health promotion on dementia

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


2/49

Dementia: what is it?

Elisabeth Serrano Prieto


3/49

Ten glorious seconds

Ten Glorious Seconds

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=468


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.



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

http://www.nhs.uk/Conditions/Dementia/Pages/Introduction.aspxhttp://www.nhs.uk/Conditions/Dementia/Pages/Introduction.aspx


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

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.pdf


7/49

Differentiating normal aging and dementia



8/49

Types of dementia1. Alzheimers Disease

2. Vascular Dementia

3. Lewy Body Dementia

4. Other rarer causes of Dementia


9/49

Types of dementia:

Alzheimers Disease (AD)



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.



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.



12/49



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)



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.



15/49



16/49

Types of dementia:

Vascular Dementia (VaD)


17/49

Vascular dementia (VaD)

VaD: secondmost common cause of

dementia.

Decline in mental abilities due to brain

damage from cerebrovascularor

cardiovascularproblems.



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)



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



20/49



21/49

Types of dementia:

Lewy Body Disease (LBD)



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.



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.



24/49

Rarer Causes of dementia

Creuzfeldt-Jakob Disease

Huntingtons Disease

Chronic Traumatic Encephalopathy (Boxers Syndrome)

Dementia due to HIV

Parkinsons Disease



25/49

Ethical Issues


1. Driving

2. Competence orcapacity

3. Valid consent


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.



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).



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.



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



30/49

The ethics of consent in delirium studies Journal of Psycvhosomatic

Reseach 65 (2008) 283-287Elisabeth Serrano Prieto


31/49

COMMUNICATION



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



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



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

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.pdf


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

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.asp


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.



37/49

MINI MENTAL STATE EXAM

Case example of deterioration on the same

exam:

Example



38/49

VERA Framework



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.



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)



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.



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.



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.



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.



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



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.



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.aspx


48/49

Conclusion

Effective communication is one of the key

points for excellent healthcare.

Remember VERA!

Read Good Medical Practice Guidelines

Good luck!



49/49

Thank you all for listening!

health promotion on dementia

Documents