The Guidebook for
Dementia Care（excerption）～ for the standardized practice in Japan ～Japanese Nursing Association

The Guidebook for
Dementia Care（excerption）～ for the standardized practice in Japan ～Japanese Nursing Association

Foreword“How does Japan manage the issues of aging?”
We’ve been routinely asked such a question for some years at the international
conferences and meetings including ones hosted by the ICN. With all the baby
boomers turning 75 years of age or over in 2025, Japan will experience an unprecedented super-aging society in the world.
We thought we knew, but when asked for an answer by the countries fromwhich we had been learning, it made us, the nurses in Japan, realize that wewere facing to “unprecedented issues” that had to be solved.
Around that time a projection was announced by the Ministry of Health, Labour and Welfare that the number of people with dementia in Japan will reachover seven million in 2025. Dementia will no longer be a rare disorder if one
out of five aged 65 or over is diagnosed with it.
While JNA had been offering programs to prepare dementia care specialists,
now we strongly recognized that we needed to give support to every nurse sothat she/ he might provide appropriate care to the people with dementia basedon appropriate knowledge.
Our goal is to establish a society where the people with dementia can spend
their time comfortably throughout their lives, together with their loved ones
and families and people in their community. This coincides with the philosophy of “Community-based integrated care systems” currently promoted in Japan.
As described in the JNA’s Future Vision of Nursing, nursing practice is to support and sustain human life, living and dignity of all generations with any
health condition including people with dementia, as well as the elderly in thelocal community.
Then, where do we start? As a professional association of nurses, we, first, decided to create the primer of fundamentals for all the nurses involved in dementia care, which goes back to Nationwide Forum for Nurses (II) in June,3

2015.
Responding to my declaration to create “The Guidebook for Dementia Care”
by the following June, the Executive and staff members in charge together
with the authors made a great effort, and their hard work paid off and came toremarkable fruition.
The book covers all subjects from fundamentals of dementia, the latest healthcare policy, care practice to cases of community collaboration, and is strongly
recommended for practicing nurses, newly graduated nurses and nursing students.

Suga Sakamoto, RN, RNW, PhD
President of JNA
June 20164

Preface

Requested by the Japan Academy of Gerontological Nursing, JNA authorized
dementia nursing as one of the designated fields of the Certified Nurse Systemand started preparing Certified Nurses in Dementia Nursing in April, 2005.
However, given the rapid increase of the elderly that need dementia care in
Japan, not only the specialist nurses but also all the nurses should learn dementia care.
In addition to the education of specialist nurses and CE courses for general
nurses on dementia care, JNA has been sharing issues and challenges in dementia care at the Nationwide Forum for Nurses II (including nursing care,
residential care facilities, home care and etc.) , responding to the “Five-Year
Plan for Promotion of Measures Against Dementia (Orange Plan)2 announced
by the Ministry of Health, Labour and Welfare in 2012. This Forum is targetedat nurses working in long-term care and home care settings and held by the
JNA Professional Committee for Nurses II, which was established in 2011.
Given dementia measures evolved from the “Orange Plan” to the “Comprehensive Strategy to Accelerate Dementia Measures (New Orange Plan)” and thepractice of dementia care would particularly be of great significance in Japan,
President of JNA delivered a keynote speech titled “The Future of Dementia
Care that JNA Promotes” at the Nationwide Forum for Nurses II in 2015.
When she declared that JNA would create a guidebook for dementia care by
our next General Convention, I was completely startled because it was not on
our agenda for the year.
Yet, it was true that there was not an appropriate textbook in Japan that fills
the needs of those nurses who’d practice and/ or learn dementia care.
Started in the end of 2015 FY, the editorial board had extensive meetings todevelop a plan of a guidebook, to which a number of the specialist nurses andother healthcare providers contributed. The product, The Guidebook for Dementia Care, is comprised of nine sections including fundamentals of symptoms of dementia, ethical standard, symptom assessment, ADL assessment,
5

fundamental of care management, support for families and so on. It is easy tounderstand with multiple illustrations, graphs, charts and diagrams.

