Working with Persons Living with Dementia: Practical Strategies. Objectives

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1 Working with Persons Living with Dementia: Practical Strategies Presented by: Loretta Bartz, OTR/L VP of Clinical Strategies HealthPRO-Heritage Objectives Describe the importance of our primary goal: to maintain the highest level of independence to ensure on-going quality of life for individuals living with Dementia. Learn how modifying an approach, the environment and/or a task can significantly enhance task performance. Identify the key principles of living in their world and excessive disability; understand how these principles play a role in either enhancing/inhibiting an individual s success. List the 7 stages of Dementia and common functional elements associated with each stage. Develop strategies for enhancing/facilitating functional performance by leveraging the residual strengths of individuals living with Dementia. 2 1

2 Understanding Dementia Psychiatrist Dr. Barry Reisburg divided the progression of dementia into seven stages known as the Global Deterioration Scale (GDS). Level One: No Cognitive Decline Level Two: Very Mild Cognitive Decline Level Three: Mild Cognitive Decline Level Four: Moderate Cognitive Decline Level Five: Moderately-Severe Cognitive Decline Level Six: Severe Cognitive Decline Level Seven: Very Severe Cognitive Decline Cognitive Stages Stages can be conceptualized as the developmental process in reverse. Last things learned (higher cognitive skills, judgment, tact, etc.) are the first skills lost. Signs & symptoms will vary slightly from one individual to another. Each individual living with Dementia is unique! Identify & leverage strengths to comprehensively address needs. 2

3 Overall Goal To maintain the highest level of independence and ensure quality of life. To achieve, consider modifications related to: Our approach and our way of interacting with each individual. The environment around the individual. The task they are performing. 5 Working with Persons Living with Dementia: Key Principles 1. Live in their world: Must learn to live in their world rather than expect them to conform to our structure in our world. 2. Learned helplessness: Take over doing tasks, and a person living with Dementia begins to lose skills within three days. Instead: Foster independence; utilize creative strategies to allow individuals to do as much as they are able. 3

4 Working with Persons Living with Dementia: Key Principles Effective communication: Key strategies 1) Slow down 2) Get down low 3) Allow ample time Avoid the following: Do not argue with the individual. Do not order the individual to do anything- rather, ask for their help. Do not tell the individual what she/he cannot do Do not be condescending. Do not ask a lot of direct questions that rely on a good memory. Do not talk about the individual as if she/he were not there. Dementia Care Golden Rules THE RULE Eye Contact Body Language Gestures Demonstrations Hand on Hand Reassurance Verbal Cues Environmental Cues DESCRIPTION Use direct eye-to-eye contact for all interactions. Remain calm and use a positive tone of voice and body language. Use visual cues to enhance the understanding of directions. Use visual cues to enhance the use of an object. Provide physical assistance cues to enhance the use of an object. Provide gentle touch, verbal compliments and validation. Repeat questions in simple and short statements; use one-step directions; break tasks down; go slow; use a calm speech pattern. Use written notes, pictures, objects, artwork, signs, and labels to orient a resident to their environment. 4

5 Understand Each Cognitive Stage To predict behaviors To develop strategies to support continued function within their environment despite cognitive loss To respond appropriately to the unique needs of each individual. Cognitive Stage Four May realize a problem with their memory exists Begin articulating concerns (e.g.: My memory isn t what it used to be. ) Become easily confused, especially with new situations, large crowds, and/or when fatigued or stressed. May need time alone when over stimulated. Avoid tasks they find too challenging. 5

6 Cognitive Stage Four May require prompts/reminders to initiate tasks such as: Meal times; walking to dining area Opening closets Gathering personal items for bathing/dressing Turning on water for a shower Will remain quite functional New learning can occur, with repetition and support. Don t realize they have memory problems. Can maintain ~ 5 minutes of new learning (e.g.: social conversation) but quickly forgets details/info. Should be redirected to the next topic if they are repeating themselves. Think they do not belong in the facility, or they are just visiting. Engage them by making them your assistant. Pair this person with others at a lower level. 6

7 Highest risk for elopements They don t think of themselves as residents. Can become very upset and often want to leave. Therapeutic fibbing is appropriate (A common technique used when caring for patients with Dementia in order to prevent increased anxiety, hurt, emotional damage) Have a family member record a short message specific to what generally would occur in the home environment. Playing such a message may encourage calm. (e.g.: Hi honey, I m running late. I ll pick up the stuff you asked for and I ll see you in a few minutes. Love you. ) Recording can be often repeated since individuals at this stage have 5 minutes of new learning. 7

8 Individuals should be 100% independent with self-care. If not, determine the following: Can he/she locate clothing? Are personal items situated similarly as they were at home? Would signage and/or photos to help locate items? Use words that have personal meaning, are relatable, common vernacular (e.g.: don t say briefs if they call them bloomers ) Use the color When making signs or labels Only color seen in late stages of dementia For clothes or placemats, for ease of use/identification Provides highest contrast Allows for more focus on prominent objects/tasks 8

