Podcast, Season 2 -

Dr. Al Power – Dementia Beyond Behaviour

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Dr. Al Power is a highly influential geriatrician, author and educator who’s work focuses on transformational models of care. He has released several books including Dementia Beyond Drugs, and Dementia Beyond Disease which examine traditional approaches to dementia care and how fundamental issues in how we conceive of dementia set clinicians and carers up for failure in many ways.

This conversation is all about behaviour – more specifically what is called Behavioural and Psychological Symptoms of Dementia (BPSD). And how that common approach to understanding the actions of people living with dementia leads to misunderstandings, mis-treatments and a greatly reduced quality of life for care recipients.

It’s an approach that he believes leads directly to the overuse of anti-psychotic medication (also called chemical restraint), and ultimately locks care partners in a cycle where they cannot address the needs of care recipients.

Dr. Power proposes an alternative to these models, where people living with dementia are seen as the same as everyone else – with a complex set of needs for their well being, that extend beyond physical care. Through this model and removing “behaviour” from the vocabulary of dementia care, he believes we can drastically improve the quality of care for people living with dementia.

Transcript


Ash de Neef: Well, Al thank you so much for joining us on the podcast today.

Dr Al Power: It’s a pleasure.

Ash de Neef: Now I think a lot of our listeners will know a bit about you and the work that you do. So maybe, can we start with talking about behavior. And bringing it back to a really simple idea of when people talk about behavior in dementia care, what do they mean?

Dr Al Power: Good question. Behavior is an interesting word, and it’s one that I have tried to avoid, as you can imagine. The problem with language is that it does take on the flavor. It sort of reflects people’s mindset, but it also can help set people’s mindset. And the trouble with the word behavior and behavior, I suppose, in the strictest definition is not a good or a bad thing.
If I’m thirsty and I get a drink, that’s a behavior, you know? But in the context of dementia, behavior has become pretty much exclusively pejorative term. No one ever talks about behaviors with the person with dementia, without talking about something that’s challenging them or that they’re finding difficult.
And so when a word has that much of a judgmental flavor, I just try to take away from my vocabulary. And it’s not to say there’s an easy replacement. But I think most people are talking about the words and the actions of people with dementia and most often in a labeling, or judgmental or pathologising way.
It’s not about the nice times people are having, it’s usually about challenges or difficulties or distress.

Ash de Neef: So it’s, it’s a word often used by care partners, as you would say, for the care recipients when they’re displaying behavior, quote unquote, that is the hard for the care partner to deal with?

Dr Al Power: To deal with, to understand, to respond to – any of those things.
But it becomes, the person. The behavior kind of sets it in the person’s arena too, if it’s your behavior, then you’re the problem. Whatever it was came from you. It’s your dementia. It’s not what I was doing, it’s not your environment, and it’s not the context.
And so it pulls you away from seeing the larger picture. And I think that’s why people often miss opportunities to help because they just see it as the person’s problem. And of course, that’s the slippery slope to drug use too.

Ash de Neef: So what is the larger picture?

