BO8 208 Yakel - Rehab Summit · 2018. 7. 12. · • To document patientParticipation, Engagement,...
Transcript of BO8 208 Yakel - Rehab Summit · 2018. 7. 12. · • To document patientParticipation, Engagement,...
1
To comply with professional boards/associations standards:• I declare that I (or my family) do not have a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship.•Requirements for successful completion are attendance for the full session along with a completed session evaluation.•Vyne Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity.
Session 208: Innovations in Dementia Rehab: A Modern, Multidisciplinary Guide to Staging & Interventions
Jane Yakel, MS, CCC‐SLP
Leading the Way in Continuing Education and Professional Development. www.Vyne.com
Have You…..?
• Have you ever FELT, HEARD OR SAID…
“there is nothing you can do for this patient”
2
Real Scenario Director of Rehab
Why am I telling you this?
We are THE service providers. It is our ethical, professionally responsibility to serve the patient all the way
through the seasons of their disease
Know there is something to do at every StageKnow WHY to do something, before How to do it,
then know What to do and When to do it
In human beings, action is preceded by belief.
Philosophy and Principles of Seminar
Learn Today…Implement Tomorrow!
Recognize What You See
Know Your Patient
Know What Therapy Is…and Know How to Document It!!
Take Time to Think!
Recognize What You See
“If you have seen one patient with Dementia, you have seen one patient with Dementia”
...Alzheimer;s Disease Assoc
Important to:• Stage patients
• Recognize the symptoms / behaviors of each stage
• Know the Needs of the Patient at every stage
• Utilize Appropriate Techniques Successfully
Staging Drives Intervention
3
KnowHow to do What and When
Know How
• To implement EB techniques at appropriate Stages
• To justify necessity
• To document patient Participation, Engagement, Interaction• To document Skilled Intervention
• To do all this with Confidence!
Intellectual Understanding Alone is InadequateIt is never as easy to implement
as it is to understand
Dementia
What is it???
Dementia
Reversible Irreversible
4
Reversal “Dementia” Loss
Drugs/prescribed medications/combinations
Emotional (severe depression)
Metabolic (thyroid, parathyroid, adrenals& pituitary, dehydration)
Eyes and/or ears declining (sensory losses)
Normal pressure hydrocephalus
Tumor (malignant/benign)
Infection (syphilis, encephalitis)
Anemia (B12, foliate, thiamine)
Different diagnosis of Irreversible “Dementia”
• Alzheimer’s Disease – AD
• Vascular Dementia ‐ VaD
• Frontotemporal Dementia ‐ FTD
• Lewy Body Dementia – LBD
• Mixed Dementia – MD
• Primary Progressive Aphasia ‐ PPA
• Huntington’s Disease‐ HD
• Parkinson’s Disease – PD
Irreversible “Dementia” Loss
Looking at the Changes in
“Dementia”
Over the Years
The Times ,They Are A-Changin’
….Bob Dylan
5
Changes in Intervention
Dementia Staging
Developmental Ages to the Stages
Approaches to Therapy
Functional Outcome Expectations
Successful Intervention Techniques
• Scale focusing on an individual’s
• level of functioning & activities of daily living
• and cognitive decline
• Dementia Staging -
Staging
Tool is designed to identify a person’s cognitive status through using focused, Skilled Observation
They provide useful frames of reference for understanding how the disease unfolds and for making future plans
No single staging instrument is complete in the sense that it is excellently
validated and shows specific reliability of clinical applicability
It is important to utilize THREE forms of assessments
tools to adequately Stage a Person
Dementia Staging Tool
6
Staging• Clinical “Skilled Observation”• Mini‐Mental State Examination (MMSE)• Saint Louis University Mental Status (SLUMS)• Global Deterioration Scale (GDS)• Functional Assessment Staging (FAST)• Dementia Severity Rating Scale (DSRS)• Clinical Dementia Rating (CDR)• Brief Cognitive Rating Scale (BCRS)• Direct Assessment of Functional Status (DAFS)• Bedford Alzheimer's; Nursing Severity Scale (Bans‐S)• Dementia Severity Scale (DSS)• Functional Rating Scale (FRS)• Routine Task Inventory (RTI)• Gottfries‐Brane‐Steen Scale (GBS)• Hierarchic Dementia Scale• Montreal Cognitive Assessment “Recognize What You See”
Jane Yakel M.S. CCC‐SLP
Developmental Ages
Dr. Barry Reisberg, New York University, outlined developmental ages to the seven (7)
