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It’s all about approach:
Theory and Practice for Interacting with the Person Living with Dementia
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Objectives Describe reason for specialized knowledge related to dementia care in LTC Differentiate between Normal and Not Normal Aging Apply practical approach and technique for interacting with the person living with dementia Define Teepa Snow Gem States
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Dementia Care in LTC Residents with dementia are expected to receive care specialized to their needs. This includes not just nursing care but other areas like therapy, activities, dietary and so on too. Each caregiver can provide key info to recognizing stages of dementia and training staff strategies to optimize care, maintain ADL and mobility for as long as possible and ensure safety and maximum hydration and nutrition. Activities are key to keeping the dementia resident engaged and active and safe.
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Long Term Care Caring for people with dementia is challenging to Long Term Care because these individuals require more effort to establish personalized services. This is especially true if members of your care staff are not well versed in the disease process and equipped with strategies to achieve safe and successful care of the individual. Caring improperly for the dementia resident can cause them to decline clinically losing abilities and mobility faster than necessary; staff to become overwhelmed; and create survey issues as well as negative outcomes for the resident and facility.
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Dementia Defined Dementia-general term for loss of memory and other mental abilities that interfere with daily life. Dementia-is characterized by a decline in memory, language, problem-solving, and other cognitive skills –such as judgement, reasoning, planning--that affects a person’s ability to perform everyday activities Most Common for individuals over 65, though about 200,000 under age 65 have been diagnosed with Early onset AD
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Dementia Defined Diagnosed through a combination of tests, differentiating from occasional forgetfulness that occurs with normal aging and from depression, malnutrition and medication side effects. The disease is generally broken down into stages: EARLY—MIDDLE—LATE As the symptoms of increase, the demands placed on caregivers increase. Care becomes more physically and emotionally challenging, demanding and consuming.
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DEMENTIA Alzheimer’s Disease Young Onset Late Life Onset
Lewy Body Dementia Alzheimer’s Disease Young Onset Late Life Onset Other Dementias Genetic syndromes Metabolic pxs ETOH related Drugs/toxin exposure White matter diseases Mass effects Depression(?) or Other Mental conditions Infections – BBB cross Parkinson’s Vascular Dementias (Multi-infarct) Fronto- Temporal Lobe Dementias
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Normal Aging vs. Not Normal Aging
Introductions- Begin with understanding of “Normal”- how things should work. Gives us ability to recognize “Not Normal” with the understanding that Not Normal doesn’t always = Dementia- Important concept! Emphasize- concept of brain failure- connect to CHF etc Ask for “share” (what might be not normal but not dementia) Begin Video begin: 38 sec end at 3:32- AELS Cycle 1 Share- Has something like this happened to you? Noticed in others? Process- why do you think it happens? What seemed funny but also anxiety provoking? Connect-When your brain gets anxious-nervous it can dump cortisol (a stress hormone we’ll learn more about later)… makes you become even more distressed, cause brain to function differently, changes breathing/ heart beat Breathing deeply can help drop cortisol allowing you to think, process, control your emotions. Apply- 3 deep breaths. Normal Aging vs. Not Normal Aging Teepa Snow’s Positive Approach to Care Training Module
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Start Video 40:06 Not Normal
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NOT Normal Aging NORMAL Aging
Can’t recall a word. Describe the word to get it to pop up. Give people time to process information. Go more slowly. Slower to think. Slower to do. May hesitate more. More likely to look before they leap. Will know the person, but not find the name. May pause when word finding New data reminds me of old data Unable to think the same Unable to do as before Unable to get started on a task Will get stuck in a moment of time Unable to think things out Unable to successfully place a person Words won’t come even with visual, verbal, or touch cues Confused between past and present Personality and/ or behaviors will be different Share- Let’s see how many we got Process- turn to partner, table and think about how comfortable you are with recognizing the difference between normal and not normal type behaviors- Language, thinking, processing remembering- rate your self on a scale of 1 to 10 knowledge and assessment of normal and not normal. Connect- what are some of the key things you can listen for, look for and consider to help tell the difference? Apply Think of 1 to 2 situations where you can look for, listen, pay attention to possibility of not normal. Where and when will you practice? Start video- 46:50
