6.0 Application to practice and reporting

6.0 Application to practice and reportingUsing the CAUSEd model, this module explores the role of triggers in the development of changed behaviour and considers strategies for supporting the person living with dementia and the type of reporting that is required for each individual.

We will also consider how to apply what we have learnt throughout the course to embed in our practice in order to provide high quality person-centred approach to support.

Learning outcomes• Understand the purpose of individual support plans• Identify potential triggers for behaviour associated with

dementia• Identify a range of options for managing the impact of

behaviour change for a person living with dementia• Identify how you can integrate the learning from the course

into your support practice

Dementia EssentialsCHCAGE005 Provide support to people living with dementia

Participant manual

Module 6

© 2020 Dementia Australia

IntroductionThis is a Dementia Training Australia (DTA) course, funded by the Australian Government and delivered by Dementia Australia.

DTA is a consortium led by the University of Wollongong and consisting of Dementia Australia, La Trobe University, Queensland University of Technology, and the University of Western Australia.

DTA is delivering a coordinated national approach to dementia training for individuals and organisations, with the ultimate goal of improving the care and wellbeing of people with dementia by upskilling the workforce.

For more information about DTA please visit dta.com.au

This course has been designed to provide the essential background knowledge needed to work more effectively as a support provider for people with dementia. It is an accredited course intended for delivery to staff in the aged care industry, rather than family carers. The underlying approach is from the perspective of someone employed to provide support in a professional setting. Examples and case studies used throughout reflect this focus.

Dementia Essentials delivers the national unit of competency, CHCAGE005 Provide support to people living with dementia, which is a core unit in CHC43015 Certificate IV Ageing Support.

AcknowledgementsDementia Training Australia is supported by funding from the Australian Government under the Dementia and Aged Care Services Fund.

4 Dementia Essentials

PRE-CLASS ACTIVITIES

Activity Completed

Short readings • Case study Jack • CAUSEd model

Answer the questions for case study Jack

Write your reflections on the discussion board in Communities of Practice (CoP)

CHANGED BEHAVIOUR• As dementia progresses and the symptoms begin to impact on the person’s everyday

life you may see changing behaviour emerge.

• As the person experiences cognitive change, the person’s abilities to understand, follow instructions, problem solve and cope with the changing world around them, life becomes more difficult and at times stressful.

• People with dementia have difficulty interpreting what is happening to them and often cannot identify the cause of their distress or take action to remedy it.

Identifying triggers for behaviour associated with dementia are directly related to the Aged Care Quality Standards:

• Standard 1 Consumer dignity and choice to be included and treated with respect, to exercise choice and independence about their own care and is supported to take risks to live the best life they can.

• Standard 2 Ongoing assessment and planning with consumers is undertaken in partnership with the consumer and has a focus on optimising health and well-being in accordance with the consumer’s needs, goals and preferences.

• Standard 5 Organisation’s Service Environment to provide a safe and comfortable environment that promotes the person’s independence, function and enjoyment.

• Standard 6 Feedback and complaints consumers and families feel supported to provide feedback and make complaints. Consumers are engaged in the process and action is taken to inform continuous improvements.

• Standard 8 Organisational governance minimising the use of restrictive practice and supporting consumers to live the best life they can.

MODULE 6.0 APPLICATION TO PRACTICE AND REPORTING

Module 6 5

Case Study PART 1: JACKRead the case study below and answer the questions.

Reflect back on the online learning for Module 1 & 2 and the case study Jack. Read the below information regarding his first week living at the residential aged care facility.

Support workers report that Jack, who was diagnosed with Alzheimer’s disease and was only admitted to the residential care facility a week ago, is refusing to go into the bathroom to have a shower (he has not showered since he arrived). He simply stops at the door of the bathroom and will not budge. Repetitive reassurance by the workers only seems to make him anxious and his anxiety sometimes tips into anger if carers persist. His hygiene is at risk. Jack had been cared for at home by his wife Elsie until recently when she suffered a serious heart attack, from which she is still recovering. The decision to place Jack into a facility was made on the advice of Elsie’s specialist who feels Elsie’s own health is seriously compromised by having to care for Jack.

Please note: the below questions are part of the written assessment questions for module 6.

What is the changed behaviour?

Why is it a risk?

When does the behaviour occur?

Where does the behaviour occur?

Who is involved when the behaviour occurs?


What emotions are being expressed?

How do the carers normally respond to the behaviour?

Case Study PART 2: JACKIn the Module 6 classroom, without knowing more we will apply the CAUSEd approach and analyse potential triggers experienced by Jack.

