Enhancing Mobility & Reducing Fall Risk: A New Way of Approaching It!

Transcription

1 Enhancing Mobility & Reducing Fall Risk: A New Way of Approaching It! Why Do People MOVE? What are Your Mobility Problems??? - What are the key problems at your facility? - What have you tried? - What has worked? DEMENTIA - What hasn t worked? - Why? Alzheimer s Disease Early - Young Onset Normal Onset 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 Teepa Snow, Teepa Positive Snow, Approach, Positive Approach, LLC to be LLC reused to only be reused with permission. only with permission. Four Truths About Dementia - At least 2 parts of the brain are dying - One related to memory & the one other - It is chronic can t be fixed - It is progressive it gets worse - It is terminal it will kill, eventually Alzheimer s At Least Two Forms Young Onset Late Life Onset 1

2 Positron Emission Tomography (PET) Alzheimer s Disease Progression vs. Normal Brains Normal Early Alzheimer s Late Alzheimer s Child Normal Brain Alzheimers Brain G. Small, UCLA School of Medicine. Teepa Snow, Teepa Positive Snow, Approach, Positive LLC Approach, to be reused LLC to only be with reused permission. only with permission. Young Onset Alzheimer s - 3 groups genetics, Down s, life style - Young family kids often involved - Mis-diagnosis & non diagnosis is common - Work may be first place to notice - Relationships are strained early - misunderstood - Services are a problem usually - Finances are problematic - Executive decision making & sequencing DOWN - New info lost - Recent memory worse - Problems finding words - Mis-speaks - More impulsive or indecisive - Gets lost - Notice changes over 6 m 1 yr - Lasts 8-12 years Typical treatment for Alzheimers - Try an AChEI as soon as diagnosis is made - If side-effects are too much try another one - Stay on the AChEI until groups of thought - Placement in a facility - Considering other med stops near end - Not sure if helping or hurting taper and see - Try Namenda mid-stage disease - Stay on Namenda as above Vascular Dementias - Secondary - Old term MID - Many variations - CADASIL - genetic 2

3 Vascular Dementia - Sudden changes stepwise progression - Other conditions: DB, HTN, heart disease - So, damage is related to blood supply/not primary brain disease: treatment can plateau - Picture varies by person (blood/swelling/recovery) - Can have bounce back & bad days - Judgment and behavior not the same - Spotty loss (memory, mobility) - Emotional & energy shifts Vascular dementia - CT Scan - The white spots indicate dead cell areas - mini-strokes Latest Thinking About Vascular Treatment? - Lots of similarity with Alzheimer s - Manage blood flow issues CAREFULLY! - Watch for and manage depression Lewy Body Dementia - Movement problems - Falls - Visual Hallucinations animals, children, people - Fine motor problems hands & swallowing - Episodes of rigidity & syncopy - Nightmares or Insomnia - Delusional thinking - Fluctuations in abilities - Drug responses can be extreme & strange - Can become toxic, can die, can become unable to move - Can have an OPPOSITE reactions Latest Thinking about Lewy Body Treatment - Try AChIs Start Low & Go Slow - Then Try Namenda early Start Low & Go Slow - BE VERY careful about anti-psychotic meds (not Haldol) - Balancing movement losses & aid to function not working? - Parkinson s meds may/may not help movement BUT may make hallucinations and delusions worse - Anti-depressants may be used to help anxiety, sleep, & depression can increase confusion, movement & drowsing - Sleep aids or Anti-anxiety meds can cause paradoxical rxs 3

