Working with People with Dementia and Other Cognitive Impairments

PowerPoint Presentation Working with People with Dementia and Other Cognitive Impairments Terry R Barclay, Ph D Clinical Neuropsychologist Brought to you by Background Neuropsychologist Training UCLA.

Working with People with

Dementia and Other Cognitive

Impairments

Terry R Barclay, Ph.D.

Clinical Neuropsychologist

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 Alzheimer’s Research Center

 Independent practice, Edina – Practice:

Normal (Healthy) Aging

 Characteristic pattern:

– Sensory declines (i.e., hearing, vision)

– General slowing of information processing

– Intelligence remains stable

– Mild decrease in:

 Ability to recall names of people, places, objects

 Mental flexibility

 Memory

 Independence in daily activities

What is Dementia?

A disease of the brain that causes a

decline in memory and intellectual

functioning from some previously higher

level of functioning severe enough to

interfere with everyday life.

Dementia is NOT normal aging Brought to you by

Common Signs of Dementia

 Memory loss

– Newly learned information vs old memories

 Disorientation to time, place, and people

 Language problems

 Diminished concentration

 Visual-spatial and perception problems

– Sense of direction

 Difficulty with complex tasks and learning new concepts

 Problems with abstract reasoning, problem-solving,

judgment

 Changes in personality / mood / behavior Brought to you by

How is Dementia Diagnosed?

 Complete medical history

Dementia vs Alzheimer’s

What is the difference between

dementia and Alzheimer’s

disease?

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Roses Tulips

Mums Pansies

Daisies

Flowers

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Alzheimer’s dementia

Vascular dementia

Parkinson’s dementia

Many Causes of Dementia

 Wernicke-Korsakoff’s Syndrome

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Alzheimer’s Disease is

One Type of Dementia

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Alzheimer’s Disease Is:

 A progressive, degenerative, neurological disease

of the brain

 A steady decline in memory and cognitive

functioning severe enough to interfere with

everyday life

 Related to specific chemical and structural

changes in the brain

 NOT reversible

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 What is Alzheimer's D

isease?

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Middle Stage AD

Fluctuating disorientation

Diminished insight

Learning new things becomes difficult

Declining recognition of acquaintances,

distant relatives, then more sig relationships

Mood and behavioral changes

Functional declines

Alterations in sleep and appetite

Wandering

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Late Stage AD

 Severe disorientation to time and place

 No short term memory

 Loss of speech

 Difficulty walking

 Loss of bladder/bowel control

 No longer recognizes family members

 Inability to survive without total care

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 Frontotemporal Demen

tia

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Why is Recognition Important?

5.1 million Americans have Alzheimer’s

disease (AD)

– New case every 72 seconds

– 1 in 8 people over 65

– 1 in 2 people over 85

Approximately 50% are never diagnosed

Almost 10 million people in U.S caring for a

person with AD or related dementia

(Alzheimer’s Disease Facts and Figures 2007 published by the Alzheimer’s Association www.alz.org )

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Why is Recognition Important?

 Crisis-driven utilization of healthcare services

– 1/3 of people with dementia require hospitalization

– Family education and support

(Silverstein & Maslow, 2006; U.S Centers for Medicare and Medicaid, 2000)Brought to you by

What Makes Recognition Difficult?

 Poor understanding of healthy aging

 Baseline variability in education,

intelligence, personality factors

 Lack of insight = not seeking help

 Clinician fear of damaging relationship

 Erroneous belief that “nothing can be

done”, “no good medication treatment”

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Recognition Triggers

 Poor historian

– Deferring to spouse or family/friends

– Tangential, circumstantial responses

– Losing track of conversation

– Talking only about topics they know well

 Repeats questions or other

information

 Difficulty following instructionsBrought to you by

Recognition Triggers

experiences functional difficulties under

stress

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 Subjective interviews often FAIL

to detect dementia until later

stages

 Mental status – Intact older

adults should be able to:

 Describe 2 current events in some detail

 Describe what happened on 9/11, New Orleans disaster, etc.