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Working Memory and Communication
To understand more about communicating with our PLWD… Working memory vital terms - not just long term and short term Have to wire together all parts of brain- complex (wrap hand around head) Humans can hold- manipulate all at the same time- 5-8 items At least 5 pieces of information minimally- healthy – complicated, but I can Cycle 8: Experience: Make coffee- put in working memory as I’m working through process (no relationship established because I didn’t make to kitchen when…) Telephone rings- attention-new data friend- no name- have to find question? meet- at the mall, 2 p.m at time, at macy’s, chocolate store new- have to find thing she likes- Circumlocution - brown hairy ball Dementia- stress- watch for message of “im full” stop talking- Work with them, don’t fight with them- Pushing your Agenda- So when you get a negative reaction- they are communicating- listen to them How do I get back to coffee??? Young, wiring will visually track to see if visual cue prompts recall- A little older- visually track, then system two- auditory- talk to yourself- may have to travel back to original setting- sensory motor, walk through the steps- waiting in working memory- All normal aging Share: What are some features you noticed in normal aging- (write in column) share- Process: with partner discus why do you think there is so much misunderstanding of normal aging? What are some of the features of normal aging that can create friction, stress, problems between people interacting trying to help each other? Connect: how has learning about your brain affected your thinking? Apply: review: How should you greet someone? Hi Joelle, it’s Emily” If someone seems to be looing for a word what is a great option to give the person a chance? – (silently count) To prompt or remember more than 5 things what might be helpful (lists) If you ask me to how to get somewhere and I’m older what might I do when describing directions (use old landmarks to help locate locations) Working Memory and Communication
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5 Senses How Humans Take In Data
What you see What you hear What you feel/ touch What you smell What you taste Introduce hand- 5 digits and remember to incorporate movement! Again understanding what’s normal helps us identify not normal 1- visual processing 2- auditory processing 3- sensory motor processing Skill fingers Sense of smell Sense of taste -Strong fingers (strongly preserved/ primitive)
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Visual Data The most powerful sensory input.
People with dementia pay more attention to what they see than what they hear. *Normal Visual Changes Vs. Changes in Dementia Thumb- see it - start to think of it Occipital area processes visual input- complex wiring in between and huge space (interlace fingers)
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Vision Center – BIG CHANGES
University of Alabama imaging Both 80 y/o Cycle 2 Experience Normal: 20 y/o full 180 awareness (145 actual visual) 145 safety vision / straight ahead curiosity – 75 y/o will have lost 45 deg. of visual field – normal aging vision change- slower to process visual data Share- does this change in vision affect you at all? Process- why is it different? What did you want to do when someone approached? Connect- how could your resident’s without dementia be at risk? (falls) Experience Dementia: Partner up- trial approach with each set of vision changes, especially in relation to approach Come in about 20 more degrees- Early stage dementia 7/10 no dx (scuba vision) Hands out lines up with shoulders- create circle- 12/18 in of visual circle between early and middle stage- (binocular) Monocular vision (depth perception) Social vs. Task vision – meal time? Share: What happened? How did it make you feel (especially approach)? Process: why do you think it feels different? Connect- How does this relate to someone living with dementia? How might they react Apply- Confrontational Vs. Supportive Stance
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Confrontational Stance vs. Supportive Stance
Public Space: more than 6 feet Social interactions Personal Space: 6 feet to arm’s length Friendly/conversational Intimate Space: within arm’s reach Physical / touch / contact Experience
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Vision Losses Edges of vision – peripheral field Depth perception
Object recognition linked to purpose SLOWER to process – scanning & shifting focus Preserved ‘See’ things in middle field Looking at… curious When interacting with the PLWD- consider what’s preserved, work with that…
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Auditory Data What do we often do wrong? Care partners like to talk.
The person with dementia is focused on how we look visually and they are not processing the content. Normal: Pointer finger- We hear something – but then we look towards it always going back to visual. We often skip primary and overload with auditory (secondary) PLWD: Visual and intonation is processed, but not content- grasping visual cues not content cues We have to be the one to change.
