presented by sue m. paul otr/l baker rehab group november 18, 2011
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The Head, Hands, Heart Dementia Assessment System
Presented by Sue M. Paul OTR/LBaker Rehab GroupNovember 18, 2011
Objectives
Understand memory and sensory processing in the demented brain.
Identify the hallmark characteristics of each stage of dementia.
Identify skills and deficits that could benefit from therapy services.
Understand the assessments available to determine a level of dementia.
Identify best practices and interventions for developing treatment plans and goals.
Pretest
Common Types of Dementia
Alzheimer’s disease Parkinson’s disease (20%) Vascular (Multi-infarct) Lewy Body (fluctuations and
hallucinations) Creutzfeld-Jakob (Mad Cow) Pick’s disease (Frontotemporal) Korsakoff’s Syndrome (ETOH)
Dementia Statistics
http://www.alz.org/documents_custom/2011_Facts_Figures_Fact_Sheet.pdf
Therapy Training
Only taught “traditional learning” in school
Old days, insurance wouldn’t pay if dementia was a diagnosis
Compensation not viewed as rehabilitation
Learn neuromuscular strategies for brain injury, CVA, and pediatrics, but not specific to Alzheimer’s brain.
Paradigm Shift
Access the Alzheimer’s brain through non-traditional approaches
Pull from neuro and pediatric techniques used in other settings
Rehabilitate, then compensate (yes you can do both)
Focus on someone with a non-Alzheimer’s brain to carry out interventions
Inside the Brain
Temporal Lobe
Language comprehension
Short term memory
Long term memory Explicit memory-
new learning
Frontal Lobe
Executive function Multitasking Judgment Abstract thinking Mental flexibility Problem solving Attention Initiation Inhibition Language production Persistence Volition
Occipital Lobe
Visual recognition People Things
Parietal Lobe
Sensory Cortex Motor Cortex Some attention
and language
Cerebellum
Automatic motor tasks (ADLs)
Motor control/smooth movements
Balance/gait Sustained
attention/effort (brainstem)
Mental speed Posture
Hippocampus
Critical for laying down declarative memory
Must have bilateral damage to hippocampi to affect memory (not usually memory loss from cva)
Very susceptible to Alzheimer’s disease and epilepsy
Caudate Loop where memories are born
Amygdala
Just in front of the hippocampus Perceives fear, and initiates fight or
flight “Un-erasable” memory (PTSD) Some people are genetically wired for
higher level of fear (panic disorder) Amygdala is bigger in people with
bipolar disorder “Conditioned” fear response- stuck in a
fear circuit
Sue’s Amygdala
Types of Memory
Working memory- most short term, repeats directions or adding numbers in head, forgotten as soon as attention stops
Declarative memory- long term memory, laying down new memory, hippocampus dependent
Procedural memory- most durable, actions, habits, and skills that are learned by repetition, cerebellum involved
Procedural Memory
Also known as Implicit Memory Learning without awareness Motor Memory
* Does not pass through hippocampus*
Motor Learning
Task specific Use automatic patterns (feeding,
translation) Repetition breeds performance No generalizing
4 A’s of Alzheimer’s
AmnesiaAphasiaApraxiaAgnosia
Cortical Atrophy
BREAK!
Activity #1
Assessments
Routine Task Inventory Global Deterioration Scale/ FAST MMSE Clock Test Placemat
*Flip Book*
The Theory of Retrogenesis
The Theory of Retrogenesis
“ Retrogenesis is the process by which degenerative mechanisms reverse the order of acquisition in normal
development.”
BACK TO BIRTH
The Theory of Retrogenesis
Developed by Dr. Barry Reisberg Basis of Functional Assessment
Staging Test (FAST) Basis of Global Deterioration Scale
(GDS)
The Allen Cognitive Theory
“Functional cognition encompasses the complex and dynamic
interactions between an individual’s cognitive abilities and the activity context that produces observable
performance.”
