DCW Competency Review 2026

Pennsylvania requires certain documents to be current in your personnel file. Keeping your own file up to date is part of being an independent contractor — nobody does it for you.

Send in anything that has expired or is about to expire: your car insurance, your driver’s license, your green card, and your TB rule-out documentation.

DCWs who do not keep their credentials that are mandated by the state up-to-date will not receive referrals for work and will not be paid for any assignments until their credentials have been made current. This is not a penalty Silver Lining chooses to apply — the state does not permit us to refer you until your file is in compliance.

The DCWs are permitted to empty a Foley Catheter Bag and they are permitted to change the Foley bag from day to night but they are not permitted to do anything with the catheter itself. When it comes to a Colostomy Bag, the DCWs are permitted to empty it, change it to a new one but they are not allowed to change the wax wafer.

DCWs are not permitted to administer eye drops of any kind. They are not permitted to attend to feeding tubes, give fleet enemas, give suppositories and perform wound care. DCWs are not permitted to do Accucheck finger sticks. They are not permitted to prepare insulin or give insulin injections. No injections of any kind may be given by a DCW. Nothing can be done by the DCWs that is invasive to the client.

If you are ever unsure whether a task is inside your lane, the answer is to stop and call the office. You will never be in trouble for asking.

This is the rule DCWs most often get wrong, so read it slowly.

DCWs are not permitted to give the client any medication directly out of the prescription bottle. You may remind the client that it is time to take their medication and hand them the bottle, but you may not remove the medication from the bottle yourself. If the client has a medication box, the DCW is not allowed to fill the box. The pill box is filled by the client, a family member, a nurse, or a pharmacy — by anyone except you.

Putting all of that together: there is no situation in which a DCW may pour out, sort, prepare, or administer a client’s medication. Reminding and handing over the bottle is the whole of what you may do.

If you come back from time off and the pill box is empty, do not fill it and do not assume somebody else already handled it. Call Silver Lining at 215-885-7701 for direction on what to do.

You are not permitted to perform Accucheck finger sticks, and you may not prepare or give insulin. If the client tests their own blood sugar, you are permitted to advise the client of the reading — reading a number out loud to the person it belongs to is not a medical task. What you may not do is perform the test, interpret it, or act on it with insulin.

DCWs must contact Silver Lining when a client goes on Hospice as Silver Lining works in conjunction with the Hospice Company and the procedure for giving medication is different.

When you work in someone’s home, you learn things about them that they never chose to share with the world. You see their medicines, their mail, their family arguments, their bad days. All of it belongs to them, not to you. Keeping it private is part of the job.

The rule is simple: what you see and hear in a client’s home stays there. The only people you discuss a client with are the Silver Lining staff who need to know in order to do their jobs, and you have those conversations somewhere private — not in a lobby, not in an elevator, not in a parking lot. There are two limits, not one: the right person, and the right place.

This includes things people do not always think of:

Never discuss one client with another client. Not even if they live in the same building and already know each other, and not even if you leave the name out.

You do not confirm who your clients are. If a neighbor stops you and asks how someone is doing, the answer is that you are not able to talk about anyone you work with, and then you change the subject. Even saying “she’s doing fine” tells them you work there.

Nothing about a client goes on social media. No names, no details, no photos, no matter how private you believe your account to be. Leaving the name out does not make a post anonymous — a street, an illness and a schedule are enough for somebody to work out who you mean. There is nothing about a client that is safe to post.

No photographs of the client or inside the home, unless Silver Lining has asked you to and it has been arranged in advance. Photos taken “to be helpful” are how most privacy problems start.

Mail and paperwork are private too. If a client’s mail or bank statements are sitting open on the kitchen table, leave them alone. Do not read them, do not open or sort them, and do not photograph them. This is also the fact pattern behind most accusations made against caregivers.

Not with your own family, either. They do not know the client, but the client did not agree to be a story told at your dinner table.

The client decides who hears about her care — not the caregiver, and not whoever pays the bill.

If a family member calls and asks you questions, and you have not been told that they are allowed that information, do not guess and do not simply answer because they are family. Tell them politely that you will have the office call them, and then let your coordinator know they asked. That is not being unhelpful. It is protecting your client and protecting yourself.

Confidentiality is never a promise to stay silent when somebody may be in danger.

If a client tells you something private and asks you to promise not to tell anyone, but what she said makes you think she is not safe, tell her kindly that this is something you have to pass on because you care about her safety — and then call your coordinator. You do not have to lie to her, and you should not.

Caregiving is close work. You are in someone’s home, helping with the most personal things there are, often for years. Real affection grows, and that is a good thing — it is why families trust us. But the relationship still has edges, and the edges exist to protect you as much as the client.

Things the law does not allow. DCWs are not permitted to be the client’s power of attorney and they are not allowed to assume guardianship for the client or witness any client signatures on any forms or documents. A client may not sign her home care papers over to you, and she may not name you in her will. Pennsylvania regulation forbids anyone connected to a home care registry from becoming a client’s power of attorney or guardian — not for medical decisions, not for financial ones, not even if the client has no family and asks you herself, and not even if a lawyer draws up the papers. The rule follows you personally because of your connection to Silver Lining, so being “off duty” makes no difference. If a client raises it, tell her you are not permitted, and call your coordinator. (28 Pa. Code § 611.57(b))

Money is where good caregivers get into trouble without meaning to.

DCWs are not permitted to use the client’s credit card or debit card or checks for any reason, and they are not allowed to assist the client with his or her finances. When you run errands, take cash — no more than $50 — and bring back the receipt and the change. If a client hands you her card, explain that you are not permitted to use it, take cash instead, and let your coordinator know.

DCWs are not allowed to borrow money from the client or the client’s family. If a client notices you are short and offers to lend you money, thank her and decline, and let your coordinator know she offered.

Silver Lining policy on gifts: DCWs may not accept gifts, tips, or money of any kind from a client or a client’s family, on top of your pay — no matter the amount, no matter the occasion, and no matter how freely it is offered. If a client offers you a gift, thank her warmly, explain that you are not permitted to accept it, and let your coordinator know it was offered.

That last part — telling the office — is the part people skip, and it is the part that protects you. If money later goes missing in that house, the caregiver who reported the offer at the time is in a completely different position from the one who never mentioned it.

The test to use when you are not sure: if you would not want your coordinator to find out about it later, do not do it. And if you are already wondering whether to mention something, that is your answer. Call and mention it.

1-800-490-8505 — the Pennsylvania statewide abuse hotline. It is answered 24 hours a day, seven days a week.

Pennsylvania has separate laws for adults 60 and over and for adults 18 to 59 with a disability, but both use this same number. That means you never have to work out which law applies before you call. One number, every time.

If nobody is in immediate danger: call the hotline yourself first, then call your Silver Lining coordinator.

The duty to report belongs to the person who saw it — that is you. Telling the office is required as well, but under Pennsylvania law it comes after the report, not instead of it. Reporting only to your employer does not satisfy the duty. So the order is hotline first, office second.

If somebody is in danger right now — your client has a fresh injury, she is frightened, and the person she is afraid of is still in the house — that is different. Call 911 first. The hotline is not an emergency line. Then the hotline, then the office.

The standard in the law is reasonable cause to suspect. You do not have to see it happen. The client does not have to confirm it. You do not have to be sure.

