Alzheimer's Disease and Related Dementia (ADRD)

Cognitive Disabilities Model

• developed by OT Claudia Allen

• referred to as the Allen Cognitive levels

• identifies levels by remaining abilities

• Allen Cognitive Lacing Screen (ACLS), Allen Diagnostic Model (ADM), and Routine Task Inventory Expanded (RTI-E)

  • From this theory, two other OTs have expanded the work

  • Kim Warchol with Best-Abilities Care Model

  • Teep Snow with the Positive Approach to Care

Theory of Retrogenisis

• developed by Barry Reisberg, M.D.

• hypothesis that development occurs in reverse

• “first in-Last out” - the first things you learn, stays with you the longest

• compares alzheimer stages to developmental stages or ages

• Global Deterioration Scale (GDS) and Functional Assessment Staging Tool (FAST)

Person Centered Care Approach

• developed by Thomas Kitwood, Ph.D.

• Person as the focal point of caregiving

• Care is focused on quality of life, well-being, and dignity

• Core values include choice, dignity, respect, purposeful living, self-determination

What is Dementia?

• dementia is not a specific disease, it is an overall term covering a wide range of specific medical conditions

• general term for a loss of ‘thinking abilities’ severe enough to interfere with daily life

Dementia is irreversible, this includes…

• Alzheimer’s Disease (AD)

• Vascular Dementia (Multi-infarct Dementia)

• Lewy Body Dementia

• Frontotemporal Dementia

Alzheimer’s Disease

• most common type of dementia; accounts for 60-80%

• progressive neurodegenerative disease

• no known cure

• two abnormal structures

  • plaques- protein beta-amyloid build in the spaces

  • tangles- protein tau build in cells

• characterized by the loss of function- loss of independence in daily life activities such as mental functions like memory and learning

• progression is in a continual slope

Vascular Dementia

• commonly occurs with Alzheimer’s

• only around 5-10% occurs alone, more common in men

• caused by blocked or reduced blood flow causing oxygen deprivation

• memory loss may or may not be a significant symptom

• Symptoms:

  • impaired planning and judgement

  • uncontrolled emotion

  • decreased attention span

  • impaired social skills

  • difficulty with word finding

• Progression is in a step pattern! - different things disappear at different unexpected time

Lewy Body Dementia

• third most common cause of dementia

• deposits of alpha-synuclein proteins inside a neuron

• Symptoms:

  • hallucinations, most visual

  • trouble with visual information

  • parkinsonian movement features

  • confusion and alertness that varies significantly

• Clinical diagnosis; biomarkers are beginning to be found and utilized for diagnosis

Frontotemporal Dementia (FTD)

• nerve cell damage in frontal and temporal lobes

• caused by 1) Tau and 2) TDP43

• Used to be referred to as Pick’s disease

• Behavior variant frontotemporal dementia (bvFTD)

  • personality changes, conduct, judgement, empathy

  • occurs in 50s and 60s, can be seen as early as 20s

• Primary progressive aphasia (PPA)

  • speaking, writing, comprehension

  • normally seen in midlife

• Disturbances of motor

  • changes in muscle and motor functions

Additional types of ADRD:

• Korsakoff Syndrome: deficiency in thiamine (B-1)

  • most common cause is alcohol abuse

• Parkinson’s Disease dementia:

  • early on tremors, shakiness, shuffling, stiff movements

  • as brain changes spread, often affect mental functions

• Huntington’s Disease:

  • single defective gene on chromosome 4

  • uncontrolled movement of arms, legs, head, and face

  • decline in memory, concentration, judgement, ability to plan and organize

• Mixed dementia

What does “function” include?

an activity or purpose intended for a person or thing, everything we do

4 components of function:

• sensory

• emotional

• physical

• cognitive

  • memory

  • attention

  • problem solving

  • sequencing

The Cognitive Skills Hierarchy

1. Foundational level: arousal, alertness, awareness, consciousness, attention, concentration

2. Memory- short and long term

3. Problem-solving, sequencing

4. Reasoning, organization

5. Judgment, insight

6. Executive functions

What is memory?

power or process of remembering what has been learned, things learned and kept in the mind

4 types of memory:

• short-term

• long-term

• procedural

• working

What is short-term memory?

• holding of information for a short period of time

• can be anywhere from seconds, to minutes, to days

• Example: remembering what you had for breakfast

  • Impact: if you forgot you didn’t eat breakfast and then you might start to feel unwell and don’t know why, or other cases overat

    • this can happen with meds which is dangerous

• someone with short-term memory will ask a lot of questions, you’ll see restlessness

What is long-term memory?

