Communicating with the Cognitively Impaired Alzheimer's and Dementias

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@allceus.com Counselortoolbox you I'd like to welcome everybody to today's presentation on communicating with the cognitively impaired. I am Dr. Donnelly Snipes. Today we're going to define cognitive impairment and explore symptoms of cognitive impairment in Alzheimer's and other dementias, as well as fetal alcohol spectrum disorders. FASDs are a little bit different than dementias, but it's important to recognize that there is a significant level of cognitive impairment, especially in terms of communication abilities with people on the FASD spectrum. We'll review APA treatment guidelines for counselors working with persons with Alzheimer's, identify methods for effective communication and how to handle difficult behaviors, and finally identify specific issues and interventions for a person with a fetal alcohol spectrum disorder. The symptoms of cognitive impairment pretty obvious for most of us, but we want to look at what's going on. The development of multiple cognitive deficits manifested by both memory impairment and or aphasia, which is a language disturbance apraxia, which is the inability to carry out motor activities despite intact motor function agnostia, which is failure to recognize or identify objects despite intact sensory function or disturbance in executive functioning such as planning, organizing, sequencing and abstracting. In dementia, you'll probably see impaired ability to learn new information, impaired ability to recall information, disturbance in executive functioning. They have a lot of difficulty planning and organizing. And agnostic is also quite frequent. They and it may not be multisensory. It could be one sense they could see something that they knew before. My mom had this right before she passed, there was a bird flying out the window and we'd always gone birding together. And I pointed it out. I was like, oh, that was just. That was a huge Hawk. And she looked at me and she said, hawk. That's a word I just learned the other day. Hawk. She was very, she couldn't identify it and she was just very proud of herself or very happy to have learned what it was called. So that would be something that you would look at in terms of agnostia. Other symptoms that you might see in people with cognitive impairment, attention deficits, perception issues, difficulty with insight and judgment. If you have difficulty processing things cognitively, then you're probably going to be more likely to have difficulty making insightful decisions and potentially making decisions that show good judgment, because good judgment means you've got to be able to foresee the consequences of your choices. Problems with organization, orientation to person, place and time. Difficulty with processing speed, problem solving, reasoning, and metacognition. In the course on case management for people with dementia, we went over the difference between normal aging and dementia, and what we see in normal aging versus dementia is a matter of degree. People who are aging normally are going to take a little bit longer to process information. It's going to take a little bit longer to learn. They may be forgetful occasionally. That's just normal aging. If it becomes significantly more intense than what you would consider normal aging, then you want to look toward getting assessed for a diagnosis of dementia. People in normal aging will often start having problems with balance and coordination. Their eyesight goes, their depth perception goes a little bit. They may be on medications that affect their balance and coordination. That's not dementia. That's normal aging. People who have dementia also have problems with balance and coordination that are more pronounced and tend to get worse over time. It is important to know the difference between normal aging and dementia because the earlier we can provide some supportive interventions, the better chance we have to delay the progression of the disease. Causes of Cognitive Impairment Weirnicki Korsakoff Syndrome now, the nice thing about Korsakoff syndrome or Weirnicki Korsakoff Syndrome is that in many cases it's actually relatively reversible if the person gets medical care quickly and, well, if they get medical care quickly for the problem. Vascular dementia can be caused by stroke or anything else that impedes blood flow to the brain. And we're going to talk about some of those things in a minute. Alzheimer's disease, fetal alcohol spectrum disorders, brain injury from a car accident or a football accident or just a bad fall or boxing. We've seen a lot of boxers who end up having a lot of cognitive impairment. Those are all sources of brain injury that can cause swelling in the brain, which may decrease the availability of oxygen in that area of the brain for a period of time, which can lead to later cognitive impairment and hyper or hypoglycemia also have been strongly associated with cognitive impairment. With those things, the acute symptoms are often well controlled once the blood sugar issues are stabilized. However, there is a strong correlation between having type 2 diabetes and the development of dementia later in life, especially if the person has significant, relatively frequent hypo hypoglycemic episodes. And if you've ever been around somebody with diabetes, this is when they can't stand up. They get the shakes really bad. They need to have some orange juice. You know, that would be a severe hypoglycemic episode. When that happens, the brain triggers the HPA axis. Cortisol is released, which can be neurotoxic. And in order to get the body to dump any glucose it has from anywhere, the body's going, hello, I can't function without this glucose. And they hypothesize that that bathing the brain in cortisol because of those repeated hypoglycemic episodes may be a trigger for later life dementia. So it's really important that people with diabetes control their blood sugar. They didn't see the same thing as much in people who had type 2 diabetes, where their blood sugar was really stable and controlled. The AD8 and the Mini Cog are two possible tools