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For the slides from this
presentation, visit:
www.teepasnow.com/presentations
Slides will be available for 2 weeks
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educational purposes only. This material may not be copied, sold or
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Teepa Snow and Positive Approach® to Care
Any redistribution or duplication, in whole or in part, is strictly prohibited, without the expressed written consent of Teepa Snow and
Positive Approach, LLC
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Best Practices in
Dementia Care
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Quiz Time!
- What do we know?
- What do we think we know?
- What don’t we know?
- What surprised us most?
- What can we do about it?
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Question #1:
Senile Dementia and Alzheimers are
two different words for the same
condition
a.True
b.False
c.I don’t know
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Dementia Alzheimers Memory Problems
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About 90-95% of the general public think
Dementia Alzheimers Memory Problems
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Better Answer:
Dementia Alzheimers Memory Problems
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Best Answer:
Dementia Alzheimers Memory Problems
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Having dementia
does not equal and is more
than just Alzheimers
does not equal and is more
than just memory problems
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Why is Dementia Different as
the Journey Happens?
- It typically takes a long time
- The person will change, and change, and change,
and change….
- The person is being changed, even as they remain
- Others are evolving and changing over the journey
- How it was is not how it is
- Change can happen day to day, minute to minute,
or may not happen for months… and then it
does!
- What should happen/work, doesn’t always
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Question #2:
About how many types, forms, or causes of dementia are there?
a. 2-3
b. 5-10
c. 20-40
d. Over 100
e. I have no idea
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Possible Value of Animal
Fluency Screening:
- Name as many animals as you can
- Give one minute: don’t highlight time limit
- Count each animal named: not repeats
- Use it to establish a baseline
-Normal/Not Normal old guidelines: 12
normal for > 65 and 18 for < 65
-New: Compare you to you over time - quick
notice of a change
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Question #3:What is one of the most common losses of ability
someone will experience when they get any form
of dementia?
a. Loss of ability to hear sound
b. Loss of ability to recognize familiar voices as
familiar
c. Inability to know another person is upset by
noticing their tone of voice
d. Loss of formal language skills – vocabulary,
comprehension, speech production
e. I have no idea
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Understanding Language – Big Change
Changes in
Language Skills• Vocabulary
• Comprehension
• Speech Production
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Hearing Sound – Not Changed
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Question #4:
What is the how much of your brain
tissue will you typically lose by the end
of the condition?
a. About 95%
b.About 65%
c. About 50%
d.About 30%
e. I don’t know
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For all that is lost,
some remains!
• 1/3 of brain remains
• Know what still works
• Know how we support in areas of loss
used with permission from Alzheimers:The Broken Brain, 1999
University of Alabama
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Normal
Brain
Alzheimers Brain
Used with permission from Alzheimers:The Broken Brain, 1999 University of Alabama
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Sensory Strip
Motor Strip
White Matter
Connections:
Big Changes
Formal Speech
and Language
Center:
Huge Changes
Automatic
Speech
Rhythm – Music
Expletives:
Preserved
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Executive
Control
Center
Changes:
• Being logical,
reasonable, rational
• Controlling impulses
• Making decisions
• Initiating-
sequencing-
terminating-
transitioning
• Being self-aware
• Seeing other
perspectives
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Vision Center – Big Changes
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HippocampusBig Changes:
• Learn and remember
• Way-finding• Passage of
time
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Executive
Control
Center:
Emotions
Behavior
Judgment
Reasoning
Wiring –
connecting,
bringing data in
and sending
data out
Storage units
- data
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Question #5:
What is the first change with dementia?
a. The brain begins to shrink
b. The chemistry of the brain changes
c. The person’s personality changes
d. The person’s behavior changes
e. I don’t know
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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)
Alzheimers Disease Progression vs. Normal
Brains
G. Small, UCLA School of Medicine.
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Four Truths About Dementia:
1. At least 2 parts of the brain are dying -
one related to memory and another part
2. It is chronic – can’t be fixed
3. It is progressive – it gets worse
4. It is terminal – it will kill, eventually
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Question #6:
What is it called when you have dementia
and continue to think you are as skilled as
you were before, even though you are
making mistakes now?
