Handout - American Physical Therapy Association

Stage-Specific Assessment and Intervention
Strategies for Individuals With Progressive
Dementia and Their Caregivers
William Dieter, PT, DPT, GCS
James Eng, PT, DPT, MS, GCS
Patricia Hoffman, OTR/L, BCG
Marvin Lawson, OTR/L, BCG
June 11th, 2016
Objectives
At the conclusion of this course, participants will be
able to:
• Be familiar with the most prevalent forms of dementia, reversible
dementias, and general guidelines for clinical approaches
• Be familiar with the stages of dementia based on the Global
Deterioration Scale (GDS)
• Understand clinically important differences between these stages of
dementia and apply appropriate strategies to maximize function in
each
• Understand how to communicate and determine appropriate
interventional strategies and goals to optimize movement in patients
with dementia
• Be able to document interventions and goals for patients with
dementia that qualify for Medicare reimbursement
Incidence, Cost, and Prevalence
• 5.4 million Americans living with Alzheimer’s disease
• Someone in America develops Alzheimer’s every 67
seconds
• $226 billion spent by Medicare and Medicaid in 2015
• 60% of caregivers rate emotional stress as high or
very high
WHAT DO YOU THINK OF WHEN
YOU HEAR THE WORD
DEMENTIA?
Mind shift:
What they can’t do
What they CAN DO
What is Dementia?
Dementia is progressive and
marked by
• Memory disorders
• Personality changes
• Impaired reasoning
Common Types
• Alzheimer’s
• Vascular Dementia
• Lewy Body Dementia
• Parkinson's Disease
Dementia
• Fronto-temporal Dementia
• Mixed Dementia
Reversible
• Depression
• UTI
• Medication side effects
• Excess use of alcohol
• Thyroid problems
• Vitamin deficiencies
• Delirium
Keep this in mind
• Problems with new learning/remembering new
information
• Old memories remain intact
• Utilize procedural memory
– Memories based on repetitive activity
• Often present well into late stages of AD; highly
impacted in PDD/LBD
Brain Changes in Alzheimer’s
Brain Changes in Alzheimer’s
• Preserved in Alzheimer’s
– Emotions
– “They may not remember you, but they will
remember how you made them feel”
– Music and rhythm
• Physical activity vs exercise – Potter et al
How does this change the activities you
would do with your client?
Pharmacological Intervention’s
for Alzheimer’s
• Lessen symptoms and slow progression, does not cure the
disease
• 2 classes of FDA approved treatment
• Cholinesterase Inhibitors
– Exelon (Rivastigmine): early to moderate stages
– Aricept (Donepezil): all stages
• Glutamate Regulator
–
Namenda (Memantine): moderate to severe stages
• Can be used in combination
•
Namzaric
Evaluation
and
Screening
Standardized Cognitive Assessments
Mini-Mental State Exam
(MMSE)
• Widely used in medical
practice
– Learned performance
• Takes 5 to 10 minutes
• Cutoff
– No impairment = 24-30
– Mild impairment = 18-23
– Severe impairment = 0-17
Montreal Cognitive
Assessment MoCA
• Gaining popularity
• Takes 10 to 15 minutes
• More sensitive than the
MMSE for early dementia
• Cutoff at 26 or greater =
dementia not likely
Short Blessed Test
Short Blessed Test
Writers
Irving Shulman
Gabriel Garcia Marquez
Iris Murdoch
Abe Burrows
Global Deterioration Scale
• Dr. Barry Reisberg
• Neuroretrogenesis
– Abilities are lost in the opposite direction they
were learned
– Treatment plan should follow that path
– There are 7 specific stages of dementia
progression
• Collectively, these stages are called the Global
Deterioration Scale
1
2
3
4
5
6
7
?
GDS/Cognitive Age Conversion
STAGE
GDS
Normal Adult
1
Cognitive
Age
25+
Aging Adult/MCI
2
18-24
MCI/Early Dementia
3
12-17
Early/ Mod Dementia
4
8-12
Moderate Dementia
5
5-7
Severe Dementia
6
2-5
Severe/ End Stage
7
0-2
Artists
Willem de Kooning
Norman Rockwell
Stages of Dementia According to
the Global Deterioration Scale
Stage 1
• Short-term memory
problems/loss is a key
symptom
• More stress you are under
the greater your memory
problems become
• May or may not be
pathological
Stage 2
• Generally no problems
functioning at work, at home or
during leisure activities due to
the use of compensatory
strategies
• No one knows that the
individual is having lapses of
memory
Stage 3
I know, but nobody else does
• The individual realizes that what
is happening to his memory is
not due to stress
• Compensatory strategies are
breaking down
• Still no one knows….but the
individual now knows
Stage 4
Lost in Space: “What’s happening?”
