Environmental Safety in Assisted Living: Aging Gracefully

You.

Hey there everybody, and welcome to this presentation on environmental safety and case management.

I'm your host, Dr. Donnelly Snipes.

In this brief presentation, we're going to.

Explore considerations for environmental safety for people with cognitive issues, as well as severe and persistent mental illness and even addictions. Ideally, the environmental safety assessment can be done with the patient and by a case manager, but if it needs to be, it can be done by the family with the use of a condition specific checklist. So if the person has dementia or if they got their hip replaced, there should be a condition specific checklist that the family can use and go around their house and make sure that the environment is as safe as possible.

A lot of times case management services.

For things like, you know, after somebody has a hip replaced may not be compensable by Medicaid, for example.

So it's important to reach out to.

Medicaid and Medicare and the long term care insurance companies and who whomever else the private insurance, if the person has it, to find out what services can be billed for and what services are going to be need to be integrated through other means.

For people with dementia, for example TBI.

Or other cognitive impairment, there are a number of environmental considerations depending on the stage of the disease. This can include forgetting how to use household appliances, getting lost on their own street, losing track of time and forgetting to eat or bathe, becoming easily confused, suspicious or fearful, having trouble with balance, or experiencing changes in sensory perception.

Now some of these issues can also.

Come up with people with severe and persistent mental illness. So it's important to know what the particular issues are that your client is dealing with.

In terms of keeping a.

Safe environment, making sure that it is routine, structured and consistent. The same things at the same time of day with the same people can be very comforting to a lot of people.

So whenever possible, even if you're working.

With somebody who doesn't have dementia, this can be very comforting and helpful to.

People, especially in situations where the person.

Has dementia or schizophrenia. If there are Multiple caregivers like CNAs.

Place a photo of each caregiver in a place where the patient can see.

It so they can connect the picture with the face. So you may have a picture of, you know, the CNA and it says my nurse. And maybe there's four of them because the same one doesn't come all the time, but that way when the person comes, the patient can see the client, the provider's face and they can look on their, on their board and they can see the picture of the person and know that that person's supposed to be there.

When new caregivers join the team, have.

Them introduced by existing caregivers or family members. That way, again, the patient has a connection and knows that this isn't just somebody who walked in off the street.

Sometimes it can be helpful to add a simple schedule.

Use words on a dry erase board or sometimes pictures. If the person is non verbal, this.

Can remind the person to do basics.

Like eating, taking medication, bathing, check for soiling if they're incontinent, or do housework. There was one client that I worked with who had schizophrenia who did very well. Once we got a whiteboard and we put a very basic schedule up there for him and he did have all of these issues. And once we did that, he was good about checking the schedule. There wasn't too much on there where it was overwhelming. And his, his family actually created push notifications on his mobile device, which he never let leave his side to remind him to check his schedule so he didn't miss any of those things.

It's best to keep it in an.

Environment that is tranquil and calm. If having a lot of activity agitates the person.

Now, sometimes people prefer to be around.

Some activity and they get lonely if they don't have activity. So that is going to be dependent on the person and sometimes even dependent on the day. Especially with people with cognitive disorders, some days can be much better than others and every day is just kind of a unique adventure.

Continuity is also important. Keeping furniture in the same place that.

Routine schedule and memorabilia within sight. When people have cognitive issues or have difficulty remembering or start getting stressed out, for example, in people with severe autism spectrum disorders, sometimes if they have something that they recognize, it can help them get grounded and they can focus on that and get recombobulated, for lack of a better word.

You want to keep the environment free.

Of distractions to avoid overstimulation or under stimulation.

Remember that stimulation is not just about.

