advanced skills for dementia care: using the levels of cognitive function to guide communication...

Advanced Skills for Dementia Care: Using the levels of cognitive function to guide communication & routines to

promote safety & function in early-stage disease.

Melanie Bunn, RN, MSmelanie.bunn@yahoo.com

Normal Aging (Diamond)

• More forgetful

• More time to learn new information

• More time to retrieve old information

• Might be more of who they’ve always been or wanted to be!

Difference between aging and diseaseNORMAL Aging

• Slower to think• Slower to do• Hesitates more• More likely to ‘look before

you leap’• Know the person but not the

name• Pause to find words• Reminded of the past• For you, its worse…• But, you can compensate

NOT Normal Aging

• Can’t think the same• Can’t do like before• Can’t get started• Can’t seem to move on• Doesn’t think it out at all• Can’t place the person• Words won’t come – even

later• Confused about past versus

now• Can’t compensate or adapt

Mild Cognitive Impairment

• Is it a variation of aging? disease in its self? disease precursor?

• More than forgetfulness: storage not a retrieval problem (short term memory loss)

• More than forgetfulness: language, complex problem solving (executive function)

• Risk factor for dementia (50% will develop dementia in 5 years)

Mild Cognitive Impairment

• More than aging

• More than 1 area of brain function

• Still can do but takes lots effort and practice

Caregiving GemsProgression of dementia

Cognitive Decline & ActivitiesHand under hand

Adapted from work done with and by

Teepa Snow, Melanie Bunn & Claudia Allen

Understanding the modelAll people with dementia are precious

Levels might change depending on situationEmphasis on what people can do…

not just what they can’t do

Diamonds:Living in the present

Still ClearSharp - Can Cut

Hard - Rigid - InflexibleMany Facets

Can Really Shine

DiamondsWhat still works?

• Do well in familiar places & situations

• Use old routines & habits

• Control important ‘roles’ & ‘territory’/maintain control

• Very ‘independent’ or seeking constant reassurance

• Can manage self care• Can manage routine

IADLS with supervision

• Can use visual cues & signage

• Expresses needs verbally

• Real? Fake? - Hard to be sure

DiamondsWhere do they struggle?

• Has trouble with new routines and locations

• Place & time confusion• Resents take-over• Becomes anxious and

frustrated easily• Gets lost or confused• Misplaces things• Misinterprets what’s

going on

• Word finding problems

• Losing ability to abstract

• Logic problems• Lose ability to see

others’ perspective• May or may not have

insight into losses• May try to “escape”

Diamonds, How do we help? Accepted not Corrected

• Keep to routine & be prepared to help more with changes (traveling)

• If something works or seems to help, get an extra

• Don’t worry about the small mistakes/unusual choices

• For the future: – Notice how they do things

now – Ask how they used to do

things

• Cues and clues• Fill in the blanks• “I’m sorry, I’m so sorry, I’m so very sorry”• Be willing to be the one who’s wrong

(apologize)• Learn how to help instead of taking over• Simpler is better

DiamondsSpecifics of activities

They need:• Familiar activities & routines with variation in specifics but not

category

• Projects they can complete independently

• Opportunities to serve or volunteer

• Simplified…but not baby/fied versions of life-long preferred activities

CUING

Visual

Verbal

Tactile

• Always cue in this order:– Visual– Verbal– Tactile

• With Diamonds:– Visual: move more slowly– Verbal: simply, concrete– Tactile: Follow their lead (need

to touch, need to be touched

Verbal CommunicationWhat doesn’t work?

• Telling the truth (reality orientation)• Telling lies (therapeutic lying or fiblets)• Answering “yes” or “no” questions with “yes”

or “no”• Trying to explain, use logic, reason• Ignoring the person• Trying to be the one who’s “right”

What does work

• Establish a relationship with the person– Introduce self (my name is…and you are…)– Make casual, connecting comments &

conversation• Speak slow and low • Simplify but don’t baby-fy• Wait for response• I’m sorry, I’m so sorry, I’m so very sorry

Empathetic CommunicationMeet them where they are

• Start with the feelings– “Looks like”, “sounds like”– “Seems like”, “feels like”– Don’t be afraid to talk about feelings

• Get more information– “Tell me about…”– Repeat words and phrases– Move to remembering

• Move from talking to doing– “Could you help me?”– “Would you try?”– Related to topic– Familiar and positive

6 Ps• Problem• Person• Possible Cause• Plan• Practice • Pass it on

What’s the PROBLEM?

• Is it a problem?– Recurrent– Different from usual behavior– Has a component of risk

• Whose problem is it?– Person with dementia– Family caregiver– Paid caregiver

What’s the PROBLEM?

• When does it happen?• Where does it happen?• Who’s around? Alone?• How often does it happen?• How long does it last?• How does it seem to start?• How does it seem to stop?• What makes better?• What makes worse?

Who’s this PERSON?

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

Who’s this PERSON?

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?

Who’s this PERSON?

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

What’s the POSSIBLE CAUSE?

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

What’s your PLAN?

• Nursing• Social work• Activities• Rehab• Dietary• Housekeeping• Maintenance• Front desk• Business

• Person with dementia

• Family

• Clergy

• Neighbors

• Others

PRACTICE Your Plan

• Give it a chance to work

• Watch what happens and when

• Make adaptations & try again

PASS IT ON

• If not better…

REWORK

• If better…

CELEBRATE!!!

6 Ps• Problem• Person• Possible Cause• Plan• Practice • Pass it on

Common Safety Issues

• Driving

• Medications

• Living alone

• Nutrition

• Avoid never, try not now

• Will you try?• Avoid, forever• Let the person express

and talk about feelings• Keep things familiar and

routines the same

Issues About Routine

• Which is the priority?– Is the time?– Is it the order?

• We have to do them– They can’t keep the routines– But they need the routines

• Use muscle memory as much as possible

Needs of families

• Time away• To have their perspectives accepted/respected• Be included with the person with dementia• To be supported– Role change– Relationship change – Decisions

• To be educated, the way they learn • Help how to share, when to share

Summary

• It’s hard to tell– Is there a problem?– Who has the problem?

• It’s more important to be in the relationship than to be alone

• Get information from multiple sources • Early diagnosis makes a difference – Health disparity is real– Cultural impact is real