IMPORTANCE OF EFFECTIVE COMMUNICATION AND STRATEGIES

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NEW HAMPSHIRE

DEMENTIA

TRAINING 6 HOUR

MODULE 4UNDERSTANDING BEHAVIORS AND

COMMUNICATIONS-THE

IMPORTANCE OF EFFECTIVE

COMMUNICATION AND STRATEGIES

TO MINIMIZE BEHAVIORS

C&V SENIOR CARE SPECIALISTS,INC ALL RIGHTS RESERVED 2020

CASE STUDY-MR.R

Mr. R. is an 80-year-old man with moderate/middle stage Alzheimer’s disease and type 2 diabetes. Mr. R. lives with his 75-year-old wife who is his primary caregiver. Mr. R. and Mrs. R. have been married for 50 years and used to enjoy dancing, singing, and going to church.

Mrs. R. often gets impatient with Mr. R. and yells at him when he is too slow in getting dressed and eating and he becomes resistant to these activities. Recently Mr. R. started wearing the same clothes everyday and refusing to bathe. Mrs. R. also gets easily frustrated when her spouse wanders around the house and follows her. Mr. R. frequently misplaces things, like his handkerchief and glasses and accuses his wife of stealing these items.

Mrs. R. is exhausted, frustrated and burnout from caring for her husband 24/7, she feels like she has no time to herself and is ready to place her husband at a higher level of care. Mr. R’s MD has contacted your home health agency to evaluate the challenging behaviors and suggested Mrs. R. get assistance from Home Care.

What are the behaviors you see in this case?

Think about what could be causing these behaviors?

How would you start to solve some of the behaviors?


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“IF WE SPENT AS MUCH TIME TRYING TO UNDERSTAND BEHAVIOR AS WE SPEND TRYING TO MANAGE OR CONTROL IT, WE MIGHT DISCOVER THAT WHAT LIES BEHIND IT IS A GENUINE ATTEMPT TO COMMUNICATE.”


UNDERSTANDING BEHAVIORS

What is a behavior?

The manner in which a person acts or performs; any or all of the activities of a person, including physical action learned and unlearned, deliberate or habitual.

What is a “challenging behavior?”

Behavior that prevents the person from participating in normal life activities; presents a serious physical risk to safety of person and others.


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USING A PROBLEM-

SOLVING

APPROACH TO

CHALLENGING

BEHAVIORS

A particularly effective approach to

managing challenging behaviors is to

identify the cause of the behavior

using the problem-solving approach in

which caregivers determine the root

cause of a behavior and treat it—

usually with effective communication,

environmental modifications and a

toolbox of strategies.



1-WHAT IS THE BEHAVIOR or COMMUNICATION?

❖ What is this person attempting to communicate?

❖ What is the need that is not being fulfilled?

2-WHEN

❖ Ask yourself what happened just before the problem behavior started. Did something specific trigger that

behavior?

3-WHERE

❖ What is going on in the environment when behavior occurred?

4-WHY-WHAT CAUSED THE BEHAVIOR?

❖ Unmet physical needs-pain, thirst, hunger, dehydration, UTI

❖ Stressed, frustrated, depressed, scared, tired, rushed

❖ Environment-loud, too stimulating

5-HOW (DO YOU DEAL WITH BEHAVIOR?)

❖ Communication Tips

❖ Validate, Validate

❖ Body language, facial expressions

❖ Don’t argue

❖ Give Space

❖ Distraction-activities, toolbox, music, food, hobbies, distractions, picture albums,

1-Reassess

2-Rechannel

3-Reassure

4-Reconsider

REASSESS

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1-WHAT IS THE BEHAVIOR or COMMUNICATION?

❖Agitated

❖Resistance to care @ dressing and bathing

2-WHEN

❖ Behavior occurs when you ask the client to shower

3-WHERE

❖ You are telling client it is time to bathe

4-WHY?

❖ Doesn’t want to bathe, scared, doesn’t understand what is being asked

❖ Stressed, frustrated

❖ 5-HOW (DO YOU DEAL WITH BEHAVIOR?)

❖ Communication Tips

o Don’t argue

o Walk away and re-approach in 5-10 minutes- “Let’s freshen you up so your daughter can take you

to lunch”

o Offer to wash up at sink, break tasks into steps-use verbal and tactile cues

UNDERSTAND

WHAT MAY BE

CAUSING THE

BEHAVIOR

Socialization/Interactions

Emotional needs

• Comfort

• Security

• Purpose

• Belonging

• Control

• Fear for today and tomorrow

• Boredom


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WHEN YOU SEE A BEHAVIOR

1-Reassess

2-Rechannel- Redirect and distract them

3-Reassure- Person lives in a world they cannot

understand. Speak to them with a calm voice and

offer reassurance.

