Evidence-Based Practices in Dementia Care

Judith Davagnino, LCSW, COACH Program Director

Vanessa Burshnic, PhD, CCC-SLP GRECC Advanced Fellow

Jayme Tetro, LCSW Community Living Center

Evidence-Based Practices

1. Communication skills

2. Montessori (tailored activities)

3. Reminiscence

4. Environmental modification

5. Music

6. Behavioral activation

WHAT IS DEMENTIA

Dementia is a brain disorder affecting cognitive and executive functioning. It destroys vital brain cells, causing memory loss, confusion, impaired judgment, personality changes, disorientation, and the ability to communicate.

COMMUNICATION SKILLS

Communication is a basic human need.

We communicate verbally and non-verbally.

COMMUNICATION SKILLS

VERBAL COMMUNICATION

Be aware of your voice: Tone

Speed of speech

Inflection

Words

NON-VERBAL STRATEGIES

STAYING PLEASANT, CALM AND REASSURING

People with dementia often “mirror” the mood of the caregiver (may react with anger, sadness or happy feelings when the caregiver is angry, sad or happy)

Patients may respond to what is being said by reading non-verbal cues

Be aware of your body language

Smile often

COMMUNICATION STRATEGIES

M – Maximize attention (attract attention, avoid distraction, one thing at a time)

E - Expression (relax, calm, show interest)

S – Simple (short, simple, familiar, clear choices)

S - Support (give time, repeat/remind as needed)

A - Assist with visual aids (gestures, objects, pictures)

G - Get their message (listen, watch, detective work)

E - Encourage & engage in communication(Smith et al., 2011)

facial expressionseye contact

gesture familiar objects

body posture/language

Call Wanda at 3pm.

written cues

MEMORY STRATEGIES

R - Reminders (prompt, written words, pictures)

E - Environment (permanent place for things)

C - Consistent routines (keep/make familiar routine)

A - Attention (avoid distraction, focus attention)

P - Practice (use or lose it, practice new skills)

S - Simple Steps (break into simple steps, allow extra time)

(Smith et al., 2011)

QUIZWhat is the most important

element when communicating with a person living with

dementia?

1. Verbal communication2. Reality orientation3. Non-verbal communication

References• Glenner, J. A., Stehman, J.M., Davagnino, J., Galante, M.J., Green, M.L. (2005) When Your Loved Has

Dementia: A Simple Guide for Caregivers. John Hopkins University Press.

• Smith, E. R., Broughton, M., Baker, R., Pachana, N. A., Angwin, A. J., Humphreys, M. S., Mitchell, L., Byrne, G. J., Copland, D. A., Gallois, C., Hegney, D., & Chenery, H. J. (2011). Memory and communication support in dementia: Research-based strategies for caregivers. International Psychogeriatrics, 23(2), 256–263. https://doi.org/10.1017/S1041610210001845.

• Mehrabian, A. (1981) Silent Messages: Implicit communication of emotions and attitudes.

Montessori for People with DementiaVanessa Burshnic, PhD, CCC-SLPAdvanced Fellow | Speech-Language PathologistDurham VA Geriatric Research, Education, & Clinical Center

Learning Objectives

Learners will be able to:• List at least two principles of the

Montessori approach to caring for people with dementia.

• Discuss ideas for engaging people with dementia in meaningful roles and activities.

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B r i e f B a c k g r o u n d

• Dr. Maria Montessori (1870-1952)• Italian physician and educator • Educational approach for children

• Montessori for Dementia: • Montessori principles adapted for

older adults • Tested and developed by

researchers, clinicians, and architects

• 2014 guidelines and quality standards: MontessoriDementia.org

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Principles / Key Components

Prepared environment

Meaningful roles & activities

Respect and dignity

• Limit unnecessary stimuli• Cues; memory supports• Sensory support

• Care for self, others, and community

• Person-centered• Strengths-based

• Honor choices• Maximize independence

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P r e p a r e d E n v i r o n m e n t

Physical Space

Visual Cues

Materials

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P h y s i c a l S p a c e

• Adequate lighting / low glare• Organized / decluttered• Décor reinforces activity• Personal artwork• Plants to care for• Activities are accessible

• Independence• Choice

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Visual Cues

• Can be used for:• Orientation • Initiation• Instruction

• Many PWD have preserved reading ability (Benigas & Bourgeois, 2011)

• And when reading is impaired, colors and pictures can support comprehension (Calkins, 2018)

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Visual Cues: Orientation & Initiation

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Visual Cues: Invitational signage

”Please help arrange the flowers.” “Take time to write a note to your loved one.”

