• rapid mood change
• stubborn resistance
• pacing or wandering
• paranoia
• crying
• hysterical laughter
• sudden self-isolation, refusal to speak
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Remember, all behavior has a reason. It is a response to external, internal, or invisible stimuli. But you handle a catastrophic reaction differently from a behavior problem. With a catastrophic reaction you take specific steps immediately to make the situation manageable and then think about it later, to keep it from happening again. The immediate well-being and safety of both you and your partner is your prime concern. With a behavior problem you need to be the detective and determine causes as you try for a solution. A behavior problem can be managed gradually because it is not an immediate, serious, dangerous, or potentially dangerous situation.
Bea’s husband, Theo, is moderately impaired but becomes extremely anxious and even angry if he cannot concentrate on things he used to be able to do with ease. The city was repairing the road in front of
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Box 3-5. What to Do If a Catastrophic Reaction Occurs
1. Reassure your partner (“Everything will be okay; it’s all right”). Make sure you act, look, and sound relaxed and calm (positive interaction techniques). Caution: If the person is very angry, reassure from a distance.
2. Reduce all outside stimulation and hazards. Stimulation includes loud music, a barking dog, children running or playing close by, the dishwasher running, the television, or anything else that could be irritating. Remember the importance of having a calm, pleasant, and reassuring environment. Remove objects that could cause harm, such as scissors or hot coffee.
3. If reducing stimulation and removing hazards is not feasible, remove your partner. For example, if the dog barking bothers your partner, close the window or try to mask the sound with soft music. If that doesn’t help, take your partner to another area of the house. Don’t try to force your partner to move, however, as he or she will only become more upset. Stay calm, pleasant, and reassuring.
4. Reassure again. Try touch now if your partner was too upset to approach before. Don’t get too close if the person is still very angry.
5. Redirect to an easy, soothing activity in a quiet area. This does not mean a card game or anything too challenging or stimulating. It might be quiet, soothing music. Sing or hum along. You might try holding hands or giving your partner a neck rub. Looking at a favorite photo album or eating a favorite cookie might be good. Note: Think about putting some of your partner’s favorite soothing things in a spot easy for you to get to “just in case” a catastrophic reaction takes place.
6. Be patient. Waiting for a catastrophic reaction to stop can seem like forever.
7. If you cannot stop it or if the person’s anger is directed at you, leave your partner alone if it is safe (remember to remove hazardous objects). “Alone” means ten feet away or in a corner so you are inconspicuous (someplace where you can see your partner but he or she cannot see you is best). You do not want to become part of the problem or a greater part of the problem. If you try to stay too close by, try to soothe your partner when he or she is not ready, or try to argue, the person’s anger may be redirected toward you or may increase toward you.
8. When your partner is calmer, return as if nothing has happened. Don’t ask, “Why were you angry?” or “Why did you yell at me?” It hurts when you are trying to do your best and your partner lashes out at you. Remember, however, it is the disease talking. Your partner cannot help it and may not even remember the incident afterward.
9. After it is over, you need to think about the incident. It is probably the last thing in the world you want to think about again, but it is necessary. Remember, common causes of catastrophic reactions are the same as those for behavior problems. They are just sudden, more severe reactions. Perhaps take notes in your care-giver notebook. Try to think it through to see whether there is anything you can do to try to keep it from happening again.
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the house one morning. The noise of jackhammers and the trucks was very loud. Theo could not concentrate on his favorite game show. He turned off the television and spent the rest of the morning pacing around the living room.
Theo usually helped Bea make sandwiches for lunch but could not concentrate and kept stopping as the noise continued. He finally went to the front door and started to go out. He appeared very angry, and Bea was afraid he would run in front of the trucks or, at the very least, start shouting at the workers. She stepped in front of him and told him to stop. He then transferred his anger to her, told her “No,” and pushed her against the doorjamb. He ran out the door, waved his arms, and told the workers they had to stop. A next-door neighbor, who often helped Bea out and knew Theo had dementia, finally approached Theo calmly and got him to go back inside with him.
After the incident Bea assessed what she had done wrong. She realized that the loud noises had made Theo upset and that, because she had stepped in front of him, he had transferred his anger to her. She also realized that the neighbor stepping in when she was not there was what is called a “change of face.” It is when a calm person not associated with the original problem is able to step in and distract an angry person with dementia. They had discussed it in a support group.
