Transcript Search of Literature Best evidence

Non-pharmacological
Dementia Care:
Preventing Challenging Behaviors
Social Work Conference
Illinois State University
Dr. Marty Sparks
March 19, 2014
Content Outline
• Establishing baseline
• Definition: Diagnostic Criteria
• Theory/evidence base
– Retrogenesis (Reisberg)
– Hierarchy of Human Needs (Maslow)
• Interventions to address
– Conference objectives
– Stage and need
– Challenging behaviors
• Participant comments/questions
Identifying Baseline
• Objective Measures
– Functional (IADLs, ADLs)
– Cognitive (including depression)
• Psychosocial and behavioral histories
– Personality characteristics
– Personal care preferences(likes, dislikes)
– Lifelong patterns (background)
Identifying Baseline
• Background Information
– Cultural, societal factors
– Environmental factors
– Interactional factors
(Key concepts: patient’s characteristics, life
story, and environment – to individualize
guidelines (Vickland, 2012)
Use of Baseline Information
• To tailor care to the
needs of the person
• To tailor care to the
capabilities of the
person
• To make care
consistent with the
individual’s life
context.
DSM-5 Diagnostic Criteria
Major Neurocognitive Disorders (NCD)
A. Evidence of significant cognitive decline from
previous level in one or more domains (learning
and memory, attention, executive function,
language, perceptual-motor [visual perception,
praxis, gnosis], social cognition)
B. Cognitive deficits interfere with independence in
everyday activities.
C. Cognitive deficits not exclusively in context of
delirium
D. Not better explained by another mental disorder
DSM-5 Criteria: Alzheimer’s Disease
A. Criteria are met for major or mild NCD
B. Insidious onset and gradual progression of
impairment
C. Criteria met for probable or possible AD:
1. Evidence of genetic mutation
2. All three of the following:
a. Decline in memory and learning and at least
one other cognitive domain.
b. Steadily progressive, gradual decline in
cognition, without extended plateaus
c No evidence of mixed etiology
D. Not better explained by CVD, NDevelopmentalD,
effects of substance, or another disorder
Retrogenesis Theory
As the disease progresses, the patient’s
knowledge and skills (physical, social,
coping) regress in reverse developmental
order, and responses may be influenced
by memories of the corresponding
developmental stage of childhood.
(Reisburg et al., 1984-2002)
Advantages to Reverse
Development Approach
• Don’t expect person to behave like normal adult
• Know that interacting with as though fully
functional adults causes more harm than good
• View behaviors as normal for stage, not as
problematic
• Illness becomes predictable, understandable
• We know approaches that work
• We meet their needs rather than expect them to
meet ours
Instrumental ADLs
Prediction of Loss
•
Mild Stage
– Managing Money
– Managing Medications
– (communication changes)
– (awareness, ?denial or depression)
• Moderate Stage
– Managing Transportation (Driving)
– Shopping
– Doing Housework/Laundry
– Preparing Meals
– Using Telephone
Phone
• Normal usage
• Call with
programmed phone
or list of numbers
• Answer phone
• Talk if handed
phone
• (Out of sight, out of
mind)
• Unable to use
Basic ADLs
Prediction of Loss
• Moderately Severe Stage
– Dressing, Bathing, Toileting
– (pacing, wandering)
– (resistance to care)
– (agitation, aggr ession)
– (hallucinations)
• Severe Stage
– Continence
– Feeding (malnutrition)
– Transfer
Dressing
•
•
•
•
•
•
Must reassess each day to know what
they can do
Lay out clothes
Hand clothes to them in order
Start arms into sleeves/legs into pants
Button buttons, zip zippers
No pull overs, comfortable clothing
Put clothing on for patient
Eating
•
•
•
•
•
•
•
•
•
Set up plate
Prepare food on plate – cut, butter,
Hand utensil
Have finger foods
Ignore forgotten manners
Assist feed
Feed more often
Alter consistency of foods
Use high nutrition, supplemental drinks
Fluids
•
•
•
•
•
•
•
•
Regular container any place
Supervised drinking
Place container in hand
Plastic container with lid
Assist to hold container
Hold container and give fluids
Sports cup and/or straw
Unable to drink
Lewy Body DSM-5 Criteria
C. Disorder meets a combination of core
and suggestive diagnostic features (based
on numbers of each)
1. Core diagnostic features:
a. Fluctuating cognition with variations
in attention and alertness.
b. Recurrent visual hallucinations: well
formed and detailed
c. Spontaneous features of
parkinsonism, after cognitive decline
starts
Lewy Body DSM-5 Criteria Cont’d
2. Suggestive diagnostic features:
a. meets criteria for rapid eye
movement sleep behavior disorder
b. Severe neuroleptic sensitivity
NCD due to Parkinson’s
Disease
• Mild or major neurocognitive disorder met.