The Allen Cognitive Theory
Developed by Claudia Allen, OTR/L Originally called the Cognitive
Disabilities Theory, Allen described observations categorized by the functioning of psychiatric patients.
Basis of Routine Task Inventory, Allen Cognitive Level Screen, and the placemat activity
Allen Cognitive Levels
See handout
Placemat Activity
Administered as supportive assessment of suspected dementia level.
Not a standardized test
Good, subjective tool for sizing up organizational skills, visual processing, and personality changes
“Make yours look like mine”
Mini Mental State Exam
MMSE Developed by Marshall Folstein in
1975 Score 25/30 considered normal Early stage Alzheimer’s usually falls
between 19 and 24. Disadvantages- need to account for
age, education, and ethnicity Physicians love it
Digit Repetition Test
Clock Drawing Test
Trail Making Test
Introduce HHH
Flip book Data collection Website Procedure for printing
Early Stage
Early Stage
Allen Level 4GDS 4MMSE <25Developmental Age 4-12
*Goal Directed*
Early Stage
Rigid, inflexible thinking Egocentric Independent familiar ADLs Denies impairment, defensive Depression, anxiety, fear, anger Needs assistance with finances,
appointments, medications, home management
HEAD Cognitive
skills/Communication: Understands beginning,
middle, and end of an activity.
Can seek help but may not remember emergency procedures.
Rigid, likes routine. Self-centered communication,
confabulates, high verbal output.
Recognizes highly visible striking cues in the environment.
Limited reading comprehension.
New learning possible with maximum repetition if highly valued.
Believe that nothing is wrong with them.
Well, maybe you say it’s wrong but that’s just the way I like it.
My way is the best way.
Copyright © 2003
HEADPrecautions: Unable to
understand precautions, complications, hazards.
Written language is not reliable.
Signs are not really effective.
Copyright © 2003
HEADFeeding: May eat too fast or
too slow. Annoyed with others
eating near them. Complains about food.
Grooming: May neglect unseen
surfaces (back of head).
Sequencing errors.
If you tell me to go brush my teeth I will stay on task.
I just may forget to use toothpaste or rinse out my mouth.
Copyright © 2003
HEADDressing/Bathing: Performs familiar self
care with decreased attention to unseen surfaces.
Follows routine. Remembers what they
are doing throughout task.
Clothing selection may be based on striking features (brightest shirt in the closet).
Quality may not be good.
I am really drawn to bold, striking visual input.Did you ever notice that I choose bright clothing and wear too much make-up?
Copyright © 2003
HEADToileting: May neglect parts
of the task. May require verbal
reminders to initiate task.
Completes the task although quality may not be good.
This is a huge loss of dignity for me- and a very overwhelming
task at times.
Copyright © 2003
HEADFunctional Mobility: Able to navigate using
familiar landmarks. Transfer skills depend
on familiarity of environment.
Carries walker if distracted, but will correct with cues.
Notices barriers above and below knee.
Trunk becoming more rigid.
I can remember new things with tons of patience and practice!
Early Stage Treatment
Early Stage Observations
Decreased trunk rotation Weak core Stooped posture- looking to floor for
stability Shoulder internal rotation and
adduction Cannot sustain verbal commands
Early Stage Interventions Cognitive remediation Compensation Adaptation and Modification Balance Body awareness Core strengthening Facilitate the tough conversations
Driving Additional care Living arrangements
Early Stage Treatment
Organize environment Put strategies in place Use motor learning/repetition to
bypass hippocampus Introduce adaptive equipment now Cognitive remediation to the fullest
extent possible- evaluate reading and memory.
If they do it, they will remember it (marking calendar, schedule...)
Early Stage Treatment
Don’t ask for permission or approval. Use positive, affirming conversation- use “we” not “you”.
Use activities with hidden agenda Constantly evaluate motor skills and
weaknesses Practice concepts like in/out, sorting,
categorizing- and generalizing skills to other tasks
Early Stage Treatment
Stop talking! Allow extra time to process verbal
commands Use gestures/demonstration
frequently Always sequence left to right Scavenger hunts:
Above/below knee level Above/below eye level
BREAK!
