A Person Centered Approach to Decreasing Behaviors · PDF fileA Person Centered Approach to Decreasing Behaviors Margaret Kimbell, RN, MSA, DHA, CDP Bettina Suarez ... Dakheel-Ali,

Dementia Care A Person Centered Approach to

Decreasing Behaviors Margaret Kimbell, RN, MSA, DHA, CDP

Bettina Suarez Palacios, RN, BSN, MBA, RAC

Erickson Living

Objectives

• The purpose of this activity is to enable the learner to define Person Centered Approaches to Dementia care and how quality of life and quality of care can be one fluid act of kindness.

• The purpose of this activity is to describe the Think Comfort behavioral approach to understanding the actions and expressions of elders with cognitive impairment.

• The purpose of this activity is to describe the strength based three tiered approach to engagement for elders with dementia; meeting their needs while also decreasing neuropsychiatric symptoms.

What does aging mean to you?

• Peripheral (side) vision is reduced

• Presbyopia - diminished sharpness of vision and focusing, reading glasses are required

• Lens of the eye becomes cloudy diminishing the amount of light

• Glaucoma – loss of side vision

• Macular degeneration – loss of central vision

Vision Changes

Hearing Changes

• High-pitched sounds such as "s" or "th" are hard to distinguish from one another

• Background noise further complicates hearing difficulty

• Men's voices are easier to hear than women's

• Other people's voices sound mumbled or slurred

• Ringing in the ears

Presbycusis – slow progressive loss of hearing caused by changes to inner ear

Decrease in • Number of taste buds • Sensitivity to salt and sweet first

• Bitter and sour last longer • Amount of saliva production

Smell and Taste Changes

• Smell may diminish after age 70

• Use it or lose it

• Overall cognition (thinking) depends upon health of the brain

• The brain’s processing slows but given the opportunity….. processing does occur

• Forgetfulness – normal aging memory lapses

• Memory loss – disease related changes that are disabling affecting hobbies, social activities, relationships, etc.

Brain Changes

Person-Centered Approach

“Caring enough to understand the individual and customizing our approach to recognize the person’s gifts, their needs, their preferences, and their goals”

Self-

Actualization

Esteem

Love & Belonging

Safety

Physiological

Person-Centered Approach Model

Abraham Maslow’s Hierarchy of Human Needs

Self-Actualization

…continuous desire to fulfill potential, to “be all that I can be.”

Morality, Creativity, Problem Solving, Spontaneity, Lack of Prejudice, Acceptance

Communication

Honoring desires and wishes

Helping elders meet their needs

Death and dying

Grief

of Facts, Being All that I Can Be

Esteem

Self-respect

Appreciation for life’s contributions

Dignity

Recognition of accomplishments

Independence Self-esteem,

Confidence, Achievement, Respect of Others, Respect by Others,

Freedom

Love & Belonging

Get to the know the person and what is important to them

Relationships – past and present

Sense of community

Sadness and depression

Loneliness and social

anxieties

Therapeutic touch

Friendship, Family, Sexual Intimacy

Safety

Falls

Lifting and transferring

Lack of restraints/side rails

Health and well-being

Environmental hazards

Security of Body, Of Employment, Of Resources, Of Morality, Of the Family, Of

Health, Of Property

Physiological

Pain

Nutrition

Bowel and Bladder

Hydration

Pain management

Wound Care

Breathing, Food, Water, Sex, Homeostasis, Sleep, Excretion

Person-Centered Approach

• Helping the person make as many choices in their life as they can

• Making the person the center of care guided by their choices

• Remember, it’s not about staff’s work routine, it is about what helps the person achieve all levels of the pyramid!

Your role in supporting learning!

Activities Contributing to Learning Effectiveness

Pre-Work

Learning Event

Follow-Up

Chronic health conditions can be associated with cognitive health disorders

Cognitive Health

• Heart disease

• Stroke

• Diabetes

• Arthritis

• Cancer

• Immobility

• Infection

Depression

Anxiety disorders

Delirium

• What can cause memory loss?

• Depression

• Vitamin deficiency

• Thyroid imbalance

• Medications

• Alcohol abuse

• Dehydration

Brain Changes

Many causes of memory loss can

be reversed!

