Non-Pharmacological Approaches to Dementia Care

Hello and welcome to the EPOCH Exchange, the podcast where we have real conversations about senior life, senior living, dementia care, and the amazing people who make it all happen. I’m Erica Labb, Director of Team Member Engagement and Culture at EPOCH Senior Living, the premier senior living provider in the Northeast.

And I’m Sarah Turcotte, Area Community Liaison for several of our bridges by EPOCH and Waterstone Communities. Together, we’ll be your host, bringing you stories, insights, and expert voices from across our organization and beyond.

Whether you’re a caregiver, a family member, a professional, somebody navigating the early stages of dementia, this podcast probably has something for you.

Each episode, we’ll be joined by guests who are making a difference from community leaders to care, team members and clinical experts.

Today, we’re talking about non-pharmacological approaches to dementia care, and we are joined today by one of our very own team members at Bridges by EPOCH in Andover. Uh, where we specialize in dementia care. We welcome Rosemary Ombewa

Welcome.

Thank you for having me.

Thank you for being here.

Yeah, it’s so great.

So, Rosemary is our Wellness Director of Bridges by EPOCH at Andover. Rosemary has been a nurse since 2007 as wellness director at this highly regarded memory care assisted living community. Rosemary leads with integrity, inclusivity, and a whole lot of energy and humor.

Rosemary, please start, just tell us kind of how you landed here being a nurse in senior living.

Uh, I actually started in pediatrics, so my nursing career started in pediatrics, which I did for probably two or three years. It was too sad for me, so oh yeah, I shifted, uh, then I started, um, geriatrics, and I think what has glued me to geriatric care is you learn so much.

You learn so much from the elderly. So, anytime I come to work, I know I’m gonna learn something. So it’s something that has always interested me and just to encompass everything about their life and to work with them through this journey.

That’s Really beautiful.

Mm-hmm.

Really is.

Thank you so much for sharing your story, Rosemary. And I’d also like to share before we kind of dive into our topic and conversation, that Rosemary was also recognized in the Boston Globe Salute to Nursing by being nominated by a Bridges by EPOCH family member. The family member shared the following nomination about you, Rosemary.

She said Rosemary is a very kind and exceptionally proficient at listening to my family’s concerns. She’s ready to accept suggestions and offer her medical opinion when necessary as she helps with my husband in a memory care unit. She is soft spoken, which provides calm. even in difficult situations.

She’s my go-to person whenever I need help or need something explained about my husband’s care. And I think that’s a true testimony to the compassion and dedication that you share with our residents and their families. So, congratulations.

Thank You. Thank you.

And you know, with that being said, you know, people are going to you and you are helping to develop their care plans and, you know, when families hear medical intervention, they might think of pills. But how do you define non-pharmacological care?

Uh, so how I would basically describe non-pharmacological care, it’s really how do you support someone without medications?

How do you support them when they’re in this journey? You know, memory loss, uh, confusion, how do you walk them through without giving medications? And these are the everyday things we do.

You know, it’s how you make somebody feel comfortable, um, heard and respected. And it could be anything. Having the same routine, playing calm music, uh, before we get into medications. I pride myself in being a very non, very conservative with medications. So I always, always go for the non-pharmacological first before I start the meds.

Yeah.

Really sounds like your goal is to, you know, with these approaches to not just stop the behavior, but is it more to understand, you know, the needs behind it?

Yeah. So we call them quote-unquote behaviors, but I really look at it as feelings. You know, anytime somebody’s quote-unquote acting out, they’re telling us something.

Are they in pain? Are they hungry? Do they feel unsafe? So we really need to focus on the feeling first before we jump into, you know, medications.

So, you know, focusing on how to help this person feel heard or more comfortable, what can we do?

You’re a detective.

Yeah, yeah.

You know, and that’s what I tell, um, the nurses and the aides as well. Let’s not jump into medications first. Let’s try and figure out what is going on. Do they need to go to the bathroom? Are they hungry? Are they thirsty before we jump?

