Safety and Dementia

Supporting individuals living with dementia presents unique challenges and responsibilities. These challenges encompass risks to individuals' health and wellbeing like wandering, falls, medication issues, malnutrition and more. Let’s take a closer look at some of the common risks associated with caring for clients with dementia.

Activity - Fill in the missing words

We have examined the potential health and well-being risks faced by individuals with dementia. Now, let's explore how you can effectively mitigate these risks.

Activity - Reflect

Think about a specific experience or situation you've encountered while working with clients with dementia where you had to address or manage a particular risk? What strategies did you employ, and what were the outcomes?

Falls and injury

• Pay attention to various environmental hazards such as loose mats to trip over or water to slip in.
• Painful feet and unsuitable footwear (favourite old slippers) can contribute to falls.
• Providing walking aids and ensuring a clutter-free and well-lit space can reduce the risk of falls.

Medication management

• To ensure proper medication management for individuals with Dementia use a pill organiser.
• Establish a routine in consultation with a medical professional, for timely medication intake.
• Ensure safety by storing medications securely.
• Use simple and clear language when providing instructions for medication. For instance, you can say, "Here's your blood pressure pill. Put it in your mouth and drink some water."

Agitation and aggression

• Be aware of the warning signs and try developing strategies to stop it starting.
• Ensure there’s an unrushed and consistent routine.
• If possible, work out what’s causing the behaviour and take care of those underlying feelings.
• Avoid confrontation by either distracting their attention or suggesting doing something else – such as having a drink together, going for a walk or looking at a magazine.
• Make sure they get enough exercise and participate in meaningful activities.

Malnutrition and dehydration

• To mitigate these risks you should closely monitor the patient's food and fluid intake.
• Keep eating simple – offer easy-to-eat food
• Rather than large meals try the ‘little and often’ approach
• Keep in mind a person’s past history with food – don’t give them food they didn’t like in the past, or make them eat in a different way or at different times of the day.
• Watch food temperatures – some people with dementia aren’t able to tell if food is hot or cold.
• The person may get dehydrated because they have forgotten to drink or can’t recognise thirst anymore – set a routine for offering them drinks (jelly, custard or ice cream can be substituted in small amounts).
• Check for problems that could be causing pain with their teeth, dentures or the mouth in general, such as ulcers.
• Where possible, a good strategy is for the person with dementia is to eat with others so they can pick up cues about what to do. (Alzheimers New Zealand, 2021)

Wandering

• Implement safety measures such as secure entry and exit points and use identification bracelets with contact details.
• Provide opportunities for the person to engage in structured, meaningful activities throughout the day
• Identify the time of day the person is most likely to wander (for those who experience “sundowning,” this may be starting in the early evening.) Plan things to do during this time — activities and exercise may help reduce anxiety, agitation and restlessness.
• Ensure all basic needs are met, including toileting, nutrition and hydration.
• Consider reducing – but not eliminating – liquids up to two hours before bedtime so the person doesn’t have to use and find the bathroom during the night.
• Reassure the person if he or she feels lost, abandoned or disoriented.

Depression

• To mitigate the risks of depression and social withdrawal you can encourage exercise and social activities.
• Reminisce and do life story activities.
• Foster a sense of belonging and involve family and others in social interactions and companionship.

Dental health

• Mitigate oral health risks by reducing the amount of sugar in the diet and encourage them to drink plenty of water.
• If you need to help someone to clean their teeth, using an electric toothbrush is more efficient.
• Explain exactly what you are going to do if they are anxious about the procedure.

Personal care

• To mitigate the risk of personal care tasks leading to negative outcomes or distress in a person with dementia, consider breaking down the tasks into simple steps and gently explain each step using simple, respectful language.
• Encourage the person to do as much as possible themselves.
• Be mindful of sensory sensitivities.
• Adjust the environment to minimize sensory overload, such as using soft lighting, playing calming music, or using familiar scents.

Constipation

• To mitigate constipation in dementia patients, ensure they maintain proper hydration by offering regular fluids throughout the day.
• Incorporate a diet rich in fibre through fruits, vegetables, and whole grains to promote regular bowel movements.
• Additionally, encourage physical activity and regular bathroom breaks to facilitate regularity and reduce the risk of constipation.

Activity - Scenario

Read the scenario and select the most appropriate answer for each question based on the scenario.

