A social interactional model for understanding behavior among people with dementia

1. A social interactional model for understanding behavior among people with dementia Linda J. Garcia, Ph.D. (Ottawa) Jean Kozak, Ph.D. (Vancouver) Michèle Hébert, Ph.D. (Ottawa) Neil Drummond, Ph.D. (Calgary) Jocelyn Charles, M.D. (Toronto) Dementia Net: Bridging Gaps in Service Provision

2. Which behavior? • Physical and verbal aggression • Wandering • Suspiciousness/Paranoia • Agitation • Stereotyped vocalizations or screaming • Uncooperative behaviour Dementia Net: Bridging Gaps in Service Provision

3. Recommendations(Day et al., 2000) • Small size units Physical • Remove non-cognitively impaired Social • Offer respite care Social • Relocate in units not individually Social • Noninstitutional design Physical • Moderate levels of environmental stimulation Physical/Social • Incorporate higher light levels Physical • Use covers over panic bars and door knobs Physical • Outdoor areas with therapeutic design features Physical • Make toilets more visible Physical • Eliminate factors that increase stress in bathing Physical/Social Dementia Net: Bridging Gaps in Service Provision

4. Social Environments • May ease the burden of care and help improve quality of life. • Notion of place and importance of congruence with that space. (Diaz Moore, 1999) • Morgan & Stewart (1999) • Optimal stimulation • Human Contact • Safety and Supervision • Individualized Care • Flexibility Dementia Net: Bridging Gaps in Service Provision

5. The importance of communication • Communication as an avenue to social environments. • “Whilst the importance of communication in the care of older people with dementia has been recognised, there has been very little study of the ways in which residents with a cognitive impairment seek each other and socially interact.” (Hubbard et al., 2003, p. 101) Dementia Net: Bridging Gaps in Service Provision

6. Communicating your intention http://www.mullein-fields.org/ Dementia Net: Bridging Gaps in Service Provision

7. Conversation and Dementia • Turn taking • Repair strategies • Topic management http://www.hc-sc.gc.ca/english/media/photos/index.html Dementia Net: Bridging Gaps in Service Provision

8. Communication as an ability • “Literature = use small words, use one-step commands, use appropriate pitch, have little background noise, etc. The literature seldom expands beyond helpful communication hints to include interactive theories or frameworks. ” (Touzinsky, 1998) • Communicating one’s intention reflects something much more fundamental than turn taking and analyses of conversational breakdowns. (Goldwaithe, 1997) Dementia Net: Bridging Gaps in Service Provision

9. Goals of communication(Simmons-Mackie & Damico, 1995) Transactional: convey information Interactional: establish/maintain interpersonal relationship http://www.niapublications.org/pubs/portfolio/html/aspects.htm http://www.hc-sc.gc.ca/english/media/photos/index.html Dementia Net: Bridging Gaps in Service Provision

10. Transactional or Interactional? • Which is impaired in dementia? • Which should we concentrate on? • Whose perspective determines these answers? http://www.hc-sc.gc.ca/english/media/photos/index.html Dementia Net: Bridging Gaps in Service Provision

11. Communication as a life habit • Four social levels on which people communicate: (Verderber, 1984). First two still there in later stages (Kelley 1997). • Sheer pleasure of interaction (topic unimportant); • To demonstrate ties with other people; • Build and maintain relationships; and • Define the nature of the relationship – how they stand in the relationship (power and affection). • Residents have active conversations when staff not there. (Hubbard et al 2003) Dementia Net: Bridging Gaps in Service Provision

12. Dementia Net: Bridging Gaps in Service Provision

13. Dementia Net: Bridging Gaps in Service Provision

14. Functional communication • How can the person use his environment to achieve his goals? • How do the social environmental factors hinder the attainment of his goals? • Communication social phenomenon; as a tool for social integration. • To intervene, need to isolate the role of the environment Dementia Net: Bridging Gaps in Service Provision

15. Ecological Model of Aging (Lawton, M.P., & Nahemow, L., 1973) Positive affect & adaptive behaviour High marginal ZONE OF MAXIMUM PERFORMANCE POTENTIAL Negative affect & maladaptive behaviour marginal ZONE OF MAXIMUM COMFORT Negative affect & maladaptive behaviour COMPETENCE Low Weak Strong ENVIRONMENTAL PRESS Dementia Net: Bridging Gaps in Service Provision

16. Gibbs-Ward & Keller 2005 Dementia Net: Bridging Gaps in Service Provision

17. Disability Creation Process : An explanatory model of the causes and consequences of disease, trauma and other disruptions to a person’s integrity or development. Risk Factors Cause Personal Factors Environmental Factors Organic Systems Capabilities Integrity Impairment Ability Disability Facilitator Obstacle Interaction Life Habits Social Participation Handicap Situation Dementia Net: Bridging Gaps in Service Provision • RIPPH / SCCIDIH 1998

18. A picture over time T1 T2 Tn • Model flipped upside down. • Individual and social/physical environment. • Interactions elements CHANGE over time. Dementia Net: Bridging Gaps in Service Provision

19. INTERACTION Using the social context to explain behavior Life Habits Social interactions – problem behavior Personal Factors Environmental Factors Social context Organic Systems Capabilities Communication and memory problems Organizational context Brain malfunction Physical context Risk Factors Fougeyrollas et al. (1998) Dementia Net: Bridging Gaps in Service Provision

20. Different points of view Dementia Net: Bridging Gaps in Service Provision

21. Conclusions • The DCP model can be used to reflect on the impact of social environments and behavior. • Must focus on life habits. • Look at communication from an interactional perspective. • Isolate the environmental factor and deal with this – obstacle to whom? • « In conversations where pleasure and interpersonal connectedness are the goal, it is not necessary to « fine-tune » the content. » (Kelley) • the Life Habit has been accomplished. Dementia Net: Bridging Gaps in Service Provision

22. References • Linda.garcia@uottawa.ca Dementia Net: Bridging Gaps in Service Provision