Transcript Stage specific non-pharmacological interventions

STAGE-SPECIFIC NON-PHARMACOLOGICAL
INTERVENTIONS FOR PERSONS WITH
COGNITIVE IMPAIRMENT
DOLLY DASTOOR Ph.D
Program in Dementia with Psychiatric Co-morbidity
Douglas Mental Health University Institute,
Alzheimer Disease International,
Toronto , March 27, 2011
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Stage specific non-pharmacological
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 In collaboration with
 Hildegard Brack, PH.D Psychologist
 Celine Brunelle, B.Sc Nurse Clinician
 David Fontaine, PH.D Psychologist
 Nancy Grenier, B.Sc Occupational Therapist
 Lisa O’Reilly, B.A Recreational Therapist
 Katherine Thibodeau MSW. Social Worker

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Conflict of Interest Disclosure
Dolly Dastoor Ph.D
Has no real or apparent
Conflicts of interest to report
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 Globally the population is aging
2007 11% over 60 (700 million)
2050 22% over 60 (2 billion)
Increased longevity comes with increased
functional and cognitive impairment
Incidence and prevalence of dementia is rising
2011, 500,000 Canadians with Dementia;
2031, 750,000 Canadians with Dementia,
Dementia is the leading cause of disability,
People can live up to 11.9 years with disability.
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 Models of best practices are needed to ensure the well-
being of older people in the health system (World
Health Organization 2001)
 A model of care refers to conceptual elements for
delivery of health care considering patient, provider
and system issues
 A model of care was developed for people with
dementia based on the paradigm shift from custodial to
individualized care
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 A MODEL BASED ON A CONTINUUM OF CARE
WITH STAGE SPECIFIC INTERVENTINS HAS BEEN
DEVELOPED AT
 MOE LEVIN CENTRE , PROGRAM IN DEMENTIA
WITH PSYCHIATRIC CO-MORBIDITY
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THE PROGRAM FOR DEMENTIA WITH
PSYCHIATRIC CO-MORBIDITY (PDPC) PROVIDES:
► HIGHY-SPECIALIZED CLINICAL CARE
► TEACHING
► RESEARCH
To a clientele with mild to severe cognitive loss,
combined with psychiatric and behavioral problems.
It offers a continuum of services – from a MEMORY
CLINIC, TO A DAY CENTRE, TO AN INPATIENT UNIT
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Program in Dementia with
Psychiatric Co-morbidity
Moe Levin Centre
Memory Clinic
Mild To Moderate Cognitive Loss
Day Centre
Mild to Moderate Cognitive Loss
Inpatient Unit
Severe Cognitive Loss
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Families
McGill Centre
for Aging
Douglas Institute
Research Centre
CLSC
Research
Patient
Treatment
Management of
behavioral
problems
Training
Home care
Other
Organizations
Community
CHSLD
Hospitals
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In the absence of any cure for dementia at the present time , we provide
interventions along a continuum which will:
 DELAY DISEASE PROGRESSION
Memory Clinic (cognitive retraining, clinical drug trials,
psycho education, pharmacotherapy )
 DELAY FUNCTIONAL DECLINE, IMPROVE QUALITY OF LIFE
Therapeutic Day Centre (symptomatic therapies, Nintendo
Wii, computer assisted cognitive
stimulation, relaxation, Coping Strategies)
 SUPPORT DIGNITY, CONTROL PSYCHIATRIC SYMPTOMS
In-patient Unit (animal assisted therapy, music,
reminiscence, social interactions,
sensory stimulation, pharmacotherapy)
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Stage specific non-pharmacological
interventions- MEMORY CLINIC
The Memory Clinic is a non-sectorized service which offers external
evaluation to adults of all ages with different degrees of memory
loss which may be accompanied by dementia-related psychiatric
symptoms.
The primary symptom must be cognitive impairment
The specialized interdisciplinary clinic team can:
Identify cognitive losses and evaluate the stages in
memory impairment, clarify diagnosis, Inform clients
and their families of the changes related to the illness,
Propose treatment plans for management of disturbing
behaviors Provide the appropriate follow-up ,Enrollment
in non-pharmacological and pharmacological research
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protocols
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INTERVENTION AND FOLLOW-UP
Pycho education for the patient and their family (including
how to access services)
Pharmacotherapy
SPECIALIZED INTERVENTIONS
Therapeutic Day Centre
Cognitive Retraining program
Participation in Clinical Drug Trials
Links with the CLSC, Alzheimer Society, etc.
