Learn about simple resident engagement techniques for those with dementia and the power of educating caregivers from Clinical Psychologist, certified Alzheimer’s Disease and Dementia care trainer, and co-owner of NeuroEssence, Dr. Jennifer Stelter.
Author of The Busy Caregiver’s Guide to Advanced Alzheimer Disease through Johns Hopkins Press can be ordered today.
Welcome to Bridge the Gap podcast, a senior living podcast with Josh and Lucas. An exciting topic on today with a former guest of our program. We want to welcome Jennifer Stelter. She’s an author and a clinical psychologist. Welcome back to the program.
Dr. Jennifer Stelter
Thank you so much for having me. I appreciate it.
We’re excited about the new content that you’ve just put out. You have written a book called The Busy Caregiver’s Guide to Advanced Alzheimer’s disease. And you’ve written this through the John Hopkins Press. And today we’re going to go over four main points around the topics of staffing shortages and senior living and how even today you can do simple resident engagement techniques with those that have dementia, different sensory approaches that can free up the staff time, but also be engaging your residents. Labor’s a big issue today, but also resident engagement coming out of the last two years of a real nightmare situation. Senior living senior housing’s kind of big value proposition is an engagement and not isolation. And so I think this is a really important topic, especially related to dementia. Can you walk us through a couple of these main points to educate our audience?
Dr. Jennifer Stelter 02:02
Absolutely. I wanted to start first by talking a little about where the staffing shortages are at this point. And still, senior living facilities are seen in 80% to 90% decrease or 80% to 90% kind of bandwidth if you will, that these facilities are still reporting staffing shortages, and it’s just astounding. And we hope obviously that as things start to reconcile with the pandemic, these senior living facilities will start to increase their employment and the advantages for these staff. But still again, 80%, 90% are still reporting that they’re having staffing shortages. And the other component of this too, which is harder, I think for these staffing facilities, although they’ve been able to, so some states have actually moved towards nursing students being able to act as licensed practitioners and some non-certified staff who’ve had minimum training.
Dr. Jennifer Stelter 02:57
As long as they’re trained by their facility, they can provide direct care. I think that’s great for this issue with the staffing shortages, but really the problem is these individuals who are not yet fully trained in their own education and experience, and they’re coming on and they’re providing direct care, they’re going to be at a loss as well of what to do with individuals, especially if they have dementia. Because when we look at, where we’re at nursing homes, they are at about a 48% population of people who have dementia and really between assisted living and nursing homes, 80% of individuals have cognitive issues. It’s really, of course, rampant in senior living. And so when you have staffing shortages, and then you have people coming on who aren’t really fully trained, it does cause an issue of how do I truly engage my residents, right?
Dr. Jennifer Stelter 03:49
And so I’ve seen this time and time again, when we talk about, well, you know, how hard could it really be to engage a resident, but this scenario I’m going to kind of playout for you guys happens countless times. So let’s just say you have an untrained staff member, let’s just say a CNA, who is working with individuals who have dementia and they’re approaching this resident because maybe it’s lunchtime and they need to bring the resident to the dining area for lunch. And they come up behind the resident with the intent that I’m doing my job, I’m going to go ahead and move them, wheel them into the dining area. And they end up startling the resident because they’re approaching from behind, and not knowing that that will startle the residents or that the resident wasn’t able to be aware that that staff member was there.
Dr. Jennifer Stelter 04:37
And so what happens is maybe then that resident starts to act out because they’re having difficulty communicating that they’re scared or they’re confused as to where they’re going because they weren’t told. And so they might dig their heels into the ground. They might try to swat back and hit the CNAs hand, at some point, when the CNA maybe goes around to lock their wheelchair, once they’re in the lunchroom, maybe the resident, unfortunately, maybe spits or hits the CNA because they’re just trying to protect themselves, which the CNA doesn’t know. And then from there, the CNA is confused. They’re feeling a little disheartened because “I’m just trying to help this person. Why are they doing this to me?” They don’t know. So the resident isn’t distressed, the CNA is in distress and of course, the CNA is going to do what they’re trained.