that you can use to screen for cognitive impairment. And what a screening does is basically just identify whether this is something that warrants further attention and kind of starts differentiating it from normal aging. Now, there are some false positives with these. You may have somebody who's experiencing normal aging, and they test positive on the screening test. A further assessment would indicate that they don't have a problem. But it's always better to err on the side of caution, if you will. And to answer your question, Nancy, yes, interestingly, and I can't remember the numbers from the class yesterday, but. But depression. People with depression show a higher level of cortisol in their system. And people with depression, I believe, are like 40% more likely to develop dementia than people who don't have depression. And they found that was especially true in the melancholic type of depression. When you're looking at people, especially people who are aging, think about when people start to get older and their friends and family members start dying off and they start to feel a little more isolated, especially after retirement. We see this happen when they are going through a life transition and they don't have the same social interaction that they used to. A lot of people go through a period, at least, of developing depression. Preventing depression, or intervening early so it's not sustained has been hypothesized to be one of nine factors that could be addressed to reduce the cases of dementia by as much as 35%. Okay, so there are multiple tools you can use to screen. Most of us are not neuropsychologists, so we're not going to be the ones doing the full assessment test. But it's important to be aware of if somebody's decompensating patients should be screened for cognitive impairment. If the person, family members, or others express concern about changes in his or her memory or Thinking, especially sudden changes. Now, again, after a trauma, we tend to be a little bit more forgetful. So my grandfather, for example, right after my grandmother passed away, he was really forgetful, and he was having a hard time adjusting to his new normal for the first few months. Well, no, go figure. They'd been married for almost 50 years. There was a lot of stuff that was different. Did that mean he was developing dementia? No. So we want to take into consideration all of the biopsychosocial factors that may be going on, but also not rule it out. Just kind of put it on the back burner to watch. Sometimes if you observe problems or changes in a patient's memory or thinking, and this can be at any age, don't fool yourself to think that dementia only happens to people over the age of 65. It doesn't. There is early onset dementia, which can start in the early 40s. There's also frontotemporal dementia, which is much more common in younger people. And, you know, anybody who's had a stroke, yada yada. So we want to make sure that we don't miss something, because we're just assuming that dementia only happens to people over 65. That being said, if you have a client who was a heavy drinker, then it is important if they decide that they are going to, you know, quit drinking. You know, they're just like, you know what? I don't want to drink anymore, so I'm going to quit. And they start having psychological symptoms, cognitive symptoms, that may be the early warning sign of Wernicke Korsakoff syndrome. And it's a medical emergency. They need to get to the hospital. Alcohol detox, interestingly, is just one of your more nefarious detoxes. But I digress. So you want to watch your patients, whether you're working in substance abuse or anywhere else. If you're working with teenagers, if you're a school counselor and you're working with a football player and you start to see changes in the patient's memory or thinking, that's a great big old warning sign. You know, it doesn't necessarily mean, you know, they didn't necessarily have to have injury on the field where they passed out and, you know, were completely unconscious for any period of time, it can be sustained. Repetitive head injuries. We need to all be on the watch for that. Okay? If the patient is 80 or older, we want to watch for dementia because it is one of those conditions of aging that is not uncommon, especially when people get over the age of 80, if they have Low education. We want to look for a difference between their IQ and their achievement. If we see a significant difference, they may be having trouble processing information. If they have fetal alcohol spectrum disorders, the likelihood that they're having difficulty processing information is really high because people with FASD can talk generally above their own chronological age, but the information that they hear and they receive and they can actually understand is usually far below their chronological age. So they talk a good talk, but they may not understand 60 to 80% of what they're hearing. We need to take that into consideration. A lot of stuff with FASD that we just can't possibly cover in this class. The other issue with education, they found that education is one of those things that is strongly correlated with the development of dementia later in life. My hypothesis is that people with higher education, as they go through life are exposed to fewer stressors. You know, they're able to. They don't have to worry about where their next meal is coming from. They don't have to struggle to keep their house, those sorts of things. So they're exposed to less stress throughout their life. They also have access to better nutrition. They found links between nutrition and cognitive problems. Not great research, but there have been some links drawn. And they have access to better medical care because they can afford to go to the doctor. So if they have something like high blood pressure or diabetes or thyroid issues, that's going to probably get treated sooner than somebody who doesn't have those benefits. Therefore, higher education levels help a person be healthier and less stressed, which can prevent dementia. But if they have a lower education, you know, you might be on the lookout because it could indicate that