Interventions to Minimize Behavioral Symptoms of Dementia: Moving Beyond Redirection Part III Margaret Hoberg MSN, GN

1. Interventions to Minimize Behavioral Symptoms of Dementia: Moving Beyond Redirection Part III Margaret Hoberg MSN, GNP-BC Siobhan McMahon MSN MPH GNP-BC

2. Objectives Learning Objectives • Explain the effects of dementia on thinking, emotions and communication • Use a theory to help explain behavioral and communication changes associated with dementia and to guide interventions • Respond to behavioral changes with a calm, validating approach • Comprehensively assess verbal and nonverbal messages, including those that are associated with stress • Develop a plan whose non-pharmacological interventions reflect an understanding of and respect for the person and their preferences.

3. Interventions based on the Need-driven Dementia-Compromised Behavior Theory • Treat Acute Illness • Treat pain • Treat unmet physical need • Treat unmet psychological or social need:

4. Interventions based on the Need-driven Dementia-Compromised Behavior Theory • Treat unmet psychological or social need: • Recreational activities • Individualized for long standing patient preferences for social stimulation • Physical environments that minimize social and spatial crowding • Staff trained to be sensitive and to validate the non-verbal expression of emotion • Individualized schedules that use varied activities to correct arousal imbalance • Using validation all the while

5. Interventions based on the Need-driven Dementia-Compromised Behavior Theory • Under-arousal: multi-sensory stimulation, live music, lemon aromatherapy, simulated presence • Over-arousal activities : simulated presence or recording; aromatherapy with lavender; listening to preferred or live interactive music. Additional learning activity Review web-site page for activity ideas and choose one of the videos in the right hand column to view http://www.thiscaringhome.org/spec_concerns/agitated-activities.php

6. Interventions based on the Need-driven Dementia-Compromised Behavior Theory Simple Pleasures • Tetherball (fabric covered balloon attached to the ceiling for repetitiveness • Un-inflated balloons filled with birdseed (squeezies) for those with restlessness • Wave machines (clear plastic salad dressing bottle partially filled with water, mineral oil, food coloring, sequins, glitter and a few pennies or shells for those with repetitive hand movements • Hot water bottles covered with polar fleece helped those with verbal outbursts

7. Need-driven Dementia-Compromised Behavior Theory Simple Pleasures • Resource publication • Link to simple pleasures book

8. Interventions based on the Need-driven Dementia-Compromised Behavior Theory What is essential for staff and volunteer training? • Define dementia and identify several causes • Describe symptoms and stages of AD • Explain how it is diagnosed • Tips for communication and visits Tools and reminders to download and make available to staff and visitors Make visible tips from sources such as “best friends” • Best Friends Hand out: 30 fun things to do Provide information about behavioral symptoms of dementia • Alzheimer's Association Information Booklet about Behavioral Symptoms of Dementia

9. Interventions based on the Need-driven Dementia-Compromised Behavior Theory Communication strategies • Unconditional positive regard • Validation • One idea at a time • Assist with word finding • No arguing • Avoid sarcastic humor • Use the word Yes as often as possible • Avoid the words no, don’t, stop. • Give simple choices (e.g. do you milk or juice instead of what do you want to eat) • Don’t quiz or test

10. Interventions based on the Need-driven Dementia-Compromised Behavior Theory Non Verbal Strategies • Eye contact • Smile! • Use pictures instead of words • Validation • Use appropriate touch • Be aware of your own non-verbal messages. • No arguing • Assume that all nonverbal expressions of the person with dementia are attempts to communicate needs or feelings.

11. Interventions based on the Need-driven Dementia-Compromised Behavior Theory Additional Learning Activity Watch this short video describing good ways to help people with dementia using verbal, visual and tactile communication http://www.thiscaringhome.org/spec_concerns/vid_2_3helpingtechniques.php

12. Validation • Stresses importance of “going with the person”into their reality • Validates feelings in whatever “time” is real to them • Views all behavior as purposeful • Listen carefully for meaning • Respond to “emotional” message

13. Validation • Advantages • Reduces risk of sending “You are Wrong” messages • Addresses person in more positive way • Often leads to reminiscence, review of life events • Promotes self worth • Person-centered approach

14. Validation Disadvantages • Person may respond to approach “in the moment” but not retain information • Feels reassured briefly then forgets again • Repeats questions over and over • May not be successful in reassuring person • Irritability, anxiety may continue

15. Validation: Examples Don’t confront a person’s mis-belief. Distract and redirect instead. Person: “I’m going home!” Don’t: “Your house has been sold. You live here now.” Do: “It’s pretty late now. Stay here with me; we have a place for you that I think you will like and it is safe. We’ll go tomorrow.”

16. Validation: Examples Validate the person’s reality. Avoid “No”, “stop”. “You Are Wrong” messages. Person: “Papa’s coming to get me.” Don’t: “Papa is dead. He’s been dead for years!” Do: “Papa loves you. Papa’s a good man.”“I forget. Tell where Papa lives.” “Papa called. He’ll come tomorrow, not today.”

17. Validation: Examples Listen carefully to “nonsense.” What might message mean in person’s reality? Person: “Hurry up! Up, up, up, up there! Go! Go! Go! Up there! Up there! Whoaaaaa!” Don’t: Assume message has no meaning Do: Ask family, significant other “where” person might “be” in his/her reality. Do words make sense based on history?

18. Validation Misbelief vs. delusion or hallucination? • False beliefs may be “harmless” or quite distressing to the person. All are quite real to the individual, and may be • Frightening or upsetting • Helped by providing information • Reduced by reassurances of safety • Related to “real life” events (illusions) • May be pleasurable

19. Validation • Don’t: • Reason • Argue • Confront • Remind them they forgot • Question recent memory • Quiz • Take it personally!!!

20. Validation • Do: • Allow time for your message to “sink in” • Slow down. Take your time -- even when you are in a hurry! • Take “but” out of your vocabulary • “But we just talked about that” • “But I just told you why not” • “But that’s tomorrow, not today” • “But that’s not yours”

21. Validation Approaches Sorry, My fault! • Do: • Distract them to a different subject, activity • Accept the blame for misunderstandings (even if when you know better!) • “I’m sorry. I didn’t mean to frighten you.” • “I’m sorry if that that hurt.” • Leave the room to avoid confrontations • “I’m going to the kitchen now. I’ll be back.” • “Let’s stop now. We’ll do this later.”

22. Validation • Do: • Respond to feelings, not words • Be patient, cheerful, reassuring • Go with the flow! You’re going to work?But you are on vacation this week!!!!! Stay home with us . . . Please?

23. Validation Do: • Listen carefully to type and extent of false beliefs • Monitor level of distress experienced by the person • Persistent, severe, and troubling beliefs may reduce comfort and function • Short-term, low-dose medication may be needed if depression is present or psychosis is causing fear and paranoia • Assess for underlying triggers and try all other interventions first!!

24. Interventions based on the Need-driven Dementia-Compromised Behavior Theory Where does redirection fit in? • Identified as a generic intervention to use when a person is in danger • Involves gently guiding the person • Best reserved for high risk situations and think of it as stepped redirection instead of redirection. • E.g. instead of saying Mr. Johnson, ‘don’t , stop etc.’. First make eye contact, indicate you share his concerns and will work with him to find an answer. Then ask / invite him to join you or someone for a cup of coffee or suggest you need help doing …. • Kovach et al categorized redirection as a “static” response to a persons needs and did not find that it was effective.