Dr Al Power: So I always start by saying, what is my opinion versus what is established you know consensus out there. And this is where I push back on most of the profession. The medical profession, researchers, Alzheimer’s advocacy organizations, media, you name it. This is a big pushback.
And I actually just gave a talk on this at another conference earlier today. To me, the idea that people’s words and actions are what they call “behavioral and psychological symptoms of dementia” is a narrow mindset that sets us up for failure and eliminates the possibility of really reaching for largest success.
And because that terminology says that these are symptoms of dementia. So it suggests that brain diseases making me want to do what I’m doing.
What I say is that there’s a subtle, but very, very important difference. And that is the brain disease is real. It causes some real symptoms, which in my mind are such things as difficulty retrieving memories. Maybe changes in how we communicate our needs or our wants.
It might be how well we can cope with stressors in our environment. It might be planning and problem solving skills. So we have these disabilities. And so when we are challenged by any kind of a situation, we may be more likely to be visibly upset. Or to respond in ways that maybe don’t make sense to other people because that’s what our brain does. But that is different than saying the dementia was the root cause of our distress.
So to take the simplest example in the world, and this may seem too simple, but I can connect it to the more complex things. And I often threaten people with this in my talks.
I say, look, “how about if I just pair all of you up in the audience and you go to the shower room and your partner strips you naked and gives you a shower “and see how people get nervous when they talk about that.
But then I say to them, “suppose your partner put you under the shower and the water was too cold. What would you do?” Well, you might say the water is too cold, or you might reach over and turn up the heat to your liking. A person living with dementia, who maybe cannot communicate that. Who is more surprised or unable to cope with the sudden shock might not say that they might yell or scream or they might strike out at the person.
So the dementia has modulated how the person responded to the situation. But the dementia did not cause it – the cold shower did. And when we see these as symptoms of dementia, then we’ll use an anti-psychotic. Or we’ll use some lovely non-pharmacological intervention, like playing some soft music in the background or having some aromatherapy, but we never turn up the temperature of the shower. And so that that’s the most simplistic form.
But it can be taken over into such things as not having choice or control in your environment. Not having familiar caregivers taking your clothes off not being engaged in things that give you a sense of purpose. Not having connections to the larger world, not being, having communication paced or given in the way that you can understand or be understood.
So all of these things can also be stressors like the cold water, but once again, when we say that what the person did was a symptom of dementia we miss that.
And then everything we do is reactive and short term, whether it be a pill or an intervention and it never lasts. And that’s okay, it’s a self-fulfilling prophecy.
Because we tried it, it didn’t work. And we said, well, of course not, they have dementia. It’s incurable. When really the approval, which I’m talking about, which we’ll get into can not only help the person, but can help prevent this from happening. Help succeed in the long-term to just eliminate these so-called behaviors instead of just kicking them down the road with an intervention.

Ash de Neef: Hmm. Well let’s dig into this alternative that you’re talking about. What is it?

Dr Al Power: Well, for me, it is about being proactive and strength-based and helping fulfill the things that are challenged by dementia. And I’m using the term well being here, and I’ll explain where I got that from.
But there’s two things that challenge the well being of a person with dementia.
One of them is the disease itself or the condition, whatever the disease that causes it. All those symptoms I talked about and more make it hard to maintain your own well being. But also the environment and the approach of care partners and the systems of care also can erode those aspects of well being as I alluded to.
And so both intrinsic and extrinsic factors make it hard for you to maintain your own well being. So many people living with dementia in any living environment find themselves with a low tank, as it were of well being. They have very little resilience and reserve, and it doesn’t take much to push people over the edge because they don’t have that reserve.
There are many frameworks for well being out there from Tom Kitwood right on down. But when I was looking for a subject for my second book I had mentioned one well being framework in particular, in my first book. And it came from a white paper that groups from the Eden Alternative organization wrote back 15 years ago almost.
Where they looked at the typical ways we measure quality indicators in residential care and said, “okay, what’s missing? What’s important to people that we’re not capturing?” And they looked at the larger aspect of well being and they came up with what they called Seven Domains of Well being. And I took those seven domains and they were just talking about residential care in general.
And I reordered them in a way that made more sense for me from a teaching standpoint. And then when I did my second book was I just applied those seven domains to the experience of dementia. What are they, how are they challenged? And how can we use a different approach to help restore those for people?
So the seven domains and the way I list them are identity, connectedness, security, autonomy, meaning growth, and joy. And I would argue that those are seven aspects of well being that we all need regardless of age, ethnicity nationality, faith tradition or presence or absence of medical illness.
People with cancer need those things, people with dementia need those things.
And I think what often happens is that people are in the situation where this is not being attended to, and these are such fundamental life giving needs, but we don’t see them because of our medicalised view. And so my theory was, what if the erosion of one or more of these aspects of well being was really the root cause of a lot of this distress.
Because we don’t know enough to provide this to people like we do blood pressure measurements and medications and all the other things. We’re leaving people with an empty tank and then blaming their dementia. And so I came up with an approach that really focuses on looking at those seven domains of well-being and looking at the individual who is in question. And just saying for that person, how full is each of their glasses for identity, for connectedness, for security and then finding ways to proactively just fill those glasses.
And it’s a counter-intuitive thing because you’re not trying to fix the behavior. That’s the usual response. How do you respond to the behavior? But this says, put that aside, turn your back on it and just work in the background that say, okay, how can I give this person better feelings of security?”
And, you know, emotional, psychological security. How do I give this person more choice and control? How do I improve these feelings of purpose, give people more of a sense of purpose in their life. And my theory was, if you just did that and you gave people more of that infrastructure for well being and more reserved that kept them away from that boiling point. Then you would see people’s stress and those expressions improve.
And I’m not a researcher and I haven’t done the good prospective trial myself, but I have a colleague in the state of Arkansas who has taken this approach and has demonstrated some really amazing results. Results that I’ve not seen with any other approach across 92 residential care homes.
And so I really think there’s something there. And I think that this is something that gives people an insight they don’t have when they only look at behaviors and dementia.

