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Clinical Approaches to Dementia Prevention: Motivational Interviewing

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Clinical Approaches to Dementia Prevention: Motivational Interviewing Melanie Bunn, RN, MS, GNP melanie.bunn_at_yahoo.com Geriatric Grand Challenge Institute: Dementia Care – PowerPoint PPT presentation

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Title: Clinical Approaches to Dementia Prevention: Motivational Interviewing


1
Clinical Approaches to Dementia
PreventionMotivational Interviewing
  • Melanie Bunn, RN, MS, GNP
  • melanie.bunn_at_yahoo.com
  • Geriatric Grand Challenge Institute Dementia
    Care
  • Duke University School of Nursing
  • March, 2013

2
ObjectiveDemonstrate motivational
interviewing discuss how it helps older adults
make lifestyle changes that can modify risk
factors for dementia
3
Non-compliance
  • Acute illness 20 to 40
  • Chronic illness 30 to 60
  • Prevention 80
  • See the pattern? Why?
  • Christensen AJ. Patient adherence to medical
    treatment regimens bridging the gap between
    behavioral science and biomedicine. New Haven
    Yale University Press 2004. Current perspectives
    in psychology.

4
Why do people not change?
  • Dont know what to do
  • Dont know how to do it
  • Dont know why its important
  • Dont believe they can
  • Which do you think are the most common reasons?

5
So, you want to help people change their
behaviors?
  • The dilemma
  • How can we help our clients change
  • Because they want to change
  • Not because you want them to change?
  • Or how do we MOTIVATE change?

6
Motivational Interviewing (MI)
  • a directive, client-centered counseling style
    for eliciting behavioral change by helping
    clients to explore and resolve ambivalenceRollnic
    k S, Miller WR. What is motivational
    interviewing? Behavioural and cognitive
    psychotherapy 199523(4)325-34
  • FIRST find out what is important to the client
  • THEN Use this to motivate the client to change
  • A method to help people change for themselves

7
History
  • Motivational interviewing was developed to help
    individuals
  • Change health behaviors (prevention)
  • Manage chronic diseases (compliance)
  • Deal with substance abuse
  • But the approach can work with other behaviors
    and with teams

8
Why try MI?
  • Short, 10-20 minutes
  • Because people know how to solve their own
    problems
  • Because people prefer to solve their own problems
  • Because their solutions are more likely to work
  • Individualized
  • Buy-in

9
Transtheoretical model of change
  • Behavioral change as a process
  • Five stages
  • Precontemplation
  • Contemplation
  • Preparation
  • Action
  • Maintenance
  • Prochaska JO, DiClemente CC. Transtheoretical
    therapy toward a more integrative model of
    change. Psychotherapy 198219(3)279-88.

10
But its not that easy!
  • Not 1-2-3-4-5
  • Relapse
  • Times of motivation
  • Other influences (for better or worse)

11
Traditional care approaches
  • Tell them what to doexpect them to do it
  • Tell them what to dodont expect them to do it
  • Threaten
  • Reward
  • Encourage
  • Scare tactics
  • Bribe

12
MI general points
  • Client is in the driving seat
  • Promote motivation by asking probing questions
    that allows clients discover for themselves the
    reasons for their habits
  • Give suggestions only when asked and as
    infrequently as possible
  • Share personal experiences that are relevant to
    the situation to establish rapport and trust

13
MI general points
  • Avoid arguing, even when you strongly disagree
  • Clients will be at different stages of being
    ready to change accept level of readiness for
    making a change this time
  • Avoid being judgmental accept reasons for not
    making a change in their habits

14
MI general points
  • People change because they want to
  • NOT
  • because
  • you want them to

15
Motivation to change
  • Knowledge alone does not usually lead to change
  • How many of you know
  • How many of you do
  • People also need to become motivated to change

16
Motivational Interviewing
  • Adapted from Levensky et all

17
4 Principles
  • Express empathy
  • Develop a discrepancy
  • Roll with resistance
  • Support self efficacy

18
Express empathy
  • Understands and accepts experience including
    ambivalence about change
  • Different from sympathy or telling your own story

19
Develop discrepancy
  • Enhance awareness of inconsistencies between
    behavior and goals and values
  • Motivate change
  • Facilitatedont identify

20
Roll with resistance
  • Dont directly oppose resistance
  • Invite, not impose, new perspectives

21
Support self efficacy
  • Belief that the person is able to do this
  • Confidence in Competence!!!

22
Getting started with MI
  • The first step is to create a partnership
  • Trustful partnerships are created by
  • Listening
  • Asking questions

23
4 Skills
  • Listening actively
  • Asking open questions
  • Affirming
  • Summarizing

24
Activity
25
How to listen
  • Clarify ? Could you explain that more?
  • Restate? What you are saying is.
  • Remain neutral ? nod, uh- huh..
  • Reflect ? It sounds like.
  • Affirm ? I think this is a plan you can achieve
  • Summarize ? So, the problem is

26
Two kinds of questions
  • Closed ended questions
  • Open ended questions
  • A key to effective MI is getting people to think
    more deeply about behaviors and choices.
  • This can be done by asking open ended questions.

