Transcript Dementia Therapy in Adult Settings- Providing Skilled Services and

Dementia Therapy in Adult
Settings- Providing Skilled Services
and Documenting Medical
Necessity
Amber Heape, MCD, CCC-SLP, CDP
Clinical Specialist- PruittHealth
Certified Dementia Practitioner
Amber Heape- Disclosures
Relevant Financial Relationships:
• Salaried Clinical Specialist for PruittHealth
• Receives honoraria for CE courses and
seminars taught, including this one
Relevant Non-Financial Relationships:
• Former SCSHA Board Member
Learner Objectives
1. The learner will delineate types and levels of
dementia.
2. The learner will analyze concepts of
evidence-based practice specific to levels of
global deterioration scale.
3. The learner will apply definitions of skilled
service to daily and weekly documentation
for medical necessity of services for patients
with dysphagia.
Reversible Dementias
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D- drug reaction, overdose, toxicity
E- emotional disorders (depression)
M- metabolic or endocrine (thyroid) issues
E- eyes and ears (sensory loss)
N- nutritional deficits
T- tumors
I- infection (sepsis, UTI, pneumonia)
A- arteriosclerosis
Non-Reversible Dementias
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Parkinsons
Multi-Infarct
Fronto-temporal
Lewy Body
Huntington’s Disease
Creuxfeldt-Jakob
Korsakoff Syndrome
Alzheimer’s Disease
Let’s Dig a Little DeeperWhat and Why?
Parkinson’s Disease (PD) Related Dementia
• 50-80% of people with PD will experience related dementia.
• Stress is #1 trigger for Parkinson’s Dementia.
• Average time from onset of PD to development of dementia is 10
years.
• Neuro-hallmark is beta-amyloid plaques and tangles.
• Symptoms:
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Slowness
Rigidity
Stooped posture
Shuffling gait
Depression
(Alzheimer’s Association, 2016)
What and Why?
Multi-Infarct (Vascular) Dementia
• 2nd most common type of dementia
• Can co-exist with Alzheimer’s
• Most common in men over 70
• Remains underdiagnosed
• Caused by reduced or blocked blood flow to the brain (CVA
or TIA).
• Symptoms similar to Alzheimer’s Dementia, difficult to
distinguish
• Some experts refer to “vascular cognitive impairment (VCI)”
instead of dementia, because of the broad range of
impairment severity.
(Alzheimer’s Association, 2016)
What and Why?
Fronto-Temporal Dementia (Pick’s disease)
• Progressive nerve loss primarily in frontal and temporal
lobes
• Onset to death is 2-12 years
• Caused primarily by a tau or TDP43 protein
• Characterized by:
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marked changes in personality and mood
Communication and motor disruption highly prevalent
Impaired judgement
Patient often unaware of decline in function
• Younger onset, with quick disease process
(Alzheimer’s Association, 2016)
What and Why?
Lewy Body Dementia
• 3rd most common type (10-25% of cases)
• Neuro hallmarks similar to PD (possibly with or without
plaques and tangles)
• Symptoms:
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Emotionally/physically labile
Hallucinations
Confusion varies widely from one day to the next
Shuffling gait and stooped posture
Depression
• These are the patients you see shuffling, looking at the
floor, and mumbling.
(Alzheimer’s Association, 2016)
What and Why?
Huntington’s Disease
• Largely based on heredity
• If parent carries defective gene, child has 50% chance of
developing
• Affects younger people (30-40)
• Symptoms:
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Confusion
Diminished coordination
Fidgety movements
Behavior changes
Memory loss
Hallucinations
(Alzheimer’s Association, 2016)
What and Why?
Creuxfeldt-Jakob Disease (CJD)
• aka Mad Cow Disease
• Infectious form of Dementia (from exposure to infected
bovine products or tissue transplantation)
• Characterized by prion protein that changes cells into
abnormal shapes and rapidly destroys.
• Rare (1 in 1 million people annually)
• Symptoms progress rapidly with no known treatment
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motor symptoms
confusion
agitation
memory loss
• 90% of patients die within 1 year of onset
(Alzheimer’s Association, 2016)
What and Why?
Korsakoff’s Syndrome
• Most common in patients with a history of EtOH
abuse
• Often preceded by Wernicke Encephalopathyacute reaction to severely low thiamine
• Symptoms:
– Motor- staggering, stumbling
– Confabulation (making up information but believing it)
(Alzheimer’s Association, 2016)
What and Why?
Normal Pressure Hydrocephalus
• Characterized by excessive accumulation of CSF in the
ventricles.
• However, excess fluid does not often present during
lumbar puncture
• Diagnosed by MRI or large volume spinal tap
• Symptoms:
– difficulty walking
– decreased executive functioning
– loss of continence
(Alzheimer’s Association, 2016)
What and Why?