a. Anosognosia
b. Denial
c. Hippocampal damage
d. Confabulation
e. I really don’t know
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Positron Emission Tomography (PET)
Alzheimers Disease Progression vs. Normal
Brains
G. Small, UCLA School of Medicine
Primitive
BrainPrimitive
Brain
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Question #7:
About what percentage of people under
age 70 have some form or degree of
active symptoms of dementia?
a. 1% - it is very rare
b. About 5-10%
c. About 25%
d. I don’t know
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Question #8:
What is an effective treatment for
dementia?
a. How we connect and respond to people
who are living with the condition
b. There are pills people can take to slow
the disease down
c. There is nothing that really helps
d. Exercise and eating right keeps it from
getting worse
e. I don’t know
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How Can We Become Better
Care Partners?-Let go of the past to be in the moment
-Go with their flow
-Be willing to try something new
-Be willing to learn something different
-Be willing to see it through another’s eyes
-Be willing to fail and try again
-Be a detective, not a judge
-Match your help to their remaining abilities
-Look, listen, offer, think
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Example of Challenges:No financial or health care POA
Losing important things
Getting lost
Unsafe task performance
Repeated calls and contacts
Refusing
‘Bad mouthing’ you to others
Making up stories
Resisting care
Swearing and cursing
Making 911 calls
Mixing day and night
Shadowing
Eloping or wandering
No solid sleep time
Getting ‘into’ things
Threatening caregivers
Undressing
Being rude
Feeling ‘sick’
Striking out at others
Falls and injuries
Infections and pneumonias
Seeing things and people
Not eating or drinking
Contractures and immobility
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
So What Can You Do When
Situations Are Challenging?
Six Pieces of the Puzzle:1. Personal history and preferences
2. Level and type of dementia
3. Other health conditions and sensory losses
4. Environmental conditions
5. Care partner approach and behaviors
6. The day and how it all fits together
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Environmental SupportPeopleTime Use
Health & Wellness &
FitnessThe Person
Brain Changes
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The Environment:Physical, Sensory,
SocialPlace, Space,
Objects, SurfacesFour Fs
• Friendly• Functional• Familiar• Forgiving
People - US:Care Partner & Others
AroundHistory - background
Awareness & Knowledge
SkillsCompetence
Relationship(s)Agenda(s)
Time:Awareness of time –where in life, time of day, passage of time
Four Categories –balanced
Work – productive –valued
Leisure – Fun – playfulWellness & Self Care
Restorative – rest/calming
Brain Changes:Dementia – type or
typesChanges in abilityRetained skills &
abilitiesGEM LevelVariability?Self-awareness
The Person:Who I have been & who I am now!
Life story – historyPersonality traitsPreferences –
likes/dislikes ValuesJoys & Traumas
Health & Wellness:Health Conditions& Physical Fitness
*Fuel & fluids*Meds & supplementsEmotions & Psychological
Conditions
Sensory Systems FunctionHealth Beliefs of NoteRecent Changes –
Acute Illnesses
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The First Piece of the Puzzle:
The person and who they have been:
personality, preferences and history
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Knowing the Person:- History
- Values and beliefs
- Habits and routines
- Personality and stress behaviors
- Work and family history
- Leisure and spiritual history
- ‘Hot buttons’ and comforts
Some ‘stuff’ we think that people do on purpose is really just who they are
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The Second Piece of the
Puzzle:
The Level and Type of Dementia
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GEMS®:
- Based on Allen Cognitive Levels
-Cognitive Disability Theory – OT based
- Creates a common language and approach to providing:
-Environmental support
-Caregiver support and cueing strategies
-Setting expectations regarding retained abilities and lost skills
-Promotes graded task modification for success
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Why Use The GEMS®?- Until we begin to the see the beauty and
value in the person has at this point, we will never care for them as we should
- Gems are precious and unique, provide a common language and characteristics
- Use familiar concepts to talk about a difficult subject
- Focus on what is valued
- Allow to us to get beyond the words ‘dementia’ and ‘Alzheimers disease’
- Open the door to talking about changes
- Allow us to speak in a ‘code’ to protect dignity
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The GEMS® Progression of
Dementia: Seeing What
Remains
Sapphires – True Blue – Slower but Fine
Diamonds – Repeats and Routines, Cutting
Emeralds – Going – Time Travel – Where?
