dementia
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Coping with Challenging Behaviors: Becoming a Good Detective NOT a Knee Jerk Judge! © Teepa Snow, Positive Approach, LLC – to be reused only with permission. What Causes Distress or Resistance? • Mis-match between: – What we expect versus what happens – What we can do versus what is needed – What was versus what is – What we want versus what we get – What we want versus what the other wants – Who we are with versus who we want to be with – Where we are versus where we want to be – Who we are versus who we want to be….. Resisting Resistance JUST Increases Resistance If It Isn’t Working STOP & Back Off Think About It Try Again – But Change Something copyright - Positive Approach, LLC 2012 Five Ways to Say “I Am Sorry!” • “I’m sorry, I was trying to help” • “I’m sorry I made you feel(emotion) angry, irritated, frustrated, sad, isolated….” • “I’m sorry I made you feel (intellectual capacity or relationship unequal) like a child, stupid, like an idiot…” • “I’m sorry that happened” (their perspective) • “I’m sorry, this is HARD!” (for both of you) copyright - Positive Approach, LLC 2012 Distress or Resistance in Helping Someone with Dementia Boiled Down to SIX Puzzle Pieces SIX Pieces to the Puzzle • • • • • • Personal history and preferences Level & type of dementia Other conditions & sensory losses & rxs Environmental conditions Care partner approach and behaviors What happened – full day & all players Examples of Challenges • • • • • • • • • • • • • • • • • • No F PoA or HC PoA – Going to MD problems ‘Losing’ Important Things Getting Lost – time, place, situation Unsafe task performance Repeated calls & contacts Refusing help & care ‘Bad mouthing’ you to others Making up stories - confabulation Undoing what is done Swearing/cursing, sex talk, racial slur, ugly words Making 911 calls Mixing day & night Sleep problems – too much or too little Not following care/rx plans denying No initiation – can’t get started Perseveration – can’t stop repeating Not talking any more • • • • • • • • • • • • • • • • • Paranoid/delusional thinking Shadowing - following Eloping or Wandering Seeing things & people not there - hallucinations Getting ‘into’ things Threatening caregivers Undressing in public – not changing when needed Problems w/intimacy & sexuality Being rude - intruding Feeling ‘sick’ – not doing ‘anything’ Use of drugs or alcohol to ‘cope’ Striking out at others Falls & injuries Dehydration & malnourishment Contractures & immobility Infections & pneumonias Issues w/ eating or drinking What Happens? Traditionally Non-Traditionally • We wait till it gets ‘dangerous’ or at least ‘risky’ • We blame … • We ‘knee jerk’ react • We treat the immediate • We become ‘parental’ • We become judges • We give up • We go thru the motions • We go to drugs – #1 • ABC ‘Annoying’ behaviors • Become a detective • Get EVERYONE involved early and often • Re-look & monitor - lots • Change what is easiest first • Change what can be controlled • Celebrate all improvements • Start by changing OURSELVES –anti-anxiety & anti-psychotic So What Can You Do???? What Can YOU Control? OR NOT! CONTROL… – The environment – setting, sound, sights NOT CONTROL – The person & who they have been – The task demands & the day… how things fit together – The type & level of impairment … NOW – How you choose to help – (The ‘meds’) • Personality, preferences & history – Other medical conditions & sensory status & what all the ‘meds’ do to/for the person For the person with “problem behaviors”… REFRAME… Get interested and excited be challenged! Rethink ‘Challenging Behaviors’ REFRAME as Unmet Needs Top TEN! Unmet Physical Needs • Hungry or Thirsty • Tired or Over-energized • Elimination – need to/did • Discomfort – not right for me Unmet Emotional Needs • Angry • Sad • Lonely • Scared – Temperature, texture, fit, senses • BORED • IN PAIN!!! – Joints - skeleton – Inside systems (head, chest, gut, output) – Creases or folds & skin – Surfaces that contact other surfaces Now… Describe the Behavior • If possible – get another person to watch OR consider video to investigate • Use objective language to describe “THE BEHAVIOR” • Investigate NON-CHALLENGING BEHAVIOR - investigate what is going on when ‘the behavior’ is NOT happening….. • Check it out from all perspectives… 360 Investigate Carefully!!! From Microscope to Telescope…. • Use a sensory approach – look, listen, feel, smell, taste, movement • Check out the environment – Look at public, personal, intimate space issues – Get in their ‘shoes’ & position • Pay attention to cues and responses • Look at timing, sequencing, & responses Build a TEAM Don’t be a Lone Ranger Why a Do You Need Others? • • • • Life happens 24/7 Six pieces make it complicated & multi-factorial The six pieces affect everyone – including YOU Each