As its contents are broken down into short sections, the reader may start reading at any part.
This guidebook is assuredly valuable to all the nurses from those who takecare of people with dementia for the first time, those who are striving for better outcomes, to the leaders responsible for developing a care system in theirpractice settings.
I invite you to read and employ it for practice, education and training.
Last but not least, I’d like to thank all the contributors and editors for working
so hard under such an extremely demanding schedule.

Noriko Saito, RN, PHN, MNS
Executive Officer of JNA
June 2016

6

Contents

Part

Ⅰ

Fundamentals of dementia and its treatments
1. Definition, Overview and Epidemiology of dementia,
2. Diagnosis of Dementia
3. Characteristics of Primary Diseases Causing Dementia① Alzheimer's disease② Vascular dementia③ Dementia with Lewy bodies④ Frontotemporal dementia

4. Characteristics of depression
5. Characteristics of delirium
6. Pharmacologic treatment
7. Non-pharmacologic treatment
8. Prevention and early screening

Part

Ⅱ

Understanding People with Dementia (PWD)
1. View point of understanding PWD
2. How PWD perceive the world
3. Dementia care: its past and the future

Part

Ⅲ

Ethical issues in dementia care
1. Support for decision-making process for better treatment
2. Ethical dilemmas in care
3. Restrictions of mobility, and risk management
4. An analysis and approach for ethical dilemmas in care
5. Provision of information for PWD

Part

Ⅳ

Assessment of symptoms and treatment of PWD
1. Assessment of symptoms of PWD
2. Assessment tools and application in care
3. Assessment and care of cognitive dysfunction
4. Assessment and care for people with BPSD
① Approach for accepting cave and treatment② Restlessness③ Suspicion and delusions

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④ Depression⑤ Aggression⑥ Treatment refusal

5. Assessment, care (of PWD) with depression
6. Assessment, care (of PWD) with akathisia

Part

Ⅴ

Assessment, care the daily life of PWD
1. View point of life, care of PWD
2. Adjustment of rhythm of life and point in care (environmental interventions)
3. Assessment, care and treatment of functions in daily living① Communication② Diet③ Personal hygiene④ Continence⑤ Physical activities (transfer)

4. Fall prevention of PWD
5. Infection prevention of PWD

Part

Ⅵ

Care management in diverse practice settings
1. View point of care management of dementia
2. Care management in general hospitals① Outpatient service, examination diagnostic and other tests, admission and discharge② Surgery3. Care management in psychiatric hospitals: outpatient service, examination,
diagnostic and other tests, admission and discharge
4. Care management in long-term care facilities
5. Care management in visiting nursing services
6. Responsibilities of a nurse managers in dementia care
① Developing a dementia care system② Education of dementia care for the staff

Part

Ⅶ

Support for PWD and their families
1. Attributes of the families of PWD
2. Methods of assessment of the family supporting PWD

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3. Specific ways of support for the family
4. Discharge support of PWD
5. Support groups for PWD and their families
6. End-of-life care of PWD

Part

Ⅷ

Care and treatment of comorbidities of PWD
1. Care and treatment of PWD with a stroke
2. Care and treatment of PWD with bone fractures and osteoarthritis
3. Care and treatment of PWD with aspiration pneumonia
4. Care and treatment of PWD with cardiovascular diseases
5. Care and treatment of PWD with diabetes
6. Care and treatment of PWD with renal failure
7. Care and treatment of PWD with dry skin
8. Care and treatment of PWD with pressure ulcer
9. Care and treatment of PWD with cataractPart

Ⅸ 	Community integrated care system and dementia care
1. The Comprehensive Strategy to Accelerate Dementia Measures (NewOrange Plan)
2. Community integrated care system① Building “Integrated Community Care System”② Developing partnerships with multiple groups, associations and sectors.
③ Responsibilities of a public health nurse at an integrated community care support
center

3. Consultation and support regarding dementia
New fee addition for dementia care in the revision of the reimbursement of medical fees in2016.