• the storage and recall of information over long period of time

• can be anywhere from days, to weeks, to years

• Examples: phone numbers, addresses

  • Impact: can help people feel safe, can be a resource for caregivers

What is procedural memory?

• part of long-term memory

• remembering how to do things; motor memory

• Example: driving home from school, riding a bike, putting keys in a certain spot, self-feeding

  • Impact: you feed yourself from the time you’re around 1 yrs old, getting into the bathroom and knowing what to do

What is working memory?

• retaining information for a brief period of time while then manipulating that information

• helps the brain organize info for storage

• considered an executive function

  • Example: having an old phone and a new phone, and trying to figure out how to actively use it

    • Impact: can end in extreme frustration

What is attention?

the act of carefully thinking about, listening to, or watching someone or something

level of alertness

4 types:

• selective

• divided

• switching

• sustained

What is selective attention?

processing one source of info at the expense of others

• Example: “squirrel,” when someone stops talking because they become distracted by another

  • Impact: seeing something else and go towards that and forget what they’re doing in the first place, makes others feel ignored and not cared about

What is divided attention?

processing two or more information sources at the same time

the idea of multitasking

• Example: listening and taking notes at the same time, driving and listening to the radio and watching google maps

  • Impact: huge safety concern, information may fall out or get behind

What is switching attention?

processing one source of information followed by another source

executive function

• Example: someone is getting dressed and then the phone rings

  • Impact: the come out of their room without pants on, cause they forgot to go back to the task at hand

you’ll see confusion, a lot of things left undone, people trying to figure out what they were doing before they got interrupted

What is sustained attention?

maintaining focus on one source of information over a period of time

mental energy

• Example: sitting in class for 6 hours all day long, someone eating dinner

  • Impact: puts a fork down and people assume that they are done eating so they take the food away

What is problem solving?

ability to recognize a problem and then formulate and implement solutions

components include:

• recognizing problem

• identity the source of the problem

• devise a solution to the problem

• carry out that solution to correct problem

• assess effectiveness

ex. the older mom told the son that her breaks stopped working, the son saw a ton of scrapes against the side of the car, the mom explained that she used the cars on the side of the road to slow down, she definitely problem-solved but not effectively

What is sequencing?

ability to direct oneself through the steps of an activity

someone may be able to do something, but is not able to do it effectively

• ex. making a sandwich, activity analysis involves sequencing

What is the Best ability to function?

• comes from allen cognitive levels

• each level is described by the remaining abilities

• these abilities are what provides us with the ‘just right challenge’

• matching task complexity with cognitive ability

• is written in % of cognitive assistance

• we can think of it as terms of developmental age (we do not want to speak of a person as ‘acting like a 2 yr old’)

Allen Cognitive Levels

1. Automatic actions

2. Postural actions

3. Manual actions

4. Goal-directed activity

5. Independent learning

6. Planned activities

Level 1

• Dementia stage: end stage, severe

• Developmental age: 0-12 months/infant

• BATF: Total Cognitive Assistance

• GDS: 7

• likely bed bound, mute, and requires total care

• perceptual awareness 14” from face; monocular vision

• can still feel love and experience relationships

• Primary remaining abilities:

  • response to sensory stimuli

  • swallow

  • vocalize

  • partial ROM

Level 1 care approaches

Care Approaches

• provide meaningful sensory stimuli

• provide stimuli directly in front of person

• gain persons’ trust and agreement

• promote movement (AROM, PROM)

Caregiver Knowledge

• understand what’s going on

Contractures

• skin break down

• aspiration

• weight loss

Level 2

• Dementia stage: late stage

• Developmental age: 12-18 months

• BATF: Maximum Cognitive Assistance

• GDS: 6-7

• Gross motor movements

• Mobility

• Simple communication (limit amount of pronouns, say names)

• Possible self-feeding and drinking

• Perceptual awareness 23” from face; monocular field

Level 2 care approaches

Care approaches

• wait for a response (some people take 10-15 seconds to respond)

• use verbal, visual, and tactile cues to gain attention and assist in processing directions (tap the chair you want them to sit at)

• gain the person’s trust and agreement

Caregiver knowledge

• effective communication and engagement

• hospice/end stage complications

• safety/fall prevention

• promotion of movement

• swallowing

Level 3

• Dementia stage: middle stage

• Developmental stage: 8 months - 3 years (really big gap!)

