Transcript Athletic Goals - Alzheimer's Association

B. Heath Gordon, Ph.D.1,2,3
11.08.13
1. G.V. (Sonny) Montgomery VAMC
2. UMMC School of Medicine, Division of Geriatrics
3. Private Practice, Jackson, MS
None
Upon completion of this 1-hour learning activity, attendants
should be able to:
1.
Identify the primary types and causes of dementing illnesses
2.
Describe the cognitive and behavioral features of different
dementing illnesses
3.
Identify a behavioral model and techniques for managing
challenging behaviors in loved ones with dementia
Multiple cognitive deficits:
Memory
Impaired ability to learn new things or recall old information
Plus (one or more of the following):
Language disturbance
Difficulty performing motor activities (w/ intact motor ability)
Failure to recognize or identify objects (w/ intact senses)
Impaired planning, organizing, sequencing, or abstracting ability
Symptom must interfere with daily life
Represents a decline from a higher level of functioning
Does not occur exclusively during an episode of delirium
Not better accounted for by another mental health
condition
Major and Mild Neurocogitive Disorders (NCDs)
Evidence in cognitive decline in one or more areas based on
1.
2.
Self-report or an informant, AND
Clinical assessment
Subtypes of NCD are specified
E.g., Probable major neurocognitive disorder due to Alzheimer
disease, with behavioral disturbance, moderate
Greater alignment with consensus criteria
E.g., Probable vs. Possible Alzheimer disease
Progressive disease
Metabolic disorders
Vascular disease
Endocrine disorders
Trauma
Epileptic disorders
Tumors
Toxic reactions
Substance-induced
Anoxia
Infection
Vitamin deficiency
Alzheimer disease (DAT)
Vascular dementia (VaD)
Dementia with Lewy bodies (DLB)
Frontotemporal lobar dementia (FTD)
Parkinson’s disease
Substance-induced
Huntington’s disease
persisting dementia
Multiple sclerosis
HIV-related dementia
Pick’s disease
Dementia pugilistica
Hydrocephalus
Multiple etiologies
Creutzfeld-Jacob disease
Memory impairment:
Learning & Recall
One or more impairments in the following:
Speech and/or understanding language = aphasia
Skilled movement = apraxia
Object recognition = agnosia
Judgment, planning, switching tasks, etc. = executive functioning
Cognitive deficits represent a significant decline
Gradual start and decline in cognition (vs. sudden)
Deficits cause significant impairment in social or occupational
functioning
Generally a gradual onset with initial difficulty
remembering recent events (perhaps mood
changes) that becomes global and affects longterm memory
Accounts for ~60-80% of all dementing illnesses
Due to neuronal atrophy, synapse loss, abnormal
accumulation of neuritic plaques and neurofibrillary
tangles
Memory impairment:
Learning or Recall
One or more impairments in the following:
Speech and/or understanding language
Skilled movement
Object recognition
Judgment, planning, switching tasks, etc (executive functioning)
Cognitive deficits represent a significant decline
Focal neurological signs and symptoms or lab evidence
indicative of cerebrovascular disease
Deficits cause significant impairment in social or occupational
functioning and are a significant decline
Generally an abrupt onset of cognitive deficits and
step-wise pattern of decline
Multiple injuries to the brain due to inadequate
blood supply
Where injury occurs determine type of cognitive deficits
Impairment in memory
memory retrieval > new learning
Deficits in attention/concentration
Impairment in judgment
Personality and mood changes
Stroke A ≠ Stroke B
Motor cortex
Motor function, fine motor coordination
Premotor cortex
Frontal eye fields, motor planning
Prefrontal cortex
“Executive functions”
Planning, organizing, monitoring, inhibiting
Motor speech area
Dysexecutive syndrome
Poor problem-solving, reasoning, sequencing, maintaining
behaviors (perseverative)
Poor motivation
Poor insight and judgment
Slow learning, environmental dependence, poor memory
attention, forgetting temporal sequence of events
Blunted and apathetic affect but anger when aroused
Emotionally dysregulated
Behaviorally disinhibited
Impulsive
Poor smell discrimination
Pseudopsychopathic syndrome
Disorganized
Lack of social graces
Poor appreciation for feelings of others or negative aspects of behavior
Associated with anterior cingulate
Akinetic and apathetic with bilateral damage
Little initiation of movement or speech
