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2/9/2012 Objectives Interventions for Treating Persons with Dementia Megan L. Malone, M.A. CCC‐SLP Presented at the annual convention of the ohio speech language and hearing association March 9, 2012 Acknowledgements 1. Describe a model of memory and learning in dementia. 2. Describe two functional goals that are appropriate for patients with dementia appropriate for patients with dementia. 3. Provide three different intervention ideas to use in treatment with persons with dementia. Why Am I Here?? • Information shared in this presentation is provided through the work of various organizations & professionals: – Menorah Park Center for Senior Living/Myers Research Institute, Beachwood, OH , , – State of New York, Department of Aging – Ellen Somers, St. Camillus; Kelli Hawver, Teresian House – Hearthstone Alzheimer’s Care, Woborn, MA. – Northern Speech Services – National Institute on Aging – Retirement Research Foundation Some Things to Ponder… • Memory... is the diary that we all carry about with us. ~Oscar Wilde, "The Importance of Being Earnest“ • Memory is a way of holding onto the things you love, the things you , g y ~From the television show are, the things you never want to lose. The Wonder Years • Memory is what tells a man that his wife's birthday was yesterday. ~Mario Rocco • The man with a clear conscience probably has a poor memory. ~Author Unknown Copyright 2012 Do Not Duplicate Without Permission Population Overview • For every 100 elderly patients in a nursing home in a given year, 38 will recover or stabilize so they can be discharged. , , g • About 91% of the 1,650,000 US nursing home residents are over the age of 65. • The average length of stay for a resident in a LTC setting is 2.44 years. • The average stay for a Medicare rehabilitation patient is about 23 days. 1 2/9/2012 Population Overview • Some common diagnoses addressed in the older adult population: – Dementia – CVA – Brain Injury – Mental Illness – Dysphagia – Additional Disabilities Dementia Review Dementia Review • Dementia is not a specific disease • Dementia is a descriptive term for a collection of symptoms that can be caused by a number of disorders that affect the brain of disorders that affect the brain. • Diagnosis is made if two or more brain functions such as memory and language skills are significantly impaired without loss of consciousness. Mistaken Beliefs About Dementia • Diseases: – Alzheimer’s disease – Vascular dementia – Lewy Body dementia y y – Huntington’s disease – Creutzfeldt‐Jakob disease – Alcohol related dementia – Brain Injury – Cancer Research Tells Us… • Dementia is the loss of mental functions involving thinking, memory, reasoning, and language to such an extent that it interferes with a person’s daily living. • Dementia is a group of symptoms that can include: – Language disturbances (e.g., aphasia, dysphasia, anomia) – Problematic behaviors (e.g., repetitive questioning, wandering) – Difficulties with activities of daily living (e.g., dressing, personal grooming) – Personality disorders (e.g., disengagement, aggressive behaviors) Copyright 2012 Do Not Duplicate Without Permission • Individuals with dementia cannot learn or remember information • Best way to care for persons with dementia is to make them comfortable, accept their idiosyncrasies, and be patient with them Circumvent the Deficits • Persons with dementia do have weaknesses in the areas of learning and memory BUT a number of strengths exist as well. – Ability to learn procedures Ability to learn procedures – Ability to read • Research has shown that the learning of information and its retention depends heavily on how it is presented. 