PRACTICAL SOLUTIONS TO REHAB DEMENTIA CARE PART 1 PROMOTING EACH PERSON S BEST ABILITY TO FUNCTION

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1 The Dementia Problem PRACTICAL SOLUTIONS TO REHAB DEMENTIA CARE PART 1 PROMOTING EACH PERSON S BEST ABILITY TO FUNCTION Efficient, practical & compassionate service is more important than ever before Aging population Growing need for dementia care Intro to the cognitive disabilities model of care Age related changes impacting function Physical changes in strength, coordination, energy levels Digestive and excretory system changes Medications may have side effects that impact appetite, alertness, or physical functioning Immune system changes Chronic Pain Sensory loss Sleep problems MORE Difficulties In Dementia Decreased attention/concentration to complete a task. Easily distracted. Reduced hunger/thirst awareness, dysphagia, aversion to textures Disorientation to time, spatial awareness Reduced ability to communicate Intolerance to excessive stimulation Confusion about what is expected Inability to sequence through multiple steps Feelings of loss (of self, of the familiar, of security ) Who is at risk? Vascular Dementia Any patient with a condition : That impacts blood flow That effects glucose levels That reduces oxygen levels That requires multiple medications That effects nutrient absorption That causes sleep impairment That leads to chronic pain That is accompanied by depression Represents 20% of dementia cases Characterized by neurological signs and systematic progression of symptoms Early gait changes Risk factors are HTN and CAD An Interdisciplinary Dementia Program Model for Long Term Care, Kim Warhol, OTR/L, Topics in Geriatric Rehabilitation Vol20, No.1, pp Lippincott Williams & Wilkins, Inc. 1

2 Dementia with Lewy Bodies Alzheimer s Disease Progression Accounts for 20% of dementia cases Early signs are not memory problems, but difficulties with attention, logic, time, and spatial thinking. Often show fluctuations in cognition not seen in other types Characterized in first year by parkinsonian movement, visual hallucinations, and early gait changes. An Interdisciplinary Dementia Program Model for Long Term Care, Kim Warhol, OTR/L, Topics in Geriatric Rehabilitation Vol20, No.1, pp Lippincott Williams & Wilkins, Inc. Artwork used with permission 2008 Alzheimer s Association Early stage: Learning and memory, thinking and planning problems Mild-Moderate stage: More learning, memory, planning problems. Also, speaking and understanding speech and sense of where the body is in relation to objects around them (proprioception & spatial awareness) is impaired. Advanced stage: Most of the cortex is seriously damaged due to widespread cell death. Lose communication ability, self care skills, & ability to recognize loved ones. Late Loss ADL s How do we start? Late loss ADLs are those self care abilities that remain intact the longest in the presence of cognitive decline Bed Mobility Toileting Transfer Eating Recognize cognitive impairment even at early stages when verbal skills are strong Define cognitive ability using an evidence based measure (stage the dementia) Establish reasonable treatment plans within the capabilities of the resident Train all caregivers, so that we are all speaking the same language regarding cognitive ability. Work together to build an environment that provides comfort, just right stimulation, and safety for differing levels of cognitive ability Functional Considerations for Rehab New learning Attention Predicting Problems Cognitive Disabilities Model Focuses on functional cognition and new learning ability Tests provide accurate predictor of function in familiar (e.g. brushing teeth) & unfamiliar tasks (e.g. learning to use a walker) Remaining abilities & expected deficits have been clarified for each dementia stage & help facilitate optimal care giving and planning in areas such as fall prevention An Interdisciplinary Dementia Program Model for Long Term Care, Kim Warhol, OTR/L, Topics in Geriatric Rehabilitation Vol20, No.1, pp Lippincott Williams & Wilkins, Inc. 2

3 What is the ACLS and RTI? Abilities are analyzed based on: ACL=Allen Cognitive Level Screen Presenting an unfamiliar task to determine how the resident problem solves and follows directions RTI=Routine Task Inventory Categorizes ADL performance based on caregiver observation of routine activities. These tests are based on the research of Claudia Allen & colleagues that has been ongoing since the early 1970s. Studies support the use of these tools to measure cognitive change, analyze activity performance, and develop reasonable treatment goals that promote meaningful activity within the patient s capacity to function. What they will pay attention to Motor control expectations Communication ability What do the ACL scores mean? 6 levels arranged in a continuum of clinically observable, qualitative differences in ability to perform functional activities There are 26 modes of performance within the 6 categories that allow for more sensitive measurement of function Lower score=lower functional expectation Resource: Brief History of the Allen Battery by Cathy Earhart March Abstract thought, reasoning, planning ahead Lives and works independently New learning Can work, with a job coach Min assist to anticipate hazards & prevent social conflict; May live alone with weekly checks Supervision for changes in routine Basic self care independence on routine Out of sight, out of mind Can form new habits with practice Handling objects Communication w/ nouns & verbs Structured ADLs with assist Gross motor skills Answer yes/no Respond to stimuli Comfort measures Prevent skin breakdown, contractures, etc. How do these tests help us? Research shows that using the Allen Cognitive Levels helps to accurately predict how much help the resident will need with self care, how best to cue them, what to reasonably expect them to recall and how much supervision they require for safety. Understanding remaining abilities fosters a realistic optimism for success in life Cathy Earhart, OTR/L Use the ACL to guide individualized approaches For issues such as: Falls Wandering Rummaging Resisting care Toileting & incontinence Eating problems Activity planning Discharge planning 3

