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long term care

toothbrushesProviding mouth care to the elderly who have dementia, brushing their teeth in particular, is often a challenging task for caregivers. Thanks to Rita Jablonoski, PhD who has 30+ years nursing home experience, we can explain a few things and offer some advice on the topic. If you have encountered someone who is resisting mouth care, even biting during it, this information should be helpful.

First, the best place to do mouth care is at a sink (bathroom is best, but even the kitchen sink will work) because the familiar setting will ease the anxiety being experienced by the person who has dementia. A mirror at eye level, whether the person is standing or sitting, is also helpful as it helps to reinforce self-care memories.

Second, smile a lot! This may sound overly simple, but the mouth care you are trying to give may seem threatening to someone with dementia. If you have a big smile on your face they may be less threatened. Also lower the pitch of your voice because this makes it easier for them to hear you (as we age, it is harder to hear the higher pitches.)

Allow them to do as much as possible. If you are afraid they aren’t doing a good enough job, however, you have a few options. You can guide their hand or pantomime the mouth care to guide them along. Try putting the toothpaste on the brush for them. It may also be helpful to just let them hold a toothbrush while you do the mouth care.

Some things to avoid include trying to reason with someone who has dementia as this will only increase the likelihood of their resistance. Instead, use simple one-step instructions, giving them time to process the request before you repeat it. Resist the urge to talk to them in a baby-talk manner using plural pronouns such as, “It’s time for us to brush our teeth.” This is called “elderspeak” and has been documented by nurse researchers as a guarantee for care resistance. It also raises dignity issues. People with dementia will forget many things, but they will not forget that they are an adult.

Try singing while performing mouth care if you meet with resistance. This will sometimes distract the person with dementia and if they sing along, you will have easier access to their teeth. Giving them something to hold on to such as a stuffed animal may provide comfort and help melt their resistance. Talking about their favorite things also serves to distract and relax someone with dementia. Sometimes getting creative works too. Rita describes an approach that worked for a lady in a wheelchair who clenched her teeth during mouth care. The staff tried sitting her in front of a mirror as they stood behind her, reaching around to do mouth care. This worked like a charm in her case as long as she could see herself in the mirror.

One more thing. Remember to use tepid water as gums recede as we age, making teeth especially sensitive to cold water. And make sure the toothbrush has soft bristles.

An alternative to brushing is flossing, but not with the typical waxed string. This flossing is done best with a small toothpick-like device called a proximal brush or interdentate stick. They can be used like toothpicks to go in between the teeth, and when dipped in mouthwash they are even better. After this type of flossing, tooth brushing may be met with less resistance. Rita recommends having the resident say “EEEEEEEEEEE” during this particular type of mouth care.
Rita admits that there is no sure way to get people with dementia to cooperate with a caregiver’s efforts to brush their teeth, but the advice she offers is to just keep trying. Her decades of experience has proven that eventually resistance will diminish with time.

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pain elderlyApproximately 88% of seniors experience chronic pain. [1] The simple process of aging leads to conditions (the most common being arthritis) that can cause chronic pain. Seniors are typically less active which makes them vulnerable to muscle rigidity and joint calcification, all potential pain makers. As we age, because our sensation decreases, we become less coordinated and our movement (mobility) less fluid. This dynamic of aging greatly contributes to the statistic that one in three adults age 65 and older experience a fall each year. [2] And unfortunately as we age, healing from injuries takes longer.

About 20% of older adults take pain medications several times a week, usually for joint or muscle related pain. But, there are many other types of pain experienced by the elderly, especially those who live in nursing homes.

Nursing home residents typically have suffered many losses. Home, career and an independent lifestyle are given up to satisfy their need for 24-hour care. Pile on just a tad of chronic pain and you’ve got a recipe for a downward spiral into helplessness, anxiety and depression.

And nowhere is this dynamic more prevalent that in the nursing home setting.

If not taken seriously by caregivers, reports of pain by an elderly person can be discounted. When reports of pain are not taken seriously, it can be very upsetting to the person in pain which in turn makes their pain management more challenging as pain levels may be reported inaccurately or not at all.

