Functional Outcomes in Individuals with Cognitive or Mental Health Impairments
June 10, 2016
Disclosure
Functional Outcomes in Individuals with
Cognitive or Mental Health Impairments
• The speakers have no financial or other material gains to
disclose with regard to this presentation.
NEXT Conference 2016
Danille Parker, PT, DPT, GCS, CEEAAMarquette University, Milwaukee WI
Michele Stanley- PT, DPT, GCS, CEEAA St. Mary's Hospital, Madison WI
Session Learning Objectives
• After completing this session, you will be able to:
– Identify signs and symptoms consistent with cognitive deficits and
identify appropriate standardized tests/measures for client situations.
– Develop goals based on CARE score and client cognition to
measurably improve functional outcomes
– Utilize assessment results to design treatment strategies for a variety
of patient presentations
What is Cognition?
• Merriam-Webster
Definition:
– Conscious mental activities:
the activities of thinking,
understanding, learning, and
remembering
• Cognition:
– Mental Processing
– Decisions
– Execution
– Outcomes
– Adjustment
Course Outline
• 10 min: Introduction-What is cognition
• 30 min: Complexities of mental health disorders- acute and
chronic
• 15 min: Assessment tools and tips- CARE
• 15 min: Case Studies
• 15 min: Developing treatment strategies
• 5 min: Questions
What is Cognitive Impairment?
• Merriam-Webster
Definition:
– The state of being
diminished, weakened or
damaged especially mentally
or physically
• Trouble remembering,
learning new things,
concentrating, or making
decisions that affect their
everyday life.
This information is the property of D.Parker and M. Stanley and should not be copied
or otherwise used without express written permission of the authors
• Cognitive impairment
(CI) ranges from mild to
severe.
– Mild: Begin to notice
changes in cognitive
functions, still able to do
everyday activities.
– Severe: Lose ability to
understand, talk, or write,
resulting in the inability to
live independently
1
Functional Outcomes in Individuals with Cognitive or Mental Health Impairments
What is Dementia?
• Dementia:
– An acquired progressive deterioration of intellectual function
caused by diffuse changes in the central nervous system.
– Dementia is a syndrome of global cognitive decline that most likely
occurs for the first time in old age.
• National Institute of Neurological Disorders and Stroke:
– "… [A] word for a group of symptoms caused by disorders that
affect the brain. It is not a specific disease. 4
Stats and Facts
• More than 16 million people in the US are living with
cognitive impairment (CI).
• People with CI report more than 3x as many hospital
stays as those who are hospitalized for another
condition.3
• Of all people >65, 10% have some form of dementia.
• >50% of NH residents demonstrate cognitive deficits
severe enough to interfere with function.
WHY DOES IT MATTER TO PT?
• Cognitive impairment is a complication
– Will impact patient participation and overall assessment
– One factor that will influence your goals
– Modifies your treatment approach and plan of care
– Considerations for discharge
GLOBAL CHARACTERISTICS OF
COGNITIVE IMPAIRMENT
•
•
•
•
•
•
Impairment of Short Term Memory (STM)
Impairment of Long Term Memory (LTM)
Impairment of abstract memory
Impairment in judgment
Personality changes
Impairment of motor planning/task actualization
June 10, 2016
Major determinants to home discharge
•
•
•
•
•
•
•
Patient cognitive status
Patient activity level and functional status
Nature of the patient's current home/accessibility
Availability of family or companion support
Ability to obtain medications and services
Transportation for follow-up visits
Availability of services in the community to assist the
patient with ongoing care
ABILITIES GENERALLY PRESERVED
WITH ALL COGNITIVE DISORDERS
• Emotional Conditioning
– They may not remember your name
– They may not remember what you have done
– They will remember how you made them feel
This information is the property of D.Parker and M. Stanley and should not be copied
or otherwise used without express written permission of the authors
2
Functional Outcomes in Individuals with Cognitive or Mental Health Impairments
TYPES OF COGNITIVE DISORDERS
• Acute Disorders*:
• Potentially reversible
• Chronic Diagnoses with
CI implications
– Delirium
– Depression
– Post-Traumatic/PostOperative
– Medication or Electrolyte
• Anesthesia
• Hospitalization
• Sepsis/bacteremia
June 10, 2016
TYPES OF COGNITIVE DISORDERS
• Chronic Disorders*:
• Irreversible cognitive impairments
– Renal Disease
– Alzheimer’s
– Vascular disease
• DM
– Cardiac
• MID
• CHF
• BP/HTN
– Subcortical disorders
• PD, Hungtington’s, DLB, Picks
– Pulmonary
• COPD
– Sleep Deprivation
ACUTE COGNITIVE DISORDERS:
PATIENT PRESENTATION
• Perception:
• Orientation:
– hypersensitive to light or
sound
– visual, auditory, or tactile
hallucinations.
• Memory:
– impaired, less STM. New
info difficult to learn
– Disorientation to time and
place or self
ACUTE DISORDERS: DELIRIUM
• Definition: an abrupt change in mental status and
behavior
– Global, fluctuating impairment in cognitive process
– Alteration in attention.
• Thinking:
– Illogical and disjointed
thoughts. Difficulty with
problem solving and word
finding.
• Alertness:
• Relatively quick onset, most often related to a variety of
physical causes
• Can become fixed and unresponsive to treatment unless
identified and treated at an early stage.
– hypo or hyper alert
Delirium Screening Tool
Confusion Assessment Method
Delirium
• Mechanism: Electrolyte or chemical disturbances
influencing the blood/brain barrier (K+ and Na++
pumps)
• Predictors:
– Discharge from hospital <10 days after surgery/hip fracture;
prolonged ICU stay; new CVA or seizure disorder; LewyBody or acute Parkinson diagnosis, drug abuse, ETOH
withdrawal, acute infections, poisons, ANESTHESIA
response
• Monitor/test: Confusion Assessment Method (CAM)
Coding: 0 = No 1 = Yes
Acute Onset and Fluctuating Course
A. Different from Baseline mental status?
B. Acute Onset and Fluctuating Course
New abnormal behavior fluctuate during the day or in severity?