leading up to now, they've had a really stressful life or haven't had the benefits of all of those things that I just talked about. If they have a history of type 2 diabetes, as we mentioned before, they're at risk. If they've had a stroke, they are at risk. Interestingly, with vascular dementia, somebody can have a stroke and seem to recover, then five, six, seven weeks, maybe two months after the stroke, may start developing dementia. Don't assume that if they have a stroke and they get out of the hospital three days later or whatever, and they seem to be fine, that there was no cognitive insult or brain insult. You want to keep alert for that for several months after somebody has a stroke. If they have depression, look for it. When people are clinically depressed, they have a harder time remembering things. That takes longer to process. It's harder to learn. That's not surprising, but we do want to look to see if the cognitive symptoms are getting worse? Partly because, like I said earlier, we know that there's a strong correlation between, between people having depression, especially late life depression, and the development of dementia if they have trouble managing money or medications, or episodes of confusion or disorientation, which, you know, clinically we call delirium. You want to screen for cognitive impairment. Important aspects of management include educating the patients and families about the illness. What is it? What's the prognosis? Can it be slowed down? What can we do? There are a lot of things that can be done. What are the possible treatments that are available? What are the sources of additional care and support that are available not only to the person with dementia, but also their caregivers? And this includes support groups, respite care, nursing homes, and other long term care facilities. The patients and families also need to know about the need for financial and legal planning due to the patient's eventual incapacity. There are attorneys that specialize in these sorts of issues. You don't want to just go to any generalist. You want to go to attorneys that specialize in elder care law or medical law. Behavior oriented treatments can be helpful at a certain point because they help identify the antecedents and consequences of problem behavior. If a person with cognitive issues, cognitive impairment, is acting out in certain ways that are unhelpful, and it can be, you know, throwing temper tantrums, it can be wandering, it can be, you know, pulling all their clothes out of their closet. Whatever it is, if it's a behavior that's potentially problematic for some reason, then behavior oriented treatments look at what led up to this, what leads up to this, and what are the consequences? What are the benefits to this? What is the person trying to achieve? Generally, we need to remember that behavior has meaning. And a lot of people with cognitive impairments, especially advanced cognitive impairments, may not be able to communicate what their needs are or what's wrong with. Therefore, they try to fix it themselves. They try to figure out a way to make the pain or the discomfort or the sadness go away. We need to look at what's the function of this behavior, what are they trying to achieve? We can reduce the frequency of problematic behaviors by changing the environment to alter the antecedents and consequences. There's a syndrome called sundowning that is not uncommon in people with cognitive impairment and dementia that in which they get progressively agitated as the day goes on. They get overwhelmed, basically. I mean, think about. Well, I hate to draw the parallel, but think about young Children when if they've had a really busy day and it's been just exhausting and lots of stuff stuff, or there's been lots of input, they can be more overwhelmed and crankier, more irritable towards the end of the day. People with cognitive impairment may also have the same problems because they are struggling a lot harder to deal with life on life's terms. And when you are constantly inundating them with input, it can get overwhelming. So we want to look at the antecedents to what's happening and again, we want to alter the consequences. If that person is trying to communicate something, then if we can help them figure out a better way to meet that need and remind them of it when they do that behavior, then eventually we can segue them over to the preferred behavior. Stimulation oriented treatments such as recreational therapy, art therapy, music therapy and pet therapy, along with other formal and informal means of maximizing pleasurable activities for patients is really important. We want to aim for at least one meaningful activity every day. What does the person like to do? And one of the things that can be really helpful is engaging with the person, if you can, before the cognitive impairment becomes severe and identify what it is they like to do and what benefits that served to them, in what way was that made them feel happy or content or empowered or whatever it is. Those are the activities we want to try to help them continue to do or find reasonable replacements for them as they get older or as they progress. One of the things I talked about yesterday was if somebody loves walking their dog at a certain point, their coordination and balance and stuff may be to the, to the degree that they can't walk their dog anymore. So what could they do? If they just love spending time with Fido, then possibly being able to go out in a fenced backyard where Fido can run free and they can spend time and they can still throw the ball, but they're not having to control a leash and their balance at the same time. Emotion oriented treatments include supportive psychotherapy to address issues of loss in the early stages of dementia. Family members need this too, not just the person with cognitive impairments. Once that diagnosis is given, then the family is going to have to adjust and accept the fact that their loved one is putting probably going to decline at some point over the next 20 to 30 years. That's a long time. With adequate early intervention, a lot of people can stay in stage one for quite a while before