Ambers – In the Moment - Sensations
Rubies – Stop and Go – Big Movements
Pearls – Hidden in a Shell - Immobile
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Sapphires- Us on a good day
- Clear and true to ourselves
- May feel ‘blue’ over changes
- Some are ‘stars’ and some are not
- Can typically choose our behavior
- May have other health issues that affect behaviors
- Recognize life experiences, achievements and values
- Can follow written info and hold onto it
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Diamonds-Sharp, hard, rigid, inflexible, can cut
-Many facets, still often clear, can really shine
-Are usually either Joiners or Loners
-Can complete personal care in familiar place
-Usually can follow simple prompted schedules
-Misplaces things and can’t find them
-Resents takeover or bossiness
-Notices other people’s misbehavior and mistakes
-Vary in lack of self-awareness
-Use old routines and habits
-Control important roles and territories, use refusals
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Emeralds:
-Changing color
-Not as clear or sharp, more vague
-On the go, need to ‘do’
-Flaws may be hidden
-Time traveling is common
-Are usually Doers or Supervisors
-Do what is seen, but miss what is not seen
-Must be in control, but not able to do it correctly
-Do tasks over and over, or not at all
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Ambers:-Amber Alert- Caution!
-Caught in a moment
-All about sensation and sensory tolerance, easily
over or under-stimulated
-May be private and quiet or public and noisy
-No safety awareness
-Ego-centric
-Lots of touching, handling, tasting, mouthing,
manipulating
-Explorers, get into things, invade space of others
-Do what they like and avoid what they do not like
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Rubies:-Hidden depths
-Major loss of fine motor finger and mouth skills,
but can do gross motor skills like walking,
rolling, rocking
-Comprehension and speech halted
-Wake-sleep patterns very disturbed
-Balance, coordination, and movement losses
-Eating and drinking patterns may change
-Tends toward movement unless asleep
-Follows gross demonstration and big gestures for
actions
-Limited visual awareness
-Major sensory changes
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Pearls:-Hidden in a shell: still, quiet, easily lost
-Beautiful and layered
-Spends much time asleep or unaware
-Unable to move, bed or chair bound, frequently fall forward or to side
-May cry out or mumble often, increases vocalizations with distress
-Can be difficult to calm, hard to connect
-Knows familiar from unfamiliar
-Primitive reflexes
-The end of the journey is near, multiple systems are failing
-Connections between the physical and sensory world are less strong but we are often the bridge
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The Third Piece of the Puzzle:
Other medical conditions
Psychological or psychiatric conditions
Sensory status: vision, hearing, sense of
touch, balance, smell, taste
Medications
Treatments
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The Fourth Piece of the Puzzle:
The Environment:
Physical
Sensory
Social
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The Fifth Piece of the Puzzle:
People and Their Behaviors
-Care Partners
-Family Members
-Friends
-You!
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Getting The Person to Do
Something:
Form a relationship first,
then work on task attempt!
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Positive Physical
Approach™:
-Pause at edge of public space (6 feet)
-Gesture and greet by name
-Offer your hand and make eye contact
-Approach slowly within visual range
-Shake hands and then maintain Hand-under-Hand®
-Move to the side
-Get to eye level and respect intimate space
-Wait for acknowledgement
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Hand-under-Hand® Assistance:
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A Positive Approach(To the Tune of Amazing Grace)
Come from the front
Go slow
Get to the side,
Get low
Offer your hand
Call out the name, then wait…
If you will try, then you will see
How different life can be.
