Stage-Specific Assessment and Intervention Strategies for Individuals With Progressive Dementia and Their Caregivers Presented by:
R. Lockwood Murphy, PT, DPT, CSCS Regional Director FOX Rehabilitation
October 24, 2017
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
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 a set of symptoms – reflects a gradual decline in memory and/or behavior – caused by gradual loss of working brain cells
• Alzheimer's Disease is one form of progressive dementia • There are over 50 other identified causes of dementia
What is Dementia? Dementia is progressive and marked by • Memory disorders • Personality changes • Impaired reasoning
TYPES OF MEMORY • Episodic memory
– Memories of things you have personally experienced
• Things you have done, people you have seen • Highly impacted in AD; may remain intact in PDD/LBD
• Semantic memory
– Everything else you know: learned knowledge • Highly impacted in AD
• Procedural memories
– Memories based on repetitive activity • • • •
Action based Can be achieved with extra time Assisted by environmental cues, “landmarks” Often present well into late stages of AD; highly impacted in PDD/LBD
COMMON TYPES OF DEMENTIA • Alzheimer's Disease
• Vascular Dementia • Lewy Body Dementia • Parkinson's Disease Dementia • Fronto-temporal Dementia • Mixed Dementia
Alzheimer’s • Most common type (60 -80%) • Modern medical description by Alois Alzheimer in 1906, who found plaques and tangles in the brain • Rare in earlier times because few people lived to a very old age
Alzheimer’s - Statistics • 5.4 million Americans living with Alzheimer’s disease • By 2050, an estimated 16 million will develop Alzheimer’s disease
• 1 in 7 are living alone • $140 billion in costs to Medicare and Medicaid (2012), $226 billion (2015) • 60% of caregivers rate emotional stress as high or very high
• 1/3 of caregivers report symptoms of depression
Progression of Alzheimer’s • Duration of illness is generally 6 to 12 years • The later the diagnosis, the shorter the lifespan • Onset is usually after age 65 • Before age 65 called “early onset”
Keep this in mind • Problems with new learning/remembering new information • Old memories remain intact • We call these memories residual memories • The client’s ability to access residual memory erodes • 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 • Hippocampus most affected – Loss of memory – Loss of spatial orientation • Frontal lobe • Loss of executive function, inhibitions • Parietal and temporal lobes – Disorientation in space – Loss of language – Loss of memory • Occipital Lobe – Progressive loss of peripheral vision/ binocular vision
• Hypothalamus – Loss of temperature regulation
Preserved in Alzheimer’s • Emotions • Amygdala is the emotional center • Last area to be damaged • Capitalize on for making connection with patients
• “They may not remember you, but they will remember how you made them feel” • Music and rhythm
• Stored opposite the language center • Often undamaged
• Physical activity vs exercise – Potter et al
How does this change the activities you would do with your client?
OTHER COMMON TYPES OF DEMENTIA
VASCULAR DEMENTIA • Also known as multi-infarct or vascular cognitive impairment • Often due to series of small TIAs that block arteries
• Symptoms overlap with AD however memory may not be as seriously affected • May be focal loss, rather than global
DEMENTIAS 1. Dementia with Lewy Bodies (DLB) – Problems with motor planning, memory, judgment and behavior – Severity and alertness of symptoms may fluctuate daily – As disease progresses, physical symptoms similar to Parkinson’s: rigidity, bradykinesia 2. Parkinson’s Disease Dementia (PDD) – 80% of PD patients will develop PDD – Physical symptoms followed by cognitive changes – Day time sleepiness
DEMENTIAS • Both DLB and PDD: – Visual hallucinations and/or sensitivity to neuroleptics – Have exaggerated Extrapyramidal Symptoms (EPS) with neuroleptics – On autopsy: Lewy bodies present (abnormal deposits of protein) – May show wide mood swings – Tend to retain episodic memories longer than in AD
