PAC Certification Pre Skills Class It’s All In Your Approach! Get started –GREET --THANK This session this morning PAC – Positive Approach to Care Level 1. Kendal has taken on this Positive Approach to care training to help identify ways we can help people living with dementia live enjoyable, meaningful lives. So this session is called “It’s all in your Approach!” Because, as we’ll talk about today, it is all in how we approach those living with dementia that sets us and them up for success. My background How I came to this PAC Today, we’ll talk about what we can do as caregivers, to trying to help people living with dementia live lives that make sense, and how we can make our lives as caregivers more effective and helpful. Rather than getting ourselves into trouble. A lot of times, all too easy to think it’s all them and their “behaviors” and what we don’t realize is that we start a lot of what ends up being a problem for folks.

Agenda: 9:30 Introductions and PAC Principles 10:00 Relationship vs. Agenda 10:15 Break 10:30 Brain Failure 11:00 Thinking vs. Primitive Brain and Cues 12:00 Lunch Break 1:00 Behavior vs. Expressive Communication 1:30 Three Zones of Human Awareness 2:00 Positive Physical Approach™ (PPA™) 2:30 Special Situations and Emotions with PPA™ 2:45 Break 3:30 Hand-under-Hand™ (HuH™) 4:00 GEMS™ Introduction 4:30 Wrap up

Introduction: Beliefs The relationship is MOST critical NOT the outcome of one encounter We are a KEY to make life WORTH living People living with Dementia are Doing the BEST they can We must be willing to CHANGE ourselves DRAW: Element, Animal, Symbol of your leisure/something that defines you PAIR UP IDareas of overlap INTRO the other person via your area of overlap The agenda for us IS QoL – not just “Clean” and “Not Falling” As coaches, we know OUR agenda will be met when we establish a relationship. That’s the selfish way of putting it. But it’s ok--We need to see it from the staff point of view, and sometimes help meet our staff’s needs: “Clean” and “Not Falling” That’s Their agenda. The relationship: no no no no. You know you can’t walk –Rather, try: Hey! Joan! Take her hand. Looks like you’re headed somewhere. We are a KEY: Who’s the only people they see? We’re it many times. Doing the BEST they can: Write this Dementia = Brain Failure We must be willing to CHANGE ourselves: Confabulation: I can sit there, pee in that chair and get up—”You see that one right there? She goes around and pees in seats. See, I’m all wet!” Where the brain makes up information b/c I would never pee in the seat!

Believe: It Takes TWO to Tango … or Tangle Learn to DANCE with our partner We must be willing to STOP & BACK OFF Being ‘right’ doesn’t necessarily translate into a good outcome Program based on some core beliefs. A tango is working together All too often we tangle with folks living with dementia The reason that happens is that we as caregivers don’t get it FIND A PARTNER Decide who has dementia. – you decided NO to whatever your caregiver wants to do. Caregivers: you know you’re right! Sitting there – wet. Take a look at your hand. It’s a caring hand. But you have things to do. They’re wet. You know they’ve been sitting there for two hours, and you know they’re wet! People with dementia, do you like this? No! Put your hand up. Push back Lemme ask you – where are you going? Nowhere. Caregivers, I’m going to ask you to ease off just a little – don’t go away! Just ease off. Go this way, go this way. Now what’s happening?

The person’s brain is dying Brain Failure What is happening? The Brain is doing its best to support life. Normal aging-brain doesn’t fail The person’s brain is dying

Normal Brain Brain with Alzheimers

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? 3 ways to adjust for someone living with dementia. Right Left

Positron Emission Tomography (PET) Alzheimers Disease Progression vs Positron Emission Tomography (PET) Alzheimers Disease Progression vs. Normal Brains Early Alzheimers Late Alzheimers Normal Child G. Small, UCLA School of Medicine.

Positron Emission Tomography (PET) Alzheimers Disease Progression vs Positron Emission Tomography (PET) Alzheimers Disease Progression vs. Normal Brains Early Alzheimers Late Alzheimers Normal Child Primitive Brain Primitive Brain G. Small, UCLA School of Medicine.

