Presented by Sue M. Paul OTR/L
Baker Rehab Group
November 18, 2011
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Understand memory and sensory processing
in the demented brain.
Identify the hallmark characteristics of each
stage of dementia.
Identify skills and deficits that could benefit
from therapy services.
Understand the assessments available to
determine a level of dementia.
Identify best practices and interventions for
developing treatment plans and goals.
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Alzheimer’s disease
Parkinson’s disease (20%)
Vascular (Multi-infarct)
Lewy Body (fluctuations and hallucinations)
Creutzfeld-Jakob (Mad Cow)
Pick’s disease (Frontotemporal)
Korsakoff’s Syndrome (ETOH)
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http://www.alz.org/documents_custom/2011
_Facts_Figures_Fact_Sheet.pdf
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Only taught “traditional learning” in school
Old days, insurance wouldn’t pay if dementia
was a diagnosis
Compensation not viewed as rehabilitation
Learn neuromuscular strategies for brain
injury, CVA, and pediatrics, but not specific to
Alzheimer’s brain.
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Access the Alzheimer’s brain through nontraditional approaches
Pull from neuro and pediatric techniques
used in other settings
Rehabilitate, then compensate (yes you can
do both)
Focus on someone with a non-Alzheimer’s
brain to carry out interventions
Language
comprehension
 Short term memory
 Long term memory
 Explicit memory- new
learning
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Executive function
Multitasking
Judgment
Abstract thinking
Mental flexibility
Problem solving
Attention
Initiation
Inhibition
Language production
Persistence
Volition
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Visual recognition
 People
 Things
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Sensory Cortex
Motor Cortex
Some attention and
language
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Automatic motor tasks
(ADLs)
Motor control/smooth
movements
Balance/gait
Sustained
attention/effort
(brainstem)
Mental speed
Posture
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Critical for laying down declarative memory
Must have bilateral damage to hippocampi to
affect memory (not usually memory loss from
cva)
Very susceptible to Alzheimer’s disease and
epilepsy
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Just in front of the hippocampus
Perceives fear, and initiates fight or flight
“Un-erasable” memory (PTSD)
Some people are genetically wired for higher
level of fear (panic disorder)
Amygdala is bigger in people with bipolar
disorder
“Conditioned” fear response- stuck in a fear
circuit
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Working memory- most short term, repeats
directions or adding numbers in head,
forgotten as soon as attention stops
Declarative memory- long term memory,
laying down new memory, hippocampus
dependent
Procedural memory- most durable, actions,
habits, and skills that are learned by
repetition, cerebellum involved
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Also known as
 Implicit Memory
 Learning without awareness
 Motor Memory
* Does not pass through hippocampus*
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Task specific
Use automatic patterns (feeding, translation)
Repetition breeds performance
No generalizing
 Amnesia
 Aphasia
 Apraxia
 Agnosia
Activity #1
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Routine Task Inventory
Global Deterioration Scale/ FAST
MMSE
Clock Test
Placemat
*Flip Book*
“ Retrogenesis is the process by which
degenerative mechanisms reverse the order
of acquisition in normal development.”
BACK TO BIRTH
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Developed by Dr. Barry Reisberg
Basis of Functional Assessment Staging Test
(FAST)
Basis of Global Deterioration Scale (GDS)
“Functional cognition encompasses the complex
and dynamic interactions between an
individual’s cognitive abilities and the activity
context that produces observable
performance.”
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Developed by Claudia Allen, OTR/L
Originally called the Cognitive Disabilities
Theory, Allen described observations
categorized by the functioning of psychiatric
patients.
Basis of Routine Task Inventory, Allen
Cognitive Level Screen, and the placemat
activity
See handout
“Make yours look like mine”
Administered as
supportive assessment
of suspected dementia
level.
 Not a standardized
test
 Good, subjective tool
for sizing up
organizational skills,
visual processing, and
personality changes
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MMSE
Developed by Marshall Folstein in 1975
Score 25/30 considered normal
Early stage Alzheimer’s usually falls between
19 and 24.
Disadvantages- need to account for age,
education, and ethnicity
Physicians love it
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Flip book
Data collection
Website
Procedure for printing
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http://headhandsheart.com/login.asp
Allen Level 4
GDS 4
MMSE <25
Developmental Age 4-12
*Goal Directed*
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Rigid, inflexible thinking
Egocentric
Independent familiar ADLs
Denies impairment, defensive
Depression, anxiety, fear, anger
Needs assistance with finances,
appointments, medications, home
management
Well, maybe you
say it’s wrong
but that’s just
the way I like it.
My way is the
best way.
Cognitive skills/Communication:
Understands beginning, middle, and
end of an activity.
 Can seek help but may not
remember emergency procedures.
 Rigid, likes routine.
 Self-centered communication,
confabulates, high verbal output.
 Recognizes highly visible striking
cues in the environment.
 Limited reading comprehension.
 New learning possible with
maximum repetition if highly
valued.
 Believe that nothing is wrong with
them.
