Training package on long-term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide)

iIntegrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) ii iIntegrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Integrated Care for Older People (ICOPE) Training package on long-term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) ii Title: Training package on long-term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) ISBN: 978-92-9022-838-7 © World Health Organization 2021 Some rights reserved. 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Printed in India iii Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Foreword v Acronyms and abbreviations vii Section 1: Introduction 1 Section 2: Training methodologies 9 Section 3: Session plan 17 Section 4: Conducting the training 21 Annexure I 27 Annexure II : PowerPoint presentation slides 31 Contents Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) iv vIntegrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Population ageing is a global phenomenon that is increasingly observed in the WHO South-East Asia Region. The proportion of people in the Region over the age of 60 is currently more than 10% but is expected to double over the next three decades. By 2050 the proportion of people in the Region over the age of 80 is expected to triple, from 1% to 3%. Concurrent with the Region’s demographic transition is an epidemiological transition characterized by an increase in noncommunicable diseases and associated chronic disabilities. Older people across the Region are increasingly dependent on family caregivers for maintaining their basic, instrumental and advanced activities of daily living. Health systems must increasingly explore the many issues related to long-term care of dependent older populations in their homes and in institutions, as highlighted by the WHO Decade of Healthy Ageing, and as outlined in the Region’s Framework for Healthy Ageing 2018- 2022. This manual is designed to contribute to this process and to empower volunteer long- term care givers to provide the best care possible. It is envisioned that this manual will be implemented alongside the Region-wide roll-out of the WHO Integrated Care for OIder People (ICOPE) approach, which all countries have now been oriented on. I urge all stakeholders to leverage this package to promote healthy ageing so that together we can achieve the future we want for present and coming generations. Dr Poonam Khetrapal Singh Regional Director WHO-South-East Asia Region Foreword Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) vi vii Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Acronyms & abbreviations ADL : activity of daily living FLHW : frontline health worker ICOPE : integrated care for older people Mini-Cog : mini-cognitive assessment MNA : mini-nutritional assessment NCD : noncommunicable disease PPT : PowerPoint SEARO : Regional Off ice for South-East Asia TUG test : timed-up and go test WHO : World Health Organization Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) viii 1Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Introduction 1 SECTION Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 2 This manual is an instruction guide for facilitators to provide competence-based training for volunteers to develop a cadre for formal caregiving in long-term care systems. The training is intended to assist in learning and improving the skills of the volunteers to provide regular care to older people with compromised intrinsic capacity as well as functional abilities, in home or institutional settings. Facilitators are required to consult both the Facilitator’s Guide and the Participant’s Manual while training participants through interactive presentations, demonstration, group discussions, role plays, etc. The Facilitator’s Guide contains detailed training methodologies, structure of the individual training sessions and guidelines for assessment of participants. The Participant’s Manual contains diff erent modules to assist participants with step-by-step learning of various aspects of long-term care. Training resources are based on the “Integrated Care for Older People: Training package on long-term care in home or institutional settings in South- East Asia Region (Participant’s Manual)” which will be the primary reference material for participants. Facilitators should be conversant with the contents of the participant’s manual. Training objectives The training module has been designed in a comprehensive manner and is intended to provide a holistic approach to short-term human resource development, with a focus on volunteers to provide care to older people requiring long-term care in home or institutional settings. The information on old age care contained in these modules is meant to be incorporated into the everyday clinical practice of the caregiver-turned-volunteers. The training package will be useful for knowledge as well as skill enhancement of the volunteers. The training is expected to improve care of older people with compromised intrinsic capacity and functional ability, who require long-term care for their well-being. The objectives include both knowledge enhancement and skills development. Knowledge-based objectives By the end of the training, participants will be able to: » Describe ways to provide general care to older people with compromised intrinsic capacity and functional ability in-long-term care settings, either at home or in an institution. » Describe the management of geriatric syndromes, and other common issues in older people. Skill-based objectives By the end of the training, participants will be able to: » Perform screening, assessment as well as management of age-related declines in intrinsic capacity and functional status. 3Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) » Provide holistic care to older people either at home or in an institution, based on the available resources. » Provide preventive, promotive as well as rehabilitative services to older people. » Provide support to caregivers in the family, as well as manage the caregiver burden syndrome. Participant’s profi le This training is intended for volunteers who are motivated to be formal caregivers who deliver long-term care to older people in home or institutional settings. Volunteers should have completed at least a secondary level of education (Grade 10). Facilitator’s profi le Facilitators should have adequate knowledge of, and skills in the subjects concerned. They should preferably undergo training of trainers to be conversant with objectives, methodologies, session plans and the training materials. They should be conversant with the management of issues of older people, in their respective fields. Facilitators should preferably be nurses, dealing regularly with the health care of older people. Course coordinator One facilitator will be designated course coordinator with the following responsibilities: » Check the audio-visual system for proper functioning. » Check the availability of all training aids. » Ensure that sessions are conducted as per schedule. » Introduce the course. » Oversee administrative aspects, including the maintenance of records. » Check for general facilities like running water, washrooms, power back-up, refreshments etc. » Check the functioning of all equipment. » Check the availability of an adequate number of instruments and consumables, including those required for simulation sessions. Batch size of participants and number of facilitators The total number of participants should be 20 per batch. The number of facilitators per batch should be at least four. Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 4 Training materials The following training materials will be provided: » “Integrated Care for Older People: Training package for long-term care in home or institutional settings in South-East Asia Region” (Facilitator’s Guide). » “Integrated Care for Older People: Training package for long-term care in home or institutional settings in South-East Asia Region” (Participant’s Manual). » Flash drives containing PowerPoint presentations, digital images, videos of various assessment tests. » Flip charts. Checklist of equipment and supplies required for the training Participant’s handbook containing the modules for diff erent training sessions Participant’s log sheets Flash drives containing PowerPoint presentations Pens, pencils, erasers, sharpeners Writing pad Agenda for the training programme Material for participants’ folders Remarks 5Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Name tags of participants and facilitators Attendance sheet for participants and facilitators Pens, pencils, A4 size paper, note pads, staplers, punching machines, cello tape, measuring tape Laptop, LCD projector, extension cords, projection screen, microphone, podium Flip charts and stand, marking pens of various colours, large clips to hold flip chart paper Whiteboard, duster, chart papers, tapes for posting papers on boards PowerPoint presentations, images for demonstration, flash cards Printouts of pre- and post-training knowledge assessment questionnaires, checklists, log sheets Standees per group Measuring tape Stopwatch Chair without armrests Material for demonstration sessions Remarks Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 6 Training site The theoretical training should be held in a well-equipped hall. Practical sessions should preferably be carried out in a well-equipped long-term care centre. The readiness of a proposed training site should be assessed by a competent person, using the checklist provided below. S.N. Items Remarks 1 Infrastructure for classroom teaching: » Hall with a minimum seating capacity of 25 (to accommodate 20 participants, 4 facilitators and 1 observer), seating arrangement preferably U-shaped. » Classroom should be well-lit and ventilated. » Lights and fans, or air-conditioner in working condition. » Audio-visual facilities in the classroom. » Electricity (sockets and extension cords) and electrical power backup. » Toilet facilities, drinking water supply. 2 Training aids » Audio-visual aids with accessories: LCD projector, TV monitor or projection screen, microphone. » Other teaching aids: Staplers, highlighters, stapler pins, punching machine, scissors, A4 size plain paper, colored sticky labels, cello tape, whiteboard, marker pens and duster. » Computer facilities: Internet facility accessible to participants, printer, photocopier. 7Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Duration of clinical training The total duration of the clinical training will be three days. Details of the training schedule and session plans are given in later sections. Dos and don’ts for facilitators Strictly adhere to the session plan and the session contents Be conversant with the session plan and the training materials, prior to start of training Make adverse/negative comments on any participant Be shy, nervous or worried Use one-way teaching without any interaction Ignore participant’s queries Make presentations without facing the participants, or by avoiding eye contact with them Use teaching aids or materials other than the prescribed ones Rush through any of the sessions Ensure that the training site is ready, prior to onset of training Maintain a friendly and supportive environment Call participants by their name, as much as possible Speak clearly and loudly Spend enough time with participants, so that all their queries can be answered Give simple and clear instructions to participants Ensure clear visibility of the presentations/demonstrations, for all participants Encourage participants to interact and be involved in all the sessions Do Don’t Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 8 9Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Training methodologies 2 SECTION Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 10 Introduction The training on “Integrated Care for Older People: training of volunteers for long-term care in homes or institutions” involves knowledge development through the participant’s manual, interactive presentations, demonstrations and skill enhancement, through facilitated group learning activities and clinical sessions. Facilitators should meet daily after all the sessions are over, to review the day’s activities and plan for the next day’s training, and to ensure availability of all training materials and teaching aids. All facilitators should agree about each other’s roles and responsibilities, prior to the start of the training. Primary components of the training Classroom training Real patient assessment and demonstration at the long-term care institution The second component includes facilitated group learning activities for which breakout groups should be formed, as instructed in box below. Formation of breakout groups Organize participants into smaller groups during the opening session. Each group should not have more than 5 participants. Designate one facilitator to each group. Print a list showing the groups to which participants and facilitators have been assigned. Display the list in the classroom and clinical stations for all participants to see. Instruct participants not to change groups. Guidelines for conducting classroom training » Conduct all interactive presentations and designated group learning activities in the breakout groups, in the classroom. » Start each day’s session in the classroom by reviewing the previous day’s activities, and discussing relevant queries posed by the participants. Let participants respond to each other’s queries. The facilitator may provide the correct explanation, if participants are not able to do so themselves. » Review the day’s timetable along with the participants. 