Enter Stage Right: A Script
For Dementia Intervention
Jocelyn Alexander, MA CCC-SLP
Michele Kramer, MA CCC-SLP
Therapy Partners
ASHA CONVENTION 2010
Philadelphia, PA
Objectives
Be able to differentiate and describe the different
stages of dementia and utilize the appropriate
assessments to accurately reflect and document
the patient's cognitive level/stage.
 Be able to identify appropriate intervention
strategies and techniques based on the patient’s
cognitive level and develop effective functional
maintenance programs to maximize the
independence at the patient's current cognitive
level.
 Be able to develop appropriate short- and longterm goals that will maximize the patient's skills
and provide caregiver training for optimal followthrough of the strategies and techniques.

Myths
 Patients
with dementia are not
candidates for therapy.
 Medicare does not cover treatment for
Dementia patients.
FACTS
Medicare does support skilled intervention for
this population:
 “Dementia is the general loss of cognitive
abilities including impairment of memory,
and may include one or more of the
following: aphasia, apraxia, agnosia, or
disturbed planning organizing, and abstract
thinking abilities….Throughout the course of
their disease, patients with dementia may
benefit from pharmacologic, physical,
occupational, speech-language, and other
therapies.” (CMS Transmittal AB-01-135,
Sept. 25, 2001)
FACTS
Interdisciplinary team approach can be very
effective in slowing functional decline
 Medicare covers claims for services rendered so
long as there is CLEAR documentation of:
Need for intervention
Plan of action
Progress made
Functional discharge plans

