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Managing rehabilitation challenges of patients with dementia

Managing rehabilitation challenges of patients with dementia. Tom Holmes, OTR, MA The University of Texas Health Sciences Center April 2008. DSM IV-R Definition. Dementia: memory impairment + (aphasia, apraxia, agnosia or disturbance in executive functioning)

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Managing rehabilitation challenges of patients with dementia

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  1. Managing rehabilitation challenges of patients with dementia Tom Holmes, OTR, MA The University of Texas Health Sciences Center April 2008

  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. Types of Dementia • Lewy Body • Frontotemporal dementia • Multi-infarct dementia • Binswanger’s disease • Alzheimer’s disease • others

  4. 2nd most common form of dementia1 Central feature2 Dementia + Deficits in attention, frontal-subcortical skills, visuospatial ability. Core features (need 2) Fluctuating cognition Recurrent visual hallucinations Spontaneous motor features of parkinsonism. Lewy Body dementia

  5. 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. Frontotemporal dementia3

  6. Frontotemporal A patient’s response to: “Make a slice of toast and put some butter and jam on it”

  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. 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. Brain Pathology and behavior

  10. Brief Literature Review Therapy and Dementia

  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. 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. 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. 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. Meta-analysis of Exercise and Dementia7 • 300 articles found ---- 30 reviewed • Significant positive effect on physical perf. cognitively impaired (p.<.001) • Cog. Impaired benefited morethan controls/comparisons • Mean training duration 23 weeks (2-112wks), 3.6 sessions/week, 45 min.

  16. Clinical applications during rehabilitation sessions

  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. 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) ???? Physiological Symptoms

  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. 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 Re-Direction

  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. 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. 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. Functional-taskexercise8 Components: Vertical, horizontal, carrying, lying-sitting-standing transitions Wii programs? ADLs in a simulated environment. “Chores” ADL’s in patient’s environment. Therapeutic Activities (97530)

  25. Pleasant Events Schedule9(used with permission of Dr. Linda Teri) used with permission of Dr. Linda Teri

  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. ORIF If cannot follow, mobilize without restrictions5 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 Dealing with precautions

  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. Contracture management • Prevention through PROM, standing • De-cerebrate posturing in late stages? • Skilled therapy for orthotics, ultrasound/heat and stretch, establishing PROM programs.

  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. 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. 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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