person will have a different perspective & information… • To optimize positive outcomes, it works best if we – Have a common goal – Start off in the same place – Have a game plan – Move in a planned, consistent direction – Check in regularly – Make adjustments as needed • CELEBRATE the AH HA moments & share the AH OHs What Makes ‘BEHAVIORS’ Happen? • SIX pieces… – The type & level of cognitive impairment … NOW – The person & who they have been • Personality, preferences & history – Other medical conditions & sensory status – The environment – setting, sound, sights – The whole day… how things fit together – People - How the helper helps • Approach, behaviors, words, actions, & reactions What Happens When Someone Has Dementia One piece of one part of the puzzle called ‘antecedents’ A Quick Example of Complexity… One piece of one part of the puzzle Level & type of impairment seen NOW The Three D’s: Is it dementia? Is it JUST dementia? Is it dementia PLUS? Dementia Delirium Depression What’s What? What’s What – For Each D • • • • • • • • Onset Hx & Duration Alertness & Arousal Orientation responses Mood & Affect Causes Treatment for the cause/condition Treatment for the behavioral symptoms Delirium • • • • • • • • Onset – sudden - hours to days Duration – ‘cured’ or ‘dead’ - short Alertness & Arousal – fluctuates, hyper or hypoOrientation responses – highly variable Mood & Affect – highly variable - dependent Causes – physiological physical, psychological Tx condition – ID & Treat what is WRONG Tx behavior – manage for safety only – short term only, don’t mask symptoms Depression • • • • Onset – recent - weeks to months Duration – until treated or death – mnths-yrs Alertness & Arousal – not typically changed Orientation responses – “I don’t know”, “I can’t say”, “Why are you bothering me with this, “I don’t care” • • • • Mood & Affect – flat, negative, sad, angry Causes – situational, seasonal or chemical Tx of condition – meds, therapy, physical activity Tx of behavior – schedule & environmental support, combined with meds help – Dementia • • • • Onset – gradual – months to years Duration – progressive till death Alertness & Arousal – gradual changes Orientation responses – right subject, but wrong info, angry about being asked, or asks back • • • • Mood & Affect – triggered changes Causes – brain changes – 60-70 types Tx – chemical support – AChEIs & glut mod Tx behavior- environment, help, activity, drugs • • • • • • Determine First – Is this Dementia, Delirium, OR Delirium? Delirium can be dangerous & deadly Get a good behavior history – look for change Assess for possible PAIN or discomfort Assess for infections Assess for med changes or side effects Assess for physiological issues – dehydration, blood chemistry, O2 sat Be Aware of Acute Confusion • Symptoms – – – – – – – Suddenly worse Very different Very agitated Having hallucinations More extreme Harder to work with More confused • Causes… – – – – – – – Medications Fever Infection Dehydration New place More restrictions Medical condition is worse 2nd – Is it Dementia or Depression • Depression is treatable • Many elders with ‘depression’ describe themselves as having ‘memory problems’ or having ‘somatic’ complaints • Look for typical & atypical depression • Look for changes in appetite, sleep, self-care, pleasures, irritability, ‘can’t take this’, movement, schedule changes If it looks like dementia… • Explore possible types & causes • Explore what care staff & family members know and believe about dementia & the person • Determine stage or level compared with support available & what we are providing • Seek consult and further assessment, if documentation does NOT match what you find out DEMENTIA Alzheimer’s Disease •Young Onset •Late Life Onset Vascular Dementias (Multi-infarct) Lewy Body Dementia FrontoTemporal Lobe Dementias Other Dementias •Genetic syndromes •Metabolic pxs •ETOH related •Drugs/toxin exposure •White matter diseases •Mass effects •Depression(?) or Other Mental conditions •Infections – BBB cross •Parkinson’s Normal Brain Alzheimers Brain Positron Emission Tomography (PET) Alzheimer’s Disease Progression vs. Normal Brains Normal Early Alzheimer’s Late Alzheimer’s Child The Real Three D’s Dementia Depression Delirium REALITY… • Its NOT 3 clean or neat categories • The 3 are MIXED together • Which ‘D’ is causing what you are seeing NOW? • Are all three D’s being addressed? – Immediate – Short-term – Long-term What Could It Be? • • • • • • • Another medical condition Medication side-effect Hearing loss or vision loss Depression Acute illness Severe but unrecognized pain Other things… Drugs that can affect cognition • Anti-arrhythmic agents • Antibiotics • Antihistamines decongestants • Tricyclic antidepressants • Anti-hypertensives • Anti-cholinergic agents • Anti-convulsants • Anti-emetics • • • • • • Histamine