Medicare regulations require the assessment of
patient baseline competency to initiate treatment
and the availability of support personnel for a
maintenance program.
Why use cognitive staging?
 In
September 2001, Medicare issued a
new Program Memorandum that
prohibited the denial of therapy claims
based solely on the diagnosis of
Alzheimer’s or related dementias.
 Throughout the course of their disease,
patients with dementia may benefit from
pharmacologic, physical, occupational,
speech-language, and other therapies.”
(CMS Transmittal AB-01-135, Sept. 25,
2001)
Why use cognitive staging?
“Each facility must provide the
necessary care and services to attain
the highest practicable physical,
mental, and psychosocial well-being.”
(OBRA 1987)
The Global Deterioration
Scale
 Developed
by Barry Reisberg, M.D.
1982
 Consists of 7 stages
 Only used for patients with dementia
 Can accurately delineate all stages
throughout the entire course of
dementia, from the earliest to most
severe
 Clinical rating instrument—can
incorporate varying educational,
cultural, socioeconomical, and other
biases into determining the stage of
Stages of the GDS
(Reisberg et al, 1982)
GDS Stage 1 (No Cognitive
Decline)
 No
complaints of memory deficits
 Appear normal clinically
GDS Stage 2 (Very Mild
Cognitive Decline)
 “Forgetfulness”
phase
 Complaints from patient of mild
forgetfulness
 No objective evidence of memory
deficit during clinical interview
 No objective deficits in employment or
social situations
 Patient displays appropriate concern
regarding symptoms
GDS Stage 3 (Mild Cognitive
Decline)
 Clear-cut
clinical deficits first appear
 Objective evidence of memory deficit
is obtained only through interview with
skilled professional
 Possible concentration deficits
 May demonstrate decreased ability to
recall names of newly introduced
people
 Reads passage of a book and may
retain relatively little material
GDS Stage 3 (cont’d)
 Obvious
impairments noted in
demanding employment and social
situations
 Close family members notice wordfinding difficulties
 May get lost traveling to unfamiliar
locations
 Denial increases, along with anxiety
(mild to moderate)
 Losing the ability to negotiate difficult
situations
GDS Stage 4 (Moderate
Cognitive Decline)
 Clear-cut,
widespread deficits
apparent during clinical interview
 Displays decreased knowledge of
recent events in their own lives, and of
current events in the world around
them
 Possible deficits in recall of personal
history
 Significant difficulties with traveling
alone and managing finances
GDS Stage 4 (cont’d)
 Can
no longer perform complex tasks
accurately and/or efficiently
 May be oriented to time and person
 Recognizes familiar vs. unfamiliar
persons
 May be exit-seeking
Psychological changes:
 Denial becomes primary defense
mechanism
 Flattening affect, withdrawal from
previously challenging situations
GDS Stage 5 (Moderately
Severe Cognitive Decline)
 Can
no longer survive without some
assistance
 Unable to recall a major relevant aspect
of their current lives
 Somewhat disoriented to time or place
 Know their own name and generally
names of spouses and children
 May not require assist with ADLs but
need help to choose appropriate clothing
 Greater risk for elopement
GDS Stage 6 (Severe Cognitive
Decline)
 May
forget name of spouse, but recalls
own name
 Largely unaware of all recent events and
life experiences
 Knowledge of personal history is sketchy
 Generally unaware of surroundings,
year, or season
 Difficulty counting from 10 backward
and, at times, forward
 Require substantial assistance with
ADLs
GDS Stage 6 (cont’d)
 Diurnal rhythm becomes disturbed
 Distinguishes familiar vs. unfamiliar
persons
in their environment
 “Word salad” aphasia present in speech
Personality/emotional changes:
 Delusions
 Obsessive symptoms
 Anxiety, agitation, even violent behavior
 Cognitive abulia (loss of willpower due to
patient cannot carry a thought long enough to
determine a purposeful course of action)
GDS Stage 7 (Very Severe
Cognitive Decline)
 All
verbal abilities are lost (frequently,
no speech present, only grunting)
 Patient is incontinent, requires near
total assist for ADLs
 Psychomotor skills lost
 Generalized cortical and focal
neurologic signs/symptoms are mostly
present
GDS Assessments
 Brief
Cognitive Rating Scale (BCRS)
 Functional Assessment Staging Tool
(FAST)
 Functional Linguistic Communication
Inventory (FLCI-gives modified FAST)
Also related:
 Allen Cognitive Levels
Brief Cognitive Rating Scale
(Reisberg & Ferris, 1988)
 Assesses
GDS stage via 5 axes
(concentration, recent memory, past
memory, orientation, and physical
functioning/self-care.
 Conducted in a clinical interview
format.
 Ideal for patients who are variably
cooperative and attentive, when other
psychometric and mental status
assessments may be unobtainable.
Brief Cognitive Rating Scale
 Ratings
assigned to each axis are
totaled, then divided by 5 to get the
average.
 The average score gives the GDS
stage.
Functional Assessment Staging
Tool
(Reisberg, 1988)
 Observation
tool which assigns a GDS
stage.
 Evaluator checks all descriptions
which match the patient’s current
functioning.
 The GDS stage is the highest
consecutive level of disability.
Correlating the GDS and ACL
 Cognitive
Levels of Dementia Table
 Brief Cognitive Rating Scale
 GDS
 FAST
Application/Treatment
I did the assessments and
got the level…
What do I do now?!
(Voyzey, 2009)
Application/Treatment
 Each
program must have a clearly
defined purpose, procedure,
supportive work flow assignments,
and outcome measures that link to the
quality indicators and quality
measures.
Application: GDS Stage 1
 No
treatment is indicated
 Normal adult performing within
functional limits
Application: GDS Stage 2
 Use
of memory compensatory
strategies such as:
oMnemonic devices
oDescribing characteristics of
persons/objects (circumlocution)
oSongs/music
Application: GDS Stage 3
 Written
cues:
oReminders for medication administration
oDaily journal to record events
oTo-do lists
oReminders for safety
 Schedules/calendars
oFor activities, appointments, favorite TV
shows
Application: GDS Stage 4
 Allow
patients to express preferences for
foods, hobbies/activities, entertainment,
clothing, etc: making their own choices is
important!
 Use familiar pictures of family, self, and/or
pets in room and outside to assist in
identifying room
 Familiar sequenced tasks: simple cooking,
crafts, or puzzles (use procedural memory!)
 Reminiscence activities
 Use of pictures to help sequence ADLs or
locate items
Application: GDS Stage 5
Label actions as they are being performed
 Talk about common objects/items and discuss how
they are used
 Do not attempt reality orientation
 Activities that require sorting, identifying, or
categorizing
 Use procedural memory: folding laundry/towels,
setting a table
 Do not ask open-ended questions; give choices:
“What do you want to wear today?” vs.
“Do you want to wear your blue shirt or your red
shirt today?”

Application: GDS Stage 6
 Identify
body parts to communicate pain or
discomfort
 Get into a routine and STICK TO IT!
 Continue to encourage choice-making
whenever possible
 Incorporate therapeutic interventions for
word-finding, memory, and receptive
language with familiar activities that have
meaning
 Encourage use of gestures to indicate
wants/needs
Application: GDS Stage 7
 Use
olfactory stimuli:
oCoffee grounds, essential oils (vanilla,
lavender, peppermint)
 Incorporate
music:
oCastanets, bells, tambourines
oPlay music during treatment
 Use
tactile stimuli:
oTextured materials to stimulate attention
 Use
photo albums to encourage
vocalizations and attention
Application: Helpful Hints
 Remember
sun downing: patients can shift
between levels when this occurs
 BE FUNCTIONAL! Relate treatment
activities to daily living
 Choose activities that can be easily adapted
for many levels
 Use adequate lighting to decrease risk of
falls due to poor visual discrimination
 Remember, the first things gained are
generally the last ones lost (retro genesis)
Treatment - Groups
 Increase
participation in Group
Therapy with residents with common
stages.
 Utilize the Group Therapy code 92508
for treatment.
Documentation
 Medical
Necessity
 Change in function
 Description of deficits
 Setting appropriate goals
 Tying treatment to a function
Coding- 784.69
Other Symbolic Dysfunction






