A Positive Approach

By Tracy Wood,2014-06-28 11:38
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A Positive Approach ...

Caring for Someone with Dementia

    How You Help Makes a Difference

    Teepa Snow, MS, OTR/L, FAOTA ? Education Director, Eastern NC Chapter, Alzheimer‟s Association

     The ability to remember information… The ability to use words and language… The ability to understand what is being said…

    The ability to control your impulses,

    Reprinted with permission from: A Broken Brain. Dementia temper, & moods Education & Training Program , University of Alabama, 1995.


    It Takes TWO to Tango … or tangle… ? By managing your own behavior, actions, words & reactions you can change the outcome of

    an interaction.

    ? Being „right‟ doesn‟t necessarily translate into a good outcome for both of you

    ? Deciding to change your approach and behavior WILL REQUIRE you to stay alert and make

    choices… it is WORK

    ? It‟s the relationship that is MOST critical NOT the outcome of one encounter

As part of the disease people with dementia „tend to‟ develop typical patterns of speech,

    behavior, and routines. These people will also have skills and abilities that are lost while others

    are retained or preserved.

    Typically Lost can’t use Preserved can or may use

     Memory skills Memory skills

    - immediate recall - long ago memories

    - short term memory - emotional memories

    - clarity of time and place - confabulation

    - depth of categorical information - procedural memories

    - relationships & specifics - awareness of familiar versus unfamiliar

     Understanding skills Understanding skills

     - interpretation of abstract meaning - „gets‟ the concrete meaning

     - early - misses ? words - picks out familiar or meaningful words

     - later misses ? words - covers well

     - subtle emotions, „unspoken‟ agreements - facial expressions that are consistent

    - at the end most words with the message being sent

     Language use skills Language use skills

     - specific word finding - desire to communicate

     - descriptive abilities - ability to use hands or actions to describe

     - reading for content - reading aloud

     - content of speech - rhythm of speech

     - spoken communication - para-verbal communication (how you say it)

     - words - music and song

     - meaningful „yes‟ and „no‟ - automatic speech

     - socially acceptable expressions of emotion - swearing, sex words, „socially unacceptable‟ words

     - verbal communication of needs and desires - non-verbal communication of needs and desires

     Emotional & Impulse control skills Emotional & Impulse control skills

     - ability to „demand‟ respect - desire to be respected

    - ability to limit or control emotions - ability to feel emotions and have needs

     - ability to control impulsive speech - say what is on your mind with errors

     - ability to control impulsive actions - do what you want to do

     - don‟t act out when „pushed‟ - sometimes, feel badly after its done

     - ability to keep private thoughts and - sometimes, behaving differently in „public‟

     and actions in private places if cues are strong

     Motor Skills & Sensory Processing Motor Skills & Sensory Processing

    - at first very little as far as skills go - the movement patterns for pieces of tasks

    - later initiation or getting started - gross motor movements last longer than fine motor

    - later parts of tasks get left out/skipped - can often do the mechanics BUT not safely or well - mis-interprets sensory information - looks for stuff seeks out things - organized scanning is lost - mouth (lips, tongue), fingers and palms, soles of feet,

    - visual field is restricted & genitalia or „private body parts‟ - may become hypersensitive OR - recognize faces, voices familiar from not familiar

     hyposensitive to touch, sound, light…

     Progression of the Disease Levels of Cognitive Loss

    Level 5 Early Loss Running on Routine Repeating Stories

     Some word problems and loss of reasoning skill

     Easily frustrated by changes in plans or routines

     Seeks reassurance but resents take over

     Still does fairly well with personal care and activities

     Tends to under or over estimate skills

Level 4 Moderate Loss - Just Get It Done! Wanting a Purpose and a Mission

     Gets tasks done, but quality is poor

     Leaves out steps or makes errors and WON‟T go back and fix it

     Can help with lots of things needs some guidance as they go

     Likes models and samples uses others‟ actions to figure out what to do

     Asks “what /where/when” LOTS

     Can do personal care tasks with supervision & prompts

     Still very social BUT content is limited and confusing at times

    Level 3 Middle Loss - See It Touch It Take It Taste It Hunting & Gathering

     Handles almost anything that is visible

     Does not recognize other‟s ownership

     Can still walk around and go places

     Language is poor and comprehension very limited

     Responds to tone of voice, body language and facial expression

     Loses the ability to use tools and utensils during this level

     Does things because they feel good, look good, taste good refuses if they don‟t

     Stops doing when it isn‟t interesting anymore

     Can often imitate you some But not always aware of you as a person

    Level 2 Severe Loss Gross Automatic Action Constant GO or Down & Out

     Paces, walks, rocks, swings, hums, claps, pats, rubs….