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Hearing of Sound – Not Changed
Hearing vs understanidng
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Understanding Language – BIG CHANGE
Demo brain dysfunction Asymmetrical attack- most often with Left- language processing – R rhythm intact Experience- Language on the Left- Rhythm on the Right…. Biggest challenge in dementia care- Who has to change?
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Understanding Loss Preserved Ability Can’t interpret words
Misses some words Gets off target Preserved Ability Can get facial expression Hears tone of voice Can get some non- verbals Learns how to cover
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Sensory Motor Data 3rd – Sensory motor- feel something do something ,
do something feel something What do we sometimes do wrong? 3rd – Sensory motor- feel something do something , do something feel something- middle finger- rub on back of hand If you skip one and two- flip the bird, not a great way to start Oldest sensory motor is hand/eye – Loose skill before strength – so the PLWD will likely have a strong grip… Hands weaved on top of head to demonstrate importance / huge area of brain used to process (hard wired together) Cycle 3: Experience- partner touch without vision/auditory Light touch- alerting / hyper awareness Share- What happened for you? How did it make you feel? Process- What did you find yourself wanting to do? Why do you think it felt the way it did? Connect- What do you think you would say or feel if you had dementia How does this apply to PLWD when we are trying to help them do things like ADLs? Gait? Experience- Touch self- how does it feel different= why? Closed circuit sending and receiving is intact Demo HUH with Joelle- show how closing the circuit improves acceptance. Take a few minutes and practice HUH-
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Make a Note No touching until you’ve done a visual/ verbal
Don’t do “to” someone…do “with” someone Dementia robs skill before robbing strength Use “hand under hand” to support Cycle 4 – HUH works for most- but PPA is appropriate for EVERYONE (this scenario demonstrates that) Experience- startle scenario – Challenging Impulse Control- tab 2- pg 3 After complete- So not only are we presenting ‘data’ out of sequence, we are challenging an already inhibited impulse control- Limbic system is the core of our existance- regulates elimination, temperature control Amydala: alert/aware; risky; danger Cortisol…..
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Executive Control Center
Emotions Behavior Judgment Reasoning Frontal Lobe- During your share you said you wanted to fight flight freight but our “normal” frontal lobe allows….. Safety, initiate, sequencing, terminating AND being able to see something from someone else’s point of view. Connect- how is the PLWD … Apply- knowing this what can we do differently…. Move into PPA Cycle 5 Experience- Use HUH pump to demonstrate attention getting- (hand/pressure allows kinesthetic response to draw vision- ONCE ALREADY ESTABLISHED!) Share: what did you do? What happened? Process: in group or as large group- why? …. Connect have you ever noticed eye contact drawing hand contact or hand contact causing eye contact before in your own expereicnes? Do you think this might have an impact on anyone you have tried to help who had dementia? Apply: Practice
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Approach Matters Use a consistent Positive Physical Approach™
Pause at edge of public space Gesture and greet by name Offer your hand and make eye contact Approach slowly within visual range Shake hands and maintain Hand-Under- Hand™ Move to the side Get to eye level & respect intimate space Wait for acknowledgement After Partner practice Emphasize: I don’t want to do things to you, but with you… Figure out ways to share communication because I’m determining what you can do… Cycle 6 Experience was practice Share have you notced that people in later stages seem to have trouble understanding what you want them to do and doing it? Have you ever thought what that might be? Process how does this activity and processing help you better understand why problems sometimes arise when we are trying to help someone LWD Emphasize wiring between auditory commands- sensory- motor ect. --- Given what we know of patient are we using wrong system for what strengths they have remaining?? Apply- think of at least one situation you could use this approach and share with table .
