Journal of Gerontological Nursing

Your Turn

Abstract

Functional status is a vocabulary concept that is central to the care of human beings and thus also to the field of gerontology. People whose functional status is classified as assisted living/personal care are those who do not qualify yet for needing skilled care and yet no longer qualify for independent living/residential care. This means that regardless of what pathologies have caused these changes in abilities, the primary aspects of functioning that this set of individuals needs assistance with are the instrumental activities of daily living (IADLs) (e.g., planning meals, using transportation, shopping, handling finances, using the telephone, managing medications).

Because we have been asked to identify the critical success factors for people with dementia who are at this level of functioning, we first must match their needs regarding IADLs with their needs according to the progression of their dementia so the related standards of care for each level may be implemented accordingly. Using the Global Deterioration Scale (Reisburg, Ferris, Leon, & Crook, 1982), we may empathize with people and their subjective reports of memory loss at Level 2 (very mild cognitive decline). However, evidence of thentransition from independence to the early need for assistance with life skills (personal care) becomes more clear at Level 3 (mild cognitive decline) and continues through Level 4 (moderate cognitive decline). Although the clinical characteristics for people at Level 5 (moderately severe cognitive decline) begin to match more closely the functional status qualifications for people needing skilled care, the presence of both a family caregiving network and a set of respite services (e.g., adult day center) can delay how soon someone at this level actually moves from the category of personal care to skilled care because family caregivers are filling in for the individual's limitations with the basic activities of daily living. People who do not have the opportunity for a network of family caregiving with respite and are living in a group setting may be classified from assisted living to skilled care with less delay.

Because the care of people with dementia can seem so intangible to those who are less aware of the substance behind and impact of behavioral approaches, a conceptual framework for dementia care that encompasses not only skilled care but also assisted living/personal care can provide a language to substantiate the difference made by the presence of professional nursing. The well-developed Progressively Lowered Stress Threshold (PLST) Model (Hall & Buckwalter, 1987; Hall & Laloudakis, 1999) delivers us from this plight. The central advantage of this framework is its ability to compress the primary complication when managing people with dementia- the additional presence of delirium (simply put, delirium can be defined as the temporary loss of emotional control that also puts one at risk for the temporary loss of cognitive and psychomotor control). By delaying the onset, holding the escalation, and limiting the duration of that collection of dysfunctional behaviors that characterize delirium, the environment for people with dementia instead can focus on providing the structure as well as the rituals and routines that promote life role behaviors.

While reflecting on the question that has been posed, the word "critical" clearly infers our need to identify that which is essential as well as influential. However, some readers may focus their responses on the word "success," which implies a greater emphasis on nursing outcomes, while others may focus their responses on the word "factors," which implies a greater emphasis on nursing interventions. Regardless of the approach to response, assisted living settings, where the presence of nursing traditionally has been limited, represent a prime site for the additional use of the seminal…

The following question was asked of the readers of the Journal of Gerontological Nursing:

What are the critical success factors for providing quality dementia care in assisted living?

From the perspective of the residents and their families who are, after all, the customers, affordability is the critical factor. Organizations need to collaborate with states to devise innovative ways to deal with the issue of affordability. Perhaps a voucher system would allow those in need of support to choose the appropriate type and level of care. SeniorCare is a proposed addition to Medicare which would offer some government-sponsored longterm care protection. Coverage may include assisted living facilities.

The best model for assisted living is community based, providing wellness information to seniors as well as assisted living. Ideally, the social environment should provide a link to those who are healthy and familiar to the residents. Families should work in partnership with the staff of assisted living facilities.

The next major success factor is a therapeutic environment that encourages people's abilities rather than simply supporting their needs, an environment that maximizes residents' competence in their daily lives by providing compatible roommates (although private rooms are preferred), increasing opportunities for socialization, and providing family-style meals and appropriate activities. Staff should function as a team to assist residents as necessary rather than a maid-servant relationship and a package of services. Cross-trained staff need continuous dialogue and education to adapt to differences in quality of life for individual residents. Each resident should have a specific "named helper" among staff.

Ideally, people should be able to age in place in the privacy of their own apartment for as long as possible. When they no longer can live independendy and require social and supportive services, the choices should allow them to feel useful with dignified life purpose in a homelike environment. Residents should be able to choose mealtimes, time of rising and going to bed, furnishings in their rooms, pets, and personal initiatives. The key to providing quality care is a successful integration of health needs with the more predominant psychosocial and emotional needs. Residents should exercise control and autonomy over life and the care they receive for as long as they are able. We must accept the fact that a balance of autonomy and choice includes a certain amount of risk. This further reinforces the need for a partnership with families.