2 2/9/2012 Video Example: Learning in Dementia Learning & Memory in Dementia: Model of Memory (Squire, 1994) Declarative Memory Procedural y Memory Facts Events Skills Habits World Knowledge Vocabulary Simple Classical Conditioning Priming What We See in Many Facilities… • Caregivers in facilities (nurses, rehab therapists, activities professionals, nursing assistants) tend to base their interventions on abilities/skills found in declarative memory • This leads the person with dementia to experience: – failure failure in given tasks in given tasks – a reduction in self‐esteem, – a reluctance to take an active role in facility programs and in their own lives Research Tells Us… • Problematic Behaviors can stem from unmet needs in the areas of: – Physiology (undiagnosed/untreated pain) – Safetyy ((fear of being hurt) g ) – Love and Belonging (fear of being abandoned) – Self‐actualization (lack of having a meaningful role in the community) Jiska Cohen‐Mansfield Copyright 2012 Do Not Duplicate Without Permission The Challenges of Challenging Behavior: Breaking Down A Case g Questions • To effectively address a problematic behavior and develop an appropriate course of action, we need to ask “Why Why did the person with dementia did the person with dementia demonstrate this behavior?” • Keep in mind…Behavior is never random. 3 2/9/2012 Finding the “Why” • Brainstorm all possible reasons for behavior – Physiologic – Environmental – Lack of meaningful engagement Lack of meaningful engagement – Personal (need for attention, social contact, reassurance, etc.) • “Who Owns the Problem?” • Ask person directly! Challenging Behaviors Associated with Dementia 1. 2. 3. 4. Wandering Repetitive Question Asking Decreased Intake Medication Adherence Circumvent the Deficits • Maximize remaining abilities to overcome challenges & develop appropriate interventions g • Find individual strengths for each resident and build on them – Observe resident – Ask family & staff – Provide opportunities • Engage in activities/Provide roles Challenging Behavior Brainstorm 1. Wandering What strategies have you used or seen work for this common challenging behavior?? Challenging Behavior Brainstorm Challenging Behavior Brainstorm 2. Repetitive Question Asking 3. Decreased Intake What strategies have you used or seen work for this common challenging behavior?? What strategies have you used or seen work for this common challenging behavior?? Copyright 2012 Do Not Duplicate Without Permission 4 2/9/2012 Case Study: Decreased Intake Case Study Video Example: Decreased Intake • 82 year‐old female • Dementia; 8 MMSE • Seen by speech therapy for assistance with self‐feeding lf f di • Example Goal: ‘R’ will consistently respond to cue to recall presence of food tray and initiate self‐feeding 80% of trials. Challenging Behavior Brainstorm GOAL: Remembering to place pills on a pill template every Sunday evening. 4. Medication Adherence What strategies have you used or seen work for this common challenging behavior?? PROMPT: Trainer asks, “What do you do every Sunday?” RESPONSE: Participant responds, “I place my pills on my chart.” Low Vision Issues • Many older adults encounter difficulties with vision (glaucoma, macular degeneration, cataracts, etc.) • Must create therapy activities & instructions Must create therapy activities & instructions that are visible & clear for the client • May need to make recommendations to adapt environment to encourage communication, engagement, & enhancement of oral intake Copyright 2012 Do Not Duplicate Without Permission Low Vision Issues • Keep in Mind: – Patients with low vision need well lit areas to read & eat. Position clients near natural light (window) if possible or use a full spectrum light (Tensor light) to flood area where they will be focusing. – Use primary colors and high contrast materials • • • • • • • Black print on white background (or pastel colors) Reds, blues, greens easiest to discern Use tactile materials (sandpaper, puffy paint) Use non‐slip materials to reduce errors and embarrassment Think high contrast when it comes to food and plate and utensils Make sure print is large enough to read easily (Reading Test) Find and utilize resources – National Federation for the Blind (http://www.nfb.org) – Local Sight Centers 5 2/9/2012 Can you go We are here Where is it One and only Not now • • • • • • • • • • • • • • • • Vision Test Documentation Form CLIENT: _______________ UNIT: _____________________ DATE: _____/_____/______ EXAMINER: ________________ INSTRUCTIONS: ** STOP when the person makes ANY mistake. Evidence‐Based Treatment: Montessori & Spaced Retrieval p We are trying to find out how big to print words so people can read them easily. Would you please help us by reading this first sentence [POINT to “Can you go”] out loud? (Client reads sentence). Thank you! Please read the next sentence [Point to “We are here.”]