Assessment and Treatment Strategies for Adults with Dementia Part I:

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Assessment and Treatment Strategies for Adults with Dementia Part I: Using the Progression of Dementia to see GEMS, not loss Speaker Disclosure Beth Nolan is the Director of Cer2fica2ons and Research for
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Assessment and Treatment Strategies for Adults with Dementia Part I: Using the Progression of Dementia to see GEMS, not loss Speaker Disclosure Beth Nolan is the Director of Cer2fica2ons and Research for Posi2ve Approach LLC For more info and resources: 1 Objectives: 1. Describe characteristics and needs about what it means to be living with each GEMS cognitive and physical abilities. 2. Identify GEMS levels for PLWD as a means of IDing other skills Part I: Sapphire, Diamond, Emerald Part II: Amber, Ruby, Pearl 3. Demonstrate how this tool can be used as supportive means of communication to change the way we help people live with dementia Normal Brain Brain with Alzheimers Used with permission from The Broken Brain: Alzheimers, 1999 University of Alabama 2 Positron Emission Tomography (PET) Alzheimer s Disease Progression vs. Normal Brains Normal Early Alzheimer s Late Alzheimer s Child G. Small, UCLA School of Medicine BIG Language CHANGE Hearing Sound Unchanged 3 Sensory Strip Motor Strip White MaCer ConnecDons BIG CHANGES Right Left Automatic Speech Rhythm Music Expletives PRESERVED Right Left Formal Speech & Language Center HUGE CHANGES The GEMs to understand how to give the right setting and care so they SHINE 4 GDS: Reisberg s Global Deterioration Scale (7) CDR: Clinical Dementia Rating (5) ACL: Allen Cognitive Levels (6) FAST: Functional Assessment Staging System Brief Cognitive Rating Scale HDS: Hierarchic Dementia Scale DSRS: Dementia Severity Rating scale Six Clinical Phases of Cognitive Decline FRS: Functional Capacity Scale GAD: Global Assessment of Dementia Gem DemenDa AbiliDes Based on Allen Cogni.ve Levels - A Cogni2ve Disability Theory OT based - Creates a common language and approach to providing: ü Environmental support ü Caregiver support and cueing strategies ü Expecta2ons for retained ability and lost skill ü Promotes graded task modifica2on - Each Gem state requires a special seong and just right care ü Visual, verbal, touch communica2on cues - Each can shine - Encourages in the moment assessment of ability and need ü Accounts for chemistry as well as structure change 5 Now for the GEMS Sapphires True Blue Slower BUT Fine Diamonds Repeats & Routines, Cutting Emeralds Going Time Travel Where? Ambers In the moment - Sensations Rubies Stop & Go No Fine Control Pearls Hidden in a Shell - Immobile Sapphires Brains are Still True Blue! Clear & True No dementia You and Me on a GOOD Day Normal Aging No Dementia Some are Stars Some are Not Slower but still shining 6 Sapphires Clear & True No dementia May feel blue over changes Importance of time true to lifetime Can make their own setting right Will still need us in their lives Will like to shine at times Will set their own pace They can CHOOSE Diamonds Still Clear Sharp - Can Cut Hard - Rigid - Inflexible Many Facets Can Really Shine 7 Diamonds Uses Routines & Old Habits to function Can complete personal care in familiar place Follows simple prompted schedules - mostly Misplaces things and can t find them Resents takeover or bossiness Notices other people s mis-behavior & mistakes Territorial refusals! Varies in lack of self-awareness copyright - Positive Approach 2013 Common Diamond Issues IADLs Money management Transportation - Driving Cooking Home maintenance & safety Caring for someone else Pet maintenance Med administration Unfamiliar settings or situations Hospital stay Housing change Change in family Change in support system MD visits New diagnoses Traveling or vacations copyright - Positive Approach Emeralds Changing color Not as Clear or Sharp - Vague Good to Go Need to DO Flaws are Hidden Time Traveling Common Emerald Issues Doesn t do care routinely thinks did Makes mistakes in sequence unaware Repeats some care routines over & over Gets lost can t find where to do care Afternoon or Evening Got to go home Limited awareness of real needs Hunger, thirst, voiding, bathing, grooming Has other stuff to do 9 Connect ID common interest Say something nice about the person or their place Share something about yourself and encourage the person to share back Follow their lead listen actively Use some of their words to keep the flow going Remember its the FIRST TIME! expect repeats Use the phrase Tell me ABOUT General Vision Changes Sapphire: lost about 45 o of field Diamond: tunnel vision Emerald: binocular vision Amber: binocular vision; loss of object recognition Ruby: monocular Pearl: movement, familiar/unfamiliar 10 Receptive Language Changes Sapphires: crowded & loud spaces more challenging, high pitched harder Diamonds: Slower, missing consonants Emeralds: missing about 1/4 words, needs pauses better with rhythm Ambers: 2-4 words; catches some key words out of context Rubies: social chit-chat, music, rhythm, tone of voice Pearls: familiar and friendly, calm or excite Expressive Language Changes Sapphires: word finding a little slower, pauses Diamonds: varies with affect, word finding