New App Created for People with Dementia

My colleague Gail Elliot in Ontario, Canada has used her never ending creativity to develop a fun program for people with dementia.  Here’s what she has to say about it:

It is often a challenge to find things that people with dementia can do successfully that truly engage the person in the activity.  An iPad app has been developed for people with dementia, but in fact it could be used by anyone who loves guessing games, called "Best Guess".  I was sure that people who grew up before the age of computers and other progressive technology might be resistant to using the iPad.  However, when I introduced the game to someone who was very agitated, because he was frustrated with having little to do that would leave him feeling like the competent man he used to be, he reluctantly agreed to work with me on the first couple of questions and then completely took over the device and played the game until lunch was served 40 minutes later.  He laughed when he read the answers that were the incorrect answers and brilliantly lit up when he checked the correct answer. In fact, he beamed when the "Well Done" icon appeared on the screen.  Some questions were more difficult so he did not feel it was childish.  The successful answers outnumbered the two he got wrong.  

I have since used the Best Guess app with a number of people in various stages of dementia and have learned that once I get them started I can actually walk away and leave them to enjoy the game on their own.  Many read the questions out loud and laugh when they read the "silly" answer.  

What a pleasure to see people with dementia engaged in an activity that adds joy and feelings of competence.  Give it a try!  Since it is a new app it is hard to find if you go directly to iTunes.  Use the generic Google search bar.  When you bring up Google's home page type in "iTunes Best GuessDemenitiAbility" and you will see it come up.  OR go to www.dementiability.com and find the link on that website.

Enjoy the game!

Gail Elliot, BASc, MA

Gerontologist and Dementia Specialist

New Methods to Support Wayfinding for Persons with Dementia

I recently served as Principle Investigator on a National Institutes of Health Small Business Innovative Research grant in partnership with the Center for Applied Research in Dementia. The purpose of our recent research was to develop and implement a signage system for long-term care that supports wayfinding for persons with dementia. Recognizing where one is and where one is going are critical aspects enabling persons with dementia to be self-sufficient. In unfamiliar situations people rely on environmental cues to find their way. When these cues are not easily interpreted due to cognitive impairment, autonomy gives way to dependency. The search for information to aid orientation may cause frustration, anger or agitation (Zgola and Bordillon, 2001). Poor wayfinding abilities have been found to impact resident safety, create conflict between residents (Rosswurm, et al., 1986), and cause unnecessary burden to nursing home staff (Everitt, et al., 1991). Residents who cannot identify paths to desired locations exhibit anxiety, confusion, mutism, and panic (Passini, et al., 2000). The stress caused by disorientation may result in feelings of helplessness, raised blood pressure, headaches, increased physical exertion, and fatigue (Carpman and Grant, 2001).

In dementia, the capacity for decision-making is reduced to decisions based on immediate and visually accessible information (Passini, et al., 2000). Since less visual information is taken in by persons with dementia (Koss and Gilmore, 1998), and they experience other visual challenges such as contrast and depth perception deficits, spatial disorientation, and difficulty judging certain colors, it is imperative that all cues in the environment are created using evidence-based design guidelines.

While the effectiveness of some cueing systems has been empirically tested, more research is needed to provide designers, care staff, and administrators with guidelines that can make a significant difference in environments for people with dementia. Thus, the purpose of this research study was two-fold:

1) gather information about the color, contrast and pictogram preferences of persons with dementia for dining room, activity room, bedroom, and restroom signs; and,

2) use this information for creating signs that increase wayfinding independence.

For this study, we used two methods to collect data. First, in the Human Factors phase, we had 28 persons with dementia identify the characteristics of the signage they preferred. Next, in Wayfinding Observations phase, 23 persons with dementia were observed walking to different locations in the care community pre- and post-intervention (i.e., before and after installing new signs designed based on resident preferences).

Phase 1 was carried out by having the persons with dementia view many different signs on easels placed out in front of them. Participants indicated which sign they preferred and their choices were recorded. From this process we were able to determine which combination of words, colors, and pictograms were the most favored.

Signage with a colored background were preferred over signs with a white background. The participants preferred bright green to dark green or white, bright magenta compared to dark purple or white, and bright royal blue compared to the dark navy blue or white.

In trials that assessed preference for the placement of words (before or after the pictograms), there was a trend to prefer the words to precede the pictogram on the sign, but not a strong preference. Participants were asked their preferences on eight pictograms. For activity room signage, the preference was for a pictogram of people seated playing a game compared to both the pictograms of a TV and people standing/waving. There was a trend to prefer the pictogram of a bowl of soup over a knife and fork or people seated at the table for the dining room signage. Participants preferred a pictogram of a toilet over a pictogram of a shape of the person (man standing) to indicate the restroom. Once we collected all of the data from the Phase 1, we used this data to develop a set of signs that were used during the wayfinding observations in Phase 2.

