9/10/2015
Beth Reigart, MPH, OTR/L
Clinical Performance Specialist
RehabCare.
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Identify four standardized cognitive assessments
to stage dementia
Identify the stages of dementia
Understand function based performance within
the dementia disease process
Understand the use of validation and space
retrieval strategies for ADL re-training
Develop an activity program for early, middle and
late stage dementia patients.
Utilize Tai Chi as a fall prevention strategy with
dementia residents
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Cognition is one of the most important
performance component areas greatly
impacting one’s ability to function.
By determining the cognitive level of your
patient, you can increase function and safety
and decrease behavior issues by compensating
for the deficits and capitalizing on remaining
abilities.
Our role as a consultant is key … clinical
interventions, caregiver education and
environmental modification.
Fiscal intermediaries (FIs) “may not install edits that
result in the automatic denial of services based
solely on a diagnosis of dementia.
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Standardized cognitive performance testing
96125
Standardized cognitive performance testing
per hour of a qualified health care
professional’s time, both face to face time
administering tests to the patient and time
interpreting these test results and preparing
the report.
Standardized musculoskeletal assessment
97750
◦ Berg
◦ Tinetti
◦ Timed Get up and Go
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Cognition describes the acquisition, storage,
transformation, and use of knowledge.
Cognition might include a wide range of mental
processes including:
◦ Attention
◦ Perception
◦ Memory
◦ Imagery
◦ Problem-solving, Reasoning & Decision-making
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Claudia Allen
◦ Allen Cognitive Level (ACL) used to assess
cognition, disability and suggests a treatment
approach. The assigned level indicated the
cognitive function the patient has the potential to
perform
◦ Allen Diagnostic Model (ADM) use of standardized
craft activities to evaluate and treat patients with
cognitive disabilities.
◦ Both are copyrighted and require the purchase of
the training materials and supplies.
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Global Deterioration Scale (GDS)
◦ Developed to identify and rate the stages of primary
degenerative dementia and age associated memory
impairment.
◦ Copyrighted and free to use
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St Louis University Mental Status Exam
(SLUMS)
◦ Screening tool to identify mild cognitive
impairments in the elderly
◦ Copyrighted and free to use
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Montreal Cognitive Assessment (MoCA)
◦ Rapid screening instrument for mild cognitive
assessment. Assesses attention, concentration,
executive function, memory, language, visual
perception, conceptual thinking, calculations and
orientation.
◦ Copyrighted but no fee to use
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Determines the current state of dementia
Provides guidance to the potential abilities
Provides information regarding limitation
Used to guide treatment
Helpful to determine the optimal living
enviroment
Can be replicated to document progression of
the disease
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American Alzheimer’s Association
Global Deterioration Scale
Claudia Allen Levels
Clinical Dementia Rating Scale
Stage 1:
No Cognitive DeclineI n this stage the person functions normally, has no memory loss, and is mentally healthy. People with NO dementia
would be considered to be in Stage 1.No Dementia
Stage 2:
Very Mild Cognitive Decline This stage is used to describe normal forgetfulness associated with aging; for example, forgetfulness of
names and where familiar objects were left. Symptoms are not evident to loved ones or the physician.No Dementia
Stage 3:
Mild Cognitive Decline
This stage includes increased forgetfulness, slight difficulty concentrating, decreased work performance. People may get lost more often
or have difficulty finding the right words. At this stage, a person's loved ones will begin to notice a cognitive decline. Average duration: 7
years before onset of dementia Early Stage
Stage 4:
Moderate Cognitive Decline
This stage includes difficulty concentrating, decreased memory of recent events, and difficulties managing finances or traveling alone to
new locations. People have trouble completing complex tasks efficiently or accurately and may be in denial about their symptoms. They
may also start withdrawing from family or friends, because socialization becomes difficult. At this stage a physician can detect clear
cognitive problems during a patient interview and exam. Average duration: 2 years Middle Stage
Stage 5:
Moderately Severe Cognitive Decline
People in this stage have major memory deficiencies and need some assistance to complete their daily activities (dressing, bathing,
preparing meals). Memory loss is more prominent and may include major relevant aspects of current lives; for example, people may not
remember their address or phone number and may not know the time or day or where they are. Average duration: 1.5 years
Stage 6:
Severe Cognitive Decline (Middle Dementia)
People in Stage 6 require extensive assistance to carry out daily activities. They start to forget names of close family members and have
little memory of recent events. Many people can remember only some details of earlier life. They also have difficulty counting down from
10 and finishing tasks. Incontinence (loss of bladder or bowel control) is a problem in this stage. Ability to speak declines. Personality
changes, such as delusions (believing something to be true that is not), compulsions (repeating a simple behavior, such as cleaning), or
anxiety and agitation may occur. Average duration: 2.5 years Late Stage
Stage 7:
Very Severe Cognitive Decline (Late Dementia)
People in this stage have essentially no ability to speak or communicate. They require assistance with most activities (e.g., using the
toilet, eating). They often lose psychomotor skills, for example, the ability to walk. Average duration: 2.5 years
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CDR-0 -- No dementia
CDR-0.5 -- Mild
Memory problems are slight but consistent; some difficulties with time
and problem solving; daily life slightly impaired
CDR-1 Mild
Memory loss moderate, especially for recent events, and interferes with
daily activities. Moderate difficulty with solving problems; cannot
function independently at community affairs; difficulty with daily
activities and hobbies, especially complex ones.
CDR-2 -- Moderate
More profound memory loss, only retaining highly learned material;
disoriented with respect to time and place; lacking good judgment and
difficulty handling problems; little or no independent function at home;
can only do simple chores and has few interests.
CDR-3 -- Severe
Severe memory loss; not oriented with respect to time or place; no
judgment or problem solving abilities; cannot participate in community
affairs outside the home; requires help with all tasks of daily living and
requires help with most personal care. Often incontinent. close
Sample
Assessment Tool
Mild Loss
Early Stage
Moderate Loss
Middle Stage
Severe Loss
Severe Stage
1 to 3
4 to 5
6
7
MMSE
25 to 30
15 to 24
5 to 15
< 10
Allen’s Cognitive
Levels
5.0 to 6.0
4.0 to 4.8
3.0 to 3.8
0.2 to 2.8
7
6-7
3-5
1-2
Global
Deterioration
Scale
FIM
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Moves beyond palliative approaches
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Defines current cognitive ability
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Guides the use of adaptations to optimize
interaction with others and the environment
Focus is on maintaining highest functional
level of person and quality of life
Relies on Successful Interdisciplinary Team
◦ Developed with significant rehabilitation input
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Functionally Independent
Mild Cognitive Losses
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Moderate Cognitive Losses
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◦ Early stages of dementia
◦ Precautionary measures to insure safety
◦ Middle stages of dementia
◦ Requires assistance
 Significant safety risk
 Benefits from task segmentation and increased visual contract
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Severe Cognitive Losses
◦ Severe/Advanced stages of dementia
◦ Low frustration tolerance
 Responds to calming techniques
 Sensory modulation
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ADL Retraining
 Therapeutic activities 97530
 Self-care/home management training 97535
 Community/work reintegration training
97537
Functional Mobility
 Neuromuscular reeducation 97112
 Therapeutic activities 97530
What about Cognitive Re-Training 97532?
Mild Cognitive Imp
Mild Dementia
Moderate Dementia
Severe Dementia
Disease progression has
begun to impair memory and
ability to perform complex
tasks that require new
information and skills.
Cognitive impairments start
to affect activity
performance
Mild verbal disturbances
may be noted.
May withdraw from normal
routine.
Neuropsychological testing
indicates abnormalities but
does not meet criteria for
diagnosis of dementia.
Duration may be up to 7
years.
Cognitive function declines to the
point where activities of daily living
become impaired.
Short-term memory loss more
pronounced
Long-term memory intact but with
some loss
Loss of judgment and problemsolving abilities
Loss of concrete thinking
Disorientation to time and place;
still knows self and family
Some word loss; talks around idea
but can make self understood
Can find own room but gets lost
easily
Remembers past life
Some appreciation of lost skills
Becomes angered when confronted
with losses.
Currently 65-95% of diagnoses
occur here. Symptoms include:
No short-term memory
Almost no long-term declarative
memory
Difficulty understanding others
and making self understood.
Sometimes can be understood
when making simple requests.
Unaware of surroundings, time,
season and year.
Cannot find own room
Urine incontinence may start
initially in later part of this stage
Sleep-cycle stages
Personality and emotional
changes; easily agitated/anxious or
evidence of sadness
Repetitive questions and
behaviors
Delusions or hallucinations
Combative behavior if rushed or
threatened
No initiation of any activity w/o
prompts
Sexual behaviors may emerge
Abilities for speech, walking,
smiling and eating are lost.
Specific characteristics include:
Extremely limited verbalizations;
sounds similar to grunting,
moaning or words are nonsensical.
No awareness of person, place or
time
Incontinent of urine and feces
No awareness of purpose of
objects
Total dependence on others for
care
Loss of motor skills, trunk control
Combative if frightened.
Overstimulated
Swallowing problems, which
often necessitate texture alteration
to puree and thickened liquids
Weight loss in last stage of
illness; not able to consume
enough intake to sustain self
May suffer from recurring
pneumonia due to aspiration of
food/liquid
Sleeps more
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Functions
Deficits
Residual Abilities
Orientation
Disoriented for time; confused
Oriented to place and person
Memory
Rapid forgetting of recent events; misplaces objects;
gets lost easily.
Excellent recognition memory; average span; can
reminisce; preserved procedural/habit
memory
Attention
Distractible; difficulty concentrating
Associating
Difficulty with complex associative reasoning.
Follows 3-step commands
Sequencing
Trouble ordering components of complex activities
and events.
Can order components of similar familiar activities.
Cognitive-Linguistic
Diminished reading comprehension; spelling errors
in writing, mild word recall problems;
vocabulary shrinking; difficulty composing
letters; forgets what he/she wants to say;
reduced output.
Grammar and syntax intact; can express needs; can
answer choice yes/no questions; conversant;
generates examples; describes objects,
feelings; comprehends language; copies
Perception
Mild perceptual deficits; diminished sense of smell.
Generally good for ADLs
ADLs
Difficulty with finances, housekeeping, shopping,
travel, keeping track of medications, some
difficulty with telephone
Can bathe, feed and dress self; continent
Reasoning
Difficulty with complex reasoning, implied
information
Able to solve routine problems
Simple associative reasoning of part to whole,
function to object, color with objects, items
in a class
Functions
Deficits
Residual Abilities
Orientation
Disoriented for time and place
Oriented to spouse; knows name and spouse’s name
Memory
Rapid forgetting; decreased knowledge of current
events
Good recognition memory; can reminisce with
assistance; preserved procedural/habit
memory
Attention
Highly distractible; drifts from topic and activity
Can specify examples; can repeat
Associating
Unable to carry out complex associative reasoning
Retains simple associations; can do simple
categorization.
Sequencing
Difficulty sequencing even familiar activities
Can do simple sequencing with assistance.
Cognitive-Linguistic
Poor comprehension of written information; word
recall problems; dwindling verbal output;
difficulty generating a series of meaningful
ideas; poor written skills; tangential; misses
the point.
Grammar and syntax intact; reads at word level;
expresses needs with assistance; follows 2stage commands; can copy. Usually
understands gestures
Perception
Moderate visual perceptual deficits. Diminished
sense of smell
Usually sufficient for ADLs
ADLs
Unable to handle finances, housekeeping, shopping,
transportation, medications and laundry;
difficulty dressing; dangerous driving.
Can bathe with assistance; generally continent; feeds
self.
Reasoning
Problem-solving skills significantly diminished.
Can solve simple problems with cueing.
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Functions
Deficits
Residual Abilities
Orientation
Disoriented for time, place, environment, and
sometimes body parts.
May know own name; usually responds to
greeting.
Memory
Devastated episodic memory; degraded
knowledge of concepts; agnosia (can’t
label what he/she sees).
Some preserved recognition memory; often
preserved procedural/habit memory.
Attention
Very limited, highly distractible; diminished
sensitivity to context; unable to track
multi-party conversation
Will attend to pleasant stimuli for variable
periods of time.
Associating
Confusion about common associations; object
with function, category membership;
attributes of objects
Often can match like objects; retains knowledge
of simple associations
Sequencing
Difficulty sequencing even familiar activities
May carry out some highly routine procedures
without assistance/
Cognitive-Linguistic
Utterances often nonsensical; unable to write
meaningfully; greatly diminished
vocabulary; concrete; diminished
output; poor reading comprehension
Form of language generally intact; limited
ability to express needs. May answer
yes/no questions; often can read at a
word level. May retain some social
aspects of communication.
Perception
Poor sense of smell. Moderate visual perceptual
deficits
Responds to stimuli if within visual field
ADLs
Cannot perform instrumental ADLs; incontinent
of bladder, later bowel; unable to bathe
and dress self.
Often can transfer; sometimes feeds self.
Reasoning
Unable to solve most simple problems
Little, if any, reasoning capabilities.
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Determine range of function
◦ Initial assessment of cognitive and physical function
◦ Identify intact residual abilities
◦ Reassess cognitive and physical function periodically
and with condition changes
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Obtain information of prior routines, habits,
occupation and interests and hobbies
Identify basic skills & strategies to increase
functional abilities
Design the skilled intervention program
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Basic Facilitation Strategies
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Caregiver Presentation/Approaches
Simplification of Procedure/Task
Routine & Consistency
Type & Frequency of Cues
Mirroring
Hand over Hand Assist
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Environmental Considerations
Interactional Strategies
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Presentation/Approaches
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◦ Be in visual proximity to the patient
◦ Approach slightly from side, not from behind
◦ Ensure that patient is aware of caregiver before
proceeding
◦ Eye level
◦ Use of calm approach
◦ Identify skill to the patient before each caregiving session
◦ Give one-step directions
◦ Provide verbal prompts and delay by 5 seconds
physical assistance after a verbal prompt
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Simplification
◦ Task segmentation and sequencing
◦ Communication
 Keep topics concrete
 Eliminate pronouns
 Use simple, close ended questions
◦ Choice – Forced choice between 2-3 items
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Routine & Consistent
◦ Integrate person’s prior routines into daily
schedule
◦ Provide consistent, daily schedule
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Cues
◦ Written (often intact for single words through end
stage)
◦ Pictures (camouflaged exits)
◦ Other visual displays
◦ Non-verbal
◦ Olfactory (popcorn to stimulate hunger)
◦ Auditory (rooster to walk-up; traffic noise)
◦ Tactile (important in severe stage)
Mirroring
Hand over Hand Assistance
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Use black and white line drawings of the object or
representative symbols to facilitate comprehension.
Examples: Outline of toilet for bathroom
Use written single words to identify room, object, other
Be selective in use of colors.
◦ Peach, pink, beige, ivory, light blue, green, and lavender are
relaxing colors.
◦ White, yellow, orange and red are livelier, more stimulating
colors.
◦ Alternating black and white color segments can appear as
holes that need to be avoided.
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Mirrors can be confusing due to the perceptual
discrimination deficits in the later stages of the disease.
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Lighting
◦ Daily exposure to bright light
◦ Stimulates secretion of hormone melatonin, which is 10x
in the body at night than in the day.
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Seating
◦ Importance of good seating for individuals who sit for
extended periods of time, have poor circulation, or
limited mobility in/out of chairs.
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Social Environment
◦ Move away from central services to decentralized services
in cluster areas.
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Sensory Considerations: Color; Acoustics; Aromas
◦ Red stimulates brain
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“Bring out a Positive Emotion”
◦ The amygdala in the brain retains the person’s ability to
sense emotion and mood; one of the major treatment
goals is to maintain positive emotion.
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3 “Rs”
◦ Reassure
◦ Redirect
◦ Re-approach (Rescuer technique)
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Validation Therapy
Use of Procedural Memory
◦ Includes Reminiscence approaches
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Use of Prior Interests and Hobbies
MANAGEMENT STRATEGIES FOR INDIVIDUAL WITH DEMENTIA
Strategy
Presentation/
Approach
Simplify
Explanation
Maintain Calm Manner
Eye Level
Slightly to side
Insure person knows you are there before doing
anything else
Allow adequate response time
Break tasks, communication and choices into
simpler steps, but do try to offer simple and safe
choices
Cues
Prompts that are given by the caregiver, or are
present in the environment ( example: Holding
up a fork to cue time to eat; Can also be in form
of pictures, sounds, aromas, touch)
Mirroring
Caregiver demonstrates the task (example:
Caregiver goes through the motion of combing
own hair )
Hand Over Hand
Assist
Caregiver places own hand gently over hand of
resident to guide the resident
Early Stage Dementia
May need to be as close as 24
inches before person is aware of
caregiver
Middle Stage Dementia
May need to be as close as 14
inches before person is aware of
caregiver
Late Stage Dementia
May need to be as close as 8
inches before person is aware of
caregiver
Tasks: Can perform 6 to 8 steps
of familiar task
Tasks: Can perform 2 to 4 steps
of familiar tasks:
Communication: Able to
understand and speak routine
language; Some word finding
difficulties;
Choices: Allow person to make
choices
May need simple cues to start
and complete a task
Communication: Break
directions into simple steps; may
have difficulty with the written
word
Choices: Simplify to 2 safe
choices
May need simple cues to start
and complete a task
Tasks: May be able to perform 1
or 2 steps of familiar task
Communication: Speaks 1 to 2
words; May be able to give yes
or no responses to questions
Choices: Provide one item at a
time
Mirroring may be helpful for
tasks that are new
Mirroring to start and finish tasks
Mirroring to start and finish tasks
May be needed occasionally
Helpful to start and possibly
complete a task. Example ,
persons in advanced stage
dementia may be able to still feed
themselves if provided Hand
over Hand Assist
Routines should include frequent
rest periods
Sensory cues may be helpful
(music, aromas)
*Provide a daily routine that has enough
Routines help maintain
Routines help maintain
activity and structure, but is not under or over
independence
independence
stimulating
Following prior routines reduces Following prior routines reduces
*Consistent staff working with same residents
anxiety and enhances positive
anxiety and enhances positive
whenever possible
emotions
emotions
*Learn about and follow resident’s prior
routines whenever possible
KEY: Reduce demands on episodic and working memory; increase reliance on procedural memory; use validation techniques; focus on prior interests & hobbies to promote
success and personal comfort.