• The cat is out of the bag
– Others are aware of
disease
• Placement often occurs now
• Person continues to be socially
appropriate
• Person often depressed as
he/she mourns the future
• Learned “helplessness” can
occur (3 Day Decline!)
• Initial incontinence may occur
• Potential elopement risk
Stage 5
Dressed & ready, with nowhere to go
•
Maintains all social graces
–
•
Continue to be concerned with how they look
Individual no longer aware cognitive decline
–
Retains new information for
about 5 minutes
•
Less frustration, depression
•
Always “Just Visiting”
–
•
Elopement risk
Potential balance deficits
–
Intrinsic and extrinsic
Stage 6
Let’s Get Relaxed
• May look disheveled
– May lose dentures, eyeglasses, and/or hearing
aides
• Needs a jump start to do just about everything
– Physical activity more important than ever
• “90 Second Rule” usually works
to attain continence
• Altered temperature regulation
– Often layers clothing due to
feeling exceedingly cold
Stage 6 – Continued
• Gait pattern progresses to smaller step length, and shuffling feet
• Visual changes
– Usually lose peripheral vision
– Visual gaze begins to drop and eventually will be about 1-2 feet in front
– Depth perception erodes
• Incontinence continues
Stage 7
If it looks, feels or tastes good, I’ll do it
• Dominated by senses
• Not all behaviors are
what you think they are
(moaning could be pain
or self entertainment)
• Unable to express needs
verbally, so you have to
be a detective
• May be in a wheelchair
because of falls
• Needs significant help with
bed mobility, transfers
• Walking
– Requires assistance if able
– Ability likely depends on
prior activity level
General Therapy Principles
• Relate to function
• Make it measurable and demonstrate medical necessity
– Understand your skilled interventions
• Focus on habilitation, not rehabilitation
• Stage specific
• Caregiver education
General Behavioral Management
• Identify and manage negative behaviors
• Trial various methods
– Reimbursable by Medicare
– Make require several trials
• Make sure you document
– What, why, outcomes of trails
– Skilled intervention
General Communication Guidelines
• Control the Environment
– Simplify the space
– Remove clutter
– Provide a calm atmosphere
– Eliminate or minimize background noise
– Sufficient light, without glare
– Sufficient warmth, eliminate drafts
– Open vs closed environment
Communication Example
Teepa Snow
Politicians
Winston Churchill
Margaret Thatcher
Ronald Reagan
GDS STAGES Interventions and Goals
Overview
GDS STAGES Interventions and Goals
Overview: ICF Framework (WHO, 2001)
GDS STAGE 1 Interventions and Goals
I forget things – because I am stressed
Preliminary Screening
• Cognition: (Short Blessed)
• Body function & structures:
– Balance (TUG, DGI, 4 Stage Balance Test,
Fullerton, FGA)
• Dual Tasking for higher challenge
– Functional Strength (5xSTS, 30sec STS, Arm
Curl)
– Posture (Occiput to Wall Distance)
– Endurance (6 or 2 min walk)
– Gait Speed
• Activities and Participation: Family/patient identify
GDS STAGE 1 Interventions and Goals
I forget things – because I am stressed
Goals:
• Establish gold standard baseline
• Document for future reference
• Use to justify medical necessity
GDS STAGE 2 Interventions and Goals
Compensatory strategies
Screens illuminate subtle changes
•
•
Early gait deficits/falls may be early indicator – Alzheimer’s
Association
Compensatory strategies may appear exaggerated/rigid
– Alarms
– Lists
– Routines (park in same spot, put keys in refrigerator)
GDS STAGE 2 Interventions and Goals
Compensatory strategies
Interventions
• Consider alternative strategies for communication and
reminders
– Color coding, signs. Consult Occupational Therapy
– “Pill box” binder for Home Exercise Program
• Challenging activities while minimizing frustration (Line
dancing)
• Introduce Power Exercises - Steves et al
• Proactive home safety strategies and precautions
GDS STAGE 2 Interventions and Goals
Compensatory strategies
Balance Considerations
• Provide insight into deficits without overwhelming
• Incorporate strengthening and balance components into
routine activities