FRONTOTEMPORAL DEMENTIAS • Includes Pick’s disease, primary progressive aphasia, semantic dementia, and others – Often misdiagnosed as psychiatric disorder • Change in personality and behavior Impulsivity Loss of social inhibitions Decline in personal hygiene • Difficulty with language • Minimal memory deficits are noted in early stages • No pharmaceutical treatments available • Commonly in persons between age of 50-60 years
DIFFERENTIATING FTD’S FROM ALZHEIMER’S • Comprises 10 to 20% of all dementia cases – Affects 50 to 60 thousand Americans
• 50 – 70% of cases are sporadic (NOT genetic) • Onset typically in 50’s, but ranges from 20’s to 80’s • Social behavioral decline
• Memory generally preserved • Earlier language deterioration • Lasts 2 to 10 years (from time of diagnosis)
MIXED DEMENTIA • Most common is AD and Vascular Dementia • Can be any combination of dementia diagnoses • Symptoms will be a composite of the mix
REVERSIBLE DEMENTIAS Some Examples:
•Depression •UTI •Medication side effects •Excess use of alcohol •Thyroid problems •Vitamin deficiencies
Evaluation and Screening
Standardized Cognitive Assessments Mini-Mental State Exam (MMSE)
Montreal Cognitive Assessment MoCA
• Widely used in medical practice
• Gaining popularity
–
Learned performance
• Takes 5 to 10 minutes
• Takes 10 to 15 minutes
• Roughly correlates with GDS
• More sensitive than the MMSE for early dementia
• Not sensitive to mild cognitive impairments
• Cutoff at 26 or greater = dementia not likely
• Cutoff – No impairment = 24-30 – Mild impairment = 18-23 – Severe impairment = 0-17
Short Blessed Test • A screen to determine if further testing maybe necessary • Complete 6 tasks • Scores are weighted 0-4 normal cognition 5-9
questionable impairment (evaluate for early dementing disorder)
10+
impairment consistent with Dementia (evaluate for dementing disorder)
Writers Irving Shulman
Gabriel Garcia Marquez
Iris Murdoch
Abe Burrows
Artists
Willem de Kooning
Norman Rockwell
Actors Arthur O’Connell
Arlene Francis Charles Bronson
Geraldine Fitzgerald
James Doohan
Robin Williams Estelle Getty
Margaret Rutherford
Burgess Meredith
Politicians
Winston Churchill
Margaret Thatcher
Ronald Reagan
Musicians Malcolm Young
Casey Kasem
Tommy Dorsey
Glenn Campbell Rudolf Bing
Others
Singer, Amy Grant – Caregiver for her Parents
Rosa Parks
Pat Summit B. Smith
Harry Ritz Otto Preminger
Actors
Charlton Heston
Rita Hayworth
DETERMINIMG STAGES OF DEMENTIA • Fast Scale • Allen Cognitive Scale • Global Deterioration Scale
FAST SCALE Stage
Stage Name
Characteristics
Mental Age (years)
1 2 3 4 5 6a 6b 6c 6d 6e 7a 7b 7c 7d 7e 7f
Normal Aging Possible MCI MCI Mild Dementia Moderate Dementia Mod/Severe Dementia Mod/severe Dementia Mod/Severe Dementia Mod/Severe Dementia Mod/Severe Dementia Severe Dementia Severe Dementia Severe Dementia Severe Dementia Severe Dementia Severe Dementia
No Deficits Subjective functional deficits Difficulty with complex tasks IADLs become affected Needs help selecting proper attire Needs help putting on clothes Needs help bathing Needs help toileting Urinary Incontinence Fecal Incontinence Speaks 5-6 words Speaks only 1 word clearly Can no longer walk Can no longer sit up Can no longer smile Can no longer hold head up
Adult Aging Adult 12+ 8-12 5-7 5 4 4 3-4 2-3 1.25 1 1 0.5-0.8 0.2-0.4 0-0.2
ALLEN COGNITIVE SCALE •
Developed by Claudia Allen, OTR/L
•
Identifies 6 cognitive levels and 4 modes of function within each level
•
Best Practice recommends using 2 of the following to obtain level – Allen Cognitive Level Screen – Allen Diagnostic Module – Routine Task Inventory
Global Deterioration Scale (GDS)
Global Deterioration Scale • Dr. Barry Reisberg
• Neuroretrogenesis
1 2
– Abilities are lost in the opposite direction they were learned
3
– Treatment plan should follow that path
5
– There are 7 specific stages of dementia progression
• Collectively, these stages are called the Global Deterioration Scale
4 6 7 ?
