This document discusses the need for person-centered care approaches in long term care settings for individuals with dementia. It outlines key concepts of person-centered care including validating individual experiences and meeting underlying needs to reduce behaviors. Effective training models like VIPS and assessments like Dementia Care Mapping are described. Barriers to implementation include staff turnover, but research shows person-centered care can improve outcomes for residents and staff.

1. Person Centered Care and Dementia:
Valuing the person and providing dignified care in Long
Term Care settings
Trish Davis GRO651
05-02-2014

2. The Need for Dementia Care
 5.4 million Americans are living with Alzheimer’s disease
 By 2050 as many as 16 million will have the disease
 Alzheimer’s disease is the 6th leading cause of death in the US (4th
leading cause for African Americans)
 Dementia cost the US $200 billion in 2012 ($140 billion through
Medicare and Medicaid)
 Other types of dementia: vascular, Lewy body and frontotemporal
(Alzheimer’s accounts for 60-80% of all dementia cases)
(Alzheimer’s Association, 2013)

3. A Call to Action
 NAPA – National Alzheimer’s Project Act, developed by HHS and
signed into law by President Obama in 2011
 Affordable Care Act (2010) – Services funded by Centers for Medicare
and Medicaid (CMS) must be provided for in a person centered care
manner
 Inspector General’s Office has reported an overuse of antipsychotic
medications of persons with dementia in nursing homes
 CMS has launched education initiative to reduce antipsychotic
medications in nursing home residents
www.aspe.hhs.gov/daltcp/napa/NatlPlan2013.shtml

4. Current Review
• Does the Implementation of Person-Centered Care as a
Standard of Long Term Care Demonstrate a Mutually
Beneficial Outcome Between Staff Performance and
Resident Response
• Methods:
• Key Words – Alzheimer’s disease, personhood, person-centered
care, dementia and long term care
• 46 relevant articles
• Included 29 in review

5. Assessments & Training
Assessments:
• Dementia Care Mapping (DCM)
• Person-Centered Assessment Tool (P-CAT)
• Personhood in Dementia Questionnaire (PDQ)
• Hierarchy Model of Needs in Dementia (HMND)
Training:
• VIPS Communication Skills Training
• Validation Therapy (VT)

6. Ground Floor Players
• Tom Kitwood: Dementia Reconsidered: The Person
Comes First
• Need Driven Behaviors & Validation Therapy
• Dementia Initiative: The Dementia Chasm “White Paper”
Pioneers:
• Eden Alternative
• Greenhouse Initiative
• Pioneer Network

7. Effects
relationship
and care
•Need driven
•Often
medicated
Avoidance
•Isolation
•loneliness
Lost within
context of
disease
•Memories
•Executive
function
Becomes task
oriented
•Person
becomes list
of ADLs
Person-
hood
CareStigma Behavior
Psychological and Care
outcomes of Dementia

8. Person
Centered
Care
(PCC)
Social
Psycho-
logical
biological
Spiritual
Personhood of Individual and
Person-Centered Care

9. Core of Person Centered Care
Each individual has:
• Life experiences
• Beliefs
• Interests
• Character
• And continues to
experience life
(Buron, 2008)
Key concepts:
• Person is not their
dementia illness, but the
condition is only one part
of their current
experience.
• Carers must “enter the
world” of the person with
dementia to interpret
need, thus the drive
behind the behaviors.

10. Belonging
•Being
known
•Acceptance
•relationship
Physiological
needs
• ADLs
•Food/shelte
r
•Safety
Lifelong
beliefs
•World view
•Values
•Traditions
Self
Esteem
•Autonomy
•Feeling safe
•Needs
heard
Social
Psycho-
logical
Biological
Spiritual
Active Person Centered Care

11. Inactive Person Centered Care
Resident is
agitated and
repeatedly tries to
open front door
Staff chemically
or physically
restrain resident
Resident is
apathetic and
resists activity
Staff ignore
resident due to
his silence
Resident
becomes
aggressive in
the evening
Resident is
given a
sedative

12. Hierarchy of Needs in Dementia
(HMND)
Self Actualization
Being useful
Freedom
Meaningful
Esteem Needs
Self esteem/self image
Responsibility
Privacy
Belongingness and love needs
Affect attachment, social contact
Enjoyment of activities
Safety Needs
Security, financial situation
Biological and physiological needs
Basic life needs, physical and mental health
Scholzel-Dorenbos, (2010)
Consequences of unmet need:
Unmet goals of patients & caregivers
Behavioral symptoms
Increased caregiver burden
Decreased health-related
quality of life
Institutionalization
Higher one
is on
pyramid,
the fewer
behavior
responses

13. Need Driven Behavior (NBD)
• “Behaviors” stemming from expression of a need
• Behaviors can originate from unmet biological, psychological, social
or spiritual needs
• Common to treat the behavior and not the underlying problem
(restraints or removal)
• If originating need is unmet, or if need is under-evaluated and
mistreated, cascading effects can occur
• Unmet needs can cause aggression, repetitive movements, verbal
outbursts, apathy, withdrawal (the “behaviors”)
(Kovach, 2005)

14. NDB Examples (Kovach, 2005)
Thirst
• Primary need – fluids
• NDB 1 – repetitive movement
• Outcome of unmet need–
constipation & abdominal
discomfort
• Secondary need – increased
fiber & stool softener
• NDB 2 - aggression
Circadian Disturbance
• Primary need – activity/rest
schedule, light/dark therapy
• NDB 1- sundowning with
calling out
• Outcome of unmet need –
social ostracism
• Secondary need – increased
socialization
• NDB 2 – repeated
apprehensive queiries

15. Validation Therapy (VT)
Knowing an individual and meeting that individual’s
needs…
“Using empathetic listening, emotional and physical
mirroring and therapeutic touch to join the person with
dementia in their own reality.” (Parkinson, 2008 p.210)
http://youtu.be/QFKcPGZkuQ4
Naomi Feil

16. Utilizing Validation Therapy
Resident calls out same time of day,
“Somebody help me! Somebody help me!”
Person centered care response:
Staff:
“It sounds like you are afraid, is that how you
feel right now? I am here with you, and
everything is all right. What can I do for you to
help?
By knowing this resident, staff realizes that she
is reacting to finding husband had died in their
bed 20 years ago. Due to symptoms of
dementia, she relives that trauma.

