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NEW HAMPSHIRE
DEMENTIA
TRAINING 6 HOUR
MODULE 4UNDERSTANDING BEHAVIORS AND
COMMUNICATIONS-THE
IMPORTANCE OF EFFECTIVE
COMMUNICATION AND STRATEGIES
TO MINIMIZE BEHAVIORS
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CASE STUDY-MR.R
Mr. R. is an 80-year-old man with moderate/middle stage Alzheimer’s disease and type 2 diabetes. Mr. R. lives with his 75-year-old wife who is his primary caregiver. Mr. R. and Mrs. R. have been married for 50 years and used to enjoy dancing, singing, and going to church.
Mrs. R. often gets impatient with Mr. R. and yells at him when he is too slow in getting dressed and eating and he becomes resistant to these activities. Recently Mr. R. started wearing the same clothes everyday and refusing to bathe. Mrs. R. also gets easily frustrated when her spouse wanders around the house and follows her. Mr. R. frequently misplaces things, like his handkerchief and glasses and accuses his wife of stealing these items.
Mrs. R. is exhausted, frustrated and burnout from caring for her husband 24/7, she feels like she has no time to herself and is ready to place her husband at a higher level of care. Mr. R’s MD has contacted your home health agency to evaluate the challenging behaviors and suggested Mrs. R. get assistance from Home Care.
What are the behaviors you see in this case?
Think about what could be causing these behaviors?
How would you start to solve some of the behaviors?
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“IF WE SPENT AS MUCH TIME TRYING TO UNDERSTAND BEHAVIOR AS WE SPEND TRYING TO MANAGE OR CONTROL IT, WE MIGHT DISCOVER THAT WHAT LIES BEHIND IT IS A GENUINE ATTEMPT TO COMMUNICATE.”
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UNDERSTANDING BEHAVIORS
What is a behavior?
The manner in which a person acts or performs; any or all of the activities of a person, including physical action learned and unlearned, deliberate or habitual.
What is a “challenging behavior?”
Behavior that prevents the person from participating in normal life activities; presents a serious physical risk to safety of person and others.
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USING A PROBLEM-
SOLVING
APPROACH TO
CHALLENGING
BEHAVIORS
A particularly effective approach to
managing challenging behaviors is to
identify the cause of the behavior
using the problem-solving approach in
which caregivers determine the root
cause of a behavior and treat it—
usually with effective communication,
environmental modifications and a
toolbox of strategies.
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1-WHAT IS THE BEHAVIOR or COMMUNICATION?
❖ What is this person attempting to communicate?
❖ What is the need that is not being fulfilled?
2-WHEN
❖ Ask yourself what happened just before the problem behavior started. Did something specific trigger that
behavior?
3-WHERE
❖ What is going on in the environment when behavior occurred?
4-WHY-WHAT CAUSED THE BEHAVIOR?
❖ Unmet physical needs-pain, thirst, hunger, dehydration, UTI
❖ Stressed, frustrated, depressed, scared, tired, rushed
❖ Environment-loud, too stimulating
5-HOW (DO YOU DEAL WITH BEHAVIOR?)
❖ Communication Tips
❖ Validate, Validate
❖ Body language, facial expressions
❖ Don’t argue
❖ Give Space
❖ Distraction-activities, toolbox, music, food, hobbies, distractions, picture albums,
1-Reassess
2-Rechannel
3-Reassure
4-Reconsider
REASSESS
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1-WHAT IS THE BEHAVIOR or COMMUNICATION?
❖Agitated
❖Resistance to care @ dressing and bathing
2-WHEN
❖ Behavior occurs when you ask the client to shower
3-WHERE
❖ You are telling client it is time to bathe
4-WHY?
❖ Doesn’t want to bathe, scared, doesn’t understand what is being asked
❖ Stressed, frustrated
❖ 5-HOW (DO YOU DEAL WITH BEHAVIOR?)
❖ Communication Tips
o Don’t argue
o Walk away and re-approach in 5-10 minutes- “Let’s freshen you up so your daughter can take you
to lunch”
o Offer to wash up at sink, break tasks into steps-use verbal and tactile cues
UNDERSTAND
WHAT MAY BE
CAUSING THE
BEHAVIOR
Socialization/Interactions
Emotional needs
• Comfort
• Security
• Purpose
• Belonging
• Control
• Fear for today and tomorrow
• Boredom
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WHEN YOU SEE A BEHAVIOR
1-Reassess
2-Rechannel- Redirect and distract them
3-Reassure- Person lives in a world they cannot
understand. Speak to them with a calm voice and
offer reassurance.
