Looking at Brain Change in a Positive Light Teepa Snow’s GEMS Looking at Brain Change in a Positive Light Shelly Edwards Business Development Coordinator shellye@teepasnow.com NDACP

Workshop Objectives Discuss the value & importance of seeing people living with dementia as having retained abilities, value, & benefiting from the right support & care to optimize performance & quality of life. Identify 6 GEMS – highlighting GEM characteristics. Compare & contrast 6 states of cognitive function & ability as GEMS

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 Watch Care Skills video: AELC each GEM after watching Teepa PRACTICE

The GEMS… Sapphires: True Blue – Healthy Brain Diamonds: Routines & Routines Rule - Clear/Sharp 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 Role Play Diamond / Amber

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

Sapphire True Blue Optimal Cognition: flexible in capacity Normal aging will slow, yet not change ability More time to process with stress True to self: likes/dislikes are the same Able to learn: takes more practice Stress, fatigue or pain can induce Diamond moments Time to recharge or heal can restore to Sapphire

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

Diamond Clear and Sharp Routines and Rituals Rule: likes familiar May resist change or won’t let things go Rigid under pressure: limited perspective Becoming protective: may be territorial or isolate Repeats self: hard to integrate new information Can cover mistakes in social interaction Symptoms may or may not be dementia related

Emeralds Green and On the Go with a Purpose Naturally Flawed

Emerald Green and On the Go with a Purpose Naturally Flawed Desires independence: noticeable ability change Vocabulary and comprehension diminishing Communication becoming vague May neglect personal care routines On the go: needs guidance and structure Difficulty finding way to and from places May be lost in time

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

Amber Caught in a Moment of Time Caution Required Focused on sensation Will react to how things: look, sound, feel, smell or taste Lives in the moment: not socially aware No safety awareness: typically very busy Difficulty understanding and expressing needs No ability to delay needs or wants Needs help with tasks: may resist Hard to connect with: may exhaust care partners

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

Rubies Deep and Strong Others stop seeing what is possible Retains rhythm: can sing, hum, pray, sway and dance Understands expressions and tone of voice Losing ability to understand language Limited skill in mouth, eyes, fingers, and feet Can mimic big movements: gross motor abilities Loss of depth perception; monocular vision Falls prevalent: can only move forward Care Partners will have to anticipate unmet needs

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

Pearls Hidden Within a Shell Person is still there Moments of connection take time and will be short Knows familiar: unmet needs may cause distress Unable to move by themselves: fetal position, still and quiet Primitive reflexes have taken over: difficulty swallowing Brain failure shuts down body: diminishes need too eat or drink Care Partners need to give permission to let go

Connection & Communication Positive Personal Connections Positive Action Starters

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

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

Give SIMPLE INFO And then WAIT!!!! Visual matched WITH verbal It’s about time for… tap your watch/wrist Let’s go this way. Point Here’s your socks. Hold up their sock Coffee or tea? Raise coffee carafe then tea bag DON’T ask questions you DON’T want to hear the answer to… Acknowledge their response/reaction LIMIT words – Keep it SIMPLE And then WAIT!!!!

What makes situations happen? SIX pieces… The person & who they have been Personality, preferences & history Other conditions & sensory status & meds/fluids/fuels The type & level of cognitive impairment(s) … NOW People - How the helper helps & others Approach, behaviors, words, actions, & reactions The environment – setting, sound, sights – 4 F’s The whole day… how things fit together – finding balance

What Makes ‘Behaviors’ Happen? Medical Condition and Sensory Status (fuel, fluids, meds) Dementia -Type(s) -Stage -Retained abilities -Lost abilities Person: -personality -preferences -history, then & now 6 pieces to the puzzle 3 pieces belong to them (non-modifiable) 3 pieces belong to us (modifiable) Surface Space Sensations Social People/Helpers -approach -behaviors -words -actions -reactions Time: Structure of the Day -Balance; wait -Rest -Self-care, wellness -Leisure/fun -Productive/work Environment -Friendly -Familiar -Functional -Forgiving -Surface -Social -Sensations -Space