References Assessment tools for dementia care

9

Part

IV

Assessment of symptoms andtreatment of PWD

Part IV Assessment of symptoms and treatment of PWD

4. Assessment and care for people with BPSD

①Approach for accepting careand treatment
Approaches predicting anxiety and confusion of PWD uponadmission to the hospitals and assisted living facilities.
PWD are likely to be anxious and confused.
They may become anxious, wondering, “Where
am I?”, “Why does my body ache?”, or “What are
all these tubes around me?”, even though they
were already informed of the need for admission.
First, a team of care providers need to findwhich approach would help them perceive theirsurroundings (verbal/ nonverbal comprehension),
to take account of their retention of memory (impairment of short-term memory), then to repeat amessage with patience, accordingly.
Allocate a room to the PWD which is nearenough to the nurse station for easy observationsand visits.
It is necessary to detect complications early
and to reduce stress, observing patient’s response
to frequent visits and monitoring alterations in facial expressions, sleep condition, restlessness, ag-

itation and other conditions.
It is also advantageous to create a dementiafriendly environment using signage and visual aids
to show the name of the hospital and disease, andplacing a calendar and a clock at a place where
they can see from their bed.
Give explanations patiently and thoughtfully,
assess person with dementia the PWD’s abilities
and apply them in practice.
Some of PWD may have a concern that they
don’t have enough money; that they don’t know ifthey have a place to sleep or food to eat; that they
have to “go home” because their families are worried. When faced with such a case, explain tothem they don’t need to worry or ask their families to stay on the admission day, until the evening. Asking them what makes them concerned isalso effective.

Understanding a causal relationship among physical,
social and psychological contributing factors
Dementia, in addition to the development ofmultiple cognitive deficits is often exhibited with
BPSD (behavioral and psychological symptoms ofdementia), which can be major contributing factors that diminish the quality of life of PWD andtheir caregivers.

BPSD, associated with the damaged regions of
the brain and progress of cognitive dysfunctions,appear with the influence of other physical andpsychological states, inadequate interpersonal
stimuli and other environmental factors.
For example, some person with dementia PWD
accidentally pull out the tubes and catheters,

12Part IV Assessment of symptoms and treatment of PWD

while they are receiving the IV treatments andtube feedings. When it happens, they often don’tcomprehend why they need the IV or why they
have tubes in their nose. Even though they were
informed of the need of care and treatment, they
can’t help but react, as physical sensation such as
discomfort and pain precedes because of memory
impairment.
In such actions, care staff are apt to consider
using physical restraints, thinking providing safe
care and treatment is impossible.
However, if the care staff alter the ways of communication, person with dementia may be able toretain in mind the need of care and treatment.
Perhaps, some clues can be found by altering
the predisposition of the care staff, so that they
may consider the possibility of oral rehydration,
antibiotics and feeding instead of tubes and IVs.

Avoid assuming that PWD cannot understandmedical treatment; that they will not understandwhat types of care they receive, but think of themethod, timing and arrangement of information
provision appropriate for their impaired and limited cognitive ability.
For instance, by placing display boards which
illustrate the treatments and care process, personwith dementia PWD may see the same familiar information anytime and by giving the same explanation repeatedly, they may have a better recognition of their situation.
Care staff should understand the temperamentof each PWD and try to engage in persistent but
thoughtful message delivery. Be sensitive to thecausal relationship among the person with dementia PWD’s physical, social and psychologicalfactors, and grasp the person-specific clinical presentation of each PWD.