. (Client reads). ** Now this one [Point to “Where is it?”]. (Client reads) .** How about this one? [Point to “One and only.”] (Client reads.) ** And this one. [Point to “Not now.”] (Client reads.) ** Thank you so much for helping us. Please indicate the smallest size lettering that the client was able to read by placing a check mark (√) next to the sentences read correctly. If the client was only able to read individual words during the test, circle the words they were able to read. 72 point (Can you go) 48 point (We are here) 36 point (Where is it) 24 point (One and only) 16 point (Not now)****Vision test results:____________________________________ © Myers Research Institute 2009 Vision Test Montessori • Montessori‐Based Programming He who is served is limited in his independence. p ‐Maria Montessori Who was Montessori? Maria Montessori Maria Montessori – Programming method that use Montessori educational principles to provide constructive engagement, meaningful activity, and practice of skills to older adults. – Uses principles from the Montessori classroom to help older adults maintain independence and learn new skills older adults maintain independence and learn new skills. – Camp and other researchers have documented the use of this programming method with persons with Alzheimer’s Disease and have found that it increases overall participation in activities, as well as rates high in staff satisfaction (Camp, 2002; Skrajner, 2007). – Therapists can use these methods to address goals in treatment. Who was Montessori? Montessori worked with underprivileged children thought by underprivileged children thought by some to be “insane” (1870‐1952) Copyright 2012 Do Not Duplicate Without Permission 6 2/9/2012 Who was Montessori? – The Key to a Better Life For Children: • Education • Active roll in the classroom • Proper environment (Children’s Houses) Montessori‐Based Dementia Programming® Montessori‐Based Dementia Programming® Method of CREATING and PRESENTING activities based activities based upon models of learning and rehabilitation Video Example of Montessori Programming GOAL To create persons who are as independent as p possible, able to make , choices, and who are treated with respect and dignity Key Montessori Principles Key Montessori Principles Montessori‐Based Activities Should: Montessori‐Based Activities Should: • Consist of materials that are aesthetically pleasing and are taken from the everyday environment • Have a clear objective that is meaningful to the person • Use external cues/templates • Be demonstrated first, at a slow pace with as little vocalization as , p possible • Consist of materials are free of unimportant letters, numbers, words, or markings • Be placed in a single container or on a single tray • Be an error‐free source of success for people Copyright 2012 Do Not Duplicate Without Permission • Begin with an invitation • Be broken down into their component parts and practiced • Have closure, ending with asking the person if they enjoyed the activity and if they would like to participate in it again sometime 7 2/9/2012 Five Classes of Montessori‐Based Activities Activities of Daily Living Montessori‐Based Dementia Programming® • Categorization • Word finding • Reminiscence Sensorial Experience – Access long‐term memory – Stimulate language usage Cognitive Stimulation Cognitive Stimulation • Reading • Using cues‐verbal and visual Motor Activities Group Activities Treatment: Montessori • Materials are taken from the everyday environment (familiarity) Treatment: Montessori Slow down your movements Match your speed to the person with dementia LET GO of idea that an activity has to be done LET GO of idea that an activity has to be done the “right” way • Materials are designed to p promote independence in p daily living and positive engagement Goal is engagement & stimulation Encourage reminiscence • Each activity is presented at its simplest level. Each activity that follows builds upon the previous activity. Activities should be an error‐free source of success for people Treatment Reading Roundtable • More Goal and Activity Examples: – Goal: Recalling family member’s names to increase communication and socialization in visits • Obtain family pictures and