RUBY MODULE › Ruby_Module.pdf · The Ruby Module Senior Gems® SENIOR GEMS® is based on GEMS™,...

The Ruby Module

Senior Gems®

SENIOR GEMS® is based on GEMS™, techniques, strategies, and overall approach to care which was created and devel-oped by Teepa Snow, Positive Approach, LLC. GEMS and POSITIVE APPROACH are trademarks of Positive Approach, LLC. SENIOR GEMS® is a registered trademark of Senior Helpers. ©2011 SH Franchising, LLC

Mid-Stage to Late Dementia

RUBY MODULE

Why do we use the Gems?

The Senior Gems® are based on the Allen Cognitive Disability Theory. Each gem

represents a stage of dementia from normal aging through late-stage dementia.

We use the gems to help us understand the changes that are taking place and

to know what our clients are still able to do in order to provide the best care

possible.

Dear Learner,

This training guide was designed for you to complete as a self-study

activity. Please do the following in order to ensure successful comple-

tion:

First, read through EVERYTHING. There is a lot of important

information throughout the guide. If you find something that

will be helpful to you and your clients, underline or highlight

that information.

If you have a question, please ask: ________________________

Once you are finished, take the quiz at the end and review

these answers with your supervisor. You will need to answer

eight out of 10 questions correctly to pass.

The packet will be yours to keep, but you must turn the quiz in

to your supervisor.

Due Date: _________________

Taking the time to complete these learning guides show that you care

about your clients and want to provide the best service possible. Thank

you for your hard work and dedication!

Pre-Quiz

Test what you already know about

Rubies!

1. When working with a Ruby, it is

best to tell them quickly what

you want to do before they for-

get.

True or False

2. The best way to get a Ruby’s

attention is to come up from be-

hind and grab their arm.

True or False

3. As a caregiver, you should yell

while talking to your client so

they understand you better.

True or False

If you answered FALSE to all of these

questions, you are well on your way

to working effectively with Rubies.

The Ruby Module

Senior Gems®


What’s Inside?

Introduction p. 1

Objective p. 2

Characteristics of Rubies p. 2

Emerald and Amber Review p. 3

Communicating with Rubies p. 4

Activities p. 5

Transitions p. 5

Music p. 6

Safety p. 7-8

Continence Management p. 9

Eating and Weight Loss p. 10

Health Risks p. 11

What Have You Learned? p. 12

Transitioning to the Next Gem p. 13

Quiz p. 14

Caregivers completing this learning module will be able to

identify characteristics of a Ruby, effective communication

skills, ways to address safety concerns, and health risks

that a client can have at the Ruby stage.

Characteristics of Rubies

On the Gems scale, Ruby represents mid- to late-stage dementia. A ruby was chosen to represent

this stage because of the color red. In the stoplight sequence, red means “stop.” At this stage, fine

motor in the mouth, eyes, fingers, and feet stop. As caregivers, we must also remember to stop or

slow down with our actions when treating clients. Below are some basic characteristics of a Ruby:

Loss in fine motor skills in their mouth, fingers, and soles of their feet

More frequent falls because of the loss of fine motor skills

Weight loss and skin problems due to difficulties eating

Struggle with going from walking to sitting

Vision has become monocular

No longer get into things, but like to carry things

Sleep/wake cycle is destroyed

May seem as though they are “lost in the world”

The Ruby Module

Senior Gems®


Before we get started with Ruby, let’s do a review of Emeralds and Ambers. For each statement be-

low, identify whether or not they are true by circling either TRUE or FALSE. If you have not completed

the Diamond and Emerald Modules, move ahead to page 4.

1. Television may not be appropriate for an Emerald due to their

inability to tell the difference between what is real and what is on TRUE or FALSE

