Heather L. Menne, PhD

Margaret Blenkner Research InstituteBenjamin Rose Institute

11900 Fairhill RoadSuite 300

Cleveland OH 44120hmenne@benrose.org

15 September 20092009 Ohio Association of Area Agencies on Aging Annual Conference

Columbus, OH

This program is implemented in conjunction with the Ohio Department of Aging and the Alzheimer’s Association- Northwest Ohio and was made possible by a grant from

the Administration on Aging (90AE0329).

Reducing Disability in Alzheimer’s Disease in Ohio

Program TeamBenjamin Rose Institute

Sue Ambro

David Bass

Justin Johnson

Heather Menne

Ohio Department of Aging

Marc Molea

Mozelle Mackey

Alzheimer’s Association – Northwest Ohio Chapter

Salli Bollin

Cheryl Conley

Kristine Gale

Bob Hausch

Linda Pollitz

Marilyn Ward

Marty Williman

Consultants

Linda Teri

Stacy Wegley

Benjamin Rose Institute

Sue Ambro

David Bass

Justin Johnson

Heather Menne

Ohio Department of Aging

Marc Molea

Mozelle Mackey

Alzheimer’s Association – Northwest Ohio Chapter

Salli Bollin

Cheryl Conley

Kristine Gale

Bob Hausch

Linda Pollitz

Marilyn Ward

Marty Williman

Consultants

Linda Teri

Stacy Wegley

Objectives

• To explain the importance of evidence-based research and the translation to practice.

• To describe the exercise and behavior management intervention components of “Reducing Disability in Alzheimer’s Disease” program.

• To share preliminary baseline information about the caregiver and care receiver participants from northwest Ohio.

What is “evidence-based”?• Department of Health and Human Services,

Substance Abuse & Mental Health Services Administration

• National Registry of Evidence-based Programs and Practices (NREPP)• http://www.nrepp.samhsa.gov/

• Evidence-based practice . . . generally refers to approaches to prevention or treatment that are validated by some form of documented scientific evidence . . . Evidence often is defined as findings established through scientific research, such as controlled clinical studies . . . Evidence-based practice stands in contrast to approaches that are based on tradition, convention, belief, or anecdotal evidence.

• Chronic Disease Self-Management Program

• Matter of Balance• Healthy Ideas• Active for Life

Examples of Evidence-based Programs

“Translation” of a Program

Balance

Community reality vs. Program fidelity

RE-AIMReach: The number and representativeness of

individuals who are willing to participate in a program.

Efficacy/Effectiveness: The impact of an intervention on important outcomes (e.g., negative effects, quality of life).

Adoption: The number and representativeness of settings and agents who are willing to initiate a program.

Implementation: In settings this refers to intervention agents’ fidelity to an intervention’s protocol. For individuals this refers to clients’ use of the intervention strategies.

Maintenance: The extent to which a program becomes institutionalized or part of the routine organizational practices. For individuals, maintenance is the long-term effect of a program on outcomes. www.re-

aim.org

Reducing Disability in Alzheimer’s Disease (RDAD)

• Developed and tested in Seattle at the University of Washington: Linda Teri, Sue McCurry, Rebecca Logsdon, et al.

• Intervention used home-based exercise and caregiver training in behavioral management techniques.

• Goal was to help reduce functional dependence and to delay institutionalization of the person with dementia.

Original RDAD Results

Teri et al. JAMA. 2003;290:2015-2022. Reprinted from training session given by L.Teri in March 2009.

