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Presented by Sue M. Paul OTR/L Baker Rehab Group November 18, 2011.

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1 Presented by Sue M. Paul OTR/L Baker Rehab Group November 18, 2011

2  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.

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4  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)

5  _Facts_Figures_Fact_Sheet.pdf _Facts_Figures_Fact_Sheet.pdf

6  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.

7  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

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9  Language comprehension  Short term memory  Long term memory  Explicit memory- new learning

10  Executive function  Multitasking  Judgment  Abstract thinking  Mental flexibility  Problem solving  Attention  Initiation  Inhibition  Language production  Persistence  Volition

11  Visual recognition  People  Things

12  Sensory Cortex  Motor Cortex  Some attention and language

13  Automatic motor tasks (ADLs)  Motor control/smooth movements  Balance/gait  Sustained attention/effort (brainstem)  Mental speed  Posture

14  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

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16  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

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18  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

19  Also known as  Implicit Memory  Learning without awareness  Motor Memory * Does not pass through hippocampus*

20  Task specific  Use automatic patterns (feeding, translation)  Repetition breeds performance  No generalizing

21  Amnesia  Aphasia  Apraxia  Agnosia

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23 Activity #1

24  Routine Task Inventory  Global Deterioration Scale/ FAST  MMSE  Clock Test  Placemat *Flip Book*

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26 “ Retrogenesis is the process by which degenerative mechanisms reverse the order of acquisition in normal development.” BACK TO BIRTH

27  Developed by Dr. Barry Reisberg  Basis of Functional Assessment Staging Test (FAST)  Basis of Global Deterioration Scale (GDS)

28 “Functional cognition encompasses the complex and dynamic interactions between an individual’s cognitive abilities and the activity context that produces observable performance.”

29  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

30 See handout

31  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”

32  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

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37  Flip book  Data collection  Website  Procedure for printing

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40  Allen Level 4  GDS 4  MMSE <25  Developmental Age 4-12 *Goal Directed*

41  Rigid, inflexible thinking  Egocentric  Independent familiar ADLs  Denies impairment, defensive  Depression, anxiety, fear, anger  Needs assistance with finances, appointments, medications, home management

42  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

43 Precautions:  Unable to understand precautions, complications, hazards.  Written language is not reliable.  Signs are not really effective. Copyright © 2003

44 Feeding:  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

45 Dressing/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

46 Toileting:  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

47 Functional 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!

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49  Decreased trunk rotation  Weak core  Stooped posture- looking to floor for stability  Shoulder internal rotation and adduction  Cannot sustain verbal commands

50  Cognitive remediation  Compensation  Adaptation and Modification  Balance  Body awareness  Core strengthening  Facilitate the tough conversations  Driving  Additional care  Living arrangements

51  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...)

52  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

53  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

54 Activity #2

55  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?

56  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

57  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

58 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.

59  Allen Level  GDS 5  Developmental Age years old *Decreased sense of task completion*

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61  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

62  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

63  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

64  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 out that window right here in Chantilly. Copyright © 2002

65  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

66  Behaviors:  Pacing, repetitive actions  Agitated, worried, trembling hands  Unpredictable with social interactions  Confused, acts randomly Have you seen my mother? Has anyone seen my mother ? Copyright © 2002

67  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 out that window right here in Chantilly. Copyright © 2002

68  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

69  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

70  Implicit/Procedural Motor Learning!  Specific transfers  Gait training with demonstration  Post-It Notes  Count the pictures  Reciprocal, gross motor movements

71  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

72  Balloon batting  Ue rom  Open hand  Automatic response  Sitting or standing  Balance training  Alternate/reciprocal  Postural adjustments

73  Post-It Notes  Place at different heights around room  PNF patterns/ rotation  Above/below knee level and eye level  Search inside cabinets and drawers

74 Activity #3

75 Ed Pretty steady attention span Breezes through it Cannot follow pattern or remember to refer to it.

76  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.

77  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.

78  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?

79  Tap into long term memory for functional use of hands  Haptics  It’s all about the hands!  RELEASE!  Instinctual play  Doll  Dog

80  Allen Cognitive Level < 2.8  GDS 6 and 7  Developmental age infant to 1.5 years * Unable to Release*

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82 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

83 Precautions:  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

84 Cognitive 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

85 Feeding:  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

86 Dressing/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

87 Toileting:  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

88 Functional 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

89  Lift someone under the arms, legs will flex  Have person pull up at bar, legs will extend to bear weight.

90  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*

91  Seating and Positioning  Functional use of hands  Interaction with environment  Caregiver training for quality of life issues  Aspiration  Skin breakdown  Comfort/pain  Contractures  Touching

92  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.

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94 Activity #3

95  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

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97  Find the exit signs  Count the pictures on the wall  Pull off the post its  Balloon batting

98  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

99 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!

100  “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

101  Balloon  Pen, screwdriver, paintbrush, toothbrush, flashlight  Lipstick, mascara, nail file, nail polish, brush  Post-it Notes  Painter’s tape

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104  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?

105  Determine the level of dementia  Visualize one level down the road  Use the backdoor to the brain  Implicit/motor memory  Demonstration  Repetition and consistency

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107  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.

108  _xml.html _xml.html  iles/Articles/Retrogenisis%20Theory.PDF iles/Articles/Retrogenisis%20Theory.PDF  iles/Articles/Alz%20Disease%20and%20Implici t%20Memory.PDF iles/Articles/Alz%20Disease%20and%20Implici t%20Memory.PDF  iles/Articles/Routine%20Task%20Inventory%20 Expanded0023.PDF iles/Articles/Routine%20Task%20Inventory%20 Expanded0023.PDF

109  ms/files/Articles/Assess%20Approach%20of %20Pt%20w%20dementia.PDF ms/files/Articles/Assess%20Approach%20of %20Pt%20w%20dementia.PDF  ms/files/Articles/Primitive%20Reflexes%20i n%20AD%20.PDF ms/files/Articles/Primitive%20Reflexes%20i n%20AD%20.PDF

110  Sue M. Paul OTR/L Chief Operating Officer Baker Rehab Group

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