8/12/2019 Health Promotion on Dementia
1/49
Introduction to dementia and
effective communication for
healthcare professionals with
patients living with dementia
Elisabeth Serrano
8/12/2019 Health Promotion on Dementia
2/49
Dementia: what is it?
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
3/49
Ten glorious seconds
Ten Glorious Seconds
Elisabeth Serrano Prieto
http://www.tengloriousseconds.com/index.php?option=com_content&view=article&id=94&Itemid=468http://www.tengloriousseconds.com/index.php?option=com_content&view=article&id=94&Itemid=4688/12/2019 Health Promotion on Dementia
4/49
Facts About Dementia in the UK
According to Dementia.org.uk, dementia is one ofthe main causes of disability in later life, ahead ofsome cancers, cardiovascular disease and stroke.
Over 820,000 people are estimated to besuffering from late onset dementia in the UK in2010
By 2025, the number is expected to rise to onemillion. By 2051, it is projected to exceed 1.7
million One in three people over 65 will die with a form
of dementia.
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
5/49
Dementia
Definition:
Dementia is a syndrome(a group of related symptoms) that is associatedwith an ongoing decline of the brain and its abilities. These include:
memory
thinking
language understanding
judgement
People with dementia may also become apathetic, have problems controllingtheir emotions or behaving appropriately in social situations. Aspects of theirpersonality may change or they may see or hear things that other people do
not, or have false beliefs. Most cases of dementia are caused by damage tothe structure of the brain. People with dementia usually need help fromfriends or relatives, including help in making decisions.
Definition taken from NHS, available at: http://www.nhs.uk/Conditions/Dementia/Pages/Introduction.aspx
Elisabeth Serrano Prieto
http://www.nhs.uk/Conditions/Dementia/Pages/Introduction.aspxhttp://www.nhs.uk/Conditions/Dementia/Pages/Introduction.aspx8/12/2019 Health Promotion on Dementia
6/49
General early symptoms
Patients should seek help without delay if their memory is not as goodas it used to be and especially if they:
struggle to remember recent events, although they can easily recallthings that happened in the past
find it hard to follow conversations or programmes on TV
forget the names of friends or everyday objects cannot recall things theyhave heard, seen or read
notice that they repeat themselves or lose the thread of what theyare saying
have problems thinking and reasoning
feel anxious, depressed or angry about memory loss find that other people start to comment on their memory loss
feel confused even when in a familiar environment.Extract from: http://www.slh.nhs.uk/media/documents/worried-about-your-memory-poster.pdf
Elisabeth Serrano Prieto
http://www.slh.nhs.uk/media/documents/worried-about-your-memory-poster.pdfhttp://www.slh.nhs.uk/media/documents/worried-about-your-memory-poster.pdfhttp://www.slh.nhs.uk/media/documents/worried-about-your-memory-poster.pdfhttp://www.slh.nhs.uk/media/documents/worried-about-your-memory-poster.pdfhttp://www.slh.nhs.uk/media/documents/worried-about-your-memory-poster.pdfhttp://www.slh.nhs.uk/media/documents/worried-about-your-memory-poster.pdfhttp://www.slh.nhs.uk/media/documents/worried-about-your-memory-poster.pdfhttp://www.slh.nhs.uk/media/documents/worried-about-your-memory-poster.pdfhttp://www.slh.nhs.uk/media/documents/worried-about-your-memory-poster.pdfhttp://www.slh.nhs.uk/media/documents/worried-about-your-memory-poster.pdf8/12/2019 Health Promotion on Dementia
7/49
Differentiating normal aging and dementia
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
8/49
Types of dementia1. Alzheimers Disease
2. Vascular Dementia
3. Lewy Body Dementia
4. Other rarer causes of Dementia
8/12/2019 Health Promotion on Dementia
9/49
Types of dementia:
Alzheimers Disease (AD)
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
10/49
Alzheimers Disease
Most common cause of dementia
Symptoms: gradual decline in thinking
abilities. Nearly all brain functions (memory,
movement, language, judgement, behaviour,
and abstract thinking) are eventually affected.
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
11/49
Alzheimers Disease (AD)
Characteristics:
Two abnormalities in the brain:
- Amyloid plaques: unusual clumps of a betaamyloid protein, and degenerating bits of
neurons and other cells.
