Managing rehabilitation
challenges of patients with
dementia
Tom Holmes, OTR, MA
The University of Texas Health Sciences C...
DSM IV-R Definition
Dementia: memory impairment + (aphasia,
apraxia, agnosia or disturbance in
executive functioning)
+ im...
Types of Dementia
• Lewy Body
• Frontotemporal dementia
• Multi-infarct dementia
• Binswanger’s disease
• Alzheimer’s dise...
Lewy Body dementia
• 2nd
most common form
of dementia
1
Central feature
2
• Dementia +
• Deficits in attention,
frontal-su...
Frontotemporal dementia3
• Equal in prevalence
to AD in patients <65.
3 Clinical variants
Behavioral variant
• personality...
Frontotemporal
A patient’s response
to: “Make a slice of
toast and put some
butter and jam on it”
Binswanger’s Disease4
• Named after Dr. Otto Binswanger (1894)
• Anatomic pathology
generalized white matter atrophy.
mult...
Binswanger’s Symptoms
• Frequent falls and syncopal episodes
early
• Gait ataxia and rigidity
• UE functioning fairly well...
Brain Pathology and behavior
Brief Literature Review
Therapy and Dementia
Intensive Geriatric Rehabilitation
after hip fracture.5
• Finland, patients with hip fractures
• 120 patients after hip fr...
Huusko (2000)
• No LOS difference between standard care
and Geriatric unit- no memory impairment
or severe dementia.
• Sig...
Rolland et. al. (2007)6
• Multi-center, randomized controlled single
blind study in Toulouse, France.
• Inclusion: Can tra...
Rolland (2007) results
• ADL scores significantly declined both groups,
but Exercise group declined at 1/3 slower rate
(p<...
Meta-analysis of Exercise and
Dementia7
• 300 articles found ---- 30 reviewed
• Significant positive effect on physical pe...
Clinical applications during
rehabilitation sessions
Six strategies to manage
behavioral challenges
• Treat / Manage physiological symptoms
• Improve communication
• Re-direct...
Physiological Symptoms
• Is the person
experiencing pain?
• Is the patient
distracted by basic
urges (hunger, thirst,
need...
Improve communication
• Non-verbal communication- eye’s focus,
voice tone, inflection and volume, posture
• “No” may mean ...
Re-Direction
Goal: Stop the current
behavior from
occurring and re-
direct patient to
another stream of
behavior.
• Hypoth...
Maintaining exercise within a
session.
• Repeated prompts to continue
• Exercising to a Metronome
• Pair patients 2-3 so t...
Substitute with incompatible
behavior
• Use this if patient engages in a persistent,
repetitive behavior that interferes w...
Meaningful Activities
• What do you want to accomplish? Goals?
• Activity Analysis: required component skills
• Know somet...
Therapeutic Activities (97530)
• Functional-task
exercise
8
• Components:
Vertical, horizontal,
carrying, lying-
sitting-s...
used with permission of Dr. Linda Teri
Pleasant Events Schedule9
(used with permission of Dr. Linda Teri)
Hip fracture rehabilitation
• Home based vs In patient (Giusti et al
2007).
• Fear of falling again and pain: use BWST?
• ...
Dealing with precautions
ORIF
• If cannot follow, mobilize
without restrictions
5
• Limit mobility to transfers
only for 1...
Prompting and Cueing
• Manual guidance
• Gesturing
• Vocal instructions
• Written instructions/photos
• Cueing (e.g. use o...
Contracture management
• Prevention through PROM, standing
• De-cerebrate posturing in late stages?
• Skilled therapy for ...
Weakness, Debility
• Exercises: early stage
• Cueing each repetition or after 5-6 reps. may be
needed
• Group activity ben...
Fall prevention tips
• Take patient to bathroom when they are
with you in therapy.
• Voice alarms, bed alarms
• Anticipate...
Resources
• www.DementiaCareSpecialists.com (workshop
training by Kim Warchol, OTR)
• American Occupational Therapy Associ...