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When Words Don’t Work Well
Hand-under-Hand™ Uses established nerve pathways Allows the person to feel in control Connects you to the person Allows you to DO with not to Gives you advance notice of ‘possible problems’ Connects eye-hand skills Use the dominant side of the person Partner practice
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Use Hand-Under-Hand™ Connecting – comforting and directing gaze
Guiding and helping with movement Getting eye contact and attention Providing help with fine motor Offering a sense of control, even when you are doing almost everything
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Smell and taste Data Strong and Primative
No safety awareness- keeps curiosity. Ring finger- smell Pinky- open mouth Affected opposite way – will keep curiosity and loose safety awareness Children curiosity – someone else is in charge of their safety awareness Children- Sell padded, insulated non fragil Dignity vs need for safe environment- life time of independence not wanting to be managed like we are their parents or bosses. Consider geriatric bones etc. Recap all together – development, loss of function- limbic system including amygdala and moving out to frontal lobe regulation Cycle 7 Share- have you ever had an interaction with a child where they started to do something unsafe b/c they’re curious Pocess- how did you handle it? What happened? Connect- given what you now know, does what happened make sense? Apply- now think of the PLWD- ask same questions- do you have a better understanding of what happened? What’s one thing you plan to change in your care routine based on what you’ve learned?
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Sensory Changes Loss Preserved Ability Awareness of body and position
Ability to locate and express pain Awareness of feeling in most of body Preserved Ability 4 areas can be sensitive Any of these areas can be hypersensitive Need for sensation can become extreme Review the info on the slides The 4 areas on the body are: Lips, tongue mouth Palms and fingers Soles of feet Genitalia In the discussion indicate that the four areas of the body that tend to stay sensitive are: lips, tongues, and mouth -palms of hands and fingers -soles of the feet -genital area Discuss how these areas of sensitivity might affect public behavior, what you see, what the person might do or say… Share examples and observations
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Self-Care Changes Loss Preserved Ability initiation & termination
tool manipulation sequencing Preserved Ability motions and actions the doing part cued activity Indicate that this is one of the later areas to be affected. Discuss how these changes might present problems that come up for law enforcement: Driving Getting around safely outdoors Unsafe behaviors in stores or in the community Getting in trouble over and over …
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Language Loss Preserved Ability Can’t find the right word Word Salad
Vague language Single phrases Sounds & vocalizing Can’t make needs known Preserved Ability Singing Automatic speech Swear words, sex talk, forbidden words
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Critical Messaging Know your agenda, don’t show your agenda!
Connect before you redirect! What you do for me you take from me!
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Start Video 40:06 Gem States
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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
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Sapphires – True Blue – Slower BUT Fine
Diamonds – Repeats & Routines, Cutting Emeralds – Going – Time Travel – Where? Ambers – In the moment - Sensations Rubies – Stop & Go – No Fine Control Pearls – Hidden in a Shell - Immobile
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Tips Start Video 40:06
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People living with dementia need care partners to think about and act on what they want, need, and think. Watch and Observe What they show you- how they look What they say – how they sound What they do – physical reactions
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Supportive Communication
Make a connection Offer your name – “I’m (NAME)… and you are…” Offer a shared background – “I’m from (place) …and you’re from…” Offer a positive personal comment – “You look great in that ….” or “I love that color on you…”
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Emotional Communication
Validate emotions EARLY –“It’s really (label emotion) to have this happen” or “I’m sorry this is happening to you” MIDWAY – Repeat/reflect their words (with emotion) LISTEN for added information, ideas, thoughts EXPLORE the new information by ‘watching and listening’ (wonder what they are trying to communicate) LATE – Check out their ‘whole’ body – Observe face, posture, movement, gestures, touching, looking Look for NEED under the words or actions
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Keep it SIMPLE USE VISUAL combined VERBAL (gesture/point)
“It’s about time for… “ “Let’s go this way…” “Here are your socks…” DON’T ask questions you DON’T want to hear the answer to… Acknowledge the response/reaction to your information… LIMIT your words – SIMPLE is better always Wait, Pause, Slow Down
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For ALL Communication If what you are trying is NOT working… STOP
Back off THINK IT THROUGH… Then, re-approach And try something slightly different
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Care Partners Need To… Take care of yourself
Understand the symptoms and progression Build skill in support and caregiving Build skill in communication and interactions Understand ‘the condition’ of brain change Identify and utilize local resources Set limits for yourself
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The Basics for Success Be a Detective NOT a Judge
Look, Listen, Offer, Think… Use Your Approach as a Screening Tool Always use this sequence for CUES Visual - Show Verbal - Tell Physical – Touch Match your help to remaining abilities
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It Takes TWO to Tango … or two to tangle…
Realize… It Takes TWO to Tango … or two to tangle…
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