C. Inattention: Difficulty focusing attention/distractible?
D. Disorganized Thinking: rambling, irrelevant, illogical,
unpredictable flow of conversation or ideas?
Altered Level of Consciousness
E1. Alert (Normal)
E2. Vigilant (hyperalert), Lethargic, Stupor, Coma
A.
IF YES for A, B, OR C And YES for either D or E2, delirium is
likely and should be reported.
This information is the property of D.Parker and M. Stanley and should not be copied
or otherwise used without express written permission of the authors
3
Functional Outcomes in Individuals with Cognitive or Mental Health Impairments
Delirium
• Assessment
June 10, 2016
Acute Disorders: Depression
• The pt. with depression will have:
– All functional test scores become “dependent” as performance is
not usual
• Set goals based on projected improvement
• Treatment
– Slower onset of symptoms
– Longer history of somatic complaints and a lower self esteem
– Tend to be on the hypo side of alertness.
• Depression affects a number of cognitive variables:
– Ability to process information
– Comprehension
– Ability to learn new information
– Compliance
– Bedrest doesn’t resolve so if not combative, get them moving
– Simple and routine activities avoid frustration
– Limit sensory stimulation
• Depression affects episodic memory, perceptual speed,
and visual-spatial ability, frontal lobe functioning.
Acute Disorders:
Mental Illness/Depression
• Mechanism: chemical changes in neurotransmitters;
serotonin; higher cortisol and other stress hormones
• Cognitive/behavioral manifestations: pain, fatigue,
insomnia increases while appetite decreases
• Frequent infections
• Suspect Depression as a factor in persons after MI; with
PD; DM; MS/ALS; Stroke; Cancer; CRF
• Treatment: Pharmacology, Rehab- improve motivation
(Self-Efficacy), improved perceived outcomes.
• Monitor/test: CNA/RA activity reports, GDS, MoCA,
tests of safety/multitasking (TUG-Cognitive)
Acute Disorders:
Post Operative Cognitive Decline
•
•
•
•
Post Operative Cognitive Dysfunction
• Mechanisms: not well understood; probably related to
stress/systemic inflammatory reactions
• Behavioral/cognitive symptoms: decreased memory,
perception, processing speed, irritability
• Monitor/Testing: tests for executive function (trail
making), CAM, Visuospatial functioning (CLOX)
Elective or Emergent
Incidence of POCD is 10-60% of older patients.
25% have cognitive dysfunction at 1 week post-surgery.
There appears to be no change in incidence, duration
with type of surgery
Observed Risk factors for POCD
•
•
•
•
•
•
•
Older age
Longer operation/anesthesia
Little education
Respiratory complications
Post-op infection
Second operation during same hospitalization
Retrospective studies suggest that it doesn’t correspond
to type of anesthesia or post-op pain control
This information is the property of D.Parker and M. Stanley and should not be copied
or otherwise used without express written permission of the authors
4
Functional Outcomes in Individuals with Cognitive or Mental Health Impairments
Literature Review - POCD
• A Mayo study with 1638 procedures found no significant
association between exposure to procedures requiring general
anesthesia after age 45 and incident persisting
dementia.(Sprung, 2013)
• Postop delirium and cognitive decline are adverse events that
occur frequently in elderly patients. Preexisting patient factors,
medications, and various intraoperative and postoperative
causes have been implicated in the development of
postoperative delirium and cognitive decline (Fong,2006)
• POCD was not significantly associated with registered
dementia over a median follow-up of 11 years. (Steinmetz,
2013)
Acute Disorders:
Sleep Apnea/Sleep Deprivation
• Lack of sleep can result in significant deterioration in
cognitive functioning, particularly short term memory
and attention.
• Sleep deprivation can also result in poor judgment,
irritability, depression or anxiety.
• All of these symptoms often disappear suddenly when
normal sleep is restored with appropriate treatment
• One night of bad sleep = 12% reduction in cognition.
June 10, 2016
Acute Disorder:
Medication/Electrolyte Imbalance
• Sodium (Up/Down)
– Memory loss, deficit of attention, alterations in sleep-wake cycles,
hallucinations and delusions.
• Potassium
– Apathy, inability to recite months backward, difficulty with
repetitive tasks, disorganized thought processes, lethargy, reduced
awareness and altered levels of consciousness.
• Calcium (Up)
– Difficulty focusing, trouble maintaining conversations, mood
swings, personality changes and problems with following
commands.
Chronic Systemic Disorders with
CI implications
System
Impairment/Condition
Hypothyroidism, hyperthyroidism, peri‐
Endocrine
Metabolic
Immune/ Infections
Cardiovascular
Cerebrovascular
Pulmonary
Chronic Systemic Disorders with
CI implications
System
Impairment/Condition
Renal Failure, uremia, UTI
Renal
Neurologic Encephalopathy, head trauma, cancer (esp. with brain Other
mets), CVA
Chronic drug or alcohol use
Medication (anticonvulsants, antidepressants, antiemetic, antihistamines, antipsychotics, benzodiazepines, narcotics, sedative‐hypnotics, Zantac, Tagamet)
menopause, menopause
Severe anemia, fluid and/or electrolyte imbalances: dehydration
AIDS, toxoplasmosis, malaria, fungal or TB meningitis, Lyme’s disease, Neurosyphilis
CHF
TIA, CVA (cerebral insufficiency), post anoxic encephalopathy
COPD, Hypoxemia ( arterial O2 ), Hypercapnia (CO2 )
Chronic Systemic Disorders with CI
Implications: Diabetes
• Mechanism: altered blood-brain barrier with measurable
tissue changes
• Cognitive/behavioral manifestations: decreased
attention, judgement, processing speed
• Monitor/test: Blood sugar with new activities, BP and
pulse, executive function (SLUMS), safety tests (Allen,
CPT)
Post‐Op /Anesthesia recovery, Severe Anemia, Sarcoidosis, sleep apnea, vasculitis, vitamin deficiencies (B‐12, folate, niacin, thiamine).
