Collaborative Care for the Advanced Dementia Patient

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Collaborative Care for the Advanced Dementia
Patient
Michelle Tristani, MS/CCC-SLP Rehab Clinical
Specialist
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Interdisciplinary Pilot Study Overview

• Pilot Foundation Theories
• Pilot Roles and Procedures
• Pre-Implementation Survey
• Pilot Study Rehab Nursing Assessment Tools
• Tool Kit Implementation
• Post-Implementation Analysis
• Functional Maintenance Program Implementation
• Pilot Study Feedback Future Directions

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Communication is key to quality of life. We
need to implement cognitive programming that is
skilled care and billable while impacting not
only the living environment for residents but
also the work environment for the staff with whom
they interact. Lou Eaves
Foundation Theories for the Pilot Study
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Cognitive Approach Assumptions

• Cognition underlies all behaviors
• Cognitive disability impairs the individuals
  cognitive ability to perform a motor action
• Cognitive disability data can be obtained from
  functional observation
• Cognitive capacities (information processing)
  limitation of the individual can be gleaned by
  observing the quality of functional performance
• Cognitive hierarchy levels speak to the
  qualitative differences in routine task behaviors
  that are observed
• Environmental Compensations are the most viable
  interventions for long-term cognitive
  disabilities from pathological
• brain conditions

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Information Processing Model

• Processing starts with sensory input
• Sensorimotor associations
• Interpretive processes from sensory cues
• We pursue activities with varying goals, ranging
  from movement, to cause and effect, to
  investment in producing a high-quality outcome
• Motor actions
• Elicited by sensory cues
• Guided by sensorimotor actions
• Observed in activity performance
• Activities are placed within a patients range of
  comprehension and control.

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Statement of Risk Safety risk Risk due to
inability to communicate
Link Dx to cognitive status ? What Dx is
responsible for cognitive change? Consider
cognition as a barrier to functional progress
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The Cognitive - Communication Hierarchy
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Development of a Functional Communication Outcome

• Consider how communication / language (auditory
  processing, auditory, gestural reading
  comprehension, verbal, written gestural
  expression) are impacted via cognitive skills
• Consider assessment of visual versus auditory
  attention, concentration, and memory
• Consider preserved skills (procedural memory,
  reading comprehension, written expression) to
  compensate for weaknesses
• Consider assessment amelioration of sensory
  deficits

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KEY RELATIONSHIP

• Dementia related behaviors are a call for
• Comfort
• Communication
• Movement

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Task Analysis Clinical Reasoning

• Analysis of Task Analysis of Behavior

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THE CUEING HIERARCHY

• MODALITY 
• STRENGTH 
• WEAKNESS
• FLEXIBILITY
• NONSPECIFIC
• SPECIFIC

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Relocation to a LTC FacilityChanges and
Adaptive Challenges

• New setting
• Loss of possessions
• Lack of privacy
• New communication partners
• Role of resident / patient
• Communication styles differ
• Rules of successful LTC living differ from
  outside world
• Fears and anxieties emerge about
• LTC as a prelude to death failing health
  institutionalization loss of decision making
  increased dependence loss of finances
  separation from loved ones feelings of
  rejection incompetence patient role
• Adapted from Enhancing Communication Services in
  Extended Care Settings

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Cognitive Collaborative Care Pilot Study

• 7 Randomly selected skilled nursing facilities on
  the east coast of the US
• A collaborative programming model for cognitive
  management was implemented in the 7 facilities
• Pilot Study Goals
• Identify preconceived beliefs of healthcare
  providers that negatively impacted consistent
  care
• To ameliorate these obstacles via caregiver
  education and training
• To ascertain if positive outcomes were gained
  from the use of three, cognitive leveled tool
  kits that targeted preserved cognitive skills,
  with patients who had moderate to severe dementia
  
• Positive outcome as measured by
• Cohen Mansfield Agitation Inventory,
• ASHA NOMS scores, ACL scores and Caregiver
  Assessment

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Patient Identification Need for Skilled Rehab
Services

• Rehab evaluation and treatment procedures would
  proceed per typical, best practice patient
  identification of need
• Change in status
• Risk
• New treatment approach
• Reasonable expectation for improvement