they really start developing notable signs of cognitive impairment. Reminiscence therapy has some modest research support for Improvement of mood and behavior. Now, one of the things with reminiscence therapy, therapy that's really important, you're not talking with somebody and saying, tell me about what high school was like, because that puts them on the spot. And if they can't remember high school, then they may feel even more agitated and helpless. With reminiscence therapy, you engage the client in activities that might trigger memories and let the memories float to the top. You can get out their jewelry box and let them handle their jewelry and they may tell you when they got a bracelet or a ring, if they like to cook when they were younger, you know, you can cook a meal together and they may start sharing with you during that process that this used to be their kid's favorite meal or whatever it is. But the reminiscence therapy helps bring those positive memories to the forefront. Because a lot of people with cognitive impairment, they can't remember things in the recent past and it's difficult for them to reach out. Picture books are also very helpful. Anything that can bring back that memory. You can also go online and find digitized versions of, you know, like redbook magazine from 1950, if that's when your client was, you know, a 20 something. And so they can see things that will trigger images. I know when I look at magazines or pictures or something from the 80s and they have the big hair and, you know, everybody was dressed like Madonna and yada yada, it brings back memories. So take them back to that period when they were a young adult or a teenager and let them explore it and then let them share with you as things come up. The key here is tolerate, anticipate, and don't agitate. People with cognitive impairment are almost never trying to do something to be contrary. They are inability to to or they are unable to communicate what their needs are and they're trying to communicate to you. They maybe they're bored, maybe they're too hot, maybe they're too cold, and it's sometimes it's a guessing game. And the same behavior can mean something different on different days, which means that the caregivers have to constantly be sort of sleuthing as to what might have triggered this behavior and what they're hoping to get out of it. Anticipating means, you know, obviously being aware. If you know that, you know, maybe you have to take the person to the doctor and that's going to be an ordeal. And bring a kit with you of things that that person might like to do that might help them self soothe. Whether if the person likes to Knit or if they like to do the Rubik's Cube or pet emotional support animal, whatever it is that might help them stay calm. If you're anticipating something that might be stressful for them, and when they're doing a behavior, you know, try not to agitate them. If they're taking all their clothes out of the closet, you don't want to tell them to go away and start putting the clothes back in. They were doing it for a reason. We need to understand what that reason is. Or as soon as you get them back in the closet, they're going to pull them out again and it's going to be this power struggle. So trying to understand what's going on with that person. And sometimes you just got to pick your battles sometimes. And we may get to this in a minute. There was one client who didn't want to sleep on their bed. They wanted to sleep on the floor. And instead of arguing with the client that you have to sleep up in the bed, the caregivers decided to move the mattress to the floor. And the person was willing to sleep on the mattress on the floor, but they didn't want to be up in the bed for some reason. Why will never know. But that was a way of compromising and joining them in their reality. As Marcella says, communication, written, oral and body language signs are really important to evaluate. Some people with dementia are not going to be able to write because they may be too shaky. And that's okay. Not everybody with dementia is shaky, but some people are. Let the client write, draw, or speak to communicate. Whatever way they can get it out, let them get it out. If they need to point to pictures. And at a certain point with certain types of dementia, they may get to the point where they can't speak very clearly and they're not able to swallow very well. So verbalization may be difficult. So they may have to point to things. You can show them pictures of different foods, you know, show them a picture menu and ask them to point to which one they want to eat. Use real objects when possible. If you want to show them something, show them an apple instead of a picture of an apple. That's not practical for every meal, but it can be helpful. Use picture books and posted lists when you need to. Now, obviously this is for people in advanced stages of cognitive decline, but when they get there, posted lists are really helpful to remind them what they need to do when and for some you'll need to use pictures, others you can use words. Storyboards are a way to discuss a behavior or incident. So you can use pictures and even little cartoon things. You just need to make sure they're big enough the person can see them to discuss what happened. And again, since the person may not be able to articulate what's going on, a alternative to this is to use figurines and basically play therapy. Act it out. Have them explain to you what happened so you can understand a little bit more what they're trying to tell you. Use assistive devices when needed. Glasses, hearing aids and large font are really helpful. Have spare reading glasses and hearing assistance as available as possible. People may misplace them. Reading glasses, you can go down to the dollar store and get them for a dollar. Hearing assistance is a little more expensive, but you can get non prescription hearing amplifiers if you will, hearing aids for as little as about $150. If you have a person who habitually loses their hearing aids, that's really important. Interestingly, they found that hearing loss in old age is also associated with the onset of dementia. And