Primitive Brain is in Charge of: Survival – Autonomic protective – fright, flight, fight Pleasure seeking – needing joy Thriving – Running the Engine Vital systems Wake-sleep Hunger-thirst Pain awareness and responses Infection recognition & control Learning New and Remembering it Information Places Awareness Time Awareness

Hippocampus BIG CHANGE Learning & Memory Center Way finding Time Awareness Learning & Memory Way finding, working memory, episodic memory-dementia cuts the timeline Amygdala –limbic system structure I want what I want when I want it Fight, fright, flight Impulses, fear, pleasure: sex, sweet, salty, fat

Understanding Language – BIG CHANGE 21 seconds Unless someone like (you) cares a whole awful (lot), nothing is going to get (better) its not. Understanding Language – BIG CHANGE

Hearing Sound – Not Changed “Yelling” Tone, pitch, volume, intensity Hearing Sound – Not Changed

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

Vision Center – BIG CHANGES

Vision Changes With each new level of vision change, there is a decrease in safety awareness. 1. Loss of Peripheral Vision 2. Tunnel Vision 3. Binocular Vision Object Confusion (discriminating senses) Monocular Vision 6. Loss of Vision

INPUT – Data In: What you see What you hear What you feel/ touch What you smell What you taste Have you ever done or seen: person living with dementia being startled, being touched without understanding what is going on, talking too much to someone living with dementia, person living with dementia resisting an approach or care? examples

How Can We GIVE Information? Visual Cues - Show Verbal Cues - Tell Tactile Cues - Touch

Visual Verbal Touch: How you help… connect Sight or Visual cues Verbal or Auditory cues Touch or Tactile cues

Visual Cues Signs Pictures Props – Objects Gestures Facial expressions Demonstrations

Verbal Cues Keep it simple Directed Matched to visual cues BREAK OUT SESSION

Touching Cues Place an item or tool in hand Touch with a finger or hand Hand guidance Hand on shoulder or back Hand-under-HandTM contact Hug BREAK OUT SESSION

5 Physical and 5 Emotional Unmet NEEDS: 5 Physical and 5 Emotional Move furniture: “What am I telling you?”

5 Unmet Physical Needs: Hungry/Thirsty Too much/too little energy Elimination Discomfort – to be explored: sensations, spaces, social situations, surfaces Pain

5 Unmet Emotional Needs: Angry Sad Lonely Scared Bored

BREAKOUT SESSION Practice Giving Cues Try to guess the agenda: Eat/drink Movement/walking Undressing/dressing/changing Clean-up shirt/hair Come to…(dinner, trip, garden, etc…) Time for…(dinner, trip, visit, etc..) Do an activity BREAK OUT SESSION

To REST To RESTORE To REVIVE BREAK! To REST To RESTORE To REVIVE

BREAKOUT SESSION Practice Giving Cues Try to find out if the person is: Hungry/Thirsty Tired Lonely Bored Too hot or cold Hurting – (fell last night on her left elbow) BREAK OUT SESSION

3 Zones of Human Awareness Public Space – 6 ft away or more Visual Interactions & Awareness Personal Space – 6 ft to arm’s length Conversations & Friendship Intimate Space – within arm’s reach Intense Physical Closeness Stand in each space: what do we do in each space? Stand in front, to side, (over) person. Dominant side how does this feel differently?

Use the Positive Physical Approach™ To Connect

Positive Physical Approach™ 1. Stop moving 6 ft out 2. Greet: “hi” sign (open by face), say name 3. Moves 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 * = if in public space and you start the interaction Slow is 1 step per second

3 Zones of Human Awareness Public Space – 6 ft away or more Visual Interactions & Awareness Personal Space – 6 ft to arm’s length Conversations & Friendship Intimate Space – within arm’s reach Intense Physical Closeness Stand in each space: what do we do in each space? Stand in front, to side, (over) person. Dominant side how does this feel differently?

Step 1: Stop moving 6 ft out Pause at the Edge of Public Space Stop moving - 6 ft Let the person NOTICE you in public space ( give them time to do this) Acknowledge the person’s OWNERSHIP of personal space Respect their space!

Step 2: Greet-Give ‘hi’ sign Bring flat, open palm up near face Visual cue to look at you Say “HI!” and use preferred name, if known Verbal cue to look at you Look Friendly Smile Make eye contact

Step 3: Say name, offer hand Seek permission to enter PERSONAL SPACE SHOW person what you want to do Watch for their reaction/response If there’s hesitation STAY in PUBLIC space Turn your body SIDEWAYS – supportive stance See what happens next – no better? hold back

Step 4: Move slow Move Slowly toward the person While offering your hand in greeting Smile and look friendly 1 second = 1 step Respect SLOWED processing time Decreased ability to do two things at one time

Step 5: Move into SUPPORTIVE stance Shift toward dominant side – hand shake side Turn your TRUNK sideways to the person Stay at ARM’S length Keep face & chest back

Hand-under-Hand™ When ca we use HUH?