27
Open ended questions
  • Question that allows many responses
  • Invites a story/ explanation
  • There is no one word answer (which would be
    closed-ended)
  • Encourages communication

28
Practice question skills Change these to Open
Ended Questions
  • Did you smoke this week?
  • Dont you want to lose weight?
  • Will it be hard to take your medications like the
    doctor ordered?
  • Dont you know youre not supposed to eat all
    that salt?
  • Did you do your exercises?
  • Do you want to get sick and die?
  • Did you take your medications like youre suppose
    to?
  • You didnt drink any alcohol this week, did you?

29
Be careful with WHY questions
  • Seem accusatory
  • Resulting in defensiveness
  • Leading to strengthening of positions
  • Break down in communication

30
Affirming
  • Recognize strengths, abilities, efforts
  • Must be sincere, adult, accurate, believable
  • Builds confidence and enthusiasm

31
Summarizing
  • Use when the person finishes to make sure you
    understand and the person knows you understand
  • Helpful for transitions
  • Keep it short
  • Ask for confirmation of your understanding

32
Stages of change
  • Willing
  • Able
  • Ready

33
Willing
  • Are you interested in changing? Why?
  • What do you want to change?
  • How important is it to you to change?
  • Are you happy where youre at and have no
    interest in change? OR
  • Are you torn between wanting to change and
    staying the same (on the fence)? OR
  • Is your desire to change strong enough for you to
    start taking action?

34
  • How WILLING Am I to Make the Change Needed to
    Achieve My Goal?
  • Behavior

Reasons I have for Not Changing Reasons I have for Changing
What benefits am I getting by staying the same, not changing? What are my fears about changing? What is the worst outcome I can imagine if I dont change? What would my life be like if a miracle happened and I was able to change tomorrow (benefits of change)?
35
How WILLING are You to Change?
  • The ruler of change
  • On a scale of 0 to 10, how strong are the reasons
    you gave on the left side of the Decision Balance
    chart for not changing?
  • On a scale of 0 to 10, how strong are the reasons
    you gave on the right side of the chart for
    changing?

0 1 2 3 4 5 6 7 8 9 10
Very weak Very Strong
0 1 2 3 4 5 6 7 8 9 10
Very weak Very Strong
36
Are your reasons for staying the same stronger
than your reasons for changing?
  • If so, youre not quite willing to change.
  • What is your role with people who are not
    thinking about change?
  • Help them increase their motivation and/or
    decrease their resistance so they start thinking
    more about making a change
  • Ask,
  • What would it take to reduce your reasons for
    staying the same?
  • What would it take for you to increase your
    reasons for changing?

37
Are your reasons for staying the same about the
same as your reasons for changing?
  • If so, you are thinking about change but are
    split between taking action and staying the same
  • When youre on the fence like this, its hard to
    take action
  • Whats your role with people who are on the
    fence?
  • Ask questions to help them increase their
    motivation and/or decrease their resistance so
    they can get over the fence to the side of taking
    action

38
Are your reasons for changing greater than your
reasons for staying the same ?
  • If so, you are not only thinking about making a
    change but you are willing to prepare and take
    some action to make a change.
  • What is your role with people who are ready to
    take action?
  • Take the next step
  • Are you ABLE?

39
Able
  • Do you have what it takes to change?
  • Ability?
  • Confidence?
  • Can you overcome the barriers and setbacks that
    can make it difficult to change?

40
ABLE - Assessing your confidence and ability to
achieve your goal
  • Understanding your confidence and ability can
    help you
  • Redefine your goals if your sense of confidence
    and ability is low (such as, start with smaller
    goals)
  • Start thinking about what it would take to
    increase your confidence or your ability to
    change.

41
ABLE Confidence and Ability
  • Score your confidence, from 1 to 10, to make a
    change
  • Score your ability to make change.

0 1 2 3 4 5 6 7 8 9 10
None Low Medium Very High
0 1 2 3 4 5 6 7 8 9 10
None Low Medium Very High
42
Increasing your confidence ability to change
  • Increase your motivation by asking questions
    evoking change talk
  • Ask yourself,
  • What would it take to increase my confidence to
    make this change (the change being eating
    smarter, moving more, stop smoking, etc)?
  • Ask yourself,
  • What would it take to increase my ability to
    make this change?