 Name the current President and 2 immediate predecessors

 Describe medical history and names of some medications

Objective Assessment

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Objective Assessment

 Brief objective measures:

– Mini-Cog

– Mini-Mental State Exam (MMSE)

– St Louis University Mental Status Exam (SLUMS)

– Montreal Cognitive Assessment (MOCA)

 Free online, public domain (except

MMSE)

 Do not have to be an MD, PhD, or RN

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Do NOT

– allow patients to give up prematurely or skip

questions

– deviate from standardized instructions

– offer multiple choice answers

– bias score by coaching

– be soft on scoring

– Score ranges already padded for normal errors

– Deduct points where necessary (be strict)

Assessment Tips

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How to Facilitate Diagnosis

 Follow your instinct, use objective assessment

whenever possible

 Encourage wellness “check-up” with primary

doctor

 Ask family members to:

– Write down main concerns

– Accompany person to doctor’s visit

– Push for formal memory testing in office

– Ask for referral to neurologist, if needed

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“Rapid Onset” Confusion

 Unrecognized pain

 Sleep deprivation

 Immobility

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Communication & Interviewing

Techniques

 Morning typically best

 Familiarity helps those with dementia feel safe

and comfortable

 Rapport building

– Heightened sensitivity to other people’s moods,

feelings, body language and tone of voice

– Warm smile, relaxed demeanor, sense of humor

– Person needs reassurance and understanding in order to

feel comfortable

– Withholding judgment builds trust

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Setting The Stage

 Ask all family, caregivers, and others to

leave the room

 Begin with simple orienting information

 Ask how person likes to be addressed

 Indicate that your visit is a friendly one

 Speak in a low conversational tone

 Move one step at a time

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Setting The Stage

 Scan the environment, reduce

distractions

– Ask to turn off TV or radio

– Ask to close windows to traffic noise

Setting The Stage

 Build rapport until person

shows softer facial expressions,

relaxed body language

 Posture

– Face the person squarely and look them in the eyes

– Ask permission to sit near them to be at eye level

– Never tower over head

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The Interview

– Smile, use sense of humor

– Project a casual and laissez faire demeanor

Communication Strategies

 Validation

– Most people do not spend enough time doing this

– “Join their team”

– Express directly that person’s thoughts and opinions are important and deserve attention

 Focus on underlying feelings

– Observe emotions and body language

– What is the person communicating?

– Memories from the past can trigger emotions from the past

– Offer emotional statements, such as “that must have

been very upsetting”

Verbal vs Non-Verbal

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Communication Strategies

 Slow down

– Be careful to match the pace of the individual

– Speak at leisurely pace, in shorter sentences

– Be patient and give them time to respond

– Try not to interrupt

 Paraphrase

– Acknowledge what the other person is saying

 Be active

– Enhance your message with gestures, inflection, objects

– Ask for clarification when needed

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Communication Strategies

 Distraction

– If the person becomes agitated, do not argue

– Distract them with more pleasant, benign topic

 You do not have to understand

everything that is said

– Interpret the emotion

– Mirror their facial expressions and body language

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Communication Strategies

– Some individuals may make assertions that are not true to

cover for memory loss

– Trying to argue them out of such beliefs is usually futile

because person is not lying

– Circle back around to topic later

 Reluctance to participate

– Often fear of someone finding out how bad things are

getting & losing freedoms

– Help individual feel in control (e.g., join with them,

acknowledge fear, offer choices)

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Communication Strategies

 Avoidance

– If person begins to move away from questions, changes

subject, becomes tense – go back to building rapport

Getting People to Accept Help

 Work from the familiar

– Who is already a trusted part of their routine?

– Which trusted person is available and willing to

introduce new things?

 Take small steps

– Is there a way to start something as a “social visit” or

“one time trial”?

– Would they try it out with a trusted escort?

– Could the service (or provider) come to them?

– Have a good plan that is shared with all involved

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Getting People to Accept Help

 Routine is security

– How can you build things into their existing

structure/routine?

 Reassure fears of losing control

– Give control to them wherever possible through

choices, opinions, being involved in decision

making, etc

 Focus on their values and interests

– How can you tie the service or intervention into

what the person already likes or enjoys? Brought to you by

Keeping PWD at Home

 Promote:

– Family education about dementia

– Regular (annual) visits to the doctor

 Formal memory loss work-up

 Empower family members to join

– Increased (daily) physical activity, mobility

– Regulated sleep patterns (short naps okay)

– Balanced diet, frequent hydration Brought to you by

Keeping PWD at Home

– Frequent social interactions (but not over

stimulation)

– Regular mental stimulation

– Early support and intervention for mood

disturbances

– Safety (medication adherence, cooking, driving)

– Psychological, medical, social, and respite support

for caregivers

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– Meeting of the Minds (St Paul, March)

– One stop shop

 Local memory disorders clinics, support groups, novel community programs, home supports, service referrals, healthcare and legal planning, etc

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Community Resources

 Memory Clubs

– Validated education and support program

– Wilder Foundation (651-280-2295)

Statewide care planning and support

– Family Memory Care

– Early Memory Care

– 800-333-2433

 Coach Broyles’ Playbook for

Alzheimer’s Caregivers

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