Dementia and Alzheimer’s Disease

Curriculum Prepared for Specialty Coursework1/09

Course Description

COURSE DESCRIPTION: This is an introduction to the possible causes and ramifications of dementia and particularly Alzheimer’s disease.

This course will emphasize the physical, psychological and sociological aspects of dementia an its impact on individuals, families and care givers. Topics include communication, dealing with difficult behaviors, research and how we can best structure the environment to meet the needs of an individual with dementia.

Course Objectives

COURSE OBJECTIVES:

The general objectives of this course are to provide students with background information about dementia with emphasis on Alzheimer’s disease. Course work will include segments on definitions, etiology, physical, psychological and sociological aspects of the disease and it’s impact not only the individual but also on the caregivers. Sensitivity awareness, cultural diversity, customer satisfaction, specific techniques to assist individuals diagnosed with dementia will be discussed. Improving the quality of life and reducing caregiver’s stress are at the forefront of this course.

Upon successful completion of this course, the student should be able to:

1. Define terms common to dementia and Alzheimer’s disease

2. Identify and evaluate personal feelings about memory loss/fear

3. Identify behaviors common to a person with dementia

4. Articulate the concept of Validation Therapy

5. Demonstrate communication concepts through role playing

Upon successful completion of this

course, the student should be able to:

6. Demonstrate specific activities to which have been seen as successful when programming for an individual with dementia

7. Discuss similarities and differences between cultures concerning caring for a person with dementia and be able to identify the need to provide individualized quality care based upon the findings.

8. Discuss ways to treat a person with dementia as a whole person who once lived a vital role and a person deserving of quality care and respect

9. Name at least 3 state and national organizations / regulations providing information and regulations services for individuals with dementia

10. List and define state regulations concerned with the care of individuals with dementia

Upon successful completion of this course, the student should be able to:

11.List and describe at least 4 possible living environments /day programs for individuals with dementia

12. Define the term, explain and demonstrate the principles of Montessori learning in relationship to persons with dementia

13. Discuss research that is being conducted to assist in understanding the cause and progression of the disease.

What is Dementia?

Dementia is a word used for a group of brain disorders that gradually reduce a person’s ability to perform daily activities.

The most common type of dementia is Alzheimer’s disease.

Alzheimer’s Disease

Is a progressive disorder that takes away a person’s memory, judgment, thinking and ability to learn and carry out daily activities.

It affects approximately 5 million people in the US.

About 60 percent of dementias are due to Alzheimer's disease, and about 15 percent are due to vascular disease.

Behavioral Characteristics of a person with Alzheimer’s Disease

Person may be physically healthy but require 24-hour a day assistance.

At some point will forget names of family and friends

May become withdrawn and have a change in behavior

May become aggressive Physical health will eventually decline

Symptoms of Alzheimer’s Disease

Forgetfulness Confusion Trouble organizing or expressing

thoughts Change in personality or behavior

Typical occurrence of manifestations of Alzheimer's disease.

Onset of cognitive symptoms Shopping and managing finances Bathing Continence Feeding Self Behavioral Problems Feeding Self Nursing Home Placement Death

Etiology (possible causes)

Aluminum herpes simplex type I virus (HSV1); defective DNA repair head trauma Personality type Heredity other

Getting the diagnosis of dementia

Fear/panic Loved ones don’t want to believe the

diagnosis Acceptance

Impact of diagnosis on a caregiver

Fear Denial Frustration Panic Guilt Acceptance

Confessions of a Dutiful Daughter-video

What were the symptoms did the person with Alzheimer’s exhibit?

How did the daughter feel about her mom’s diagnosis?

What did the daughter learn about how to deal with her mom’s behavior?

What did you learn about the disease from the video?

Stages of Dementia (Tests to determine dementia)

Mini-mental Brief Cognitive Rating Scale Global Deterioration Scale for

Assessment of Primary Degenerative Dementia

Other

Stages of Alzheimer’s Disease

Stage 1 No cognitive decline

Stage 2 Very mild Cognitive decline

Stage 3 Mild cognitive decline

Stage 4 Moderate Cognitive Decline

Stage 5 Moderate Severe Cognitive Decline

Stage 6 Severe Cognitive Decline

Stage 7 Very Severe Cognitive Decline

Stage 1

Stage 1 No cognitive decline

No subjective complaints of memory deficits. No memory deficit evident on clinical interview.

Stage 2 (forgetfulness)

Very mild Cognitive decline Subjective complaints of memory deficits

forgetting where one has placed familiar objects

Forgetting names one formally knew well

No objective deficits in employment or social situations/no evidence of memory deficit on clinical interview.