Ash de Neef: Well that sounds very different. And the potential there is really exciting.
At its core it feels like something that we’re hearing a lot on the podcast, which is people who are living with dementia are still people. They still have the same needs as everyone else, which sounds simple and obvious to say out loud, but that’s so often forgotten.
Now you’ve also spoken about the use of anti-psychotic medication, just in this conversation. And you’re quite outspoken about it’s overuse in a lot of situations. Does this approach tie into reducing the use of medication do you think?

Dr Al Power: Absolutely. Because once again, when people blamed these expressions on dementia and whatever simple interventions they try are not terribly successful, then the next choice is to reach for the pill bottle. And traditionally that’s been anti-psychotics, they’ve certainly come under the gun over the past decade, which I’m glad to see. Because that was, as I’ll explain later, that was the impetus for me writing my book in the first place – was to try to explain to people why I didn’t want to use drugs that they all wanted to use.
And my colleagues thought I was under prescribing and thought I was a problem because I wouldn’t give people drugs when the nurses would call me.
And I hadn’t found out well enough to explain thoroughly, why I thought it was wrong because it was the standard of care. And that’s where my first book came from, was trying to write down on paper in a very organized way, why it was wrong and what else we might do.
And even though anti-psychotics have come under the gun, what we see is people just switching to other pills – what I call drug diversion.
In regulatory terms, that means stealing narcotics to sell on the street, but I use it to mean stopping the anti-psychotics so your numbers look better. And then giving people a drug like Adavan or a different class of psychotropic medication. Which doesn’t trigger the anti-psychotic, but it’s still as futile and is potentially harmful because it’s not getting at the real root cause.
And what we’re seeing in a place like Canada, who has now legalized marijuana, is people are stopping the anti-psychotics and giving marijuana. But once again, I’m not anti-marijuana, but to use it in that sense is the same mindset of, “you have a behavior.”
I have to give you a drug to stop it instead of, “what is that you need or what is it that’s missing? What is this not supporting your well-being that we are not attending to?” So it’s just another drug in that context unfortunately.

Ash de Neef: Mm, well, it reminds me of something that Jason Burton said on the podcast. Just asking the question, “is this the best that we can do? Can we not do any better than just giving people drugs to solve symptoms?”

Dr Al Power: Great question. The other thing about the whole, the BPSD the symptoms of dementia mindset is it does give you an outlet. Everybody uses the same boiler plate. Always try non-pharmacologic approaches first. That’s their out. But if you truly inhabit a mindset that says this is coming from incurable brain disease, you will not put the effort or creativity into trying those approaches that you need to.
Before you default to the pills, you’ll try it. You’ll say, “well I tried it, but of course it didn’t work. And so let’s go to the pills.” So it’s never really taken people as far as what I think this paradigm does. And I think that’s the reason why a lot of the non-pharmacologic approaches don’t have better evidence in research than they do, because they’re still applied with that same mindset of when you do this, I will respond with this approach that I thought of.
And that may not meet your individual need, because I don’t know you. I’m going to try and massage with all the 30 people I’ve randomized in the care home. And guess what? Some of them don’t need to have a massage. They need choice and control. They need somebody familiar taking their clothes off, you know?
And so it’s no surprise that these things don’t work when they study them like that. It’s all that research paradigm still follows that reductionistic thinking that that goes the wrong way. There’s nothing reductionistic about dementia. People are individuals, they are unique and they can have the exact same brains, but everyone’s going to experience it and express it differently, and unless you know that person.
It’s complex and people try to make it simple and you can’t make it simple. So what I’ve tried to do with the well being framework is I’ve tried to bridge between people that want a formula and people that understand this is complex, but can’t be overwhelmed by, “I just don’t know what to do because everybody’s different”.
So what I do is I give people something that. You know, a toehold, I give them Seven Domains of Well-Being, so they have a bit of an algorithm. But then within that, they have to look at the individual and they have to apply it specifically to that person who they have to know well.
So that kind of balances the complex with a little bit more of a directive thing and it’s the best compromise I’ve found to help people deal with the complexity of the brain as best as possible.

