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presentation HandoutscontentsDisclaimer ........................................2Presentation Slides ........................3Handout A ................................... 19Handout B .................................... 20Handout C .................................... 21Handout D ................................... 22Handout E .................................... 24Handout F .................................... 25Handout G ................................... 27References .................................... 28Meet the Speaker ........................ 30

presentation Handouts

Fall 2011 Webinar series#2 - Friday, Nov. 18, 2011 @ 1PM EST

Behavior concerns amongst residents with dementia may effectively be stopped, minimized or reduced by using appropriate interventions and assessment tools. Alfred Norwood discusses how your care team can design, implement & evaluate interventions that fit the behavior which may result in positive changes. These positive changes may include improved resident mood/behavior and cost effective reduction of time spent in daily care by caregivers.

Learning objectives

• Discusshowtheprocessofhumanbehaviorcan be affected by age and disease.

• Discusseffectiveinterventionstostop,minimize or reduce behavior concerns.

• Discussunderusedtoolsacareteamcanuse for improving resident mood and behavior.

presentation Handouts

Effective Interventions for Residents with Behavior Concerns

Presented by: Alfred W. Norwood, BS, MBAPresident and Founder of Behavior Science, Inc

november 18, 2011Webinar @ 1:00 pM

effective Interventions for Residents with Behavior concerns

sponsoRed By www.avilainstitute.org518.537.5000

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dIscLaIMeRThis webinar is intended for educational purposes only. It is not a substitute for formal medical training in one of the health care professions, nor is it a substitute for professional medical advice. For more specific information you may have to consult a health care professional.

dIscLosuRe oF Vested InteRest The presenters have no personal, professional or financial disclosures to make in relation to this presentation.

dIscussIon oF unLaBeLed useThere will be no discussion of off-label use of medication during the presentation.




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November 18, 2011 1:00 – 2:00 PM EST Webinar

Effective Interventions for Residents with Behavior Concerns

Education Arm of the Carmelite Sisters for the Aged and Infirm

Presented by: Alfred W. Norwood, BS, MBA

Normal Aging of the Brain Normal Brain Aging:

• Cell loss (Not seen in some studies). • Plaques and tangles.

• Occur in normal aging as well as Alzheimer’s. • Number of tangles is related to Alzheimer’s.

• Decrease in white matter (Glial cells). • Decrease in cortical size.

Normal Brain Aging Causes: • Increased time to retrieve information. • Less able to learn/retain new information. • Decrease in attention and concentration.

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No Dementia Solutions Soon1

Approved drugs treatments for Alzheimer’s. – Cholinesterase inhibitors (donepezil, rivastigmine,

galantamine). – NMDA receptor antagonist (memantine).

Provide symptomatic relief. Poorly affect the progression of the disease. New disease-modifying drugs developed include

– Drugs to reduce β amyloid (Aβ) production, – Drugs to prevent Aβ aggregation, – Drugs to promote Aβ clearance, – Drugs targeting tau phosphorylation.

Unfortunately none of these drugs has demonstrated efficacy in phase 3 studies.

1 New pharmacological strategies for treatment of Alzheimer's disease: focus on disease-modifying drugs; Salomone S, Caraci F, Leggio GM, Fedotova J, Drago F; British Journal of Clinical Pharmacology (Oct 2011)

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Dementia is Progressive Loss

1st Hippocampus Neurons Die

2nd Frontal Lobe Neurons Die

3rd Rest of the Brain Cells Die

Forgets words, concepts, people. Disoriented to time & location. Remembers habits, repetitive actions. Losses concept of self. Sensory losses (sight/hearing). Less Sensory integration. Reduced attention span/focus. Loss of logical/conscious thinking. Can’t predict what happens next.

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Losses cause Confusion Confusion from:

Over stimulation Environment e.g. Shift change, loud activities. ADLs e.g. Too fast instructions, Too complex

activity e.g. Eating. Under stimulation

Up at night e.g. Can’t predict what’s next; seek stimulation.

Time of day Fatigue e.g. afternoon exhaustion. Non conscious memory e.g. must make dinner.

Cognitive dissonance Morning bath vs. Evening shower.

Unmet needs Hungry, thirsty, in pain etc. 5

FIGHT

FLIGHT

Resisting Care Hitting, slapping

Yelling

Apathy

Withdrawal

Wandering

Elopement Hides, hoards

Anger Biting, spitting

Anxiety Paranoia CHRONIC ILLNESS

STRESS

Confusion

Confusion Causes Stress

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What is Stress? A uncontrollable response to threats2: Anything novel or unpredictable. Anything I don’t have control over. Being evaluated by others. 3 Absolute threats: Witness violence, wild animal, cold/heat. Reaction the same for everybody. Implied threats: Public speaking. Reaction differs by person.

2. Lupien et al; The effects of stress and stress hormones on human cognition: implications for the field of brain and cognition; Brain & cognition 2007 3. Dickerson Sally S; Gable Shelly L; Irwin Michael R; Aziz Najib; Kemeny Margaret E; Social-evaluative threat and proinflammatory cytokine regulation: an experimental laboratory investigation. Journal of the American Psychological Society / APS 2009;20(10):1237-44.

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Fight or Flight Reaction Short Term

• Induce Behavior. • Imprint Emotional Memory. • Increase Cognitive Performance.

Long Term • Stop Neurogenesis (Hippocampus). • Reduce Attention & Memory (Frontal Lobe). • Increase Fear Response (Amygdala). • Increase BP, Diabetes, Arterial Disease. • Suppress Immune Functions.

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What is a Behavior Problem ?

To Researchers Apathy Depression Agitation Irritability Delusions Anxiety Wandering Hallucinations Elation/mania

To CNAs Wandering Physical Aggression Restlessness Delusions Sleeplessness Anxiety Screaming Agitation Crying/cursing/

questions

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The Problem with Behavior Problems Not easily quantifiable or “well described”. Disengaged physicians. Nursing staff is the chokepoint.

– Minimal face to face pro communications. – RNs more administrative than resident care. – Aides feel they doing custodial duty. – Avoid/minimize difficult residents. – Training lacks “feedback & reinforcement”. – Task & medical job focus. – Trial/error, low efficacy, high cost, drug scripts

reduce nursing staff responsibility. – Environmental limitations. – Regulatory limitations.

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What is Behavior ?

Activity. Due to changes in Stimulation.

External Stimulation e.g changes in:

Noise Light Temperature

Internal Stimulation e.g. changes in:

Pain Thirst, hunger Schedule Orientation

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Rules of Behavior In Life Rewarded behavior is repeated. Unrewarded behavior is not repeated. Punished behavior is avoided.