Routine &
Consistency
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ADLS BY STAGE OF DEMENTIA
Stage
GDS Score
MMSE
Attention Span
Mild Dementia
4 to 5
(4.6 – 5.5)
15 to 24
About 15 minutes
Ambulation;
Mobility;
Transfers
May be able to learn to use assistive device
if given simple, repetitive instructions;
May get lost in unfamiliar places;
Place cues in environments
May enjoy gliders/rockers
Bathing
General tips for approach; simplify; routine.
May need set-up for bathing but will be able
to complete the tasks with cues (modified
independence)
Maintain dignity
(Consider
personal
routines)
Grooming and General tips for approach; simplify; routine.
May need set-up for grooming but will be
Dressing
(Consider
personal
routines)
able to complete the tasks with cues
(modified independence)
Toileting
General tips for approach; simplify; routine.
Provide cues/reminders to use toilett
Can complete familiar task independently
with cues
Follow general tips for cuing.
Involve in meal planning and simple
preparation
(Consider
personal
routines)
Eating
(Consider
personal
preferences)
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Moderate Dementia
Severe Dementia
5 to 6
(5.6 to 6.7)
5 to 15
About 2-3 minutes
6 to 7
(6.8 to 7.0)
< 10
Fleeting; a few seconds
Benefits from increased “figure-ground”
contrast to see important features in the
environment;
Provide safe & interesting wandering paths
May fall over items in walking path
Benefits from using gliders/walkers
General tips for approach; simplify; routine
Will need set-up; allow additional time to
perform simple steps at independent level if
possible.
Warm room; reduce noise and echoes;
home-like décor
May benefit from music, relaxing aromas
May need to be covered
If anxious, wash hair at separate time
Start with washing feet, then legs, etc.
General tips for approach; simplify; routine.
Allow safe choices of clothing & make-up
Will need set-up
Use cueing and mirroring to start and start
finish tasks
Some may pace
Create a safe and interesting walking path
Many are non-ambulatory
Provide safe and comfortable positioning
May be able to help with transfers if given cues
or mirroring
General tips for approach; simplify; routine
Allow additional time to perform simple steps at
independent level if possible
Warm room; reduce noise and echoes; homelike décor
May benefit from music, relaxing aromas
May need to be covered
If anxious, wash hair at separate time
Start with washing feet, then legs, etc.
May need something to “hold”
General tips for approach; simplify; routine.
Use mirroring and hand-over-hand assist to start
and finish tasks
Provide a choice between two items of clothing
when possible
Easily frustrated unless task is very simple
May require complete assist
General tips for approach; simplify; routine.
Easily startled
Easily frustrated unless task is very simple
May require complete assist
Follow general tips
Mirroring and hand-over-hand assist.
Contract between plate/food/table
Simplify to one item at a time
Frequent nourishment and liquids
Provide finger foods
General tips for approach; simplify; routine.
Be sensitive to privacy needs
Cues to start and finish tasks
Allow to perform simplified steps
Follow general tips
Cueing; mirroring to start & finish
Contrast between plate/food/table
Simplify choices; reduce and fork
May need finger foods
Out-of-season clothes should be stored out of
sight so they do not pose a selection problem.
If difficulty selecting the appropriate clothes is
demonstrated, the caregiver can lay the clothes out
on the bed and eliminate this difficulty.
It is important to establish a routine consistent
with that individual’s procedure in the past.
◦ Example: If the person always showered and dressed before
breakfast, the same routine should be implemented. In
addition, the same order of putting on the clothes should
be trained as individuals with Alzheimer’s disease benefit
from repeat practice in lieu of variable practice.
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Incontinence in Alzheimer’s disease is mostly due
to one or more of the following factors:
◦ Inability to locate the bathroom
◦ Recall of the intent (to go to the bathroom) after finding
it
◦ Inattention to body signals regarding a full bladder or
“impending” bowel movement
◦ Reduced concerns about socially appropriate behaviors
with frequent episodes of voiding or defecating outside
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An effective intervention strategy is prompted
voiding with a defined, predictable routine that is
usually conducted every 2 hours.
Use the same step-by-step approach every time
Avoid questions, instead provide simple, concise directions
Simulate home ADL routine as much as possible
Gather all necessary items in advance to avoid having to leave
the individual later
Always inform individual what is going to occur in short,
softly spoken phrases
Always draw curtains or close door
Model aspects of the task
Monitor water and room temperatures
Give complete baths only when necessary
Separate out aspects of the task
Respect reasons for resistance
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Color code tape (path) to the individual’s room;
color code closet
Put picture of toilet on bathroom door
Routinely have designated staff to help the
individual search for room
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Allow him/her time to locate his/her room
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Have his/her room with personal pictures/names
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Move his/her clothes to eye level shelves
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Re-organize his/her most used items to lower shelf
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Intervention to unlock the communication
barrier to help to elicit desired outcomes.
The therapist how to tap into a resident’s
thought processes to achieve a desired
response.
Using these techniques enables the resident to
be actively involved in their exercise programs,
improve their gait pattern, and participate in
purposeful ADLs.
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Use of standardized assessment to stage the
disease
Use of activity checklists, social history and
patient interests, values and beliefs
Individualize care plans
Emphasis on consistency with strong
caregiver and family training.
Work
Routines
Values
Beliefs
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Indoor Leisure
Outdoor Leisure
PTSD
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Purpose of the Program:
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To provide functional oriented activities which promote the cognitive and physicals skills to promote
their optimal quality of life.
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The program is based on coding activities based on the functional performance components.
Benefits of the Program:
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Create balance in the variety of activities provided by the facility
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Increase understanding of the importance of activities with all residents
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Encourage teamwork
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Provide additional method to maintain gains achieved in therapy by complementing the restorative
program
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Promote creativity and imagination of residents, families and staff
The Rainbow Coding System:
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Purple: activities which promote their cognitive skills
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Green: activities which allow use of their eyes and hands
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Yellow: activities which promote balance, strength and coordination

Orange: activities which promote their sensory awareness
Successful Program Development:

Use of small group of residents

Identified color codes for current activities

Identify method to assess patient’s activity needs

Identify ways to identify resident’s appropriate color

Development of a committee with representatives from all disciplines
Remember that this is a journey … not a destination
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
10am
Family Wellness Walk
9am
Balance Class
9am Flexibility Class
9am
Balance Class
9am
Flexibility Class
9am
Balance Class
10am
Family Wellness Walk
1:00 Sing Along
10am Aromatherapy
10am
Cooking
10am
Hand Massages
10am Cooking
10am
Aromatherapy
1:00pm
Current Events
1pm
Family Wii‐habilitation
2pm
Chair Aerobics
2pm
Strengthening Class
1pm
Wii‐habilitation
2pm
Chair Aerobics
2pm
Strengthening Class
4pm
Family Wii‐habilitation
4pm Meditation
3pm
Choir Practice
3pm
Yoga
4pm
Meditation
4pm
Poker
Balance
Flexibility
Endurance
Strength
Mental
Coordination Sensory
25
9/10/2015
•
•


















Identify sensory activities which may be used
to decrease or prevent distress.
Allows opportunity to have readily available
resources for self monitoring behavior
Activity tool box for male patients; nuts and bolts, sandpaper and block of wood, face mask, lock and key,
flashlight, small wrench, tape, keys on ring, remote control, fishing supplies (without hooks)
Activity box for female patients: Playing cards, makeup, compact mirror, crafts, brush, toothbrush, soft sensory
items for fine motor manipulation, art supplies, homemaking supplies (such as, wisk, spatula, measuring spoons
and cups, cookie cutters, wooden spoons, etc)
Activity apron that have different clothing closures on them, such as zippers, buttons, ties, etc. Consider
different textured fabric (i.e. velvet, feathers, fun fur, felt, brick-brack, fringe, lace, Velcro)
Books on tape
Sound machine
Stuffed animals for patients to keep
Garden gloves
Playing cards
PVC piping for men to assemble to screw on and off (could use regular pipes, but too heavy)
Peg board
Sensory supplies (the rubber balls with rubber spikes on them, stress balls, yarns balls, soft cotton balls,
aromatherapy scented items, blanket, brush, lotion)
Certain arts and crafts that can be done with some supervision, such as paints, beading on string (large wooden
ones), collages, painting plastic stain glass forms, etc
Knitting or crochet materials for the ladies who used to knit or crochet (large crochet needles recommended)
Theraputty, animal squeezers, stress balls
Puzzles large type, Large print books or magazines
Sunglasses, Mirror, Electronic hand games
Neck pillow, Coloring books and crayons
Blocks, balls
26
9/10/2015
Tai Chi for Balance
Link: http://www.instituteforrehabilitativeqigon
gandtaichi.org/tai-chi-for-balance-andfalls-prevention/
Password: 97HTWOL6
Dynamic Warm Up
Link: http://www.ascentwellness.com/IA5928/
Password: 5937KW
27
Saint Louis University
Mental Status (SLUMS) Examination
Name
Is patient alert?
Age
Level of education
1
1. What day of the week is it?
1
2. What is the year?
1
3. What state are we in?
4. Please remember these five objects. I will ask you what they are later.
Apple
Pen
Tie
House
Car
1
2
5. You have $100 and you go to the store and buy a dozen apples for $3 and a tricycle for $20.
How much did you spend?
How much do you have left?
0
6. Please name as many animals as you can in one minute.
0-5 animals
1 5-10 animals
2 10-15 animals
5
7. What were the 5 objects I asked you to remember? 1 point for each one correct.
0
8. I am going to give you a series of numbers and I would like you to give them to me backwards.
For example, if I say 42, you would say 24.
87
1 649
1 8537
3 15+ animals
9. This is a clock face. Please put in the hour markers and the time at
ten minutes to eleven o’clock.
2 Hour markers okay
2 Time correct
1
10. Please place an X in the triangle.
1
Which of the above figures is largest?
11. I am going to tell you a story. Please listen carefully because afterwards, I’m going to ask you
some questions about it.
Jill was a very successful stockbroker. She made a lot of money on the stock market. She then met Jack, a
devastatingly handsome man. She married him and had three children. They lived in Chicago. She then
stopped work and stayed at home to bring up her children. When they were teenagers, she went back to
work. She and Jack lived happily ever after.
2
2
What was the female’s name?
When did she go back to work?
1
2 What work did she do?
2 What state did she live in?
Scoring
High School Education
27-30 ○ ○ ○ ○ ○
20-27 ○ ○ ○ ○ ○
1-19 ○ ○ ○ ○ ○
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
Reference: [email protected]
Normal
MCI
Dementia
Less than High School Education
20-30
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 14-19
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 1-14
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
○ ○ ○
○ ○ ○
Aging Successfully, Vol. XII, No. 1
1
Step-by-Step Design for
Resident Individualized Plan of Care
The following two page tool is meant to assist in documenting resident behaviors in
order to appropriately stage him/her using the Global Deterioration Scale to determine
appropriate interventions.
Instructions:
1. On page, check each clinical and behavioral characteristic present/observed.
2. Following each characteristic is a number in parentheses. Add the number of
responses, which are followed by the #4 and record in the appropriate box. Repeat
this process for the #5, #6 and #7.
3. Total the number of responses (number of characteristics checked) and record.
4. Multiply the number of four by four and record.
5. Multiply the number of five responses by five and record.
6. Multiply the number of six responses by six and record.
7. Multiply the number of seven responses by seven and record.
8. Add the totals of the #4s, #5s, #6s and #7s and record.
9. To obtain the estimated GDS stage, divide the total score (sum of #4s, #5s, #6s and
#7s) by the total number of responses and record.
10. Page two is a quick reference guide of cognitive residual abilities for each of the
general stages of dementia.
11. The skilled therapeutic intervention section illustrates the most appropriate treatment
strategies based on residual abilities to assist in developing a functional
maintenance program to focus on enhancing and retaining their abilities. Refer to
the Dementia Clinical Training Took Kit for specific descriptions and examples.
Step-by-Step Design for
Resident Individualized Plan of Care
Patient Name: ______________________________________
Diagnosis:__________________________________________
Precautions:________________________________________
Room No: ______________
Physician:_______________
MCA MCB
Other
Check off those clinical and behavioral characteristics that are present.
 Oriented to time & place (4)
 Memory deficits in personal history (4)
 Recognition of familiar persons & faces (4)
 Decreased ability to travel & handle
finances (4)
 Personality & emotional changes (6)
 Can no longer live w/o assistance (5)
 Onset of peripheral vision loss (6)
 Knowledge of facts regarding self & others
(5)
 Sense of reality based on misperception (5)
 Some disorientation to time &/or place (5)
 I/S with toileting & eating (5)
 Difficulty choosing proper clothes to wear
(5)
 No noticeable changes in posture or gait (5)
 Largely unaware of recent events/life
experiences (6)
# of 4’s
x4=
# of 5’s
x5=
Total # of
Responses
Sum of
4’s; 5’s;
6’s; 7’s
 Knowledge of past life; can be sketchy (6)
 Unaware of surroundings, year, season (6)
 Require assist w/ADLs; becomes
incontinent (6)
 Can distinguish familiar/unfamiliar persons
(6)
 Intact ability to travel to familiar locations (4)
 Denial is dominant defense mechanism (4)
 All verbal abilities are loss (7)
 No recognition loved ones/familiar persons
(7)
 Wandering pattern (6; 7)
 Progress to loss of ambulation (7)
 Resists caregiving w/unfamiliar persons (6;
7)
 ADLs are total assist (7)
 Will accept, but can't initiate interaction (7)
 Incontinent of urine (7)
# of
6’s
# of
7’s
Sum of 4’s; 5’s;
6’s; 7’s / Total #
of Responses
x6=
x7=
Estimated GDS
Stage =
Step-by-Step Design for
Resident Individualized Plan of Care (cont.)
Patient Name: ______________________________________
Diagnosis:__________________________________________
Precautions:________________________________________
Residual Abilities
Area of Cognition
Orientation
Memory
Attention
Association
Sequencing
Mild ( GDS 4)
Oriented to person and
place
Excellent recent
memory; average
attention; preserved
procedural memory
Follows 3-step
commands
Simple reasoning of part
to whole, function to
object, color w/objects,
items in class
Can order components
of simple familiar
activities
Moderate (GDS 5)
Oriented to person;
knows name & family
names
Can reminisce with
assistance; preserved
procedural memory
Attention to task is good;
can specify examples;
can repeat
Can do simple
categorization and
associations
Severe (GDS 6-7)
Oriented to self;
responds to greetings till
stage 7
Preserved procedural
memory; some
immediate memory until
stage
Will attend to pleasant
stimuli
Can often match like
objects
Grammar & syntax
intact; can describe
basic needs, feelings &
wants; conversant;
generates examples,
copies and language
Generally able to
complete ADLs
Grammar and syntax
intact; reads at single
word level; expresses
needs, wants, feelings
with assistance
May carry out some
highly routine
procedures with
assistance
Limited ability to
express needs; may
answer yes/no
questions; may retain
some social graces
Usually sufficient for
ADLs
Responds to stimuli in
the visual field
ADLs
Can bathe, feed, dress
self; continent
Can bathe with
assistance; feeds self
Often can transfer,
generally unsafe;
sometimes feeds self
Reasoning
Able to solve everyday
routine problems
Can solve very simple
everyday problems
w/assist
Little, if any, reasoning
abilities
Communication & Expression
Perception
Can to simple 2-3 step
sequencing with
assistance
Room No: ______________
Physician:_______________
MCA MCB
Other
Ex Severe (GDS 7)
Disoriented x 4
Preserved intact procedural
memory
Respond to music and/or gentle,
tactile stimulation to face,
shoulders
No associative language skills;
rarely initiate activity
Unable
Eyes generally closed; will open
eyes to music and/or tactile
stimulation
Late to end stage, curled in fetal
position, toileted, turned to
prevent skin-breakdown, and
tube fed
Unable
Nonverbal communication
consisting of smiling, crying, or
singing; may initiate physical
movement of hands and feet
Skilled Therapeutic Intervention
Direct Restorative Tx
Indirect Restorative Tx (FMP)
Cog Retraining-Internal
Cog Retraining-External
Models of Compensation
Environmental Modification
ADLs Procedural Memory
Shift stimulus input to visual
Visual Memory Cue Cards
Caregivers-Program Facilitators
Hydration & Nutrition Management
Mild ( GDS 4)
X
X
X
X
X
Moderate (GDS 5)
X
X
X
X
X
X
X
X
X
X
Severe (GDS 6-7)
Ex Severe (GDS 7)
X
X
X
X
X
X
X
X
X
X
X
X
X
Instructions To the Administration of the Mini
Page 1 of 1
FAST SCALE ADMINISTRATION
The FAST scale is a functional scale designed to evaluate patients at the more moderate-severe stages of dementia
when the MMSE no longer can reflect changes in a meaningful clinical way. In the early stages the patient may be
able to participate in the FAST administration but usually the information should be collected from a caregiver or,
in the case of nursing home care, the nursing home staff.