Dr. Jennifer Stelter 05:23
They’re going to go to the nurse. They’re going to tell the nurse what’s going on. And then that nurse unfortunately is going to assess the situation, if they assess that the resident was aggressive and did act out, because maybe that nurse is not trained as well in dementia care. Because again, it’s one of these individuals who are nursing student who aren’t quite licensed yet, don’t have the experience. They decide to give the PRN medication, psychotropic medication that will help decrease the agitation of the resident. And unfortunately then the resident, let’s just say 24 hours later falls in the nursing home, right? Then is sent to the hospital. So all these things spiral out of control because we have staff that aren’t trained and they don’t have the resources needed to be able to do their job effectively, right?
Dr. Jennifer Stelter 06:12
So time and time again, we see this, but what’s important is that if we can engage our residents in an appropriate way with some basic techniques, it’s going to be really helpful for them, for these, new staff coming on and for the staffing shortages, that there’s things that they can do in the facilities with these residents that won’t lead to some of these kinds of behavioral, negative behavioral expressions I call them right? With that said with model that I had talked about in my new book, it’s called the Dementia Connection Model, and really the main approach to care. And there is sensory stimulation, as you mentioned. Why that particular approach to care, right? And that’s very familiar in our industry. It’s not something new that I created, right. But it’s a piece of the model that talks about why we use sensory stimulation.
Dr. Jennifer Stelter 07:02
And it’s really for two reasons. Because one, when we take in any stimuli through our senses, our limbic system in our brain is either directly or indirectly influenced. And the limbic system is an important part of this process because in there we have our amygdala, which is responsible for generating our emotions and our hippocampus, which is responsible for our memories. And so when we take in the stimuli, we are influencing our feelings. We are influencing our memories, right? And so that’s why sensory stimulation is so effective with people with dementia, but a second reason why it’s even more effective for them. And I explain this in my model, the Dementia Connection Model, the first pillar of that is understanding what’s going on. And that’s through the Theory of Retrogenesis. Now the theory was actually developed by Dr. Barry Berg years ago through his research.
Dr. Jennifer Stelter 07:58
And so I tied together his theory with this use of sensory stimulation in the dementia connection model. And what’s happening is as their, he found that as the disease is progressing individual moderate to late-stage, start to experience their world much differently than you and I, right. And they start to live in the past, but all of their skills go in reverse as well, from their ability to cope, to take care of themselves, to communicate, their language, everything goes in reverse. They start to experience the world very similarly. And what he found specifically was the ages of a child from age seven years old to four weeks old. And so people who are moderate to late-stage, he even – this was an interesting fact just to throw it out there too, is he actually even saw that the physical size of the brain was similar to a young child as well.
Dr. Jennifer Stelter 08:55
So when you take someone with late-stage dementia, the size of their brain is the same size as someone who’s below the age of eight. And so everything goes in reverse. And so we look at how do children navigate their world in the first few years of life? How do they learn, right? Because I kind of joke about this sometimes, but when a child is, infant is firstborn and within those first years, they might start to coo and babble and play with their language. And they’re associating though, who is mama, who is dadda, right? By hearing those words over and over again, they’re seeing who mom and dad are, right? And they can smell them as well. So these are different senses that they’re taking in information and they’re learning through those senses, what they’re what’s in front of them, how to navigate, right.
Dr. Jennifer Stelter 09:48
They didn’t pick up a book, right? Here’s the joke, right. They don’t pick up a book and they read about it and say, “oh, this is my mother. Okay. Now I know to call her that, right?” They don’t do that. Or they have no concept of that. They can’t even read, right. So the idea here is because we know people with dementia are going to go back into an earlier state. They’re going to learn differently by using their senses, just like children do, because the theory does prove that that’s what has occurring essentially. So they’re going to use what they see and hear and taste and touch and smell to learn now how to navigate their world, how to communicate, all of those things, right? So that’s also why sensory simulation is so important because that’s going to be their main source of connecting with you as the caregiver or connecting with the staff.
Dr. Jennifer Stelter 10:35
Whomever’s in front of them, they’re even their, if they have a roommate or whatever it might be, that’s how they’re going to connect now. So it’s really important that through sensory simulation, that we’re focusing on this to being positive. What’s positive for this person versus this person, right? And as long as we are continuously flowing in these positive stimuli, this will influence positive feelings and positive memories, right. And that’s where the connection comes in, that’s why I called the dementia connection model, because it’s really about connecting that individual to the caregiver, to the staff member, to their environment, right. Where they, it’s a win-win for everybody. If you’re a resident or your loved one is happy, you’re happy, right. If your loved one or resident’s happy, their roommate’s happy, their friends are happy, whoever’s in the community those kinds of things too.
