Directing an Directing an Alzheimer’s/Dementia Alzheimer’s/Dementia

Care UnitCare Unit

Funded by:Funded by:Indiana State Department of HealthIndiana State Department of Health

Co-sponsored by:Co-sponsored by:IAHSAIAHSA

IHCAIHCA

HOPEHOPE

Module 1:Module 1:Review of Dementia and Care Review of Dementia and Care

PracticesPracticesIn this section, we will cover:In this section, we will cover: Definition of dementia and Alzheimer’s diseaseDefinition of dementia and Alzheimer’s disease Alzheimer’s disease progressionAlzheimer’s disease progression Differences between dementia, depression, and Differences between dementia, depression, and

deliriumdelirium Importance of person centered care and its Importance of person centered care and its

implementationimplementation Importance of stress management with family Importance of stress management with family

and staffand staff

What is Dementia?What is Dementia? Dementia is a disease processDementia is a disease process

– Progressive decline in cognitive functionProgressive decline in cognitive function– Memory lossMemory loss

Over 170 irreversible dementiasOver 170 irreversible dementias– HIV, Vascular, Lewy Body, Parkinson’s, HIV, Vascular, Lewy Body, Parkinson’s,

Alzheimer’sAlzheimer’s Some forms are reversible (treatable)Some forms are reversible (treatable)

– Thyroid disorders, drug interactions, Thyroid disorders, drug interactions, dehydrationdehydration

Alzheimer’s DiseaseAlzheimer’s Disease Most common form of irreversible Most common form of irreversible

dementiadementia– Nearly 70% of all dementias are Alzheimer’sNearly 70% of all dementias are Alzheimer’s– Over 4.5 million Americans have Alzheimer’sOver 4.5 million Americans have Alzheimer’s– It is estimated that 60% of all nursing home It is estimated that 60% of all nursing home

residents have Alzheimer’s diseaseresidents have Alzheimer’s disease Alzheimer’s is not normal agingAlzheimer’s is not normal aging

– Learning new information make take longerLearning new information make take longer– May be difficult to filter out noiseMay be difficult to filter out noise

Brain ScanBrain Scan

StagesStagesEarlyEarly Needs Needs

remindersreminders Daily Daily

routines routines difficultdifficult

Concentrat-Concentrat-ion is ion is difficultdifficult

MiddleMiddle May need May need

hands on hands on carecare

May get lost May get lost easilyeasily

Changes in Changes in personalitypersonality

LateLate Severe Severe

confusionconfusion Needs hand Needs hand

on care for on care for most most personal personal carecare

May not May not recognize recognize self or self or familyfamily

Areas of the Brain AffectedAreas of the Brain AffectedCognitionCognition MemoryMemory LearningLearning LanguageLanguage Praxic Praxic

FunctionFunction Abstract Abstract

thinkingthinking Psycho-Psycho-

motor speedmotor speed

BehaviorBehavior Communi-Communi-

cationcation SafetySafety Personal Personal

care care deterioratesdeteriorates

Lapses in Lapses in clarityclarity

Hallucina-Hallucina-tions tions

DelusionsDelusions

EmotionEmotion Disregulated Disregulated DisorganizedDisorganized Apathy (loss Apathy (loss

of energy, of energy, willingness)willingness)

Lability Lability (moods (moods change)change)

Delirium, Depression, and Delirium, Depression, and DementiaDementia

DeliriumDelirium– Acute onset, can be treatedAcute onset, can be treated– Altered state of consciousnessAltered state of consciousness

DepressionDepression– Gradual onset, can be treatedGradual onset, can be treated– Look for signs, such as low self-esteemLook for signs, such as low self-esteem

DementiaDementia– Gradual onset, might be treatedGradual onset, might be treated– Memory loss and decline in cognitive functionMemory loss and decline in cognitive function

MedicationsMedications Cholinesterase Cholinesterase

InhibitorsInhibitors– CognexCognex– AriceptAricept– ExelonExelon– ReminylReminyl

Glutamate ReceptorsGlutamate Receptors– NamendaNamenda

Person Centered CarePerson Centered Care Person centered care is truly putting the Person centered care is truly putting the