have client assist you in cutting and gluing them to flash cards and gluing them to “flash cards” with their names for with their names for face/name recognition practice and matching. Emily John Copyright 2012 Do Not Duplicate Without Permission 8 2/9/2012 Memory Squared Memory Squared Video Example Spaced Retrieval • Spaced Retrieval (SR) – Technique used to help persons with cognitive impairments recall important information over progressively longer intervals of time. – First used to address face‐name learning in non‐impaired individuals – Has been used successfully with patients with Alzheimer’s Disease, Traumatic Brain Injury, Parkinson’s Disease, and Dementia related to HIV (Bourgeois et. al, 2001; Camp, et. al, 2008; Neundorfer, et. al, 2004; Malone et. al, 2007) – Is an effective tool that therapists can use to help clients reach their goals in rehab therapy and is billable and reimbursable. – Takes advantage of the procedural memory system and is success‐based. Copyright 2012 Do Not Duplicate Without Permission 9 2/9/2012 Spaced Retrieval Screen Treatment: Spaced Retrieval • Goal: “Client will recall location of daily schedule to complete ADL’s independently & improve participation in meals and with peers 90% of trials ” 90% of trials. – Question: “Where should you look to find your daily schedule?” – Answer: “Look at my walker” Treatment: SR Trial 1 (0 Seconds): Client Responds CORRECTLY Trial 2 (10 Seconds): Client Responds CORRECTLY Trial 3 (30 Seconds): Client Responds CORRECTLY Trial 4 (1 Minute): Client Responds INCORRECTLY Therapist provides client with correct response (“Look at my walker”), asks the client the prompt question again, allows the client to respond, and returns to the interval at which the client was last successful. • Trial 5 (30 Seconds): Client Responds CORRECTLY • Trial 5 (1 Minute): Client Responds CORRECTLY • Client continues session; Therapist then probes through other therapy activities to see if carryover of skill is occurring. • • • • • Problem Behaviors with SR Solutions: Prompt Question/Answer Examples • Disorientation – “Where do you live?” (Answer: Name of Facility) – “What is your room number?” (Answer: Room #) – “What What is your address? is your address?” (Answer: Client (Answer: Client’ss address) address) • Repetitive Questioning – Dependent upon question being asked Copyright 2012 Do Not Duplicate Without Permission Problem Behaviors with SR Solutions: Prompt Question/Answer Examples • Naming – “If you don’t know the name of something, what should you do?” (Answer: “Describe It”) – What is your husband/wife/son’s name? (Answer: Target name) – Who runs the activities here? (Answer: Staff member’s name) • Disengagement – What can you read to remind you of your family? (Answer: “Read my memory book”) – What can you check to see what is planned for the day? (Answer: “Activity Schedule”) – What can you look at to find something to do? (Answer: “My list of activities”) 10 2/9/2012 SR Case Study One Case Study 1: Video Clip • Goal: ‘R’ will recall strategy to improve safety when going from stand to sit position to improve safety and decrease fall risk at the initial trial of 3 consecutive therapy sessions initial trial of 3 consecutive therapy sessions using spaced‐retrieval. “ – Question: “What should you do before you sit down?” – Answer: “Reach for the arms of the chair” Treatment: SR • • • • • Spaced Retrieval Video Example SR Case Study 2 90 year‐old female; 12/30 MMSE Alzheimer’s Disease; CHF Goal areas: disorientation, anomia, executive function Goal: “Client will demonstrate strategy of describing items when unable to directly name them in order to increase communication of wants and needs to staff and family 80% of trials. – Prompt Question: “If you don’t know the name of something, what should you do?” Response: “Describe it.” Spaced Retrieval • Goal possibilities are endless • SR goals are NOT written any differently than other goals. FUNCTIONAL GOAL = SR GOAL Copyright 2012 Do Not Duplicate Without Permission Spaced Retrieval • Measurement of goal attainment can be by percentage (“80% of time”) or by recalling and demonstrating target response for a set number of sessions (3 sessions recommended) depending on the type of goal. – “Client will recall strategy of