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Why Do They Do That?Understanding Symptoms and
Behaviors in Dementia Care
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PET Scan of 20-Year-Old Brain PET Scan of 80-Year-Old Brain
PET and Aging:
ADEAR, 2003
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As we age, processing
speed may slow, but
we do not lose function in
our brains, unless:
Something Goes Wrong with
Our Brains
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So, What is Dementia?
- It is not part of normal aging! It is a disease!
- It is more than just forgetfulness, which is part of normal aging
- It makes independent life impossible, eventually
- It changes everything over time
- It is not something the person can control
- It is not always the same for every person
- It is not a mental illness
- It is real
- It is hard at times
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What is Dementia?
It is both
a chemical change in the brain
and
a structural change in the brain
So…
Sometimes they can and sometimes they can’t
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Four Truths About Dementia:
1. At least 2 parts of the brain are dying:
one related to memory and another part
2. It is chronic – can’t be fixed
3. It is progressive – it gets worse
4. It is terminal – it will kill, eventually
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What Are the Most Common
Issues With Dementia?Not going to the doctor
No financial or health care PoA
Losing important things
Getting lost
Unsafe task performance
Repeated calls and contacts
Refusing
‘Bad-mouthing’ you to others
Making up stories
Resisting care
Swearing and cursing
Making 911 calls
Mixing day and night
No solid sleep time
Paranoid/delusional thinking
Shadowing
Eloping or wandering
Seeing things and people
Getting ‘into’ things
Threatening caregivers
Undressing
Being rude
Feeling ‘sick’
Striking out at others
Falls and injuries
Infections and pneumonias
Not eating or drinking
Contractures and immobility
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Why Do These Things
Happen?Everything is affected:
• Thoughts
• Words
• Actions
• Feelings
It is progressive:
• More brain dies over time
• Different parts get hit
• Constant changing
It is variable:
• Moment to moment
• Morning to night
• Day to day
• Person to person
Dementia is predictable:
• Specific brain parts
• Typical spread
• Some parts preserved
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Why Might These Things Not
Happen?
• Dementia is individualistic
• The person ‘doesn’t have it in them’
• The situation doesn’t come up
• Other conditions keep it from happening
• Caregivers have great skills
• The dementia isn’t bad enough yet
• You get lucky!
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Need
Want
Like
Threat
Dangerous
Aroused/Risky
Alert/Aware
Pleasure
Amygdalae:
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Primitive Brain is in
Charge of:Survival –
• Autonomic protective: Fright, flight, fight + hide or seek
• Pleasure seeking: Meeting survival needs and finding joy
Thriving – Running the Engine
• Maintain vital systems: BP, BS, Temp, Pain, Oxygen
• Breathe, suck, swallow, digest, void, defecate
• Circadian rhythm
• Infection control
Learning New and Remembering:
• Information
• Places (spatial orientation)
• Passage of Time (temporal orientation)
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Top Ten Unmet Needs:
Hungry or thirsty
Tired or over-energized
Elimination: need to/did
Temperature: too hot/cold
Pain:
• Joints - skeleton
• Inside systems (head, chest, gut, output)
• Creases or folds of skin
• Surfaces that contact other surfaces
Angry
Sad
Lonely
Scared
Bored
Unmet Physical
Needs:Unmet Emotional
Needs:
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Common Issues at each
GEMS® State:
Sapphires
Diamonds
Emeralds
Ambers
Rubies
Pearls
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Common Diamond
Issues:Activities of Daily
Living:
• Money management
• Transportation/driving
• Cooking
• Home maintenance and safety
• Caring for someone else
• Pet maintenance
• Medication administration
Unfamiliar Settings or Situations:
• Hospital stay
• Housing change
• Change in family
• Change in support system
• MD visits
• New diagnoses
• Traveling or vacations
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Be Prepared For Repeats!
- Expect repeated stories, questions, or requests
- For repeated stories, use “tell me about it”
- Write down or repeated stories because you may
need them for supportive communication later
-Make sure you are connected to respond
-Repeat a few of their words in a question
-Answer their question, then:
-Go to new words, use enthusiasm!
-A new place
-Add a new activity (possibly related)
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Common Emerald
Issues:
- Doesn’t do care routinely, but thinks they did
- Makes mistakes in sequence but are unaware
- Repeats some care routines over and over
- Resists or refuses help
- Gets lost, can’t find where to do care
- Limited awareness of real needs such as
hunger, thirst, voiding, bathing, grooming
because have other ‘stuff’ to do
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More Emerald Issues:
- Afternoon or evening: “Got to go home!”
- Daytime: “Got to go to work!”
- Looking for people/places from the past
- Losing important things, thinking others
stole/took them
- Doing private things in public places
- Having emotional meltdowns
- Treating strangers like friends and visa-versa
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Common Amber Issues:
- Getting into other’s things, taking others’
belongings
- Bothering others
- Not able to make needs known
- Not understanding what caregivers are doing
- Not liking being helped/touched/handled
- Not liking showers or baths
- Repetition of sounds/words/actions
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Common Ruby Issues:- Safe mobility due to fatigue, wandering, and
falls
- Intake and hydration: amount, safety
- Rest time and place: nighttime waking
- Shadowing others, invading places
- Not staying in one place, not settling for meals
- Reactions to hands on-care due to sensations
- Identifying and meeting needs
- Contractures and skin: bruises, tears, rashes, pressure wounds
- Infections: UTI, yeast, URI, pneumonias
- Circulation
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Common Pearl
Issues:
- Not interacting much
- Crying out but can’t make needs known
- Skin and hygiene problems
- Weight loss
- Reflexes make care challenging
- Repeated infections
- Not eating or drinking
- Not able to sit up safely
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So What Can You Do????