The importance of observing facial expressions
and behaviors
In the case of people without dementia, theirdirect complaints of pain and numbness can be
more crucial than objective observations andcould lead to early detection of complications andidentification of stressors.
In contrast, because the PWD rarely complainof symptoms or contrary they present a variety ofthem, it is difficult to make accurate assessment
and diagnosis.
It is important to make observations of their
physical conditions as well as monitoring throughfrequent visits their responses, changes in facial
expressions and complaints, sleep conditions,
restlessness and agitation.

Even if the person with dementia do not complain of pain or discomfort, carefully look at theirfacial expressions and behaviors for any change
when the care staff moves theirs body.
When encountering refusal of physical movements and care, review the procedures and anticipate any possible pain and discomfort concurrently.
The care team should develop the care planthat minimize the person with dementia PWD’s
pain and discomfort, employing validated nonverbal pain assessment tools and measuring thepain levels by the their reaction before and afteradministering analgesics.

13

C ASE A Patient refusing to receive the IV treatment previously agreed
Mr. A, in his 80’s, had Alzheimer’s disease (middle-stage), and was admitted for a femoral fracture
and underwent the hip replacement surgery.

1) Condition after surgery
After the surgery, patient A agreed on an IV
treatment such as administering antibiotics, yet
when receiving venipuncture later, he started
screaming for help and resisted the treatment,
making it difficult.

3) Key points of careFirst, it is vital, as a team, to discuss the manners of explanation suitable to the patient’s comprehension (verbal/non-verbal comprehension)and his capacity of memory retention (immediate
memory), then customize the approaches to explain the procedures in order.

We now have an IV
treatment.
Sure.

Help, me!

(Bewildered)2) Care we actually provided
Because of memory impairment, patient A, being incapable of understanding the validity of any
treatment accompanied by discomfort, may havereacted at the moment of venipuncture.
Following this incident we asked him to use his
glasses and hearing aids he had been using, andexplained the purpose of the treatment with somevisual aids so that he could thoroughly understand it. Then while having him confirm the IV
bottle, the catheter and the insertion point, we
explained the procedures in order and were able
to insert the needle without resistance.
Then, we secured the venous access applying
dressing without pressing a hard catheter hub
against his skin, looped the IV tubing on his limb
to prevent dislodgement of the catheter from tension on the line and secured the tubing with tape.

14

Furthermore, venous access was covered witha towel so that it might not be visible to the patient, and we explained to him that he was with
an IV each time of visit. Now, patient A neither
touched the tubing nor did he pull out the IV line.

If a patient regularly uses the glasses and hearing aids, suggest their use continued for smoothcommunication, with the aid of both writings anddrawings.
Or, show them the IV bottles, needles and insertion sites so that he can retain a solid, uninterrupted image until the time of the IV treatment
and keep a sense of security.
An IV treatment makes anybody uncomfortable, causing pain and discomfort. Therefore, it isessential for nurses to be watchful to eliminate
possible discomfort factors such as redness anditch caused by fixing the insertion sites.

glasseshearing aid

Part IV Assessment of symptoms and treatment of PWD

Part IV Assessment of symptoms and treatment of PWD

4. Assessment and care for people with BPSD

②Restlessness
The state of restlessness
Tranquility indicates the state of being tranquil,of calm behaviors and of being calm. The state ofrestlessness in clinical practice includes fidgeting,jittering, wandering and inattention and it can bea hindrance for the bed rest or increase the risks
of falling, which can be a direct cause of the secondary health problems and administrative difficulties. Thus, it is considered as BPSD.

In our hospital, the Dementia Support Team
(DST) is assigned to support nurses caring for
PWD in the wards. Restlessness is one of the toplisted subjects among the cases reported to theteam. It could be, among BPSD, a symptom which
creates more difficulties in the person with dementia care process.

Key points in assessment
First, consider such fundamental extraneous
factors as in Table 1, then observe the PWD.
Next, evaluate the possible contributing factors

for restlessness (Table 2). Analyzing what causes
restlessness in detail is essential in order to makesuitable care plans.

