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Dementia Therapy and Program Development In Skilled Nursing Facilities

By: Peggy Watson M.S., CCC-SLP and Nancy Shadowens M.S., CCC-SLP Consultants In Dementia Therapy PLLC

Contribution by: Stephanie Mayer, M.D. Editor: Califia Suntree

2008 Consultants in Dementia Therapy. All rights reserved


Dementia spares no one. It crosses cultural, ethnic and gender lines to touch the lives of patients, families and friends. Chances are, there is someone in your family dealing with its effects. As a physician, it spans most specialties and affects the care of millions every day. Although primary care physicians and neurologists may be the providers most directly responsible for its medical management, dementia changes the way subspecialists and surgeons must care for these patients as well. Many questions are raised when a diagnosis of dementia is made. Can the patient still consent for treatments? Who should sign DNR/DNI, Power of Attorney, or Advanced Directive papers? How will they care for themselves post-operatively? Can they remember instructions? Medications? Wound care? Will they take in proper nutrition for healing? All these will affect the type of procedure performed or medication prescribed, and where the patient must be followed post-procedure or post-operatively. As therapists, you are well aware that many of these issues cause patients to need skilled nursing, PT, OT and SP care. Although many of the causes of dementia can be slowed with certain medications, this is not the end of the treatment of this disease. Often, people think of dementia treatment as futile and ineffective as these patients will invariably progress. Why should we intervene if they won't even remember what we worked on this morning by the afternoon? Many providers are not aware that there are relatively simple, inexpensive and effective treatment strategies that can be used daily with your dementia patients to help stimulate the cognitive skills that are preserved, and help them function at the highest level possible at their particular stage of involvement. This will instill a sense of satisfaction in you, the family, and most importantly, even if only transiently, the patient. While it is true that they will eventually progress, and what they could understand this month might be too involved next month, we must be dynamic in our strategies just as the disease is in its course.

The state of affairs today has unfortunately gone the way of a daily struggle between managed care companies and health care providers. Policies with loop holes and demands of exact wording which must be documented in exact places by exact times causes providers and then facilities not to be paid for proper treatment and care rendered. Many health care professionals are not aware that they can be reimbursed for their services to this patient population. Unfortunately, care we so generously and lovingly provide to these dementia patients is often the care we are not paid for. Furthermore, many providers have realized that they cannot give as much time to these patients because they simply must be as cost efficient as possible. Sadly, in this case, our dementia patients may fail to get the time and treatment they deserve. I hope that you will leave this course feeling empowered and excited knowing that there are treatment strategies and specific interventions which can help preserve mental and physical function in this patient population, and that you and your facility can be reimbursed for your time. Your facility and most of all, your patients and their families will be grateful for your knowledge and implementation of these strategies.


Stephanie Mayer, MD

Normal Aging vs. Dementia

"Normal aging" describes natural changes that occur in the absence of any organic brain disease. People can grow old and continue to be independent. However, there are developments that generally occur in the brain in even healthy individuals who are 60 years old and up. Common age related changes include decreased hippocampal, frontal and temporal lobe volumes. These changes result in decreases in immediate memory, sustained attention, and the ability to generate words. Before a diagnosis of dementia is made, general guidelines emphasize the need to see a pattern of development over six months, and a diagnosis is not made unless there is impairment in memory, social functioning and independent living. This is due to the fact that aging varies from person to person. Typical Aging:

Independence in daily activities


Dependent on others for ADL's Unable to recall instances where memory loss was noticed by others Decline in memory for recent events Frequent wordfinding problems Gets lost in familiar area Noted loss of interest in social activities - Abnormal performance on mental status exams

Complains of memory loss but able to provide detail regarding incidents of forgetfulness Recent memory for important events intact Occasional wordfinding problems Will not get lost in familiar area

Maintains social skills and enjoys socialization - Normal performance on mental status exams

The family plays a key role in determining the presence of dementia. The caregiver is generally given questions to complete regarding historical events, mental status changes, behavioral changes, recent falls or loss of balance, medication history and supplements. Based on multiple criteria, the interviewer will be able to determine the presence of dementia vs. normal aging.


