1. 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.

2. 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: Positive Physical Approach™ (PPA™)
2: Special Situations and Emotions with PPA™
2: Break
3: Hand-under-Hand™ (HuH™)
4: GEMS™ Introduction
4: Wrap up

3. 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!

4. 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?

5. 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

6. Normal Brain
Brain with Alzheimers

7. 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

8. 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.

9. 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.

10. 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

11. 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

12. 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

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

14. 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

15. Vision Center – BIG CHANGES

16. 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

17. 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

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

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

20. Visual Cues Signs Pictures Props – Objects Gestures Facial expressions
Demonstrations

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

22. 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

23. 5 Physical and 5 Emotional
Unmet NEEDS:
5 Physical and 5 Emotional
Move furniture: “What am I telling you?”

24. 5 Unmet Physical Needs: Hungry/Thirsty Too much/too little energy
Elimination
Discomfort – to be explored: sensations, spaces, social situations, surfaces
Pain

25. 5 Unmet Emotional Needs:
Angry
Sad
Lonely
Scared
Bored

26. 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

27. To REST To RESTORE To REVIVE
BREAK!
To REST To RESTORE To REVIVE

28. 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

29. 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?

30. Use the Positive Physical Approach™
To Connect

31. 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

32. 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?

33. 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!

34. 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

35. 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

36. 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

37. 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

38. Hand-under-Hand™
When ca we use HUH?

39. 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

40. 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

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

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

43. 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

44. 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

45. 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.

46. To REST To RESTORE To REVIVE
BREAK!
To REST To RESTORE To REVIVE

47. Hand-under-Hand™
When ca we use HUH?

48. 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

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

50. High Risk

51. 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

52. 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

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

54. 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!

55. 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!

56. 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!

57. 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

58. 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

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

60. Clear and Sharp Routines and Rituals Rule
Diamonds
Clear and Sharp
Routines and Rituals Rule

61. Emeralds
Green and
On the Go with a Purpose
Naturally Flawed

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

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

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

65. 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

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

67. 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!