In Dementia All behavior communicates. Most behavior is not conscious. Much behavior can still be learned. Punishment doesn’t work. Positive Reinforcement does work. Proactive beats Reactive Interventions.

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What is a Behavior Problem? B

EHAV

IOR

NEGATIVE

POSITIVE

RESIDENT STAFF CONTROL 13

What is Behavior Management?

BEH

AVIO

R

NEGATIVE

POSITIVE

RESIDENT STAFF CONTROL

PR

OA

CTI

VE

AC

TIV

E

REA

CTI

VE

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BEH

AVIO

R

NEGATIVE

POSITIVE


PR

OA

CTI

VE

AC

TIV

E

REA

CTI

VE

Behaviors Aggression Yelling Agitation No Sleep Non Compliance Wandering Elopement Not Eating Medical Strategies Pain Medication Psychotropic PRN Behavioral Strategies Punishment Calming One on One Removal Isolation Planned Ignoring


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What is Behavior Management? B

EHAV

IOR

NEGATIVE

POSITIVE


PR

OA

CTI

VE

AC

TIV

E

REA

CTI

VE

Warning Signs Increased Movement Start Verbalizations Withdrawal Complaining Rocking Attention Seeking Other ? Religion Medical Strategies Physical Examination Sedative Meds Pain Medication/TIMS Sleep Medication Behavioral Strategy Reduce Stress Give Attention Distraction Rewards Planned Ignoring Busy Box Work/Helping Preferred Music

16


BEH

AVIO

R

NEGATIVE

POSITIVE


PR

OA

CTI

VE

AC

TIV

E

REA

CTI

VE

Medication Monitor Health Pyschotropic Meds Other Environment Sensory Appropriate Wayfinding Repetitive/Structured Reminiscent Standard Therapy Behavioral Reality Validation Reminiscence Alternative Therapy Art Therapy Music Therapy Activity Therapy Complementary Therapy Aroma Therapy Bright Light Therapy Resident Plans Advice Guidelines Behavior Plans Unit/Team ADL Rituals Comfort Zones Transition Plans

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Behavior Management Strategies

BEH

AVIO

R

NEGATIVE

POSITIVE


PR

OA

CTI

VE

AC

TIV

E

REA

CTI

VE

Medication Monitor Health Pyschotropic Meds Other Environment Sensory Appropriate Wayfinding Repetitive/Structured Reminiscent Standard Therapy Behavioral Reality Validation Reminiscence Alternative Therapy Art Therapy Music Therapy Activity Therapy Complementary Thrpy Aroma Therapy Bright Light Therapy Resident Plans Advice Guidelines Behavior Plans Unit/Team ADL Rituals Comfort Zones Transition Plans

Warning Signs Increased Movement Start Verbalizations Withdrawal Complaining Rocking Attention Seeking Other ? Religion Medical Strategies Physical Examination Sedative Meds Pain Medication/TIMS Sleep Medication Behavioral Strategy Reduce Stress Give Attention Distraction Rewards Planned Ignoring Busy Box Work/Helping Preferred Music

Behaviors Aggression Yelling Agitation No Sleep Non Compliance Wandering Elopement Not Eating Medical Strategies Pain Medication Psychotropic PRN Behavioral Strategies Punishment Calming One on One Removal Isolation Planned Ignoring

Drug Intoxication Delirium • Drug Intoxication • Lewy Body • Medical (infection, B12 etc.) Depression/ Agitation • Morning • Evening (sundowning) • Continuous Pain • When moved • Continuous

WILD CARDS

H-A see Handout a on page 19




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Behavioral Wildcards4-8 Drug Intoxication 42% of over 65 admitted to hospital (mostly reversible). 4 Depression5 (mostly reversible) 10 %, with 1-2 % experiencing a major depression. 32% in long term care facilities. Feeling sad, depressed all the time. Reduced energy, interest, capacity to enjoy. Delirium Nursing Home Residents In hospital Treatment 70%6

(mostly reversible). Fast onset or comes and goes. Decreased concentration, disorganized. Decreased level of conscious.

Pain 4. Cyndie K Mannesse, et el; Adverse drug reactions in elderly patients as contributing factor for hospital admission: cross sectional study; BMJ 1997;315:1057–8 5. Patricia A. Parmelee1, Ira R. Katz1,2 and M. Powell Lawton; Incidence of Depression in Long-term Care Settings; Journal of Gerontology Volume 47, Issue 6Pp. M189-M196 6. Marcantonio ER. Dementia. In: Beers MH, Jones TV, Berkwits M, Kaplan JL, Porter R, eds. Merck Manual of Geriatrics. 3rd ed. Whitehouse Station, NJ: Merck & Co, Inc; 2000:357-371. 7. Jothika N. Manepalli, MD, Mehret Gebretsadik, MD, Jaime Hook, MD, and George T. Grossberg, MD; Differential Diagnosis of the Older Patient With Psychotic Symptoms Primary Psyciatry; August 2007 8. Philippe Voyer; Predisposing Factors Associated With Delirium Among Demented Long-Term Care Residents; Clinical Nursing Research, Vol. 18, No. 2, 153-171 (2009)

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British Study Use of Antipsychotics9 “Anti-psychotic drugs appear to have only a limited positive effect in treating these symptoms but can cause significant harm to people with dementia.” 180,000 people with dementia are using antipsychotic

medication. Of these, up to 36,000 will benefit from the treatment. Negative effects of use of antipsychotic medication is:

An additional 1,620 cerebrovascular adverse events, Around half of which may be severe, and An additional 1,800 deaths per year on top of those that

would be expected in this frail population.

9 Banerjee S. The Use of Antipsychotic Medication for People with Dementia: Time for Action. Department of Health, 2009

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A British follow-up Study10 People with Dementia antipsychotic drug 17.7%, an antidepressant 28.7% hypnotic/anxiolytic 16.7 %

People without Dementia antipsychotic drug 17.4 % antidepressant drug 2.7 % hypnotic/anxiolytics 2.2%

Conclusions: • Over one in six patients are currently prescribed antipsychotic drugs known to be of little benefit and causing significant harm, • Changing this will require investment in services to support alternative management strategies for people with behavioral and psychological disturbance associated with dementia.

10 BRUCE GUTHRIE1, STELLA ANNE CLARK2, COLIN MCCOWAN1 The burden of psychotropic drug prescribing in people with dementia: a population database study; Age and Ageing 2010; 39: 637–642

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The British Solution11 Exclude treatable physical or environmental causes of distress.

It is unacceptable to treat depression or physical pain with an antipsychotic or by sedating them and thereby rendering them quiet and more tolerant of that poor care.

Where no treatable cause is identified and e behavior is not distressing pharmacological interventions are not justified. Doctors are very often under pressure from carers and staff to ‘medicate to make a person more manageable’ and this must be resisted.

