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Preventing Agitation in LTC Residents with Dementia

Joint Provider Surveyor Training Conference

September 14, 2010

Shelly E. Weaverdyck, PhD

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Today’s Messages• Specific parts of the brain

play role in specific episodes of agitation.

• Brain changes affect person’s cognition: ability to understand and respond.

• Agitation results from impaired cogntion: misinterpretation, feeling “at sea”, and uncertainty.

• Intervene by addressing causes /triggers of agitation..

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Today’s 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

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.4

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.

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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@umich.edu

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Four Factors to Consider

To help a person feel relaxed and comfortable, examine four factors:

• Person

• Environment

• Caregiver interactions

• Task and Daily routines

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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:– Person’s cognitive, emotional, or physical

condition.– What’s happening in the environment around a

person.– Caregiver interaction with a person.– How we time and organize a particular task.

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Focus today is on Cognition:Address the Whole Person

• Assess physical, emotional, spiritual, cognitive • Understanding the person’s 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.

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.

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Causes of Dementia

• The most common cause of dementia is Alzheimer’s Disease.

• Other causes are:– Dementia with Lewy Bodies– Frontotemporal Dementia– Vascular Dementia

(See Caring Sheets #11, 12, 13 on website)

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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

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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.

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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.

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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.)

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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.

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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 can’t 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.

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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.

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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 it’s done.

• Control impulsive responses to thoughts and desires.

• Identify the order of steps for a task.

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When the Frontal Lobe Becomes Damaged, You May:• Have difficulty focusing on a task and

paying attention to what’s 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.

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You May Also:• Need short simple words and sentences.• Refuse a bath because you can’t think of how

to do it.• Leave a shower before you’re done because

you think you’ve been there long enough.• Be unable to stop from striking or grabbing

someone because you can’t control impulses or switch gears quickly.

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Three Types of Dementia

• Alzheimer’s 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)23

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 person’s cognitive abilities and needs

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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 person’s cognitive ability has changed, the more we will know how to help.

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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. 26

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.

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A Bathing Illustration (continued)

• Expressive phase - person’s 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 - person’s body has to be able to respond to the brain’s instructions. Arthritis, muscle weakness or pain can make this very difficult.

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Sensory Phase:Explanations & Examples

• Person’s 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.

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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.

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Executive Phase:Explanations & 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; Don’t call attention to mistake.

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Expressive Phase:Explanations & 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 doesn’t think about it. Distraction can be useful.

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Motor Phase:Explanations & Examples

• Pain is a very common cause of distressing behavior in moderate to severe impairment.

• Many people with cognitive impairment don’t 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.

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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?

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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?

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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?

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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? 37

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 can’t hear or understand me very well?

• Does he remember what he sees, hears, or figures out?

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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?

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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 doesn’t think about the task or how to do it?

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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?

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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?

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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.

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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

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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?

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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 person’s needs/preferences? Is it consistent? Is it paced comfortably?

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• 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 person’s and this caregiver’s goals both met? Are this person’s goals identified? Are expectations appropriate? Is doing only part of the task or modifying the task sufficient? Is enough time allowed?

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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.

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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.

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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”)

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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.51