4-Reconsider-Try to see the world from the

individual’s perspective. What could be going on?


PROCESS FOR PROBLEM SOLVING:

INTERVENTIONS

*Always consider physical issues –

especially pain

*How we communicate

is a huge issue –


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RECOGNIZING

PAIN


PAIN ASSESSMENT IN DEMENTIA

FIVE DESCRIPTIVE ELEMENTS

Breathing

Negative Vocalization

Consolability

Facial Expression

Body Language


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WE NEED TO THINK DIFFERENTLY

Take time to learn the person’s “life

story”- family, work, hobbies, interests,

likes and dislikes. Use this knowledge to

establish rapport and find an approach

that will work.

Use remaining abilities.

Be creative!


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PROCESS FOR PROBLEM SOLVING: INTERVENTIONS

WHAT ABOUT OTHER CAUSES?

HUMAN FACTORS

How we approach a person with dementia when communicating, engaging in a task , or providing daily care will sometimes determine a positive or negative behavior. Research shows that about 90% of challenging behaviors are caused by the caregiver’s behavior – the person with Alzheimer’s is merely responding to what he perceives coming from the caregiver.


This Photo by Unknown Author is licensed under CC BY-SA


COMMUNICATION

FUNDAMENTALS

When you arrive at their home

INTRODUCE YOURSELF

“Hi. Mrs. B –I’m Suzanne from ABC Home

Care”

WHY YOU ARE THERE

“I’m here to help you today get ready to go to

your doctors”.

“I’m here to help freshen you up before your

visit with your daughter later and help you eat

breakfast”

EXPLAIN WHAT YOU ARE GOING TO DO

BEFORE YOU START THE ACTIVITY

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http://www.geripal.org/2013/12/the-dementia-caregiver-improving-their.html

https://creativecommons.org/licenses/by-sa/3.0/

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KEY COMMUNICATION

FUNDAMENTALS

1-Speak slowly and clearly-call your client by name

2-Maintain eye contact

3-Approach from the front

4-Get at the client’s level

5-Give the client time to respond (60-90 second rule)

5-Ask one question at a time-keep the message simple, no

long explanations

6-Listen carefully


COMMUNICATION

AROUND ADLS

1-Describe what you are doing

2-Break down instructions

3-Use verbal and tactile cues

“John put your right arm in the

right sleeve, tap right shoulder,

next “John put your left arm in

left sleeve, tap left shoulder”

4-Give your client time to

participate


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COMMUNICATING….

USE KEY STEPS:

- Use verbal, tactile cues

- Break down instructions

- Approach from the front

- Banish “Don’t you remember?

- No quizzing

APPROACH MATTERS

Get excited - “I know how much you love Diana Ross; we

can put on some music to listen to together

Don’t ask - “I’m making double chocolate brownies, I love

chocolate and know you do too, lets go make some brownies”

Ask for Help - “I’m getting dinner ready could you help me

wash the beans?”

Do it in front - Always approach from the front at eye level

Remove concerns and fears – “We can sit near the

bathroom at the concert”


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THE WAY WE PHRASE SOMETHING MATTERS

Use positive words

Negative words leads to….Stigma, Labels, Fear,

Dehumanization, Diminishing person, Poor Care

Example:

“Mr. Green don’t go near that door”(N)

“Mr. Green lets get our coats and go for a walk”(P)

“Why can’t you sit down?”(N)

“Sit with me and help cut up some vegetables. I could

really use your help.”(P)


TO CONNECT WITH SOMEONE WITH ALZHEIMER’S TAKE

ON THEIR PERSPECTIVE AND JOIN THEM WHERE THEY

ARE

“ I think someone is rearranging my clothes at night” YES

“I want to go home now.” YES “Mrs. B you are home and I am here to keep you safe”

THIS EXAMPLE CAUSES NEGATIVE REACTION AND AGITATION

“I have a beautiful baby boy” “NO you don’t”-

AND “would you like to have a cup of tea?”

AND “Would you like to make some

cookies?”

Emotional memory lingers. Human emotion

and connection cannot be destroyed with

Alzheimer’s.

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COMMUNICATION COMMANDMENTS

Give instructions one step at a time and keep simple

Remember 60-90 second rule

“Thou Shall Not Reason!”

“Thou Shall Not Argue!”

Be aware of your own and individual's non-verbal communication.

Use signage

What are the emotions behind the words?-validation

Quiet, calm, non-rushed

Avoid distracting environment

Sometimes the truth hurts

Smile, hug, human touch

Name tags at a family event


THE PERSON WITH AD CANNOT

CHANGE, SO WE NEED TO….