Waiting for proof is the most common reason abuse goes unreported, and it is the wrong instinct. If you suspect it, you call.

If you report in good faith and the investigation finds nothing, nothing happens to you. Pennsylvania law gives immunity to anyone who makes a good-faith report, and it is illegal for anyone — a family, a client, or Silver Lining — to punish or retaliate against you for reporting. You cannot be sued for it, taken off the registry for it, or billed for the investigation.

Fear of retaliation is the second most common reason people stay quiet. It should not be, because the protection is real.

Pennsylvania recognizes seven categories. Use Pennsylvania’s words:

• Physical abuse
• Sexual abuse
• Emotional abuse — this counts. A family member who repeatedly calls your client stupid and worthless, or threatens to “put her in a home” whenever she asks for help, is committing emotional abuse, and it is reportable. Words are abuse.
• Caretaker neglect — a family member who handles your client’s money and refuses to buy the food or medicine she needs, even though she has the money for it, is committing caretaker neglect.
• Financial exploitation
• Abandonment — the son who is her only caregiver and leaves for two weeks without telling anyone and without arranging any help has abandoned her, and that is reportable.
• Self-neglect — a person failing to provide for her own care.

Self-neglect is reportable, and it is the most common report there is in Pennsylvania — roughly a third of all reports, and about half of the cases that turn out to be substantiated. This is the one most caregivers assume does not count. If your client lives alone, has stopped bathing, the food in the refrigerator has spoiled and she is not taking her medicine — and she tells you she is fine — that is reportable. It is still reportable when nobody else is involved.

Bruises. Older adults bruise easily, so not every bruise is a worry. What should make you stop and think is the pattern: bruises at different stages of healing, in places that do not normally get bumped, and an explanation that changes each time you ask. A single bruise on a shin, thin skin that tears on furniture, or a bruise on the back of the hand where an IV was placed are all ordinary.

Looking at the pattern rather than the bruise protects families from being wrongly accused just as much as it protects clients.

Money. You see the mail, the visitors and the checkbook, which puts you in the best position of anyone to notice financial exploitation. A warning sign is something like a new name recently added to her bank account that she cannot explain. Paying her own bills, giving to her church, and having family visit often are not warning signs.

Is anyone in danger right now? If yes, call 911.

Call the hotline, 1-800-490-8505. Reasonable suspicion is enough.

Call your Silver Lining coordinator at 215-885-7701.

Write down exactly what you saw and heard — in plain facts, with the date and time, and no conclusions about who did it or why. “Bruise on left upper arm, four small round marks, client said she did not want to talk about it” is worth far more than “I think her son is hurting her.”

Keep caring for your client, and let the investigators do their work.

Do not confront the family member, do not go looking around the home for more evidence, and do not tell the neighbors. A well-meaning caregiver who confronts a family member can put the client in more danger and can damage the investigation.

This is the hardest one, and it is the one most likely to actually happen. A client tells you what has been going on, and then begs you not to tell anybody.

You report it anyway — and you tell her gently and honestly that you have to, because keeping her safe comes first. You do not deceive her, and you do not pretend you will keep it to yourself.

If you need to speak to a Coordinator, the Payroll Department or the Administrative team Monday to Friday 9 am to 4 pm, you must call 215-885-7701 and ask for the person or department you need. This number will be answered by a live person. If for any reason the staff is working from another location, this number will be answered by our answering service, Holy Redeemer. They do not just answer the incoming calls for Silver Lining so please have patience.

The other cell numbers that you have for coordinators are work phones and they are not monitored unless the person is on call. Please do not rely on them.

If you need to submit your timesheet or any other form of documentation, you must email it to time@slhomecare.com. Your second option is to take a picture of your timesheet and/or documentation and text the picture to 215-806-5190. Lastly, you can fax your timesheet and/or documentation to 215-886-6985. Sending your timesheet and/or documentation by any other method is not recommended.

How do you know it arrived? When you email or text your timesheet and/or documentation to the sources noted above, you will receive a message acknowledging your submission. That acknowledgment is your proof. If you do not receive it by the end of the next business day, please contact us at 215-885-7701. If you choose to fax, then you will have to call 215-885-7701 to confirm receipt.

If you are scheduled and cannot go, call 215-885-7701 and speak to your coordinator or another LIVE person. Do not text a coordinator’s cell, do not email it, and do not leave it to chance. You need to know that your client will be covered.

This matters more than it may sound. A client left with nobody, when the office did not know, is client neglect and job abandonment — and that is a far more serious thing than a missed shift.

On a weekend or after hours, call the same number, 215-885-7701. The answering service will take your name and telephone number, and you wait for a return call from the Coordinator on call.

Being late to your cases may result in removal from the registry. What keeps that from happening is simple and it is two things: call Silver Lining to let them know, and write the actual time you arrived on your timesheet. Never put down a time you did not work, and never let a late arrival go unreported.

If you are on a live-in assignment and you need to pick up a prescription for yourself, or leave for any other reason, call Silver Lining and get direction from your Coordinator or the Coordinator on Call before you go. Do not simply step out, and do not arrange cover yourself.

Call Silver Lining and speak to your coordinator about the procedures for future care to your client. The procedures for medication are different once Hospice is involved, so this call is not optional.

Speak clearly, slowly and directly. Maintain face-to-face contact whenever possible so the client can see your face. Lower the pitch of your voice rather than raising the volume, reduce background noise, and use written words, gestures or pictures if they help.

Do not shout, and do not put your face inches from theirs. Shouting distorts words and makes them harder to understand, not easier, and standing too close is uncomfortable and takes away the client’s dignity.

Universal precautions — sometimes called Standard Precautions — mean this: treat everyone’s blood and body fluids as if they could be infectious, every single time. Not only the clients you have been told something about, and not only when something looks unclean. Every client, every shift.

You will not always be told when somebody is carrying an infection, and often the client does not know either. That is exactly why the rule applies to everyone.

Wash your hands before and after every personal care task, before handling food, after using the bathroom, and after any contact with body fluids.

Wash your hands after you remove your gloves — every time. Gloves are not a substitute for handwashing. Hands get contaminated when gloves are taken off, and gloves can have small tears you cannot see.

Wear gloves any time you might touch blood, body fluids, or broken skin. That includes toileting and brief changes, cleaning up any spill of body fluid, handling soiled linens, and caring for a client with an open sore or rash.

Hold soiled linens away from your clothes and skin, never shake them, and put them straight into a hamper or basket. Never put them on the floor or on furniture. Soiled bed linens are full of microorganisms that should not be spread around the room.

Scabies is caused by a tiny mite that burrows under the skin.

Symptoms. The most common symptom is an intense itchy, pimple-like rash. The itching is usually worst at night. A rash commonly appears in the armpits, along the belt line, at the waist and on the buttocks.

How soon symptoms appear — and this catches people out. If a person has never had scabies before, it can take 4 to 8 weeks after contact for any symptom to appear. During all of that time they can pass it to other people without knowing.

If the person has had scabies before, a repeat exposure produces symptoms in 1 to 4 days — much sooner than the first time, because the body already recognizes the mite.

How it spreads. By the scabies mites themselves; by direct, prolonged, skin-to-skin contact; and it spreads readily in crowded conditions, especially in institutions. All of these are true at once.