     Ignores people and small objects

     Doesn‟t stay down long in any one place

     Not interested in food significant weight loss expected at this level

     Can grossly imitate big movements and actions

     Generally enjoys rhythm and motion music and dance

    Level 1 Profound Loss - Stuck in Glue Immobile & Reflexive

     Generally bed or chair bound can‟t move much on own

     Often contracted with „high tone‟ muscles

     Poor swallowing and eating

     Still aware of movement and touch

     Often sensitive to voice and noise

     Difficulty with temperature regulation

    Limited responsiveness at times

    A Positive Approach

    ? Come from the FRONT let them know you are coming ? Go SLOW reaction times slow as we age it takes longer for info to get in

    ? Get to the SIDE be supportive NOT confrontational

    ? Get LOW don‟t use your height to intimidate ? Offer HAND let them start the interaction

    ? Call NAME the name that person PREFERS! ? THEN wait…….

? Start Message

    ? Give basic information

    “It‟s time to…”

    ? Give simple choices

    this or that (orange juice or milk) (eat or go to the bathroom first)

    ? Give single step directions

    break down the task (to go to eat…. lean forward…, pull your feet in…

    ? Ask the person to HELP you

    it feels better to give than to receive!

    ? Ask the person if they will at least TRY??????

    sometimes you‟ll try even if you don‟t think you can!

    ? DON’T Ask “Are you ready?…??? “or “Do you WANT to…?”

    ? DON’T have verbal diarrhea

? WAIT for a response (silently count to 10)

    IF No response … ask again

    IF Responding ….

    ? Give positive STROKES - Feedback

    ? “Good job!” ? smile, nod

    ? “ Yes!” ? hug

    ? “That‟s it” ? stroke or rub


    Keep it Calm!

    Keep it Adult!

    Keep it Positive!

    Keep it Simple!

    AVOID Flight, Fright, or Fight… they waste your time!

    Communicating - Talking

    First - ? Once the person is listening and responding

    ALWAYS use the positive physical approach! to you THEN -

     ? Redirect his attention and actions to Then - something that is OK OR

    ? Pay attention to the THREE ways you communicate ? Distract him with other things or

    - activities you know he likes & values 1 - How you speak

    - Tone of voice (friendly not bossy or critical) Always BE CAREFUL about personal space and

    - Pitch of voice (deep is better) touch with the person especially when s/he is

    - Speed of speech ( slow and easy not distressed or being forceful

     pressured or fast)

    2 - What you say 3 - How you respond to the person

    THREE basic reasons to talk to someone ? use positive, friendly approval or praise (short,

    1 - To get the person to DO something (5 specific and sincere)

    approaches to try) ? offer your thanks and appreciation for his/her

    1 - give a short, direct message about efforts

    what is happening ? laugh with him/her & appreciate attempts at 2 - give simple choices about what the humor & friendliness person can do ? shake hands to start and end an interaction 3 - ask the person to help you do ? use touch - hugging, hand holding, comforting something only IF the person wants it 4 - ask if the person will give it a try 5 - break down the task - give it one If what you are doing is NOT working - step at a time ? STOP! ** only ask “Are you ready to…” If you ? BACK OFF - give the person some are willing to come back later ** space and time ? Decide on what to do 2 - Just to have a friendly interaction - to differently… talk to the person ? Try Again! ? go slow - Go with Flow ? acknowledge emotions - "sounds like…, Key Points About 'Who' the person Is…. seems like…, I can see you are…" - preferred name ? use familiar words or phrases (what the - introvert or extrovert person uses) - a planner or a doer ? know who the person has been as a person - a follower or a leader what s/he values - a 'detail' or a 'big picture' person ? use familiar objects, pictures, actions to help - work history - favorite and most hated jobs or parts & direct of jobs ? be prepared to have the same conversation - family relationships and history - feelings about over & over various family members