11 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) For each session » Follow the instructions for conducting training, as per the corresponding modules given in section 5 of the facilitator’s guide. » Present the learning objectives at the beginning of each session. » Use the PowerPoint presentation included in the teaching aids for each module. » Facilitated group learning activities in the classroom include: Role plays Case-based discussions Patient demonstration. » At the end of each day, ask participants to summarize the day’s activities and key points. » Brief participants on the next day’s agenda. Guidelines for delivering PowerPoint presentations Purpose: PowerPoint presentations serve as excellent teaching tools that help the transfer of knowledge through focused content, clear messages and eff ective visuals. They enhance the learning process by allowing participants to analyze, interpret and interact on topics covered. Know the subject well by reading individual modules, and the information in the participant’s manual that is relevant to the PowerPoint presentation Familiarize yourself with the contents and sequence of the presentation Refer to the key points for discussion in the corresponding module provided in the manual You may add your own notes to emphasize issues of local importance Rehearse the presentation so that you cover all important points within the given time-limit Preparation 01 02 03 04 05 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 12 Delivering the presentation Check the seating arrangement to make sure that slides are clearly visible to participants Introduce yourself, if not already done Speak clearly and ensure that all participants can hear you Inform participants that they are free to ask questions anytime during the presentation, and can do so one at a time, by raising their hands Introduce the topic and give an overview of the content of the presentation Face the participants and not the slides, while making presentations You may use a pointer, stick or pencil to indicate a specific part of the presentation Explain each slide slowly, highlighting the key points Never read from slides or from the notes Make sure you cover all the information provided in the notes accompanying each slide Maintain the logical order of ideas in the presentation Do not give extra information except for updates, or relevant national/ regional guidelines Make the presentation interactive by asking participants questions in between slides. This will also allow you to assess their understanding Keep the interactive discussion focused on the topic of the presentation Strictly adhere to the time-limit of the presentation Summarize key points at the end of the session Thank participants after the presentation 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 Allow time for questions from participants. Provide complete answers 13 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Guidelines for managing role play Purpose: Role plays are conducted to give participants an opportunity to practice and improve their knowledge and skills of communication and counselling in a non-threatening, simulated environment, before applying the same on clients. Role plays help in changing the attitudes of participants towards the problems concerned. Check the list of suggested role plays Identify, or ask participants to volunteer to enact the specified roles Brief participants about the background situation and focus of the role plays described in the module Clearly describe each role to the participants Encourage adherence to the counselling steps given in the checklists, while enacting role plays for counselling Assign the role of observers to the remaining participants Observer participants should give feedback at the end Set a time-limit for the role play (approximately 60 minutes) Organizing a role play 10 11 12 13 14 15 16 1708 07 06 05 04 03 02 01 Ask participants to speak loudly wand clearly 09 Ensure the role play remains focused on the given situation Thank the group after the role play is over Ask participants (actors) how they felt while performing the role After completion of the act, facilitate debriefing by asking observer participants to provide constructive feedback Discuss what else could have been addressed during the role play Provide constructive feedback and necessary improvements for the benefit of the whole group Encourage all participants of the group to ask questions Always ensure complete answers are given Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 14 Guidelines for conducting case-studies Purpose: Case studies allow participants to analyze a situation or a case thoroughly and will reveal interesting and useful information on their attitudes. Case studies are preferably done in small groups to allow everyone to participate, including those who might not speak in a larger group. Preparation » Check the suggested case-study. » Familiarize yourself with the case study and the issue to be discussed. » Prepare a slide of the case study for projection during the session or have printouts of it for distribution to the groups. How to conduct case studies? » Identify groups for discussion of case studies and let each group select their group rapporteur. » Project the slide of the selected case study describing a familiar problem/situation or distribute handouts of the case study to the small group. » Include images where appropriate and show the images along with the case study. » Allow participants to go through the problem/situation and discuss the diagnosis of the case, and the management and rationale for the recommendations with the participants. » Assign time for group work (approximately 15 minutes). » Ask group rapporteurs to present their group’s point of view on the case, along with a further course of action and its rationale, if appropriate. » Facilitate the necessary corrections with explanations and ask one member of the group to record the key points on a flip chart. » Ask one participant to present a final summary of the case and the course of management. » Encourage all participants to ask questions and give feedback. 15 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Guidelines for conducting patient demonstrations Purpose: Patient demonstrations are conducted to give participants an opportunity to practice and improve their knowledge and skills of assessment, communication and counselling, in a real-world setting. Such demonstrations help in changing attitudes of participants towards the problems concerned. How to conduct real case scenario demonstrations? » Identify groups for discussion of case scenarios, and let each group select their group rapporteur. » Arrange for participation of residents of the long-term care centre. » Explain to the resident what is being done. » Remind participants to behave ethically and with empathy for the resident. » Assign time for group work (approximately 90 minutes). » Ask group rapporteurs to present their group’s point of view on the case, along with a further course of action and its rationale, if appropriate. » Facilitate the necessary corrections with explanations and ask one member of the group to record the key points on a flip chart. » Ask one participant to present a final summary of the case and the course of management. » Encourage all participants to ask questions and give feedback. Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 16 17 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Session plan 3 SECTION Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 18 Time Session title Method Day 1 09:30–10:00 Registration 10:00–11:00 Opening session 11:00–12:00 Pre-training assessment 12:00–13:00 Long-term care and its components PPT presentation 13:00–14:00 Break 14:00–14:45 Preventive and promotive aspects of care giving PPT presentation 14:45–15:30 General care for older people in homes or institutions: Care for sleep/rest and sleep hygiene PPT presentation 15:30–16:00 Bed-making Demonstration 16:00–17:00 Bathing, body wash, hair care, brushing and combing of hair for Dummy/patient demonstration 17:00–17:30 Wrap-up of Day 1 Course coordinator Day 2 09:00–09:30 Recap of Day 1 and overview of Day 2 Course coordinator 09:30–10:00 Break 10:00–11:00 Oral hygiene in conscious and unconscious older people Dummy/patient demonstration 11:00–12:00 Care for eyes, ears and nose Dummy/patient demonstration 12:00–13:00 Perineal care Dummy/patient demonstration 13:00–14:00 Break 14:00–15:00 Care during the transfer of older persons and the use of assistive devices PPT presentation with procedure video 15:00–16:00 Care for older persons with pressure ulcers PPT presentation 16:00–16:30 Wrap-up of Day 2 Course coordinator 19 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Time Session title Method Day 3 09:00–9:30 Welcome, check-in followed by recap of Day 2 and overview of Day 3 Course coordinator 09:30–10:00 Break 10:00–11:00 Falls in older persons: prevention and interventions PPT presentation 11:00–12:00 Care for older persons with dementia PPT presentation 12:00–13:00 Care for incontinence PPT presentation 13:00–14:00 Break 14:00–15:00 First aid and emergency care PPT presentation 15:00–16:00 Post-training knowledge assessment Course coordinator 16:00–17:00 Reflections from participants: current practices, challenges and opportunities Course coordinator 17:00–17:30 Closure of session. Course coordinator Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 20 21 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Conducting the training 4 SECTION Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 22 Opening session 20 min Objectives of the training Course coordinator 20 min Introduction of facilitators and participants through introduction in pairs. 20 min Ground rules and dos and don’ts for participants, use of handbook 60 min Pre-training assessment Session plan Time Topic/Objective Methodology/Instructions/ Activities Materials/ Resources Session-1: Long-term care & its components 60 min  Introduction Components of LTC Models of LTC Skills required by LTC providers Guidelines for caregivers for LTC » Show objectives of the session » Summarize the content using PPT (50 min) » Respond to questions (10 min) Markers Whiteboard PPT Session 2: Preventive and promotive aspects of caregiving 60 min  Nutrition Role of caregivers in nutritional therapy for older people Nasogastric tube-feeding in older people Prevention of dehydration Risk factors for dehydration Symptoms and signs Strategies to prevent dehydration Encouragement for avoiding smoking, tobacco- chewing and alcoholism Common vaccines indicated for older people and their schedule Guidance on physical activity for older people Types of physical activities Methods of intergenerational engagement » Show objectives of the session » Summarize the content using PPT (50 min) » Respond to questions (10 min) Whiteboard Marker PPT 23 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Session 3: Care for sleep/rest and sleep hygiene 60 min  Role of caregivers in addressing sleep issues in older people Sleep hygiene » Show objectives of the session » Summarize the content using PPT (50 min) » Respond to questions (10 min) Whiteboard Marker PPT Session 4: Bed-making for older people 60 min Techniques of bed-making Unoccupied bed: open and closed Occupied bed Video demonstration » The facilitator displays videos of bed-making techniques. » The facilitator asks the other participants for their comments on the demonstration. » The facilitator gives his/her feedback. » The facilitator responds to the questions and doubts of the participants. » The facilitator thanks the actors, as well as the other participants. Audiovisual system Session 5: Bathing and bodywash for older people; hair care, brushing and combing of hair 60 min Proper techniques of personal care to older people Demonstration and discussion (Refer to annexure for details of procedure) » Divide the participants into proportionate groups (a maximum of 5 in each) » Demonstrate proper bathing and body washing techniques » Demonstrate hair care, techniques for brushing and combing of hair » The facilitator now asks the observer-participants for their comments » The facilitator gives his/her feedback on the techniques » The facilitator responds to questions and doubts of the participants » The facilitator thanks the actors, as well as the other participants Dummy/ Patient for demonstration Whiteboard Marker Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 24 Session 6: Oral hygiene in conscious and unconscious older people 60 min Proper techniques of oral care in conscious older people Proper techniques of oral care in unconscious older people Demonstration and discussion (Refer to annexure for details of