If you suspect scabies in a client’s home, call Silver Lining. Do not diagnose it and do not treat it.

What it is and why it happens. C. diff is a bacterium that causes infection of the bowel. Antibiotics are the usual trigger: they kill off the good bacteria in the gut, which allows C. diff to grow unchecked. That is why a client who has recently been on antibiotics is the one most at risk.

The main symptoms are severe abdominal pain and diarrhea. Other common symptoms include fever, nausea, and loss of appetite.

How it spreads. By contact with contaminated surfaces or equipment. C. diff forms spores that survive on surfaces for a long time.

⚠ The most important thing in this whole module: alcohol hand sanitizer does NOT kill C. diff spores. If your client has or is recovering from C. diff, you must wash your hands with soap and water and wear gloves. Hand sanitizer will feel like you have cleaned your hands and will have done nothing at all.

In the home, all of the following matter together: wash hands with soap and water (not sanitizer), wear gloves for any contact with stool or soiled items, and clean bathroom surfaces and anything frequently touched with a bleach-based cleaner. Wash soiled laundry separately and on the hottest setting the fabric allows.

Where they are found. Around the bed, usually in the seams — of the mattress, the box spring and the bed frame. They are found around the globe; they are not a sign of a dirty home and they are not confined to any one country or kind of housing.

How to check. Look along the seams of the mattress and the bed frame for live bugs, shed skins, and rusty or dark spots.

What they feed on. Blood — from humans and animals. That is all they feed on.

Do they cause harm? They do cause skin irritation and rashes. The bites itch, and scratching can lead to a skin infection.

What to do. If bed bugs are found in a client’s home, report it to Silver Lining immediately. Do not attempt to treat the home yourself and do not tell the client to.

The best way to protect against influenza is to get a flu vaccine every flu season.

Influenza is a contagious disease that can lead to serious complications, hospitalizations or even death. Even healthy children and adults can get very sick from it and spread it to family, friends and those who are in their care.

Why yearly? Two reasons, and both are true: the vaccine is updated season to season to match the viruses expected that year, and a person’s immune protection declines over time, so annual vaccination is needed for optimal protection.

When to get it. For the Philadelphia area, get vaccinated in September or October — ideally by the end of October. It takes about two weeks after vaccination for the protective antibodies to develop, so this timing means you are protected before flu activity picks up.

Types available:

• A regular flu shot, approved for people ages 6 months and older
• A high-dose shot, approved for people 65 and older — this is the one for seniors
• The nasal spray flu vaccine, approved for people 2 through 49 who are not pregnant

Side effects are mild: soreness, redness, tenderness or swelling where the shot was given. Flu shots cannot give you the flu — they are made from killed virus.

What causes it. Shingles, also called herpes zoster, is caused by the varicella-zoster virus — the same virus that causes chickenpox. After you have chickenpox the virus stays in your body and can cause shingles later in life.

Symptoms. A red, itchy, painful rash with blisters, usually appearing in a band on one side of the body, because it follows a nerve path. Early signs before the rash are headache, intolerance to light, generally feeling unwell, fever, and abnormal skin sensations and pain. The rash forms over a couple of days, becomes blisters, then crusts over. It can last 7 to 10 days and healing can take up to 4 weeks. Shingles on the face can go into the eye and damage vision.

How it is diagnosed. By a health care professional through clinical examination — by looking at the rash. There is no routine test a caregiver could arrange.

Who is at higher risk. Older adults and people with weakened immune systems.

Long-term problems. Yes. The common complication is long-term nerve pain called postherpetic neuralgia (PHN), in the area where the rash was, lasting months or years after the rash clears. It can be severe and debilitating.

Can it be passed on? Shingles itself cannot be passed from one person to another. But the virus can spread from the blister fluid to someone who has never had chickenpox or the chickenpox vaccine — and that person would develop chickenpox, not shingles. This is why the rash must be kept covered.

Can it be prevented? Yes — through the shingles vaccine (a recombinant zoster injection). It is recommended for adults 50 and older, and for adults 19 and older who have a weakened immune system. By preventing shingles the vaccine also protects against PHN.

Caring for a client with shingles. Follow the doctor’s treatment plan and start the medication as soon as possible — shingles medications are far more effective the sooner they are started. Manage the symptoms: rash, pain, and the inability to care for themselves because of pain. Wear gloves and wash your hands frequently. Keep the area covered. Discourage scratching, which can spread the virus and open the skin to a new infection. Follow the doctor’s or nurse’s instructions when cleaning the rash or blister area — secondary skin infections can happen if the sores become contaminated. Cold compresses and calamine lotion can help. Shingles medications can require several doses a day, so remind your client when to take them. Some prescription painkillers must be monitored closely to prevent overdose, which is harder when the client is in pain and uncomfortable. If your client has questions about treatment, refer them to their doctor or visiting nurse.

Call 911 when there is a threat to life or limb, right now: no response, chest pain, trouble breathing, stroke symptoms, severe bleeding, choking, a bad fall, a fire.

Call the office at 215-885-7701 for everything that is a change or a concern but not an emergency: a new symptom, a fall with no injury, a client who seems unwell, a supply that has run out.

When you are not sure, call 911. Nobody has ever been in trouble for calling 911 for a client.

⚠ After any 911 call, you must also call Silver Lining at 215-885-7701 and report what happened — even after the paramedics have taken over and your client is safe. The office cannot help a client, or a family, that it does not know about.

You find your client on the floor and they do not respond when you speak to them or touch their shoulder.

Call 911 first. Not the office, not the family, not the doctor. Then stay with them until help arrives, and call Silver Lining afterwards.

B.E. F.A.S.T. is how you remember the warning signs of a stroke:

• B — Balance: sudden loss of balance or coordination
• E — Eyes: sudden trouble seeing in one or both eyes
• F — Face: one side of the face droops
• A — Arm: one arm drifts down or is weak
• S — Speech: speech is slurred or does not make sense
• T — Time: time to call 911

If one side of your client’s face is drooping and their speech is slurred, call 911 right away and note the time the symptoms started. That time matters enormously — some stroke treatments can only be given within a few hours of onset, and the hospital will ask you.

Your client had stroke-like symptoms for ten minutes and then felt completely normal again. This still needs medical help now.

A spell that passes is a TIA — see Module 12. It is a warning, not an all-clear. A significant number of people who have a TIA go on to have a full stroke, and the highest risk is in the first 48 hours. Do not wait to see if it happens again.

A grease fire in a pan on the stove: slide a lid over the pan and turn off the burner. Never throw water on a grease fire and never carry a burning pan. If there is no lid, a baking sheet works.

Smoke filling the kitchen and the fire spreading: get the client and yourself out of the house first, then call 911 from a safe place. People are the priority. Do not stop to gather belongings, and do not try to fight a spreading fire.

Clothing on fire: stop, drop and roll — or smother the flames with a towel or blanket. Do not let them run.

No smoking and no open flames anywhere near the oxygen. No candles, no gas stove burners nearby, no space heaters with an exposed element. Oxygen itself does not burn but it makes everything else burn ferociously fast. This rule is absolute.

Also: you do not adjust the flow rate. That is a prescription. If you think it is wrong, call the office.