Read the CAUSEd approach and bring copy with you to the Module 6 classroom as will be used during Case Study Part 2: Jack.

KEY MESSAGES• A systematic approach to identifying the underlying cause of changed behaviour can

prompt timely support and reduce stress, especially for the person.

• By identifying potential triggers, the CAUSEd model assist with planning to minimise occurrences of changed behaviour.

• It is helpful to work with others in your team to discuss and identify possible triggers to changed behaviour.

• Other people, especially those in the support relationship, can provide valuable information and ideas.

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CAUSEd model

Communication • Does the person need glasses or hearing aids?• Does the person understand what is being said to them?• Are they being understood?• Do they understand what is expected of them?• Have they misinterpreted someone’s tone of voice?• Do they find body language threatening?

Activity • Is the activity of interest to the person?• Is it too complex?• Is it sufficiently challenging?• Is the activity intrusive?

Unwell/unmet needs

• Is there an underlying physical cause? For example, infection, constipation, dehydration.• Are they feeling pain?• Does medication contribute to the behaviour?• Is the person comfortable?• Is the person tired or fatigued?• Are emotional needs being met?• Is the person bored or lacking exercise?• Can the person make their own choices?• Are the person’s habits and routines respected?

Story Aspects of the person’s life story that might impact include:• personality• family• significant events in their life• work history• achievements • losses• cultural backgrounds• routine

Environment Physical environmental factors:• noise• lighting• visibility• private spaces• activity of other peopleSocial environment: • interaction with friends and family• family dynamics• inclusion• familiar belongings• language spoken

dementia • What type of dementia?• What strengths and abilities does the person still have?• What changes occur with this type of dementia?


Application to practice

Write your response to the reflection question on the discussion board in Communities of Practice (CoP).

Reflection on our support practice enables us to achieve better self-awareness of our knowledge, understandings and skills to assist ongoing improvements. In order to provide high quality person-centered approach to support, we need to reflect how to apply what we have learnt throughout the course to embed in our practice.

Review the participant manual, assessment materials and additional resources for modules 1 to 5. Reflect upon your experiences in the workplace and the learning environment, then respond to the below reflective questions.

Reflection questions:

What were you trying to achieve in undertaking this course?

So what are my new understandings gained from modules 1–5?

Now what do I need to do in order to improve my support practice?

Module 6 9

KEY MESSAGESFrom July 2016, initial assessments for Aged Care Services or Home Care Packages are conducted by the Aged Care Assessment Team (ACAT) via the myagedcare.gov.au Government portal. A local Aged Care Assessment Service (ACAS) will undertake an assessment of the needs of the consumer and work in consultation with them to find appropriate provider/s for the services they require.

A case manager or advisor will be assigned to them from the provider to assist in consulting with the consumer in the creation of their care plan and setting goals to devise a plan that will achieve what they desire.

Under Consumer Directed Care (CDC), the funding for services is attached to the consumer allowing for them to be involved in the decision making process.

Then when entering into a Residential Aged Care facility, care plans may have a clinical focus as the consumer may be less independent and require more focus on their medical needs however this shouldn’t take away from the importance of understanding the person as an individual and their background.

Individual support plans• Plans are created at the time of assessment and are a working document

• The plan may contain details about a person’s physical, medical, social, emotional, cultural, lifestyle, sexuality and spirituality needs

• May also contain information about the types of services the person needs

• Plan is developed in partnership with the client and their carer and be driven by client goals

• Plan is enabling and optimises health and wellbeing


FURTHER INFORMATION:Families can be an immense help when collecting this information and their help should be enlisted.

A person with dementia will have changing needs over time and support plans need to reflect this.

Planning considerations

Person-centred approach – activities offered should be appropriate to the age, culture, preferences and interests of the person.

Safety and comfort balanced with autonomy and risk-taking – although safety must be assessed, activities should allow an acceptable level of risk.

Maintain routines – this may help to reduce anxiety and stress by providing familiar and known activities.

Create opportunities for both social interaction and private time.

Evaluate effectiveness – it is important to assess whether activities carried out were successful and to reflect on points that could be improved.1

KEY MESSAGESA support plan should:• be developed in partnership with the person and their carer

• be driven by client goals

• be enabling

• optimise health and wellbeing

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KEY MESSAGESA support plan is a working document- as dementia is a progressive condition changes will occur. A support plan needs to be regularly reviewed and adapted as the condition changes.

The person will develop new symptoms, you will see changes in abilities, changes to general health and physical functioning sometimes we see changes in behaviour.

Explain that behaviour changes are often recorded in a person’s plan. When strategies are used to reduce changed behaviour, these too are recorded.