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Copyright © 2003
Precautions:
 Unable to understand
precautions,
complications,
hazards.
 Written language is not
reliable.
 Signs are not really
effective.
Copyright © 2003
If you tell me to go brush
my teeth I will stay on task.
I just may forget to use
toothpaste or rinse out my
mouth.
Feeding:
 May eat too fast or too
slow.
 Annoyed with others
eating near them.
 Complains about food.
Grooming:
 May neglect unseen
surfaces (back of head).
 Sequencing errors.
Copyright © 2003
I am really drawn
to bold, striking
visual input.
Did you ever
notice that I
choose bright
clothing and wear
too much makeup?
Dressing/Bathing:
 Performs familiar self care
with decreased attention to
unseen surfaces.
 Follows routine.
 Remembers what they are
doing throughout task.
 Clothing selection may be
based on striking features
(brightest shirt in the closet).
 Quality may not be good.
Copyright © 2003
This is a huge loss
of dignity for meand a very
overwhelming task
at times.
Toileting:
 May neglect parts of
the task.
 May require verbal
reminders to initiate
task.
 Completes the task
although quality may
not be good.
Copyright © 2003
I can remember new
things with tons of
patience and practice!
Functional Mobility:
 Able to navigate using
familiar landmarks.
 Transfer skills depend on
familiarity of environment.
 Carries walker if distracted,
but will correct with cues.
 Notices barriers above and
below knee.
 Trunk becoming more
rigid.
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Decreased trunk rotation
Weak core
Stooped posture- looking to floor for stability
Shoulder internal rotation and adduction
Cannot sustain verbal commands
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Cognitive remediation
Compensation
Adaptation and Modification
Balance
Body awareness
Core strengthening
Facilitate the tough conversations
 Driving
 Additional care
 Living arrangements
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Organize environment
Put strategies in place
Use motor learning/repetition to bypass
hippocampus
Introduce adaptive equipment now
Cognitive remediation to the fullest extent
possible- evaluate reading and memory.
If they do it, they will remember it (marking
calendar, schedule...)
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Don’t ask for permission or approval. Use
positive, affirming conversation- use “we” not
“you”.
Use activities with hidden agenda
Constantly evaluate motor skills and
weaknesses
Practice concepts like in/out, sorting,
categorizing- and generalizing skills to other
tasks
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Stop talking!
Allow extra time to process verbal commands
Use gestures/demonstration frequently
Always sequence left to right
Scavenger hunts:
 Above/below knee level
 Above/below eye level
Activity #2
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Dementia Level
Goals
Treatment Plan
Caregiver Instruction
 What skills do you want to maintain?
 What information is most useful to caregivers?
 What are your recommendations for functional
maintenance program (ISP?)
 How much assistance/supervision is necessary?
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Repeats herself
Denies deficits
Walks with a cane, looks at floor
Can put on clothes, but doesn’t take season
or occasion into account
Can print name but not write signature
Husband talks her through ADLs, complains
that she is distracted and it takes a long time
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Anxious about showering, trembles. Exiting
stall shower is very unsafe and upsetting
Toilets herself but uses too much toilet paper
Sundowns- wants to go home to mama and
daddy
Doris
• Repeats self
throughout activity
• Needs
encouragement to
continue
• “This is dumb.”
• “I’ve done this
before.”
• “I’m no good at
handiwork.”
• I need my glasses.
 Allen Level 3.0- 3.8
 GDS 5
 Developmental Age 1.5-3 years
old
*Decreased sense
of task completion*
You may notice
that I play with my
food or grab other’s
food from their
plates. I’m easily
distracted and
overstimulated.
Feeding:
May reach for food from
other place settings or
centerpiece
 Unable to complete meal
without redirection and
set-up
 Plays with food and
utensils
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Copyright © 2002
I am sometimes very
resistant to care. Don’t
you sneak up on me or
just might get slugged!
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Self-care skills:
May initiate action with
familiar object- but not
sustain to completion
Resistant to care
Layers clothes until all
items used up, unable to
orient clothing or sequence
task
Needs supervision or
assistance with toileting
Copyright © 2002
I hate confinement and
may try to get out! I
want to
walk walk walk!
Functional Mobility:
Limited head/neck/trunk
movement during walking
 Does not scan environment
 Has trouble stopping, may
trip
 May be impulsive
 Frequent fallers
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Copyright © 2002
I have to get out of
here. I’m late for
work and the train is
on that other thing
over the @#%*! out
that window day
@#%*! right here in
Chantilly.
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Cognitive skills/
communication:
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Able to name objects
Decreased sense of task
completion
Needs verbal cues to sequence
steps of an activity
Responds best to
demonstrated instructions
Word finding problems
Loses the thread of a story
Jargons, incoherent sentences
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Copyright © 2002
I love to use my
hands...and
touch
everything! I
tend to get into
things I shouldn’t
and carry them
around with me.
Precautions:
At risk for falls
Unable to understand
precautions,
complications, or hazards
 Does not recognize need
for help
 At risk for accidentspoison, sharp objects,
elopement
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Copyright © 2002
Have you
seen my
mother?