Ash de Neef: A lot of the ideas that we’re talking about here and the approaches that you’re mentioning, they seem like they would require a large amount of culture change within care organizations within communities. Where does this change start from do you think?

Dr Al Power: Boy there’s a lot of different opinions about that.
I’ve worked in a culture change field for a long time, primarily through the Eden Alternative at the beginning. Which I discovered in 1997 and spent a week with Bill Thomas, the founder in 1998 and then was actively involved with them since.
But also through the greenhouse project, the small house model in the US and through some other cultural change movements as well. But when I talk about my approach, I basically talk about three pillars. The first pillar is to take away the very bio-medically focused definition of dementia. And instead, just see it through the lens of individual shifting experience. So that you were looking through that person’s eyes and saying, “okay, how am I perceiving and experiencing the world differently as a result of my brain changes?”
And it’s more of a disability approach because it says, “okay, instead of me trying to make you think like I do and see the world like I do – how can I accommodate you?”
So I often equate it to we give people the wheelchairs ramps. So what are the cognitive ramps that we can give people whose brains are changing to help them accommodate?
So that’s the first pillar. Second pillar is to use the well being framework as sort of our approach rather than just mitigating disease.
And the third is the culture change part, and that is really transforming the system of care. Because neither the beautiful definition nor the well being focus will work, if you still work within the system that puts those institutional rigid priorities in front of what the person needs to live well.
And so that’s, that is an essential part. And I think anybody who goes into a care home and tries to bring a new philosophy. If they don’t change the systems, it’s not going to work very well.

Ash de Neef: Well, they might have a situation like you were describing before where your colleagues thought you were under prescribing and you’re completely off the mark with, with how you’re dealing with it.

Dr Al Power: And you know it’s not like I was right then they were wrong. I mean, I was in some ways asking my colleagues in the nursing department to do things that we had not evolved far enough to necessarily do for some people. So, you know, I had seen enough people have remarkable results from certain approaches that I knew there was more potential.
But sometimes what a person needs your system just hasn’t been transformed enough that you can meet that person’s needs and sometimes your backs against the wall. And you have to give a pill, not because it’s the right thing, but because you’re approaching a critical situation. And until you can change your staffing or change your approach or your flexibility to meet that person’s needs, you may create a potentially dangerous situation.
But I do believe that we can find ourselves in a place in a world where – just like physical restraints have become – where the anti-psychotic can be the rare exception and not the rule.
If you look at the 16,000 care homes in the United States, residential care homes, the average anti-psychotic use is down to about 14% or it was before COVID, that may have changed. It got down to a little over 14%. That’s people with them without dementia who don’t have a psychiatric illness, so the people without dementia kind of dilute that number.
The best guess is that if you just looked at people with dementia in care homes is probably up in the 20% range is where the care homes are at. But there are 200 care homes at any given time in the U S that are using 0%. And there are hundreds more that are using 1-3%.
And so once again, if you believe these are symptoms of incurable disease, how do you explain the hundreds of care homes that have learned how to not use them at all? And so once again, that challenges the idea that this is all about the brain disease and that there isn’t something else important going on.

Ash de Neef: So if the ideal is to get to usage in 0% of cases, what can care providers do to take those first steps to move beyond drugs?

