Collaborative Care for the
Advanced Dementia Patient
Michelle Tristani, MS/CCC-SLP
Rehab Clinical Specialist
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Interdisciplinary Pilot Study Overview
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Pilot Foundation Theories
Pilot Roles and Procedures
Pre-Implementation Survey
Pilot Study Rehab & Nursing Assessment Tools
Tool Kit Implementation
Post-Implementation Analysis
Functional Maintenance Program Implementation
Pilot Study Feedback & Future Directions
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Foundation Theories for the Pilot Study
“Communication is key to quality of
life. We need to implement cognitive
programming that is skilled care and
billable while impacting not only the
living environment for residents but
also the work environment for the staff
with whom they interact.”
– Lou Eaves
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Cognitive Approach Assumptions
— Cognition
underlies all behaviors
— Cognitive disability impairs the individual’s cognitive
ability to perform a motor action
— Cognitive disability data can be obtained from functional
observation
— Cognitive capacities (information processing) & limitation
of the individual can be gleaned by observing the quality
of functional performance
— Cognitive hierarchy levels speak to the qualitative
differences in routine task behaviors that are observed
— Environmental Compensations are the most viable
interventions for long-term cognitive disabilities from
pathological
brain conditions
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Information Processing Model
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Processing starts with sensory input
Sensorimotor associations
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Interpretive processes from sensory cues
We pursue activities with varying goals, ranging from
movement, to cause and effect, to investment in producing
a high-quality outcome
Motor actions
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Elicited by sensory cues
Guided by sensorimotor actions
Observed in activity performance
Activities are placed within a patient’s range of
comprehension and control.
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Link Dx to cognitive status ∆
What Dx is responsible for
cognitive change?
Consider cognition as a
barrier to functional progress
Statement of Risk
Safety risk
Risk due to inability to
communicate
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The Cognitive - Communication Hierarchy
Executive
Functions
Judgment, Insight
Reasoning, Organization
Problem Solving, Sequencing
Short Term Memory & Long Term Memory
Foundation Level
Cognitive Skills:
Arousal, Alertness, Consciousness
Awareness, Attention, Concentration
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Development of a
Functional Communication Outcome
• Consider how communication / language (auditory
processing, auditory, gestural & reading comprehension,
verbal, written & gestural expression) are impacted via
cognitive skills
• Consider assessment of visual versus auditory attention,
concentration, and memory
• Consider preserved skills (procedural memory, reading
comprehension, written expression) to compensate for
weaknesses
• Consider assessment & amelioration of sensory deficits
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KEY RELATIONSHIP
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Dementia related behaviors are a ‘call for’:
Ë Comfort
Ë Communication
Ë Movement
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Task Analysis Clinical Reasoning
Analysis of Task
Analysis of Behavior
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THE CUEING HIERARCHY
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MODALITY
STRENGTH
WEAKNESS
FLEXIBILITY
NONSPECIFIC
SPECIFIC
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Relocation to a LTC Facility:
Changes and Adaptive Challenges
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New setting
Loss of possessions
Lack of privacy
New communication partners
Role of resident / patient
Communication styles differ
Rules of successful LTC living differ from “outside world”
Fears and anxieties emerge about:
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LTC as a prelude to death; failing health; institutionalization; loss of
decision making; increased dependence; loss of finances; separation
from loved ones; feelings of rejection; incompetence; patient role
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Adapted from: Enhancing Communication Services in Extended Care Settings
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Cognitive Collaborative Care Pilot Study
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7 Randomly selected skilled nursing facilities on the east coast
of the US
A collaborative programming model for cognitive
management was implemented in the 7 facilities
Pilot Study Goals
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Identify preconceived beliefs of healthcare providers that negatively
