AIPP Conference Call: Quality Partners Grant & The + Approach
May 12, 2015
My name is Dusty Linn and I have my Master’s in Social Work and am an LCSW. I
have worked as a Social and Activity Consultant for 14 years in LTC. At this time I
am the Grant Coordinator for the Quality Partners. The Quality Partners include
our Office of Long Term Care Director, the Executive Director of the Arkansas
Health Care Association, representatives from AFMC and AIPP as well as nursing
home stakeholders and other representatives from OLTC. The focus last year and
moving into 2015/2016 of the Quality Partners grant is the reduction of
antipsychotics in residents with Dementia. This past year you may have attended
one of the trainings presented on “The Positive Approach: I Make the
Difference”. We also presented a panel discussion training for licensed nurses
and put together a pre-conference intensive workshop at AHCA’s Spring
Convention last month.
I would like to give you a sampling of the information we provide in our +
Approach training as well as a lay out of what we anticipate the roll out of the
grant this upcoming year to look like. We would love for you to make plans to
attend any or all of the trainings we anticipate providing this year.
I feel I have to start off explaining why in the world this has become such a focus.
Many of you are already very much involved in your journey at reducing
antipsychotic use among residents with Dementia. You have bought into the idea
that this is best for our elders, but can you explain that well to the families and
staff you work with? Although this is a national initiative laid out by CMS, that
isn’t always a sufficient reason for us to change the way we do things. So, think
with me for a minute about what antipsychotics are used for – they are used to
address the biochemical changes particular to the brain in individuals with mental
illness. They substitute or increase/decrease certain chemicals in the brain to
help them be able to see things from our reality. We are always instructed not to
argue with those with mental illness who are delusional because what they
believe is very real to them. When the antipsychotics are given to them, it gives
them an opportunity to perceive reality as it is not as their mind is “fooling” them
to believe. In the diagnosis of Dementia we are looking at brain death. The only
exception to this is the forms of Dementia that are reversible such as Dementia
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brought on by a medication side effect or an illness such as a UTI. If we provide
residents with Dementia an antipsychotic exactly what are we treating? Once a
portion of the brain is dead, it cannot be healed so a fixated belief that an 80 year
old woman lives at home with her parents and that she is 18 and courting her
soon to be husband will not be altered by an antipsychotic. The additional reason
for reducing these medications is the severe side effects that we see. There is a
pervasive belief that the newer antipsychotics (often referred to as atypical
antipsychotics) such as Risperdal or Seroquel do not have the same side effects as
the older antipsychotics (often referred to as typical antipsychotics). What has
been discovered is that many of the side effects are the same – they just take
longer to manifest. What if I told you I wanted to do an experiment and give each
one of us on this call an antipsychotic for a week so we could journal and record
our experiences? I don’t think any of us would be lining up to do that, yet we give
these medications to frail elders who frequently have complicated diagnoses and
are on other medications. Did we mean to hurt them? NO! But now that we
know better we must do better.
One of the topics covered it on Normal v. Not Normal Aging. For any of you who
have received the Teepa Snow video “The Art of Care Giving”, you have an expert
right on video who can help cover this topic for you. Please refer to that and use
it at your in-services and think about making it part of your orientation process.
Here is a portion of what is covered for that topic:
 It is “normal” to have forgetfulness. With “normal” aging we can retrace
our steps and the cues around us help us to remember (most of the time)
what we were doing.
 “Normal” aging can include:
o Difficulty with word recall but can describe it reasonably well
o Slower to think or do
o New data reminds me of old data (retracing my steps)
 With “not normal” aging we are unable to retrace the steps and we can’t
get back to the earlier information.
 “Not normal” aging can include:
o Defensiveness – I’m not wrong. You are.
o Delusions – The brain’s effort to interpret the situation will often lead
to inaccurate conclusions.
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o Paranoia – Inaccurate conclusions and the continued belief I am
correct will often lead to the inability to trust other’s interpretations
of the situation
o Unreasonable – When a disease, such as Dementia, effects the brain,
certain areas die and therefore processing information can become
impossible. So, when you tell me something and I disagree and hold
onto that belief despite information to the contrary, you see me as
unreasonable.
o Inability to hold onto new information
When we as caregivers come into a resident’s room with a distinct purpose
in mind and the resident is adamant they don’t want that type of care at
that time, how much explanation will change their mind?