43
Optimism about change
  • People with high confidence and a high sense of
    their ability to make the change
  • More likely to occur when external supports are
    there to help people change.
  • Ask questions that can uncover these supports.

44
Optimism about change
  • Questions that help you define the supports
  • What encourages you to believe that you can
    change?
  • What else would help you change?
  • Who else would help you change?
  • You are one of the most important supports
  • You can give people a higher sense of confidence
    and ability and encourage their optimism.

45
Ready
  • If you are willing and able,
  • How will you do it? Do you have a plan?
  • Can you troubleshoot as your plan unfolds?
  • Are you prepared with alternate plans if barriers
    and obstacles arise that can cause setbacks?
  • Are you prepared to monitor your progress in
    completing the steps in your plan?

46
Ready
  • Setting goals and making plans for action
  • Being prepared for dealing with setbacks

47
Set and plan a goal SMART method
  • If you are Willing and Able, you are Ready to
    take the actions needed to make your goal.
  • But to create success, define a goal in a way
    that is Specific, can be Measured, is Action
    oriented, is Realistic, and is set in a specific
    Time frame.

48
SMART Method Some Examples
  • Whats wrong with the following goals?
  • I will start walking.
  • Ill put down exercise as my New Years
    resolution.
  • I will swim an hour everyday.
  • I will start exercising when it gets warm.
  • I will be more active.
  • Ill run in a marathon next spring.
  • Ill buy an exercise bike.
  • Soon Ill start a walking program.

49
Set and plan a goal SMART method
  • If you use the SMART method to set your goals, it
    will increase the chances that you will achieve
    them .
  • Specific
  • Measurable
  • Action oriented
  • Realistic
  • Time focused

50
Set and plan a goal SMART method
  • Write down your personal goal in a way that
    incorporates all these elements of a SMART goal.
  • Use Worksheet to record your SMART goal
  • Specific
  • Measurable
  • Action Oriented
  • Realistic
  • Time focused

51
Ready Dealing with barriers and setbacks
  • After taking action and beginning to change a
    habit, setbacks will occur
  • Lapses and relapses are natural parts of the
    change process
  • The key to staying motivated is to view setbacks
    as learning experiences, not as failures

52
Ready Dealing with barriers and setbacks
  • Setbacks are not failures
  • You can help people acquire this attitude
  • A Progress Check can be helpful in identifying
    setbacks and learning from them

53
Ready - Progress check
  • My goal was_____________
  • I was______ successful in reaching my goal
  • What helped______________
  • ______________was difficult
  • I learned that________________

54
READY - Staying Ready and Motivated
  • When you make your goal,
  • Dont Forget to Reward Yourself!!!
  • A reward provides an incentive to stay motivated.
  • Try the whenthen
  • Add note the reward shouldnt sabotage your
    goal!!!


55
Follow up
  • Always include in your plan
  • Provide encouragement for any change in the right
    direction, even if people fall short of the goal
  • Focus on sense of control and success

56
AskProvideAsk
  • What do you know?
  • This is what I know
  • What do you think or feel?

57
Practice
  • Get with a partner
  • Choose roles
  • Person with CHF who is not compliant with
    medication regimen
  • RN using motivational interviewing to help person
    improve medication compliance
  • PRACTICE

58
MI
  • Is the person willing? able? ready?
  • Set a SMART goal
  • Specific
  • Measurable
  • Action Oriented
  • Realistic
  • Time

59
Traps
  • Confrontation (leader gives reasons or
    suggestions, client counters)
  • Question-answer (leader asks serial questions
    with client giving short answers)
  • Expert trap (leader gives direction, advice,
    client responds passively)
  • Premature focus (leaders priority)

60
Final point
  • Motivation and Emotion come from the same Latin
    word MOVERE meaning to move
  • We MOVING towards being better!!! Not perfect!!!

61
How does MI help older adults make lifestyle
changes that can modify risk factors for
dementia?
62
References/Resources
  • https//www.miclab.org/sites/default/files/images/
    Lundahl201020Meta-analysis.pdf
  • Miller WR, Rollnick S, editors. Motivational
    interviewing preparing people for change. 2nd
    ed. New York Guilford Press 2002
  • Levensky ER, Forcehimes A, ODonohue WT Beitz K.
    Motivational Interviewing. AJN 2007 107(10)
    50-58
  • (http//www.nursingcenter.com/pdf.asp ?AID744988
    _)
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