2. Ambers are hypersensitive in the four main sensory spots: lips/

tongue/mouth, palms/fingers, soles of feet, and genetalia. TRUE or FALSE

3. Emeralds are fully aware that they need help and enjoy asking

for help. TRUE or FALSE

4. Due to hypersensitivity in the finger tips, activities should not be

incorporated into an Amber’s day. TRUE or FALSE

5. Ensuring the bathroom is kept warm is one way you can reduce

stress surrounding the bathroom. TRUE or FALSE

6. When working with an Emerald it is important to keep both ac-

tivities and any instructions short and simple. TRUE or FALSE

7. When giving an Amber a bath, you should scrub the person

quickly so they aren’t in the bathtub too long. TRUE or FALSE

8. Ambers overstimulate themselves in the four hyper sensitive ar-

eas to embarrass you. TRUE or FALSE

9. It is up to you to change your behavior to maintain the most

effective communication possible when working with an Amber. TRUE or FALSE

10. Emeralds will often tell a story or ask a question multiple times.

It is best to tell them that they are repeating themselves. TRUE or FALSE

11. When working with an Amber, using visual and verbal cues will

help them better understand what you are asking them to do. TRUE or FALSE

1. True 2. True 3. False 4. False 5. True 6. True 7. False 8. False 9. True 10. False 11. True

The Ruby Module

Senior Gems®


At this stage in dementia, communication can be very difficult—both for them to understand us

and for us to understand them. It is difficult for a Ruby to understand or comprehend what you are

saying to them. They can only understand about every fourth word you are saying. A Ruby is los-

ing fine motor skills in their mouth so their speech will become very difficult to understand; auto-

matic social chitchat is the exception. Due to the right side of the brain being preserved, social

chitchat, rhythm and music will be very easy to understand. At this point in the disease, you will

need to communicate with the office or your supervisor for any important questions or if there are

any problems.

When you are trying to communicate with a Ruby, there are a few important things to remember:

1. Slow down: slow down your words and directions when talking to a Ruby.

2. Speech: be careful not to talk too loudly; Rubies have a comprehension problem, not a hearing

problem. Talking too loudly tends to make them turn away from you and not work with you.

Using rhythm in your speech will also help for better understanding.

3. Use showing & demonstrating: due to the brain not being able to comprehend what you are

saying, you need to show or demonstrate what you want your client to do. Be sure they are

paying attention to you (using Positive, Physical, Approach), be at their side, and show them

what you want them to do.

4. Don’t be confrontational: being at their side, rather than in front of them, will help a Ruby feel

at ease. Since their vision is monocular, standing in front of them may feel confrontational or

as if they are being trapped.

Visual, Verbal, Touch

Using visual, verbal, touch cues will go a long way in communicating with a Ruby. Touching a Ruby

before they can see or hear you can result in them becoming scared or startled. Visual and verbal

cues allow them to see and hear you first and also make a connection. Once that connection is

made, you will be able to touch and complete the task.

Make a friendly visual connection. Then

show the person what you want them to do.

As simply as possible, tell the person what

you want them to do.

If needed, touch the person to establish a physical

connection or help them with the task.

The Ruby Module

Senior Gems®


The loss of some fine motor skills, especially in their fingers, can make doing activities difficult. But it

is still important to make activities part of the day. At this stage, activities should utilize their gross

motor skills; activities that use the whole hand and not just the fingers. Learn about things they used

to like doing and adapt them to fit your Ruby.

Some examples are:

Remember that with Rubies, it is about the activity, not the product. While it can be easy to treat

these types of activities as children’s activities, it is important to treat your client as an adult; make

the activity meaningful for them. As a caregiver, you may become the activity; by listening to you,

watching you, or looking at your hands. Rest time after meals can also be a great activity for Rubies.

Have them sit in a quiet spot, lower the lights, and have some soft music on. Also remember to use a

softer, calmer voice when speaking to your client during this time.

Clapping

Singing along

Wiping

Dancing

Rubbing

Folding

Pushing

Stirring

TransitionsTransitions

It is important to think about transitions when planning activities for your Ruby. This includes getting

up, getting down, stopping, and starting. Transitions are activities themselves and need time so they

should be built into the daily schedule. Make transitions fun for your Ruby and not just “something

that has to get done.” Use your visual, verbal, touch cues to engage your Ruby and get them interest-

ed in the transition. Sing songs or recite poems to help get them interested in the transition or move-

ment. Remember Rubies experience a loss in fine motor skills in their feet and have monocular vision,

so fall risks are a factor. Walk with your Ruby while moving from one place to another and help guide

them when they are getting up or getting down.

The Ruby Module

Senior Gems®


Music is a great tool to use when working with a Ruby. The right side of the brain, which

controls rhythm and music, is preserved throughout the disease. When used appropriately, music can

help shift a person’s mood, manage their stress level, and help stimulate positive interactions.

Making it Work

It can be tricky when picking the best music for your Ruby. The most important thing to remember is to

keep them in mind. People associate music with important events or people in their lives. Be sure to ob-

serve their reactions to a song. If you notice any distress or agitation, this could be evoking a negative

memory so you will want to move onto a new song.