procedure) Divide the participants into proportionate groups (a maximum of 5 in each) Demonstrate proper brushing and oral hygiene techniques in older people The facilitator asks participants for their comments The facilitator gives his/her feedback on the techniques The facilitator responds to the questions and doubts of the participants The facilitator thanks the actors, as well as the other participants Dummy/ patient for demonstration Whiteboard Marker Session 7: Care for eyes, ears and nose 60 min Proper techniques for care of eyes, ears and nose in older people Demonstration and discussion (Refer to annexure for details of procedure) » Divide the participants into proportionate groups (a maximum of 5 in each) » Demonstrate proper techniques for the care of eyes, ears and nose in older people » The facilitator asks participants for their comments » The facilitator gives his/her feedback on the techniques » The facilitator responds to the questions and doubts of the participants » The facilitator thanks the actors, as well as the other participants Dummy for demonstration Whiteboard Marker 25 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Session 8: Perineal care 60 min Proper techniques for perineal care in older people Demonstration and discussion (Refer to annexure for details of procedure.) » Divide the participants into proportionate groups (of a maximum of 5 in each) » Demonstrate proper perineal care techniques in older people » The facilitator asks the participants about their comments » The facilitator gives his/her feedback on the techniques » The facilitator responds to the questions and doubts of the participants » The facilitator thanks the actors as well as the other participants Dummy for demonstration Whiteboard Marker Session 9: Care for transfer of older person and use of assistive devices 60 min Guidance for transfer of older persons into, or out of bed Moving the person up and down in a supine position. Lifting of an older person Use of assistive devices for transferring an older person Assistive devices for mobility Show objectives of the session Summarize the content using PPT (50 min) Respond to questions (10 min) Whiteboard Marker PPT Session 10: Falls in older persons: Prevention and interventions 60 min  Risk factor for falls in older persons Assessment of fall risk by TUG test Prevention of falls in older people and in mobile and immobile older people » Show objectives of the session » Summarize the content using PPT (50 min) » Respond to questions (10 min) Whiteboard Marker PPT Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 26 Session 11: Care for older person with dementia 60 min Introduction to dementia Role of caregivers in the non-pharmacological management of dementia Dementia-friendly setups » Show objectives of the session » Summarize the content using PPT (50 min) » Respond to questions (10 min) Whiteboard Marker PPT Session 12: Care of older person for pressure ulcers 60 min Guidelines for caregivers to prevent pressure sores Special considerations in care of pressure points » Show objectives of the session » Summarize the content using PPT (50 min) » Respond to questions (10 min) Whiteboard Marker PPT Session 13: Care of older person for incontinence 60 min Application of cloth diapers Use of bedpans, urinals, commodes Condom drainage of urine Indwelling catheter care » Show objectives of the session » Summarize the content using PPT (50 min) » Respond to questions (10 min) Whiteboard Marker PPT Session 14: Care of older person for incontinence 60 min Management of: » Syncope » Hypoglycaemia » Choking and » Falls » Show objectives of the session » Summarize the content using PPT (50 min) » Respond to questions (10 min) Whiteboard Marker PPT 27 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Annexure I Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 28 Example of opening session (Session length: 60 minutes) » Welcome participants. » Display a slide showing the overall objectives of the training. Explain the objectives. » Self-introduction of facilitators and participants:  Explain to the participants that a few minutes will be spent on the introduction of facilitators and participants. For the introduction of facilitators and participants, write the following points on a flip chart:  Your name  Place where you currently work  A few words about the organization you work for  Nature of your work. You and your co-facilitators should introduce yourselves first, based on the points listed on the flip chart. Ask each participant to introduce himself or herself briefly, based on the same points. » Inform participants about the ground rules (show as a slide and explain). Ground rules for participants Adhere to the training schedule according to session plans Maintain an attendance record for certification Go through the subjects discussed during various sessions at the end of the day, for better understanding and discussion with the facilitator 29 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Attend all clinical sessions according to the schedule Participate in group activities according to the session plan Complete the specified number of worksheets during each clinical session, and get them certified by the facilitator Ensure and respect the privacy and rights of clients in examination rooms » Inform participants about the available facilities (lunchroom, toilets, computers, internet facility etc.) » Inform them about the reimbursement of expenses and give them the names of the support staff providing secretarial assistance. » Display a slide showing the contents of the folder given to the participants and ask them to verify them. » Explain the parts of the training package. » Divide participants into smaller groups as per the instructions given in Box 1, for group learning activities. » Discuss the overall session plan: Show the agenda of the training in a slide (modify session time according to local needs). » Discuss how to use the participant’s handbook Ask participants to take out the participant’s handbook from the folder. Display the slide on the structure of a sample module. Explain that each module presents key information to complement the materials in the corresponding chapter. Participants are required to be well-versed with the contents of the chapter, before they attend clinical sessions. Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 30 Display the slide listing dos and don’ts and instructions for participants; discuss. Reach the training venue at least 15 minutes before the session starts each day Cross-talk among yourselves during teaching sessions Use mobile phones or do anything to distract your colleagues during training sessions Hesitate to ask questions Make racist, or gender- biased comments Eat in the classrooms Put your mobile phones in silent mode Be familiar with training sessions and training materials provided Interact with facilitators as and when required, and get doubts cleared Get to know your group members and stay with your allocated group during group activities Listen carefully to the instructions given by facilitators for the clinical sessions Be respectful of each other, and considerate to fellow colleagues Do Don’t » List participant’s expectations Put up a flip chart with the heading, “Expectations”. Ask each participant to mention at least one expectation. Note it on the flip chart. At the end, discuss how expectations will be addressed during the training. 31 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Annexure II PowerPoint presentation slides Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 32 Talking points LTC 1: Long-term care and its components Slide 1: At some point of time large majority of us will lose our autonomy and independence. At this phase, there will dependence on other for every activity of daily living. When this phase of life is prolonged to months and years, we will need long-term care, the quantum of which will vary depending on the loss functionality. In this session, components of long-term care (LTC) will be discussed. Slide 2: LTC is a major component of WHO SEARO’s priority in old age care as presented in this figure. LTC refers to a continuum of medical and social services designed to support the needs of people living with chronic health problems that aff ect their ability to perform everyday activities. Long-term care has been one of the guiding principles of WHO-SEAR Regional Framework for Healthy Ageing 2018-2022. Read out all the components and speak a line or two on each of them. Slide 3: In this slide, a quick reference is made to the rise in the proportion of older people between 2017 and 2050. Long term care and its components Source: Regional Framework on Healthy Ageing (2018-2022). WHO Regional Office for Sourth-East Asia [51] LTC : One of the guiding principles of WHO SEAR Framework on Healthy Ageing Population Ageing in WHO-SEAR 33 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Household living arrangements of older people in WHO-SEAR Slide 4: In this slide, a quick reference is made to living arrangement of older population in SEAR countries. In many societies older people live alone or with the spouse if alive. Such families need assistance in care giving in situations of prolonged illness. Demographic and epidemiologic transitions are resulting in dramatic increases in the proportion of older people in the world, where longer life expectancies and chronic disabilities of old age are impinging upon the health and social fabric of the countries. Increasing prevalence of chronic disabilities and morbidities of long duration among older people, and dwindling capacities of the informal/family support mechanisms in taking care of rising long-term care needs of older people, urgently require public policies to address the consequences of these changes. Slide 5: In this slide, definition and goals of LTC has been provided. Read the points on the slide and discuss with examples. Slide 6: In this slide, various risk factors that predict the necessity of long-term care are provided. Increasing age, female gender, frail status, multi-morbidity, poor family support, disabling chronic diseases such as dementia and Parkinson’s disease, elder abuse, etc., are factors that place individuals at the risk of long-term care requirements. Read the points on the slide; and discuss with examples. • WHO defines LTC as “The activities undertaken by others to ensure that people with or at risk of a significant ongoing loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity. • Goal of long-term care: To ensure that an individual who is not fully capable of long-term self-care can maintain the best possible quality of life with the greatest possible degree of independence, autonomy, participation, personal fulfilment and human dignity. Long term care for older people: Introduction • Old age • Female gender • Frail status • Multi-morbidity • Poor family support • Disabling chronic diseases (e.g. Alzheimer’s disease and other forms of dementia and Parkinsonism) • Elder abuse Risk factors predicting the necessity of LTC Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 34 Slide 7: In this figure, various components of LTC have been provided. Read out the points and discuss with examples. Slide 8: Medical and nursing care as well as social support to the care recipients are important components of long-term care. Social care is basically related to supporting the older people in the instrumental and advanced activities of daily living. Various models of long- term care are in practice worldwide. Long-term care is provided in the home or in the institutional settings. The nature and amount of care depends on the pattern of morbidity, disability and the level of dependence. Slide 9: In this slide, various models of LTC have been discussed. Read the points on the slide; and discuss with examples. Slide 10: In this slide, various activities in home based LTC have been discussed. Read the points on the slide; and discuss with examples. Components of long-term care Medical and nursing care at home or LTC institutions: • Includes administration of medications, complex care and procedures, palliative and hospice care and rehabilitative and preventive services. • It is carried out by skilled health professionals. Social care: • Includes support to basic and instrumental ADL in home or institutional settings. • Basic ADL: Independent of culture and education and include bathing, dressing, going to the toilet, transferring (moving from place to place), continence and feeding. • Instrumental ADL: These are dependent on culture and socio-economic status and include using a telephone, shopping, preparing meals, housekeeping, cleaning clothes, using public transport, taking medication and handling money and nowadays the ability to use technology (e.g., cell phones, e-mail, and the internet). It can be carried out by trained non-health professionals. Components of LTC • Institution-based long-term care (for example, palliative care centres, hospital-based long-term care centres) • Community-based long-term care (for example, old-age homes, long-term care centres, physiotherapy centres, day-care centres, community-based rehabilitation facilities) • Home-based