With guest Susan Wehry, M.D., Commissioner VT Department of Disabilities, Aging and Independent Living

For being here For all you do For participating

+ ACTIVATE Inspire Transform

 Discuss the (new) dementia care  Use new tools  State readiness to facilitate learning  Bust barriers/Build buzz

 Adult learners  Set aside AND draw from experience  Re-think outcomes

 Activate Learning  The New Culture: why now?  Tools of the trade  OASIS  Hand in Hand  Let’s Get Practical

 Recap  Nothing Succeeds Like Success  HSAG Tool Kit: Balancing Dementia Care  DSD of the Year!  Bust the Barriers  Putting it All Together

Identify your goal

 Knowledge and Experience  Personal history and concerns  Bias and perceptions  Language

 Rocks, rolls and rules  Seniors, Elders, Older adults, Consumers  Residents, Patients, People-First

It’s a brave new syzygy world

 High prevalence of dementia  Affordable Care Act 2010  CMS National Partnership  AHCA/NCAL Quality Initiative  OIG report  New Guidance

 New needs  knowledge, skills, attitudes, partnerships  New opportunities  HCBS  Quality  Workforce development  New risks

Person-Centered Care

Political correctness Personal computer PC Care

 A philosophy  Values fundamental humanity of the people in our care AND the people who care for them  A set of best practices to improve outcomes  A base on which to build successful non-pharmacologic strategies

 The process and manner by which carers maintain the personhood of those who receive services  The Bradford Group

 I see you  I see our common humanity  I see your uniqueness It implies recognition, respect and trust… Thomas Kitwood, Dementia Reconsidered, 1997

The Residents’ Point of View NCCNHR 1985 From B&F Consulting

Who did what wrong  what process would make it less likely to happen again Error prevention  Culture of quality & safety Culture of Continuous Quality Improvement

 Fewer falls pressure ulcers acquired catheters  Less Turnover Absenteeism  Higher occupancy * Staff feel valued and respected

 Improved  Sleep  Mood  Appetite  Better transition home from sub-acute care  Fewer  Falls  Pressure Ulcers  Less  Agitation  Depression From B&F Consulting

The New York Times October 12, 2006 JAMA 36:  Meta Analysis Confirms:  Effectiveness in Dementia is Weak

 No benefit and cognitive decline with quetiapine  AGIT-AD Ballard et al, BMJ, 2005  Meta Analysis shows effectiveness is weak  JAMA 306: RCTs in dementia  Lower survival rates

New York Times April 11, 2005FDA Black Box Warning 2005  Warning  Increased Mortality in Elderly Patients with Dementia related Psychosis

 Causes of death (Ballard et al, 2010)  Pneumonia  Stroke  Pulmonary embolism  Sudden cardiac arrhythmias  Likely mediating factors  Dehydration  Over sedation  QT prolongation

 Increased falls  Failure to thrive  Increased risk pressure ulcers  Diminished quality of life

DOCTORS NURSES SURVEYORS DIRECT CARE STAFF

 Data shows antipsychotics cause harm  Data shows they are of limited use  The side effects negatively effect quality of life  Regulators require we be concerned as do elder rights

After a break See you in 15 minutes

I don’t know what to do!

Underlying principles

Those who care for them

 Ways of knowing  Ways of processing  Ways of learning

Well-being, strengths, personhood

In their shoes Loss exercise

PERSON with Dementia

 The process and manner by which carers maintain the personhood of those who receive services The Bradford Group

All behavior communicates All behavior has meaning

All behavior expresses core human needs

Behavior

MEANING ESTEEM & SELF RESPECT BELONGING & AFFECTION SAFETY AND SECURITY PHYSIOLOGIC INTEGRITY With or without dementia

DIGNITY MEANING RESPECT

What is this person trying to tell us?

+ ENGAGE Model Respect CARING

 4 Modules/8-10 hours learning activities  Who’s Who  Person-Centered (Dementia) Care and Recovery  All About Behavior (2)  Interventions  Learning outside the classroom

 Training Manual  Resource Guide  DVD  Video clips  Power points  Podcasts

Behavioral and Psychological Symptoms of Dementia

 Brain-behavior relationships of 5 As  Medical approach to symptom control

 Memories

 Regulate emotions  Fear  Anger

WHO a person is, is as important as WHAT he or she has

PatienthoodPersonhood What causes behavioral and psychological symptoms? What is this person trying to tell me?

Shifts primary perspective person rather than disease abilities rather than inabilities relationships rather than task

 Old paradigm:  Behavioral symptoms common  Goal is elimination  New paradigm:  Not all behaviors are symptoms  Behaviors are efforts to communicate Need, desire  Goal is interpretation, addressing need, preventing

Current (old) model Emerging model  Loss of ability to modulate  Lump together  Explaining  Intervention  Unmet human need  More precision  Understanding  Prevention

 Slapping thighs  Clapping  Yelling  Screaming  Self-referred  Something is wrong with me  Do something!

 Hitting out  Kicking  Pinching  Biting  Threatening  Swearing

 Common triggers  Fear  Anxiety  Frustration  Medications  Sensory loss  Crowded or noisy environments  Abrupt, tense or impatient staff

FEAR

STOP LEAVE ME ALONE!

WHERE AM I?

I can’t get away! I have to fight!

 Is there a history?  NOT a green light for dismissal  Is there a pattern?  What works/what doesn't  What do we know?  How can we  Create sense of safety  How can we change our behavior?

DAY 2

 Environment  Eden Alternative  (loneliness, helplessness, boredom)  Music  (Massage)  Recreation  (Aromatherapy)