Where no treatable cause is identified and the individual is clearly distressed, a trial of an antipsychotic may be considered

A frank discussion of both benefit and risk with relatives and carers is essential and almost invariably helpful.

11 Adrian Treloar, FRCP, MRCPsych, MRCGP et al; Ethical dilemmas: should antipsychotics ever be prescribed for people with dementia? ;The British Journal of Psychiatry (2010) 197: 88-90

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Delirium Fluctuate between lucidity confusion and disorientation. Changes in attention span; may be extremely short

attention spans. Changes in patients’ sleep-wake cycles

e.g. sundowning/insomnia. Becoming very quiet and withdrawn or agitated. Drastic change in physical activity; becoming lethargic

or hyperactive.

23

Common Causes of Delirium Urinary tract infections and/or fever that persists. Side effects of many different medications. Interactions between medications. A disorder of metabolism. An electrolyte imbalance, even a minor one. An imbalance in acids and bases levels in the body. Dehydration. Loss of the body’s ability to maintain normal

temperature (hypothermia).

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Proactive Delirium Management12

Identify High Risk Residents

– Old age, – existing dementia, – male, – previous history, – significant medical history, – Poor eyesight/hearing, – Frailty, – Immobility

– Sudden changes in mental state – Unexplained Confusion – Shouting – Restlessness – Emerging Hypo-activity – Sleeping Difficulties

– Appropriately lit environment – Minimize # o f staff providing care – Make resident familiar with care staff – Staff will explain & introduce care – Train staff on recognizing delirium – Train on sundown syndrome management – Staff ensure use of glasses/hearing aides – Staff reminds resident of time and date – Review medication /drug interaction

Recognize & Treat Symptoms

Use Proactive Strategies

H-B

12 Tabet, N, Howard, R; Non-pharmacological intervention in the prevention of delirium; Age & aging, 2009, 38: 374-379

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Depression Signs & Symptoms • Reduced energy and concentration. • Decreased appetite, weight loss. • Sleep complaints – early morning awakenings

and frequent awakenings. • Somatic Complaints – e.g. gastrointestinal problems,

constipation, heartburn, nausea, vomiting, colitis, migraines, headaches, back aches, and skin disorders.

• Pseudo dementia – e.g. memory loss, withdrawal, ignoring.

• Episode with ‘melancholic features’ – e.g. hypochondriasis, hopelessness, feelings of worthlessness, paranoia and suicidal ideation.

26

Depression leads to losses In relation to healthy subjects, depressed, older

subjects showed impairments in: 13 – attention, – working memory, – visual memory, – verbal memory, – new learning, and – executive function

Cerebrovascular disease rather than

glucocorticoid-mediated brain damage are responsible for the persistence of cognitive deficits in depression in older age. 14

13. John T. O’Brien, et al; A Longitudinal Study of Hippocampal Volume, Cortisol Levels, and Cognition in Older Depressed Subjects; Am J Psychiatry 161:2081-2090, November 2004 14. Sebastian Köhler, et al; White matter hyperintensities, cortisol levels, brain atrophy and continuing cognitive deficits in late-life depression The British Journal of Psychiatry (2010) 196: 143-149

27

see Handout B on page 20




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Depression leads to Dementia Late-life depression and even depressive symptoms

are risk factors for mild cognitive impairment and Alzheimer disease 15

Depressed people deposit more amyloid-beta plaques speeding Alzheimer’s disease 16

Depressed people performed lower in: 17 – episodic memory, – verbal fluency, – information processing, – executive function, and – visuospatial ability

. 15. Jorm AF. History of depression as a risk factor for dementia: an updated review. Aust N Z J of Psychiatry. 2001;35:776-781 16. Dong H, Csernansky JG; Effects of stress and stress hormones on amyloid-beta protein and plaque deposition; J Alzheimers Dis. 2009 Oct;18(2):459-69. 17. Butters MA, Bhalla RK, Mulsant BH, et al. Executive functioning, illness course, and relapse/recurrence in continuation and maintenance treatment of late-life depression: is there a relationship? Am J Geriatr Psychiatry. 2004;12:387-394.

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Depression leads to Illness Depression Increases Risk of18: 1st stroke by 50%, Additional strokes by 250% Heart disease, cancer, pneumonia Suicide Chronic Depression can cause19: Chronic headache, osteoporosis Increases risk of return to addictive behaviors

18 Journal of Epidemiology. 1997;7:210 British Medical Journal. 1998;316:1714 --1719. 19 Archives of General Psychiatry. 1998;55:259 --265. American Journal of Psychiatry. 1997; 154(5):630--634. The Journal of the American Medical Association. 1998; 279:1720

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Depression reduced by 20

SNF aerobic exercise Mind-body relationship training, Life Review sessions (Group, 1 hour per week)

Problem Solving (as required)

Interpersonal Therapy (Individual, 1 hour per week)

Resistance Training Education and Support for Unit Staff

20 SAMHSA Older Americans Technical Assistance Center “Evidence-Based Practices for Preventing Substance Abuse and Mental Health Problems in Older Adults.”

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Use Pain Medication 21 Rates of other adverse events (i.e., constipation, delirium,

dehydration, pneumonia) were not found to be higher among chronic opioid users compared to those taking no analgesics or nonopioids.

A trend toward a lower risk of falls with use of any analgesics

No changes in cognitive status or mood status, or increased risk of depression with use of any analgesics, including opioids

The use of long-acting opioids may be a relatively safe option in the management of persistent nonmalignant pain in the nursing home population, yielding benefits in functional status and social engagement.

21 Aida Won; Long-Term Effects of Analgesics in a Population of Elderly Nursing Home Residents With Persistent Nonmalignant Pain; J Gerontol A Biol Sci Med Sci (2006) 61 (2): 165-169.

