Strategies for ADL Care in Dementia

Caregivers in nursing homes face many challenges in providing daily care for residents who are living with dementia. The need for assistance with ADLs can be profound. Yet at times, it may seem a resident is fighting against daily care tasks. A resident may stiffen their body, become verbally or physically aggressive, or grip onto furniture to prevent you from doing your job, say Backhouse et al. in a recent article for Dementia.

Difficulties in providing ADLs can generate stress among caregiving staff and residents alike. Inability to complete ADLs can threaten a resident’s well-being. While CMS standards ensure a resident’s right to refuse care, caregivers are also obligated to assess and document reasons for refusal, while exploring person-centered interventions.

Framing the behavior

“Dementia is a progressive neurological condition with a range of cognitive and behavioral symptoms,” the authors remind us. This means that “behaviors related to dementia can be framed and termed in different ways.” It’s sort of a you-say-potato dilemma. For example, what a caregiver may understand as “agitation” may be registering as “frustration” for the resident with dementia.  

Burley et al., who investigated terminology, noted that some of the language used to describes BPSDs is often stigmatizing and unproductive. They advocate for “a reconceptualization of BPSD terminology.” One of their examples is: “the term ‘agitated/hard to handle’ would benefit by clearer, contextualized description, such as ‘frustrated with cognitive decline, discriminatory behavior and inadequate support systems.’"

How we frame our understanding of challenging behaviors and what we call them can have an impact, explain Backhouse et al. They suggest that one way to look at resistance is to consider it as “meaningful communicative actions by the care recipient invoked from the care interaction.”

In fact, communication is key, the authors say. A resident who has dementia “may not understand the caregiver’s intentions, resulting in either intentional or reactional refusal of care.”

Person-centered care: five strategies

The authors identified five strategies used by both family and nursing home caregivers, which all relate to person-centered care:

• Finding the right moment to care: This can involve addressing unmet needs first, changing the timing of care, or leaving and returning later.
• Using specific communication strategies: Encouraging the resident and explaining what you are about to get the resident on board.
• Simplifying, leaving, or adapting care: Adapting care is a type of problem-solving that builds on your understanding of the person. An example could be using dry shampoo for a resident who is uncomfortable taking a shower today.
• Having confidence in care: The emotional tone of a caregiver is a powerful influence. A positive, confident approach can sometimes make the resident feel more comfortable about the caregiving activity.
• Seeking support from others when safety is at risk: In some situations, teamwork makes it easier to assist the resident and protects everyone’s safety.

If a resident is experiencing BPSDs such as paranoia or delusions, neuropsychiatric assessment, diagnosis, and clinical consultation are fundamental to creating an effective plan of care.

Know the resident first

Effective care strategies build on the idea of knowing the person, the authors emphasize. This can be challenging if a resident is not able to communicate well. Involving family members “can help the resident with dementia maintain a sense of identity and help staff get to know the residents,” according to the blog, Dementia Care: Families Can Improve Quality of Life.

Knowing each person you are caring for and recognizing their reality are fundamental to person-centered care.  Backhouse et al. note that getting to know the resident can help staff establish successful routines and help build trusting relationships. For training and support in working with your residents, reach out to the GuideStar Eldercare team. We’re here to help.