Alzheimer’s Disease
• Most common type of dementia (60-80% of cases)
• Progressive, and not a “normal” part of aging
• Characterized by memory difficulty, especially newly
learned information
• Can be diagnosed pre-mortem now
• One neuro-hallmark is abnormally high numbers of betaamyloid plaques and tangles.
• Primary neuro-hallmark is “wasting away” of the brain
• Current research focus is attempting to slow or prevent AD
• Symptoms differ by stage
(Alzheimer’s Association, 2016)
What About Mild Cognitive
Impairment?
• Cause is not completely understood at this time
• Cognitive and memory changes are noticeable to
others, but are not severe enough to seriously interfere
with ADLs.
• People with MCI may get better
• Compensatory activities may slow decline or assist in
progress
• May lead to AD
• Experts recommend re-evaluation every 6 months to
diagnose improvement/decline.
(Alzheimer’s Association, 2016)
Diagnosing Dementia
• Family and medical history
• Neurological exam
– CT
– PET
– MRI
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Physical exam
Bloodwork
Psychological exam
Mental status exam
Can the SLP Diagnose Dementia?
• Diagnosis must be made by a medical doctor
• Mental status/stage testing may be conducted
by the SLP
• What if we see signs and there is no
diagnosis?
– Contact MD with concerns and testing results
– Request consult
– Treat the symptoms under our scope of practice
Global Deterioration Scale
• Developed by Dr. Barry Reisberg
• http://www.fhca.org/members/qi/clinadmin/
global.pdf
• 7 stages of degenerative dementia
– Stage 1: normal
– Stages 2-3: pre-dementia
– Stages 4-7: diagnosed dementia
Global Deterioration Scale
• 7 Stages
– GDS 1- Normal adult
– GDS 2- Forgetfulness
– GDS 3- Early Confusional State
– GDS 4- Late Confusional State (Mild Dementia)
– GDS 5- Moderate Dementia
– GDS 6- Severe Dementia
– GDS 7- Late/Severe Dementia
GDS Level 1
• GDS 1- Normal adult
– No cognitive changes evident
– Normal aging
– Normal brain function
GDS Level 2
• GDS 2- Forgetfulness (Age equivalent- 25+)
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Executive Function deficits
Mild Cognitive Impairment
Unknown timeline for progression
Minimal brain tissue loss
At risk for AD
Impulsive at times
Can complete self-care
Recovers quickly from mistakes
Often self-corrects
Misplaces familiar objects
Highly functional social skills
Scores well on orientation test, requires cognition exam for diagnosis
No problems completing tasks or at social functions
Therapy to focus on complex tasks, teaching cognitive activities for
independent practice, use spaced retrieval for memory?
GDS Level 3
• GDS 3- Early Confusional State (likely to progress to AD)
(Age Equivalent- Teens to 20’s)
– Beginning Dementia
– Stage may last 1-4 years or more
– Minimal brain tissue loss
– Memory deficit on intensive interview
– Attempts to conceal deficits or use humor to offset
– Family often aware of increasing challenges
– Difficulty with new and complex situations
– Skips steps in tasks
– Can learn new strategies
– Difficulty handling finances, medication at times
– Difficulty with reading comprehension
– Work best with structured daily routines
– May live alone, but with daily supervision
– Therapy to focus on safety awareness, higher functioning tasks (and when to
ask for help!)
– Spaced retrieval can be helpful for memory
GDS Level 4
• GDS 4- Late Confusional State (Mild Dementia)
(Age Equivalent- 8-12 years)
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4 oz. brain tissue loss
Stage lasts 1-4 years or more
Routines are crucial
Withdraws from challenging situations
Problem solving skills are basic
Talk the talk, but can’t walk the walk
Safety deficits
May live alone, but with frequent daily assistance
Therapy to focus on safety awareness, problem solving, sequencing
daily tasks, environmental orientation
– Montessori approach useful
– Lists are utilized for names, phone numbers, etc.
– Amnesia, Aphasia, Agnosia, and Apraxia begin
GDS Level 5
• GDS 5- Moderate Dementia (Age equivalent- 4-8 years
old)
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½ to 1 pound brain tissue loss
Stage lasts 1-3 years
Tactile stimulation important
Easily distracted, requires frequent redirection
Purposeful wandering/ sun downing
Word-finding abilities intact with familiar objects only
Actions can be random, with little awareness of difficulties
Cannot live alone; requires 24 hour care
Therapy to focus on attention to task, positive redirection,
simple sequencing, procedural memory, facility
orientation, using graphic cues
– Montessori approach useful
GDS Level 6
• GDS 6- Severe Dementia (Age Equivalent- 2-4 year old)
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1- 1 ½ pounds brain tissue loss
Stage lasts 1-3 years
Functional communication impaired
Random actions/may yell out
Purposeless wandering
High Fall risk
Difficulty with daily tasks, refuses to change clothing
Difficulty self-feeding, weight loss
Requires visual, verbal, and tactile cues
Therapy to focus on simple, functional communication,
orientation to surroundings, staff training.
