhelmed with the rapid changes and have difficulty responding to the increased stimulation. The best care environment for the Alzheimer’s patient is one where a daily routine is established that maximizes independence while maintaining personal safety.
For some families, there may be only one or two individuals capable of assisting with care and supervision. As it is not humanly possible for one person to provide care 24 hours a day, seven days a week, a good alternative would be to hire companion services to be with them during the times that you are unable to. When this is not an option, it is time to consider alternative living arrangements such as a residential special care unit, commonly found in assisted living facilities, where the special needs of the Alzheimer’s patient are met. Should you find it necessary to choose this option, be careful to shop around and visit the various facilities available. The following suggestions will help you when making a decision on which program is best for your loved one:
Tips to follow when selecting an Alzheimer’s care facility:
Ask the facility to describe their philosophy related to the care of patients with Alzheimer’s disease. If they are not able to describe a specific approach and philosophy, it may not be the best choice.
Ask to have the admission criteria explained, and what other types of diagnosis would the residents in the program have. If the program allows a mixed population, wherein psychiatric disorders are mainstreamed with residents who only have dementia, it is usually not as therapeutic as an environment that focuses primarily on Alzheimer’s disease and related dementias.
Ask if it would be possible to visit with family members of existing residents and inquire as to how their loved one has progressed since joining the program. There is no greater testament of the quality of a program than those who have experienced the care provided.
Ask what success stories the program coordinator would like to share with you. Most programs focused on quality Alzheimer’s care will have readily available stories of how residents showed improvement in their social interaction, mood, and sometimes even in their physical abilities.
Observe how staff interacts with the residents. Do they treat them with a child like approach or are the residents treated as adults with adult focused activities and environment? Are staff attentive to residents, or do they seem to ignore their presence? Ask to see the posted activity calendar and see if the types of activities provided would be of interest to your loved one.
Observe the hygiene of the residents. Are they neatly groomed and freshly shaven? Are their fingernails clean?
Observe the interaction of the residents with each other. Are they socializing with one another, seeking the companionship of one another, or are they sitting isolated and withdrawn with limited interaction?
Ask how the facility handles residents when behaviors surface that are difficult to manage. Is their first response “medication management” wherein the residents are given tranquilizers to calm them? Do they talk about techniques such as redirection and reminiscing to bring the resident to a better place of mind?
Observe the physical layout of the program. Is there a secured setting that requires the use of some security measure of the entrance to come and go, or does the facility depend on a bracelet or anklet monitor that alarms upon exit, but does not prevent the resident from leaving? This is important to evaluate if your loved one has any signs of wandering.
Is independence promoted with a secured yard area wherein the resident is free to come and go? Is there a gardening area and walking pathway to provide adequate space to “pace” or “walk off” nervous energy?
Observe what types of television programs are allowed in the T.V. room. Do you see evidence of titles such as Lawrence Welk, I Love Lucy, Andy Griffith or other similar shows that recap pleasant times from the past, or are the programs geared toward the tastes and times of the facility staff?
Last but not least, be sure to visit the facility after hours and on weekends and evaluate if the program is consistent with what you observed during your guided tour. In a good program, you will notice very little change.
Placing a loved one in a facility, even one that has an excellent program designed specifically for the care of those with Alzheimer’s disease, is often a difficult task for loved ones. What I always tell family members to help with the process is this: “If the doctor gave you a prescription and told you that giving your mother one pill each day would help to slow the progression of her illness, and increase her chances for a healthy normal life, would you give it to her?”
Always, the answer is, “Yes, I would.” At that point, I explain that the therapeutic environment found in a quality special care unit for patients with Alzheimer’s disease is equivalent to that pill. When the right environment is provided with the right care approach the progression of the disease is proven to be slower and the overall functional ability of the resident is increased. The patient becomes better able to cope with the demands of daily life and finds more opportunities for success, which increases their overall sense of well being and confidence.
Regardless of whether the patient lives at home or in a facility based Alzheimer’s program, there are several components necessary in the environment to make it therapeutic. The first component is to implement every measure possible to ensure the physical safety of your loved one.
The following checklist will assist you to make the changes necessary in your home to accomplish this initiative:
#1. Purchase an external door alarm that sounds when the patient opens their bedroom door at night. There are many types to choose from, but my favorite hangs on the door knob and has a loud sound anytime the door is opened. This will alert you should they get up and begin to wander during the night.
#2. Store all chemicals and caustic liquids in a locked cabinet or closet. Sadly, a gallon of bleach could be mistaken for a milk carton, or a bottle of cleaner mistaken for tea.
#3. Utilize keyed deadbolts on external doors to prevent unassisted exiting when in the home setting.
Note: It is NEVER appropriate to lock someone with Alzheimer’s disease in a room or environment wherein they are unsupervised. The deadbolt is to be utilized only when there is someone present in the home that could safely assist the patient with exiting should an emergency situation arise, such as a fire.
#4. Purchase an Alzheimer’s identification bracelet to be worn by the patient at all times. The bracelet provides information on who to contact should the patient become lost or inadvertently separated from you.
#5. Prepare a “search and rescue” kit just in case your loved one ever became lost and needed to be found. This kit should be kept in an air tight plastic bag, and include an article of clothing worn by your loved one, such as a sock or T-shirt, several recent photos that show a close up of their face, and a list of places that your loved one may try to reach if they were lost, such as the address of where they lived most of their life, a favorite store, the address of a close friend that they used to visit frequently, etc. The article of clothing would be useful to assist K-9 units to quickly track anyone traveling on foot and the other items would help the police in search and rescue efforts.
#6. Remove throw rugs that are prone to slipping or flipping up on the edges when walked on, to prevent falls when pacing or wandering behaviors are present. Ensure adequate lighting is present to increase visual accuracy when ambulating around objects. Keep hand tools, drills, saws and sharp instruments such as knifes and scissors in locations that are not accessible to the patient. These items should be used with caution and close supervision to prevent accidental injury.
A therapeutic environment also includes taking great care to keep medications stored safely out of reach and maintaining a compliant medication regimen. There have been many unfortunate instances wherein someone with Alzheimer’s disease was injured through accidental ingestion by accessing either their own medications or the medications of others. Family members also need to become familiar with the medications prescribed for their loved ones, including the purpose of the medications and the possible side effects to watch for, should an adverse reaction occur. Since the ability to communicate feelings and physical manifestations effectively is impaired, becoming educated on what would be a negative response to medications can assist you in seeking timely medical attention when reactions occur.
Last but not least, a therapeutic care environment requires an abundance of patience and love. We tend to thrive best when we are accepted for who we are rather than ridiculed or made to feel incompetent for what we are not. Does it matter if the socks they just matched while helping to fold the laundry are not correct? Is it important to point out that when they helped you set the table they put two spoons out and no fork? If they feel they have done something helpful and are unaware of the errors, it is best to accept that they have done their best and compliment them on a job well done. If they are helping to rinse the dishes, wait until they have moved on to other interests to go behind them and re-rinse the glasses in the dish rack that still have soap bubbles present. Praise, encourage and support all efforts that are contributing to the routine household duties. You will be surprised how welcomed the affirmation will be to your loved one!
“When we recall the past, we usually find it is the simplest things-not the greatest occasions-that in retrospect give off the greatest glow of happiness.”
–Bob Hope
Posted in Alzheimer's and Dementia Care, Perspectives on Alzheimer's on March 12, 2014