Key points in careFirst, extraneous factors in Table 1 need to be
removed. Next, approaches meeting each factor

in Table 2 should be developed.

Table 1 Observation checklist
physical symptoms

Does a person with dementia have constipation, fever, dehydration, pain,
acute exacerbation of chronic diseases and etc.?

Environmental factors

Are there unpleasant stimuli (noises, lights, odors)?
Are there familiar objects in the person with dementia surroundings?

Timing of the appearance of symptoms

Do the symptoms emerge at certain times of the day

Triggers and purpose of the behaviors

Find out the triggers preceding the episodes of restlessness. (Think how
old person with dementia think they are (in their cognition) and what responsibilities they think they have to fulfill?)

Sleep/awake cycle

Observe hours of sleep, frequency of night-time arousals and day-time
drowsiness and sleep quality.

15

1. Delirium

It may also be helpful to conduct an interview
regarding the person with dementia life cycle andto create an approach to meet the person withdementia purposes for “going back home”.

(skipped)

2. Akathisia
Akathisia is a condition marked by uncontrollable motor restlessness. It is hard for patients, but
is often overlooked.
Because it develops as a side effect of antipsychotic medications, consult with the attending
physician to modify the drugs or the dose.

3. Sundowning syndrome
Because it is a behavior related to the habit ofreturning home in the evening it is often called
sundowning syndrome. It is a common symptom
in a clinical practice, but its mechanism has yet tobe known.
It is believed to be related to the busy hours of
the shift changes in the evening or the preparation of suppers in the hospitals and care facilities
in the evening. Therefore, creating a calming environment is significant. Furthermore, circadianrhythm disturbance is also considered to be acontributing factor. Providing daytime activities
and moderate rest to ensure nighttime sleep are
crucial.

4. Wandering
Wandering, defined as “to move about without
a definite destination or purpose” in American
Heritage Dictionary. Each pattern has its own
contributing factor, therefore planning an approach suiting each pattern is needed.
The examples of patterns are shown in Table 3.
If patients appear to be restless but not troubled, be flexible, monitor them carefully for accidents such as falls, allow them to enjoy walking
around freely to a certain degree, overseeing patient’s fatigue.
Sharing documents of their daily conditions inorder to find potential risk factors for wandering
can also be a clue to a plan for the care and treatment.

Table 2 Contributing factors and assessment for restlessness
Definition

Contributing factors

Point in assessment

Delirium●Acute onset●Predisposing and precipi- ●Demonstrating restlesstating factors interacting
ness within a few days
●Exhibiting slight deterioration of consciousness
with multiple aggravating ●Low responsivenessfactors

Akathisia●A type of extrapyramidal ●Adverse side- effects of ●Complaints of fidgeting
symptoms
antipsychotic medication ●Unable to keep still while
complaining●Showing such involuntary
movement as longstepped gait

Sundowning syndrome●B P S D e m e r g i n g a n d ●O ften appearing at the ●Occurrs in the evening
time of minimum staffing ●The PWD try to perform
worsened in the afternoon or evening
in the facilities
former roles, showing
the occasional signs ofimpatience

Wandering/pacing●Wandering around with ●Disorientation (confusion ●P atterns depending on
no apparent aim
in sense of direction)
contributing factors andpatient’s aim or purpose●Looking for an exit
●Boredom, anxiety

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Part IV Assessment of symptoms and treatment of PWD

C ASE Restless throughout day and night during the hospitalization
Mrs.B, in her 90’s, had Alzheimer’s disease, and was admitted for acute decompensated heart failure.

1) Conditions at the beginning of admission
With dyspnea, being agitated and incapable ofstaying in bed, she spent most of the time in awheelchair, saying, “I don’t have time to lie inbed” or “I have to feed my grandkid”. She wasrestless day and night, but occasionally was
drowsy because of sleeplessness at night.