This information is the property of D.Parker and M. Stanley and should not be copied
or otherwise used without express written permission of the authors
5
Functional Outcomes in Individuals with Cognitive or Mental Health Impairments
Literature Review-Diabetes Mellitus
• Patients with diabetes are approximately 1.5 times more
likely to experience cognitive decline than individuals
without diabetes mellitus (Cooper 2015)
• The increased risk of cognitive decline and dementia in
elderly subjects with diabetes is due to dual pathology,
involving both cerebrovascular disease and cortical
atrophy (Biessels, 2006)
Literature Review-Pulmonary
June 10, 2016
Chronic Systemic Disorders with CI
Implications: Pulmonary
• Mechanism: Hypoxia or anoxia from reduced oxygen
intake – acute or chronic
• Cognitive/behavioral manifestations: “giving up favored
activities/hobbies,” better compliance in groups vs
independent ex, isolation/reducing social contacts,
polypharmacy
• Monitor/test: vital signs, respiratory rate and SpO2 ;
tests of activity tolerance (6 min walk, 2 min walk, etc.);
tests of safety/multitasking (Gait speed, 4 item DGI,
Cognitive TUG, etc.)
Chronic Systemic Disorders with CI
Implications: Cardiac
• Population-based study (n=1927 55% with COPD) suggests
COPD associated with 2x ↑ odds of having MCI (Singh, 2014)
• Memory, verbal fluency, and executive function were impaired
in survivors (of acute RDS). Long-term cognitive impairment
was present in 55% of sample (MIkkelson, 2012)
• Hospitalization for pneumonia associated with an ↑ risk of
dementia (P =0.01). (Shah, 2013)
• Patients who were treated for pneumonia – including those
hospitalized even 1x in 9 yrs. and who did not require critical
care – were more than twice as likely to develop new cognitive
impairments. (Davydow, 2012)
• Mechanism: Hypoxia or anoxia from reduced blood
flow – acute or chronic
• Cognitive/behavioral manifestations: deficits in memory
and attention
• Monitor/test: vital signs (BP is the most critical,
followed by HR then respiratory rate)
• Tests of activity tolerance (6 min walk, 2 min walk, etc.)
MoCA and SLUMS
Literature Review-Cardiac
Chronic Systemic Disorders with CI
Implications: Hyper/Hypotension
• CI is a common and predictable effect of CHF that
contributes to decreased compliance to prescribed
therapy and increased hospital readmissions (Cohen,
2007)
• CI was found in 26% of patients with heart failure
(Zuccala, 2001)
• MCI is highly prevalent amongst typically older highrisk patients hospitalized with AFib. Routine assessment
of cognitive function (MoCA) is indicated for this
patient group. (Ball, 2013)
• Cardiac disease is associated with increased risk of nonamnestic cognitive impairment (Roberts, 2013)
• Mechanism: Hypoxia or anoxia from reduced blood
flow – acute or chronic
• Cognitive/behavioral manifestations: anxiety, fatigue
with routine activity, SOB, delayed word finding and
thought processing
• Monitor/test: vital signs (BP is the most critical) before,
during, after activity; Tests of activity tolerance; tests of
completion like Trailmaking or Clock Drawing Tests
This information is the property of D.Parker and M. Stanley and should not be copied
or otherwise used without express written permission of the authors
6
Functional Outcomes in Individuals with Cognitive or Mental Health Impairments
CHRONIC DISORDERS: DEMENTIA
• Common types of dementia
–Alzheimer's, vascular (multi-infarct dementia),
Parkinson’s associated, Lewy Bodies, frontal-temporal
lobe degeneration (including Picks’s disease)
• Symptoms
–Depression, anxiety, paranoia, inappropriate social
behavior, anger, emotional perseveration, delusions,
confabulation
CHRONIC DISORDERS:
MULTI-INFARCT DEMENTIA (MID)
• Usually of more rapid onset
• Occurs in younger individuals
• Progresses in a step wise
fashion
– abrupt worsening and plateaus of
function.
• Pt often has focal neurologic
deficits
– paresis and paresthesia
– Gait disturbance
• Occurs in 14-20% of patients
with dementia. Another 16-20%
have a combination of AD and
MID.
• Patient Med Hx:
– Hypertensive
– Diabetes
– Generalized atherosclerosis.
• Irreversible brain damage
resulting from repetitive
ischemic injury caused by
emboli or bleeding.
• Normalization of BP is the most
effective intervention known.
• Monitor/test: vital signs, tests of
safety, balance and gait
CHRONIC DISORDERS:
PICKS DISEASE AND
FRONTOTEMPORAL DEMENTIA
June 10, 2016
Red Flags Suggesting a Dementia
Red flag
Diagnosis
Abrupt onset, Stepwise
deterioration
Vascular dementia
Prominent behavioral changes,
Profound apathy
Frontotemporal dementia, vascular dementia
Progressive gait disorder
Vascular dementia, normal pressure hydrocephalus,
Parkinson’s disease dementia
Prominent fluctuations
-Consciousness
-Cognitive abilities
Delirium due to infection, medications or other causes,
dementia with Lewy bodies, temporal lobe epilepsy,
obstructive sleep apnea syndrome, metabolic disturbances
Hallucinations or delusions
Delirium due to infection, medications or other causes,
dementia with Lewy bodies
Frequent falls
Progressive supranuclear palsy, dementia with Lewy
bodies
Extrapyramidal signs or gait
Parkinsonian syndromes, vascular dementia
Eye movement abnormalities
Progressive supranuclear palsy, Wernicke’s
encephalopathy
CHRONIC DISORDERS:
DEMENTIA WITH LEWY BODIES (DLB)
• Associated with Visuospatial and executive dysfunction.
• Patient presentation:
– Early deficits in attention and visuospatial function, severe
hallucinations, spontaneous Parkinsonism, alterations in alertness
and attention, sleep disorder
• Meds typically used to treat hallucinations and agitation
often don’t work with people who have DLB.
– Meds may even exacerbate the symptoms.