For those you’re caring for!
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Then, Connect Emotionally:
- Make a connection
-Offer your name: “I’m (name) and you are…?”
-Offer a shared background: “I’m from (place)
and you’re from…?”
-Offer a positive personal comment: “You look
great in that!” or “I love that color on you.”
-Make a positive observation: “What beautiful
flowers!” or “Great photo!”
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Connecting Emotionally:- Identify a common interest
-Say something nice about the person or their place
-Share something about yourself and encourage the person to share back
-Follow their lead and listen actively
-Use some of their words back to keep the flow going
-Remember it’s often the ‘first time’ for them, so expect repeats
-Use the phrase “Tell me about…”
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Supportive Communication
• Repeat a few of their words with a question at
the end
• Avoid confrontational questions
• Use just a few words
• Go slow
• Use examples
• Fill in the blanks
• Listen, then offer empathy:
“Sounds like…” or “Seems like…” or “Looks
like…”
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Then, Get it Going!
- Give Simple and short information
- Offer concrete choices
- Ask for help
- Ask the person just to try
- Break the task down to single steps at a time
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The Sixth Piece of the Puzzle:
The Day and How it All Fits Together:
Daily routines and programming
Filling the day with valued engagement
GEMS® state programming
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Examples of Meaningful
Activities:
• Productive Activities: sense of value and
purpose
• Leisure Activities: having fun and
interacting
• Self-Care and Wellness: personal care of
body and brain
• Restorative Activities: re-energize and
restore spirit
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Using Music-Two Categories:
Quiet and Calm:
•Soothing rhythm
•Slow speed
•Deep pitch
•Quiet themes
•Personal
background
Stimulate and Excite:
•Upbeat rhythms
•Faster speeds
•Higher pitches
•Fun/play themes
•Personal
background
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Know Your Residents:
Favorite artists
Favorite types of
music
Favorite songs
Meaningful Songs
•Comfort songs
•Fun songs
•Life story songs
History with music,
dance,
performances
Dislikes
Volume preferences
Times of high action
Times of relaxation
Background sounds
preferences
Seating/space
preferences
Signals of enjoyment
and distress
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Now that you are aware
of the Six Pieces of the
Puzzle, reframe
‘problem behaviors’
as ‘unmet needs’
Get interested, excited,
and be challenged!
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Top Five Unmet Needs:
Hydration and Nourishment
Wake-sleep and active-rest cycles
Elimination: all forms
Find Comfort: 4Fs 4Ss
Pain-free:
• Physical – body
• Emotional – relationships
• Spiritual – belonging/purpose
Angry
Sad
Lonely
Scared
Bored – Lacking
Purpose
Physical Needs: Signals of Emotional
Distress:
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Bonus Question:Which message would you prefer if you had
dementia?
a. You seem incompetent, let me help you
b. I am glad to see you. I could use your help.
c. There is clearly something wrong with you
and I don’t know what to do
d. You are scaring me and I want you out of
here
e. There is clearly something wrong with you
and I am going to call the authorities for
help
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
The content contained in this presentation is strictly for informational purposes. Therefore, if you wish to apply concepts or ideas
contained from this presentation you are taking full responsibility for your actions. Neither the creators, nor the copyright holder
shall in any event be held liable to any party for any direct, indirect, implied, punitive, special, incidental or other consequential
damages arising directly or indirectly from any use of this material, which is provided as is, and without warranties.
Any links are for information purposes only and are not warranted for content, accuracy or any other implied or explicit purpose.
This presentation is copyrighted by Positive Approach to Care and is protected under the US Copyright Act of 1976 and all other
applicable international, federal, state and local laws, with ALL rights reserved. No part of this may be copied, or changed in any
format, sold, or used in any way other than what is outlined within this under any circumstances without express permission from
Positive Approach to Care.
Copyright 2017, All Rights Reserved
Teepa Snow and Positive Approach to Care
DISCLAIMER
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