Documenting changes can help the support team to adapt support but also to develop early interventions to minimise the impact of changes, especially relating to behaviour.

Reporting behaviour changesIt is important to:

• Communicate changes

• Be objective

• State clearly what you see

• Avoid judgement or interpretation


KEY MESSAGESSometimes the behaviour can:• place the person at risk

• place the carer (professional/family) at risk

• affect the ability to support the person

• reduce the quality of life of the person or those around them

• require intervention to help the situation.

Early intervention is the key. Having identified and reported a change in behaviour the team need to develop a support plan that promotes safe and effective strategies to support the person and their carer.

The team will need to problem solve why the change has occurred and what might be the trigger for the change.

Problem solving• Gather specific and short descriptions about the situation: – What is the changed behaviour? – Why is it a risk? – When does the behaviour occur? – Who is involved when the behaviour occurs? – What emotions are being expressed? – How does the person behave and how do others usually respond?

• Followed by Why – the trigger or cause

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KEY MESSAGESDeveloping interventions• Analyse the gathered information to identify the likely CAUSE(s) or trigger(s)

• Decide how to best respond in light of the likely CAUSE(s) or trigger(s) – What are my options? – What is the best option? – What is the plan of action (including a back up plan) – Implement the action/intervention – Evaluate the effectiveness – Document at all points

Case Study: Jack• Alzheimer’s Disease

• Admitted 1 week ago

• Refusing to go into bathroom to shower

• Stops at door

• Repetitive reassurance increases anxiety, anger

• Hygiene at risk

• Cared for by wife Elsie

• Jack in care due to Elsie’s heart attack last week

Problem solving for JackGather specific and short descriptions about the situation:

• What is the changed behavior?

• Why is it a risk?

• When does the behavior occur?

• Who is involved when the behavior occurs?

• What emotions are being expressed?

• How do the carers normally respond to the behavior?


Session 1: Nature of dementia/Impact of dementia

Session 2: Changed behaviour/Person-centred support

ACTIVITY Review and reflection

Module 6 15

Session 3: Communication

Session 4: Purposeful and meaningful engagement


Session 5: Elder abuse and restraint/The supportive environment

Session 6: Application to practice and reporting

Module 6 17

What were you hoping to achieve in undertaking the course?

So what are my new understandings gained from this course?


Now what do I need to do in order to improve my support practice?

Module 6 19

GlossaryThe following resources were used in generating this glossary: At your fingertips - Dementia Alzheimer’s and other dementias, H. Cayton, Dr. N. Graham, Dr. J. Warner; The Australian Oxford Paperback Dictionary, F. Ludowyk, B. Moore

Acetylcholine

Agnosia

Apraxia

Aphasia

AIDS

Alzheimer’s disease

Amyloid

Anticholinesterase drugs

Antioxidants

Antipsychotic drugs

Aricept

Blood pressure

Brain scan

Bradykinesia

Cerebral cortex

Cholesterol

Cholinergic

Cholinesterase inhibitor

Chromosomes

One of a group of chemicals known as neurotransmitters. Found throughout the brain, acetylcholine enables nerve cells to communicate with each other. In Alzheimer’s disease, the levels of acetylcholine are lower than usual.

Inability to recognise familiar objects, people, sounds, shapes or smells.

Inability to make familiar movements despite having muscular strength and co-ordination.

Impaired ability to produce, comprehend or use language.

Abbreviation for Acquired Immune Deficiency Syndrome.

The commonest cause of dementia. It usually begins after the age of 65 and results in gradual, progressive loss of memory and other functions of the brain.

A protein that is found in the brains of people with Alzheimer’s disease. It is deposited throughout the brain in microscopic clumps known as plaques. Its function is unknown and it may be the cause of the deterioration of brain function.

Also known as cholinesterase inhibitors, these dementia drugs stop the breakdown of acetylcholine. Aricept and Exelon are examples.

Substances such as vitamin E, C and beta carotene are thought to protect the body cells from the damaging effects of oxidation.

A range of tranquillisers, also known as neuroleptic drugs, that help to reduce symptoms of aggression.

The brand name for donepezil, a cholinesterase inhibitor.

The amount of stress placed on the walls of the arteries, veins and heart chambers by the flow of blood.

A general term to mean any investigation that produces pictures of the brain. A CT scan or MRI scan shows slices through the brain. A SPECT scan shows the brain’s blood supply.

An abnormal condition that features slowness of speech and movements.

The outer layers of the brain, involved in thinking, memory and the interpretation of perception or the senses.