• Monitor/test: MoCA, tests of safety, balance, gait
CHRONIC DISORDERS:
ALZHEIMER’S DISEASE (AD)
• Most common form
• Difficult to differentiate from Alzheimer’s disease.
• Presentation includes
– personality change, language impairment, apraxia, impulsivity,
apathy, carbohydrate craving, mania, grandiose illusions, loss of
insight.
– Impaired attention, abstraction, planning, problem solving, or
executive function
– 50-60% of reported dementia cases
• Characterized by:
– slow onset disorientation
– memory loss (episodic memory first complaint)
– reduced ability to reason and make sound judgments
– loss of social skills
– development of regressed or antisocial behavior.
• Monitor/test: MoCA, tests of safety, balance, gait
This information is the property of D.Parker and M. Stanley and should not be copied
or otherwise used without express written permission of the authors
7
Functional Outcomes in Individuals with Cognitive or Mental Health Impairments
June 10, 2016
NEUROMOTOR CHANGES
• Balance problems, shuffling gait, fear of falls, and motor
impersistence.
• Apraxia (poor motor initiation)
• Agnosia (poor object recognition)
• Ataxia (motor in-coordination).
• Cognitive impairments: poor judgment, memory deficits,
emotional lability, and orientation loss.
Stages of AD
• Early Stage (I) (2-4 years)
– Mild memory deficit, difficulty with complex tasks, social
withdrawal, moodiness, time disorientation, poor judgment.
• Middle Stage (II) (lasts several years)
– Mod to severe memory deficit, disorientation to time and place,
language disturbance, personality and behavioral changes. Apraxia
and agnosia demonstrated. Require assistance
• Late Stage (III) (no time limit)
– Intellectual functions virtually un-testable, Verbal communication
severely limited, incapable of self-care, incontinence. Righting
postures and explosive sounds/behaviors. Ataxic.
• Terminal Stage (IV)
– Unaware of environment, mute, bedridden, joint contractures,
pathological reflexes, myoclonus
Cognition Assessment Tools
ASSESSMENT TOOLS
• Vital Signs (Functional activity tolerance)
• Functional Assessments: Establish a baseline
– STEADI
– CARE
– Gait Speed
– Balance
– Functional Strength: sit to stand
Many reliable and valid
tools available to utilize with
individuals with CI
•
•
•
•
•
•
•
•
SLUMS
MoCA
FAST- Functional Assessment Staging Tool
Clock Drawing Test/ 7 minute Cognitive Screen
CLOX
MiniCog
MMSE- Mini Mental State Exam
See recommendations from AGPT Cognitive and Mental Health SIG
– http://geriatricspt.org/members/special-interest-groups/index.cfm
– Mission Cognition: Advancing the Role of the PT in Chronic Progressive
Cognitive Impairment. CSM 2016 February 17-20, 2016
Depression Assessment Tools
• GDS –Geriatric Depression Scale
– https://www.healthcare.uiowa.edu/igec/tools/depression/GDS.pdf
• GDS –Global Depression Scale
– https://www.researchgate.net/profile/Marie_Asberg/publication/226970
65_A_New_Depression_Scale_Designed_to_be_Sensitive_to_Change/
links/09e41513f85c708fee000000.pdf
• BDI –Beck Depression Inventory
– http://mhinnovation.net/sites/default/files/downloads/innovation/resear
ch/BDI%20with%20interpretation.pdf
• PHQ-9 –Patient Health Questionnaire -9
– http://www.integration.samhsa.gov/images/res/PHQ%20%20Questions.pdf
Assessment Tips:
Cognitive Impairment Suspected
• Environment Modifications
– Sensory distractions must be kept to a minimum (noise, clutter).
• Short activities with rest breaks
– because of the client’s distractibility and memory deficits.
• Multiple cues should be used- SIMPLE
– Presented individually giving people time to respond
– visual, verbal, and tactile
• Communication in single step commands without the
use of lead in statements.
• Zung Self-Rating Scale
– http://www.depression-test.net/support-files/zung-sfds.pdf
This information is the property of D.Parker and M. Stanley and should not be copied
or otherwise used without express written permission of the authors
8
Functional Outcomes in Individuals with Cognitive or Mental Health Impairments
Continuity Assessment Record and
Evaluation (CARE)
• Deficit Reduction Act of 2005
• Standardized patient information across LTCHs, IRFs, SNFs,
HHA and recommended for Acute hospitals
• Non-proprietary and reduced administrative burden cost to use
for providers
• Extensive reliability and validity testing
• Update of IRF-PAI, OASIS, and MDS
MOBILITY (all patients)
•
•
•
•
•
•
Roll left and right (side to side in both directions)
Sit to lying (EOB to flat on bed)
Lying to sitting (EOB, feet flat, no back support)
Sit to stand: from chair or EOB
Chair/bed<->chair transfer: to/from chair or w/c
Toilet transfer: on and off commode or toilet
MOBILITY
WHEELCHAIR
AMBULATING
• Walk 10 feet (3 meters)
on level, open space once
standing
• Wheel 50 feet with two
turns (once seated) –indicate
manual or motorized
• Walk 50 feet and make 2
turns
• Wheel 150 feet in a corridor
–indicate manual or
motorized
June 10, 2016
SELF-CARE
• EATING: use suitable utensils, bring food to mouth, swallow –
includes modified consistency
• Oral hygiene: use suitable items to clean teeth or dentures
• Toileting: maintain perineal hygiene, adjust clothes before and
after; ostomy opening care
• Wash upper body: wash and dry while seated in bed or chair
• Walk 150 feet (45 meters)
in a corridor or similar
space
CARE Definitions
6
5
4
INDEPENDENT –NO ASSISTANCE OF ANY
KIND
SET-UP OR CLEAN-UP , ASSIST ONLY PRIOR TO