Scenario

John, an 80-year-old male resident in a dementia care facility, has been displaying concerning signs of risk to his health and well-being. He frequently wanders the facility, sometimes becoming disoriented and agitated. Lately, he's been refusing to eat, and his weight has noticeably decreased. He has a history of falls and has recently been experiencing constipation. John's personal hygiene has also been neglected, and he often becomes anxious and agitated during personal care routines.

Ac

Safe support practices in the context of aged care and dementia care encompass a range of strategies and approaches aimed at ensuring the safety, well-being, and dignity of individuals receiving care.

These practices may include:

• Person-Centred Care: Focusing on the individual's preferences, needs, and values to provide tailored care that respects their autonomy and dignity.
• Safety Measures: Implementing physical safety measures such as fall prevention, environmental modifications, and medication management to reduce risks.
• Effective Communication: Employing clear and compassionate communication techniques to facilitate understanding and build trust with individuals, including those with cognitive impairments.
• Crisis Prevention: Identifying potential crisis situations and proactively addressing them to prevent harm or distress to the person with dementia or others.
• De-escalation Techniques: Learning how to calm and redirect individuals in moments of agitation or confusion without resorting to physical restraint or coercion.
• Medication Management: Safely administering and monitoring medications, especially in cases where individuals require medication for managing symptoms or behaviours.
• Documentation: Maintaining accurate and detailed records of care provided, changes in condition, and incidents to ensure continuity and accountability in care.
• Ethical Considerations: Upholding ethical principles in care delivery, including respecting privacy, consent, and maintaining confidentiality.
• Continuing Education: Staying updated with the latest best practices and approaches in dementia care through ongoing training and education.
• Collaboration: Working as part of a multidisciplinary team to ensure a holistic approach to care, involving family members, healthcare professionals, and other support workers.

Activity - Reflection

Before we take a closer look at some of these safe support practices, reflect on your current role in aged care. What safe support practices do you currently implement in your workplace, and how do these practices contribute to the well-being and safety of the individuals you care for?

Personal-centred care

People with dementia have the right to enjoy the highest possible quality of life and quality of care by being engaged in meaningful relationships which are based on equality, understanding, sharing, participation, collaboration, dignity, trust and respect...The first and most important objective is to ensure that a person-centred philosophy of care is well understood and put into practice” (Alzheimer Society, Canada).

You have acquired a solid foundation in person-centred care. Now, let's build upon that knowledge by applying it to clients with dementia.

A person-centred approach is about establishing connections, nurturing and maintaining relationships, celebrating individuality, and providing a safe, supportive environment with high levels of dignity and respect for those within the care setting.

This approach acknowledges that dementia is just one aspect of a person's identity, shifting the focus away from the disease itself and towards the person's unique qualities and who they are as a person.

Why use a person-centred approach?

A person-centred approach aims to address the gaps that are often present in aged care practices. In the past, it was typical for the psychological and emotional needs of people living with dementia in aged care to be overlooked. By adopting a person-centred approach, the stigmas and assumptions associated with people living with dementia can be challenged, resulting in improvements to current care practices and workplace cultures.

Watch

Watch this video about person-centred care in caring for clients with dementia. Take notes and write down three things you can do to provide person-centred care to your dementia clients.

Explore valuable insights into the priorities of individuals transitioning to aged residential care by delving into personal stories and watching informative videos on the New Zealand Dementia Foundation's website.

Safety measures

Take a moment to reflect on your existing knowledge of risk management and dementia-friendly environments, and now, apply this knowledge to the context of implementing safe support practices within your role as a support worker.

Activity: Forum

In the safety measures forum thread, share a short list of ways that you could create a safe environment for your clients in your role as a support work. 

Safe support practices and the stages of dementia

As dementia advances through its various stages, the challenges and risks faced by individuals and support workers evolve. To ensure the safety and well-being of those with dementia, it's crucial to tailor support practices to the specific stage of the condition.

Safe support practices for stage 1 - early-stage dementia

Safe support practices for stage 2 - moderate dementia

Safe support practices for stage 3 - advanced Dementia

Using your understanding of stage 3 advanced dementia and safe practices, use the following documentation tool to identify five strategies for delivering person-centred support to clients in this advanced stage.

Communicating with a person living with dementia can be challenging, but there are several strategies and principles that can help to enhance communication and promote understanding. Here are several verbal and non-verbal communication strategies that can help to promote engagement and understanding.

