1. A Team Oriented Approach for People with Dementia This is NO TIME to be a Lone Ranger!

2. What Does It Take To Make A GOOD Dementia Care Situation? Know each PERSON! Understand ACTIVITIES! Make & Use a SCHEDULE! Build staff SKILLS! Manage the ENVIRONMENT! Resources to succeed

3. Know each Person Health Status medical conditions, medications, limitations & abilities Life History Who the person has been… Personal history and background Cognitive Status thinking, memory, processing skills and limitations Emotional status psychological condition and mental health & limitations Routines and Habits patterns of behavior, daily routines, time use & schedules Sensory Status sight, hearing, touch, balance, coordination, temperature regulation

4. Design Each Day 8 am – coffee circle 8:30 – songs of joy 9 am – time to ‘go’ 9:15 – take a hike – walk’n’roll 10 am – cool down & stretch 10:30 – watering hole 11 am - ‘use your brains’ games 11:30 - time to ‘go’ – wash up 11:45 – ‘set-‘em up’ crew 12 noon – let’s eat 12:30 – clean up crew 1 pm – music and meditation 1:30 – coupons clipping 2 pm – time to ‘go’ 2:15 – let’s dance Make a schedule and follow it Be structured BUT allow flexibility Create a FLOW for the day Build up and then slow down Circadian rhythms Offer a variety of activities every day Leisure, work, rest, self-care, groups and 1:1, passive and active Create Group schedules BUT also build individual schedules Not everything is for everybody! Build a Foundation of Familiar and Favorite Activities Add a few special events and something different

5. Understand Activities Modify and Structure the Activity for Success Change the materials, the complexity, the setting, the help offered, the task demands, or the purpose of the activity Analyze the Activity… What do you need to do it? What skills, abilities, interests? What is the activity all about? Doing something or making something? What type of activity is it??? Self-care, leisure, work, rest… Spiritual, social, physical, cognitive, passive, active, solitary

6. Build Staff Skills Environmental Management skills Using space & keeping up the place Problem-solving skills Figuring out what to do when it does not work right Client Interaction Skills How they work with clients… Group Leading Skills Getting people together & having fun Customer Relations Skills With families, clients, volunteers Documentation Skills Record keeping and reporting Practical Hands-on Skills Crafts, games, cooking, working… Planning & Time Management Skills What to do & when to do it! Peer Relationship Skills Helping each other Observation skills What they see, hear, sense…

7. Pay attention to the lights, sounds, seating, work surface, space… Manage the Environment Do the ‘right stuff’ in the ‘right place’ Match what you do to where you are… Use the space well Plan and place for BEST effect Create & Use Storage Make set-up & clean-up part of the activity Change it around – if you need to - to make it work! Keep it ADULT Make sure supplies, activities, and games are meaningful Play & laugh with folks, not at them Give out tools and materials ‘just in time’ Control the activity so clients are successful – not overwhelmed - not out of synch Make it look friendly Get me to want to come

8. Enough Supplies & Materials The right equipment for clients’ needs Good quality lighting Skilled leadership for the activity Good work surfaces Seating that works Enough help for each person A BACK-UP Plan

9. Know Who You Are & Who Your Team Mates Are

10. Who Are You as a Team Member? What About Your Team Members? What About Your Elder? What About Their Supporters?

11. It’s Like Putting Together a Jigsaw Puzzle What is your life experience with dementia? Who are you personality-wise? How do you learn new information best? What is your relationship to the person & others? What is the environment of care? Where in the progression of the condition is the person? What are the resources available?

12. Personality Traits Who are you? Introvert-Extrovert Lots of Details – Big Picture only Logical – Emotional Planning ahead – Being in the moment Who is the person you are trying to help? Who are your team mates? What does this mean?