Dementia is not a specific disease. It's an overall term that describes a wide range of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities.

Dementia

http://www.alz.org/what-is-dementia.asp

Disease/Condition = Dementia Symptoms

Disease/Condition Dementia Symptoms

• Alzheimer’s

• Parkinson’s

• Stroke

• Infection of Brain

• Thyroid Deficiency

• Vitamin Deficiency

Progressive decline in: •Remembering •Paying attention •Speaking and under-standing

language •Problem solving •Orienting to day, year, season •Orienting to where they are •Orienting to who they are

Aphasia

Agnosia

Apraxia

The Four “A”s of Dementia & the Brain

What does the person experience?

Dementia Experience

• Poor judgment and decision making

• Inability to manage a budget

• Losing track of the passage of time or the season

• Difficulty having a conversation

• Misplacing things and being unable to retrace steps to find them

Feelings

The Fear and Anxiety of Dementia

• Dementia affects the brains ability to: – Deal with uncertainty and change

– Communicate concerns and fears

– “Self-sooth,” keep fears from becoming an overwhelming experience

• Chronic pain, common in the elderly, further increases anxiety as individuals with dementia cannot tell us they are in pain

• Inability to cope with anxiety and fear can result in defensive actions

– Verbal aggressive behavior and/or

– Physically aggressive behavior

How Can We Help? Emotions and Feelings Remain

Emotions continue even when the event

cannot be remembered

Understanding Actions & Expressions

Actions

Body Language

E XPRE S S I ONS

Communication Techniques

Be aware of your non-verbal communication

Center yourself!

Be aware of the non-verbal

communication signs the

person is showing to you

Understand How the Person Feels

Triggers to Actions/Expressions

Expressions

Triggers Emotions

Actions

Communication Techniques

Communicate care and comfort

Speak simply, smile, good eye contact

Use Gentle Touch

Music, singing, or reading

Favorite smells

Understanding the person’s non-verbal message

Validate Feelings & Emotions

Self-

Actualization

Self-Esteem

Love & Belonging

Safety

Physiological

Maintaining their dignity at all times

Exploring how they feel

PCA Think Comfort Model

Case Studies

• DON role in understanding actions and expressions

• Tracking actions and expressions - tools

• Route Cause Analysis adapted to the situation –

Think Comfort

• Finding the plan of care and services that matches

the needs/wants/desires of the person

• Staff critically thinking to obtained positive outcomes

• Decreasing antipsychotic medication utilization

Think Comfort!

Behavior

1. Agitated

2. Attempting to leave

3. Calling out repeatedly

4. Combative behaviors

5. Choosing not to take their medications

6. Resisting Care

7. Rummaging and Hording

8. Socially inappropriate behaviors

9. Wandering

Expression 1. I am overstimulated or bored

2. I want to go outside

3. I am in pain

4. You are not listening to me

5. I do not like the taste of the pills

6. I am cold; I am embarrassed; I do not know who your are

7. I am trying to find something or I do not wish to loose what is familiar

8. I want to be loved

9. I do not see anything familiar and am trying to find my home

The Resident Cannot Change, so...

Change the caregiver’s approach (ex - one instruction at a time)

Change the environment (ex - remove distractions)

Change the task (ex - are you trying to do something “for” or

“with” the person?)

Active Engagement ……..

• Supports relationships • Love and Belonging

• Engages the person in daily life • Self Esteem and Choice

• Offers a variety of creative and interesting choices • Self Actualization

• Allows for spontaneity • Just enjoyment of life!

Daily engagement ………………

• Allows the person to be productive

• Allows the person to experience success

• Retains and continues to build skills

• Provides the ability to control daily life

• Fulfills spiritual needs

• Experiences growth and learning

• Supports fun and enjoyment of life!

Levels of Programming

• Self Directed

• Structured

• Guided

Self- Directed Programming

Structured Programming

Guided Programming

A Person Centered Approach to Decreasing Actions/Expressions

Engagement in meaningful activities

is one of the most critical elements of an exceptional memory care program.