Imagine like if you put yourself in their shoes and you think about what if I needed something, like I was really hungry and I couldn’t articulate it, how frustrating that would be.

And how angry I could become. And then that looks like behavioral. You know, I remember back when I started in this industry, like 25 years ago, it was like, you didn’t even think of behavior like that. It was just something you wanted to stop at no matter what it took, but you didn’t look at it that way. I love that approach.

And you know, a lot of times you’ll have families who just want the behavior to stop, and they’ll want the medications. Right.

There are times that we end up using meds and, because, maybe that behavior at the time the volume is too high that we can’t reach the resident. So, we’ll use, we start with low-dose medications to just bring the volume down a little bit so that we can address the feelings.

Absolutely.

That’s great

Because It’s, it can be a balancing act, right? It doesn’t have to be solely controlled by medications, but working hand in hand with non-pharmacological approaches, and, you know, therapeutic doses of medication can really make a nice combination. And I think it might be helpful if we get into kind of some scenarios that maybe family member caregivers might be seeing or facing, so that you can maybe share some insight on how to approach some of these matters.

You know, like one of the scenes that we’re gonna paint here is, you know, maybe a resident or someone’s loved one may appear very anxious. They start packing a bag and insisting that they need to leave right now to maybe go home or to pick up their children from school. Even though their children are actually adults. Can you explain how someone might work through a situation like that?

Yeah. You know, so these are the times that, um, we use a lot of validation and redirection and, um, we don’t worry about focusing on the reality.

We, we focus on the feeling. So, when somebody comes to you and says, oh, I need to pick up my kids. You know, somebody may be like, no, your kids are grown. You don’t need to pick up your kids. So that’s actually confusing to them. So, it means that we are not acknowledging their feelings, you know, at this stage of the game, we are focusing on the feelings more than the facts.

And we wanna find out why do they feel the need to go pick up their kids? Do they feel safe? Do they feel anxious about something? So our response really should be on the feelings. And not the actual facts.

So, anytime somebody comes with, um, or a resident says, oh, I, I need to see my husband and, you know, they passed away years ago, we can’t come out and say, oh, well he’s dead.

Right? Which I’ve seen people do.

 It’s, but we should focus on like, alright, what’s making the residents say this? Do they feel nervous about something? Do they feel unsafe? Are they missing someone?

So, we provide what’s missing. And we are addressing the feelings.

So, can you give an example of a response you might try?

So say, I, I, you know, I, I’m a resident of yours, and I say, I gotta go, it’s three o’clock, I gotta go pick up my kids. How, how might you or your team member address me or deal with me?

You know? So what I like about, um, Bridges is that we do get a lot of our information before a resident moves in. And we do have our, um, I’m trying to think. Um, Inspiration forms.

Inspiration forms.

So these inspiration forms help us to bridge that gap. You know, so anytime somebody says, oh, I need to go home, I need to go home right now, Mr. Jones, I see you are very concerned about this. So first of all, we are validating their feelings. Right. So, we do acknowledge that, all right, I see you wanna go home, but we can say something like, um, you know, the feeling behind it. You know, do you feel, tell me about your kids.

Mm-hmm.

You know, and then hopefully you can pivot it to something else. Let’s have a seat here, and you can share a warm drink or something. And that usually kind of pivots everything to a different direction. You’re not arguing that you’re not going to pick up your kids, but more of like, tell me more about your kids.

Tell me about them. So, rather than that reality orientation, you’re really trying to still validate and talk about the people and person that they’re trying to connect with.

Mm-hmm.

But rather than saying your kids are grown or they’re working, maybe like you were saying, it’s, you know, well, what school did they go to?

Mm-hmm.

Yeah.

You know, do they play sports after school? Or what did they play? That type of thing is, I think, more reassuring than having to go through the confusion of what do you mean my kids are grown? Especially if someone’s living in that long-term memory. So, I really appreciate that.

