When You Forget That You Forgot: Recognizing and Managing Alzheimer’s Type Dementia, Part II : When You Forget That You Forgot: Recognizing and Managing Alzheimer’s Type Dementia, Part II
Revised by Marianne Smith (2005) from K.C. Buckwalter and M. Smith (1993), “When You Forget That You Forgot: Recognizing and Managing Alzheimer’s Type Dementia,” The Geriatric Mental Health Training Series, for the John A. Hartford Center of Geriatric Nursing Excellence, College of Nursing, University of Iowa
Goals for Today : Goals for Today
Review common sources of stress for people with dementia
Review care principles based on the Progressively Lowered Stress Threshold (PLST) model
Apply basic principles to care routines and approaches
Behaviors in Dementia : Behaviors in Dementia New “language” of dementia care
Behavioral and Psychological Symptoms in Dementia (BPSD)
Need-Driven Dementia-Compromised Behaviors (NDB)
PLST Behaviors
Avoid negative labeling; focus on unmet needs
PLST Behaviors : PLST Behaviors Increased anxiety
Night awakening
Catastrophic behaviors
Sundowning syndrome
Purposeful wandering
Confusion, agitation
Combative behavior
Diminished reserve
Resistance More likely to occur as stress increases
PLST: Sources of Stress : PLST: Sources of Stress Fatigue
Multiple competing stimuli
Noise, confusion
Television, radio, public address
Too many people
Too many things going on at once
Eating dinner
Taking medications
Meal-time entertainment
PLST: Sources of Stress : PLST: Sources of Stress Physical Stress
Illness, medication side-effects
Hunger, thirst, discomfort
Changes
Caregiver
Routine
Environment: Internal (hunger, pain) and external (noise, confusion, stimulation)
PLST: Sources of Stress : PLST: Sources of Stress Demands that exceed abilities
Decisions that are too complex
Tasks that are outside abilities
Negative and restrictive feedback
“Don’t do that!”
“Your parents are dead”
“But this IS your house”
“No, you’re not going to work”
PLST: Care Planning Goal : PLST: Care Planning Goal GOAL - To act like a “prosthetic device” that supports the person do what what he/she is able to do
Interventions serve like memory “crutch” that fills in for lost abilities
Supports person to be autonomous in spite of lost abilities
Keeps stress at manageable level throughout the day
PLST: Care Planning Goal : PLST: Care Planning Goal Normal Stress Threshold A.M. P.M. Lowered Stress Threshold Dysfunctional Behavior Anxious Behavior
Interventions : Interventions PREVENTION is truly “the best medicine” in dementia care!!
Keep stress at a manageable level
Use person-centered approaches
Interventions : Interventions Person-Centered care: Think about the person “behind the disease”
Lifelong habits, preferences, coping methods
Long-standing personality
Personal history
Life experiences
Personal strengths, abilities, resources
Interventions : Interventions Multiple factors influence quality of care and life!
Environmental influences
Personal: internal feelings; unmet needs
Physical: objects, activities, sensory input
Social: people, interactions
Facility and care routines
Disease-related disability
Person’s strengths/limitations
Interventions: PLST Principles : Interventions: PLST Principles Underlying Assumptions:
All people need some control over themselves and their environment
All behavior has meaning
Behavioral symptoms are a sign of discomfort
Persons with dementia live in a 24-hour continuum
Interventions: PLST Principles : Interventions: PLST Principles Six basic ways to improve care:
Maximize safe function by supporting losses in a prosthetic manner
Provide unconditional positive regard
Use anxiety and avoidance to gauge activity
Interventions: PLST Principles : Interventions: PLST Principles “Listen” to the person with dementia (what does the behavior “tell you”?)
