Intervention Approaches to Dementia Related Conditions 2009

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					Intervention Strategies for Dementia Related Conditions
Tracey Vause Earland, MS, OTR/L OT 558 November 4, 2009

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Describe the state of Behavioral Health in older adults Recognize the stages of Dementia Discuss how various frameworks/approaches guide Dementia Intervention Identify effective treatment plans and implementation strategies based on assessment & Research Develop an Action plan for caregivers incorporating (social & physical) environmental strategies

Today we will highlight:
- Allen’s Cognitive Disability Model - “Common Sense Behavior” (Nygard) - Snoezelen - Validation Therapy - Montessori’s Approach (Dr. Camp’s work) -Environmental Skill-building Program (ESP)

Mental Health and the Older Adult

20% of older adults are diagnosed with mental illness  Many of these older adults receive no or inadequate treatment  OTs will see Older adults with cognitive disabilities secondary to:
Stroke, TBI, Schizophrenia Anxiety disorder, substance abuse, Developmental Disabilities, Alzheimer’s Disease

Key Facts About Dementia

>5.3 million diagnosed with Alzheimer’s disease or related disorders (ADRD) in USA >14 mill will have ADRD by year 2050 >80% of patients cared for at home Average course of disease is 8 years

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Range from 4 to 20 years


Most common form of dementia is Alzheimer’s disease


Every 70 seconds, someone develops Alzheimer’s disease

NIA, NIH, U.S. Department of Health & Human Services

What is Dementia?
is defined as loss of memory and intellect that interferes with routine personal, social or occupational activities.  Dementia is not a disease; It is a group of symptoms that may accompany certain diseases or conditions.  Other symptoms include changes in personality, mood, or behavior
 Dementia

Why would an OT get a referral for a client with Dementia?

3 Basic Stages of Dementia
Mild/early dementia behaviors include:
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Can perform ADLs/IADLs (additional time, use of memory aides) attempts to wander and leave, forgetting how to return suspicious, and delusional behaviors related to short term memory loss fear of being alone trouble handling money & paying bills Lack of insight, poor judgment about safety still don't think they need assistance easily upset/agitated anxiety personality changes, emotional withdrawal, flatten affect and denial loss of spontaneity and sense of initiative

3 Basic Stages of Dementia
Middle/Moderate stage include:
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person resists change (even their clothing) Increase memory loss and confusion may not recognize family or familiar people Needs assistance with ADLs, verbal, visual, & tactile cueing language comprehension problems increase Mood shifts with anger, paranoia, frustration, verbal/physical aggressiveness Increase dependence on caregiver (cueing, supervision, handson care) Inability to drive safely or maintain a job


3 Basic Stages of Dementia
Late/Severe stage include:
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difficulty recognizing & using common everyday objects very distracted, very inattentive to any task or event unable to effectively communicate wants & needs weight loss may have trouble feeding & swallowing (forgetting how) may become unable to walk, incontinent, dependent Increase sleeping total dependence on caregiver

Global Deterioration Scale (Reisberg,1983) another scale ( 7 stages)

Cognitive Disability
 “A

restriction in voluntary motor action originating in the physical or chemical structures of the brain and producing observable limitations in routine task behavior (p.31)

….Say what???
Allen, CK ed: Occupational therapy for psychiatric diseases: measurement and management of cognitive disabilities, Boston, 1985, Little Brown & Company

Allen’s Cognitive Disabilities Framework (ACLs)
Assumptions: 1. just right challenge according to cognitive level 2.Respond to different cues depending on cognitive level Can do, may do, will do People with dementia have potential
 Underlying

Role of Occupational Therapist
using Cognitive Disabilities Model

Role of Occupational Therapist
using Cognitive Disabilities Model

Identify and address Safety concerns
the potential triggers of behavior issues implement strategies to minimize them caregiver education/skill-training

 Analyze

 Provide

Allen’s 6 Cognitive Levels
Reflexive behaviors  2. Postural actions  3. Manual actions  4. Goal-directed Actions  5. Exploratory Actions  6 Planned Actions (typical)
 1.

ACL 5: Tx considerations
•Establish regular routine •Repetitive practice •“Hands-on” teaching Techniques •“Try out” period for asst. Devices •Don’t talk to while working •Safety & security Intervention

ACL 4: Tx Considerations  Task Simplification  Task/materials provide recognition cues  Natural environment cues trigger procedural memory  Use repetition of procedure skills Modify environment for mobility  Learn new tasks – require at least 3 weeks drilling  4.4 ACL – 100% failure of hip precautions

ACL 3: Tx Considerations  Objects serve as cues for performance  Short sentences, Demo, hand over hand@, non-verbal communication  Set out supplies  Repetitive object-based activity provides meaningful occupation  Safety modifications

ACL 1 & 2:Tx Considerations  Attention is focused on movement, touch, sounds  Provide comfort-care routines for ADLs to CGs  Safety & fall precautions  Positioning  Movement, sensory & behavioral mgmt.  Visual input within visual scan.