receptor blockers Immunosuppressant agents Muscle relaxants Narcotic analgesics Sedative hypnotics Anti-Parkinsonian agents Washington Manual Geriatrics Subspecialty Consults edited by Kyle C. Moylan (pg 15) – published by Lippencott, Wilkins & Williams , 2003 Another Complication: Progression More changes over time Not a stable condition Progression of Dementia What Level Is the Person At? Gems Approach to Changes © Teepa Snow, Positive Approach, LLC – to be reused only with permission. Rationale - 3 systems – all use numbers - Each has value – together confusing - People are not numbers - Until we begin to the see the beauty and value in what the person is at this point in time – we will never care for them as we should - Gems are precious and unique – common language and characteristics © Teepa Snow, Positive Approach, LLC – to be reused only with permission. Stages – in a positive way Sapphires Diamonds Emeralds Ambers Rubies Pearls GEMS a positive approach… Sapphires – True Blue – Slower BUT Fine Diamonds – Repeats & Routines, Cutting Emeralds – Going – Time Travel – Where? Ambers – In the moment - Sensations Rubies – Stop & Go – No Fine Control Pearls – Hidden in a Shell - Immobile Diamonds Still Clear Sharp - Can Cut Hard - Rigid - Inflexible Many Facets Can Really Shine Diamonds • Know Who’s in Charge – Respect Authority • Can do OLD habits & routines • Become more territorial OR less aware of boundaries • Like the familiar – FIGHT CHANGE • Can pull it together to make you look bad • Know how to push your buttons • Want to keep roles the same • Tell the same stories ask the same ?s Emeralds Changing color Not as Clear or Sharp - Vague Good to Go – Need to ‘DO’ Flaws are Hidden Time Traveling Emeralds Think they are FINE Get emotional quickly Make mistakes – don’t realize it Do over and over OR Skip completely Ask – “What? Where? When?” Like choices Get lost in past life, past places, past roles • Need help, DON’T know it or like it! • • • • • • • Ambers Amber Alert Caution! Caught in a moment All about Sensation Explorers Ambers • Get into stuff • Fiddle, mess, touch, taste, dig, tear, fold….. • Move toward action and noise OR away • Sensory tolerance • Sensory need • Mouth, fingers, feet, genitalia • Can’t figure it out… react physically Rubies Hidden Depths Red Light on Fine Motor Comprehension & Speech Halt Coordination Falters Wake-Sleep Patterns are Gone Rubies • • • • • • • • Fine motor stops Hard to stop and hard to get going Limited visual awareness One direction – forward only Can’t figure out details – but do copy us SLOW to change On the go or full stop Use music and rhythm Pearls Hidden in a Shell Still & Quiet Easily Lost Beautiful - Layered Unable to Move – Hard to Connect Primitive Reflexes on the Outside Second Piece of the Puzzle The person & who they have been • Personality, preferences & history Life Long Personality Traits & Preferences Make a Difference • We are more of who we have always been… UNLESS • We have always been covering up who we really are – we decide to ‘let go’… OR • Dementia robs us of our ability to be the way we want to be… OR • Dementia causes us forget ‘how’ we are supposed to be and lets us be ‘free’ Personal Preferences Matter • • • • We like what we like! With DEMENTIA the ‘likes’ can change Old preferences will need to be revisited The Challenge is to HONOR what is important BUT change what is needed • Our willingness to meet the person’s changing NEEDS is essential • Changes are made harder by our sense of LOSS and GRIEF Some Personal Preferences • • • • • • • • Appearance Behaviors Language Daily routines Foods & Drinks Music Touch & Textures & Noise & Space Worship – Spiritual practices How Does Dementia Affect This? • • • • • • • Memory Language – understanding & production Self-care skills Sensation Emotional control Reasoning & thinking Vision How Might This Work with YOU? Personality traits Personality Traits Who are you? • Introvert-Extrovert • Lots of Details – Big Picture only • Logical – Emotional • Planning ahead – Being in the moment Who is the person you are trying to help? First – How You… • Come to decisions… • Get re-energized • Feel about ‘boundaries’ and ‘space’ Introvert - Extrovert Introvert • Likes to be alone • Likes to think it out • Likes personal space • Needs alone time • Private • Shares little • Decides on own after thinking it through Extrovert • Thinks out loud • Talks it out • Seeks out people • Shares a lot • Not good with boundaries • Gets opinions before ‘deciding’ Second – How do you… • • • • Like to get information Like to do things Decide whether to do something Approach an unfamiliar task Details – Big Picture Details • Needs to know HOW • Specifics of what to do • Wants detailed info – to do it ‘RIGHT’ • Likes doing the familiar and routine • Likes a check list – follows it • Likes to DO it Big Picture • Needs to know WHY • Likes to ‘fly by the seat…’ • Likes to hear the big plan • Likes to try out new and different ways of doing things • Likes to experiment • Likes to TALK it out first Third – What makes ‘sense’? • • • • How do you ‘judge’ things? How do you decide if things are ‘OK’ What matters most to you? What DRIVES your behavior and actions? Logical - Emotional Logical • Head First • Fair • Reasonable • Rational • Likes to discuss differences of opinion • How other people ’behave’ Emotional • Heart First • Nice • Kind • Empathetic • Prefers to avoid disagreements • How other people ‘feel’ Fourth – How You… • • • • • • Use time Feel about TIME – the future versus now Plan ahead versus like surprises Feel about KNOWING what is expected Feel about ‘deadlines’ Feel about making decisions Planning Ahead – In the Moment Planning Ahead • Aware of the future • Sets priorities - plans • Likes routines • Likes a schedule • Likes to do things as planned • Decide & move on! • Needs to be in CONTROL In the Moment • Being flexible • Go with NOW issues • Not forward thinking • Running late • Putting ‘other’ things off • Consider options…. • GO WITH THE FLOW Some ‘stuff’ we think/feel people do on purpose is really just ‘WHO’ they are Which is BETTER? There is no BETTER Just Different… Just Ranges… What About Residents? • Life long patterns… – Introvert versus Extrovert – Detail versus Big Picture – Thinker versus Feeler – Plan versus Go with the Flow Extrovert – needing others or Introvert – needing space Big Picture – the PLAN - the possible or Details – just the FACTS – the familiar Emotions Rule – Feelers – others’ feelings aware or Fairness Rules – Thinkers – others’ behavior aware Future Oriented – Plan Ahead or Now Oriented – Go with the Flow What if You Don’t Get What You Need at Work? • You still need it! • You will feel drained and empty if you don’t get your needs met! • It’s not about what is ‘better’ its about recognizing what you prefer and what you need! What About the Person with Dementia? • • • • They are at HOME They have needs – how will we help? How can we change the environment to help? Who needs to know this? Third Piece of the Puzzle Other medical conditions Psychological or psychiatric conditions Sensory status – vision, hearing, sense of touch, balance, smell, taste Medications Treatments Drugs that treat symptoms • Antidepressants • Mood stabilizers • Antipsychotics • Anxiolytics/Benzodiazepines Antidepressants • Zoloft, Welbutrin, Celexa/Lexapro, Remeron, Effexor • Newer medications are much better tolerated • Used to treat typical and atypical (agitated) depression • Match symptoms of depression to drug choice Mood stabilizers • Depakote, Neurontin, Tegretol, Lithium • Used for agitation and mood swings • Take time to work (adjust brain chemicals) so be patient with dose changes Antipsychotics • Risperdal, Zyprexa, Seroquel, Geodon, Abilify • Use for hallucinations that frighten people, delusions (false, fixed beliefs) and spontaneous/unprovoked aggression • Newer drugs are better but may still cause permanent side effects Anxiolytics/Benzodiazepines Sleeping medications • Ativan, Buspar, Xanax, Sonata, Ambien • “Dehydrated alcohol” • Used for sleep and anxiety • Often effects occur after symptom is resolved • Side effects can include short term memory loss, falls, confusion BENEDRYL: The anti-Aricept MD-allergy specialist Fourth Piece of the Puzzle Environment Physical Sensory Social Looking At the Environment What Helps – What Hurts??? Supportive Environments • Include 2 Factors – What you LIKE… Supportive Environments • Include 2 Factors – What you LIKE… – What’s GOOD for you! Supportive Environments The 3 Positive P’s • Physical Environment • People—the ways they act and respond • Programming Finding Balance • Support or impair • Too much or too little The Supportive Sensory Environment • • • • • What you See What you Hear What you Feel What you Smell What you Taste Fifth Piece of the Puzzle Daily Routines and Programming Filling the Day with Valued Engagement Gem Level Programming Examples of Meaningful Activities •Productive Activities – sense of value & purpose •Leisure Activities – having fun & interacting •Self-Care & Wellness – personal care of body & brain •Restorative Activities – re-energize & restore spirit Productive Activities • Helping another person • Helping staff • Completing community tasks • Making something • Sorting things • Fixing things • Building things • Organizing things • Caring for things • • • • • • • • • Counting things Folding things Marking things Cleaning things Taking things apart Moving things Cooking/baking Setting up/breaking down Other ideas…. Leisure Activities Active Passive • • • • • • • • • • • • • • • Socials Sports Games Dancing Singing Visiting Hobbies Doing, Talking, Looking