Know your agenda, but don’t show your agenda.
We all have agendas and we take them with us wherever we go. An agenda
is our list of things to do today both inside and outside of work.
When we enter the world of a resident with Dementia, they have their own
thing going on or their own agenda for that moment. It may not appear
that way to us, but they do. When we shove our agenda in their face, they
will begin to get very defensive and our thorough explanation of why this is
needed will be ineffective most of the time.
Imagine care giving as a dance. There’s two of you involved. One will lead and
one will follow. Sometimes you will take the lead and other times the resident
takes the lead and you must follow. Residents with Dementia may not remember
your name or where they are at, but they are very good at interpreting emotion.
They will know if you are in a rush or if you have an agenda you are trying to push
on them. So, know your agenda, but don’t show your agenda.
A portion of the +Approach training also focuses on types of Dementia and
specific differences in the way the brain is being effected which leads to residents
behaving in different ways. For instance, Lewy Body Dementia is frequently
manifested by seeing children, people or animals. Often times these are scary for
the resident or take on sexual content. If you didn’t understand Lewey Body
Dementia you might automatically resort to a medication because you see the
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distress it causes the resident. I’m going to only hit the high point regarding the
different types of Dementia and some of the different ways the disease is
manifested in different individuals.
 Dementia is both a structural change and chemical change occurring in the
brain. This means cells are shrinking and dying and this is permanent while
chemical changes (how well the brain cells talk to each other) are variable.
This leads to good days and bad days for residents with Dementia.
 It is very important to understand that Dementia is brain failure. The brain
is dying.
 Dementia is the 5th leading cause of death in the United States. There is
currently no treatment for the disease. The medications we provide only
assist with the side effects of the disease, but do not slow the progression
of the disease or reverse it in any way.
 There are 4 truths about Dementia
o At least 2 parts of the brain are dying
o It is chronic and it can’t be fixed
o It is progressive and will get worse
o It is terminal in almost all cases
 Dementia is the umbrella term similar to Heart Disease being an umbrella
term. There are several different types of heart disease that fall under that
and there are several different types of Dementia that fall under that
umbrella as well.
 Alzheimer’s is the most common of the Dementias. Here are some of the
characteristics related to Alzheimer’s
o New information is lost first
o Problems with word finding
o More impulsive or indecisive
o Gets lost easily
o Will sometimes realize they don’t know and other times will insist
you are incorrect
o Can “go backwards in time” and their reality is no longer in the here
and now
 Vascular Dementia is the 2nd most common of the types of Dementias.
Anything vascular has to do with blood flow. So, the blow flow to the brain
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has been effected in this type of Dementia. It can be because of stroke or
other issues. Here are some characteristics related to Vascular Dementia
o Can have sudden changes in ability. One day knows who you are and
the next can’t recall your name and this ability doesn’t return.
o With the sudden changes also comes plateaus. Will stay with one
type of functioning for weeks or months and then wake up with lost
ability again.
o Judgement and behavior are not the same
o Spotty loss of memory – not very predictable
o Emotional at times
o Energy shifts
 Lewy Body Dementia is another type of Dementia. Some of the
characteristics of Lewy Body are
o Movement problems – falls
o Intention tremors – hands don’t shake unless they go to do
something like pick up a cup
o Visual hallucinations – this focuses on animals, children and people
o Episodes of rigidity – can’t move or be moved easily. Brain doesn’t
tell the body to move.
o Nightmares or Insomnia
o Delusional thinking
 Fronto-Temporal Dementia affects the frontal and temporal lobes of the
brain. The frontal lobe controls impulses and the temporal lobe controls
language. So the following characteristics are seen in these residents
o Very impulsive
o Lose ability to control their behavior
o Uninhibited in their food, drink, sex, emotions and actions
o Says unexpected, rude or mean things
o Can’t speak or get words out at times
o Can’t understand what is said
o Uses nonsense words
o Obsessive-Compulsive tendencies – hoards or collects items or things
must be done a certain way all the time
 Another type of Dementia is ETOH related Dementia. These residents
typically only respond through the pleasure center of their brain so if they
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can’t eat it, enjoy it or have sex with it, they want nothing to do with it.