13. Introvert - Extrovert Introvert Likes to be alone Likes to think it out Likes personal space Needs alone time Private Extrovert Think out loud Talk it out Seek out people Share a lot Not good with boundaries

14. Details – Big Picture Details Lots of facts and figures Specifics of what to do Likes to get going - doing Big Picture Likes to know WHY Likes to think about it before doing anything Likes to hear the big plan

15. Logical - Emotional Logical Head First Fair Reasonable Rational Emotional Heart First Nice Kind Empathetic

16. Planning Ahead – In the Moment Planning Ahead Aware of the future Sets priorities - plans Likes routines Likes a schedule Likes to do things as planned Needs to be in CONTROL In the Moment Being flexible Go with the flow No forward thinking Running late Putting other things off GO WITH THE FLOW

17. Life Experience Talents & Skills Previous and Current Careers or Jobs Volunteer Activities or Hobbies Other Caregiving Roles Care Receiving Roles Helping & Support Roles Knowledge about the Medical Community Exposure to Dementia Knowledge about ‘Aging’ Issues

18. Learning Preferences We are all smart in different ways Its not about if you are smart, it about HOW you are smart! You learn best if your preferred learning style is used! If you know, you can ask for what you need!

19. Multiple Intelligences (how do you learn?) Verbal/Linguistic (word smart) Spatial/Visual (picture smart) Logical/Mathematical (number smart) Bodily/Kinesthetic (body smart) Musical/Rhythmical (music smart) Intrapersonal (myself smart) Interpersonal (people smart) Naturalistic (nature smart) Existential (big picture smart)

20. Memory Loss Losses – Immediate recall – Attention to selected info – Recent events – Relationships Preserved abilities – Long ago memories – Confabulation! – Emotional memories – Motor memories

21. Memory Changes… So, what will work better – – Ask about what happened this morning OR -Talk about her wedding day 50 years ago -Point out that she hid her own purse OR - Recognize it is missing and she is upset about it & we need to do something about it

22. A Positive Approach (To the Tune of Amazing Grace) Come from the front Go slow Get to the side, Get low Offer your hand Call out the name then WAIT… If you will try, then you will see How different life can be. For those you’re caring for!

23. Most people are…. Really good at THREE intelligences OK at THREE intelligences Not good with THREE intelligences

24. Using Multiple Intelligences Know your own preferences Identify the preferences for others on the team – meet needs to work well together Integrate strategies for better function

25. Your Relationship What is your history? Who had what roles? Who else was involved? Who else might you act like, look like, or sound like? What is changing? How much?

26. Believe in Yourself Acknowledge your skills and talents Recognize your limitations Explore what is needed Look for the matches Identify the missing pieces Decide on what to do Decide on what NOT to do Get help for what is needed Be GOOD to yourself!

27. Once You Have the Team…

28. Knowing the Person History Values and beliefs Habits and routines Personality and stress behaviors Work & family history Leisure and spiritual history Hot buttons & comforts

29. Health & Illness Mobility problems? Pain? Sensory problems? Mental health issues? Other diagnoses of importance?

30. Now on to Understanding Dementia –

31. Is It Dementia? Or Something Else? What Kind of Dementia? How ‘Bad’ Is It? What Does It Mean for Life & Care?

32. PET Scan of 20-Year-Old Brain PET Scan of 80-Year-Old Brain PET and Aging ADEAR, 2003

33. As We Age, WE DO NOT lose function in our Brains, UNLESS… Something Goes Wrong with Our Brains

34. Other words we sometimes use… Senile Hardening of the arteries Crazy “Not right” “Stubborn & Ornery” “Losing it” “Just getting old” “Not trying” More forgetful “Pleasantly confused”

35. What is the Difference Between Forgetfulness & Memory Loss that Comes with Dementia? Is there a CLEAR Difference? YES… Maybe… It all depends

36. BUT, Couldn’t It Just Be Forgetfulness or Getting Old? There is a difference At first it may be hard to tell Then you start to notice patterns One of these things start to show changes… – Memory- Problem solving – Word finding- Behavior

37. Drugs that can affect cognition Anti-arrhythmic agents Antibiotics Antihistamines - decongestants Tricyclic antidepressants Anti-hypertensives Anti-cholinergic agents Anti-convulsants Anti-emetics Histamine receptor blockers Immunosuppressant agents Muscle relaxants Narcotic analgesics Sedative hypnotics Anti-Parkinsonian agents Washington Manual Geriatrics Subspecialty Consults edited by Kyle C. Moylan (pg 15) – published by Lippencott, Wilkins & Williams, 2003

38. How Can We Figure This Out? Screening Sharing Knowing More about Dementia BUT also About Other Conditions

39. Screening Options OLD – MMSE New – SLUMS – 7 minute screen – Animal fluency – 1 minute # of animals – Clock Drawing – 2 step – Full Neuropsychological testing panel