it could be because. And that's not true of people who are born deaf or who are deaf from an early age. It's just people who start losing their hearing or when they get older. So the speculation is that as the hearing starts to go, people may feel more isolated and that can contribute to depression. The other theory is that the hearing loss may be an early warning sign of dementia onset. Either way, we need to be aware that hearing is really important. When you try to communicate with them, get their attention first. Make sure they're looking at you. Don't you. Don't stand with a bright window behind you so you're totally illuminated and the glare obscures their vision. Make sure they can see you. Sit down and make direct eye contact. Don't tower over them. Orient them to who you are and why you're there. They may have seen you yesterday, but they may not remember yesterday. They may have seen you an hour ago and may not remember you, and that's okay. So every time you walk in, you know, say hi to them. If they recognize you, great. But make sure that they feel comfortable. Establish rapport before jumping into business and address the person by name. Instead of walking in and going, hi, I'm Dr. So and so and hi Sarah, how are you today? I'm Dr. So and so and I'm here to take your blood pressure, whatever it is. Use simple language and speak slowly and distinctly. It's harder for them to process as we get older. It takes a little bit more time. Ask them questions directly. Don't ask their caregiver, even if their caregiver is there, just like you would when dealing with in other situations, like if you have a client who is under the influence of substances and really not able to respond very well, you're still not going to look to that caregiver and go, well, let's talk about John like he's not in the room. Don't do that. Talk to John. And if the caregiver has to answer, they can. But you want John to know that you want to understand what his situation is. Make eye contact. Turn lights on if it's too dark, but avoid so much light as to cause glare. One of the things that we really want to be aware of, especially for clients who experience sundowning, is light levels. Sundowning is partly because of disrupted circadian rhythms. We, we want to make sure they're not sitting in the dark all day long. They need access to bright light, whether it's from the sun or bright light therapy. But they found that bright light therapy is really effective with people who experience more sundowning. It helps them sleep better at night and be able to tolerate more stuff during the day. Set a positive mood. Sometimes laughter helps, you know, tell a joke or ask, you know, you probably wouldn't want to ask them to tell you a joke, but tell them a joke. Tell them something that might be funny. If you've got an animal with you that is cute, you know, allow them to interact with that animal for a minute, especially if they'll do something silly. Have the client explain what they heard from you. If you tell them something, have them explain it back. So your medicines are going to be changed and you're going to start taking this pill at morning and at night. So what did you understand me to say? And you have to break it down very simply for them. Repeat the destruct the instructions as many times as needed and write them down. If the person is still in those early stages of cognitive decline and they're still living independently, write instructions down. They have those services now that will package people's medication in nice little packets for each dosing time that they have to do it. You can use apps to remind them to take their medication. And those apps can be really annoying if you don't take your medication on time. So it's a good prompt for them. You can also have a daily activity chart in a prominent place in the house so they can remember, you know, they've got to eat breakfast, they've got to take a shower, they've got to do all these different things. They can put a little check mark by it each time they do it. So when their caregiver comes in to check on them that day, they know that everything got done. A lot of people with cognitive impairment will forget to eat and that just exacerbates the problem. Don't give people multi part instructions if they've got cognitive impairment. Ask them one thing at a time. Would you like to come in and sit down? Let them answer. Would you like to have a snack? Let them answer. Break long discussions into several short talks. You don't want to take somebody with cognitive decline and say, all right, we're going to sit here and we're going to talk for 50 minutes because that's a therapy hour. 10 minutes, 10 minutes is really good. Avoid using abstract concepts. Use yes or no or simple answerable questions. So abstract can be things like are you sleepy? The person may not know how to answer that. But if you say, do you want to go to bed? That's a simple yes, no answer. And it gives them an action. Do you want to do this? Instead of saying, are you thirsty? Would you like some tea? If you're offering them food, instead of saying what do you want for lunch? Because that could be overwhelming and they may not be able to come up with the words, ask them, you know, do you want pizza, a hamburger or macaroni and cheese? You see what I like for lunch. But whatever it is, give them two or three options that they can choose from. If you have a cart and they can see the food and they can choose, great. If that would obviously be more in a long term care facility. If you are a home caregiver, just giving them the options as they get further along in their decline, you may need to show them the pictures on the menu when they're trying to get dressed. As cognitive decline gets worse, people will have difficulty choosing clothes, especially choosing clothes that are weather appropriate. Caregivers can take out the inappropriate clothes. So in the summer, take out all the sweaters and the long sleeve stuff that's going to be too hot and leave the shorter sleeve stuff if that's. If they're still having difficulty putting outfits together, you can put them everything together on one hanger so their