They can be very difficult to motivate for care.
Another type of Dementia can be related to genetic syndromes, such as
Huntington’s chorea. These residents truly have little control over their
movement. They will have Parkinson’s like movements and sometimes will
repeatedly request a coke then when they get it will throw it on the staff
who gave it to them. When asked why they did it they respond “I don’t
know” because it was truly an involuntary movement.
Another type of Dementia is associated with Multiple Sclerosis.
Still others can be brought on by tumors or Depression or Parkinson’s.
One type of Dementia that is reversible is a Dementia brought on by an
infection or medication side effect. When the infection is gone or the
medication is discontinued, the Dementia subsides.
It is possible for residents to have more than one type of Dementia at the
same time.
Additional topics include understanding Sensory deficits as we age and how they
are impacted by Dementia as well. This impacts our ability to communicate with
residents with Dementia and their ability to understand us. They interpret the
world differently and frequently miss most of the verbal message we give which
puts us in a situation that can get complicated very quickly. Many of us have
heard the phrase “they can’t come to where we are, so we must go to where they
are”. We know this in our head but how do we demonstrate that during care?
This is where our focus on the +Approach and the hand under hand technique
become imperative. We have to change our minds about how we are doing
things and then follow it through with behavioral changes in how we provide
care. Change is difficult and requires practice so it is essential to get buy in from
your direct care staff. This will make a difference, but it will require us to do
things differently. This training provides you alternatives to doing things “to”
residents and assists you in doing things “with” residents. This is an intervention
that actually does NOT require more time. It’s just a different way of doing
things.
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It is difficult to simply tell you how to do the +Approach or the Hand Under Hand
Technique. That is why so much of the training we do is interactive. We show
you how and then you do it. Experiential learning is the best way to understand
new information and retain the information. When you experience it, you begin
to get it. Then you wonder how we missed it! All the trainings we conduct are
based off the trainings of Teepa Snow. Many of you know of her or have seen her
present. Her website provides many additional resources if you feel you have
begun to grasp this concept and are ready for the next step.
One of the wonderful things about the Quality Partners grant is that it has
afforded us the opportunity to bring in experts in this field to present information
on the topic of reducing antipsychotics in residents with Dementia as well as
allowing us to bring Teepa’s training here to our state. The end of July (27th to the
31st) Dr. Al Power author of “Dementia Beyond Disease” and “Dementia Beyond
Drugs” will be presenting in 4 locations in our state. Please mark your calendars.
Dr. Power has practiced medicine for 25 years and the last 18 years have been in
the LTC setting. He understands our challenges and is prepared to show us the
short-comings of using only a biomedical approach to caring for residents with
Dementia.
Additionally, AIPP is hosting Teepa Snow on August 11th in Little Rock. Please
know that we are doing our best to coordinate education opportunities to
remove all of our excuses for not continuing on the journey in reducing
antipsychotic medications in residents with Dementia. People do not come into
and stay in the LTC field when they lack compassion. So let’s empower that
compassion with knowledge.
This upcoming year, please check the AHCA and AIPP’s website (aipp.afmc.org) for
educational opportunities through the Quality Partners grant. We aren’t slowing
down! This fall we will again be providing trainings throughout the state of
Arkansas to all staff with emphasis on the direct care staff through the
“+Approach: I Make the Difference”. Last year we conducted this in 7 different
locations. I anticipate that many trainings again this fall. We also anticipate doing
another Intensive training similar to AHCA’s Spring Convention this fall as well.
We are also pursuing other national speakers, such as, Naomi Feil, who has
developed “Validation therapy” which is a technique in developing our skills in
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communicating with residents with Dementia. All of the training we are bringing
will complement each other. You will hear the same theme being taught from
each presenter. Each speaker will bring to us a new challenge and new
opportunities for growth in the continued journey in reducing antipsychotic use in
residents with Dementia.
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