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Aggression in Dementia and the Role of Aggression in Dementia and the Role of

Aggression in Dementia and the Role of - PowerPoint Presentation

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Aggression in Dementia and the Role of - PPT Presentation

Aggression in Dementia and the Role of NonPharmacological Interventions Kim Schlegel MSW RSW Lisa Joworski TRS RTRO Brynn Roberts MSc OT OT Reg Ont Case Study Ms Josephine Allegro ID: 774251

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Aggression in Dementia and the Role of Non-Pharmacological Interventions Kim Schlegel, MSW, RSW Lisa Joworski , TRS, R/TRO Brynn Roberts, MSc. OT, OT Reg. (Ont.)

Case Study – Ms. Josephine Allegro91 year-old widow currently living in long-term care.Diagnosis of Alzheimer Dementia in moderate stage.Josephine came from home where she was previously living independently.Recently reverted back to native Italian language. Josephine has shown increasing physical aggression and verbal aggression during bathing care. At times she requires 3 or 4 staff members to complete the task. Josephine paces continuously during the afternoon until dinner and is verbally non-aggressive as she calls out in Italian. Staff worry about her risk for exhaustion or falls. When staff approach her she becomes verbally aggressive and on two events she has struck out when staff try to redirect her. Josephine worked as a seamstress and was a homemaker. She raised 6 children with her husband.

Why is studying this important?Dementia is on the rise- at home and internationally  Behavioural and Psychological Symptoms of Dementia Agitation and Aggression

Defining AggressionPhysical/AggressivePhysical/Non-Aggressive Verbal Aggressive Verbal Non-Aggressive

The Four Models of Behavioural AssessmentBehavioural/Learning Model Behaviours are: Used because they have been reinforced over time. Reduced Stress Threshold Model Behaviours are: Responses to heightened vulnerability to the environment Biological Model Behaviours are: Symptoms of the underlying brain damage Unmet Needs Model Behaviours are: Communication to staff that there is an unmet need

Hierarchy of Needs In Dementia Scholzel-Dorenbos , Meeuwsen & Olde Rikkert (2010) Integrating unmet needs into dementia health-related quality of life research and care: Introduction of the Hierarchy Model of Needs in Dementia. Retrieved from Aging & Mental Health, 14.1, p.117

Case Study: JosephineBehavioural/Learning ModelBehaviours are: Used because they have been reinforced over time. Reduced Stress Threshold Model Behaviours are: Responses to heightened vulnerability to the environment Biological Model Behaviours are: Symptoms of the underlying brain damage Unmet Needs Model Behaviours are: Communication to staff that there is an unmet need How would each of these four models explain Josephine’s responsive behaviours?

Alzheimer’s DiseaseStage Functional Deficits Things to Consider Mild MMSE 21-26 Forget names and current events Complex tasks are difficult Items of value go misplaced Complicated interests abandoned Prompting for self-care required Denial of having a problem exists Withdraws and develop behaviour problems Help to feel competent and valued Can do old habits and routines and likes familiarMay want full attention or less contactChange is difficultTells the same stories and asks the same questionsModerate MMSE 10-20Greater assistance requiredSleep disturbedDifficulty remembering important thingsOrientation affectedGreater independence early. Then greater dependence later in this stageBecome agitated, isolated and anxiousMay become delirious with infectionWant to feel like they have a purposeGets lost in past life, places and roles, so go with the flowMemory leads to thoughts of others taking their memorable itemsNeeds help, but does not know it or like itCan become emotional quickly

Alzheimer’s DiseaseStage Functional Deficits Things to Consider Severe MMSE 0-10 Remembers own name, but can forget partners Unable to solve problems Full assistance with bathing and toileting. Difficulty with walking and falls risk starts Delusions and hallucinations may continue Anxiety, aggression and agitation occurs Sleep disturbance continues Likes rhythmic movements and actions Fascinated by watching others Like to pick-up, hold, carry, rub or grip things Fine motor movements are lost Big movements are kept Limited visual awarenessOne direction – forward, cannot back upEnd StageMMSE 0Unable to talkOnly recognize spouseMay scream out at timesFull assistance with eating and drinkingResistant to careUnable to walkIncreased risk and incidence of infection.Likes pleasant sounds and familiar voicesLike warmth and comfort feelingsAware of the world around them for short periodsLimited movementHard to connect with them

Frontotemporal Disease (FTD)Stage Functional Deficits Consider: Mild Disinhibition , apathy and overeating Problems with planning, organization and memory Impaired judgement with financial decisions Social Withdrawal: less interest in family, friends, babies. May be inappropriate with strangers and lose social manners. Impulsive actions Behaviours can be managed with changes in lifestyle & environment May still be capable of managing household tasks Independent with self care with little helpModerateSymptoms more pronounced Compulsive behaviours Cognitive: Mental rigidity, forgetfulness,Severe deficits in planning and attention.Further deterioration with motor co-ordination, cognition, emotions and learning depending of side of brain affected. Utilize compulsive behaviours as a strength (ie. hole punching, cleaning, painting, wordsearches, math sheets) Modify/decrease steps in activities to ensure the task is failure freeSevereApathy, loss of empathy, disinhibition with language difficulties and memory loss. Focus on remaining strengths , interests (music, counting)