shirt, their pants or their skirt and their skivvies are all on the same hanger. So you know all that's going to go together. Eliminate distractions when you're talking to people with cognitive decline. Other people, animals and the TV or radio. Now there's the therapy animals that'll Sit nicely on people's lap and not make a fuss and those aren't a big deal. Or you've got the ones like my Brewster who want to play and as soon as you start talking, they're going to bring you the ball. And if you don't play the ball, play ball with them. They're going to start pawing at you and being inappropriate. Those animals probably need to be sequestered for a short period of time. Involve family and friends in your communications. Listen with your eyes, your ears and your heart. Try to figure out what the person's communicating. We know that 80% of communication is nonverbal anyway. We should be able to get a general idea. Then we can ask, is this what you. Is this what you're looking for? Communicate in a place that's comfortable for the person whenever possible, and don't argue over the correct answer if he calls. If somebody calls you their mother and you're actually their therapist, you know, that might not be the time to argue that point. Also remember that that may be their reality and Marcella said it earlier, join them in their reality just like you would with someone who is schizophrenic, for example, because their reality is very real to them and arguing with them doesn't change the fact that of what's going on in their reality. Remember the good old days. Remembering the past is often a soothing and affirming activity. Many people with dementia may not remember what happened five minutes ago, but they can clearly recall their lives five years earlier. Always avoid asking questions that rely on short term memory, such as asking what they had for lunch. And if you have to ask questions about the past, ask general questions like what do you remember about being a kid? You know, that gives them, you know, 10, 15 years to choose from reality. Orientation therapy is a psychosocial approach that employs a formal or informal class that reorients the client by means of continuous stimulation with repetitive orientation to the environment. So they're basically being repetitively reminded of where they are, what the date is, who the people are, personal information in order to help them get oriented to this reality. There may be a use for that. I personally would probably find that very frustrating. Activities such as category sorting and games can be used to stimulate language, increase active engagement in the environment, and decrease purposeless behaviors. People need to have a sense of meaning. So if people are in a facility or at home, maybe they're home by themselves, they're homebound and they feel bored. They don't feel like they have a sense of meaning. Then they may become more agitated and engage in seemingly purposeless behaviors. Remember, behaviors have a purpose. We just need to understand what that purpose is. Spaced retrieval training is an intervention that gives individuals practice at successfully recalling information over progressively longer intervals of time. It's being used to teach new and forgotten information and behaviors to people with dementia, including orienting them to time and place, encouraging them to look at activity calendars and daily schedules, and maybe training a person with a hip fracture and dementia to remember to lock the wheelchair brakes before standing and transferring. This is something you know initially they're going to have the person do it and then right away they're going to say, all right, now what do you, what's the first thing you need to do before you try to stand up? And then, you know, they may back it off and they may get the person back in their wheelchair and talk for two or three minutes and say, okay, what is it you need to do before you can transfer? And then repeat the process to five minutes before they ask again. And when they get to that place where the person can't remember, that's the threshold and they can start there the next time. And they know when they teach somebody something, they can only remember it for six minutes. So then they're going to try to start nudging it up to the seven minutes than eight minutes. SRT encourages recalling information over increasingly longer periods. When retrieval is successful, the interval is increased. The strength of association between concepts and semantic memory depends on how they're activated. We want to ask them, where are you? What do you do when you get up in the morning? Where do you keep your glasses? Or like I said, what do you do before you get out of your wheelchair? Or tell me how to get out of your wheelchair? We need to ask very specific questions and maybe repeat those questions so they get used to what that answer is. When you're working with somebody with fetal alcohol spectrum issues, it's important. And people with advanced dementia in many cases don't expect the person to be reasonable or act their age at a certain point. Especially with Alzheimer's dementia, the person age regresses and they are not going to act the age of a 72 year old or however old they are when you're talking with them. Start asking questions that will get you yes responses first and use short questions just to get them out of being stuck in a no loop. If they're being contrary that day, they're not trying to be contrary, they may not feel well. And a lot of times problem behaviors indicate an underlying issue. We need to understand what that is. It can be poor nutrition, it can be poor sleep, it can be illness, it can be painful. We need to try to figure out what that might be. Be non judgmental and start every interaction, not every day, every interaction with a clean slate. You know, morning may not have been so good, but it's lunchtime now. Let's, let's try again. Be attentive to your nonverbal and para verbal communication because people with cognitive impairment may not understand all the words you're using, especially if they're going through a crisis. If they're really upset, think about when you're really