managing rehabilitation challenges of patients with dementia
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Managing rehabilitation challenges of patients with
dementia
Tom Holmes, OTR, MAThe University of Texas Health Sciences Center
April 2008
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
Types of Dementia• Lewy Body
• Frontotemporal dementia
• Multi-infarct dementia
• Binswanger’s disease
• Alzheimer’s disease
• others
Lewy Body dementia• 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.
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.
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.
multiple lacunar infarcts in white matter,
pons and basal ganglia.
lateral ventricular enlargement.
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
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 fracture on specialized geriatric unit.
• 123 patients receive standard care in hospital
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)
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
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
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.
Clinical applications during rehabilitation sessions
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
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)
• ????
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.
Re-DirectionGoal: 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
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.
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.
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
Therapeutic Activities (97530)
• Functional-task
exercise8
• Components: Vertical, horizontal, carrying, lying-sitting-standing transitions
• Wii programs?
• ADLs in a simulated environment.
• “Chores”
• ADL’s in patient’s environment.
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?
• Weight bearing or mobility precautions
Dealing with precautions
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
Prompting and Cueing
• Manual guidance
• Gesturing
• Vocal instructions
• Written instructions/photos
• Cueing (e.g. use of alarm watch, notebook, cue card)
• Situational cue
Contracture management
• Prevention through PROM, standing
• De-cerebrate posturing in late stages?
• Skilled therapy for orthotics, ultrasound/heat and stretch, establishing PROM programs.
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
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
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”