Enter Stage Right: A Script For Dementia Intervention

Transcription

1 Enter Stage Right: A Script For Dementia Intervention Jocelyn Alexander, MA CCC-SLP Michele Kramer, MA CCC-SLP Therapy Partners ASHA CONVENTION 2010 Philadelphia, PA

2 Objectives Be able to differentiate and describe the different stages of dementia and utilize the appropriate assessments to accurately reflect and document the patient's cognitive level/stage. Be able to identify appropriate intervention strategies and techniques based on the patient s cognitive level and develop effective functional maintenance programs to maximize the independence at the patient's current cognitive level. Be able to develop appropriate short- and longterm goals that will maximize the patient's skills and provide caregiver training for optimal followthrough of the strategies and techniques.

3 Myths Patients with dementia are not candidates for therapy. Medicare does not cover treatment for Dementia patients.

4 FACTS Medicare does support skilled intervention for this population: Dementia is the general loss of cognitive abilities including impairment of memory, and may include one or more of the following: aphasia, apraxia, agnosia, or disturbed planning organizing, and abstract thinking abilities.throughout the course of their disease, patients with dementia may benefit from pharmacologic, physical, occupational, speech-language, and other therapies. (CMS Transmittal AB , Sept. 25, 2001)

5 FACTS Interdisciplinary team approach can be very effective in slowing functional decline Medicare covers claims for services rendered so long as there is CLEAR documentation of: Need for intervention Plan of action Progress made Functional discharge plans Medicare regulations require the assessment of patient baseline competency to initiate treatment and the availability of support personnel for a maintenance program.

6 Why use cognitive staging? In September 2001, Medicare issued a new Program Memorandum that prohibited the denial of therapy claims based solely on the diagnosis of Alzheimer s or related dementias. Throughout the course of their disease, patients with dementia may benefit from pharmacologic, physical, occupational, speech-language, and other therapies. (CMS Transmittal AB , Sept. 25, 2001)

7 Why use cognitive staging? Each facility must provide the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being. (OBRA 1987)

8 The Global Deterioration Scale Developed by Barry Reisberg, M.D Consists of 7 stages Only used for patients with dementia Can accurately delineate all stages throughout the entire course of dementia, from the earliest to most severe Clinical rating instrument can incorporate varying educational, cultural, socioeconomical, and other biases into determining the stage of

9 Stages of the GDS (Reisberg et al, 1982)

10 GDS Stage 1 (No Cognitive Decline) No complaints of memory deficits Appear normal clinically

11 GDS Stage 2 (Very Mild Cognitive Decline) Cognitive Decline) Forgetfulness phase Complaints from patient of mild forgetfulness No objective evidence of memory deficit during clinical interview No objective deficits in employment or social situations Patient displays appropriate concern regarding symptoms

12 GDS Stage 3 (Mild Cognitive Decline) Clear-cut clinical deficits first appear Objective evidence of memory deficit is obtained only through interview with skilled professional Possible concentration deficits May demonstrate decreased ability to recall names of newly introduced people Reads passage of a book and may retain relatively little material

13 GDS Stage 3 (cont d) Obvious impairments noted in demanding employment and social situations Close family members notice wordfinding difficulties May get lost traveling to unfamiliar locations Denial increases, along with anxiety (mild to moderate) Losing the ability to negotiate difficult situations

14 GDS Stage 4 (Moderate Cognitive Decline) Cognitive Decline) Clear-cut, widespread deficits apparent during clinical interview Displays decreased knowledge of recent events in their own lives, and of current events in the world around them Possible deficits in recall of personal history Significant difficulties with traveling alone and managing finances

15 GDS Stage 4 (cont d) Can no longer perform complex tasks accurately and/or efficiently May be oriented to time and person Recognizes familiar vs. unfamiliar persons May be exit-seeking Psychological changes: Denial becomes primary defense mechanism Flattening affect, withdrawal from previously challenging situations

16 GDS Stage 5 (Moderately Severe Cognitive Decline) Severe Cognitive Decline) Can no longer survive without some assistance Unable to recall a major relevant aspect of their current lives Somewhat disoriented to time or place Know their own name and generally names of spouses and children May not require assist with ADLs but need help to choose appropriate clothing Greater risk for elopement