Managing rehabilitation challenges of patients with dementia ...
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  • Memory impairment plus two or more cognitive impairments
  • Lewy body- A lewy body is an extracellular protein that ----to the neuron and is present in an over
  • American Academy of Family Physicians web page. (2006).
    Neef, D. and Walling, A. (2006). Dementia with Lewy Bodies: An emerging disease. American Family Physician, 73(7), 1223-1229.
    Lewy body is a eosinophilic cytoplasmic inclusion.
    Implications for PT- information for caregivers, family. Also, if you see Parkinsonism and patient has hallucinations but no DX of LBD, then may need to pursue accurate diagnosis. Patients with LBD can have adverse reactions to medications used to treat hallucinations. Also, compensatory strategies for PD.
    Fluctuations may be over minutes, hours or days. Often variations in attention and alertness.
    Parkinsons symptoms include bradykinesia, rigidity, falls but NOT tremor. Orthostatic hypotension and consipation are prominent.
    Depression is common. Visual hallucinations in about 80% of the Pts. (vivid and visual) Can have severe reactions to antipsychotic medications.
  • 3. Lippa, C. F. (2006). Special issue: Frontotemporal dementia. American Journal of Alzheimer’s Disease and Other Dementias, 22(6).
  • 4. Olsen, C. G. and Clasen, M. E. (1998). Senile dementia of the Binswanger’s type. American Family Physician, 58(9), 1-7.
  • Memory loss is less profound than in Alzheimer’s dementia. Mild reflex asymmetries, hemiparesis Also present are apathy, loss of interest in usual activities, depression, confusion, paranoia.
    Implications for therapy: If patient is not taking their blood pressure medication, insist that they take it. Disease is better controlled by controlling blood pressure. Work on overbuilding balance and gait strength in early staged patients.
    No known treatment.
  • Cartoon of brain of Alzheimer’s patient. Distinguishing anatomic features of AD is an over-abundance of plaques (amyloid deposits) and tangles (made of tau protein accumulations)
    The red stiples indicate location of plaques in typical Alzheimer patient.
    Sources used to make slide
    Bouras, C., Giannakopoulos, P., &amp; Vallet, P.G. (1996). Regional distribution of neuropathological changes in Alzheimer’s disease. In R. Becker &amp; E. Giacobini (Eds.), Alzheimer’s disease: From molecular biology to therapy (pp. 25-29). Boston, MA: Birkhauser
    Pansky, B., Allen, D.J., &amp; Budd, G.C. (1988). Review of neuroscience (2nd ed.). New York: Macmillan
    Selkoe, D.J. (1991). Amyloid protein and Alzheimer’s disease. Scientific American, 265(5), 68-78.
    Snell, R. S. (1997). Clinical neuroanatomy for medical students (4th ed.). Philadelphia, PA: Lippincott-Raven.
    The location of plaques are indicated by the red stiples.
  • Search of PubMed. Key words: Dementia, physical therapy, Alzheimer’s, hip fracture, rehabilitation
  • 5. Huusko, T. M., Karppi, P., Avikainen, V., Kautiainen, H. and Sulkava, R. (2000). Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia. British Medical Journal, 321, 1107-11.
  • So with Finnish patients in Finland, a specialized unit is helpful at facilitating recovery in patients with dementia. Odds of successful rehabilitation in patients without dementia were found to be 20 times higher than for a patient with dementia. Average stay in a geriatric ward was 34.8 days.
    Significance partially due to smaller group size.
    Geriatric ward: geriatrician internist, specialty trained general practioner, nurses with training in care of older adults, social worker, neuropsychologist, OT, PT
  • Rolland, Y., Pillard, F., Klapouszczak, A., Reynish, E., Thomas, D., Andrieu, S., Riviere, D., Vellas, B. (2007). Exercise program for nursing home residents with Alzheimer’s disease: A 1 year randomized controlled trial. Journal of the American Geriatrics Society, 55, 158-165.
