Transcript Understanding Difficult Behaviors

Strategies for Success:
Dealing with Dementia Behaviors
without Drugs
Part I
Elizabeth Edgerly, Ph.D.,
Bonnie Bollwinkel, LCSW
Northern California & Northern Nevada
Alzheimer’s Association
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A 3 Part Training Series
• This presentation is funded and supported by :
• The California Culture Change Coalition
• Centers for Medicare & Medicaid Services
(CMS)
• The California Department of Public Health
• For the California Partnership to Improve
Dementia Care and Eliminate the Misuse of
Antipsychotics in Nursing Homes
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Objectives for this workshop
To better understand Alzheimer’s disease
To learn the principles and practical
techniques in communication.
To introduce the practical techniques in
addressing challenging behaviors without
the use of antipsychotic medication
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Steps to Success
Understand dementia
Maximize functioning
Effectively communicate
Learn what to expect
Choose “battles”
carefully
Try general strategies
Try specific approaches
Get help!
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Understand Dementia
What is happening in the
brain?
Functions affected by
disease
Which type of dementia is
it?
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What is Dementia?
A syndrome that describes a group of
symptoms which can be reversible or
progressive
Dementia itself is not a disease or a
specific diagnosis
Dementia is not a part of the normal
aging process
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Dementia
Reversible Dementias
Vascular Dementia
Frontal-temporal
Dementia
Lewy Body Disease
Alzheimer’s Disease
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What is Alzheimer’s Disease?
Alzheimer’s disease:
Is the most common form of dementia
Is a brain disorder
Causes problem with memory, thinking and behavior
Is not a normal part of aging
Is a progressive disease
Has no cure
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The Progression of Alzheimer’s
Memory
changes
Language
problems
Activities of
Daily Living
a Challenge
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• Short term and gradually long term memory
impaired
• Forget names of friends and family
• word finding trouble
• “empty speech”
• impaired comprehension
• Independent living and driving become
hazardous
• Wandering and behavior changes are common
• Physical changes are more pronounced
What does Alzheimer’s look like?
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Brain of Normal Elderly Person
Brain of Alzheimer’s Patient
Which lobes are affected?
tParietal
Occipital u
tFrontal
tCerebellum
tTemporal
Which Functions?
Language, Sense of
temp, touch, pain
Vision
Judgment,
reasoning
Memory, language, hearing
Basic functions,
breathing
The Hippocampus
Understanding how it
feels to have
Alzheimer’s disease
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What changes?
Memory
Executive
functions
Behavior
Visual-Spatial
Perception
Language /
Communication
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Confusion: A central problem in dementia
Source or stimulus for emotional
and behavioral problems
Ability of cognitive powers to keep
confusion at bay dwindles as disease progresses
Evokes feelings and needs that
PWD cannot meet
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Alzheimer’s Disease: A Disease of Emotions
Confusion
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Discomfort
Behavior
Maximize Functioning
Aricept,
Exelon,
Razadyne
Socialization
Memantine
(Namenda)
Nutrition
Exercise
Mental
Stimulation
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Use of Medication
• Identify reason for use
• Know the person with dementia
– Look for preferences, connection to life history
• Eliminate causes of behavioral response:
– Environmental, physical, psychological,
spiritual, new medical conditions
• Antipsychotic medication should always be
a last resort to managing behavior
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Summary : Part I
•
•
•
•
What is Alzheimer’s?
What is Dementia?
Changes that occur in the brain
The role of Confusion in understanding
behavior
• Goals of Treatment
• Use of medication
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Strategies for Success:
Dealing with Dementia
Behaviors Without Drugs
Part II
Elizabeth Edgerly, Ph.D.
Bonnie Bollwinkel, LCSW
Alzheimer’s Association of
Northern California and Northern
Nevada
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A 3 Part Training Series
• This presentation is funded and supported by :
• The California Culture Change Coalition
• Centers for Medicare & Medicaid Services
(CMS)
• The California Department of Public Health
• For the California Partnership to Improve
Dementia Care and Eliminate the Misuse of
Antipsychotics in Nursing Homes
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Objectives for Part II
• Explain Role of Effective Communication
• Identify Principals of Compassionate
Communication
• Review Communication Challenges &
Benefits
• Provide Strategies for Effective
Communication
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Effectively Communicate
“Effective communication skills
represent the most basic behavior
management technique, and are
essential to the implementation of all
other behavioral techniques.”
Alan Stevens, Ph.D, and Louis Burgio, Ph.D.
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Effective
communication
and Positive
approach
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Prevention
& reduction
of
symptoms
Communication: Beyond Words
Three major parts in human face to face
communication:
Body language
Tone of voice
Words used
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Principles for Understanding
and Communicating
Understand what isn’t possible to
change
Thoughts, attitudes and actions
significantly impact behavior
All behavior has meaning
Connecting overrides the task
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Communication Challenges
Difficulty:
•
•
•
•
•
•
Remembering & understanding words
Thinking rationally
Speaking logically and following instructions
Responding to questions
Identifying location/type of pain
Providing history of illness
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Benefits of Compassionate Communication
Fosters selfesteem
Reduces
frustration
Benefits
Strengthens
independence
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Enhances
relationship
What Can You Do?
Communication Strategies
Speak slowly and clearly.