OR AFTER ACTIVITY
SUPERVISION OR TOUCHING ASSIST, VERBAL
CUES OR STEADYING AT ANY TIME
3
PARTIAL/MODERATE ASSIST – ASSIST WITH
LESS THAN 50% OF PHYSICAL WORK
2
1
SUBSTANTIAL/MAX ASSIST –HELPER
PROVIDES >50% OF EFFORT
DEPENDENT (ANY ASSIST OF 2 EVEN IF
PATIENT IS PROVIDING SOME OF EFFORT)
Severity/Complexity Modifiers
CH
0 PERCENT IMPAIRED
CI
AT LEAST 1 PERCENT BUT LESS THAN 20%
IMPAIRED
CJ
AT 20 PERCENT BUT LESS THAN 40% IMPAIRED
CK
AT LEAST 40% BUT LESS THAN 60% IMPAIRED
CL
AT LEAST 60% BUT LESS THAN 80 % IMPAIRED
CM
AT LEAST 80% BUT LESS THAN 100% IMPAIRED
CN
100% DEPENDENT
This information is the property of D.Parker and M. Stanley and should not be copied
or otherwise used without express written permission of the authors
9
Functional Outcomes in Individuals with Cognitive or Mental Health Impairments
SETTING GOALS
G CODE/CARE CROSS-WALK
CH
CI
0 PERCENT IMPAIRED
AT LEAST 1 PERCENT BUT LESS
THAN 20% IMPAIRED
AT LEAST 20 % BUT LESS THAN 40%
IMPAIRED
AT LEAST 40% BUT LESS THAN 60%
IMPAIRED
AT LEAST 60% BUT LESS THAN 80 %
IMPAIRED
AT LEAST 80% BUT LESS THAN 100%
IMPAIRED
100% DEPENDENT
CJ
CK
CL
CM
CN
6
5/4
4/3
3
2
2
1
TREATMENT GOALS: ACUTE
COGNITIVE DISORDERS
• Interdisciplinary Goals:
– address the patient’s emotional needs
– alter the environment so that the patient’s remaining skills can be
used
– augment the patient’s capacity to successfully undertake ADL’s
– educate the family
– provide emotional and physical support to the family and caregivers
and give the patient and family a realistic prognosis.
Case Study: Edith of “da Nile”
February
August
•
•
•
•
•
•
•
•
•
•
•
•
SLUMS: 26/30
CLOX 1: 13/15
CLOX 2: 14/15
ACL: 5.0
SpO2 89% RA/ex
150 FT Walk: no AD -24
sec= 1.9 mps
June 10, 2016
SLUMS: 15/30
CLOX 1: 9/15
CLOX 2: 13/15
ACL: 4.4
SpO2 86% RA/rest
50 feet: > 2 min, 4WW ,
25% assist, 2 rests
CLINICAL MEASURES
GAIT SPEED
➢ .14-.16 m/s MDC
➢ .5 mps MCID
6 MINUTE WALK
➢ 110 FEET MDC
➢ 180 FEET MCID
BERG
➢ 5 points MCID
FUNCTIONAL GOALS
Getting to bathroom in time;
crossing at a street light
POMA
➢ 5 points MDC
➢ 9 points MCID
5TSTS/30 SECOND CHAIR STAND
➢ 2.3 SEC/ 2 REPETITIONS MCID
STATIC POSITIONS: 4 STAGE
BALANCE
➢ 5 SEC/POSITION MCID
Safety walking in the room or hall;
removal of chair alarms
Walking to the dining room;
walking across a parking lot;
walking thru store
Safety when walking in a
household, senior center
Measure of strength
Transfer independence
Safety in kitchen tasks, hygiene,
dressing
Predicting Outcomes
Behavior for success
in desired setting
•
•
Mobility/strength/balance
Mobility/activity
tolerance
Self-care
Sustainable,
Measureable,
Desirable
Can Do, Will do, May
do
•Meaningful to client
•Best practice measures
•Reduce Risk
Case Study: Treatment Goals
• Will demonstrate improved gait speed for short distances (2040 feet) with supervision and walker to maintain functional
continence during daytime 75% of the time. (baseline
incontinent >50% after reaching bathroom door, mod assist)
• Will demonstrate improved functional strength by completing
5TST < 25 seconds with 1 cue (baseline 35 s with 5 cues)
• Will walk 400 feet with walker and supervision with
respirations </=20 for comfortable community access
• LTG: Will ambulate independently for 10 minutes
continuously with SpO2 >/=88% on RA
This information is the property of D.Parker and M. Stanley and should not be copied
or otherwise used without express written permission of the authors
10
Functional Outcomes in Individuals with Cognitive or Mental Health Impairments
Case Study: Edith of “da Nile”
September/SNF discharge
• SLUMS: 27/30
• CLOX 1: 14/15
• CLOX 2: 14/15
• ACL: 5.4
• 150 ft walk: 4WW about
1 minute (gait speed
1.3mps) independent
with oxygen; 600m/10
min (1m/s)
• Continent
Overall Picture
• Nicotine patch
• 2L NC with exercise
• 2L at night
• BF and family very
supportive when the
relationship between oxygen
and personality, behavior
explained.
• Highly stylized O2 tanks
• Scooter for “bad back”
June 10, 2016
Case Study: SAM
• Admission DX: Cerebellar Ataxia
• BP: 202/110 standing; 180/90 sitting; 184/89 supine at PT Home Admit. Hospital PT:
• BP: 160/90 supine; 174/96 sitting; 180/102 standing • Berg 26/56
• Four Stage Balance: Feet together: 4 sec; Staggered: 7 sec; Tandem: Unable to hold, assist to attain; SOL: Not able
• Pronator Drift; Past‐pointing ‐ Dysmetric ; Rapid alternating finger flexion: slow, dysmetric
• MoCA: 21/30
Case Study: SAM’s Goals
Case Study: HOWARD
Two Weeks
• Will demonstrate improved balance by increasing Berg
Balance Score by 20 points
• Will demonstrate comfortable ambulation for household
distances (150 feet) with BP remaining </= 150/80 and no
more than supervision with walker
4 Weeks
• To demonstrate ability to be safe for home toileting and
transfers, will increase performance on Four Stage Balance
Test to 30 sec for Romberg, Staggered, and Tandem Stance
• Will demonstrate comfortable ambulation for community
distances (10 min continuous walking) with BP remaining </=
150/80 and independence with least restrictive assistive device
Diagnosis: Uncompensated congestive left diastolic heart failure
• PT Evaluation
• Bed Mobility: supervision, use of railings, HOB raised, added
time and effort with 2 cues
• Orthostatic BP changes
• Transfers: Mod assist (15% physical help) and walker
• Ambulation: Mod assist, walker, 300 feet with oxygen at 2L
and gait speed 0.8 m/s
• 30 second chair stand: 3 repetitions
• MoCA: 22/30
GOALS?