If the power goes out and the concentrator stops: switch to the backup tank if there is one, call the oxygen company, and call 911 if the client has any trouble breathing at all. Then call the office.

If your client is choking and cannot cough, speak or breathe, call 911 and give abdominal thrusts if you have been trained to do them.

If the client can still cough forcefully, let them cough — coughing is more effective than anything you can do, and interfering can make it worse.

Your client with diabetes is suddenly shaky, sweaty and confused, but can still swallow.

Give them fast-acting sugar — juice, regular (not diet) soda, or glucose tablets — stay with them, and report it. If they cannot swallow safely, or they do not improve, call 911.

Remember the boundary from Module 1: you may give juice. You may not give insulin, and you may not do a finger stick.

Put on gloves, press firmly on the wound with a clean cloth, and call 911. Keep pressing — do not lift the cloth to check. Add another cloth on top if it soaks through.

The rule is at least three feet between the heater and anything that can burn — curtains, bedding, furniture, paper, clothing. Plug it directly into a wall outlet, never into an extension cord or power strip, and never leave it running when everyone is asleep or out of the room.

You and your client both start feeling headachy and dizzy at the same time, on a winter day, with no illness going around.

Get everyone outside and call 911. Two people falling ill together, in a heated house, is the classic sign of carbon monoxide. It has no smell and no colour. Do not stay inside to investigate and do not open windows and wait.

A tornado warning is issued while you are on shift. Stay with your client, move to an interior room away from windows — a hallway, a bathroom, or a basement if there is one — and let the office know when it is safe to do so.

Leaving a client alone in a dangerous situation is abandonment. You stay.

Before you need any of it, find out and write down:

where the client’s medication list is kept

the house address and the phone number there — you will need to give the address to a 911 dispatcher, and in an emergency people forget it

where the exits are

Each year, millions of older people — those 65 and older — fall. In fact, more than one out of four older people fall each year but less than half tell their doctor. Falling once doubles your chances of falling again.

• One out of five falls causes a serious injury such as broken bones or a head injury.
• Each year, 3 million older people are treated in emergency departments for fall injuries.
• Over 800,000 patients a year are hospitalized because of a fall injury, most often because of a head injury or hip fracture.
• Each year at least 300,000 older people are hospitalized for hip fractures.
• More than 95% of hip fractures are caused by falling, usually by falling sideways.
• Falls are the most common cause of traumatic brain injuries (TBI).
• In 2015, the total medical costs for falls came to more than $50 billion. Medicare and Medicaid shouldered 75% of these costs.

Falls send a great many older people to the hospital. Anyone who tells you otherwise is wrong.

Many falls do not cause injuries. But one out of five falls does cause a serious injury such as a broken bone or a head injury. These injuries can make it hard for a person to get around, do everyday activities, or live on their own.

Many individuals who fall, even if they are not injured, become afraid of falling. This fear may cause a person to cut down on their everyday activities. When a person is less active, they become weaker, and this increases their chances of falling. They do not become stronger — the opposite happens.

Falls can cause broken bones, like wrist, arm, ankle, and hip fractures.

Falls can cause head injuries. These can be very serious, especially if the person is taking certain medicines (like blood thinners). An older person who falls and hits their head should see their doctor right away, to make sure they do not have a brain injury. That applies whether or not they are on a blood thinner.

Research has identified many conditions that contribute to falling. These are called risk factors, and many can be changed:

• Lower body weakness
• Vitamin D deficiency
• Difficulties with walking and balance
• Use of medicines, such as tranquilizers, sedatives, or antidepressants. Even some over-the-counter medicines can affect balance.
• Vision problems
• Foot pain or poor footwear
• Home hazards such as broken or uneven steps, throw rugs or clutter that can be tripped over

Most falls are caused by a combination of risk factors. The more risk factors a person has, the greater their chances of falling.

Ask your doctor or healthcare provider to evaluate your risk for falling and talk with them about specific things you can do.

Ask your doctor or pharmacist to review your medicines to see if any might make you dizzy or sleepy.

Ask your doctor about taking vitamin D supplements.

Do strength and balance exercises. Exercises that make the legs stronger and improve balance are what work. Tai Chi is a very good example of this kind of exercise.

Have your eyes checked by an eye doctor at least once a year, and update eyeglasses if needed. If your client has bifocal or progressive lenses, a pair with only the distance prescription can be safer for walking outdoors — those lenses can make things seem closer or farther away than they really are. Never use somebody else’s glasses — not a spouse’s, not a late partner’s. The wrong prescription makes a fall more likely, not less.

Get rid of things the client could trip over. Loose throw rugs, electrical cords across walkways, and clutter are the three big ones. Report them — and with the client’s permission, fix them.

Add grab bars inside and outside the tub or shower and next to the toilet.

Put railings on both sides of stairs.

Make sure the home has plenty of light. Add more or brighter bulbs. Keeping the lights dim does not make a home safer — it makes it more dangerous.

Keep frequently used items in cabinets that can be reached without a step stool.

Use non-slip mats in the bathtub and on shower floors.

At night, if your client wants to walk to the bathroom, turn on the light and make sure the path is clear before they get up. Most night-time falls happen on a route the person has walked a thousand times, in the dark, around something that was not there yesterday.

On stairs, carry less so you can hold the handrail and see every step. Make two trips with the laundry rather than one.

You are no use to anybody injured, and back injuries end careers.

Let the client do as much as they safely can.

Keep a wide stance, bend your knees, and keep the client close to your body. Never bend from the waist — this is also true when you are making a bed and tucking sheets under a heavy mattress.

Never twist at the waist while you are supporting weight. Move your feet and turn your whole body instead.

Before the transfer:

• Lock both wheel brakes on the wheelchair and move the footrests out of the way. This is the single most commonly skipped step and the most common cause of transfer injuries.
• Place the chair on the client’s stronger side, at a slight angle to the bed. People pivot toward their strength.
• Make sure the client is wearing non-skid shoes or slippers that close around the heel. Loose slip-on slippers and socks alone are how people go down.

The dangle. Before a client stands up after lying in bed, have them sit on the edge of the bed for a minute until any dizziness passes. Blood pressure drops when people sit up suddenly, and a client who stands straight from lying down is a client who faints.

During the transfer. If the client can bear some weight but moves slowly, let them do as much as they safely can, and move together on a count of three so you are both going at the same moment.

Walking with an unsteady client. Position yourself slightly behind them, on their weaker side — the side they would fall toward.

There is no shortcut that makes a walker safe, and every “helpful” habit people invent around one is a hazard:

• Do not let a client pull on the walker to stand up from a chair. A walker is not an anchor — it tips. They push up from the arms of the chair, then reach for the walker once they are standing.
• Do not let them use a walker on the stairs. Ever.
• Do not hang bags on it, and do not let them carry things in the hand that should be on the grip. Weight hung on the front is what tips a walker over.

Setting a walker’s height or changing its wheels is not a DCW task either — that is arranged through the client’s therapist or supplier. If a walker looks wrong for the person using it, report it.

Do not try to hold them up. You cannot stop a falling adult, and trying is how both of you end up injured.

Hold them close and slide them gently down your own body to the floor, protecting their head. Then check them where they lie.

Do not rush them up, even when they insist they are fine and want to get straight up. Have them stay still while you check for pain or injury, then help them use sturdy furniture to get up slowly.