Patients referred back to the community after 6 months
FOLLOW-UP
Generally 6 months with the exception of
patients with Mild Cognitive impairment (MCI)
patients waiting for MRI and PET appointments and analysis
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INTEGRATION OF RESEARCH AND CLINICAL WORK
The Memory Clinic is now integrated in research protocols
and in the development of Cognitive Retraining Programs
Establishing a clinical data base for the Memory Clinic to
track executive function and drug efficacy in patients
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COGNITIVE RETRAINING
 Intervention Technic for early stage cognitive
loss
 Alternative treatment
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COGNITIVE RETRAINING PROGRAM
20 week program divided into 3 sections:
Two groups of 8 patients (morning and afternoon)
1. Relaxation and Tai Chi
2. MEMO : memorization strategies
3. Computer assisted stimulation
4 weeks
8 weeks
8 weeks
LAB funded by the Foundation
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STIMULATION
COGNITIVE-Individual
 Stimulation of cognitive functions viz
memory and concentration/attention
 Different soft ware used and different
exercises (ex. visual memory, verbal
memory, attention, language,
calculation, …) according to the
needs of the participants
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RESULTS
Experimental Group 17 MCI vs 9 control
Groupe témoin 8 TCL et 8 contrôles,
N=42
Pre et post test measures : 3 principal criteria related with episodic
memory
1. Delayed Recall : name –face association
2. Immediate Recall with delay of 12 words
3. Delayed Recall with written material
(N+V)
(M des lieux)
(PRST)
Results: Significant improvement in the 3 measures
for the expérimental group compared to the control group
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Belleville,S., et al.Cognitive training for persons with mild cognitive impairment. Int Psychogeriatris 2008. 20(1): p 57-66
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 THERAPEUTIC DAY CENTRE
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The Therapeutic Day Centre specializes for people
suffering from Mild to Moderate Dementia
(MMSE 12 to 26)
Maximum per day 10
Most live in the community, either alone or with a family member. Some
live in a private residence.
Transportation is provided for patients living in the territory of the
Institute (Verdun, LaSalle and Lachine areas)
If outside these areas, the family has to provide transportation
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EVALUATION
 100 % of the patients are referred from the Memory
Clinic with a complete evaluation
 OT evaluation completed if needed
 Groups are organized based on level of cognitive
functioning and the language spoken. The patient is
assigned to an appropriate group.
 Length of stay 3-6 months
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INTERVENTIONS
Therapeutic groups (reminiscence, relaxation)
Cognitive Stimulation (group discussions)
Individual cognitive stimulation with the
computer (every Thursday and Friday)
Animal Assisted Therapy
Theme related activities for special occasions
Nintendo Wii (bowling & Wii Fit)
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 Nintendo Wii
 GENERAL USE :
 Adaptation of the technical aids
technique (remote)
 Adaptation of different needs of each
group (ex. level of help offered rappel
de la consigne, give step by step
instructions, physical help)
 Presents an environnement
stimulating and pleasant for
physical exercises
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 SPECIFIC USE
 Wii Fit « Step » Aerobic
 Improvement of equilibrium dynamic,
of coordination and laterality
 Help social abilities
 Help with concentration
*Can be used according to the level of
functioning of the client
**Adequat space is important – space
large enough to accomodate the group
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Wii BOWLING
SPECIFIC USE OF REMOTE
CONTROL
 Improvement of mobility
and static equilibrium
 Improvement of social
habits
 Improvement in
concentration
 Easily adaptable for clients
with more severe cognitives
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Nintendo Wii (Bowling et « Step » en action)
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Therapeutic Garden
 SENSORY GARDEN (fines herbes,
flowers, etc.)
 Appreciation of nature and
outdoors
 Inviting space (members
participated in the design of the
therapeutic garden)
 Memories of their past
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The perceived success of the DAY CENTRE program lies in the collaborative
partnership with the families, the small group setting to develop individualized
intervention programs and close work with the Memory Clinic to review patient
needs, identify gaps and area for enhancement
The specialized team of Occupational Therapist, Recreational Therapist, and
Rehab Assistant are developing innovative therapeutic programs which can be
exported to the community Day Centres
*The Therapeutic Day Centre has been transformed from
a respite care model to an active therapeutic setting *
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MOE LEVIN UNIT IS A
MEDIUM TERM TREATMENT SETTING WITH
18 BEDS
(moderate to severe cognitive loss with
behavioural and psychiatric problems)
Non-sectorized
Treats people, aged 65 and over, (and people under 65
with a dementia profile).