I have to feed my grandkid

after lunch, ensuring she could rest for a while.
Given her heart conditions, we positioned her
in semi-Fowlers’ position for the night.
Since she used to spend a great deal of time fortaking care of her grandchild, we made a requestof her grandchild to write a letter which wishedfor her quick recovery and employed consistent
approaches to inform her of the importance oftreatments together with the well-being of her
grandchild by showing the letter.
Oral medication, fluid restrictions and diettherapy for heart failure were concurrently implemented during hospitalization.

3) At a later time Outcome
Because impairment of her short-term memory
was severe, she often forgot about the need of leg
elevation and her hospitalization; however, an approach with the help of the letter from the grandchild improved her recognition of surroundings.
She periodically complained of pain for peripheral edema, apparently caused by long hours of
being in a sitting up position.

2) Care we actually provided
We allotted time for letting her lie on the bed
and elevate her legs during the day for pain relief.
And we also let her take a nap for a half an hour

At the beginning, she remained uneasy evenwhen encouraged to take a nap. Gradual reduction of physical symptoms (dyspnea on exercise,leg edema) because of the effectiveness of treatment made it possible for her to take rest, improving her daytime drowsiness.

Table 3 Wandering patterns
False recognition●When disorientation worsens, PWD suddenly lose the idea where they are.
●Wandering off on the way back or while looking for the exit

Inclination (impatience)●Goal-oriented: e.g., leaving their home believing they are going to work in themorning (former workers) or going shopping in the evening (former house
wives).
●Accompanied with compulsion and impatience

Aimless stereotyped behavior●Aimless or purposeless walking

Alterations of consciousness●Wandering with slight disturbance of consciousness even in the daytime●Wandering half awake●Often accompanied with hallucination and/ or delusion

17

We found that she became physically active inthe morning when she awoke and in the evening,
trying to prepare a meal to fulfill a responsibility
from her earlier life.
After developing consistent approaches, we repeatedly told her that “we have arranged supper
for three people (for her, her husband and grandchild)” in the evening, and that “breakfast forthree people is ready” in the morning. Hearing
this, she became calm.

Get well soon,
grandma.

4) Recommendation
Aside from being unable to recognize admission
because of impairment of short-term memory anddisorientation, this is an example that abominable
symptoms such as dyspnea and edema caused byheart failure induced confusion.
When a person with dementia exhibits difficulties to keep still in bed, consult with the attending
physician and ask instructions for the right position.
In the case, what made her taking a rest possible was the comfortable positioning and the effectiveness of treatment.
Arranging surroundings is also essential, so thatPWD necessary treatment and nursing care may
be provided to PWD.
As described in the case, in which we took advantage of the letter and approaches considering
her life history and routines, it is vital to build anfamiliar approaches which enables person withdementia to give their full attention to the treatment.

18Part IV Assessment of symptoms and treatment of PWD

4. Assessment and care for people with BPSD

⑥Treatment refusal
What is refusal of care?
Not accepting care and treatment, refusal or
resistance in other words, is generally consideredpart of aggression. No major differences are recognized in the approaches to both “refusal” and“aggression”.

Before discussing approaches for rejection ofcare, the effects which assistance and care bringabout to the PWD must be taken into consideration.

PWD tend to show aggression when they receive offensive stimuli from the outside, which
may be distorted by the visual and hearing impairment and/ or by their persecutory delusion.

For example, when one is absent from work because of a fever and need to ask somebody for
help, he or she may have the sense of guilt, inferiority, anxiety of the job, irritation over things theycannot control, impatience, uneasiness of recovery and fatigue for the ill.

Decline in frontal and temporal lobe function
causing loss of control, decline in the function of
the brain serotonin system, and acceleration in
norepinephrine functions and other factors activate sense of anger.

Other person may become more dependent,
demanding more attention and care, which also
indicates anxiety.

There are other related cases affected by psychology symptom such as hallucination, misidentification and impatience (Table 1).
The causes of anger in PWD described in thesection of “Aggression” are also applied to a refusal of care.

