It’s All in Your Approach: Supporting Persons Living With Dementia Beth A. D. Nolan, Ph.D. Director of Certifications and Research bethn@teepasnow.com NDACP

Speaker Disclosures Beth Nolan is the Director of Certifications and Research for Positive Approach® LLC

Objectives: Understanding the changes in the brain with dementia: Impact of the amygdala on us, and those living with dementia, on family, on staff Demonstrate care partnering skills of Visual-Verbal-Touch, and the Positive Physical Approach™ Describe the use of Hand-under-Hand™ to guide and assist

It Takes TWO to Tango … or Tangle… The relationship is MOST critical NOT the outcome of one encounter Being ‘right’ doesn’t necessarily translate into a good outcome

I'm sorry I made you angry INTELLECTUAL CAPACITY Five Ways to Say, INTENT I'm sorry I was trying to help EMOTION I'm sorry I made you angry INTELLECTUAL CAPACITY I'm sorry, I had not right to make you feel that way THAT HAPPENED I'm sorry, it should NOT have happened THIS IS HARD I'm sorry, this is hard, I hate it for you “I Am Sorry!”

Changing Attitudes through Building Awareness, Knowledge and Skill What is Dementia? Changing Attitudes through Building Awareness, Knowledge and Skill

Brain with Alzheimers Normal Brain used with permission from The Broken Brain: Alzheimers, 1999 University of Alabama

The person’s brain is dying Brain Failure The person’s brain is dying © Teepa Snow, Positive Approach, LLC – to be reused only with permission.

DEMENTIA Alzheimer’s Disease Lewy Body Dementia Vascular Dementias (Multi-infarct) Lewy Body Dementia Diffuse LBD Parkinsonian type dementia Other Dementias Genetic syndromes Metabolic pxs ETOH related Drugs/toxin exposure White matter diseases Mass effects Depression(?) or Other Mental conditions Infections – BBB cross Alzheimer’s Disease Young Onset Late Life Onset Fronto- Temporal Lobe Dementias

Four Truths About Dementia At least 2 parts of the brain are dying often the hippocampus(memory) is damaged early It is chronic can’t be fixed It is progressive it gets worse It is terminal eventually

Positron Emission Tomography (PET) Alzheimer’s Disease Progression vs Positron Emission Tomography (PET) Alzheimer’s Disease Progression vs. Normal Brains Normal Aging Early Alzheimer’s Late Alzheimer’s 18 month old child G. Small, UCLA School of Medicine G. Small, UCLA School of Medicine

Executive Control Center Impulse Control Be Logical Make Choices Start-Sequence-Complete-Move On Self Awareness See Others’ Point of View Right Left How could these brain changes impact daily life? Right Left

Hearing Sound – Unchanged So, what is the problem? Are they understanding the words and their meaning? BIG Language CHANGE Hearing Sound – Unchanged

Amygdala Left Right DANGEROUS Aroused/ Risky Alert/ Aware NEED Want Like Use left and right thumbs – this slide coincides with the trainer standing facing the learners. Like: I like what I like when I like it…when I get what I like “AHHH” Alert and Aware: we are all alert and aware Want: if I don’t get what I like – it feels Risky Need: If I don’t get what I want – it feels DANGEROUS and I have an UNMET NEED

Primitive Brain is in Charge of: Survival – Autonomic protective – fright, flight, fight + hide or seek Pleasure seeking – meeting survival needs & finding joy Thriving – Running the Engine Maintain vital systems (BP, BS, O2sat, Temp, pain) Breathe, suck, swallow, digest, void, defecate Circadian rhythm Infection control Learning New and Remembering: Information Places (spatial orientation) Passage of Time (temporal orientation) Thrive to survive declines but the DESIRE to survive stays

Vision Changes BIG VISION CHANGES Loss of Peripheral Awareness With each new level of vision change, there is a decrease in safety awareness. Loss of Peripheral Awareness 2. Tunnel Vision 3. Binocular Vision Binocular + Object Confusion (discriminating senses) Monocular Vision 6. Loss of Visual Regard Vision changes BIG VISION CHANGES © Teepa Snow, Positive Approach, LLC – to be reused only with permission.

