Interventions to Minimize Behavioral
Symptoms of Dementia:
Moving Beyond Redirection
Part III
Margaret Hoberg MSN, GNP-BC
Siobhan McMahon MSN MPH GNP-BC
Objectives
Learning Objectives
1.
Explain the effects of dementia on thinking, emotions and
communication
2.
Use a theory to help explain behavioral and communication
changes associated with dementia and to guide interventions
3.
Respond to behavioral changes with a calm, validating
approach
4.
Comprehensively assess verbal and nonverbal messages,
including those that are associated with stress
5.
Develop a plan whose non-pharmacological interventions reflect an
understanding of and respect for the person and their preferences.
Interventions based on the Need-driven
Dementia-Compromised Behavior Theory
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Treat Acute Illness
Treat pain
Treat unmet physical need
Treat unmet psychological or social need:
Interventions based on the Need-driven
Dementia-Compromised Behavior Theory
Treat unmet psychological or social need:
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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 nonverbal expression of emotion
Individualized schedules that use varied activities
to correct arousal imbalance
Using validation all the while
Interventions based on the Need-driven
Dementia-Compromised Behavior Theory
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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/agitatedactivities.php
Interventions based on the Need-driven
Dementia-Compromised Behavior Theory
Simple Pleasures
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Tetherball (fabric covered balloon attached to the ceiling for
repetitiveness
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Un-inflated balloons filled with birdseed (squeezies) for those
with restlessness
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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
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Hot water bottles covered with polar fleece helped those with
verbal outbursts
Need-driven Dementia-Compromised
Behavior Theory
Simple Pleasures
 Resource publication
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Link to simple pleasures book
Interventions based on the Need-driven
Dementia-Compromised Behavior Theory
What is essential for staff and volunteer training?
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Define dementia and identify several causes
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Describe symptoms and stages of AD
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Explain how it is diagnosed
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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”
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Best Friends Hand out: 30 fun things to do
Provide information about behavioral symptoms of dementia
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Alzheimer's Association Information Booklet about Behavioral
Symptoms of Dementia
Interventions based on the Need-driven DementiaCompromised Behavior Theory
Communication strategies
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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
Interventions based on the Need-driven DementiaCompromised Behavior Theory
Non Verbal Strategies
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Eye contact
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Smile!
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Use pictures instead of words
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Validation
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Use appropriate touch
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Be aware of your own non-verbal messages.
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No arguing
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Assume that all nonverbal expressions of the person with
dementia are attempts to communicate needs or feelings.
Interventions based on the Need-driven DementiaCompromised 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_3helpi
ngtechniques.php
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
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Listen carefully for meaning
Respond to “emotional” message
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
Validation
Disadvantages
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Person may respond to approach “in the moment” but not
retain information
Feels reassured briefly then forgets again
 Repeats questions over and over
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May not be successful in reassuring person
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Irritability, anxiety may continue
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.”
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.”
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?
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
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Frightening or upsetting
Helped by providing information
Reduced by reassurances of safety
Related to “real life” events (illusions)
May be pleasurable
Validation
 Don’t:
 Reason
 Argue
 Confront
 Remind them they forgot
 Question recent memory
 Quiz
 Take it personally!!!
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”
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Validation Approaches
 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.”
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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.”
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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?
Validation
Do:
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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!!
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Interventions based on the Need-driven DementiaCompromised Behavior Theory
Where does redirection fit in?
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Identified as a generic intervention to use when a person is
in danger
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Involves gently guiding the person
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Best reserved for high risk situations and think of it as
stepped redirection instead of redirection.
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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.