- Neurofribillary tangles: bundles of twisted
filaments found within neurons made of a
protein called tau.
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
12/49
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
13/49
Alzheimers Disease
As the disease progresses patients are more
limited in their daily activities. Emotions and
behaviour are also affected.
Patients may become disorientated, suffer
delusions.
During the later stages patients lose the
ability to control motor functions
(swallowing, bowel and bladder control)
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
14/49
Alzheimers Disease
On average, patients with Alzheimer's disease
live for 8 to 10 years after they are diagnosed.
However, some people live as long as 20 years.
Patients with Alzheimer's disease often die of
aspiration pneumonia because they lose the
ability to swallow late in the course of the
disease.
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
15/49
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
16/49
Types of dementia:
Vascular Dementia (VaD)
8/12/2019 Health Promotion on Dementia
17/49
Vascular dementia (VaD)
VaD: secondmost common cause of
dementia.
Decline in mental abilities due to brain
damage from cerebrovascularor
cardiovascularproblems.
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
18/49
Vascular dementia (VaD)
Characteristics:
Unlike AD VaD patients often maintain theirpersonality and normal levels of emotionalresponsiveness until the later stages of thedisease.
People with VaD often wander at night, and
suffer from other problems commonly foundin stroke patients (depressionandincontinence)
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
19/49
Risk factors predisposing individuals to VaD
Hypertension
Cardiovascular disease
Smoking
Excessive alcohol consumption
Diabetes Mellitus
Lower educational background
Hyperlipidemis
Old age
History of previous strokes
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
20/49
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
21/49
Types of dementia:
Lewy Body Disease (LBD)
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
22/49
Lewy Body Disease
Lewy body dementia (LBD) is the third mostcommon types dementia.
LBD usually occurs sporadically
Abnormal structures, known as Lewy bodies,develop inside the brain.
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
23/49
Lewy Body Dementia
Characteristics
In Lewy body dementia, cells die in the brain'scortex (outer layer), and in a part of the mid-braincalled the substantia nigra. Many of theremaining nerve cells in the substantia nigracontain abnormal structures called Lewy bodies.
Memory impairment, poor judgement,confusion. LBD also includes visual
hallucinations, parkinsoniansymptoms. LBD patients live an average of 7 years after
symptoms begin.
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
24/49
Rarer Causes of dementia
Creuzfeldt-Jakob Disease
Huntingtons Disease
Chronic Traumatic Encephalopathy (Boxers Syndrome)
Dementia due to HIV
Parkinsons Disease
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
25/49
Ethical Issues
Elisabeth Serrano Prieto
1. Driving
2. Competence orcapacity
3. Valid consent
8/12/2019 Health Promotion on Dementia
26/49
1. Driving and dementia
Driving is unsafe for people with dementia and
can also endanger others.
Healthcare professionals need to remind a person
with a diagnosis of dementia of the patients legalobligation to inform the UK Driver and Vehicle
Licensing Agency of their condition.
If there are concerns that a patient who shouldnot be driving is doing so, it is a permissible
breach of confidentiality to inform the DVLA.
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
27/49
2. Competence/Capacity
General criteria for competence:
A person should be able to:
Understand information relevant to the required decision
Use the information rationally, e.g. make a risk/benefitcomparison
Appreciate the situation and its consequences
Communicate choices
In legal and medical jargon the terms are different but meanthe same: COMPETENCE (MEDS), CAPACITY (LAWYERS).
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
28/49
3. Valid consent
Health and social care professionals should always
seek valid consentfrom people with dementia.
This should entail informing the person of options,
and checking that he or she understands, that thereis no coercionand that he or she continues to
consentover time.
If the person lacks the capacity to make a decision,the provisions of the Mental Capacity Act 2005
must be followed.
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
29/49
Proposals currently being put forward
Capacity Assesment
Proxy consent: relatives
Fluctuating capacity Proposals for change:
Graduated consent for graduated risk
Joint consent Risk assessment
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
30/49
The ethics of consent in delirium studies Journal of Psycvhosomatic
Reseach 65 (2008) 283-287Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
31/49
COMMUNICATION
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
32/49
What would you do?
