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Cognitive-neurological focus for occupational therapists

Jessica Cockbain

on 21 December 2011

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Transcript of Dementia

Early Stages Mid-Stages Late Stages How many people in the world currently have dementia? 2010 – 35.6 million people

As a reference point the current population of Canada is 34.5 million End of Life Predementia Trends in Interventions Mischief Lester is looking at the camera and he’s thinking about something he can get away with!  Mischief Lester is going to get into everything.  He’s looking for mischief!  It shows in his eyes.  He’s going to find a woman.  But if he gets into mischief, he’s going to get a licking.  

I feel sorry for the bag!  Does he have a diaper on?  Maybe he took it off.  I know kids who do that.  

Our story will end with Mischief Lester having a diaper on.  And it ends with his mother laughing.  The end! TimeSlips Music Therapy Results of a weekly Music Therapy session with elderly clients with moderate/severe dementia over a 2 year period:
- lower blood pressure
-maintained cognition
-reduced agitation Takahashi & Matsushita, 2006) Animal-Assisted Therapy Dolls/stuffed toys
Reminiscence Therapy
Physical Excercise The therapeutic use of pets with
clients living with dementia has been shown to lead to: Reduced agitation
Increased physical activity (if mobile)
Improved eating
Reports of increased pleasure and overall well-being Llewellyn-Jones & Filan, 2006 Increased difficulty with:
Language /expression/word finding
Memory for names and faces
Memory for recent and past events
Misplacing or losing objects
Repetitive questions & stories
Learning new information Spirituality: (area unique to OT in allied health, in centre of CMOP-E)
Providing education to caregivers about access to palliative care services
Preventing injury, controlling pain, carrying out valued activities
Modifications to the environment for individuals and caregiver that best suits their needs Palliative care is not synonymous with death; it’s about helping the individual to have the best life they can with the time they have left (CAOT, 2011). Symptoms OT Intervention Behaviour Use of memory aids (e.g. schedules)
Habit training
Grading tasks
Adjust occupational demands
Decrease environmental distractions
Attention-focusing group
Consideration of former habits, routines, and rituals
Use of caregivers Continued memory loss (can incl. caregiver)
Significant short term memory loss
Assistance needed in ADLs
May have incontinence
Behavioural and psychological changes are common
Disrupted sleep
Perseverations/repetition of simple activities Now what? Create opportunities to engage in work/volunteer tasks adapted to client’s behavioural status
Behaviour awareness education

Emotional self-regulation strategies
Implement basic safety precautions for the individual
Promote engagement in exercise and physical activity
Modify environmental and activity demands as needed Small changes begin to be noticeable in the areas of:
Overall personality
Changes in sensitivity
Irritability & frustration

Wandering and disorientation
Decreased participation in leisure activities Symptoms OT Intervention Now what? Symptoms OT Intervention Now what? Thinking and Judgment Increasing levels of:
Personality Change
Physical and Verbal Aggression
Labile affect:

Obsessive behaviour
Self injury
May have uncontrollable delusions/paranoia/hallucinations Reduce frustration/agitation
Let client explain what is upsetting them
Stay calm in order to keep the client calm
Redirect focus on a favourite activity How many people in the world will
have dementia by 2050? Increasing memory loss and confusion
Increasingly shorter attention span
Cannot find right words
Impairments (and occasional loss of) reading, writing, and numbers
Poor historians
Frequent confabulation
Continue to use engrained routines based in procedural memory Refusal to eat
Delusions and paranoia
Disorientation to place and time
Changes in sexual behaviour -
Obsessive and repetitive behaviour
Sleep disturbances
Restlessness How many people in Canada currently have dementia? How many people in Canada develop
dementia each year? Memory aids
Photo book
Playing familiar music
Pictures of family/staff
Keep items in a consistent and visible location
Rephrasing, repetition and further explanation Small changes and challenges begin to be noticeable
in these areas:

Executive Function Skills
Decision Making and Problem Solving

Ability to follow instructions
Changes in Social Behaviour How much does dementia cost Canadians? Address possible unmet needs, promote relaxation and provide structure for agitated behaviour
Healing Touch How many people over 65 have dementia? Projected to increase to over 115 million people

As a reference point – larger than the current population of Mexico Aphasia
Loss of language skills
Loss of ability to read
Recognition of faces
Memory and writing impairments
Inability to recall simple life details
e.g. home address
Little recent memory
Perseveration Compensation may no longer be possible
OT will collaborate with caregivers/family to ensure location of care is most appropriate
Consider caregiver burnout
Use yes or no questions
Use body language and facial expressions/gestures to aid in communication 1.5% of the population currently have dementia,
Half a million Canadians

As a reference point – this is approximately equivalent to the population of Newfoundland. This year alone, more than 103,000 Canadians will develop dementia. This is equivalent to one person every five minutes.

