A different approach to dementia care

To provide some insight into the behaviours that come with dementia in an aging population, Northern Health staff are being educated through the Gentle Persuasive Approaches program.

"What we knew 20 years and even 10 years ago, has changed completely," clinical nurse educator Brenda Miller said. "What is more important is for us to understand who the person was so we can get a better idea of their interests, their likes and dislikes and things they did in their life that were meaningful."

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Miller gave a teacher or nurse as an example of a person whose instincts are towards caring for and helping others.

"That caring may come out as their disease progresses," Miller said. "They may not be able to tell us that but understanding that may have been important to them so that's what we try to provide them an opportunity to do again. We really look at the person's history not so much to try to understand what the disease is doing because what we know the disease does is it changes the person."

The focus is not what the patient can't do anymore but what they can do, Miller added.

"Our focus is to keep that person as independent and functional for as long as possible," Miller said.

Core foundational focus is on needs, interests, skills and abilities and how to maximize those even when memory loss is present.

"The burden on the independent caregiver (at home) is as great as it is on the amount of care we need to try to provide here for a person," Miller said.

Similar programs to Gentle Persuasive Approaches (GPA) are offered to people who are caring for a loved one with dementia through the Alzheimer's Association of B.C.

More than 1,200 staff members of Northern Health have taken GPA since 2011.

It's a course that offers the patient's perspective.

"The person with dementia certainly sees the world from different eyes than the nurses," Miller said. "We have to focus on improving our communication skills and we have to understand that it's our body language that counts just as much as the words we say. With advancing dementia communication skills deteriorate dramatically so the person with dementia depends on what they see, so this could be good advice for someone at home taking care of someone with dementia. Don't complicate the message you're trying to give with too many words. Show them with your body language what you want from them."

That could include signs like pointing to your watch and then making a gesture of holding a spoon and bringing it to your mouth for time to eat.

"So you're using a lot of animated body language to be able to reinforce the message," Miller said.

Part of the Gentle Persuasive Approaches program sees staff validation where they recognize patients may be living in a different time and place in any given moment.

"Staff has to recognize that and then work within those boundaries," Miller said. "We create the setting where a person can just be what they want to be without us arguing with them, without us correcting them, without us pressuring them to come to a reality they just can't understand in the moment so rather than arguing or confronting the person we just accept them for where they believe they are or who they are or what they think they're doing in this moment."

Correcting a person or arguing with a person with dementia is not a successful strategy, she added.

"No adult likes to be told what to do," Miller said. "We try to ask them so we say things like 'would you like to join us?" Making it an invitation is a much more successful strategy. So we ask things like 'would you like to have your bath, come and eat,' things like that because we're still talking about adults here."

In a care facility choices are limited so staff offer options whenever they can.

"It could be as simple as coffee or tea, do you want to wear something pink or blue, but offering choice is probably the number one strategy for gaining cooperation wherever possible," Miller said.

When a person with dementia in a long-term care facility is uncooperative it may be a result of unmet needs. Things to consider are pain, hunger, loneliness, boredom, medication side effects and illness and it takes a bit of investigation.

"Any medical condition that limits a person, whether you had a stroke, have dementia or arthritis - an adult doesn't like to be limited in what they're doing and this is a disease that does create limitations, so we try to again help that person to be as independent as possible and when we do that we get successes," Miller said.

Gentle Persuasive Approaches is taught throughout the Northern Health Authority in all long-term care facilities as well as hospitals where people are waiting for a bed in a facility.

"This is one approach on how we express person- and family-centred care," Miller said. "I think it's our northern way of doing things."

At every one of Northern Health facilities there are advocacy meetings between the patient, their family and Northern Health staff to make sure everyone can share what is important, Miller added.

Miller said an evaluation of the GPA program was conducted and not only did it improve clinical knowledge but practical knowledge as well.

Miller offers tips for those who are at-home caregivers that has seen great success in facilities.

Peripheral vision diminishes to a great extent in people with dementia - to as little as the size of a basketball in front of them - so everything has to be placed where the person can see it, including cups and plates.

People should know that particularly with Alzheimer's disease longtime memories are preserved while short term memory is not, she added.

"We have two main goals in nursing, that's pain control and that includes physical and psychological pain, that's number one," Miller said. "And number two, we do what makes them peaceful and calm."

If a person remains calm and at peace the rest will follow, she added.

"So that's one of our main goals to achieve calm and peace and that can be challenging, don't get me wrong," Miller said. "But when we achieve that the person is less distressed, less anxious - they're happy and that's person- and family-centred care."

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