Substance found in animal fats and oils, and is also made in the body. It is necessary for the making of vitamin D in the skin and for making various hormones. Too much cholesterol can be responsible for deposits in blood vessels and eventual restriction of blood flow.

Referring to acetylcholine. For example, a cholinergic neurone is a brain cell that contains the chemical acetylcholine.

An alternative name for anti-cholinesterase drug.

Microscopic thread-like structures that are present in all cells. They are collections of genes, which contain the genetic information that is transmitted from generation to generation.


CJD (Creutzfeldt Jakob disease)

Cognition

Cognitive tests

Community care

Complementary medicine

Confabulation

Confusion

Dehydration

Delirium

Dementia

Depression

Diabetes

Diagnosis

Disinhibition

Disorientation

Donepezil

Down syndrome

A very rare form of dementia caused by an infectious agent called a prion. As well as loss of memory, CJD commonly causes muscle jerking, blindness and problems with walking. Death occurs within a year or so.

The faculty of knowing or perceiving things.

Tests that assess how well a person can think and how well his or her memory is working.

A term covering health and social care services delivered to people in the community, usually in their own home.

An approach to health care that explores alternatives to conventional treatments. Acupuncture, homeopathy, aromatherapy and spiritual healing are examples of complementary therapies.

Producing false memories to replace memories that are no longer capable of being stored. A person may guess an answer or imagine an event and then mistake it for an actual memory. Although it may be seen by others as lying, the person is unaware that their memories are false or inaccurate.

A state in which problems with memory and concentration impair the function of the mind.

A state in which there is insufficient water in the body. It occurs when a person’s fluid intake fails to balance fluid loss through sweating, vomiting or diarrhoea.

Features confusion, speech disorders, anxiety and sometimes hallucinations. Often has a rapid onset and lasts from hours to weeks. Fluctuations in conscious state.

A term used to describe impairment of brain function, involving memory, thinking and concentration. Dementia usually becomes progressively worse, eventually making it impossible for someone to cope with living without help. There are many causes of dementia, including Alzheimer’s disease, vascular dementia, Lewy body disease and Pick’s disease.

An illness in which the main symptoms are feeling low, tearfulness and loss of enjoyment. Depression can affect sleep, appetite, motivation and concentration. It is treatable.

Occurs when the amount of sugar in the blood cannot be regulated. There are several types of diabetes.

The process of identifying and naming a disease from a person’s symptoms and signs. Getting a diagnosis may only involve talking with the doctor and having a physical examination. In other cases, special investigations may need to be done as well.

Loss of feelings of shame or embarrassment that normally help control a person’s actions. Disinhibition results in inappropriate or improper behaviour.

A state in which someone loses their awareness of time and place. For example, they may fail to recall the date or even the year, and may not be able to say where they are.

The generic name of Aricept, a dementia drug that is a cholinesterase inhibitor. It works by increasing the amount of a certain substance (acetylcholine) in the brain.

A genetic condition caused by an extra copy of chromosome 21 that results in slowed growth, abnormal facial features and intellectual disabilities.

Module 6 21

Enduring Power of Attorney (EPA)

Epileptic seizures

Exelon

Frontotemporal dementia

Frontal lobes

Galantamine

Generic

Genes

Geriatrician

Hallucination

HIV

Huntington’s disease

Incontinence

Korsakoff’s syndrome

Lewy body disease

Limbic region

Memantine

A legal document in which one person gives another the power to handle his or her financial affairs. An EPA can only be drawn up if the person handing over this power can understand what he or she is doing. The EPA comes into force only after it has been officially registered.

Caused by a group of nervous system disorders that produce an uncontrolled electrical discharge in the brain.

The brand name for rivastigmine, a dementia drug that improves the function of nerve cells in the brain. It works by preventing the breakdown of a chemical that is important for the processes of memory, thinking, and reasoning.

A dementia in which the disease process mainly affects the frontal lobes of the brain. Memory is affected less than in other dementias, but there may be major problems with loss of motivation and disinhibition.

Parts of the cerebral cortex situated at the front of the brain. This is the area of the brain that controls movement of the body. It is also involved in ‘higher functions’, such as planning ahead, problem-solving and initiative.

The generic name of Reminyl, a type of dementia drug that is a cholinesterase inhibitor. It works by increasing the amount of a certain substance (acetylcholine) in the brain

A generic drug is a drug that is sold under its official medical name (its generic name) rather than under a patented brand name.

Material contained within the chromosomes. Genes carry the blueprint for the body; information that dictates how our bodies are built up, including the colour of our eyes and skin, how tall we are, our gender and many other details. Some genes have defects, or mutations, that cause disease.

A doctor who specialises in the treatment of physical illnesses in older people.

