Dementia & Quality of Life versus PPE & Covid-19

The challenge never to compromise on our resident and staff safety. People living with Dementia and Alzheimer’s disease face genuine challenges when it comes to:

• Remembering people.

• Perceptions – of people and places.

• Orientation of areas, orientation to people they hold dear to their hearts, and adjustment to their regular routine.

• Altered sense of self due to changes in personality (from brain demise).• Altered understanding of brain function (depending on the type of dementia involved).

• The gradual introduction of Psychosis into their world, due to altered chemical states in the brain and disentanglement of vital brain neurons.

• Increased levels of anxiety, due to fear of failing and letting others down. At Nazareth Care, it is imperative that despite all the above, we introduce Quality of Life through person-centered approaches (combining Occupational therapy, clinical care, and family involvement). 

This method takes into consideration the person before dementia became apparent. We have to realize that the person that has dementia, has a limited view of current self-most of the time so they begin to internalize and revert to any form of typical memories of self that they can find and stabilize on. Therefore, it is difficult for families to understand why their loved ones do not recognize them. We have to remember that if the individual with dementia has the reality that they are 50 and not 85, then in their minds, their child is 20 and not 50, so they would probably only recognize a photo of their child at age 30.

We base activities and interests on the person before the illness settled in. We gain information from the families and social workers through our excellent tool called Nazareth Care Lifelong Story Book, and from here, we develop Quality of Life Passports. 

We then create working ‘’toolboxes’’ full of information to center and ground the person, surrounding them with items, music, and familiarity based on their current world that they remember. This is vital to Quality of Life. It helps alleviate fear and reduces confusion. Similarly, we reduce medication in the form of sedation so that the person is not sleepy and more confused. We like to get to know the real person instead of getting to know the side effects of medication. 

Now we face new challenges. The introduction of PPE (masks, visors, and ‘’space suits’’ and gloves) into the world of Dementia and Alzheimer’s residents.

It is already difficult working in a unit where the residents see the barrier with regards to care uniforms and nursing epaulets (they just do not understand it and fail to approach someone that is dressed differently; this is due to suspicion and anxiety)versus regular clothing.

We as RNs in the unit, tend to come to work with our epaulets on and then take them off during the day, only wearing them in meetings or around clients – this allows us to become more approachable at the level of the resident. We prefer scrubs with a simple first name on it.

When we approach residents, we point to our names and pronounce it and never ask the resident: ‘’ Who am I?” thus making them more anxious, like they have to answer a test. We give them our names. ‘’Good morning Mr. X, it is me, Melody…. look here is my name ….”. With repetition, some residents learn our names and touch your name on your top or name badge and try and say it.• Regardless of PPE, our mood is easily felt by our residents. As our residents ‘’loose’’ more of their sense of reality, they gain more perceptual abilities and absolutely rely on their senses. They can detect even a micro change in one’s voice, tone, and speech, and they will hold you accountable for it. They will either calm down or become nervous and anxious about the changes as their stable is again changing and ‘’threatened’’ in their world.

When wearing a mask in dementia/Alzheimer’s unit:

o Most residents tend to have some form of hearing impairment – especially with Alzheimer’s disease. This is normal as the auditory nerves are infringed upon by the disease. We need to remember that masks muffle our voices, so we need to speak more clearly and more audibly, without shouting Instinctually, the residents try and rip them off from our faces as they are afraid of ‘’this being with no mouth or nose’’. If the resident does this, we have to wash and disinfect their hands to prevent contamination from contact with our mask. We always need to knock when entering a resident’s private space. This prepares them for us entering the room, and as we enter the room, it is vital to say: ‘’Hello Mr. X, it is me Melody – do not be alarmed, I am wearing a mask to protect you from a virus, and I want to keep you healthy.’’ If the resident is sitting facing towards you upon entering the room, remain far away first and pull your mask down, unhooking the elastic from one of your ears, and say: ‘’Mr. X, look it is me Melody, but I have to wear this mask to keep you safe’’, put the mask on again properly and then walk up to him or her.

If you are not in a good frame of mind, or anxious – do not go into the resident’s room, as you will not gain their trust and you will not gain the desired effect that you wanted to as they will only be picking up on your mood, affect (body language) and their input of who you are i.e. your face is half missing, and they will be left anxious, confused and just irritated, lost and sometimes scared.• Sometimes it is good to make a game out of it, in a group gathering or when the resident is eating food and getting in a good sensory input; go to them and say: ‘Look at me Mr. X, I look so funny – I am sure you can laugh at me today’’ and turn it into a positive.• If we know the resident is severely depressed and can greet from a doorway, sometimes we need to wear our visor and remove the mask so that they can see who we are.• We need to remember that visors, reflect in the sun and this is very scary for Alzheimer’s residents with visual hallucinations. Reactions vary, and we need to be sensitive to the resident.• If the resident is suspicious, and you know the resident’s likes and dislikes, hum their favorite tunes and songs when in their presence to deter them from the unknown. Bring them back the known.• Always ask permission of the resident before you approach them in PPE, hold their hand, or touch them. Remember, to them; you are a stranger in strange clothing.• Once again, bring back the familiar – place a sticker on your PPE – and put your name tag on.• Keep your voice as consistent as possible.• Remember other communication tools i.e. blackboards to write on, if the resident cannot hear you and remember to service and unblock (care for resident hearing aids), they are much needed due to muffled speech from behind a mask and visor.• Remember that a person can see if you are happy and smiling behind a mask, due to the expression in your eyes – so be happy and let the PEE, mask, and visor not be a barrier. Never compromise on resident safety.

Written by Melody Ziervogel, Quality of life, and Dementia Care for Nazareth Care Africa. 

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