PWD are not exception. When assisting, keep
in mind that they become resistant to care andtreatment because they experience fatigue from
illness (PWD may feel psychological and cognitive
fatigue caused by overthinking and too much attentiveness), anxiety, impatience and self-accusation.
In our hospital, we have a dementia support

Table 1 Contributing factors for to irritability
Physical factors●Functional disorder of neurotransmitter (serotonin, norepinephrine)●Visual and hearing impairment●Adverse side effects of anti-dementia drugs●Frontal and temporal lobe dysfunction

Psychological factors●Persecutory delusional cognition●Hallucination (visual, auditory, olfactory)●Premorbid personality (nonreciprocal behavior, self-restraint/inhibition, impatience, misidentification)

Environmental factors●Unpleasant stimuli●Offensive stimuli

Source: early period of BPSD dorrespondence guidelines

19

team (DST), multi-desciplinary dementia support
team. The DST is dispatched to each ward, conducts an assessment of troubling cases, and discusses care plans together with nurses in theward.
Among the reports to the DST, the following
are the examples of treatment refusal: rejection oforal medication, daily personal care services (including changing diapers, bathing, dressing, oral
and dental care, ambulation and etc.), urethralcatheterization, eating and others.
We’ll discuss rejection of oral medication andbathing in the next case.

Approaches for rejection of oral medication
C ASE 1 A question from a family: “Can we mix medications with food?”
Mr. C, in his 80’s, had Alzheimer’s disease. We were consulted by his family regarding mixing medications with food.

1) Key points in care
①Investigate the causes for rejection
The patient used to take his drugs himself, butwhen the family decided to manage the scheduleand gave it after a meal, he forgot to take it. Next
time, the family tried to put them into his mouth,he spit it out. Later they attempted again, but herefused and firmly said he would not take it.
We concluded he grew suspicious because hisfamily suddenly took over the matter. We proposed them that they should let him handle it as
he used to, encouraging him and watching overhim so that he would take it.

Because he wasn’t prescribed multiple medications, he managed the medication himself. He
used to open the package, put the pills in his
hand, then swallowed them. This time he had one
kin of pill prescribed. As it was in a blister pack,the family took it out and put it in his mouth, ensuring he took it.
③Evaluating progress of cognitive functions deterioration and BPSD, discussing methods fororal intake.
Total score was 20 on MMSE. He sometimes repeated the same questions.
We advised the family to hand him a pill in ablister pack one at a time at first. If he would
swallow it with the package still on it, then, thefamily should take the pill out, place it in his handand ask him to take it. We also suggested that thefamily should explain to him it was prescribed byhis primary care physician and then put it in his
hand, if he is stuck.

2) Recommendation②Confirming the prior procedures of his medication management

20

Following the procedures, he took the pill.
Avoid mixing medications with food as much as
possible. He might even stop eating, if he thought
the mixture tastes terrible. In addition, supportshould be minimal so that it may not interferewith his ability.

Part IV Assessment of symptoms and treatment of PWD

There are some occasions to mix medications
with strong-tasting food (e.g., chicken noodle
soup or chocolate pudding) to mask the flavor. It
should be saved as a last resort to avoid food-druginteractions. Consult with a pharmacist or physician before doing so.

Could you put the pill in his hand?

C ASE 2 Noncompliance to medication regimen despite repeated explanations bynursesMr. D, in his 80’s, had vascular dementia and exhibited verbal aggression and agitation. He wasprescribed liquid medicine but highly resistant, being continuously agitated.