Activity #2
Figure It Out!
Dementia Level Goals Treatment Plan Caregiver Instruction
What skills do you want to maintain? What information is most useful to
caregivers? What are your recommendations for
functional maintenance program (ISP?) How much assistance/supervision is
necessary?
Doris
Repeats herself Denies deficits Walks with a cane, looks at floor Can put on clothes, but doesn’t take
season or occasion into account Can print name but not write
signature Husband talks her through ADLs,
complains that she is distracted and it takes a long time
Doris
Anxious about showering, trembles. Exiting stall shower is very unsafe and upsetting
Toilets herself but uses too much toilet paper
Sundowns- wants to go home to mama and daddy
Doris
• Repeats self throughout activity• Needs encouragement to continue• “This is dumb.”• “I’ve done this before.”• “I’m no good at handiwork.”• I need my glasses.
Middle Stage
Allen Level 3.0- 3.8GDS 5Developmental Age 1.5-3 years old
*Decreased sense of task completion*
Middle Stage
HANDS Feeding: May reach for food
from other place settings or centerpiece
Unable to complete meal without redirection and set-up
Plays with food and utensils
You may notice that I play with my food or grab
other’s food from their plates. I’m
easily distracted and
overstimulated.
Copyright © 2002
HANDS Self-care skills: May initiate action with
familiar object- but not sustain to completion
Resistant to care Layers clothes until all
items used up, unable to orient clothing or sequence task
Needs supervision or assistance with toileting
I am sometimes very resistant to care.
Don’t you sneak up on me or just might
get slugged!
Copyright © 2002
HANDS Functional Mobility: Limited
head/neck/trunk movement during walking
Does not scan environment
Has trouble stopping, may trip
May be impulsive Frequent fallers
I hate confinement and may try to get
out! I want to
walk walk walk!
Copyright © 2002
HANDS Cognitive skills/
communication: Able to name objects Decreased sense of task
completion Needs verbal cues to
sequence steps of an activity
Responds best to demonstrated instructions
Word finding problems Loses the thread of a
story Jargons, incoherent
sentences
I have to get out of here. I’m late for work and the train is on that
other thing over the @#%*! out
that window day @#%*! right here
in Chantilly.
Copyright © 2002
HANDS Precautions: At risk for falls Unable to understand
precautions, complications, or hazards
Does not recognize need for help
At risk for accidents- poison, sharp objects, elopement
I love to use my
hands...and touch
everything! I tend to get into things I
shouldn’t and carry them around with
me.
Copyright © 2002
HANDS Behaviors: Pacing, repetitive
actions Agitated, worried,
trembling hands Unpredictable with
social interactions Confused, acts
randomly
Have you seen my mother?
Has anyone
seenmy
mother?
Copyright © 2002
HANDS Cognitive skills/
communication: Able to name objects Decreased sense of
task completion Needs verbal cues to
sequence steps of an activity
Responds best to demonstrated instructions
Word finding problems Loses the thread of a
story Jargons, incoherent
sentences
I have to get out of here. I’m late for work and the train is on that
other thing over the @#%*! out
that window day @#%*! right here
in Chantilly.
Copyright © 2002
HANDS Self-care skills: May initiate action
with familiar object- but not sustain to completion
Resistant to care Layers clothes until all
items used up, unable to orient clothing or sequence task
Needs supervision or assistance with toileting
I am sometimes very resistant to care.
Don’t you sneak up on me or just might
get slugged!
Copyright © 2002
HANDS Functional Mobility: Limited
head/neck/trunk movement during walking
Does not scan environment
Has trouble stopping, may trip
May be impulsive Frequent fallers
I hate confinement and may try to get
out! I want to
walk walk walk!
Copyright © 2002
Middle Stage Treatment
Implicit/Procedural Motor Learning!