Integrating Allen’s framework in Group Tx

Cannot label or identify the Cognitive Level without conducting standardized assessment (ADM, Routine Task Inventory, Cognitive Performance Task)


Use your skilled observation of daily occupations to identify behaviors typical of Low – moderatehigh cognitive levels  Groups lend opportunity for client to safely engage in meaningful activity in optimal environmental conditions

1. “Common Sense Behavior”
 Nygard

L.(2004). Responses of persons with Dementia to challenges in daily activities: A synthesis of findings from empirical studies. AJOT 58(4): 435-445 looked at strategies (possible interventions) people with mild dementia used in performing daily occupations

 Study

Response strategies (common sense behaviors) included:
 Visibility

 Tactility
 Auditory

input  Temporal modifications  Use of verbal language  Written language  Support of Habituation & familiarity

Clinical implications:
OTs we should support and maintain adequate adaptive behaviors – as long as it’s beneficial & safe for the person.  HOW? -Facilitate the perceptual input from the environment - Provide opportunities to practice existing habits & routines
 As

2. Snoezelen Sensory Approach
environment designed to stimulate the primary senses of touch, taste, sight, sound & smell without the need for intellectual activity  Trust & Relaxation key components  No unrealistic expectations, no need to produce something
 Multi-sensory

Snoezelen Sensory Approach

Snoezelen Tx considerations:
different sensations slowly  Introduce elements of choice  Introduce personal items  Observe client carefully, monitor reactions and record  Length of time dictated by client’s wishes  Sensory Integration principles compliment this approach
 Introduce

Literature Review
 Van

Weert et al.’s study investigated the effect of an integrated Snoezelen® program

 Significant

treatment effects were found on the behavior & mood of nursing home residents with dementia
Van Weert, J. C. M., van Dulmen, A. M., Spreeuwenberg, P. M. M., Ribbe, M. W., Bensing, J. M. (2005) Behavior and mood effects of snoezelen integrated into 24-hour dementia care. Journal of the American Geriatric Society, 53, 24-33.

Literature Review cont.

An early study by Robichaud et al.’s, explored the efficacy of multi-sensory interventions Results suggested that the behavior & functioning of institutionalized adults with dementia improved with multi-sensory interventions


Robichaud, L., Hebert, R., Desrosiers, J. (1994). Efficacy of sensory integration program on behaviors of inpatients with dementia. The American Journal of Occupational Therapy, 48(4), 355-360


Implications to Occupational Therapy Practice
Multi-Sensory approaches in occupation therapy with Older Adults with Dementia Disorders may be effective in order to:
• • • • • • • Reduce agitation Decrease disruptive behaviors Promote effective interventions Increase outcome measures Stimulate action/engagement in meaningful occupations Improve quality of life for older adults with Dementia Disorders Provide effective strategies for caregivers of older adults with Dementia Disorders

3. Validation Therapy
 Program

initiated in 1960s by Naomi Feil  A method of communicating  “validate” or accept the values, beliefs and “reality” of the dementia person – even if it has no basis in your reality.

4. Montessori’s Approach in Dementia Care:
Maria Montessori worked with children in Italy.  OT intervention is based on several of Montessori’s priniciples.
 Dr.

Montessori Approach - Dr. Cameron
Camp, psychologist and early pioneer of this approach with dementia

Use real life materials that are pleasing  Progress from simple to complex  Progress from concrete to abstract  Structure materials L to R, top to bottom  Allow learning to progress in a sequence  Minimize risk of failure  Use as little vocalization as possible when demonstrating activities  Match your speed of movement to the speed of the clients when presenting activities

 Make

the materials and activity selfcorrecting  Adapt the environment to the needs of the client  Let client select the activities whenever possible  Accommodate for vision problems

WHAT IS ESP? (Environmental Skill-building Program)

theory and evidence-based program  Evidence shows ESP can:
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Decrease behavioral occurrences among individuals with dementia Maintain ability of dementia patients to engage in everyday activities of living Enhance family caregiver skill, mastery, sense of confidence Decrease family caregiver upset, burden and depression

Core Principles
 Client-centered

relevant/specific/sensitive  Tailored/customized  Active involvement of caregiver and dementia patient if appropriate  Problem-solving oriented

 Culturally

Triadic Model - PEO
 Behavior

is a Consequence of Person/environment Interaction

 (Occupational)

Behavior is the outcome of interaction between person – environmentoccupation

Behavior as a Consequence of Person/Environment Interactions
Individual with Dementia

Caregiver Physical Environment

Therapeutic Intervention includes:
Modifying Daily Tasks/Task Simplification 2. Simplifying Communication 3. Modifying physical environment 4. Activity engagement

How to Simplify Tasks

Reducing Complexity
• • • • Reduce number of steps of task Help person initiate task Stick with familiar tasks (link to former roles) Introduce activities involving repetitive motion


Pace Activity
• Keep to routines • Introduce regular rest breaks


Relax Rules
• Make tasks error free • Ignore harmless mistakes

2. Simplify Communication
-Use a very specific1-2 step verbal prompt - Avoid using negative words – using calming words. - Use light touch to redirect CR - Pay attention to body language - Reduce choices & stimuli

3. Modifying the Environment

4. Activity Engagement

Designing an Action Plan for caregivers that’s based on an Triadic/PEO model
 Video:

Grace - complete an action plan

(Consider ESP, Montessori approach, Validation, Snoezelen principles)

Do you know the stages of Dementia & Allen’s cognitive levels?  Can you compare the various frameworks/approaches that guide Dementia Intervention?  Based on assessment, skilled observation and clinical reasoning, can you plan a treatment intervention based on these frameworks?  Can you prepare an Action plan for a caregiver who’s family member exhibits ADL dysfunction due to dementia-related behaviors?

Last thing….
 Answer

2 Questions:

1. What was the most important thing you learned during this class? 2. What important Question remains unanswered for you?

Allen, C. K. (1985). Occupational therapy for psychiatric diseases: Measurement and management of cognitive disabilities. Boston: Little, Brown, and Company.

Alzheimer’s Association (2009). 2009 Alzheimer’s Disease Facts and Figures. Retrieved April 6 from
Heltemes, M (2009). Occupational Therapy for clients with Dementia in Assisted Living Facilities. OT Practice, pp. 10-13 Pollard, D. V. & Olin, D. (2005). Allen Cognitive Levels: Meeting the Challenges of Client Focused Services. 2nd Edition. Monoma, WI: Selectone Rehab.

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