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SLP Pilot Study Roles

• SLP Assessment Tools SLUMS, Functional
  Linguistic Communication Inventory, ASHA FACS
• Together with OT will complete the Cohen
  Mansfield Agitation Inventory
• Functional Skills Inventory
• Submit patient documentation from eval to
  discharge, Cohen Mansfield Agitation Inventory
  and the Functional Skills Inventory for analysis
• Pre and Post Survey completion
• Determine which tool kits and strategies are most
  effective in reducing behaviors
• Train staff document in the patient care plan
  the recommended approaches activities (FMP)

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OT Pilot Study Roles

• OT Assessment Tools Allen Cognitive Level (OT
  Leather Lacing, Routine Task Inventory and/or
  Placemat Test)
• Together with SLP will complete the Cohen
  Mansfield Agitation Inventory
• Send patient documentation from eval to
  discharge, Cohen Mansfield Agitation Inventory
• Pre and Post Survey completion
• Determine which tool kits and strategies are most
  effective in reducing behaviors
• Train staff and document in the patient care plan
  the recommended approaches and activities (FMP)

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Nursing and Activities Involvement

• Charge Nurses, RNs, LPNs, CNAs, Activities
  professionals are asked to complete the Pre and
  Post Cognitive Pilot Study Survey
• Nursing and Activities staff implement the
  cognitive tool kits as recommended via SLP and /
  or OT staff
• Use of the recommended items for the moderate to
  severely cognitively impaired patients was
  similar to implementation of a Functional
  Maintenance Program upon discharged from Rehab
• The cognitive tool kits serve as another
  treatment procedure to reduce patient agitation,
  anxiety and increase attention and communication
  with staff

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Pre-Implementation Survey

• Use scale strongly disagree, disagree, neutral,
  agree, strongly agree
•  Patients with moderate to severe dementia are
  managed effectively consistently in this
  facility
• 20 SA/A, 24 N, 56 D/SD
• Carryover of rehabilitation interventions are
  easily duplicated by non-rehab personnel in the
  facility, on all shifts
• 20 A, 7 N, 74 D/SD
• One shift is better than another shift in
  managing patients with moderate to severe
  dementia
• 65 A/SA, 25 N, 10 D
• If agreed then, Which shift is the most
  successful in management of the cognitively
  impaired patient Choices 7-3, 3/11 or 11/7
• 7-3 96
• 3-11 0
• 11-7 4

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Pre-Implementation Survey

• Use scale strongly disagree, disagree, neutral,
  agree, strongly agree
• Sometimes patients with moderate to severe
  dementia become agitated for no reason
• 38 A/SA, 10 N, 53 D/SD
• Sometimes it is acceptable to allow patients with
  moderate to severe dementia to yell for a few
  minutes
• 33 A, 23 N, 46 D/SD
• Medications should always be administered to
  patients with moderate to severe dementia to
  reduce maladaptive behaviors
• 3 A, 10 N, 88 D/SD
• There has been dementia care education
  opportunities provided at least annually in this
  facility
• 25 A/SA, 25 N, 51 D/SD
• Dementia is a natural part of the aging process
• 23 A, 10 N, 68 D/SD

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Pilot Study Rehab Nursing Assessment Tools
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Allens Diagnostic Materials - ADM
Placemat and bookmark - two of 30 functionally
based craft assessment tools Standardized
assessment tool Offers tools for a variety of ACL
levels 3.0 and above More readily accepted by
both genders Can assess ability with partial
completion
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Allens Diagnostic Materials - ADM

• Leather Lacing
• A visuomotor task
• Provides a quick estimate of the patients
  capacity to learn.
• Barriers include patient visual perceptual
  deficits, hand dominance, tremors, deafness,
  inability to understand directions, and
  hemiplegia
• Standardized on both psychiatric and
  neurologically impaired populations
• Quick, simple to administer
• Appropriate for clients ACL 3.0 and above
• Requires fairly adequate fine motor and visual
  abilities
• May be perceived as female gender specific