Never lift a client from the floor by yourself. If they cannot get up with light assistance, call for help.

⚠ Report every single fall to Silver Lining at 215-885-7701 the same day — including falls where the client was not hurt, and falls the client asks you not to mention. Every one.

⚠ Any client who hits their head in a fall should see their doctor right away, even when they say they feel fine.

⚠ And if they take a blood thinner, get medical help immediately. A head bump on a blood thinner can cause bleeding inside the skull that shows no symptoms for hours. This is the one where “she seems fine” has cost lives.

ADLs — Activities of Daily Living — are the personal care tasks: bathing, grooming, dressing, toileting, transferring and eating.

IADLs — Instrumental Activities of Daily Living — are the everyday household tasks that keep a home running: shopping, cooking, laundry and errands.

The single most important principle across both: do not do everything for them. Help your clients to care for themselves as much as possible. Look for tasks that are challenging but not frustrating, and help them succeed in doing them. Doing everything for a client takes away the abilities they still have, and it takes away their dignity.

The following attitudes will help you give the best possible care:

Remember and follow the goals of the client’s plan of care.

Do not take their behavior personally.

Put yourself in their shoes.

Treat clients with dignity and respect, as you would want to be treated.

Work with the symptoms and behaviors you see.

Work as a team, and work with family members.

Encourage communication.

Take care of yourself.

Assist with grooming — help the people in your care feel attractive and dignified. Small things carry real weight here. Soaking, filing and painting a client’s nails, styling her hair the way she has always worn it, or helping a man have a proper shave can change how a person feels about their whole day.

When your client says they need the bathroom, help them right away. Do not finish what you are doing first and do not ask them to wait. Making a client wait is how falls happen — they try to get there alone — and it is how accidents happen, which costs them their dignity.

When cleaning a female client after toileting, always wipe front to back, to keep germs away from the urinary area. Wiping the other way is the most common cause of urinary tract infections in older women.

If you find an incontinence brief is wet, change it promptly. Wash and dry the skin properly, and report any redness you see. Skin left wet against a brief breaks down fast — see Module 9.

Good daily mouth care means brushing twice a day with a soft brush, and reporting bleeding gums or mouth sores to the office. Mouth care is skipped more often than any other personal care task, and poor mouth care leads to pain, to a client not eating, and to infection.

Dentures: clean them over a towel or a basin of water — dentures shatter when dropped on a hard sink, and replacing them is expensive and slow. Store them in a labeled cup with water or denture solution, never dry, and never wrapped in a tissue where they get thrown away.

When a client has poor circulation to the legs and feet, elastic stockings are ordered. These stockings help prevent swelling and blood clots and improve circulation. They are called “anti-embolic hose” or “elastic stockings.” They need to be put on before the client gets out of bed.

Wash your hands.

Wash your hands.

Explain the procedure to the client, speaking clearly, slowly and directly. Maintain face-to-face contact whenever possible.

Provide privacy for the client.

The client should be in the supine position (on his or her back) in bed. With the client lying down, remove socks, shoes or slippers, and expose one leg.

Turn the stocking inside out at least to the heel area.

Gently place the foot of the stocking over the toes, foot and heel. Make sure the heel is in the right place — the client’s heel must sit in the heel of the stocking. A stocking with the heel out of position bunches and cuts off the circulation it was meant to help.

Gently pull the top of the stocking over the foot, heel and leg.

Make sure there are no twists or wrinkles in the stocking after it is on. It must fit smoothly.

Repeat for the other leg.

Some clients spend much or all of their time in bed. Careful bedmaking is essential to their comfort, cleanliness, and health. Linens should always be changed after personal care procedures such as sponge baths, or any time bedding or sheets are damp or soiled, or in need of straightening. Bed linens must be changed frequently for these reasons:

• Sheets that are damp, wrinkled, or bunched up under a client are uncomfortable. They may prevent the client from resting or sleeping well.
• Microorganisms thrive in moist, warm environments. Bedding that is damp or unclean encourages infection and disease.
• Clients who spend long hours in bed are at risk for pressure sores. Sheets that do not lie flat under the client’s body increase the risk of pressure sores because they cut off circulation.

An occupied bed is made with the client in bed. An unoccupied bed is made while no client is in it. When making the bed, use a wide stance and bend your knees. Avoid bending from the waist, especially when tucking sheets under the mattress.

• Wash your hands.
• Explain the procedure to the client. Maintain face-to-face contact whenever possible.
• Provide privacy if the client desires it.
• Place clean linen on a clean surface within reach — a bedside stand or chair. Never place clean linens on the floor.
• If the bed is adjustable, adjust it to a safe working level, usually waist high. Lower the head of the bed. If the bed is movable, lock the bed wheels.
• Put on gloves.
• Loosen top linen from the end of the bed on the working side. Unfold the bath blanket over the top sheet to cover the client, and remove the top sheet.
• Make the bed one side at a time. If the bed has side rails, raise the side rail on the far side. This protects the client from falling out of the bed while you are making it. Assist the client to turn onto his or her side, away from you toward the raised rail.
• Loosen the bottom soiled linen, mattress pad, and protector on the working side.
• Roll the dirty linens from the head to the foot of the bed, tucking snugly against the client’s back.
• Place and tuck in clean bottom linens, finishing with the bottom sheet free of wrinkles. Make hospital corners.
• Smooth the bottom sheet out toward the client. Roll the extra material toward the client and tuck it under the client’s body.
• If using a waterproof pad or a draw sheet, centre it, tuck the side near you, then smooth and tuck as with the sheet.
• Raise the side rail nearest you. Go to the other side, lower that rail, and assist the client to turn onto the clean bottom sheet. Protect the client from any soiled matter on the old linens — the dirty linens should not touch the client, and they should not touch you.
• Loosen the soiled linen. Check for personal items. Roll it from head to foot. Avoid contact with your skin or clothes. Place it in a hamper or basket. Never put it on the floor or furniture. Never shake it. Soiled bed linens are full of microorganisms that should not be spread around the room.
• Pull and tuck in the clean bottom linen on this side, finishing free of wrinkles.
• Ask the client to turn onto her back. Keep her covered and comfortable, with a pillow under the head. Raise the side rail.
• Unfold the top sheet over the client. Ask her to hold it while you slip the blanket or old sheet out from underneath, and put it in the hamper.
• Place a blanket over the top sheet, matching the top edges. Tuck the bottom edges under the mattress and make hospital corners. Loosen the linens over the client’s feet. Fold the top sheet over the blanket about six inches.
• Remove the pillow. Do not hold it near your face. Remove the soiled pillowcase by turning it inside out and place it in the hamper.
• Put a clean pillowcase on each pillow and place it under the client’s head or as the client desires.
• Remove and discard your gloves. Wash your hands. Keeping your gloves on when you are finished spreads whatever is on them through the rest of the house.

Keep your gloves on for the whole of the soiled-linen part of the job. They come off at the end, once the dirty linens are in the hamper and the clean bed is made — never partway through, and never before you have finished handling anything soiled.

Bedsores — also called pressure sores or pressure injuries — are ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, and/or wearing a cast for a prolonged period. The most common place to find one is the buttocks area, but as you will see below they are by no means limited to it.