Play or sing songs that will help provoke happy memories for your client; talking to the family will

help you to determine what these songs are. Be aware that this make provoke a lot of emotions.

Pick songs from their young adult years, songs they are familiar with. Since their long-term memory

is still in tact, they are more likely to have the strongest response and the best chance for engage-

ment.

Unfamiliar songs can also be beneficial; they do not carry any emotions or memories. This will be

helpful in managing stress and to promote relaxation.

Use music with an upbeat tempo if you want to promote movement, activity, or dancing. Walking to

the beat of a song can help improve balance. Use music with a slower tempo if you want to prepare

for bed time or promote relaxation.

Look up songs that are appropriate based on your client’s birthday—in the time frame that they

grew up.

You are My Sunshine Twinkle, Twinkle, Little Star

I’ve Been Working on the Railroad Moon River

What are some other songs you can sing?

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The Ruby Module

Senior Gems®


Safety Due to monocular vision and the loss of fine motor skills, safety becomes a major concern for a Ruby.

Rubies have trouble with 1. balance, 2. remembering where they are, and 3. often times forget how to

use household items. As a caregiver there are steps you can take to help ensure your client stays safe.

Use the Senior Gems® Environment Checklist to evaluate the home. (For any major safety changes

that need to be done in the home, please contact your supervisor.)

Environment

Due to monocular vision, a Ruby cannot see their surroundings when walking. They can become easily

confused by a multi-colored rug, thinking it is a step rather than another color. They can easily trip

over anything that may be in their path (bunched rug, electrical cord, steps). Due to loss of fine motor

skills in the feet, falling is a risk factor; they are unable to move their feet to adjust their balance.

Ensure there is a clear pathway for your client to walk in when walking alone. Make sure not to

leave anything in their path (i.e. a laundry basket, groceries).

Check for adequate lighting and be sure the lights are on in any rooms that your client may be

walking into. A dark room can result in falls.

Tuck or hide electrical cords behind furniture.

Ensure all rugs are laying flat and have no bunches. If the rug continually bunches, talk to your su-

pervisor about potentially removing the rug.

Place a baby gate to block any stairways to ensure your client won’t attempt to go up or down

stairs, which could result in falls.

Close/lock the doors to any rooms that would not be appropriate for your client to go into unac-

companied. For example, the laundry room, garage, or bathroom.

Walk with your client whenever possible and use your cues if stepping up or over something is

necessary.

The Ruby Module

Senior Gems®


Safety Household Items

At this stage, individuals forget what common household items are and how to use

them. For example, they may try and use a razor to brush their teeth or a knife to

brush their hair. To them, this is completely normal. Be sure to put any unsafe items out of view. This

includes razors, scissors, knives, and any other items that are sharp and unsafe. You should also un-

plug any appliances, as well as placing the cord out of view, that your client can easily access to en-

sure they are not turning it on or using it inappropriately. This includes microwaves, stoves, or coffee

makers.

Most accidents in

the home occur

during daily activi-

ties such as eating,

bathing, and using

the restroom.

Show What You Know!! Read the scenario below. Identify what is unsafe and how to make it safe.

You arrive at Mrs. Smith’s house to start your daily shift. When you walk in the house, the first thing

you notice is the rug in the front hallway is bunched and not laying flat as well as full access to the

main stairs to go to the second floor. You walk into the living room to greet Mrs. Smith and you notice

a laundry basket sitting in the middle of the floor. The caregiver who was there before you mentions

that it is time to take Mrs. Smith to eat her dinner. While walking Mrs. Smith to the kitchen, you no-

tice the electrical cord to the hallway lamp in the pathway as well as a steak knife sitting out on the

kitchen counter.

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The Ruby Module

Senior Gems®


Continence ManagementContinence Management At this stage in dementia, it is quite common for people to lose control of their bladder, their bowels, or

both. While incontinence is not an inevitable symptom of dementia, there are quite a few reasons why a per-

son may experience incontinence. Treatable medical conditions such as urinary tract infections and constipa-

tion can cause incontinence as well as side effects of medication. If this is a new behavior, call your supervisor

to discuss the next steps in determining if this is due to another medical condition or the progression of de-

mentia.

Due to the progression of the disease, incontinence is quite often a result of not remembering where the

bathroom is and not being able to recognize the need to use the bathroom. Since Rubies will not be able to

verbally communicate their need to use the bathroom or don’t know they need to use the bathroom, it is im-

portant to recognize the nonverbal cues:

Tugging on clothing

Facial expressions

Sudden silence or hiding behind furniture

Be sure to look out for these nonverbal cues and escort your Ruby to the bathroom if you notice any of these

behaviors.