upset. You don't process half of what people are saying. Well, compound that with having difficulty processing anyway, and it's going to be problematic. The person is likely attuned to your appearance and your sound. So if you look calm and you sound calm, then they're less likely to get agitated. If you start getting agitated, then they're going to start getting agitated. If you start getting frustrated, you may be feeling what they're feeling. They may already be frustrated and they just don't know how to communicate it. Be aware that there's a lot of transference and countertransference stuff that can go on, and you want to pay attention to what might be prompting it. Try not to get frustrated that you just dealt with the same type of issue yesterday. It may seem like the same issue, but to the person, it may be a completely unique and unrelated crisis. If they don't remember yesterday, then it's not the same thing because they don't remember dealing with it. It's not that they aren't paying attention. It's that their brain isn't letting them make that connection. They're not able to learn that material right now. Handling troubling behaviors Try to accommodate the behavior, not control the behavior. Here's the example of the person that insisted on sleeping on the floor. Okay. Instead of arguing, put the mattress on the floor. There are worse things in life. Remember that we can change our behavior or the physical environment a whole lot easier than someone with cognitive impairment can change their behavior or their reactions. A lot of times they have regressed to a much more vulnerable state. We want to make sure that they always feel safe and loved and attended to. Changing our own behavior often results in a change in the patient's behavior because they're not perceiving the frustration. When you walk in the room, they're not sensing that you're already irritable to be there. So we Want to take a deep breath, change our behavior. I encourage clinicians that work with people with dementia look at every day like it is a puzzle. You know, go in there and be a detective. Approach it with curiosity instead of animosity. Check with the doctor. Behavioral problems often have underlying medical reasons, so make sure that they're getting all of their medical needs met, and it's not that their caregiver is being abusive or neglectful in any sort of way. People with cognitive impairment often don't communicate and can't communicate that something's wrong. If they fell and they've got really bad pain, they may not be able to communicate it. And if you're looking and you may not see a whole lot of swelling or bruising or maybe it's in a place that you don't see because, you know it's their hip or something, then you may not know. My grandmother had spinal stenosis, which is an impingement of the nerves coming out of her neck. And she had excruciating pain radiating down her arm, and she couldn't even lift her arm. And she's a tough woman. So for her not to be able to soldier through it, it was. It was pretty wicked. But we didn't understand that at first. And, you know, once that got treated, she was. Her mood improved and a lot of other issues kind of subsided. Again. Behavior has a purpose. People with cognitive impairment typically cannot tell us what they want or need. We want to figure out what their needs are. Think about what our human needs are. We want to be loved. We want to be safe. We want to have a sense of meaning. You know, how hard is that? We want to have something to do. We don't want to be bored all the time. We want to be comfortable, not too hot, not too cold, not too hungry, not too stuffed, all of those things. If your person with cognitive impairment also has other physiological issues, you know, it's going to be important to monitor those. Like, if they've got diabetes and they're not able to tell you that they feel like their blood sugar is getting too low or too high, it's important to make sure the caregiver is, you know, Johnny on the spot with that. Remember that what works today may not work tomorrow, and what works right now may not work two hours from now. Because there are multiple influences on behavior. It can be the people you know, I know my son will do. When he was a toddler, he would do things for his preschool teacher that, like, wash his hands, that I used to have to fight with him tooth and nail to get him to wash his hands at home. But he was, you know, they couldn't get him out of the bathroom there. Go figure. And so it could be the person that is asking the client to do something. That may be it, it could be the location, it could be that they can handle doing it at 10 o' clock in the morning, but by 5:30 in the evening they are over it and completely overstimulated. And the troubling behaviors begin or they become more resistant, if you will. We want to understand what's going on, which is where a good behavior analyst will be super helpful at identifying what types of things to log or track in order to get baseline information to identify the antecedents and the consequences of the behaviors. And the natural progression of the disease process can make things not work anymore or make different things work. The key to managing difficult behaviors is being creative and flexible to any given issue. You know, just alright, what's going to work Today? Behavior occurs for a reason. It could be something you said or did. It could have triggered a memory, it could have triggered a misunderstanding. You know, as cognitive abilities decline, misunderstandings may arise. It could be a change in the physical environment, you know, too light. If a fluorescent light starts flickering and making a, you know, that horrible sound it makes before the ballast goes out, that could be annoying the person and they may not be able to tell you. We don't know. We need to look. The route to changing behavior is disrupting patterns that we create. So we want to try a different approach. It's like, okay, if this person is agitated and uncomfortable in the common area, maybe we can walk out to the patio or maybe I can take them back to their room and we can sit there for a minute and they can