17 GDS Stage 6 (Severe Cognitive Decline) May forget name of spouse, but recalls own name Largely unaware of all recent events and life experiences Knowledge of personal history is sketchy Generally unaware of surroundings, year, or season Difficulty counting from 10 backward and, at times, forward Require substantial assistance with ADLs

18 GDS Stage 6 (cont d) Diurnal rhythm becomes disturbed Distinguishes familiar vs. unfamiliar persons in their environment Word salad aphasia present in speech Personality/emotional changes: Delusions Obsessive symptoms Anxiety, agitation, even violent behavior Cognitive abulia (loss of willpower due to patient cannot carry a thought long enough to determine a purposeful course of action)

19 GDS Stage 7 (Very Severe Cognitive Decline) Cognitive Decline) All verbal abilities are lost (frequently, no speech present, only grunting) Patient is incontinent, requires near total assist for ADLs Psychomotor skills lost Generalized cortical and focal neurologic signs/symptoms are mostly present

20 GDS Assessments Brief Cognitive Rating Scale (BCRS) Functional Assessment Staging Tool (FAST) Functional Linguistic Communication Inventory (FLCI-gives modified FAST) Also related: Allen Cognitive Levels

21 Brief Cognitive Rating Scale (Reisberg & Ferris, 1988) Assesses GDS stage via 5 axes (concentration, recent memory, past memory, orientation, and physical functioning/self-care. Conducted in a clinical interview format. Ideal for patients who are variably cooperative and attentive, when other psychometric and mental status assessments may be unobtainable.

22 Brief Cognitive Rating Scale Ratings assigned to each axis are totaled, then divided by 5 to get the average. The average score gives the GDS stage.

23 Functional Assessment Staging Tool (Reisberg,, 1988) Observation tool which assigns a GDS stage. Evaluator checks all descriptions which match the patient s current functioning. The GDS stage is the highest consecutive level of disability.

24 Correlating the GDS and ACL Cognitive Levels of Dementia Table Brief Cognitive Rating Scale GDS FAST

25 Application/Treatment I did the assessments and got the level What do I do now?! (Voyzey, 2009)

26 Application/Treatment Each program must have a clearly defined purpose, procedure, supportive work flow assignments, and outcome measures that link to the quality indicators and quality measures.

27 Application: GDS Stage 1 No treatment is indicated Normal adult performing within functional limits

28 Application: GDS Stage 2 Use of memory compensatory strategies such as: omnemonic devices odescribing characteristics of persons/objects (circumlocution) osongs/music

29 Application: GDS Stage 3 Written cues: oreminders for medication administration odaily journal to record events oto-do lists oreminders for safety Schedules/calendars ofor activities, appointments, favorite TV shows

30 Application: GDS Stage 4 Allow patients to express preferences for foods, hobbies/activities, entertainment, clothing, etc: making their own choices is important! Use familiar pictures of family, self, and/or pets in room and outside to assist in identifying room Familiar sequenced tasks: simple cooking, crafts, or puzzles (use procedural memory!) Reminiscence activities Use of pictures to help sequence ADLs or locate items

31 Application: GDS Stage 5 Label actions as they are being performed Talk about common objects/items and discuss how they are used Do not attempt reality orientation Activities that require sorting, identifying, or categorizing Use procedural memory: folding laundry/towels, setting a table Do not ask open-ended questions; give choices: What do you want to wear today? vs. Do you want to wear your blue shirt or your red shirt today?

32 Application: GDS Stage 6 Identify body parts to communicate pain or discomfort Get into a routine and STICK TO IT! Continue to encourage choice-making whenever possible Incorporate therapeutic interventions for word-finding, memory, and receptive language with familiar activities that have meaning Encourage use of gestures to indicate wants/needs

33 Application: GDS Stage 7 Use olfactory stimuli: ocoffee grounds, essential oils (vanilla, lavender, peppermint) Incorporate music: ocastanets, bells, tambourines oplay music during treatment Use tactile stimuli: otextured materials to stimulate attention Use photo albums to encourage vocalizations and attention

34 Application: Helpful Hints Remember sun downing: patients can shift between levels when this occurs BE FUNCTIONAL! Relate treatment activities to daily living Choose activities that can be easily adapted for many levels Use adequate lighting to decrease risk of falls due to poor visual discrimination Remember, the first things gained are generally the last ones lost (retro genesis)

35 Treatment - Groups Increase participation in Group Therapy with residents with common stages. Utilize the Group Therapy code for treatment.

