Lessons In TR

I went to a nice seminar on Dementia at the local Community College yesterday to get some disabilities continuing education hours. This prompted me to condense all my notes on this topic. Hope it helps!

Dementia, Alzheimer’s, and Seniors

About Dementia

Dementia is a disease or condition of the brain that causes global progressive deterioration (1).

There are over 100 types of dementia, but most are rare. The top 3 forms of Dementia you will see in your clients are:

• Alzheimer’s Dementia
• Vascular Dementia
• Lewy Body Disease

Symptoms of Dementia:

• Attention – easily distracted
• Orientation – varies between fully aware and disoriented
• Gradual onsest, progressive decline
• Impaired judgement
• Distracted easily, can’t block out stimuli
• Possible language issues (aphasia, agnosia, apraxia)
• Difficulty learning, short term memory declines before long term
  • It’s not normal forgetting. “The normal adult forgets, remembers that she forgot, and later may remember what she forgot. An Alzheimer’s patient forgets, forgets that she has forgotten…” -Dan Blazer, MD
• Possible hallucinations
• Personality is altered or extreme
• In the late stages may be irritable when tired
• Pacing, restless when needs not met

Symptoms are similar to those of other issues. This can make it hard to diagnose, go undiagnosed, or be incorrectly diagnosed as dementia when it’s something else that’s treatable. Overlapping issues include:

• Mental illness
• Reversible Dementia – symptoms caused by other things that can be such as medications, drug use, vitamin deficiency, UTI (which can totally upset your system)
• Depression
• Delirium
• TBI
• Stroke (in which victims may get better)

Preparations For Working With Dementia

• Meet with the participants and their families at the retirement center before the program to
  • Discuss the program
  • Evaluate the participants (how much support is needed, balance, emotional level, size, etc.)
  • Inquire about specific issues, food needs, etc.
  • Talk with caregivers about how to approach each individual
• Prepare Staff
  • Have specialist come talk to staff about dementia and Alzheimer’s
• Horse choice
  • Patient for long mounting time
  • The calmest demeanor
  • Consider gaited horses for smooth riding
• Prepare Volunteers
  • Volunteers meet with Instructor before each lesson to discuss appropriate interaction
  • Prepare them for the possibility that senior participants may pass away
• Other
  • You may need more than one instructor with senior groups, especially if you have two groups of one doing groundwork and the other riding.
  • Each lesson ask caregivers any emotional/physical issues the participant had during the week

Adaptations for Specific Symptoms

Some of these may be shown by seniors without dementia, so I included them in the title too.