I, I saw once, um, someone say to a resident with children very similar, like validating the feelings. Um, and it was a, it was a stay at home mom and felt like she should be doing something. It’s the time of day when you sort of get ready for the kids to come home, and they made a snack.

And by the time they were done making the snack and eating the snack, it just was no longer an issue. They sort of got off on other topics and like, whether it was the time of day that sort of resolved it on its own, but they got like off track, and then it was, it eased her mind. And like you said, to your point, like she was onto other things.

By the time the cookies were made or the cheese and crackers or whatever it was, she, she was like, happy and onto other things.

Yeah. You forget it’s time to pick the kids up. So, you do something else.

It’s such a, um, compassionate way. You know, people talk about fiblets and this and that, and it’s like, I feel like it’s compassionate lying or compassionate storytelling or story weaving because you are really thinking, you’re feeling focused, and you’re like, what is the most gentle way to help this person through these difficult emotions they’re having right now? Um, without harming them. You know? Um, because that’s what we, it’s like harm reduction, you know?

I love how you say, just continue, always bring it back to the feeling. It keeps you on the right path, I think.

Mm-hmm.

And is there ever a time where validation therapy might be better serving someone? I think about, you know, people might have these memories or intuitions of things that may be negative and causing, you know, anxiety, but sometimes their, you know, memories might be coming up positive. I don’t know. Is there a time where validation therapy might be better served or the better choice?

Uh, I feel like validation is always the better choice, because anytime we go the opposite of what somebody’s feelings are, it just increases their frustration. So, validating and agreeing with whatever is going on is us sliding into their feelings.

Mm-hmm.

So, we don’t necessarily focus on the facts. Uh, but just the feelings we are, we are more focused on how do we get them from either a negative feeling to a positive feeling.

Yeah. The only time that one time where I, I found reality therapy was helpful was someone kind of had it in their head, and they said, did my husband pass?

And I took a breath, and I said yes.

Mm-hmm.

Because I was like, Ugh, I don’t know what to do with this. So, I took the risk because she asked. And I think, like, had she not asked, I wouldn’t have shared that, but since she asked, I wanted to be truthful.

Mm-hmm.

But like, and, I think it was coming from too, your, if you listen to what you shared, she wasn’t looking for her husband. Where is my husband? I need to meet him. I need to find him. She asked you, did my husband pass away rather than…

Right. Where is my husband?

Exactly.

Right.

So, it was like that for me said, oh, she’s really needs this. Which also, I guess, is validation. You know, and happens to be real. Yeah.A reality.

But I think it’s weighing when reality orientation is going to help someone through the moment versus making it worse. And I think that you shared some really great ideas.

Yeah. It’s so interesting. Yeah. Um, let’s do another one.

Yeah. I like that. Do you like that?

Let’s try again. Not to put you on the spot.

Um, a resident consistently gets agitated or aggressive around 4:00 PM. I’m sure you’ve never seen that before. The TV is on, and the shift change is happening. So, for those that don’t know, um, typically it’s a seven-to-three, three-to-eleven, eleven-to-seven shift, uh, for the workers. And they’re leaving around this time, three or four o’clock, they’re all leaving, and new ones are coming in, um, and the lights are dimming. Maybe it’s winter time, and you know, it’s dark outside.

And this could be happening at home for someone too, especially with the time of day. People can experience sundowning whether they’re at Bridges or at home.

Oh my gosh. Yes. Absolutely.

Um, how can we use environmental changes? We’ll start within the environment to deescalate or to deescalate behavioral changes that come with us or to, to, um, stop them from, prevent them from even happening in the first place.

Mm-hmm. So start maybe environment.

Okay. Uh, so sundowning afternoon, people going home, you know, TV’s are loud, it’s usually almost like a perfect storm of a situation for a resident because so much is going on. And, so, some of the things we can do is modify the environment, you know, um, like in my community, uh, specific household residents are always ready to leave at three o’clock because of the change of shift. I’ll see you later. And they’re like, Ooh, what’s going on? I need to be leaving too. So, what we have done is modify the environment.