long-term care Models of long-term care It consists of following models: • Informal services: Support the individuals in household chores – generally provided by an unskilled person. • Formal personal care services: Support the individuals in personal care, such as bowel and bladder care and various components of ADL and IADL. • Skilled home care: Support the individuals requiring a higher degree of care other than ADL and IADL, for example, bedsore care, tube-feeding, etc. It is usually provided by trained personnel. • Home-based primary care: Support the individuals for medical conditions that do not prompt institutionalization, provided by skilled human resources with formal training, for example, vaccination, treatment of minor ailments • Hospital at home model: Support the individuals with complex, acute and chronic medical conditions, including the terminal illnesses, especially for persons who have transfer difficulty for various physical reasons. This facility is provided by skilled health personnel, for example, pain management in terminal cancer, home-based Continuous Ambulatory Peritoneal Dialysis (CAPD), thoracentesis, paracentesis, etc. Home-based long-term care 35 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Slide 11: The caregivers should follow certain guidelines to provide quality as well as dignified care to the needy older people. Read the points on the slide; and discuss with examples. Slide 12: Read the points on the slide; and discuss with examples. Slide 13: Read the points on the slide; and discuss with examples. The caregivers should be respectful towards the personal, social, religious and spiritual attributes of an older person while providing care. The caregivers should provide care not only to the physical but also the emotional aspects of the person receiving care. • Consider the individuality of older people. • Do not attempt to alter lifelong character and behaviour. • Handle them gently and maintain privacy while providing care. • Communicate effectively. Make sure they can hear you. • Encourage independence as far as possible. • Assist in achieving emotional stability. • Support them during their periods of anxiety. Guidelines for caregivers for long term care of the older people • Give them time to express their feelings. • Praise even for minimal achievements. • Encourage contact with others. • Protect them from injuries, falls, and accidents with proper instructions/arrangements. • The older people are highly prone to develop pressure damage/ bed-sores. So, provide a comfortable bed, and smooth and wrinkle-free bed linen. • Ensure adequate hydration and nutrition. Encourage to do active range of motion exercises. • Maintain body alignment, posture, and mobility. • Help them to establish a good sleeping pattern. • Try to engage them in certain activities during the daytime, so that they can sleep well during night-time. Guidelines for caregivers • Caution them about self-use of drugs especially analgesics and narcotics. Because of the poor eyesight and forgetfulness, they may not be able to understand the instructions or the importance of drug treatment. So, reinforce verbal instructions with written instructions about their drugs. Explain the side effects and watch for them. • Arranging a drug schedule coinciding with the regular activity helps persons to remember to take drugs. Otherwise, alarms may be set in their mobiles or even drug reminders are also available which may be made used. • End of life care is a vital and integral part of long-term care services. When older people are at the end of their lives, caregivers can make a difference to them and their families by creating and facilitating an environment that addresses their psychological, social, cultural and spiritual needs. Guidelines for caregivers Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 36 Talking points LTC 2: Care for older people in home or institutions: Care for sleep/ rest and sleep hygiene Slide 1: Due to prolonged immobility and co- morbidities; older people in LTC have substantial issues of falling asleep. In this session we will discuss about strategies for addressing sleeplessness. Slide 2: After the end of this session, participants will be able to address sleep problems of older patients receiving LTC. Slide 3: Every individual needs adequate rest and sleep for normal cognitive function. Older people need 6-8 hours of sleep at night. Sleep disturbances are common symptoms in older people. Sleep deprivation and insomnia lead to altered appetite; fatigue; decreased ability to perform tasks that require high-level coordination; increased traff ic accidents, home accidents, falls and irritability, emotional instability, decreased immune response, diff iculty with memory and concentration, pain, and impaired judgment. Care for older people in home or institutions: Care for sleep/ rest and sleep hygiene Learning Objectives To enumerate and practice ways and means of addressing sleeplessness in LTC recipients Care for sleep and rest • Every individual needs adequate rest and sleep for normal cognitive function. • Older people need 6-8 hours of sleep at night. • Sleep disturbances are common symptoms in older people. • Sleep deprivation and insomnia lead to: ¾ Altered appetite ¾ Fatigue ¾ Decreased ability to perform tasks that require high-level coordination; ¾ Increased home accidents and falls ¾ Irritability, emotional instability ¾ Decreased immune response ¾ Difficulty with memory and concentration and impaired judgment. 37 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Slide 4: In this slide, the role of caregivers in addressing sleep issues in older people is discussed. Read out all the points and discuss in detail with examples. Slide 5: In this slide, sleep hygiene is discussed. Read out all the points and discuss in detail with examples. Sleep hygiene refers to actions that tend to improve and maintain good sleep. The older people should be encouraged for certain lifestyle changes that help them to improve their sleep quality. Controlling fluid intake in late evenings, avoiding caff einated drinks and smoking before sleep, avoiding diuretics in late evenings can relieve nocturia. Slide 6: In this slide, bed making for older people is discussed. Read out all the points and discuss in detail with examples. Modifications in and around the bed can also promote quality sleep. A comfortable and clean bed can also promote quality sleep in older people. Role of caregivers in addressing sleep issues in older people • Be aware of the duration of sleep and whether the disturbance is in initiation or continuation of sleep. • If the sleep issues are significantly affecting the daily activities as well as social engagement of the person, seek specialist consultation for further assessment and management. • Noise should be reduced to a minimum; environmental distractions should be eliminated. • Plan bedtimes and wake up times to meet the individual’s needs and desires. • Avoid using the bed for watching TV, writing bills, and reading. • Place beds in low positions, using night-lights and placing call bells within easy reach for safety reason. • Older People with impaired physical mobility should be assisted with voiding before retiring. • Provide comfort measures to promote sleep. • Implement Good Sleep Hygiene protocols in the home/institution. Sleep hygiene refers to actions that tend to improve and maintain good sleep. Sleep Hygiene • Sleep as long as necessary to feel rested (usually seven to eight hours for adults) and then get out of bed. • Maintain a regular sleep schedule, particularly a regular wake-up time in the morning. • Try not to force sleep. • Decrease liquid intake after 7 PM in the evening. • Avoid caffeinated beverages after lunch and dinner. • Avoid alcohol near bedtime (e.g., late afternoon and evening). • Avoid smoking particularly during the evening. • Adjust the bedroom environment as needed to decrease stimuli (e.g., reduce ambient light, turn off the television or radio) • Avoid prolonged use of light-emitting screens (laptops, tablets, smartphones, e-books) before bedtime. • Resolve concerns or worries before bedtime. • Encourage for exercise regularly for at least 20 minutes, preferably more than four to five hours prior to bedtime. • Avoid daytime naps, especially if they are longer than 20 to 30 minutes or occur late in the day Bed-making for older people General guidelines for bed making: • Provide privacy to the older person. • Wash hands before handling clean linen and after handling soiled/dirty linen. • Never shake soiled linen to prevent the spread of micro-organisms. • Hold soiled linens away from the body to avoid contact with caregiver’s clothes and to avoid spreading micro-organism. • Linen for one person is never placed on another person's bed to avoid transporting micro-organism from person to person. • Tighten loose linens as necessary. Tuck them properly to make them wrinkle free. It is important for preventing pressure damage to skin. • Save time and energy by making one side of the bed before going to another side. • Move any furniture away from the bed to provide ample working space. • Properly dispose soiled linens to limit the person secretion and avoid contamination with other furniture. Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 38 Talking points LTC 3: Falls in older person at home or institutions Slide 1: Advanced age and all conditions that lead to deficits in mobility are associated with increased risk of falls. In this session we will discuss fall and its prevention among LTC recipients. A serious fall can result in decreased functional independence and quality of life. Most falls occur in the daytime and at home. So, it becomes necessary to make the home environment suitable for older people. Caregivers play a significant role in preventing fall in mobile as well as an immobile older person. Slide 2: In this slide, general facts about falls are discussed. Read all the points and discuss in detail. Slide 3: In this slide, general facts about falls are discussed. Read all the points and discuss in detail. Falls in older person at home or institutions Introduction Advanced age is one of the risk factors for fall. Serious fall can result in decreased functional independence and quality of life. Most falls daytime and at home. So, it becomes necessary to make the home environment suitable for older people. Caregivers play a significant role in preventing occur in the all in mobile as well as an immobile older person. Falls in Old Age Falls can be an important cause of morbidity and disability in old age. Annual more than one-third of older population fall each year. Half of falls are recurrent. Risk of fall increases in presence of dementia and Parkinson’s Disease. 39 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Slide 4: In this slide, general facts about falls are discussed. Read all the points and discuss in detail. Slide 5: In this slide, home care interventions for prevention of falls are discussed. Read all the points and discuss in detail. Slide 6: In this slide, prevention of falls among immobile people is being discussed. Read all the points and discuss in detail. Slide 7: In this slide, prevention of falls among immobile people is being discussed. Read all the points and discuss in detail. Falls in Old Age Falls are a risk factor for fractures and brain injury which can often be fatal. Fear of fall can be major disability in old age. 60% of falls occur at home mostly in bedroom and bathroom. Falls can be due intrinsic (personal) factors or extrinsic (environmental) factors. Prevention of fall in immobile older people The caregiver should:……………….. Do not routinely assist with transfers or bathing activities unless necessary. Encourage older people to perform ADL and IADL independently. Use gestures and nonverbal cues when helping older people move if they are anxious or have difficulty understanding and following verbal instructions. Recognise that wheelchairs are not a good mobility device and often serve as a mobility restraint. Discourage the use of wheelchairs whenever possible. Ensure that chairs fit older people. Chair seat should be 3 inches above the height of the knee. Raising the height of a chair can dramatically improve the ability of many older people to stand up. Low, deep, soft seats with armrests that too far apart reduce a person's ability to get up and down without help. Provide a raised toilet seat if needed. If an older adult is mainly immobile, provide opportunities for socialisation and sensory stimulation (e.g., television and visits). Immobility and a lack of social support and sensory input may result in confusion or depression in the older people Home care interventions to prevent or reduce fall in older people The caregiver should: Assess the home environment for factors that create barriers to physical mobility. Refer to occupational therapy services if needed to assist an older adult in restructuring home and daily living patterns. Refer to home health aide services to support the older adult and family through changing levels of mobility. Reinforce need to promote independence in mobility as tolerated as providing unnecessary assistance with transfers and bathing activities may promote dependence and a loss of mobility Provide support to older people with long-term impaired mobility. Teach the person/family member to prevent falls: 9Teach an older person to get out or in of bed slowly when transferring from the bed to the chair or vice-versa. 