Step 6: Hand-under-Hand™ Go into Hand-under-Hand™ from a normal handshake Provides protection for them AND you Connects you with them while giving them a sense of control

Step 7: Move to side, get low Get to their level SIT, kneel, or squat Respect INTIMATE space Allow eye contact with limited visual field Get focus on your face not your chest or middle

If You Can’t Get LOW… Stay greater than arm’s length away Use Verbal Connections If it’s not working, get a seat

Step 8: Make connection Make friendly statement Wait for a response or acknowledgement Be sure you have a connection before you start your care

Step 9: Deliver a Message Give visual cues first Offer verbal information next Use touching last AND only if the person is aware of your plan

BREAKOUT SESSION PPA Special Situations: Think it thru… What Should YOU Do The person is standing up You enter their room The person starts the interaction The person is blind The person is deaf or hard of hearing The person is at a table The person is in a corner or facing a door The person is asleep The person doesn’t offer their hand back The person tells you to stay out

Positive Physical Approach To the tune of Amazing Grace Come to the front, Get low Get to the side, Get low Offer your hand, Call out their name Then wait….. If you will try, then you will see How different life can be For those you’re car-ing for.

To REST To RESTORE To REVIVE BREAK! To REST To RESTORE To REVIVE

Hand-under-Hand™ When ca we use HUH?

Hand-under-Hand™ Assistance Helps assist doing WITH not for Protects them and us! Helps direct gaze – eye-hand coordination Pressure in the palm is calming Helps assist doing WITH not for Protects: Keeps you from hurting their wrist, arm, or fingers Keeps the person from squeezing your knuckles Keeps the person from swinging or hitting Helps direct gaze – eye-hand coordination Pressure in the palm is calming

Hand-under-Hand™: protects aging, thin, fragile, forearm skin

High Risk

Try with Hand-under-Hand™: To get the person to stand To get the person to walk To get the person to drink To get the person to sit down

Try with Hand-under-Hand™: To comfort To visually direct – look at To get started - initiate To help with detail - assist To move or change direction

This Little Light of Mine) I Will Change! (to the tune of This Little Light of Mine) By Teepa Snow

I am gonna meet and greet Before I start to treat I am gonna meet and greet Before I check your feet I am gonna meet and greet Before I help you eat How I start sets us up to succeed!

No more just “Getting’ it Done” I’m gonna DO with you No more just “Getting’ it Done” I’m gonna help you thru No more just “Getting’ it Done” We’re gonna work, we two Cause if I do it ALL, we BOTH LOSE!

I’m gonna laugh and dance with you Not just watch and frown I’m gonna laugh and dance with you Not just stand around I’m gonna laugh and dance with you We’ll really go to town For the POWER of JOY I have found!

Gem Dementia Abilities Based on Allen Cognitive Levels A Cognitive Disability Theory – OT based Creates a common language and approach to providing: Environmental support Caregiver support and cueing strategies Expectations for retained ability and lost skill Promotes graded task modification Each Gem state requires a special ‘setting’ and ‘just right’ care Visual, verbal, touch communication cues Each can shine Encourages in the moment assessment of ability and need Accounts for chemistry as well as structure change Teepa Snow, Positive Approach, LLC - to be re-used only with permission

The GEMS… Sapphires True Blue – Healthy Brain Diamonds Clear/Sharp – Routines & Routines Rule Emeralds Green/On the Go with Purpose– Naturally Flawed Ambers Caught In a moment of time – Caution Required Rubies Deep & Strong – Others stop seeing what is possible Pearls Hidden in a Shell – Beautiful Moments to Behold

True Blue Optimal Cognition, Healthy Brain Sapphires True Blue Optimal Cognition, Healthy Brain

Clear and Sharp Routines and Rituals Rule Diamonds Clear and Sharp Routines and Rituals Rule

Emeralds Green and On the Go with a Purpose Naturally Flawed

Caught in a Moment of Time Caution Required Ambers Caught in a Moment of Time Caution Required

Deep and Strong Others Stop Seeing What Is Possible Rubies Deep and Strong Others Stop Seeing What Is Possible

Hidden Within a Shell Beautiful Moments to Behold Pearls Hidden Within a Shell Beautiful Moments to Behold

Choose one of each to try… Putting it all together GEMS™ State Task/agenda Unmet need/situation Adapt PPA™ and HuH™ BREAK OUT PRACTICE How can we use what we know ? Three ways to adapt

What Have You Learned About Your Own… What Specific Awareness? What Specific Knowledge? What Specific Skill?

What Are You Going to Do About It? What Specific Awareness Do You WANT TO WORK ON? What Specific Knowledge Do You WANT TO WORK ON? What Specific Skill Do You WANT TO WORK ON? Give it FIVE minutes a day!