RDAD: Reasons for InstitutionalizationRDAD: Reasons for Institutionalization

50

18

27

191924

0

10

20

30

40

50

60

Patient BehavioralProblems*

Patient Impairment or Illness

Patient Increased ADLImpairment

RDAD RMC

Nu

mb

er

of

Pers

on

s

**PP<.08.<.08.

RDAD: Change in Percent of RDAD: Change in Percent of Subjects Exercising at Least 60 Subjects Exercising at Least 60

Minutes a WeekMinutes a Week

63

-11

8

26

-5

-15-10-505

1015202530

3 Months 12 Months 24 Months

RDAD RMC

RDAD Components• 12 1-hour sessions over 3 months, then

monthly follow-up for 3 months • Exercise training

• Aerobic/endurance activities• Strength training• Balance• Flexibility training

• Problem-solving/behavior management techniques• Maximize cognitive function• Use ABCs to problem-solve difficulties• Pleasant events• Enhance caregiver resources and skills

Strength Training Examples

• Dorsiflexion: sit on a firm chair and cross one leg over the other. Raise the toes toward the ceiling. Return to start position.

• Knee Extension: sit on a firm chair. Raise foot until knee is straight, pointing toes to nose. Return to start position.

Reprinted from training session given by R. Houle in March 2009.

Strength Training Examples

• Hip Flexors: Stand with feet shoulder width apart. Hold onto stationary object for support. Bend hip and bring knee slowly to chest. Slowly return to starting position.

Reprinted from training session given by R. Houle in March 2009.

Balance Exercise Examples

• Functional Base of Support: Sit on a firm chair. Lean forward, raise arms, lean back, lean to each side, and turn to each side.

Reprinted from training session given by R. Houle in March 2009.

Balance Exercise Examples

• Advanced Walking Skills: Step over an obstacle (e.g., piece of paper). Step back. Feet apart, feet together, feet apart, feet together.

Reprinted from training session given by R. Houle in March 2009.

Flexibility Exercise Examples

• Neck Stretch: Sit on a firm chair with hands in lap. Turn head slowly side to side. Next, bring ear to shoulder, keeping shoulders relaxed. Next lower chin to chest, and return to original position.

Reprinted from training session given by R. Houle in March 2009.

Flexibility Exercise Examples

• Ankle Stretch: Sit on a firm chair. Extend one leg out and point and flex toes. Make circles with ankle in both directions. Repeat with other ankle.

Reprinted from training session given by R. Houle in March 2009.

Behavior Management Techniques

• ABCs• Activator – Behavior – Consequence• Changing activators and consequences, you

can change behaviors• e.g., Mom loses her eyeglasses so she

rummages all around the house and becomes upset when she cannot find them.

• Pleasant Events• Identify “pleasant events” that the person

with dementia can still enjoy• If necessary, adapt prior “pleasant events” to

suit the persons current abilities

Reducing Disability in Alzheimer’s Disease (RDAD) in Ohio

• Funding from the Administration on Aging

• Program began in 2008 and is currently being implemented in Northwest Ohio, through the Alzheimer’s Association – Northwest Ohio Chapter

• Other program partners are the Ohio Department of Aging (oversight) and the Benjamin Rose Institute (evaluation)

• In March 2009, 7 trainers/staff from the Alzheimer’s Chapter were trained by Dr. Linda Teri and her colleague Ray Houle.

Ohio RDAD Progress

Family Status

Number

Percent

Recruited 80 100%

Assigned 32 40%

Active 29 36.25%

Not eligible 9 11.25%

Discharged 10 12.50%

Completed 0 0%

2 families have completed 12 sessions (3 months)

11 families have completed 7 sessions (1 month)

Ohio RDAD Participants

Based on 23 families Caregivers

Persons with

Dementia

Demographics

Gender (% Female) 69.6% 52.2%

Age (mean) 70.1 80.0

Education (percent more than high school)

56.5% 34.6%

Income ($20,000-$39,999) 61.9% --

IWD Impairment

Short Blessed Test (mean) -- 8.17

Number of other health conditions (mean)

-- 3.39

Caregiving Situation

Years providing care (mean) 3.74 --

Caregiver type (% spouse) 60.9% --

Care partners live together (% yes)

87% --

Ohio RDAD Participants: Persons with Dementia

Based on 23 families Persons with

Dementia

Physical Assessment

Functional Reach trial 2 (mean) 6.6 inches

Activity and Health

Number of minutes of exercise in past week (mean)