We don’t just exit all at the same time. And we tried, also, to position the residents away from the main exit.

Mm-hmm.

So, they’re sitting more towards, uh, the intersection of the household, and they don’t have to experience all these things. The TV volume has to always be low. And then aroma therapy, which has been super, super helpful for this household.

What kind of scents do you use?

Peppermint.

Peppermint.

Peppermint.

So it’s more relaxing and it’s good to breathe, too.

So, supporting the environment that way. And they’re not focused on, Ooh, I need to go home. Everybody’s going home.

So, and, in the home, you can do that too. So when you think about if the, if the afternoons are a high activity point in the household, can you turn the TV down? Can you switch the TV to maybe light classical music?

Mm-hmm.

Can you do aromatherapy at home and, um, maybe you have helpers at the home or people coming in, and just to have them maybe excuse themselves a little more quietly when they’re leaving? Rather than making a big production, I gotta get home and cook dinner for my family. And then people are like, well, what am I supposed to be doing?

Mm-hmm.

So, all of those things, those wonderful things. And I love the addition of the aroma therapy. I hadn’t really thought of that, you can do at home too. Which is Great.

And the lighting, too. You guys do a great job with the lighting. It’s important to, before the sun’s going down, make sure we’re turning on these lights. So that, that transition from, you know, daytime to nighttime isn’t as jolting for someone who’s experiencing sundowning.

And, and then the home, you can do that as well.

Mm-hmm.

Um, I also think like art music activity, how, what are some ways you, um, offer options for people to sort of distract them maybe, or to also have meaningful things to do that time of day? What are some things you guys intervene with?

Yeah. Towards the end of the day, we focus more on things that are more calming. You know, we try to reduce the stimuliization in the household. A lot of it for us is hand massages.

Ooh.

You know, just sitting at the table again, we use the lavender lotions, which will have a calming effect, sitting at the table and just, you know, chit-chatting about just regular everyday stuff. And even at that time, somebody may come up and say, oh, I think it’s time to go pick up my kids. Again, we use validation and redirection. That has really helped.

I love it.

Mm-hmm.

And, you know, talking about activities, I think that might segue into kind of our next scenario, because I think a lot of times people who are living with cognitive impairment and memory loss oftentimes start to withdraw or isolate from activities or hobbies that they once enjoyed.

Mm-hmm.

Um, you know, things like, you know, maybe they’re nonverbal or having trouble with aphasia, and maybe they’re refusing to do activities or join in, you know, how do you use things like art or music to reach someone who’s stopped talking?

Uh, so I, I think music is a big one because it touches those, uh, neurological senses that we really can’t. And I, you see, in most situations, somebody who’s even non-verbal, when they hear music that they used to love, they start humming. You know, so this is the, uh, the other piece that the inspiration forms helps us a lot, ’cause we get to know what did Mr. Jones like to do?

So, we tap that into even when they’re in the final stages of this disease, that they can’t speak. But, oh, he loved Frank Sinatra, so we wanna make sure we are playing that. A lot of times, you’ll see residents, you know, tapping or shaking their heads even when they’re non-verbal. So, music touches those senses that sometimes we can’t.

Mm-hmm.

You know, changing environments for the residents, even when they’re non-verbal. We do have a huge community room where we have activities every day, so just bring them from point A to B, you know, changing that environment, stimulating them in that way. That helps as well.

I remember back when Sarah and I worked with a resident, um, at, uh, Bridges assisted living who wouldn’t shower. She really didn’t like to shower. She was scared. Um, and we knew she loved gardening. So, we had the team clip out maybe a hundred pictures of gardens, and we laminated them, and we basically wallpapered the interior, her shower stall with them.

Mm-hmm.