In the second phase, residents were accompanied on three different routes in the care community before and after installing the new signs. Time to walk to each location as well as the type and number of errors were noted. In general, a majority of participants showed improvement from baseline to post-test, especially with regard to time to navigate routes, though this showed variability across routes and locations. Overall, we found patterns of improvement in wayfinding in residents with dementia in two residential settings on a variety of outcomes. This was accomplished without any intervention other than placing the signage into these environments. Given the results of this study, we must consider that traditional approaches to signage in long-term care communities may not be adequate to support persons with cognitive impairment. There are still many aspects of signage that require in depth study, such as resident preference for other placement options, additional color choices, and the size and shape of signs. Regardless, if preferred designs of environmental cues are in place in dementia care

facilities, residents should be able to navigate more independently, thereby reducing their level of frustration and increasing their autonomy.

You can all of the details about the study in the full article:

Brush, J., Camp, C., Bohach, S., & Gertsberg, N. (2015). Creating supportive wayfinding for persons with dementia. Canadian Nursing Home, 26(1), 4-11.

©2015 Jennifer Brush, may not be reprinted or distributed without permission

Decorations and Dementia: A Few Things to Consider

I would like to welcome my friend and colleague Rev. Katie Norris, a guest blogger for us this month. Rev. Katie and I collaborated on a book called Creative Connections that will be available through Health Professions Press by April 2015. Christmas is just around the corner. Many of us are excited to decorate our homes and spend time with our families. For families living with dementia, the holidays can create additional stress and sadness. Persons with dementia may not be able to participate in the gift choosing, or house decorating any more. Persons with dementia may not even recognize their family who come to visit. Rev. Katie brings up some important points in this blog that remind us to view the world through the eyes of someone with dementia.

My Mom has always decorated our house for the holidays. At Christmas we had a huge tree with more ornaments than should have been put on it. She hung green garlands with red berries around the doors and put electric candles in every window of the house. She had two life-sized wooden Nutcracker cutouts and a beautiful Santa statue. And of course, we always switched out our daily dishes to the Christmas Spode, and made sure the tablecloth matched the plates.

My Mom has had Lewy Body dementia for eight years, and for many years we kept up all of the decorations in the house. First with Mom helping us decorate, and now we take care of it because she no longer can. After a while, the amount of decorations decreased, not only because it was a lot of work, but also because people with dementia function best in a clutter-free, familiar environment. Noticing that fewer decorations made Mom’s living space easier to function in helped me see the many issues that can come up when we think about decorating a house or care community for people with dementia. I wanted to share some of the issues that can happen with decorations in the hopes that you can asses how many decorations would work for your loved one with dementia in order to help them have a pleasant holiday season.

Decorations can make a once familiar space very unfamiliar. Knick-knacks, trees, holiday cards on the mantle, statues, etc… all add clutter to the environment. A distracting and unfamiliar environment can increase agitation and bring about some negative behaviors.

Decorations can make it harder for a person with dementia to find the items they use every day, and can decrease their independence. For example, a simple snowman shaped soap dispenser may be so unfamiliar, that your loved one stops washing their hands, or it makes the sink look so different that they can no longer turn on the water.

There are also many safety issues with decorations. A cute holiday throw rug is perfect for ending up with a fall and broken hip. Food shaped decorations can lead to an attempt to eat the item and are a choking hazard.

Lights on a Christmas tree cast shadows and can make it harder for a person with dementia to see and function in a room. Twinkling lights are highly distracting and jarring. This can not only lead to falls, but it can trigger or worsen the visual hallucinations often found in dementia. We also tend to use a lot of electrical decorations at the holidays, and the cords can increase the risk of falls.

Decorations can also increase behavioral issues. If the person with dementia feels the decorations should not be there, you may end up with negative behaviors, such as throwing the decorations in the trash, or your loved one rearranging all the decorations. It could even increase or trigger wandering outside of the house. If the house looks so different to them, they may think they are not in their own home and thus try to leave. Going after them and trying to convince them that this is their home can lead to arguments, or physical behaviors such as pushing or hitting.

Be careful when changing the plates and utensils you normally use. My Mom loves the Spode Christmas pattern and we used to change out our daily plates for the Spode every year. However, a patterned plate is cluttered and can cause frustration and picking at the plate after their food is already eaten. The pattern can also make it hard for a person with dementia to see what is food, and what is not. If they are unsure, they may just not eat, which is very common for people with dementia. Solid colored plates that have high contrast to the food you will be eating is best. For instance, turkey and mashed potatoes are hard to see on a white plate, but you could eat those items on a green plate. Fancy utensils may not only be uncomfortable because your loved one is not used to them, but also because they may be harder to hold if the handles are carved and curved, or very delicate.