The FAST scale has seven stages:
1 which is normal adult
2 which is normal older adult
3 which is early dementia
4 which is mild dementia
5 which is moderate dementia
6 which is moderately severe dementia
7 which is severe dementia
FAST Functional Milestones.
FAST stage 1 is the normal adult with no cognitive decline. FAST stage 2 is the normal older adult with very mild
memory loss. Stage 3 is early dementia. Here memory loss becomes apparent to co-workers and family. The patient
may be unable to remember names of persons just introduced to them. Stage 4 is mild dementia. Persons in this
stage may have difficulty with finances, counting money, and travel to new locations. Memory loss increases. The
person's knowledge of current and recent events decreases. Stage 5 is moderate dementia. In this stage, the person
needs more help to survive. They do not need assistance with toileting or eating, but do need help choosing
clothing. The person displays increased difficulty with serial subtraction. The patient may not know the date and
year or where they live. However, they do know who they are and the names of their family and friends. Stage 6 is
moderately severe dementia. The person may begin to forget the names of family members or friends. The person
requires more assistance with activities of daily living, such as bathing, toileting, and eating. Patients in this stage
may develop delusions, hallucinations, or obsessions. Patients show increased anxiety and may become violent. The
person in this stage begins to sleep during the day and stay awake at night. Stage 6 is severe dementia. In this stage,
all speech is lost. Patients lose urinary and bowel control. They lose the ability to walk. Most become bedridden and
die of sepsis or pneumonia.
http://geriatrics.uthscsa.edu/educational/med_students/fastscale_admin.htm
2/13/2008
Functional Assessment Staging of Alzheimer’s Disease. (FAST)©
STAGE
1.
SKILL LEVEL
No difficulties, either subjectively or objectively.
2.
Complains of forgetting location of objects. Subjective word finding difficulties.
3.
Decreased job function evident to co-workers;
difficulty in traveling to new locations. Decreased organizational capacity.*
4.
Decreased ability to perform complex tasks (e.g., planning dinner for guests),
handling personal finances (forgetting to pay bills), difficulty marketing, etc.
5.
Requires assistance in choosing proper clothing to wear for day, season,
occasion.
6a.
Difficulty putting clothing on properly without assistance.
b.
Unable to bathe properly; e.g., difficulty adjusting bath water temperature)
occasionally or more frequently over the past weeks.*
c.
Inability to handle mechanics of toileting (e.g., forgets to flush the toilet,
does not wipe properly or properly dispose of toilet tissue) occasionally or
more frequently over the past weeks.*
d.
Urinary incontinence, occasional or more frequent.
e.
Fecal Incontinence, (occasional or more frequently over the past week).
7a.
Ability to speak limited to approximately a half dozen different words or fewer,
in the course of an average day or in the course of an intensive interview.
b.
Speech ability limited to the use of a single intelligible word in an average day
or in the course of an interview (the person may repeat the word over and over.
c.
Ambulatory ability lost (cannot walk without personal assistance).
d.
Ability to sit up without assistance lost (e.g., the individual
will fall over if there are no lateral rests [arms] on the chair).
e.
Loss of the ability to smile.
STAGE••________
*Scored primarily on the basis of information obtained from a
knowledgeable informant and/or caregiver.
©1984 by Barry Reisberg, M.D. All rights reserved.Reisberg, B. Functional Assessment Staging
(FAST). Psychopharmacology Bulletin. 1988:24: 653-659.
Sensory Diet Exploration: Activity Checklist
Name: ______________________
The following is a checklist of things people may use or do in order to help decrease
&/or to prevent distress. Please take a moment to check off those things that seem to
be helpful for you! Each of these activities employs all or most of the sensory areas.
However, they are categorized to help you identify some of the specific sensorimotor
qualities you may want to focus on.
 Movement
o Riding a bicycle
o Running or jogging
o Walking/hiking
o Aerobics
o Dancing
o Stretching or isometrics
o Lifting weights
o Yoga or Tai Chi
o Swimming
o Jumping on a trampoline
o Rocking
o Shaking
o Golf
o Re-arranging furniture
o Gardening
o Yard work
o Shopping
o Taking a shower
o Cleaning
o Driving
o Chopping wood
o Washing the car
Others: _______________________________________________________________
 Different Types of Touch & Temperature
o Blanket wrap/weighted blanket o Getting a massage
o Holding/chewing ice
o Soaking in a hot bath
o Using arts/crafts supplies
o Warming up to a fire/wood stove
o Pottery/clay work
o Petting a dog, cat, or other pet
o Holding a pet
o Planting or weeding
o Warm/cold cloth to head/face o Hot/cold shower
o Hand washing
o Washing the dishes
o Using a stress ball
o Fidgeting with something
o Twirling your own hair
o Going barefoot
o Getting a manicure/pedicure o Washing or styling your hair
o Bean bag tapping/brushing
o Cooking or baking
o The feel of certain fabrics
o Being hugged or held
o Knitting/crocheting/sewing
o Being in the shade/sunshine
o Using powders/lotions
Others: _____________________________________________________
Adapted from Wilbarger, 1995 and Williams & Shellenberger 1996; Champagne, 2004
 Auditory/Listening
o Enjoying the quiet
o The sound of a water fountain
o The sound of a fan
o People talking
o White noise
o Music box
o Wind chimes
o Singing
o Humming
o Whistling
o Plays/Theater
o Live concerts
o Radio shows
o Ocean sounds
o Rain
o Birds chirping
o Ticking of a clock
o A cat purring
o Using the telephone
o Use of a ipod
o Listening to music
o Relaxation or meditation CDs
Others: _______________________________________________________________
Vision/Looking
Looking at:
o Photos
o The sunset or sunrise
o Snow falling
o Rain showers
o Fish in a tank
o Autumn foliage
o Art work
o A bubble lamp
o A mobile
o Waterfalls
o Cloud formations
o Stars in the sky
o Ocean waves
o Watching sports
o Movies
o Animal watching
o Window shopping
o Photography
o Reading
o Looking through different colored sunglasses
o A flower gardens
o Water or fish swimming
o Looking through picture books
Others: _______________________________________________________________
❀Olfactory/Smelling
o Scented Candles
o Essential oils
o Cologne/perfume
o Baking/cooking
o Coffee
o Aftershave
o Freshly cut grass
o Flowers
o Tangerines/citrus fruits
o Herbs/Spices
o Chopped wood
o Smell of your pet
o Linens
o Scented lotions
o Incense
o Herbal tea
o Mint leaves
Others:
_________________________________________________________________
3
Adapted from Wilbarger, 1995 and Williams & Shellenberger 1996; Champagne, 2004
Gustatory/Tasting/Chewing
o Chewing gum
o Crunchy foods
o Sour foods
o Chewing ice
o Sucking a thick milkshake
o Chewing on your straw
o Yawning
o Deep breathing
o Biting into a lemon
o Eating a lollipop
o Drinking coffee/cocoa
o Drinking herbal tea
o Drinking something carbonated
o Listerine strips
o Mints
o Hot balls
o Chewing carrot sticks
o Spicy foods
o Eating a popsicle
o Blowing bubbles
o Chocolate
o Strong mints
Others: _______________________________________________________________
Additional Questions:
What kind of music is calming to you?
________________________________________
What kind of music is alerting to you?
________________________________________
Do you prefer bright or dim lighting when feeling distressed?
______________________
Are there other things that are not listed that you think might help? If so, what?
______________________________________________________________________
After reviewing all of the activities you have checked off and listed, what are the
top
five things that are the most helpful when you are feeling distressed?
1. _________________________________________________________
2. _________________________________________________________
3. _________________________________________________________
4. _________________________________________________________
5. _________________________________________________________
Adapted from Wilbarger, 1995 and Williams & Shellenberger 1996; Champagne, 2004
Stages of Dementia
Mild Cognitive Imp
Mild Dementia
Moderate Dementia
Severe Dementia
Abilities for speech, walking, smiling
Disease progression has Cognitive function declines to Currently 65-95% of diagnoses occur
and eating are lost. Specific
here. Symptoms include:
the point where activities of
begun to impair memory
characteristics include:
daily living become impaired.
and ability to perform
• No short-term memory
complex tasks that require
• Extremely limited
• Short-term memory
• Almost no long-term declarative
new information and skills.
verbalizations; sounds similar
loss more pronounced
memory
to grunting, moaning or words
• Cognitive
• Long-term memory
• Difficulty understanding others and
are nonsensical.
impairments start to
intact but with some
making self understood.
affect activity
• No awareness of person,
loss
Sometimes can be understood
performance
place or time
when making simple requests.
• Loss of judgment and
• Mild verbal
• Incontinent of urine and feces
problem-solving
• Unaware of surroundings, time,
disturbances may
abilities
season and year.
• No awareness of purpose of
be noted.
objects
• Loss of concrete
• Cannot find own room
• May withdraw from
thinking
• Total dependence on others
• Urine incontinence may start
normal routine.
for care
• Disorientation to time
initially in later part of this stage
• Neuropsychological
and place; still knows
• Loss of motor skills, trunk
• Sleep-cycle stages
testing indicates
self and family
control
• Personality and emotional
abnormalities but
• Some word loss; talks
• Combative if frightened. Over
changes; easily agitated/anxious
does not meet
around idea but can
stimulated
or evidence of sadness
criteria for diagnosis
make self understood
• Swallowing problems, which
• Repetitive questions and
of dementia.
• Can find own room but
often necessitate texture
behaviors
• Duration may be up
gets lost easily
alteration to puree and
• Delusions or hallucinations
to 7 years.
thickened liquids
• Remembers past life
• Combative behavior if rushed or
• Weight loss in last stage of
• Some appreciation of
threatened
illness; not able to consume
lost skills
• No initiation of any activity w/o
enough intake to sustain self
• Becomes angered
prompts
when confronted with
•
May suffer from recurring
• Sexual behaviors may emerge
pneumonia due to aspiration of
losses.
food/liquid
• Sleeps more
Suggested Strategies
Early Stage Cognitive Impairment
Name:
Therapist Signature:
PRESENTATION/APPROACH
_____ Gain trust – provide
sensitivity/understanding
_____ Eliminate clutter/distractions
_____ Begin with using person’s name.
_____ Place objects within 24-48 inches
SIMPLIFY
_____ Set out safe supplies so they are visible and
within arm’s reach at appropriate time(s)
_____ Maintain what is familiar within safe limits
_____ Keep supplies in same place
_____ Use familiar equipment/supplies
_____ Provide reminders to start activities/ADL’s
_____ Provide close supervision for safety
_____ Provide _________ supervision for quality
_____ Distant supervision for problem solving
_____ Provide _______assistance for problem
solving unfamiliar/complex situations
_____ Provide _______assistance for problem
solving (all situations)
_____ Establish and maintain daily routine
_____ Incorporate preferences into routine: _____
____________________________________
_____ Avoid change if possible
_____ Maintain what is familiar to resident
COMMUNICATION
_____ Provide invitation and reminders to
manage schedule/appointments
_____ Provide concrete explanations and
communication
_____ Allow choices
_____ Avoid complex written directions
_____ Use labels for ________________________
_____ Use lists for __________________________
_____ Use memory book ____________________
_____ Use calendar for ______________________
_____ Verify information provided by resident
Date:
_____ Assist as needed with word finding
_____ Simplify choices and assist as needed
CUES
_____ Needs occasional verbal cues if unfamiliar
or complex task
_____ Set out supplies at appropriate time of day
for activity performance
_____ Personalize walker/equipment to prompt
use
_____ Place call light in obvious location to remind
to use
ROUTINE & CONSISTENCY
_____ Follow prior known routine & preferences
_____ Honor food likes/dislikes
AMBULATION
_____ Provide reminders to use_______________
while walking
_____ Maintain safe environment for walking
_____ Provide _______supervision for safety
_____ Provide cues to ______________________
while walking
_____ Clutter free walking area/path with places
to sit along path
_____ Proper shoes and orthotics as needed
_____ Visual aids in place
_____ Provide appropriate lighting
_____ Decrease glare
_____ _____________________provided to assist
resident in locating his/her room or familiar
location
BATHING
_____ Provide repetitive situation – routine and
consistency
_____ Provide _________________supervision for
Safety
_____ Provide __________________assistance for
problem solving
Continued on back of sheet
Name:
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Suggested Strategies
Early Stage Cognitive Impairment
BATHING (cont)
Promote independence
Provide safe/familiar supplies within sight at
preferred time __________________for
shower/bath
Provide ___________________assistance
for set-up and clean-up
Check to insure thoroughness for hygiene
and dignity
Use ____________________technique to
gain agreement to bathing if resident does
not believe they are in need of shower/bath
Provide verbal cues/suggestions to change
action/insure proper hygiene and/or safety
GROOMING & DRESSING
Provide ___________________supervision
for safety and problem solving
Provide verbal cues/suggestions for safety,
problem solving or to change actions
Provide repetition, routine and consistency
Provide set-up of safe, familiar supplies
within line of sight at preferred times:
____________________________________
Provide _______________assistance for
set-up and clean up
Use ________________________________
___________________________________
technique, to gain agreement, if they do not
believe they need to change clothing
Maintain supervision for safety
Use familiar grooming products when
possible
TOILETING
Provide set-up of safe, familiar supplies
within sight
Be sure toilet paper is in on roll in holder
Provide _________________supervision
_____ Provide longer time to complete activity
Date:
_____ Provide reminders to toilet (as needed)
_____ Discreetly check results for hygiene and to
maintain dignity
_____ Check for soiled laundry and/or odors
_____ Provide assistance for problem solving in
“new or unfamiliar” situations
EATING & DRINKING
_____ Eats independently
_____ Provide routine and consistency in dining
_____ Provide _______ cues to eat/drink
_____ Provide _________________assist for
problem solving_____________________
_____ Provide ________________cues/assistance
for use of adaptive equipment
_____ Allow to sit in same place during each meal
_____ Follow:______________________________
____________________________________
routine/preference as much as possible
_____ Reduce unnecessary noise/distractions
ADDITIONAL APPROACHES
_____ ____________________________________
____________________________________
____________________________________
_____ ____________________________________
____________________________________
____________________________________
_____ ____________________________________
____________________________________
____________________________________
_____ ____________________________________
____________________________________
____________________________________
_____ ____________________________________
____________________________________
_____ ____________________________________
____________________________________
_____ ____________________________________
Name:
Suggested Strategies
Early Stage Cognitive Impairment
Date:
Suggested Strategies
Middle Stage Cognitive Impairment
Name:
Therapist Signature:
PRESENTATION/APPROACH
_____ Eliminate external distractions (noise,
clutter etc.)
_____ Eliminate internal distractions (ex. toileting
prior to activity)
_____ Make eye contact.
_____ Begin with using person’s name.
_____ Place objects within 14-18 in.
_____ Use short sentences and phrases.
_____ Allow adequate processing and response
time
SIMPLIFY
_____ Break familiar activities into single steps
_____ Provide cues, sequencing through each step
_____ Use familiar objects
_____ Provide safe objects
_____ 1:1 intervention during ADLs
_____ Anticipate and minimize safety problems
_____ Don’t rely on resident recalling or
remembering information
_____ Move slowly.
_____ Watch for non-verbal response.
COMMUNICATION
_____ Wait 10–20 seconds for response
_____ Speak slowly, couple with gestures
(visual/tactile)
_____ Anticipate needs
_____ Use nouns
_____ Ask close ended questions.
_____ Provide only 1 step directions
_____ Provide 2 choices
_____ Make choices for resident based on
information known about the resident
_____ Avoid written cues
_____ Look for non verbal communication
CUES
_____ Needs cues to process/follow 1 step
directions
_____ Cue through steps of familiar activity
Date:
_____ Cue through steps to engage in daily routine
_____ Cues needed to process and follow 1 step
Directions
_____ Primarily verbal cues with occasional visual
and tactile cues (gestures)
_____ Frequent verbal cues with visual and tactile
cues
_____ Environmental cues (ie shave in bathroom)
MIRRORING
_____ May mirror behavior. Demonstrate
appropriate behavior for situation/activity
Hand Over Hand
_____ Intermittent to initiate and complete task
ROUTINE & CONSISTENCY
_____ Incorporate personal routine & preferences
_____ Honor food likes/dislikes
AMBULATION
_____ 1 step directions with cues for use of
assistive device
_____ 1 step directions for steps of transfer
sequence
_____ Provide figure/ground color contrast in the
environment
_____ Provide meaningful activity to reduce
excess walking and or attempts at rising
_____ Clutter free walking area/path with places
to sit along path
_____ Proper shoes and orthotics as needed
_____ Visual aids in place
_____ Provide appropriate lighting
_____ Decrease glare
BATHING
_____ Set up safe environment and supplies
_____ Provide 1 step directions and appropriate
cues (verbal and visual/tactile as needed) to
sequence through each step
_____ Promote independence
Continued on back of sheet
Name:
Suggested Strategies
Middle Stage Cognitive Impairment
BATHING (cont)
_____ Insure safety – grab bars, physical
assist/close supervision as needed, adjust
water temperature
_____ Keep resident warm and covered
_____ Have shower area warm, reduce noise
Provide home like atmosphere
_____ Music/aromas to promote relaxation
_____ If anxious, offer sponge bath vs shower
_____ Simply explain each step of activity
_____ Move slowly and gently
_____ Use familiar products when available
_____ Gain trust and agreement by bathing feet
first and then moving upward
_____ Offer hair wash at beauty shop if anxious
GROOMING & DRESSING
_____ Set up supplies in safe environment
_____ Provide 1 step directions and appropriate
cues (verbal and visual/tactile as needed) to
sequence through each step
_____ Encourage independence
_____ Place objects in left to right sequence
_____ Place items in hand to initiate
_____ Maintain privacy and dignity – keep covered
_____ Maintain supervision for safety
_____ Provide safe choices of clothing, make up
etc.