Dr. Jennifer Stelter 11:27
When we talk about this idea of what are things that with the staffing shortages, what can staff do to engage residents so that way they’re having to be -by-side with these residents all the time trying to engage them because they’ve got things they’ve got to do too, right? So the reality is that there are a few things that they can do that would allow them to set up what the person would do. The resident, as well as be able to from afar, monitor the residents. We never not don’t want to monitor the residents, of course we do, but maybe they could get some of their documentation done. Maybe some cleaning done. Maybe it’s a nurse passing medications, those kinds of things where they can observe the residents from afar after they’ve been set up with things to do that are sensory-based.
I’m sitting here as an operator and I’m thinking of our, our listeners, which are a lot of people out all across the country operating these communities or in the communities actually doing this work. As you know, our industry is for the most part state-regulated. And this idea of, some states don’t even have standardized training. They just kind of say a certain number of hours have to be on a core of dementia training, but then other states don’t even have that. So I can imagine our listeners right now are sitting there thinking, “wow, this is so good. We need to do this. How do we do this with all of our team members and how much time should I dedicate to adequate training, not just meeting a minimum standard, how much time should I be devoting to every new team member as they come on board and then annually kind of thereafter to do this and make sure everybody’s really equipped because obviously, that means better quality of care. And they’re probably going to be happier in their job too. So maybe we lower turnover, we increase occupancy, we improve quality of care. So I say all that to say, what do you see as for that operator? How much time should they be designating for this type of training their team members?
Dr. Jennifer Stelter 14:15
Sure. I think it’s definitely something where it should be ongoing. I know some states and as you mentioned, some states don’t have this, but some states, there’s an orientation requirement within a certain period of time and then there’s annual requirements thereafter. Right? And then, like you said, there’s some states that don’t have anything at all, which really I think is a detriment to those residents. And of course the staff as well. There’s some core areas that I think really need to be at someone’s forefront when they’re going to train. And roughly that takes probably about six to eight hours of training to cover those areas. I think definitely what we can get better at, as an industry is training that staff before they hit the floor. And I know there’s not always time for that, but unfortunately what happens is that scenario that I gave earlier, why is that a detriment to everybody?
Dr. Jennifer Stelter 15:08
I’m going to start with kind of the operators like you mentioned. It’s a detriment to the operators in their facilities because when you have unnecessary falls, right. And you’re using unnecessary psychotropic medication, that can be proved because there were no, non-pharmacological techniques used before, right? You’ve got a hospitalization on your record. You’re talking your quality measures are going to plummet. if this is a case scenario that happens repeatedly, you’re going to go ahead and have your quality measures plummeted. And then your five-star rating goes down and skilled nursing, right. And so it’s a detriment for them because those staff are not trained before they hit the floor, right. It’s a detriment to the staff because then they feel incompetent because they want to do right. These CNAs, the nurses, and other senior living staff they want to do right.
Dr. Jennifer Stelter 15:57
And when they can’t, because they don’t feel properly trained or supported, they leave, they wanna quit their job and go on, do something else or go to another company that will give them that training. Right? Because it’s important that we invest in our staff. So they feel like they’re being taken care of. So they lose if we don’t do that. And of course, most importantly, the residents lose, you know, because they are experiencing this, this high level of distress because staff are interacting with them who aren’t trained and it’s causing all of these negative emotions and that’s just not fair to them. That’s not good quality of life. On top of that, if falls and things like that occur, then they have pain. Then they have confusion and all of these things that can be prevented simply by staff training. So definitely training six to eight hours before they hit the floor on key areas.
Dr. Jennifer Stelter 16:47
And then annually thereafter, there needs to be refreshers because this industry can keeps growing. We keep learning about this disease. There’s still no cure, but the research that still comes from it is valuable to individuals to stay up to date on their, on their information. And I just want to say too, that through the building of my model and things like that my company neural essence, we’re building out an Institute called the Dementia Connection Institute. And people can look at our website, Dementia Connection Institute.org and find us there. We’re building out a classroom with this required training. That’s online. You can take it your convenience as well as we do live training. So lots to offer through the Institute, and we’re excited to hear to launch it in early 2022.