It is the person experiencing the pain who knows just how much of it they are feeling. Pain is whatever the (older) person says it is, and exists whenever they say it does. But if on older person stops reporting pain to their caregivers, it is difficult to help them. Here are the signs to look for when someone is in pain: [3]

  • Facial expressions such as grimacing, breathing changes or sighing heavily are signs of pain or distress.
  • So are unusual body movements such as wincing or limping.
  • Behavioral changes such as not wanting to eat, sleep or socialize can be signs of pain.
  • Also emotional changes such as crying or irritability may be a sign that someone is experiencing pain even though they are not admitting it. 

Certified Nursing Assistants (CNAs) are trained to report any unusual change in their nursing home residents, especially signs of pain. And CNAs routinely report unusual pain to their charge nurse, but the savvy CNA knows that there are also other ways to help their residents who are experiencing pain.

Many pain-relieving alternatives may be included on a resident’s care plan such as a warm shower or bath, the application of heat or cold, or regular repositioning. But because CNAs spend so much time with nursing home residents, they can do other things that will encourage relaxation and perhaps even relieve pain. The following activities can be carried out by a CNA or any other caregiver in any setting, because they are techniques that utilize simple kindness and gentle human touch.

Listening is first

In the CNA world, we call it Therapeutic Communication. It bears repeating that senior citizens who live in nursing homes have, for the most part, experienced many losses. At a minimum they have given up their independent lifestyle. Compound the sadness they may be feeling, with the chronic pain that typically accompanies old age and you have a double dose of pain.

CNAs are taught to encourage residents to talk by asking open ended questions and then listening. CNAs know how important it is to be authentic when listening to a resident who is sharing their feelings. When a CNA is truly listening to a resident, the result is validation for the resident. This feeling of validation for someone who may be feeling disenfranchised can be a great source of comfort and a miracle pain reliever – at least in an emotional sense.

Empathy is Essential

It is not enough to just “feel sorry” for someone who is suffering if you want to help ease their pain. The empathetic CNA is able to “feel” their residents’ pain (while not taking it own as their own) in a way that enhances the care they give. This empathetic approach to caregiving shows in ways that only the nursing home resident can feel. When a CNA delivers daily care with empathy (vs sympathy) the result for the resident spreads across the board into all areas of their life in the nursing home – and makes it better, therefore helping with any pain they may be feeling.

Restorative Care Helps with Chronic Pain

People who live in nursing homes, as opposed to those who are there for short term rehabilitation from an injury or illness, receive Restorative Care. Restorative care is designed to optimize a resident’s experience in the nursing home by involving them in as many aspects of their activities of daily living (ADLs) as is possible, with independence fostered in every aspect of their care. Involvement in social activities is encouraged. Choices abound. It would be easy for a resident in a nursing home to feel as if they are giving up control, but with the right recipe of Restorative Care, they will feel empowered by the choices and decisions they are making for themselves. Good Restorative Care makes for a happier resident. A happier resident naturally experiences less pain.

Simple Ways to Help with Physical Pain

A soft, gentle touch in the form of a hand, foot or back massage can also help to alleviate physical pain. The benefit of gentle, relaxing massage is well documented. [4] Gentle stroking, kneading and light pressure can lubricate joints and assist in the pain management of people who suffer from the stiffness of arthritis according to the Touch Research Institute. Massage for the elderly also has physical and mental benefits that can improve their health and general well-being. At a minimum, a gentle massage of the hands, feet or back can result in a deeper, longer and more regenerative sleep and an overall state of greater well-being. A therapeutic massage given by someone trained in the treatment of the elderly can result in increased range of motion, strengthening of muscles and improved posture. But a soothing massage from a caregiver can go a long way in improving the quality of life for someone living with chronic pain.

Most nursing home residents who live with chronic pain are under the watchful eye of a physician and nursing staff who know the benefits of pain medication. And every nursing home resident benefits from being under the watchful eye of a caring CNA who listens to them and from time to time administers a kind and gentle human touch.

Bo Ramsey is a CNA Instructor at Express Training Services, LLC at the Destin Training Center. ETS is home based in Gainesville, Florida and has several other training centers in Florida that offer fast-track instruction for certification in many healthcare occupations. For more information call 866-346-0660 or go to expresstrainingservices.com

[1] http://pain.about.com/od/whatischronicpain/a/elderly_and_pain.htm

[2] http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

[3] http://www.partnersagainstpain.com/pain-management/caregiver.aspx

[4] http://www.pacificcollege.edu/acupuncture-massage-news/articles/979-therapeutic-benefits-of-massage-for-the-elderly.html

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