Activity, but it's also input from smell, sight and sound. Paying attention to these things is really important for people with any condition. You know, if they're recovering from a, a hip replacement, for example, if the dog next door is barking all day long, it can cause a lot of stress and irritability on the person, which can sometimes prompt them to do things that they're not supposed to do, like try to get out of the bed so they can yell at the dog. So we do want to pay attention to annoyances over stimulation, but also what do they want in their environment for Adequate stimulation. I would lose my mind if I had to sit in a room where it was just like dead silent all day long and all I could hear was the birds chirping and all I could do was stare at the walls. You know, I just. I can't do that now. So it's important to know what is it that is the appropriate level of stimulation for that person remembering. Again, especially with dementia, it's important to remember that any given day, at any given time, stimulation levels may need to be adjusted because it's just not. It's not going to be the same thing. You can't just predict, well, yesterday it was this way, so today it's going to be the same. No, it. It's important to pay attention to the cues that you get from the patient.

Orientation and visual cues can also be.

Helpful like calendars displaying one day at a time, so not something that has the whole month, but one day at a time so they know it's May 15th or what, whatever.

Use contrasting colors for emphasis and camouflage colors to de.

Emphasize things. If you want somebody to notice something, you know, obviously use something that is a much more contrasting. When you look at the color wheel, colors that are opposite of one another are more contrasting like purple and yellow for for example.

Be sensitive to lighting and glare.

Use soft lighting, soft bulbs to eliminate shadows. Have a dull finish on floors and turn on lights at least two hours before sunset. To reduce the incidence of sundowning in people with dementia.

Remove or cover mirrors if necessary.

Sometimes mirrors can be anxiety provoking for people with with severe and persistent mental illness or dementia. Make sure there is adequate lighting though. Check stored food for spoilage with any person if it's a physical disability or cognitive, severe and persistent mental illness, or even if they're recovering from addiction. They may not be paying attention to their the dates of their food. So check for food spoilage. Lock up unsafe items like guns, poisons, medications and tools that may be used accidentally and hurt the person. Or unfortunately, they may look to some of these things and use them for intentional self harm and we want to prevent that.

Secure hazardous areas like pools, stairs, the.

Stove and the garage.

This is especially true for people who.

Get confused easily or have difficulty with mobility or balance.

Remove clutter and clear pathways.

That just makes most people happy, but it also removes any trip and fall hazards. Take knobs off the stove and unplug appliances like the microwave if needed.

Cover thermostats.

Sometimes people can get agitated and adjust the thermostat and get it either too hot or too cold.

Avoid look alike objects like edible versus.

Non edible fruit for example, or candy versus medicine. Gummy vitamins for example, maybe mistaken by somebody for gummy candies. And they may eat too many of them. So it's important to make sure that anything that they have is clearly identifiable as safe and or edible or not safe and or not edible.

Keep the water heater at 120 degrees.

Or less for anybody who has difficulty with who has a severe and persistent mental illness or dementia. People, for example, with autism spectrum disorders, with schizophrenia and with dementia often have difficulty with sensory processing. And these sensory differences can mean that if you have your hot water heater turned way up, they may not feel the heat when they are exposing themselves to it and they may inadvertently burn themselves. So keeping the water heater below 120 degrees prevents scalding.

Helpful devices for people who have mobility or balance problems.

Grab bars, a handheld shower, a bath chair, and non slip mats that you put in the bathtub so you know they don't fall down when they're on that slippery surface. All of those can be helpful even for somebody with something like pots or postural orthostatic tachycardia syndrome, which happens in younger people. They can start having a tachycardia episode and get very dizzy first, you know, without warning. So having these devices available can be very helpful for them as well.

For people who could get in trouble.

Getting locked into a, a bathroom or something and not know how to get out.

Remove the lock or cover the latch.

On the bathroom door.

For people who are or were acutely.

Suicidal, who have been discharged but are still struggling, you know, generally they are discharged, you know, pretty quickly from crisis stabilization. Again, it may be important to remove the lock from the bathroom door for a brief period of time. Not invading their privacy obviously, but, but to prevent the loss of precious time should something happen.

Tack down tape down.

You know, you can get that double stick tape, electrical cords and rug corners so people don't trip over them. Use chairs with arms so people don't accidentally slip out of them.

Now the all CEU's case management certification.

Course contains room by room suggestions for improving safety for people with cognitive dysfunctions and severe and persistent mental illnesses.

Case managers should regularly screen people who.

Use alcohol, people who have bypass surgery, and people who are severely underweight for cognitive decline due to medication side effects, liver functioning decline, depression and Korsakoff syndrome.