Lack of interest and indifference
Emotional blunting
Memory impairment (amnesia with confabulation)
Incontinence
Lower extremity weakness
Memory impairment:
Learning & Recall
One or more impairments in the following:
Speech and/or understanding language
Skilled movement
Object recognition
Judgment, planning, switching tasks, etc (executive functioning)
Cognitive deficits represent a significant decline
Evidence from medical exam of related illness
Deficits cause significant impairment in social or occupational
functioning
Associated with abnormal structures called Lewy Bodies in the brain
Gradual start and progression of cognitive decline
Fluctuating cognition and variability in alertness/attention
Abrupt confusion
Memory deficits (memory retrieval more than learning new information)
Parkinsonism
Bradykinesia (loss of spontaneous movement)
Rigidity (muscle stiffness)
Tremor
Shuffling gait
Visual hallucinations (well-formed, detailed, recurrent)
Frequent falls
Memory impairment:
Learning & Recall
One or more impairments in the following:
Speech and/or understanding language
Skilled movement
Object recognition
Judgment, planning, switching tasks, etc (executive functioning)
Cognitive deficits represent a significant decline
Evidence from medical exam of related illness
Deficits cause significant impairment in social or occupational
functioning
Loss of brain tissue in frontal and temporal lobes
Associated with abnormal structures in the brain (Pick’s Bodies)
Gradual start and progression of cognitive decline:
Behavioral & personality changes are significant
loss of personal (hygiene) and social (tact) awareness
Disinhibited and impulsive
Loss of initiative, indecision, lack of spontaneity
Impairment in speech and/or understanding language
Object recognition impairment
Impairment in skilled movement
Models for Understanding Behavior
Different types of disruptive behavior/agitation
Mixing three models
Matching Interventions to Disruptive
Behaviors
Based on environmental links
Individualized to ability and preference
Behavioral Disturbances: Behaviors we don’t want
to see but are present.
Physically Aggressive
Hitting
Kicking
Biting
Physically Non-Aggressive
Pacing
Inappropriate disrobing
Verbal Aggression
Cursing
Screaming
Threatening
Verbally Non-Aggressive
Crying
Repeated Questions
Constant Requests
Behavioral Deficits: Behaviors we do want to see but
are not present.
Decreased social skills
Apathy/Decreased display of emotion
Physical dependency/ADL limitations greater than indicated
by illness/disease
Unable to interact with their surroundings
Behaviors Rated by Dimension
VERBAL/VOCAL
VERBALLY NONAGGRESSIVE
-complaining
-negativism
-repetitive questions
-constant, unwarranted requests
for attention
NONAGGRESSIVE
VERBALLY AGGRESSIVE
-cursing and verbal aggression
-making strange noises
-verbal sexual advances
-screaming
AGGRESSIVE
PHYSICALLY NONAGGRESSIVE
-repetitious mannerisms
-inappropriate robbing and disrobing
-eating inappropriate substances
-handling things inappropriately
-pacing, aimless wandering
-intentional falling
-general restlessness
-hoarding things
-hiding things
PHYSICAL
PHYSICALLY AGGRESSIVE
-physical sexual advances
-hurting self or others
-throwing things
-tearing things
-grabbing
-pushing
-spitting
-kicking and hitting
-biting
(Cohen-Mansfield, 2000)
Role of Individual Qualities
Personal History, Habits, Preferences
Personality Style
Neurological/Brain structure and chemistry
Mental & Physical Abilities, Deficits
Role of Environmental Qualities
INTERNAL NEEDS:
Physical
Emotional
EXTERNAL DEMANDS:
Physical Surroundings
Social Surroundings
A connection occurs between
antecedents, behavior, and
consequences
Disruptive behavior is learned through
reinforcement from others
Goal: reinforce positive, appropriate
behavior and do not reinforce
negative, disruptive behavior
Based on Cohen-Mansfield, 2000
Unmet Needs Model
Life long habits
& Personality
Environment
Physical
Psychosocial
Unmet needs
and
Direct effects of
dementia
Need-Driven
Behavior
Current abilities
Physical & Mental
Person Environment Fit Model
Learning Behavior Model
All models focus on the reason or cause for the
behavior.
Need to understand behavior before you act
Does not decrease the person’s ability to interact,
which is already difficult.
Focuses on psychosocial interventions, and
does not have the drawbacks of medication.