4 Fronto-Temporal Dementias - Many types Typically Younger Onset - Frontal impulse and behavior control loss (not memory issues) - Says unexpected, rude, mean, odd things to others - Dis-inhibited food, drink, sex, emotions, actions - OCD type behaviors - Hyperorality - Temporal language loss - Can t speak or get words out - Can t understand what is said, sound fluent nonsense words FTDs - FvFTD frontal varient of FTD - FTD frontal-temporal lobe dementia - TLD non-fluent aphasia - TLD fluent aphasia Temporal Lobe Non-Fluent Aphasia Can t NAME items Hesitant speech Not speaking Worsening of speech production over time Echolalia Mis-speaking Word salad Receptive inability Other skills intact early 25% never develop global dementia Temporal Lobe Fluent Aphasia Has smooth delivery More nonsense words Word salad May think they make sense Expect rhythm back Fixates on a few phrases Chit-chats if enjoying company Volume control varies limited awareness of others needs There are frequently 1-2 value words mixed in to speech Picks up on value words they hear they then connect & want to talk more FvFTD Mis-behavior Impulsivity Dis-inhibition Inertia Obsessive compulsive behaviors Inattention Lack of social awareness Lack of social sensitivity Lack of personal hygiene Becomes sexually overactive or aggressive Becomes rigid in thinking Stereotypical behaviors Manipulative Hyper-orality Language may be impulsive but unaffected OR may be reduced or repetitive FTD (Pick s Disease) Frontal Issues Poor decision making Problems sequencing Reduced social skills Lack of self-awareness Hyper-orality Ego-centric Dis-inhibited food, drink, words, actions OCD behaviors early Excessive emotions Temporal Issues Reduced attempts to talk Reduced content in speech Poor volume control Public use of forbidden words Sing-song speech Can t understand others words 4

5 Pick s Disease PET Scan Latest Thinking About FTD Treatments - Consider Namenda earlier - Look at SSRI medications - May use medications used to treat OCD - May NOT use AChI Medications What if it doesn t seem to be one of these? - Atypical or other dementias - Mixed picture Other Dementias - Genetic syndromes Huntington s Chorea - ETOH related Wernickes or Korsakoffs - Drugs/toxin exposure heavy metals, pesticides - White matter diseases - MS - Mass effects tumors & NPH - Depression and Other Mental Conditions - Infections BBB cross C-J, HIV/Aids, Lyme - Parkinson s 40% about 5-8 yrs in - Progressive Supranuclear Palsy Positron Emission Tomography (PET) Alzheimer s Disease Progression vs. Normal Brains Normal Early Alzheimer s Late Alzheimer s Child G. Small, UCLA School of Medicine. 5

6 Learning & Memory Center Hippocampus BIG CHANGE Normal Brain Alzheimers Brain Understanding Language Teepa Snow, Positive BIG Approach, LLC CHANGE to be reused only with permission. Hearing Sound Not Teepa Snow, Changed Positive Approach, LLC to be reused only with permission. 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 6

7 Why should you focus on mobility? - Building block for all ADLS - less mobility = more caregiving problems - your behavior affects their behavior - mobility skills can be changed - you can t safely ignore it - it affects interaction abilities - it is very visible, for better or for worse. Vision Center BIG CHANGES Simple Message - People MOVE to Meet NEEDS - People STOP MOVING to Meet NEEDS What Should You Do About Mobility??? - Screen and establish baselines - Communicate expectations to direct care staff - Model what you want to see! - Train direct care staff - Monitor staff performance and help fix - Monitor resident performance thru staff and with your own eyes - Teach staff to dynamically screen each time What? Key Elements of Risk Assessment Falls history Secondary Diagnosis Uses Ambulatory Aids IV therapy Gait abnormality Mental Status F Falls History - Fluids A Ambulation Aids L - Locomotion (gait) L - Lucidity (cognition) S Secondary Dx What can we DO about mobility? - Promote SAFE movement in caregiving - help people be mobile - improve movement skills - put movement into our schedules - learn how to help - limit too much mobility with environmental cues 7

8 How can you promote safe mobility? - Use a positive approach - Structure and monitor the environment - Use walking aids correctly - Slow DOWN! - Practice, practice, practice - Know your skills and limits A Positive Approach - Come from the front - Go slow - Get to the side - Get low - Offer your hand - Call out the name - THEN WAIT.. A Positive Approach - Come from the front - Go slow - Get to the side - Get low - Offer your hand - Call out the name - THEN WAIT.. Come from the front! - Approach within visual range - Remember, 45 degrees to the side is usual range for someone over 70 - If eye contact is attempted acknowledge it! Go SLOW! - Allow for recognition and awareness - Give the person a chance to get with it - Ability to process slows with time - Going too fast creates RESISTANCE Get to the side - Be supportive not confrontational - respect personal space - provide safety for self and resident - keep pose relaxed - best position to help is to the side 8