inhaling prior to speaking in order to demonstrate appropriate vocal volume during 80% of structured sentence production” OR – “Client will demonstrate strategy of locking wheel chair brakes prior to standing to increase safety at the beginning of 3 consecutive therapy sessions using SR” 11 2/9/2012 Spaced Retrieval Building A Caseload Using SR • SR is considered to be a MODALITY or APPROACH that therapists may use to help clients reach their goals. • SR does not fit one particular diagnosis SR does not fit one particular diagnosis category – Use the ICD 9 Code that corresponds to the goal area you are addressing • How long do SR sessions generally last and how often should they occur? • The length and frequency of SR treatment sessions is dependent on many factors • There is no set standard time limit or frequency of sessions that with SR treatment of sessions that with SR treatment. • Most SR sessions are between 30 or 45 minutes long. • In general, the more often a person is seen for SR the more quickly he/she will attain SR goals. • Use SR to teach compensatory swallowing strategies = Use the ICD 9 code for Dysphagia Speech Therapy Weekly Treatment Note Name: Susan Jones Date: 6-6-08 to Physician: Dr. Smith 6-12-08 S: Client has been pleasant and responsive to treatment sessions. O: 1. Recall and demonstrate chin tuck strategy during meals: 30/50 trials average per session (60%) [Baseline 0; Goal: 80%] 2. Recall and demonstrate safety strategy of taking smaller bites during meals: 35/50 trials average per session (70%) [Baseline 0; Goal 80%] A:Client can recall both swallowing safety strategies utilizing the spaced retrieval technique (approach for recalling information for longer periods of time). Client able to recall use of both strategies for up to 24 hours. No visual cueing necessary. P: Using What You’ve Learned Continue plan Type of Treatment 92506 Speech Evaluation 92507 Speech Therapy 92610 Dysphagia Evaluation 92526 Dysphagia Treatment 97532 Cognitive Skills Development (each 15 min) Date 6-6 Date 6-7 Date 6-8 Date 6-9 X X X X Date 6-10 Date Date X Functional Goal Setting & Writing • Case Study • 82 year‐old male; Dementia, CHF, Asthma; Diabetes; Former Musician; Wife is deceased; Children live out of town • Assessment Results: MMSE : 13/30; able to read 48 pt. sized Arial font; Client passed Spaced Retrieval Screen Functional Goal Setting & Writing • Base goals on findings of evaluation, client interviews, & staff/family input • Must be individualized, functional, and measureable • Must show that goal is appropriate for skilled services of SLP • Patient history and level of functioning should warrant goal i hi dl l ff i i h ld l being addressed • Goals should utilize “evidence‐based” and “best practices” for treatment • Explain “why” the goal is being addressed within the goal (Caniglia, 2003) (Caniglia, 2003) – “Client will recall and demonstrate use of chin tuck during swallowing 80% of trials in order to decrease risk of aspiration” Copyright 2012 Do Not Duplicate Without Permission 12 2/9/2012 Functional Goal Setting & Writing Functional Goal Setting & Writing • COGNITION: • Client will navigate path to room by using landmarks independently to reduce wandering and increase safety 85% of trials. • Client will correctly recall names of family members to increase communication and socialization during visits 80% of trials. • Client will use a calendar to orient self to date, time, and daily , , y activities to decrease disorientation & increase attendance and participation in facility activities 90% of trials. • Client will utilize personal list of leisure activities to constructively engage self to prevent wandering and agitation 80% of trials. • Client will correctly match names with peers on unit to promote socialization and interaction during meals 80% of trials. • Client will recall strategy to name items through description 90% of trials. • Client will recall strategy of utilizing call button to alert nursing staff and prevent unassisted ambulation 85% of trials. • Client will recall reason for needing medications to promote compliance with nursing staff 80% of trials. • Client will recall strategy to properly match own clothing to increase independence in ADL 90% of trials. • Client will utilize