Case Study: Howard
• Hospitalized for 5 days with admitting Dx: AMS changes/delirium ; discharged DX: CHF
• BNP of 1850 on admission
• Aggressive diuresis over 3 weeks with return to “feeling like myself again”
• After 2 weeks in SNF: Mobility, balance, coordination WNL; slightly de‐conditioned but anxious to return to tennis and home
This information is the property of D.Parker and M. Stanley and should not be copied
or otherwise used without express written permission of the authors
11
Functional Outcomes in Individuals with Cognitive or Mental Health Impairments
Developing Treatment Strategies
Set the Stage for Success
• Optimize physiology
– Hydration, hunger, rest, anxiety, after pain meds if indicated
• Understand Executive Function
– What do they notice
• Capitalize on Motor/muscle memory
– What can they control
Treatment Strategies:
Clients with Cognitive Impairment
• Slow down:
– take your time in all aspects
• Explain:
– thoroughly, frequently,
constantly, short phrases, and
repetitively if necessary.
• Reorient to task
• Focus on maintaining the highest level of function.
• Patients who have dementia can learn…slower
• If a patient is sent to PT because of weakness and falls
– Determine cause and adapt treatment (Inattention?)
– Embed strengthening and balance training in functional activity
– Retrain primary caregiver –elicit empathy, acknowledge anger
– Environmental assessment/home visit
– What is allowed
– instructions, programs,
environment
Treatment Strategies Across all causes for
Cognitive Impairment
• Modify the environment for success
• Sensitivity to Cultural Mores
• Simplify:
June 10, 2016
• Avoid change:
– Change should be avoided in
the environment, with the
personnel, and in all aspects
of programming.
• Encourage familiarity:
– Familiar objects, exercises
should mimic familiar
activities, and familiar people
should be encouraged to
visit.
Treatment Strategies:
Learning and Processing at a Deeper Level
Turn on the Frontal Lobe during training
• Predictions
– What will happen if you transfer from you wheelchair without the
brakes on
• Postdictions
– What did you do to make sure you transferred from the wheelchair
to the bed safely
• Retention testing
– Announced beforehand
– “This will make a great test question” or “I am going to ask you
some questions after we are all done with the transfer about your
safety”
EXECUTIVE FUNCTIONING
• The ability to pay attention and inhibit behaviors and
thoughts are very much related.
– If we are unable to inhibit paying attention to irrelevant stimuli then
we won’t be able to pay attention well enough to comprehend or
remember new information.
• With decreased executive function and decreased
memory= falls
• Continence can be related to paying attention to internal
cues –and moving quickly enough to attend to them
Literature Review: Exercise to
Improve Executive Function
• Exercise: (aerobic and strength) Adults who exercise are 61%
less likely to get dementia
• Increased leg strength associated with slower cognitive loss in
women (Steves, 2016)
• Results suggest that exercise is associated with increased levels
of high-arousal positive affect (HAP) and decreased levels of
low-arousal positive affect (LAP) (Hogan, 2013)
• There is evidence that aerobic physical activities which improve
cardiorespiratory fitness are beneficial for cognitive function in
healthy older adults, with effects observed for motor function,
cognitive speed, delayed memory functions and auditory and
visual attention. (Cochrane, 2008)
This information is the property of D.Parker and M. Stanley and should not be copied
or otherwise used without express written permission of the authors
12
Functional Outcomes in Individuals with Cognitive or Mental Health Impairments
Fun Ways to Enhance Executive Function
• State the color the word is written in, not what the word
says.
• Sentence Inhibition Activity:
• Word generating activities
– Generate as many names as possible in a certain category
• Great way to enhance attention and executive function
prior or during functional activity!
GUIDELINES FOR TREATMENT
– Conveys caring and support
to a patient who is going
through an uncontrollable
change and may desperately
need support.
• Encourage independence:
– Simplify commands and
label items for ease of
recognition (names/picture
on doors)
Treatment Strategies in Patients with
Depression
• Increase motivation for the rehab process
– Increase self-efficacy
– Increased perceived outcome expectations
• What’s in it for me?
– The captain wanted to stay with the sinking…
– Could you please pass the salt and…
• Touch:
June 10, 2016
• Respect individual:
– Encourage the patient to
discuss and demonstrate
previous successes and
accomplishments.
– Display pictures of the
patient in memorable
moments.
– Respect modesty and dignity.
– Behavior= outcome expectations + self-efficacy
• Enhancing Self-Efficacy
– Make therapy relevant
– Find meaningful and purposeful tasks
– Recognize the decreased confidence and SE
– Set a greater number of reachable goals
– Provide opportunities to succeed – and reinforce success
GUIDELINES FOR TREATMENT
• Educate and support the
family:
– Be prepared to confront
denial in the family and
patient.
– Provide information on
additional support services
for CI patients.
– Frequently bring up the topic
of additional support.
– Reinforce that the patients
behavior is not volitional.
This information is the property of D.Parker and M. Stanley and should not be copied
or otherwise used without express written permission of the authors
• Listen to the patient:
– Even if the patient is not
making sense, try to listen.
• Take care of yourself:
– Working with pts. with CI
can be emotionally
exhausting.
– If a patient is combative or
abusive, tell the patient that
this type of behavior upsets
you and take a self time out
from the patient…treat later
or another day if needed.
