Reframing Challenging Behaviors

Transcription

1 Handouts are intended for personal use only. Any copyrighted materials or DVD content from Positive Approach, LLC (Teepa Snow) may be used for personal educational purposes only. This material may not be copied, sold or commercially exploited, and shall be used solely by the requesting individual. Copyright 2017, All Rights Reserved Teepa Snow and Positive Approach to Care Any redistribution or duplication, in whole or in part, is strictly prohibited, without the expressed written consent of Teepa Snow and Positive Approach, LLC Reframing Challenging Behaviors Teepasnow.com/resources/presentation by Using Positive Approaches to Care What Causes Distress or Resistance? Mis-match between: What we expect versus what happens What we can do versus what is needed Reframing the Situation: Learning to Interpret & Respond When Dementia is Part of the Picture & Meet Unmet Needs What was versus what is What we want versus what we get What we want versus what the other wants Who we are with versus who we want to be with Where we are versus where we want to be Who we are versus who we want to be.. 1

2 Why Is This So Difficult for People Living with Dementia? MANY abilities are affected Thoughts Words Actions Feelings It is variable Moment to moment Morning to night Day to day Person to person Place to place Some changes are predictable BUT complicated Specific brain parts Typical spread Some parts preserved It is progressive More brain dies over time Different parts get hit Constant changing What Do We Notice First? In most cases BEHAVIOR!!!! What behaviors are we talking about? So WHY is this happening? What is DRIVING the Behavior? My Examples No F PoA or HC PoA Paranoid/delusional thinking Going to MD problems Shadowing - following Losing Important Things Eloping or Wandering Getting Lost time, place, situation Seeing things & people not there - Unsafe task performance hallucinations Repeated calls & contacts Getting into things Refusing help & care Threatening caregivers Bad mouthing you to others Undressing in public not changing when needed Making up stories - confabulation Problems w/intimacy & sexuality Undoing what is done Being rude - intruding Swearing/cursing, sex talk, racial slur, ugly words Feeling sick not doing anything Making 911 calls Use of drugs or alcohol to cope Mixing day & night Striking out at others Sleep problems too much or too little Falls & injuries Not following care/rx plans - denying Contractures & immobility No initiation can t get started Infections & pneumonias Perseveration can t stop repeating Problems w/ eating or drinking Not talking any more Rethink Challenging Behaviors REFRAME as Unmet Needs 2

3 A New Look at Amygdala Activity for 2018 An Ever-Changing Appreciation of Our Brains! Top Five Human Needs and Emotional Indicators of Distress Five Expressions of Emotional Distress Angry irritated angry furious Sad dissatisfied sad hopeless Lonely solitary lonely abandoned/trapped Scared anxious scared terrified Lacking Purpose disengaged bored useless Five Human Needs Intake Hydration, nourishment, meds Energy Flow tired or revved up directed inward or outward Output Urine, feces, sweat, saliva, tears Comfort 4 Fs and 4 Ss PAIN Free!!! Physical, emotional, spiritual Left DANGEROUS Aroused/ Risky Alert/ Aware Amygdala Right NEED Want Like 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, O 2sat, 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) Scale of Emotional States LEFT Amygdala - Distress Best Practice When It Comes to Engaging Amygdalae Building Self Awareness & Supporting Change in a Positive Direction Or at Least a Less Negative Place Low Amygdala Active Alert Irritated Bothered Dissatisfied Blue Missing it Not getting it Missing freedom/control Nervous Anxious Disengaged Antsy Medium Amygdala Stressed at Risk Angry Frustrated Sad Unhappy Lonely Disconnected Confined/restricted Scared Worried Bored Roaming High Amygdala in Control Endangered Furious Enraged Devastated Hopeless Abandoned Isolated Imprisoned Terrified Panicked Useless Purposeless Frantic 3

4 Scale of Emotional States Scale of Emotional States - RIGHT Amygdala - Pleasure Low Amygdala Active Alert Irritated Bothered Dissatisfied Blue Missing some Missing freedom/control Nervous Anxious Disengaged Antsy Medium Amygdala Stressed at Risk Angry Frustrated Sad Unhappy Lonely Disconnected Confined/restricted Scared Worried Bored Roaming High Amygdala in Control Endangered Furious Enraged Devastated Hopeless Abandoned Isolated Imprisoned Terrified Panicked Useless Purposeless Frantic Low Amygdala Active Liking It Medium Amygdala Stressed Wanting to Do More Excited Hyped Up Hysterical High Amygdala in Control Need Something Happy Boisterous Slap Happy or Delirious Connected or In Control Can t seem to get it Controlling or Clingy Energized Rev ed Racing Around Full of Purpose Committed Demanding Others Get Purpose What Makes BEHAVIORS Happen? SIX pieces The person & who they have been Personality, preferences & history Other medical conditions & sensory status The type & level of cognitive impairment NOW People - How the helper helps - Approach, behaviors, words, actions, & reactions The environment setting, sound, sights The whole day how things fit together First Piece of the Puzzle The person & who they have been Personality, preferences & history Life Long Personality Traits & Preferences Make a Difference We are more of who we have always been UNLESS We have always been covering up who we really are we decide to let go OR Dementia robs us of our ability to be the way we want to be OR Dementia causes us forget how we are supposed to be and lets us be free Personal Preferences Matter We like what we like! With DEMENTIA the likes can change Old preferences will need to be revisited The Challenge is to HONOR what is important BUT change what is needed Our willingness to meet the person s changing NEEDS is essential Changes are made harder by our sense of LOSS and GRIEF 4