The average age : 73 years (range 50 to 93 years)
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Agression
Physical and verbal
Agitation
Wandering
Resistance to personal care (e.g. hygiene)
Refusal to take medications
Disorganized for ADL
Hallucinations, delusions, paranoid behaviour
SYMPTOMS SUPERIMPOSED ON SEVERE
COGNITIVE DEFICITS
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Cohen-Mansfield Agitation Inventory
Neuropsychiatric Inventory (NPI)
Cohen-Mansfield Agitation Inventory
NON-AGGRESSIVE
AGGRESSIVE
TOTAL
NPI
PHYSICAL
VERBAL
PHYSICAL
VERBAL
2008-09
32.48
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6.95
22.7
7.17
45.00
2009-10
40.75
28.61
9.79
30.41
8.24
62.63
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AT THE 18 BED UNIT
FOCUSED PERSON-CENTERED CARE-GIVING
The physical, psychological, social, spiritual needs are evaluated
with the view of maintaining quality of life , preserving dignity
and personhood
SUPPORTIVE ENVIRONMENTS
The environment is specially designed on environmentbehavior principles to minimize the effect of loss of function
PHARMACOLOGY
The use of appropriate medication by specially trained
psychiatrist to reduce psychiatric symptoms associated with
dementia
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IDENTIFICATION OF THE PATIENT: NOT BEING A FILE
NUMBER
Assessing the person as a whole: who was the person, who is the
person and who will be the person
Preserving personhood
Assessing and meeting needs
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INTERVENTION
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Snoezelen Therapy (a multisensory stimulation approach)
Music Therapy decreases aggressive behaviors, relieves anxiety and
agitation)
Walking Program (to maintain mobility and balance)
Animal Assisted Therapy (stroking animals has a soothing effect)
Pastoral Services (maintains earlier life connections)
Dietary Program
Constant social interaction with the PABs ( provides stimulation at the emotional ,
and cognitive , and helps maintain social graces)
Family support provided by psycho-education
Team meeting with families where treatment options and long term plans are
discussed, any questions which the family may have are answered
Regular formal meetings either in person or on phone with family members
Psychotherapeutic support if and when needed
*FAMILY IS CONSIDERED AN INTEGRAL PARTNER IN THE TREATMENT OF THE
PATIENT*
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SNOEZELEN ROOM
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INTERVENTION SUPPORTIVE ENVIRONMENT
The most important and effective intervention is to provide the best
fit between the environment and the behavior, with the
environment compensating for the sensory and functional losses of
the person with dementia
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 E-B Principles –Walking
Path
 Straight connection between
common space
 Day light at the end of the corridor,
helps in way finding
 Destination or event at the end of
the corridor, no dead end
 Photographs with a theme as wall
hangings for orientation
 Floor materials different for
different areas of the building nonglare floor
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E-B Principles Environment as a
Behavior Regulator
Each common space is clear in its meaning,
dining area, living area, bedroom
 There is no mistaking the identity
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Camouflage alarm
and exit door
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E-B Principles Garden access and security
- Garden adjacent
- Lock on ramp entrance
- Lock on gate
- Garden can be surveyed
- Planters, activity areas
- Walking path (figure of 8)
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TEACHING
Graduate
CLINICAL
Undergraduate
Pharmacological
Nursing
Psychiatric
Fellowship
Bapinenzemab
Social Work
Psychology
Diploma in
Psychiatry
Medical
Patients of the
PDPC Program
(Centre Moe Levin)
Therapeutic
Recreation
Visiting
Fellows
MSc
Psychiatry
Students
RESEARCH
Internships
Internant
Externant
Snoezelan
Y-Secretase
inhibitor
Nicotinic L7
agonist
Insulin
Resistance
As preclinical
marker
Therapeutic
Relations
NonPharmacological
Cognitive
Retraining
Meditation
Caregiver
Workshops
Psycholinguistics
Community Partners
Transfer of Knowledge
IM Resident
MUHC
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1 Teaching to families:
5 week training twice a year
(English and French )
2 Professionals:
students of all disciplines, workshops for CHSLD staff
(in person centered approach, specialized activities for
people with dementia, for behavioral management
issues) to CLSC professionals, video conferences,
seminars, TV , radio, newspaper articles, conferences.
3 Community at large:
Public lectures in Libraries,
CHSLD, special interest groups
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MODEL THAT HAS WORKED
 GEOGRAPHICALLY LOCATED IN ONE BUILDING facilitates
communication of information between staff of the three arms
 ACCESSIBILITY OF DIFFERENT ARMS OF THE SERVICE according
to the needs of the patients (continuum of care model)
 SPECIALLY ADAPTED ENVIRONMENT (Scottish National
Guidelines 2006 Best Practices: interventions delivered by
clinicians with expertise in dementia and in dedicated settings,
improves outcomes)
 HOMOGENOUS PATIENT POPULATION (experience based:
patients discharged improved in their functionality and
behaviors, regress in non-homogenous settings of the CHSLD)
(Best Practices Scottish National Guidelines 2006)
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 PSYCHO-EDUCATION FOR FAMILIES
(Recommendation 17: Best Practices in the Treatment of
Alzheimer’s Disease in managed care. American Journal of
Geriatric Pharmacotherapy, June 06)
 CAREGIVERS SHOULD RECEIVE COMPREHENSIVE TRAINING
on interventions that are effective for people with dementia
(Scottish Guidelines 2006)
SMALL GROUPS which permits individualized attention (Day
Centre)
ACTIVITIES SUITED FOR THE LEVEL OF FUNCTIONING
COGNITVIE STIMULATION offered to individuals with dementia

(Best practices Scottish Guidelines 2006)
STAFF WHO CAN PROVIDE EMPATHY, respect, compassion to both the
patient and the family
HOLISTIC APPROACH to patient care
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