Stage 3 (Early Confusion)

Mild cognitive decline

May become lost when traveling to a familiar location Co-worker’s become aware of poor performance Word and name finding evident to others Retain little of what is read Objects of value may become lost Concentration deficit may be evident while testing Denial in patient Mild to moderate anxiety accompanies symptoms

Stage 4(Late confusion)

Moderate Cognitive Decline Clear cut deficit on clinical interview

Current and recent events Memory of one’s personal history Concentration on serial subtractions Decreased ability to travel, handle finances No decreases in:

Orientation to person and time Recognition of familiar faces Ability to travel to familiar places

Stage 5 (Early Dementia)

Moderately Severe Decline Person can not survive without some

assistance Unable to recall a major event in their lives Frequently disorientation to time (day, season)

Counting back… Remembers facts about family, can toilet

and eat without assistance but may need help with choosing proper clothes to wear.

Stage 6 (Middle Dementia)

Severe Cognitive Decline May forget names of individuals very close to them Unaware of all recent events and experiences in their lives Retain some memories of the past but very sketchy May have difficulty counting Need assistance with activities of daily living

May become incontinent Personality and emotional changes occur Will most often remember own name Delusional behavior-accusing others of treating them poorly Obsessive behavior

Stage 7 (Late Dementia)

Very Severe Cognitive Decline All verbal abilities are lost Requires assistance in toileting/eating Loss of basic psychomotor skills

(walking) The brain appears to no longer tell the

body what to do.

Stage 4 Activities

Play cards, chess and checkers Painting ,drawing Knitting/Crocheting Ceramics/clay work Reading Exercise Horticulture/gardening Pet facilitated Therapy

Stage 5 Activities

Play cards, chess and checkers Painting ,drawing Knitting/Crocheting Ceramics/clay work Reading Exercise Horticulture/gardening Pet facilitated Therapy

Stage 6 Activities

Play cards, chess and checkers Painting ,drawing Knitting/Crocheting Ceramics/clay work Reading Exercise Horticulture/gardening Pet facilitated Therapy

There is a Bridge Video

Discuss the video in relationship to material provided to date

Communicating with a person with dementia

Validation Therapy Validation is a method of communicating

with and helping disoriented very old people. It is a practical way of working that helps reduce stress, enhance dignity and increase happiness.

Validation Training

Validation is built on an empathetic attitude and a holistic view of individuals. When one can "step into the shoes" of another human being and "see through their eyes," one can step into the world of disoriented very old people and understand the meaning of their sometimes bizarre behavior.

Validation Training cont.

VALIDATION THERAPY NAOMI FEIL

adapted from The Validation Breakthrough: Simple Techniques for

Communicating with People with Alzheimer's -Type Dementia

Naomi Feil (1993)

Ten Principles of Validation

All people are unique and should be treated as individuals. All people are valuable, no matter how disoriented they are. There is a reason behind the behavior of disoriented old people. Behavior in old age is not only a function of changes in the brain's anatomy, but

reflects physical, social and psychological changes that take place during the lifespan.

Behaviors of older people can be changed only if the person wants to change them. Old people should be accepted non-judgmentally. Each stage of life has particular life tasks to be completed. Failure to complete

these tasks may lead to psychological problems. When recent memory fails, older adults restore balance to their lives by retrieving

memories from the past. Painful feelings that are expressed, acknowledged and validated by a trusted

listener will diminish. Painful feelings that are ignored will gain strength. Empathy builds trust, reduces anxiety and restores dignity.

TECHNIQUES OF VALIDATION:

The techniques of Validation are simple to learn and can be performed within the course of atypical day. By using these techniques, caregivers can improve the lives not only of the people for whom they care, but for themselves as well. Different validation techniques are appropriate for different stages of resolution.

 

Technique 1. Centering

1. Focus on a spot about two inches below your waist.

2. Inhale deeply through your nose, filling your body with air. Exhale through your mouth.

3. Stop all inner dialogue and devote all of your attention to your breathing.

4. Repeat this procedure slowly, eight times.

 

Technique 2: Using Nonthreatening, Factual Words to Build Trust

People in Resolution do not want to understand their feelings. They retreat when confronted with their feelings. Caregivers should avoid asking disoriented older people why something happened, or why they did what they did. Instead, caregivers should focus on factual questions - who, what, where, when, and how.

 

Technique 3: Rephrasing

People in Resolution often find comfort in hearing their own words spoken by someone else. To rephrase, the caregiver repeats the gist of what the person has said, using the same key words. The tone of voice and the cadence of speech should also be imitated. If a person speaks quickly, also speak quickly.