Case manager should also be attentive to.

Signs of abuse or neglect, whether it be emotional, financial, physical or sexual.

Additional considerations for people with severe and.

Persistent mental illness or addictions. Eliminate alcohol and unnecessary drugs from the home or secure them in a place that is only accessible to a trusted person. Drugs and alcohol and psychotropics don't mix. Tylenol, if you take too much of it, can be toxic to the liver very, very easily. People may feel that like they're in pain and they may take an nsaid like naproxen or ibuprofen. And when they don't get relief soon enough, they may start taking more. So it's important to make sure that people are protected from over medicating, overdosing themselves, or mixing medications that could be harmful.

Develop a crisis plan with the person in the event they are triggered.

This is, you know, if they have autism spectrum disorders, if they have schizophrenia and they start decompensating or start having hallucinations and delusions, if they are clinically depressed, if they are in early recovery from addiction. A crisis plan can be very helpful because the person will be able to tell you prior to the crisis what is it that you can do that's most helpful. I worked with one client who had schizophrenia and he had delusions that a voice in his head was telling him to cause himself harm. And he recognized that this isn't what something he wanted to do. So when he was having problems, when his delusions and and hallucinations were bad, when they were not controlled by the medication, There were things like listening to music with headphones on that he found to be very soothing and helpful. Well, without him telling us that, we would not have known. So the fact that we developed a.

Crisis plan ahead of time Enabled us.

To meet his needs effectively when he did have some breakthrough hallucinations.

Eliminate access to potential weapons if the person tends to wander or engage in.

Impulsive behaviors when they're experience experiencing a manic, depressive or psychotic episode. Consider locking up the car keys, credit cards, and securing online bank accounts. In these days of online banking, people.

Even if you put credit cards in.

A lockbox somewhere, people can get online and access their money through online banking.

So it is important to work with.

A financial advisor to figure out ways.

To secure that money so the person.

Has access to it to get their needs met, but they don't have access to it. In the middle of, for example, a manic or psychotic episode.

Develop a plan with the family for handling aggressive or acting out behaviors in.

A way that keeps everyone safe. A lot of times people with severe and persistent mental illnesses are living with others and or they have others in Their family that come by and check on them at least.

And if the person, if the patient.

Should become aggressive or act out, it's important that the family feels empowered and knows, you know, what is it that I can do to, to handle this situation?

Consider going through the home and putting away or eliminating triggers for anxiety, depression.

Aggression or drug use, such as pictures of dead relatives or ex partners, trophies or reminders of things of the reminders of things that they used to do but can't do anymore.

So anything that is going to trigger.

Dysphoria, it is important to consider is this something that we really want? Bombarding the person on a daily basis right now, they may want to keep it there. Like I have a picture of my mother in the living room and I wouldn't want it to go away. That would make me very sad. However, you know, that might not be true for my best friend.

So it's important to work with the.

Person and identify anything that could be a dangerous trigger of dysphoria or relapse.

Ensure people with anxiety issues feel safe. Have curtains that can be drawn at.

Night, for example, or even during the day. Maybe they don't like people walking by and being able to see them. Make sure door and window locks work, make sure their outside lights work, and even consider getting. Having them get a dog. That's obviously not appropriate for everybody because they can't take care of the dog or they can't have the dog where they live. But sometimes it can be helpful. And if the dog is an emotional support animal, in many cases, if the person can demonstrate the need through the appropriate letters, etc. They can have an amort, an emotional support animal that can help them allay their anxiety so they can get better sleep.

Add things to the environment that make people feel happy, safe and calm, and.

Maintains motivation for recovery. So it's not just about eliminating the stuff that makes them depressed or anxious. It's about adding things that makes them smile, that makes them feel happy and relaxed. And that can be smells, you know, candles or aromatherapy or even the little glade plugins or whatever. It can be.

Sights, pictures that are.

On the wall, or it can be sounds or, and it can be sounds. You can get the tabletop, waterfalls. You can have white noise machines that play ambient sounds like birds chirping in the background.

Whatever it is that helps the person.

