Enhancing Mobility in Dementia Care: Q&A With Teepa Snow

After presenting a recent webinar, Dementia Care: Enhancing Mobility and Reducing Fall Risks, Teepa Snow received many questions regarding this important topic. We’re featuring the questions and answers here so you can learn more. We include valuable insights on everything from communication techniques to walker alternatives.

And for more expertise on dementia care, please visit the free monthly podcast Ask Teepa Anything!

Q: I’m interested in knowing more about assistive devices and the use of those with our residents with dementia. Can you refer me to any resources that may speak more about this?

A: Unfortunately, there are studies that have shown that people living with dementia, especially in the mid to late stages, are often not able to learn how to safely and consistently use assistive devices. Here are some examples of more information about this topic:

• Effect of Learning to Use a Mobility Aid on Gait and Cognitive Demands in People with Mild to Moderate Alzheimer’s Disease: Part I and Part II.
• The Attentional Demands of Ambulating With an Assistive Device in Older Adults With Alzheimer’s Disease.
• Challenges of Mobility Aids and Dementia Explored.
• Dementia and Falls Among the Elderly.

Q: What would you recommend as an alternative to a walker for someone who struggles with using it correctly but has balance issues?

A: Whenever possible, a care partner to accompany the individual during movement is the best option, typically while in the Hand-under-Hand® position. Another option is to create fairly narrow paths using very sturdy furniture that is at an appropriate height for individuals to grasp while moving. Wall-attached handrails are another option. Also, walkers that have forearm supports can help keep an individual more upright and can be a safer option than a regular walker. I do not typically recommend four-point canes, because they can be difficult to use correctly and consistently for those living with dementia and can easily cause tripping issues.

Q: I have residents whose impaired cognition make it impossible for them to use a walker, but they still wish to be mobile and impulsive. It’s difficult because we do not have enough staff to be with our residents at all times. Any advice?

A: If someone likes to get up quickly and without warning, and they are not safe to do so, encourage them to sit at a sturdy table that is directly in the line of sight of staff. When the individual wants to get up, they either have to push back from the table or push the table forward. Immediately, the staff should say, in an excited rather than accusatory or angry tone of voice, “Ooh! James! Can you do me a favor and sit tight for a second, and I will be right there?” This should buy the staff a second to get to them and assist the transition.

Q: We have someone that is a fall risk with a front-wheeled walker at this point, and it’s also not safe for him to push his wheelchair. What is the best option to keep him as safe as possible? He is unstable without a device but does try to get up.

A: You can certainly assist him in moving using Hand-under-Hand. Another option is to get a shopping cart or other cart with a handle at a similar height, fill with sandbags or other weights, and have the individual walk behind that. Shopping cart handles are typically at a good height to keep individuals in more of an upright position than wheelchairs or walkers.

Q: If a resident likes to lower to the floor, safely and with intention, to crawl around, is this something that should be encouraged to continue?

A: Crawling allows mobility in a safer manner than walking for some individuals, so this shouldn’t be discouraged. If individuals are moving in this manner, extra attention should be paid to infection control and cleaning measures. Also, they should be encouraged, with assistance if needed, to work on safely transitioning from the floor to a sturdy chair.

Q: If a patient moved slowly on the floor from bed or wheelchair, is that a fall?

A: No, if it was a controlled transition from the bed to wheelchair, that is not considered a fall. A fall is an uncontrolled transition between positions.

Q: I have a frequent faller (30 times in 4 weeks). She is on hospice care and suffers from anxiety. Her daughter would like to place mattress on the floor as an intervention, have you seen any luck in placing a mattress on floor?

A: This amount of falls makes me wonder what this individual is seeing or experiencing. Often, we will see this level of falls in diseases like Lewy Body dementia, where their brain is either causing them to see things that are not there or causing them extreme disturbances with their equilibrium. You might want to investigate the room for shadows/objects that may be contributing to hallucinations. If it seems that being flat on her back is causing issues with her equilibrium, you could try elevating the head of the bed to see if that helps. Regarding the mattress, if a mattress is being placed on the floor next to the bed in attempt to cushion the falls, I haven’t seen much success with this. The reason is that the individual is trying to get out of bed onto an unstable surface, which typically causes more falls. If you are lowering the bed to floor level, then this can be somewhat successful, although monitoring is still required if the individual may try to get up off the floor mattress.