36 Documentation Medical Necessity Change in function Description of deficits Setting appropriate goals Tying treatment to a function

37 Coding Other Symbolic Dysfunction Other Symbolic Dysfunction loss of the ability to distinguish the significance of stimuli; may be auditory, visual, olfactory, tactile, or gustatory. Inability to recognize, understand, or interpret sensory stimuli in the absence of sensory defects. Also, the selective loss of knowledge of specific objects due to emotional disturbance, as seen in schizophrenia, hysteria, or depression. Inability to write (letters, syllables, words, or phrases) due to an injury to a specific cerebral area or occasionally due to emotional factors. loss of ability to perform familiar, purposeful movements in the absence of paralysis or other neural sensorimotor impairment. Inability to execute complex coordinated movements resulting from lesions in the motor area of the cortex but involving no sensory impairment or paralysis. Form of aphasia involving impaired ability to perform simple arithmetic calculations.

38 97532 Development of Cognitive Skills to improve Attention Memory Problem Solving Includes: Compensatory Training, Direct (Oneon-One) Patient contact by a provider Per 15 min. increment

39 Cognitive Therapy Cognitive skill training may be medically necessary for patients with acquired cognitive deficits resulting from head trauma, or acute neurologic events including cerebrovascular accidents. Impaired functions may include but are not limited to the ability to follow simple commands, attention to tasks, problem solving skills, memory, ability to follow numerous steps in a process, perform in a logical sequence and ability to compute.

40 Cognitive Therapy Cognitive skill training should be aimed towards improving or restoring specific functions which were impaired by an identified illness or injury, and expected outcomes should be reasonably attainable by the patient as specified by the plan of care.

41 Reason For Referral Patient referred for ST due to new onset (or exacerbation/decline) of cognitive-communicative deficits indicating the need to improve cognitive linguistic skills, analyze communication abilities, design and instruct on adaptive techniques and develop and instruct caregivers on compensatory strategies.

42 Reason For Referral Patient exhibits difficulty with problem solving and short term memory impacting their ability to communicate effectively and perform ADL s safely. Therapy is recommended in order to enhance patient s quality of life and ability to communicate thoughts, ideas, opinions, and/or feelings as well as to increase ability to participate in activities of daily living safely with decreased assist from caregivers.

43 Goals All goals need to be patient based

44 Goals LTG s Patient will increase orientation to temporal concepts to 100% of opportunities given cues by trained caregivers to improve ability to communicate complex thoughts, ideas, and opinions and/or feelings.

45 Goals STG s Patient will in crease functional problem solving skills to min/close supervision on 85% of opportunities and occasional cues in order to increase safety during daily living tasks and to facilitate return to home. Patient will generate multiple solutions to problem situations with 80% accuracy and occasional verbal cues in order to increase safety of daily living tasks and decreased assistance from caregivers.

46 Goals STG s Patient will demonstrate auditory comprehension of complex yes/no questions with 100% accuracy in order to communicate complex thoughts, opinions, ideas and/or feelings. Patient will demonstrate increased short term recall for functional daily life information with 85% of opportunities using visual aids as assisted by trained caregivers in order to decrease level of assist of caregivers.

47 Dementia Documentation: Positive prognostic behaviors Stimulability Orientation Ability to follow directions Attention span Self-expression Ability to solve problems Ability to imitate Medical stability Motivation to walk, talk, and be more independent Ability to selfmonitor/correct Recent history of independence

48 Documentation ID the stage the resident is in. Set appropriate expectations for the persons living with the dementia resident. Learn how to communicate. Plan ahead for upcoming stages.

49 Engaging the Resident in Therapy Make the resident your focus; determine what he/she likes as a reward Build rapport; help them recognize you as a person who is friendly and supportive Modify the environment eliminate distractions to increase focus; know their personal/cultural history Work closely with staff, learn what works and what does not Use multi-sensory cues Use positive statements and praise for efforts leading to completion of task.