Feel as relaxed and grounded and content as possible is going to help manage their symptoms and maintain their recovery.

In terms of addictions in, in particular, if the person is doing ambulatory detox.

Which means they are going in like once a day to see the doctor, but they are staying at home most of the rest of the time. Ensure they and their caregivers are aware of the treatment protocols and have them make sure they're monitoring for changes in blood pressure, heart rate, and cognitive functioning, all of which can be a medical emergency. It's really important in most cases that people who are doing ambulatory detox are staying with someone who can kind of be their eyes and ears and notice if they're starting to medically or psychologically decompensate.

A thorough cleaning of the house and car to remove the smells and remnants.

Of the substances can help reduce relapse triggers.

Don't forget to check in drop ceilings.

Under mattresses and change air filters when you're doing this.

Encourage the person in recovery to connect with a support group and provide them.

With a list of online support groups like in the Rooms and crisis lines that are available 24 hours a day. Relapse triggers don't just happen between nine and five. A lot of the strongest triggers may happen, you know, at the wee hours in the morning. So it's important that people have a lifeline, have somebody they can reach out to if they feel triggered in order to help them tolerate the distress, tolerate the urge until it subsides.

While a sober living home is the.

Best possible option, it's often not available to people because they have families, they don't want to leave, or they cannot afford a sober home.

Encourage them to change their phone number so dealers and using friends are not contacting them.

Some people send out a blanket text message to everybody in their phone that they're in recovery and don't contact me with offers to party. And that's. That can be if they keep the.

Phone or if they change, even if.

They change their phone numbers. That way they're letting people know, you know, I didn't die, I didn't drop off the face of the earth, but I'm in recovery and, and I need some boundaries right now.

They may send a second message to.

The people they know they can trust to be supportive with their new number.

Encourage them to avoid people, places and.

Things that will trigger them, like don't drive through the neighborhood where the bar is, or, you know, try to take a bus route that doesn't go past a place or something that's going to trigger you.

This also includes not opening the door.

To people who show up unannounced and may be triggering. I had one client who Told me that in her neighborhood, the crack dealers would show up at her door like the Avon lady, quote, unquote. And it made me giggle a little bit when she said that, but I recognized her frustration at that point. She was in her upper 60s and she was struggling with severe and persistent illness as well as in early recovery from addiction.

So it was really hard.

And she was living alone, so it was really hard for her when this happened. And it's important to recognize that it does happen. Dealers will show up at people's doors and be like, hey, haven't heard from you in a while. And helping them recognize that they can set boundaries and they, they are under no obligation to open that door for that dealer.

Develop a relapse prevention plan for handling.

Unavoidable triggers like seeing alcohol and beer at the grocery store.

And have the person consider putting a.

Co signer on their bank account that prevents withdrawals of over a certain amount, like $50. Now this should not be the case manager. This needs to be somebody that they trust, somebody that they're willing to give legal access to.

And put credit cards and debit cards.

In a safety deposit box or other safe location so the person is not tempted to try to get a cash advance on off of those cards in order to go buy drugs or alcohol.

If the person's working, have their paycheck direct deposited into their account. Encourage them to set up autopay for.

As many bills as possible. Ensure all of their medical providers are aware that they're in recovery. That way you don't have somebody prescribing Demerol when it's really not needed.

Have a medical history in the glove.

Box of the person's car that identifies their diagnoses, their medications, and their preferences regarding pain management and opioid medications.

This is most helpful if the person.

For example, gets into a car accident. A lot of times law enforcement will go into the glove box to try to figure out who they are, but also they will see the medical history there and they'll be able to give that to the paramedics.

There's a fair amount of overlap in developing a safe environment for people with.

Cognitive, physical or mental health issues.

Removing potential harms and negative triggers and.

Adding positive triggers can improve the environment of care.

Each individual is different, and making a.

Comfortable, secure environment requires involving them in the process to the extent possible. And when we're talking about people, especially people with dementia, it's also important to recognize that no two days are ever the same. So being flexible and curious about what is triggering them on any particular day is going to be another skill that needs to be developed to maintain a safe environment for the. For that person.