_____ Provide 2 choices (clothing items etc.)
_____ Use familiar grooming products when
possible
TOILETING
_____ Set up all supplies
_____ Provide 1 step cues to sequence through
completion of all steps of activity
_____ Assist as needed to insure good hygiene
_____ Toilet transfer with _____ assist, verbal,
visual and tactile cues as needed
_____ Do not leave unattended on toilet
_____ Follow established toileting schedule
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Date:
EATING & DRINKING
Provide set up – simplify, removing items
that are not needed
Eliminate internal & external distractions
Provide _______ cues to eat/drink
Provide cue to initiate
Check consumption frequently during meal
and cue to continue as needed
Offer food 1 item at a time on separate
bowls/plates
Provide cues to alternate solids and liquids
Reduce unnecessary table clutter
Eliminate what is not needed
Reduce unnecessary noise/distractions
Provide color contract between food and
plate: ____________________________
Provide color contrast between plate and
table: ____________________________
Pre-cut food and remove knife
Closely supervise hot beverages
ADDITIONAL APPROACHES
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
Name:
Suggested Strategies
Middle Stage Cognitive Impairment
Date:
Name:
Suggested Strategies
Late – End Stage Cognitive Impairment
Therapist Signature:
PRESENTATION/APPROACH
_____ Eliminate all distractions.
_____ Make eye contact.
_____ Begin with using person’s name.
_____ Be close to person (as close as 8-14 in).
_____ Use single words / short phrases
_____ Allow time to respond.
_____ Present objects at eye level.
SIMPLIFY
_____ Single steps with appropriate level cues
_____ Gross motor aspects of activities
_____ Place dining objects directly in hand and
provide 1 step cues
_____ Use familiar objects
_____ Move slowly.
_____ Watch for non-verbal response.
COMMUNICATION
_____ Wait 20-30 seconds for response
_____ Speak slowly, couple with gestures
(visual/tactile)
_____ Anticipate needs
_____ Interpret facial expressions, vocalizations
_____ Caregiver must understand non-verbal
communication
_____ May respond with yes/no or phrases
_____ Provide 2 choices
_____ Avoid non-specific words, use nouns
_____ Make choices for resident based on
information known about the resident
_____ Monitor responses
CUES
_____ Sensory cues – music and aromas
(meaningful from long term memory)
_____ Constant verbal, visual and tactile cues
_____ Wait for subtle response
_____ Cues needed to process and follow 1 step
directions
_____ Environmental Cues (ie shave in bathroom)
Date:
MIRRORING
_____ May mirror behavior. Demonstrate
appropriate behavior for situation/activity
Hand Over Hand
_____ Provide to gain attention to activity,
coupled with verbal directions/cues to
initiate & complete task
ROUTINE & CONSISTENCY
_____ Incorporate personal routine & preferences
_____ Honor food likes/dislikes
_____ Include frequent rest periods
AMBULATION
_____ Non ambulatory – provide AA/PROM with
sensory stimuli.
_____ Provide safe/comfortable positioning
_____ Splints and positioning devices for
contracture management
_____ Provide cues for resident to assist with
rolling
_____ Provide cues for resident to grasp/hold rail
_____ 1 step directions with cues to use assistive
Device
_____ 1 step directions to sequence through
steps of transfer
_____ Increase figure/ground color contrast
_____ Provide meaningful activity to reduce
excess walking and or attempts at rising
_____ Clutter free walking area/path with places
to sit along path
_____ Proper shoes and orthotics as needed
_____ Visual aides in place
_____ Provide appropriate lighting
BATHING
______ Provide appropriate cues (verbal, visual,
tactile) to elicit movement of body parts
_____ Limit time of ADL to 15-30 minutes
_____ Keep resident warm and covered
_____ Have shower area warm, reduce noise
Continued on back of sheet
Name:
Suggested Strategies
Late – End Stage Cognitive Impairment
BATHING (cont)
_____ Homelike décor
_____ Music/aromas to decrease agitation and
promote relaxation
_____ Sponge bathing as appropriate
_____ Simply explain each step of activity
_____ Move slowly and gently
_____ Use familiar products when available
_____ Set up safe environment to prevent falls
_____ Adjust and monitor water temperature
_____ Gain trust and agreement by bathing feet
first and then moving upward
_____ Hair washed at beauty shop if anxious
_____ If anxious offer sponge bath
_____ Provide something to “hold”
_____ Ensure proper alignment and support of
body, including feet
GROOMING & DRESSING
_____ Promote participation – 1 step cues - verbal,
visual and tactile cues
_____ Inform resident of each step of activity
_____ Limit time to 15-30 min
_____ Hand over hand assist for oral hygiene
(higher level 1)
_____ Maintain privacy and dignity – keep covered
_____ Provide support of posture and feet
_____ Move slowly and gently
_____ Use familiar grooming products when
possible
TOILETING
_____ Verbal and tactile cues – toileting & pericare at bed level
_____ Set up all supplies
_____ Promote as much participation as possible
-postural movement, hold grab bar,
_____ Toilet transfer with _____ assist, verbal,
visual and tactile cues
_____ Assist with clothing management & hygiene
_____ Do not leave unattended
Date:
_____ Insure proper postural support of trunk and
feet
_____ Follow toileting schedule/routine
_____ Follow bowel and bladder program
EATING & DRINKING
_____ Insure safe and proper position –
head/neck, trunk and feet supported as
needed
_____ Visual, verbal, tactile cues
_____ Mirroring
_____ Hand over hand assist
_____ Finger foods
_____ Reduce external distractions
_____ Reduce internal distractions (ex. toileting)
_____ Gain attention prior to providing food/drink
_____ Allow significant response time
_____ Provide food and drink slowly
_____ Provide color contrast between
plate/food/table
_____ Provide 1 item at a time
_____ Provide frequent nourishment and liquids
_____ Use coated spoon between full bites
_____ Use adapted cup
_____ Place cup in hand with cues to drink
ADDITIONAL APPROACHES
_____ ____________________________________
____________________________________
____________________________________
_____ ____________________________________
____________________________________
____________________________________
_____ ____________________________________
____________________________________
____________________________________
_____ ____________________________________
____________________________________
____________________________________
_____ ____________________________________
Name:
Suggested Strategies
Late – End Stage Cognitive Impairment
Date:
Basic Activities of Daily Living: Using Adaptive Equipment
Using adaptive equipment includes recognizing a physical disability, recognizing an object as a substitute for normal activity, accepting the
equipment, and learning to use the equipment.
Level
GDS
2.0
Behavior
USING ADAPTIVE EQUIPMENT
Assistance
In early stage, patient discusses/compares
methods of equipment use to select best
approach. May be concerned with social
implications of equipment use.
Patient varies spatial properties (posture,
position or objects in space) in learning use
of equipment. Maneuvers wheelchair in
tight space, uses extension aids, one handed
can openers/appliances. Varies use to
discover better methods. May resist
following recommended use until a problem
is encountered. May not attend to hidden or
secondary properties, such as energy
expenditure, load on reacher. May not
anticipate routine maintenance of equipment.
May choose not to use equipment when it
requires too much energy or it is too timeconsuming.
As the disease progresses within this stage,
patient may have trouble varying spatial
properties, such as required by maneuvering
wheelchairs in small spaces or using
reachers. Still attends to all tangible
properties of objects and environment,
including qualities of floor and terrain that
affect ambulation.
Safety problems become more apparent
towards later stage 2.0 in that patient does
not consider spatial or surface properties
before actions (slowing gait for uneven
terrain). May choose not to use equipment.
Goal
Precautions
Patient will compare methods to
solve problems in equipment use.
Caregiver will identify potential
secondary effects to avoid
undesirable consequences.
Caregiver provides explanations of
potential secondary effects to be
avoided for safety or other reasons.
Reminds patient to perform routine
maintenance or checks needs for
patient. Equipment may be stored
away from view. Demonstration of
undesirable outcomes may increase
understanding and compliance with
suggested precautions.
As the disease progresses within this
stage, Caregiver monitors application
and use of new equipment until welllearned. Continues to point out
secondary effects to be considered for
safety reasons. Assists with
identifying simple principles of
judging distance and space, such as
checking door width in public
restroom for wheelchair access.
Patient will learn use of equipment
requiring neuromuscular
adjustments and will solve
problems requiring attention to all
tangible features with caregiver
assistance to avoid harmful effects.
Caregiver will supervise use of
appropriate adaptive equipment
until well-learned and will identify
secondary effects to be avoided for
safety reasons. Caregiver will
provide appropriate maintenance.
As the disease progresses within
this stage,
Patient will learn use of requiring
neuromuscular adjustments with
caregiver assistance to avoid
harmful effects.
Caregiver: Same as above.
Watch for impulsive behaviors
that may be unsafe.
Level
GDS
3.0
ACL
4.8 to
4.6
Behavior
ACL 4.8: Recognizes the loss of gross motor
capability, marked loss of strength, ROM,
coordination, or balance and can name
several visible effects of loss during the
process of doing an activity. May not
anticipate the effects of the loss in a new
activity. May learn a series of new actions
by rote, attending to all striking visible
effects on objects. May learn to use walker
with wheels, swivel eating utensils. May
don arm slings and prostheses, checking for
correct positioning by close examination.
Does not do neuromuscular adjustments or
anticipate secondary effects.
ACL 4.6: As the disease progresses within
this stage, Recognition of physical disability
is same; may be able to make a spontaneous
adjustment in position, duration, or strength
for a better effect (reducing downward
pressure on walker with wheels with better
mobility). Such adjustments may not be
sustained. May attempt to adjust one feature
of equipment (location of strap, foot rest)
without awareness of secondary effects
(edema, posture).
GDS
4.0
ACL
4.4 to
4.0
May recognize loss of gross motor
capability, marked loss of strength, ROM,
coordination, or balance as restricting ability
to complete a series of actions. May be
trained to use adaptive equipment that
requires a sequence of familiar actions
(walker) slowly, one step at a time. Does not
anticipate hazards, such as failure to lock
wheelchair brakes before transfer. Does not
generalize use of one piece of equipment to
similar piece of equipment; once learned,
may resist changes in equipment. May be
trained to don equipment as part of routine
dressing.
Assistance
Caregiver monitors application and
use of equipment until well-learned.
Caregiver provides explanation of
secondary effects or hazards to be
avoided. Caregiver solves problems
requiring neuromuscular adjustments
and monitors and provides for
maintenance of equipment.
As the disease progresses within this
stage, Caregiver supervises donning
complex equipment and checks
adjustment of all equipment. Takes
care of maintenance; stores equipment
in easy to access locations. Monitors
use until well-learned. Checks
environment to remove safety hazards
(rugs or slippery floors that impede
wheelchair, walker use).
Caregiver supervises donning
complex equipment and checks
adjustment of all equipment. Takes
care of maintenance; stores equipment
in easy to access locations. Monitors
use until well-learned. Checks
environment to remove safety hazards
(rugs or slippery floors that impede
wheelchair, walker use).
Goal
Patient will learn use of new
equipment that does not require
continuous neuromuscular
adjustments with caregiver
assistance to avoid harmful effects.
Precautions
Allow enough time for adapted
activity performance.
Monitor for undesirable effects
of patient’s adjustments.
Caregiver will supervise use of
appropriate adaptive equipment
until well-learned and will identify
secondary effects to be avoided for
safety reasons. Caregiver will
provide appropriate maintenance.
As the disease progresses within
this stage,
Patient will use adaptive equipment
by using familiar movement
patterns and will make simple
spontaneous adjustments for better
effects with caregiver assistance to
avoid harmful effects.
Caregiver will supervise
application and use of adaptive
equipment, and maintain
equipment to avoid undesirable
medical complications.
Patient will use adaptive equipment
using familiar movement patterns
to complete routine tasks with
assistance from caregiver to avoid
harmful effects.
Caregiver will supervise
application and use of adaptive
equipment, and maintain
equipment to avoid undesirable
medical complications.
Monitor for correct positioning.
Patient may forget to use
equipment.
Level
GDS
4.0,
cont.
ACL
4.4 to
4.0
GDS
5.0
ACL
3.8 to
3.6
Behavior
As the disease progresses within this stage,
patient acceptance of adaptive equipment is
dependent on both the sequence of familiar
actions and its outcome to do highly valued
tasks. Understands purpose of equipment
when effect is immediate; does not
understand secondary effects such as
contracture prevention or energy
conservation. If equipment requires
neuromuscular adjustments in positioning or
use, patient may abandon use or use in an
unsafe manner (leaning on crutches or
walker).
May recognize the visible effects of a
physical disability when this is pointed out
but may not understand the medical cause.
Knowledge of deficit may increase
acceptance of adaptive equipment.
Patient may imitate a familiar action to use a
piece of equipment (washing body with hand
mitt). May be able to learn to use familiar
object or adaptive device using a normal
action after much repetitive drilling.
GDS
6.0
ACL
3.4 to
3.0
At initial stage, patient may recognize loss of
gross motor capability, limb or grasp. May
not note loss of strength, coordination,
ROM. May accept adaptations that allow
dominant hand to be used in a normal
manner (built-up spoon). Does not imitate a
modification of a normal action but repeats
habitual actions over and over, or until
distracted. May be able to propel wheelchair
forward or backward but cannot get around
furniture or through small doors.
Assistance
As the disease progresses within this
stage, Caregiver supervises
application or applies adaptive
devices for patient. Points out visible
cues to assist patient in correct
application. Stores equipment in
visible locations to assist in
remembering to use equipment.
Wheelchairs may be preferred for
ambulation disabilities as patient may
not be able to safely use crutches or
walkers.
Goal
Precautions
Caregiver points out visible effects of
enhanced performance with adaptive
equipment or uses visible effects of
disability to assist with acceptance of
equipment and compliance with safety
precautions.
Caregiver will apply and supervise
use of all appropriate adaptive
equipment to avoid undesirable
medical conditions.
Watch for falls in transfers or in
ambulation with a new physical
disability. May wander and get
lost. Watch for discomfort that
may result in striking out.
Uncomfortable positioning
devices may be refused or
removed.
In addition, Caregiver applies and
supervises use of all adaptive
equipment. Wheelchairs preferred for
ambulation difficulties; extra locks
may prevent wandering. Clears space
to increase mobility and avoid
damage to furniture. Splints, slings,
and other passive positioning devices
need to be regularly checked. Stops
repetitive actions
Caregiver applies and supervises use
of all adaptive equipment.
Wheelchairs preferred for ambulation
difficulties; extra locks may prevent
wandering. Clears space to increase
mobility and avoid damage to
furniture. Splints, slings, and other
passive positioning devices need to be
regularly checked. Stops repetitive
actions.
Patient will perform familiar
actions with aid of appropriate
adaptive equipment with assistance
to avoid harmful effects.
Remove potentially harmful
adaptive equipment.
Caregiver will apply and supervise
use of all appropriate adaptive
equipment to avoid undesirable
medical conditions.
Patient will perform familiar
actions with aid of appropriate
adaptive equipment with assistance
to avoid harmful effects.
Watch for falls in transfers or in
ambulation with a new physical
disability. May wander and get
lost. Watch for discomfort that
may result in striking out.
Uncomfortable positioning
devices may be refused or
removed.
Remove potentially harmful
adaptive equipment.
Level
GDS
6.0,
cont.
ACL
3.4
Behavior
May be able to propel wheelchair forward or
backward but cannot get around furniture or
through small doorways; forgets to lock
brakes and may get lost if allowed outside.
May contribute loss of abilities to nonmedical case, such as “I am weak because
you don’t feed me enough.”
Assistance
ACL
3.2
As this stage advances, patient may still
recognize loss of gross motor capability,
limb or grasp. Spontaneously grasps piece
of equipment and begins associated action
based on the appearance of equipment. Does
not sequence actions or note effects. Stops
and stops on command.
Caregiver applies equipment (bed
rails, safety straps, anti-pressure
cushions) and monitors for correct fit.
Caregiver selects and maintains all
equipment. Pushes wheelchair and
locks to prevent aimless wandering.
Security locks, gates, extra locks on
wheelchairs, may prevent getting lost.
Slip proof mats and treads prevent
falls in the bathroom. Shower chair,
tub bench, transfer tub bench, raised
toilet seat, and may be used to assist
positioning.
Patient will do associated actions
with equipment that resembles
familiar objects.
At end stage 6, patient will grasp a piece of
equipment offered or eye level or may
put/throw it down. Does not use crutches,
canes, or walkers.
No awareness of physical disability. No
understanding of purpose of equipment. Sits
in wheelchair but is unable to propel or
propels for a short distance without
awareness of destination. Uses grab bar
when cued and may assist with use of
transfer bar (ACL 2.4). May push or pull
with upper extremities to shift body position
in wheelchair when cued (ACL 2.8). May
attempt to sit, stand, walk, use arms in
normal manner requiring restraint to prevent
falls. May refuse to wear uncomfortable
equipment.
Caregiver assists same as 3.2.
Wheelchairs are preferred for
ambulation and built-up utensils may
be offered at eye level.
Caregiver applies equipment (bed
rails, safety straps, anti-pressure
cushions) and monitors for correct fit.
Caregiver selects and maintains all
equipment. Pushes wheelchair and
locks to prevent aimless wandering.
Security locks, gates, extra locks on
wheelchairs, may prevent getting lost.
Slip proof mats and treads prevent
falls in the bathroom. Shower chair,
tub bench, transfer tub bench, raised
toilet seat, may be used to assist
positioning.