When considering whether or not to decorate for the holidays, it is very important to know your loved one well. They may not be at a point where decorations make the house unfamiliar, and in fact, if you did not decorate, they may feel that is too much of a change. Assess whether or not you need to bring out all the decorations, or just some really important ones. In any stage of dementia though, decorate in the least cluttered way possible. For example, don’t tack holiday cards on the wall, or arrange them in the middle of your kitchen table.

It may also be good not to decorate in places where the person with dementia takes care of activities of daily living. Leave the decorations and changes out of the bathroom, kitchen table, bedroom, and around their main sitting or working area.

Think about the reason for your decorations and what you want to get out of decorating. Many of us are attached to tradition and decorating. We do it because it is a way to express love and care for our family and friends. It is a way to make our time together more festive and beautiful. If decorating the house brings more confusion and discomfort to our loved one with dementia, we have defeated the purpose of the meaning of the decorations. Rather than increasing joy and interaction, we increase confusion, which then can drastically increase feelings of worthlessness in our loved one.

Any event is about the relationships we foster, and the quality of time we get to spend with each other. Assess if your decorations meet the needs of your family interactions at this time, taking into consideration the changes brought about by dementia.

To start, I would suggest picking a few of your most favorite decorations and see if putting those up do not change the environment too much for your loved one, and work from there. This way you can still create the holiday atmosphere and keep your loved one comfortable and safe.

Blessings,

Rev. Katie

Why is Montessori Successful with People with Dementia?

“The essence of independence is to be able to do something for one’s self.”

People with dementia are often confronted with what they are no longer able to do or understand. In turn, the Montessori principles are designed to focus on what they are still capable of doing. This person-centered way to approach dementia focuses on the person's capabilities, grabbing their interest, and showing them respect. All Montessori principles have been designed to work with a certain type of memory (implicit or procedural), that is less affected by dementia. Implementing the practices of Montessori with older adults with dementia has also been shown to increase engagement in activities and positive moods.

We know that people with dementia need structure and order in their environment and activities, and often become upset when changes are made to their surroundings. The Montessori principles supports this desire of structure in that the materials are taken from the everyday environment and each lesson/ task is taught at its simplest level. Additionally, using the Montessori approach with people with dementia has been useful in assessing their cognitive, motor, and sensory functioning as well as social skills.

Who was Maria Montessori?

In a few weeks I’ll be visiting Sydney, Australia to attend and teach at the Montessori Environments for Dementia International Conference. In the time leading up to the conference, I thought I would share with you some information about the Montessori philosophy and why it is successful for people who are living with dementia. 

  

“The environment must be rich in motives which lend interest to activity and invite the child to conduct his own experiences.”  Maria Montessori

 

Who was Maria Montessori?

 

Maria Montessori, acclaimed for her revolutionary educational methods, was born in 1870 in Italy. Having an immense thirst for knowledge from early childhood, Maria entered an all-boys technical school at the age of 13 and from there gained admittance to the University of Rome’s medical school.  After graduating in 1896, Maria became the first female doctor in Italy, paving the way and becoming a role model for women of all ages.

Specializing in pediatrics and rehabilitative medicine, Maria opened a childcare center in 1907. She designed learning materials and a classroom environment around the children’s natural desire to learn. She believed that education is a natural process carried out by the child and is not acquired by listening to words but by experiences in the environment.  Her school rapidly became a success and by 1910, Montessori schools were renowned worldwide. The “Montessori Method”, as it is now called, is used as a way to approach dementia care.

 

Tips for Better Communication

            For all of us, not just someone with dementia, the ability to communicate and express our needs is of utmost importance. In order for someone with dementia to have a good relationship with a care partner, healthy and frequent communication is a key ingredient. If your loved one with dementia begins to lose social skills, he or she might become more withdrawn or isolated. As the person without dementia, you are the one capable of understanding and changing your approach when it comes to communication. If your loved one with dementia is having increased difficulty communicating, capitalize on what skills remain to compensate for any lost abilities. Think about what has changed and what is preserved.

 

 

Below are some simple strategies to help encourage communication and connect with your loved one with dementia more effectively:

 

Always speak respectfully using adult language.  As a professional care partner, refrain from using childlike speech and always treat a person with dementia as an adult. There are other ways to convey affection without disparaging the person with dementia. Smile, address the person by name, and shake his or her hand instead.

 

Keep the pitch of your voice low.  Sometimes when a person doesn’t immediately understand, we have a habit of speaking louder to get our point across. Raising your voice only distorts speech and will more often than not upset the person being spoken to. To keep communication from getting difficult, speak in a warm, friendly manner.

 

Be aware of body and facial gestures and expressions. People with dementia pay attention to nonverbal messages of all kinds. Use these effectively to further encourage communication. The opposite is also true. As a care partner, pay attention to your partner’s body and facial gestures as well. Their nonverbal messages will communicate what they are not able to communicate verbally. In addition, eye to eye contact represents that their attention is focused on you.