    Geriatrician assessed patients at baseline, 6 months, 12 months.
    Outcomes: 1. Katz ADL score (0-6, 0 = unable to perform, .5= needs little help, 1.0 = able to complete without help.)
    2. 6 meter walk test, 3. get up and go test, 4. 1 leg balance test, 5. Mini-nutritional assessment, 6. Neuropsychiatric Inventory (NPI). 7. Montgomery-Asberg Depression Rating Scale.
    Exercise Group: Same OTR completed all exercise groups, 2-7 participants per group and matched according to MMSE and physical performance scores. Music accompanied each session and sessions occurred 2 X week for 1 hour. Exercise trail thoughout the facility with path going by participant’s rooms.
    Trail stations: 1. squats or repeated sit to stands, hip abduction, toe raises. 2. stepping over cones and hoops, 1 or 2 leg balance, standing on foam mats, 3. flexibility station 4. strength station, walked for at least ½ of the session.
    Routine medical care: typical care with Physiotherapy as needed.
  • Remember that with Dementia decline is expected so slowed decline is good.
    Walking speed results: .33m/s to .41m/s exercise; .33 m/s to .36 m/s routine care
    5 falls during the exercise sessions.
    Could this exercise trail be set up as a restorative program or functional maintenance program in nursing homes? Can you have group activities?
  • Heyn, P., Abreu, B. C., Ottenbacher, K.J. (2004). The effects of exercise training on elderly persons with cognitive impairment and dementia: A Meta-analysis. Archives of Physical Medicine and Rehablitation, 85, 1694-1704.
    Method: computer data base search. Inclusion criteria: 1. randomized trials with control or comparison condition. 2. subjects older than 65 3. baseline MMSE less than 26 or dx by MD as having cognitive impairment or dementia 4. noted exercise program or fitness or recreational therapy or rehab service 5. reported means, SDs, t test or F test and n values 6. minimum of 5 subjects in each group 7. 1 dependent variable from health related physical fitness measure, functional, cognitive or behavioral category 8. Journal article, master’s thesis, doctoral dissertation 1970-october 2003.
    Critical review of articles: Delphi list and PEDro scale
    Calculated effect size for each article.
    Cognitively impaired benefited more than controls in strength, cardiovascular fittness, functional performance, behavioral measures and cognitive tasks.
  • Know the person’s pain behaviors and pass on that information to the nurses, fellow therapists. Ask the nurse aides to tell you the patient’s pain behaviors, ask the family members.
    Once you identify the behavioral manifestation of a physiological process, note it in the chart and tell others what you found.
    LISTEN TO FAMILY MEMBERS for they can tell you key information. For example: case of doing therapy on severely demented man who spent most of day in bed. Patient would not move limbs- daughter said “Its probably gout”. Sure enough, blood level revealed increased crystals and once treated for gout, he moved more.
  • The person is communicating something to you. It is your job to find out what the person is telling you with non-verbal behavior.
    Talk to the person with dementia. Ask that person what is it like to have a memory loss? Ask them what can you do to better communicate with them?
    Would a printed sign cuing patient to “Do 10 repetitions” or “This is the Rehabilitation Center” help orient the person to the task at hand.
  • Your treatment session may consist of new continuous redirection. That is ok and may be what is needed.
    Someone may be making frequent requests to “go home”. Chances are if they are at this level of dementia, reorienting them to “You are at the Rehabilitation Center” will not work. What are they communicating by this request? Fear? Hunger? ( I want to go home and eat a snack) Is the task to hard? Do they know who you are?
    Ask- What do you miss about home? Are you uncomfortable?
    Person continues to wander away from the session- bring the session to them and set up stations along the wandering path.
    Clinical pearl: if you need a wandering person to change direction 180 degrees, walk them in a circle instead of making them turn around.
    Other indications for use of re-direction?
  • Examples of feedback: Some equipment has a LED readout of the force exerted when moving the equipment, place a countdown timer or hour glass within view and instruct patient to stop when sand is gone or timer is “0”.