9Teach and encourage to use assistive devices such as a cane, a walker, or crutches to increase mobility. 9Teach family members and caregivers to work with the older people during self-care activities such as eating, bathing, grooming, dressing, and transferring rather than having older people person as a passive recipient of care. 9Encourage older person to maintain as much independence as possible which helps in preserving and maintaining mobility skills. Prevention of fall in immobile older people The caregiver should: Help the mostly immobile older people to achieve mobility as soon as possible, depending on physical condition. Encourage the person to attend a low-intensity aerobic chair exercise class that includes stretching and strengthening chair exercises. Initiate a walking program in which an older person walks with or without help every day as part of daily routine. Have older people flex and extend feet several times after sitting up, then stand up slowly with someone watching; if the health professionals have suggested the presence of postural hypotension. Be very careful when getting a mostly immobile older person up. Be sure to lock the bed and wheelchair and have sufficient personnel to protect the older person from falls. Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 40 Talking points LTC 4: Care of older people with or at high risk for pressure sores Slide 1: Older persons receiving long-term care generally have major impairment in mobility and are usually bed bound for prolonged periods. Pressure on particular parts of the body during prolonged rest leads to pressure sores or bed sore. In this session we will discuss about pressures and its prevention. Slide 2: In this slide, we will learn the fundamentals of pressure sore management; that is prevention is better/easier than cure. Read the points on slide and explain. Slide 3: In this slide, we will discuss about risk factors of pressure sore. Read the points on slide and explain. Older people with significant limited mobility, significant loss of sensation, malnutrition, inability to reposition themselves and those with significant cognitive impairment are at the greatest risk for the development of pressure ulcers. Other than the intrinsic factors, various extrinsic factors like undue and prolonged pressure; shear, friction, moisture, abnormal posture also led to the development of pressure ulcers. Care of older people with or at high risk for pressure sores Introduction • Prevention: Frequent positioning, massaging and providing proper devices on pressure points • Treatment of already developed pressure sore is lot more time and resource demanding. • So, prevention of pressure ulcer development is the norm in older people with poor mobility for so many reasons. Pressure ulcers Greatest risk factors for pressure ulcers in older people: • Older people significant limited mobility: Bed-bound • Significant loss of sensation • Malnutrition • Inability to reposition themselves • Significant cognitive impairment Stages of Pressure Sores 41 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Slide 5: In this slide, common sites for pressure sore are demonstrated in cartoons. Show the pressure points and explain. Older people can acquire pressure ulcers in diff erent body positions, in diff erent areas of the body. Most of the health professionals are aware about the development of pressure ulcers in the supine or lateral decubitus positions. But pressure ulcers can occur even in the sitting position, even in a wheelchair. In supine position, pressure damage can occur in occiput (head), shoulders, elbows, over the buttock areas and heal of the clients. In lateral decubitus position, these can occur over the ear, shoulder, outer side of elbow, hip, outer and inner side of knee, heel and ankles. In sitting position, pressure damage can occur over the shoulder blades, buttocks, heel and ball of the foot. Slides 6 and 7: Management strategies for pressure sore are discussed in these slides. As pressure ulcers evolve form lower grades to higher ones over days, the caregivers should be vigilant for any skin changes that might be the harbinger for deep seated pressure ulcers. Provision of air-mattress, periodic position changes, regular Pressure ulcers Slide 4: In this slide, common sites for pressure sore are demonstrated in cartoons. Show the pressure points and explain. Possible sites of pressure ulcers Guidelines for caregivers to prevent or manage the developed pressure sore • Assess the ulcer prone persons for redness, discolouration or blister on the pressure points. • Explain to the person about the need for care of pressure points. • Attend to the pressure points as often as necessary to stimulate circulation. The back is washed with soap and warm water, dried and massage with powder. Avoid using excessive alcohol for back rub because it dries the skin and causes skin damage. Attend to the pressure areas like iliac crest, ankles, heels, elbows and other pressure points. • Use special mattresses and beds, e.g., air and water mattresses • Use the comfort devices to take off the pressure from pressure points, e.g., air cushions, cotton rings etc. • Change the position of the person every 2 hourly so that another body surface bears weight. • Use a bed cradle to take off the weight of the bed linen of the person • Keep the person’s skin well lubricated to prevent cracking by using powder • Protect the damaged skin. Damaged skin can be further irritated and macerated by urine, faeces, sweat. Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 42 care of skin, caution while shifting the bed-bound person, adequate nutrition and physical therapy can prevent the development of pressure ulcers to a larger extent. Read the points on these slides and explain. Slide 8: In this slide, some special considerations in care of pressure points on bony prominence over which pressure damage can occur are discussed. Read the points on this slide and explain. Slide 9: In addition to all other strategies, early detection by repeated inspection is important in prevention. In this slide early detection strategies are discussed. Read the points on this slide and explain. Guidelines for caregivers to prevent or manage the developed pressure sore • Provide the person with adequate fluid and with a nourishing diet that is high in protein. • Attend to the pressure points as often as necessary to stimulate circulation. The back is washed with soap and warm water, dried and massage with powder. Avoid using excessive alcohol for back rub because it dries the skin and causes skin damage. Attend to the pressure areas like iliac crest, ankles, heels, elbows and other pressure points. • Lift the person before giving and taking bedpans; otherwise, it can cause friction. • Provide smooth, firm and wrinkle-free bed on which person can take rest. • Cut short the fingernails of the persons to avoid scratching on the skin. • Use an adequate amount of cotton under splints and plaster casts. • Change the linen as soon as they become wet. After each urination and defecation back must be attended. • Teach the persons and their relatives the hygienic care of the skin. • Document the location of pressure ulcer. Special considerations in care of pressure points (bony prominence over which pressure damage can occur): • Do not use a rubber air ring or any doughnut - they create much pressure where you do not want it and block the flow of blood to skin inside the ring. • Do not wear sanitary belts - they can lead to pressure sores. • Do not wear clothing with heavy seams, nylon underwear or tight clothing. • Do not put articles in pants pockets or on the seat of the wheelchair. • Do not use alcohol on dry skin. • Do not make the person sit in bed with the head raised for long periods - these cause the skin to be squeezed over the lower end of the spine and can lead to sores. What to look for and do as a care giver? • Redness, abrasion/scrape, blister, or shallow crater on unbroken skin lasting 15-30 minutes or more. • Texture changes - the skin feels “mushy” rather than firm to the touch. • A grey or black scab. Do not remove the scab. If a bed sore is beneath it, this could cause damage or lead to infection. • Try to change the position, if there is no change even after 15 -30 minutes seek medical help. • Do not try to massage or apply anything unless advised by the health professional. 43 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Slide 1: Health promotion and disease prevention is a life-long activity. Older people receiving LTC also qualify for health promotion and disease prevention. In this session, we will discuss strategies for health promotion and disease prevention in this group. Slide 2: At the end of the session, the participants will be able to implement strategies for health promotion and disease prevention in older people receiving LTC in this group. Slide 3: Maintaining adequate nutrition is essential for life. In this slide, issues related to nutrition in old age are enumerated. Older people are particularly vulnerable to malnutrition. The process of ageing also aff ects nutrient needs. Careful nutritional assessment is necessary for both the successful diagnosis and development of comprehensive treatment plans for malnutrition in this population. Read each point and discuss with examples. Talking points LTC 5: Preventive and promotive aspects of caregiving Preventive and Promotive Aspects of Care-giving Learning objectives • To enumerate and implement the strategies for health promotion in the older people in home and institutions. Nutrition in Old Age • Older people are particularly vulnerable to malnutrition. • The process of ageing also affects nutrient needs. • Degenerative diseases such as cardiovascular and cerebrovascular disease, diabetes, osteoporosis and cancer, which are among the most common diseases affecting older persons, are all diet-affected. • Micronutrient deficiencies are often common in older adults due to a number of factors such as their reduced food intake and a lack of variety in the foods they eat. • Malnutrition in the older people is often underdiagnosed. • Careful nutritional assessment is necessary for both the successful diagnosis and development of comprehensive treatment plans for malnutrition in this population. Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 44 Slide 4: The caregivers play a vital role in promoting the nutritional status of older people requiring long-term care. The caregiver should provide nutritious and a balanced palatable diet to the older person depending upon his/ her ability to chew and swallow. The caregivers should be aware that the protein requirement increases with age and various health conditions. Read each point and discuss with examples. Slides 5 and 6: Often, it becomes essential to feed a person through a naso-gastric tube to maintain nutrition. The caregivers should also be well versed with the techniques of tube-feeding. In these two slides techniques of naso- gastric tube feeding is explained and demonstrated. Read each point and discuss. Slide 7: Older people are vulnerable to dehydration due to physiological changes in the ageing process, but this can be complicated by many physical or psychological illnesses. Inadequate fluid intake is a major contributor to preventable dehydration. Many older people are reluctant to drink to avoid the need to go to the toilet, particularly at night, but restriction of overall fluid intake does not reduce urinary incontinence frequency or severity. Role of Caregivers in Nutritional therapy for older people • Utilise the services of a registered dietician when the older person is being discharged from the hospital. Request to provide written diet chart individualized for the older person. • Encourage the older people as well as the family members to increase protein intake in older people. • The persons with difficulty chewing should have dental and oral care checked and possibly be given mushy food. • Persons with difficulty swallowing, e.g. stroke persons, may need Naso-gastric tube feeding and sometimes percutaneous endoscopic gastrostomy (PEG) feeding. • The caregiver needs to learn the technique to provide tube feeding. • In persons who are indoor for various health reasons, the caregivers should have a high index of suspicion for Vitamin-D deficiency. Consult with the specialist regarding it during visits. • Vitamin-B 12 deficiency may occur in vegetarian older people. Consult with the specialist regarding it during visits. Nasogastric tube feeding in older people Procedure: • Wash your hands. • Measure the correct amount of formula and warm it to the desired temperature. • Clamp the tube. • Attach a syringe to the feeding tube. • Pour the formula into the syringe. • Unclamp the tube. • Allow the formula to run through the tube. • Try to start the feeding when the person is calm. You may have to "push" the feeding to get it started. To do