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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)

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Managing rehabilitation challenges of patients with dementia l.jpg

Managing rehabilitation challenges of patients with dementia

Tom Holmes, OTR, MA

The University of Texas Health Sciences Center

April 2008


Dsm iv r definition l.jpg
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 l.jpg
Types of Dementia

  • Lewy Body

  • Frontotemporal dementia

  • Multi-infarct dementia

  • Binswanger’s disease

  • Alzheimer’s disease

  • others


Lewy body dementia l.jpg

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.

Lewy Body dementia


Frontotemporal dementia 3 l.jpg

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 dementia3


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Frontotemporal

A patient’s response to: “Make a slice of toast and put some butter and jam on it”


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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.


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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



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Brief Literature Review

Therapy and Dementia


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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


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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)


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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


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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


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Meta-analysis of Exercise and Dementia7

  • 300 articles found ---- 30 reviewed

  • Significant positive effect on physical perf. cognitively impaired (p.<.001)

  • Cog. Impaired benefited morethan controls/comparisons

  • Mean training duration 23 weeks (2-112wks), 3.6 sessions/week, 45 min.



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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 l.jpg

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)

????

Physiological Symptoms


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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.


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Goal: 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

Re-Direction


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Maintaining exercise within a session. re-direct patient to another stream of behavior.

  • 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.


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Substitute with incompatible behavior re-direct patient to another stream of 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.


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Meaningful Activities re-direct patient to another stream of behavior.

  • 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


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Functional-task re-direct patient to another stream of behavior.exercise8

Components: Vertical, horizontal, carrying, lying-sitting-standing transitions

Wii programs?

ADLs in a simulated environment.

“Chores”

ADL’s in patient’s environment.

Therapeutic Activities (97530)


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Pleasant Events Schedule re-direct patient to another stream of behavior.9(used with permission of Dr. Linda Teri)

used with permission of Dr. Linda Teri


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Hip fracture rehabilitation re-direct patient to another stream of behavior.

  • 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 l.jpg

ORIF re-direct patient to another stream of behavior.

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

Dealing with precautions


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Prompting and Cueing re-direct patient to another stream of behavior.

  • Manual guidance

  • Gesturing

  • Vocal instructions

  • Written instructions/photos

  • Cueing (e.g. use of alarm watch, notebook, cue card)

  • Situational cue


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Contracture management re-direct patient to another stream of behavior.

  • Prevention through PROM, standing

  • De-cerebrate posturing in late stages?

  • Skilled therapy for orthotics, ultrasound/heat and stretch, establishing PROM programs.


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Weakness, Debility re-direct patient to another stream of behavior.

  • 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


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Fall prevention tips re-direct patient to another stream of behavior.

  • 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


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Resources re-direct patient to another stream of behavior.

  • 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”


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