• BATF: Moderate Cognitive Assistance- except feeding which is minimal

• GDS: 6

• uses hands to pick up and manipulate familiar objects

• eye hand coordination

• notices effects of actions on objects

• follows one step directions with cues

• perceptual awareness is to elbow/knees; binocular vision

• significant range of abilities; represented on a continuum of high and low

  • High level: verbal, some redirection, less frequent cues

  • Low level: verbal, visual, tactile, more frequent cues, frequent redirection, frequent stops/starts

Level 3 care approaches

Care approaches:

• use verbal, visual, and tactile cues to gain attention and assist in processing directions

• break activity into one step parts and cue at each step

• use familiar objets to access procedural memory

• gain the person’s trust and agreement

Caregiver knowledge:

• effective communication and engagement

• knowing level of assist, avoiding excess disability

• avoidance of behaviors (knowing triggers)

• safety/fall prevention accommodations

Level 4

• Dementia stage: early stage

• Developmental age: 4 years to 10/12 years

• BATF: minimum cognitive assistance- except feeding which is upervision

• GDS: 4-5

• goal directed in simple, familiar activities

• follow routines- very dependent on these

• some new learning, some simple problem solving

• perceptual awareness egocentric; binocular vision

• significant range of abilities; represented with a high and low

  • High level: independent with basic ADLs, uses lists, notes, calendars, practice for complex or new

  • Low level: supervision and set up, reminders, assist with complex or new

Level 4 care approaches

Care approaches:

• set out or make supplies visible

• provide assist for problem solving

• establish and maintain a daily routine

• gain the person’s trust and agreement

Caregiver knowledge:

• prevent excess disability by promoting use of abilities

• promote effective communication

• safe environment

Level 5

• Dementia stage: mild cognitive impairment

• Developmental age: teens to early 20s

• BATF: independent to supervision depending on task

• GDS: 2-3

• follows simple written instructions

• understands primary effects of actions; may not understand secondary

• ability to learn through trial and error

• beginning to have lapses in judgement, memory, attention, may show impulsivity

• perceptual awareness beginning egocentric; tunnel vision

Level 5 care approaches

Care approaches

• compensatory strategies

• gain the person’s trust and agreement

Caregiver knowledge

• potential safety hazards

• establish medication routine/compliance

• walker training

Level 6

• Dementia stage: no dementia

• Developmental age: 25+ years

• BATF: independent

• GDS: 1

What is communication?

• the exchange of information

• ‘behavior’ is communication

• Difficulties may include…processing requests and directions, difficulties voicing desires and needs, and resembling communication of infant

• Expressive

  • speech

  • body language

  • facial expresson

• Receptive

  • comprehending message from others

Processing challenges approach

• speak in short sentences

• visual demonstration and tactile cues to go with words

• wait for response

Memory challenges approach

• use nouns/avoid pronouns

• use close ended questions

• avoid reality checks “remember?”

Attention challenges approach

• make direct eye contact

• begin with name

• gain and maintain attention before beginning

• eliminate distractions

Behavior challenges approach

• trust and agreement

• tone of voice, body language, and facial expression

Behavior is communication…

• dementia causes people to act unpredictably

• people with dementia communicate through behaviors

• recognize that behavior is communication and identify the trigger

• behavior problems can arise from:

  • pain (number one cause, there’s a specific pain scale for dementia)

  • fear

  • inability to express unmet need

  • loss of sense of self

  • inappropriate expectations from a caregiver

What does a behavior management plan consist of?

• Who: who was involved in the incident?

• What: what was the behavior?

• Where: where did the incident occur and is there a pattern?

• When: when did incident occur and is there a pattern?

• Why: what happened prior?

• How: how did you respond? was it effective?

Behavior problems may look like…

• resisting care

• physical and verbal aggression

• anxiety

• sundowning

• transfer trauma

• sad mood or depression

• wandering

How to minimize or prevent behaviors…

• come back later (always the first option)

• use interests

• gain trust and agreement

• allow for as much control as possible

• reduce stressors

• check for pain

• help to develop relationships

• minimize time left alone

• listen and support

• anticipate unmet needs

• engage in valued activities

• challenging behavior

What is therapeutic fibbing?

Try other tactics first

• distraction

• respond to the emotion rather than the behavior

Mix it up

• don’t always resort to this technique - it doesn’t work with everyone!

Safety and well-being rule

• only use when necessary to create safety, enhance QOL, and ensure well-being

Let it be

• if the client is happy and not in danger, let them stay in their personal reality

Intuition

• do what feels right

Engagement: Montessori method

Purpose

• help persons with dementia be engaged by meaningful activity

• teach loved ones new ways of connecting

Principles

• sense of purpose and capture interest

• activities that relate to the past

• invite the person to participate

• offer choices (no more than 2)

• talk less, demonstrate more

• match their speed

• engagement is success

Engagement: Sensory

Visual engagement

• bright colors

• familiar objects to look at

Provide for motor movement

• active movements throughout the day

• fidget toys

• rocking chairs, air cushion

Activate sense for task preparation

• smells of food or cooking before eating

• smells of shower

• relaxing music to calm or favorite music to alert