158.81

Number of days unable to do daily activities (mean)

1.48

Number of days stayed in bed in past week (mean)

1.26

Number of falls in past month (mean) 0.77

Rate health now Excellent/Very Good (%)

30.4%

Good (%) 39.1%

Fair/Poor (%) 30.4%

Health compared to 1 year ago

Much/Somewhat Better (%)

4.3%

About the Same (%) 65.2%

Much/Somewhat Worse (%)

30.4%

Ohio RDAD Participants: Caregivers

Based on 23 families Caregivers

Health

Rate health now Excellent/Very good (%) 43.5%

Good (%) 43.5%

Fair/Poor (%) 13.0%

Information Needs

Understanding relatives’ memory problems (% yes)

34.8%

Knowing the causes of your relatives’ behavior problems (% yes)

40.0%

How to manage the behavior problems (% yes) 86.7%

Find ways to use voice and body language to interact with relative (% yes)

64.7%

Helping relative participate in activities he/she enjoys (% yes)

93.3%

Getting other family to assist with your relative (% yes)

55.0%

Ohio RDAD Case Example

• Spousal care dyad • Both almost 70 years old, and living

in the community• Wife has been providing care to

husband since 2003• Husband has a diagnosis of

Alzheimer’s disease as well as arthritis

Ohio RDAD Case Example

Time 1 Time 2

Cognitive and Functional Assessment

Short Blessed Test 28 (max) --

Walking speed (trial 1) 5.15 sec 3.78 sec

Balance assessmentNeeded

assistanceNo assistance/

Did not comprehend

Reach assessment 5.5 in Did not comprehend

Activity and Health

Number of minutes of exercise in past week

1200 min “paces all day”

Number of days unable to do daily activities

0 0

Number of days of stayed in bed in past week

0 0

Number of falls in past month 3 5

Rate health now Good Very good

Ohio RDAD Case Example

Time 1 Time 2

Information Needs

How to manage the behavior problems yes no

Find ways to use voice and body language to interact with relative

yes no

Helping relative participate in activities he/she enjoys

yes no

Getting other family to assist with your relative

yes no• Responded “very satisfied” for the 7 questions about satisfaction with the program.

This is a very good program. I only wish I had started before my husband was so advanced. The only reason I stated “no” on additional information is because [trainer] has provided me with excellent brochures, books, and articles . . .

Ohio RDAD Case Notes

• Caregiver states that person with dementia is sleeping better. When he started the program, he struggled to get out of the chair but now is using level 1 of chair exercises to get up and down.

• Caregiver states he can see a difference in his dad.  He says he (his dad) asks, "When is the exercises lady going to be here?“

Additional RDAD Information• Teri, L., Gibbons, L.E., McCurry, S.M., Logsdon, R.G.,

Buchner, D.M., Barlow, W.E. et al., (2003). Exercise plus behavioral management in patients with Alzheimer disease: A randomized controlled trial. Journal of the American Medical Association, 290(15), 2015-2022.

• Teri, L. McCurry, S.M., Buchner, D.M., Logsdon, R.G., LaCroix, A.Z., Kukull, W.A. et al., (1998). Exercise and activity level in Alzheimer’s disease: A potential treatment focus. Journal of Rehabilitation Research and Development, 35(4), 411-419.

For information about the Program in Northwest Ohio, please contact Salli Bollin, Executive Director of the Alzheimer’s Association - Northwest Ohio Chapter at 419-537-1999.

Margaret Blenkner Research Institute

Established in 1961, the Margaret Blenkner Research Institute of the Benjamin Rose Institute conducts applied aging research to enhance the lives of older adults and those who care for them. MBRI shares its knowledge with local, national, and international audiences. MBRI’s current program focuses on four major topics: Services and Interventions; Family Caregiving; Quality of Long-Term-Care Services; and Program Evaluation.