17. Person Centered Care Assessment
and Training
Dementia Care Mapping
• “Mapper” tracks resident
responses and activities
• Two code documentations:
• Behavioral Category Code (BCC)
• Well/ill-being (WIB)
Review of 34 DCM studies:
 BCC – watching, eating, drinking
 Low WIB – withdrawn, repetitive
action
 High WIB – creative activity,
exercise, media engagement
 Provides feedback to staff
(Brooker, 2005)
VIPS
• V – value
• I – individual
• P – perspective
• S – social environment
Study of 26 staff in 4, 1-hour
sessions:
 Education, group exercises, role
playing sessions, vignettes
6-week post assessments:
 Staff spent more time engaging
with residents
 More interactive leisure activities
(Passalacqua, 2012)

18. Useful Assessments;
Training Programs Needed
Training Programs
PDQ
P-
CAT
DCM
Person-Centered Care Assessment
Tool (P-CAT)
Evardsson (2009)
• 13-item measure assessing PCC
• Evaluates personalization of care
• Organizational support
• Degree of environmental accessibility
Personhood in Dementia Questionnaire
(PDQ)
Hunter (2013)
• Identifies areas needing implementation
of personhood decision making
• Useful for developing institutional strategies
of PCC

19. Summary
• NDB and VT are ground floor understandings and
techniques for person-centered care
• VT and VIPS are valid and reliable training models to
increase staff understanding of personhood and person-
centered care in long term care settings, thus valuing the
resident and his/her needs
• DCM, P-CAT and PDQ are valid assessments for long
term care and can evaluate person-centered care
methods and performance

20. Anticipate
needs
Empathize
•History
•Beliefs
•Preference
•Medical
needs
Person Centered
Being
Known
Future
Present
Past
Validate
Person

21. Implementing
PCC
Awareness
Education
Training
Change
Life
Story
Book
Culture
Change
practitioners
invest
Validation
Therapy
Dementia
Care
Mapping
VIPS

22. Barriers to Implementation of PCC:
• High staff turnover – CNA turnover rate is ~ 65%
• Turnover rate can cost $250,000 - $400,000 annually
• Few discretionary funds for PCC training
However, research has shown that successful PCC training
and efforts for sustainability increase job satisfaction and
retention of staff, and decrease resident behaviors and
prescribed antipsychotic medications.
(Buron, 2008)

23. Recommendations towards PCC
• Dementia leadership launch a
nationwide campaign (breast
cancer movement) across
research, policy and practice
sectors for programs designed
at training, implementation,
education and sustainability.
www.ccal.org/national-dementia-
initiative/white-paper
• Research – validate reliable
gold standards of PCC training,
implementation and
sustainability based on holistic
dimensions
• Policy – Educate
administrators, government and
healthcare sector leaders on
effectiveness of PCC
• Practice – sustainability in long
term care, hospitals, home
health care throughout all
levels of care

24. References
• Alzheimer’s Association. 2013. 2013 Alzheimer’s Disease Facts and Figures.
www.alz.org/downloads/facts_figures_2013.pdf. Retreived March 20th, 2014.
• Buron, B. (2008). Levels of personhood: A model for dementia care. Geriatric Nursing,
29(5), 324-332.
• Brooker, D. (2005). Dementia Care Mapping: A review of the research literature. The Gerontologist, 45(1), 11-18.
• Dementia Initiative. 2013. Dementia Care: The Quality Chasm.
www.ccal.org/national-dementia-initiative/white-paper. Retrieved February 24th,
2014.
• Edvardsson, D., Fethersonhaugh, D., Nay, R., Gibson, S. (2009). Development and initial testing of the person-
centered care assessment tool (P-CAT). International Psychogeriatrics, 22(1), 101-108.
• Feil, N. (1989). Validation: An empathetic approach to the care of dementia. Clinical Gerontologist, 8(3), 89-94.
• Kitwood, T. (1997) Dementia Reconsidered: The Person Comes First. Buckingham, U.K.: Open University Press.
• Kovach, C.R., Noonan, P.E., Matovina, A., Schlidt, T.W. (2005). A model of
consequences of need-driven, dementia-compromised behavior. Journal of Nursing
Scholarship, 37(2), 134-140.
• Parkinson, E. (2008). Developmental transformations with Alzheimer’s patients in a
residential care facility. The Arts in Psychotherapy, 35, 209-216.
• Passalacqua, S., Harwood, J. (2012). VIPS communication skills training for paraprofessional dementia caregivers:
An intervention to increase person-centered dementia care. Clinical Gerontologist, 35, 425-445.
• Scholzel-Dorenbos, C., Meeuwsen, E.J., Olde Rikkert, M. (2010). Integrating unmet needs into dementia health-related quality
of life research and care: Introduction of the Hierarchy of Needs in Dementia. Aging and Mental Health, 14(1), 113-119.
• United States Department of Health and Human Services (HHS). 2013. National Plan
to Address Alzheimer’s Disease: 2013 Update.
www.aspe.hhs.gov/daltcp/napa/NatlPlan2013.shtml. Retrieved March 20th, 2014.