A perception (hearing, seeing, smelling or feeling something) without appropriate stimulus. For example, hearing voices when there is no-one there. Hallucinations are quite common in people with dementia.

Abbreviation for Human Immunodeficiency Virus.

Also sometimes called Huntington’s chorea, a disease in which mental deterioration is accompanied by involuntary twitching and muscle spasms.

Involuntary or inappropriate passing of urine or faeces. Help is available from continence advisors.

A memory disorder caused by lack of vitamin B1 (thiamine) sometimes caused by alcoholism.

A type of dementia in which abnormal collections of proteins called Lewy bodies, occur in the brain. People with Lewy body disease typically show more variation in their mental abilities from day-to-day than is usual with other dementias.

Situated deep inside the brain, this region is responsible for functions such as eating, sleeping, consciousness and emotions.

A dementia drug, which works by altering chemicals called NMDA receptors in the brain. It may slow the progression of dementia in some people.


Memory

MRI scan

Neuroleptic drugs

Neurologist

Neurone

Neurotransmitters

Occiptal lobe

Parietal lobes

Parkinson’s disease

Person-centred care

PET scan

Pick’s disease

Posterior Cortical Atrophy

Prevalence

Progressive Supranuclear Palsy

Reality orientation

Reminiscence therapy

Reminyl

Rivastigmine

Temporal lobes

The retention in the mind of information that may be recalled later.

Abbreviation for Magnetic Resonance Imaging scan. A type of brain scan that creates pictures using a powerful magnetic field rather than X-rays.

Another name for antipsychotic drugs.

A doctor who specialises in the diagnosis, treatment and management of diseases of the nervous system.

A nerve cell.

A group of chemicals in the brain that enables nerve cells to communicate with each other. Groups of adjacent nerve cells tend to use the same neurotransmitter. Examples include acetylcholine, serotonin and dopamine.

Part of the cerebral cortex situated at the back of the brain, responsible for interpreting what is seen.

Part of the cerebral cortex situated on either side of the brain above the ears. Responsible for anything to do with order and structure.

A chronic disease of the nervous system that is characterised by slowness of movements, a tremor and an expressionless face. Some affected people also develop dementia.

A holistic approach to dementia care focusing on the individual and utilising aspects such as the person’s past history, routines, personal preferences and needs.

Abbreviation for Positron Emission Tomography scan. A sophisticated brain scan which is able to look at the brain in great detail. It is not generally available in clinical practice.

A rare dementia which commonly affects younger people than Alzheimer’s disease. It affects language and personality before there is any significant change in memory.

Refers to gradual and progressive degeneration of the outer layer of the brain (the cortex) in the part of the brain located in the back of the head (posterior).

Rate of occurrence.

A rare condition that causes problems with control of gait, balance and vision.

A psychological treatment in which every opportunity is taken to make people with dementia aware of the time, where they are and the world around them.

A treatment that aims to stimulate people’s memories by means of old films, pictures, music, etc.

The brand name for galantamine, a dual-action dementia drug. It is anticholinesterase drug and also works by stimulating areas of the brain called nicotinic receptors.

The generic name for Exelon, a dementia drug.

Parts of the cerebral cortex situated behind the temples, and responsible for our memory.

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Sedative drugs

Side effects

Snoezelen

Stroke

Syndrome

Thyroid

Tranquillisers

Validation

Vascular dementia

Vitamins

Drugs used to reduce symptoms of anxiety and agitation and to help people sleep. Sedative drugs increase confusion in people with dementia.

The unwanted ‘extra’ effects that occur in addition to the desired therapeutic effects of a drug. Most drugs have some side effects. These will vary from person to person and commonly disappear when the body becomes used to a particular drug.

A special room designed to gently stimulate the senses and to calm people who are agitated.

A result of a haemorrhage in the brain, or of a blood clot in an artery of the brain, leading to paralysis of part or all of one side of the body, or loss of speech, or loss of consciousness or death. The paralysis may be sudden or gradual in onset.

A group of signs and symptoms that occur together and are typical of a particular disorder or disease.

A gland in the neck that produces a chemical known as thyroid hormone. This hormone is essential to the workings of the body. Thyroid hormone deficiency is a rare cause of dementia.

Drugs used to help people who are very anxious. These drugs can cause increased confusion in people with dementia.

A technique used in caring for people with dementia that focuses on feelings rather than confusion.

A type of dementia associated with problems affecting the circulation of blood to the brain, such as may result from a series of small strokes.

Chemical compounds essential to health that are found in many foods. Vitamin deficiency is a rare cause of dementia.


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6.0 Application to practice and reporting