13
Functional Outcomes in Individuals with Cognitive or Mental Health Impairments
June 10, 2016
1. Ancelin ML, De Roquefeuil G, Scali J, et al. Long-term post-operative cognitive decline in the elderly: the effects
of anesthesia type, apolipoprotein E genotype, and clinical antecedents. J Alzheimers Dis. 2010; 22 Suppl 3:10513. doi: 10.3233/JAD-2010-100807.
2. Angevaren M, Aufdemkampe G, Verhaar HJ, et al. Physical activity and enhanced fitness to improve cognitive
function in older people without known cognitive impairment. Cochrane Database Syst Rev. 2008 Apr
16;(2):CD005381. doi: 10.1002/14651858.CD005381.pub2.
3. Ball J, Carrington MJ, Stewart S. Mild cognitive impairment in high risk patients with chronic atrial fibrillation: a
forgotten component of clinical management? Heart. 2013; 99(8) 542-7.
4. Bedford PD. Adverse cerebral effects of anaesthesia on old people. Lancet. 1955; 269(6884):259-63.
5. Biessels GJ, Koffeman A, Scheltens P. Diabetes and cognitive impairment. Clinical diagnosis and brain imaging
in patients attending a memory clinic. J Neurol. 2006; 253(4):477-82.
6. Bohannon RW. Six minute walk test: A meta-analysis of data from apparently healthy elders. Topics Geriatr
Rehabil. 2007;23(2):155-160.
7. Boissonault W. Primary Care for the Physical Therapist: Examination and Triage. Philadelphia, PA: Saunders
Elsevier; 2005.
8. Buchman AS, Tanne D, Boyle PA, Shah RC, Leurgans SE, Bennett DA. Kidney function is associated with the rate
of cognitive decline in the elderly. Neurology. 2009;73(12): 920-927.
9. CMS.Medicare Learning Network. 2015. http://www.cms.gov/outreach-and-education/medicare-learningnetwork-mln/mlnproducts/downloads/g-codes-chart-908924.pdf. Accessed April 24, 2016.
10. CMS. Medicare Learning Network. 2015. http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/Post-Acute-Care-Quality-Initiatives/CARE-Item-Set-and-BCARE.html http://www.nlm.nih.gov/medlineplus/ency/article/000740.htm. Accessed April 24, 2016.
11. Cohen MB, Mather PJ. A review of the association between congestive heart failure and cognitive impairment.
Am J Geriatr Cardiol. 2007; 16(3)171-4.
12. Cooper C, Sommerlad A, Lyketsos CG, Livingston F. Modifiable predictors of dementia in mild cognitive
impairment: A systematic review and meta-analysis. American J of Psychiatry. 2015; appi.apj.2014.1 DOI:
10.1176/appi.spj.2014.14070878.
13. Davey A, Elias MF, Robbins MA. Decline in renal functioning is associated with longitudinal decline in global
cognitive functioning, abstract reasoning and verbal memory. Nephrology Dialysis Transplantation. 2012;
DOI: 10.1093/ndt/gfs470.
14. Daveydow DS, Hough C, Levine D, et al. Functional disability, cognitive impairment, and depression after
hospitalization for pneumonia. Am J Med. 2013;DOI:10.1016/jamjmed 2012.12.06.
15. Donoghue D, PROP group, Stokes EK. How much change is true change? The minimum detectable change of the
Berg Balance Scale in elderly people. J Rehabil Med. 2009;41(5):343-6.
16. English CK, Hillier SL, Stiller K, Warden-Flood A. The sensitivity of three commonly used outcome measures to
detect change amongst patients receiving inpatient rehabilitation following stroke Clin Rehabil 2006;20(1):525.
17. Fong HK, Sands LP, Leung JM. The Role of postoperative analgesia in delirium and cognitive decline in elderly
patients: a systematic review. Anesthesia & Analgesia.2006; 102 (4) 1255-1266. doi:
10.1213/01.ane.0000198602.29716.53.
18. Goldberg, A, Chavis, M, et.al. The five-times-sit-to-stand test: validity, reliability and detectable change in older
females. Aging Clin Exp Res, 2012;24: 339-344.
19. Goodman C, Snyder T. Differential Diagnosis for Physical Therapists: Screening for Referral. Philadelphia, PA:
Saunders Elsevier; 2007.
This information is the property of D.Parker and M. Stanley and should not be copied
or otherwise used without express written permission of the authors
14
Functional Outcomes in Individuals with Cognitive or Mental Health Impairments
June 10, 2016
20. Hartley, G, Strunk, E, Lusardi, M. Section on Geriatrics Recommended outcome measures for Medicare
functional limitation/severity reporting. GeriNotes.2013; 20(3), 28-32.
21. Hogan CL, Matta J, Carstensen CL. Exercise holds immediate benefits for affect and cognition in younger and
older adults. Psychol Aging, 2013; 28(2): 587-594.
22. Inouye SK. The Short Confusion Assessment Method (Short CAM): Training Manual and Coding Guide. Boston,
MA: Hospital Elder Life Program.2014.
23. Institute of Medicine. Beyond myalgic encephalomyelitis/chronic fatigue syndrome: redefining an illness.
February 10, 2015. http://www.iom.edu/Reports/2015/ME-CFS.aspx. Accessed February 26, 2015.
24. Johnson, Kate. Pain negatively affects cognition in fibromyalgia. Medscape. Feb 06, 2012. Accessed February
26, 2015.
25. Lewis C, Bottomley J. Geriatric Rehabilitation: A Clinical Approach. Upper Saddle River, NJ: Prentice Hall Health;
2008.
26. Lewis C. Aging: The Health Care Challenge. Washington, DC: F.A. Davis; 2002.
27. Lin JH, Hsu MJ, Hsu HW, et.al. Psychometric Comparisons of 3 Functional Ambulation Measures for Patients
With Stroke. Stroke. 2010; 41(9):2021-5.
28. Lindquist LA, Go Lise, Fleisher J, et al. Improvements in cognition following hospital discharge of community
dwelling seniors. J Gen Intern Med 2011; 26(7):765-70.
29. Lusardi MM, Pellecchia GL, Schulman, M. Functional performance in community living older adults. J Geriatr
Phys Ther. 2003;26(3):14-22.