As a reference point – over the course of this 2 hour presentation, this is equivalent to 24 people in Canada being diagnosed with dementia. $15 billion annually

As a reference point - This is approximately the equivalent of buying every Canadian an Ipad 1 in 11 over 65 have dementia

As a reference point – once we are all over 65, this would be the equivalent to 6 people in our class developing dementia. For example, this could be our whole learning team. Educate client and family members on strategies in targeted areas of thinking and judgement

Using activity analysis to simplify tasks that have become more difficult to understand

Take basic safety precautions as needed Judgement errors
Unsafe actions Insensitivity towards others Now what? Thinking and Judgement Impairments OT Interventions Ex. Reminders, Checklist of Important Things to remember when completing tasks
- Enables person to maintain reasoning skills with direct and systematic instruction Ex. breaking down complex recipe into steps on cue cards Ex: recommend self shut off appliances, house doors that lock automatically Now what? Repetitive statements/ movements
Problems organizing thoughts or thinking logically
Increasing concentration difficulties
Difficulties with decision making, following instructions, safe judgment
Changes in language or behaviour
Perceptual-motor problems Increasing changes and challenges begin to be noticeable
in these areas: Thinking and Judgment
Impairments OT Interventions Strategic Labelling in Environment

Environmental adaptations to enable concentration

Caregiver Support and Education Ex. Remove distractions, eliminate noises Ex. Posting steps involved in tasks, labelling where everything is kept,
(for example, coat in closet, shoes by door - Education on supporting and strategies to use with individual
- Discussion about care options to ensure appropriateness
- CCAC referral for home care and support
- Caregiver Respite - Day away programs - Will be discussed in ADLs/IADLs Memory and Language ADLs/IADLs Severe deficits in the following areas:

• Attention and concentration
• Comprehension/Understanding
• Decision making, judgement and safety
• Following instructions
• Changes in language and behaviour Thinking and Judgment
Impairments Now what? Slight further possibility of compensation for thinking/judgement skills
OT works with caregiver/family to ensure provision of care is appropriate
OT works with other health care professionals and family members to maintain client QOL OT Interventions Behavioural
Changes Interventions Assessments Behavioural Changes Interventions Behavioural Changes Interventions Outline OT and Dementia -means of communication and connection with client and family/caregivers An occupational therapist can be involved with all the progressive stages of dementia:
Early-stage Dementia
Middle-stage Dementia
Late-stage Dementia
End of Life
As the progression of dementia is unique and varies from person to person, the area of practice may also vary.
Long-term or Complex Care facility
Day Away
Outpatient Continuum of Care in Dementia - 7 Stages OTs can be involved in all of these stages except for diagnosis Unique progression of dementia for every individual will determine amount and type of OT involvement Differential Diagnosis

Sensitivity of Assessments in Different Stages of Dementia
Differences in Progression of Dementia

Selection of Appropriate Assessment Tools Basic Screening Tools
Functional Performance Assessments
Scales of Dementia Progression
Caregiver Assessment Unique Presentation of Certain Subtypes in Mild Stage
Individual Differences 4 D’s Considerations for OT Assessment in Dementia Research & Trends Bilingualism Effects of Stress SilverAlert The Global Deterioration Scale looks at the overall progression of dementia from normal function to very severe cognitive decline

Can be used by OTs and also as outcome measure in research trials

Designed for Alzheimer’s disease but can also be used to determine the stages of other types of dementia

Well supported by the evidence base The Global Deterioration Scale (GDS) 7 clinically identifiable stages

Alzheimer's diseases represents 50-75% of cases
OT will need to account for early-stage variation in unique subtypes discussed by using additional assessment tools The GDS will frame our presentation - so refer
to the posted handout throughout! Now what? Assist/encourage to create a supportive network
Assistive technology
Build on past skills and habits to maintain function Memory aides