They can happen when a person is bedridden, unconscious, unable to sense pain, or immobile. A client who cannot feel pain will not shift away from the pressure, which is exactly why the sore forms.

Bedsores are a serious problem for seniors. Once one develops it is often very slow to heal — days, months, or even years, depending on the person’s condition and other diseases such as diabetes. Some need surgery to heal.

A bedsore develops when the blood supply to the skin is cut off. As the skin dies, the sore first appears as a red, painful area, which eventually turns purple. Left untreated the skin can break open and become infected. A bedsore can become deep and extend into the muscle and bone.

Two things about how fast this happens, and they surprise people:

• Damage can begin in as little as an hour. You do not have a comfortable margin.
• It starts deep under the skin, before you can see anything on the surface. By the time a red mark shows, damage has already been done underneath. This is why prevention beats inspection, and why “there was nothing there this morning” is not reassuring.

Wetness makes it far worse. Leaving a client in a wet incontinence product day after day will cause bedsores on its own — wet skin breaks down at a fraction of the pressure dry skin can take.

Bedsores often happen on the:

• Buttocks area (on the tailbone or hips)
• Heels of the feet
• Shoulder blades
• Back of the head
• Backs and sides of the knees

And anywhere a device presses. If your client wears oxygen through a nasal cannula, check behind the ears and on the bridge of the nose, where the tubing rests. The ear is the single most common site of pressure injuries caused by medical equipment — about one in five of them. CPAP straps and catheter tubing do the same thing. There is no part of the body where a pressure sore cannot happen.

Bedsores are divided into 4 stages, from least severe to most severe:

• Stage 1. The area looks red and feels warm to the touch. With darker skin the area may have a blue or purple tint. The person may complain that it burns, hurts, or itches.
• Stage 2. The area looks more damaged and may have an open sore, scrape, or blister. The person complains of significant pain and the skin around the wound may be discolored.
• Stage 3. The area has a crater-like appearance due to damage below the skin’s surface.
• Stage 4. The area is severely damaged and a large wound is present. Muscles, tendons, bones, and joints can be involved. Infection is a significant risk at this stage. Slightly red skin is a Stage 1 sign, not a Stage 4 one.

A wound is not assigned a stage when there is full-thickness tissue loss and the base of the ulcer is covered by slough or eschar. Slough may be tan, grey, green, brown, or yellow. Eschar is usually tan, brown or black.

A health care provider inspects the area that is red or an open wound, and stages it according to its appearance. This is not something a DCW does or decides. Your job is to look, report what you see, and describe it plainly.

Inspect the skin every day for areas of redness — the first sign of skin breakdown — with particular attention to bony areas. Every day, not weekly, and not only when something hurts.

Other methods of preventing bedsores, and preventing existing sores from getting worse:

Providing good nutrition — without enough calories, vitamins, minerals, fluids and protein, bedsores cannot heal no matter how well the sore itself is cared for.

Turning and repositioning a client in bed every 2 hours.

Sitting upright and straight in a wheelchair, and shifting their weight every 15 to 20 minutes — leaning forward, then to one side, then to the other. Sitting still is worse than lying still, because all the weight is on one small area.

Providing soft padding in wheelchairs and beds to reduce pressure.

Providing good skin care by keeping the skin clean and dry.

Encouraging an ambulatory client to get up and move around every eight hours.

Treatment is decided by the client’s healthcare provider and wound care team, with the client and family — not by a DCW. It may include removing pressure from the area, protecting the wound with medicated gauze or special dressings, keeping the wound clean, ensuring good nutrition, removing damaged or dead tissue (debridement), skin grafts, negative pressure wound therapy, and antibiotics for infection.

Bedsores are never treated by amputating the limb or body part. If you hear that, it is wrong.

Healthcare professionals will watch a bedsore closely and will document its size, depth, and response to treatment.

Your role is prevention, daily inspection, keeping the skin clean and dry, repositioning, and reporting what you see.

Because one-half to two-thirds of our body weight is water, we need 64 ounces, or eight 8-ounce glasses of water or other fluids a day. Water is the most essential nutrient for life. Without it, a person can only live a few days. Water assists in the digestion and absorption of food, helps with waste elimination, and through perspiration helps maintain normal body temperature.

The fluids we drink — water, juice, soda, coffee, tea, and milk — provide most of the water our bodies use. Some foods are also sources of water, including soup, celery, lettuce, apples, watermelon and peaches. Fats such as butter and olive oil contain no water at all.

⚠ Do not limit fluids because a client is incontinent. This is a common and harmful mistake. Never withhold or discourage fluids for that reason, unless the client’s doctor has given written instructions to do so for another medical reason. Restricting fluids causes dehydration, confusion, urinary infections and falls — and it usually makes the incontinence worse, not better. Follow a toileting schedule instead.

Prepare the meals set out in the client’s care plan. Diets are there for a reason — thickened liquids, low salt, diabetic, soft textures — and a well-meant substitution can be dangerous. If something in the plan is unclear, or the client asks for something different, ask the office. Do not decide on your own.

Difficulty swallowing is clinically known as dysphagia, and occurs when one’s esophagus does not function properly. When a person with dysphagia eats or drinks, they cannot swallow correctly. This swallowing disorder causes discomfort, coughing, choking and even aspiration of food particles and saliva into the lungs, which can lead to a serious, potentially life-threatening infection.

Causes include multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), Parkinson’s disease (PD), stroke, various forms of dementia, and head and neck injuries — including a head injury from a car accident, often made worse by a breathing tube during a hospital stay. Other conditions contribute too, such as gastroesophageal reflux disease (GERD) and growths in and around the esophagus.

Seasonal allergies do not cause dysphagia.

The signs are recognizable but often subtle. When they occur it is important to address them as soon as possible:

Aspiration pneumonia

Additional time and effort spent at meals

Food, liquid or saliva leaking out of the mouth at any time

“Cheeking” foods instead of swallowing them

Gurgling sounds or voice during and after meals

Frequent coughing, gagging or choking while eating

Weight loss — not weight gain

Dehydration

Chest congestion

In Alzheimer’s and dementia clients, some degree of difficulty swallowing will occur during the course of the disease, and it is a common indicator of disease progression. The cause is a loss of gag reflex and/or a decrease in level of consciousness, which requires increased care and supervision.

Dysphagia often presents in late-stage dementia clients who have difficulty communicating and may be nonverbal, so caregivers must watch carefully for any signs. Aspiration pneumonia — caused by dysphagia — is one of the most common immediate causes of death in Alzheimer’s clients.

If swallowing issues appear in the early or middle stages, a family member may misread the subtle signs and assume their loved one is acting out or does not like the food. What they do not think of is that the client has dysphagia. Perseverance and encouragement cannot solve it, and undiagnosed dysphagia puts the client at real risk.

The first thing to do is make a doctor’s appointment for the client, and see whether a referral to a speech-language pathologist is needed.

A swallowing study is performed by a Speech Language Pathologist (SLP). The SLP assesses the type and severity of the dysphagia and determines the next steps for minimizing choking and preventing aspiration.

The type of dysphagia diet prescribed depends on the cause and extent of the client’s swallowing difficulties. For some, a normal diet with softer foods and smaller bites is effective; others need foods pureed and liquids thickened to a certain consistency. This requires the expertise of an SLP — incorrect diet modifications can make eating and drinking more dangerous, not less.