Modify the environment to support losses and enhance safety
Encourage caregivers to participate in ongoing education, support, self-care, and problem-solving
Interventions: PLST Principles : Interventions: PLST Principles Many ways principles are applied in practice
Highly individualized
Basic strategies reviewed here
PLST: Care Planning : PLST: Care Planning Reduce ENVIRONMENTAL STRESS
Caffeine
Misleading stimuli
Unending spaces
Unneeded noise
Extra people
Large rooms, unending spaces
PLST: Care Planning : PLST: Care Planning Compensate for lost abilities by adjusting APPROACHES
Use calm consistent approach & routine
Do not try to reason
Do not ask to “try harder”
Do not try to teach new routines
Do not encourage to recover lost skills
PLST: Care Planning : PLST: Care Planning Compensate for lost abilities by adjusting ROUTINES
Limit choices to ones person can make
Monitor changes in environment
Reduce, eliminate changes in pace
Routine = Familiarity and comfort
Repetition does not become “boring” to person with dementia
PLST: Care Planning : PLST: Care Planning Allow for LOWERED STRESS threshold
Plan rest periods in morning and afternoon
Maximize routines
Alternate low and high stimulus activities
Reduce stimuli when reactions occur
Look for triggers
Document incidents in specific terms: Be descriptive!!
PLST: Care Planning : PLST: Care Planning Provide unconditional POSITIVE REGARD
Use 1:1 communication, gentle touch
Eliminate “you are wrong” messages
Distract vs. confront
Simplify communication
Use Validation vs. Reality orientation
Don’t confront hallucinations or delusions
Positive Regard: Communication : Positive Regard: Communication Adjusting communication strategies shows respect and helps increase
Cooperation
Comfort
Dignity
Communication Strategies : Communication Strategies First, simplify the MESSAGE!
Short, understandable words
Simple sentences
One noun + one verb = ENOUGH
No lengthy or complex messages
Take pronouns out
Avoid “there, that, those, they, him, her, it”
Use nouns instead
“Sit in the Chair” vs. “Sit here”
Communication Strategies : Communication Strategies Simplify the message, continued…
Tell the person who you are
Call the person by name
Cue the person by providing information
Next, simplify your STYLE!
Slow down
Say words clearly
Avoid slang or other unfamiliar words
Communication Strategies : Communication Strategies Simplify your style, continued…
If you increase volume, lower tone
Increase volume ONLY if hard of hearing
Speak directly to person: Allow lip reading
Ask a question? WAIT for a response
Give time to think
Be patient
Ask ONLY ONE question at a time
Communication Strategies : Communication Strategies Simplify your style, continued…
If you repeat a question, repeat it EXACTLY
Do not “re-phrase” to clarify
Ask same simple question again
Wait for an answer
Go ahead - Laugh
Self-included humor is okay
Don’t be afraid to laugh at yourself or the situation -- just don’t laugh at the person!
Communication Strategies : Communication Strategies Third, pay attention to NONVERBAL messages
Pretend a room of people are watching, listening to your nonverbal style
Use gestures to help them understand
Point
Demonstrate
Use your hands, face, body to help them get the meaning
Communication Strategies : Communication Strategies Make sure you have and keep their attention
Stand in front of the person
Make eye contact; smile
Move slowly
Don’t threaten with sudden movements
Avoids catastrophic reactions
Walk with the person
Over emphasize & exaggerate expressions
Communication Strategies : Communication Strategies Last, AVOID “You are wrong” messages
No, you’re not going to work today.
No, you can’t visit your father. He’s dead.
No, this is your home now.
No, that isn’t yours. Put it back.
No, you can’t go now.
No, we just talked about that!
Positive Regard: Validation : Positive Regard: Validation Show respect through use of “validation”
Caregivers are often taught to use “reality orientation” (RO)
In dementia, Validation Therapy principles are more valuable
So what is the difference?!