this, place a plunger into the syringe and push slightly. Remove the plunger gently and allow the formula to flow in by gravity. • Continue adding formula into the syringe until the prescribed amount is given. • When the syringe is empty, flush the tube with the prescribed amount of warm water. • After the feeding, clamp the tube. Nasogastric tube feeding Dehydration in older people • Older people are vulnerable to dehydration • With ageing, there is reduced sensation of thirst • Inadequate fluid intake is a major contributor to preventable dehydration. • Many older people are reluctant to drink 45 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Slide 8: In this slide, risk factors for dehydration are listed. Read each point and discuss with examples. Slide 9: Dehydration can have various negative consequences in older people and can lead to hemodynamic disturbances as well. Read each point and discuss with examples. Slide 10: In this slide, signs of dehydration are enumerated. The caregivers should be aware about the signs and symptoms of dehydration in older people. Dry mucous membranes, loss of skin elasticity, fall in blood pressure, drowsiness, confusion, dizziness, decrease in urine output can occur depending in the severity of dehydration in the older person. Read each point and discuss with examples. Slide 11: The caregivers should follow various hydrating strategies on observing dehydration in the older people. Similarly, the strategies should also be directed towards prevention of dehydration. Read each point and discuss with examples. Common risk factors for dehydration • Older age: Reduced sensation of thirst • Residing in long-term care • Requiring assistance with foods and fluids • Incontinence • Cognitive impairment/confusion: Reduced sensation of thirst • Depression • Multiple medications, particularly diuretics and laxatives: Increased water excretion • Decreased thirst • Acute illness, fever, diarrhoea and vomiting Consequences of dehydration • Disturbed Mental performance and increases feelings of tiredness. • Low blood pressure, weakness, dizziness and increased risk of falls. • More likely to develop pressure sores and skin conditions. • Severe dehydration can lead to renal failure. • Constipation. Signs of dehydration • Dryness of the mouth, lips and tongue • Sunken eyes, • Dry inelastic skin, • Drowsiness, confusion or disorientation, • Dizziness and low blood pressure. • Reduced and more concentrated urine output. • (In general, urine that is odourless and pale in colour generally indicates good hydration, dark strong-smelling urine is a common symptom of dehydration.) Strategies to Prevent dehydration • Determine an individualized daily fluid intake goal. • Be vigilant when the older person is not drinking enough and help them to drink more. • Identify and overcome barriers to drinking like worries about not reaching the toilet in time, physical inability to make or to reach drinks, and reduced social drinking and drinking pleasure. • Provide preferred fluids. • Have fluid available at all times. • Make sure water is fresh and looks palatable — perhaps by adding a few slices of lemon or orange or ice cubes. • Offer fluids regularly throughout the day. • Offer fluids at routine events such as before physiotherapy or other activity or medication rounds. • Offer a variety of hot and cold fluids. • Provide assistance to drinking if required. • Provide aids for drinking if needed such as special cups. • Offer at least a full glass of fluid with medications • Encourage families and visitors to offer fluids and encourage wet foods such as pureed fruit, yogurt, jelly, custard and soup. • Record the volume of urine passed every time. Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 46 Slide 12: Older people are vulnerable to various complications related to smoking, alcohol intake as well as tobacco chewing. These are associated with dreadful health conditions which are diff icult to manage at most of the times. In this slide an account of important addictions is provided. Read the points and explain. Slide 13: The caregivers should encourage the older people to quit such harmful habits and also make the family members aware of the services that help in quitting those addictions. Read the points and explain. Slide 14: As in other age groups older persons in LTC also benefit from specific disease prevention strategy with vaccines. As people age, the immune system weakens and it can be more diff icult to fight off infections. The older person is more likely to get diseases namely; flu, pneumonia, and herpes zoster; and also have complications that can lead to long-term illness, hospitalization, and even death. The caregivers should be aware of the fact that specific vaccines are necessary even for the older people. They should also be aware of the places where such vaccines are available. Encouragement for avoiding smoking, tobacco chewing and alcoholism • Alcohol intake in excess increases the potential for diseases such as cardiomyopathy, cirrhosis of the liver, atrophic gastritis, chronic pancreatitis, peripheral neuropathy, dementia, falls and accidents, malnutrition, immune-suppression and social isolation. • Cigarette smoking is the leading preventable cause of morbidity and mortality in old age. Smoking is responsible for most of the respiratory problems in the older people. It causes a variety of cancers. Smoking is an important cause of ischaemic heart disease and stroke. It is also associated with osteoporosis. • As in many SEARO countries, chewing tobacco is seen in greater percentage against smoking, and which leads to cancer of buccal cavity and is the most common concern of elders, that to mostly in villages. Role of caregivers in preventing addictions in older people • The caregivers should encourage the older people to quit alcohol, smoking and tobacco-chewing. • The caregivers should make the family member aware of the expert services which would help in quitting alcohol, smoking or tobacco-chewing. Encouragement for routine immunization of older people • The caregivers should be aware of the fact that specific vaccines are necessary even for the older people. • They should also be aware of the places where such vaccines are available. • Specific immunizations recommended in old age are Pneumococcus, Influenza virus and Tetanus. 47 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Slide 15: Specific immunizations recommended in old age are: Pneumococcus, Influenza virus and Tetanus at periodic intervals. This slide provides details of such vaccines. Read the points and explain. Slide 16: Physical activity as a strategy for health promotion is eff ective at every stage of life. LTC recipients need to be encouraged to be physically active. Strong evidence demonstrates that compared to less active men and women, older adults who are physically active have: lower rates of coronary heart disease, hypertension, stroke, diabetes, colon and breast cancer; a higher level of cardiorespiratory and muscular fitness; healthier body mass and composition and enhanced bone health; and higher levels of functional health, a lower risk of falling, and better cognitive function. Read the points on slide and discuss. Slide 17: There are various types of physical activities for older people; the do- ability of whose depends upon the health condition of an individual. In coordination with the therapists and the physicians, the caregivers should encourage the older people to engage in best possible physical activities as per WHO recommendation. Read the points on slide and discuss. Immunization schedule for older people Vaccination Period Influenza vaccine (Prevention against flu) Annually administered (generally administered before the onset of winter ) Tetanus toxoid (Protection against tetanus) Every ten years Pneumococcal vaccination (Protection against pneumonia, meningitis, sepsis caused by the bacteria (Streptococcus pneumoneae) ¾ At 65 years or above irrespective of the health condition ¾ Between 60-65 years if following conditions are present: x Chronic disease of lungs, heart, liver or kidney x Any cancer x Diabetes mellitus x Chronic smoking Encouragement for physical activity • Ageing causes a progressive decline in power, strength and endurance of muscles. • Sedentary lifestyle and lack of physical activity accelerate this decline. • Physical inactivity is associated with higher risk of morbidity and mortality including non-communicable diseases as well as cancers. WHO recommendation of physical activity • Older people with normal mobility should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous- intensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorous-intensity activity. • Aerobic activity should be performed in bouts of at least 10 minutes’ duration. • Muscle-strengthening activities, involving major muscle groups, should be done on 2 or more days a week. • Older people, with poor mobility, should perform physical activity to enhance balance and prevent falls on 3 or more days per week. • When older people cannot do the recommended amounts of physical activity due to health conditions, they should be as physically active as their abilities and conditions allow. Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 48 Slide 18: Read the points on slide and discuss about suitability of various types of activities which is suitable for a particular patient. Slides 19 and 20: In these two slides, various strategies for inter-generational engagement has been discussed as a means of health promotion. It also helps to alleviate the mental stresses and also strengthens the bond, love and aff ection between diff erent generations of family members. The caregivers should encourage the family/community members of the care-recipient as well as the older person for intergenerational engagement through various methods; both in-person and virtual ones. Read out the points on the slides and discuss in detail. Type of physical activity Type of physical activity Effect and Examples Moderate intensity Cause older people to get warmer, breathe harder and their hearts to beat faster, but they should still be able to carry on a conversation. Eg. Brisk walking Vigorous intensity Cause older people to get warmer, breathe much harder and their hearts to beat rapidly, making it more difficult to carry on a conversation. Eg. Climbing stairs, running Strength exercise Cause older people to use all the major muscle groups Eg. Carrying or moving heavy loads such as groceries, activities that involve stepping and jumping such as dancing, chair aerobics, dancing Improving balance and coordination Yoga, Tai-chi, Nordic walking Minimizing sedentary behaviour Reducing time spent watching TV Taking regular walk breaks around the garden or street Breaking up sedentary time such as walking part of the way while doing a long journey Intergenerational engagement At homes: • Encourage younger generation to teach older people the techniques of using mobile phones, social platforms in smart phones. • Encourage older people to share their experiences or demonstration of arts/skills to the younger people. • Encourage older people to participate in religious, spiritual activities and social activities within the limits of their physical capacity. Intergenerational engagement……… At institutions: • Encourage the family member (especially grandchildren) to talk to older people in institution using virtual platforms or by personal visits. • Facilitate communication with the family members and close friends using technologies. • Encourage and facilitate the visit of youths to the institutions to serve and provide companionship to the older residents, as volunteers. 