major Clinical Stages of Alzheimer's Disease,
and spoke to
“Retrogenesis”
First In – Last Out Theory is essential in understanding
and preparing
the patient and the family for the best
Quality of Life
7
Born
Die
First In – Last Out
Patterned sequencing in reverse order
Born
Die
First In – Last Out
Patterned sequencing in reverse order
Stage 3 +12 y/oStage 4 8 yrs
Stage 5 5-7 y/oStage 6 3 -5 y/o
Stage 7 2 y/o
The Reversal of Normal Human Development
Holds demanding job Difficulty with a demanding job
Requires help with complex tasks, finances
Help with selectingand putting on clothes
Needs help withtoileting
Loses ability tosmile or hold up head
Handles simple finances
Goes to bathroom unaided
Holds head up and smiles
8
Therapy Approaches
Specialized Treatment for Dementia
Person Centered ApproachCaregiver Centered
Patient Centered ApproachInterventions are individually and specifically designed for the patient
Caregiver Centered - Paradigm ShiftTraining the Caregiver is paramount;
they ultimately are the ones delivering service
Dementia DocumentationChanges
FrequencyDuring the Stages, the frequency of services increases
Paradigm shiftDuring the Stages, the delivery of service
switches from the Patient to the Caregiver
DurationDuring the Stages, the duration of services decreases
9
Justification of Medical Necessity…Tammy Hopper 2016
Documentation Need Documentation Statement
Prior Level of Functioning Documented decline in participation in daily life activities, (instrumental & basic), decline in social & group activities
Statement of Risk Related to Safety ndividual at significant risk for social isolation, decreased food & fluid intake, behaviors that may effect staffs ability to provide care, safety concerns due to decrease orientation, increased agitation
Statement of Risk Related to Quality of Life
Resident at significant risk for decreased quality of life due to a new onset of social isolation
Statement of Reasonable Expectation of Improvement
Multiple scientific studies support the use of print & graphic cueing systems to increase orientation & quality of life & decrease negative behaviors in clients with dementia
Stages of Dementia
Seven Major Clinical Stages
Staging DementiaSeven (7) Stages of Dementia with definite signs and symptoms at each stage
1. Normal2. Normal Aging3. Mild Cognitive Decline4. Moderate Cognitive Decline5. Moderately‐Severe Cognitive Decline6. Severe Cognitive Decline7. Very Severe Cognitive Decline
10
Stages of Dementia
Stage 1
Normal
Stage 1
NormalAt any age, persons may potentially be free of objective or subjective symptoms of cognition
and functional decline and also free of associated behavioral and mood changes
We call mentally healthy persons at any age… Stage 1, or Normal!!
Stages of Dementia
Stage 2
Normal Aged Forgetfulness
11
Stage 2 Normal Aged Forgetfulness
Half or more of the population over the age of 65 experience subjective complaints of cognitive and/or functional difficulties
___Difficulty recalling names as well as 5‐10 yrs. ago
____Can not remember where they have placed things____Can not remember the correct word (noun)____Difficulty concentrating____Not notable to external observers
“I remember the face, I can’t remember the name”
Terms suggested for condition… most satisfactory terminology
“Normal Aged Forgetfulness”
Stages of Dementia
Stage 3
Mild Cognitive Impairment
Mild Cognitive ImpairmentReported change in cognition,
preferable collaborated by informant
One or more impaired cognitive domains
for age and education
Not all MCI’s progress to dementia (statics vary)• 25% ‐ 50% progress to dementia within 5 yrs
• 25% ‐ persist with MCI all their lives
• 25% + will improve
12
Stage 3Mild Cognitive Impairment
Manifest subtle deficits in diverse ways____Repeating queries
____Compromised Executive Functions
____Job performance declines
____Decrements in new learning become evident
____Manifest concentration deficits
____Begin to experience…Anxiety…may be evident
Stage 3Mild Cognitive Impairment
The prognosis is variable
• May know something is wrong …but often they do not tell anyone
• When concerns become noticeable …patient at end of stage
• Results in clinical consultation
Mean duration of state is approximately 7 yearsCognitive Assistance is 6%‐25%
Developmental Age Comparison: 12+ years
Stage 3Mild Cognitive Impairment
Treatment – SLPTeach Compensation!!!
