Therapy's role in dementia management: therapists who understand dementia can significantly enhance residents' functioning.

Doris, a woman with late-stage dementia, was a pacer. For 12 months she had been pacing the halls of the nursing home, striking out at and hitting those who passed by. She frequently fell. She couldn't sit at the dining table long enough to finish a meal, so she was fed by an aide while restrained. Doris's family was distraught and, needless to say, the nursing home's quality indicators were suffering. The state gave the nursing home a violation on "human dignity."

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Linda Riccio, then a dementia-management-trained OT at the home, and currently regional vice-president for Aegis Therapies, evaluated Doris. "The nursing home hadn't realized that Doris had severe tunnel vision and an inability to scan below the waist," she says. "When she sat down to eat, she couldn't see her food. She also had macular degeneration and, because the whole building was decorated in earth tones, she couldn't distinguish objects in the environment. That's why she struck out at people and why she fell."

Riccio's training in dementia management gave her a perspective slightly beyond traditional therapy, as well as an alternative set of resources with which to treat Doris. "We altered her environment to help her function better," says Riccio. "We set up her food in a visual space that she could comprehend and used bright colors for dishes and utensils. The first day she sat for 20 minutes and fed herself. The staff had never seen her do that."

To solve the aggressive hitting problem, Riccio worked with the facility to move Doris to a room where her walking path wouldn't intersect the path of incoming visitors. "We even made sure laundry carts weren't left in the halls, says Riccio, explaining, "She struck out because she was surprised by unexpected people she couldn't see and movement and noise that startled her."

Those simple changes returned Doris to the dining room, minimized her falls, and reduced the incidents of hitting. "We were able to offer something other than medication to intervene in her behavior," says Riccio.

During the course of their illness, residents with Alzheimer's disease will experience increasing problems with weight loss, falls, and disruptive and abusive behavior, and the facility will face having to use psychotropic medications--all areas that CMS measures as part of quality indicators (QIs). The advantage of having a therapy team with all three disciplines trained in dementia management is twofold: their expertise can (1) slow the progression of the disease and (2) help minimize those disruptive behaviors and other difficulties that frequently lead to restraints, loss of movement, and other QI triggers.

"Unfortunately, in some facilities we sometimes see one therapist trained in dementia," says Riccio. "What happens is that the speech-language pathologist may intervene on a weight-loss issue when it really involves the OT. Or the PT might intervene in a fall that is really a problem for the speech-language pathologist because the resident cannot understand cueing. It's important that all disciplines be involved."

While nursing staff and social workers have skills that identify dementia in general, therapists trained in dementia break down cognitive decline into three stages: early, middle, and late. "Therapists work with the nursing staff to identify key behaviors in the three stages so their intervention is more rightsized to that patient's cognitive needs," says Riccio. "Therefore, fewer quality indicators spiral out of control."

Dementia-trained therapists are able to identify 52 cognitive levels of performance during activities of daily living--and the nuances can be important for treatment, notes Susan Fischer, a PT and team leader at Beverly Healthcare Brookview in Indianapolis. She gives the example of a woman identified at a "low 2" level. "There is no way she is going to learn to walk with a walker," says Fischer. "At that level, we know that someone must walk with the resident." Therapists without dementia training would not be likely to pick up on that distinction.

"If you don't have a therapy partner to assist you in the disease process, then the residents tend to cycle through early to middle to late stages of dementia much more quickly, and their issues emerge more predominantly," says Riccio. For example, a gentleman with middle-stage dementia may persist in eating only half of his meal and suffer from weight loss. Because he has typically fed himself, the staff may see him as more independent than he really is and conclude that he apparently suffers from an appetite suppression problem. But the dementia-trained therapist sees a middle-stage dementia resident with too short an attention span to finish the meal. By working with the staff to create customized cues--e.g., chewing, indicating food on the spoon, performing a two-step or five-step command--the therapist can help respond to the individual's specific needs.

Or take the case of a resident with dementia who is no longer responding to verbal cues. The dementia-trained therapist recognizes that the disease has probably progressed to the late stage, when visual cues become more effective.