GDS Level 7
• GDS 7- Late/Severe Dementia (Age equivalent- infant)
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1 ½-2 pounds brain tissue loss
Mostly bedbound
Total care required
Stage lasts 1-2 years
High risk of falls
May respond positively to music or soothing sounds
Grabs/ grasps objects
Dysphagia
Sometimes nonverbal communication
Generally unaware of surroundings
Therapy goal to assess communication of
wants/needs/pain, dysphagia, training staff
Jimmo vs. Sebelius
Since the Jimmo vs. Sebelius settlement in 2013,
therapy services can no longer be denied due to
a diagnosis of dementia. There is no longer an
“improvement standard.” Instead, the issue is
whether the skilled services of the professional
are needed. Without services, will the patient
have a decline or potential for major decline?
Delaying Accelerated Onset
• The American Academy of Neurology produced a study in 2009 that
suggests that people who are “destined to develop dementia” can
delay the onset of accelerated memory decline by doing brain
exercises.
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Reading
Writing
Crossword Puzzles
Board Games
Card Games
Group discussions
Music
Current events recollection
• Participants who didn’t do these type of activities lost their
memory 3 times as quickly as those who did cognitive exercises 7
days per week.
Documentation!
• Should be tied back to an appropriate medical
diagnosis (LCD) or narrative to explain how
diagnosis led to decline
• Must demonstrate medical necessity of
services (why did it require the SLP for this
treatment?)
• Reasonable goals and objectives, related to
impairment level
Daily Notes Should…
• Justify billing codes being used.
• Demonstrate the skilled interventions of the
therapist
• Must be linked to a goal.
• Demonstrate medical necessity.
• Demonstrate progression.
GDS 2/3
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Facilitated Montessori-based activity of executive functioning skills to improve
patient’s ability to organize and self-administer medications properly at return
home. Spaced Retrieval Training successful at 30 seconds, 1 minute, 2 minutes
(x2). Patient struggled with memory skills over 2 minutes.
Instructed patient in recall of safe transfer sequence with 7/7 acc and verbal
cueing. Pt responded to safety questions regarding safe transfer sequence with
accuracy in 3/4 trials(75%). Pt recalled walking sequence x 4 steps with difficulty
recalling need to step first on weaker leg, right leg. Rehearsal technique used to
improve recall of 4 steps in walking sequence with 4 rehearsals with errorless
learning.
Guided patient in completing sequencing pattern for transfer in 5/7 attempts with
verbal cueing. Pt sequenced pattern for walking in 3/4 acc after multiple
rehearsals and demonstration for improving comprehension. Pt recalled pattern
with self-correction up to 5 min delay with 2/4 acc. Pt problem solved in
structured task of Tangram completion with timely completion and mod assist
necessary on 1/4 tasks, min assist provided on 3/4 tasks.
Reinforced use of spaced retrieval strategy for increased recall of functional
information. Pt recalled 4/4 functional information items at intervals of 30
seconds, 1 minute, 2 minutes, 4 minutes, 8 minutes, and to ¾ items at 16 minutes
with min verbal cueing provided by SLP utilizing spaced retrieval strategy.
GDS 2/3
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ST graded recall of functional information in order to increase communication competence
and safe integration within the environment. Pt demonstrated accuracy on 18/20 trials of
functional information presented in lists of 5 items. ST assessed safety awareness and
identification of potentially hazardous situations in order to increase safe interaction within
the environment. Pt demonstrated accuracy of 10/10 trials independently of hazard
recognition.
ST graded recall of functional information in order to increase safe interaction within the
environment. Pt demonstrated accuracy on 7 out of 10 trials given minimal verbal cues of
information presented verbally with visual aid assistance. ST instructed patient and daughter
on ways to maintain cognitive stimulation and activity when at home which includes, but is
not limited to reading, word searches, cross words ands puzzles. Daughter verbalized
understanding and patient agreed to continue.
Instructed Pt in safety awareness for ADL's, including identifying potential safety hazards in
her room. Pt able to correctly identify 7/10 safety hazards in her room environment with min
verbal cueing provided by SLP. Pt recalled daily events without verbal cueing provided by SLP.
Incorporated computer-assisted cognitive interventions to increase short-term recall skills.
Instructed patient in use of personal device to increase cognitive stimulation upon discharge
home this week. Patient demonstrated ability to access programs for intervention and ability
to actively utilize 4/5 identified applications. Recommended 30 minutes of cognitivestimulating activities per day upon discharge home (including computer-assisted
interventions) in order to maintain gains made during plan of care.
