Progression)of)Demen-a:) Discovering)GEMS™))) …Progression)of)Demen-a:) Discovering)GEMS™)))...
Transcript of Progression)of)Demen-a:) Discovering)GEMS™))) …Progression)of)Demen-a:) Discovering)GEMS™)))...
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Progression of Demen-a: Discovering GEMS™
Seeing More Than LOSS!
Melanie Bunn, RN, MS [email protected]
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Structural Brain Failure
• One way street
• Depending on type of demen-a, changes happen in different areas resul-ng in different changes
• Currently, medica-ons DO NOT impact
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Normal Brain Alzheimers Brain
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Memory
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Memories
• Losses – Where & when you are – What is going on – Where you want to go – What you want to do
• Preserved abili-es – Confabula-on! – Emo-onal memories – Motor memories
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Vision
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Vision
• Reduc-on in visual field • Binocular vision • Monocular vision RESULTS • Change in depth percep-on • Risk of injury & fall • Startles
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Hearing Sound – Not Changed
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Understanding Language – BIG CHANGE
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Issues of Understanding
• Losses – Can’t interpret informa-on – Can’t make sense of words – Gets off target
• Preserved abili@es – picks up on facial expression – picks up on tone of voice
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SENSORY MOTOR STRIP
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Sensory Changes
• Losses – Awareness of body and posi-on – Ability to locate and express pain – Awareness of feeling in most of body
• Preserved Abili-es – 4 areas can be sensi-ve – Any of these areas can be hypersensi-ve – Need for sensa-on can become extreme
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EXPRESSIVE LANGUAGE
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OTHER LANGUAGE
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Language Issues
• Losses – Can’t find the right words – Not able to say what you mean – Can’t make needs known
• Preserved abili-es -‐ – automa-c speech – singing – swearing – turn taking
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Frontal lobe Impulse control
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Issues of Impulses & Emo-ons
• Losses – becomes labile and extreme – think it -‐ say it – want it -‐ do it – see it -‐ use it
• Preserved – desire to be respected – desire to be in control – regret aZer ac-on
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Self-‐Care Changes
• Losses – ini-a-on & termina-on – tool manipula-on – sequencing
• Preserved Abili-es – mo-ons and ac-ons – the doing part – cued ac-vity
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Chemical failure
• Fluctua-ons • Extremely good moments and… Extremely bad moments • Different in different situa-ons • Different at different -mes of the day • Especially: visits with health care professionals, lawyers, DMV, family from out of town
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PET Scan of 20-Year-Old Brain PET Scan of 80-Year-Old Brain
PET and Aging
ADEAR, 2003
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Positron Emission Tomography (PET) Alzheimer’s Disease Progression vs. Normal Brains
G. Small, UCLA School of Medicine.
Normal Early
Alzheimer’s Late
Alzheimer’s Child
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Caregiving Gems & Progression of demen-a
Adapted from work of
Teepa Snow, Melanie Bunn & Claudia Allen
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Understanding the model All people with demen-a are precious
Levels might change depending on situa-on Everyone’s journey will be different Emphasis on what people can do…
not just what they can’t do
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ACTIVITY
• Using what you know about changes in structural and chemical brain func-on on behavior, communica-on/interac-on, visual procession, func-on, memory, reason & decision making
• Think about… • Then discuss… • How to adapt cuing, support/care/helping & the environment to a person func-oning at each level
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Think about it!!! Talk about it!!! • How might you modify cuing? – Sight or Visual cues
– Verbal or Auditory cues
– Touch or Tac-le cues • How do we change our support/care/helping?
• How do we work with the environment?
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First Connect Then Do
• 1st – Visually • 2nd – Verbally • 3rd – Physically • 4th – Emo-onally • 5th – Spiritually -‐ Individually
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Diamonds: Living in the present
S-ll Clear Sharp -‐ Can Cut
Hard -‐ Rigid -‐ Inflexible Many Facets
Can Really Shine
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Diamonds What s-ll works?