Patient will grasp and feed self
with built up spoon; will use
wheelchair.
Same as 3.4
Caregiver will apply and monitor
use of all adaptive equipment to
avoid undesirable medical
complications.
Watch for falls in transfers or in
ambulation with a new physical
disability. May wander and get
lost. Watch for discomfort that
may result in striking out.
Uncomfortable positioning
devices may be refused or
removed.
ACL
3.0
GDS
7.0
ACL
2.8 2.0
Goal
Precautions
Same as 3.4
Same as 3.4
Caregiver will apply and supervise
use of all appropriate adaptive
equipment to avoid undesirable
medical conditions.
Patient will cooperate with
transfers, positioning, by grabbing
bars or pushing/pulling when cued
by caregiver.
Level
GDS
7.0,
cont.
ACL
1.8 –
1.0
Behavior
No awareness of physical disability. No
understanding of purpose of equipment.
With tactile cues, may hold up arms, legs, or
trunk while splint or straps are applied.
Assistance
Caregiver applies equipment (bed
rails, safety straps, anti-pressure
cushions) and monitors for correct fit.
Caregiver selects and maintains all
equipment.
Goal
Caregiver will apply and monitor
use of all adaptive equipment to
avoid undesirable medical
complications.
Precautions
Check for improper fit or
positioning of equipment that
may restrict blood flow or cause
discomfort.
Patient will cooperate by holding
body parts against gravity (ACL
1.8)
Resource: Allen, C., Earhart, C., & Blue, T. (1992). Occupational Therapy Treatment Goals for the Physically and Cognitively Disabled. Bethesda, MD: The
American Occupational Therapy Association, Inc.
Environmental Modifications & Compensation: Architectural Barriers and Safety
Environmental compensations are used to reduce disabilities and prevent medical complications associated with residual physical impairments.
Following are guidelines per stage of cognitive function. The stated levels use a cross-walk between the Global Deterioration Scale (GDS) and the
Allen Cognitive Level (ACL); it is important to recognize that the crosswalk is simply a guide and not a definitive final determination. An
individual with dementia can demonstrate fluctuating levels of function over the course of the day, week and month and may flex between levels.
In addition, individuals with dementia typically do not reside in nursing homes until the latter stages of dementia, commonly Stages 5-6-7 on the
GDS or Stages 1-2-3 on the Allen Cognitive Scale.
Key Principles for Intervention:
1. The concept of environmental function is to elicit function and enhance quality of life through a well-designed environment,
2. The priority of care for an individual is modification of the environment to facilitate remaining residual abilities.
3. Consistent with this care priority, the individual must be able to find whatever he/she is looking for, recognize it, and then use it safely.
4. The care or therapeutic need is given priority over the aesthetic effect of any change in the environment.
5. Specific modifications are listed in list format at end of table.
Level
GDS
2.0
ACL
5.0-5.8
Functional Outcome
Compensate for impaired mobility and
architectural barriers to reduce personal care,
locomotion, and/or body disposition
disabilities, and prevent medical
complications.
ARCHITECTURAL BARRIERS AND SAFETY
Treatment Methods
Caregiver Assistance
Collaborate with patient and caregiver Standby: To provide cuing to
to anticipate home/work and
anticipate hazards, provide more
environmental barriers. Identify need efficient actions.
for safety equipment, relevant
adaptive equipment, and other
environmental adaptations. Plan
actions for patient to use relevant
assistive/adaptive equipment. Begin
training patient in standard procedures
with environmental aids. Anticipate
need for extra assistance and provide
a plan to direct others. Teach
caregiver methods to facilitate
carryover.
Precautions
Make final assessment of
equipment needs after making a
home visit and before ordering
equipment.
Level
GDS
3&4
ACL
4.0 to
4.8
GDS
5&6
ACL
3.8 to
3.0
Functional Outcome
Compensate for impaired mobility and
architectural barriers to reduce personal care,
locomotion, and/or body disposition
disabilities, and prevent medical
complications.
Compensate for impaired mobility and
architectural barriers to reduce personal care,
locmotor, and/or body disposition
disabilities associated with patient care;
prevent medical complications and protect
environment.
Treatment Methods
Collaborate with caregiver and patient
to confirm future needs. Emphasize
avoiding potential problems and
simplifying task environment. Teach
caregiver to identify and remove
potential safety hazards in the home
and community. Adapt home
environment to minimize barriers and
avoid potentially hazardous situations,
such as nonslip mats, rearrangement
of furniture, grab bars, bath bench,
etc. Initiate training of patient in
standard procedures. Train caregiver
in methods and supervise performance
with patient to facilitate compliance
with safety standards.
Collaborate with caregiver to confirm
future needs. Protect patient by
adapting home/living environment,
including but not limited to: non-slip
treads, stabilizing rugs, wiping up
floor spills, avoiding changing basic
familiar pattern of furniture, safety
rails, using stove burner and electrical
outlet covers. Begin rote teaching for
integration into procedural memory in
standard procedures with
environmental aids. Protect
environment by using toilet seat cover
locks and removing valuables that can
be knocked over. Train caregiver in
methods and supervise performance
with patient.
Caregiver Assistance
Minimum: To continue training
patient with environmental aids;
removal of safety hazards and
assisting with unfamiliar
architectural barriers.
Precautions
Caregiver to prevent medical
complications associated with
potential safety hazards.
Make at least two home visits:
one with caregiver to confirm
before ordering equipment and
one with caregiver and patient
to practice methods in situationspecific settings.
Do not expect patient to
generalize procedures learned in
clinic to home and community
environments.
Moderate: To continue rote
teaching with practice; complete
sequencing of standard procedures;
protect patient and environment.
Same as ACL level 4.0 – 4.8.
Patient and environment need to
be protected due to absence of
goal directed behavior on the
part of the patient.
Simplify verbal instructions
with the patient, i.e., noun +
verb.
Level
GDS
7.0
ACL
2..0 –
2.8
Functional Outcome
Compensate for impaired mobility and
architectural barriers to reduce personal care,
locmotor, and/or body disposition
disabilities associated with patient care;
prevent medical complications and protect
environment.
GDS
7.0
Compensate for impaired mobility and
architectural barriers to reduce personal care,
locmotor, and/or body disposition
disabilities associated with total patient care;
prevent medical complications and protect
environment.
ACL
1.8 to
1.0
Treatment Methods
Collaborate with caregiver to
anticipate future needs, including
environmental adaptations and safety
equipment. Initiate facilitating
postural actions to use grab bars and
bath seats. Provide environmental
adaptations to ensure patient safety,
such as padding guardrails, use of
joint pads, restraints, positioners, etc.
Adapt home environment to facilitate
wheelchair/bed maneuverability.
Train caregiver in methods and
supervise performance with patient.
Collaborate with caregiver to
anticipate future needs. Provide
environmental adaptations to ensure
patient safety, such as padding
guardrails, applying joint pads and
positioning devices. Train caregiver
in proper positioning techniques.
Caregiver Assistance
Maximum: To facilitate postural
actions to use environmental aids;
protect patient and environment.
Precautions
Caregiver to prevent medical
complications.
Protect the environment in the
event the patient is mobile
through his/her own actions.
Total: To position and protect
patient.
Caregiver to prevent medical
complications.
Resource: Allen, C., Earhart, C., & Blue, T. (1992). Occupational Therapy Treatment Goals for the Physically and Cognitively Disabled. Bethesda, MD: The
American Occupational Therapy Association, Inc.
SPECIFIC MODIFICATION
One of the greatest concerns facing caregivers for individuals with Alzheimer’s disease, both in the home
environment and in assisted/long-term care settings, is potentiality for wandering away and becoming
lost. Exit control and maintaining the least restrictive environment can be difficult goals to achieve
simultaneously; the following is a list of ideas that may be utilized.
1. Simple Methods to Prevent Elopement (Individuals with Alzheimer’s disease that leave without
supervision or the capability of finding their own way back.)
• Home setting – Move the door lock from their normal placement near the doorknob to either the
top or bottom of the doorway.
• Identification band or metal ID bracelet with inclusion of name, address and telephone number
for added safety.
• Conceal entrances and exits that must remain unlocked through the one of the following
• Wall or screen placed across the entrance to conceal it;
• Horizontal min-blinds the same color as the door;
• Lightweight cotton covering the same color as the door.
• Any plans to place visual barriers on exits should be reviewed by the fire marshal before use.
2. Secure Systems Outdoors
• Outdoors area must also be secured.
• Automatically locking doors;
• If stockade fence – soften look with plants.
3. Electronic Systems
• Alarm systems of varying sophistication are available,
• Consideration – cost factor
4. Spaces for Wandering and Pacing
• Pacing is one common characteristic of individuals with Alzheimer’s disease and is a need that
•
needs to be met.
Regularly scheduled exercise may help provide a satisfying substitute.
5. Outdoors Spaces
• Fenced in back yards at home and outdoor parks at long-term care facilities are ideal for outdoor
•
•
wandering.
Flat surfaces and secure gates are needed so the person can wander or pace without constant
supervision or constant companion.
The way back to the house/facility should be visible from all corners of this outside area.
6. Indoor Spaces
• Long hallways and large day areas are often chosen for wandering or pacing by the individual
•
•
•
with Alzheimer’s disease.
Careful attention needs to be given to maintaining the wide hallways free of clutter, carts and
“bunching” of slow moving residents in wheelchairs.
Sturdy handrails for unsteady walkers are highly recommended.
Keep in mind that long hallways and the glare from overhead lights may increase the perceptual
deficits common in the later stages of the disease/syndrome.
7. Places to Gather
•
•
Key is to promote pleasant, comfortable settings for social interaction.
Intent – homelike living areas, not bare.
8. Furniture Arrangement
• Consider arrangement of chairs and sofas in “conversational groupings” to encourage
•
conversation.
Chairs arranged in rows or lined up against a wall discourage social interaction.
9. Televisions
• A television placed in a day room can draw individuals together and enhance the social
•
atmosphere.
One aspect to remember – Individuals will experience increased difficulty comprehending the
television programs and/or discriminating through the background noise as disease progresses;
consideration needs to be given to areas without television in the background or eliminating
distractions during primary activities of daily living.
10. Places to Get Away
• Places to get away from the crowds and noisy areas offer a quiet space for peace and quiet.
• Available space for this purpose is rare in long-term care.
• Consideration – Can a “quiet spot” be identified in your setting?
11. Natural Areas
• Access to outdoor areas where one can experience the sounds and sights of outside promotes
•
relaxation and ‘sense of peace’ for people with Alzheimer’s disease.
This is an important adjunct for quality of life.
12. Sensory Input
• One of the greatest opportunities for environmental modification is sensory input.
• Utilization of sensory input through the visual modality and use of texture can enhance intact
•
•
functional abilities.
Attention should be focused on minimizing extraneous background noise and smells.
One consideration would be for staff to reduce “rushing from one task to another” with moving
more slowly and keeping voice low when helping residents.
13. Visual Input - Considerations
• Use black and white line drawings of the object or representative symbols to facilitate
•
•
•
•
•
•
comprehension. Examples would include the outline of a toilet for a bathroom and knife, fork,
and spoon for the dining room.
Use written single words to identify room, object, other
Be selective in use of colors.
Peach, pink, beige, ivory, light blue, green, and lavender are relaxing colors.
White, yellow, orange and red are livelier, more stimulating colors.
Alternating black and white color segments can appear as holes that need to be avoided.
Mirrors can be confusing due to the perceptual discrimination deficits in the later stages of the
disease.
14. Olfactory Inputs – Overall, reduce or eliminate strong and offensive odors.
15. Aural Inputs
• Loud noises can trigger agitation and restlessness.
• Quiet time with lights dimmed can facilitate a calm and restful state and reduce sundowning
syndrome.
Basic Activities of Daily Living: Bathing
Bathing includes using soap, water, towel, and toiletries to clean, rinse, dry, moisturize, and deodorize body and hair. Bathing may be done in bed,
bathroom tub or shower. Excludes grooming.
Level
GDS
2.0
ACL
5.8 to
5.0
GDS
3.0
ACL
4.8 to
4.6
GDS
4.0
ACL
4.4 to
4.0
Behavior
Initiates and completes routine bathing
routine bathing independently. Attends to
all surface qualities of skin, nails, hair, and
may make bath product selections based on
the subtle effects produced by these
products. May not read labels of new
products; may fail to consider passage of
time, alter rate of bathing, or to anticipate
hazards in a new environment.
May coordinate bathing schedule with
others. Attends to all striking features of self
and bathing environment. Checks quality of
results on completion. May learn a new
procedure, such as bathing to conserve
water) by rote. Understands secondary
effects when they are explained; examples
include need to conserve water, drying
effects of prolonged or too frequent bathing,
scheduling baths to avoid inconvenience to
others. Reports low supplies to caregivers.
Initiates bath, shower and shampoo at
customary time and follows typical schedule
invariantly. May collect supplies from
familiar locations. May want same products.
May use excessive amounts of shampoo or
lotion thinking that “more is better.” May
not do fine-motor adjustments to open tight
or unusual containers. May resist changing
routine to accommodate heat or exercise.
Little or no awareness of sharing bathing
space and supplies with others; may not
hang up towels, clear area of toiletries, etc.
BATHING
Assistance
Caregiver explains secondary effects
(i.e., frequency, conservation, social
rules if shared space) as needed.
Caregiver explains secondary effects
(i.e., frequency, conservation, social
rules if shared space) as needed.
Caregiver provides needed supplies in
open cupboards or shelves.
Goal
Patient will complete routine
bathing independently and will
check quality. Patient will
understand explanations of
secondary effects.
Caregiver will explain secondary
effects that may result in harm or
undesirable social consequences/
Patient will initiate and complete
routine bathing with variations in
daily schedule, product use, or
product storage with assistance to
avoid harmful or undesirable
effects.
Precautions
Remove unforeseen hazards.
Caregiver explains consequences of
changes in product use or routine.
Caregiver purchases familiar bathing
supplies, clearly labeled, and stores in
visible location within 24 inches of
tub/shower. Check for results. Point
out missed hidden body parts.
Patient will initiate and complete
bathing by securing own supplies
from visible locations, with
assistance to avoid harmful effects.
Caregiver will provide familiar,
safe set-up and be available to
solve problems, check results.
May become upset if routine
products are not available.
Allow ample time for task
completion. Protect from
unforeseen hazards, such as
slippery floor, electrical
appliances near water.
Level
GDS
4.0,
cont.
ACL
4.4 to
4.0
GDS
5.0
ACL
3.8 to
3.6
GDS
6.0
ACL
3.4 to
3.0
Behavior
As the disease progresses within this stage,
patient will recognize need for bath but may
initiate at inappropriate time. Collect
supplies from visible location and follows
routine but may miss small or hidden places,
such as back of head, ears, and fingernails.
Awareness of environment diminishes with
failure to ask for help when a problem is
present such as no soap or unfamiliar
controls on the faucets. May not note wet
floors.
Actions of washing follow perimeter of
body; may try to do back. May stop when
problem is encountered, such as no shampoo
or soap, but may not ask for help. May
forget steps in a sequence (rinse or dry).
Does not measure amounts of shampoo,
lotions, or deodorant.
Picks up washcloth, soap, towel, and wipes
easy to reach body parts. Starts and stops
actions on command. Does not sequence
actions. May wash in one spot, forget to use
soap. May forget to rinse or dry off. May
stay in tub or shower for long time if
allowed. May initiate bath or shower at odd
time.
As the disease progresses within this stage,
patient may spontaneously grasp washcloth,
soap and/or towel and initiate associated
movement.
At later stage 6, patient grasps washcloth,
soap, towel or shampoo or puts them down
when placed in hand. May do back and forth
movements for brief periods.
Assistance
As the disease progresses within this
stage, caregiver places needed
supplies in arm’s length, visible.
Demonstrates unusual controls on
faucets; opens unusual product
dispensers. Uses anti-slip mats. May
leave unsupervised with set-up.
Goal
Patient will complete bath or
shower with set-up to avoid
harmful effects.
Precautions
Store supplies in hidden
cupboards or lock bathroom
door to limit bathing at
inappropriate times. Watch for
floods, falls. May take 2-3
times average to complete task.
Reminds patient when to bath;
prohibits too frequent bathing.
Provides essential safe tools at proper
times. Sequences with verbal cues
through correct routine. Pre-measures
amounts of shampoo or lotion.
Reminds patient to wash hidden areas.
Washes hard to reach areas for
patient. Checks water temperature.
Early Stage 6: Reminds patient when
to bath; prohibits too-frequent
bathing. Provides essential safe tools
at proper times. Sequences with
verbal cues through correct routine.
Pre-measures amounts of shampoo or
lotion. Reminds patient to wash
hidden areas. Washes hard to reach
areas for patient. Checks water
temperature.
Patient will follow cues to
complete bathing and shampooing
routine and will state when he or
she is done.
Restrict access to harmful
materials. Expect waste if
allowed to measure amounts.
Do not leave unsupervised for
more than a few minutes.
As the disease progresses within this
stage, additional caregiver assistance
is required. Caregiver hands bathing
tools to patient while in bath or seated
in shower. Starts and stops actions
with short commands.
Caregiver will initiate and
supervise bathing. Will
demonstrate modifications for
more effective results.
Patient will sustain familiar actions
to complete a bath or shower and
shampoo with assistance to
sequence actions.
Watch for impulsive actions that
may result in falls.
Do not leave alone. If showers
are attempted, watch for
flooding and falls. Check water
temperatures. Patient may leave
tub or shower before done.
Caregiver will initiate and
supervise bath and shampoo; will
sequence through actions.
Patient will start and stop actions
on command.
If shower is attempted,
caregiver will get wet.