Well that is great information. And congratulations on that launch. Of another great bit of information is innovation and approaches that are coming down the pike that are already out there that maybe some of our listeners aren’t aware of that are fairly practical, and fairly affordable. And you highlight many of those. Can you give us some examples of that?
Dr. Jennifer Stelter 17:57
Absolutely. and I’m going to also point out what senses are we tapping into because that’s important to understand that because that’s got to be at our forefront. What senses are we tapping into? Does this person enjoy it so it would be considered positive stimuli. And so first I want to talk about, a lot of people may be familiar with animatronic pets, right? And you see kind of one right here, our little cat and then also our dog. So actually Joy for All pets is one who developed the animatronic pets. Now if for some reason you don’t have access to it being animatronic, you can use any kind of lifelike stuffed animal, okay. I use the word lifelike because we want to make sure that these interactions are served with dignity, right? Because our senior folks deserve that. And so even though in my model, we talk about the Theory of Retrogenesis and how people with dementia, they’re experiencing the world as very similarly to how children do, we do not treat people with dementia like children, right?
Dr. Jennifer Stelter 18:57
But there are similar techniques we can use with the understanding of where they’re at developmentally now, but we will always want to approach them with dignity and respect. And so the animatronic pets are great because they’re multi-sensory right. They’re visual. These particular pets, you can hear them, you turn them on, they’re auditory, it’s a tactile stimulation, right. And so it’s very multi-sensory in nature. It can also be olfactory too, as you may see here I’m big into aromatherapy. And so you can actually put a couple of dabbles of the essential oil, like lavender on the lapel of the dog, and then you’re going to have that olfactory stimulation and lavender’s very calming for the person with dementia. And so you’re kind of approaching them in a multi-sensory respect where they get that interaction, but also they’re staying calm, cool and collected.
Dr. Jennifer Stelter 19:45
And as we know, pets are provided unconditional love, right. And so there’s just that connection already. That’s served based on what pets do for us. Because I know not even now to today, it’s hard to get actual certified pet therapists in the facilities still because some may still be reserved to not bring in that extra, they’re being cautious because of COVID. So with that said they may have not con recontacted their pet therapist yet to come back in. So these are a great supplement because you can do this morning, noon and night, and it’s a one time cost. You’re not continuously paying a pet therapist or trying to book them if you will, if they’re for free. So with that said, the animatronic pets are a great way to be multisensory. I mean, I have worked with people with dementia and offered these to them, and they could sit for hours, brushing them and talking with them and taking them on walks and all those kinds of things that they love to do with them.
Dr. Jennifer Stelter 20:40
I would suggest a training in this just because there are questions that might be thrown your way from the resident that may catch you off guard and, “how do I respond to that? Right.” So a good training would be beneficial with that. But when you are just some basics, when you’re approaching them, you want to show them the pet and look at their facial expressions, their body language, do they seem to want to interact with the pet? If they don’t maybe A) they don’t like pets or that particular pet or B) they’re just not having it right now or they’re just not into it. So you don’t want to force it upon them, but it’s always important to show them that, and then say “hi, can you help me with taking care of my pet? Can you watch her for a while?”
Dr. Jennifer Stelter 21:20
Things like that. So that way they know to interact with it. And that can go you know, all too, while we see residents kind of congregating around nursing stations and facilities, so that can easily go on a nursing station. It can go on a couch of some sort or even on the resident’s lap and they can interact with it, which is a lot of fun. So the other thing I want to mention too is very similar to the pets is Dolls, right. And so Infant doll therapy, I know it’s controversial still, which I think is a shame because infant dolls can provide so much interaction. It’s very multisensory in nature. Just like the pets where it’s visual, some are auditor in nature where some dolls that you get them can make noises. We just recommend stay away from ones that cry because nobody likes that that can be distressful.