• Do well in familiar places & situa-ons
• Use old rou-nes & habits
• Control important ‘roles’ & ‘territory’/maintain control
• Very ‘independent’ or seeking constant reassurance
• Can manage self care • Can manage rou-ne IADLS with supervision
• Can use visual cues & signage
• Expresses needs verbally
• Real? Fake? -‐ Hard to be sure
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Diamonds Where do they struggle?
• Has trouble with new rou-nes and loca-ons
• Place & -me confusion • Resents take-‐over • Becomes anxious and frustrated easily
• Gets lost or confused • Misplaces things • Misinterprets what’s going on
• Word finding problems • Losing ability to abstract
• Logic problems • Lose ability to see others’ perspec-ve
• May or may not have insight into losses
• May try to “escape”
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Diamonds, How do we help? Accepted not Corrected
• Keep to rou-ne & be prepared to help more with changes (traveling)
• If something works or seems to help, get an extra
• Don’t worry about the small mistakes/unusual choices
• For the future: – No@ce how they do things
now – Ask how they used to do
things
• Cues and clues • Fill in the blanks • “I’m sorry, I’m so sorry, I’m so very sorry”
• Be willing to be the one who’s wrong (apologize)
• Learn how to help instead of taking over
• Simpler is bener
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Think about it Talk about it
• How might you modify cuing?
• How do we change our support/care/helping?
• How do we work with the environment?
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Emeralds: Living in the past
Changing color Not as Clear or Sharp -‐ Vague Good to Go – Need to ‘DO’
Flaws are Hidden Time Traveling
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Emeralds What s-ll works?
• Uses visual informa-on to figure out what to do
• Able to do familiar ac-vi-es from the past…with support
• Does tasks repe--vely • Follows samples & demos
• Likes to be in control of self and environment
• Uses language to tell stories, express some needs
• Two Kinds of DOING (Doers or Supervisors)
• S-ll aware of some social norms/rela-onships
• Aware/interested in engaging/helping others
• Having a ‘job’ or ‘purpose’
• Being an ‘adult’ • Geong finished & doing
something else • Wants to be busy
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Emeralds Where do they struggle?
• Have trouble with order of tasks & ac-vi-es
• Skips steps • ‘Don’t need your help’ • Has a mission in mind • May do things over and over if visual cue there
• Living in the past—expecta-ons, rou-nes
• May leave to go where used to be
• Can’t do an ac-vity without visual prompt
• Specifics and content in speech are poor
• Doesn’t like to be done to—may be hard to “help”
• Limited anen-on span—gets it done then finished
• S-ll wants privacy for private ac-vi-es
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Emeralds How do we help?
• An-cipate when the problems might occur and prepare to help before the problem starts
• Help with sequencing • Use visual cues – Keep tools in sight – Offer tools
• Reduce distrac-ons
• Maintain rou-nes • Try to help do things the way they used to: – Recent past – Remote past
• Focus energy on the most important part of the ac-vity
• Right place, right -me, right response
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Empathe-c Communica-on: Verbal Meet them where they are
• Start with the feelings – “Looks like”, “sounds like” – “Seems like”, “feels like” – Don’t be afraid
• Get more informa-on – “Tell me about…” – Repeat words and phrases – Move to remembering
• Move from talking to doing – “Could you help me?” – “Would you try?” – Related to topic – Familiar and posi-ve
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Think about it Talk about it
• How might you modify cuing?
• How do we change our support/care/helping?
• How do we work with the environment?
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Ambers: Living in the moment
Amber Alert Cau-on!
Caught in a moment All about Sensa-on
Explorers
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Ambers What s-ll works?
• Respond to visual cues • Aware of parts of things • LOTS of touching,
handling, mouthing, manipula-ng
• Focus on fingers/mouth • All about sensa-on… • Do what they like & avoid
what they don’t • Can s-ll use hands and
fingers
• Can s-ll do, once you get them started
• Respond to emo-ons of individuals & environment
• Can s-ll use social phrases
• Communicate with “fill in the blank
• Can s-ll imitate…one step at a -me
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Ambers Where do they struggle?