Semantic Dementia:Stage: Functional Deficits Consider: Mild: Left side of brain : Difficulty finding words or name for something. Right side of brain : Decline in empathy or awareness of other’s emotions Offer communication techniques ( ie . pictures, model actions, note pad, whiteboard) Use humour for + redirection Ask for help with tasks that require modified, repetitive steps Moderate: Left and right begin to appear similar. Some behaviours similar to FTD. Difficulty understanding expressive communication, recognizing names/faces. Reading/ writing declines. Some remaining strengths with numbers, colours and shapes. Try simple wordsearch games, large piece jigsaw puzzles (25-100pc)Sorting: artificial money, dice, coloured stickers poker chipsSevere: Language significantly impacted. Behaviours similar to FTD. Left side: more interest in non -verbal activities (ie. expressive arts, music)Right side: may prefer games with words and symbols.

Progressive Non Fluent Aphasia:Stage: Functional Deficits: Consider: Mild: Increased difficulty speaking and producing languages Symptoms incl. slowed speech, trouble getting words out can understand expressive communication and knows what he or she wants to say Moderate: Significant problems with speech Increased use of short sentences May use extra articles and/or adjectives ( ie . “that thingy over there”)Try board or number of pictures to help express their meaning. Skills remain intact with numbers, colours, shapes Able to read emotion – empathize and validateReading/writing still good Severe: Essentially mute BPSD similar to FTD Some develop Parkinson’s like motor problems like muscular rigidity and stiffness. Non Verbal Communication is key. Use a pro-attention planKnow psychosocial history: interests in music, animals, spiritualitySensory Stimulation End stages involves difficulty with swallowing, chewing, moving, bladder.+Time needed to process task at hand,Comfort measures

Lewy Body DementiaCommon Change : Description: Consider: * Distorted Perceptions Very common, up to 80% of people experience hallucinations . Often of children and animals. Do not argue or rationalize. Use validation. Visual/Spatial difficulties Difficulty judging depth/recognizing distance between self and objects Monitor for falls; utilize high contrast colours (colourful tape)Parkisonian symptomsSlowed movements, difficulty walking, balance impairment, rigidity, stooped posture, shuffling walk, tremor at times, reduced facial expression, difficulty swallowing, weak voice, small handwritingMonitor for risk of falls; refer to PT/OT for assessmentSleepREM sleep disturbance, active dreams, sleep walk, talk in sleep. Increases in frequency as dementia progressesHave a plan for nighttime; provide low stimulation and appropriate activities to engage in at night; music, tea. * Rapid mood changesCan shift rapidly through anger, depression, tearfulness. Heightened sensitivity to stimuli (noise, quick movements)Keep stimulation low, be mindful of movements (move slowly!); Keep predictable, consistent schedule. * RigidityUnable to move past a topic of conversation or to physically moveValidate, allow time for processing, provide time and space, do not try to re-direct, answer questions/ comment each time as thought it is new

Types of non-pharmacological interventions reviewed:Sensory interventionMusic, Massage/touch, White noise, Sensory stimulationSocial contact One to one, Pet visits, Simulated presence therapy and videos Behavioural therapy Differential reinforcement, Cognitive, Stimulus control Staff training Activities Structure Walks Physical activities Environmental interventions Wandering areas, Natural and enhanced environments, Reduced stimulation environments Medical/nursing care interventions Light therapy, Sleep therapy, Pain management, Hearing aids, Removal of restraintsCombination therapiesIndividualized Interventions

Social ContactSuccessful Interventions Pet Therapy / Animal Assisted One to one interaction Simulated Interactions / Presence Reminiscence Take Home Thought: Any contact was found to be effective in reducing verbally non-aggressive behaviours Reminiscence was found to be effective in reducing resistance to care Real human contact was found to be the most effective

Exercise and Activity Therapy Successful Interventions: Interventions to consider: Low intensity work-outs Walking programs Free access to outdoor area Activity programs ADL’s Stage of dementia Take Home Thought: Low intensity programs can be successful in reducing physical aggression and agitation- but know the person’s stage & needsActivity is Prevention: Activity is important in maintaining capabilities!

Caregiver TrainingSuccessful Interventions Formal and informal caregiver education: Focused on education on recognizing, preventing, and planning for aggressive behaviours Focused on dementia, and using the ABC model or behavioural mapping “Culture shift” Caregiver modelling Bathing without Battle Take Home Thought: This is our “time saving” intervention! Even 3 sessions with nursing home staff could lead to less aggressive acts!

