Congratulations to Rachel Mackessy-Lloyd!

Rachel was the 2018 Lantern Review scholarship winner. Rachel Mackessy-Lloyd CRNP, MSN, RN, BSN is studying at George Washington University and plans on finishing her certificate by the fall of 2019.

Decreasing Environmental Vulnerability in Dementia Clients

W.W. is an 84 year male with dementia who was in the Vietnam War and has a prior diagnosis of PTSD. Typically he is very agreeable and keeps to himself at the nursing home. This past weekend at the nursing home a staff member walked into the common room and he was standing on the table naked with a broom, yelling and screaming that the nursing home was under attack and he had to save everyone. He would not let anyone near him. The staff member called security and the client had to be physically and chemically restrained.

The client experienced this break from reality due to elevated stress levels that put him in an emotional state where his PTSD could easily be triggered. Early intervention in the client’s environment and regime could mitigated this sensory overload and the client would likely not have had this severe of an outburst. Physical and chemical restraints would not have been required and the client’s integrity would have remained intact. Using restraints increase risk of injury, strips the client of their independence and damages their sense of self. Educating the staff on how to meet the client’s needs and proactively prevent psychotic episodes will systematically decrease the need for restraints and result in better outcomes for the client.

First, the air conditioning in the nursing home was broken and the common room was much hotter than usual. This reduced W.W.’s stress-threshold and put him at an increased risk of an psychotic episode. A number of residents had complained about the air conditioning over the past week, but the repair was delayed due to a part being backordered. To mitigate this problem in the future, the nursing home facility should implement a response plan for system outages like this to ensure that the temperature of the facility is kept at a reasonable level and the clients are well hydrated. This could be achieved by having fans or portable air conditioning units on hand in case the central system is down for service.

Due to the problem with the environment controls in the facility, W.W. was already experiencing elevated levels of stress. The triggering event, however, was the showing of a war documentary in the common room as part of a resident program leading up to Memorial Day. The documentary focused on the army helicopter ambulance corps, and the audio included loud sounds of gunfire and shouting. When the client started watching the documentary, it put him back in a war-time frame of reference and he lost his ability to differentiate reality from his past experiences. In W.W.’s case, the nursing home should be aware of the client’s history and implement alternative activities for clients who are at risk of experiencing a break from reality. The volume in the common area should be kept to a reasonable level.
These early interactions do not require a significant amount of resources to implement. Facility staff would need to be educated on the different risk factors for the clients housed in the facility, as well as best management practices that can be implemented to reduce environmental stressors and prevent harmful and disrupting behaviors.

A journal article in the American Journal of Geriatric Psychiatry discusses nonpharmacologic interventions for dementia clients. The environmental vulnerability/reduced stress-threshold model is discussed. The model states, “the concept of progressively lowered threshold, persons with dementia progressively lose their coping abilities and therefore perceive their environment as more and more stressful”. It goes on to describe reduced stimulation in environments including white noise machine, neutral décor and paint colors, and camouflaging exits.  This paper proposes the implications of best practices which would include the examination of the client’s overall environment to minimize vulnerability due to reduced stress threshold. These practices could include adequate temperature control, non-triggering media exposure and limiting external stimuli. It is often taken for granted how easily a normally functioning person can adapt to an unfamiliar environment; for a client with dementia this ability is impaired and they are not able to adapt easily. They can quickly become overwhelmed and demonstrate negative, potentially unsafe behaviors.

Clients with dementia cannot self regulate and their emotional processing ability is limited. This can lead to psychotic episodes because the client feels overwhelmed and cannot express their frustration and needs appropriately. This inability to regulate is consistent with sensory processing disorder. This disorder is typically given to children on the autism spectrum, but it easily applies to clients with dementia as well. “Sensory processing disorder is a condition in which the brain has trouble receiving and responding to information that comes in through the senses” (Sensory Processing Disorder, 2017). Treatment for sensory processing disorder relies heavily on early intervention by promoting self regulation. Displaying pictures conveying different emotions can increase emotional awareness. Another simple intervention would be to increase communication with a clients; even nonverbal clients will benefit from regular communication increasing cooperation. Training staff to promote client self regulation will improve client outcomes by decreasing use of physical and chemical restraints which improves the quality of life for a clients.

Cohen-Mansfield, J. (2001). Nonpharmacologic Interventions for Inappropriate Behaviors in
Dementia: A Review, Summary, and Critique. American Journal of Geriatric Psychiatry, 9(4), 361-381.
Sensory Processing Disorder. (2017, January 8) In WebMD. Retrieved from
https://www.webmd.com/children/sensory-processing-disorder#1