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 [email protected]
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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