Change the caregiver’s approach (ex-one instruction at a

time)

Change the environment (ex-remove distractions, noise)

Change the task (ex-will you help me find my purse or we

are going out later, so I’d like to help you freshen up?)


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SYMPATHY(feeling for someone, pity)

VS.

EMPATHY(feeling with someone-we feel their story, putting yourself in their shoes)

“I want to go home” Think about how you would feel if you got dropped off.

Reply with an empathetic response: “Tell me about your home? Who did you live with? What was your favorite room?


CULTURALLY

APPROPRIATE

COMMUNICATION

Use of silence

Personal space

Eye contact

Non-verbal communication

Cultural responses to emotions

Cultural interpretations of social issues

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AGGRESSION

& AGITATION CAUSES

PAIN

DEPRESSION

CAREGIVER’S APPROACH

TOO MUCH NOISE

BEING RUSHED

FRUSTRATION

FEELING INADEQUATE

CHANGE IN ROUTINE

FATIGUE

PSYCHOSIS

RESPONSES

BACK OFF! –DON’T TOUCH, CROWD OR GET BACKED INTO A CORNER

ENSURE SAFETY OF OTHERS

CALMLY ASK “WHAT CAN I DO TO HELP YOU?”

SAY OVER AND OVER “I CAN SEE YOU ARE UPSET, I WANT TO HELP YOU, WHAT CAN I DO TO MAKE YOU FEEL BETTER?”

ENCOURAGE PERSON TO MOVE TO QUIET PLACE

AFTER PERSON CALMS DOWN REVIEW EVENTS LEADING UP TO INCIDENT – COULD YOU HAVE DONE ANYTHING DIFFERENT TO PREVENT AGGRESSIVE BEHAVIOR.

USE DISTRACTIONC&V SENIOR CARE SPECIALISTS,INC ALL RIGHTS RESERVED 2020

AGITATION AND AGGRESSION

REPETITION, REPETITION, REPETITION…….

CAUSES OF REPETITION

▪ Lack of short-term

memory-repeating same

thing over and over

▪ Hunger- ”When are we

going to eat?”

▪ Pain-Saying “Help me”

▪ Boredom

Need for movement-Pacing

RESPONSES

1. Give your client something to

do. Redirect into repetitive

behaviors such as folding

towels, manipulating Legos,

etc.

2. Write in BIG LETTERS

ANSWER TO QUESTIONS

3. Provide finger food –

encourage grazing

4. Medicate to relieve pain


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SUNDOWNING

Increased agitation, confusion, nervousness and

hyperactivity that may begin in the late afternoon and

build throughout the evening, often as the sun sets.

-Most sundowning emerges in middle-stage dementia

and slowly worsens as the disease progresses.

Why does this happen? More tired in the late

afternoon, confused by changing amounts of light, scared

by shadows, reacting to your feelings of being tired.


SUNDOWNING RESPONSES

1. Adequate exercise during the day

2. Keep individuals awake during the day

3. Plan activities or outings in the morning

4. Comfort and reassure, play soothing music

5. Decreased stimulation before time of sundowning

6. Provide distraction – food + drink; music, doll baby, picture

album, comfort items

7. Try to maintain a predictable routine for bedtime, waking, meals

and activities.

8. Utilize bright light therapy. Increase indoor lighting before dusk.

Research suggests light therapy may reset the body's circadian

rhythm, or inner biological clock.

9. Remove excess stimuli (turn down or turn off TV and radio)

reduce clutter.

Be twice as patient and kind during these

hours.

WHY?

1. Fatigue

2. Stress

3. Disturbance in Routine

4. Low Lighting

5. Shadows


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SUSPICIOUSNESS/PARANOIA

SUSPICIOUS BEHAVIOR – DON’T TAKE PERSONALLY;

DON’T ARGUE OR CONVINCE; OFFER A SIMPLE ANSWER;

REDIRECT PATIENT’S ATTENTION

DEALING WITH FALSE ACCUSATION – EX: STOLEN PURSE

Validate feelings- “Mrs. B. I am so sorry that you lost your

purse again. You must feel terrible.”

Offer to help-”Mrs. B , let me help you find your purse.”

Begin to distract –after a few minutes-”Should we go in the

kitchen and get a snack?’ or “Let’s add some pictures to

the photo album”.

Keep talking for 5 minutes or more.


Hallucinations

❑Visual hallucinations can be vague or clearly

defined. May see intruders or deceased

relatives.

❑Auditory may hear voices of deceased family.

❑ In some forms of dementia, hallucinations are

more common- dementia with Lewy

bodies and Parkinson’s disease dementia.

❑Hallucinations in people with dementia with

Lewy bodies usually take the form of brightly

colored people or animals.

https://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=1408

What to Do?