  • If a person does not sit down, then engage in activities standing up. If person will not sit still, then would person sit in a rocking chair and engage in treatment.
    Case example: Patient would cuss during treatment sessions and during exercise. She would maintain an exercise for several repetitions and would stay on task but she cussed. I asked what word could she substitute for the cuss word and after bartering, I suggested “cheese” She smiled and liked the word. So, if she would cuss, I would immediately prompt her “…say cheese” and she would say “cheese”. I asked her “what word do you say when you want to cuss? She answered cheese”. I reinforced this behavior and pattern. Soon she would say “cheese” instead of cussing.
  • Grading- cognitively and motoric complex or challenging could be 1. patient must follow instructions or multiple step task and complete an unfamiliar task. E.g., using theraband during an activity
    Criteria for a successful activity: sustaining of the activity, does pt appear to be engaged as evidenced by scanning the environment, looking in the right direction and staying on task.
    Activity analysis: proprioceptive, kinesthetic, vestibular, muscular, tactile, smell, cognitive (sequencing, memory, problem solving, recognition, etc)
    You may need to continue prompting and provide guidance.
    If you identify something that works, pass on the information- tell everyone.
  • 9. de Vreede, P. L., Samson, M.M., van Meeteren, N.L.U., Duursma, S.A., Verhaar, H.J.J. (2005). Functional-Task Exercise versus resistance strength exercise to improve daily function in older women: A randomized, controlled trial. Journal of the American Geriatrics Society, 53, 2-10.
    The authors studied functional task exercises vs traditional resistance training impact on daily functioning performance. The functional tasks consisting of the 4 components (vertical movement, horizontal movement, carrying objects and lying-sitting-standing transitions). For example, one task included rising from a chair, step onto a raised platform and remove different objects from a shelf. Grade the activity by changing distance, weight of objects, number of objects.
    Chores: hanging laundry, sweeping, pushing a vacuum, casting a fishing reel, crushing cans.
    Have audience list 5 chores that involve stepping.
  • Logsdon, R.G. &amp; Teri, L. (1997). The Pleasant Events Schedule-AD: Psychometric properties of long and short forms and an investigation of its association to depression and cognition in Alzheimer’s disease patients. The Gerontologist, 37(1), 40-45.
    Copy of the schedule is posted on the course’s internet site.
  • BWST= body weight supported treadmill. Bellelli, G., Guerini, F., Trabucchi, M. (2006). Body weight supported treadmill in the physical rehabilitation of severely demented subjects after hip fracture: A case report. Journal of the American Geriatrics Society, 54(4), 717-718.
  • 5. Huusko, T. M., Karppi, P., Avikainen, V., Kautiainen, H., Sulkava, R. (2000). Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: Subgroup analysis of patients with dementia. British Medical Journal, 321, 1107-1111.
    Study in Finland. Staff and MD’s agreed that if patient cannot follow the weight restrictions, then patient can be mobilised without restrictions.
    I spoke with an orthopedic surgeon about this topic. Dr. Kim Foreman mentioned surgeons can make the repair stronger by installing load sharing hardware, limit mobility to transfers only for a month.
    Brush and Camp (1998)- Spaced retrieval memory training- Training for new learning by adding increasing increments of time spaces between opportunity to complete standing or pants donning and cue to begin tasks. Based on mastery of one interval before moving onto to next interval. “Show me how you begin to stand up”, if correct, then try again in one minute. If not, provide corrective feedback. Reinforce with praise and attention for correct performance. If correct, then increase time interval by double (2, 4,16, 32 minutes).
    Sessions involve rote training to follow precautions-drill it into them for 30 minutes, go back same day and try again.
    Memory Notebook or cues: audio reminder to “not bend over”, pocket book with large print statements to not bend over, keep leg straight, etc.
  • May need to use fading of manual guidance or placing hand over hand an then fade the contact.
