Preventing Agitation in LTC Residents with Dementia

1
Preventing Agitation in LTC Residents with
Dementia

• Joint Provider Surveyor Training Conference
• September 14, 2010
• Shelly E. Weaverdyck, PhD

2
Todays Messages

• Specific parts of the brain play role in specific
  episodes of agitation.
• Brain changes affect persons cognition ability
  to understand and respond.
• Agitation results from impaired cogntion
  misinterpretation, feeling at sea, and
  uncertainty.
• Intervene by addressing causes /triggers of
  agitation..

3
Todays Format

• Causes of Agitation Effects of brain changes in
  specific parts of brain on cognitive functioning
• Parts of brain and cognition affected in 3 types
  of dementia AD, DLB, FTD
• Causes of agitation in AD, DLB, FTD
• Four Factors to assess for role in cognitive
  functioning and resulting agitation
• Four factors to address cognition with
  intervention
• Individualizing intervention Person and situation

4
See Resources for More Info

• See Handouts for this session
• See Caring Sheets Currently Available for list
  of MDCH Caring Sheets about Dementia that are on
  website listed at end
• See Additional Handouts handout and email S
  Weaverdyck for electronic copies of individual
  handouts
• See websites listed in handouts.

5
And More Resources CIAP

• Cognitive Impairment Assessment Protocol (CIAP)
  by S Weaverdyck.
• The CIAP Environment (Yes/No format) and CIAP
  Caregiver Interactions (4-Point format) are in
  your handouts.
• Description in later slide.
• Email S Weaverdyck for additional electronic
  copies.

6
And the CIIP as Resource

• Cognitive Impairment Intervention Protocol (CIIP)
  by S Weaverdyck.
• Some of the interventions listed in the CIIP are
  included in this presentation.
• Description in later slide.
• Email S Weaverdyck for additional copies.
• S Weaverdyck sweaverd_at_umich.edu

7
Four Factors to Consider

• To help a person feel relaxed and comfortable,
  examine four factors
• Person
• Environment
• Caregiver interactions
• Task and Daily routines

8
Four Factors as Cause/Triggers

• Brain changes and resulting effects on cognition
  can cause agitation.
• 4 Factors that can make it harder or easier for a
  person with cognitive impairment might be
• Persons cognitive, emotional, or physical
  condition.
• Whats happening in the environment around a
  person.
• Caregiver interaction with a person.
• How we time and organize a particular task.

9
Focus today is on CognitionAddress the Whole
Person

• Assess physical, emotional, spiritual, cognitive
• Understanding the persons medical and emotional
  status is extremely important.
• Why? For example, it will give us ideas of what
  to say and how to touch a person who may be
  experiencing pain.
• It will also allow us to have realistic
  expectations.
• Because a person functions as a whole person.

10
Effects of Brain Changes Cognitive Impairment

• Brain changes cause cognitive impairment.
• Cognitive impairment is a decreased ability to
  think, understand remember.
• Dementia gets worse over time.
• A person goes through stages of dementia, as
  brain pathology spreads across the brain.

11
Causes of Dementia

• The most common cause of dementia is Alzheimers
  Disease.
• Other causes are
• Dementia with Lewy Bodies
• Frontotemporal Dementia
• Vascular Dementia
• (See Caring Sheets 11, 12, 13 on website)

12
(No Transcript)
13
Hippocampus

• The hippocampus creates your memory of recent
  events and tells you what to remember, such as
• What you just said.
• What you had for lunch.
• That your daughter just visited.
• To remember the towel someone showed you rather
  than the food someone else is eating

14
When the Hippocampus Becomes Damaged, You May

• Repeat a question or concern.
• Forget something someone just said.
• Forget that a daughter just visited.
• Be surprised and angry when a caregiver begins to
  take off your clothes because you forgot you just
  agreed to take a shower.

15
Left Temporal Lobe

• The left temporal lobe helps you understand
  language and speak.
• When it is impaired, you may
• Make nonsense sounds.
• Use the wrong words.
• Say yes when you mean no.
• Not understand what someone tells you.
• Not understand what you read.
• Use swear words without realizing it.

16
Right Parietal Lobe

• Helps you locate and arrange objects in space.
• Tells your brain to pay attention to everything
  in your visual field (i.e., everything in the
  space you see.)

17
When the Right Parietal Lobe Becomes Damaged, You
May

• Use excessive energy putting an arm into the
  armhole of a shirt.
• Put a glass down on the edge of a plate, rather
  than beyond it.
• Have difficulty responding to stimuli in the left
  part of the visual field.
• Have difficulty tolerating clutter, many objects,
  and movement in the environment.

18
You May Also

• Feel angry, frustrated, or fatigued from all the
  confusing stimuli in the environment.
• Respond better when a caregiver approaches from
  the front.
• Resist stepping into a tub or shower because you
  cant see
• The height of the side of the tub or edge of the
  shower.
• Where your feet or hands should go.
• How deep the water is.