PERSON firstPERSON first CharacteristicsCharacteristics

– Behaviors are a desire to communicateBehaviors are a desire to communicate– We must maintain and uphold the value of the We must maintain and uphold the value of the

personperson– Promote positive healthPromote positive health– All action is meaningfulAll action is meaningful

Person Centered Care, Cont.Person Centered Care, Cont. Core psychological needs must be met Core psychological needs must be met

to provide quality careto provide quality care– LoveLove– InclusionInclusion– AttachmentAttachment– IdentityIdentity– OccupationOccupation– ComfortComfort

Implementing Implementing Person Centered CarePerson Centered Care

RecognitionRecognition NegotiationNegotiation Collaboration/Collaboration/FacilitationFacilitation

PlayPlay TimalationTimalation CelebrationCelebration

RelaxationRelaxation ValidationValidation HoldingHolding

Person Centered Care Person Centered Care and Familiesand Families

Know what families are looking forKnow what families are looking for– Kindness and respectKindness and respect– Looks are importantLooks are important– The extrasThe extras

Be sensitive to the emotions family Be sensitive to the emotions family members may be experiencingmembers may be experiencing

Module 2:Module 2:Administrative PracticesAdministrative Practices

In this section, we will cover:In this section, we will cover: The role of the unit manager and its The role of the unit manager and its

responsibilitiesresponsibilities Review of human resources practicesReview of human resources practices Philosophy of carePhilosophy of care Admission/discharge requirementsAdmission/discharge requirements Policies and procedures of a special Policies and procedures of a special

care unitcare unit

Role of the Unit ManagerRole of the Unit Manager Identify your commitmentIdentify your commitment

– Become dementia-capableBecome dementia-capable Know the disease processKnow the disease process Know types of supports for familiesKnow types of supports for families Be willing to provide services for those with Be willing to provide services for those with

dementiadementia EvaluateEvaluate

– Evaluate for effectiveness of careEvaluate for effectiveness of care Quality indicatorsQuality indicators CommunicationCommunication

Empowerment!Empowerment! Challenge the processChallenge the process Inspire and share visionInspire and share vision Enable others to actEnable others to act Model the wayModel the way Encourage the heartEncourage the heart

Ownership and LeadershipOwnership and Leadership

ChallengeChallenge InspireInspire EnableEnable

ModelModel EncourageEncourage EmpowerEmpower

Philosophy of CarePhilosophy of Care Create mission statement and purposeCreate mission statement and purpose Approach to careApproach to care What’s “special” about special care?What’s “special” about special care? Communicate the messageCommunicate the message

Characteristics of Characteristics of Good Dementia WorkersGood Dementia Workers

CompassionCompassion Respect and Respect and honorhonor

DependabilityDependability

FairnessFairness HonestyHonesty IntegrityIntegrity

SupportiveSupportive Appreciation of Appreciation of teamworkteamwork

FlexibilityFlexibility

CreativityCreativity Sense of funSense of fun EnergeticEnergetic

WarmthWarmth Sense of Sense of humorhumor

Unconditional Unconditional positive regardpositive regard

Skills of Good Dementia Skills of Good Dementia WorkersWorkers

AssessmentAssessment EnergyEnergy

Problem solvingProblem solving Dementia-capable Dementia-capable communicationcommunication

ObservationalObservational RespectfulRespectful

Conflict resolutionConflict resolution PrioritizingPrioritizing

Hiring Staff with KnackHiring Staff with Knack Ask current staff for recommendations Ask current staff for recommendations

and to participate in processand to participate in process Look for nontraditional candidatesLook for nontraditional candidates Walk candidate around unitWalk candidate around unit Can the candidate have fun?Can the candidate have fun? Share your philosophyShare your philosophy Ask for storiesAsk for stories

From: Best Friends Staff. Bell and Troxel.From: Best Friends Staff. Bell and Troxel.