Nursing and Medical Care Correlations: Interventions to try: Pain : Verbalizing, Physical aggression Sensory impairment : Agitation Discomfort : Verbal aggression and non-aggressive behaviours; Physical aggression 1) Pain Management: http://pda.rnao.ca/content/management-pain-non-pharmacological-management 2) Deep breathing 3) Modified daily activity 4) Changing the pace 5) Allowing breaks6) Scheduling to allow for downtime7) Changing body position during care and rest8) Increasing pleasant activity9) Offering sensory aids (hearing aids)

Environmental Changes Successful Interventions Interventions with Limited EVB effect Covering doorknobs and doorways with curtains/blinds* Having free access to outdoor environments & gardens ( greater freedom of movement). Normal natural light versus bright light. Smaller tables and group sizes Neutral wall colours Moderate noise level; Low volume television, radio, and telephones Structured daily routine Nature songs with large matching photos Engagement more successful in afternoon (between 2:00-5:00 p.m.) versus the morningCovering doorways has some contradictory results*Covering doorways with mirrors can lead to increased agitation.Evidence on special care environments is mixed. Take Home Messages:Create choice & freedom Home-like environment: Use natural light and soundsMaintain low stimulationCoverings are contradictory- but try them! Depends on the person.

Sensory Interventions Successful Interventions Interventions with Limited EVB effect Glider-swing/Rocking chair Music Music vs. music therapy Recreation Therapy Spa baths Massage and touch Bright Light Therapy Aromatherapy Snoezlen /multi-sensory room Natural Elements MusicLength of effect

Person-Centered CareSuccessful Interventions Getting to know the person: Who is this person? What is their personality? What do they like? Dependent variable in care- we cannot change the person! We must accept them for who they are Utilize this information in their care plan: Shows significant reductions in behaviours! Person-centered bathing Use of music Person-Centered vs. Person-Driven Care Take Home Message: The first step is accepting this person for who they are Know the client: Formal and informal caregivers working closely together is our best tool for success! Use the All About Me to help gather information

StimuliStimulus CategoryStimuli Used Live social A real baby, a real dog, and one-on-one socializing Reading Reading a large print magazine. Self-Identity Individualized stimuli matched to each participants past identity with respect to occupation, hobbies or interests. Music Listening to music. Work Stamping envelopes, folding towels and sorting envelopes. Simulated Social A life-like baby doll, a childish-looking doll, a plush animal, a robotic animal and a respite video. Manipulative A squeeze ball, a tether ball, an expanding sphere, an activity pillow, building blocks, a fabric book, a wallet for men, a purse for women, and a puzzle.BaselineNo stimulation provided / usual careTable 2. Predetermine Stimuli: The order of stimuli was randomized.Cohen-Mansfield, J.S., Marx, MM.S., Dakheel-Ali, M., Tegier, N.G., Thein, K. & Freedman, L. (2010). Can agitated behaviour in nursing home residents with dementia be prevented with the use of standardized stimuli. Retrieved and adapted from Journal of American Geriatric Society, 58, p. 1461

The Ten Absolutes of CaregivingNever Argue – Instead AgreeNever Reason – Instead Divert Never Shame – Instead Detract Never Say “Remember” - Instead Reminisce Never Say “I told you” – Instead Repeat & Regroup Never Say “You can’t” – Find out what they CAN DO ! Never Command or Demand – Instead Ask or ModelNever Condescend – Instead Encourage and PraiseNever force – Instead, Reinforce

Take Home Messages Physical Aggression Physical Non-Aggression Verbal Aggression Verbal Non-Aggression Pain Discomfort Low-intensity programming (walking) Caregiver training/education Any type of social contact Task-specific activities Person-centered care plan Music (Bathing) Reminiscence social contactLow-intensity programming (walking)Unrestricted outdoor spaceDoor/window coverings Sensory aidsSocial interventions (recreation)Person-centered care planMusic (agitation)PainDiscomfortLive social contactTask-specific activitiesMusicSocial interventions (recreation)Touch/MassageAny type of contactHome-like environmentLow stimulating environmentDiscomfortMusicSocial opportunities (recreation)Task-specific tasksTouch/Massage

Resources & LinksDementia Care Leaders for long term care homes: Eden Alternative: www.edenalt.org Sherbrook Community Centre: www.sherbrookecommunitycentre.ca Dementia Village : www.cnn.com/2013/07/11/world/europe/wus-holland-dementia-village/index.html Positive Video Links: Eden Alternative : http:// www.youtube.com/watch?v=ZKRMd-r2dN8 Wattle’s Innovative Program for People Living with Dementia: www.youtube.com/watch?v=1LCRrcxlrXE.

Resources & LinksMontessori : https://globalnews.ca/video/1360548/a-new-way-of-caring-for-those-with-dementiaDementiability Free Resources: www.dementiability.com Teepa Snow (Dementia Care Educational Resources): www.dementiacareacademy.com Music Resources: Java Music Club : www.javamusicclub.com Room 217 : www.room217.ca Ipod Project: www.imnf.org

Resources & LinksAnimal Assisted Therapy/Visits:Canada’s Guide to Dogs: www.canadasguidetodogs.comSt. John Ambulance: http://www.sja.caHand Massage: https://www.youtube.com/watch?v=tAJ6JsITQo0&feature=youtu.be Multi Sensory: http://www.youtube.com/watch?v=I-puYfZQGN8&list=PLeepEjmy_AglymCxHgUivtcwyziSyVZvL&index=4 Activity Resource Catalogues/Websites: Concepts du Sablier : www.sablier.com Nasco Seniors Spectrum: www.enasco.com

Questions?Thank You!

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