The next day the work continued. Bea put on soft music to mask the noise a little and led Theo to the television in the bedroom—at the back of the house—to watch his show. When she saw him getting a little angry and heading for the front door, she called him back softly. She did not mention the noise but told him she needed his help with something in the backyard (away from the noise). She gave him the hose to water the garden because he always enjoyed this. She did not hover over him asking if he was all right; had she done so, she might have become part of the problem again. She stayed inside watching him through the window, and she could tell when he became more relaxed. When he was calm, she went out, did not mention the incident, and thanked him for watering. They went for a drive and had lunch out to avoid the noise for the rest of the afternoon. When they got back, Bea again turned on soft music. Fortunately, the roadwork was completed by the end of that day, and they did not have to cope with the noise again.
Caregivers: Try not to worry too much. You may never face a catastrophic reaction with your partner, but it is best to be prepared!
4 Safety for You and Your Family Member with Dementia
Goal: This chapter will help you protect yourself and your partner in three different ways. It will tell you how to use good body mechanics when assisting your partner to move about; protect both of you from infection through the use of good infection-control techniques; and make your home environment safe.
Use Good Body Mechanics
Using good body mechanics means using your body in the correct and safe way for tasks such as lifting or moving objects or helping someone up or down to a chair or bed. Good posture, balance, and the use of your largest and strongest muscles are very important. We must all use good body mechanics to protect our backs and other muscles all the time and certainly in caregiving.
Body mechanics are ways the parts of your body work together when you move. Good body mechanics require good body alignment, using your center of gravity, and having a base of support. It will save you energy, and it will prevent injury when you push, pull, or lift objects or assist your partner.
Good Posture
Lifting and moving things are common tasks, and there are correct ways to do them. When you are performing these tasks, use good posture. You should have your:
• head erect
• shoulders back
• buttocks pulled in
• chest high
• stomach muscles tight
• back straight (as you begin to lift)
Good Body Alignment
Good alignment—having your body parts in the proper relationship to one another�
��is the heart of good posture and is essential to good body mechanics. Remember when your mother used to say, “Sit up straight”? When you did, your body was aligned well. When your body is in good alignment, several good things happen:
• You have more lung capacity and can breathe more easily.
• Blood circulates better, food digests easily, and your kidneys function more efficiently.
• Your body is in balance and is better protected from muscle strain and injury.
• You avoid complications from immobility, such as contractures and muscle atrophy.
For your body to be in good alignment, you need to:
• Keep a wide base of support. This will keep you more stable while you move or lift your partner. Your feet should be twelve inches, or hip width, apart. Your feet are your foundation.
• Have a stable center of gravity. Your center of gravity is the point where the most weight is concentrated in your body. When you are standing, your weight is centered in your pelvis. When you lift or move something, you must bend your knees so that your center of gravity is lower, giving you more stability. Bend your back as little as possible in the movement. This protects you from injury and falls.
Use good body mechanics whenever you lift or move something because even small lifting tasks can cause injury. Be sure to use them when:
• cleaning a floor
• carrying trash or the trash can
• picking up and/or carrying luggage
• putting things in the closet
• helping your partner adjust him- or herself
• taking off your partner’s shoes or pants when he or she is in a chair or bed
• helping your partner into or out of the bathtub or shower
Transferring, Positioning, Lifting, Ambulation, and Use of Assistive Devices
Ensuring your and your partner’s safety when you are transferring, positioning, lifting, and ambulating him or her depends on the use of good body mechanics. There are several other important safety guidelines.
Think ahead. You must assess the load and the stress on your body that a task will cause. As a caregiver, you may be taking on some additional household chores that you are not used to doing. When you are tired or stressed, you tend to forget to “think before you act.” You may pick up something or move something without paying any attention. When you are tired or stressed, it is even more important to assess whether or not you can do the task safely.
Walk through the task mentally first. You need to figure out if, by using good body mechanics and other rules of lifting, such as positioning or transferring, you are physically able to do the job.
If you have any doubt about it, ask a neighbor or family member to help. If any aspect of caring for your partner is too strenuous for you, you may need to consider home care for the heaviest tasks. If you continue to do it alone, you may injure yourself, and then you and your partner will both need care! It’s not worth the risk.
Assess the environment for safety. Can you complete the task at hand safely in the existing environment (the surroundings through which you must move)? Do you have a clear pathway? Is the floor wet? Is the telephone cord in the way?
Communicate with your partner. If the person can understand, decide exactly what you are going to do together. Agree on verbal cues to use before starting. If your partner can no longer communicate verbally, you should still communicate in other ways. Just because the person cannot communicate verbally does not mean he or she does not understand. Always communicate what you are about to do verbally and nonverbally (using touch or visual cues).
Allow extra time when working with your partner. With someone who has dementia, you must redefine success. If your idea of success is for your partner to move and do things as he or she has always done, then you are setting yourself and your loved one up for failure. The person has a disability and can no longer function the way he or she used to and cannot do things in the same amount of time as before.