regroup. Maybe a different person needs to be around trying to figure out what it is over and above what they can communicate is going to be really important. And try a different behavior. A positive redirection. If they are bored and they are, you know, just pulling out books and magazines off the shelf, but they can't read them anymore anyway because their cognitive abilities aren't there. Okay, well that's not helpful. What can we give that person to do that will help them address their boredom? Painting is helpful. Coloring, drawing, you know, anything I like to give, as long as they're safe with them. I like to use colored pencils as opposed to crayons because it can be seen as offensive to give somebody who is an adult crayons. So I usually try to give them colored pencils that they can work with or or any sort of painting. You just have to judge based on your people. Some people will just love finger paints, others again will find that offensive. Other Tips Create routines and stick to them Changes in routines is one of the biggest causes of agitation in people with cognitive impairment. Eliminate distractions from their classroom, their home environment, wherever they are. If the person starts getting distracted or agitated, use a cue to help them get focused back on you. A lot of times distraction or agitation means they feel out of control of something and if you have that connection with them and they know that you're going to help them solve it, if you can get their attention then that you can have a reasonable communication. To try to understand what that problem is, only post necessary information such as schedules, classroom expectations, and information that's to be used for instruction or daily living. Try not to have lots of stuff all over everywhere because then they can't figure out what they need to focus on versus what's just a picture. Establish show what the process or the completed project looks like first. If you're doing any sort of activity. That way they can visualize maybe what they're getting ready to do. Establish clear starting and ending times. If the person is having difficulty with understanding time, that may not be super helpful, but for other people it will be. Watch the person to ensure that they don't lose focus. Practice reciprocal conversations whenever possible and this is more for people with fasd. And then this link here takes you to the Social Skills toolbox for people with fetal alcohol spectrum issues. Working with people with cognitive impairment can be frustrating. It's important not to confuse chronological age with communicative age. We want to make sure that we're communicating in a way that the person understands regardless of how many calendar days they've been alive. KISS stands for Keep it simple, Sam or Silly or whatever you want to put for that last S. Simple requests, simple words, simple schedules. Eliminate distractions when you're trying to communicate with someone that has a cognitive impairment of some sort of don't expect short term memory. Don't expect them to remember what happened five minutes ago. You can use pictures, lists and storyboards to prompt memories because sometimes the memory is kind of in there, but it's just not connected to any pathways, so to speak. So if you do something and you establish a schedule in the morning, you may create a storyboard and then when you come back in the afternoon, you can bring out the storyboard and review it with the person. Then go through the schedule spaced retrieval Training has shown effectiveness in improving memory in people with cognitive impairment, especially people with any sort of cognitive impairment that is non progressive, maybe it could be due to a brain injury from a car accident or something, spaced retrieval training can be effective in improving memory in them. Many people with fetal alcohol spectrum issues will present in mental health practices without a fetal alcohol spectrum disorder diagnosis. We want to pay attention to this, especially the communicative issues. Many clients who misuse alcohol and or try to self detox can precipitate a cognitive impairment through thiamine deficiency and stroke. And make sure to conduct ongoing assessments for cognitive impairments. Because cognitive impairments can progress. Dementia does progress if it's a. Like I said, if it's a one time thing. If it's not a progressive cognitive impairment, you can often see a lot of improvements. But if it is progressive, like in vascular dementia, Parkinson's disease or Alzheimer's, I'm sorry, dementia with Lewy bodies or Alzheimer's disease, those are progressive. So it's important to conduct ongoing assessments to see where the person is and understand what their needs might be at that particular point in time. The University of Kentucky has free CEUs for nurses, social workers and CNAs if you need more CEUs. And there's an Alzheimer care curriculum that you can also download if you need more help. I am going to be adding a dementia care curriculum to all CEUs in short order probably by the end of December. I don't want to overwhelm myself too much, but it's based on the nice, an international curriculum. I can't remember what NICE stands for, but the NICE Standards for Dementia Care. So that is like a 360 page text that it will take me a while to go through. In the meantime, there's this class. There is also the Dementia case management class that goes over in depth. More information about preventative factors that we can use to either prevent people from developing dementia and or slow the progression of the disease and so you can learn more about those interventions that might be helpful tools for treatment planning. Between writing notes, filing insurance claims and scheduling with clients, it can be hard to stay organized. That's why I recommend TherapyNotes. Their easy to use platform lets you manage your practice securely and efficiently. Visit therapynotes.com to get two free months of TherapyNotes by just using the promo code CEU when you sign up for a free trial at therapynotes.com. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. 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