impacted consistent care
To ameliorate these obstacles via caregiver education and training
To ascertain if ‘positive outcomes’ were gained from the use of three,
cognitive leveled tool kits that targeted preserved cognitive skills,
with patients who had moderate to severe dementia
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Positive outcome as measured by
Cohen Mansfield Agitation Inventory,
ASHA NOMS scores, ACL scores and Caregiver Assessment
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Patient Identification – Need for Skilled Rehab
Services
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Rehab evaluation and treatment procedures
would proceed per typical, best practice
patient identification of need
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Change in status
Risk
New treatment approach
Reasonable expectation for improvement
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SLP Pilot Study Roles
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SLP Assessment Tools SLUMS, Functional Linguistic
Communication Inventory, ASHA FACS
Together with OT will complete the Cohen Mansfield
Agitation Inventory
Functional Skills Inventory
Submit patient documentation from eval to discharge, Cohen
Mansfield Agitation Inventory and the Functional Skills
Inventory for analysis
Pre and Post Survey completion
Determine which tool kits and strategies are most effective in
reducing behaviors
Train staff; document in the patient care plan the
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recommended approaches & activities (FMP)
OT Pilot Study Roles
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OT Assessment Tools – Allen Cognitive Level (OT Leather
Lacing, Routine Task Inventory and/or Placemat Test)
Together with SLP will complete the Cohen Mansfield
Agitation Inventory
Send patient documentation from eval to discharge, Cohen
Mansfield Agitation Inventory
Pre and Post Survey completion
Determine which tool kits and strategies are most effective in
reducing behaviors
Train staff and document in the patient care plan the
recommended approaches and activities (FMP)
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Nursing and Activities Involvement
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Charge Nurses, RNs, LPNs, CNAs, Activities professionals
are asked to complete the Pre and Post Cognitive Pilot Study
Survey
Nursing and Activities staff implement the cognitive tool kits
as recommended via SLP and / or OT staff
Use of the recommended items for the moderate to severely
cognitively impaired patients was similar to implementation
of a Functional Maintenance Program upon discharged from
Rehab
The cognitive tool kits serve as another treatment procedure
to reduce patient agitation, anxiety and increase attention and
communication with staff
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Pre-Implementation Survey
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Use scale: strongly disagree, disagree, neutral, agree, strongly agree
Patients with moderate to severe dementia are managed effectively &
consistently in this facility
Ë 20% SA/A, 24% N, 56% D/SD
Carryover of rehabilitation interventions are easily duplicated by nonrehab personnel in the facility, on all shifts
Ë 20% A, 7% N, 74% D/SD
One shift is better than another shift in managing patients with moderate
to severe dementia
Ë 65% A/SA, 25% N, 10% D
If agreed then, ‘Which shift is the most successful in management of the
cognitively impaired patient – Choices: 7-3, 3/11 or 11/7
Ë 7-3 = 96%
Ë 3-11 = 0%
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Ë 11-7 = 4%
Pre-Implementation Survey
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Use scale: strongly disagree, disagree, neutral, agree, strongly agree
Sometimes patients with moderate to severe dementia become agitated
for no reason
Ë 38% A/SA, 10% N, 53% D/SD
Sometimes it is acceptable to allow patients with moderate to severe
dementia to yell for a few minutes
Ë 33% A, 23% N, 46% D/SD
Medications should always be administered to patients with moderate
to severe dementia to reduce maladaptive behaviors
Ë 3% A, 10% N, 88% D/SD
There has been dementia care education opportunities provided at least
annually in this facility
Ë 25% A/SA, 25% N, 51% D/SD
Dementia is a natural part of the aging process
Ë 23% A, 10% N, 68% D/SD
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Pilot Study Rehab & Nursing Assessment
Tools
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Allen’s Diagnostic Materials - ADM
Placemat and bookmark - two of 30
functionally based craft assessment tools
Standardized assessment tool
Offers tools for a variety of ACL levels 3.0
and above
More readily accepted by both genders
Can assess ability with partial completion
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Allen’s Diagnostic Materials - ADM
Leather Lacing:
A visuomotor task
Provides a quick estimate of the patient’s capacity to learn.