Mrs. Smith needed to get her husband, Henry, ready to go to the day care center at 9:00 A.M. At 7:45 she woke him up to get dressed. She told him that he must get up. Ten minutes later she went back to the bedroom, and he was still lying in bed.
Henry did not understand her directions, did not remember them, and did not have the organization of movement skill necessary to sit up in bed. Mrs. Smith became stressed and frustrated. She knew she must help him sit up. She then:
• Tried to relax and took time to think through how to get her husband up from bed.
• Assessed the room for safety, adjusting the position of the chair where he would sit.
• Made herself slow down, realizing that she hadn’t allowed enough time; she resigned herself to arriving at the center late.
• Made sure she communicated well with Henry; she told him what she was doing and what she needed him to do as she helped him, step by step (see chap. 3 for information on good interaction techniques).
Important: Dangling is an odd term, but it is important when assisting your partner to get up safely, and it is important for you to do too! It refers to sitting at the side of the bed for one to three minutes to gain balance and adjust to an upright position before standing up. It is a good practice for all of us as we grow older.
Transferring
Moving someone from one position and place to another is called “transferring.” In addition to the use of good body mechanics, it is helpful to keep in mind several basic points when transferring:
• If your partner has a weak side due to injury or illness, plan the move so that the stronger side is moved first.
• Assess if it may be safer to use a gait/transfer belt (a wide canvas belt that fits around the waist of the one you are assisting to transfer or walk).
• Be sure the furniture involved (bed and chair or wheelchair, for example) will not move or tip. Make sure a wheelchair is locked.
• Give yourself plenty of room. Check your environment (for example, see if the wastebasket, towel rack, chair, or footstool in the bathroom are out of your way or are positioned where you need them).
Positioning
Positioning is moving a person into a more comfortable or beneficial body position. Too much pressure on one area for too long can cause a decrease in circulation.
Correct positioning helps a person obtain good body alignment and promotes well-being and comfort.
Changing positions frequently prevents muscle stiffness and skin breakdown. Pressure sores from skin breakdown are very dangerous because they can become very difficult to heal.
To position someone correctly, remember to use good body mechanics. You may need:
• pillows to provide support
• positioning devices (such as a back rest, a wheelchair positioning cushion, or other items to help with good body alignment and prevent complications from incorrect positioning)
Figure 4-1 shows the proper positioning for someone lying in bed.
Lifting
When lifting your partner, you will need to use good body mechanics. Remember to:
Fig. 4-1. Proper positioning for lying in bed.
Fig. 4-2. Incorrect and correct lifting technique.
• assess your load
• check your base of support
• face what you are lifting
• bend your knees
• contract your stomach muscles as you begin the lift
Figure 4-2 shows correct and incorrect lifting techniques.
Ambulation
A person’s ability to walk is called “ambulation.” It is important that we all walk regularly. Even a few times around the block each week with your partner can make a difference in oxygen intake, decreased stress, increased lung expansion, and strengthened muscles. It can also be a time to become closer to your loved one as you are outside enjoying life together.
You need to make walking inside and out safe for your partner. You must be a scout, looking out for dangers ahead. Your part
ner’s shoes should be skid resistant and must fit well. Shoestrings must be tied. The area in which you are walking must be free of clutter and anything your partner could trip over. During walks outside, watch for sidewalk cracks, uneven edges, branches, stones, and sudden changes in level. Hold your partner’s arm to steady him or her and walk more slowly in areas that appear uneven. Make sure your partner uses that walker or cane if he or she has one!
Assistive Devices
If your loved one uses a cane or walker, you will need to know the correct way to use these assistive devices to prevent falls or muscle strain. Ask your physician first and then, when you purchase a device, make sure the salesperson provides a demonstration and written instructions with a diagram. (Important: You may be able to be reimbursed for the purchase of this equipment through Medicare or your health insurance if you have a doctor’s prescription.)
Use Standard Precautions for Infection Control
Safety in the home includes removing risks of infection. Standard precautions are effective methods of infection control used by medical professionals. You must treat all body fluids as if they are infectious. Even though they did not necessarily say it in these terms, this is why your parents taught you to wash your hands after you use the bathroom.
Hand Washing
The easiest and most important way to fight the spread of infection is to wash your hands properly. Hand washing reduces the spread of disease and provides significant benefit with little or no effort or cost. Clean hands can’t prevent colds because many viruses are transmitted through the air when an infected person coughs or sneezes; however, many viruses can cling to skin or inanimate surfaces such as doorknobs and railings.
The quick-and-easy hand washing done by most of us does not remove the risk of infection. It is important not to touch any dirty utensils or parts of the bathroom that are not clean during and after hand washing. This includes the sink, faucets, soap dish or container, and wastebasket. Here is a list of hand washing steps using standard precautions:
Joy A. Glenner Page 6
