BO8 208 Yakel - Rehab Summit · 2018. 7. 12. · • To document patientParticipation, Engagement,...

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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”

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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


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


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

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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


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

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Stage 4


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


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

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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”

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Stage 5


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


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


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

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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

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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


Stage 6


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”

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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


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

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Stage 7


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


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”

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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!

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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

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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

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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

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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

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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

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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

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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.

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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!


Memory is what makes us young or old

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Definition

An intervention technique that respects the life and experiences

of an individual; also referred to as “Life Review”

Purpose

Participation

Engagement

Social Interaction


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

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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

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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

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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


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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)


Let’s Practice

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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

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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

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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

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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

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Thank You

Jane Yakel M.S.CCC-SLP

Dementia Intervention

BO8 208 Yakel - Rehab Summit · 2018. 7. 12. · • To document patientParticipation, Engagement,...

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