 

Technique 4: Using Polarity

The technique of polarity involves asking the person to think about the most extreme example of his or her complaint. By thinking about the worst case, the person being Validated expresses his or her feelings more fully, thereby finding some relief. For example, to Validate a woman who complains that the food is inedible, the Validating caregiver asks, "Is that the worst chicken that you ever ate?"

The caregiver knows that the woman is venting her frustration over her poorly fitting dentures. She knows that the woman needs someone to listen to her anger. By letting her release this anger by complaining about the food, the caregiver helps relieve the women's anxiety.

 

Technique 5: Imagining the Opposite

Imagining the opposite often leads to the recollection of a familiar solution to the problem, providing the old-old person trusts the Validating caregiver. An 85 - year - old woman complains that a man enters her room each night.

To Validate her the caregiver asks her to think about times when the man does not appear: "Are there nights when he doesn't come?" By prompting her to think about a situation in which the man does not appear, the caregiver helps the women recall how she dealt with a similar situation earlier in her life.

Technique 6: Reminiscing

Exploring the past can re-establish familiar coping methods that the disoriented person can tap to survive present day losses. By using words such as "always" and "never" the caregiver can trigger earlier memories. For example, by asking, "Did you always have a hard time sleeping, Mrs. J., even when your husband was alive?", the caregiver may help trigger earlier memories of coping with a problem that the person had forgotten.

Technique 5 and Technique 6 are used together. One technique follows the other to help the old-old restore familiar ways of overcoming stress.

 

Technique 7: Maintaining Genuine, Close Eye

Contact

The very old person in Time Confusion and Repetitive Motion feels loved and secure when the nurturing caregiver shows affection through close eye contact.

Even older people with impaired vision sense the concentrated focus of the Validating caregiver who looks directly into their eyes. Their anxiety is reduced. Often, they will become aware of present day reality.

 

Technique 8: Using Ambiguity

Time Confused people often use words that have no meaning to others. By using ambiguity, caregivers can often communicate with the Time Confused even when they don't understand what is being said. For example, a Time Confused person may cry, "These catawalks are hurting me!" The caregiver can respond by asking, "Where do they hurt?" The pronoun "they" substitutes for the unknown word "catawalks." Using "he" "she" "it" "someone" and "something" fills in for the non-dictionary words. Time Confused people keep communicating and withdrawal to Vegetation is prevented.

Technique 9: Using a Clear, Low, Loving Tone of Voice

Harsh tones cause disoriented people to become angry or to withdraw. High, soft tones are difficult for many older adults to hear. It is important to speak in a clear, low, nurturing tone of voice. Often, a nurturing voice triggers memories of loved ones and reduces stress.

Technique 10: Observing and Matching the

Person's Motion and Emotions (Mirroring)

People in Time Confusion and Repetitive Motion often express their emotions without inhibition. To communicate, it is important to take stock of their physical characteristics and the ways in which they move. The caregivers should observe their eyes, facial muscles, breathing, changes in color, chin, lower lip, hands, stomach, position in the chair, position of the feet, and the general tone of their muscles to match these postures. When the person being Validated paces, the caregiver paces. When the person being Validated breathes heavily, the caregiver breathes heavily. Done with empathy, mirroring can be effective in helping to create trust. It allows the caregiver to enter the emotional world of the Time Confused person and to build a verbal and nonverbal relationship. Mirroring the sometimes bizarre motions of disoriented people can be an upsetting experience and not all caregivers will want to try this technique.

Technique 11: Linking the Behavior with the Unmet Human Needs

Most people need to be loved and nurtured, to be active and engaged and to express their deep emotions to someone who listens with empathy. Ex: A 93 year old woman lovingly smoothes out each wrinkle of a paper napkin. Nothing is out of place. A waitress who does not understand Validation takes the napkin out of the old woman's hand and shakes it. The old woman begins to yell at the top of her voice, "Help! Help!" Instead of medicating or restraining, the Validating caregiver gives the old women the napkin. Together, they fold it carefully, lovingly, smoothing out each wrinkle. "Does this make you feel safe and warm?" asks the caregiver. The old woman smiles. She strokes the napkin, "Ma, I love you." Somehow, the napkin has become a soft, loving mother for this old woman. The caregiver links the folding to the human need for love. When the old-old pound, pace, rub, or pat, the Validation caregiver links the behavior to one of 3 human needs - love, usefulness (restoration of movements associated with work) or the need to express raw emotions.

Technique 12: Identifying and Using the Preferred Sense

Most people have a preferred sense. For some that is vision; for others it is the sense of smell, for yet others it is the sense of touch. Knowing a person's preferred sense is one way of building trust, since it enables the caregiver to speak the person's language, to step into the person's world. One technique for determining which sense a person prefers is to ask that person to think about and describe an experience from the past. The first sense the person uses often reveals the person's preferred sense.