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Routine Task Inventory

• Part of initial interview to determine PLOF and
  activities
• Activity Analysis Based Cognitive Screening - RTI
• Non standardized assessment
• Only Allens tool to assess clients below ACL 3.0
• Very quick, easily completed in the course of ADL
  completion
• Requires thorough understanding of ACL levels and
  modes
• The intrinsic importance of an activity is
  apparent when an individual engages in a task
• Observations of performance that objectively
  describe behavior usually have the greatest
  credibility

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Cognitive Performance Test - CPT

• Standardized Home Management tool
• Test encompassing functional ADL task analysis
• Excellent tool for higher functioning clients
• Requires specific tools and environmental set up
  to complete
• More time/attention span required for completion
• Developed to provide a standardized, ADL-based
  instrument for the assessment of functional
  levels
• Focuses on the degree to which particular
  deficits in information processing impact daily
  living tasks
• Composed of common ADL tasks, familiar and
  routine to reduce performance anxiety of
  patients with dementia, which are graded to
  correspond to the Allen Cognitive Levels

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Distinction Between the RTI and CPT

• RTI
• Assumes that the therapist will incorporate this
  test along with the leather lacing tool. The tool
  is not a "stand alone test"
• Data is gathered via by observation of functional
  tasks, interviewing the patient, and interviewing
  the caregiver
• CPT
• This was created as a stand alone test.
• This test does not involve a self report or
  caregiver report to be factored in
• A portion of the functional activities are done
  with the patient, for example, demonstration,
  unlike the RTI
• Both tools are similar in that they use
  functional activities

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Evaluation Assessing From Groundwork Up

• Claudia Allen Levels
• Level One Automatic Actions
• Level Two Postural Actions
• Level Three Manual Actions
• Level Four Goal Directed Activity
• Level Five Independent Learning Activities
• Level Six Planned Activities

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Functional Linguistic Communication Inventory
FLCI

• Evaluation of functional communication
• Recommended for patients with moderate severe
  cognitive loss
• Ease of administration 30 minutes
• Advantages disadvantages
• Correlates well w/ Cognitive Severity Scale
• Subtests include
• Greeting and naming - Answering questions
• Writing - Sign comprehension
• Object-to picture matching - Word reading
  comprehension
• Following commands
• Pantomime, gesture and conversation

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ASHA FACS

• Pre-requisite 3 informal communicative contacts
  w/ patient
• Survey 7 - Point scale of the patients level of
  communicative independence defined by the need
  for assistance and / or prompting by another
  person.
• Assessment domains include
• Social Communication
• Communication of Basic Needs
• Reading / Writing / Number Concepts
• Daily Planning

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Saint Louis University Mental Status
Examination (SLUMS)

• Consists of 11 questions
• Score range 0 to 30
• High School Educationlt High School
  Education
• 27-30 Normal 20-30
• 20-26 MCI 15-19
• 1-19 Dementia 1-14

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Cohen Mansfield Agitation Inventory

• A 7 point rating scale for assessing the
  frequency with which people show certain
  behaviors
• 29 descriptors rated 1-7 during a 2 week period
• Patients scored pre and post tool kit
  implementation
• 10-15 minutes to complete
• Training manual can be accessed via the author
• Research Institute on Aging at the Hebrew Home of
  Greater Washington
• http//www.researchinstituteonaging.org
• Hcsjcm_at_gwumc.edu
• Cohen-mansfield_at_hebrew-home.org

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Personal History Interview

• Establish
• Occupational history
• Experiences
• Patterns of daily living
• Interests
• Values
• Needs

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Personal History Interview

• By developing the personal history you can
  enhance
• Treatment Approach
• Patient/Therapist Relationship
• Family/Caregiver training
• Successful environmental adaptations
• Behavioral Approaches
• Treatment Outcomes

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Validation Therapy

• Developed by Naomi Feil between 1963-1980
• VT helps disoriented people reduce stress,
  enhance dignity and increase happiness. VTs
  objective is to restore dignity to the elderly,
  teach empathy, and to show alternatives to
  pharmacological physical restraints.
• Naomi Feil
• Validation The acceptance of the reality and
  personal truth of anothers experience
• An effective combo Validation and Redirection
• Reality Orientation versus Therapeutic Lying
  versus Validation Therapy
• Need for more controlled research studies