Dr. Jennifer Stelter 22:15
And so with that said it can be visual, it can be auditory, but again, it could be olfactory. If you decide to put a couple of essential oils on the baby’s clothes, you get that olfactory sense as well. But with the dolls, you want to make sure you have accessories, which is so much fun. Their clothes, diapers, bottles burp cloths, things like that because they can interact with the baby, but they can also interact with just the accessories. So oftentimes residents, they are homemakers growing up, they would love to do the laundry. So maybe they could sort and organize the burb cloths, or the clothes, or the socks or whatever it might be, which also adds a component of cognitive stimulation. They’re using their executive functioning skills in their frontal lobe where they’re organizing and sorting by color or by size or something like that. Which is again, hours and hours of joy that it can bring them.
Dr. Jennifer Stelter 23:08
And again, the staff can just be in the background doing their documentation, cleaning, passing out meds, whatever they need to do, obviously to help with that. So this is a wonderful approach as well. Another one is adult coloring, which serves all of us, not just individuals with dementia. There’s been a ton of research that shows it helps lower anxiety, helps boost mood. And that’s a form of visual and tactile stimulation. And what’s wonderful about it, particularly for people with dementia is they get to process how they’re feeling on paper when they can no longer find the words. And that’s why we do actually encourage coloring for young children because before the age of four, they can’t articulate how they’re feeling, but when they color it comes out, it helps a release. And so in the research that they found, when people with dementia, it provides that same resource where they can divulge and process those feelings on paper or through their craft, if they’re painting or whatever it might be in terms of an art project.
Dr. Jennifer Stelter 24:10
But as long as you have the supplies there that are appropriate for them and the things that they’re coloring or that they’re drawing are appropriate as well, meaning not cartoon like, that a child would play with, right. We don’t want to do that. But if it’s a nice vase, maybe picture or it’s a scene of a beach, or maybe a countryside, something that they can identify with from their history, they could spend an hour, two hours doing that and really have a lot of joy from it. Which would be helpful as well. Another one, I just have two more that I want to talk about. One is any kind of puzzles. So if they’re maybe a little higher functioning and they can do it more independently, this is a form of visual and tactile stimulation. But even more importantly, of course, cognitive stimulation where we’re working different parts of their brain to keep those skills alive.
Dr. Jennifer Stelter 24:56
And I talk about that in another piece of my model, which is called rehabilitation. And it’s really about trying to reinforce those skills that are still there over and over again. So they keep them longer. Right? And so the puzzles are great because they come in all different kinds of sizes. You can get ones with very minimal pieces and some that are more difficult, right? So depending on the functioning level of that person you’ll wanna get the appropriate puzzle, but it can also be things that they enjoy, word searches, or if they enjoy Wheel of Fortune, there’s so much that they can can do there too. Again hours of fun that can be helpful. And then last, I want to talk a little about some technology based tools that are out there too. Where if you set the individual up on an iPad or a laptop, and they’re able to still work through and function through that again, based on level of functioning, there are beautiful things that you can put up there, like scenes of landscapes and different kinds of music and slide shows.
Dr. Jennifer Stelter 25:58
Linked Senior’s a great opportunity for that. And then new on the scene is Memory Lane TV. And so these are just some great resources I want to share with you as well, because they’re can really help with some of the technology based tools that help to really provide that appropriate engagement too. So again, these are things that a staff member can set up the resident with, observe from afar, get some of their duties done because maybe they’re short staffed that day and the resident is engaged, and this will help to avoid things like the aggressive behaviors, the falls, the wandering, the repetitive behaviors, these negative behavioral expressions that occur when a resident is bored, or frustrated, or feeling anxious because they’re not sure what they should be doing, right. These are things that can help really serve the resident and serve the staff at the same time. And that’s a win-win
Wow, Dr. Jennifer, Stalter what a wealth of information. Actually, we are just scratching at the very surface of the wealth of information she brings. Thank you for spending very valuable time for us today, Lucas, she had me at coloring. Okay. If I can go to a senior living community and, and get paid to color, I am all in 100% because I still do that with my kids and love that activity so it’s really cool to hear the therapeutic side of that. You’re in communities every day, a lot of information to take in.
Dr. Jennifer Stelter
Well, we’ll make sure that we put all of this in the show notes for easy access to all of our listeners. Also go to BTGVoice.com, connect with us there and all of our content. We’ll have a transcript of the show. If you’d like to dive in in a little more detail. And then also access any of our social sites, make sure you connect with us there. Thank you for your time today, doctor, and thanks to everybody for listening to another great episode of Bridge the Gap.