• Note taking, list making, phone lists, med organizers
• Begin use of calendar, appointment / memory book
• Attack problems from solutions, giving choices
• Identify most successful environments for attention, communication anxiety levels
•Family caregiver training & education for carryover
13
Stage 3
Mild Cognitive ImpairmentManagement
Counseling regarding desirability of continuing in complex & demanding roles
A “strategic withdrawal” from stressful situations–Alleviates psychological stress–Reduces subjective and overtly manifest anxiety
Stages of Dementia
Stage 4
Moderate Cognitive Decline
Stage 4
Moderate Cognitive Decline
Differential diagnosis can be made with considerable accuracy in this stage
Most common functioning deficit is:
“decreased ability to mange COMPLEXactivities of daily life”
Functional capacities become compromised
14
Stage 4
Moderate Cognitive Decline
Common Deficits
____Major events may not be recalled
____Mistakes made recalling day, month, or season
____Decreased ability to manage finances, pay rent / bills
____Writing correct date & amount on check
____Prepare meals for guests
____Market for oneself and family
____Ordering food from a restaurant – “you order”
____Activities needs to be supervised
Stage 4
Moderate Cognitive Decline
Management – Need Support
• Dominate Mood is flattening of affect & withdrawal
• Patient seems less emotionally responsive,
expected to be related to the denial of their deficit
• Aware of their deficit, (painful), denial enters ‐ psychological defense
• People in stage 4 don’t like to interact with stage 5 & 6
• Withdrawing from participation in activities and conversations
Stage 4Find Out:
Who the person is
• Social, workaholic, introvert/extrovert
What the person did for a living
• Lawyer, doctor, office worker, housewife
The persons hobbies / interests
• Woodworking, artwork, needlework
Mean duration of this stage is 2 years
Cognitive Assistance: 26% - 45%
Developmental Age Comparison: 8-12 years
15
Stage 4Moderate Cognitive Decline
Treatment – SLP
Teach Compensation!!!
l Teach sequential tasks overly and practice with written & verbal compensations (Ability-Based Approach)
l Log of days events to increase functional information recall
• Modify environment for communication success
• Increase initiating and maintaining communication using
• Family caregiver training & education for carryover
Stages of Dementia
Stage 5
Moderately-Severe Cognitive Decline
Stage 5Moderately-Severe Cognitive Decline
Deficits of significant magnitude as to prevent
catastrophe‐free independent community survival
Characteristic Functional Deficit is:
“decreased ability to manage BASICactivities of daily life”
16
Stage 5
Moderately-Severe Cognitive Decline
Common Deficits
– Choosing proper clothing for weather/occasions
– Wear same clothes day after day
– Requires counsel regarding choice of clothing
– Needs assistance with adequate and proper food choices
– Assure rent and utilities are paid
– Difficulty managing phone, managing medications
Stage 5
Moderately-Severe Cognitive Decline
Common Deficits
____Inconsistent in, or can not, recall major events &/or aspects of current life
____Decreased remote memory
____Orientation, correct year not recalled (assessment)
____Calculation deficits, difficulty counting backward from
____Information loosely held, recall address on certainoccasions, but not others
Stage 5Moderately-Severe Cognitive Decline
Management – Needs Support / Supervision
Patients who are NOT given adequate support or properly supervised may
–Demonstrate behavioral problems such as anger and suspicious
– Strangers may become a problem
–May become paranoid
–Depression sets inMean duration of this Stage is 1.5 years
Cognitive Assistance: 46%-70%Developmental Age Comparison: 5-7 years
17
Stage 5Moderately-Severe Cognitive Decline
Treatment – SLP
Caregiver Training
• Start training staff and caregivers
• Educate staff/caregivers of gestural language w/ verbal cues
• Educate most successful level of questioning, choices, y/n
• Increase visual and environmental information
• Double time for them to eat, presentation of meals
Stages of Dementia
Stage 6
Severe Cognitive Decline
Stage 6Severe Cognitive Decline
Five successive sub-stages are identifiable
____6a Difficulty putting clothing on properly without assistance
____6b Unable to bathe properly, e.g., difficulty adjusting bath water temperature
____6c Inability to handle mechanics of toileting e.g., forgets toflush toilet, does not wipe properly/dispose of toilet tissue
____6d Urinary incontinence, occasional or frequently
____6e Fecal incontinence, occasional or frequently
18