• Occurs after Parkinson’s disease has been
established.
• Insidious onset and gradual progression
• Not attributable to another medical
condition
• No evidence of mixed etiology
• Parkinson’s disease clearly precedes
DSM-5 Criteria
Frontotemporal NCD
C. Either 1 or 2
1. Behavioral variant:
a. Three or more of the following
i. Behavioral disinhibition
ii. Apathy or inertia
iii. Loss of sympathy or empathy
iv. Perseverative, steroptyped or
compulsive/ritualistic behavior
v. Hyperorality or dietary changes.
Frontotemporal NCD: DSM-5 Criteria
b. Prominent decline in social cognition
and/or executive abilities
2. Language variant:
a. Prominent decline in language ability
(speech production, word finding, object
naming, grammar, or word comprehension)
D. Relative sparing of learning and memory and
perceptual-motor function
Maslow’s Hierarchy of Human
Needs (5 Stage Model)
Self
Actualization
Self-Esteem
Love Belonging
Safety
Physiological
Contributing Factors for
Challenging Behaviors
• Unrealistic expectations
• Control issues
• Anger, anxiety, fear
(Threat perception: Jablonski, 2011)
• Medications
Rethinking Dementia Care
Non-pharmacological Approaches
• Meet person’s needs rather than forcing
person to conform to needs of setting.
• Focus change on transforming the
environment not the person.
• Address spirit and psyche to increase wellbeing and quality of life.
• Prevent boredom; maintain normalcy
• Focus on lifelong patterns and preferences
Culture Change, Person-centered Care
Communication Regression
Mild Stage
•
•
•
•
•
•
Repetitious
Difficulty word finding/difficulty spelling
Lose train of thought
Can use reminders
Can make decision, use logic (sometimes)
May want to retain control
Communication Regression
Moderate Stage
• Usually understandable communication in
known situations/about known topics
• Can process one-command requests
• Can answer yes-no questions
• Withdraw/Less verbal communication
• Difficulty organizing words logically
Communication Regression
•
•
•
•
•
•
Moderately Severe Stage
Words don’t make sense or fit the situation
Respond according to other’s behavior
Respond according to early life/ life long
experiences
Decreased verbal communication
Maintain social graces
Have lucid moments
Communication Regression
Severe Stage
• Except for lucid moments, no verbal
communication
• Decreased non-verbal communication
• Continues to respond to non-verbal
communication
• May vocalization in non-language
Interaction/Behavioral Interventions All
Stages by Need
Esteem (Independence)
Respect, honor
Call by preferred name (recognize)
Be calm, don’t raise voice or argue
Talk about things familiar, meaningful to patient
(reminisce); Use clear, direct statements
Negotiate, collaborate, partner
Allow to do everything possible; unobtrusively do
what s/he cannot do
Focus on strengths; acknowledge, don’t
emphasize, deficits
Interaction Interventions All Stages
by Need
Love/Belonging







Allow flexibility, negotiate, collaborate
Simple greeting, careful listening
Gentle touch, subtle wave
Briefly orient to room, unit, schedule
Keep tone low and pleasant
Display a level of affection and sense of humor
Music: Method and type may vary by stage
Interaction Interventions All
Stages by Need
•
•
•
•
•
•
•
Safety/Security
Address fear of abandonment
Family member present
Be with, affirm support
Social conversation, speak softly
Read, sing to/with
Don’t confront, force, or control
No violence on TV/DVDs
Interactional Interventions
Moderate, Moderately Severe,
Severe Stages
•
•
•
•
•
•
•
Don’t reorient
Don’t use logic
Reminisce
Distract, redirect
Foster peace
Respond as though words make sense
Use concrete language
Interactional/Behavioral
Intervention: Play
Spontaneity and self-expression
Joy in the moment (linger in moment)
Enjoyable now (coffee/cookie break)
Capacity to suspend logic
Lifelong pleasures
Children, pets present
Nonverbal Communication










Touch/hold hand
Light Massage/smooth brow
Smile/Laugh/facial expression
Be in line of vision
Provide loving care
Keep comfortable
Gift of presence
Protect from embarrassment
Guide patient in unobtrusive manner
Environmental changes
Environmental Interventions
• Modify according to preference
• Use controlled sensory stimulation
– Sight
– Touch
– Hearing
– Smell
– Taste
• Provide inside and outside walking
pathways (pacing)
Environmental Interventions
•
•
•
•
•
•
To prevent resistance during bathing:
Accommodate preference: shower, tub, bed;
morning, evening; covered, uncovered
Pleasant: Colorful, private, heated floors, soft
music, no glare, plants
Needed objects: In sight, organized
Water temp of choice, pleasant aroma
Temperature warm, warm towel/bath blanket
Handheld shower head – no water on face
Hallucinations
Contributing Factors
• AD regression –
– They are living in
different reality
– Flash backs
• Other dementias
Non-Frightening Hallucinations
•
•
•
•
•
•
Acknowledge the hallucination
Talk about it
Enter their reality
Move to reminiscence
Then to distraction
Have an enjoyable conversation
(Deal with own discomfort)
Frightening Hallucinations
• Acknowledge, talk about
• Work to resolution maybe using validation
therapy (Naomi Feil)
• Remove the frightening object (good
lighting may help)
• Stay with
• Observe for recurrence
(Deal with own discomfort)
Terminal Hallucinations
(Awareness of Death)
Angels and/or departed family member
• Usually the gift of presence/therapeutic
use of self is appropriate (silence, being
with)
• Maybe say, ‘Nice to see them again.’ or
‘Comforting, isn’t it?’
