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

• Changes in the brain: cause loss in abilities and behavioral and psychological symptoms of dementia.

• 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

• Changes in the brain: Affect the person’s abilities but do not determine the person’s reaction or impact his/her uniqueness

• 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

ERVING GOFFMAN

Normalcy is never recognized by the attendant of a milieu where abnormality is the normal expectancy.

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

• Well-being is not dependent on ability

• 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

• Medical: • Diagnosed with Alzheimer’s disease three years ago• Arthritis in his right hip and sacral vertebrae

• 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

• Drinks red wine with his dinner and enjoys some chocolates

• Decreased engagement in activities; naps frequently throughout the day

• 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

• Put any behavioral expression aside

• Determine possible ways to enhance John’s well-being

• 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

• Complete ongoing assessment of well-being (not only when in crisis)

• Collaborative effort with team input

• 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

• On most days he is cooperative during personal care

• One morning, Mandy, experienced verbal aggressiveness when trying to assist him with bathing

• Mandy quickly left the bathroom requesting that the nurse administer a medication to help John to calm down

• 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

• Reactive – needed but not enough

• MUST also proactively address the person’s well-being

• Focus on the person – expressions not symptoms

• If at first you, don’t succeed…

QUESTIONS?

QUESTIONS?