9 Subtle change from Stage 5 - Stage 6 is characterized by stiff neck syndrome Individuals have difficulty rotating the head Instead: turn their whole body to locate items Make sure there is adequate space to do so Keep clutter to a minimum Individuals cannot perform 2+ simultaneous actions Identify how to adapt tasks to allow for one motor action at a time Delayed processing towards end of Stage Five May take up to 90 seconds to process info Give one direction at a time. Wait up to 90 seconds! Do not add more information or change verbiage; this will result in increased confusion or no response Rather use other cognitive cues/assistance i.e.: Visual Cues Environmental Cues Gestural Cues Demonstration Tactile Cues 9

10 Do not use STOP signs to keep Individuals from certain areas Many Individuals will stop and then proceed Instead: use Dead End or closed signs on doors - OR- Incontinence is not a normal part of Dementia Occurs because cannot locate a bathroom Note: All doors may look similar; unable to determine which door leads to a bathroom Also, since they think they are just visiting, refer to as Men s/women s restrooms; or Toilet 10

11 Cognitive Stage Six Level of visual gaze is subtly different At Stage 5: Will look at speaker during conversations At Stage 6: Gaze progresses downward -Eye to chin (early stage) -Eye to chest (mid stage) -Eye to 1-2 feet from floor (late stage) Do not stand directly in front of Individual Instead: get down, align with level of their gaze Adjust signage to align level of their gaze inches from the floor is ideal position for most Cognitive Stage Six Ronnie Regan Post name given by the individual (whether it is a maiden name or one from a previous marriage) Use address given by the individual instead of labeling signage with the name 11

12 Cognitive Stage Six Vison changes (loss of peripheral vision) are common Do not stand to side/behind when talking/instructing Instead: Get down to align with gaze when instructing Easily startled by those who approach from beyond visual field. (Often times, residents may strike out unprovoked in response) Ensure a individual cannot see you in a mirror appearing from behind Stay out of the visual field and don t TALK as individual navigate sequencing tasks Cognitive Stage Six Depth perception diminishes, and they may have difficulty with: Transitions between flooring changes Dark colors or shadows that impede perception Stride length becomes shorter; individuals tend to shuffle more and catch their toes when walking Instead: Use Reveal Lights by GE (Full spectrum lights help to decrease shadows/provide better contrast) Do not use rubber sole shoes! Instead: Use leather soles to allow feet to glide more easily or use duct tape at toes 12

13 Cognitive Stage Six Promote safe and comfortable toileting Prompted voiding and habit training do not work! Instead: Assist individual to toilet ~1 hour following meals Nervous system is intact, just delayed Give them sufficient time! Allow for 90 seconds to void. Sitting on cold toilet seat will be met with resistance by some Instead: heat seat with a blow dryer Cognitive Stage Six May be independent with certain self-care tasks Note: tasks must likely be completed in their way Identify what their way is Because new learning does not take place, use familiar items in familiar contexts (e.g.: soap bars vs liquid soap to wash hands) Question: When bathing, what do you wash first?? 13

14 Cognitive Stage Six Tasks related to feeding: Help with first scoop of food; initiate feeding activities when necessary Observe & identify feeding patterns; do not try to change these habits Never stand while assisting with feeding tasks Instead: sit at a level aligned with the person to encourage a natural chin tuck. Cognitive Stage Six Donning / doffing clothing and shoes Individuals become sensory in-tune to their bodies, so if they are removing clothing, find out why by starting with these questions: Is the shoe too tight? Are the clothes irritating/itchy? Is it to hot? Identify what environmental cues are contributing to the behavior. Note what has been communicated to the resident 14

15 Cognitive Stage Seven Individuals are focused on senses (taste, touch and smell) Do not talk too much Instead, communicate using senses touch, hearing, olfactory, and guiding through the movements. Many are craving sensory input. Be aware of signs such as: -Rocking and other repetitive movements -Hand wringing -Repetitive mouth movements -Crying -Withdrawn behaviors, eyes closed -Music -Familiar sounds -Familiar tastes -Familiar smells Use sensory input to illicit long term, ingrained memories such as: familiar sounds, tastes, smells Residents at Cognitive Stage Seven Diet and eating Puree food no longer looks like food. Encourage residents to view pureed food as soup Grind Diet features bite-sized finger foods so residents can manage without use of utensils Taste receptors change Only sweet and bitter receptors remain Stimulate appetite: add sugar/sugar substitute/syrup to stimulate sweet receptors 15

16 Residents at Cognitive Stage Seven To assess pain/discomfort: Observe body language and expressions. Pupils will dilate if in pain PAINAD scale which assess pain using a 3-point scale Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4(1):9-15. Conclusion Remember, our primary goal is to maximize quality of life while fostering a continued level of independence for each person who is living with dementia. Utilize your knowledge of each cognitive stage Leverage strengths identified Develop effective strategies to maximize the independence of the individuals living with dementia. Use concepts presented here to develop alternative approaches and techniques to work with the individual. 16

17 Questions Loretta Bartz, OTR/L VP of Clinical Strategies HealthPRO-Heritage