49 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Talking points LTC 6: Care for older person with dementia in home or long-term institutions Slide 1: Dementia is one of the commonest indications for long-term care worldwide. In the early stage of dementia, most people function independently and need minimal support from the caregivers. As the disease progresses, intensive, around- the-clock care is usually required and the needs of the person living with dementia will change and deepen. In this session we will discuss carte giving challenges in dementia in detail.. Slide 2: This slide provides general facts about dementia. Read out the slide and discuss each point in detail. Slide 3: This slide provides needs of a patient with dementia. Read out the slide and discuss each point in detail. Care for older person with dementia in home or long-term institutions Introduction: Dementia • Deterioration in cognitive functions and the ability to perform everyday activities. • Affects memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgment. • Consciousness is not affected. • Commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behaviour, or motivation. • One of the commonest indications for long-term care worldwide. • In the early stage of Alzheimer's, most people function independently and need minimal support from the caregivers. • As the disease progresses, intensive, around-the-clock care is usually required. • As the disease advances, the needs of the person living with Alzheimer's will change and deepen. An older person with late-stage dementia • Needs assistance walking and eventually is unable to walk • Needs full-time help with personal care • Has difficulty eating and swallowing • Is vulnerable to infections, especially pneumonia Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 50 Slide 4: In this slide, the role of caregivers on non-pharmacological management of dementia in home or institutions will be discussed. Read out the slide and discuss each point in detail. Slide 5: The caregivers should encourage the person with dementia to make use of assistive devices; facilitate reality orientation to the person with dementia and encourage the family members or the institution to make the infrastructures more dementia friendly. Read out the slide and discuss each point in detail. Slide 6: Dementia carte requires a dementia friendly environment. In subsequent slides we will discuss the components of dementia friendly environment. The caregivers should encourage the family members at home or authorities in the institutional settings for the creation of dementia friendly environment. Dementia friendly environment aids in cognitive well-being of the patients as well as reduces their stress. Role of caregivers on non-pharmacological management of dementia in home or institutions Encourage the person with dementia to make use of assistive devices: • Assistive technologies are devices or systems that can help a person with dementia remain as independent as possible despite reduced ability. • Assistive technologies can be simple devices such as notepads, diaries and calendars, to walking sticks, walking-frames, wheel-chairs but can also involve telecare items such as detectors of gas, smoke or falls. • The caregivers should be aware about the availability of such services. • The caregivers should involve the physiotherapist or the occupational therapist for the use of assistive devices. Role of caregivers on non-pharmacological management of dementia Facilitate Reality orientation to the person with dementia: • An informal approach is usually used as part of everyday care; for example, each time a carer interacts with the person with dementia they inform them of pertinent information. e.g. date, day, time of the day, self-introduction etc. Encourage the family members or the institution to make the infrastructures more dementia friendly Dementia friendly Home/ Institutions 51 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Slide 7: In this slide, we will discuss lighting requirements in dementia patient’s environment. Read out the slide and discuss each point in detail. Slide 8: In this slide, we will discuss noise levels in dementia patient’s environment. Read out the slide and discuss each point in detail. Slide 9: In this slide, we will discuss flooring requirements in dementia patient’s environment. Read out the slide and discuss each point in detail. Slides 10, 11 and 12: In this slide, we will discuss color requirements in dementia patient’s environment. Read out the slide and discuss each point in detail. Better lighting • Helps in avoiding confusion as well as minimizes the risk of falls. • Try to reduce glare, shadows and reflections. • Lighting should be good, even and natural. • Curtains should remain open in the day. • The tree/branches blocking direct sunlight into the rooms should be cut back. • Adequate lighting in the stairs and the toilets. • Light switches should be made easily accessible and straightforward. • Regular eye-check: Assessment of visual acuity and correction if required. Reduction of excess noise • Helps in reducing confusion; promotes quality sleep. • Carpets, curtains absorb background noise; so, they may be added to the person’s room. • Switch off the radio or television when not in use. • Regular ear check-up. Safer flooring • Try to avoid rugs or mats on the floor, as some people with dementia may become confused and think the rug or mat is an object that they need to step over, which could lead to trips or falls. • Shiny or reflective flooring may be perceived as being wet, and the person with dementia may find it difficult to walk over it. So, avoid it. • The color of the matt on the floor must contrasts with the walls. It might help to avoid colors that can be mistaken for real things, such as green (grass) or blue (water). Contrasting Colors To prevent confusion among objects in the premises. • The colours on walls and floors should contrast. • Furniture should be in bright or bold colours that contrast with the walls and floors. • Doors should have contrasting colours. • Toilet seat in contrasting colour to the rest of bathroom. • Plates/dishes in contrasting colour to the table/table-cloth. Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 52 Slide 13: In this slide, we will discuss light requirements in dementia patient’s environment. Read out the slide and discuss each point in detail. Avoid reflections • To prevent confusion and distress among persons when they fail to recognize themselves. • Remove or cover large mirrors. • Close curtains in the evening to prevent reflection in the window-glass. Labels and signages: (in contrasting colour to the background) • In cupboards, doors, toilet door • Putting photos on cupboards and drawers to show what is inside them. • See-through doors can help. Additional arrangements can further help a person with dementia: • Large LCD clocks in the room which display time, date as well the day/month/year • Reminder devices: e.g. for medications • Flat walking surface to prevent falls. • Avoid slippery rugs/mattress on the floor. • Bathrooms should have non-slippery floors. • Metallic grab bars Bathroom modification 53 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Slide 1: Loss of urinary bladder control or urination is termed as urinary incontinence. In this session we will discuss about urinary incontinence in older persons in long-term care. Slide 2: In this slide, general facts about urinary incontinence is being discussed. Read out the points and discuss in detail with examples. Slide 3: In this slide, care of urinary incontinence by applying adult diapers is being discussed. Read out the points and discuss in detail with examples. Talking points LTC 7: Care of incontinence CARE OF INCONTINENCE Introduction • Involuntary loss of urine in sufficient amount or frequency • It is very common and is a potentially disabling problem • Often neglected by the person as well as the health professionals Care for incontinence: Applying adult cloth diapers • Undo the tabs on each side of the diaper. • Roll the gown up as far as it will go. • Proceed to roll the person over on their side away from you. Note: you never move a person by their shoulders, arms or any other place but the hips. • Start wiping the soiled area with moist towelettes until completely clean. • Have your garbage bag open next to you so you can continue to throw the towelettes away. • After wiping, the person is then rolled back on their side away from you. • Place fresh linen under the person if the bedding is soiled, then place the hospital pad under the person. • When placing the pad under the person, roll up one side of the pad and place it directly under the persons bottom so it will be easy to reach when the person is rolled on their back. Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 54 Slide 4: In this slide, care of urinary incontinence by applying adult diapers is being discussed. Read out the points and discuss in detail. Slide 5: In this slide, care of urinary incontinence by applying bed pan is to be discussed. Slide 6: In this slide, care of urinary incontinence by applying bed pan is to be discussed. Read out the points and discuss in detail. Slide 7: In this slide, care of urinary incontinence by applying bed pan is to be discussed. Read out the points and discuss in detail. Applying adult cloth diapers: Procedures……….. • Apply the moisturizing cream on the person’s skin and then the adult diaper under their bottom. • Proceed to roll the person over on their other side towards you and flatten out the hospital pad and make sure the diaper is nice and smooth over the person’s skin. • Fasten the velcro tabs on the diaper again smoothing out any wrinkles that occur and pull the hospital gown gently down in place. • Cover the person with blankets, making sure the person is in the middle of the bed to prevent them from falling out onto the floor. • Take your garbage bag out to an outside trash can, put soiled linens away. • Remove and throw away your latex gloves. • Wash your hands with warm, soapy water. • Clean and disinfect the used articles. • Return equipment. Care for incontinence: Providing bedpan • Used to assist older person void or pass stool when he /she is unable to access the bathroom. Assisting in providing bedpan/step of procedure • Wash your hands. • Identify yourself by name. Identify the person by name. • Explain the procedure to the resident. Speak clearly, slowly, and directly. Maintain face- to-face contact whenever possible. • Provide for person’s privacy with curtain, screen, or door. • Adjust bed to a safe working level, usually waist high. Before placing bedpan, lower the head of the bed and lock bed wheels. • Put on gloves. • Ask the person to remove undergarments or help him/her do so. • Place bedpan near his/her hips in the correct position. • If the resident is able, ask him/her to raise hips by pushing with feet and hands at the count of three. Slide the bedpan under his/her hips. If the resident cannot do this him/herself, place your arm under the small of his back and tell him to push with his heels and hands on your signal as you raise his hips. Place the bedpan underneath the resident. If a resident cannot help you in any way, keep the bed flat and roll the resident onto the far side. Slip the bedpan under the hips and gently roll the resident back onto the bedpan, keeping the bedpan centred underneath. Assisting in providing bedpan/step of procedure………. • Remove and discard gloves. Wash your hands. • Raise the head of the bed. Prop the resident into a semi-sitting position using pillows. • Check the bedpan to be certain it is in the correct position. Make sure the blanket is still covering the resident. Place toilet tissue and washcloths or wipes within the resident's reach. Ask the resident to clean his hands with the hand wipe when finished, if he is able. • Place the call light within the resident's reach. Ask the resident to signal when done. Leave the room. • When called by the resident, return and put on clean gloves. • Lower the head of the bed. Make sure the resident is still covered. Do not overexpose the resident. • Remove bedpan carefully and cover bedpan. • Provide perineal care if assistance is needed. For female residents, wipe from the front to the back. Dry the perineal area with a towel. Help the resident put on the undergarment. Place the towel in a hamper or bag and discard disposable supplies. 55 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Slide 8: In this slide, care of urinary incontinence by applying bed pan is to be discussed. Read out the points and discuss in detail. Slide 9: In this slide, care of urinary incontinence by providing urinal is to be discussed. Read out the points and discuss in detail. Slide 10: In this slide, care of urinary incontinence by providing urinal is to be discussed. Read out the points and discuss in detail. Slide 11: In this slide, care of urinary incontinence by providing commode is to be discussed. Read out the points and discuss in detail. Assisting in providing bedpan/step of procedure………. • Take the bedpan to the bathroom. Empty the bedpan carefully into the toilet unless a specimen is needed. Note colour, odour, and consistency of contents before flushing. If you notice anything unusual about the stool or urine (for example, the presence of blood), do not discard it. You will need to inform the caregiver. • Turn the faucet on with a paper towel. Rinse the bedpan with cold water first and empty it into the toilet. Place bedpan in the proper area for cleaning or clean it according to facility policy. • Remove and discard gloves. • Wash your hands. • Make the resident comfortable. Remove bath blanket and cover resident. • Return bed to lowest position. Remove privacy measures. • Place call light within the resident's reach. • Report any changes in resident to the caregiver. • Document procedure using facility guidelines. Care for incontinence: Providing urinal • Wash your hands. • Identify yourself by name. Identify the resident by name. • Explain the procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. • Provide for resident’s privacy with curtain, screen, or door. • Adjust bed to a safe working level, usually waist high and lock bed wheels. • Put on gloves. • Place a protective pad under the resident’s buttocks and hips, as in earlier procedure. • Hand the urinal to the resident. If the resident is not able to help himself, place urinal between his legs and position penis inside the urinal. Replace covers. • Remove and discard gloves. Wash your hands. • Place wipes within the resident's reach. Ask the resident to clean his hands with the hand wipe when finished, if he is able. Leave call light within reach while the resident is using the urinal. Ask the resident to signal when done. Leave the room. Care for incontinence: Providing urinal • When called by the resident, return and put on clean gloves. • Remove urinal or have resident hand it to you. Empty contents into the toilet unless the specimen is needed, or the urine is being measured for intake/output monitoring. Note colour, odour, and qualities (for example, cloudiness) of contents before flushing. • Turn the faucet on with a paper towel. Rinse the urinal with cold water first and empty it into the toilet. Place urinal in the proper area for cleaning or clean it according to facility policy. • Remove and discard gloves. • Wash your hands. • Make the resident comfortable. • Return bed to lowest position. Remove privacy measures. • Place call light within the resident's reach. • Report any changes in resident to the caregiver. • Document procedure using facility guidelines. Care for incontinence: Assisting in providing commode or toilet • Wash your hands. • Identify yourself by name. Identify the person by name. • Explain the procedure to the person. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. • Provide for person’s privacy with curtain, screen, or door. • Help person out of bed and to the portable commode or bathroom. Make sure the resident is wearing non- skid shoes and that the laces are tied. • If needed, help resident removes clothing and sit comfortably on the toilet seat. Put toilet tissue within reach. • Provide privacy. Leave call light within reach while the resident is using the commode. Ask the person to signal when done. Leave the room. • When called by the person, return and apply gloves. • Give perineal care if help is needed. Wipe female person from front to back. • Help the person to wash hands after using the commode. Dispose of a soiled washcloth or wipes properly. Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 56 Care for incontinence: Assisting in providing commode or toilet Help the person back to bed. Make the resident comfortable. Make sure sheets are free from wrinkles and the bed free from crumbs. Remove the waste container. Empty into the toilet. Note colour, odour and the consistency of contents. Rinse container. Pour rinse water into the toilet. Place container in the proper area for cleaning or clean it according to facility policy. Remove and dispose of gloves properly. Wash your hands. Return bed to lowest position. Remove privacy measures. Place call light within the resident's reach. Report any changes in resident to the caregiver. Document procedure using facility guidelines. Slide 12: In this slide, care of urinary incontinence by providing commode is to be discussed. Read out the points and discuss in detail. 57 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Slide 1: Older people are at high risk of developing life threatening and acute symptoms from time to time in addition to the underlying long-term care issues. In this session we will discuss the strategies for handling such emergencies. Talking points LTC 8: First aid and emergency care in home and institutional settings First Aid and Emergency Care in Home and Institutional Settings First Aid and Emergency care Owing to ageing as well as various health conditions as well as environmental factors, older people can have various conditions in the home as well as institutional settings which can have profound health implications and need utmost attention. Few of the common emergency conditions that can arise in older people in home or institutional settings are as follows: • Syncope (fainting) and fall • Hypoglycaemia • Choking • Burns Syncope (fainting) and fall in home or institutions • Syncope is one of the commonest cause for falls in the home and institutional settings. • Institutionalized older people and house bound individuals are prone to syncope. • Often the cause of syncope is treatable; hypotension can be improved by simple actions. • Older people are vulnerable to episodes of low blood pressure. There are several reasons for this: ¾Being less active and sitting for longer periods ¾Medications that affect blood pressure ¾Drink less fluid than younger healthy people. ¾Infection related illnesses: During illness, blood pressure tends to fall, and, in some individuals, this becomes a big problem when they stand up (postural hypotension), causing them to fall and sometimes black out. Slide 2: Due to ageing as well as various health conditions as well as environmental factors, older people can develop various conditions in the home as well as institutional settings. These conditions may have profound health implications and need utmost attention. Syncope and falls, hypoglycemia, choking and burns are few of them. Read out the slide and discuss the points in detail. The caregivers should be well versed with the first-aid measures if somebody develops any of the acute conditions in the home or the institutional settings. Similarly, the caregivers should be aware of various emergency conditions related symptoms and signs. Upon observing those, the older person should be immediately rushed to the hospital. Slide 3: In this slide, we will discuss fall and syncope or fainting. Read out the slide and discuss each point in detail. Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 58 Slide 4: In this slide, we will discuss how to manage fall. Read out the slide and discuss each point in detail. Slide 5: In this slide, we will discuss about hypoglycemia or low blood sugar which can cause fainting. Read out the slide and discuss each point in detail. Slide 6: In this slide, we will discuss about hypoglycemia. Read out the slide and discuss each point in detail. Slide 7: In this slide, we will discuss about the role of caregiver in hypoglycemia management. Read out the slide and discuss each point in detail. What to do if an older person falls? If an older person is syncopal and discovered on the floor, then the following action should be followed: ¾The individual should be quickly assessed for any injury following the fall. ¾If the person is sitting up, then assist him/her to a lying down position. ¾If unconscious and not injured, once on the floor the legs should be raised with the body remaining on the floor and this should speed up recovery. ¾If recovery is slow, the individual should be placed in the recovery position. ¾Upon recovery, allow the individual to slowly sit up and then gradually help them to their feet. ¾If symptoms of dizziness and light headedness continue, the individual should be assisted to lie down again. ¾If, despite the above, symptoms continue or there is further loss of consciousness, call for help for promptly transferring the person to a health facility. ¾If an older person experiences an unexplained syncopal episode more than once, then they should be seen by the specialists. Hypoglycaemia (Low blood glucose) • Hypoglycaemia can be life threatening if not recognised and intervened promptly. • The caregiver should be vigilant for following symptoms of hypoglycaemia in older people especially who are on insulin preparations or oral medicines for the control of their blood sugar levels. Symptoms of hypoglycaemia • A low blood sugar level triggers the release of epinephrine (adrenaline), the “fight-or-flight” hormone which can cause the symptoms of hypoglycaemia such as thumping heart/ palpitation, sweating, tingling, and anxiety. • If the blood sugar level continues to drop, the brain does not get enough glucose and stops functioning as it should. This can lead to blurred vision, difficulty concentrating, confused thinking, slurred speech, numbness, and drowsiness. • If blood sugar stays low for too long, starving the brain of glucose, it may lead to seizures (abnormal body movements), unconsciousness, and very rarely death. Role of caregivers in hypoglycemia management • Measure the blood sugar of the symptomatic older person using glucometer. Usually, the blood sugar is below 70 mg/dL in hypoglycaemia. • If the older person is poorly responsive, unconscious or developing abnormal movements, rush to a physician or trained nurse for help. • If the person is conscious, the following intervention should be promptly done to prevent further deterioration of symptoms: • Provide 15 grams of carbohydrate to raise the blood sugar of the older person and check it after 15 minutes. • If it’s still below 70 mg/dL, have another serving. • Repeat these steps until your blood sugar is at least 70 mg/dL or the symptoms resolve. [15 gram of carbohydrate is equivalent to: 4 ounces (1/2 cup) of juice or regular soda (not diet); 1 tablespoon of sugar, honey, or corn syrup] 59 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Slide 8: In this slide, we will discuss about measuring blood sugar to detect hypoglycemia. Read out the slide and discuss each point in detail. Slide 9: In this slide, we will discuss about choking; which can be fatal if left unaddressed immediately. Read out the slide and discuss each point in detail. Slide 10: In this slide, we will discuss about first aid for choking. Read out the slide and discuss each point in detail. Slide 11: In this slide, we will discuss about burns; which can be fatal if left unaddressed immediately. Read out the slide and discuss each point in detail. Measurement of blood glucose by Glucometer: Procedure • Wash and dry the hands of the older person preferably with warm water as it may help the blood flow. • Many types of glucometers turn on automatically when a strip is inserted. • Choose the spot. Don't check from the same finger all the time. Using the side of the fingertip may be less painful than the pads. • Prepare the lancing device/lancet and prick the selected site to get a drop of blood. • Touch and hold the test strip opening to the drop until it has absorbed enough blood to begin the test. • View the test result and take the proper steps if the blood sugar is high or low, based on your healthcare professionals' recommendations. • Discard the used lancet properly. • Record the results in a logbook. Choking • It is a medical emergency that should be promptly dealt with. • Choking occurs when a foreign object lodges in the throat or windpipe, blocking the flow of air. In older people, a piece of food, tooth or denture are often the culprit. • Symptoms of choking: The caregivers should be vigilant for the following symptoms of choking: ¾Inability to talk ¾Difficulty breathing or noisy breathing ¾Squeaky sounds when trying to breathe ¾Cough, which may either be weak or forceful ¾Skin, lips and nails turning blue or dusky ¾Skin that is flushed, then turns pale or bluish in color ¾Loss of consciousness First aid for choking: Heimlich maneuvers • If the person is able to cough forcefully, the person should keep coughing. • Stand behind the person. Place one foot slightly in front of the other for balance. • Wrap your arms around the waist. Tip the person forward slightly. • Make a fist with one hand. Position it slightly above the person's navel. • Grasp the fist with the other hand. Press hard into the abdomen with a quick, upward thrust, as if trying to lift the person up. • Perform between six and 10 abdominal thrusts until the blockage is dislodged. • If the blockage doesn’t get dislodged; transfer the older person to a health facility urgently. Burns First aid in burns: • Remove the older person from the burning area, douse the flames with water or smother flames with a blanket. • Remove any clothing or jewellery near the burnt area of skin. But don’t try to remove anything that is stuck to the burnt skin as it could cause more damage. • Cool the burnt area with cool or lukewarm running water for 20 minutes as soon as possible after the injury. • Never use ice, iced water, any creams or greasy substances like butter or oil. • Keep the older person warm using a blanket or layers of clothing to prevent hypothermia. Avoid putting them on the injures area. • Rush the person immediately to the healthcare facility. Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 60 Emergency transfer of an older person to a healthcare facility If the caregiver observes following in an older person; rush him/her to the emergency of a health care facility: • Bleeding that will not stop • Breathing problems (difficulty breathing, shortness of breath) • Change in mental status (such as unusual behavior, confusion, difficulty arousing) • Chest pain • Choking • Coughing up or vomiting blood • Fainting or loss of consciousness • Feeling of committing suicide or murder • Head or spine injury • Severe or persistent vomiting • Sudden injury due to a motor vehicle accident, burns or smoke inhalation, near drowning, deep or large wound, or other injuries • Sudden, severe pain anywhere in the body • Sudden dizziness, weakness in any part of body, or change in vision • Swallowing a poisonous substance • Severe abdominal pain or pressure. Slide 12: In this slide, we will discuss about emergency transfer of an older person to health care facility. Read out the slide and discuss each point in detail. 61 Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) Integrated Care for Older People (ICOPE): Training package on long term care in home or institutional settings in South-East Asia Region (Facilitator’s Guide) 62