Case scenario:
An elderly dementia patient tries to leave the
ward as she says that she has to go home to
cook her fathers tea. She is angry when you
ask her to stay on the ward as she fears he is
expecting her home soon and she will be in
trouble
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
33/49
Methods to improve communication
Communication vs conversation:
Seven step guide
Good Medical Practice Guidelines
NICE Guidelines
VERA Framework
19 tips for communicating with PLWD
Other methods: singing for the brain
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
34/49
Good Medical Practice Guidelines
Good communication22 To communicate effectively you must:
(a) listen to patients, ask for and respect their views
about their health, and respond to their concerns
and preferences
(b) share with patients, in a way they can understand, the
information they want or need to know about their
condition, its likely progression, and the treatmentoptions available to them, including associated risks
and uncertainties
(c) respond to patients questions and keep them informed
about the progress of their care
(d) make sure that patients are informed about how
information is shared within teams and among thosewho will be providing their care.
23 You must make sure, wherever practical, thatarrangements
are made to meet patients language and communication
needs.
Full text available at: http://www.gmc-uk.org/static/documents/content/GMP_0910.pdf
Elisabeth Serrano Prieto
http://www.gmc-uk.org/static/documents/content/GMP_0910.pdfhttp://www.gmc-uk.org/static/documents/content/GMP_0910.pdfhttp://www.gmc-uk.org/static/documents/content/GMP_0910.pdfhttp://www.gmc-uk.org/static/documents/content/GMP_0910.pdf8/12/2019 Health Promotion on Dementia
35/49
NICE Guidelines
http://www.gmc-uk.org/guidance/index.asp
Good Medical Practicehttp://www.gmc-uk.org/static/documents/content/GMP_0910.pdf
Consent:http://www.gmc-uk.org/static/documents/content/Consent_0510.pdf
Interactive Case Studies:http://www.gmc-uk.org/guidance/index.asp
Advice for medical students:http://www.gmc-uk.org/education/undergraduate/professional_behaviour.asp
Elisabeth Serrano Prieto
http://www.gmc-uk.org/guidance/index.asphttp://www.gmc-uk.org/static/documents/content/GMP_0910.pdfhttp://www.gmc-uk.org/static/documents/content/Consent_0510.pdfhttp://www.gmc-uk.org/guidance/index.asphttp://www.gmc-uk.org/education/undergraduate/professional_behaviour.asphttp://www.gmc-uk.org/education/undergraduate/professional_behaviour.asphttp://www.gmc-uk.org/education/undergraduate/professional_behaviour.asphttp://www.gmc-uk.org/education/undergraduate/professional_behaviour.asphttp://www.gmc-uk.org/education/undergraduate/professional_behaviour.asphttp://www.gmc-uk.org/guidance/index.asphttp://www.gmc-uk.org/guidance/index.asphttp://www.gmc-uk.org/guidance/index.asphttp://www.gmc-uk.org/static/documents/content/Consent_0510.pdfhttp://www.gmc-uk.org/static/documents/content/Consent_0510.pdfhttp://www.gmc-uk.org/static/documents/content/Consent_0510.pdfhttp://www.gmc-uk.org/static/documents/content/GMP_0910.pdfhttp://www.gmc-uk.org/static/documents/content/GMP_0910.pdfhttp://www.gmc-uk.org/static/documents/content/GMP_0910.pdfhttp://www.gmc-uk.org/guidance/index.asphttp://www.gmc-uk.org/guidance/index.asphttp://www.gmc-uk.org/guidance/index.asp8/12/2019 Health Promotion on Dementia
36/49
NICE GUIDELINES
Patients who show a Mild Cognitive
Impairment, should be assessed as soon as
possible, as most patients who show MCI,
have a 50% chance of later developingdementia.
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
37/49
MINI MENTAL STATE EXAM
Case example of deterioration on the same
exam:
Example
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
38/49
VERA Framework
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
39/49
VERA FRAMEWORK
Published as an article to offer guidance forstudent nurses communicating with patients withdementia.
The framework is based on 4 key concepts:
validation, emotion, reassurance, activity. Framework was developed in response to
students who said they find it useful to havestructured guidance on how to interact with
people who have dementia. The VERA frameworkoffers a means of interpreting communicationand responding appropriately.