loss of the ability to distinguish the significance of
stimuli; may be auditory, visual, olfactory, tactile, or
gustatory.
Inability to recognize, understand, or interpret sensory
stimuli in the absence of sensory defects. Also, the
selective loss of knowledge of specific objects due to
emotional disturbance, as seen in schizophrenia, hysteria, or
depression.
Inability to write (letters, syllables, words, or phrases) due to
an injury to a specific cerebral area or occasionally due to
emotional factors.
loss of ability to perform familiar, purposeful movements
in the absence of paralysis or other neural sensorimotor
impairment.
Inability to execute complex coordinated movements resulting
from lesions in the motor area of the cortex but involving no
sensory impairment or paralysis.
Form of aphasia involving impaired ability to perform simple
arithmetic calculations.
97532
 Development
of Cognitive Skills to improve
Attention
Memory
Problem Solving
Includes: Compensatory Training, Direct (Oneon-One) Patient contact by a provider
Per 15 min. increment
Cognitive Therapy
 Cognitive
skill training may be medically
necessary for patients with acquired
cognitive deficits resulting from head
trauma, or acute neurologic events
including cerebrovascular accidents.
 Impaired functions may include but are not
limited to the ability to follow simple
commands, attention to tasks, problem
solving skills, memory, ability to follow
numerous steps in a process, perform in a
logical sequence and ability to compute.
Cognitive Therapy
 Cognitive
skill training should be
aimed towards improving or restoring
specific functions which were impaired
by an identified illness or injury, and
expected outcomes should be
reasonably attainable by the patient as
specified by the plan of care.
Reason For Referral
 Patient
referred for ST due to new
onset (or exacerbation/decline) of
cognitive-communicative deficits
indicating the need to improve
cognitive linguistic skills, analyze
communication abilities, design and
instruct on adaptive techniques and
develop and instruct caregivers on
compensatory strategies.
Reason For Referral
 Patient
exhibits difficulty with problem
solving and short term memory impacting
their ability to communicate effectively and
perform ADL’s safely.
 Therapy is recommended in order to
enhance patient’s quality of life and ability
to communicate thoughts, ideas, opinions,
and/or feelings as well as to increase ability
to participate in activities of daily living
safely with decreased assist from
caregivers.
Goals
 All
goals need to be patient based…
Goals
LTG’s
Patient will increase orientation to
temporal concepts to 100% of
opportunities given cues by trained
caregivers to improve ability to
communicate complex thoughts, ideas,
and opinions and/or feelings.
Goals
STG’s
Patient will in crease functional problem
solving skills to min/close supervision on
85% of opportunities and occasional cues
in order to increase safety during daily
living tasks and to facilitate return to
home.
Patient will generate multiple solutions to
problem situations with 80% accuracy and
occasional verbal cues in order to
increase safety of daily living tasks and
decreased assistance from caregivers.
Goals
STG’s
Patient will demonstrate auditory
comprehension of complex yes/no
questions with 100% accuracy in order to
communicate complex thoughts, opinions,
ideas and/or feelings.
Patient will demonstrate increased short
term recall for functional daily life
information with 85% of opportunities
using visual aids as assisted by trained
caregivers in order to decrease level of
assist of caregivers.
Dementia Documentation:
Positive prognostic behaviors
 Stimulability
 Orientation
 Ability
to follow
directions
 Attention span
 Self-expression
 Ability to solve
problems
 Ability
to imitate
 Medical stability
 Motivation to walk,
talk, and be more
independent
 Ability to selfmonitor/correct
 Recent history of
independence
Documentation
 ID
the stage the resident is in.
 Set appropriate expectations for the
persons living with the dementia
resident.
 Learn how to communicate.
 Plan ahead for upcoming stages.
Engaging the Resident in
Therapy
Make the resident your focus; determine what
he/she likes as a reward
 Build rapport; help them recognize you as a person
who is friendly and supportive
 Modify the environment—eliminate distractions to
increase focus; know their personal/cultural history
 Work closely with staff, learn what works and what
does not
 Use multi-sensory cues
 Use positive statements and praise for efforts
leading to completion of task.