OrientationOrientation Normal aging vs. dementiaNormal aging vs. dementia Dementia process and progressionDementia process and progression Communication techniquesCommunication techniques Behaviors and approachBehaviors and approach Philosophy, policies, proceduresPhilosophy, policies, procedures Admission/discharge criteriaAdmission/discharge criteria How to work with familiesHow to work with families Stress reduction techniquesStress reduction techniques

Stress!Stress! Stress can lead to poor quality care, Stress can lead to poor quality care,

quality of life, and abuse and neglectquality of life, and abuse and neglect Signs of stressSigns of stress

– Too little or too much sleep, nightmaresToo little or too much sleep, nightmares– FatigueFatigue– Headaches, backaches, joint painHeadaches, backaches, joint pain– Diarrhea/constipationDiarrhea/constipation– Frequent accidentsFrequent accidents

AssessmentsAssessmentsMedicalMedical FunctionalFunctional EmotionalEmotional

SocialSocial CognitiveCognitive BehavioralBehavioral

Special needsSpecial needs Special Special interestsinterests

HabitsHabits

InterventionsInterventions TalentsTalents ReligionReligion

Ascertain validity of diagnosesAscertain validity of diagnoses Level of functioningLevel of functioning PreferencesPreferences Family wishesFamily wishes Advanced directivesAdvanced directives

Care PlansCare Plans Focus on individual needsFocus on individual needs Flexibility to enable a person to live the Flexibility to enable a person to live the

life he or she would wantlife he or she would want Emphasis on resident’s own sources of Emphasis on resident’s own sources of

self-esteem and pleasureself-esteem and pleasure Regular reevaluationRegular reevaluation Build in specific objectives and Build in specific objectives and

strategiesstrategies

Immediate Problem AnalysisImmediate Problem Analysis TaskTask

– Too complicated, too many steps, not modified, Too complicated, too many steps, not modified, unfamiliarunfamiliar

EnvironmentEnvironment– Too large, too much clutter, excessive stimulation, no Too large, too much clutter, excessive stimulation, no

clues, poor sensory, unstructured, unfamiliarclues, poor sensory, unstructured, unfamiliar Physical healthPhysical health

– Medications, impaired vision/hearing, acute illness, Medications, impaired vision/hearing, acute illness, chronic illness, dehydration, constipation, depression, chronic illness, dehydration, constipation, depression, fatigue, physical discomfortfatigue, physical discomfort

MiscommunicationMiscommunication

The 11 W’sThe 11 W’s Who has the behavior?Who has the behavior? What is the specific behavior?What is the specific behavior? Why does it need to be addressed?Why does it need to be addressed? What happened just before?What happened just before? Where does it occur?Where does it occur? What does the behavior mean?What does the behavior mean? When does the behavior occur?When does the behavior occur? What is the time, frequency?What is the time, frequency? Who is around?Who is around? What is the outcome?What is the outcome? What is the DESIRED change?What is the DESIRED change?

Transfer/Discharge CriteriaTransfer/Discharge Criteria Educate family during pre-admission Educate family during pre-admission

and in care plan meetingsand in care plan meetings Compare reassessment data to Compare reassessment data to

admission/discharge criteriaadmission/discharge criteria Utilize RAI/MDS assessment data, RAPS, Utilize RAI/MDS assessment data, RAPS,

and care plan processand care plan process Is the resident still compatible with the Is the resident still compatible with the

mission?mission? Be consistent!Be consistent!

Module 3:Module 3:Educating StaffEducating Staff

In this section, we will cover:In this section, we will cover: Basic principles of adult education, including Basic principles of adult education, including

needs of adult learnersneeds of adult learners Types of audiences within facilityTypes of audiences within facility Techniques for assessing for types of Techniques for assessing for types of

educational needseducational needs Understand materials providedUnderstand materials provided Explore and assess potential internal and Explore and assess potential internal and

external resources for educational servicesexternal resources for educational services

Basics of Adult EducationBasics of Adult Education Adults who attend educational Adults who attend educational

opportunities have made a great effort opportunities have made a great effort to attendto attend