4-Reconsider-Try to see the world from the
individual’s perspective. What could be going on?
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PROCESS FOR PROBLEM SOLVING:
INTERVENTIONS
*Always consider physical issues –
especially pain
*How we communicate
is a huge issue –
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RECOGNIZING
PAIN
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PAIN ASSESSMENT IN DEMENTIA
FIVE DESCRIPTIVE ELEMENTS
Breathing
Negative Vocalization
Consolability
Facial Expression
Body Language
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WE NEED TO THINK DIFFERENTLY
Take time to learn the person’s “life
story”- family, work, hobbies, interests,
likes and dislikes. Use this knowledge to
establish rapport and find an approach
that will work.
Use remaining abilities.
Be creative!
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PROCESS FOR PROBLEM SOLVING: INTERVENTIONS
WHAT ABOUT OTHER CAUSES?
HUMAN FACTORS
How we approach a person with dementia when communicating, engaging in a task , or providing daily care will sometimes determine a positive or negative behavior. Research shows that about 90% of challenging behaviors are caused by the caregiver’s behavior – the person with Alzheimer’s is merely responding to what he perceives coming from the caregiver.
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This Photo by Unknown Author is licensed under CC BY-SA
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COMMUNICATION
FUNDAMENTALS
When you arrive at their home
INTRODUCE YOURSELF
“Hi. Mrs. B –I’m Suzanne from ABC Home
Care”
WHY YOU ARE THERE
“I’m here to help you today get ready to go to
your doctors”.
“I’m here to help freshen you up before your
visit with your daughter later and help you eat
breakfast”
EXPLAIN WHAT YOU ARE GOING TO DO
BEFORE YOU START THE ACTIVITY
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KEY COMMUNICATION
FUNDAMENTALS
1-Speak slowly and clearly-call your client by name
2-Maintain eye contact
3-Approach from the front
4-Get at the client’s level
5-Give the client time to respond (60-90 second rule)
5-Ask one question at a time-keep the message simple, no
long explanations
6-Listen carefully
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COMMUNICATION
AROUND ADLS
1-Describe what you are doing
2-Break down instructions
3-Use verbal and tactile cues
“John put your right arm in the
right sleeve, tap right shoulder,
next “John put your left arm in
left sleeve, tap left shoulder”
4-Give your client time to
participate
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COMMUNICATING….
USE KEY STEPS:
- Use verbal, tactile cues
- Break down instructions
- Approach from the front
- Banish “Don’t you remember?
- No quizzing
APPROACH MATTERS
Get excited - “I know how much you love Diana Ross; we
can put on some music to listen to together
Don’t ask - “I’m making double chocolate brownies, I love
chocolate and know you do too, lets go make some brownies”
Ask for Help - “I’m getting dinner ready could you help me
wash the beans?”
Do it in front - Always approach from the front at eye level
Remove concerns and fears – “We can sit near the
bathroom at the concert”
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THE WAY WE PHRASE SOMETHING MATTERS
Use positive words
Negative words leads to….Stigma, Labels, Fear,
Dehumanization, Diminishing person, Poor Care
Example:
“Mr. Green don’t go near that door”(N)
“Mr. Green lets get our coats and go for a walk”(P)
“Why can’t you sit down?”(N)
“Sit with me and help cut up some vegetables. I could
really use your help.”(P)
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TO CONNECT WITH SOMEONE WITH ALZHEIMER’S TAKE
ON THEIR PERSPECTIVE AND JOIN THEM WHERE THEY
ARE
“ I think someone is rearranging my clothes at night” YES
“I want to go home now.” YES “Mrs. B you are home and I am here to keep you safe”
THIS EXAMPLE CAUSES NEGATIVE REACTION AND AGITATION
“I have a beautiful baby boy” “NO you don’t”-
AND “would you like to have a cup of tea?”
AND “Would you like to make some
cookies?”
Emotional memory lingers. Human emotion
and connection cannot be destroyed with
Alzheimer’s.
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COMMUNICATION COMMANDMENTS
Give instructions one step at a time and keep simple
Remember 60-90 second rule
“Thou Shall Not Reason!”
“Thou Shall Not Argue!”
Be aware of your own and individual's non-verbal communication.
Use signage
What are the emotions behind the words?-validation
Quiet, calm, non-rushed
Avoid distracting environment
Sometimes the truth hurts
Smile, hug, human touch
Name tags at a family event
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THE PERSON WITH AD CANNOT
CHANGE, SO WE NEED TO….