19
The Frontal Lobe Helps You

• Do more than one thing at once.
• Prioritize what to focus on.
• Sense how much time is passing.
• Empathize with how someone else might be feeling.
• Recognize the difference between the past,
  present, and future.

20
The Frontal LobeAlso Helps You

• Switch your attention from one idea or task to
  another.
• Know when a task is done.
• Keep focused on a task until its done.
• Control impulsive responses to thoughts and
  desires.
• Identify the order of steps for a task.

21
When the Frontal Lobe Becomes Damaged, You May

• Have difficulty focusing on a task and paying
  attention to whats going on.
• Be overwhelmed when a caregiver talks and touches
  at the same time.
• Have difficulty following the logic of an
  argument.
• Need the most important words said first in a
  sentence.

22
You May Also

• Need short simple words and sentences.
• Refuse a bath because you cant think of how to
  do it.
• Leave a shower before youre done because you
  think youve been there long enough.
• Be unable to stop from striking or grabbing
  someone because you cant control impulses or
  switch gears quickly.

23
Three Types of Dementia

• Alzheimers Disease gradually all four areas of
  brain
• Dementia with Lewy bodies Fluctuations,
  unpredictability, visuospatial, hallucinations,
  logic
• Frontotemporal Dementia Insight, initiative,
  obsessive, perseveration
• (See Caring Sheets 11, 12, 13 on website)

24
Assessment for Intervention

• See where each of the four factors is making a
  task or experience harder for this person.
• Identify problems then change The environment,
  Communication strategies, The task itself
• Confirm the changes are accommodating this
  persons cognitive abilities and needs

25
Focus of Intervention

• Because of brain changes, a person needs the
  environment and the caregiver to compensate for
  impaired cognitive functions.
• The more we know about how a persons cognitive
  ability has changed, the more we will know how to
  help.

26
5 Phases of Cognitive Processing

• 1. Sensory Phase Receive information from the
  environment through the five senses.
• 2. Comprehension/Perception Phase Brain
  recognizes and understands information received
  from the senses.
• 3. Executive Phase Information organized and
  manipulated to decide on a desired response.
• 4. Expressive Phase Brain tells body what to do.
• 5. Motor Phase Body physically responds.

27
A Bathing Illustration

• Sensory phase - person has to be able to see the
  washcloth and hear the instructions.
• Comprehension/ perception phase - person has to
  be able to recognize the words and know what they
  mean.
• Executive phase - person has to be able to use
  functions such as memory and logic.

28
A Bathing Illustration (continued)

• Expressive phase - persons brain has to be able
  to tell them how to take the washcloth, and how
  to coordinate all the appropriate movements
  involved in the task.
• Motor phase - persons body has to be able to
  respond to the brains instructions. Arthritis,
  muscle weakness or pain can make this very
  difficult.

29
Sensory PhaseExplanations Examples

• Persons ability to feel through her skin may be
  affected. A soft touch on her arm may feel like
  being hit or may send pins and needles up her
  arm.
• The feel of the temperature of a room or of water
  may change minute by minute for a person with
  cognitive impairment.

30
Comprehension/Perception Explanations Examples

• This person may read notes and signs well, but
  may not understand what he is reading.
• She may respond more quickly when approached from
  one side versus the other.
• A person with cognitive impairment rarely
  comprehends the environment the same way the
  caregiver does. Objects may be closer or farther
  away than they realize.

31
Executive PhaseExplanations Examples

• Executive functions most complex usually most
  impaired.
• Shifting from one activity to another is
  difficult Allot enough time for shifting
  gears.
• Misjudging amount of time that has passed is
  common.
• Person does not know when she makes a mistake.
  Discreetly assist Dont call attention to
  mistake.

32
Expressive PhaseExplanations Examples

• Word finding difficulty is common with
  cognitive impairment.
• Using song or rhythm when walking or performing a
  task can be helpful.
• A person with cognitive impairment may be able to
  do tasks more easily if she doesnt think about
  it. Distraction can be useful.

33
Motor PhaseExplanations Examples

• Pain is a very common cause of distressing
  behavior in moderate to severe impairment.
• Many people with cognitive impairment dont
  exercise enough and may have difficulty moving
  body parts.
• Distances may be too far for a person to easily
  navigate, and they become tired and confused
  before being asked to perform a task.

34
Cognition-Sensory

• 1. Can this person receive information from the
  environment through the five senses?
•  How well does he SEE and HEAR me?
• If he needs glasses, is he using them?
• Are the glasses clean?
• If he needs a hearing aid, is he using it?
• Does the hearing aid need adjusting?
•  How does she FEEL or experience my touch?

35
Cognition-Sensory

• Does she know I am touching a particular body
  part?
• Does the touch feel as soft or as hard as I
  think?
• Does the cloth, water, or surface feel
  comfortable?
• Does the temperature seem to feel the same to her
  as it does to me?
• Does she feel like the temperature is stable and
  not changing from one minute to the next?