Staging Information

Effective management of each dementia patient requires an indepth look at spared (preserved) versus impaired capabilities. Staging the patient is how you determine what the main elements of your intervention will be. The following stages are comprehensive and go far beyond the original `mild moderatesevere' or `earlymiddlelate' ratings. There are seven distinct stages. However, therapists in the SNF setting will be primarily responsible for administering intervention programs for stages 5, 6 and 7. By the time patients reach stage 5, they become a safety risk and generally cannot be responsible for themselves. As a result, stage 5 is when we see the most admits to an SNF. The patient's family has likely been seeing `out of the ordinary' behaviors for some time. Perhaps a family member has been caring for their loved one at home, but due to progressing dementia is no longer able to provide for them. At this point the family makes the difficult decision to place their relative in assisted living or a nursing home in an effort to keep their loved one safe. The seven stages of dementia are outlined in the Global Deterioration Scale (GDS). Stages 1 ­ 3 are predementia, stages 4 ­ 7 are considered involved dementia stages when safety becomes a concern. Stage 4 characteristics: looks, behaves and communicates normally they have the ability to conceal deficits depression may occur because they begin to see and recognize the signs of dementia function well in familiar surroundings but may get lost in new surroundings or get lost driving to a new location

Stage 5 characteristics:

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looks, behaves and communicates normally for rote events and rote responses social skills are relatively good as they are unaware of deficits perception of what is going on around them is based on misperception due to short term memory loss

able to maintain a thought long enough to give it immediate action, but may lose the thought if it takes too long to complete needs to be supervised due to short term memory loss can be delusional or paranoid due to short term memory loss and resulting misperceptions of reality


Stage 6 characteristics: Stage 7 characteristics:

©2008 Consultants in Dementia Therapy. All rights reserved

looks become somewhat unkempt verbal communication becomes more difficult as word finding decreases increased short term memory loss, unable to form new memories posture, gait and balance becomes a mobility safety issue peripheral vision becomes affected causing additional mobility safety issues simplification of ADL's is important with increased supervision and often mod. to max assist simplification of communication is important may begin to hoard items incontinent

looks have become abnormal can easily become upset unable to initiate interaction or hold a thought reacts to stimuli often causing noncompliance incontinent the brain may be unable to send signals to the body for mobility of any kind max assist for all ADL's communication limited to one word or short phrases, may be mute unable to recognize or use common utensils major difficulty with gait, balance and posture unsafe mobility, may be limited to a wheel chair


FTags and

Why Skilled Nursing Facilities Don't Want Them

LongTerm Care Survey ­ Guidance to Surveyors

A facility that a Medicare surveyor determines is not in compliance with certain regulations will get an FTag corresponding to that regulations number. It is in this manner that the nursing home's quality of services is monitored. Below are several Medicare surveyor guidelines for the longterm facility. Find the link to the complete long term care Medicare regulations and surveyor guidelines under `support websites' on the website We cannot stress enough that you should be familiar with these regulations and follow them closely. Medicare investigators look for fraudulent therapeutic intervention. Stay within the boundaries and you will be able to provide your patients with therapy for an often overlooked and difficult population. The following are excerpts from the Medicare long term facility regulations and Surveyor Guidelines Regulation 483.25: Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing, in accordance with the comprehensive assessment and plan of care. Use FTag 309 for quality of care deficiencies. Regulation 483.45 (a) (1) (2) and FTag 406 (a): Provision of Services ­ If specialized rehabilitative services such as, but not limited to, physical therapy, speechlanguage pathology, occupational therapy and mental health rehabilitative services for mental illness and mental retardation, are required in the resident's comprehensive plan of care, the facility must (1) provide the required services; or (2) obtain the required services from an outside resource (in accordance with Reg. 483.75 (h) of this part) from a provider of specialized rehabilitative services. Reg. 483.45 Guidance to Surveyors Probe for SpeechLanguage Pathology: (a) What did the facility do to improve auditory comprehension such as understanding common, functional words, concepts of time and place and conversation? (b) What did the facility do to improve speech production? (c) What did the facility do to improve the expressive behavior such as the ability to name common, functional items? (d) What did the facility do to improve the functional abilities of residents with moderate to severe hearing loss who have received an audiologic evaluation? For example, did the facility instruct the resident how to effectively and independently use environmental controls to compensate for hearing loss such as eye contact, preferential seating, use of the better ear? (e) For the resident who cannot speak, did the facility assess for a communication board or an alternate means of communication? 4