Adults have unique and individual needsAdults have unique and individual needs The educator is the organizer, guiding The educator is the organizer, guiding

learninglearning

Successful LearningSuccessful Learning Be prepared with extra informationBe prepared with extra information Make the program safe and interestingMake the program safe and interesting Make the learning goals clear, and stick Make the learning goals clear, and stick

to themto them Clarify the criteria of evaluationClarify the criteria of evaluation Promote self-empowermentPromote self-empowerment Emphasize the felt needs of learnersEmphasize the felt needs of learners Provide a variety of learning techniquesProvide a variety of learning techniques

Alternative Methods of Alternative Methods of TeachingTeaching

Cross trainCross train Bulletin or graffiti Bulletin or graffiti boardsboards

Articles or newslettersArticles or newsletters Mini in-servicesMini in-services

Group activitiesGroup activities OrientationOrientation

Audiences and NeedsAudiences and Needs FamiliesFamilies

– Care plan, modeling, coaching, family Care plan, modeling, coaching, family handbook, family programshandbook, family programs

Resident councilsResident councils– Understanding disease process, administrative Understanding disease process, administrative

practices, working with staffpractices, working with staff Specific staff groupingsSpecific staff groupings

– Nursing, activities, night shiftNursing, activities, night shift

Techniques for AssessmentTechniques for Assessment Gather ideasGather ideas

– Observation, questionnaires, records, Observation, questionnaires, records, interviews, informal gatheringsinterviews, informal gatherings

Determine needs Determine needs – Organization, people, taskOrganization, people, task

CreateCreate– Objectives, content, techniques, organization, Objectives, content, techniques, organization,

visual aidsvisual aids

Educational MaterialsEducational Materials Overview of DementiaOverview of Dementia Person Centered CarePerson Centered Care Communication StrategiesCommunication Strategies Understanding BehaviorsUnderstanding Behaviors Activities of Daily LivingActivities of Daily Living Family DynamicsFamily Dynamics

Internal ResourcesInternal Resources Who is the best educator?Who is the best educator?

– Not everyone is right for every subjectNot everyone is right for every subject Who has an interest in educating?Who has an interest in educating? What can each person contribute?What can each person contribute?

– Line staffLine staff– AdministrativeAdministrative– ManagersManagers

External ResourcesExternal Resources ConsultantsConsultants Medical DirectorsMedical Directors Alzheimer’s AssociationAlzheimer’s Association Service agenciesService agencies ESLESL

Module 4:Module 4:Regulatory Standards and Reducing Regulatory Standards and Reducing

Deficient PracticesDeficient PracticesIn this section, we will cover:In this section, we will cover: Overview of commonly sited F-tagsOverview of commonly sited F-tags Key safety concerns and potential solutionsKey safety concerns and potential solutions Relationship between person centered care Relationship between person centered care

and resident rightsand resident rights Family needs and potential opportunitiesFamily needs and potential opportunities Potential situations leading to abuse and Potential situations leading to abuse and

neglectneglect Possible quality indicatorsPossible quality indicators

F-TagsF-Tags 154: Right to be informed154: Right to be informed 157: Notification of changes157: Notification of changes 164: Privacy and confidentiality164: Privacy and confidentiality 207: Equal access to quality care207: Equal access to quality care 221/222: Resident behavior and facility practices221/222: Resident behavior and facility practices 223: Abuse223: Abuse 224/226: Staff treatment of residents 224/226: Staff treatment of residents 240: Quality of life240: Quality of life 241: Dignity241: Dignity

F-Tags, Cont.F-Tags, Cont. 242: Self-determination242: Self-determination 243/244: Participation in resident and family 243/244: Participation in resident and family

groupsgroups 245: Participation in other activities245: Participation in other activities 246: Accommodation of needs246: Accommodation of needs 280: Care plans280: Care plans 281/282: Professional standards of quality281/282: Professional standards of quality 309: Quality of Care309: Quality of Care 310: Activities of Daily Living310: Activities of Daily Living

F-tags, Cont.F-tags, Cont. 323/324: Accidents323/324: Accidents 353: Nursing services353: Nursing services 495: Competency495: Competency 497: Regular in-service education497: Regular in-service education 498: Proficiency of nurse aids498: Proficiency of nurse aids