1) Key points in care
①Organizing medications
Because the elderly patients may see multiple
physicians, medications are not consolidated. Not
knowing about their medications, they are unable
to discontinue, thus would routinely keep taking
them.
They may lose track of their medications. And
more medications may be added without being
noticed, which could cause a physical disorder.
Their medications need to be organized sortedout at some point.
②The vicious cycle of obsessions to take medications as directed
Nurses think their job is to administer drugs,
thus they are determined to do it by all possiblemeans. In fact, the nurse was baffled, saying thatthe patient B ignored explanation and refused
medications.
When a person with dementia is adamant in refusal and is agitated, efforts to create a good interpersonal relationship could worsen the aggravation.
We suggested that nurses try once and give up

if an attempt failed, because the patient needed
to be ready to listen.
Forcing him to take medication when he is notready only makes procedures harder and daunting to perform.
Discussing with his physician, we let him grasp
the situation.
③Consistent methods and assessment of administering oral medications
We proceeded with avoiding repeated reminder
for medication, giving the patient time and shuffling the nurses.
The ward nurse tried this approach for a week
and was able to find the timing somehow. The patient, slowly but surely, started taking his medication with the approach.
④Find shape, size, and other attributes of medications which suit to the patient
We asked person with dementia B’s pharmacist
to find forms of medications adapted to him,
which include tablets, capsules, powders and liquids. Tablets come as chewable tablets, oral disintegration tablets, extended-release tablets, sugar-

21

coated tablets, enteric-coated capsules and sublingual tablets. Patches are increasingly becoming
common these days.

2) Recommendation
Try not only to develop a regimen for the patient’s drug intake but also evaluate it, when thepatient rejects oral medications. Making it as daily
routines, with setting a regular time, will help
nurses seeing the efficacy.

In addition, consultation with the pharmacist
and the physician in regard to sorting out the
medications and prescribing as minimum number
as possible for easy oral intake should be necessary.
In this case, we consulted the pharmacist since
it was particularly about medications; however,asking for expert advice and professional knowledge from other specialists may be also helpful inpursuit of effective care.

Approaches for bathing resistanceC ASE 3 Refusing to bathe even when nurse invited
Mrs. E, in her 80’s, had dementia with Lewy bodies. She was noncompliant to regular bathing, andwas aggravated when asked persistently.

1) In the beginningIn our hospital, bathing is implemented during
the day. She had cataracts, being almost blind.
She didn’t even want to be touched, much less tobe assisted by another person. She was also coldsensitive, and hardly took a bath at home.
Her family said it would be fortunate, if she
could bathe once a month at the day care center.
When she bathed at home, the family assisted
her just the right time that she went to bathe, butthey had difficulty in predicting exactly when she
did.

2) Key points in care
As she had dementia with Lewy bodies (DLB),
we stopped getting her to bathe, but just foundout the time she was in a good mood or exhibiteddelusional behaviors. Since she could not takebathe for herself, we arranged some nurses to attend her, but to a minimum of one or two, taking
into account her need for privacy.
Nurses felt rushed when other patients lined
up in turns. So we prompted her twice a day inthe morning and afternoon to bathe after other
patients had finished bathing trying not to disturb

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her preferences. When she was still resistant, weonly gave her a foot bath and cleaned only the
genital areas after her using the toilet.
We ensured that the bath room was warm
enough, then invited her when she went out ofroom, at the end of rehab, before meal times andat other occasions.
Using the same approach and a familiar nurse,
we tried to encourage her telling that she would
have some fun after bathing or that she was expecting visits of her family or guest, but any attempt did not work well. We asked her family toinvite her and bathe together, but couldn’t ask
many times over, because it was burdensome tothem.

3) Recommendation
Bathing three times a week is not required. In
our meeting, we decided that we would prepare
the environment that might lead her to bathe, andthat we would keep on encouraging with patience.
Later, she started responding to the nurse’s invitation and bathed once a week or every other
week.
There is no “universal approach” but we needPart IV Assessment of symptoms and treatment of PWD

to be flexible to the person with dementia preferences and find an approach for each individual
and assist the person.
Both success and failure are learning experiences, which help nurses enrich their knowledge
and skills.

The more challenging the cares are the more
the care staff gain.
It may be because we give our full attention to
the person trying to figure out what is be best forher/ him.

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