Writing Appropriate Goals

Your goals will reflect spared capabilities identified by the presenting stage determined by the evaluation. For example, it would not be appropriate to write goals suited to a stage 4 for a patient who has advanced to a stage 5, because a stage 5 cannot function as a stage 4 anymore. Always relate goals to functional outcomes for the patient within the SNF environment. LongTerm Goals describe the desired end result over the expected duration of therapy. ShortTerm Goals describe expected progress for the specified billing period.

All goals should be: a) functional for the patient's capabilities according to staging b) skilled, measurable, attainable, reasonable and necessary.

Manifestations of mental and psychosocial adjustment in each of the stages can be broken down into these five major areas:

Mobility Communication Socialization Behavior Swallowing

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Skilled vs. unskilled intervention

Clarify need for expertise of a skilled therapist to treat the patient

Unreasonable amount of time for setting up the Functional Maintenance Program

It should not take more than 2 ­ 3 sessions to complete caregiver training of compensatory strategies, whether these are for mobility, communication, socialization, behavior or dysphagia (swallowing)

Missing documentation

Therapist states on evaluation that the patient's gait has become unsteady, however, the nursing notes do not mention this

Insufficient documentation

Patient receiving physical therapy 5 x's week, tolerating well

Conflicting documentation

Nurses: patient able to walk to bathroom unassisted daily Therapist: patient requires mod assist of 1 for toileting ADL

Patient is inappropriate for skilled intervention

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documentation does not support expectation that the patient will achieve stated goals


Texas Speech and Hearing Association Welcomes You To:

Dementia Therapy and Program Development in Skilled Nursing Facilities Speakers: Peggy Watson M.S., CCCSLP Nancy Shadowens M.S., CCCSLP

Please turn off or silence cell phones


Dementia diagnosis requirements: Impairment of memory and at least one other cognitive domain Represent a decline from previous level of functioning

VASCULAR DEMENTIA (VaD) Also called multiinfarct dementia (MID)




Also called `Picks Disease' Three Main Presentation Types: 1.Personality/Behavior 2. Language ­ fluent 3. Language ­ nonfluent



PD is a progressive degenerative disease classically affecting motor control and causing: tremors balance gait problems rigidity





SOME TO CONSIDER Chronic Malnutrition Chronic Dehydration Hypotension Orthostatic Hypotension MedicationRelated Dementia



More to consider: Alcohol and Substance Abuse Infectious Diseases Human Immunodeficiency Virus (HIV) Depression Brain Tumors Thyroid Dysfunction

Examples of functional change

Identify Functional Change

PT: Patient complains of pain Difficulty repositioning in bed Decreased range motion

Examples of functional change


Examples of functional change

Increasingly confused, disoriented, Change in memory Impaired safety and judgment

OT: Ability to self feed has changed Decreased upper body strength Change in grooming/hygiene

Therapy Screening Tools

· SLP Screens:

MiniMental Global Deterioration Scale Brief Cognitive Rating Scale Set test

*Nursing notes reflecting functional change in status. *Nursing notes reflecting an `event'. Functional change should be accompanied by an `event'.

· OT and PT: Screen using visual identification of physical and cognitive impairments in relation to function and safety, wheelchair positioning, ambulation and transfers.

Potential Events: Illnesses Exacerbation of chronic conditions Other


SLP's · FLCI: Functional Linguistic Communication Inventory · ABCD: Arizona Battery for Communication Disorders of Dementia · FROMAJE: Function, Reason, Orientation, Memory, Arithmetic, Judgment & Emotional Status · FAST: Functional Assessment Staging Test OT's · ADL Stage Specific Checklist · Kohlman Evaluation of Living Skills (KELS) · Global Deterioration Scale (GDS) · Allen Cognitive Levels

PT's · Berg Balance Measure · Tinetti Assessment Tool · Gait Assessment Rating Scale (GARS) · A thorough range of motion (ROM) and tone assessment in lower extremities/trunk that could contribute to an increased fall risk.