Barriers include patient visual perceptual deficits, hand dominance, tremors,
deafness, inability to understand directions, and hemiplegia
Standardized on both psychiatric and neurologically impaired populations
Quick, simple to administer
Appropriate for clients ACL 3.0 and above
Requires fairly adequate fine motor and visual abilities
May be perceived as female gender specific
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Routine Task Inventory
Part of initial interview to determine PLOF and activities
Activity Analysis Based Cognitive Screening - RTI
Non standardized assessment
Only Allen’s tool to assess clients below ACL 3.0
Very quick, easily completed in the course of ADL completion
Requires thorough understanding of ACL levels and modes
The intrinsic importance of an activity is apparent when an
individual engages in a task
Observations of performance that objectively describe
behavior usually have the greatest credibility
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Cognitive Performance Test - CPT
Standardized Home Management tool
Test encompassing functional ADL & task analysis
Excellent tool for higher functioning clients
Requires specific tools and environmental set up to complete
More time/attention span required for completion
Developed to provide a standardized, ADL-based instrument for the
assessment of functional levels
Focuses on the degree to which particular deficits in information processing
impact daily living tasks
Composed of common ADL tasks, familiar and routine to reduce performance
anxiety of patients with dementia, which are graded to correspond to the
Allen Cognitive Levels
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Distinction Between the RTI and CPT
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RTI
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CPT
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Assumes that the therapist will incorporate this test along with the
leather lacing tool. The tool is not a "stand alone test"
Data is gathered via by observation of functional tasks, interviewing
the patient, and interviewing the caregiver
This was created as a stand alone test.
This test does not involve a self report or caregiver report to be
factored in
A portion of the functional activities are done with the patient, for
example, demonstration, unlike the RTI
Both tools are similar in that they use functional activities
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Evaluation: Assessing From “Groundwork”
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Claudia Allen Levels
Ë Level One: Automatic Actions
Ë Level Two: Postural Actions
Ë Level Three: Manual Actions
Ë Level Four: Goal Directed Activity
Ë Level Five: Independent Learning
Activities
Ë Level Six: Planned Activities
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Functional Linguistic Communication Inventory
– FLCI
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Evaluation of functional communication
Recommended for patients with moderate – severe cognitive loss
Ease of administration – 30 minutes
Advantages & disadvantages
Correlates well w/ Cognitive Severity Scale
Subtests include:
Ë Greeting and naming
- Answering questions
Ë Writing
- Sign comprehension
Ë Object-to picture matching - Word reading & comprehension
Ë Following commands
Ë Pantomime, gesture and conversation
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ASHA FACS
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Pre-requisite – 3 informal communicative contacts w/
patient
Survey “7 - Point scale of the patient’s level of
communicative independence defined by the need for
assistance and / or prompting by another person”.
Assessment domains include:
Ë Social Communication
Ë Communication of Basic Needs
Ë Reading / Writing / Number Concepts
Ë Daily Planning
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Saint Louis University Mental Status Examination
(SLUMS)
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Consists of 11 questions
Score range: 0 to 30
High School Education< High School
Education
27-30
Ë 20-26
Ë 1-19
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Normal
20-30
MCI
15-19
Dementia 1-14
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Cohen Mansfield Agitation Inventory
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A 7 point rating scale for assessing the frequency
with which people show certain behaviors
29 descriptors rated 1-7 during a 2 week period
Patients scored pre and post tool kit implementation
10-15 minutes to complete
Training manual can be accessed via the author:
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Research Institute on Aging at the Hebrew Home of
Greater Washington
http://www.researchinstituteonaging.org
— [email protected]
— [email protected]
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Personal History Interview
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Establish
Ë Occupational history
Ë Experiences
Ë Patterns of daily living
Ë Interests
Ë Values
Ë Needs
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Personal History Interview
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By developing the personal history you can
enhance
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Treatment Approach
Patient/Therapist Relationship
Family/Caregiver training
Successful environmental adaptations
Behavioral Approaches
Treatment Outcomes
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Validation Therapy
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Developed by Naomi Feil between 1963-1980
“VT helps disoriented people reduce stress, enhance dignity and
increase happiness. VT’s objective is to restore dignity to the
elderly, teach empathy, and to show alternatives to
pharmacological & physical restraints.”