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Tool Kit Inventory

• 3 Leveled Tool Kits
• Individualized to encompass activities
  appropriate for each patients preserved abilities
  to increase effective communication thus
  reducing behaviors
• Tool Kits were implemented for appropriate
  patients during the Pilot Study period 45 days
• Tool Kit categories were general ideas Rehab,
  Nursing and Activities professionals may
  interchange items based on individualized patient
  need and recommendation

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Tool Kit Types

• Attention Kit Moderate Cognitive Impairment
• Exploration Kit Moderate Severe Cognitive
  Impairment
• Relaxation Kit Severe Cognitive Impairment

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ATTENTION KIT

• Stickers - Coins
• Cents Money Word Index Cards
• Flying Gliders Planes
• Nuts and Bolts
• Tape Measure
• Screw Anchors - Colored
• Dice - 5
• Playing Cards

• Chess Sets
• Checkers
• Calculators
• Rulers
• Crossword Puzzle Books
• Word Search Books
• Hanging Basket Grow Kit
• Scissors

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EXPLORATION KIT

• Magazines - Assorted
• Stickers - Geometric
• Coloring Books and Crayons (Jumbo)
• Stickers Sports, Animals, Rainbow, Smiles,
  Letters, Hearts
• Pencil Boxes
• Playdough
• Trisonic FM Radio with earphones
• Magnifying Glass

• Cell Phones
• Marbles
• Tool Set - Toy
• Notebooks
• Colored Paper Notebooks
• Velvet Art and Crayons
• Shopping List Pads
• Sorting Activities
• Wooden puzzles
• Flower Braclet Set (sorting)
• Poker Chips in Rolls - 4 Colors
• Chip Tray(For sorting)

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RELAXATION KIT

• Bubble Ball Jr.
• Textured Footballs
• Handballs - Glitter
• Textured Plastic Bat with Rope
• Baby Bottles
• Fur Real Pet Dogs and Birds
• Newborn Baby Alive Sip Snooze
• American Flags

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Rehab Post Pilot Survey Analysis

• How many cognitively impaired patients did you
  evaluate during the pilot period (6 weeks)?
• Less than 5 94
• 5-10 6.3
• More than 10 0

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Rehab Post Pilot Survey Analysis

• If a patient was not appropriate for the
  Cognitive Tool Kit select why
• Too high level 12.5
• Too low level 43.8
• Other 43.8
• Impaired Arousal, Vision, no Dementia Dx, DC to
  hospital, Staff had difficulty following through,
  Manager, dont eval, dont treat

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Rehab Post Pilot Survey Analysis

• How many patients did you recommend the cognitive
  tool kit interventions for?
• 25 total for 7 facilities in 6 week period

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Rehab Post Pilot Survey Analysis

• Select the type of cueing you found patients in
  the Pilot responded best to
• Visual 87.5
• Auditory 62.5
• Tactile 62.5

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Rehab Post Pilot Survey Analysis

• Did your patients demonstrate a preserved
  strength that you could identify?
• Yes 93.8
• Increased attention to task and conversation,
  communication of positive emotion, decreased
  anxiety,
• No 6.3

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Nursing and Rehab Post Pilot Survey Analysis

• Identify your level of agreement with the
  following statements.
• Understanding the appropriate use of the
  prescribed tool kits was easily conveyed to
  caregivers across all shifts.
• 57A/SA, 30N, 9D, 9SD
• The prescribed tool kits were easily used by
  non-rehabilitation personnel.
• 57A/SA, 26N, 17D
• Negative and/or socially inappropriate behaviors
  of patients with moderate to severe dementia were
  significantly reduced with the use of the
  prescribed tool kits.
• 43A/SA, 43N, 13D

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Nursing and Rehab Post Pilot Survey Analysis