Dr Al Power: The first step I think is to really just start looking at dementia differently to, really look at that person’s shifting experience. To start to understand the perspective of the person. Start to pull themselves away from the idea that everything is a dementia related behavior, and to start reading up on some of these alternative ideas.
And it’s not just mine. It goes back to Tom Kitwood, who was the first person that really talked about sort of a different paradigm of living with dementia.
Another really important thing operationally is just to start holding conversations and conversations that involve the hands-on care partners so that they have a voice.
Because they bring a lot of experience and they bring a lot of deep knowledge of the person. And so I did a little subversive things in my care home work where for instance, they would have a care plan meeting and it was always set around the doctor’s schedule.
And it would be me and the nurse manager and the social worker and the family member, and maybe the person with dementia.
I had to insist on that, but the carer was always somewhere else doing some work. And I would always say, “well, where’s the primary care?” They’d say, “Oh, she’s giving somebody a shower and I’ll say, okay, well, let’s come back when the carer can be available, and that would be really difficult.
But the truth was when we got that person in the room, they always had insights that nobody else knew because they spend the most time with people.
So engaging people, and then the other thing is, and I know you’ve talked to Daniella Greenwood.
She has to have talked about consistency. She’s done groundbreaking work with a model for consistent care. And this is so important to have that trust familiarity deep knowing that comes from consistent relationships. So that’s an early thing to do in the, culture change world. And Daniella convinced me in my work with her that that needs to be an early step.
I used to think of something you did farther down the line, but she convinced me that until you have that consistency, it’s hard for other initiatives to take hold because people are always shifting, rotating assignments and shifting. Shaking up their ideas and it’s hard for them to get any toehold.
And the other thing I think is great from the education standpoint is too, thank you for doing this early on, is to hear the voices of people living with a diagnosis. You had Christine Bryden on.
All the advocates out there who are speaking about their experience and maybe a person who can travel to a conference doesn’t represent everybody. But they know a lot more about the changing brain than you or I do because they felt it. And I call them the true experts in the word experience and expert have a similar root of course. And I call myself a professional student of dementia. I don’t call myself an expert. But the people I’ve learned the most from some cases -my greatest teacher I consider was the late Dr. Richard Taylor.
Whom I got to know and traveled with and did writing and work with and to understand in the way that they can express that nobody else can.
I did a seminar in Brisbane for Dementia Training, the early progenitor of dementia training Australia, the DTSC. And we had a two day seminar and Christine lives near there and we got together and so I asked her if she would just come in for an hour on the second day. And she just came in and did a Q and a, and nothing I did during the other 13-14 hours came close to her discussion with the class about what her life was like with dementia.
And just simple things like what it’s like to use a public washroom. And finding the door on the way out and knowing what your door is right. And things like, the new faucets that may not be intuitive how to use them. Soap dispensers, things that people don’t think about, but really bringing the awareness of what it’s like to live that, and what you’ve challenged with that we don’t see in our daily life.
And every time I do that, every time I brought somebody in, it’s been just mind boggling for people to attend.

Ash de Neef: Can we talk about distraction? This is something that I’ve never really been able to articulate why it’s doesn’t sit right with me. And maybe you can help me get to the bottom of it. But this idea that care partners are using distraction as a way to deescalate emotional situations.

Dr Al Power: I love that it bothers you. That’s the first thing I’ll say, because it’s taught in so many different ways and it bothers me too. And I’ve gone so far as to say in many of my talks, to just to be provocative that I think that there are four things that never work that we should not do. And that’s re-orientation, redirection, distraction and deception.
These are all care partners centered maneuvers. They are, “what can I do to get you away from me so that I can do whatever I was doing before?” They do not seek to understand the root of the person’s needs. They are really to put the person in the place where they are not distressed, nce again, focused on what I need to accomplish.
And they never last, and I ask people, “if you distract somebody, how long they come back to you with the same question, five minutes, half hour?”
It’s certainly not six weeks, that’s for sure. Even if the question doesn’t make sense to you, the person is expressing something that they’re feeling. And until you validate, acknowledge that and explore that it’s just going to keep coming up.
It’s like a pain that never goes away. And I will sometimes say to people once again, just to be simplistic. If you were my supervisor at work and I came to you and said, “Boy, I’m just really feeling down.” And just express something that was bothering me about my work, something that felt unfulfilled. And you said to me, “Uh, yeah, boy that’s really hard. I understand. That’s really difficult. Hey, how are Richmond they had a great football game the other day?”
Would you feel like I listened to you? Would you feel like I answered your problem? But that’s kind of what distraction is. It’s a way of pushing the real root cause to the side.
And same thing with deception. Deceiving people never works. And in the times when people find out you’re deceiving them, it destroys whatever trust in the relationship you have.
These are things that gloss over the fact that the person is expressing something more deeply.
And so this is where we need to look at that person. Then we can look at the well being domains. We can look at symbolic expressions of need, maybe that are going on. We can just look at maybe a miscommunication. Maybe they said mother instead of daughter and they were talking about somebody else.
So there are lots of ways we can explore what’s next behind the person’s actions or their words. But to simply try to move them on to something else is just a short-term, a band-aid that is not going to last at all. So I’m with you. I don’t teach those things and I say you’ve got to go deeper.