The Person and Who They’ve Been Personality traits Introvert or Extrovert Detail or Big Picture Logical/thinking or Emotional Planner (controlling) or In the Moment Preferences…MATTER We like what we like, we want what we like Likes can change Appearance, routine, foods, music Personal history 1st piece

Medical Condition & Sensory Status* Fuel and fluids Other medical & psychiatric conditions Sensory status – vision, hearing, sense of touch, balance, smell, taste Medications and treatments 3rd piece *may have ability to modify or attenuate some of these

Dementia (The 3 D’s) 2nd piece Delirium: dangerous and deadly Possible PAIN, infections, med changes/side effects, physiological changes (dehydration, blood chemistry, O2 saturation) Depression: treatable Most elders with depression describe themselves as having memory problems or somatic complaints Look for changes in appetite, sleep, self-care (sudden), pleasures, irritability, ‘I can’t take this’ Dementia Type(s) Stage Retained abilities Lost abilities With Delirium – rapid onset and fluctuating: Changes in memory & thinking Changes in understanding & speaking Changes in impulsivity & initiation Changes in judgment & processing Changes in personality & preferences Loss of independence & changes in self care abilities Changes in self-awareness & tolerance for change With Depression: Reduced effort in initiation, concentration, and focus Gradual loss in ability to think and remember details Less interest in surroundings, events, and people Increasing sense of inability and worthlessness or senselessness Increased sadness or distress – anger/frustration/agitation Greater isolation or loss of connections Increased complaints of discomfort, pain, dissatisfaction with life With Dementia: -Explore possible types and causes -Explore what care staff and family members know and believe about dementia and the person -Determine stage or level compared with support available and what we are providing -Seek consult and further assessment, if doc doesn’t match what you find out 2nd piece

Environment 4 F’s: Friendly, Familiar, Functional, Forgiving What helps? What hurts? Physical (sensory experience) People or how to engage socially Programming: to support what they like and need 4 S’s: Surface, Social, Sensations, Space Surface: Sit-stand-lie down-work Social: People-activities-role-expectations Sensations: See-hear-feel-smell-taste Space: Intimate-personal-public 4th Piece

US! People & Caregivers People around Our history 5th piece People around Our history Awareness, knowledge, & skills Competence?? Relationship PPA™, HuH™ Positive Action Starters Our agenda

US! People & Caregivers Should NOT: Argue Make up stuff not true Ignore behavior problems Try a possible solution only once Give up Let them do whatever they want Force them to do what you want Remember who has healthy brain We have to control us; we can change They’re doing the best they can! 5th piece

Structure of the Day Time Awareness: Where in life Time of Day Balance of Meaningful Activities Productive: give value and purpose Leisure: have fun, interact Self-care, wellness: personal care, body & brain Restorative: re-energize and restore spirit 6th piece Daily routines and programming Second piece we can control Filling the day with valued engagement Gem level programming Types of Meaningful Activities Productive: give value and purpose Leisure: have fun, interact Self-care, wellness: personal care, body and brain Restorative: re-energize and restore spirit

Progression of the Condition To the tune of This Old Man The LIVING GEMS®

SAPPHIRE true, you and me The choice is ours, and we are free To change our habits, to read, and think and do We’re flexible, we think it through!

DIAMOND bright, share with me Right before, where I can be I need routine and different things to do Don’t forget, I get to choose!

EMERALD – go, I like to do I make mistakes, but I am through EMERALD – go, I like to do I make mistakes, but I am through! Show me only one step at a time Break it down and I’ll be fine!

AMBER – HEY!, I touch and feel I work my fingers - rarely still I can do things, if I copy you What I need is what I do!

RUBY – skill – it just won’t go Changing something must go slow Use your body to show me what you need Guide, don’t force me. Don’t use speed!

Now a PEARL, I’m near the end But I still feel things through my skin Keep your handling always firm and slow Use your voice to calm my soul.

6 Pieces of the Puzzle Medical/ Dementia Person: Sensory People/Helpers Time Environment

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