Activities help residents maintain

their functional abilities and can enhance quality of life. Alzheimer’s Association

References • Cohen-Mansfield, J., Marx, M. S., Regier, N. G., & Dakheel-Ali, M. (2009). The impact of personal characteristics on engagement in nursing home residents with dementia. Int. J. Geriat. Psychiatry, 24(7), 755-763.

doi:10.1002/gps.2192

• Cohen-Mansfield, J., Thein, K., Dakheel-Ali, M., & Marx, M. S. (2010). Engaging nursing home residents with dementia in activities: The effects of modeling, presentation order, time of day, and setting characteristics. Aging & Mental Health, 14(4), 471-480. doi:10.1080/13607860903586102

• Cohen-Mansfield, J., Marx, M. S., Dakheel-Ali, M., Regier, N. G., Thein, K., & Freedman, L. (2010). Can Agitated Behavior of Nursing Home Residents with Dementia Be Prevented with the Use of Standardized Stimuli? Journal of the American Geriatrics Society, 58(8), 1459-1464. doi:10.1111/j.1532-5415.2010.02951.x

• Roberts, G., Morley, C., Walters, W., Malta, S., & Doyle, C. (2015). Caring for people with dementia in residential aged care: Successes with a composite person-centered care model featuring Montessori-based activities. Geriatric Nursing, 36(2), 106-110. doi:10.1016/j.gerinurse.2014.11.003

• Vance, D. E., & Porter, R. J. (2001). Montessori Methods Yield Cognitive Gains in Alzheimer's Day Cares. Activities, Adaptation & Aging, 24(3), 1-22. doi:10.1300/j016v24n03_01

• Chirileanu, R. D., Simu, M., Rosca, C., Males, S., & Tocai, R. (n.d.). Mild Cognitive Impairment-Current Relevance of the concept, 2008.

• Flo, E., Gulla, C., & Husebo, B. S. (2014). Effective Pain Management in Patients with Dementia: Benefits Beyond Pain? Drugs Aging, 31(12), 863-871. doi:10.1007/s40266-014-0222-0

• PULSFORD, D., & DUXBURY, J. (2006). Aggressive behaviour by people with dementia in residential care settings: a review. Journal of Psychiatric and Mental Health Nursing, 13(5), 611-618. doi:10.1111/j.1365-2850.2006.00964.x

• Inouye, S. K. (2015). Enhancing Cognitive Aging: Clinical Highlights of a Report From the Institute of Medicine. Annals of Internal Medicine, 163(4), 307. doi:10.7326/m15-1228

• Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2014). Management of Neuropsychiatric Symptoms of Dementia in Clinical Settings: Recommendations from a Multidisciplinary Expert Panel. Journal of the American Geriatrics Society, 62(4), 762-769. doi:10.1111/jgs.12730

• Ducharme, F., Kergoat, M., Coulombe, R., Lévesque, L., Antoine, P., & Pasquier, F. (2014). Unmet support needs of early-onset dementia family caregivers: a mixed-design study. BMC Nurs, 13(1). doi:10.1186/s12912-014-0049-3

• Hopper, T., Bourgeois, M., Pimentel, J., Qualls, C. D., Hickey, E., Frymark, T., & Schooling, T. (2013). An Evidence-Based Systematic Review on Cognitive Interventions for Individuals With Dementia. American Journal of Speech-Language Pathology, 22(1), 126. doi:10.1044/1058-0360(2012/11-0137)

• Cipriani, G., Vedovello, M., Nuti, A., & Di Fiorino, M. (2011). Aggressive behavior in patients with dementia: Correlates and management. Geriatrics & Gerontology International, 11(4), 408-413. doi:10.1111/j.1447-0594.2011.00730.x

• Bell, V., & Troxel, D. (1997). The best friends approach to Alzheimer's care. Baltimore, MD: Health Professions Press.

• Thomas, W. H. (1996). Life worth living: How someone you love can still enjoy life in a nursing home : the Eden alternative in action. Acton, MA: VanderWyk & Burnham.

• Power, G. A. (2010). Dementia beyond drugs: Changing the culture of care. Baltimore: HPP/Health Professions Press.

• Calkins, M. P. (2001). Creating successful dementia care settings. Baltimore, MD: Health Professions Press.

Question and Answer

• Margaret Kimbell [email protected]

410-402-2481

• Bettina Suarez Palacios [email protected]

410-402-2275