Specific transfers Gait training with
demonstration Post-It Notes Count the pictures Reciprocal, gross
motor movements
Middle Stage Interventions Neuromuscular Re-education AROM Core strengthening Cognitive compensation ADL focus on highly familiar tasks Balance training/fall prevention Enabling devices
Bed handles Grab bars Rollator if familiar
Middle Stage Treatment
Balloon batting Ue rom Open hand Automatic response Sitting or standing Balance training Alternate/reciprocal Postural
adjustments
Middle Stage Treatment
Post-It Notes Place at different heights around room PNF patterns/ rotation Above/below knee level and eye level Search inside cabinets and drawers
BREAK!
Activity #3
Ed
• Pretty steady attention span• Breezes through it• Cannot follow pattern or remember to refer to it.
Ed
Moved into ALF 3 years ago with wife. She died shortly after. Retired optometrist.
Was very high functioning but depressed for several months. Quick decline in mental status after suffering a fall and hip fracture.
Moved to memory care unit six months ago.
Will not participate in activities. Will not sit through entire meal. Very sweet and pleasant.
Ed
Staff has him labeled as sexually inappropriate because he tries to touch them all the time.
Loses the thread of a story, poor word finding
Anxious and wandering at times, socially withdrawn other times.
Helps with putting shirt on but is easily distracted and stops what he’s doing.
Walks down hall holding onto railing and furniture. Multiple falls.
Figure It Out!
Dementia Level Goals Treatment Plan Caregiver Instruction
What skills do you want to maintain? What information is most useful to
caregivers? What are your recommendations for
functional maintenance program (ISP?) How much assistance/supervision is
necessary?
Middle Stage Treatment
Tap into long term memory for functional use of hands
Haptics It’s all about the
hands! RELEASE!
Instinctual play Doll Dog
Late to End Stage
Allen Cognitive Level < 2.8GDS 6 and 7Developmental age infant to 1.5 years
* Unable to Release*
Late Stage
HEART
Allen Level 1: Mostly bedbound Can move limbs
and head Total assistance
for self care and mobility.
Developmental age infant
Allen Level 2: Can overcome
gravity Can sit, stand
and/or walk (mobility)
Have a sense of balance, although not good
Developmental age 1-2 Copyright © 2002
HEARTPrecautions: Contractures Skin
Breakdown Falls Aspiration
Because I can’t move or communicate well, I’m really at risk for contractures, falls,
and skin breakdown. YOU can prevent this from happening to
me!
Copyright © 2002
HEARTCognitive Skills/
Communication: Speech mostly
unintelligible, mumbles incoherently
Unable to follow most verbal commands
Poor attention span, distracted by moving objects
A funny trick I know:I may only be able to say
one or two words, but I can sing a whole song without
any errors.
Copyright © 2002
HEARTFeeding: May be able to
feed self with limited or extensive assistance
More successful with finger foods
Can sip from a cup held to lips until very end stages- don’t introduce a straw too early!
I can only see things less than 12 inches from
my face. Bring the world to
me!
Copyright © 2002
HEARTDressing/Bathing/Grooming: Has no idea what
to do with objects Assists caregivers
by holding positions, moving limbs, and standing
I have a major fear of falling. I may resist, hit, or kick but it’s
only to protect myself from injury. I’m not just being
difficult.
Copyright © 2002
HEARTToileting: Needs assistance
with managing clothing, perineal hygiene, and positioning on toilet
Frequently incontinent
Inappropriate toileting locations- sometimes the same place over and over.
Can assist caregiver by holding onto grab bar.
You may know me by my
“death grip”. I have a hard time releasing things from my hands.
Copyright © 2002
HEARTFunctional
Mobility: Higher level
“hearts” walk aimlessly, pace, rock, and march.
Lower level “hearts” can only respond with a grimace or glance.
Seek stability and comfort
Enjoy gross motor activities- without a sense of purpose.
