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”