Patient will grasp familiar bathing
tools when placed in hand.
Remove sharp or dangerous
objects from reach. Do not
leave patient. Watch for falls on
wet floor.
Caregiver will initiate and
supervise bathing; providing
assistance.
Level
GDS
7.0
ACL
2.8
ACL
2.6 2.4
ACL
2.2 to
2.0
ACL
1.8 to
1.6
ACL
1.4 to
1.0
Behavior
Uses grab bars to get in and out of tub.
May walk to bathroom and step into tub with
assistance. Moves body parts on command.
May be able to bend at waist to put head
under faucet for shampoo.
Sits for sponge bath. Moves extremities.
Moves trunk to assist or prevent falling to
one side. May do a pivot transfer with
assistance. Aware of caregiver’s efforts to
bathe.
May move arms or legs, or may roll over to
assist with bathing with proprioceptive cues.
May hold trunk or other body part against
gravity with continuous cuing. May resist
bathing.
No awareness of need to bathe. May move
away from caregiver’s touch.
Assistance
Caregiver baths patient (sponge or
seated tub bath). Cues to walk to
bathroom. Uses bathing chair, nonskid bath mats. Dries patients in both
to avoid falls.
Same as 2.8
Caregiver gives sponge bath to patient
in bed or seated in chair. Gives verbal
commands to move body parts.
Goal
Patient will cooperate with bathing
by using grab bars to stabilize.
Caregiver maintains cleanliness to
avoid undesirable medical
complications.
Patient will cooperate with bathing
by moving body parts.
Caregiver maintains cleanliness to
avoid undesirable medical
complications.
Precautions
Baths recommended avoiding
falls. May be frightened by risk
of fall and refuse to enter tub.
Grasp of grab bars may be too
weak or tight. Moves slowly
Baths recommended to avoid
falls. May be frightened by risk
of fall and refuse to enter tub.
Watch for discomfort, which
may result in striking out.
Watch for falls.
Caregiver gives sponge bath to patient
in bed with passive supports.
Touches body parts to cue desired
movements.
Caregiver maintains cleanliness to
avoid undesirable medical
complications.
Monitor for skin problems.
Patient may resist both.
Caregiver gives sponge bath to patient
in bed.
Caregiver maintains cleanliness to
avoid undesirable medical
complications.
Monitor for skin problems due
to uncleanliness.
Resource: Allen, C., Earhart, C., & Blue, T. (1992). Occupational Therapy Treatment Goals for the Physically and Cognitively Disabled. Bethesda, MD: The
American Occupational Therapy Association, Inc.
Basic Activities of Daily Living: Dressing
Dressing includes selecting and putting on clothes with consideration for the time of day, temperature, season, comfort, and how garments go
together. Dressing includes obtaining clothes from storage areas, dressing and undressing in a sequential fashion, fastening and adjusting clothing
and shoes, and applying and removing assistive or adaptive equipment, protheses, or orthoses.
Level
GDS
2.0
ACL
5.8 to
5.0
GDS
3.0
ACL
4.8 to
4.6
Behavior
Speculates and plans for dressing needs,
including considering all properties of
garments, demands of social situation,
donning time, personal resources, for
routine, special events.
DRESSING
Assistance
None needed
As the disease progresses within this stage,
the criteria for wardrobe may be
idiosyncratic or “to be different.” Results
may be odd or idiosyncratic. Varies
strength, range of motion, in donning tight
fitting garments or shoes and working
clasps, ties, straps.
Caregiver offers explanations of
undesirable secondary effects of
selections. Check for proper donning
of complex adaptive equipment.
Searches for desired clothing items in drawer
or closet and considers all striking features
of garments including color, pattern,
condition, and general fit. May not attend to
less striking features such as cleanliness,
fabric type, or current style in making
selection. May don clothing slowly,
checking results by examining in mirror
from several angles on completion. Learns
by rote a sequence of new actions, such as
putting on prosthesis. May recognize
predictable problems with fit or function of
adaptive equipment. As the disease
progresses within this stage, fine motor
adjustments (jewelry fasteners, small bows,
necktie, and buckles) may be abandoned.
Changes one item in a familiar outfit to
produce a “new” outfit; does not consider hw
change affects whole look. Follows
suggested ideas for spatial adjustments, i.e.,
location of scarf, strap on splint.
Caregiver points out consequences of
selection, such as being underdressed
or overdressed for the weather or
occasion. Demonstrates new
sequences of actions.
Goal
Patient dresses self, including
putting on and removing adaptive
equipment, independently and in a
timely fashion.
Patient will consider coordination
of clothing for pleasing effects
with caregiver assistance to
identify social consequences.
Caregiver will explain secondary
effects of selections to avoid
undesirable consequences.
Patient will dress self
independently and will vary
combinations one feature at a time.
Patient will select garments
considering all striking features
with caregiver assistance to
consider secondary effects.
Caregiver will explain secondary
effects of selection to avoid
undesirable consequences.
Precautions
May resist suggestions to alter
selections based on secondary
effects.
Allow additional time for new
garments for making new
combinations.
Monitor for appropriateness of
new combinations.
Level
GDS
4.0
ACL
4.4 to
4.0
GDS
5.0
ACL
3.8 to
3.6
GDS
6.0
ACL
3.4 to
3.0
Behavior
Initiates dressing at customary time of day.
Selects items from wardrobe but may fail to
consider time of day, temperature, season,
cleanliness, coordination of color. May want
to wear the same outfit over and over or to
an event because “I wore it there before.”
May miss subtle problems such as shirt out
in back, skirt too short for slip, missing
buttons, tears. Dons items slowly in correct
sequence; may use accessories incorrectly.
May be trained to initiate dressing at a
particular time of day. Dons all common
articles of clothing slowly with some errors
in sequence. Recognizes when dressing is
completed (all body is covered). Stops when
a problem occurs, such as a broken zipper;
may not ask for help. May imitate a
modification of a habitual action (pulling on
shoes).
Picks up garment in close proximity and
begins to don it. Associates action with
garment type. May stop before completion,
but may resume on command. May pick up
any nearby garment. May be unable to don
tight-fitting garments, hosiery, or do
fasteners.
As the disease progresses within this stage,
patient grasps garment offered at eye level or
puts/throws it down. May walk away.
Assistance
Caregiver simplifies selections by
reducing number of available
garments, or groups garments in ready
to wear combinations. Suggests
changes for inappropriate choices.
Caregiver groups clothing items in
drawers or closet to assist in proper
selection or provides corrections to
poor selections. Assists with small,
hidden, unusual fasteners.
Demonstrates simple modifications in
habitual actions that increase effective
donning; expect to repeat such
instruction next time. Puts on and
adjusts adaptive equipment.
Caregiver hands garment to patient
and cues to move. Guidelines for
Assistance:
1. Selects clothes.
2. Positions garments next to body
part and cues patient to move when
appropriate. As this stage
progresses, the caregiver will need
to hand garment to patient, one at a
time.
3. Redirect attention as necessary.
4. Works fasteners, laces.
5. Applies adaptive equipment.
6. Monitors clothing for periodic readjustment
Goal
Patient will initiate and complete
dressing at customary time of day
with assistance in selecting and
donning.
Caregiver will provide assistance
in selection and donning, will
check results, and correct errors.
Will apply and adjust adaptive
equipment.
Patient will complete dressing with
caregiver assistance.
Caregiver will provide assistance
in donning and doffing, will check
results and correct errors. Will
apply and adjust adaptive
equipment.
Patient will complete dressing with
caregiver assistance.
Patient will grasp and being correct
actions of donning familiar
garments.
Patient will grasp garments when
handed to him/her.
Caregiver will select and assist
with donning clothes and adaptive
equipment.
Precautions
Allow ample time for
completeness of dressing (2-3
times average rate).
May be upset if familiar
combinations are not available.
May argue with suggested
corrections of errors.
May argue with caregiver
suggestions to change
selections. Monitor all adaptive
equipment for proper fit to
avoid medical complications.
May reject offered garment.
Avoid unfamiliar, tight fitting
apparel.
Level
GDS
7.0
ACL
2.8
Behavior
This stage shows a progression from
extensive assist to dependent status. The
following grooming characteristics may be
present.
ACL
2.8
Stands, sits, grabs onto bars, railing, or other
support for stability while being dressed.
Usually moves slowly.
ACL
2.6 2.2
ACL
2.0
Assistance
Caregiver will dress patient, apply
adaptive equipment to avoid
medical complications.
Caregiver selects garments and
dresses patient. Uses loose-fitting,
easy to remove garments.
Sits while being dressed. Pushes arm or leg
through garment when held next to body
part. May remember and initiate familiar
dressing movements (raising arms
overhead).
Caregiver selects clothes. Positions
garments nest to body part and cues
patient to move when appropriate.
Works fasteners, laces; applies
adaptive equipment. Monitors
clothing for periodic readjustment.
Sits while dressed by caregiver. Moves
extremities or trunk to assist with donning.
Caregiver selects garments. Verbally
commands or tactile cues to move
trunk or body parts. Loose fitting
garments.
ACL
1.8
Patient may move arm or leg to assist with
donning garments, and equipment when
used..
ACL
1.6 to
1.0
Unable to select, obtain or don clothing or
adaptive equipment.
Goal
Caregiver selects garments. Verbally
commands or provides tactile cues to
elicit cooperative gestures. Loose
fitting garments preferred.
Caregiver selects garments and
dresses patient.
Patient will use grab bars or other
objects for stability while dressing.
Patient will push arms and legs
through garments when cued to
assist with dressing.
Caregiver will dress patient, apply
adaptive equipment to avoid
medical complications.
Patient will move arms, legs, trunk,
in response to cues to assist with
dressing.
Caregiver will dress patient, apply
adaptive equipment to avoid
medical complications.
Caregiver will dress patient, apply
adaptive equipment to avoid
medical complications.
Caregiver will dress patient, apply
adaptive equipment to avoid
medical complications.
Precautions
Inspect for signs of binding,
skin redness from ill-fitting
garments or adaptive
equipment. Ensure stability
(chair with back or wheelchair).
Watch for needed readjustment.
Dons shoes, pants while seated
to avoid falls.
Same as 2.8 (above)
Same as 2.8
May resist dressing.
Inspect for signs of binding,
skin redness from ill-fitting
garments or adaptive
equipment.
Inspect for signs of binding,
skin redness from ill-fitting
garments or adaptive
equipment.
Resource: Allen, C., Earhart, C., & Blue, T. (1992). Occupational Therapy Treatment Goals for the Physically and Cognitively Disabled. Bethesda, MD: The
American Occupational Therapy Association, Inc.
Basic Activities of Daily Living: Eating
Eating includes sitting at the table, putting food in the mouth, cutting food into bite-sized pieces, chewing and swallowing without letting food
escape, removing food that soils from face, hands and clothing, adjusting pace and sequencing according to food temperature; adjusting
seasonings, and opening packages.
Level
GDS
2.0
ACL
5.8 to
5.0
GDS
3.0
ACL
4.8 to
4.6
Behavioral Characteristics
Seeks information about tangible secondary
properties of food, either through reading
label or asking about ingredients before
eating to comply with special diets. May
attempt to discern table etiquette in order to
comply with social standards in a new
situation.
As the disease progresses within this stage,
patient may be aware of socially appropriate
table manners but may chose not to alter
behavior. May express strongly held food
preferences. May understand explanations
of food groups and dietary restrictions but
choose to not alter diet. May not see crumbs
or small spills but cleans up when cued.
Attends to all striking visible features of
food and social situation. Eats and attends to
social conversation though may not be able
to talk and eat at the same time. Manages all
utensils use. Follows a schedule prepared by
others of mealtimes or special dietary needs.
May need to be reminded to check for less
tangible food properties (temperature,
spiciness) and may not be able to apply
principles of dietary restrictions. Can learn to
use new utensils or procedures of eating new
foods by rote.
EATING
Assistance
Caregiver assists with identifying all
properties of food to comply with
dietary restrictions.
Goal
Patient will feed self independently
and will learn use of new utensils
by varying actions. Patient will
comply with dietary restrictions
with assistance from caregivers.
Precautions
May not comply with dietary
restrictions.
Caregiver will identify applications
of dietary restrictions in new foods.
Caregiver assists with identifying all
properties of food to comply with
dietary restrictions.
Patient will feed self independently
and will learn use of new tools or
utensils.
Caregiver will identify applications
of dietary restrictions in new foods.
Monitor new food for
compatibility with dietary
restrictions.
Level
GDS
3.0,
cont.
ACL
4.8 to
4.6
GDS
4.0
ACL
4.4 to
4.0
Behavioral Characteristics
As the disease progresses within this stage,
patient alter rate of eating upon request but
may not sustain. Attempts to vary actions to
open an unusual container or to cut food
more effectively but may not succeed.
Initiates coming to table at routine times of
day. Uses common utensils in customary
fashion. May see and clean up/request help
for highly visible spills or dropped food
items, but doesn’t anticipate these errors,
such as pouring liquids to fast, tilting plate
being passed, and picking up hot plate
without hot pad. Attempts to
comply/replicate standard social behavior for
table manner when reminded. May have
trouble waiting for others, for food to cool or
be served, but understands the explanation
for the delay. Recognizes well-learned
special diets. May resist changes in diet and
menu.
As the disease progresses within this stage,
patient may not attend to spillage or crumbs
and use of knife/fork may be clumsy. May
be unable to eat and talk at the same time but
indicates awareness of others at the table.
Overfills liquid containers. May refuse to
try unfamiliar foods.
Assistance
As the disease progresses within this
stage, caregiver demonstrates use of
unfamiliar utensils or procedures.
Caregiver monitors compliance with
special diets. Assists with unusual
containers. Reminds patient of
standard social manners. Warns
patient to take precautions when
passing hot, heavy, or liquid dishes.
Goal
As the disease progresses within
this stage,
Patient will feed self with
conventional utensils and will
comply with reminders of standard
table manners and dietary
restrictions.
Caregiver will remind patient of
standard table manners and will
monitor compliance with dietary
restrictions.
Patient will feed self with
conventional utensils and will
comply with reminders of standard
table manners and dietary
restrictions.
Caregiver will remind patient of
standard table manners and will
monitor compliance with dietary
restrictions.
As the disease progresses within this
stage, regular mealtime routine with
familiar food items is preferred by the
patient. Caregiver trains in highly
desirable social manners. Reminds
patient to check for temperature of hot
foods and assists with cutting of
difficult items. Cues patient not to
overfill glasses and mugs.
As the disease progresses within
this stage, Patient will feed self
with conventional utensils and,
with assistance, will comply with
special dietary instructions. Will
learn to follow highly desirable
social routines, one step at a time.
Caregiver will provide for patient’s
nutritional needs and will train in
desirable social and table manners
as needed.
Precautions
As the disease progresses within
this stage,
Watch for handling of hot,
heavy or liquid dishes.
May resist changes in diet or
new restrictions.
Watch for handling of hot,
heavy or liquid dishes.
May resist changes in diet or
new restrictions.
Level
GDS
5.0
ACL
3.8 to
3.6
GDS
6.0
ACL
3.4 to
3.0
Behavioral Characteristics
May be trained to present self at dining area
at regular mealtimes. At an earlier stage 5,
the patient can follow a routine such as
waiting for others before eating, passing
dishes, sitting until all are finished, checking
surrounding areas for spilled food, wiping
mouth with napkin. Performance at later
stage 5 is dependent on imitating identified
target behaviors. Does not engage in social
conversation at the table.
May anticipate meal times based on familiar
signs (kitchen activity/smells). Uses all
utensils except knife; cuts with side of spoon
or fork. Eating is self-absorbed and rate may
be rushed with patient not stopping to
swallow between bites or chewing
inadequately. May eat strongly preferred
food items only (candy) and does not
understand need to eat balanced diet, follow
dietary restrictions, or other amounts.
As the disease progresses within this stage,
patient demonstrates no awareness of others
at the same table, does not talk, pass dishes,
observe usual manners. Unaware of spilled
food on table, self or floor. May chew
noisily or loudly. May ask for food at any
time of the day when hungry.
Assistance
Caregiver trains patient in highly
desirable social manners, one at a
time over several weeks. Provides
assistance with new containers or
difficult cutting that requiring
neuromuscular adjustments.
As the disease progresses at this stage,
caregiver demonstrates desired
modeling of target behaviors,
including standard table manners,
with elicited imitative responses. Cues
patient when to wait for food to cool
and be prepared or served.
Plans and supervises special dietary
needs.
Caregiver reminds patient of
mealtimes. Serves appropriate
serving sizes or restricts access to
undesirable food items to prevent
overconsumption. Cuts meats or
other difficult items. Pours liquids.
Reminds patient to dispose of trash in
proper container. Plans and
supervises all special dietary needs.
As the disease progresses within this
stage, the Caregiver cues patient to
chew longer or slow down as
necessary.
Goal
Caregiver will provide for patient’s
nutritional needs and will train in
desirable social and table manners
as needed.
Patient will feed self using
conventional eating utensils, with
assistance, to comply with special
dietary needs.
Precautions
May overeat if given free access
to preferred food items. Cannot
follow dietary restrictions.
Failure to observe manners may
alienate others.
Check food and beverage
temperatures
Patient will be trained to
follow/imitate highly desirable
social and table manners and
routines.
Caregiver will provide for
nutritional needs with appropriate
food portions, restricting access to
undesirable foods, assisting with
cutting and containers.
Patient will feed self with
conventional utensils with
assistance in cutting foods and
opening containers.
May overeat if given free access
to preferred food items. Cannot
follow dietary restrictions.
Failure to observe manners may
alienate others.
Check food and beverage
temperatures.