Cognitive
___ Deficits are so severe that patient may display little or no knowledge when queried regarding their current life
___ Confuse wife with their mother___ Misidentify/uncertain of the identity of close family
members
Speech___ Breakdown in ability to articulate, (neologisms, paucity)___ Speech often does not make sense ___ Can not answer questions or follow directions
Stage 6
Severe Cognitive Decline
Stage 6
Severe Cognitive Decline
Emotional ChangesCan no longer channel energies independently into productive activities
Begins to fidget, pace, move objects around, place items where they do not belong
Hypersensitive!! Temper, doesn’t wear glasses, dentures, easily startled
Manifest forms of purposeless or inappropriate activities
May develop verbal outbursts, threatening, violent behavior may occur
Develop fear of being left alone
Mean duration of this stage is 2.5 yearsCognitive Assistance: 71%‐85%
Developmental Age Comparison: 2‐5 years
Stage 6Severe Cognitive Decline
Treatment – SLP
Caregiver Training
• Educate staff on specific & individualized ways to communicate, (touch, eye contact, gestures with words)
• Identify patterns in paraphasias & educate caregivers to anticipate specific to the patient
• Modify memory aids, room to include single words and pics
• Y/N questioning approach, relate questions to “the now”
19
Stages of Dementia
Stage 7
Very Severe Cognitive Decline
Stage 7
Very Severe Cognitive DeclineConsistent Assistance with basic activities of daily life
Six successive sub-stages are identifiable
___7a Ability to speak limited to approx a half dozen words in a course of interview
___7b Speech limited to single intelligible word in average day
___7c Ambulatory ability lost – needs personal assistance
___7d Inability to sit up without assistance
___7e Loss of ability to smile, grimacing facial movements
Stage 7
Very Severe Cognitive Decline
Physical / Neurological Changes–Evident rigidity–Physical deformities in form of contractures–Neurological reflex changes
– Re‐emerge of grasp and sucking, Babinski reflex
Frequent proximate cause of death• Pneumonia• Decubital ulcerations
20
Stage 7
Very Severe Cognitive Decline
Family• Family members do not know what to do at this stage• Teach them how to offer stimulation, give them some
tools to interact with patient• Educate on Validation, Reflective Listening, Re‐Direction
Main Interventions are “Damage Control”• Swallowing / dysphagia / diet• Skin breakdown• Contraction Management
Need Consistency in Delivery
Stage 7
Very Severe Cognitive Decline
Intervention Strategies
• Avoid aspiration, provide pericare and swallow opportunities
• Provide stimulation through senses, i.e., music, tactile furry stuffed animals, calming smells, lavender
• Maintain hygiene / hydration
Do you see your ROLE at every
Stage of Dementia?
• Lets never say
“there is nothing I can do for this patient”
21
Justification of Medical Necessity…Tammy Hopper 2016
Documentation Need Documentation Statement
Prior Level of Functioning Documented decline in participation in daily life activities, (instrumental & basic), decline in social & group activities
Statement of Risk Related to Safety Individual at significant risk for social isolation, decreased food & fluid intake, behaviors that may effect staffs ability to provide care, safety concerns due to decrease orientation, increased agitation
Statement of Risk Related to Quality of Life
Resident at significant risk for decreased quality of life due to a new onset of social isolation
Statement of Reasonable Expectation of Improvement
Multiple scientific studies support the use of print & graphic cueing systems to increase orientation & quality of life & decrease negative behaviors in clients with dementia
Dementia Intervention
Evidence‐Based Treatment Multi‐Disciplinary Approach
Principles of Dementia Intervention
• Reduce demands on impaired systems
• Increase alliance on spared ones – Strengths
• Use personally meaningful & culturally appropriate stimulus to evoke, positive emotion and action
• Recruit significant others into treatment
• Minimize factors that contribute to excess cognitive‐communication disability, i.e., hearing, meds, stress
• Manage ours, the clients and the families expectations!
22
Evidence-Based Interventions
TechniquesErrorless Learning
Spaced Retrieval Training
Memory Books / Aids
Montessori‐Based Dementia
Ability‐Based Approach (RED)
Reminiscence Therapy
CommunicationValidation Therapy
Reflective Listening
Re‐Direction
Errorless Learning
Errorless Learning should be a Core Characteristic!