And then invited her to come see the flowers and played music. And made sure the room was really warm. Like, so it was almost like, um, a garden, you know? Like a real garden or a greenhouse. And it, it, it allowed that resident to enjoy art and music and allowed our team to give her a shower, which she was, uh, needed, also. So, it was really like thinking outside the box.

Mm-hmm.

And trying to, um, avoid the behaviors before they happen. Avoid the communication that I hate showers. I’m scared, it’s cold in here. You know, I’m bored or whatever it is. Try to outthink it before it happens, so that then we don’t have the hitting during the shower. You know, out of fear.

Yeah.

Cause she’s saying, I’m afraid you’re scaring me. So what we did was, how can we make it the best experience ever. You know, for this person. Well, we know it’s scary. We know it’s, the shower stalls ugly, we know the, you know, or whatever it is. You know, like, um, and tried to erase that before it even came up. And so, all these interventions, the aroma therapy, the music, the touch therapy, so few of us get touch as we age.

Mm.

All of that contributes. You don’t even know how many behaviors you’ve stopped by doing that.

Which is kind of cool, you know, touch, uh, modifying the environment, like you say. So, showers are more pleasant because, ooh, my garden is in here. You know, so, you know, modifying the environment and just really focusing on the feelings.

Yeah.

I love it.

And just touching, you know, again, on the therapeutic value of music, it really truly is, you guys set the stage every day, and families can do this at home. You know, little things like you were saying, playing that upbeat, you know, music more in the early daytime hours.

Mm-hmm.

And then transitioning to that, you know, more, you know, instrumental during the day can really set the stage. I wanted to share another example of a resident that we worked with, you know, who had anxiousness and agitation during the sundowning hour, and how music really helped, you know, come 3:30, 4 o’clock, she would start to rock in her chair and rock and rock and cry almost hysterically. And what we did, we actually tried several things, and, of course, we were going to look at medication ’cause things weren’t working.

But before then, we found the power of music and actually created a, an uh, playlist for her where we could put headphones on her and play music that was meaningful to her.

And for folks at home, just so you know, they say, especially if you have a loved one with dementia, playing music from someone’s late teens to early twenties can often resonate most with that person.

Mm-hmm.

But what happened with this resident is rather than sitting there shaking and hysterically crying, she was holding the headphones and shaking and singing her favorite music and we never had to go to a, a, a medical intervention.

Mm-hmm.

Because we used the power of music. So, I love that we’re Yeah, good. We’re exchanging these great, you know, recommendations.

And another one I was just thinking of, gosh, it’s like bringing back all these memories. We had a crowd, um, like a few friends that really had a tough time at four o’clock, and we started doing a ride at four o’clock. So, and that’s something people can do at home.

So, we got everybody on the bus, played music and, like, went for a ride, sometimes stopped for cocoa, or, or a cold drink depending on the weather. Um, but that’s something you can do at home too. Like, sometimes, just getting outside, getting some fresh air, getting in the car, riding around, and seeing the sites gives you a sense of community. It’s just enough of an environment shift, environment shift to uh, reset.

That one was something we used for quite a while and it just with this little group of folks was just what we needed to get it. You know, just to say, hey, we’re not gonna do this every day.

This is a trouble time for us. Let’s get outta here before it starts and see what happens.

That’s a good point. We do that a lot at the Bridges, too. You know, like if a resident insists that they have to go, if they insist that they have to go home or whatever, we’ll get out of the household.

Yeah.

We’ll walk around, go to the concierge, grab a cup of coffee, pastries, and then we segue into something else, and we are back to the household.

But the change of scenery helps calm them down

And you’re not saying no. You know what I’m saying? And I think that’s huge.

Right.

Not saying no because then we’re not getting frustrated with being told no.

Right.

And you know, one thing before we, uh, get ready to wrap things up, ’cause I do think it’s important, you know, sometimes things can come up suddenly, like almost like a sudden aggression. You know, someone who is typically very calm suddenly lashes out, hits a caregiver during lunch. The immediate reaction might be: they need medication to calm down.