• Base words and behaviors on patient’s
behavior
Song Demonstrating Sensitivity
and Communication when
Dealing with Altered Reality
• http://www.youtube.com/watch?v=txCUwS
Ko1kg
Raymond, by Brett Eldredge
Non Pharmacologic Interventions
Problem Behaviors (AAN)
• Music, during meals and bathing; walking or other light
exercise (Guidelines)
• Practice Options
– Simulated presence therapy, such as the use of
videotaped or audio-taped family
– Massage; Pet therapy
– Requests made at the patient’s comprehension
level
Pacing and Wandering
Contributing Factors
• Physical or psychological
need
–
–
–
–
Thirst/hunger, Elimination
Discomfort
Interaction
To ‘go home’ or fulfill former
obligations
• Internal restlessness r/t
illness or medication
Pacing/Wandering
Interactional/Behavioral Interventions
• Anticipate needs, assist to or meet needs
•
•
•
•
Verbal interaction activities
Exercise pattern, regular time daily
Social/Recreational activities of interest
Relaxation activities
Pacing/Wandering
Environmental Management
• Safety – when constantly walking
– Safe inside and outside walking paths
– Fenced yard, door knob covers or locked doors,
gates, visual barriers(shear curtains, camouflage)
– Decorate soft, uncluttered walkway
– No breakables, sharps within sight/reach
– Medicine out of sight/reach
– Strategically placed chairs or broad-based rockers
Wandering
Environmental Management
• Stimulating – meaningful
– Birds, bird feeders, games
– Windows, picture albums
with old pictures
– Animals, people
Caregivers
Most Important People!!
Informal
Formal
Needs Identified by Caregivers
•
•
•
•
Emotional and social support
Information
Financial support
Accessible and appropriate facilities
• (Vaingankar, et al., 2013)
Challenging behaviors occur more often after
transfer to a new setting, particularly if there is
no known person present. (Replace continuity
of care with continuity of setting and caregivers.)
Caregiver Emotions
–Conflict
–Anger/guilt
–Uncertainty
–Sadness
–Fear, Anxiety
–Worry, Burden
–Pleasure
–Fulfillment
–Reward
–Satisfaction
Relieving Caregiver Burden by
Reducing BPSD
• Cognitive enhancer meds (Levy, Lanctot, Farber, Li, &Herrmann,
2012)
• CG learning positive care management strategies
and ways to react to challenging behaviors (Norton et al,
2013)
• Educated, guided involvement in home, residential,
or community (Brodaty & Arasaratnam, 2012; Gitlin, Mann, Vogel,
Arthur, 2013)
• “Spiritual beliefs might help caregivers to find
meaning in caregiving and thus appraise
…behavioral problems as less stressful.” (Marquezgonzalez, Lopez, Romero-moreno, Losada, 2012)
Family Caregiver
• Refer to
– Illness-specific Association, other
– Illness-specific support group
– Attorney; Financial planner
– Care alternatives: Adult day care, home
health, companion, respite, home-bound
meals, etc.
– Websites
– Counselor
Family Caregiver
• Provide information about
– What to expect
– What can be done
– How to do what needs to be done
– What resources are available
– Treatment options
– Person to call
– How to assess and evaluate services, including
nursing homes
Caregiver Reminders
•
•
•
•
•
•
•
•
•
I can take care of myself
I can simplify my lifestyle
I can allow others to help
I can focus on what patients can still do
I can receive love and support from others
I can know that I am doing the best I can
I can take one day at a time
I can sing, laugh, enjoy life
I can take some time for myself