– Laundry down steps (if safe)
– Carrying groceries, helping to put dishes away
– Dancing, bowling, singing in choirs
• Posture awareness and remediation
- Impairment level
- Yoga
GDS STAGE 2 Interventions and Goals
Compensatory strategies
Sample Goals for Stage 2
• Caregiver will verbalize understanding of environmental
adaptations to eliminate clutter and minimize fall risk
• Patient will ambulate independently outdoor uneven
surfaces for >1,000 feet without loss of balance during
house care activities (participation)
• Patient and/or caregiver will adhere to home physical
activity program to maintain activity levels consistent
with AHA guidelines
• Objective measures on standardized tests (e.g. TUG, 6
minute walk, sit to stand)
GDS STAGE 3 Interventions and Goals
I know, but nobody else does
Screens illuminate subtle changes
•Early gait deficits/falls may be early indicator – Alzheimer’s
Association
•Dual tasking difficulties correlate with Alzheimer’s
•Compensatory strategies may not work consistently
–Alarms
–Lists
–Routines (park in same spot, put keys in refrigerator)
• Driving considerations
GDS STAGE 3 Interventions and Goals
I know, but nobody else does
Interventions
• Begin the conversation (caregiver suspects, train the
trainer)
• Consider alternative strategies for communication and
reminders
– Color coding, signs. Consult Occupational Therapy
– “Pill box” binder for Home Exercise Program
• Challenging activities while minimizing frustration (Line
dancing)
• Medications effective at early stage: Exelon and Aricept
• Introduce Power Exercises
• Proactive home safety strategies and precautions
GDS STAGE 3 Interventions and Goals
I know, but nobody else does
Interventions (continued)
• Begin to adapt environment to make movement easy
–
–
–
–
Cushions on favorite chairs to raise seat height
Hand rails on stairs
Grab bars near showers, toilet, bathroom sink
Stander security pole near bed
• Looking Ahead
– Introduce concept of new devices (rollator walker, stair
glides)
– Introduce new strategies for bed mobility(supine to
sidelying to sit)
– Address potential issues that might facilitate inertia
GDS STAGE 3 Interventions and Goals
I know, but nobody else does
Balance Considerations
• Provide insight into deficits without overwhelming family
• Incorporate strengthening and balance components into
routine activities
– Laundry down steps
– Carrying groceries
– Dancing, bowling, singing in choirs
• Posture awareness and remediation
- Yoga
GDS STAGE 3 Interventions and Goals
I know, but nobody else does
Sample Goals for Stage 3
• Caregiver will verbalize understanding of potential and
progression of Dementia process
• Patient and caregiver will transition/tolerate use of
alternative devices (be specific about device and activity)
• Patient and/or caregiver will adhere to home activity
program to maintain physical activity levels consistent
with AHA guidelines
• Objective measures on standardized tests (e.g. TUG, 6
minute walk, sit to stand, posture)
– With alternative devices or adaptations
GDS STAGE 4 Interventions and Goals
Lost in Space: What’s Happening?
Screening
•Medication and cognition:
– May be on Aricept, Exelon, Razadyne, or progressed to
Namenda
– Potential side effects: Headache, constipation, dizziness,
confusion, skin irritation
•Utilize simple standard test: (TUG or DGI vs Berg)
•Assess functional activities focusing on burden of care
– Highlight assistance of spouse, caregiver
– Focus on health and safety of spouse
– Document and differentiate types of assistance (e.g., min
physical, mod verbal)
• Critical to depicting effects of Dementia
GDS STAGE 4 Interventions and Goals
Lost in Space: What’s Happening?
Screening (continued)
•Associate all objective changes with respect to safety, fall risk,
efficacy:
–
–
–
–
How long does getting down the stairs take?
How long does car transfers take
How long does it take to get in and out of bed?
Did the person have a fall recently, or was found on the floor?
•Consult Speech Language Pathology (SLP) to assess swallowing
– Baseline assessment
GDS STAGE 4 Interventions and Goals
Lost in Space: What’s Happening?