Create opportunities to enhance daily involvement with community activities
Improve sleep routines and sleep hygeine Prompting to bathe Difficulty with water temperature May need but resist assistance Now what? Assess swallowing
Modify diet Limit clothing selection
Take and wash clothes at night Discuss: Client centeredness with ADLs Modeled after a similar program in Florida
Ontario first province to implement Silver Alert
Similar to the Amber Alert program used for missing children, Silver Alert will be used by communities to alert the public when a vulnerable person with dementia wanders from their home or long term care facility Types of Dementia Escott, 2011 What is Dementia? DSM-IV Criteria Bilingualism may delay the onset of Alzheimer’s disease and other dementias by up to four years

Bilingual people have been shown to have increased attention skills (executive function)

Phenomenon "Cognitive Reserve" Dementia is an acquired syndrome resulting from various diseases or disorders of the brain that affects a person’s cognitive abilities and functional abilities

Key areas dementia impacts include:
- Language
- Memory
- Personality
- Behaviour
- Judgement
- Physical capacities
- Ability to complete ADLs and IADLs Must be severe enough to cause a significant impairment in social or occupational functioning
Change represents a decline from previous level of function Baycrest, 2011 Irvine, 2006 Recent and Ongoing Research (University of California)
Stress hormones have been found to exacerbate the formation of brain lesions that lead to Alzheimer’s and other dementias
New research suggests that managing stress could slow down the progression of dementia
Spouse of an individual with Alzheimer's up to 6 times more likely to be diagnosed with Alzheimer's (ScienceDaily, 2011).
What are the implications of these findings for OT practice? Communicating with
Individuals who have Dementia Orientation Environment Body Language Concrete Words Simple Language Dementia Team 12
Heather, Jess, Tonya, Katie, Julie & Amanda OT 844 “Alice hadn't needed to refer to the recipe in years. It was a simple recipe, and she'd made it every Christmas Eve since she was a young girl. How many eggs? It had to be more than six, or she would've taken out only one carton. Was it seven, eight, nine?
She tried skipping over the eggs for a moment, but the other ingredients looked just as foreign. Was she supposed to use all of the cream or measure out only some of it? How much sugar? Was she supposed to combine everything all at once or in a particular sequence? What pan did she use? At what temperature did she bake it and for how long? No possibility rang true. The information just wasn't there. What was wrong with me?”

- Still Alice, by Lisa Genova Baycrest, 2011, Florida Department of Family and Children's Services, 2010 Presentation of Impairments
and OT Interventions “Alice ransacked the laundry basket, the bedside tables, the dresser drawers, the bedroom closets, her jewelry box, the linen closet, the medicine cabinet. The downstairs bathroom. She ran back down the stairs, seating, manic.
John stood in the hallway, ankle deep in the coats she had torn out of the closet.
“What the hell happened in here?” he asked.
“I’m looking for something.”
She couldn’t name it, but she trusted that somewhere in her head, she remembered and knew.
“I’ll know when I find it”.
- Still Alice, by Lisa Genova “ Alice sat in a big, comfortable white chair and puzzled over the clock on the wall. It was the kind with hands and numbers, which was much harder to read than the kind with just numbers.
Five maybe?
“What time is it?” she asked the man sitting in the other big, white chair.
He looked at his wrist.
“Almost three thirty”
“I think it’s time for me to go home.”
“You are home. This is your home on the Cape.”
She looked around the room - the furniture, giant windows, trees outside the windows.
“No, this isn’t my house. I don’t live here. I want to go home now”
- Still Alice, by Lisa Genova Often linked to feelings about to memory loss For client (self-awareness), family and employers (if applicable) Unaffected No Symptoms Suspicious, Irritable, Restlessness, Teary, Frustrated 2 Memory loss: familiar objects/names
Not obvious to others
Unaffected presentation on cognitive assessments
No functional defecits 1 Now what? Now what? 3 4 Deficits become evident to others
ADL/IADL ability may start to decline
Defecits appear on cognitive assessments
Denial Now what? Clear deficits in clinical interviews
Personal history memory loss begins
Functionally unaffected
Defecits appear on cognitive assessments
Denial Community Community 5 Major gaps in memory
Some time/place disorientation
Independent in basic ADLs
May need help with some tasks such as choosing appropriate clothing Learning Objectives 2 years Community
Assisted living Assisted Living (some) 1.5 years Neurodegenerative causes (unknown)
Cerebrovascular causes
Infection-related causes
Toxic and metabolic causes
Traumatic causes By the end of this two hour seminar students will:
Understand the role of the OT in dementia assessment and intervention
Recognize the key cognitive and neurological elements involved with the progressive stages of dementia
Be able to apply the Global Deterioration Scale (GDS) as it relates to the progression of the disease
Identify the most appropriate interventions to use in each stage of the disease
Apply the knowledge presented in the Case Study of Alice Discussion 6 7 Fun Quiz
Dementia Overview and DSM-IV
Dementia Subtypes
Dementia Assessments
GDS Progression
Clinical presentations and OT interventions
- Thinking and Judgment
- Memory and Language
- Behaviour
Future Research and Up and Coming OT Interventions
Alice Case Study Discussion Dementia
Team 12:
Heather, Jess, Katie, Tonya, Julie and Amanda
OT 844 Quiz 2010 – 35.6 million people