I can turn my head to track a moving object even at the last stages
of my disease.
Give me moving stuff to look at!
Copyright © 2002
Fetal Tuck vs. Pull to Stand
Lift someone under the arms, legs will flex
Have person pull up at bar, legs will extend to bear weight.
Primitive Reflexes Reappear Sucking reflex Rooting reflex Palmar grasp reflex Babinski reflex
*The areas of the brain that are last to be myelinated during
development are the most vulnerable to death*
Late Stage Interventions
Seating and Positioning Functional use of hands Interaction with environment Caregiver training for quality of life
issues Aspiration Skin breakdown Comfort/pain Contractures Touching
Late Stage Treatment
ADLs for object recognition How do they hold it in their hand?
Pull to stand Self feeding Visual tracking, turning head,
reaching for items Use reflexes to elicit movement-
rooting, protective extension, hand-to-mouth movement patterns.
Use Backdoor Access
BREAK!
Activity #3
Alice
Nonverbal Bilateral UE/LE
contractures Rigidity Death grip Falls forward out of
chair Inconsistently uses fork
appropriately, puts everything in mouth
Does not consistently bear weight for transfers
What’s the best way to do this?
Visual Attention/Body Awareness
Find the exit signs Count the pictures on the wall Pull off the post its Balloon batting
The Head, Hands, Heart Program
Completed by OT online near end of episode
Copy is sent to physician and family Copy placed in ALF chart if
applicable Used as a tool to educate caregivers
and give objective recommendations based on dementia findings
Documentation Tips
Make it smart! What is the purpose of your intervention?▪ To improve..▪ Trunk and pelvic stability?▪ Functional reach on a stable base?▪ Sequencing and task organization?▪ Postural deformities?▪ Risk of falls?▪ Risk of contractures?▪ Risk of skin breakdown?▪ Socialization and interaction with environment?
Who cares how you get there!
Seating and Positioning
“Upright and midline posture necessary for:” Improved air exchange Improved socialization Preventing abnormal postures Promoting functional use of upper
extremities Improved communication Decreased caregiver burden Preventing falls and decreased skin
integrity
Toolkit on a Budget
Balloon Pen, screwdriver, paintbrush,
toothbrush, flashlight Lipstick, mascara, nail file, nail
polish, brush Post-it Notes Painter’s tape
Equipment
Equipment
The Secret Sauce
Start with what you know Don’t listen, watch. What does this disease looks like at the
end? What are the associated complications
of Alzheimer’s? What can you do to put off the
inevitable? What works? What doesn’t work?
The Secret Sauce
Determine the level of dementia Visualize one level down the road
Use the backdoor to the brain Implicit/motor memory Demonstration Repetition and consistency
Research and Evidence
Research and Evidence
Alzheimer’s research- prevention Estrogen Insulin Antioxidants Anti-inflammatory Genetics
Alzheimer’s research- therapies Aricept stops breakdown of acetylcholine Namenda works by binding to the NMDA
receptor and preventing excessive excitation by glutamate.
References
http://www.wiredtowinthemovie.com/mindtrip_xml.html
http://www.bakerrehabgroup.com/assets/cms/files/Articles/Retrogenisis%20Theory.PDF
http://www.bakerrehabgroup.com/assets/cms/files/Articles/Alz%20Disease%20and%20Implicit%20Memory.PDF
http://www.bakerrehabgroup.com/assets/cms/files/Articles/Routine%20Task%20Inventory%20Expanded0023.PDF
References
http://www.bakerrehabgroup.com/assets/cms/files/Articles/Assess%20Approach%20of%20Pt%20w%20dementia.PDF
http://www.bakerrehabgroup.com/assets/cms/files/Articles/Primitive%20Reflexes%20in%20AD%20.PDF
The Dementia Queen
http://thedementiaqueen.com/about/
Sue M. Paul OTR/LChief Operating Officer
Baker Rehab Grouphttp://www.bakerrehabgroup.com
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