a personal diary to log daily events/thoughts to facilitate conversation with staff and family 85% of trials. • Client will recall strategy to feed self with one verbal cue 80% of trials to increase independence and caloric intake. • Client will utilize personal memory book to remain constructively engaged and promote conversation with others 90% of trials. • Client will recognize caregivers to promote compliance during bathing 80% of trials. Functional Goal Setting & Writing • • • • • • • • • SWALLOWING: Client will recall strategy of using chin tuck during meals to prevent aspiration 90% of trials. Client will recall strategy of clearing pocketed food in buccal cavity to prevent aspiration 90% of trials. Client will recall strategy of alternating solids and liquids during meals to decrease risk of aspiration 90% of trials. p Client will utilize strategy of supraglottic swallow during meals to decrease risk of aspiration 80% of trials. VOICE/SPEECH: Client will recall strategy of taking deeper breaths prior to speaking to promote increased volume and sub‐glottal pressure and increase communication 90% of trials. Client will recall proper placement of articulators to produce alveolar sounds and increase communication abilities and intelligibility in conversation 80% of trials. Client will utilize strategy to use optimal vocal register to prevent the reoccurrence of vocal polyps 80% of trials. Functional Goal Setting & Writing • Goal must be meaningful to the client • Activities to meet goal must be interesting, match abilities, and be success‐oriented • Use terminology that the client, staff, and family can understand – EExample: Ask client what they would call a “Memory Book” l A k li h h ld ll “M B k” before terming it that; Use client response to work on goal, increasing the likelihood they will remember and use it. • Circumvent deficits Functional Goal Setting & Writing • Avoiding Appeals – Following the aforementioned guidelines, you should not experience a denial of your claim. – If, however, you are denied, be sure to: • Provide appropriate documentation where needed (explain pp p ( p rationale for goal; why and how it is being addressed and cite why client is likely to benefit from treatment) • Further explain necessity of the need for the skilled service • Provide citations of treatment intervention, medicare guidelines, etc. if needed – 2001 CMS Program Memorandum “Medical Review of Services for Patients with Dementia” – http://www.cms.hhs.gov/Transmittals/downloads/AB‐01‐135.pdf Functional Goal Setting & Writing • Client Input: Client wants to do more “on his own” and doesn’t enjoy being around “all of the sick people”. Feels “bored” and misses his family and old way of life. p pp g ; • Staff Input: ‘R’ found napping in other residents’ rooms; often leaves cane in room; tends to take large bites of food when eating, leading to choking; wears cologne, sometimes in “excessive amounts” – Work around areas of weakness • Example: Dementia – Inattention may lead to client forgetting what they are working on in treatment and why. Remind them throughout session or write down treatment activities so he/she knows what to expect and when they will be finished. Copyright 2012 Do Not Duplicate Without Permission • Family Input: Satisfied with care; would like a way to communicate with their father and update him on family events beyond talking on the phone 13 2/9/2012 Functional Goal Setting & Writing Functional Goal Setting & Writing • Where should we start? y Evaluate assessment results, clients strengths/weaknesses, staff and family input y Which areas warrant the most need? Prioritize! • Safety • Disorientation • Communication; Socialization y Which areas are most effectively treated by a skilled service? y Forgetting cane when walking y Taking too large of bites during meals y Addressing disorientation to help client locate room – Always ask the question “Why is this happening?” in order to get to the root of the issue. • Are repetitive questions being asked because client is seeking information (actual answer to question) or seeking attention? • Is the client wandering because they do not know where their room is or because they are seeking social contact, attention, etc.? • SLP’s can target behavioral challenges in