Errorless LearningDefinition
• No mistakes!!
How to Do It
• Immediately correct an incorrect answer with the correct answer
The goal for people with significant cognitive decline is for them to know the correct answer…
…not to mentally retrieve the answer
23
Spaced Retrieval
“The spacing effect is one of the oldest and best documented phenomena
in the history of learning and memory research”
Spaced Retrieval - SRT
Definition and Ultimate Goal
Retention and recalling of information over progressively longer intervals of time
Capitalizes on the strength of procedural
Assure the intervention is Patient-Centered, identify exact problem and WHY it is a problem
Problem
Why
Spaced Retrieval
24
Locking Wheelchair BrakesExample of Therapist/Patient Conversation
• Therapist: Show patient the locks on wheelchair, ask them what they call them or tell them the name. Keep same vocabulary!
• Patient: “It is the wheelchair brakes” Patient names the locks
• Therapist: Design a prompt question “What do you do when you get in and out of a wheelchair?”
• Patient: “I lock my brakes.” Train the patient to say “I lock my brakes (verbal response) having the patient put their hands on the wheelchair brakes and lock the brakes (physical response) while reciting the response.
Goal: Patient will lock wheelchair brakes 100% of time when transferring in/out of wheelchair by formulating a systematic procedural memory through use of spaced retrieval intervention strategies with 10% verbal cues to remain safe and decrease fall risk within 4 weeks.
Drink to Prevent Dehydration
Example of Therapist/Patient Conversation
• Therapist: Show patient a glass of water and ask them what they call it, patient to identify the item. Keep same vocabulary!
• Patient: “It is a beverage”. Patient may say “It is water”. Assure you use the patient’s personal vocabulary.
• Therapist: Design a prompt question “What do you do when you see a beverage?”
• Patient: “I drink it.” Train the patient to say “I drink it (verbal response) having the patient pick up the glass and drink it (physical response) while reciting the response.
Goal: Patient will increase oral intake of liquids, 6 glasses per day, through enhancing the procedural memory system utilizing spaced retrieval strategies, 10x per day with 100% visual cues to meet hydration needs within 2 weeks
Spaced Retrieval
Yelling Out: When am I going home?
Problem: Patient causing self anxiety, a safety risk if she tries to get out of bed, absorbing a great deal of staff time
Why: Patient is looking for social contact and unaware of call button or how to use it
Goal: Patient will decrease repetitive questions by 50% and utilize spare time with purposeful activity, by developing procedural memory through SRT to decrease anxiety level and increase comfort within 4 weeks
Goal: Patient will recall and demonstrate appropriate use of call button 95% of time by developing procedural memory utilizing SRT with 10% visual cues to decrease self anxiety and increase safety risk within 2 weeks
25
Montessori-Based Dementia Programming
For an older person experiencing memory loss, the use of theMontessori method can preserve skills
Montessori-Based Dementia
DefinitionStructured, stimulating activities that are appropriate to individual’s cognitive abilities
PhilosophyOriginally designed for children however proven to work with patients with degenerative cognitive deficits
Purpose / RationalIncrease participation, engagement, social interaction,assist and maintain their highest level of functioning
Montessori-Based Dementia Intervention
People with dementia need an environment that places the information they need into the environment allowing
active participation with materials & tasks
26
Montessori-Based Dementia Intervention
Ability Based Therapy
“RED”
The Purpose of Life is a Life of Purpose
Ability-Based Intervention“RED”
Recognize – External Cues – Doing
Three Key Elements in Ability-Based Intervention
Recognize: All the patient has to do is recognition
External: Cues/materials that give feedback and direction
Doing: Helps prolong ability, gives purpose
• Accuracy doesn’t count – keep the patient engaged
27
Definition: Doing…Doing…Doing!!!
Patients with cognitive impairments do not become……
“Comfortably Numb”
They need to be USEFUL!!! The task they “do” specifically doesn’t matter.