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Standard Non-Pharm Therapies22 Behavioral therapy (A) Assess for triggers (STEAM), behaviors and reinforcers (ABC: antecedents,

behaviors & consequences) Use data, individual’s preferences, context in which the behavior takes place; and

reinforcement strategies to reduce the behavior Reality orientation (B) Fight memory loss & disorientation by reminding of facts about selves & their

environment Use devices such as signposts, notices & other memory aids Validation therapy (C) Communicate by empathizing feelings & meanings hidden behind their confused

speech and behavior Emotional content of what is being said that is more important than the person’s

orientation to the present Reminiscence therapy Relive past experiences, especially those that might be positive and personally

significant using art, music and artifacts to provide stimulation. Can improve behavior, well-being, social interaction, self-care and motivation

H-C

22 Simon Douglas, Ian James and Clive Ballard; Non-pharmacological interventions in dementia; Advances in Psychiatric Treatment (2004) 10: 171-177

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Alternative Therapies 22 Art therapy (B) drawing & painting provide individuals with the opportunity for self-expression & a chance to exercise some choice (colors & themes). Can provide meaningful stimulation, improve social interaction and improve levels of self-esteem. Music therapy (B+) Using a musical activity (e.g. singing or playing an instrument), or merely listening to songs or music Increases in levels of well-being, better social interaction, improvements in autobiographical memory, reduced abnormal vocalizations, agitation Better results from music preferred when patient was 15-25 years old Activity therapy (B) Physical recreations such as dance, sport and drama Can reduce the number of falls, improve mental health, sleep while reducing daytime agitation and night-time restlessness & fulfilling a need for soothing, non-sexual physical contact Complementary therapy (C) Massage, reflexology, reiki, therapeutic healing, herbal medicine. Not much research on efficacfy either for or against Aromatherapy (B) Inhalation, bathing, massage and topical application lavender and melissa balm Shown significant reductions in agitation, with excellent compliance and tolerability Bright-light therapy (B) Reduce the fluctuations in diurnal rhythms that may account for night-time disturbances and ‘sundown syndrome’ (recurring confusion or agitation in the late afternoon or early evening) in people with dementia. Some evidence for improving restlessness and with particular benefit for sleep disturbance

H-C

22 Simon Douglas, Ian James and Clive Ballard; Non-pharmacological interventions in dementia; Advances in Psychiatric Treatment (2004) 10: 171-177

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see Handout c on page 21

see Handout c on page 21




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Diversionary Activities

Person Centered Provide activities which are rewarding

– Music – Establish mood, function – Best preferred from age 15 -25

Religious/spirituality – Standard for cognitively intact – Reassuring for depressed, low cognitive

Work – Familiar jobs, show accomplishment

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Person Centered Activity 23

Study found: Tailoring activities to capabilities of individuals with dementia resulted in

– Reduction in behavioral symptoms and – Improvement in quality of life. – Reductions in time spent in daily care by

caregivers.

23 , Gitlin et al., 2009, The Gerontologist Gitlin et al.,American Journal of Geriatric Psychiatry (in press)

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Person Centered Activity

Moderate 24

Indoor gardening effective for: sleep, agitation, cognition Fewer behaviors

Severe 25

Sensory-focused strategies: aroma, preferred or live

music, and multi-sensory

stimulation.

24 Lee Y, Kim S. Effects of indoor gardening on sleep, agitation, and cognition in dementia patients - a pilot study. Int J Geriatr Psychiatry. 2008 May;23(5):485-9. 25 Kverno KS, Black BS, Nolan MT, Rabins PV. Research on treating neuropsychiatric symptoms of advanced dementia with nonpharmacological strategies, 1998-2008: a systematic literature review. Int Psychogeriatr. 2009 Oct;21(5):825‐43.

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Use Lots of Music Why Music ? No “earlids”. It is a “stream” of stimulation. Music screens are “procedural memory”.

– Peak memory built during/after puberty. – Familiarity, simplicity keep stream flowing. – Knowing induces relaxation, melatonin. – Complex, unfamiliar builds stress, cortisol.

H-D

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Person Centered Religious Early Stage Dementia:

– A perpetual novena; lighting a candle for a specific prayer request.

Middle Stage: – Attending complete religious services – Attending abbreviated liturgical service – Singing Hymns

End Stage: – Holding and reciting the Rosary, – Engaging in ritualistic prayer, – Holding religious icons and singing songs.

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Simulate a Comfort Zone 26 7-day-a-week program is staffed by specially trained

nursing assistants who provide activities of daily living in an unhurried manner, with a ''loving touch'' approach to care.

Residents were involved in the program for at least 30 days showed a decrease in residents' withdrawal, social interaction, delirium indicators, and trend for decreased agitation.

26 Simard J, Volicer L. Effects of Namaste Care on residents who do not benefit from usual activities. Am J Alzheimers Dis Other Demen. 2010 Feb;25(1):46‐50.

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see Handout d on page 22 and 23




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What is a Behavior Intervention ? The systematic design, implementation, and evaluation of procedures that result in positive changes in behavior.

These procedures include: – Environmental modifications, – Staff or other resident behavior modifications – Distractive activities & devices – Need satisfaction – Teaching new/renewed skills

These procedures are designed to provide the resident: – Reduced anxiety – Reduced behaviors – Increased pleasure

These procedures – Provide the resident’s Least Restrictive Environment – Respect the resident’s human dignity and personal privacy – Assure physical freedom, social interaction, individual choice – Do not include procedures that cause pain, punishment or trauma.

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Three Levels of Interventions Behavior Advice Done by Social Work & Activities Preferences & points of engagement Selected, used & measured by care staff Behavior Guidelines Done by care team (STEAM & ABC) Things to do

– If warning signs seen – Doing troublesome ADLs

Behavior Plans Done by care team with clinical team For frequent, severe high impact or MDS 3.0 Proactive, reactive things that must be done Measured efficacy against specific goals

Behavior Plans

Behavior Guidelines

Behavior Advice

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Three Types of Interventions Proactive Advice about needs before problems arise.

Active Guidelines to calm residents calm so needs can

be addressed.

Reactive Plans address challenging behaviors if they occur. Allow resident to calm to a point where it is possible

to address needs (proactive + active).

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Proactive Advice Non Verbal Redirect to another

activity Eye contact Close Proximity Touch Effective use of space Body posture Facial expression Access to preferred

Objects Environment Control

Verbal Ventilation Distraction Reassurance Understanding “Modeling” Humor One-to-one Coping strategies Natural consequences Positive language

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Active Strategies

Communication Have you offered an opportunity for the individual to communicate using objectives, signs, symbols, or speech, and have you responded positively?

Choice Have you offered another activity and encouraged the individual to choose?

Environment Have you offered a change of location or setting e.g. a smaller space, a low distraction area and have you adapted the environment to support the individual?

Physical Needs Have you considered hunger, thirst, pain, heat, cold, tiredness, activity or need of the toilet?

Interaction Have you offered a change of staff member and responded to the need for attention?

Therapeutic Alternatives

Have you offered music, massage, aromatherapy?

Relaxation Have you tried deep breathing, slow breathing, yoga?

Calming Techniques Have you used verbal and nonverbal calming to include: reflection, empathy, reassurance, redirection, incentives and rewards?

Listening Techniques

Have you listened, read the signs, picked up cues, and given prompts rather than hurrying to give advice?

Sensitivity Have you helped to restore the individuals confidence and dignity by sensitivity rather than being confrontational and have you offered a constructive functional activity?

H-E

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Recapping

Evaluating Behaviors Treating the behavior De-escalation process

45

H-F

see Handout e on page 24

see Handout F on page 25 and 26




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QUESTIONS?

