Changing the way we view and respond to behaviors in memory care‌ Rita Altman, RN, MSN| SVP of Memory Care & Program Services, Sunrise Senior Living Patrick Doyle, Ph.D.| Corporate Director of Dementia Care, Brightview Senior Living
Objectives 1) Describe the various perspectives of behaviors commonly associated with dementia
2) Understand and practice a proactive approach to enhance resident’s well-being and address resident distress 3) Use a systematic, empirically-based process to react to and address a problematic behavioral expression
Perspectives of Dementia
Dementia – Biomedical View •
Dementia: decline in cognitive and functional status to a loss in abilities (thinking, learning, doing, etc.) & personhood
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Changes in the brain: cause loss in abilities and behavioral and psychological symptoms of dementia.
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Behavioral and psychological symptoms caused by dementia etiology/physiology. Influential factors: • • • • •
Type of dementia – etiology Brain regions affected Stage of dementia Cognitive function Co-morbid physical or psychological conditions
Dementia – Social/Relational View •
Dementia: Mind is changing; Personhood is stable
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Changes in the brain: Affect the person’s abilities but do not determine the person’s reaction or impact his/her uniqueness
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Behavioral Expressions: Are driven by the person living with dementia. Influential factors: • • • • • •
Personhood: life history, values/morals, coping styles, culture, etc. Physical environment Relationships/supports/interactions Person’s reaction to interactions Brain damage Person’s reaction to changes in the brain
Normalcy is never recognized by the attendant of a milieu where abnormality is the normal expectancy. ERVING GOFFMAN
A Path to Well-Being (Power, 2013)
A Path to Well-Being Method (Power, 2013) •
Focus on well being prevent distress from happening • Anticipate the triggers, meet needs, produce well-being • Proactive - rarely supplies a quick fix
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Well-being is not dependent on ability
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Go deeper to avoid the vicious cycle: • problem trigger intervention failure drug/hospital
Experiential Path to Well-Being (Eden Alternative & Power, 2013)
Case study Part I •
John, age 82, a dapper former marine, lawyer and circuit court judge
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Medical: • Diagnosed with Alzheimer’s disease three years ago • Arthritis in his right hip and sacral vertebrae
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Favorite activities: • Swimming, playing tennis, soaking in the hot tub, listening to classical and jazz music, walking and relaxing with his dog Jury, and watching vintage Perry Mason movies
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Drinks red wine with his dinner and enjoys some chocolates
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Decreased engagement in activities; naps frequently throughout the day
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Behavioral expressions: • Refusing his wife’s offers to assist him to change his clothing or take a bath • Verbally and physically aggressive when bathing or using the toilet
Rapid Whiteboard Session: The Path to Well-Being Take the next few minutes •
Think about John’s basic story and background
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Put any behavioral expression aside
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Determine possible ways to enhance John’s well-being
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Document on one or more of the domains of well-being whiteboards
Sharing and Discussion •
What were a few suggested well-being enhancers for John?
Take Home: Best Practices •
Complete an initial assessment of domains of well-being • Identify proactive, person-centered enhancements
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Complete ongoing assessment of well-being (not only when in crisis)
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Collaborative effort with team input
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Not effective in addressing immediate dangerous situations • Sometimes that is needed…DICE Approach
Case Study Part II •
John has now lived in the memory care neighborhood for a month
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On most days he is cooperative during personal care
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One morning, Mandy, experienced verbal aggressiveness when trying to assist him with bathing
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Mandy quickly left the bathroom requesting that the nurse administer a medication to help John to calm down
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Returned with her co-workers Jacob and Sue. The three care assistants experience even greater aggressiveness
The DICE Approach (Kales, et al., 2014)
DICE Approach
Describe- Caregiver describes the problematic behavior • Context (who, what, where, and when) • Social and physical environment • Person’s perspective • Degree of distress to person and caregiver
DICE Approach
Investigate- Provider investigates possible causes of problem behavior • Person – history, preferences, social needs, etc. • Medication side effects • Pain, functional limitations • Medical conditions • Psychiatric comorbidity • Severity of cognitive dysfunction
DICE Approach
Investigate • Poor sleep hygiene • Sensory changes • Fear sense of loss • Caregiver effects/expectations • Social and physical environment • Cultural factors
DICE Approach Create- Provider, caregiver and team collaborate to create and implement plan • Include knowledge of the person • Respond to physical problems • Provide caregiver education and support • Enhance communication with the person • Create meaningful activities for the person • Simplifying tasks • Ensuring the environment is safe • Increasing or decreasing stimulation in the environment
DICE Approach
Evaluate- Provider evaluates whether “Create” interventions have been implemented by caregiver and are safe and effective • Have there been any unintended consequences?
Take Home: Behavioral Expressions •
Person-centered and proactive is the best practice
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Reactive – needed but not enough • MUST also proactively address the person’s well-being
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Focus on the person – expressions not symptoms
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If at first you, don’t succeed…
QUESTIONS? QUESTIONS?