As a reference point – current population of Canada is 34.5 million Gradual loss of vocabulary and verbal ability
Incontinent, assistance required for toileting
Feeding assistance needed
Loss of ability to walk independently and sit without support Complex Care Facility 2.5 years 2.5 years ? Community Assisted Living Complex Care Facility End of Life Executive functioning Agnosia Aphasia Apraxia Essential feature for diagnosis is memory impairment and one or more of the following impairments: Alzheimer's Society www.alzking.com 1. As OT’s what can you do to help me make Christmas bread for next year?
2. If my dementia is Alzheimer’s, what is going on with me neurologically?
Why can’t I remember? 1. What would the OT do for me in this case?
2. What can you do as OT’s to support my husband John? 1. At this point, how can you support me and the man in the chair, who is my husband John? Mrs. Doris, an 85 year old woman, was admitted to hospital two weeks ago after a serious fall and hip fracture. You are asked to see Mrs. Doris as she is having difficulty recovering and responding to treatment due to confusion.
Prior to this admission Mrs. Doris had been living alone in her own home. Her husband passed away less than a year ago and her two children live out of province. Mrs. Doris has maintained an active lifestyle and has always been very close to her friends and neighbours. Until recently she has continued to drive her car and enjoy her involvement with the ladies bridge club at her church.
After meeting with Mrs. Doris and reviewing her history, you become aware of the following:
• slow decline over the last 6 months
• forgetting where she put her purse and keys
• increased difficulty with cleaning and cooking
• mixing up several appointments
• no longer attending weekly bridge games at the church
• not seen out of home or driving her car
1. As the OT, you are brought in to address Mrs. Doris’s basic ADLs related to her hip fracture. How would you tailor your assessment, interventions, and interactions for Mrs. Doris, keeping in mind what you have learned about Mrs. Doris’ history? Mobility Take Home Message Assessment Stage of Dementia
that can be assessed Pros Cons Setting Used References
Agrell, B., & Dehlin, O. (1998). The clock-drawing test. Age and Ageing, 27, 399-403.
Alzheimer Society of Canada (2009). Alzheimer’s disease: The Global Deterioration Scale (GDS). Retrieved on May 29, 2011, fromhttp://www.alzheimer.ca/english/disease/progression-intro.htm
Alzheimer Society of Canada (2010). Alzhemier’s Disease statistics. Retrieved June 1, 2011, from http://www.alzheimer.ca/english/disease/stats-intro.htm
Alzheimer’s Society (2011). The Mini Mental State Examination (MMSE). Retrieved on May 29, 2011, from http://alzheimers.org.uk/site/scripts/documents_info.php?documentID=121
Alzheimer’s Society (2011). The progression of dementia. Retrieved June 2, 2011, from www.alzheimers.org.uk/site/scripts/documents.php?categoryID=200363
American Association of Neuroscience Nurses (2008). Procedural memory and emotional attachment in Alzheimer Disease: Neuropsychological staging of AD. Journal of Neuroscience Nurses, 40(2), 96-102.
AMPS Project International (2011). The AMPS and the A-ONE. Retrieved June 1, 2011, from http://www.ampsintl.com/AMPS/related/AONE.php
Baycrest (2011). Memory loss and dementia. Retrieved June 3, 2011, from http://www.baycrest.org/memoryandaging/
Bickel, H. (1996). The Hierarchic Dementia Scale: Usage. International Psychogeriatrics, 8(2), 213-224.
Brown, C. & Stoffel, V.C. (2011). Occupational therapy in mental health: A vision for participation. Philadelphia, PA: F. A. Davis.
Burns, A., & Iliffe, S. (2009). Alzheimer’s Disease. Retrieved June 2, 2011, from http://www.bmj.com/content/338/bmj.b158.short
Burns, T., Mortimer, J.A., & Merchak, P. (1994). Cognitive performance test: A new approach to functional assessment in Alzheimer’s disease. Journal of Geriatric Psychiatry and Neurology, 7(1), 46-54.