Some of these strategies include:

• Verbal communication strategies
• Non-verbal communication strategies
• Culturally sensitive and safe communication strategies

Verbal communication strategies

1. Speak clearly and concisely: Use simple, clear language and speak in a calm, reassuring tone.
2. Use short sentences: Long, complex sentences can be difficult for a person with dementia to understand.
3. Repeat important information: Repetition can help the person to remember important information.
4. Use positive language: Use positive language and avoid using negative words or phrases that may cause distress.
5. Ask simple questions: Use closed-ended questions that require a yes or no answer to help the person feel more comfortable.
6. Avoid arguing or correcting: Correcting or arguing with a person with dementia can cause frustration and confusion.

Non-verbal communication strategies

1. Use body language: Use non-verbal cues such as facial expressions, gestures, and touch to help convey meaning.
2. Maintain eye contact: Maintaining eye contact can help to establish a connection and show that you are listening.
3. Smile: Smiling can help to create a positive and welcoming atmosphere.
4. Use touch: Appropriate touch, such as a gentle hand on the shoulder, can help to convey reassurance and support.
5. Use visual aids: Visual aids such as pictures, photographs, and objects can help to reinforce communication and improve understanding. It's important to remember that every person with dementia is unique, and communication strategies should be tailored to the individual's needs and preferences. 

Below are some clear communication guidelines that will help you while working with a person with dementia.

Culturally sensitive and safe communication strategies

Taking cultural differences into account and respecting the person's cultural background, language, and beliefs ensures effective communication. Some effective strategies include:

1. Being aware of cultural norms and values: Understanding the cultural norms and values of the person can help you tailor your communication approach and avoid misunderstandings.
2. Using familiar language and terminology: Using language and terminology that is familiar to the person can help to enhance communication and promote understanding.
3. Being respectful of cultural beliefs and practices: Being respectful of cultural beliefs and practices can help to promote a sense of trust and respect in communication.
4. Using visual aids: Using visual aids such as pictures or drawings can help to support communication and enhance understanding.
5. Avoiding assumptions: Avoiding assumptions about the person's cultural background or beliefs can help to promote a sense of respect and understanding.
6. Listening actively: Actively listening to the person's responses and validating their feelings can help to promote a sense of understanding and trust in the communication.
7. Seeking support from cultural advisors: Seeking support from cultural advisors or interpreters can help to promote effective communication and understanding.

It's important to note that these strategies may need to be adapted based on the individual needs and preferences of the person living with dementia. Communication should always be tailored to the person's individual needs and abilities, and care should be taken to ensure that the person feels heard, understood, and valued.

Some other communication and therapeutic techniques include:

• Reality orientation
• Reassuring words, phrases, and body language
• Validation
• Reminiscence

Reality orientation

Using verbal cues or physical aids to remind the person of their surroundings or current situation to increase their sense of awareness and understanding. Examples include:

1. Use clocks and calendars: Place clocks and calendars in the person's room or living space to help them keep track of the time, date, and day of the week.
2. Provide familiar objects: Provide familiar objects such as family photographs, favourite books, or music to help the person feel more comfortable and connected to their past.
3. Label objects and rooms: Label objects and rooms in the person's living space to help them navigate their surroundings and reduce confusion.
4. Encourage conversation: Engage the person in conversation about their past experiences, including family and friends, hobbies, and interests. This can help to stimulate their memory and keep them connected to their personal history.
5. Avoid correcting or contradicting: If the person makes a mistake or has a misunderstanding, avoid correcting or contradicting them. Instead, validate their feelings and try to redirect the conversation to a more positive or neutral topic.

Reassuring words, phrases, and body language

Using calm and soothing words, gentle touch, or a reassuring tone of voice to provide comfort and reassurance to the person. Examples include:

1. Use a calm and reassuring tone of voice: Speak in a calm and reassuring tone of voice to convey a sense of empathy and understanding.
2. Use simple language: Use simple language and avoid complex sentences or abstract concepts that may be difficult for the person to understand.
3. Repeat key phrases: Repeat key phrases or concepts that may be important to the person to help them maintain their focus and memory.
4. Use positive reinforcement: Provide positive reinforcement by using words or phrases such as "good job" or "well done" to encourage the person and reinforce their sense of accomplishment.
5. Use non-verbal cues: Use non-verbal cues such as a gentle touch, a smile, or a nod to convey empathy and understanding.
6. Use physical gestures: Use physical gestures such as holding the person's hand, offering a hug, or sitting close to them to provide comfort and support.
7. Validate their feelings: Acknowledge the person's feelings and emotions and reassure them that their feelings are valid and understandable.