– Naomi Feil
Validation = “The acceptance of the reality and personal truth
of another’s experience”
An effective combo – Validation and Redirection
Reality Orientation versus Therapeutic Lying versus Validation
Therapy
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Need for more controlled research studies
Tool Kit Inventory
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3 Leveled Tool Kits
Individualized to encompass activities appropriate
for each patients preserved abilities to increase
effective communication & thus reducing behaviors
Tool Kits were implemented for appropriate
patients during the Pilot Study period – 45 days
Tool Kit categories were general ideas Rehab,
Nursing and Activities professionals may
interchange items based on individualized patient
need and recommendation
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Tool Kit Types
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Attention Kit: Moderate Cognitive Impairment
Exploration Kit: Moderate – Severe Cognitive
Impairment
Relaxation Kit: Severe Cognitive Impairment
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ATTENTION KIT
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Stickers - Coins
Cents & Money Word –
Index Cards
Flying Gliders Planes
Nuts and Bolts
Tape Measure
Screw Anchors - Colored
Dice - 5
Playing Cards
Chess Sets
„ Checkers
„ Calculators
„ Rulers
„ Crossword Puzzle Books
„ Word Search Books
„ Hanging Basket Grow Kit
„ Scissors
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EXPLORATION KIT
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Magazines - Assorted
Stickers - Geometric
Coloring Books and Crayons
(Jumbo)
Stickers – Sports, Animals,
Rainbow, Smiles, Letters, Hearts
Pencil Boxes
Playdough
Trisonic FM Radio with
earphones
Magnifying Glass
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Cell Phones
Marbles
Tool Set - Toy
Notebooks
Colored Paper Notebooks
Velvet Art and Crayons
Shopping List Pads
Sorting Activities
Wooden puzzles
Flower Braclet Set (sorting)
Poker Chips in Rolls - 4 Colors
Chip Tray(For sorting)
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RELAXATION KIT
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Bubble Ball Jr.
Textured Footballs
Handballs - Glitter
Textured Plastic Bat with Rope
Baby Bottles
Fur Real Pet Dogs and Birds
Newborn Baby Alive Sip & Snooze
American Flags
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Rehab Post Pilot Survey Analysis
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How many cognitively impaired patients did you
evaluate during the pilot period (6 weeks)?
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Less than 5 – 94%
5-10 – 6.3 %
More than 10 – 0%
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Rehab Post Pilot Survey Analysis
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If a patient was not appropriate for the Cognitive
Tool Kit select why
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Too high level – 12.5%
Too low level – 43.8%
Other – 43.8%
— Impaired
Arousal, Vision, no Dementia Dx, DC to hospital,
Staff had difficulty following through, Manager, ‘don’t eval,
don’t treat’
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Rehab Post Pilot Survey Analysis
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How many patients did you recommend the cognitive
tool kit interventions for?
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25 total for 7 facilities in 6 week period
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Rehab Post Pilot Survey Analysis
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Select the type of cueing you found patients in the
Pilot responded best to…
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Visual – 87.5%
Auditory – 62.5%
Tactile – 62.5%
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Rehab Post Pilot Survey Analysis
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Did your patients demonstrate a preserved strength that
you could identify?
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Yes – 93.8%
— Increased
attention to task and conversation,
communication of positive emotion, decreased anxiety,
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No – 6.3%
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Nursing and Rehab Post Pilot Survey Analysis
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Identify your level of agreement with the following
statements….
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Understanding the appropriate use of the prescribed tool kits was easily
conveyed to caregivers across all shifts.
— 57%A/SA, 30%N, 9%D, 9%SD
The prescribed tool kits were easily used by non-rehabilitation personnel.
— 57%A/SA, 26%N, 17%D
Negative and/or socially inappropriate behaviors of patients with moderate
to severe dementia were significantly reduced with the use of the prescribed
tool kits.
— 43%A/SA, 43%N, 13%D
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Nursing and Rehab Post Pilot Survey Analysis
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Identify your level of agreement with the following
statements….
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There was an improvement in rehabilitation intervention carryover
regarding patients with moderate to severe dementia, across all shifts.
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Management of behaviors of patients with moderate to severe dementia
improved as a direct result of the use of the prescribed tool kits.
