P.I.E.C.E.S.

P.I.E.C.E.S. is a non-pharmacological assessment tool used by healthcare professionals to help them determine causes for behavioural and psychological symptoms associated with dementia. The acronym P.I.E.C.E.S. stands for:

Physical. Intellectual. Emotional. Capabilities. Environment. Social.

Physical causes for behaviours

There are a number of possible physical causes that may trigger a behaviour so time is required to eliminate or at least determine which, if any, of the following physical elements might be causing a reaction:

  • Pain (such as arthritis).
  • Sensory loss (poor eyesight, poor hearing).
  • Difficulty walking.
  • Temperature – cold, hot.
  • Medication – what are they taking – anything new or anything recently discontinued?

Intellectual causes for behaviours

Due to the impact dementia has on the brain, there are intellectual impairments that individuals with dementia deal with that can cause agitation or other behaviours. Healthcare professionals refer to them as the Seven A’s which help explain the frustration a patient faces:

1.Anosognosia is the lack of insight or awareness. The person with dementia does not know they have dementia and they believe they are fine. “There’s nothing wrong with me.”
2.Amnesia is the loss of memories such as facts, experiences or information. The patient may know who they are but has trouble learning new information or forming new memories.
3.Altered Perception is the inability to recognize themselves – their own reflection. Living in the past – living 25 years in the past becomes their reality.
4.Aphasia is a problem with language. There are four kinds:
  • Expressive: know what you want to say but can’t say what you mean
  • Receptive: hear the voice or see the print but can’t make sense of the words
  • Anomic: trouble using the correct word for places, object or events
  • Global: can’t speak, understand speech, read or write
5.

Apathy is the absence or suppression of interest or motivation.

(Click here for more in-depth information on Apathy)

6.Agnosia is the loss of the ability to recognize objects, faces, voices or places, but still have an ability to think, speak and interact with the world normally.
7.Apraxia is a motor speech disorder where messages from the brain to the mouth are disrupted. The person is unable to move their mouth, lips or tongue to the right place to make sounds correctly even though their muscles are not weak.

Emotional causes for behaviours

How is the person feeling in their body? Potential emotional causes for behavioural issues include:

  • Anxiety
  • Depression

Everyone has a baseline level of anxiety they can withstand. For a person with dementia, their perceptual disconnect impacts their threshold for anxiety. Their world can be frightening which heightens their state of anxiety

If you imagine that the objects they see are distorted, language doesn’t sound the same, or they may not recognize their own reflection, this altered state can impact their mood which in turn affects their behaviours.

Anxiety is fueled by the fact that an individual with dementia has no control over their world – they can no longer navigate their time. Instead, they must rely on others to decide their day and schedule their activities for them.

Behaviour(s) caused by anxiety may include:

  • General state of upset.
  • Shadowing – following the caregiver around constantly.

Capabilities – How they affect behaviour

Caregivers need to assess what the individual with dementia is and is not capable of doing and then create opportunities for him or her to help themselves. On some level the individual with dementia is aware of their limitations, but if you need to replace some objects with unbreakable ones, make them as safe and ‘adult’ as possible – not childish.

There is a risk of caregivers doing too much for the person with dementia. Don’t assume they can’t do things for themselves. Tasks may take longer and they may not remember the order of things but they are still able to perform acts such as dressing themselves.

Create a list with the proper order of garments, put it on the wall, and point to the list so your loved one can follow it and dress themselves. If followed repeatedly, day after day, their “procedural body memory” will take over and your loved one will look for the list to get dressed. It can become a routine, but this requires consistency.

Environment – How does their environment affect behaviour?

Take a fresh look around the environment.

  • Eliminate clutter.
  • Create clear, open and safe spaces to walk around in and be able to touch things without fear.
  • Is it too hot or too cold? Check the room and water temperature.
  • Is the room properly lit? Is it too bright, or too dark? Be aware that darkness can create shadows. Shadows can be frightening and may increase falls.
  • Too many people or too much noise can cause confusion and anxiety, which can manifest as a behaviour such as shouting or agitation.

Social – How does social activity affect behaviour?

The social aspect is all about the person – who they were. It’s very important. A person with dementia may not be able to express themselves as they once did, but their ‘person’ has not left with the disease.

The Montessori method for dementia programming can be very effective for working with patients – the method’s philosophy is: We define ourselves by the activities we do. The activities are important, but the ability to have activities that hold meaning for us is very important.

The challenge is to create opportunities that still have meaning for the person with dementia when their cognitive abilities are compromised. It requires planning, careful observation and thought.

The most effective interventions are built on ‘who’ the person was. So, the best thing you can do for your loved one with dementia is to create a document that tells other people who your loved one was. It should include the highlights, low moments and difficulties faced throughout their lives.