Change the caregiver’s approach (ex-one instruction at a
time)
Change the environment (ex-remove distractions, noise)
Change the task (ex-will you help me find my purse or we
are going out later, so I’d like to help you freshen up?)
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SYMPATHY(feeling for someone, pity)
VS.
EMPATHY(feeling with someone-we feel their story, putting yourself in their shoes)
“I want to go home” Think about how you would feel if you got dropped off.
Reply with an empathetic response: “Tell me about your home? Who did you live with? What was your favorite room?
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CULTURALLY
APPROPRIATE
COMMUNICATION
Use of silence
Personal space
Eye contact
Non-verbal communication
Cultural responses to emotions
Cultural interpretations of social issues
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AGGRESSION
& AGITATION CAUSES
PAIN
DEPRESSION
CAREGIVER’S APPROACH
TOO MUCH NOISE
BEING RUSHED
FRUSTRATION
FEELING INADEQUATE
CHANGE IN ROUTINE
FATIGUE
PSYCHOSIS
RESPONSES
BACK OFF! –DON’T TOUCH, CROWD OR GET BACKED INTO A CORNER
ENSURE SAFETY OF OTHERS
CALMLY ASK “WHAT CAN I DO TO HELP YOU?”
SAY OVER AND OVER “I CAN SEE YOU ARE UPSET, I WANT TO HELP YOU, WHAT CAN I DO TO MAKE YOU FEEL BETTER?”
ENCOURAGE PERSON TO MOVE TO QUIET PLACE
AFTER PERSON CALMS DOWN REVIEW EVENTS LEADING UP TO INCIDENT – COULD YOU HAVE DONE ANYTHING DIFFERENT TO PREVENT AGGRESSIVE BEHAVIOR.
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AGITATION AND AGGRESSION
REPETITION, REPETITION, REPETITION…….
CAUSES OF REPETITION
▪ Lack of short-term
memory-repeating same
thing over and over
▪ Hunger- ”When are we
going to eat?”
▪ Pain-Saying “Help me”
▪ Boredom
Need for movement-Pacing
RESPONSES
1. Give your client something to
do. Redirect into repetitive
behaviors such as folding
towels, manipulating Legos,
etc.
2. Write in BIG LETTERS
ANSWER TO QUESTIONS
3. Provide finger food –
encourage grazing
4. Medicate to relieve pain
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SUNDOWNING
Increased agitation, confusion, nervousness and
hyperactivity that may begin in the late afternoon and
build throughout the evening, often as the sun sets.
-Most sundowning emerges in middle-stage dementia
and slowly worsens as the disease progresses.
Why does this happen? More tired in the late
afternoon, confused by changing amounts of light, scared
by shadows, reacting to your feelings of being tired.
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SUNDOWNING RESPONSES
1. Adequate exercise during the day
2. Keep individuals awake during the day
3. Plan activities or outings in the morning
4. Comfort and reassure, play soothing music
5. Decreased stimulation before time of sundowning
6. Provide distraction – food + drink; music, doll baby, picture
album, comfort items
7. Try to maintain a predictable routine for bedtime, waking, meals
and activities.
8. Utilize bright light therapy. Increase indoor lighting before dusk.
Research suggests light therapy may reset the body's circadian
rhythm, or inner biological clock.
9. Remove excess stimuli (turn down or turn off TV and radio)
reduce clutter.
Be twice as patient and kind during these
hours.
WHY?
1. Fatigue
2. Stress
3. Disturbance in Routine
4. Low Lighting
5. Shadows
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SUSPICIOUSNESS/PARANOIA
SUSPICIOUS BEHAVIOR – DON’T TAKE PERSONALLY;
DON’T ARGUE OR CONVINCE; OFFER A SIMPLE ANSWER;
REDIRECT PATIENT’S ATTENTION
DEALING WITH FALSE ACCUSATION – EX: STOLEN PURSE
Validate feelings- “Mrs. B. I am so sorry that you lost your
purse again. You must feel terrible.”
Offer to help-”Mrs. B , let me help you find your purse.”
Begin to distract –after a few minutes-”Should we go in the
kitchen and get a snack?’ or “Let’s add some pictures to
the photo album”.
Keep talking for 5 minutes or more.
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Hallucinations
❑Visual hallucinations can be vague or clearly
defined. May see intruders or deceased
relatives.
❑Auditory may hear voices of deceased family.
❑ In some forms of dementia, hallucinations are
more common- dementia with Lewy
bodies and Parkinson’s disease dementia.
❑Hallucinations in people with dementia with
Lewy bodies usually take the form of brightly
colored people or animals.
https://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=1408
What to Do?