Entertainers Sport Program/event Presenters Lobby sitting TV programs – watched Activity watchers Being done to Self-Care & Wellness Activities Cognitive Physical • Table top tasks • • • • • • • • – Matching, sorting, organizing, playing • Table top games – Cards, board games, puzzles… • Group games – Categories, crosswords, word play, old memories Exercise Walking Strengthening tasks Coordination tasks Balance tasks Flexibility tasks Aerobic tasks Personal care tasks Rest & Restorative Activities • Sleep – Naps • Listen to quiet music with lights dimmed • Look at the newspaper • Look at a calm video on TV screen • Rock in a chair • Swing in a porch swing • Walk outside • Listen to reading from a book of faith • Listen to poetry or stories • Listen to or attend a worship service • Stroke a pet or animal • Stroke fabric • Get a hand or shoulder massage • Get a foot soak & rub • Listen to wind chimes • Aroma therapy Teepa’s Rules Music at least TWICE a DAY Something Productive for each EMERALD resident Play with people – keep it adult - watch for cues Smooth out Transitions If they can DO something support their doing, don’t do to them or for them • Encourage helping and ALWAYS say THANK YOU • Respect space preferences – introverts/extroverts • Match Sensory Experience to Preferences – Sight, sound, smell, touch, taste • • • • • Each DAY • Before Breakfast – What do we want? – How will we do it? • Breakfast • After Breakfast – What do we want? – How will we do it? • Lunch • After Lunch – What do we want? – How will we do it? • Dinner – What do we want? – How will we do it? • Bedtime – What do we want? – How will we do it? Sixth Piece of the Puzzle YOU AND OTHERS What shouldn’t we do??? • • • • • • • Argue Make up stuff that is NOT true Ignore problem behaviors Try a possible solution only once Give up Let them do whatever they want to Force them to do it So WHAT should we do??? Remember who has the healthy brain! Your Approach #1 = Be a Care Partner NOT a Care Giver Learn your Approach Use your Knowledge Build your Skills KEY SKILLS • • • • • • • • Greet before you treat Build a ‘team’ Give cues in a specific sequence Respect space and the person Wait for a response before going on Do one thing at a time STOP & Back off if it isn’t working Try something different as you approach Your Approach • Use a consistent positive physical approach – pause at edge of public space – gesture & greet by name – offer your hand & make eye contact – approach slowly within visual range – shake hands & maintain hand-under-hand – move to the side – get to eye level & respect intimate space – wait for acknowledgement THEN – Connect Emotionally • Make a connection – Offer your name – ”I’m (NAME) and you are…” – Offer a shared background – “I’m from (place) and you’re from…” – Offer a positive personal comment – “You look great in that ….” or “I love that color on you…” THEN – Get it GOING! • • • • • Give SIMPLE & Short Info Offer concrete CHOICES Ask for HELP Ask the person to TRY Break the TASK DOWN to single steps at a time Give SIMPLE INFO • USE VISUAL combined VERBAL (gesture/point) – “It’s about time for… “ – “Let’s go this way…” – “Here are your socks…” • DON’T ask questions you DON’T want to hear the answer to… • Acknowledge the response/reaction to your info… • LIMIT your words – Keep it SIMPLE • WAIT!!!! BEFORE You try to get the person to ‘Do Something’ 1st - Get Connected Make a Great 1st Impression Say Something Nice Form a Positive Relationship! How Do You Get Information from Residents About What They Want or Need or Think What they show you- how they look What they say – how they sound What they do – physical reactions Visual Cues •Signs •Pictures •Props – Objects •Gestures •Facial expressions •Demonstrations Auditory - Verbal Cues Keep it simple Directed Matched to visual cues Tactile – Touch Cues Touching a body part Handing the person an item Using Hand under hand assist Knowing the Person • • • • • • • History Values and beliefs Habits and routines Personality and stress behaviors Work & family history Leisure and spiritual history Hot buttons & comforts Health & Illness • • • • • Mobility problems? Pain? Sensory problems? Mental health issues? Other diagnoses of importance? Comparison of Fat Pads The person’s brain is dying How can we help… better? It all starts with your approach! What Makes Distress & Resistance Happen? • SIX pieces… – The type & level of cognitive impairment … NOW – The person & who they have been • Personality, preferences & history – Other medical conditions & sensory status – The environment – setting, sound, sights – The whole day… how things fit together – People - How the helper helps • Approach, behaviors, words, actions, & reactions Believe People with dementia Are doing The BEST they can! So WHAT should we do??? Remember who has the healthy brain!