5 Some Personal Preferences How Does Dementia Affect This? Appearance Behaviors Language Daily routines Foods & Drinks Music Touch & Textures & Noise & Space Worship Spiritual practices Memory Language understanding & production Self-care skills Sensation Emotional control Reasoning & thinking Vision How Might This Work with YOU? Personality Traits 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? Some stuff we think/feel people do on purpose is really just WHO they are 5

6 What About the Person with Dementia? Which is BETTER? There is no BETTER Just Different Just Ranges They are at HOME They have needs how will we help? How can we change the environment to help? Who needs to know this? Second Piece of the Puzzle Other medical conditions Sensory status vision, hearing, sense of touch, balance, smell, taste Medications 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 Third Piece of the Puzzle: Type(s) and Current State of Dementia Complicated!!!! The Three D s: Is it dementia? Is it JUST dementia? Is it dementia PLUS? 6

7 What s What For Each D Dementia Delirium Depression What s What? Onset Hx & Duration Alertness & Arousal Orientation responses Mood & Affect Causes Treatment for the cause/condition Treatment for the behavioral symptoms 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 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 If it looks like dementia Explore possible types & causes Explore what care staff & family members know and believe about dementia & the person Determine stage or level compared with support available & what we are providing Seek consult and further assessment, if documentation does NOT match what you find out Alzheimer s Disease Young Onset Late Life Onset DEMENTIA Vascular Dementias (Multi-infarct) Lewy Body Dementia Fronto- Temporal Lobe Dementias 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 7

8 Dementia What Changes? Positron Emission Tomography (PET) Alzheimer s Disease Progression vs. Normal Brains Structural changes permanent Cells are shrinking and dying Chemical changes - variable Cells are producing and sending less chemicals Can shine when least expected chemical rush Normal Early Alzheimer s Late Alzheimer s Child G. Small, UCLA School of Medicine. Learning & Memory Center Hippocampus BIG CHANGE Normal Brain Alzheimers Brain Understanding Language Teepa Snow, Positive Approach, BIG LLC to be reused CHANGE only with permission. Hearing Sound Not Teepa Snow, Positive Changed Approach, LLC to be reused only with permission. 8

9 Sensory Strip Motor Strip White Matter Connections BIG CHANGES Automatic Speech Rhythm Music Expletives PRESERVED Formal Speech & Language Center HUGE CHANGES Executive Control Center Emotions Behavior Judgment Reasoning Vision Center BIG CHANGES So, You are NOTICING CHANGES The Real Three D s Dementia Depression What Should You DO? Get it assessed Think about what needs to CHANGE! Delirium 9

10 REALITY What Could It Be? 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 Another medical condition Medication side-effect Hearing loss or vision loss Depression Acute illness Severe but unrecognized pain Other things 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 Another Complication: Progression More changes over time Not a stable condition Washington Manual Geriatrics Subspecialty Consults edited by Kyle C. Moylan (pg 15) published by Lippencott, Wilkins & Williams, 2003 Progression of Dementia What Level Is the Person At? 10

11 Now for the GEMS Sapphires Diamonds Emeralds Ambers Rubies Pearls Now for the GEMS Sapphires True Blue Slower BUT Fine Diamonds Repeats & Routines, Cutting Emeralds Going Time Travel Where? Ambers In the moment - Sensations Rubies Stop & Go Big Movements Pearls Hidden in a Shell - Immobile What shouldn t we do??? Fourth Piece of the Puzzle YOU AND OTHERS Argue Make up stuff that is NOT true Ignore problem behaviors Try a possible solution only once Give up Let them do whatever they want to Force them to do it So what SHOULD we do??? Build & Use Skills! Remember who has the healthy brain! Believe - People with dementia Are doing The BEST they can! 11

12 Fifth Piece of the Puzzle Environment Physical Sensory Social Looking At the Environment What Helps What Hurts??? Supportive Environments Supportive Environments Include 2 Factors Include 2 Factors What you LIKE What you LIKE What s GOOD for you! Supportive Environments The 3 Positive P s Finding Balance Physical Environment Support or impair People the ways they act and respond Too much or too little Programming 12