40. SLUMS Orientation – day of week, month, state (3) Remember 5 items – ask later (5) $100 – buy apples $3 and Trike $20 – What did you spend? What is left? (2) Animal fluency (0-3) ( 14) Clock drawing (4) – numbers in place, time right Shapes (2) – ID correct, which is largest Story recall (8) – recall of info from a story – 4?s

41. SLUMS - rating High School Education 27-30 – Normal 21-26 – MNCD (MCI) 1-20 - Dementia Less than High School 25-30 – Normal 20-24 – MNCD (MCI) 1-19 - Dementia

42. Animal Fluency Name as many animals as you can Give one minute Count all unique animals 12 or more normal for > 65 18 or more normal for <65

43. Clock Drawing Give a BIG circle on a blank sheet of paper Ask to draw the face of a clock - put in the numbers Watch for construction skills & outcome Ask to put hands on the clock to indicate 10:50 Watch for placement and processing

44. Scoring for Clock Drawing Variable One system 0-4 – numbers in correct areas One system 0-10 – Numbers in correct areas – Center location for hands, long hand/short hand, correct location long, correct location short – Normal >6 8 other possible systems

45. What is it NOT… NORMAL Aging Slower to think Slower to do Hesitates more More likely to ‘look before you leap’ Know the person but not the name Pause to find words Reminded of the past For you, its harder… NOT Normal Aging Can’t think the same Can’t do like before Can’t get started Can’t seem to move on Doesn’t think it out at all Can’t place the person Words won’t come – even later Confused about past versus now For you it’s VERY DIFFERENT

46. The Three D’s: What’s What & What Helps!

47. Dementia Delirium Depression What’s What?

48. What’s What – For Each D Onset Hx & Duration Alertness & Arousal Orientation responses Mood & Affect Causes Treatment for the cause/condition Treatment for the behavioral symptoms

49. Delirium Onset – sudden - hours to days Duration – ‘cured’ or ‘dead’ - short Alertness & Arousal – fluctuates, hyper or hypo- Orientation responses – highly variable Mood & Affect – highly variable - dependent Causes – physiological physical, psychological Tx condition – ID & Treat what is WRONG Tx behavior – manage for safety only – short term only, don’t mask symptoms

50. Depression Onset – recent - weeks to months Duration – until treated or death – mnths-yrs Alertness & Arousal – not typically changed Orientation responses – “I don’t know”, “I can’t say”, “Why are you bothering me with this, “I don’t care” Mood & Affect – flat, negative, sad, angry Causes – situational, seasonal or chemical Tx of condition – meds, therapy, physical activity Tx of behavior – schedule & environmental support, help – combined with meds

51. Dementia Onset – gradual – months to years Duration – progressive till death Alertness & Arousal – gradual changes Orientation responses – right subject, but wrong info, angry about being asked, or asks back Mood & Affect – triggered changes Causes – brain changes – 60-70 types Tx – chemical support – AChEIs & glut mod Tx behavior- environment, help, activity, drugs

52. Determine First – Is this Dementia, Delirium, OR Delirium? Delirium can be dangerous & deadly Get a good behavior history – look for change Assess for possible PAIN or discomfort Assess for infections Assess for med changes or side effects Assess for physiological issues – dehydration, blood chemistry, O 2 sat

53. 2 nd – Is it Dementia or Depression Depression is treatable Many elders with ‘depression’ describe themselves as having ‘memory problems’ or having ‘somatic’ complaints Look for typical & atypical depression Look for changes in appetite, sleep, self-care, pleasures, irritability, ‘can’t take this’, movement, schedule changes

54. If it looks like dementia… Explore possible types & causes Explore what support person knows and believes about dementia Determine stage or level compared with support available Seek consult for person & support person

55. Alzheimer’s Disease Early - Young Onset Normal Onset Vascular Dementias (Multi-infarct) Lewy Body Dementia 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 Parkinson’s Fronto- Temporal Lobe Dementias

56. The Real Three D’s Dementia Delirium Depression

57. REALITY… Its NOT 3 clean or neat categories The 3 are MIXED together Which ‘D’ is causing what you are seeing NOW? Are all three D’s being addressed? – Immediate – Short-term – Long-term