 

Keep the conversation going. When speaking to someone with dementia, it is up to you to keep the conversation going. Introduce topics that he or she is familiar with or enjoys to talk about. Do not worry about their responses, just be happy to engage with them.

 

Do not ignore rambling. Remember that rambling speech is a form of communication too. Even if it seems like gibberish, listen for key words and pay attention to any form of nonverbal communication.

 

Avoid arguing, quizzing, or confronting. Having conversations that include these types of communication will often make the person angry or confused. Accept person with dementia’s values, beliefs, and reality. Doing so will reduce negative communication.

 

Use a prompt to get the conversation going. A prompt as simple as eye contact or saying the person’s name is an easy way to get their attention. When giving an instruction, be very specific and demonstrate exactly what you would like the person to do.

 

 

            By combining all of these strategies, your loved one with dementia will want to participate in conversations more and as a result be a happier individual.

 

© Jennifer Brush, may not be reprinted or distributed without permission

 

Good News about Medications for Dementia

                                          

I am pleased to introduce you to Rachel Wynn, MS CCC-SLP is speaker, writer, activist, and speech-language pathologist specializing in geriatric care. I invited her to share some of her thought about about medications and dementia.  She blogs at Gray Matter Therapy, which strives to provide information about geriatric care including functional treatment ideas, recent research, and ethical care. Find her on Facebook, Twitter, or hiking with her dog in Boulder, CO.

 

Let me just state my bias up front. In my personal life, I avoid taking medications. Rather than take pain reliever for a headache, I drink water. The headache is likely due to dehydration (which is common at high altitude) or sinus distress (and water thins mucous being produced). I avoid medications, but I am not anti-medications. In fact, I take a medication every day and will likely for the rest of my life, because my body requires it. Personally, I believe medications aren’t often necessary, especially as the first intervention.

 

As a speech-language pathologist, it is not within my scope of practice to give recommendations regarding medications. However, it is within my scope of practice to understand how medications affect the body, especially when there may be side effects impacting cognition or swallowing.

 
Medications but no therapy?

One of the things I have found quite concerning is meeting someone new to my care community and seeing the list of medications they are on. They may be on a cholinesterase inhibitor and antipsychotic medications for dementia, but they have never participated in any therapy (speech-language pathology, occupational therapy, or neuropsychology). This is concerning, because there are so many benefits to therapy throughout the course of dementia.

 

In the earlier stages, therapists develop individualized compensatory strategies and routines to help people maintain their independence as long as possible. In the middle to late stages of dementia, therapists work on changing the environment to increase a person’s independence and quality of life. These interventions don’t cure dementia (but neither do any of the current medications on the market); however, they are individualized to help improve quality of life, independence, and safety without side effects.

Antipsychotic medication effects in the elderly

Antipsychotic medications are not without side effects. Common side effects of antipsychotics in the elderly include [1]:

• anticholinergic reactions
• parkinsonian events
• tardive dyskinesia
• orthostatic hypotension
• cardiac conduction disturbances
• reduced bone mineral density
• sedation
• cognitive slowing

We rightfully spend great time and energy on fall prevention efforts. How many of those antipsychotic side effects would contribute to an increased risk for falls? Most of them. Besides falls, in people with dementia sedation and cognitive slowing would complicate matters. Yet, these are very common side effects.

 
CMS sets goal to move away from antipsychotics

Given my stance on medication, especially in the treatment of dementia, I was very pleased to see this press release from the Centers for Medicare & Medicaid Services [2]. The press release states the goal CMS set to reduce use of antipsychotic medications in nursing homes by 25% by the end of 2015 and 30% by the end of 2016. This is excellent news.

 

Want even better news? Patrick Conway, MD and CMS chief medical officer said, “In partnership with key stakeholders, we have set ambitious goals to reduce use of antipsychotics because there are - for many people with dementia - behavioral and other approaches to provide this care more effectively and safely.” (emphasis mine).

 

As an advocate for person-centered healthcare, Dr. Conway’s words make my heart happy. He said, “Ultimately, nursing homes should re-think their approach to dementia care, reconnect with the person and their families, and use a comprehensive team-based approach to provide care.”

 

Way to go CMS! Now let’s chat about how CMS reimburses for these therapy services that can achieve excellent results without the side effects of antipsychotic medications…

 

References:

1. Masand, P.S. (2000). Side effects of antipsychotics in the elderly. Journal of Clinical Dementia Care Exceeds Goal to Reduce Use of Antipsychotic Medications in Nursing Homes: CMS Announces New Goal. Newsroom Center. CMS.gov, 19 Sept. 2014. Web. 19 Sept. 2014.Psychiatry, 60(8), 43-49.
2. Centers for Medicare & Medicaid Services. National Partnership to Improve