13 The Supportive Sensory Environment What you See What you Hear What you Feel What you Smell What you Taste Environments Can Support Life! Use them Wisely Sixth Piece of the Puzzle Daily Routines and Programming Filling the Day with Valued Engagement Gem Level Programming Examples of Meaningful Activities Productive Activities sense of value & purpose Leisure Activities having fun & interacting Self-Care & Wellness personal care of body & brain Restorative Activities re-energize & restore spirit Productive Activities Leisure Activities Helping another person Helping staff Completing community tasks Making something Sorting things Fixing things Building things Organizing things Caring for things Counting things Folding things Marking things Cleaning things Taking things apart Moving things Cooking/baking Setting up/breaking down Other ideas. Active Socials Sports Games Dancing Singing Visiting Hobbies Doing, Talking, Looking Passive Entertainers Sport Program/event Presenters Lobby sitting TV programs watched Activity watchers Being done to 13

14 Self-Care & Wellness Activities Rest & Restorative Activities Cognitive Table top tasks Matching, sorting, organizing, playing Table top games Cards, board games, puzzles Group games Categories, crosswords, word play, old memories Physical Exercise Walking Strengthening tasks Coordination tasks Balance tasks Flexibility tasks Aerobic tasks Personal care tasks Sleep Naps Listen to quiet music with lights dimmed Look at the newspaper Look at a calm video on TV screen Rock in a chair Swing in a porch swing Walk outside Listen to reading from a book of faith Listen to poetry or stories Listen to or attend a worship service Stroke a pet or animal Stroke fabric Get a hand or shoulder massage Get a foot soak & rub Listen to wind chimes Aroma therapy Teepa s Rules Music at least TWICE a DAY Something Productive for each EMERALD resident Play with people keep it adult - watch for cues Smooth out Transitions - If they can DO something support their doing, don t do to them or for them Encourage helping and ALWAYS say THANK YOU Respect space preferences introverts/extroverts Match Sensory Experience to Preferences Sight, sound, smell, touch, taste Before Breakfast What do we want? How will we do it? Breakfast After Breakfast What do we want? How will we do it? Lunch After Lunch What do we want? How will we do it? Each DAY Dinner What do we want? How will we do it? Bedtime What do we want? How will we do it? So A Quick Look at C Consequences What Happens? Traditionally What Happens? Non-Traditionally We wait till it gets dangerous or at least risky Behavior = Unmet Need We blame ABC Annoying behaviors We knee jerk react Become a detective We treat the immediate Get EVERYONE involved early and often We become parental Re-look & monitor - lots We become judges Change what is easiest first We give up Change what can be controlled We go thru the motions Celebrate all improvements We go to drugs #1 Start by changing OURSELVES anti-anxiety & anti-psychotic 14

15 What Can YOU Control? OR NOT! CONTROL The environment setting, sound, sights The whole day how things fit together How the helper helps - Approach, behaviors, words, actions, & reactions NOT CONTROL The person & who they have been Personality, preferences & history The type & level of impairment NOW Other medical conditions & sensory status For your persons with problem behaviors REFRAME Get interested and excited be challenged! Describe the Behavior Investigate Carefully!!! Consider video to investigate Use objective language to describe THE BEHAVIOR Investigate NON-CHALLENGING BEHAVIOR - investigate what is going on when the behavior is NOT happening.. Check it out from all perspectives 360 From Microscope to Telescope. Use a sensory approach look, listen, feel, smell, taste, movement Check out the environment Look at public, personal, intimate space issues Get in their shoes & position Pay attention to cues and responses Look at timing, sequencing, & responses What Makes BEHAVIORS Happen? DISCLAIMER SIX pieces The type & level of cognitive impairment NOW The person & who they have been Personality, preferences & history Other medical conditions & sensory status The environment setting, sound, sights The whole day how things fit together People - How the helper helps - Approach, behaviors, words, actions, & reactions The content contained in this presentation is strictly for informational purposes. Therefore, if you wish to apply concepts or ideas contained from this presentation you are taking full responsibility for your actions. Neither the creators, nor the copyright holder shall in any event be held liable to any party for any direct, indirect, implied, punitive, special, incidental or other consequential damages arising directly or indirectly from any use of this material, which is provided as is, and without warranties. Any links are for information purposes only and are not warranted for content, accuracy or any other implied or explicit purpose. This presentation is copyrighted by Positive Approach to Care and is protected under the US Copyright Act of 1976 and all other applicable international, federal, state and local laws, with ALL rights reserved. No part of this may be copied, or changed in any format, sold, or used in any way other than what is outlined within this under any circumstances without express permission from Positive Approach to Care. Copyright 2017, All Rights Reserved Teepa Snow and Positive Approach to Care 15