For Alfred Norwood’s Contact Information

contact Avila Institute 518.537.5000

or email Sr. Peter at [email protected]

Behavior Managem

ent Strategies

© 2011 Behavior Science, Inc. and Avila Institute of G

erontology, Inc.

Handout a

ResIden

tsta

FFco

ntRo

L

posItIV

e

neG

atIVe

WILd

caRd

sd

rug Intoxication

delirium

•

DrugIntoxication

•Lew

yBody•

Medical

(infection, B12 etc.)

depression/a

gitation•

Morning

•Evening(sundow

ning)•

Continuous

pain•

Whenm

oved•

Continuous

BeHaVIoR

pRoa

ctIVe

Medication

•MonitorH

ealth•

PyschotropicMeds

•Other

environment

•SensoryA

ppropriate•

Wayfinding

•Repetitive/Structured

•Rem

iniscent

standard therapy•

Behavioral•

Reality•

Validation•

Reminiscence

alternative therapy

•ArtTherapy

•MusicTherapy

•ActivityTherapy

•Com

plementaryThrpy

•Arom

aTherapy•

BrightLightTherapy

Resident plans•

Advice•

Guidelines

•BehaviorPlans

unit/team

•

ADLRituals

•Com

fortZones•

TransitionPlans

actIV

eW

arning signs•

IncreasedMovem

ent•

StartVerbalizations•

Withdraw

al•

Complaining

•Rocking

•AttentionSeeking

•Other?

Religion

Medical strategies

•PhysicalExam

ination•

SedativeMeds

•PainM

edication/TIMS

•SleepM

edication

Behavioral strategy•

ReduceStress•

GiveA

ttention•

Distraction

•Rew

ards•

PlannedIgnoring•

BusyBox•

Work/H

elping•

PreferredMusic

ReactIV

eBehaviors•

Aggression•

Yelling•

Agitation•

NoSleep

•NonCom

pliance•

Wandering

•Elopem

ent•

NotEating

Medical strategies

•PainM

edication•

PsychotropicPRN

Behavioral strategies•

Punishment

•Calm

ing•

OneonO

ne•

Removal

•Isolation

•PlannedIgnoring

Proactive Delirium Management

© 2011 Behavior Science, Inc. and Avila Institute of Gerontology, Inc.

Handout B

Identify High Risk Residents

Recognize & treat symptoms

use proactive strategies

• Oldage,• existingdementia,• male,• previoushistory,• significantmedicalhistory,• Pooreyesight/hearing,• Frailty,• Immobility

• Suddenchangesinmentalstate• UnexplainedConfusion• Shouting• Restlessness• EmergingHypo-activity• SleepingDifficulties

• Appropriatelylitenvironment• Minimize#ofstaffprovidingcare• Makeresidentfamiliarwithcarestaff• Staffwillexplain&introducecare• Trainstaffonrecognizingdelirium• Trainonsundownsyndromemanagement• Staffensureuseofglasses/hearingaides• Staffremindsresidentoftimeanddate• Reviewmedication/druginteraction

Tabet, N, Howard, R; Non-pharmacological intervention in the prevention of delirium; Age & aging, 2009, 38: 374-379

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Therapies


Handout c

standard non-pharm therapies

Simon Douglas, Ian James and Clive Ballard; Non-pharmacological interventions in dementia; Advances in Psychiatric Treatment (2004) 10: 171-177

Behavioral therapy (a)• Assessfortriggers(STEAM),behaviors

andreinforcers(ABC:antecedents,behaviors& consequences)

• Usedata,individual’spreferences,context in which the behavior takes place; and rein-forcement strategies to reduce the behavior

Reality orientation (B)• Fightmemoryloss&disorientationby

reminding of facts about selves & their environment

• Usedevicessuchassignposts,notices & other memory aids

Validation therapy (c)• Communicatebyempathizingfeelings&

meanings hidden behind their confused speech and behavior

• Emotionalcontentofwhatisbeingsaidthatismoreimportantthantheperson’sorienta-tion to the present

Reminiscence therapy• Relivepastexperiences,especiallythosethat

might be positive and personally significant using art, music and artifacts to provide stimulation.

• Canimprovebehavior,well-being,socialinteraction, self-care and motivation

art therapy (B)• drawing&paintingprovideindividualswiththe

opportunityforself-expression&achanceto exercisesomechoice(colors&themes).

• Canprovidemeaningfulstimulation,improvesocialinteraction and improve levels of self-esteem.

Music therapy (B+)• Usingamusicalactivity(e.g.singingorplayingan

instrument), or merely listening to songs or music• Increasesinlevelsofwell-being,bettersocial

interaction, improvements in autobiographical memory, reduced abnormal vocalizations, agitation

• Betterresultsfrommusicpreferredwhenpatientwas 15-25 years old

activity therapy (B)• Physicalrecreationssuchasdance,sportanddrama• Canreducethenumberoffalls,improvemental

health, sleep while reducing daytime agitation and night-time restlessness & fulfilling a need for sooth-ing,non-sexualphysicalcontact

complementary therapy (c)• Massage,reflexology,reiki,therapeutichealing,

herbal medicine.• Notmuchresearchonefficacyeitherfororagainst

aromatherapy (B)• Inhalation,bathing,massageandtopicalapplica-

tion lavender and melissa balm• Shownsignificantreductionsinagitation,

withexcellentcomplianceandtolerability

Bright-light therapy (B)• Reducethefluctuationsindiurnalrhythmsthat

may account for night-time disturbances and ‘sundownsyndrome’(recurringconfusionor agitation in the late afternoon or early evening) in people with dementia.

• Some evidence for improving restlessness and with particular benefit for sleep disturbance

alternative therapies

pG 21

How

Music is U

sed for Individual Residents


erontology, Inc.

