Transcript 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)
+ impairment in occupation or social function
+ decline from previous level
Types of Dementia
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Lewy Body
Frontotemporal dementia
Multi-infarct dementia
Binswanger’s disease
Alzheimer’s disease
others
Lewy Body dementia
• 2nd most common
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form of dementia
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Central feature
• Dementia +
• Deficits in attention,
frontal-subcortical
skills, visuospatial
ability.
Core features (need 2)
• Fluctuating cognition
• Recurrent visual
hallucinations
• Spontaneous motor
features of
parkinsonism.
Frontotemporal dementia
• Equal in prevalence
to AD in patients <65.
3 Clinical variants
Behavioral variant
• personality change
• disordered social
conduct
• insight loss
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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 Disease
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• 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
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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
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after hip fracture.
• 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)
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• 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
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Dementia
• 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 (2112wks), 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-Direction
Goal: Stop the current
behavior from
occurring and redirect 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
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exercise
• Components:
Vertical, horizontal,
carrying, lyingsitting-standing
transitions
• Wii programs?
• ADLs in a simulated
environment.
• “Chores”
• ADL’s in patient’s
environment.
Pleasant Events Schedule
(used with permission of Dr. Linda Teri)
used with permission of Dr. Linda
Teri
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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
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ORIF
If cannot follow, mobilize
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without restrictions
Limit mobility to transfers
only for 1 month
Automated feedback on
weight bearing.
Knee immobilizer to
prevent standing
Use weight bearing assist
device
Hip Precautionsreplacements
• Adduction wedge
• Knee immobilizer
• Spaced Retrieval memory
training
• Memory notebook or
cues
Prompting and Cueing
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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”