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Materials

• Appropriate weight and size• Fit in adult hands, but not too heavy • Support limited dexterity

• Support sensory and cognitive abilities• Invitation cards • Placemats for visual contrast• Non-glare laminating sheets• Use familiar materials when possible

• Organization• Keep activities in a container, basket, or tray

• Aesthetically pleasing • Use attractive, natural materials like wood, over

plastic

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E x a m p l e M a t e r i a l s

• Stencils and templates• Placemats for contrast• Trays for organization

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Meaningful Roles & Activities“Joy, feeling one's own value, being appreciated and loved by others, feeling useful and capable of production are all factors of enormous value for the human soul.”

-Maria Montessori, MD

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Designing Activities

Identify strengths

Control for Error

Implement & modify as needed

Know the person

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Know the person

• Life history• Family• Culture/values• Hobbies• Past careers • Strengths

• reading• motor skills• procedural memory

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Person-Centered Activity Examples (adapted from Douglas et al., 2018)

Previous Roles/Interests Current Role Associated Activity

Homemaker Community Preparer Setting the tableSweepingArranging flowers

Gardener Gardener Filling birdfeedersWatering plantsPulling weeds

Neighborhood Leader Neighborhood Leader Delivering mailWelcoming new residentsGreeting visitors

Military Career History Buff / Veteran Representative

Leads history reading groupHelps organize Veterans Day celebration

Teacher Literacy activity leader Making birthday cardsReading to othersAssisting with setting up group activity

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Control of Error

Templates

Visual and text cues

Material control

Modelling

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Examples for control of error

Flower Arranging

• Only supply the number of flowers that will fit in the vase

• Provide a visual cue (picture of finished product)

Setting the Table

• Placemat / template• Placing utensils in their own

bins• Hand the person one item at a

time

https://images.app.goo.gl/vnawtCvo52jTvdB96

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Signs that modifications are needed

• Getting up and leaving• Repeated vocalizations• Looking sad or depressed• Looking bored• Walking about • Using items incorrectly

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Making modifications

Reduce number of items involved

Visual and text cues

Include a template or guide

Label and/or color code matching items

Include photos of each step and/or the finished product

Hand over hand assistance

Evaluating activities through a Montessori lens

• Items marketed as “activities for people with dementia”

• But are they…• Person-centered?• Purposeful?• Controlling error?• Promoting dignity and respect?

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Learning Check

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Which item is not a component of Montessori?

A. Prepare the environment B. Target cognitive weaknesses with activities C. Enable PWD to care for themselves and othersD. Treat PWD with respect and dignity

Capitalize on strengths!

Control error with cues, templates, and materials.

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True or False?

People with dementia learn best through trial-and-error.

False!

PWD are more likely to learn and maintain skills with repeated, correct practice

When designing an activity, prevent the person from having to guess.

Constrain responses with supportive cues.

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References

Barry L. Creating a world with meaning and purpose. Australian Journal of Dementia Care 2017; 6: 17-19. Retrieved from: https://www.imags.com.au/Dementia_Care_May17/index.html#21/z

Brush, J. (2020) Montessori for Elder and Dementia Care. Health Professions Press.

Brush, J. & Norris, K. (2017) Getting Started with Montessori Volume 1: Practical Life Activities for Older Adults. Brush Development.

Brush, J. A., Camp, C., Bohach, S., & Gertsberg, N. (2015). Developing a signage system that supports wayfinding and independence for persons with dementia. Canadian Nursing Home.

Brush, J. A., Douglas, N. F., & Bourgeois, M. S. (2018). Implementation of the Montessori program in assisted living: Positive outcomes and challenges. The Journal of Nursing Home Research Sciences, 4, 64–70.

Clare, L., Wilson, B. A., Carter, G., Breen, K., Gosses, A., & Hodges, J. R. (2000). Intervening with everyday memory problems in dementia of Alzheimer type: An errorless learning approach. Journal of Clinical and Experimental Neuropsychology, 22(1), 132–146.

Douglas, N., Brush, J., & Bourgeois, M. (2018). Person-Centered, Skilled Services Using a Montessori Approach for Persons with Dementia. Seminars in Speech and Language, 39(03), 223–230.

Mahendra, N. (2001). Direct Interventions for Improving the Performance of Individuals with Alzheimer’s Disease. Seminars in Speech and Language, 22(04), 291–304.

Roberts, G., Morley, C., Walters, W., Malta, S., Doyle, C. (2015) Caring for people with dementia in residential aged care: successes with a composite model featuring Montessori based activities. Geriatric Nursing. 36: 106-110.

Sheppard CL, McArthur C, Hitzig S. A systematic review of Montessori-based activities for persons with dementia. J Am Med Dir Assoc 2016; 17: 117-122.

Wilson, B.A., Baddeley, A.D., Evans, J.J., Shiel, A. (1994) Errorless learning in the rehabilitation of memory impaired people. Neuropsychological Rehabilitation. 4, 307-326.