 

Technique 13: Touching

Touching is a technique that is usually not appropriate for Maloriented people, but is often effective with people in Time Confusion. People in Time confusion no longer distinguish between people they have known all their lives and people they have never met before. The Validating caregiver can instantly become a loved person, since people in Time Confusion can incorporate strangers into their world. People in Repetitive Motion are no longer aware of where they are. To communicate with them, the caregiver must enter their world and touch them in the same way a loved one touched them. To use touch with a Time Confused person, the caregiver should approach the person from the front, since approaching the person from the side might startle the person. Touching another person is an intimate act and caregivers - both professionals and families - must respect that some people, even when their controls are damaged do not want to be touched. Any sign of resistance to physical contact should indicate to the caregiver that touching is inappropriate. The personal space of all people, whether they are disoriented or not; must always be respected.

 

Technique 14: Using Music

When words have gone, familiar, early learned melodies return. Stored forever in the brain's circuit, early learning, reinforced through the years, remains. People in Repetitive Motion who no longer retain the ability to speak can often sing a lullaby from beginning to end. When a former sailor, now 95 years old and in Repetitive Motion, paces back and forth, his daughter Validates him by singing "Anchors Away, My Boys." The sailor stops, looks at his daughter, smiles and sings with her. The sailor does not recognize his 60-year-old daughter, nor does he know the name of the song, but he sings each word. His daughter can now communicate. She sings with her father since he can longer talk.

People in Repetitive Motion will often say a few words after singing a familiar song. Music energizes people in Time Confusion and Repetitive Motion.

 

Breaking through dementia (video)

Role play techniques presented Discuss how techniques can be

utilized in a natural setting

Interacting with a person with dementia

What can we as caretakers do to make an individual with dementia feel safe and valued?

Can a person with dementia still learn?

Montessori–Based Practice for Adults

Adult Montessori based programs reinforce functional skills which are important in promoting a positive sense of self-esteem.

The goal is to support the remaining, less impaired skills needed everyday.

Memory-Declarative

Episodic memory (past events, autobiographical information)

Semantic memory (world knowledge, concepts, vocabulary)

Procedural Memory

Preserves abilities in dementia Habits/skills Location/learning/environmental cuing Motor learning Classical Condition Repetition Priming

The ability to improve performance after initial exposure to information

Montessori –Based Activities

Utilize Procedural Memory Skills Habits Motor learning Repetition priming This is similar to “Unconscious Learning”

in Montessori’s work

Montessori-based activities and rehabilitation

Circumvent deficits Allow independent functioning Engage in meaningful activity Provide feedback and success Enhance self-esteem Let function at highest possible level Provide meaningful social roles

Montessori-based programming (activities)

Are broken down into steps Provide immediate feedback, along

with repetition Allow practice as well as closure

Conducting Montessori - Based Activities

Set-up material form left to right, top to bottom

Arrange materials form largest to smallest, most to least

ALWAYS DEMONSTRATE what is to be done first

Use as little verbalization as possible

Conducting Montessori-Based Activities

Slow down your movements Match your speed to the person with

dementia LET GO of the idea that an activity has

to be done the “right” way Goal is engagement & stimulation Encourage reminiscence

General principals of this approach include:

Utilization of familiar materials taken from the everyday environment.

Division of tasks into steps that can be practiced

Utilization of sequencing, repetition, and feedback to support intact habits.

Examples of programming

Sensory discrimination (sorting) Activities of daily living Motor activities Cognitive stimulation

Helping the Caregiver

How do cultural differences affect care giving for a person with dementia?

Service settings

Home (home health aides) Adult Day Assisted Living Nursing Homes Other

Organizations for Information/Support for Dementia/Alzheimer’s

Alzheimer's Association CareSource Alzheimer's Association. 24/7 Helpline:

1.800.272.3900 Alzheimer’s Support Group CT www.myersresearch.org

My Mother, My Father (video)

What did you observe in the video that you feel you could utilize in your care of an individual with dementia?

Problematic Behavior

Disorientation Repetitive behaviors Aggressive behavior Obsessive behavior Agitation Other

How can we help to alleviate these problems?

Validation Therapy Montessori Based-Programming Restructuring the environment Other

Agitation… It's a sign (video)

View the video and discuss-

What can I do to reduce agitation in person’s with dementia?

Research-Meeting the Needs of Individuals with Dementia

How can we slow the progression of the disease?

What medications are presently being used to aid in the reduction of symptoms of dementia?

Why is research important? What research is presently being

conducted?