DementiaCareCentral.com (2011). Causes of dementia. Retrieved June 3, 2011, from http://www.dementiacarecentral.com/aboutdementia/facts/causes
DementiaGuide, Inc. (2006). Symptom Library. Retrieved May 30, 2011, from http://www.dementiaguide.com/symptomlibrary/
DementiaGuide, Inc. (2006). Types of dementia Retrieved May 29, 2011. http://www.dementiaguide.com/community/dementia-articles/Understanding_the_different_types_of_Dementia
Egton Medical Information Systems Limited (2011a). Memory loss and dementia. Retrieved on May 29, 2011, from http://www.patient.co.uk/health/Memory-Loss-and-Dementia.htm
Egton Medical Information Systems Limited (2011b). Mini Mental State Examination (MMSE). Retrieved on June 1, 2011, from http://www.patient.co.uk/showdoc/40000152/
Escott, S. (2011). A silver lining for wandering seniors. The Spec. Retrieved June 5, 2011, from http://www.thespec.com/news/local/article/537637--silver-alert-to-bring-vulnerable-seniors-back-home
Florida’s Department of Children and Families, Adult Protective Services Program Office (2010). Alzheimer’s Disease and Dementia: A guide for adult protective services workers. Retrieved on June 4, 2010, from http://www.dcf.state.fl.us/programs/aps/docs/DementiaPamphlet.pdf
Genova, L. (2009). Still Alice. Toronto, ON: Pocket Books
Leo, R.J., & Ahrens, K.S. (1999). Visual hallucinations in mild dementia. Psychosomatics, 40, 360-363.
National Chronic Care Consortium & Alzheimer’s Association (2003). Tools for early identification, assessment, and treatment for people with Alzheimer’s disease and dementia. Retrieved on June 1, 2011, from http://www.scribd.com/doc/49848212/alzheimer-assessment
National Guideline Clearinghouse (2010). Occupational therapy practice guidelines for adults with Alzheimer’s disease and related disorders. Retrieved May 28, 2011, from http://www.guidelines.gov/content.aspx?id=16321
NYU Langone Medical Center (2011). Alzheimer’s Disease. Retrieved on June 4, 2011, from http://www.med.nyu.edu/adc/forpatients/ad.html
Office of Children and Family Services (2010). Dementia. Retrieved May 30, 2011, from http://www.ocfs.state.ny.us/ohrd/handouts/182.pdf
Rayner, A.V., O’Brien, J.G., & Schoenbachler, B. (2006). Behavior disorders of dementia: Recognition and treatment. American Family Physician, 15(4), 647-652.
Reisberg, B., Ferris, S.H., de Leon, M.J., & Cook, T. (1982). The Global Deterioration Scale for assessment of primary degenerative dementia. American Journal of Psychiatry, 139(9), 1136-1139.
Rosswurm, M.A. (1990). Attention-focusing program for persons with dementia. Clinical Gerontologist: The Journal of Aging and Mental Health, 10(2), 3-16. doi:10.1300/J018v10n02_02
Rural Health Education Foundation (2007). Dementia: Assessment and diagnosis: Facilitator’s guide. Retrieved June 4, 2011, http://www.rhef.com.au/wp-content/uploads/616a_facil_lr.pdf
Smith, E.R., Broughton, M., Baker, R., Pachana, N.A., Angwin, A.J., Humphreys, M.S., Mitchell , L., Byrne, G.J., Copland, D.A., Gallois, C., Hegney, D., & Chenery, H.J. (2011). Memory and communication support in dementia: Research-based strategies for caregivers. International Psychogeriatrics, 23 (2), 256–263.
Vann, M. (2010). How animal therapy helps dementia patients. Everyday Health. Retrieved June 5, 2011, from http://www.everydayhealth.com/alzheimers/how-animal-therapy-helps-dementia-patients.aspx While there are many professionals involved in working with individuals with dementia, OTs are possibly the most important; we can provide hope for a comfortable, quality life through the 7 stages of dementia, as well as provide ways to let the person shine through the illness.
Providing hope is essential - as this last video shows, dementia can affect hope, just as much as memory.
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