❑ If it’s not a scary hallucination, don’t argue
❑ If hallucinations are scary, reassure the client
you are there to keep them safe.
❑ It may help to distract the person, and see if this
stops the hallucinations.
❑ For visual hallucinations, consider making
changes to the environment such as improving
lighting levels, closing the shades, reducing visual
clutter and removing mirrors.
❑ For auditory hallucinations, arrange to have their
hearing checked. If the person wears a hearing
aid, check that it is working properly and
encourage them to wear it.
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WANDERING
❑ Three out of five people with this disease will wander
at some point.
❑ Is there a pattern to wandering?
❑ Same time each day?
❑ WHY DO PEOPLE WANDER?
❑ Trying to get home
❑ May be looking for bathroom
❑ May be looking for food or drink
❑ Following past routines-trying to get to work(of past)
❑ Searching for someone or something.
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❑ Have identification ready
❑ Let neighbors know family member has memory problem
❑ Encourage exercise during day
❑ Involve client in useful activities such as folding laundry, meal prep etc.
❑ Remind patient that he/she in right place
❑ Reassure patient if he/she feels lost, abandoned or disoriented.
❑Alzheimer’s Association Safe Return Program
❑GPS Bracelets
Locks at bottom or top of door
Cover door
Use of baby monitor or infrared eye alarm
Child safe plastic door knob
Night light in patient’s room
Keep lights on in hallway
Disable stove
Use of black/dark brown rugs in front of exit doors
Motion detector
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WANDERING
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SEXUALLY INAPPROPRIATE
BEHAVIOR
Stay calm,
Determine if behavior is sexual
Tell the individual, “I don’t like it when you talk to me like that.” You can’t
touch me like that” repeat as needed. Remove hand.
Disrobing – could mean the clothes are uncomfortable – individual may
be responding to skin sensitivity. May need fleece lined clothes and/or
larger size.
Going to the bathroom in wrong place – could be that individual can no
longer distinguish the correct place to do these things.
Give privacy
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BEHAVIOR CHECKLIST - WHEN TO
ALERT CASE MANAGER
If you notice any of the following changes, alert the case manager
Increased confusion/disorientation,
New onset pacing/Can’t sit still
Changes in toileting continence
Swallowing Issues
Changes in communication/Increased difficulty or unable to speak
Difficulty with hydration/eating/nutrition
Change in ability to complete ADL’s
Trouble initiating or completing tasks
Disinhibition
Personality change
Poor judgement/irritability
Isolates self, cries , appears sad, no longer wants to engage in activities
Trouble sleeping
Increased tension, startles easily, trembling
Screams or lashes out at family members, staff
Physical aggression-pushes, hits, makes fists at family members or others
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CASE STUDY-MR.R
Mr. R. is an 80-year-old man with moderate/middle stage Alzheimer’s disease and type 2 diabetes. Mr. R. lives with his 75-year-old wife who is his primary caregiver. Mr. R. and Mrs. R. have been married for 50 years and used to enjoy dancing, singing, and going to church.
Mrs. R. often gets impatient with Mr. R. and yells at him when he is too slow in getting dressed and eating and he becomes resistant to these activities. Recently Mr. R. started wearing the same clothes everyday and refusing to bathe. Mrs. R. also gets easily frustrated when her spouse wanders around the house and follows her. Mr. R. frequently misplaces things, like his handkerchief and glasses and accuses his wife of stealing these items.
Mrs. R. is exhausted, frustrated and burnout from caring for her husband 24/7, she feels like she has no time to herself and is ready to place her husband at a higher level of care. Mr. R’s MD has contacted your home health agency to evaluate the challenging behaviors and suggested Mrs. R. get assistance from Home Care.
What are the behaviors you see in this case?
Think about what could be causing these behaviors?
How would you start to solve some of the behaviors?
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CASE STUDY- MODULE 4- MR. R.
What are the behaviors you see
in this case?
Resistance to care-Not changing clothing
Shadowing/Clinging Suspiciousness/ParanoiaThink about what could be causing these behaviors?
Pain
Boredom/Decreased Activity
Confusion/Decreased Memory
Lack of a set schedule/Routine
Not enough Physical Activity
How would you start to solve some of the behaviors?
Find out Mr. R’s. Life story
Suggest and help set up a schedule based on Mr. R’s Life Story
Evaluate Mr. R. for Pain using the Faces
pain Scale or another tool
Increase Physical Activity throughout
the day
Suggest Mrs. R. purchase extra sets of the same clothing and switch out at night to
wash
Purchase multiples of the items Mr. R. is
losing
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