Carefully plan and serve meals, snacks and beverages that conform to the SLP’s prescribed diet. Try thickening liquids with a commercial thickener (like Thick-It) or with pureed fruit such as apricots and prunes. Thickened liquids do not trickle down the throat as readily as thin ones and are less likely to cause coughing, choking and aspiration.

Serve foods with thicker gravies, sauces or other condiments to add moisture that assists with swallowing.

Make ample time for meals to allow adequate chewing and complete swallowing.

Remove distractions at mealtimes to allow full concentration on eating.

Use eye contact and encouragement with visual cues, such as opening and closing your own mouth when the person is supposed to sip or bite.

Be alert to cues that indicate distraction, choking or food retained in the mouth.

Ensure your client is sitting as upright as possible while eating, not slumped forward or reclining.

Schedule meals for times of day when your client is most alert and cooperative — never when they are most tired.

Try serving smaller, less intimidating portions. Some Alzheimer’s clients do better with finger foods.

Give as much autonomy and as much time as they need. Handfeeding one bite at a time is one of the best approaches for those with more advanced dysphagia.

Regardless of whether a client is feeding themselves or you are helping, mealtimes require lots of patience. Let your client make choices and honor them — do not be forceful. Let care and respect show on your face rather than irritation at their slowness.

Where dysphagia is temporary — after a stroke or prolonged intubation — an SLP can often maintain or restore safe eating and drinking. Where it is caused by a progressive disease like Parkinson’s or Alzheimer’s, the techniques eventually lose their effectiveness. As these conditions progress, clients with late-stage dementia “forget” how to swallow, lose weight and become increasingly frail.

Once dysphagia becomes so severe that swallowing is no longer possible, the disease may have progressed to the point of considering an evaluation for Hospice care. Weight loss and the inability to feed oneself and swallow are fundamental hospice criteria.

Feeding tubes are often presented as an option, but this treatment is invasive with limited success, which is why many people set out their preferences in written advance directives.

Alzheimer’s disease causes tangled nerve fibers and protein deposits to form in the brain, eventually causing dementia. The disease gets worse, causing greater and greater loss of health and abilities. There is no known cause and there is no cure. Clients with Alzheimer’s disease will never recover. They will need more care as the disease progresses.

Alzheimer’s disease generally begins with forgetfulness and confusion. It progresses to complete loss of all ability to care for oneself. Each person will show different symptoms at different times — one may be able to read but not use the phone or remember her own address; another may have lost the ability to read but can still do simple math. Skills a person has used constantly over a long lifetime are usually kept longest.

Encourage clients to perform Activities of Daily Living. Help them keep their minds and bodies as active as possible — working, socializing, reading, problem solving and exercising should all be encouraged. Look for tasks that are challenging but not frustrating, and help your clients succeed at them. Having them do as much as possible for themselves may even help slow the progression of the disease. Never hand a client a task they cannot possibly accomplish; failing at something in front of you is humiliating and it makes the next task harder.

Do not take their behavior personally.

Put yourself in their shoes.

Treat clients with dignity and respect, as you would want to be treated.

Work with the symptoms and behaviors you see.

Work as a team. Work with family members.

Encourage communication.

Take care of yourself.

Remember the goals of the care plan.

Always approach from the front. Do not startle the client.

Determine how close the client wants you to be.

Speak in a low, calm voice, in a room with little background noise and distraction.

Use the client’s name during the conversation.

Speak slower, using the same words and phrases as often as needed.

Repeat yourself, using the same words each time.

Use signs, pictures, gestures, or written words to help communicate.

Break complex tasks into smaller, simpler ones.

Use the same procedures for personal care and ADLs with clients who have Alzheimer’s as you would with any other client. The points below are the extra things to keep in mind, not a different way of working.

Reward positive and independent behavior with smiles, hugs, warm touches, and thanks.

Develop a routine and stick to it. Being consistent is very important for clients who are confused and easily upset.

Promote self-care and encourage independence in ADLs. This maintains self-esteem and helps them cope with a difficult disease.

Take good care of yourself, mentally and physically.

Encourage fluids. Never withhold or discourage fluids because a person is incontinent. Follow schedules for toileting instead.

Mark the bathroom with a sign as a reminder of where it is and to use the toilet.

Put lids on trash cans, waste baskets or other containers if the client has a habit of urinating in them.

Lay out clothes in the order in which they should be put on. Choose clothes that are simple to put on.

Schedule bathing when the client is least agitated. Be organized so the bath can be quick.

Be flexible about bathing. Your client may not always be in the mood. Be relaxed. Allow the client to enjoy the bath. Check the skin regularly when bathing for signs of irritation.

Ensure safety by using non-slip mats, tub seats and hand-holds.

Maintain proper nutrition. Schedule meals at the same time each day. Serve familiar foods. Try smaller, more frequent meals if the person is restless. Finger foods allow eating while moving around. Keep bite-sized snacks nearby, especially favorites.

Do not serve steaming or very hot foods or drinks. Use dishes without a pattern — white usually works best. Put only one item of food on the plate at a time.

Guide the client through meals with simple instructions. Offer regular drinks to avoid dehydration.

Assist with grooming. Help the people in your care feel attractive and dignified.

Prevent infections. Follow proper procedures for food preparation and storage, household management, and Standard Precautions.

Maintain a daily exercise routine.

Share in enjoyable activities — looking at pictures, talking and reminiscing.

Agitation. A client who is anxious, uneasy or nervous may display agitation, such as throwing food, yelling or restlessness. Try to eliminate triggers. Keep routine constant. Avoid frustration. Help the client focus on a soothing, familiar activity, such as sorting things or looking at pictures. Remain calm. Use a low, soothing voice. An arm around the shoulder, patting, or stroking may be soothing for some clients.

Sundowning. When a person becomes restless and agitated in the late afternoon, evening, or night, it is called sundowning. Remove triggers. Provide snacks or encourage rest. Avoid stressful situations during this time. Limit activities, appointments, trips and visits. Play soft music. Set a bedtime routine and keep it. Plan a calming activity just before the time it usually starts. Distract the client with a simple, calm activity such as looking at a magazine. Remove caffeine from the diet. Give a soothing back massage. Maintain a daily exercise routine.

Violent behavior. A client who attacks, hits or threatens someone is violent. Frustration, overstimulation, or a change in routine, environment or caregivers may trigger it. Appropriate responses:

• Block blows, but never hit back.
• Step out of reach.
• Do not leave the client in the home alone.
• Try to eliminate triggers.
• Use the same calming techniques as for agitation or sundowning.

Never yell at a client or tell them to calm down. Raising your voice at a frightened, confused person escalates every time — it has never once worked.

Pacing and wandering. A client who walks back and forth in the same area is pacing; one who walks aimlessly around the house or neighborhood is wandering. Causes include restlessness, hunger, disorientation, need for toileting, constipation, pain, forgetting how or where to sit down, too much daytime napping, or the need for exercise. Remove the causes where you can — give nutritious snacks, maintain a toileting schedule. Let clients pace and wander in a safe and secure (locked) area where you can watch them. Suggest another activity, such as going for a walk together.