Interventions
• Consider Senior Living Community (SLC) Placement
– Factors include health of spouse, family and community
resources, type of home
• To remain at Home:
– Safety adaptions: Wearable alert device, lighting,
wandering strategies, bathroom safety (Patty and Marv?)
– Utilize signs and landmarks to facilitate spatial awareness
– Consider if these can be translatable to new environment
• Consult Speech Language Pathology (SLP) for
swallowing risk
GDS STAGE 4 Interventions and Goals
Lost in Space: What’s Happening?
Interventions (continued)
• Use repetitive, relevant, familiar tasks
– Patient still able to learn – needs tactile and verbal cueing
• Mobility: Teach new transfer sequence slowly with
demonstration and high level of repetition
– Example: Turn completely before you sit
• Optimize all sensory systems
– Minimize toxic and irrelevant distractors (TV, radio noise,
annoying people)
– Utilize pleasant and incentivizing facilitators (music,
cooking smells (olfactory may be diminished), colors,
circumstance validation, pleasant familiar pictures)
GDS STAGE 4 Interventions and Goals
Lost in Space: What’s Happening?
Moving Considerations:
• Results in immediate decline in functional level (learned
helplessness)
• “Just visiting”
• Minimized through
– Place integration
– Way finding
• May lead to depression
GDS STAGE 4 Interventions and Goals
Lost in Space: What’s Happening?
Depression
•Prevalent at this stage
–
–
–
–
Client remains aware of deficits
Others are aware
Mourning future
Displacement from homes (sometime of lifetime duration)
•Evidence exists that physical activity reduces depression
– Increased mobility and optimal functional correlated with
decreased depression
– Burden on caregiver and associated caregiver depression is
growing issue in later stages
GDS STAGE 4 Interventions and Goals
Lost in Space: What’s Happening?
Sample Goals for Stage 4
•Intervention focus shifts away from patient independence
– Patient activity always with assistance
– Caregiver performance with independence
•Patient will ambulate 500 feet from bedroom to dining
room, using a Rollator walker with minimal physical
assistance and verbal cues of caregiver
•Patient will ascend/descend 12 steps from bathroom to
living room with a cane and railing, with minimal physical
assistance and moderate verbal cues of caregiver
•Caregiver will assist patient to adhere to home activity
program safely consistent with AHA guideline
GDS STAGE 5 Interventions and Goals
Dressed and Ready, with Nowhere to Go
Screening
•Typical Profile
– Likely progressed to Namenda
– Unaware of their dementia (in the moment)
– Dependent to live
– No recall of relatively recent information (grand children)
– Disoriented to time and place
– Can’t travel independently but may wander away
– Might have trouble picking out appropriate clothes
• Mismatched shoes
GDS STAGE 5 Interventions and Goals
Dressed and Ready, with Nowhere to Go
Screening
•Typical Profile (continued)
– Fall risk
– Beginning of visual field loss
– Know spouse and children
– Can eat, dress, and often toilet after set-up
– Act and converse appropriately
– Enjoy social activities, music, singing, dancing
– Mobile
GDS STAGE 5 Interventions and Goals
Dressed and Ready, with Nowhere to Go
Interventions
Strategies
•
•
•
•
•
•
•
•
Cue to move slowly
Employ situation-specific and purposeful strategies
Use old photographs, familiar objects
Increase shape and color contrast
– Tape on grab bars
Enhance lighting
Make inaccessible heat sources, medication, cigarettes
Resort to alternative ambulatory device (should be familiar
from earlier stage)
Caregiver counseling: Don’t correct, don’t get mad
GDS STAGE 5 Interventions and Goals
Dressed and Ready, with Nowhere to Go
Interventions
Strategies (continued)
•
•
•
•
•
•
Environmental optimization safe mobility
Strategic placement of grab bars
Use assistive device, allow furniture walk
Way finding
Clutter reduction
Home activity program entirely functional (well… try
restorator)
GDS STAGE 5 Interventions and Goals
Dressed and Ready, with Nowhere to Go
Sample Goals for Stage 5
• Caregiver will transfer patient sit to stand, bed to chair
•
•
safely and independently
Caregiver will assist patient to ambulate 500 feet from
bedroom to dining room with appropriate device safely
and independently