Validation

Accepting and acknowledging the person's reality, experiences, and emotions, even if they do not match the objective reality. This can involve using phrases like "I understand how you feel" or "Tell me more about that." Examples include:

1. Listen attentively: Listen attentively to the person with dementia and try to understand their point of view. This can help to build trust and promote effective communication.
2. Acknowledge their feelings: Acknowledge the person's feelings and emotions and validate their experiences, even if they may not be accurate or consistent with reality.
3. Use phrases such as "I understand" or "I hear what you are saying": Use phrases such as these to convey empathy and understanding.
4. Redirect the conversation: If the person is expressing distress or discomfort, try to redirect the conversation to a more positive or neutral topic.
5. Avoid arguing or correcting: Avoid arguing or correcting the person, as this can lead to frustration or agitation.
6. Provide comfort and reassurance: Provide comfort and reassurance by using calming words or phrases, such as "It's okay, I'm here with you."

Reminiscence

Encouraging the person to reminisce about their past experiences, memories, and interests to promote engagement and social interaction.

1. Use sensory cues: Memories are often tied to sensory experiences, so try to incorporate sensory cues into your interactions with the person. For example, you could play music from their era or bring in items with familiar scents like lavender or cinnamon.
2. Use open-ended questions: Avoid asking questions that require a yes or no answer. Instead, ask open-ended questions that allow the person to share more detailed stories about their past experiences. For example, you could ask, "What was your favourite vacation?" or "Tell me about your first job."
3. Use visual aids: Photographs, videos, and other visual aids can help trigger memories and spark conversations. You could create a memory box filled with items from the person's past, or look through old photo albums together.
4. Focus on positive memories: Reminiscing about positive experiences can be a mood booster for people with dementia. Try to focus on happy memories and avoid bringing up difficult or painful topics.

Communication techniques to use when a person with dementia expresses distress

1. Validate their feelings: Acknowledge the person's feelings and emotions, and let them know that it's okay to feel upset or frustrated.
2. Use calming words or phrases: Use calming words or phrases such as "It's okay, I'm here with you" or "Let's take a deep breath together" to help the person feel more calm and grounded.
3. Provide physical comfort: Provide physical comfort by holding the person's hand, offering a hug, or sitting close to them to provide a sense of security and reassurance.
4. Use distraction techniques: Use distraction techniques such as singing a song, showing a photo album, or engaging in a favourite activity to help redirect the person's attention away from the source of their distress.
5. Identify and address the source of distress: If possible, try to identify the source of the person's distress and address it directly, such as providing pain relief or adjusting the environment to reduce sensory overload.
6. Avoid minimising or dismissing their distress: Avoid minimizing or dismissing the person's distress, as this can lead to further frustration or agitation.

It's important to note that these methods should be used with sensitivity and respect for the person's dignity and autonomy. Communication should always be tailored to the person's individual needs and preferences, and care should be taken to ensure that the person feels heard, understood, and valued.

Definition of Abuse and Neglect

Abuse is usually defined as any action that causes intentional harm to the person. Unintentional harm resulting from accidents may be included under the umbrella of ‘neglect’, providing the harm is caused by negligence or failure to provide a safe environment. Neglect is usually defined as a failure to provide for a person’s needs, whether intentionally or unintentionally, resulting in harm to the person’s wellbeing, for example, failure to meet a person’s physical or survival needs by providing a safe environment, sufficient food or water, shelter and health care. It also includes failure to meet social, psychological and emotional needs, such as not helping the person take part in meaningful activity and have interaction with other people, and not providing emotional support.

Abuse and neglect are most commonly carried out by people in trusted positions close to the person, such as family members and carers. Almost always, the abuser has more power than the person being abused.

Forms of Abuse

To abuse someone is to harm or hurt them in some way or violate their human or civil rights. Age Concern New Zealand outlines various categories of abuse as follows:

Psychological abuse

• Causing mental anguish, stress, or fear. This could include:
  • Ridicule and humiliation
  • Threats, coercion, and bullying
  • Control, social isolation, and prevention of choice
  • Hostility and lack of affection.