Ash de Neef: Maybe there’s a way to incentivize more constructive or more helpful behavior for the well being of the care recipients. And when we talked to Daniella Greenwood, she brought up something that I didn’t know about. In Australia, residential care facilities receive funding for each incident of behavior that is recorded.

Dr Al Power: Okay. It’s very interesting because, and you see this in subtle ways in many countries in the industrialized world. But I do know in Australia they have, I think it’s like three different levels of reimbursement and the more challenging behaviors a person expresses the higher level of reimbursement.
And we have similar things in the US as far as complexity of care. And on the surface, it makes sense. If somebody seems to be more challenging to care for, you would think that you would want to give the home more resources. But as you say, it’s a disincentive to improve.
We used to use in the US the example of somebody goes to the hospital, say with pneumonia, they become delirious. They get restrained, their muscles de-condition they become incontinent. They don’t eat they’re malnourished and they can’t even stand. And they’re don’t know where they are by the time the pneumonia is treated. So instead of going home, they send you to a residential care, you know?
So when they go to residential care in the US we get the rehab. We get a dietary consult. We get speech therapy and all of a sudden we make people stronger. We get them a better diet. We help get them oriented – we get people moving again. And when they come in, of course, because they were so badly declined in the hospital we get lots of money.
When we make that person independent and clear and continent, and back in the way you and I would all want to live, what happens? We get a cut in pay. Because the next reporting quarter says that the people don’t have those things, and so they don’t get reimbursed.
So I always thought, you know, like for instance, pressure injuries, horrible outcome. It costs thousands, tens of thousands of dollars and months to heal one pressure injury.
But you get paid a lot for it. If they would pay homes more for the high risk people that don’t get pressure injuries and penalize for the low-risk people that do. I think we would allocate our resources and our care staff differently.
And you know, our, our federal government has moved to what they call, more of a performance-based payment system, but the devil’s in the details. It sounds good on paper, but you still have to look at all those categories and all those details. And I think we still have a way to go before we’re really incentivizing, proactively the way that we need to.
It is tough because whole well being approach I’m talking about is complex. It takes time. It doesn’t give you a calm person in a half an hour like a pill does. You have to commit to doing it for several weeks. When you do, you can have amazing long term success, but it is hard to incentivize that front end investment of time and energy in learning a new skill.
And that’s why these things don’t spread quickly. And that’s why I have to keep at it with groups. To get them to do it.
But, if we have some time, I’d love to talk about my friend in Arkansas and what they’ve done with this, because she’s got some numbers that I think are pretty impressive.
Her name is Dr. Angela Norman, and she is the director of the Center for Aging at the University of Arkansas for medical sciences. She’d be a great guest too. And she approached me about five years ago at a conference, an Eden conference actually, and told me how much she enjoyed the book that I wrote that went into the well being framework and how she wanted to try it in Arkansas. And I basically said, “yeah, knock yourself out.” And I didn’t hear about it from her for awhile, but she did several things.
The first thing she did when she went back a few years ago was she went to the owner of a large chain of residential care homes and asked him to send her and her team to four homes that he thought were struggling with anti-psychotic drugs.
And she went in, she taught this well being approach, not only using it to decode distress, but using it proactively in people’s care plans. So instead of just saying how’s their blood sugar doing? How’s their blood pressure doing? Also how is their autonomy doing? How is their purpose doing? And looking at those also as things to apply proactively.
And she contacted me several months later to say that as of six months, three of those four had reduced their anti-psychotics by a relative rate of 61-71%. And when you consider that the average US home did it by 30%, over eight years for three homes to do this in six months was great.
Now the culture change lesson is the fourth one didn’t. Same company, same state, same regs, same resident population. The culture change lesson is the reason they only had a 20% improvement in that time was because their leadership wasn’t onboard. And with culture change, you need the leadership to embrace and model that philosophy and values that will drive the new way of thinking and acting.