The most critical success factor for providing quality dementia care is innovation. Organizations, and the systems in which they operate, often resort to becoming more cautious, conservative, rigid, and formalized when faced with change and declining resources. Instead, they need to look for different ways to create new value by applying creativity. If you don't do it, someone else will. An organization must "out-innovate" the competition by taking advantage of change and seizing the opportunity to produce new value. Ideas can come from many different sources including competitors, vendors, customers, followers, and all levels of staff. Vigilance, observation, and benchmarking best practices of other organizations, those that are similar as well as those that are different, are ways to produce new values that will contribute to the top line and bottom line, with quality dementia care for those in assisted living.

Marian Deutschman, PhD

Associate Professor of Communication

Buffalo State College

Buffalo, New York

Critical success factors for providing quality dementia care in assisted living include:

* A safe, secure environment without restraint.

* Permanent caregivers for each nursing shift, with permanent relief staff as well. Consistency in routine is key.

* Entering the world of the dementia residents. Do not try to bring them into your world.

* Validating dementia residents' feelings. They are true and real to them.

* Providing multi-diversion, dementia-appropriate activities that are ongoing throughout the day until early evening, and providing rest periods as needed.

* Focusing on dementia residents' strengths, while downplaying their weaknesses.

* Appealing to late-stage dementia residents' senses (e.g., aromatherapy, auditory and tactile stimulation).

* For dementia residents who are restless or who wander, a condensed, nutritional meal plan must be in place (e.g., portable food, finger foods, milkshakes).

* An ongoing staff development program with continuous updates must be present. For example, my educational programs presently occur at least twice a month, along with stress management for staff caregivers and interested parties.

Joyce Cook Planner/, RNC. CDM

RN Assessment Coordinator

Staff Development Director

Employee Health Acts

Retirement Life Care

Fort Washington Estates

Forth Washington, Pennsylvania

Success factors depend on the residents, but these are some I found with the resident I cared for most recently:

* Being really patient.

* Finding things for them to do that keep their minds busy.

* Finding foods that they like that are easy for them to eat.

* Talking with them when they want to talk (not ignoring them).

* Walking with them to keep them exercised on a regular basis.

Derrick Statt

Med-Aide, Nurse's Aide

Indian Hills Nursing Center

Council Bluffs, Iowa

Critical success factors for providing quality dementia care in assisted living:

* Community support, both laypeople and the professional community.

* Communication and collaborative interdisciplinary efforts among the facility and other facilities, institutions, and Alzheimer's associations in the area and nationally.

* Administrative support and financial commitment.

* Aggressive outcomes management team approach.

* Up-to-date knowledge of the reimbursement laws and regulations with ongoing legal support services.

* All disciplines including administration working collaboratively and consistently as an interdisciplinary dementia care team.

* All members of the facility educated and certified in care of individuals with Alzheimer's disease and related dementias, with ongoing continuing education on Alzheimer's disease and related dementias, terminal care, pain management, and other issues related to older adults and their families.

* Family involvement and support and education on a continuing basis.

* Facility designed specifically for individuals with dementia.

* All disciplines represented or available for consultations.

* All staff recognized and rewarded periodically for their commitment and efforts in their care of individuals with dementia and care of their families.

* Gerontological nurse practitioners and gerontological clinical specialists actively involved.

* Recreational therapy and pastoral care emphasized.

* The facility becomes a resource and expert in some important aspect of dementia care both in the immediate community and in professional membership and active involvement in Alzheimer's associations.

* Ability to provide continuity of care throughout the stages of Alzheimer's disease and related dementias.

Georgia P. Ameia Yen-Patton,

RN, MS, CS, GNP

Gerontological Nurse Practitioner

Southcoast Hospital Group

Charlton Memorial Hospital

Fall River, Massachusetts

Staff and family education is essential for quality care. Educating family members as to the trajectory of dementing illnesses helps to avoid unrealistic expectations that their loved ones will recover and come home. Similarly, staff education is equally as important, especially when care is being given by unlicensed assistive personnel. Unrealistic expectations as to "proper" client behavior could lead to abuse or neglect of these care-dependent older adults. A comprehensive educational program for both staff and families, therefore, will promote an exceptional quality of care.

Timothy J. Legg, RN, BSN

Director of Staff Education/

Quality Assurance

Taylor Nursing and Rehabilitation Center

Taylor, Pennsylvania

Functional status is a vocabulary concept that is central to the care of human beings and thus also to the field of gerontology. People whose functional status is classified as assisted living/personal care are those who do not qualify yet for needing skilled care and yet no longer qualify for independent living/residential care. This means that regardless of what pathologies have caused these changes in abilities, the primary aspects of functioning that this set of individuals needs assistance with are the instrumental activities of daily living (IADLs) (e.g., planning meals, using transportation, shopping, handling finances, using the telephone, managing medications).