4 Provide just right structure Activities that are age appropriate and individualized based on abilities, interests, and needs Environment & interaction that reduces anxiety, allows residents to maintain control in areas that they can Structure without sameness or lack of purpose in their day Steps to achieve this goal Use an objective means of identifying remaining cognitive ability and self care potential Train staff on how to offer the just right challenge for each resident in our care How about some examples 2.4 will walk aimlessly/wander avoiding barriers that are above the knee, but may trip over something left on the floor Resists confinement. Tries to escape. Eats and drinks with set up and mod assist to initiate / sustain actions. Needs 2-3xs the usual time to eat. 2.6 may disrobe if uncomfortable in clothes Level 3 Examples 3.0 may need you to put the washcloth or fork in their hand to remind them to start the task. May try to climb over side rails in bed or need you to actively encourage them to rest if they pace the halls. May need extra time to adjust from sitting to standing. May clog up the toilet using too much toilet paper. Level 4 examples 4.4 may be left alone for part of the day with someone to remove safety hazards and solve minor problems AND a procedure for calling help if needed Will pay attention to the environment 3-4 feet around them May initiate coming to the table at routine times or make self a sandwich. May not be able to eat and converse at the same time. May recognize well learned special diets. 4.6 may live alone with daily checks and help with bills and housework. 4

5 Care is more compassionate! We do not set goals higher than the resident can reasonably attain Care is more individualized! We can offer the types of activities that residents will predictably enjoy Care involves less trial & error! Care is more efficient! We can communicate in ways residents will best understand We can reduce behaviors by offering appropriate challenges & stimulation opportunities We have a functional means of communicating across caregivers the level of care required We can coordinate the activity calendar based on the cognitive levels represented Changes in cognitive function can be objectively measured & documented Putting it all together Case Study 1: Fred Lets review a sample patient program 92 y/o with frequent falls at home where he was ambulatory in the house without AD. History of dementia, Parkinson s, arthritis, chronic back pain, depression. New admit from home. Interventions: PT/OT with cognitive screening and fall risk assessment. ACLS/RTI score: 3.8 OT: cognitive assessment, ADL program with consistent routine, bathroom transfers, environmental modification (grab bar, raised toilet,) activities program guidance, staff education PT: assess & grade personal fall risk factors, balance activities, strengthening, back pain management, transfer training with walker, posture, restorative exercise & walk to dine program 5

6 Other Interventions for Fred Finding the individual s Just Right Challenge Develop routine: In 3 weeks, finds way to & from DR and begins walk to dine program. Performs basic ADLs with prompts to start and items set up in plain site and in order to be used/put on. Plan for slow pace and cues to keep going. Activities should be structured throughout the day to provide a calm yet sensory rich environment and avoid excessive sitting. Often enjoys meaningful music from own era, seated stretching and exercise, walks, people watching, repetitive tasks (polishing, sanding, folding, sorting) and basic crafts Scheduled toileting: Toilets with SBA for the transfer and occasional cues for thorough hygiene. He may not ask for help if he needs to go between scheduled times. Safety: Does not consistently remember safety precautions for transfers, but after consistent drilling of proper walker use has formed a new motor habit over time. Provide consistent task order and the same simple cues across caregivers to reinforce safe transitional movements/transfers/ambulation. Environment: Nightlights, no bed rails, tub seat, removal of items from floor, removal of unstable furniture due to tendency to furniture walk Therapy referral from nursing based on a change in condition or identified deficit Therapy evaluation, objective cognitive assessment, and treatment plan based on findings Individualized FMP or restorative program development with staff training on recommendations and cognitive level findings Nursing/restorative follows through with FMP or restorative program and consults with therapy if changes in the program are needed prior to the quarterly screening Intervention Cycle Join us for the next sessions: Quarterly Screens Change in Status/Skilled Need Rehab Intervention Session 2: April 9 (Assessment) April Complete self study lab practice of assessments with online videos Session 3 : April 16 (Application in treatment) Maintenance Program FMP/RNP referral Session 4: April 23 (Interventions) Certificates will be issued after session 4 with cumulative hours of sessions attended. All sessions will be recorded. Contact Holly at HTS regarding accessing recorded sessions. Proactive Medical Review & Consulting, LLC 6

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8 6 Abstract thought, reasoning, planning ahead Lives and works independently 5 4 New learning Can work, with a job coach Min assist to anticipate hazards & prevent social conflict; May live alone with weekly checks Supervision for changes in routine Basic self care independence on routine Out of sight, out of mind Can form new habits with practice 3 Handling objects Communication w/ nouns & verbs Structured ADLs with assist 2 Gross motor skills Answer yes/no 1 Respond to stimuli Comfort measures Prevent skin breakdown, contractures, etc.