    Depending on person’s cognitive functioning level, they may need repeated manual guidance to complete a task
    Situational cue- set up a situation so that the elements of the situational environment automatically cue the desired behavior. For example- if you want someone to stand up from their wheel chair to place books onto a shelf, then do the following: 1. obviously empty book shelf, 2. books lying flat on a table and within view, 3. gesture from books to shelf, ask patient to “stand-up”
  • Use of oral baclofin for treating contractures??
  • Can grade the activity with weight cuffs or number of minutes standing or required reaching.
  • Rocking chairs, locking glider chairs may work for some patients who attempt to stand up from their wheelchair. Walking or standing someone on a regular basis (ie. Every half hour when up in chair), keep patient engaged in meaningful activities.
  • AOTA- Each course is $280 for non-members, $198 for members.
    Dementia Care Specialist Qualification: $150 per person
    Dementia Care Provider Qualification: $75 per person
    Dementia Care Professionals of America $35 annual membership fee.
    Review the resources listed in the audience handout. This slide is not a comprehensive listing of dementia training but only the ones I have personally attended.
    Jolene Brackey is another author/source of ideas for interacting with patients with dementia.
  • Managing rehabilitation challenges of patients with dementia ...

    1. 1. Managing rehabilitation challenges of patients with dementia Tom Holmes, OTR, MA The University of Texas Health Sciences Center April 2008
    2. 2. DSM IV-R Definition Dementia: memory impairment + (aphasia, apraxia, agnosia or disturbance in executive functioning) + impairment in occupation or social function + decline from previous level
    3. 3. Types of Dementia • Lewy Body • Frontotemporal dementia • Multi-infarct dementia • Binswanger’s disease • Alzheimer’s disease • others
    4. 4. Lewy Body dementia • 2nd most common form of dementia 1 Central feature 2 • Dementia + • Deficits in attention, frontal-subcortical skills, visuospatial ability. Core features (need 2) • Fluctuating cognition • Recurrent visual hallucinations • Spontaneous motor features of parkinsonism.
    5. 5. Frontotemporal dementia3 • Equal in prevalence to AD in patients <65. 3 Clinical variants Behavioral variant • personality change • disordered social conduct • insight loss Semantic dementia • deficits in understanding word meaning. • associative agnosia. Nonfluent progressive aphasic • Expressive aphasia deficits. • Stuttering, agraphia, alexia.
    6. 6. Frontotemporal A patient’s response to: “Make a slice of toast and put some butter and jam on it”
    7. 7. Binswanger’s Disease4 • Named after Dr. Otto Binswanger (1894) • Anatomic pathology generalized white matter atrophy. multiple lacunar infarcts in white matter, pons and basal ganglia. lateral ventricular enlargement.
    8. 8. Binswanger’s Symptoms • Frequent falls and syncopal episodes early • Gait ataxia and rigidity • UE functioning fairly well preserved • Personality changes, apathy • Hypertension • Cerebral vascular disease • Gradual progression of memory loss
    9. 9. Brain Pathology and behavior
    10. 10. Brief Literature Review Therapy and Dementia
    11. 11. Intensive Geriatric Rehabilitation after hip fracture.5 • Finland, patients with hip fractures • 120 patients after hip fracture on specialized geriatric unit. • 123 patients receive standard care in hospital
    12. 12. Huusko (2000) • No LOS difference between standard care and Geriatric unit- no memory impairment or severe dementia. • Significant differences in LOS if patients had mild or moderate dementia (MMSE 12-17 and 18-23)
    13. 13. Rolland et. al. (2007)6 • Multi-center, randomized controlled single blind study in Toulouse, France. • Inclusion: Can transfer from chair; walk 6 meters Modified Independent; SDAT • 56 exercise group, 54 routine care group
    14. 14. Rolland (2007) results • ADL scores significantly declined both groups, but Exercise group declined at 1/3 slower rate (p<.02) • Walking speed improved both groups and exercise group improved to greater degree • No difference in # falls
    15. 15. Meta-analysis of Exercise and Dementia7 • 300 articles found ---- 30 reviewed • Significant positive effect on physical perf. cognitively impaired (p.<.001) • Cog. Impaired benefited more than controls/comparisons • Mean training duration 23 weeks (2- 112wks), 3.6 sessions/week, 45 min.