Level
GDS
6.0
ACL
3.4 to
3.0
GDS
7.0
ACL
2.8
Behavioral Characteristics
May anticipate meal times based on familiar
signs (kitchen activity/smells). Uses all
utensils except knife; cuts with side of spoon
or fork. Eating is self-absorbed and rate may
be rushed with patient not stopping to
swallow between bites or chewing
inadequately. May eat strongly preferred
food items only (candy) and does not
understand need to eat balanced diet, follow
dietary restrictions, or other amounts.
Assistance
Caregiver reminds patient of
mealtimes. Serves appropriate
serving sizes or restricts access to
undesirable food items to prevent
overconsumption. Cuts meats or
other difficult items. Pours liquids.
Reminds patient to dispose of trash in
proper container. Plans and
supervises all special dietary needs.
As the disease progresses within this stage,
patient demonstrates no awareness of others
at the same table, does not talk, pass dishes,
observe usual manners. Unaware of spilled
food on table, self or floor. May chew
noisily or loudly. May ask for food at any
time of the day when hungry.
As the disease progresses within this
stage, the Caregiver cues patient to
chew longer or slow down as
necessary.
May walk to familiar eating area without an
escort when told. May pick up spoon or cup
and begin to eat/drink without being cued.
May have difficulty keeping small food
(peas) or liquids on utensil. Does not cut
with knife. Eats food as is on plate. May eat
until plate is empty or may refuse certain
foods. Cannot alter rate of eating, which
may be very slow. No awareness of others at
table, spills, temperature of foods or table
manners.
Caregiver reminds patient of
mealtimes and escorts to table.
Precuts foods into bite-sized pieces.
Checks food temperatures. Assists
with opening containers. Cues to
wipe face with napkin.
Takes into account food preferences,
increases intake.
Goal
Caregiver will provide for
nutritional needs with appropriate
food portions, restricting access to
undesirable foods, assisting with
cutting and containers.
Patient will feed self with
conventional utensils with
assistance in cutting foods and
opening containers.
Caregiver will meet nutritional
needs of patient by precutting
foods and assisting with self
feeding as needed.
Patient will feed self with
conventional utensils with
assistance from caregiver to cut
food, open containers.
Precautions
May overeat if given free access
to preferred food items. Cannot
follow dietary restrictions.
Failure to observe manners may
alienate others.
Check food and beverage
temperatures.
Watch for choking. Precut solid
foods and avoid stringy, hard to
chew foods. Check temperature
of foods. Watch for spills with
liquids.
Consider food preferences.
Level
GDS
7.0,
cont.
ACL
2.4
ACL
2.2 to
2.0
ACL
1.8
ACL
1.6 –
1.4
Behavioral Characteristics
May walk to table and sit when told or may
follow guide to table. May pick up spoon or
cup and begin to eat/drink without being
cued. May start eating as soon as food is
seen or served. May eat slowly or not finish
meal. May be unable to get food on utensil
and may use fingers. May show no
awareness of others at the table. May ignore
spills, dribbling of food on face. Is unaware
of temperature of food and sequence of
dishes.
Sits while eating. Spontaneously picks up
food with fingers and places them in mouth.
May pick up a cup or spoon to drink or eat.
Does not note temperature of food or cut
food up into bite-size pieces. May be unable
to get good on spoon. May eat very slowly.
May need reminders to keep eating. May
place non-edible objects in mouth. Does not
note spills.
May pick up soft finger food and place in
mouth. May drink from a cup placed in
hand. Does not use utensils such as spoon or
fork. May spill food or liquid without
awareness. May push caregiver away.
Turns head, opens mouth, or swallows on
command. May sit in bed with support to
hold body against gravity. May cooperate
with hand-over-hand feeding for soft foods.
May express food preferences with grunts or
smiles.
Assistance
Caregiver reminds patient of
mealtimes and escorts to table.
Precuts foods into bite-sized pieces.
Checks food temperatures. Assists
with opening containers. Cues to
wipe face with napkin.
Caregiver assists to transfer to chair or
serves on tray in bed or wheelchair.
Precuts food. Serves easy to chew
food. Removes non-edible objects
from view. Fills cups to half-full to
prevent spills; checks food
temperature. Cues to continue eating.
Caregiver places soft finger food in
front of patient. Places cup with
liquid in hand. Cuts food into bitesized pieces and places them on food
or spoon; guides utensil to mouth with
hand-over-hand assist or feeds patient.
If receiving enteral nutrition,
Caregiver positions tube, feeds
patient, and monitor intake to ensure
adequate nutrition
For PO intake, Caregiver places soft
food on spoon and feeds patient with
verbal commands to open, swallow.
Places spoon in patient’s hand and
guides to mouth.
Goal
Caregiver will meet nutritional
needs of patient by precutting
foods and assisting with self
feeding as needed.
Precautions
Watch for choking. Precut solid
foods and avoid stringy, hard to
chew foods. Check temperature
of foods. Watch for spills with
liquids.
Patient will self- feed with spoon
or with fingers with assistance
from caregiver.
Caregiver will meet nutritional
needs of patient by precutting
foods and assisting with self
feeding as needed.
Watch for choking. Precut solid
foods and avoid stringy, hard to
chew foods. Check temperature
of foods. Watch for spills with
liquids.
Patient will self- feed with spoon
or with fingers with assistance
from caregiver.
Caregiver will provide for
nutritional needs of patient by
providing soft finger foods, liquids
in cups, and assistance with foods.
Patient will feed self soft finger
foods.
Caregiver will provide for
nutritional needs of patient with
either tube feeding or will feed a
soft diet with commands or handover-hand methods.
Watch for choking. Precut solid
foods and avoid stringy, hard to
chew foods. Check temperature
of foods. Watch for spills with
liquids.
Check weights to ensure
adequate intake.
Watch for choking
Level
GDS
7.0,
cont.
ACL
1.2 –
1.0
Behavioral Characteristics
Licks lips, salivates, or sniffs in response to
food smells. Does not open mouth or
swallow on command. Unable to meet
nutritional needs through P.O. intake. Per
advance directives, patient’s nutritional
needs met through enteral feeding.
Assistance
Caregiver positions tube and feeds
patient. Monitor intake to ensure
adequate nutrition.
Goal
Caregiver will provide for
nutritional needs of patient with
regular tube feedings.
Precautions
Check weights to ensure
adequate intake.
Resource: Allen, C., Earhart, C., & Blue, T. (1992). Occupational Therapy Treatment Goals for the Physically and Cognitively Disabled. Bethesda, MD: The
American Occupational Therapy Association, Inc.
Basic Activities of Daily Living: Grooming
Grooming includes care of the hair (combing, brushing, arranging, curling), teeth (brushing, flossing), face (washing, shaving, applying make-up
and/or lotion, and the hands (applying lotion, trimming, trimming, applying nail polish).
Level
GDS
2.0
ACL
5.8 to
5.0
GDS
3.0
ACL
4.8 to
4.6
GDS
4.0
ACL
4.4 to
4.0
Behavioral Characteristics
Independent in all grooming tasks. Makes
successful fine motor adjustments with new
grooming tools (curling iron). May not read
directions before using new products. Varies
routines, products and methods to produce
new results. Applies own criteria for judging
appropriate grooming outcomes and may not
consider social consequences of this, which
becomes more pronounced as the disease
progresses within this stage. Varies pace as
needed
Initiates grooming tasks and varies one
aspect of typical routine or one feature (hair
style, make-up) on his/her own. Checks
results of grooming, hair styling, and/or
application of make-up by close examination
when done. Corrects all errors one at a time.
Learns new grooming procedures slowly by
rote. May rigidly follow prescribed routines
such as dental appliances.
Initiates and completes a familiar routine of
grooming. Combs, brushes, styles hair or
applies make-up to match a previous
performance (i.e., a particular hairstyle).
May insist on familiar products/styles/time
of day for tasks. Works at invariant pace,
slower than average, and can’t alter pace.
Finds supplies in familiar locations. May be
unable to master use of new tools requiring
neuromuscular adjustments (curling iron).
Missing hidden spots and may prefer striking
effects in make-up, perfume (“more is
better”).
GROOMING
Assistance
Caregiver points out consequences of
selections that deviate markedly from
social standards of grooming. Points
out potential harmful secondary
effects of new procedures or products.
Reminds to check supply inventories
and make appointments.
Goal
Patient will complete routine
grooming care independently with
assistance to avoid harmful effects
in new tasks.
Caregiver will explain potential
harmful secondary effects of new
procedures / products.
Precautions
May get busy doing routines
and forget about the passage of
time.
May question need to conform
to expectations of others for
grooming.
May miss dental/hair
appointments.
Demonstrates new grooming
procedures slowly, one step at a time.
Provides explanation of secondary
effects. Provides supplies in
accessible locations or inside drawers
if familiar. Explains consequences of
variations or product substitutions.
Supervises use of potentially harmful
products.
Caregiver provides familiar, safe
objects and products for hair
arrangement, shaving, teeth and nail
care. Stores objects in familiar and
visible locations. Supervises use of
new, sharp, or harmful tools or
products
Supervises timed procedures (facial
mask, hair dyes, hot curlers). Checks
heat setting on hot curlers. Suggest
corrections for socially unacceptable
results (heavy make-up).
Patient will complete familiar
grooming routines with some
variations from his or her standard
with assistance to avoid harmful or
undesirable effects.
Caregiver will assist with error
correction and supervise use of
new or potentially harmful
products.
Patient will complete familiar
routine of grooming with
assistance in set-up to avoid
harmful effects.
Caregiver will assist with error
correction and supervise use of
new harmful materials and new
procedures and products.
Vigilance is recommended to
anticipate consequences of
changes in actions, products for
patients. Actions may be
impulsive.
Patient may be upset if usual
materials are not available.
May argue with corrections of
heavy make-up application.
Allow ample time for task
completion (at 2-3x the average
rate).
Level
GDS
4.0,
cont.
GDS
5.0
ACL
3.8 to
3.6
GDS
6.0
ACL
3.4 to
3.0
Behavioral Characteristics
As the disease progresses within this stage,
successful completion of familiar (combing,
shaving, nail care, washing face) will require
that all necessary tools/accessories are
visible and within reach
Combs, brushes hair, or shaves face or legs
until all area is covered. Recognizes
completion (all nails are trimmed). May miss
back of head, sides of face, or other hidden
surfaces. May attempt to style hair; uses
clips in front only. Brushes front surfaces of
teeth only. May forget a step of a customary
routine (using mouthwash or rinsing mouth)
and think they are done. May use all
available lotion, shampoo. Alters amounts
of make-up, toothpaste, lotion only with
assistance. May engage in impulsive actions
(shaving off eyebrows).
Spontaneously sustain actions of combing,
brushing, shaving with electric razor,
applying make-up or lotion. As the disease
progresses within this stage, the patient
grasps brush, comb or toothbrush when
offered at eye level and may do back and
forth action in one place with cueing only.
No awareness of effects. Uses too much/too
little toothpaste, lotion, make-up. Misses
obvious dirt when washing face or hands.
May start actions when objects are seen.
Assistance
Caregiver provides necessary safe
objects at appropriate time of day.
Provides correct amounts of
shampoos, lotions. Sequences actions,
demonstrates changes in locations,
amounts for more effective results.
Checks for and corrects socially
unacceptable results.
Goal
Patient will recognize completion
of grooming tasks.
Caregiver will supervise and
provide appropriate assistance to
avoid harmful effects. Caregiver
will arrange for long-term or
special dental care.
Precautions
Restrict access to dangerous or
undesirable objects. Do not
leave unsupervised with any
sharp, toxic or hot materials.
Check every few minutes if left
alone.
Assists with styling back of head,
cutting nails, correcting socially
inappropriate results.
Caregiver provides necessary safe
objects at appropriate time of day.
Sequences through actions; stops
excessive actions. Checks results.
Does hard to reach spots and corrects
errors. Arranges hair, trims nails,
flosses teeth, applies make-up, and
shaves with straight razor.
As this stage progresses, the caregiver
offers or places grooming items
(comb, brush, toothbrush with
toothpaste) within 6 inches for the
patient and provides gestural cue to
begin action associated with object.
Patient will maintain grooming
actions and cooperate with
caregiver assistance.
As the disease progresses, Patient
will initiate familiar actions of
brushing, combing or Patient will
grasp grooming objects.
Caregiver will provide tools and
objects and appropriate assistance
with cues to avoid harmful or
undesirable effects.
Restrict access to harmful or
undesirable objects. Monitor
for excessive use of materials or
actions. Do not leave alone
when using water.
Watch for discomfort that may
result in striking out. Watch for
loss of balance while bending,
standing
Level
GDS
7.0
ACL
2.8 to
1.0
ACL
2.4
ACL
2.0
ACL
1.8
ACL
1.4
ACL
1.0
Behavioral Characteristics
This stage shows a progression from
extensive assist to dependent status. The
following grooming characteristics may be
present.
Holds mouth open while standing next to
sink. Leans over at waist to spit when cued.
May stand while shaved or combed.
While seated, may hold mouth open verbal
cues. May swish water, lean to spit into
adjacent bowl. May lean forward or back to
allow for shaving or combing hair.
While seated, may open mouth and keep
open with continuous tactile cues to allow
brushing. May drink rinse water. May rotate
head to cooperate.
May turn head or open mouth on command
or with tactile cues.
Unable to comb hair, shave, care for teeth or
nails. Individual may turn head or open
mouth on command or with tactile cue.
Assistance
Caregiver leads to basin, gives verbal
cues to open mouth, drink, rinse,
bend, spit.
Caregiver initiates all grooming tasks.
Gives verbal commands to rinse, spit,
lean, turn head, close or open mouth.
Caregiver brushes teeth, holding
mouth open with hand or verbal
commands. Provides rinse water,
bowl near face to spit in.
Caregiver does all tasks. Provides
water to rinse mouth after meals; lifts
and holds head.
Caregiver does all tasks.
Goal
Caregiver will maintain all hair,
teeth, facial care needs.
Precautions
Watch for discomfort that may
result in striking out.
Watch for loss of balance while
bending, standing
Caregiver will maintain all hair,
teeth, facial care needs.
Watch for discomfort that may
result in striking out.
Caregiver will maintain all hair,
teeth, facial care needs.
Watch for loss of balance while
bending, standing
Inspect for dental problems.
Remove dentures
Caregiver will maintain all hair,
teeth, facial care needs.
Inspect for dental problems.
Remove dentures
Caregiver will maintain all hair,
teeth, facial care needs.
Inspect for dental problems.
Remove dentures
Resource: Allen, C., Earhart, C., & Blue, T. (1992). Occupational Therapy Treatment Goals for the Physically and Cognitively Disabled. Bethesda, MD: The
American Occupational Therapy Association, Inc.
Basic Activities of Daily Living: Toileting
Toileting includes recognizing the need to void, going to the bathroom, closing the door, adjusting garments, sitting down, voiding, wiping the
body clean, readjusting garments, flushing the toilet, washing and drying hands, and leaving the bathroom.
Level
GDS
2.0
ACL
5.8 to
5.0
GDS
3.0
ACL
4.8 to
4.6
Behavior
Independently performs all toileting. Can
explore a new environment to locate a
bathroom without assistance. Can figure out
use of stiff or new flush controls and learn
use of assistive devices by varying
neuromuscular effects. May not anticipate
need for toileting in new situations or
consider sanitary requirements in unusual
circumstances.
Independently performs usual toileting
routine. Notes all striking cues in a new
environment to locate a public restroom.
May not anticipate need to use bathroom
before trips, but can learn to take this
precaution for regularly scheduled events.
May learn bathroom etiquette (amount of
time, conservation of paper, putting lid down
after use) by rote.
As the disease progresses in this stage,
patient will still scan visible environment for
needed supply (toilet paper, paper towels,
soap dispenser) but may not find it unless at
or near eye level.
TOILETING
Assistance
Caregiver identifies sanitary
conditions when conventional needs
for toileting do not exist.
Goal
Patient will independently perform
toileting routine with assistance
from caregiver to following social
rules.
Precautions
Caregiver will identify desirable
behaviors for patient to maintain
social and hygienic standards.
Caregiver identifies social
conventions related to toileting when
patient must share facilities with
others. Reminds patient to use
bathroom before trip.
Patient will independently perform
toileting routine with assistance
from caregiver to following social
rules.
Caregiver will identify desirable
behaviors for patient to maintain
social and hygienic standards.
As the disease progresses in this
stage, Caregiver provides all supplies
for customary toileting routine in
visible locations. Checks for errors in
adjusting garments and assists with
fasteners as needed
As the disease progresses in this
stage,
Patient will initiate and complete
usual toileting routine when all
supplies are available with
caregiver assistance to solve
problems and avoid undesirable
effects.
Caregiver will provide appropriate
set-up and assistance with solving
problems to avoid undesirable
effects.
As the disease progresses in this
stage,
Patient may take longer than
average to complete toileting
routine.
Level
GDS
4.0
ACL
4.4 to
4.0
GDS
5.0
ACL
3.8 to
3.6
Behavior
Follows a routine of toileting without
variation in a familiar environment.
Recognizes difficulties that interfere with
completion of toileting and asks for help,
i.e., no paper, door latch that won’t close,
inability to operate flush. Checks results of
wiping and may be able to report change in
bowel or bladder habit. Does not anticipate
need to use toilet before going to an event or
location with limited access to toileting
facilities. Needs to have public restrooms
pointed out; may be unable to operate if
unfamiliar or stiff flush control. May fail to
note errors in clothing adjustment at back.
May use too much paper thinking “more is
better.” Does not consider needs of others,
such as limiting time in bathroom, lowering
seat, etc.