❑ If it’s not a scary hallucination, don’t argue

❑ If hallucinations are scary, reassure the client

you are there to keep them safe.

❑ It may help to distract the person, and see if this

stops the hallucinations.

❑ For visual hallucinations, consider making

changes to the environment such as improving

lighting levels, closing the shades, reducing visual

clutter and removing mirrors.

❑ For auditory hallucinations, arrange to have their

hearing checked. If the person wears a hearing

aid, check that it is working properly and

encourage them to wear it.


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WANDERING

❑ Three out of five people with this disease will wander

at some point.

❑ Is there a pattern to wandering?

❑ Same time each day?

❑ WHY DO PEOPLE WANDER?

❑ Trying to get home

❑ May be looking for bathroom

❑ May be looking for food or drink

❑ Following past routines-trying to get to work(of past)

❑ Searching for someone or something.

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❑ Have identification ready

❑ Let neighbors know family member has memory problem

❑ Encourage exercise during day

❑ Involve client in useful activities such as folding laundry, meal prep etc.

❑ Remind patient that he/she in right place

❑ Reassure patient if he/she feels lost, abandoned or disoriented.

❑Alzheimer’s Association Safe Return Program

❑GPS Bracelets

Locks at bottom or top of door

Cover door

Use of baby monitor or infrared eye alarm

Child safe plastic door knob

Night light in patient’s room

Keep lights on in hallway

Disable stove

Use of black/dark brown rugs in front of exit doors

Motion detector


WANDERING

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SEXUALLY INAPPROPRIATE

BEHAVIOR

Stay calm,

Determine if behavior is sexual

Tell the individual, “I don’t like it when you talk to me like that.” You can’t

touch me like that” repeat as needed. Remove hand.

Disrobing – could mean the clothes are uncomfortable – individual may

be responding to skin sensitivity. May need fleece lined clothes and/or

larger size.

Going to the bathroom in wrong place – could be that individual can no

longer distinguish the correct place to do these things.

Give privacy


BEHAVIOR CHECKLIST - WHEN TO

ALERT CASE MANAGER

If you notice any of the following changes, alert the case manager

Increased confusion/disorientation,

New onset pacing/Can’t sit still

Changes in toileting continence

Swallowing Issues

Changes in communication/Increased difficulty or unable to speak

Difficulty with hydration/eating/nutrition

Change in ability to complete ADL’s

Trouble initiating or completing tasks

Disinhibition

Personality change

Poor judgement/irritability

Isolates self, cries , appears sad, no longer wants to engage in activities

Trouble sleeping

Increased tension, startles easily, trembling

Screams or lashes out at family members, staff

Physical aggression-pushes, hits, makes fists at family members or others


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CASE STUDY-MR.R

Mr. R. is an 80-year-old man with moderate/middle stage Alzheimer’s disease and type 2 diabetes. Mr. R. lives with his 75-year-old wife who is his primary caregiver. Mr. R. and Mrs. R. have been married for 50 years and used to enjoy dancing, singing, and going to church.

Mrs. R. often gets impatient with Mr. R. and yells at him when he is too slow in getting dressed and eating and he becomes resistant to these activities. Recently Mr. R. started wearing the same clothes everyday and refusing to bathe. Mrs. R. also gets easily frustrated when her spouse wanders around the house and follows her. Mr. R. frequently misplaces things, like his handkerchief and glasses and accuses his wife of stealing these items.

Mrs. R. is exhausted, frustrated and burnout from caring for her husband 24/7, she feels like she has no time to herself and is ready to place her husband at a higher level of care. Mr. R’s MD has contacted your home health agency to evaluate the challenging behaviors and suggested Mrs. R. get assistance from Home Care.

What are the behaviors you see in this case?

Think about what could be causing these behaviors?



CASE STUDY- MODULE 4- MR. R.

What are the behaviors you see

in this case?

Resistance to care-Not changing clothing

Shadowing/Clinging Suspiciousness/ParanoiaThink about what could be causing these behaviors?

Pain

Boredom/Decreased Activity

Confusion/Decreased Memory

Lack of a set schedule/Routine

Not enough Physical Activity


Find out Mr. R’s. Life story

Suggest and help set up a schedule based on Mr. R’s Life Story

Evaluate Mr. R. for Pain using the Faces

pain Scale or another tool

Increase Physical Activity throughout

the day

Suggest Mrs. R. purchase extra sets of the same clothing and switch out at night to

wash

Purchase multiples of the items Mr. R. is

losing


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PLEASE TAKE POST-

TEST FOR

MODULE 4

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Documents

IMPORTANCE OF EFFECTIVE COMMUNICATION AND STRATEGIES