Caregiver will assist patient in adhering to home physical
activity program daily
GDS STAGE 6 Interventions and Goals
Let’s Get Relaxed
Screening
•Typical Profile
– Gait deviation, motor coordination, significant
– Visual perceptual skills degrade, include depth
perception loss
– Poor kinesthetic awareness (unaware of chair
location during turning)
– Increased physical sensitivity
– Startles easily
– Still wanders
GDS STAGE 6 Interventions and Goals
Let’s Get Relaxed
Screening
•Typical Profile (continued)
–
–
–
–
–
–
Sexual urges
Disheveled
Speaks few words
Responds better to tactile and visual cues
90 second rule
Assess pain passively
•
PainAD
GDS STAGE 6 Interventions and Goals
Let’s Get Relaxed
Interventions
•Primarily caregiver training
•Position yourself in patient’s view (on side 300)
•Cue to initiate activity
•Cue slowly, step by step – accommodate decreased
kinesthetic awareness
•Moderate tactile cues, physical assistance
•Ambulation on level surfaces and stair still possible with
assistance
– Employ safe precautions
– Remove distractions and potential physical hazards
– Expect agitated and fearful behavior
GDS STAGE 6 Interventions and Goals
Let’s Get Relaxed
Interventions (continued)
•Caregiver instruction is critical for caregiver
– Don’t correct
– Expect agitation and fear
– Don’t get mad
– Seek assistance and counseling
GDS STAGE 6 Interventions and Goals
Let’s Get Relaxed
Sample Goals for Stage 6
• Caregiver will transfer patient sit to stand, bed to chair
•
•
safely and independently
Caregiver will assist patient to ambulate 50 feet from bed
to wheelchair with appropriate device independently
Caregiver will follow home physical activity program daily
to avoid range of motion loss, wound risk
Caregiver Education Example
GDS STAGE 7 Interventions and Goals
If It Looks Good or Feels Good, I’ll Do It
Screening
•Typical Profile
–
–
–
–
Patient’s cognition at level of child
Driven by basic tactile and sensory needs
Expect inertia
May be ambulatory, but a great fall risk
Intervention
•Continued Caregiver Education
–
–
–
–
–
Situation and circumstance specific
Basic ADLs, bed mobility
Chair and bed positioning for skin integrity
DME assessment
Home activity program for maintenance
GDS STAGE 7 Interventions and Goals
If It Looks Good or Feels Good, I’ll Do It
Sample Goals for Stage 7
•Caregiver will transport patient from bed to/from chair
with appropriate device (e.g., Hoyer lift) independently
and safely with minimal patient agitation
•Caregiver will utilize protective equipment (e.g., hip
protector) to enable safe mobility and transfers
Actors
Arthur O’Connell
Arlene Francis
Charles Bronson
Geraldine Fitzgerald
James Doohan
Robin Williams
Estelle Getty
Margaret Rutherford
Burgess Meredith
Musicians
Malcolm Young
Tommy Dorsey
Casey Kasem
Glenn
Campbell
Rudolf Bing
Caregiver Education
Caregiver Education
• Early and often
• May be extensive
• Ratio provided to client vs caregiver depends on stage
• Include strategies to enable the caregiver
– Relaxation techniques
–
–
–
–
Communication strategies
Education regarding disease process
HEP programs
Specific strategies to manage behaviors
How to Document Caregiver Education
• Document specifics
– Note if additional time is required and why
• Document the caregiver’s response
– Need to highlight
•
•
•
•
•
Response
Understanding
Return demonstration
Need for follow up
Assist level and/or specific cues
How to Document Standardized Tests
• Time spent
• Actual test that was performed
• Score/outcome of the test
• Normative value or evidence based cut-offs
• Why the test is being utilized
- “Cognitive baseline”
- Identify appropriate GDS stage for appropriate
POC
Daily Documentation
•
•
•
•
•
•
•
Show skilled intervention
Be specific about trials
Explain why extra time/ trials are needed
Note level of assistance for caregivers
Emphasis on Objective portion
Note minutes for each task
Show progress
– FOMs
– Caregiver progress
Take Home Point
• If it is not written, it was not done!
• Remember, a Medicare auditor, or another auditor may
not know why the test is being performed, and will
probably have no idea as to what the normative values
are. Be sure to clarify
Others
Singer, Amy Grant –
Caregiver for her Parents
Rosa Parks
Pat Summit
B. Smith
Harry Ritz
Otto Preminger
Actors
Charlton Heston
Rita Hayworth
Questions?
THANK YOU!