Because we have been asked to identify the critical success factors for people with dementia who are at this level of functioning, we first must match their needs regarding IADLs with their needs according to the progression of their dementia so the related standards of care for each level may be implemented accordingly. Using the Global Deterioration Scale (Reisburg, Ferris, Leon, & Crook, 1982), we may empathize with people and their subjective reports of memory loss at Level 2 (very mild cognitive decline). However, evidence of thentransition from independence to the early need for assistance with life skills (personal care) becomes more clear at Level 3 (mild cognitive decline) and continues through Level 4 (moderate cognitive decline). Although the clinical characteristics for people at Level 5 (moderately severe cognitive decline) begin to match more closely the functional status qualifications for people needing skilled care, the presence of both a family caregiving network and a set of respite services (e.g., adult day center) can delay how soon someone at this level actually moves from the category of personal care to skilled care because family caregivers are filling in for the individual's limitations with the basic activities of daily living. People who do not have the opportunity for a network of family caregiving with respite and are living in a group setting may be classified from assisted living to skilled care with less delay.

Because the care of people with dementia can seem so intangible to those who are less aware of the substance behind and impact of behavioral approaches, a conceptual framework for dementia care that encompasses not only skilled care but also assisted living/personal care can provide a language to substantiate the difference made by the presence of professional nursing. The well-developed Progressively Lowered Stress Threshold (PLST) Model (Hall & Buckwalter, 1987; Hall & Laloudakis, 1999) delivers us from this plight. The central advantage of this framework is its ability to compress the primary complication when managing people with dementia- the additional presence of delirium (simply put, delirium can be defined as the temporary loss of emotional control that also puts one at risk for the temporary loss of cognitive and psychomotor control). By delaying the onset, holding the escalation, and limiting the duration of that collection of dysfunctional behaviors that characterize delirium, the environment for people with dementia instead can focus on providing the structure as well as the rituals and routines that promote life role behaviors.

While reflecting on the question that has been posed, the word "critical" clearly infers our need to identify that which is essential as well as influential. However, some readers may focus their responses on the word "success," which implies a greater emphasis on nursing outcomes, while others may focus their responses on the word "factors," which implies a greater emphasis on nursing interventions. Regardless of the approach to response, assisted living settings, where the presence of nursing traditionally has been limited, represent a prime site for the additional use of the seminal works by colleagues in the the College of Nursing at the University of Iowa. In the past decade, their published research has produced the primary tools for the nursing profession to use with informatics in proving the unequivocal difference nursing makes - two editions of the Nursing Interventions Classification (NIC) (McCloskey & Bulechek, 1996) as well as the Nursing Outcomes Classifications (NOC) (Johnson & Maas, 1997). Dr. Kathleen Buckwalter (1998), the Editor of the Journal of Gerontological Nursing, also alerted readers to the advancements made by the National Gerontological Nursing Association in identifying the gerontological core interventions from the NIC.

As long as we practice nursing based on the status quo, the critical success factors for providing quality care to anyone in assisted living will be limited. In fact, a solid theoretical foundation for the practice of nursing in personal care must include active preservation of functional status (through the application of the above principles) rather than merely maintenance of the same. Without these efforts to make a difference, one's length of stay in assisted living will be reduced, while the speed of progression of the dementia, as well as every other existing chronic illness, will be accelerated.

Crook, T. (1982). The global deterioration scale for assessment of primary degenerative dementia. American Journal of Psychiatry, 139, 1136-1139.

Barbara Hassinger Conforti,

MSN, RN, CS, CRNP

Faculty - Gerontology

Lancaster Institute for Health Education

School of Nursing

Lancaster, Pennsylvania

This question was submitted by Mary Knapp, MSN, CRNP1 NHA, FAAN, President, The Whitman Group, Huntington Valley, Pennsylvania. Her commentary follows:

Thank you for all your responses to my question. Since I first posed this question, a new publication has come to my attention, Developing an Alzheimer's/ Dementia Care Program, A Guide for Meeting the Needs of MemoryImpaired Residents by Assisted Living Federation of America (ALFA) and Assisted Living Education and Training. It is a wonderful how-to manual and training system.

REFERENCES

  • Buckwalter, K.C. (1998). Interventions for specialty practice. Journal of Gerontological Nursing, 24(7), 5.
  • Hall, G.R., & Buckwalter, K.C. (1987). Progressively lowered stress threshold: A conceptual model for care of the adult with Alzheimer's disease. Archives of Psychiatric Nursing, 1, 399-406.
  • Hall, G.R., & Laloudakis, D. (1999). A behavioral approach to Alzheimer's disease: The progressively lowered stress threshold model ADVANCE for Nurse Practitioners, 7(7), 39-46, 81.
  • Johnson, M., & Maas, M. (Eds.). (1997). Nursing outcomes classification (NOC). Sl Louis: Mosby.
  • McCloskey, J.C., & Bulechek, CM. (Eds.). (19%). Nursing interventions dassification (NIC) (2nd ed.). St. Louis: Mosby.
  • Reisburg, B., Ferris, S.H., Leon, M.J., &

10.3928/0098-9134-19991001-13

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