Hallucinations or delusions. A client who sees, hears, smells, tastes or feels things that are not there is having hallucinations. A client who believes things that are not true is having delusions. Ignore harmless ones. Reassure the client that you are there to help, and redirect them to other activities or thoughts. Do not argue with a client who is imagining things, and do not tell the client that you can see or hear the hallucination too.

Depression. Report signs of depression to the client’s family and to your coordinator immediately. It is an illness that can be treated with medication. Encourage independence, self-care and activity. Talk about moods and feelings if the client wishes. Be a good listener. Encourage social interaction.

Perseveration or repetitive phrasing. A client who repeats a word, phrase, question or activity over and over is perseverating. Respond with patience. Do not try to silence or stop the client. Answer the question each time it is asked, using the same words each time — even if it is the tenth time in an hour.

Disruptiveness. Disruptive behavior is anything that disturbs others, such as yelling, banging on furniture, slamming doors and so on. It is often triggered by a wish for attention, by pain or constipation, or by frustration. Gain the client’s attention. Be calm and friendly. Try to find out why it is happening. Notice and praise improvements, tactfully — do not treat the client like a child. Tell the client about changes in schedules, routines or environment in advance. Involve them in developing routines. Encourage safe independent activities such as folding towels, which prevents feelings of powerlessness. Help the client find ways to cope, and focus on positive activities he or she may still be able to do, such as knitting, crocheting or crafts.

Inappropriate social behavior. This may be cursing, name calling or other behavior. Try not to take it personally — the client may be reacting to frustration or stress, not to you. Stay calm. Be reassuring. Try to find out what caused it: too much noise, too many people, stress, pain or discomfort. Respond positively to any appropriate behavior. It is important to report any physical abuse or serious verbal abuse to the client’s family and to your coordinator.

Inappropriate sexual behavior. Removing clothes, touching one’s genitals, or trying to touch others can embarrass those who see it. Be matter-of-fact. Do not overreact — this may reinforce the behavior. Never yell at the client to stop. Be sensitive to the nature of the problem. Try to distract the client. A client may be reacting to a need for physical stimulation or affection — consider backrubs, a soft doll or stuffed animal to cuddle, comforting blankets, or pieces of cloth.

Reality Orientation — the use of calendars, clocks, signs and lists to help clients remember who and where they are. Useful in the early stages when clients are confused but not totally disoriented. In later stages it may only frustrate them.

Validation Therapy — letting clients believe they live in the past or in imaginary circumstances. Validating means giving value to or approving. Make no attempt to reorient the client to actual circumstances. Explore their beliefs. Do not argue. Useful in moderate to severe disorientation.

Reminiscence Therapy — encouraging clients to remember and talk about the past. Explore memories by asking about details. Focus on a time of life that was more pleasant, and work through feelings about a difficult time in the past. Useful in many stages, especially with moderate to severe confusion.

Activity Therapy — using activities the client enjoys to prevent boredom and frustration and promote self-esteem. This works best when the activity connects to who they have always been: looking at a book of birds with a client who belonged to a bird watching club, taking walks, doing puzzles, listening to music, cooking or reading. Useful throughout most stages of Alzheimer’s disease.

Report these to Silver Lining even when they seem minor: new confusion, loss of appetite, swelling, or any change in the skin. Also new pain, a change in breathing, a change in how much they are drinking, and a change in mood or behavior.

Small changes are how serious things announce themselves. A client whose ankles look more swollen than last week should be reported to your coordinator the same day.

When you report, say what you see. “Her left ankle is puffy and the sock left a deep mark, she says her shoe felt tight this morning” is useful. “I think she is in heart failure” is not — it is a guess, and it may send everyone in the wrong direction.

The same rule applies to anything you write down: plain facts, with the date and time, and no conclusions.

A TIA is a temporary blockage of blood flow to the brain. It is often called a mini-stroke, but it is really a major warning.

TIAs are caused by a clot or blockage in the brain, but the blockage is short term — the clot usually dissolves on its own or gets dislodged, and the symptoms usually last less than five minutes. Because most TIA symptoms last only a few minutes up to 24 hours, they are often dismissed and not taken seriously. This is a big mistake. TIAs may signal a full-blown stroke ahead. “Warning stroke” is a better label than “mini-stroke.”

Common warning signals, all of sudden onset:

• Weakness, numbness or paralysis on one side of the body
• Slurred speech or difficulty understanding others
• Blindness in one or both eyes
• Dizziness
• Severe headache with no apparent cause

Hiccups are not a warning sign of a TIA.

Risk factors are smoking, cardiovascular disease, diabetes, and blood clots called embolisms, and the risk increases with age. If a person has previously had a stroke, pay careful attention. Dysphagia is not a risk factor for TIA.

What to do: get medical help immediately. Trained medical staff need to evaluate the client — some signs are only visible with hospital equipment. When a TIA occurs in a young person with no clear risk factors, they may be sent to a neurologist for testing to rule out vasculitis, carotid artery dissection and other kinds of injury or infection. See Module 6 for what to do in the moment.

The statistics, and get these right:

• Approximately 15% of all strokes are foretold by a TIA.
• Among patients treated for a blockage-related (ischemic) stroke, between 7 and 40% report experiencing a TIA first.
• About one third of people who have a TIA go on to have a more severe stroke within one year.

That last figure is one third within a year — not everyone, and not within a month. The risk is highest in the first 48 hours, which is why it is an emergency, but a TIA is not a guarantee of a stroke to come.

Parkinson’s disease is one of the most common disabling diseases. It is a slowly progressive, chronic, degenerative condition. Those with PD will not have the same experience — it is truly unique to each individual. It is not possible to predict which symptoms will affect any one person, and there is currently no cure.

Common symptoms include shaking and tremors — especially of the hand at rest — muscle stiffness, joint pain, small handwriting, loss of smell, change in voice, trouble sleeping including kicking or punching movements while asleep, masked face, excessive sweating, dysphagia, constipation, anxiety, depression, and dementia with confusion and memory problems.

Masked face means the client’s face looks serious regardless of what they are feeling. This matters day to day: a client with a masked face may be delighted, or in pain, and their expression will not show it. Do not read their mood from their face — ask them.

Speech changes as the disease progresses. The client’s voice often becomes soft, they may hesitate before speaking, and speech is often monotone. Rigid muscles are common and can occur in any part of the body.

Bradykinesia — slowness of movement — is the symptom that must be present for a doctor to diagnose Parkinson’s disease. Tremor is the symptom people associate with PD, but slowness of movement is the required one.

How PD is diagnosed. There is currently no blood test for PD. Diagnosis is made by ruling out other diseases — which is why many clients see several doctors before they get an answer.

Treatment is individualized and aimed at current symptoms. Several medications may need to be tried before symptoms improve. It is important to remind your clients to take their medication as ordered — timing matters a great deal in PD.

Caring for a client with PD. As the disease progresses clients will often need all of the following: a movement therapist, physical and occupational therapy, and a speech therapist for swallowing difficulties. Following the therapists’ instructions helps the client keep some independence.

Clients often get stuck when walking. Be sure your client has their cane or walker and that their path is clear. Because PD can cause swallowing problems it is very important that the caregiver is present during mealtimes, and eating a nutritious diet is very important. Encouraging your client to stay active helps their physical and mental health.

Patient organizations exist to help clients, families and caregivers: the American Parkinson Disease Association and the Michael J. Fox Foundation for PD.