Everyone needs a responsibility, a job, a reason to get up in the morning
Find it! Have it relate to a former hobby, interests, job that the individual enjoyed in their earlier years
Ability Based Therapy“RED”
Ability-Based Interventions
Use Therapy Tasks within
• Sorting
• Categorizing
• Sequencing
• Reading
• Matching
Recognition memory that is needed to do activity… is built into the activity
Sorting
28
Sorting: Object-to-Word
Knife
Fork
Spoon
SortingSorting Old Testament from New Testament
Old Testaments New Testaments
ReadingDevelop reading groups, patients can read aloud
• Favorite poems• Anecdotes• Famous or classical stories• Reader’s Digest• Labels• Bible Quotes• Daily Newspaper
Goal: Patient will participate in a reading group 30 min/day by reading text aloud with moderate visual cues to increase turn‐taking skills, social interaction /engagement for 2 weeks.
29
Recognize – External Cues – Doing“RED”
Case StudyA caregiver was really getting frustrated with her spouse "underfoot" all day long. She knew he had once loved woodworking; but could no longer safely use power tools. So, she had her son set up a "safe" wood shop for his dad. They put it in the garage where the wife could easily keep an eye on him, and the son put all sorts of "safe" tools, sand paper, tape measures, hammers, screws, etc. out on the workbench. Every morning, the wife would pack a lunch for her spouse, gives it to him and tell him he had to go to work. She sent him to the garage where he had pencils, paper, markers, brooms, shovels, dirt, seeds, tools, etc. to mess around with. She made sure he ate his lunch. Sometimes she even "came to his work" and joined him for lunch. This made a huge difference in her tolerance level ‐ and gave him a sense of responsibility.
There is a proven link between boredom and agitation. It is sometimes very challenging to keep a person with dementia busy; but it is worth thinking about how to do that so that they have some opportunity for "failure free" activities that will alleviate boredom and help them to
have some “Meaningful” work to do!
Reminiscence Therapy
Memory is what makes us young or old
30
Reminiscence Therapy
Definition
An intervention technique that respects the life and experiences
of an individual; also referred to as “Life Review”
Purpose
Participation
Engagement
Social Interaction
Reminiscence Therapy
Therapy: Props and Themes for Context
• Pictures: favorite places, photo’s of home, places visited
• Visual: photos, slides, painting pictures, looking at objects of meaning
• Music: certain eras, favorite songs, sing along, making music using various instruments
• Smell or Taste: use smell kits, baking bread, mothers favorite perfume
• Tactile: touching objects, feeling textures, painting and pottery
Themes to Use with Reminiscence
Themes• My childhood home• My mother, my father• Our neighbors• Our town• Family life• Radio, music• Childhood games• Childhood pets• Christmas Day• Sundays
Themes
• Favorite food• Turning 21• My brothers, sisters, relatives• First Memories• I was born…• The great depression• During the war• Heroes• Childhood songs, street games• Childhood disasters
31
Facilitating and Documenting• Questions : should reduce demand on factual memory, use y/n,
choice questions. Episodic vs. Semantic Memory
SM: “When did you retire?”EM: “How do you like retirement?”
• Documentation: may require quantifying responses
# if times each person participated in group
Total # of words produced
Meaningful “on‐topic” utterances
# of initiations
Memory Books / Aids
…little threads that hold life’s patches of meaning together
Memory Books
DefinitionSmall books or albums with labeled photographs
tailored to the individual representing meaningful facts and events
Purpose• Bridges the past to the present
• Increases participation, engagement, social interaction
32
Memory Book
Rational
• Relays on spared skills of recognition
• Reduces the demands of working memory
• A distraction technique for re‐focusing and
• re‐direction during difficult situations
Written Life StoryQuestions to Ask
• How did you enjoy spend New Year’s Eve or vacation?
• Do you have a favorite book?
• Are you more of a pessimist or optimist?
• Did you hold on to the first dollar you ever made, or spend it immediately?
• What three favorite thing would you want on a deserted island?
• What really makes you “sparkle” or happy?
What advice do you have for future generations?
• Politics and political parties• Getting along with others• Money, both cash and credit• Raising children• Giving• Religion• Happiness• Coping with hard times• Love…Marriage• Work
If you had your life to live over, what one thing would you do differently?
CommunicationReflective Listening
ValidationRe-Direction
33
Reflective Listening
To say that a person feels listened to means a lot more than just their ideas get heard. It’s a sign of respect. It makes people feel valued
Reflective ListeningDefinition: Patient‐Centered Communication
Ability to seek to understand patient’s idea and offer the idea back confirming you have understood correctly ‐ single most important communication skill
Purest Form: Listening to others from a position of Empathy
(an essential part of Emotional Intelligence)
Reflective listening is deceptively simple to describe, but challenging to master!!