MontessoriDementia.org

BrushDevelopment.com

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Thank you for listening.Vanessa.Burshnic@duke.edu

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Reminiscence Therapy: An Evidence-Based Approach in Dementia CareJayme Tetro, MSW, LCSWDurham VA Community Living CenterClinical Social WorkerDecember 3, 2020

Reminiscence: What is it? The enjoyable recollection of past events A story told about a past event

remembered by the narrator Reminiscence is not simply remembering

Reminiscence: Who benefits from it?

Everyone! Specifically, reminiscence can be a

therapeutic intervention for people with various stages and types of dementia and cognitive impairment

Caregivers

(Woods, Spector, Jones, Orrell & Davies, 2005)

What are the benefits? Allows patient to be the expert

With varying types of dementia, short term memory is lost early on and long-term memories are preserved until much later in disease progression

Socialization Small group of others with dementia Family members

Decreases depressive symptoms Increases life-satisfaction Presents as a meaningful and engaging activity

(Bademli, Lök& Selçuk‐Tosun, 2018)

Reminiscence: Theory Behind It DECREASING demands on impaired brain

functions and CAPITALIZING on preserved parts of brain functioning

In the Literature… Pre/test, Post/Test study in Konya, Turkey 60 elderly individuals with dementia Weekly reminisce therapy for 8 weeks Results: Mini-mental scores improves,

quality of life scores improved, depressive symptoms decreased

(Bademli, Lök& Selçuk‐Tosun, 2018)

In the Literature, continued… Similar study in the Czech Republic 116 men and women with mild &

moderate cognitive impairment living in LTC centers

Results: Improvement in mental health, social participation, reduction in depression & elevated attitudes towards their old age and aging in general

(Siverová & Bužgová, 2018)

So… How do we use it? Individual: life review Group: introducing various objects,

sounds and shared topics/ life events

Focusing on the SensesTOUCH

HEARING

SIGHT

SMELL

TASTE

Focusing on the Senses: Taste• Stimulate memories by providing

comforting foods

• Favorite foods from childhood?

• Ask what it tastes like? What does the taste remind them of?

• If they can’t respond to these questions, try to give foods that you know they like

• Changing flavors: salty, sweet, sour, bitter, savory

Focusing on the Senses: Hearing Music

Comforting and familiar sounds

Common phrases

http://musicandmemory.org/

Video

Focusing on the Senses: Touch

Familiar objects

Familiar textures

Focusing on the Senses: Smell

Familiar scents

Soothing smells

Candles, food, flowers

Focusing on the Senses: Sight

Family Pictures

School Yearbooks

Pictures of Favorite Places

Familiar Objects

Dementia Villages: Reminiscence as a lifestyle

https://www.dementiavillage.com/

In Practice

Focus on one topic/ object at a time

Make eye contact

Don’t correct

When in doubt, stick with pleasant memories

In Practice Continued Do your research about the person

Stay at eye-level

Reduce background noise

Focus on their likes, not their dislikes

Follow their lead!

Reminiscence and COVID Social Isolation & loneliness, particularly

when living in a residential institution Recent study of COVID19 on

entertainment choices; half reported finding comfort in revisiting both TV & Music

(MRC Data Service, 2020)

(National Geographic, 2020)

https://apps.apple.com/gb/app/my-house-of-memories/id847763460?ign-mpt=uo%3D4

My House of Memories App

Reminisce + Communication Support: Memory Books

Helping people remember important information

Making conversation easier

Providing reassurance and comfort

(Bourgeois, 2014)

Questions?

ReferencesBademli K, Lök N, Selçuk‐Tosun A. The effect of reminiscence therapy on cognitive functions, depression, and quality of life in Alzheimer patients: Randomized controlled trial. Int J Geriatr Psychiatry. 2018;1–7. https://doi.org/10.1002/gps.4980

Bourgeois, M. S. (2014). Memory & communication aids for people with dementia. Baltimore, MD: Health Professions Press.

Siverová, J. and Bužgová, R. (2018), The effect of reminiscence therapy on quality of life, attitudes to ageing, and depressive symptoms in institutionalized elderly adults with cognitive impairment: A quasi‐experimental study. Int J Mental Health Nurs, 27: 1430-1439. doi:10.1111/inm.12442

Woods B, Spector AE, Jones CA, Orrell M, Davies SP. Reminiscence therapy for dementia. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD001120. DOI: 10.1002/14651858.CD001120.pub2.

https://static.billboard.com/files/2020/04/COVID-19-Entertainment-Tracker-Release-1-1586793733.pdf

https://www.nationalgeographic.com/science/2020/07/surprising-role-of-nostalgia-during-coronavirus-pandemic/#close