50 Engaging the Caregivers in Therapy We can t change the person, so we have to change OUR approach and/or environment Educate caregivers in specific successful techniques/strategies; stress increased ease of performing job, improved maintenance of resident s independence and dignity Problem-solve with caregivers to find effective strategies

51 You have it easily in your power to increase the sum total of this world s happiness now. How? By giving a few words of sincere appreciation to someone who is lonely or discouraged. Perhaps you will forget tomorrow, the kind words you say today, but the recipient may cherish them over a lifetime. --Dale Carnegie

52 Facility Implementation Program Development

53 Facility Implementation Structure your program based on facility need: o Stoplight program o1 box per stage oinclude training for nursing staff as well as auxiliary staff (activities, housekeeping, etc)

54 Facility Implementation Decide a location in which to start (dedicated Alzheimer's unit vs. whole floor) Provide in servicing to facility IDT to explain the program and benefits Establish buy-in of floor staff (nursing/aides, housekeeping, dietary, etc) Make easy-to-follow functional maintenance plans for each patient Use objective data to present information to or counsel family members

55 Facility Implementation Sample program for person-centered care Alzheimer's unit: Evaluate patients for baseline cognitive stage Current cognitive stages denoted by color and/or number codes in chart, nursing notes, etc Staff offer activities for patients from corresponding bins Use current stage to plan for next stage

56 Conclusion Cognitive staging can be a helpful clinical tool to help formulate individualized care plans for patients with dementia. Using cognitive staging can help staff, family, & caregivers be proactive and plan for future stages and needs as well as provide caregiver training for optimal follow-through of the strategies and techniques. Medicare reimburses for treatment of patients with dementia when supporting documentation meets the criteria. Cognitive staging can develop into effective facility programs and can help educate all staff members on the disease process. Remember, everyone can benefit from dementia staging and therapy intervention.

57 References

58 References 1. CMS PUBLICATION/MEDICARE REQUIREMENTS: 100-2, Chapter 8, Sections 20, CMS PUBLICATION/MEDICARE REQUIREMENTS: 100-2, Chapter 15, Sections 213, CODE OF FEDERAL REGULATIONS: 42 CFR Section >Examples of skilled nursing and rehabilitation services. 4. ELI S REHAB REPORT: Volume 16 number 1, January 2009 pages ALZHEIMER S CARE TODAY, BEST PRACTICES IN DEMENTIAL CARE: September 2007, Volume 8, issue 3, pages 212, 214, and ALZHEIMER S ASSOCIATION CLEVELAND AREA CHAPTER: An overview of memory loss fact sheet 2008.

59 References 9.CMS PUBLICATION/MEDICARE REQUIREMENTS: Chapter 2, Section Documentation Requirements for Therapy Services (Rev.53, Issued: , Effective , Implementation: ). 10. Stages of Alzheimer s Disease. Caregivers Essential Care Sheet. Alzheimer s Assoc., Miami Valley Chapter. 11. Brief Cognitive Rating Scale from Alzheimer's Outreach Reisberg, B; Ferris, SH; DeLeon, M; Crook, T (1982). The Global Deterioration Scale for Assessment of Primary Degenerative Dementia. American Journal of Psychiatry: 139(9), pp Reisberg, Barry and Ferris, SH (1988). Brief Cognitive Rating Scale (BCRS). Psychopharmacology Bulletin: 24(4); pp

60 References 14. Reisberg, B; Franssen, E; Souren, L; Auer, S; Akram, I; Kenowsky, S (2002). Evidence and Mechanisms of Retrogenesis in Alzheimer s and Other Dementias: Management and Treatment Import. American Journal of Alzheimer s Disease and Other Dementias: 17(202), pp Sloane, P and Mathew, L (1991). An Assessment and Care Planning Strategy for Nursing Home Residents with Dementia. The Gerontologist: Vol. 31, No. 1, pp Voyzey, G (2009). Intervention Strategies for the Staged Individual With Dementia. Perspectives: Gerontology (American Speech- Language Hearing Association). July 2009; 14: Warchol, K (2004). An Interdisciplinary Dementia Program Model for Long-Term Care. Topics in Geriatric Rehabilitation. Vol 20, No 1, pp