In a good dementia-management program, therapists train the facility staff in the various stages of the disease so nurses and CNAs can approach the resident in the most effective manner. "We want every staff member, whether it be the social worker, CNA, or charge nurse, to understand what to expect in each of the three levels of dementia and what quality indicators begin to go out of alignment at each level," says Riccio. "Then therapy partners with the rest of the staff to help prevent those issues from happening."

Fischer gives the example of a follow-up falls program for dementia residents who have been discharged from therapy at Brookview. Traditional therapy might call for exercises in gait training during restorative nursing. But "exercise" is not something that residents with dementia may understand. "We would prescribe more functional activities, like making the bed, flushing the toilet, reaching to take something off a hanger--activities that achieve the same goals but that the residents can understand because they're in the context of daily living activities," says Fischer. "We train the staff to understand the kind of 'talk' those clients need."

Because most therapy students graduate with an understanding of the science behind dementia but little clinical experience in its specific management, it is left to the therapy company or facility to provide that training. Unfortunately, though, skills improvement is often left to chance. "I would like to see every facility have a dementia management program," says Riccio. "In a traditional therapy program, the goal is to restore as much as possible in the specific deficit areas. That's not practical in the case of dementia. At Aegis, we train our therapists in a model of care called 'Restore, Compensate, Adapt.' First we try to maximize what we can restore. Then we teach the resident to compensate for the deficit. Then we try to adapt the environment to the problem."

The activities program can easily be adapted to the various levels of cognition. Riccio cites a facility that had a high incidence of falls, although the nursing staff had worked hard to reduce them. Therapy coordinated with the activity planners on the unit to address residents' specific needs. "One facility provided an obstacle course," explains Riccio. "We cut circles out of cardboard and put them on the walls with Velcro[TM]. The resident had to touch each circle, which required bending and reaching and using some balance skills." At an Easter egg hunt, the residents walked barefoot in the grass to help with ankle strength and had to stoop to find the eggs. In another case, two residents who needed to work on acquiring more balance and ease of weight-shifting wiped the table and chairs in the dining room after dinner. "These were simple things, but in 45 days, the number of falls came in line with or below the norm," says Riccio.

At Beverly Healthcare Bella Vista in Rapid City, South Dakota, Executive Director Steve Bakken says that without therapists trained in dementia, quality of life for residents is sacrificed. "No question, dementia management impacts quality indicators," he says. "Falls is the classic example. The approaches the therapists have come up with to help us reduce falls are generations ahead of other systems that we used because they promote mobility instead of limiting it. We've measurably decreased our falls, and the Aegis therapists who have dementia expertise contributed greatly to this."

He cites other benefits to his facility of therapist-guided dementia management: decreased use of psychotropic medication and improved skin conditions because of therapists' active involvement in resident seating and positioning. "Any quality indicators involved in behaviors are improved, as well," he adds. "And if the nursing staff and other caregivers are spending less time dealing with residents' aggressive behaviors, they can focus on the more important things."

The Nursing--Therapy Dementia Partnership Quiz to Improve Quality Indicators

Answer these questions to determine how therapy-oriented your dementia management program is:

1. Has the therapy team provided training to the facility on the different stages of dementia and how therapy interventions can assist with each stage?

2. Are there regular screenings in place for residents with dementia, and do those residents have an active functional maintenance plan in place that works to maintain them at the highest level of functioning possible?

3. Are dementia residents on the therapy caseload there primarily for dementia management every month, not just one or two months out of the year?

4. Are therapists partnering with the facility on management of quality indicators, and are residents with dementia part of that discussion?

5. Is the therapist participating in key meetings on falls, weight loss, and restraint reduction?

6. Does the Alzheimer's care director have a close relationship with the therapy team and spend time reviewing which residents have issues?

7. Are the therapy staff present daily on the Alzheimer's unit so that they can see how the residents are functioning in that environment and discover ways in which they can intervene?

8. Are the OT and Speech staff involved in the dining room process and the weight loss management process routinely on a monthly basis?

9. Do PTs work with those residents with dementia who fall frequently, and is there a good plan in place, including adaptations of the environment, for each frequent faller?

10. Are all three disciplines of therapy working with the activities director to easily adapt regular activities to meet the needs of all levels of dementia?