Clinical Approaches to Dementia Prevention: Motivational Interviewing

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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

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ObjectiveDemonstrate motivational
interviewing discuss how it helps older adults
make lifestyle changes that can modify risk
factors for dementia
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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.

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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?

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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?

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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

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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

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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

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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.

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But its not that easy!

• Not 1-2-3-4-5
• Relapse
• Times of motivation
• Other influences (for better or worse)

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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

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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

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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

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MI general points

• People change because they want to
• NOT
• because
• you want them to

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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

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Motivational Interviewing

• Adapted from Levensky et all

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4 Principles

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

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Express empathy

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

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Develop discrepancy

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

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Roll with resistance

• Dont directly oppose resistance
• Invite, not impose, new perspectives

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Support self efficacy

• Belief that the person is able to do this
• Confidence in Competence!!!

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Getting started with MI

• The first step is to create a partnership
• Trustful partnerships are created by
• Listening
• Asking questions

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4 Skills

• Listening actively
• Asking open questions
• Affirming
• Summarizing

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Activity
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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

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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.

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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

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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?
  

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Be careful with WHY questions

• Seem accusatory
• Resulting in defensiveness
• Leading to strengthening of positions
• Break down in communication

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Affirming

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

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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

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Stages of change

• Willing
• Able
• Ready

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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?

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• 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)?
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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
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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?

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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

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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?

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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?

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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.

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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
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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?

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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.

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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.

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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?

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Ready

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

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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.

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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.

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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

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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

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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

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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

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Ready - Progress check

• My goal was_____________
• I was______ successful in reaching my goal
• What helped______________
• ______________was difficult
• I learned that________________

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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!!!

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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

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AskProvideAsk

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

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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

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MI

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

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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)

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Final point

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

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How does MI help older adults make lifestyle
changes that can modify risk factors for
dementia?
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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
  _)