The listener must identify the primary feelings the speaker is having and then reflect back that understanding with an empathetic tone
Reflective Listening
34
Reflective ListeningReflective Listening avoids pitfalls listeners fall into:
• Judging • Minimizing• Discounting feelings • Giving advice• Most common pitfalls is trying to help “solve the problem”
• Reflection of Feeling – deepest form
occurs when the therapist emphasized and reflects the emotional aspects of communication through feeling statement
Reflective Listening Formula
• You’re (insert feeling word) for or because (state reason for the feeling)
• Sounds like you’re (insert feeling word or phrase)
• You seem (insert feeling word or phrase)
• It seems like you are feeling (insert feeling word or phrase)
• Looks like you’re feeling sort of (insert feeling word or phrase)
Reflective Listening
Let’s Practice
35
Reflective Listening Examples
Patient: “If that person walks into my room one more time and picks up my things, I am going to put her lights out.
Therapist: “Sounds like you are angry that she keeps taking your things”
Patient: “I hate my roommate” Therapist: “It sounds as if you are really upset with him right now
Patient: “I do not want to take a shower, why don’t you leave me alone! I don’t like you anyway”
Therapist: “Sounds like you are angry because it is shower day”
Validation
Just like children, emotions heal when they are heard and validated
Philosophy
Validate or accept the values, beliefs, and reality of what the person says, regardless of accuracy or basis in fact
Validation is an advanced skill, it builds up the basic skill
of “reflective listening”
Validation
36
ValidationWhen Reflective Listening Is Not Enough
• Validation builds upon the more basic skill of
• ...“reflective listening”
• People who inhabit the world of dementia can be in a very different place than those of us who live in "Reality“
The World of DementiaTime Memory Emotions
Case: Father speaking with his daughter
Father: I want to see my infant grandchildren, I have missed two days of work, and I have no arms.”
Daughter: Your grandchildren are grown adults, you have been retired for 17 years, and you do have arms.
Validation ConversationDaughter :Makes eye contact, uses low voice, mirrors concern,
“You have no arms, that must be difficult dad?”
Father : “I just can’t do it on my own anymore. I wet all over myself if they don’t come.”
Daughter shared the conversation with nursing staff and staff reported that he often said “I have no arms” when in the bathroom
Patient was relating feeling of ‘helplessness’ to having ‘no arms.”
Feeling of Helplessness
“Behind peoples disorientation lies a human; knowing when present time and place fade, when work goes, when rules no longer matter, when social obligations have lost meaning: a basic humanity shines through.
When their eyes fail, and the outside blurs, people look inside They use their “minds eye” to see
People from the past become real. When recent memory goes and time blurs, they begin to measure life in terms of memories, not minutes
When they lose their speech, similar sounds, rhythms and early learned movements substitute for words
To survive the present day loses, they restore the past . They find much wisdom in the past” …Naomi Feil
The Validation Breakthrough
37
Re-Direction
“If you don’t know where you are going, any road will get you there”
...Lewis Carroll
Re-Direction
Definition
The action of assigning or directing something to a new or different place or purpose
- literally to change the direction of things
Learning how to re-direct takes patienceand a lot of practice
Examples: What to say to Re-direct
Patient is restlessly pacing back and forth across the room, wondering if the mail has come, she’s not terribly steady on her feet and you’re terrified she’ll fall
Patient keeps insisting that “little men” under the sofa are snatching her snacks & tissues
Family or nurses are frustrated when a patient ask, for the tenth time, whether it is time to eat
38
Re-Direction
Let’s Practice
Re-Direction
Your mother would utter “I’m hungry, I’m starved”, over and over . She could not possibility be hungry, she had already eaten 3 times that day.
Re-direct: Okay, can you give me ten minutes to finish what I a doing and we will eat. Would you like to help me?
Your father wants to get the Volkswagon fixed so he could start driving it. He no longer drives
Re-direct: “Okay, let’s take it to the shop tomorrow, I will finish what I an doing and make an appointment
Your grandfather use to live on a farm and suddenly he remembers it is time to go feed the chickens.
Re-direct: “Okay, let me get the chicken feed”
Re-Direction
39
Thank You
Jane Yakel M.S.CCC-SLP
Dementia Intervention