What can we do to help manage our Ruby’s continence and provide a comfortable environment?

Determine the person’s daily routine— determine when the person is going on their own. This may re-

sult in some accidents, but it will help you get a sense of their toileting pattern and help set a schedule.

Set a toileting schedule—once you have determined their pattern, make a schedule and stick to it. When

planning activities into your day, be sure to include transition time to the bathroom (page 5) as well as

toileting based on your client’s routine.

Clear a path—be sure the path is clear to the bathroom. It is unlikely that your Ruby will be traveling to

the bathroom alone, but a clear path is still needed to ensure your client’s safety as well as yours when

escorting them to the bathroom.

Be supportive—if an accident does occur, do not scold the person. They are unaware that an accident

has occurred. Remember to use your cues when cleaning up your Ruby.

The Ruby Module

Senior Gems®


Weight loss is a common occurrence as the disease progresses, due to a loss in appetite

as well as the loss of fine motor skills in the mouth. Your Ruby struggles with chewing,

which can result in sucking on the item or spitting it back out; they aren’t sure what to

do with the food in their mouth. Swallowing is also an issue, which can result in choking.

As caregivers, it is important to ensure that we are adapting the eating process to meet our client’s needs.

Make sure that you are serving your Ruby smaller-sized bites. The loss of fine motor skills reduces their

ability to chew. You may need to cut out the foods that are generally harder to chew and choose softer

foods that are easier to chew.

Your Ruby can either swallow a bite of food or a drink of liquid, but typically cannot do both at the same

time and could choke. For example, taking a drink of water while there is food in their mouth to “wash it

down” or soup with chunks in it can become a choking hazard.

Sitting down for a meal may not be an option anymore and they may be more interested in “grazing.” If

this is the case, you will have to be flexible with your daily schedule and make sure to provide food and

liquids throughout the day.

Since a Ruby generally won’t be able to tell you that they are hungry or thirsty, you need to watch for

signs or signals in their behavior. This is especially important if your client is less interested in sitting down

for meals and is grazing.

The sense of thirst diminishes at this stage and your client will not realize that they are thirsty. It is your

job to make sure they are drinking plenty of fluids throughout the day to help prevent dehydration.

Providing a balanced diet will help prevent weight loss and help your Ruby maintain a healthy immune

system.

While this job can be rewarding, it can also be stressful. Make

sure you take care of yourself in the process of taking care of

your client. Remember that your supervisor and the team at

Senior Helpers is here to help. Contact your supervisor if you

are feeling stressed or need help in a particular situation.

The Ruby Module

Senior Gems®


Health Risks Health risks become a major concern at this stage in dementia. Not only do illnesses contribute to the health

risks for your Ruby, but immobility, side effects of medication, and lack of proper nutrition as well. Be ob-

servant of your client and keep an eye out for any rashes, sores, or scrapes.

Get Your Ruby Moving!

Take time each day to get your client up, moving,

and active! Remaining in the same position for too

long, whether in a bed or chair, can result in the de-

velopment of sores. These sores can be very painful

and can become easily infected. Getting your Ruby

up and moving can also help prevent blood clots and

infections.

Skin Care

At this point, your client’s skin has become thin and

can easily tear or bruise. Use Hand Under Hand

when attempting to move your client to help pre-

vent bruising and tearing. If helping your client with

the bathing process, use mild soap and blot their

skin dry. This is a great opportunity to check for any

rashes or sores.

Rubies can be prone to infections due to their lack of movement and, in some cases, their poor

nutrition and eating. Here are some tips and ideas to help lessen the occurrence of infections and

ways to recognize if your client is in pain or has an illness.

Keep teeth and mouth clean—a clean mouth and teeth will help prevent the build-up of bacteria that can

lead to pneumonia. If possible, brush your client’s teeth after every meal. But as with any activity that in-

volves one of the four sensitive areas, be cautious and understand that brushing their teeth may not hap-

pen.

Call the office if you notice any cuts, scrapes, or bruises on your client that could potentially cause infec-

tions for documentation. Since Rubies’ immune systems are lower and they are more prone to infections,

it is important to contact your supervisor to help prevent any infections.

Keeping your Ruby active and moving can help lessen their chances of getting an infection.