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61%A/SA, 35%N, 4%D
I would recommend using the types of tool kits as a means of managing
patients with moderate to severe dementia.
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44%A/SA, 52%N, 4%D
83%A, 17%N, 0%D
The cognitive pilot study and its tool kits strengthened the nursing - rehab
relationship to benefit the cognitively impaired patient.
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47%A, 26%N, 22%D, 4%SD
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FMP- A.K.A. staff / family / caregiver training & education
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How do I write a FMP?
Documentation cannot be a hindrance
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Therapist recommendations formulated from an eval
exist as a FMP?
List of recommendations = FMP
Recommendations are a hypothesis/theory
Evaluation process is needed to yield recommendations that
can be proven to be successful and therefore carried out on
a long term basis via caregivers
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FMP ESTABLISHMENT VS. IMPLEMENTATION
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Once caregivers are accurately trained,
implementation begins & skilled Rx
ends.
Discharge to Restorative or FMP
Facilitates a continuum of care
Maximizes the outcome of skilled
intervention
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DEVELOPMENT OF AN FMP
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ASK …...
Ë What do I want skilled treatment to accomplish?
Ë What do I want the resident to be able to do?
Ë Is the goal to accomplish Rx tasks with some degree of
independence or with a certain amount / type of
assistance?
Ë Are there individualized strategies that can be useful in
attaining or approaching goals that I can instruct a
caregiver in order to maintain safety and quality of life?
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RECOMMENDATIONS TO STAFF & FAMILY / CAREGIVERS
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Return demonstration
Sign-off documentation
Provides accountability and credit for attendance /
performance
Enhances the importance of a team effort - from CNA to
Rehab Manager
Written recommendations on Write on Cling Sheets, CAN
care belts, card, folders in patient room
KNOW Nursing Assistant Competency for feeding and
facility specific training modes (i.e. NEO & annually) for
basic & individualized techniques
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The Nursing Friendly Functional
Maintenance Program
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First Things 1st - Establishing Repoire - SMILE
Ë CNAs – Learn who they are & give them a reason to follow
through
Hardest job in the building – Nursing Assistant
Typical Ratio Staff:Patient
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7-3 = 1:8
3-11 = 1:12 w/ no dept head assist
Do you know the CNA's
Ë Birthday
Ë Kids Names
Ë Favorite food, drink, candy
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The Nursing Friendly Functional
Maintenance Program
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Nursing education and input regarding FMP
FMP (individualized recommendations) must be accomplished within a
realistic and appropriate time frame
Rehab awareness: FMP time for completion
Consider time of day for optimal implementation
„ Time of most need – make the most impact
Too long?
„ Try to combine w/ a functional skill / routine
„ Ask Yourself and Nursing: Is this feasible?
Positive attitude
Team player approach
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7 Facilities Follow up
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Feedback from facilities regarding the continued use of
tool kits and their perceived efficacy
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Development of patient individualized kits using ideas from the
‘main’ kits (use of large print items)
Use of patient specific lifetime props
Will use tool kit if appropriate -- some items not extremely
helpful but that is patient need dependent anyway
Biggest problem is getting other department to have time to use
items and participate
Activities reports that they are using the items as set up by SLP
with the patients that we worked with
Biggest barrier is time constraints and familiarity with rehab
scope of practice
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Pilot Study Feedback & Future Directions
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Charge Nurse LPN “I think that as the use of the kits
become more of the norm, they will be even more effective.”
How does Rehab assist in follow up from individualized
patient recommendations after discharge?
How do we to facilitate and maintain carryover between
shifts?
Proposed follow-up study: How to more effectively integrate
rehab techniques with personal meaning across the
healthcare spectrum in the management of patients with
moderate to severe dementia
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“The environments in which we live,
work, and play have profound effects
upon us. The people, objects, and events
in these environments must arouse us
enough to avoid boredom, but not so
much as to cause extreme anxiety. The
performance demands made upon us by
our environments must fit with our skills
and competencies if we are to do well.
They must match our values and interests
as well, if we are to feel satisfied.”
Roann Barris
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