GDS 4/5
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ST facilitated delayed recall of novel information in order to increase safe
interaction within the environment. Pt demonstrated accuracy on 7/10 trials given
moderate verbal cues of ST selected items. ST graded 3 step sequencing of
cognitive tasks in order to increase safe interaction within the environment. Pt
demonstrated accuracy on 4/5 trials given minimal verbal cues for sorting and
sequencing of 3 step ADL activities.
Instructed patient in completion of Montessori-based task for sequencing ADLs.
Chunking strategy used to maximize patient success. Computer-Assisted cognitive
intervention task presented for patient word-finding skills. Patient presents with
15/20 correct, which is an improvement from the 10/20 correct last recording
period.
Skilled treatment provided bedside with patient oriented to person, roommate (by
name), and confused to location/situation. Pt reoriented easily with visual/written
cues. Pt reviewed information related to orientation to place/situation, and safety
in personal room, then responded to wh- questions with 4/9 acc (44%). Rehearsal
and rephrasing used to relay info regarding use of call button in a variety of
situations; pt verbalized understanding. Pt demonstrated use of the button, and
CNA responded in role play situation x1 rehearsal. Pt verbalized understanding.
GDS 4/5
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Pt oriented via written cues and responded to orientation questions without
success. Pt difficult to redirect from environmental distractions this day. Pt
problem solving during daily task of meal setup, with increased cueing necessary
for scanning immediate environment for cues, and obtaining assistance from staff.
Staff education initiated with x 2 CNA regarding need to consistently orient pt to
call light, leave it in plain view d/t memory difficulty; verbalized understanding.
Staff verbalizes that pt has not used the call light. Repeated role playing with CNA
staff to model response to call light with pt demonstrating use of button.
ST educated pt on safety instruments within the facility in order to increase level of
safety and decrease risk of fall. Pt verbalized understanding and demonstrated use
of call light. ST instructed pt on compensatory strategies to improve recall which
includes but is not limited to chunking, lists and categorizations. Pt verbalized
understanding of recall of compensatory strategies. ST graded recall of functional
information in order to increase safe interaction within the environment. Pt
demonstrated recall of 3/5 items independently but improved to 5/5 given
moderate semantic cues.
Instructed Pt in strategies for increased sequencing skills to facilitate increased
participation and safety during ADL completion. Pt utilized problem solving skills to
completed 4 step sequencing tasks using ADL pictures with 4/10 trials with mod
verbal and visual cueing provided by SLP.
GDS 6
• Developed graphic cues for patient due to perseveration of “where
am I?” Patient was able to utilize graphic cue in 2/5 attempts.
Errorless learning approach utilized to redirect patient in simple
communication tasks with staff. Instructed CNA staff on effective
communication with patient: i.e. using short sentences, yes/no
questions instead of open-ended ones. Staff verbalize compliance.
• Guided pt in completion of convergent naming task with 0/6 acc;
max cueing. Oriented x 1, difficulty with facility orientation. Pt
responded to wh- questions regarding wants/needs in 3/6 attempts
• Patient seen in am for skilled speech therapy services. Treatment
focused on verbal expression at the word level. Training provided
for use of open -ended phrase and sentence completion to produce
accurate words. Patient able to imitate correct words; however,
unable to spontaneously generate words. Poor comprehension and
inaccurate word responses.
GDS 6
• Patient sitting up in geri-chair. Treatment focused on verbal expression
training to improve ability to express wants and needs and to
communicate effectively. Names of objects modeled for the patient with
patient able to imitate ¼ trials. Unable to spontaneously produce name of
words. Auditory comprehension tasks addressed identification of objects
in a field of 2 yet 0% accuracy. During treatment patient noted to have
marked difference in cognition. Vitals taken with O2 saturation at 88% on
2L of oxygen and heart rate at 114. Therapy discontinued and patient care
transferred to nursing.
• Facilitated bedside treatment, with patient presenting with increased
alertness. Patient presented with eye contact, followed visual stimuli of
"yes" and"no" cards in 4/10 attempts using eye gaze. Patient used head
nods, "yes" in 5/10 attempts given visual and verbal cues and "no" in 2/10
attempts given verbal, visual and tactile cues to respond to questions
related to things within his visual field, orientation to environment, pain
and body temperature.
GDS 7
• GDS 7: Assessed patient’s nonverbal
communication of wants/needs and pain. CNA
present for the assessment and provided input on
patient’s usual patterns. Patient judged to
grimace when in pain, and grasps nearby objects
or people when she is in need of something.
Attempted use of communication board for
hungry, thirsty, and bathroom scenarios. Patient
was resistive today, so strategy will be attempted
again tomorrow. Patient reacted positively to
music stimuli, and calmed when instrumental
music was provided.