Because let’s face it, the people who are caring at the bedside, if they’re given contradictory messages from the people that supervise them, and the people over to them, it’s very hard for them to change their behavior, their actions.
And so, then the state got wind of this and they came to Angela. Because they are very innovation minded and they brought her to the 25 highest prescribing care homes in the state. These weren’t people that were looking for culture change. These were people that were – some of them about to be closed down.
They were in jeopardy and they were told you have to do this, or you’re in big trouble. And so they sent them to Angela and she brought this to them. And the last I heard over 18 months, three of them have closed because they were at that much on the edge. And the other 22 had an average of 40% improvement in their in their anti-psychotics.
So once again, this is taking some of the hardest cases and they were able to accomplish that. But the most amazing thing she’s done since 2018 is she’s worked with a cohort of 92 residential care homes. So, so nearly a hundred care homes. Thousands of residents.
And the reason this was useful was because they all contracted with this large medical group to provide services. So doctors and nurse practitioners, physician assistants were all coming in from this large company. So they had some control over the physician component, and the philosophy there.
And basically Angela did on-site seminars with her team. She did regional seminars. They had a hotline, they went in and helped people with this approach.
And they eventually put in a protocol that the medical personnel had to go through before they could send somebody out to like an acute geri-psych admission or something like that.
So these 92 homes started with 13.7% anti-psychotic use among them. And once again all the people within – without dementia, without psychotic illness. And over the two years, they cut that in half to 6.7%.
So if you look at the anti-psychotic numbers in Australia, I’m not sure where they’re at now. They’re probably up close to 20%. If you look at 6.5% across nearly early a hundred care homes. That’s a pretty amazing number.
But then the next thing they did was they looked at those people that are transferred out to acute care, these geri-psych units. Because they can’t resolve it onsite and they’re concerned about the danger. And that’s the dangerous situation because in Geri-psych units, those are crisis management units.
People there get restrained, they get medicated, they get sent back. It’s not a place where there’s culture change, where there’s deep insights into creative approaches. They’re there to help resolve crises. And what they found was over the course of 2019 and a cohort of 66 of those homes, that they were actually able to reduce those discharges to acute units.
And that’s by 75% over the course of the year.
And the punch line to this whole story is there’s actually a grant, which really upsets me, that came from the national Institute of aging a few years ago. Where they are giving $11 million to five large centers, including Harvard, Mayo clinic – big centers.
To give electroshock therapy to people with dementia who they feel have difficult behaviors.
So they’re actually using up to a dozen or more courses of electro-convulsive therapy too, because that does create a sort of a sense of euphoria afterwards. And once again, they have so medicalized these behaviors that this is what they’re doing to people.
So the punch line with Angela is this. These people are chosen for this study from Geri-psych units. So that’s the referral source for people to get electro-convulsive therapy. So my question is what if those people had lived in Arkansas, they never would have gotten that because Angela never would have sent them out to a Geri-psych unit and she would have cared for them without drugs, without such a such an invasive procedure being done.
And that’s why this little semantic difference in how I see symptoms of dementia versus something deeper can lead you down a very different road. And lead you in a drastically different approach to care just by changing your mindset a little bit.
And this is why it’s so important to me to try to get people to think differently. To get back to your first question, what behavior is all about. To me that is it. That is the root cause of everything.
When you have that mindset, it leads you down that road. And then it’s very hard to go back.

Ash de Neef: Fantastic. Al, thank you so much for your time today. People can visit your website at, Al power.com. Right?

Dr Al Power: Dot net. N E T. Somebody stole the other one, some aluminum company or something.

Ash de Neef: Well, Alpower.net. People can find out more about your books and about your writing. I know you’ve got a lot of articles published online, talking about a lot of the issues we’ve been talking about today. Thank you so much for your time.

Dr Al Power: Thank you Ash. It’s been a pleasure speaking with you.

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