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

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

3. 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

4. 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

5. 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!”

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

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

8. 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.

9. 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

10. 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

11. 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

12. 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

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

14. 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

15. 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

16. 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.

17. 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

18. 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

19. 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

20. 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

21. 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!)

22. 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.

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

24. 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

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

26. High Risk

27. 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

28. Connection & Communication
Positive Personal Connections
Positive Action Starters

29. 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

30. 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….”

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