Side effects
Drug interactions
Limited value (does not increase positive behavior)
All behavior has meaning
Behavior is a way of communicating
Behavior can be a demonstration of a person’s abilities,
disabilities, and challenges they face
Understanding the reason or cause is the best way to
manage disruptive behaviors
Try psychosocial approaches before medications
Interventions must be person-centered
“A”
Antecedents
“B”
Behavior
“C”
Consequences
The ABCs of Behavioral Management
A = Antecedent
B = Behavior
C = Consequence
Antecedent: what happens before the
behavior
Consequence: what happens after the
behavior
(Burgio & Stevens)
To identify the Antecedents and
Consequences, ask the ‘W’ questions
What
Why
When
Where
Who
(Burgio & Stevens)
Time & Date:
Behavior: List & Describe:
With whom? Number of people:
Where?:
Trigger Event(s):
Interventions Tried: List & Describe:
End Result(s):
Effective?:
Why do behavioral disturbances occur?
Internal factors
Memory loss
Sensory changes
Loss of communication skill
Pain/discomfort
(Burgio & Stevens)
Why do behavioral disturbances occur?
External factors
Over stimulation
Lack of stimulation
Lack of activity
Too many demands
(Burgio & Stevens)
Why do behavioral disturbances occur?
Caregiving situations
Factors in the caregiving routine can often cause the
residents to react with a behavioral disturbance.
These factors include
Too much information
Speaking too quickly
Touching without warning
(Burgio & Stevens)
Why do behavioral disturbances occur?
Verbal
Pointing out reality is not useful with a resident who is
confused or disoriented because of dementia
The resident with dementia cannot remember the correct
information
Frequently reminding a resident of correct information
gives a negative message
(Burgio & Stevens)
Why do behavioral disturbances occur?
Nonverbal
The nonverbal message, or your body language,
emphasizes what you are saying to the resident
Body language also gives an emotional message by
showing how you feel about the resident
Remember: Even though residents with dementia
have trouble understanding what you are saying or
doing, they still can receive the emotional message.
(Burgio & Stevens)
Yelling and Screaming:
Difficult symptoms because they disturb
others
May be a means for getting attention
May be a response to over or under
stimulation, fear, pain, hunger, feeling
overwhelmed or depression
Resisting Care:
Can result from fear, feelings of
powerlessness or misunderstanding, or if
the resident feels rushed or treated roughly
Many times the person with cognitive loss is
aware at some level of his/her loss of skills;
the refusal may be the only way the person
can have control and reduce feelings of
powerlessness
Verbal Aggression:
Includes arguing, cursing, threatening, swearing, or
accusing
May be the result of a loss of impulse control
Anything that increases stress may cause this
behavior
Verbal aggression may be a cry for help
May be a response to fear, pain, hunger, feeling
overwhelmed or depression
1.
Identify yourself by name
2.
Address Patient by name
3.
Speak slowly and allow time to communicate
4.
Give one-step instructions
5.
Phrase questions in a simple multiple-choice format
6.
Use positive statements whenever possible
7.
Avoid negative statements
Effective communication involves
positive choice of words
Don’t assume that the other person
knows what you think or feel
Avoid blaming or over-generalizing
“you are trying to be difficult”
“you always . . . “ “you never . . . “
Effective communication involves active
listening.
Sit or stand to face the person at a slight angle,
to connect but allow personal space.
Avoid mind reading or judging what the other
person is thinking or feeling BEFORE you listen
“you don’t want to hear what I say”
“you are trying to be difficult” “you don’t care”
Effective communication involves
understanding
Repeat what you heard
make sure you heard what was said correctly:
“I heard you saying X, is that correct?”
gives the other person the opportunity to
correct miscommunication
Restate what the person’s actions say
Accept what feelings the person has
Positive Reinforcement
Planned Ignoring
Distraction & Diversion
Replacing Disruptive Behaviors
When Patients are behaving in a manner
that is appropriate, reward them.
Give them attention for these good
behaviors
Remember:
Reward behaviors you want to continue
Ignore behaviors you want to end or not re-occur
Ways to give positive reinforcement
Attention
Praise and Appreciation
Acknowledgement
Comfort
Positive reinforcement can be used to
change the C, Consequences.
Positive reinforcement is a consequence
When a behavior is followed by a positive
reinforcer, the behavior is likely to occur
again
Therefore, only use positive reinforcement
for behaviors you want to re-occur. Don’t
reinforce behavioral disturbances.
Rules for reinforcing behavior:
1. Give reinforcement immediately following the
desired behavior
2. Reinforcement should be given each time the
desired behavior occurs
3. Make sure that the reinforcer is meaningful and
personal to the Patient.
4. Patient should not get the reinforcer unless the
desired behavior occurs
5. The reinforcer should be short-term.
There are a variety of tools to assist in
managing behaviors to change the As & Cs
Behavior management skills such as positive
reinforcement, planned ignoring,
distraction/diversion, and replacing behaviors
can be used to decrease disruptive behaviors