Safety Concerns and SolutionsSafety Concerns and Solutions Environmental implications of Environmental implications of

physiological changesphysiological changes– Vision, hearing, thermal regulation, tactile Vision, hearing, thermal regulation, tactile

sensation, musculoskeletal, balancesensation, musculoskeletal, balance SecuritySecurity

– People with dementia may not be able to judge People with dementia may not be able to judge unsafe conditionsunsafe conditions

Physical supportsPhysical supports

Resident Rights—Bell and Resident Rights—Bell and TroxelTroxel

To be informed on one’s diagnosisTo be informed on one’s diagnosis To have appropriate ongoing medical careTo have appropriate ongoing medical care To be productive in work and play as long as To be productive in work and play as long as

possiblepossible To be treated like an adult, not a childTo be treated like an adult, not a child To have expressed feelings taken seriouslyTo have expressed feelings taken seriously To be free of psychotropic medications if at all To be free of psychotropic medications if at all

possiblepossible To life in a safe, structured and predictable To life in a safe, structured and predictable

environmentenvironment To enjoy meaningful activities to fill each dayTo enjoy meaningful activities to fill each day

Abuse and NeglectAbuse and Neglect Willful infliction of injury, Willful infliction of injury,

unreasonable unreasonable confinement, confinement, intimidation, or intimidation, or punishment with punishment with resulting physical harm resulting physical harm or pain, anguish, or or pain, anguish, or deprivation by an deprivation by an individual of goods or individual of goods or services that are services that are necessary to attain or necessary to attain or maintain physical, maintain physical, mental, or psychosocial mental, or psychosocial well beingwell being

PhysicalPhysical SexualSexual VerbalVerbal MentalMental

Family FeelingsFamily Feelings DenialDenial FrustrationFrustration IsolationIsolation GuiltGuilt AngerAnger Loss/griefLoss/grief Letting goLetting go

Conflict ResolutionConflict Resolution Denial can be healthyDenial can be healthy Educate in small dosesEducate in small doses Do not push to hardDo not push to hard Encourage support groupsEncourage support groups AcknowledgeAcknowledge ListenListen FeedbackFeedback PrivacyPrivacy

Internal ResourcesInternal Resources Staff membersStaff members LibraryLibrary AdministratorAdministrator Family counselsFamily counsels Care plan meetingsCare plan meetings

Alzheimer’s AssociationAlzheimer’s Association HelplineHelpline Family EducationFamily Education Support GroupsSupport Groups Care ConsultationCare Consultation Safe ReturnSafe Return

Strategies for Positive Strategies for Positive RelationshipsRelationships

Show supportShow support– Family tours, communication processesFamily tours, communication processes– Validate emotions, develop realistic Validate emotions, develop realistic

expectations, compliment, report good newsexpectations, compliment, report good news Promote successful visitsPromote successful visits

– Offer suggestions and supportOffer suggestions and support– Bring in family videos, picturesBring in family videos, pictures– ActivitiesActivities

Quality IndicatorsQuality Indicators Number and frequency of medication adverse effectsNumber and frequency of medication adverse effects Proportion of residents who are over-sedatedProportion of residents who are over-sedated Incidence of falls, fractures, and elopementsIncidence of falls, fractures, and elopements Prevalence of restraintsPrevalence of restraints Incidence and prevalence of skin breakdownIncidence and prevalence of skin breakdown Incidence of symptomatic urinary tract infectionIncidence of symptomatic urinary tract infection Incidence of dehydrationIncidence of dehydration Use of futile or undesired treatments Use of futile or undesired treatments Moment by moment comfort of residentsMoment by moment comfort of residents Comfort of caregiving staffComfort of caregiving staff

Quality Indicators, Cont.Quality Indicators, Cont. Ability of staff to deal confidently with situationsAbility of staff to deal confidently with situations A coherence between values expressed in A coherence between values expressed in

mission and actual practicemission and actual practice Prevalence of agitated behaviorsPrevalence of agitated behaviors Prevalence of fecal impactionPrevalence of fecal impaction Prevalence of weight lossPrevalence of weight loss Incidence of decline in ROMIncidence of decline in ROM Prevalence of little or no activityPrevalence of little or no activity