Handout d

(1)

Intervention

Morning D

isorientation

Resists/Overly dependent in A

DLs

Refusing medications/food

Evening Disorientation

Not Sleeping at N

ight

Wandering/Repetitive Vocalization

Apathetic/W

ithdrawn

Above Average Illness/Infection

Behavioral explanation

•Residentdisorienteduponawaken-

ing,increasedmorningcarediffi

culty •Residentisoverstim

ulated•A

DLisoverlydem

anding•Conflictbetw

eenhabitandADL(e.g.

schedule/steps/processes)•A

DLgeneratespatientpainorim

-pacts m

odesty

•Residentisoverstimulated,distract-

ed and/or paranoid

•Residentdisoriented•Circadianrhythm

disrupted•Residentafraidofdark/room

•Residentgetsupaftergoingtobed,m

ay refuse to go back to bed, due to under stim

ulation or confusion after going to bathroom

•Residentbored&selfstim

ulating•Residentoverstim

ulated•Residentunderstim

ulated

•Residentdepressed/disconnected•Currentenvironm

entiseitherover/under stim

ulating

•Residentfeelschronicconfusionandstress

•Excesscortisolreducesimm

unity

prescription

•PlaypreferredMorningCD

15min-

utespriortobeginningcare.Wake

slowly, gently w

ith complem

ents

•Playany10-15minutespreferredCD

priortobeginningA

DL.A

pproachwithcom

plement.Reducerequest

pace/complexity

•Inconsistentcaregiverinstructionse.g.useA

DLRitual

•PlayanyDiningCD

10-15minutes

before serving, during & after provid-

ing food/medication

•PlayanyEveningCD•BuildCD

into“bedtimeritual”

•Enforceritualuseeveryevening

•PlaypreferredEveningCDusing

repeat play button •Redobedtim

eritualwhentheyget

up referring them to m

usic playing

•Mapbehaviorfortim

e&place

•Priortotime/placeplayanym

ostpreferredEngineeredM

usicCD•Schedulecom

panionship/walk

•PlayHoliday/G

eneralCDs

•Usem

usictobuildbridge•G

raduatetoMorningCD

s/activity

•Reducedisorientationusingmul-

tiple,appropriateCDsdaily

(elevate m

elatonin/lower cortisol)

performance M

easurement

•Reducedagitationinapproach•Im

provedcompliancein1stA

DL

•Improvedm

ood,cooperation•ReducedCN

Atim

e/stress

•Improvedcom

pliance•Reducedpatientnegativereactions/

incidences•ReducedCN

Arisk/tim

e/stress•Reducedpsychotropicm

edsuse

•Reducedmedsrefusal

•Improvedtim

espenteating•Increasedfoodintake•Reduceddigestive/stim

meduse

•Positiveweightgain

•Reducedresistancetobedtime

•Reducedcaregivertime

•Longerrestorativesleeptime

•Increasednighttimespentinbed

•Reducedfatigue/sundowning

•Reducedriskincidenceoffalls•Reducedpsychotropicuse

•Reducedtimew

ander/vocalizingReducedfalls/incidencereports

•Reducedintrusions/hoarding

•Increasedengagement

•Reducedpsychotropicmeds

•Reducedmedicalvisits

•Reducedmedications

•Improvedindependence

How

Music is U

sed for Individual Residents


erontology, Inc.

Handout d

(2)

Intervention

Polypharmacy/A

DRs

OT/PT/ST N

on-compliance

Sundowners Prevention G

roup

Pseudo religious ceremony

Dining Program

The Comfort Zone

Reminiscence Program

Behavioral explanation

•Drugreactions/interactions

increase dementia behavioral

symptom

s

•Residentrejectsormisunder-

stands therapist requests & lacks

attention to focus on instruction

•Residentsbecomeagitatedatshift

change due to a combination of

fatigue and over stimulation

•Residentssufferfromparanoia

and hyper vigilance due to chronic confusion, but unable to attend conventional religious cerem

onies •Residentsw

ithmoderatetosever

dementia becom

e over stimulated

during dining. This cause agita-tion,excessdependence,pooreating and digestion

•Someresidents/participantsare

not comfortable in any conven-

tional environment. They spend

thedayagitatedandexhibitingavariety of behaviors

•Findingactivitiesthatholdtheattention of people w

ith severely im

paired cognition and mem

ory isdiffi

cult

prescription

•IntroduceEngineeredMusicinlieu

of new prescription or use m

usic to build drug holiday trial

•PlayfavoriteCDpriortorequest

•PlayappropriateEngineeredMusic

during session

•Bringsundownerstoaninsulated,

remote room

30 minutes prior to shift

change. Provide a snack and have them

listen to engineered music until

30 minutes after shift change

•Gatherresidentsw

ithsimilarreligious

backgrounds and play appropriate, engineered,religiousm

usic.Repeatthe m

ost familiar prayers of that

religione.g.HailM

ary’s,NiceneCreed,

TheLordsPrayer,theKaddish

•Rateallresidentsintermsofdining

needs and abilities. Bring high depen-dency residents to a sm

aller quieter room

.PlaygeneralDiningengineered

music

•Identifyatleast8peoplewhow

ouldfunction better in a highly structured, low

stimulation environm

ent. Provide a highly repetitive program

of daily activities in an isolated room

using one caregiver w

ith assistance for m

eals and toileting

•WeprovideaCD

withaprogression

of songs seniors have heard from

childhood to adulthood. Playing the m

usic to small groups can trigger

mem

ories and induce conversation

performance M

easurement

•Reduced“chemical”confusion

•Reducedpsychopharmuse/cost

•Reducedpsychvisits/expense

•Improvedcourseoftreatm

ent•Im

provedreimbursem

ent•Im

provedcompliance

•Reducedagitationandnursingrequirem

ents caused by comm

otion caused during shift change

•Reducedagitation•Reducedbehavioralsym

ptoms

•Relaxation•Reduceddepression

•Increasedfoodconsumption

•Increasedtimespentindining

•Increasedindependence

•Pullthat20%ofresidentsthatare

requiring80%ofnursingattention

off the unit.•Increasedresidentparticipation•D

ecreasedresidentagitation•Im

provedeating•Reducedillnesses&

comorbidity

•Didtheyparticipateindiscussion

Active Strategies


erontology, Inc.

Handout e

comm

unication

choice

environment

physical needs

Interaction

therapeutic alternatives

Relaxation

calming techniques

Listening techniques

sensitivity

Haveyouofferedanopportunityfortheindividualtocom

municateusing

objectives,signs,symbols,orspeech,andhaveyourespondedpositively?

Haveyouofferedanotheractivityandencouragedtheindividualtochoose?

Haveyouofferedachangeoflocationorsettinge.g.asm

allerspace,a low

distraction area and have you adapted the environment to

supporttheindividual?

Haveyouconsideredhunger,thirst,pain,heat,cold,tiredness,activity

orneedofthetoilet?

Haveyouofferedachangeofstaffm

emberandrespondedtothe

needforattention?

Haveyouofferedm

usic,massage,arom

atherapy?

Haveyoutrieddeepbreathing,slow

breathing,yoga?

Haveyouusedverbalandnonverbalcalm

ingtoinclude:reflection,em

pathy,reassurance,redirection,incentivesandrewards?

Haveyoulistened,readthesigns,pickedupcues,andgivenprom

pts ratherthanhurryingtogiveadvice?

Haveyouhelpedtorestoretheindividualsconfidenceanddignityby

sensitivity rather than being confrontational and have you offered a constructivefunctionalactivity?