36
Perception Comprehension

• Can this person recognize and understand the
  information received through the senses?
•  How well does he UNDERSTAND what he sees and
  hears?
• Does he know what an object is when he sees it?
• Does he recognize various colors, pictures,
  gestures?
• Does he read and understand what he reads?

37
Perception Comprehension

• Does he recognize what a word means when he hears
  it?
•  How well does she recognize WHERE an object,
  sound, or touch is?
• Does she notice objects in all parts of her
  visual field?
• Does she notice touch on all parts of her body?
• Does she see how far away an object is from her
  and other objects?

38
Executive

• How well does he recognize the improtance of the
  information and use it to make decisions, solve
  problems, and organize plans?
• Does he pay attention to a task, to an object, or
  to what I am saying?
• Does he figure out what I mean, even if he cant
  hear or understand me very well?
• Does he remember what he sees, hears, or figures
  out?

39
Executive

• Does he easily shift from one activity to
  another?
• Does he easily get started on a task or a
  response?
• Does he know how much time has passed?
• Does he recognize his own abilities, needs,
  desires, and mistakes?
• Does he easily control his impulsive responses by
  censoring or delaying what he says or does?
• Does he easily control his expression of emotions?

40
Expressive

• How well does her brain COORDINATE her own body
  parts to perform a task or to express a thought?
• Does she easily produce words when speaking?
• Does she easily produce words when writing?
• Does she speak words as easily as she sings?
• Does she do tasks as easily upon request as she
  does spontaneously, or automatically, when she
  doesnt think about the task or how to do it?

41
Expressive

• Does she easily move a body part spontaneously or
  upon request?
• Does she easily move a body part upon request?
• Does she easily spontaneously manipulate or move
  an object when doing a task such as eating and
  dressing?
• Does she easily upon request manipulate or move
  an object when doing a task such as eating and
  dressing?

42
Motor

• How HEALTHY and strong is his body?
• Is there full strength in every part of his body?
• Does each body part move easily?
• Does each body part have enough range of motion?
• Does he walk long distances easily?
• Is each body part free of pain when it moves?
• Is each body part free of pain when not moving?

43
ENVIRONMENT

• Assess the environment to see how it is making
  things easier or harder for a person to function
  and feel comfortable.
• To assess, SEE HANDOUT OF CIAP YES/NO RESPONSE
  SHEET for Assessment of the Environment
• A six-point response sheet with instructions is
  also available.

44
CAREGIVER INTERACTIONS

• Assess caregiver interactions to see how they are
  making things easier or harder for a person to
  function and feel comfortable.
• To assess, SEE HANDOUT OF CIAP FOUR-POINT
  RESPONSE SHEET for Assessment of Caregiver
  interactions

45
TASK DAILY ROUTINES

• Task Steps Are they too many too complex too
  unfamiliar too fast, too abstract?
• Modification of Task Steps Are they simplified,
  adapted when person changes, ordered
  appropriately, conducted in a proper location?

46
Task Daily Routines

• Modification of Task Objects Are they familiar ,
  appealing, and adapted when person changes?
• Timing Is the schedule of the day similar to
  this persons past and preferences? Does it meet
  this persons needs/preferences? Is it
  consistent? Is it paced comfortably?

47

• Consistency Is the task done at the same time,
  place, with the same caregiver, and in the same
  way every day?
• Task Goals Are this persons and this
  caregivers goals both met? Are this persons
  goals identified? Are expectations appropriate?
  Is doing only part of the task or modifying the
  task sufficient? Is enough time allowed?

48
Cognitive Impairment Assessment Protocol (CIAP)

• 4-part assessment instrument
• Helps lay and professional caregivers identify
  cognitive abilities and where a person needs
  additional intervention
• 4 parts assess cognition, environment, caregiver
  interactions, and tasks.
• 2 response formats (Yes/No and Four- or Six-Point
  scale) for each of the four parts.

49
Cognitive Impairment Intervention Protocol (CIIP)

• 4-part set of intervention strategies
• Helps caregivers improve support for person by
  suggesting specific interventions.
• 4 parts address cognition, environment, caregiver
  interactions, and tasks.
• List of practical concrete intervention options
  for each question listed in the CIAP.

50
Preventing Agitation

• Discover reason for agitation now for this person
  by assessing person, environment, caregiver
  interactions, and task and schedule. Accommodate
  cognitive needs.
• Look for physical emotional pain and discomfort
  (e.g., sensitivity to touch, chronic pain,
  anxiety, feeling at sea)

51
Be Realistic

• Evaluate risk to self, other residents,
  caregiver, visitors, property, etc.
• Be person-centered encourage movement, freedom
  of movement, access to other people and places.
• Too few staff and undertrained staff result in
  agitation among residents.
• Challenging environments trigger agitation.