30. Melkumova KA, Podchufarova EV, Yakhno NN. Characteristics of cognitive functions in patients with chronic
spinal pain. Neurosci Behav Physiol. 2011;41(1):42-46.
31. Meretta BM, Whitney SL, Marchetti GF, et al. The five times sit to stand test: responsiveness to change and
concurrent validity in adults undergoing vestibular rehabilitation. J Vestib Res.2006;16(4-5):233-43.
32. Mikkelsen ME, Christie JD, Lanken PN, et al. The adult respiratory distress syndrome cognitive outcomes study:
Long-term neuropsychological function in survivors of acute lung injury. Am J Respir Crit Care Med. 2012;
185(12):1307-1315.
33. Moriarty O, McGuire BE, Finn DP. The effect of pain on cognitive function: A review of clinical and preclinical
research. Prog Neurobiol. 2011; 93(3): 385-404.
34. MOCA
test
and
instructions:http://www.mocatest.org/pdf_files/test/MoCA-Test-English_7_1.pdf
http://echo.unm.edu/wp-content/uploads/2014/07/clinic-dementia-MoCA-InstructionsEnglish.pdf
Accessed April 24, 2016.
35. Pasquier F, Boulogne A, Leys D, Fontaine P. Diabetes mellitus and dementia. Diabetes Metab. 2006; 32(5
PT1):403-14.
36. Perera S, Mody SH, Woodman RC, Studenski, SA. Meaningful change and responsiveness in common physical
performance measures in older adults. J Am Geriatr Soc. 2006; 54(5):743-749.
37. Rasekaba T, Lee LA, Naughton MA, et al. The six-minute walk test: a useful metric for the cardiopulmonary
patient. Internal Medicine Journal. 2009;39(8): 495-501.
38. Ries J, Echternach J, Nof L, Blodgett M. Test-retest reliability and minimal detectable change scores for the timed
up & go test, the six-minute walk test, and gait speed in people with Alzheimer disease. Phys Ther. 2009;89:569579.
39. Roberts RO, Geda YE, Knopman DS, et al. Cardiac disease associated with increased risk of nonamnestic
cognitive impairment stronger effect on women. JAMA Neurology. 2013; 70(3):374-382.
40. Romero S, Bishop MD, Velozo CA, Light K . Minimum detectable change of the Berg Balance Scale and Dynamic
Gait Index in older persons at risk for falling. J Geriatric Phys Ther. 2011; 34(3): 131-7.
This information is the property of D.Parker and M. Stanley and should not be copied
or otherwise used without express written permission of the authors
15
Functional Outcomes in Individuals with Cognitive or Mental Health Impairments
June 10, 2016
41. Ryan JP, Fine DF, Rosano C. Type 2 diabetes and cognitive impairment: contributions from neuroimaging. J
Geriatr Psychiatry Neurol. 2014;(1): 47-55.
42. Seaquist ER. The final frontier: How does diabetes affect the brain? Diabetes. 2010;59(1)4-5. Doi:10.2337/db091600.
43. Seymour DG, Severn AM. Cognitive dysfunction after surgery and anaesthesia: What can we tell the
grandparents? Age and Aging. 2009; 38(1):147 – 150.
44. Schaubert K, Bohannon R. Reliability and validity of three strength measures obtained from communitydwelling elderly persons. J Strength Cond Res. 2005;19(3):717-727.
45. Shah FA, Pike F, Alvarez K, et al. Bidirectional relationship between cognitive function and pneumonia. Resp
Crit Care Med. 2013;188(5)586-592.
46. Singh B, Parsaik Jk, Mielke MM, et al. Chronic obstructive pulmonary disease and association with mild cognitive
impairment: The Mayo Clinic study of aging. Mayo Clin Proc 2013; 88(11)122-30.
47. Spartano ML, Himali JJ, Belser AS, et al. Midlife exercise blood pressure, heart rate, and fitness relate to brain
volume 2 decades later. Neurology. 2016; 86(14):1313-1319.
48. Sprung J, Jankowski CJ, Roberts RO, et al. Anesthesia and incident dementia: A population-based, nested, caseControl study. Mayo Clinic Proceedings 2013; 88(6):552-561.
49. Steffen T, Seney M. Test-retest reliability and minimal detectable change on balance and ambulation tests, the
36-item short form health survey, and the unified Parkinson disease rating scale in people with Parkinsonism.
Phys Ther. 2008;88(6):733-46.
50. Steffen T, Hacker TA, Mollinger L. Age-and-gender-related test performance in community-dwelling elderly
people: Six-minute walk test, Berg balance scale, Timed Up & Go test, and gait speeds. Phys Ther.
2002;82(2):128-37.
51. Steinmetz J, Siersma V, Kessing LV, et al. Is postoperative cognitive dysfunction a risk factor for dementia? A
cohort follow-up study. Br J Anaesth 2013; 110(suppl 1):i92-i97.doi:10.1093/bja/aes466.
52. Steves CJ, Mehta MM, Jackson SHD, Spector TD. Kicking back cognitive ageing: Leg power predicts cognitive
ageing after ten years in older female twins. Gerontology 2016; 62:138-149.
53. Szeman B, Naqy G, Varga T, et al. Changes in cognitive function in patients with diabetes mellitus. Orv Hetil.
2012 Mar 4;153(9):323-9. doi: 10.1556/OH.2012.29319.
54. van Harten AE., Scheeren TWL, Absalom AR. 2012. A review of postoperative cognitive dysfunction and
neuroinflammation associated with cardiac surgery and anaesthesia. Anaesthesia, 2011;67(2): 280–293.
doi: 10.1111/j.1365-2044.2011.07008.
55. Zuccala, G., Onder G, Pedone C, et al. Cognitive dysfunction as a major determinant of disability in patients with
heart failure: results from a multicentre survey. J Neurol, Neurosurg, Psychiatry. 2001; 70(1):109-112.
This information is the property of D.Parker and M. Stanley and should not be copied
or otherwise used without express written permission of the authors
16