Evaluating / Treating Behaviors


Handout F (1)

eVaLuatInG BeHaVIoRsThere are certain determinations to make or questions you can ask as you proceed with your assessment:

1. Isthebehaviornew?Ifso,whathaschangedintheenvironment,themental,emotional,orphysicalconditionhastherebeenanychangeinmedications,hasanexistingconditionworsened?

2. Isthebehaviorofsuddenonset?Didthebehaviorbegin“allatonce”asinatemperflairup,ordiditcomeongraduallyoveraperiodoftime?Whatoccasionedthetemperflairup?Whatchangedovertimethatmighthavebroughtonagradualchangeleadingtothebehavior?

3. Isthebehaviortheresultofaphysicalillnessorisitillnessrelated?Isthebehavior“normal”foraparticularillnesswhenunderstress?

4. Isthebehaviortheresultofamentaloremotionalillness?Checkforconsistencywithmen-talhealthdiagnoses,especiallyanxietyanddepression.

5. Isthebehavioraradicaldeparturefromthenormalpersonalityoftheindividual?Ifso,isita catastrophic reaction that may well be a one time occurrence.

6. Hasthepersonexhibitedthebehaviorinthepast?Isthisbehaviorconsistentwithpastbehaviorresultingfrompoorcopingskills?

7. Isthereapatterntothebehavior?Doesitoccuratthesametimeofdayornight,inthesame place, in the company of the same persons, etc.

8. Isthereconsistencyorinconsistencyinthecontentofachronicbehavior?Doesthecontent of the behavior , verbiage, or actions usually remain the same or does it change at times?

9. Istheverbalmaterialconsistentwithreality?Doestheindividualmakesenseinthecontextof present reality or does it appear that delusions, hallucinations, illusions, or magical think-ingmaybepresent?

10.Isthebehaviorescalatingoranexacerbationoffairlyconsistentbehavior?Isthebehaviorhappening with increased frequency and/or increased intensity.

If you answered numbers 3,4,5,6,8 and 9, yes, the likelihood of the cause of the behavior being other than mood are likely.

If you answer questions 1,2,7, and 10, yes, the behavior is likely to be caused by a situation. A yes answer to 6 and 10 could mean that old personality traits and poor coping mechanisms are becoming more entrenched and could signal that organicity is present.

pG 25

Evaluating / Treating Behaviors


Handout F (2)

eVaLuatInG BeHaVIoRsThere are certain clues you to observe when the individual’s behavior is beginning to escalate. The clues are emotional, verbal, actional, & visual and include but are not necessarily limited to:

• Increasingagitation,impulsiveness,andirritability.• Disturbancesofthoughtandperception.• Angerdisproportionatetoaparticularsituation.• Stayinginbedlongerthanusual;notwantingtochangeclothes.• Mistrustandsuspiciousness.• Notwantingtotalktoanyone,especiallyifthepersonhasbeenverysociableinpast.• Notwantingtoeat(Thisshouldbecheckedtodetermineifthecauseisaphysical

condition).• Thepersonseemstobelosingtouchwithhowhe/sheis,whoyouareandwherehe/sheis.• Excessfatigue.• Heightenedsensitivitytotheenvironment.• Misinterpretationofsensoryinformation.• Makingstatementsthatdonotmakessenseorthatthepersonordinarilyknowsisnottrue.• Seemstobelessconnectedtoreality.• Inabilitytoperformroutineandsimpletasksthatpersoncouldpreviouslyperform.• Facialexpressionseemstoindicateagrowinganger.• Argumentative.• Stubbornness.• Namecalling.• Startleresponseofindividualswithsensorydeficitswhenapproached.• Threats-physicalorpsychological.

tHe de-escaLatIon pRocess• Learnwarningsignsorchangesinthoughtprocesses,feelings,andbehavior(e.g.,restlessness,

increased irritability, impulsiveness, and non-compliance with care). Trust what you see, hear, and thinkandshareandcompareitwithotherstaff.Lookforpatternsinthewayapersontypicallyreacts to stress and note changes.

• Rememberthatbehaviorsarenotalwaysintentional-theyaresymptomsorattemptstocommunicate.• Keepinteractionssimple.• Removethepersonfromthestressororstressfulenvironment.• Donotcometocloseto,ortouchavolatile,highlychangedperson,allowthemtheirphysicalspace.• Youmayneedhelptodiffuseasituation,butdonotoverwhelmtheperson.Toomanypeople

may increase the sense of powerlessness of the person and cause them to react violently.• Donottrytoexplain,arguewith,orrestraintheperson.• Distractfromthethreateningsituationifpossible.• Maintainyourcalmandacalmenvironment.• Useverbalandnon-verbalresponsestosupportthepersonsabilitytostaycalm,cooperative,

and to maintain self-control. • Watchbodylanguageclosely.• Setclearandconsistentlimits.• Supporttheindividual’ssenseofself-worthandself-esteem.Allowthepersonto“saveface”.• Considerphysicalactivitiestoreleasetension.

pG 26

Distinguishing between Delerium, Depression & Dementia


Handout G

delirium

Abrupt, precise onset with identifiable date

Acute illness, generally lasting days to weeks but on occassion more than one month

Usuallyreversible,often completely

Usuallynopsychiatrichistorybut may have had episode of delirium before

Disorientationearly

Clouded,altered,changinglevel of consciousness

Variabilityfrommomentto moment, hour to hour, throughout the day

Both short- and long-term memory loss

Memory loss and abnormal thought processes predomi-nate; not depressed

Prominent physiologic changes

Strikingly short attention span

Disturbedsleep-wakecyclewith hour-to-hour variation

Marked psychomotor changes (hyperactive or hypoactive)

depression

Abrupt onset, often with prvious history

Variableduration;often recurrent pattern that is time-limited

Canbemanagedorreversed

Oftenpreviouspsychiatric history (including undiagnosed depressive episodes)

Complainsofpoorconcentra-tion and forgetfulness

“Idon’tknow”answers

Fluctuating cognitive loss

Equal memory loss for recent and remote events

Depressedmood(ifpresent)occurs first

Lessprominentphysiologicchanges, accompanied by in-crease or decrease in appetite

Attention span may be reduced; may not focus on questions

Disturbanceinsleep(insom-nia or hypersomnia) common, sleep-wake cycle variation not typical

Psychomotor retardation or activation

dementia

Gradual onset that cannot be dated

Longduration;progresses over years

Generally reversible, often chronically progressive

Usuallynopsychiatrichistory

Sometimes unaware of memory loss; disorientation later in illness

Near-miss answers

Generally stable from day to day (although cognitive loss is progressive)

Memory loss greatest for recent events

Memory loss occurs first

Lessprominentphysiologicchanges

Attention span not usually reduced

Disturbedsleep-wakecyclewith day-night reversal, not hour-to-hour variation

Psychomotor changes characteristically occurring late in the illness (unless depression develops)

pG 27




pG 28

References

1 NewpharmacologicalstrategiesfortreatmentofAlzheimer’sdisease:focusondisease-modifyingdrugs;SalomoneS,CaraciF,LeggioGM,FedotovaJ,DragoF;BritishJournalofClinicalPharmacology(Oct2011)

2 Lupienetal;Theeffectsofstressandstresshormonesonhumancognition:implicationsforthefieldofbrain and cognition; Brain & cognition 2007

3 DickersonSallyS;GableShellyL;IrwinMichaelR;AzizNajib;KemenyMargaretE;Social-evaluativethreatandproinflammatorycytokineregulation:anexperimentallaboratoryinvestigation.JournaloftheAmericanPsychologicalSociety/APS2009;20(10):1237-44.