treatment as long as the intervention is evidenced‐based, functional, and warrants the expertise of the therapist. SLP can also assist in making behavioral intervention recommendations to staff and family to target behaviors Goal Setting & Writing • Keep in mind…BEHAVIOR IS NEVER RANDOM! • May discover reasons for behavior by: – Observing the client – Tracking incidence of behavior (are there triggers or patterns?) – Talking with staff/family – Asking the client directly! Functional Goal Setting & Writing • Safety goals are client’s highest priority for treatment – Once we understand “why” the client is exhibiting the behavior, we can set a realistic and more effective goal to treat the problem. • Swallowing: – Problem: Client takes too large of bites – Why? Client’s tray was taken many times before he was finished, leading him to eat more rapidly – Strategy: Teach client too look at visual cue placed near tray that reads “Take your time and enjoy your meal. No one will take your tray until you are done. Take small bites” – Goal: “Client will recall and demonstrate ability to recall strategy of taking smaller bites during meals 90% of trials using a visual cue.” Take your time and enjoy your meal. No one will take your tray until you are done. Take small bites. Copyright 2012 Do Not Duplicate Without Permission Functional Goal Setting & Writing • Case Study: Behavioral Challenges – What are some possible reasons the following behaviors are occurring? • • • • Napping in other residents’ rooms? Taking too large of bites of food? Forgetting cane? Wearing too much cologne? – Also important to analyze: “Who owns the problem?” • Is it a legitimate safety or communication issue that needs to be addressed in treatment? • Is the “problem” more for staff and family than for the actual resident? Goal Setting & Writing • Remembering Cane – Problem: Client is unsafe to walk without cane; high fall risk – Why? Client not used to having to use cane to walk safely; does not fully understand why he needs the cane & therefore chooses not to use it chooses not to use it – Strategy: Educate client on why he needs the cane; write down reasons, biggest being to stay safe and not fall; choose area with client to keep cane so he sees it and remembers it; use Spaced Retrieval technique to teach him to remember the cane; instruct staff to offer LOTS of positive reinforcement when he uses the cane to encourage its use – Goal: “Client will recall and demonstrate use of cane to remain safe during walking and decrease fall risk 90% of trials.” 14 2/9/2012 Treatment • Case study client: Treatment session focused on remembering to use cane – Treatment session in client’s room since this is where he forgets to take his cane with him – Begin by stating to client that you are working together to keep him are working together to keep him safe by remembering cane. – Ask client what he calls the cane. May call it a “walking stick”, etc. Use client response to practice goal – Write down session activities and mark off when you complete each one. Goal Setting & Writing Today: 1._X__ Review goals: Use cane to keep safe 2. ___Decide where to keep cane 3. ___Practice remembering to use cane 4. ___Work on memory book 5. ___Take a walk to lunch with cane Case Study • 90 year‐old female • Dementia, Parkinson’s Disease; Right Foot amputation; Former artist • Loves children (used to teach art to elementary school children) • 10/30 on MMSE; Passed SR Screen • Locating Room – Problem: Client is disrupting other residents; becomes disoriented and may end up in unsafe areas – Why? Client is napping in other rooms because he cannot locate his own consistently; also enjoys the social contact and attention he receives when does this – Strategy: Teach client to look for landmarks to locate room; use meaningful cues (music note on door, since client was a musician); PRACTICE locating room using landmarks starting from different locations on unit; find activities he enjoys and increase involvement to provide social contact & attention. – Goal: “Client will learn landmarks in unit environment in order to locate room independently and decrease wandering into unsafe areas 80% of trials.” Case Study • STAFF INPUT: ‘R’ often refuses to take part in activities; often found tugging