GDS/Cognitive Age Conversion STAGE
GDS Cognitive Age
Normal Adult
1
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
GDS STAGES Interventions and Goals Overview
STAGES OF DEMENTIA ACCORDING TO THE GLOBAL DETERIATION SCALE
GDS / ALLEN / MMSE CORRELATION STAGE
GDS
ALLEN
MMSE
Normal Adult
1
6
29 – 30
Aging Adult/MCI
2
5.4 – 5.8
24 – 29
MCI/Early Dementia
3
5.0 – 5.4
21 – 23
Early/ Mod Dementia 4
4.6 – 4.8
15 – 20
Moderate Dementia
5
4.0 – 4.4
10 – 14
Severe Dementia
6
3.0 – 3.8
1–9
Severe/ End Stage
7
1, 2
0
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
• Person continues to be socially appropriate • Person often depressed as he/she mourns the future • Potential elopement risk • Learned “helplessness” can occur (3 Day Decline!)
Stage 4 - continued
Lost in Space: “What’s happening?” • Initial incontinence may occur – Inability to find the bathroom – embarrassed to ask where the bathroom is and knowing they have asked before
• Family members usually start to look for placement in Assisted Living Communities out of concern that their loved one is no longer safe living alone • Difficulty is noted with problem solving in new environments or new situations
• Says, “I can’t remember things the way I used to”
Stage 4 - continued
Lost in Space: “What’s happening?” • May become dependent upon signs to: – Find bathroom – Their room / apartment – Grooming and Hygiene articles • Everything is “new” to them • 90 day 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 – May feel like they do not live there – Highest risk for ~ 6-10 weeks
Stage 5 Dressed & ready, with nowhere to go • Continues to complete self-care, but does it “my way” • Wear hearing aides, dentures, eye glasses
• Potential balance deficits • Begin long term, repetitive training for transfer
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 6 – Continued • May stop feeding themselves due to not knowing how to start…but can be jump started by caregiver • Usually incontinent due to not realizing need to void – “90 Second Rule” usually works to attain continence
• Often wander and pace in environment
Stage 7
If it looks, feels or tastes good, I’ll do it • Tend to be dominated by their senses
• Not all behaviors are what you think they are • Unable to express needs verbally, so you have to be a detective
Stage 7
If it looks, feels or tastes good, I’ll do it May have to be fed May be in a wheelchair because of falls Lose ability to taste food, except with heavy seasoning Needs significant or total help with dressing, bathing and grooming
GDS – Strategies for Success •
Stage 1
•
Stage 2 •
•
Manage stress Compensatory strategies – alarms, lists, routines •
Pill box
•
Calendar
Stage 3 •
Assistive devices if falls have occurred
•
Be careful with dual tasking during activities
•
Adapt environment •
Bed rails
•
Elevated chairs
GDS – Strategies for Success •
Stage 4 •
Namenda – increased headaches, constipation, dizziness, confusion
•
Manage wandering – wearable alert devices
•
Repetitive, familiar tasks – STILL ABLE TO LEARN •
•
Transfers – slow, repetitive
•
Optimize sensory systems
•
DEPRESSION COMMON
Stage 5 •
No recall of relatively recent information, but do know spouse and children
•
Still mobile, still socially appropriate – tap into experiences
•
Color contrast for safety, enhanced lighting
•
Care-giver education
GDS – Strategies for Success •
•
Stage 6 • Poor positional awareness – no multi-tasking while assisting • Use more visual/tactile cues versus verbal • Expect agitated, fearful behavior – 90 second rule Stage 7 • be aware of positioning for skin breakdown • Assistance with all activities of daily living
General Behavioral Management • Identify and manage negative behaviors
• Trial various methods • Consider: – Environmental Issues – Physical Issues – Emotional Issues
Care-giver Education • Caregiver instruction is critical for caregiver – Don’t correct – Expect agitation and fear – Don’t get mad – Seek assistance and counseling
Environmental Considerations • Control the Environment • Simplify the space –remove clutter • Provide a calm atmosphere • Eliminate or minimize background noise
• Provide sufficient light, without glare • Sufficient warmth, eliminate drafts • Home safety assessment
Physical Considerations • Pain • Hunger • Thirst • Tired, fatigue
• Medical complication: fever, infection, constipation, dehydration • Side effects of medications
Emotional Considerations • Provide reassurance • Calm voice • Respond, don’t react • Distract and re-direct
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
Families and Communication Same general guidelines apply Encourage a consistent environment Schedules Daily and weekly
Physical surroundings Not a good time to redecorate!
People
Questions?
THANK YOU!