4 CyndieKMannesse,etel;Adversedrugreactionsinelderlypatientsascontributingfactorforhospitaladmission:crosssectionalstudy;BMJ1997;315:1057–8

5 PatriciaA.Parmelee1,IraR.Katz1,2andM.PowellLawton;IncidenceofDepressioninLong-termCareSettings;JournalofGerontologyVolume47,Issue6Pp.M189-M196

6 MarcantonioER.Dementia.In:BeersMH,JonesTV,BerkwitsM,KaplanJL,PorterR,eds.MerckManualofGeriatrics.3rded.WhitehouseStation,NJ:Merck&Co,Inc;2000:357-371.

7 JothikaN.Manepalli,MD,MehretGebretsadik,MD,JaimeHook,MD,andGeorgeT.Grossberg,MD;Dif-ferentialDiagnosisoftheOlderPatientWithPsychoticSymptomsPrimaryPsyciatry;August2007

8 PhilippeVoyer;PredisposingFactorsAssociatedWithDeliriumAmongDementedLong-TermCareResi-dents;ClinicalNursingResearch,Vol.18,No.2,153-171(2009)

9 BanerjeeS.TheUseofAntipsychoticMedicationforPeoplewithDementia:TimeforAction.DepartmentofHealth,2009

10 BRUCEGUTHRIE1,STELLAANNECLARK2,COLINMCCOWAN1Theburdenofpsychotropicdrugprescrib-inginpeoplewithdementia:apopulationdatabasestudy;AgeandAgeing2010;39:637–642

11 AdrianTreloar,FRCP,MRCPsych,MRCGPetal;Ethicaldilemmas:shouldantipsychoticseverbeprescribedforpeoplewithdementia?;TheBritishJournalofPsychiatry(2010)197:88-90

12 Tabet,N,Howard,R;Non-pharmacologicalinterventioninthepreventionofdelirium;Age&aging,2009,38:374-379

13 JohnT.O’Brien,etal;ALongitudinalStudyofHippocampalVolume,CortisolLevels,andCognitioninOlderDepressedSubjects;AmJPsychiatry161:2081-2090,November2004

14 SebastianKöhler,etal;Whitematterhyperintensities,cortisollevels,brainatrophyandcontinuingcogni-tivedeficitsinlate-lifedepressionTheBritishJournalofPsychiatry(2010)196:143-149

15 JormAF.Historyofdepressionasariskfactorfordementia:anupdatedreview.AustNZJofPsychiatry.2001;35:776-781

16 DongH,CsernanskyJG;Effectsofstressandstresshormonesonamyloid-betaproteinandplaquedepo-sition;JAlzheimersDis.2009Oct;18(2):459-69.

17 ButtersMA,BhallaRK,MulsantBH,etal.Executivefunctioning,illnesscourse,andrelapse/recurrenceincontinuationandmaintenancetreatmentoflate-lifedepression:istherearelationship?AmJGeriatrPsychiatry.2004;12:387-394.




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18 JournalofEpidemiology.1997;7:210BritishMedicalJournal.1998;316:1714--1719.19 ArchivesofGeneralPsychiatry.1998;55:259--265.AmericanJournalofPsychiatry.1997;154(5):630--634.TheJournal

oftheAmericanMedicalAssociation.1998;279:1720

20 SAMHSAOlderAmericansTechnicalAssistanceCenter“Evidence-BasedPracticesforPreventingSubstanceAbuseandMentalHealthProblemsinOlderAdults.”

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pG 30

Meet the speaker

alfred W. norwood, Bs, MBaPresident and Founder of Behavior Science, Inc

Alfred Norwood is the President and Founder ofBehaviorScience,Inc.(1997-present).Heisa behavioral psychologist who uses primarily ABA techniques and neurological research to resolve behaviors in community and institutional based dementia patients. Hehasworkedasaconsultantforchainfor-profit, non-profit and independent SNFs andALFsandtrainedstaffintheuseofnon-pharmaceutical, individualized care plans for residents with moderate to severe dementia. All training programs and techniques have resulted from working directly with specific nursingunits,CNA’sandresidents.Thetechniques he employs for training are the resultofextensivetrainingexperienceandhisunderstanding of the neurology of attention, consciousprocessing&memory.Hisclientsare taught to use a wide variety of easy to deploy non-pharmacological interventions for the most commonly seen behaviors to build highly individualized pro-active and effective care plans. All interventions are research based and proven in numerous successful applications. HisprogramsweretestedbyalocalCountyLTCagencyandqualifiedforreimbursementunder Medicaid waivers. Similar tests were conductedforLTCinsurancewhoalsoelectedtoreimbursepolicyholdersfortheS&LCprogram. The original program was based upon 18 months of his in home treatment conductedinpartnershipwithAlzheimer’s&DementiaOutreachprogramofViaHealthHomeCare.

Mr.Norwoodhasalsodeveloped“EngineeredMusic”.Thishighlyeffectiveinterventionisbased upon the use of individualized albums of music, preferred by dementia patients during pre-morbid times. Each song is engineered to accommodate common neural losses in thepre-frontal/frontalcortexandmedialtemporal lobe e.g. the music includes only easily understood timbres and chord structures with highly entrained and prominent melodies to enhance patient comprehension. Albums are composed of collections of songs which reinforce problematic behaviors e.g. slow tempo, minor key, songs with lyrics about evening, night or sleep used to prepare dementia patients for bed or keep them in bed. Mr. Norwood developed a process using team dynamics to force consensus on critical organization issues. The process has been used by high growth, high technology companies, companies supplying acute and long term care providers and care providing teams themselves e.g. nursing units, home healthcareteamsetc.HealsohasworkedwithLTC&ALF’sfacilitiesandPACEsitesfor15years in cost effective improvement of care for residents with dementia.

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Effective Interventions for Residents with Behavior Concernseo2.commpartners.com/users/ig/downloads/111118_Presentation... · Handout A ..... 19 Handout B ... Comfort Zones Transition