    ? look interested & friendly - social history - memberships and relationships to

    ? be prepared for some emotional outbursts friends and groups

    ? DON'T argue… - BUT don't let the person - leisure background - favorite activities & beliefs

    get into dangerous situations about fun, games, & free time

    REMEMBER - the person is doing the - previous daily routines and schedules

    BEST that s/he can - personal care habits and preferences

    AND GO with the FLOW! - religious and spiritual needs and beliefs

     - values and interests

    3 - Deal with the person's distress or - favorite topics, foods, places

    frustration/anger - favorite music and songs - dislike of music or songs

    - hot buttons & stressors ? Try to figure out what the person really

    - behavior under stress NEEDS or WANTS

    - what things help with stress? ("It sounds like…" "It looks like…" "It

    - handedness seems like…" "You're feeling…")

    - level of cognitive impairment ? Use empathy not forced reality or lying

    - types of help that are useful

     of Help - Using Your Senses

Visual - Types

     Written Information - Schedules and Notes

     Key Word Signs - locators & identifiers

     Objects in View - familiar items to stimulate task performance

     Gestures - pointing and movements

     Demonstration - provide someone to imitate

Auditory -

     Talking and Telling - give information, ask questions, provide choices

     Breaking it Down - Step-by-Step Task Instructions

    Using Simple Words and Phrases - Verbal Cues

     Name Calling - Auditory Attention

     Positive Feedback - praise, "yes", encouragement

Tactile - Touch -

     Greeting & Comforting - handshakes, hugs, 'hand-holding'

     Touch for Attention during tasks

     Tactile Guidance - lead through 'once' to get the feel

     Hand-Under-Hand Guidance - palm to palm contact

     Hand-Under-Hand Assistance - physical help

     Dependent Care - doing for & to the person

    Personal History

    Areas to Explore What Did You Find Out?

    Preferred Name Preferred Hand Living Situations & history (where are you from today &

    originally, who do & did you live

    with, what type places did you

    live in (house, apt, farm…)

    Marriage history & status (who‟s involved, has been involved, and how do you feel about them?) Family history & membership (who‟s who and how do you feel about them? Think about several generations….)

    Work history (what jobs have you had in your life? How did you feel about them? What are some jobs you would have loved to do, but never did? )

    Leisure history (what do and did you do for fun and in your spare time? How do you feel about „having fun‟? What would you like to do if you had the money? time? Skill? )

    Spiritual history (what religion do you and did you follow, how involved are you and were you, and how important is it to you? How do you feel about other religions?)

    Personal care practices & history

    (eating habits, sleeping habits,

    grooming habits, bathing


    Time Use History (schedules & routines…. When

    do you and would you like to do


    Important Life Events (what are some things that were

    very important to or happened to

    you? Do others know about

    these events?)

    Hot Buttons (what are things/activities /topics/

    actions that really tend to upset


    Level 5 - Minimal Loss ‘Needs Routines’

    Person’s Behaviors:

    Approach - Social Behaviors

    - Can initiate social greetings and interactions

    - Responds to social greetings

    - Will look to see who is at door and respond to a 'knock' - Carries on conversations - takes turns, asks questions, answers questions (*may be wrong*)

    - Seeks out familiar when stressed, unfamiliar when bored - Uses verbal cues and visual information (*may misinterpret*) - Can choose and select from among options

    - Speed may be slowed

Task Behaviors

    - Often lacks initiation for task start-up

    - Uses routines and habits to get through the day

    - Can physically perform routine self-care and 'work-related' tasks - Speed may be slowed

    - Prefers to have options and to be in-charge of activities - Follows daily routines and schedules with minimal prompts or reminders - Blames self or others for errors

    - Stops doing tasks that are too challenging or asks someone else to do them

    Caregiver Behaviors:

    Approach Behaviors

    - Use preferred name

    - Ask permission to enter space - acknowledge response

    - Engage in conversation

    - Offer information about the day, activities, self

    - Provide options for time use

Task Behaviors

    - Prompt and support start of tasks

    - Offer options for tasks

    - Follow routines

    - Hi-light changes in routines

    - Use social interaction to engage the person in tasks

    - Engage in social exchange during tasks

    Environmental Considerations:

    Approach Environments

    - Treat the 'room' as personal space

    - Make sure personal space is respected

    - Ask permission - Turn on the lights

    - Ask permission - Turn off the TV/Radio if interacting

    - Get to resident's eye level - sit down to interact or walk along side

Task Environments

    - label locations and storage spaces clearly

    - keep things in familiar spaces

    - honor location preferences

    - use hi-lighted colors or contrasts to emphasize areas

    - provide task lighting to focus attention to next task

    - limit distractions BUT honor visual and auditory preferences (TVs, radios….)

    - make sure all necessary items are present for tasks

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