at protective covering over amputation trying to remove it; often asks about family and when they last often asks about family and when they last visited • FAMILY INPUT: None, no children, never married; rarely receives visits from extended family or friends Case Study • Where should we start? • What are the priority treatment areas? Your Questions Answered… • How should we address these goals? Copyright 2012 Do Not Duplicate Without Permission 15 2/9/2012 References “We take note of all the details of a disease and yet make no account of the marvels of health.” • ‐Maria Montessori • y y Thank You! For more information, please contact [email protected] • • • • • • • • Hardy, E. (1995). Bedside Evaluation of Dysphagia. Austin, TX: Pro-Ed. Smith, W., Rosen, A. Dellarosa, D. (1997). Dysphagia Evaluation Protocol. Harcourt Assessment Wilkinson, G. S. Wide Range Achievement Test–Revision 3.Wilmington, DE: Jastak Association, 1993. Caniglia, J. (2003). Documentation Pitfalls and How to Avoid Them. ASHA Leader. Available at http://www.asha.org/about/publications/leaderonline/archives/2003/q1/030218e.htm Camp, C., Cohen-Mansfield, J, Capezuti, E. (2002). Use of nonpharmacologic interventions in nursing home residents with dementia. Psychiatric Services, 53 (11), 1397-401. Skrajner, MJ, Malone, ML, Camp, CJ, McGowan, A, Gorzelle, GJ: Research in practice I: Montessori-Based Dementia Programming® (MBDP). Alzheimer’s Care Quarterly. (2007); 8 (1): 53-64. Malone, ML, Skrajner, MJ, Camp, CJ, Neundorfer M, Gorzelle, GJ: Research In Practice II: Spaced-Retrieval, A Memory Intervention. Alzheimer’s Care Quarterly. (2007); 8(1): 65-74. Malone, M., Camp, C. Montessori-Based Dementia Programming: Providing tools for engagement. Dementia. (2007); 150-157. Bourgeois, M., Camp, C., Rose, M., White, B., Malone, M., Carr, J., & Rovine, M. (2003) A comparison of training strategies to enhance use of external aids by persons with dementia. Journal of Communication Disorders, 36, 361-379. Copyright 2012 Do Not Duplicate Without Permission Squire, LR. Declarative and nondeclarative memory: multiple brain systems supporting learning and memory. In: Schacter, DL, Tulving, E, eds. Memory Systems. Cambridge, MA: MIT Press; 1994: 203-232. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198. Reisberg, B., Ferris, S.H., de Leon, M.J., Crook., T. The global deterioration scale for assessment of p primary y degenerative g dementia. American Journal of Psychiatry, y y, 1982,, 139: 1136-1139 Randolph, C. Repeatable Battery for the assessment of neuropsychological status (RBANS). San Antonio, TX: Psychological Corporation. • Bayles, K., & Tomoeda, C. (1993). Arizona Battery for Communication Disorders of Dementia. Texas: Pro-Ed. • Swiercinsky (2001). Tests commonly used in neuropsychological evaluation. Available at http://www.brainsource.com/nptests.htm • Jurica et al., 2001. Jurica, S. J., Leitten, C. L., & Mattis, S. (2001). Dementia Rating Scale: Professional manual. Odessa, Fl: Psychological Assessment Resources. • Swigert, N. B., Steele, C., & Riquelme, L. F. (2007, March 6). Dysphagia screening for patients with stroke: Challenges in implementing a Joint Commission guideline. The ASHA Leader, 12(3), 4, 28-29. References • • American Speech and Hearing Association. “Getting Started in Long-Term Care” Available at http://www.asha.org/members/slp/healthcare/start_long.htm References • • • • • Neundorfer, M., Camp, C., Lee, M., Skrajner, M., Malone, M., & Carr, J. (2004). Compensating for cognitive deficits in persons aged 50 and over with HIV/AIDS: A Pilot Study of Cognitive Intervention. Midllife and Older Adults and HIV, 79-97. Co-published simultaneously in Journal of HIV/AIDS & Malone, ML, Skrajner, MJ, Camp, CJ, Neundorfer M, Gorzelle, GJ: Research In Practice II: Spaced-Retrieval, A Memory Intervention. Alzheimer’s Care Quarterly. (2007); 8(1): 65-74. Camp, C. J., & Malone, M. L. (2008) Mise en œuvre d'interventions d interventions de récupération espacée auprès de personnes atteintes de la maladie d’Alzheimer. Cahiers de la Fondation Médéric Alzheimer, number 3. Engel, D., Brandriet, S., Erickson, K., Gronhovd, K., & Gunderson, G. (1966). Carryover. Journal of Speech and Hearing Disorders. 31(3) 227-233. Social Services (2004), 3, 1, 79-97 16