Engaging the Caregivers in
Therapy
 We
can’t change the person, so we have to
change OUR approach and/or environment
 Educate caregivers in specific successful
techniques/strategies; stress increased
ease of performing job, improved
maintenance of resident’s independence
and dignity
 Problem-solve with caregivers to find
effective strategies
“You have it easily in your power to
increase the sum total of this world’s
happiness now. How? By giving a
few words of sincere appreciation to
someone who is lonely or
discouraged. Perhaps you will forget
tomorrow, the kind words you say
today, but the recipient may cherish
them over a lifetime.”
--Dale Carnegie
Facility Implementation
Program Development
Facility Implementation
 Structure
your program based on
facility need:
o“Stoplight” program
o1 box per stage
oInclude training for nursing staff as well as
auxiliary staff (activities, housekeeping,
etc)
Facility Implementation
 Decide
a location in which to start
(dedicated Alzheimer's unit vs. whole floor)
 Provide in servicing to facility IDT to explain
the program and benefits
 Establish buy-in of floor staff (nursing/aides,
housekeeping, dietary, etc)
 Make easy-to-follow functional maintenance
plans for each patient
 Use objective data to present information to
or counsel family members
Facility Implementation
Sample program for person-centered care
Alzheimer's unit:
 Evaluate patients for baseline cognitive
stage
 Current cognitive stages denoted by color
and/or number codes in chart, nursing
notes, etc
 Staff offer activities for patients from
corresponding bins
 Use current stage to plan for next stage
Conclusion

Cognitive staging can be a helpful clinical tool to help
formulate individualized care plans for patients with dementia.

Using cognitive staging can help staff, family, & caregivers be
proactive and plan for future stages and needs as well as
provide caregiver training for optimal follow-through of the
strategies and techniques.

Medicare reimburses for treatment of patients with dementia
when supporting documentation meets the criteria.

Cognitive staging can develop into effective facility programs
and can help educate all staff members on the disease
process.

Remember, everyone can benefit from dementia staging and
therapy intervention.
References
http://www.icd9data.com/2010/Volume1/780-799/780789/784/784.69.htm
http://www.acsu.buffalo.edu/~drstall/fast.html
http://www.zarcrom.com/users/alzheimers/4-cp8a.html
http://www.cms.hhs.gov/Transmittals/downloads/R855CP.pdf
References
1. CMS PUBLICATION/MEDICARE REQUIREMENTS: 100-2, Chapter
8, Sections 20, 30
2. CMS PUBLICATION/MEDICARE REQUIREMENTS: 100-2, Chapter
15, Sections 213, 220
3. CODE OF FEDERAL REGULATIONS: 42 CFR Section 409.33>Examples of skilled nursing and rehabilitation services.
4. ELI’S REHAB REPORT: Volume 16 number 1, January 2009 pages
4-5
5. ALZHEIMER’S CARE TODAY, BEST PRACTICES IN DEMENTIAL
CARE: September 2007, Volume 8, issue 3, pages 212, 214, and
216.
6. ALZHEIMER’S ASSOCIATION CLEVELAND AREA CHAPTER:
www.alzclv.org An overview of memory loss fact sheet 2008.
References
9.CMS PUBLICATION/MEDICARE REQUIREMENTS: Chapter 2,
Section 15 220.3-5-Documentation Requirements for Therapy
Services (Rev.53, Issued: 06-03006, Effective 01-01-06,
Implementation: 03-13-06).
10. Stages of Alzheimer’s Disease. Caregivers Essential Care Sheet.
Alzheimer’s Assoc., Miami Valley Chapter.
11. Brief Cognitive Rating Scale from Alzheimer's Outreach
http://www.zarcrom.com/users/alzheimers/4cp8aa.html
12. Reisberg, B; Ferris, SH; DeLeon, M; Crook, T (1982). The Global
Deterioration Scale for Assessment of Primary Degenerative
Dementia. American Journal of Psychiatry: 139(9), pp 1136-1139.
13. Reisberg, Barry and Ferris, SH (1988). Brief Cognitive Rating Scale
(BCRS). Psychopharmacology Bulletin: 24(4); pp 629-636.
References
14. Reisberg, B; Franssen, E; Souren, L; Auer, S; Akram, I; Kenowsky,
S (2002). Evidence and Mechanisms of Retrogenesis in Alzheimer’s
and Other Dementias: Management and Treatment Import. American
Journal of Alzheimer’s Disease and Other Dementias: 17(202), pp
202-212.
15. Sloane, P and Mathew, L (1991). An Assessment and Care
Planning Strategy for Nursing Home Residents with Dementia. The
Gerontologist: Vol. 31, No. 1, pp 128-131.
16. Voyzey, G (2009). Intervention Strategies for the Staged Individual
With Dementia. Perspectives: Gerontology (American SpeechLanguage Hearing Association). July 2009; 14: 19-27.
17. Warchol, K (2004). An Interdisciplinary Dementia Program Model for
Long-Term Care. Topics in Geriatric Rehabilitation. Vol 20, No 1, pp
59-71.