But I’d love for you, with your clinical background, just to share some things people should consider or look at before they make that sudden change.

Mm-hmm.

Sudden change, sudden aggression is uh, the body’s telling us something. Something is wrong, something is hurting. So before we quickly jump into medications, we need to be a little bit more detectives again, what is going on?

Are they dehydrated that? Do they have a urinary tract infection? So something we pride ourselves in, that’s, we wanna make sure we pull out all the issues that may be, are they in pain?

Mm-hmm.

Do they need to go to the bathroom? I always tell the aide, imagine yourself and you really have to go number two, you really have to, how do you feel? You know, You, you’re anxious, you’re sweating, you just wanna do something. Right?

So, think about all of that. So let’s, you know, rule out all these things before we jump into medications. And medications, we know what they do, the side effects, right?

Mm-hmm.

Especially for the elderly. Uh, now you’re dealing with constipation, you’re dealing with falls and we want them to enjoy the, their last days. So, if they’re chemically restrained because of meds, they’re not gonna enjoy anything that’s left for them. You know? So, it’s really important to figure out what could be the issue.

100%.

Let, let’s focus on the feeling. Are we addressing this feeling first before we jump into medications? And that’s something I’m constantly teaching the aides as well, because when they see Mrs. Jones acting up, always the nurse, they need a PRN…no, no, no, no, no.

Are they thirsty? Do they need to go to the bathroom? Are they in pain? So some, those are some of the things, um, that people can watch for at home as well.

Yeah.

Rule ’em out.

Mm-hmm.

Rule ’em out before you dive in. This is really all great advice. Rosemary, I can’t thank you enough for sharing your knowledge and expertise and, you know, before we part ways, could you just share with families maybe where they can go or lean, you know, lean on for support?

Yeah. Um, so obviously your primary doctor, right? Uh, your primary doctor is a great resource and just, um, having contact with case managers as well who can easily lead you to like a Bridges.

Mm-hmm.

You know, and I know families struggle a lot with um, the stages of the disease and what they have to do. And just something I wanna share quickly that we go through a lot, families are concerned about fiblets, you know, most families don’t like the fiblets because they do feel like, why am I all of a sudden lying to mom?

Mm-hmm.

You know, they’ve had this history of honesty all their lives. And then suddenly, I can’t tell mom the truth. And it’s really just to tell everybody out there who’s listening to this that we are focusing on the feeling.

Yeah.

You know, dementia affects how you think, how you process information. So, we are not worrying about the lies, but more of…we shift our goals to emotional comfort. You know, instead of saying, no, we are selling your house today. You, we try to think, what is that gonna make mom feel?

Right.

If she knew her house is being sold today and she’s thinking of going to that house later today, what do you mean you’re selling it? So, it’s really just about focusing on the feelings for the residents. Uh, you know, I always say families, we are on the same journey together with their loved ones. We are a team, you know, we are focusing on really, really bridging the old and the now.

Yeah. Yeah.

It’s great advice, Rosemary.

It is. And I would also just add to that, you know, like you were saying, your senior centers or Bridges somewhere in your community, there are support groups where there are other caregivers, and it is so beneficial to connect with other people who are living and going through these experiences and sharing that, you know, connection and resources with one another.

When in doubt, reach out. When in doubt, reach out, be there.

And you know, you’re not alone when you join these support groups, senior centers, you know, you, it’s a little bit of a lighter load.

Mm-hmm.

Knowing that you’re not doing this alone.

That’s true.

A hundred percent.

Well, we can’t thank you enough for being here today, Rosemary.

Thank you.

You are amazing.

Keep up the great work that you do, and we can’t thank you enough for all the support you’ve given families and our residents.

Thank you so much for having me.

And thank all of you for listening to the EPOCH Exchange.

We’ll see you next time. Till the next time.

Take care.

Bye.