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Beliefs:
- People with dementia are doing the best
they can
- Learn to dance with our partners
- Be the key to make life worth living
- What we choose to do matters
- Be willing to change ourselves
- Be willing to stop and back off and try again
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Skills We Discussed Earlier:
- Positive Physical Approach™
- Hand-under-Hand®:
- For connection
- For assistance
- Supportive Communication
- Visual, Verbal, Physical Cues
- Open and Willing Heart, Head and Hands
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Do:- Go with the flow
- Use supportive communication techniques
-Use objects and the environment
-Give examples
-Use gestures and pointing
-Acknowledge and accept emotions
-Use empathy and validation
-Use familiar phrases or known interests
-Respect values and beliefs and avoid the negative
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Don’t:
- Try to control the flow
-Use reality orientation and big lies
-Correct errors
- Reject topics
-Try to distract until you are well-connected
-Use negative visual cues
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How to Help at Each
GEMS® State:
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How to Help Diamonds:
- Apologize: “I’m sorry!” or “I didn’t mean to…”
- Friendly, not bossy – leader to leader
- Make it temporary with “Let’s just try…”
- Share responsibility, not take over
- Use as many old habits as possible
- Give up being ‘right’
- Go with the flow
- Give another ‘job’ when taking one away
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Bad Helper Habits to Break:
- Saying “Don’t you remember?”
- Not recognizing or accepting differences
- Trying to force changes in roles or
responsibilities
- Trying to take over completely
- Taking responsibility for saying “NO”
- Accepting things at face value
- Arguing with them
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- Think “So What?”… is it worth it?
- Provide ‘subtle’ supervision for care
- Provide visual prompts:
- Gestures, objects, set-up, samples,
demonstrations
- Hide visual cues to stop/prevent behavior:
- Put away, move out of range, leave
- Use the environment to cue
- Use humor, friendliness, support
How to Help Emeralds:
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Bad Helper Habits to Break:
- Noticing and pointing out errors
- Telling, not asking: “You need to…”
- Trying to take over, offering “Let me help you”
- Putting hands on, ‘fussing’
- Reality orientation, arguing, or lying
- Trying to use ‘distraction’
- Trying to go back and ‘fix’ something
- Treating them like a child
- Reacting instead of responding
- Rejecting topics of conversation
- Not going with the flow!
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- Provide step-by-step guidance and help
- Give demonstration, show
- Hand-under-Hand® guidance, may be able to
do on their own after a few repetitions,
- Offer something to handle, manipulate, touch,
or gather
- Limit talking, noise, touch, other activities
- Substitute, don’t subtract!
How to Help Ambers:
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Bad Helper Habits to Break:
- Talking too much, showing too little
- Keep on pushing
- Doing for, not with
- Stripping the environment
- Leaving too much in the environment
- Getting in intimate space
- Over or under stimulating
- Getting loud and forceful
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
- Slow yourself down
- Hand-under-Hand®
- Move with first, then guide
- Learn about patterns of ‘needs’
- Use music and rhythms to help get or
stop movement
- Use touch with care
- Use cuing
How to Help Rubies:
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Bad Helper Habits to Break:
- Touching too quickly, startling them
- Leaning in: intimate space invasion
- Talking too loudly
- ‘Baby-talking’
- Not talking to them at all
- Not showing by demonstrating
- Trying to understand what is said by being
confrontational
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- Hand-under-Hand®, or hand on forearm if their hand movement is poor
- Check for reflexes, modify help to match their needs
- Go slow!
- Use calm, rhythmic movements and voice
- Come in from back of extremities to clean
- Stabilize with one hand and work with other
- Gather all supplies for the task before starting
- Increase warmth of the room before bathing
- Use warm towels and lightweight blankets
- Use circular, rotational motions to relax joints for care
- Provide skin care for their dry and fragile skin
How to Help Pearls:
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Bad Helper Habits to Break:
- Hurrying to get it done quickly
- Don’t talk to – talk over or about
- Don’t check for primitive reflexes prior to
helping
- Not using both hands to give care
- Cleaning from the front using prying
motions
- Focusing on tasks, not the relationship
- Forgetting to look for the Pearl
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INTENT
I'm sorry I was trying
to help
EMOTION
I'm sorry I made you
angry
INTELLECTUAL CAPACITY
I'm sorry, I had no right to
make you feel that way
THAT HAPPENED
I'm sorry, it should NOT
have happened
THIS IS HARD
I'm sorry, this is hard, I
hate it for you
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Dementia cannot be cured,
but it can be treated:
- With knowledge
- With skill building
- With commitment
- With flexibility
- With practice
- With support
- With compassion
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
The content contained in this presentation is strictly for informational purposes. Therefore, if you wish to apply concepts or ideas
contained from this presentation you are taking full responsibility for your actions. Neither the creators, nor the copyright holder
shall in any event be held liable to any party for any direct, indirect, implied, punitive, special, incidental or other consequential
damages arising directly or indirectly from any use of this material, which is provided as is, and without warranties.
Any links are for information purposes only and are not warranted for content, accuracy or any other implied or explicit purpose.
This presentation is copyrighted by Positive Approach to Care and is protected under the US Copyright Act of 1976 and all other
applicable international, federal, state and local laws, with ALL rights reserved. No part of this may be copied, or changed in any
format, sold, or used in any way other than what is outlined within this under any circumstances without express permission from
Positive Approach to Care.
Copyright 2017, All Rights Reserved
Teepa Snow and Positive Approach to Care
DISCLAIMER
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