Allow enough time for the person to respond.
Repeat using exactly the same words.
Make eye contact before addressing the person.
Rely heavily on non-verbal communication.
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Tips on Communicating
with the Person with Dementia
If known, use the patient’s name when
speaking.
Convey calm in your voice, gestures &
expressions.
Use simple words phrases.
Reassure.
Break things down into steps.
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Hearing the Person with AD
Be patient
Consider words/phrases that resurface
Respond to the emotion
Consider deeper meaning
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Check the Environment
Be in plain view
Avoid bright and dark settings
Set aside a quiet place
Reduce distractions
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Adjust Your Approach
Think ahead
Give simple instructions
Ask one question at a time
Be mindful of facial
expressions and body
language
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Focus on Remaining Skills
Match activities to abilities
Establish routines and
structure
Encourage activities of
independence
Give praise and offer
compliments
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Other Helpful
Suggestions
Last Word
Connection
Other
Communication
Forms
Humor
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Review: Steps to Compassionate Communication
• Be a good listener.
• Facilitate a connection
• Check the environment
• Adjust your approach
• Focus on remaining
skills
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Strategies for Success:
Dealing with Dementia Behaviors
without Drugs
Part III
Elizabeth Edgerly, Ph.D.,
Bonnie Bollwinkel, LCSW
Northern California & Northern Nevada
Alzheimer’s Association
40
A 3 Part Training Series
• This presentation is funded and supported by :
• The California Culture Change Coalition
• Centers for Medicare & Medicaid Services
(CMS)
• The California Department of Public Health
• For the California Partnership to Improve
Dementia Care and Eliminate the Misuse of
Antipsychotics in Nursing Homes
41
Objectives for Part III
•
•
•
•
•
•
Identify common behavior issues
Discuss causes of behavior
Learn to identify when to act, not react
Build toolkit of general interventions
Understand specific approaches
Use teamwork to respond as staff
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What Challenging Behaviors
Make us Feel Uncomfortable?
Which of the following:
• Angry outbursts
• Hitting, kicking, and biting,
• Throwing things
• Yelling and screaming
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Common Behavioral Symptoms
• Anger/agitation
• Reversal of sleep
cycle
• Eating/feeding
problems
• Dressing/undressing
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• Incontinence
confusion
• Wandering
• Resistance
• Bathing problems
• “I want to go home”
Challenging Behaviors that Staff
Encounter
• Suspiciousness &
paranoia
• Excessive repetitive
actions
• Loud verbalizations
that may not be
coherent
• Walking about, pacing
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• Exit seeking or trying
to leave the building
• Verbal or physical
aggression
• Searching for things
in other resident
rooms
• Hallucinations &
delusions
Behavior Problems - Why?
• Means of
communication
• Environmental
• Age-related
changes
• Chronic pain
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•
•
•
Frustration
Sensory overload
Medications
Patterns from past
Emotional Challenges for Residents
around Activities of Daily Living
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•
•
•
•
•
Embarrassment
Anger & Resentment
Overwhelmed by task
Stress
Feeling rushed
Frustration
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•
•
•
•
Depression
Abandonment
Grief & Loss
Isolation
Confusion
Choose your battles carefully
Is it really a
problem?
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For whom?
Try General Interventions
Environment
Routines
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Activities
Try Specific Approaches
• Creativity a plus, patience a must
• The ABC model
– triggers
– behavior
– consequences
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Case Study: Mr. J
• Mr. J was hitting the staff in the nursing
home. This happened every morning. It
did not happen in the day center or at
night. The staff wanted to move Mr. J to
another place or give him antipsychotic
medication because he was “combative”.
• A=?
• B = hitting
• C= moving resident or giving medication
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Mr. J Resolution?
• A = Antecedent or Trigger
• Mr. J’s trigger was staff putting Levi’s on
him when he didn’t want them to.
• B = Behavior
• Mr. J’s behavior was hitting that got worse
as staff continued to put Levi’s on him
• C = Consequence was staff not listening
to or exploring Mr. J’s response. Behavior
got worse.
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Mr. J Resolution
• A = Antecedent=Trigger=Levi’s
• A is now eliminated by Mr. J having his
regular clothes
• B= Behavior=Hitting
• Behavior is gone as Mr. J has no reason
to object to staff
• C=consequence=Mr. J does not have to
move or take medication. Staff now wants
to work with him.
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What Can Staff Do?
Simplify tasks
Stay calm
Analyze situation carefully
Refer to CMS Hand to Hand Training
Brainstorm with others
Take a break
Self care
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Summary of Part III
• ABC Model: Always re-evaluate approach to
see if modification is needed.
• Be Proactive. Act Don’t react.
• Pay attention to feelings behind the behavior.
• Be reassuring. You set the tone.
• Modify approach to the person
• Use each other as a resource.
• Collaborate on the best approach
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Resources
• Educational Materials: www.alz.org
– Books, brochures, fact sheets & videos
• Community Agencies
– Alzheimer’s Association
– ADEAR
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Alzheimer’s Association
Services
u
u
u
u
u
u
u
Care Consultation
Information and Referral
Support Groups
Education
Safety Services
TrialMatch™
Walk to End
Alzheimer’s™
800.272.3900 I www.alz.org
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