Reality Orientation : Reality Orientation Basic Beliefs:
Disoriented person needs to be in “here and now”
Orient person to surroundings
Time, place, person, things
Assumes disoriented person can return to present if given enough information
Reality Orientation : Reality Orientation Advantages
Works well with person who is “temporarily” confused
Delirium (acute confusion)
Disorientation due to relocation
Gentle, “conversational” orientation useful with chronically confused
Tell person what is going on
Avoid “Do you know . . .?” questions (testing)
Reality Orientation : Reality Orientation Disadvantages
Person with progressive memory loss not able to retain information
Contradiction of their “reality” functions as negative and restrictive feedback
Increases frustration, anxiety, anger
Reduces self esteem
Can feel like “being tested”
Validation Therapy : Validation Therapy Stresses importance of “going with the person” to their reality
Validates feelings in whatever “time” is real to them
Views all behavior as purposeful
Listen carefully for meaning
Respond to “emotional” message
Validation Therapy : Validation Therapy Advantages
Reduces risk of sending “You are Wrong” messages
Addresses person in more positive way
Often leads to reminiscence, review of life events
Promotes self worth
Person-centered approach
Validation Therapy : Validation Therapy Disadvantages
Person may respond to approach “in the moment” but not retain information
Feels reassured briefly then forgets again
Repeats questions over and over
May not be successful in reassuring person
Irritability, anxiety may continue
Validation Therapy : Validation Therapy 1. Don’t confront the person’s mis-belief. Distract and redirect instead.
Person: “I’m going home!”
Don’t: “Your house has been sold. You live here now.”
Do: “It’s too late to go home now. Stay here with me. We’ll go tomorrow.”
Validation Therapy : Validation Therapy 2. Validate the person’s reality. Avoid “You Are Wrong” messages.
Person: “Papa’s coming to get me.”
Don’t: “Papa is dead. He’s been dead for years!”
Do: “Papa loves you. Papa’s a good man.” “I forget. Tell where Papa lives.” “Papa called. He’ll come tomorrow, not today.”
Validation Therapy : Validation Therapy 3. Listen carefully to “nonsense.” What might message mean in person’s reality?
Person: “Hurry up! Up, up, up, up there! Go! Go! Go! Up there! Up there! Whoaaaaa!”
Don’t: Assume message has no meaning
Do: Ask family, significant other “where” person might “be” in his/her reality. Do words make sense based on history?
Validation Approaches : Validation Approaches Misbelief vs. delusion or hallucination?
False beliefs may be “harmless” or quite distressing to the person. All are quite real to the individual, and may be
Frightening or upsetting
Helped by providing information
Reduced by reassurances of safety
Related to “real life” events (illusions)
Validation Approaches : Validation Approaches Don’t:
Reason
Argue
Confront
Remind them they forgot
Question recent memory
Take it personally!!!
Validation Approaches : Validation Approaches Do:
Allow time for your message to “sink in”
Slow down. Take your time -- even when you are in a hurry!
Take “but” out of your vocabulary
“But we just talked about that”
“But I just told you why not”
“But that’s tomorrow, not today”
“But that’s not yours”
Validation Approaches : Validation Approaches Do:
Distract them to a different subject, activity
Accept the blame for misunderstandings (even if when you know better!)
“I’m sorry. I didn’t mean to frighten you.”
“I’m sorry if that that hurt.”
Leave the room to avoid confrontations
“I’m going to the kitchen now. I’ll be back.”
“Let’s stop now. We’ll do this later.”
Validation Approaches : Validation Approaches Do:
Respond to feelings, not words
Be patient, cheerful, reassuring
Go with the flow! You’re going to work?But you are on vacation this
week. Stay home with us . . .
Please?
Validation Approaches : Validation Approaches Do:
Listen carefully to type and extent of false beliefs
Monitor level of distress experienced by the person
Persistent, severe, and troubling beliefs may reduce comfort and function
Short-term, low-dose medication may be needed
Try all other approaches first!!
PLST Care Planning : PLST Care Planning Problem-solving requires good documentation!
Demanding? In what way?
Disoriented? To time? Place? Or person?
Delusional? What about? What did she say? Do?
PLST: Care Planning : PLST: Care Planning Evaluate Care
Sleep patterns
Weight
Food & fluid intake
Incidents and outbursts
How often?
How long?
How severe?
Medication use
Summary : Summary Dementia is INCURABLE but not UNTREATABLE!
Preserve remaining abilities
Avoid unnecessary stress
Treat overlapping illness that makes symptoms worse
Provide education & guidance to families