Staging of Dementia

· There are seven distinct stages. However, therapists in the SNF setting will be primarily responsible for administering intervention programs for stages 4, 5 and 6. · Global Deterioration Scale

Stage 1: No Cognitive Decline Stage 2: Very Mild Cognitive Decline Stage 3: Mild Cognitive Decline Stage 4: Moderate Cognitive Decline Stage 5: Moderatly Severe Cognitive Decline Stage 6: Severe Cognitive Decline Stage 7: Very Severe Cognitive Decline

Developing Goals

Always relate goals to functional outcomes for the patient within the SNF environment. · LongTerm Goals · ShortTerm Goals · All goals should be: a) functional for the patient's capabilities according to staging b) Skilled, Measurable, Attainable, Reasonable and Necessary. (S M A R N)

Mobility · Mobility · Communication · Socialization · Behavior · Dysphagia

ST: LTG: Utilize spared functional mobility through problem solving strategies for safety and independence in SNF by mastery of the objectives. STG: Decrease demands on working memory relating to ambulation to ensure safety and decrease fall risk with the use of min verbal cues 5/7 sessions. STG: Pt will initiate 3 sit to stand sequences 8/10 trials over 5 consecutive sessions. Update/Revise: mod verbal cues/5/10 trials


OT:LTG: Pt will demonstrate functional independence with MOD I for groom/hygiene stand at sink with rolling walker by mastery of the objectives STG: Pt will complete hygiene as it relates to oral care with setup and verbal cues 5/5 sessions STG: Pt will complete grooming related to shaving to min assist with setup and min verbal cues 5/5 sessions. Update/Revise: without setup/ mod cues Update/Revise: mod assist/2 wks


PT:LTG: Pt will achieve transfer with min assist with highest safety level by mastery of objectives STG: Pt will perform safe transfers with min assist x 1 within 4 weeks. STG: Pt will increase LE strength ½ grade within 4 wks for safe transfer.


ST: LTG: Pt will utilize a communication system compatible with his/her spared skills to ensure adequate expression of basic & medical needs. STG: Pt. will express 10 basic and medical needs with 60% accuracy min. cues, 3 of 5 days to improve communication with staff. STG: Pt. will initiate expressive communication for 7 basic needs with ___% accuracy, 5 of 7 sessions. Update/Revise: Express 5/ 5 basic


ST: LTG: Decrease affective behaviors to ensure quality of life and safety in SNF environment by mastery of the objectives. STG: Decrease demands on pts. working memory to eliminate negative outbursts to 5 per session, 5 of 7 days during everyday routines. STG: Pt. will participate in 2 activities a day by relying on semantic memory to decrease affective behaviors to 5 per session, 5 of 7 sessions. Update/Revise: 0 per session/ 2 per session


OT: LTG: Pt. will utilize socialization skills relating to meal times and or activities to max potential by mastery of objectives. STG: Pt. will attend meaningful activity with min assist for ___minutes, 5 of 5 days. STG: Pt. will I.D. 4/5 environmental aids for social scheduling attendance, 5 of 5 days. Update/Revise: Mod assist/revise minutes/ 2/5

Developing Interventions

Sensory Therapy Reminiscence Therapy Validation Therapy Spaced Retrieval Montessori Therapy

Sensory Therapy:

Sensory interventions involve the patient's sense of touch, taste, hearing, smell or sight, or some combination of these.

Reminiscence Therapy:

refers to collection of memories from the past

Validation Therapy:

Communicating with a Dementia patient by validating and respecting their feelings

Spaced Retrieval:

Gradually increases the interval between correct recall of target items

Other things to consider:

Montessori for Dementia:

Connects past interest and skills with present spared skills

· Determine the time of day best for therapeutic stimulation · Correspond activities to capabilities and interests

Adapt the environment:

The goal of environmental modification is to: provide a predictable daily routine reduce stress compensate for impairment

Understand behaviors:

Outbursts and aggression are the result of something. May be a form of communication.

Children's materials: should you use them?

Provide group activities

Provide music

Thank You!

Montessori Treatment Activities

We have enjoyed being here and sharing this information with you! Peggy Watson M.S., CCCSLP Nancy Shadowens M.S., CCCSLP Consultants In Dementia Therapy LLC


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