Hippocampus BIG CHANGE Learning & Memory Center Navigation (Way finding) Learning & memory Spatial orientation SHOVE Episodic memory-dementia cuts the timeline. Way-finding, dementia washes away the roads. Time: of day, time of life, passage of time Amygdala –limbic system structure I want what I want when I want it Fight, fright, flight Impulses, fear, pleasure: sex, sweet, salty, fat

3 Zones Of Human Awareness and How We take in Data So what can cause these sitations? Changing Attitudes through Building Awareness, Knowledge and Skill

3 Zones of Human Awareness 3 Ways to We take in Data Public Space  6 ft or more away -for awareness 1. Visual What we see 2. Personal Space  6 ft to arm’s length -for conversations 2. Verbal What we hear 3. Intimate Space  Arm’s length or closer -for intense closeness 3. Touch What we touch & feel Activity: OATMEAL Standing over ,Standing in front, Standing on non dominant side, standing on dominant side AELC

Positive Physical Approach™ Stop moving 6 ft out 2. Greet: Hi sign (open by face), say name 3. Move hand into a handshake position 4. SLOWLY come in from the front -within visual range (or starts there) 5. Move into Supportive Stance 6. Hand shake–move into ‘Hand-under-Hand®’ 7. Move to side; Get low –sits or kneels 8. Make connection (wait for their response!) 9. Deliver a message – using V-V-T cues PRACTICE SESSION 1: Use groups of 3, person being approached gives 1 emotion that they felt with the approach, person approaching gives 2 things they did well and one thing they would like to work on, person observing gives 2 steps that they identified and 1 they have question about. Learners use PPA Cheat Sheets to identify steps PRACTICE SESSION 2: Groups of 3, the observer video tapes PPA and person reviews identifies 2 positive steps and 1 goal to work on, repeat 2x

Positive Physical Approach™ Stop moving 6 ft out 3. Move into a handshake 4. SLOWLY come in from front 5. Supportive Stance 6. Move into HuH® 8. Make connection (wait!)

If you can’t get low, find a chair If you can’t get back up, don’t go down. Set your stage first. Get a chair.

Hand-under-Hand™ To guide and assist HUH™

Hand-under-Hand™ Assistance Helps assist doing WITH, not for Helps protect their: fingers, wrist, arm Helps protect us: Gives you cues before a PLWD wants to strike out Gives them something to squeeze/grab onto Helps direct gaze – eye-hand coordination Pressure in the palm is calming

Hand-under-Hand™ Assistance Protects aging, thin, fragile, forearm skin

High Risk

White Matter Connections Formal Speech & Language Sensory Strip Motor Strip White Matter Connections BIG CHANGES Automatic Speech Rhythm – Music Expletives PRESERVED Right Left Formal Speech & Language Center HUGE CHANGES Right Left

Connection & Communication Positive Personal Connections Positive Action Starters

Positive Personal Connections (PPC) Greet or Meet introduce yourself and use their preferred name “Hi ___, I am ___.” or, “I am ___ and you are?” Say something NICE Indicate something about them of value Be friendly Share about you then leave a blank “I’m from Michigan, and you’re from?” Notice something Point out something in the environment Be curious Explore a possible unmet like, want or need

Positive Action Starters (PAS) Help – Be sure to compliment their skill in this area, then ask for help. “I could use your help…” Try – Hold up or point to the item you would like to use, possibly sharing in the dislike of the item or task, “Well, let’s try this.” Choice – Try using visual cues to offer two possibilities or one choice with something else as the other option. “Coffee or Tea?” “This? Or something else?” Short and Simple – Give only the first piece of information, “It’s about time to …” Step by Step – Only give a small part of the task at first, “Lean forward….”

Who has the bigger brain? YOU have the POWER to choose Thank you