Financial abuse

• Illegal or improper use of money, property, or other assets. This could include:
  • Unauthorised taking of money or possessions
  • Misuse of power of attorney
  • Failure to repay loans
  • Use of home and assets without contributing to costs
  • Scams rely on establishing a relationship with the older person with the intention of exploiting their savings and/or assets, for example, romance scams.

Physical abuse

• Infliction of pain, injury, or use of force. This could include:
  • Hitting, pushing, or rough handling
  • Over-medicating
  • Inappropriate use of restraints or confinement.

Neglect

• Not providing for physical, emotional, or social needs. This could include:
  • Inadequate food, clothing, or shelter
  • Lack of social contact or support
  • Not attending to health needs.

Sexual abuse

• Non-consensual sexual acts or exploitive behaviours. This could include:
  • Inappropriate touching
  • Sexual acts that are not wanted.

Institutional abuse 

• A policy or accepted practice within an organisation that disregards a person's rights or causes harm and distress. This could include:
  • Rigid routines that disregard a person's preferences
  • Lack of respect for a person's culture or customs
  • Inappropriate rationing of continence products.

Access these resources to learn more.

Risk Factors for Abuse and Neglect

Risk factors for being abused or neglected are associated with powerlessness. Risks for people who are dependent on others for their needs, such as children, people with disabilities, older people and people living with dementia, are higher than for people who are more able to speak up or defend themselves. People living with dementia, because of the nature of the disease, can experience significantly higher degrees of risk:

• Communication barriers may make it difficult for them to tell someone what is happening.
• Memory lapses may mean that they might not recall the abuse.
• Confusion may cause them to be unsure about what is real and what is not.
• Social isolation can mean that there is nobody to notice the abuse or support the person to address it.
• Negative stereotypes and assumptions about older people and about people living with dementia might affect the person’s credibility and make others less likely to believe them or take their accusations seriously.
• Devaluation may result in discrimination and ill-treatment.
• Hostile behaviours, aggression and personality changes associated with dementia may make others more likely to respond with aggression and ‘lash out’ – the stress of caring for a person with dementia may also cause these reactions in carers.

Other factors that can put a person living with dementia at risk of abuse and neglect include:

• A history of domestic abuse or family violence in the household (including abuse/violence initiated by the person with dementia)
• Substance abuse
• Severity of dementia
• Living in regional or remote areas
• Lack of awareness of rights and support service

Signs and indicators of elder abuse and neglect

Elder abuse and neglect can be difficult to detect, as older people may be hesitant to report abuse or may not be able to do so due to physical or cognitive impairments. However, there are several signs and indicators that may suggest elder abuse or neglect. Some of these signs and indicators are:

1. Physical abuse: Unexplained bruises, burns, cuts, or injuries; frequent falls or unexplained fractures; restrained or tied up against their will.
2. Emotional abuse: Agitation, fear, anxiety, or withdrawal; lack of interest or participation in activities they used to enjoy; a sudden change in behaviour or mood.
3. Sexual abuse: Unexplained sexually transmitted infections; torn, stained, or bloody underwear; unexplained genital or anal pain.
4. Financial abuse: Unexplained or sudden changes in financial situation; missing money or valuables; forged signatures or coercion to sign documents.
5. Neglect: Dehydration or malnutrition; untreated medical conditions; poor hygiene or living conditions; bed sores or pressure ulcers.

It's important to note that these signs and indicators may not necessarily indicate abuse or neglect and can also be caused by other factors. However, if these signs and indicators are present, it's important to investigate further to ensure the safety and well-being of older people.

Responding to Abuse and Neglect

As a support worker, you will be on the ‘front line’ for protecting your clients from harm and exploitation, so it is particularly important for you to recognise signs of abuse or neglect and to respond appropriately:

• Take care of any injuries the person has received, either by providing first aid or ensuring that the person receives appropriate medical treatment.
• Reassure the person, help them to feel safe and make sure they are physically comfortable. Collect as much information about what has happened to the person as you can.
• Report the situation as soon as possible to your immediate supervisor. Document your observations and actions accurately and objectively.
• Remember to always follow your organisation’s policies and procedures for responding to the abuse or harm, and reporting harm to your supervisor.

Activity - Knowledge check