9 Get LOW! - Respect personal space - Bend your legs NOT your back - Reduce intimidation - Easier eye contact - Safer place to be - No chicken butts! Offer your hand - Look at the person s eyes - Keep an open palm - Allow the person to be the one to get the activity going - It is automatic - It is friendly Call their name Use their preferred name Say it once Use it to get attention Help with making a connection Help with communicating RESPECT! Mrs. Jones Miss Sarah Sarah Sister Sarah Sarah Jane NOT - honey NOT always Mrs... THEN WAIT! Progression & Change It s not all about loss It s see what is precious and unique - Sapphires Diamonds Emeralds Ambers Rubies Pearls Looking at GEMS - Sapphires True Blue Slower BUT Fine - Diamonds Repeats & Routines, Cutting - Emeralds Going Time Travel Where? - Ambers In the moment - Sensations - Rubies Stop & Go No Fine Control - Pearls Hidden in a Shell - Immobile 9

10 Movement hazards by GEM - Sapphires slower reflexes OOPS - Diamonds over/under estimate skills limited learning for new skills or patterns, fear of falls - Emeralds forget devices, skipping steps, resent control or interference, emotional reactions - Ambers exploring without caution, seeking or avoiding stimulation, pain or distress - Rubies walk till they drop, no depth perception, if going can t stop, if stopped can t get going, pain - Pearls contractures, falling into or out of seating, friction, pain, hygiene, isolation, selfprotection Mobility Enhancement by GEM - Sapphires daily exercise all kinds, - Diamonds exercise programs that match background preferences & beliefs - Emeralds build into the day & rearrange stable supports in the environment use people - Ambers create safer places and space to explore based on sensory needs & tolerance, seating - Rubies help with transitions, build in time for transitions, create schedules that make sense - Pearls become the connection to the world, go slow, rotate, use rotational movements, use new ways To Get Things Going: Use positive STROKES! DO offer simple choices it s time to. break it into little steps go SLOW use voice tone ask for help ask the person to TRY DON T get verbal diarrhea ask do you want to say you need to pull on them rush them forget to talk TO them get too focused on the action - Use touch - Use praise - Use yes! - Use good! - Use Thank you for helping me out! - Use That s it.. - Use a smile! Use the Environment to HELP! Use Walking Aids Carefully Personal Things shoes personal chairs that match the person planned movement during the day clearance to get feet under use non-skid mats General Things stable surfaces right height surfaces arm rests open areas in-sight destinations railings good lighting - Use of Devices - check out skills - check out devices - monitor devices for safety - monitor for need to change - call in an expert as needed - provide support and guidance as needed 10

11 Encourage Safe Walking - Guided Walking - plan for it - offer it - document it - reinforce it Coming to Stand - Pull back feet - Lean shoulders forward - Shift weight to feet - Use arm rests - Push to front edge - Lean forward - Push up to stand Coming to Sit - Cue lean forward with shoulders - Then cue reach back to arm rests - Continue forward leaning - Sit slowly - Your hand can go to opposite hip Practice - Standing up - Walking - Sitting down - Rear Repositioning - Front Repositioning - Transfer Keys to Recall - FIRST - focus on your approach - Stabilize yourself and surfaces - Cue and support movement - Take it SLOW & stay low - Use your LEGS not your back - Give positive strokes for effort - Practice, practice practice! To Improve Mobility... - Know your skills - Improve your skills - Change your habits - Know your residents - Fix the environment and devices - Have mobility goals - Keep track of progress 11

12 Learning In Life Do It What Am I Talking About? What are YOU going to do??? Try IT out Figure IT Out!? Think about what you did - Changing from - Habits of Care - to - Active & Effective Mobility 12