• Don’t do what you want them to do
• Get into things/carry them around
• Invasive (other’s things, personal space)
• May trigger behaviors in other residents
• Put things in mouth • Trouble stopping
• May leave—following visual and tac-le cues
• Don’t respond well to verbal cuing
• Not able to use words to express needs
• Losing understanding of what things are/trouble with tools
• Don’t like to be handled …but need the help
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Ambers How do we help?
• Visual cues – Gestures – Demonstra-on
• Verbal cues – Simplify – Concrete
• Tac-le cues – Anen-on – Hand under hand
• Think about the environment
• Avoid doing too much handling
• Back off change, something and try again
• Break it down – Specific tasks – Groups of tasks
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Think about it Talk about it
• How might you modify cuing?
• How do we change our support/care/helping?
• How do we work with the environment?
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Rubies: Living in a bubble
Hidden Depths Red Light on Fine Motor
Comprehension & Speech Halt Coordina-on Falters
Wake-‐Sleep Panerns are Gone
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Rubies
• What s7ll works? • Big movements – dance
walk, roll, rock, rhythm • Hands, not fingers • Tends toward movement
unless ‘asleep’ • Follows gross
demonstra-on & big gestures for ac-ons
• Responds to emo-ons
• Where do they struggle? • Fine motor skill lost –
mouth & hands • Limited visual awareness • Major sensory changes • Major losses in mobility • Minimal language • Not able to do without
assistance—but not like it • Poor appe-te and intake
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Rubies How can we help?
• Visual – Big gestures – Exaggerated demonstra-on
• Verbal – Single words – Tone of voice
• Tac-le – Hand under hand – Move them the way they move themselves
• They can’t monitor for themselves
• Time to start stopping? – Medica-ons? – Treatments?
• Focus on comfort – Pain – Temperature
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Think about it Talk about it
• How might you modify cuing?
• How do we change our support/care/helping?
• How do we work with the environment?
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Pearls: Living inside themselves
Hidden in a Shell S-ll & Quiet Easily Lost
Beau-ful -‐ Layered Unable to Move – Hard to Connect Primi-ve Reflexes on the Outside
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Pearls • What s7ll works? • S-ll hear • Able to feel touch or
vibra-on • Smells s-ll connect • Can s-ll respond…if we
watch carefully • S-ll “in there” • Can s-ll “connect” • Moments of clarity
possible • May need permission to
“go”
• Where do they struggle? • Ex-nct reflexes return • Pulling in—fetal posi-on • Connec-ons between the
physical and sensory world are less strong
• Bed/chair bound • Limited ability to sit/stay
upright • Problems with swallowing
and ea-ng • Lose ability to maintain
basic life func-ons
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Pearls How do we help?
• Use your approach • Slow down your movements and your words
• Move with the person instead of against them/in circles
• Think about what you’re doing and how you’re doing it and is there a bener way?
• Avoid triggering reflexes • Use rhythm and singing • Focus on comfort and person’s expressed wished
• Food for sensory experience rather than nutri-on
• Keep skin, mouth moist • Use the senses
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Think about it Talk about it
• How might you modify cuing?
• How do we change our support/care/helping?
• How do we work with the environment?
![Page 51: Progression)of)Demen-a:) Discovering)GEMS™))) …Progression)of)Demen-a:) Discovering)GEMS™))) Seeing)More)Than)LOSS!)) Melanie)Bunn,)RN,)MS) melanie.bunn@yahoo.com)](https://reader036.fdocuments.us/reader036/viewer/2022071417/6115062003fc8d055d210d65/html5/thumbnails/51.jpg)
What’s the same through progression?
• Order of cuing: visual, verbal, tac-le • Slow down – Slowed processing – Observe response
• S-ll human: basic needs, basic responses • S-ll a person: with individual • Be willing and able to change yourself!
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What’s different through progression?
• Strength of response to type of cuing: visual, verbal, tac-le
• Response -me