Melanie Bunn, RN, MS m elanie.bunn@yahoo.com

1. Caring for Residents with Dementia: How to Eliminate Restraints, Minimize Antipsychotics and Reduce Fall Risk Melanie Bunn, RN, MS melanie.bunn@yahoo.com

2. Objectives List strategies for individualizing care for residents with dementia. Content: • Care interventions designed to meet the needs and preferences of residents with dementia • Designing activities of daily living to minimize behavioral symptoms • Managing the environment to reduce the effects of stress • Appropriate use of antipsychotic medications in this population List and define effective behavior management strategies for residents with dementia. Content: • Communication techniques for residents with dementia • Principles of behavior management for residents with dementia

3. Try taking 3 steps • Take the person apart • Take the behavior apart • Put everything back together

4. First let’s take the person apart • Individual • Dementia • Humans

5. What do we need to know about the: INDIVIDUAL? Physical • Health history & habits • Disease & disabilities • Sensory changes • Hand dominance • Pain & management • Energy level Emotional • Depression/anxiety (recent & remote) • How do you know? • What should you do? • Optimist/ pessimist • Personality features

6. What do we need to know about the: INDIVIDUAL? Social • Love ’em or leave ‘em (intro v extra)? • Who’s important? • Role in family & work • Type of work & meaning • Community environment Spiritual • Beliefs • Practices/rituals • Positive/negative experiences • Tolerance of others • Views of life • What gives safety & strength?

7. What do we need to know about the: INDIVIDUAL? Routines • ADLS • Organizing the day & remote • Patterns & routines, recent & remote • Best time of day • What’s the most important? Likes & dislikes • Favorites & always liked • Pet peeves & really hates • What is a comfortable place like? • Good manner issues

8. What do we need to know about DEMENTIA?

9. Vascular (Multi-infarct) Dementia DEMENTIA Lewy Body Dementia Alzheimer’s Disease 70-80 Other Dementias Fronto- Temporal Lobe Dementia

10. AD: Basic info • Changes happen over months and years, not hours or days • Usually, changes happen in a slow, steady, predictable manner • STRUCTURAL and CHEMICAL changes: • Structural: Plaques & tangles • Chemical: Neurotransmitters drop • Medications impact chemical changes, NOT structural changes

11. AD: Memory • Early on: Storage, not retrieval problem • Later on: Storage and retrieval • Retained: Emotional and motor memory

12. AD: Common changes • MOOD • Blame others: defensive • Blame self: depressed • Impulsive or indecisive • MOBILITY • Not impacted until later in disease • COMMON ISSUES • Getting lost • Making mistakes: words, finances, decisions • Can be explained…but pattern immerges

13. Alzheimer’s • New info lost • Recent memory worse • Problems finding words • Mis-speaks • More impulsive or indecisive • Gets lost • 2 major types: YOUNG or TYPICAL onset • Notice changes over 6 months – 1 year

14. Vascular disease • Changes depend on where in the brain damage occurs so… • Each person and each disease is different • Changes are often sudden, inconsistent and less predicable • Not a brain disease: a circulation disease • Big change, improvement, plateau, big change (swelling then absorbed or revascularization) • Associated with diabetes, heart disease, high blood pressure

15. Vascular Dementia • Can have bounce back & bad days • Judgment and behavior ‘not the same’ • Spotty loss (memory, mobility) • Emotional & energy shifts • Memory, mood & mobility can all be impaired…or not!

16. LBD • Fine motor changes • Using hands • Swallowing • Mobility problems • Rigidity • Tremor • Falls • Periodic limb movements • Fluctuations in abilities & function (fine one day, impaired the next) • Other changes • Syncope • Hallucinations • Delusions • Nightmares • Insomnia • Memory inconsistent (temporary loss of LT) • Attention/executive function • Visual spatial changes • REM sleep BD

17. LBD diagnosis (LBDA website) DEMENTIA plus • 3 core symptoms: • fluctuating cognition (bad days & good days) • vivid visual hallucinations and/or delusions • motor dysfunction OR • 3suggestive symptoms • REM sleep behavior disorder with acting out of dreams or excessive daytime sleepiness • abnormal brain CT/MRI • extreme sensitivity to antipsychotics/other psychotrophic medications

18. LBD: Medications Reactions can be extreme & unpredictable or opposite than expected • Parkinson’s Disease (tremors) • Don’t always help • Make thinking and hallucinations worse • Antipsychotics (hallucinations) • Don’t always help • Make mobility worse • AChEI/NMDA (thinking & behaviors) • Antidepressants