problems, mis-speaking at times of stress Emeralds: repeats phrases or words, gets stuck in social, intonation matters Ambers: repetitive, variable volume, echo Rubies: less articulated speech, babble, hum or sing, rhythmic vocalizations Pearls: sounds to single words, responsive 11 Dexterity Hand Skills Sapphires: still intact slightly slower Diamonds: Slower, limited w/ bilateral skilled integration Emeralds: individual actions are there, sequencing is challenging, more forceful Ambers: heightened use of hands, skilled tool use decreased, strong Rubies: whole hand with limited finger use hold and carry, difficulty with release Pearls: grasp strong, limited opening Body Skills Sapphires: sustained - slower Diamonds: details not as good, globally Ok Emeralds: better with dominant side, errors Ambers: strong more than skilled, limited safety awareness Rubies: whole body not segmented, front ok back not Pearls: reflexive, great trouble with gravity or speed or movement 12 People Awareness Skills Sapphires: sustained slower to ID Diamonds: recent?, older/deeper better Emeralds: recognize like/not like, Ambers: can get lost in old-new relationships, will like or not like in the moment Rubies: like or not like, familiar versus not Pearls: voices, faces, touches, smells familiar or not Place Awareness Skills Sapphires: sustained à turned around Diamonds: familiar feels best à gets lost in community & in unfamiliar places Emeralds: if OK with what is seen is OK, if not OK seeks the old familiar task or social Ambers: OK if here feels OK, otherwise will go there Rubies: may or may not have a destination more a movement or stillness pattern Pearls: is what is experienced comforting 13 Time Awareness Skills Sapphires: lifelong crunched or expanded Diamonds: more the past than now Emeralds: lost in episodes or caught in loops Ambers: in the moment not the task or sequence Rubies: in the experience, not the time Pearls: time has much less meaning Situation Awareness Skills Sapphires: sustained à tough to think Diamonds: old emotions drive new interactions Emeralds: has moments of time travel Ambers: more sensory awareness than intellectual awareness; immediate Rubies: only in moments, less body aware Pearls: more inside than externally aware 14 Assessment and Treatment Strategies for Adults with Dementia Part II: Using the Progression of Dementia to see GEMS, not loss Ambers Amber Alert Caution! Caught in a moment All about Sensation Explorers 15 Amber Activities LOTS of touching, handling, mouthing, manipulating Focus on fingers and mouth Get into things All about sensation. Invade space of others Do what they like AVOID what they do NOT Amber Interests Things to mess with (may be people) Places to explore Stuff to take, eat, handle, move Visually interesting things People who look or sound interesting OR places that are quiet and private Textures, shapes, movement, colors, numbers, stacking, folding, sorting 16 Rubies Hidden Depths Red Light on Fine Motor Comprehension & Speech Halt Coordination Falters Wake-Sleep Patterns are Gone Ruby Care Issues Contractures Skin well being bruises, tears, rashes Pressure or friction Infections UTI, yeast, URI, pneumonias Swallowing Circulation 17 Pearls Hidden in a Shell Still & Quiet Easily Lost Beautiful - Layered Unable to Move Hard to Connect Primitive Reflexes on the Outside Primitive Reflexes to Consider Startle reflex Sudden movement causes total body motion Grasp reflex touch palm grips hard can t release Sucking reflex sucks on anything near mouth Rooting reflex Turns toward any facial touch and tries to eat 18 More Reflexes Bite reflex Any touch in mouth causes bite down Tongue thrust Anything in mouth causes tongue to push forward and out Withdrawal rebound Pull away from stretch Gag reflex Any touch to tongue causes gag 3 Zones Of Human Awareness and the PPA Changing Attitudes through Building Awareness, Knowledge and Skill 19 3 Zones of Human Awareness Public Space 6 U away or more - Visual Interac2ons & Awareness Personal Space 6 U to arm s length - Conversa2ons & Friendship InDmate Space within arm s reach - Intense Physical Closeness 3 Ways We Take in Data Visual - What we see Personal Space What we hear InDmate Space What we touch & feel Positive Physical Approach 1. Stop moving 6 U out 2. Greet: hi sign (open by face), say name 3. Moves hand into a handshake posi2on 4. SLOWLY come in from the front within visual range (or starts there) 5. Move into SupporDve Stance 6. Hand shake move into hand-under-hand 7. Move to side; Get low sits or kneels 8. Make connecdon (wait for their response!) 9. Deliver a message using V-V-T cues 20 Positive Physical Approach Hand-Under-Hand To guide and assist 21 Hand-under-Hand Assistance - Keeps you from hur2ng their wrist, arm, or fingers - Keeps the person from squeezing your knuckles - Keeps them from hiong or grabbing you - Helps direct gaze eye-hand coordina2on - Pressure in the palm is calming Hand-under-Hand Assistance Protects aging, thin, fragile, forearm skin 22 High Risk Care Approaches to Consider TYPE of CARE Preventative Curative Restorative Maintenance Compensatory Sapphire *** *** *** * * * Diamond *** *** *** *** Emerald ** * * ** *** * Amber * *? * ** *** Ruby??? ** *** *** Palliative Pearl * * **** 23
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