Presentation on theme: "The Head, Hands, Heart Dementia Assessment System"— Presentation transcript:
1The Head, Hands, Heart Dementia Assessment System Presented by Sue M. Paul OTR/LBaker Rehab GroupNovember 18, 2011The Head, Hands, Heart Dementia Assessment System
2ObjectivesUnderstand 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.
6Therapy Training Only taught “traditional learning” in school Old days, insurance wouldn’t pay if dementia was a diagnosisCompensation not viewed as rehabilitationLearn neuromuscular strategies for brain injury, CVA, and pediatrics, but not specific to Alzheimer’s brain.
7Paradigm ShiftAccess the Alzheimer’s brain through non-traditional approachesPull from neuro and pediatric techniques used in other settingsRehabilitate, then compensate (yes you can do both)Focus on someone with a non-Alzheimer’s brain to carry out interventions
12Parietal LobeSensory CortexMotor CortexSome attention and language
13Cerebellum Automatic motor tasks (ADLs) Motor control/smooth movements Balance/gaitSustained attention/effort (brainstem)Mental speedPosture
14Hippocampus 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
16Amygdala 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
18Types of MemoryWorking memory- most short term, repeats directions or adding numbers in head, forgotten as soon as attention stopsDeclarative memory- long term memory, laying down new memory, hippocampus dependentProcedural memory- most durable, actions, habits, and skills that are learned by repetition, cerebellum involved
19Procedural Memory * Does not pass through hippocampus* Also known as Implicit MemoryLearning without awarenessMotor Memory* Does not pass through hippocampus*
20Motor Learning Task specific Use automatic patterns (feeding, translation)Repetition breeds performanceNo generalizing
214 A’s of Alzheimer’sAmnesiaAphasiaApraxiaAgnosia
26The Theory of Retrogenesis “ Retrogenesis is the process by which degenerative mechanisms reverse the order of acquisition in normal development.”BACK TO BIRTH
27The Theory of Retrogenesis Developed by Dr. Barry ReisbergBasis of Functional Assessment Staging Test (FAST)Basis of Global Deterioration Scale (GDS)
28The 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.”
29The Allen Cognitive Theory Developed by Claudia Allen, OTR/LOriginally 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
31Placemat Activity “Make yours look like mine” Administered as supportive assessment of suspected dementia level.Not a standardized testGood, subjective tool for sizing up organizational skills, visual processing, and personality changes
32Mini Mental State Exam MMSE Developed by Marshall Folstein in 1975 Score 25/30 considered normalEarly stage Alzheimer’s usually falls between 19 and 24.Disadvantages- need to account for age, education, and ethnicityPhysicians love it
47HEAD 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!
49Early Stage Observations Decreased trunk rotationWeak coreStooped posture- looking to floor for stabilityShoulder internal rotation and adductionCannot sustain verbal commands
50Early Stage Interventions Cognitive remediationCompensationAdaptation and ModificationBalanceBody awarenessCore strengtheningFacilitate the tough conversationsDrivingAdditional careLiving arrangements
51Early Stage Treatment Organize environment Put strategies in place Use motor learning/repetition to bypass hippocampusIntroduce adaptive equipment nowCognitive remediation to the fullest extent possible- evaluate reading and memory.If they do it, they will remember it (marking calendar, schedule...)
52Early Stage TreatmentDon’t ask for permission or approval. Use positive, affirming conversation- use “we” not “you”.Use activities with hidden agendaConstantly evaluate motor skills and weaknessesPractice concepts like in/out, sorting, categorizing- and generalizing skills to other tasks
53Early Stage Treatment Stop talking! Allow extra time to process verbal commandsUse gestures/demonstration frequentlyAlways sequence left to rightScavenger hunts:Above/below knee levelAbove/below eye level
55Figure It Out! Dementia Level Goals Treatment Plan Caregiver InstructionWhat 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?
56Doris Repeats herself Denies deficits Walks with a cane, looks at floorCan put on clothes, but doesn’t take season or occasion into accountCan print name but not write signatureHusband talks her through ADLs, complains that she is distracted and it takes a long time
57DorisAnxious about showering, trembles. Exiting stall shower is very unsafe and upsettingToilets herself but uses too much toilet paperSundowns- wants to go home to mama and daddy
58Doris 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.
59Developmental Age 1.5-3 years old Middle StageAllen LevelGDS 5Developmental Age years old*Decreased senseof task completion*
75Ed Pretty steady attention span Breezes through it Cannot follow pattern or remember to refer to it.
76EdMoved 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.
77EdStaff has him labeled as sexually inappropriate because he tries to touch them all the time.Loses the thread of a story, poor word findingAnxious 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.
78Figure It Out! Dementia Level Goals Treatment Plan Caregiver InstructionWhat 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?
79Middle Stage Treatment Tap into long term memory for functional use of handsHapticsIt’s all about the hands!RELEASE!Instinctual playDollDog
80Allen Cognitive Level < 2.8 GDS 6 and 7 Late to End StageAllen Cognitive Level < 2.8GDS 6 and 7Developmental age infant to 1.5 years* Unable to Release*
89Fetal Tuck vs. Pull to Stand Lift someone under the arms, legs will flexHave person pull up at bar, legs will extend to bear weight.
90Primitive Reflexes Reappear Sucking reflexRooting reflexPalmar grasp reflexBabinski reflex*The areas of the brain that are lastto be myelinated during developmentare the most vulnerable to death*
91Late Stage Interventions Seating and PositioningFunctional use of handsInteraction with environmentCaregiver training for quality of life issuesAspirationSkin breakdownComfort/painContracturesTouching
92Late Stage Treatment ADLs for object recognition Pull to stand How do they hold it in their hand?Pull to standSelf feedingVisual tracking, turning head, reaching for itemsUse reflexes to elicit movement- rooting, protective extension, hand-to-mouth movement patterns.
95Alice Nonverbal Bilateral UE/LE contractures Rigidity Death grip Falls forward out of chairInconsistently uses fork appropriately, puts everything in mouthDoes not consistently bear weight for transfers
97Visual Attention/Body Awareness Find the exit signsCount the pictures on the wallPull off the post itsBalloon batting
98The Head, Hands, Heart Program Completed by OT online near end of episodeCopy is sent to physician and familyCopy placed in ALF chart if applicableUsed as a tool to educate caregivers and give objective recommendations based on dementia findings
99Who cares how you get there! Documentation TipsMake 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!
100Seating and Positioning “Upright and midline posture necessary for:”Improved air exchangeImproved socializationPreventing abnormal posturesPromoting functional use of upper extremitiesImproved communicationDecreased caregiver burdenPreventing falls and decreased skin integrity
101Toolkit on a Budget Balloon Pen, screwdriver, paintbrush, toothbrush, flashlightLipstick, mascara, nail file, nail polish, brushPost-it NotesPainter’s tape
104The 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?
105The Secret Sauce Determine the level of dementia Visualize one level down the roadUse the backdoor to the brainImplicit/motor memoryDemonstrationRepetition and consistency
107Research and Evidence Alzheimer’s research- prevention EstrogenInsulinAntioxidantsAnti-inflammatoryGeneticsAlzheimer’s research- therapiesAricept stops breakdown of acetylcholineNamenda works by binding to the NMDA receptor and preventing excessive excitation by glutamate.