As the disease progresses in this stage,
patient will need to be escorted to a public
restroom. Has trouble with some fasteners
requiring fine adjustments.
May complete sequencing of toileting
actions with one or two steps left out, i.e.,
door left open, forgets to wash, zip pants up.
Can recognize completion of task and inform
caregiver when through. May not ask for
assistance with fasteners.
May be able to imitate a modification of
wiping for more desirable results, although
effects are still not noted. Examples of
modifications include wiping longer, harder,
using less paper.
Assistance
Provides all supplies for customary
toileting routine in visible locations.
Checks for errors in adjusting
garments and assists with fasteners as
needed. Monitors amount of toilet
paper used and provides precut
amounts if necessary.
Reminds patient to use bathroom
before trips and other conditions with
limited access to restrooms. Points
out locations of public facilities and
demonstrates use of unfamiliar
controls.
Goal
Patient will initiate and complete
usual toileting routine when all
supplies are available with
caregiver assistance to solve
problems and avoid undesirable
effects.
Precautions
May take longer than average to
complete toileting routine.
Caregiver will provide appropriate
set-up and assistance with solving
problems to avoid undesirable
effects.
At the latter stage 4.0 of disease
progression, patient needs to be
escorted to public restrooms.
Caregiver checks quality of result and
is available to assist with fasteners.
Pre-tears toilet paper to prevent
excessive use.
Patient will imitate modifications
of actions for better results.
Caregiver will demonstrate
modified actions, check results,
and correct errors as needed.
Failure to check results may
produce skin problems,
undesirable social problems
(appearance).
Do not leave alone in bathroom.
May fall.
Level
GDS
6.0
ACL
3.4 to
3.0
GDS
7.0
ACL
2.8
ACL
2.6
Behavior
Recognizes the need to void and goes to
familiar bathroom. Operates ordinary door
handles but may not close door while in
bathroom. Doffs and dons most clothing
items slowly; may need assistance with new
and unusual fasteners. Wipes but does not
check results and may wipe over and over
using excessive amounts of toilet paper. May
forget to flush, wash hands. May not adjust
garments, may leave shirt untucked, or
zipper open.
As the disease progresses within this stage,
patient may still recognize the need to use
toilet, walks toward the bathroom but may
get distracted on the way and not arrive on
time. May be unable to doff and don loosefitting pants. May take toilet paper in hand
but wipes ineffectively or only when cued.
May flush toilet if cued. Does hand washing
if cued. Men may miss toilet if urinating
while standing.
Slowly walks to familiar bathroom. Grabs
bar or other objects (toilet paper dispenser)
to stabilize self when sitting down or
standing up. May grip toilet paper or pants
but needs assistance in wiping and adjusting
garments.
May communicate need to use toilet
immediately before. May walk to bathroom
but not get there in time. May put hands
under water.
Assistance
Caregiver checks quality of result and
is available to assist with fasteners.
Pre-tears toilet paper to prevent
excessive use.
Goal
Patient will initiate and complete
toileting in familiar environment
with caregiver assistance to avoid
ineffective results.
Precautions
Failure to check results may
produce skin problems,
undesirable social problems
(appearance).
Caregiver will check results and
correct errors to avoid undesirable
medical and social consequences.
Do not leave alone in bathroom.
May fall.
As the disease progresses within stage
6, caregiver needs to sequence the
patient through the actions. Caregiver
leads to bathroom, or checks to make
sure the patient arrives at bathroom.
Assists to remove garments. Places
toilet paper in patient’s hand, checks
results. Assist with fasteners. Cues to
flush, washes hands. Assists males
with hitting toilet when standing up.
As the disease progresses within
stage 6,
Patient will initiate and complete
toileting with appropriate
assistance from caregiver.
Caregiver leads to bathroom on
request or at regular intervals. Assists
with garments, wipes patient,
readjusts garments, cues and assists
with hand washing. Easy to remove
garments reduce accidents. Install
grab bars for stability.
Patient will use grab bars when
standing and sitting and will
cooperate with caregiver
assistance.
Caregiver leads to bathroom on
request or at regular intervals. Assists
with garments, wipes patient,
readjusts garments, cues and assists
with hand washing. Easy to remove
garments reduce accidents.
Caregiver will provide appropriate
cues to sequence patient through
toileting activities and will check
results to ensure safe and hygienic
outcomes.
Caregiver will ask patient about
need to use toilet at regular
intervals and will provide
assistance to complete activities
Patient will communicate need to
use toilet and cooperate with
caregiver assistance.
Caregiver will ask patient about
need to use toilet at regular
intervals and will provide
assistance to complete activities.
May pull on bathroom
hardware.
Watch for falls.
Watch for falls.
Level
GDS
7.0
ACL
2.4
ACL
2.2
ACL
2.0
ACL
1.8 –
1.6
ACL
1.4 to
1.0
Behavior
Follows caregiver through open doorway to
bathroom. Sits and stands spontaneously.
May not wait to be wiped or have garments
adjusted. May put hands under water when
cued.
May cooperate with a pivot transfer to toilet.
Stands or sits on command while being
wiped and garments are adjusted.
Sits on toilet when placed by caregiver. May
lean to assist wiping when cued.
No awareness of need or no communication
of need to defecate or urinate. May
cooperate by rolling onto side to ease
placement of bedpan or assist with cleaning
when cued.
No awareness of need to defecate or urinate.
Does not assist caregiver in toileting
activities.
Assistance
Caregiver takes patient to bathroom at
regular intervals. Assists with
garments, wiping. Flushes toilet. Cues
to put hands under water and applies
soap, rinses.
Caregiver takes patient to bathroom at
regular intervals. Gives assistance
with tactile and verbal cues to do
pivot transfer. Wipes patient,
arranges clothing.
Caregiver positions patient on bedpan
or toilet at regular intervals. Wipes
and arranges clothing.
Caregiver places diapers on patient,
checks and changes regularly or
caregiver positions bedpan at regular
intervals.
Caregiver places diapers on patient,
checks and changes regularly.
Goal
Patient will follow caregiver to
bathroom and cooperate with
assistance to complete toileting.
Precautions
Watch for falls.
Patient will stand/sit on command
and cooperate with pivot transfers.
Watch for falls. Observe for
body mechanics to avoid injury.
Caregiver will control bowel and
bladder accidents and will prevent
medical complications of
incontinence.
Patient will sit on toilet and
cooperate with assistance.
Do not leave unattended on
toilet.
Caregiver will control bowel and
bladder accidents and will prevent
medical complications of
incontinence
Caregiver will control bowel and
bladder accidents and will prevent
medical complications of
incontinence.
Caregiver will control bowel and
bladder accidents and will prevent
medical complications of
incontinence.
Watch for skin breakdown.
Watch for skin breakdown.
Resource: Allen, C., Earhart, C., & Blue, T. (1992). Occupational Therapy Treatment Goals for the Physically and Cognitively Disabled. Bethesda, MD: The
American Occupational Therapy Association, Inc.
Basic Activities of Daily Living: Walking and Exercising
Walking and exercising include awareness of how to move a normal body to different locations in space or through different movement patterns.
Level
GDS
2.0
ACL
5.8 to
5.0
Behavior
Ambulates or runs to familiar and new
locations independently. In an early stage 2,
patient will plan a new route with assistance
from maps. The ability to effectively use a
map diminishes by mid-stage 2 (ACL 5.4).
Notes spatial arrangements of buildings and
streets during the walk. Discovers new
routes and remembers them. May consider
and follow recommended exercise programs,
substituting methods when indicated.
Understands secondary effects and factors to
be considered in pursuing a conditioning
program or other excise program.
As the disease progresses within this stage,
these secondary effects will need to be
explained. Patient may refuse to comply with
them and the exercise program. Ambulation
to familiar routes remains intact. Ambulation
to new locations is by trial and error; may
forget newly discovered routes and have to
rediscover them.
GDS
3.0
ACL
4.8 to
4.6
Varies routes taken within familiar
neighborhood to reach destinations
associated with routine activities. Scans
visible environment to search for desired
cue, such as a landmark, to guide direction.
Early in this stage, patient reads street signs
and attempts to use this information in
guiding route but may still be unable to find
way home if lost. Follows a verbal
explanation of a safety hazard when effects
are immediate and visible such as a railroad
crossing; may not understand less visible
hazards such as a “bad neighborhood.”
WALKING AND EXERCISING
Assistance
Goal
Caregiver provides information to
ACL 5.6: Patient will compare
assist comparisons or selections in
methods of exercise and follow
exercise programs or activities.
suggested protocols to avoid
harmful effects.
As the disease progresses within this
Caregiver will provide information
stage (ACL 5-4), Caregiver identifies
as needed to avoid harmful effects.
safety hazards that are secondary and
not visible, including need to plan for
water, food, proper dressing, first aid,
ACL 5.4: Patient will ambulate to
emergency plan for hikes in remote
new locations of desirable
areas.
activities and follow an exercise
program with assistance to avoid
Points out secondary effects of
injury.
altering exercise programs (injury,
exhaustion) and precautions for
Caregiver will provide warnings
exercise (hot or cold weather, smog
regarding safety hazards.
alerts, etc).
At end stage 2.0 (ACL 5.0), Caregiver
identifies potential hazards of walking
in unfamiliar areas.
Caregiver escorts to all new locations.
Points out landmarks to be used as
cues to guide direction in new
environment and accompanies until
well-learned. Points out visible
hazards requiring adjustments in pace
or routes. Checks performance of all
graded exercise,
ACL 5.0: Patient will walk to
desired new locations with
assistance to identify safety
hazards.
Caregiver: Same as above.
Early stage 3.0: Patient will
ambulate to desired new locations
with assistance and will scan
environment for safety hazards.
Caregiver will provide assistance
to ensure safety in walking in
community.
Precautions
Patient may refuse to comply
with exercise protocols.
Variations in usual routes do not
anticipate hazards or influence
of time of day or safety of the
route. May get lost. “Pleasure
hikes” should be supervised.
Variations in exercise programs
should be checked for safety.
Level
GDS
3.0,
cont.
ACL
4.8 to
4.6
GDS
4.0
ACL
4.4 to
4.0
Behavior
May attempt to alter pace in response to time
constraint but this is not maintained. Needs
new routes identified and learns them after
several days to weeks of practice. Learns an
exercise program by rote and does it
invariantly.
Assistance
Walks or urns within fitness capacity to
reach a predetermined familiar destination
within ½ to 1 mile. Chooses to go by
familiar routes. Notes striking features at
eye level but fails to attend to signs except as
landmarks. Poor attention to terrains
changes or activity or noise outside visual
field and may not alter pace in response to a
time constraint. May ask for assistance if
lost. May follow suggested routes given for
safety reasons but does not understand
reason behind suggestion. Needs new routes
identified by others and learns these after
several days to weeks of practice. May be
trained to follow an exercise program after
doing the program several times; may get
bored and abandon a repetitive exercise
routine. Can count up to 20 repetitions of
exercise. Does not anticipate hazards or
secondary effects of incorrect practice of
program.
Caregiver escorts to all new locations.
Points out landmarks to be used as
cues to guide direction in new
environment and accompanies until
well-learned. Points out visible
hazards requiring adjustments in pace
or routes. Checks performance of all
graded exercise,
As the disease progresses within this stage,
awareness of changes in familiar landmarks
diminishes, thus unexpected changes, such
as removal of landmark or need to detour,
creates confusion. Patient may resist going
to a new environment and prefers familiar
premises. Transfers from standing to sitting
are generally safe but slow.
Goal
Later stage 3.0: Patient will vary
routes to familiar locations with
caregiver assistance to identify
hazards.
Precautions
Caregiver will provide assistance
to avoid hazards or getting lost.
Patient will ambulate and perform
transfers independently using one
or two visual cues to navigate to
reach desired destination.
Fails to attend to potential
hazards.
Patient will ask for assistance if
lost.
Patient will learn new route or
exercise program after several days
to weeks of practice.
Caregiver will provide assistance
to avoid hazards or getting lost.
As the disease progresses within
this stage, it will be necessary to
eliminate expectation of learning
new routes with dependence on
visual cues.
Appropriate Goal (ACL 4.0):
Patient will ambulate and perform
transfers independently within a
familiar environment to reach a
desired location.
Caregiver goal: Same as above
May become very anxious to
highly stimulus-laden
environments such as airports,
malls, amusement parks,
casinos. May resist going to
such places.
Level
GDS
5.0
ACL
3.8 to
3.6
GDS
6.0
ACL
3.4 to
3.0
Behavior
Ambulates within familiar living areas
separated by closed doors or short distances
(next door neighbor, backyard). Aware of
inside and outside of premises. Aware of
destination after arrival and may express
surprise. May wander to a new location to
access a desired activity, get lost, and be
unable to retrace steps.
May imitate change in duration or amount of
graded ROM or strengthening exercise but
needs cues to maintain.
Ambulates within 2 or 3 familiar contiguous
rooms to access desirable activities, i.e.,
toilet, food, coffee, without assistance.
Follows a guide to new locations without
awareness of destination. Can alter
ambulation pace on command but is easily
distracted and reverts to previous pace. Is
often impulsive when changing body
position from sit to stand and easily loses
balance. May walk into others and does not
note differences in terrain or traffic lights.
Can complete ROM exercises with direct
supervision.
As the disease progresses within this stage,
the pace of ambulation decreases and will
move towards objects that elicit familiar
actions, such as picking up a telephone.
ROM exercises are repeated in a
perseverative fashion.
At the latter point in this stage, balance
issues become more prevalent and attention
span becomes more fleeting. Briefly
imitates ROM exercise.
Assistance
Caregiver restricts access to new or
undesirable areas by locking doors to
outside. Escorts to all new locations
outside living area. Provides cues to
modify pace as needed. Provides
direct supervision of all graded
exercise programs with appropriate
cues to ensure proper duration, force
of actions.
Caregiver restricts access to
undesirable locations or objects by
closing doors or removing objects
from view. Escorts to all new
locations. Checks position of chairs
before patient sits down. Stops
perseverative movements with verbal
commands. Directly supervises all
ROM and exercises programs.
Goal
Patient will ambulate and transfer
safely within a familiar setting with
assistance to avoid getting lost or
fatigued from overexertion.
Precautions
Wanders and may get lost
outside restricted areas.
Impulsive actions may result in
falls.
Caregiver will escort to new
locations.
Caregiver will supervise graded
exercise program to ensure proper
performance.
Patient will ambulate in restricted
areas.
Caregiver will escort to new
locations.
Caregiver will provide cues and
assistance in climbing stairs, sitting
down, and transferring.
Wanders and may get lost
outside restricted areas.
Impulsive actions may result in
falls.
Level
GDS
7.0
ACL
2.8
ACL
2.6
Behavior
Assistance
Goal
Grabs railing, bar or other objects to stabilize
position or to sit, stand, or step up. May not
note position on chairs before sitting; may
grab unstable objects. May cooperate with
upper extremity resistive exercises by
pushing or pulling with cues.
Walks to a known destination such as
bedroom or bathroom. May push or bang on
closed doors. Does not note uneven terrain.
Steps up a stair when cued.
Caregiver guides to desired locations
by walking next to or in front of
patient. Points to railings. Positions
chairs before patient sits.
Patient will stabilize self when
changing body position.
Caregiver will provide cues and
assistance in climbing stairs, sitting
down, and transferring.
May grab unstable objects or
people to prevent a fall.
Caregiver opens door to allow access
to desired destination. Assists up
stairs or steps by cues and physical
guidance. Removes area rugs and
obstacles.
Caregiver confines to safe, level
areas. Closes doors to restrict access.
Positions chair before patient sits.
Patient will walk to known
destination within restricted areas.
Caregiver will cue to climb stairs
and provide safe walking areas.
May wander or get lost if
unrestricted.
Patient will ambulated to/within
restricted areas with falling.
Caregiver will provide safe
environment.
Patient will stand and make pivot
transfers with assistance.
Caregiver will provide cues,
assistance in standing, transfer.
Patient will maintain seated
position. Caregiver will assist with
seated transfers.
Patient will cooperate with ROM
exercise by holding body parts
against gravity. Caregiver will
assist ROM exercises.
Caregiver will provide safe
environment to minimize/prevent
falls and protect against medical
complications due to immobility.
May wander or get lost if
unrestricted.
ACL
2.4
Ambulates slowly and aimlessly through
doorways and around furniture. Stands and
sits. May pace excessively.
ACL
2.2
ACL
2.0
Stands and may take a few steps with
assistance. May cooperate with a pivot
transfer. Uses “righting reflex” with upper
extremities to prevent falling.
Does not ambulate. Holds body upright
while sitting.
ACL
1.8
May raise arms to do ROM. May resist
passive ROM by pushing away.
ACL
1.6 to
1.0
Does not ambulate. Does not cooperate with
transfer from lying to sitting position. Does
not assist with passive ROM exercise.
Caregiver provides tactile and verbal
cues to assist standing, stepping, and
making pivot transfers.
Caregiver provides continuous cues to
lean to transfer from one seated
position to another.
Bed with side rails. Caregiver
provides continuous cues to do ROM
exercise or lift buttocks off bed.
Bed with/without side rails. Caregiver
turns body to maintain skin integrity.
Passive supports to maintain sitting in
bed. Passive ROM for joint mobility.
Precautions
Watch for falls. Observe proper
body mechanics to avoid back
injury.
Watch for fatigue or discomfort
that results in pushing away.
May resist by pushing away.
If used, side rails in proper
position. Check for skin
integrity.
Resource: Allen, C., Earhart, C., & Blue, T. (1992). Occupational Therapy Treatment Goals for the Physically and Cognitively Disabled. Bethesda, MD: The
American Occupational Therapy Association, Inc.