14. Working with People with Dementia

Question 1

Is compassion focused therapy always used in the context of physical health problems?

Answer 1

Nope. Only when there is obvious self-critical voice that contributes to distress or health related behaviors.

Question 2

When therapy is used for patients with mild-moderate dementia?

Answer 2

Cognitive Stimulation Therapy (CST)

Question 3

What is the gist of cognitive stimulation therapy?

Answer 3

Keep client mentally stimulated and active because if you don’t use those functions you lose them more quickly.

Question 4

For patients who don’t know what a psychologist session looks like, what should you do?

Answer 4

Ask them “what do you expect from today’s session?”
Build on their ideas and let them know what psychology assessments look like (“Puzzles and word tests to understand more about your difficulties”)

Question 5

What is the nature of the dialogue when you ask them questions to find out what the problem is about?

Answer 5

More of a conversation rather than you being the expert. Client is the expert in their situation. Note balance of power, client should tell us more about their life.

Question 6

How do you engage in emotional validation for patients with dementia?

Answer 6

• help them gradually come to terms with their dementia
• ask them how much do they understand that they are doing some things wrongly
• try to understand things from client’s POV. emotional validation is good for building rapport

Question 7

How do you explain to the client the treatment process that they are about to undergo?

Answer 7

Explain procedure in simple terms and slow down because client has cognitive impairment. Use memory aids or other tools to help them digest the information.

Question 8

To diagnose the client with dementia, they should have cognitive impairment in at least 1 of the following: (6)

Answer 8

1) language (aphasia)
- wrong use of words
- inability to remember words
2) motor activity (apraxia)
- cannot perform simple behavioral tasks (no physical disability)
3) recognition (agnosia)
- cannot recognise people or objects (no sensory impairment)
4) executive functioning
- difficulty planning, organising, controlling impulses
5) social cognition
- considering others’ feelings and wishes
6) learning and memory
- remembering recent events

Question 9

What is the development of the symptoms over time?

Answer 9

Symptoms occur gradually and become more severe over time.

Question 10

What are the main features of Alzheimer’s disease?

Answer 10

1) impaired delayed recall (fast forgetting),
2) Anterograde amnesia (loss of ability to create new memories after amnesia onset)
3) Intact working memory
4) Intact orientation to time and place until later stages

Question 11

During the feedback session when you diagnose the client with dementia what must you do?

Answer 11

1) give sufficient time for the session (1.5h)
2) work through with them the consequences of finding out they have the diagnosis
3) clear recommendations for intervention
4) Objectively - intervention can slow down progression, but decline will come. support is very important.
5) plan follow up appointment or contact for supportive counseling

Question 12

According to NICE guidelines, what intervention is suitable for clients with dementia? (4)

Answer 12

1) cognitive stimulation therapy (CST)
2) cognitive rehabilitation or occupational therapy to support functional ability (practical strategies to cope with cognitive decline)
3) Therapies for depression and anxiety (facing uncertainty about future such as loss of functioning and role)
4) caregiver support (CBT - stress management and changing unhelpful thoughts)

Question 13

What are the 4 components of cognitive rehabilitation?

Answer 13

Individually tailored approach to achieve everyday functioning.

1) psychoeducation
2) changing the environment
3) learning strategies
4) strength and resource focused

Question 14

How do you change the environment to enhance memory for clients with dementia? (3)

Answer 14

• being tidy and well organised at home and at work
• using a calendar to plan schedule
• no overloading of information, multitasking, or working under time pressure

Question 15

What are some learning strategies for clients with dementia? (3)

Answer 15

1) making links between items on a list (eg. categories, alphabetical order)
2) Using imagery to remember names
3) Expanding spaced rehearsals (get them to remember the specific important information 30sec later. If they can, double it to 1min. If cannot, half the time and do it again)
- only use this technique if information is very important and they really need to keep it in their minds

Question 16

For patients with moderate-severe dementia, what intervention is used?

Answer 16

Dementia Care Mapping (DCM). Structured observation framework for assessing the factors associated with wellbeing and distress. Shown to significantly reduce agitation.

Question 17

What must you do during the observation stage?

Answer 17

Observe them in a communal area every 5 min. Observe:

1) what client is doing
2) mood and engagement
3) quality of interaction with others and caregivers

Question 18

Why do we need to observe client every 5 min?

Answer 18

Helps us to see the whole profile throughout the whole day. If you just take a global rating, you might miss out important information. (eg. find out why client is resorting to violent behaviors to communicate)

Question 19

What are aspects of good quality of life for the client?

Answer 19

1) love - unconditional acceptance.
2) comfort - physical needs met, free from pain and disturbances
3) attachment - bond to others, feeling of safety
4) identity - continuity with past and future
5) occupation - meaningful activities with sense of purpose and worth
6) inclusion - in everyday activities

Question 20

What does it mean to take on a humanistic and social valorization approach to care for patients with dementia?

Answer 20

Recognising that all clients are human beings with dignity and have psychological needs that need to be met.
Do validation therapy - prioritise the client’s feelings and provide them with a sense of security and comfort.

Question 21

Cognitive Stimulation Therapy (CST) is based on which model?

Answer 21

Biopsychosocial model

• BIO: neurological factors, general health
• PSYCHO: mental stimulation, sensory stimulation, mood and memory, personality traits (eg. openness to new experiences)
• SOCIAL: environmental and social factors

Question 22

Cognitive Stimulation Therapy (CST) is based on which 2 models?

Answer 22

1) biopsychosocial model

2) medical model

Question 23

CST incorporates which 3 types of therapies?

Answer 23

1) Reality Orientation (RO) therapy
2) Life story/Reminiscence Therapy
3) Multisensory Stimulation

Question 24

Describe life story/reminiscence therapy.

Answer 24

Discussions about the past using visual or auditory prompts.

• Life reviews: ask person and family to recall how they dealt with past situations and use their learning and experiences to guide them in their present situation
• Life stories: conversations, life story books, collages, reminiscent boxes

Question 25

Describe reality orientation (RO) therapy.

Answer 25

Information about time, place, and person
Eg. “who are the important people in this care home?”
Use of RO boards in session

Question 26

Describe multisensory stimulation.

Answer 26

• Using all 5 senses in activities: food, music, physical games.
• The more you learn, the more neural pathways your brain will form. Active stimulation of your minds.

Question 27

What are some social factors CST targets?

Answer 27

1) disempowerment - empower them, don’t just do things for them.
2) infantilizing - don’t treat them like children
3) outpacing - getting left behind in conversations especially when we speak in english. they can’t keep up.

Question 28

Describe the CST programme.

Answer 28

• Group intervention to enhance cognitive and social functioning through a range of activities and discussion.
• 14 group sessions, twice a week
• thematic each week but each session has choice of activities (A or B)
• group is matched by cognitive ability

Question 29

What are the types of psychological difficulties that may occur in dementia?

Answer 29

1) mood - anxiety, lowered self esteem, confidence, possibly depression, frustration/anger
2) relationships - feeling isolated, how they are perceived and treated
3) psychological and behavioral distress - engage in upsetting behaviors due to unmet needs
4) carers and families - difficulties of caregiving (eg. guilt and grief when making difficult decisions for the client), satisfaction of caregiving

Question 30

What is the continuum framework for coping with dementia?

Answer 30

1) self-adjusting: adapting to challenges of dementia, accepting help from others
2) self-maintaining: maintaining identity and lifestyle as normal