You are on page 1of 49

Introduction to dementia and effective communication for healthcare professionals with patients living with dementia

Elisabeth Serrano

Dementia: what is it?

Elisabeth Serrano Prieto

Ten glorious seconds


Ten Glorious Seconds

Elisabeth Serrano Prieto

Facts About Dementia in the UK


According to Dementia.org.uk, dementia is one of the main causes of disability in later life, ahead of some cancers, cardiovascular disease and stroke. Over 820,000 people are estimated to be suffering from late onset dementia in the UK in 2010 By 2025, the number is expected to rise to one million. 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

Dementia
Definition: Dementia is a syndrome (a group of related symptoms) that is associated with 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 controlling their emotions or behaving appropriately in social situations. Aspects of their personality 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 to the structure of the brain. People with dementia usually need help from friends 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

General early symptoms


Patients should seek help without delay if their memory is not as good as it used to be and especially if they: struggle to remember recent events, although they can easily recall things 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 they are 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

Differentiating normal aging and dementia

Elisabeth Serrano Prieto

Types of dementia
1. 2. 3. 4. Alzheimers Disease Vascular Dementia Lewy Body Dementia Other rarer causes of Dementia

Types of dementia: Alzheimers Disease (AD)

Elisabeth Serrano Prieto

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

Alzheimers Disease (AD)


Characteristics: Two abnormalities in the brain: - Amyloid plaques: unusual clumps of a beta amyloid 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

Elisabeth Serrano Prieto

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

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

Elisabeth Serrano Prieto

Types of dementia: Vascular Dementia (VaD)

Vascular dementia (VaD)


VaD: second most common cause of dementia. Decline in mental abilities due to brain damage from cerebrovascular or cardiovascular problems.

Elisabeth Serrano Prieto

Vascular dementia (VaD)


Characteristics: Unlike AD VaD patients often maintain their personality and normal levels of emotional responsiveness until the later stages of the disease. People with VaD often wander at night, and suffer from other problems commonly found in stroke patients (depression and incontinence)
Elisabeth Serrano Prieto

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

Elisabeth Serrano Prieto

Types of dementia: Lewy Body Disease (LBD)

Elisabeth Serrano Prieto

Lewy Body Disease


Lewy body dementia (LBD) is the third most common types dementia. LBD usually occurs sporadically Abnormal structures, known as Lewy bodies, develop inside the brain.

Elisabeth Serrano Prieto

Lewy Body Dementia


Characteristics In Lewy body dementia, cells die in the brain's cortex (outer layer), and in a part of the mid-brain called the substantia nigra. Many of the remaining nerve cells in the substantia nigra contain abnormal structures called Lewy bodies. Memory impairment, poor judgement, confusion. LBD also includes visual hallucinations, parkinsonian symptoms. LBD patients live an average of 7 years after symptoms begin.
Elisabeth Serrano Prieto

Rarer Causes of dementia


Creuzfeldt-Jakob Disease Huntingtons Disease Chronic Traumatic Encephalopathy (Boxers Syndrome) Dementia due to HIV Parkinsons Disease

Elisabeth Serrano Prieto

Ethical Issues
1. Driving 2. Competence or capacity 3. Valid consent

Elisabeth Serrano Prieto

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 legal obligation to inform the UK Driver and Vehicle Licensing Agency of their condition. If there are concerns that a patient who should not be driving is doing so, it is a permissible breach of confidentiality to inform the DVLA.
Elisabeth Serrano Prieto

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/benefit comparison Appreciate the situation and its consequences Communicate choices

In legal and medical jargon the terms are different but mean the same: COMPETENCE (MEDS), CAPACITY (LAWYERS).

Elisabeth Serrano Prieto

3. Valid consent
Health and social care professionals should always seek valid consent from people with dementia. This should entail informing the person of options, and checking that he or she understands, that there is no coercion and that he or she continues to consent over 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

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

The ethics of consent in delirium studies Journal of Psycvhosomatic Elisabeth Serrano Prieto Reseach 65 (2008) 283-287

COMMUNICATION

Elisabeth Serrano Prieto

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

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

Good Medical Practice Guidelines


Good communication 22 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 treatment options 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 those who will be providing their care. 23 You must make sure, wherever practical, that arrangements 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

NICE Guidelines
http://www.gmc-uk.org/guidance/index.asp

Good Medical Practice


http://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

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 developing dementia.

Elisabeth Serrano Prieto

MINI MENTAL STATE EXAM


Case example of deterioration on the same exam: Example

Elisabeth Serrano Prieto

VERA Framework

Elisabeth Serrano Prieto

VERA FRAMEWORK
Published as an article to offer guidance for student nurses communicating with patients with dementia. 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 have structured guidance on how to interact with people who have dementia. The VERA framework offers a means of interpreting communication and responding appropriately.
Elisabeth Serrano Prieto

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

Emotion
This step in the vera scheme develops the idea of paying attention to the emotional content of the communication, rather than the unintelligible verbal content. Paying attention to the emotional content underlying an attempt to communicate ensures that meaning is extracted from communication that is difficult to understand. Experienced and skilled practitioners are able to respond and make a connection with people who are confused, even when the words the person uses to express him or herself are unintelligible or out of context. This is achieved by listening for and acknowledging the emotional 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 be skilled listeners and observers, and pay attention to body language, vocal tone and facial expression all of which communicate a message about a persons emotional state at the moment. This has to be accompanied by a GENUINELY felt verbal sentiment, genuine interest in the person 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, healthcare professionals avoid the CONFLICT that could be caused by insisting that their view is one that must be accepted.
Elisabeth Serrano Prieto

Reassurance
Reassurance is any verbal or non-verbal communication that 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

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 social interaction with other people as an act of joining with the person as a human being.
Elisabeth Serrano Prieto

After Activity
Recording positive or negative outcomes Discussing the 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

19 tips for communicating with PLWD


1. Do not talk to the patient as if he/she is 11. not present. 12. 2. You need the patients attention to start communication. 13. 3. Minimize distractions. 4. Move slowly and approach from the front, 14. rather than the side or behind. 15. 5. Look eye to eye. 6. Call the patient by his/her preferred ame. 16. 7. Make your verbal and nonverbal messages the same. 17. 8. Use simple, adult appropriate words. 18. 9. Dont patronize. 10. Slow your rate of speech. 19. Give one message at a time. Listen for a response and allow time for the patient to respond. Repeat the question or request using the same words, if necessary. Be patient and keep it simple. Acknowledge the patients concerns and questions. Use words that express respect and understanding. Give the patient your undivided attention. Use appropriate touch if the patient enjoys it. Look friendly: your attitude is contagious.

Marge Coalman. The invisible population. The Journal on Active Aging. Issue September 2002 Elisabeth Serrano Prieto

Possible Response to Case Scenario


Validate: Youre trying to get home in time to get tea, Joan? Emotion: You sounded quite upset and a bit worried. Reassure: We will make sure youre ok, Joan. You are not in any trouble. Activity: Come with me well make some tea to take your mind off it. The success or failure of the activity is recorded and handed over to other members of the care team.
Elisabeth Serrano Prieto

Other methods: singing for the brain

Singing for the Brain


Elisabeth Serrano Prieto

Conclusion
Effective communication is one of the key points for excellent healthcare. Remember VERA! Read Good Medical Practice Guidelines Good luck!

Elisabeth Serrano Prieto

Thank you all for listening!

You might also like