Nonverbal signs are one way of telling if your client may have an infection. If you notice any change in be-

havior or facial expressions (wincing), this may be your client’s way of letting you know that something is

not right.

Look out for any physical signs of an infection. This includes pale skin, vomiting, feverish skin, and swell-

ing. If you notice any of these signs, contact your supervisor.

Infection Prevention

The Ruby Module

Senior Gems®


Read the following scenario and pick the best way to handle the situation.

Mrs. Jones has been sitting in her chair for quite some time and you decide it is time for her to get up

and move around a little to keep her active. Pick the best answer(s) for each of the steps in getting Mrs.

Jones up and moving.

1. Mrs. Jones has a “walking loop” in the house. Before approaching Mrs. Jones, should you double-

check the “walking loop” to make sure there is no clutter? _____________

2. What is the best way to approach Mrs. Jones?

A. Come up from behind Mrs. Jones and lift her out of the chair.

B. Slowly approach Mrs. Jones using the technique of Positive, Physical Approach.

C. Run up to Mrs. Jones quickly before she falls asleep in her chair.

3. After you have approached Mrs. Jones, what is the next step you should take?

A. Grab Mrs. Jones by the arm and pull her up out of her chair.

B. Use Visual, Verbal, Touch to show and explain to Mrs. Jones what you are going to be doing.

C. Use hand under hand to get down to Mrs. Jones’ level to explain what you are going to do.

4. Mrs. Jones understands that you want her get out of her chair. How should you proceed?

A. Assist Mrs. Jones out of her chair, continuing to use hand under hand, making sure not to pull

on Mrs. Jones due to her sensitive/brittle skin.

B. Walk away and let her get up by herself.

C. Move in front of her and grab both of her hands and pull her out of her chair.

5. Once Mrs. Jones is up, you begin walking the “loop”. However, Mrs. Jones isn’t walking. How should

you proceed?

A. Yell at her and tell her to get a move on, you don’t have all day to be doing this.

B. Stand behind her and push her forcing her to move.

C. Continue using hand under hand and start singing her favorite song to get her interested and

more engaged.

The Ruby Module

Senior Gems®


The nature of dementia is that it is progressive. It is possible that you will see your client

moving from one Gem level to the next. If you think your client has transitioned, it is im-

portant to contact the Senior Helpers office. This may indicate that it is time for a reas-

sessment and adjustment to the service plan or that it is time for your client to visit the

doctor. If you start noticing any of these characteristics, your client may be transitioning

from Ruby to Pearl:

Hardly moving

Having trouble swallowing

Unaware of the world around them

Use your best judgment; if you think something is going on, it probably is. Not only could it be a transi-

tion to the next Gem level, it could be some other treatable problem.

The Ruby Module

Senior Gems®


Quiz

The Ruby Module: Late Dementia

Employee Name (Please Print):

_______________________________

Date: __________________________

I understand the information

presented in this guide.

I have completed this guide

and answered at least eight

questions correctly.

Employee Signature:

_______________________________

Supervisor Signature:

_______________________________

Directions: Circle the best answer choice, and then check your answers with

your supervisor.

1. The best way to communicate with a Ruby is by showing and demon-

strating what you want them to do.

True or False

2. When you are transitioning from one activity to the next, you should

rush your client to make sure you stick to the schedule.

True or False

3. Why are Rubies at a higher risk for falls?

A. They have lost fine motor skills and have monocular vision.

B. They are clumsy.

C. They aren’t paying attention to what they’re doing.

4. A Ruby will be able to tell you when they need to use the bathroom or

be able to go on their own.

True or False

5. The right side of the brain is preserved, making music a great tool to

use when working with a Ruby.

True or False

6. As a caregiver, you may become the activity for your client by them

listening to you or watching you.

True or False

7. At this stage, your client doesn’t realize they are thirsty. You should

make sure they are drinking plenty of fluids throughout the day.

True or False

8. No matter what, it is inevitable that your Ruby will get an infection and

there is no way of preventing them.

True or False

9. A Ruby will know not to touch a knife on the counter, so you don’t

need to worry about them if you run to the bathroom.

True or False

10. If you suspect that your client is transitioning from a Ruby to a Pearl,

you should:

A. Tell the client there’s something wrong with them.

B. Call the Senior Helpers office and let them know what you are

noticing.

C. Do nothing, it’s going to get worse anyway.

RUBY MODULE › Ruby_Module.pdf · The Ruby Module Senior Gems® SENIOR GEMS® is based on GEMS™,...

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