    16. 16. Clinical applications during rehabilitation sessions
    17. 17. Six strategies to manage behavioral challenges • Treat / Manage physiological symptoms • Improve communication • Re-direction/distraction • Behavior maintenance strategies • Substitute with an incompatible behavior • Develop/Implement meaningful activities
    18. 18. Physiological Symptoms • Is the person experiencing pain? • Is the patient distracted by basic urges (hunger, thirst, need to use bathroom)? • Refusing to participate in therapy. • Drifting off task • Not sustaining a behavior (i.e. Does not continue pedaling restorator) • ????
    19. 19. Improve communication • Non-verbal communication- eye’s focus, voice tone, inflection and volume, posture • “No” may mean “I’m afraid”- meaning of the words. • Physical gestures; go slow; 10 second rule.
    20. 20. Re-Direction Goal: Stop the current behavior from occurring and re- direct patient to another stream of behavior. • Hypothesize why person is doing what they are doing. • Give the person something new to do. • Engage person in a meaningful activity
    21. 21. Maintaining exercise within a session. • Repeated prompts to continue • Exercising to a Metronome • Pair patients 2-3 so they can benefit from imitating each other • Provide feedback on some dimension of the activity.
    22. 22. Substitute with incompatible behavior • Use this if patient engages in a persistent, repetitive behavior that interferes with treatment. • Have patient engage in behavior that occurs at the same time as the target and substitutes for it.
    23. 23. Meaningful Activities • What do you want to accomplish? Goals? • Activity Analysis: required component skills • Know something about patient’s history/personal life • Complex to simple continuum (Grading of the activity) • Match targeted muscle groups with activity
    24. 24. Therapeutic Activities (97530) • Functional-task exercise 8 • Components: Vertical, horizontal, carrying, lying- sitting-standing transitions • Wii programs? • ADLs in a simulated environment. • “Chores” • ADL’s in patient’s environment.
    25. 25. used with permission of Dr. Linda Teri Pleasant Events Schedule9 (used with permission of Dr. Linda Teri)
    26. 26. Hip fracture rehabilitation • Home based vs In patient (Giusti et al 2007). • Fear of falling again and pain: use BWST? • Weight bearing or mobility precautions
    27. 27. Dealing with precautions ORIF • If cannot follow, mobilize without restrictions 5 • Limit mobility to transfers only for 1 month • Automated feedback on weight bearing. • Knee immobilizer to prevent standing • Use weight bearing assist device Hip Precautions- replacements • Adduction wedge • Knee immobilizer • Spaced Retrieval memory training • Memory notebook or cues
    28. 28. Prompting and Cueing • Manual guidance • Gesturing • Vocal instructions • Written instructions/photos • Cueing (e.g. use of alarm watch, notebook, cue card) • Situational cue
    29. 29. Contracture management • Prevention through PROM, standing • De-cerebrate posturing in late stages? • Skilled therapy for orthotics, ultrasound/heat and stretch, establishing PROM programs.
    30. 30. Weakness, Debility • Exercises: early stage • Cueing each repetition or after 5-6 reps. may be needed • Group activity beneficial (parachute game, balloon volleyball) • Use activities as a modality
    31. 31. Fall prevention tips • Take patient to bathroom when they are with you in therapy. • Voice alarms, bed alarms • Anticipate needs and meet them • Patients who need to move should move
    32. 32. Resources • www.DementiaCareSpecialists.com (workshop training by Kim Warchol, OTR) • American Occupational Therapy Association online courses (Based on ESP program and taught by Dr. Corcoran) www.aota.org, click on “Continuing Education” link. • Dementia Care Specialist Qualification offered by Alzheimer’s Foundation of America. www.afdn.org, click on “Care Professionals”

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