• Identify your level of agreement with the
  following statements.
• There was an improvement in rehabilitation
  intervention carryover regarding patients with
  moderate to severe dementia, across all shifts.
• 44A/SA, 52N, 4D
• Management of behaviors of patients with moderate
  to severe dementia improved as a direct result of
  the use of the prescribed tool kits.
• 61A/SA, 35N, 4D
• I would recommend using the types of tool kits as
  a means of managing patients with moderate to
  severe dementia.
• 83A, 17N, 0D
• The cognitive pilot study and its tool kits
  strengthened the nursing - rehab relationship to
  benefit the cognitively impaired patient.
• 47A, 26N, 22D, 4SD

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FMP- A.K.A. staff / family / caregiver training
education

• How do I write a FMP?
• Documentation cannot be a hindrance
• Therapist recommendations formulated from an eval
  exist as a FMP?
• List of recommendations FMP
• Recommendations are a hypothesis/theory
• Evaluation process is needed to yield
  recommendations that can be proven to be
  successful and therefore carried out on a long
  term basis via caregivers

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FMP ESTABLISHMENT VS. IMPLEMENTATION

• Once caregivers are accurately trained,
  implementation begins skilled Rx ends.
• Discharge to Restorative or FMP
• Facilitates a continuum of care
• Maximizes the outcome of skilled intervention

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DEVELOPMENT OF AN FMP

• ASK ...
• What do I want skilled treatment to accomplish?
• What do I want the resident to be able to do?
• Is the goal to accomplish Rx tasks with some
  degree of independence or with a certain amount /
  type of assistance?
• Are there individualized strategies that can be
  useful in attaining or approaching goals that I
  can instruct a caregiver in order to maintain
  safety and quality of life?

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RECOMMENDATIONS TO STAFF FAMILY / CAREGIVERS

• Return demonstration
• Sign-off documentation
• Provides accountability and credit for attendance
  / performance
• Enhances the importance of a team effort - from
  CNA to Rehab Manager
• Written recommendations on Write on Cling Sheets,
  CAN care belts, card, folders in patient room
• KNOW Nursing Assistant Competency for feeding and
  facility specific training modes (i.e. NEO
  annually) for basic individualized techniques

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The Nursing Friendly Functional Maintenance
Program

• First Things 1st - Establishing Repoire - SMILE
• CNAs Learn who they are give them a reason to
  follow through
• Hardest job in the building Nursing Assistant
• Typical Ratio StaffPatient
• 7-3 18
• 3-11 112 w/ no dept head assist
• Do you know the CNA's
• Birthday
• Kids Names
• Favorite food, drink, candy

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The Nursing Friendly Functional Maintenance
Program

• Nursing education and input regarding FMP
• FMP (individualized recommendations) must be
  accomplished within a realistic and appropriate
  time frame
• Rehab awareness FMP time for completion
• Consider time of day for optimal implementation
• Time of most need make the most impact
• Too long?
• Try to combine w/ a functional skill / routine
• Ask Yourself and Nursing Is this feasible?
• Positive attitude
• Team player approach

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7 Facilities Follow up

• Feedback from facilities regarding the continued
  use of tool kits and their perceived efficacy
• Development of patient individualized kits using
  ideas from the main kits (use of large print
  items)
• Use of patient specific lifetime props
• Will use tool kit if appropriate -- some items
  not extremely helpful but that is patient need
  dependent anyway
• Biggest problem is getting other department to
  have time to use items and participate
• Activities reports that they are using the items
  as set up by SLP with the patients that we worked
  with
• Biggest barrier is time constraints and
  familiarity with rehab scope of practice

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Pilot Study Feedback Future Directions

• Charge Nurse LPN I think that as the use of the
  kits become more of the norm, they will be even
  more effective.
• How does Rehab assist in follow up from
  individualized patient recommendations after
  discharge?
• How do we to facilitate and maintain carryover
  between shifts?
• Proposed follow-up study How to more
  effectively integrate rehab techniques with
  personal meaning across the healthcare spectrum
  in the management of patients with moderate to
  severe dementia

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The environments in which we live, work, and
play have profound effects upon us. The people,
objects, and events in these environments must
arouse us enough to avoid boredom, but not so
much as to cause extreme anxiety. The
performance demands made upon us by our
environments must fit with our skills and
competencies if we are to do well. They must
match our values and interests as well, if we are
to feel satisfied. Roann Barris