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
40/49
Validation
A genuine acceptance of the client at face value and includes an empathic search for justification
of the clients experience. Validation therapy does not attempt to impose a current reality in
terms of dates or times; rather, the therapist explores the underlying meaning of the clients
behaviour and speech. This approach offers helpful communication techniques and can assist
practitioners to develop an understanding of what may appear to be confused and inappropriate
behaviour. Validation therefore is the act of giving value to a persons behaviour rather than
assuming it is merely a symptom of a degenerative brain condition . It challenges the notion that
actions with no apparent meaning or significance should be ignored or responded to
behaviourally. Acceptance of the person, regardless of behaviour, is central to the development
of a supportive and therapeutic relationship, based on unconditional positive regard. (Rogers
1961)
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
41/49
Emotion
This step in the vera scheme develops the idea of paying attention to the emotional contentof the communication, rather than the unintelligible verbal content. Paying attention to theemotional content underlying an attempt to communicate ensures that meaning is extractedfrom communication that is difficult to understand.
Experienced and skilled practitioners are able to respond and make a connection with peoplewho are confused, even when the words the person uses to express him or herself areunintelligible or out of context. This is achieved by listeningfor and acknowledgingtheemotional content of the communication and finding a matching emotional response to it.
To develop an understanding of a persons emotional communication health carers need to beskilled listeners and observers, and pay attention to body language, vocal tone and facialexpression all of which communicate a message about a persons emotional state at themoment.
This has to be accompanied by a GENUINELY felt verbal sentiment, genuine interest in theperson and a belief in ones ability to make a connection with the patient.
By trying to reach an understanding of how a patient perceives the world, healthcareprofessionals avoid the CONFLICT that could be caused by insisting that their view is one thatmust be accepted.
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
42/49
Reassurance
Reassurance is any verbal or non-verbal communicationthat seeks to
reduce a persons distress by demonstrating kindness and optimism.
Reassurance can be conveyed by saying it will be ok, or through a
kind smile or a moment of hand holding. (Teasdale 1989).
Humanistic traits, skills and attributes, and what the patient is being
told create an experience of TRUST between the patient and the
health professional. Reassuring interactions have been coupled with
an assertion of optimism.
Reassurance implies action.
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
43/49
Activity
The activity should be an attempt to engage the
person in a more structured activity that
offers a degree of occupation.
The activity that emerges may link to an
understanding of the confused behaviour or
could be designed merely to create socialinteractionwith other people as an act of
joining with the person as a human being.
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
44/49
After Activity
Recordingpositive or negative outcomes
Discussingthe effect of the interaction with
other members of the team
Moment of reflection on the practitioners
responses to the four elements of the VERA
framework.
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
45/49
19 tips for communicating with PLWD
1. Do not talk to the patient as if he/she isnot present.
2. You need the patients attention to startcommunication.
3. Minimize distractions.
4. Move slowly and approach from the front,rather than the side or behind.
5. Look eye to eye.
6. Call the patient by his/her preferred ame.
7. Make your verbal and nonverbal messagesthe same.
8. Use simple, adult appropriate words.
9. Dont patronize.
10. Slow your rate of speech.
11. Give one message at a time.12. Listen for a response and allow time for
the patient to respond.
13. Repeat the question or request using thesame words, if necessary.
14. Be patient and keep it simple.
15. Acknowledge the patients concerns andquestions.
16. Use words that express respect andunderstanding.
17. Give the patient your undividedattention.
18. Use appropriate touch if the patient
enjoys it.19. Look friendly: your attitude is contagious.
Marge Coalman. The invisible population. The Journal on ActiveAging. Issue September 2002
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
46/49
Possible Response to Case Scenario
Validate: Youre trying to get home in time to gettea, Joan?
Emotion: You sounded quite upset and a bitworried.
Reassure: We will make sure youre ok, Joan.You are not in any trouble.
Activity: Come with me well make some tea totake your mind off it.
The success or failure of the activity is recorded andhanded over to other members of the care team.
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
47/49
Other methods: singing for the brain
Singing for the BrainElisabeth Serrano Prieto
http://www.nhs.uk/Conditions/Dementia/Pages/Introduction.aspxhttp://www.nhs.uk/Conditions/Dementia/Pages/Introduction.aspx8/12/2019 Health Promotion on Dementia
48/49
Conclusion
Effective communication is one of the key
points for excellent healthcare.
Remember VERA!
Read Good Medical Practice Guidelines
Good luck!
Elisabeth Serrano Prieto
8/12/2019 Health Promotion on Dementia
49/49
Thank you all for listening!