19. Fronto-Temporal Dementias • Many types • Frontal – impulse and behavior control loss (not memory issues) • Says unexpected, rude, mean, odd things to others • Dis-inhibited – food, drink, sex, emotions, actions • OCD type behaviors • Hyperorality • Temporal – language loss • Can’t speak or get words out • Can’t understand what is said, sound fluent – nonsense words

20. How do we help?Caregiving GemsProgression of dementia Adapted from work done with and by Teepa Snow and Claudia Allen

21. Understanding the modelAll people with dementia are preciousLevels might change depending on situationEmphasis on what people can do…not just what they can’t do

22. Diamonds Still Clear Sharp - Can Cut Hard - Rigid - Inflexible Many Facets Can Really Shine

23. Diamonds Mobility: no changes Falls: can be an issue if new restrictions, injury Behavior: leaving Answers: don’t argue, don’t explain, make this a good place to be

24. Emeralds Changing color Not as Clear or Sharp - Vague Good to Go – Need to ‘DO’ Flaws are Hidden Time Traveling

25. Emeralds Mobility: no changes Falls: can be an issue if impulsive and not paying attention to environment Behavior: going back to places from the past Answers: empathetic communication, keep physically active and busy doing appropriate activities, sequencing help

26. Ambers Amber Alert Caution! Caught in a moment All about Sensation Explorers

27. Ambers Mobility: gait changes Falls: not paying attention to surroundings, changes in vision Behavior: don’t want to be helped but need help Answers: hand under hand, reducing environmental distractors

28. Rubies Hidden Depths Red Light on Fine Motor Comprehension & Speech Halt Coordination Falters Wake-Sleep Patterns are Gone

29. Rubies Mobility: gait changes, loss of arm swing Falls: loss of peripheral vision, focus Behavior: unaware of what’s around them, unable to do personal care Answers: hand under hand, slow down

30. Pearls Hidden in a Shell Still & Quiet Easily Lost Beautiful - Layered Unable to Move – Hard to Connect Primitive Reflexes on the Outside

31. Pearls Mobility: bed or chair bound Falls: slide out Behavior: reflexive resistance Answers: slow down!!!, move with the resistance

32. What do we need to know about: HUMAN BEINGS? All humans beings need…

33. Is it Really a Problem? • Risky behavior or SO WHAT??? • Recurrent • Different from socially acceptable • Puts someone at risk

34. WHO Person with dementia Family Health care provider RESPONSE Work it up Teach and support Let it be Whose Problem Is It?

35. When Where Who How often How long How starts How stops What makes better What makes worse What’s the Problem?DESCRIBE IT

36. Intrinsic factors Level of dementia Type of dementia Health care issues Sensory loss Emotional issues Spiritual distress The person and the history Extrinsic factors Physical environment Noise, sights, setting, temperature Helping approaches Approach, behaviors, words, actions, & reactions Structure of the day Pace, pattern, familiarity Identify the Possible Cause

37. Putting it back together • Your attitude • Your tools

38. Your attitude But the truth is… I’m less worried about you THINK than what you DO

39. Behaviors make sense! • To the person with dementia • To us…if we listen with our heads… and our hearts

40. Do you believe? 1. People with cognitive impairment are doing the best they can 2. Their care partners are doing the best they can 3. Caregiving is difficult… • for the person doing AND the person receiving the care • So…it’s all about the relationship!

41. If you believe that then you know, it’s all up to you… • Change YOUR behavior • How you react and respond… • What YOU do ? • What YOU say

42. The Real Problem is: BRAIN FAILURE The Real Answer is: The RELATIONSHIP Understanding the problem

43. Open your mind • Get rid of always and never • Get rid of that won’t work INSTEAD • Give a try • Try “tell me more”

44. Your tools • Communication • CONNECT with PPA • Let go of being RIGHT and focus on being KIND • Helping in helpful ways • Cuing • Hands on helping • Organizing the day • Progressively lowered stress threshold • Use individualized activities • Making the environment make sense • Building a team • Working together • With families and the community

45. CONNECT with the Positive Physical Approach • Come from the front • Open palm • Not too fast • Not in front • Establish hand contact • Change to hand under hand • Take a seat/squat/kneel

46. Empathetic CommunicationMeet them where they are • Start with the feelings • Get more information • Move from talking to doing

47. Simplify: Redirection: Distraction: Schedule, activities, environment Using the same type of activity in a different manner Replacing the negative behavior with something different Other Strategies

48. Support the positive! Try a “so what” approach Other Strategies Back off, change something, try again

49. Helping at the right level • What’s the problem? • How can I fill in the blanks? • Cue in the right order • Visual • Verbal • Tactile

50. How you help…CUE • Sight or Visual cues • Verbal or Auditory cues • Touch or Tactile cues