• Compromised balance, canes, walkers
  • Make sure footing is flat
  • Allow lots of time for mounting
  • Park their cars close by for easy un/loading
  • May need to dismount to block/lift
  • Use additional Instructors for mounting and dismounting, or else it could take a long time
  • Help rider learn to self-correct by practicing moving to the center of the saddle, with even weight on seat bones, and looking ahead
  • Spend a lot of time in warm ups with gentle stretches
• Auditory loss, of hearing or ability to block out noise
  • Keep area quiet
  • Use a very loud voice, or sound system
  • Make sure you have their attention before speaking – stand in front of them
• Vision narrows
  • Approach from the front (they may startle if approached from the side)
  • Be in front of them when giving directions (or they may not know you’re talking to them)
• Low heat tolerance
  • keep hydrated, provide water
  • use indoor arena
• Low cold tolerance
  • keep warm, provide blankets, hand warmers, warm room to take break in
  • use indoor arena
• Low stamina
  • have lots of chairs all over the barn to rest in
  • start with activities in small increments (ride for 10-15 minutes) then progress the amount of time throughout the session (ride for a half hour)
  • keep in mind that if the rider cannot talk while doing an exercise (due to lack of breath), it’s probably too hard
• Memory loss
  • Participants work with the same Volunteers every week for continuity
  • Participants may not remember they got on a horse the week before
  • May not remember to show up for lessons
  • May see difficulty with continuity between lessons
  • Use repetition and consistency
  • Incorporate things the participant already look to for directions (white board, checklists, songs, etc.)
  • Include movement and physical input to aid memory
  • Ride an obstacle course
• Procedural memory loss (forget the third step by the time they finish the first two)
  • Work on 1-2 step directions and activities, building up to more steps
  • Use visual cue cards
  • Expect a considerable amount of repetition each lesson
• Cognitive processing delay
  • Give time to process instructions – people with dementia average 10-30 seconds to process 5 words, so wait 10 seconds then repeat the EXACT same words you said, because if you fit it within that 30 second time window they may get it – but if you change even one word it starts the process all over again. If they don’t respond after a few tries, though, try something different. (2)
  • Make directions short and clear
  • Use visual aids to help
  • Task analysis – break it down into one step at a time
• Barn can evoke memories
  • Prepare volunteers to patiently listen to stories and repetition of same stories
• Hard to focus, short attention span
  • No other lessons going on at the same time
  • Provide hands on opportunities
  • Keep wait time minimal, keep the class moving (yet allow time for delayed processing, stopping to reminisce, an slow mobility when transitioning activities)
• Decreased ability to take perspective, they think of themselves first
  • Use the horse – what would make him feel good? Explain reasons for how we do things in terms of helping the horse.
• Decreased judgement, may put self in danger
  • Keep close supervision, partner rider up with volunteer at all times
  • Review horse safety
  • Establish routines to follow
• Decreased social filter, may just dismiss you if bored, say inappropriate things
  • We have to be okay with that
  • Offer different ways to engage
• Difficulty giving communication (expressive) = to help them speak…
  • Remember: all behavior is an attempt to communicate, so look for what is prompting behaviors
  • Stick to familiar words that they know and themselves use often (ex: commode instead of restroom)
  • Invent new names for words they’ve forgotten using words they still know (ex: fridge = cold box)
  • They may speak less because it’s so hard to organize words
• Difficulty receiving communication (receptive) = to help them understand…
  • See Cognitive Processing Delay above
  • Difficulty understanding sarcasm, inflection, etc. so be concrete
  • It’s tempting to talk to the caregiver instead of the person themselves, but still talk to them and treat them with respect.
  • SLOW DOWN when talking to them
  • Always identify important parties (ex: “Hi Dave it’s Pam!” This indicates they probably know you, and now they have your name.)
  • Be respectful. Ask before doing something. (ex: this mental health specialist always first knocked and asked if she could come in to the room to work with them, and they were more open to working with her because of it)
  • Limit distractions – get close, eye to eye, not from down the hall around tons of people
  • Use less words! (ex: “grab your coat and come with me” vs. “come on!”
  • Give one step directions
  • Use familiar words
  • Use nonverbal communication, gestures – ask them to show you or draw for you
  • Avoid confusing expressions (ex: “hop in!”)
  • Reassure
  • Do not criticize, argue, correct – In the early stages it may be appropriate to remind them it’s a delusion, but as they progress don’t argue with them because often the delusion includes some truth that you can’t argue with. Often delusions indicate an emotion need, so address it then move on. (ex: she says she’s going home but home is in Kentucky. She’s expressing the desire to go home because she’s anxious. Engage that emotional need, “What’s at home?” then redirect when appropriate.
  • White boards and info sheets to help them remember work IF they know to use it, usually if it’s something they already use.

You may also see:

• Depression, low self-esteem
  • Give opportunities or success
  • Maintain dignity at all times, teach to their level not below
  • Celebrate (accomplishments, success)
• Bereavement issues from loss of spouse

Life Goals

• “joy in the moment” (1)
• Maintenance or slowing down onset through:
  • Exercise – The most helpful physical exercise to prevent/delay dementia is dance! Because it works hearing, balance, social, memory, mood (30 min 3x/wk showed decrease risk by 76%, including those with mobility issues doing chair dance) (1) – so include music and patterns in lessons!
  • Social engagement
  • Mental exercise

Activity Ideas

• Introductions – share horse experience and stories
• Go outdoors and get sunshine
• Work on memory skills
• Share prior horse experience and stories
• Grooming & tool memory
• Feed treats from bucket
• Take pictures of their experience to put in a scrapbook
• Take picture with their horse to put in a frame
• Paint a horse
• Watch herd behavior in the arena

What have been your experiences working with clients with Dementia?

Sources

1. Ivey, Carol (of Dream Catchers in Virginia). “Silver Saddles Serving Seniors.” PATH Intl Strides. Sumer 2016. Vol. 22, No. 3.
2. Thompson, Dayna, M.S., LMHC. “Mental Health and Dementia: What a Clinician Should Know.” Presentation by IU Health at Ivy Tech University. 10/21/2016.
3. PATH Intl. Registered Instructor On-Site Workshop Manual
4. Henning, Kim and Hommick, Tamara (of Cheff Therapeutic Riding center, Michigan). “Silver Saddles Program Targets Seniors.” NARHA’s STRIDES Fall 2010.
5. Maraist, Jean (of Main Stay Therapeutic Riding). “Memory Centers: Day programs for seniors”. PATH Intl STRIDES. Summer 2011.

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Note: This is not professional advice, this is a blog. I am not liable for what you do with or how you use this information. The activities explained in this blog may not be fit for every rider, riding instructor, or riding center depending on their current condition and resources. Use your best personal judgment!