58. What Could It Be? Another medical condition Medication side-effect Hearing loss or vision loss Depression Acute illness Severe but unrecognized pain Other things…

59. What Should the Doctor Do? A thorough physical & medical history Blood work A neurological exam A good history from the person and the family of the ‘problem’ A complete medication review A CAT scan or MRI or PET scan Neuropsychological testing – screening for cognitive changes FOLLOW-UP and counseling or at least a referral

60. If we think it is DEMENTIA… What Kind & How Bad?

61. Ten Early Warning Signs for Some Dementias memory loss for recent or new information – repeats self frequently difficulty doing familiar, but difficult tasks – managing money, medications, driving problems with word finding, mis-naming, or mis- understanding getting confused about time or place - getting lost while driving, missing several appointments worsening judgment – not thinking thing through like before difficulty problem solving or reasoning misplacing things – putting them in ‘odd places’ changes in mood or behavior changes in typical personality loss of initiation – withdraws form normal patterns of activities and interests

62. What Should We Do If We Suspect Something Might Be Happening? Work Out Legal Support – Financial PoA Work Out Health Care Support – HC-PoA Check with Your Doctor – Raise Your Concern Consider a Neuropsychological Assessment Consider Seeing a Specialist – geriatrician, neurologist, gero-psychiatrist

63. SO… What is Dementia? It is NOT part of normal aging! It is a disease! It is more than just forgetfulness - which is part of normal aging It makes independent life impossible

64. Cognitive Changes with Aging Normal changes = more forgetful & slower to learn MCI – Mild Cognitive Impairment = typically 1 area – Immediate recall, word finding, or complex problem solving problems (½ of these folks will develop dementia in 5 yrs) Dementia = Chronic thinking problems in > 2 areas Delirium = Rapid changes in thinking & alertness (seek medical help immediately ) Depression = chronic unless treated, poor quality, I “don’t know”, “I just can’t” responses, no pleasure can look like agitation & confusion

65. Alzheimer’s Disease Early - Young Onset Normal Onset Vascular Dementias (Multi-infarct) Lewy Body Dementia 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 Parkinson’s Fronto- Temporal Lobe Dementias

66. Alzheimer’s New info lost Recent memory worse Problems finding words Mis-speaks More impulsive or indecisive Gets lost Notice changes over 6 months – 1 year

68. Positron Emission Tomography (PET) Alzheimer’s Disease Progression vs. Normal Brains G. Small, UCLA School of Medicine. Normal Early Alzheimer’s Late Alzheimer’s Child

69. Vascular Dementia Sudden changes Picture varies by person Can have bounce back & bad days Judgment and behavior ‘not the same’ Spotty losses Emotional & energy shifts

70. Vascular dementia CT Scan The white spots indicate dead cell areas - mini-strokes

72. Latest Thinking About Vascular Treatment? Lots of similarity with Alzheimer’s Manage blood flow issues CAREFULLY! Watch for and manage depression

73. Lewy Body Dementia Movement problems - Falls Visual Hallucinations Fine motor problems – hands & swallowing Episodes of rigidity & syncopy Nightmares Fluctuations in abilities Drug responses can be extreme & strange

74. Latest Thinking about Lewy Body Treatment Use AChIs Add Namenda early BE VERY careful about anti-psychotic meds Parkinson’s meds – may help movement BUT may make hallucinations and delusions worse Anti-depressants & Anti-convulsants – may be used to help anxiety, sleep, & depression – can increase confusion, movement & drowsing

75. Fronto-Temporal Dementias Many types Frontal – impulse & behavior control loss – Says unexpected, rude, mean, odd things to others – Dis-inhibited – food, drink, sex, emotions, actions – Becomes ‘stuck’ or obsessed about ‘things’ Temporal – language loss – Can’t speak or get words out – Can’t understand what is said, sound fluent – nonsense words

76. FTD/Pick’s Disease PET Scan

78. Latest Thinking About FTD Treatments Consider Namenda earlier Look at SSRI medications May use medications used to treat OCD May NOT use AChI Medications

79. So What Do You Know Now? There are conditions that are ‘not’ dementia that can look like dementia There are many kinds of dementia People can have more than one problem at a time Dementia can vary moment to moment, hour to hour, day to day, and person to person IT’s COMPLICATED & LIFE ALTERING

80. SO, Now It is Time to Go to Work in Your Teams