Q: Is there a good exercise routine you could suggest for memory care?

A: Sidestepping to music/rhythm is a great option because it helps with single leg stability and balance. Practicing standing to sitting and sitting to standing is also good exercise. Purposeful movement such as walking around the facility to collect different items, or picking up items from the floor, is another great option. Chair exercise routines should include rotational movements from the trunk, which improve bowel health, as well as reaching up high above the head and down as low as possible. You might also check out the exercise organization Total HealthWorks.

Q: How do you get CNAs and other staff in SNFs to understand the importance of mobility and out-of-room activity, especially during COVID with isolation precautions when everyone seems afraid to allow more freedom because of fear of the virus?

A: When individuals are not allowed to practice mobility skills, many will rapidly lose them. They also quickly can lose muscle mass, flexibility, and joint mobility. Unfortunately, this often leads to increased falls and an overall decline. Of course, there is also often a severe psychological toll of feeling “cooped up” and isolated and not being able to move about one’s environment.

Q: Can you give some examples of cues to encourage someone to sit (when it is necessary) beyond just verbal cues? Basic hand gestures have not been successful with a certain PLwD.

A: Stand next to the individual and hold one of their hands in yours in the Hand-under-Hand position. You may stretch your other arm across their back and place your hand on their outside hop to stabilize them. Then bend far forward at the waist. Since you are holding onto them securely, they will also automatically bend forward. Once you are both looking down at your toes, encourage them to come to a sitting position. My PowerPoint slides from the webinar showed a picture of this in action.

Q: Suggestions for a resident who may be categorized as an Amber? When standing up and down from wheelchair, they consistently get agitated with staff after a few minutes of helping. They will punch and kick staff when getting to their level to speak with them or assist to help from falling.

A: You might want to try having the individual sit in a sturdy chair with armrests rather than a wheelchair because transitions in/out of a more stable surface can typically be less distressing. If possible, have a rail on the left side of the chair that the individual might be able to use to help themselves get up. The staff can be on the right side, offering a hand as a sturdy platform of support if needed. With this individual, it also sounds important that the staff try to demonstrate on themselves what they are wanting the individual to do before trying to touch them or come too close.

Q: We have a resident who doesn’t speak any English. She continuously walks all day, and redirection can be challenging, as she doesn’t understand us. What are your thoughts?

A: I would recommend finding some songs that she is familiar with, in her native language, and keep them on a tablet or smartphone. Then when you are wanting to redirect her or encourage her to sit for a meal, you would play the music and move with her in a Hand-under-Hand position to the next activity or location. You can also use the computer to find some key phrases or words in her native language and learn them or play them on the phone or tablet when you are needing to communicate with her.

Q: What are ways we can educate staff without being condescending? I have had a lot of rebuff from staff education.

A: It may help if you approach the training/education as being for them, as something that will make their jobs less stressful and more enjoyable. Being a hands-on care partner is not easy, and being able to more effectively assist people with eating, showering, dressing, toileting, etc. will not only keep both the staff and residents safer, but help them to be happier as well. When staff take the time to form a connection first with those they are trying to help, before jumping right in to try to get the task done, time is typically saved, and the interactions are more pleasant.

Q: Any tips on using our face and expressions while wearing our masks?

A: Practice in front of a mirror with your mask on – smile, be surprised, be sad, be angry, be excited – all just using your eyes. This is a new skill for many of us and requires practice. Also, practice using the rest of your body to create expression as well such as throwing your arms wide open to indicate excitement, dropping your head to indicate sadness or despair, putting your hands on your hips to show exasperation, etc.

Q: How do the GEMS® States relate to the Global Deterioration Scale (GDS)?

A: In general, a 1 on the GDS is the Sapphire state, a 2 GDS is at the transition between the Sapphire and Diamond state, a 3 GDS is the Diamond state, a 4 GDS is a very early Emerald state, a 5 GDS is in between the Emerald and Amber states, a 6 GDS correlates to both the Amber and Ruby states, and a 7 GDS is the Pearl state.