Has anyone
seen
my mother?
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Behaviors:
Pacing, repetitive actions
Agitated, worried,
trembling hands
Unpredictable with social
interactions
Confused, acts randomly
Copyright © 2002
I have to get out of
here. I’m late for
work and the train is
on that other thing
over the @#%*! out
that window day
@#%*! right here in
Chantilly.
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Cognitive skills/
communication:
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Able to name objects
Decreased sense of task
completion
Needs verbal cues to sequence
steps of an activity
Responds best to
demonstrated instructions
Word finding problems
Loses the thread of a story
Jargons, incoherent sentences
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Copyright © 2002
I am sometimes very
resistant to care. Don’t
you sneak up on me or
just might get slugged!
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Self-care skills:
May initiate action with
familiar object- but not
sustain to completion
Resistant to care
Layers clothes until all
items used up, unable to
orient clothing or sequence
task
Needs supervision or
assistance with toileting
Copyright © 2002
I hate confinement and
may try to get out! I
want to
walk walk walk!
Functional Mobility:
Limited head/neck/trunk
movement during walking
 Does not scan environment
 Has trouble stopping, may
trip
 May be impulsive
 Frequent fallers
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Copyright © 2002
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Implicit/Procedural
Motor Learning!
Specific transfers
Gait training with
demonstration
Post-It Notes
Count the pictures
Reciprocal, gross
motor movements
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Neuromuscular Re-education
AROM
Core strengthening
Cognitive compensation
ADL focus on highly familiar tasks
Balance training/fall prevention
Enabling devices
 Bed handles
 Grab bars
 Rollator if familiar
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Balloon batting
 Ue rom
 Open hand
 Automatic response
 Sitting or standing
 Balance training
 Alternate/reciprocal
 Postural adjustments
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Post-It Notes
 Place at different heights around room
 PNF patterns/ rotation
 Above/below knee level and eye level
 Search inside cabinets and drawers
Activity #3
Ed
• Pretty steady
attention span
• Breezes through it
• Cannot follow
pattern or remember
to refer to it.
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Moved into ALF 3 years ago with wife. She
died shortly after. Retired optometrist.
Was very high functioning but depressed for
several months. Quick decline in mental
status after suffering a fall and hip fracture.
Moved to memory care unit six months ago.
Will not participate in activities.
Will not sit through entire meal.
Very sweet and pleasant.
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Staff has him labeled as sexually
inappropriate because he tries to touch them
all the time.
Loses the thread of a story, poor word finding
Anxious and wandering at times, socially
withdrawn other times.
Helps with putting shirt on but is easily
distracted and stops what he’s doing.
Walks down hall holding onto railing and
furniture. Multiple falls.
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Dementia Level
Goals
Treatment Plan
Caregiver Instruction
 What skills do you want to maintain?
 What information is most useful to caregivers?
 What are your recommendations for functional
maintenance program (ISP?)
 How much assistance/supervision is necessary?
Tap into long term
memory for functional
use of hands
 Haptics
 It’s all about the hands!
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RELEASE!
Instinctual play
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Doll
Dog
 Allen Cognitive Level < 2.8
 GDS 6 and 7
 Developmental age infant to
1.5 years
* Unable to Release*
Allen Level 1:
 Mostly bedbound
 Can move limbs and
head
 Total assistance for
self care and mobility.
 Developmental age
infant
Allen Level 2:
 Can overcome gravity
 Can sit, stand and/or
walk (mobility)
 Have a sense of
balance, although not
good
 Developmental age 1-2
Copyright © 2002
Because I can’t move or
communicate well, I’m
really at risk for
contractures, falls, and skin
breakdown. YOU can
prevent this from happening
to me!
Precautions:
 Contractures
 Skin Breakdown
 Falls
 Aspiration
Copyright © 2002
A funny trick I know:
I may only be able to say
one or two words, but I
can sing a whole song
without any errors.
Cognitive Skills/
Communication:
 Speech mostly
unintelligible, mumbles
incoherently
 Unable to follow most
verbal commands
 Poor attention span,
distracted by moving
objects
Copyright © 2002
I can only see
things less than
12 inches from
my face.
Bring the world
to me!
Feeding:
 May be able to feed
self with limited or
extensive assistance
 More successful with
finger foods
 Can sip from a cup held
to lips until very end
stages- don’t introduce
a straw too early!
Copyright © 2002
I have a major fear of
falling. I may resist, hit, or
kick but it’s only to protect
myself from injury. I’m not
just being difficult.
Dressing/Bathing/
Grooming:
 Has no idea what to do
with objects
 Assists caregivers by
holding positions,
moving limbs, and
standing
Copyright © 2002
You may know
me by my
“death grip”. I
have a hard
time releasing
things from my
hands.
Toileting:
 Needs assistance with
managing clothing,
perineal hygiene, and
positioning on toilet
 Frequently incontinent
 Inappropriate toileting
locations- sometimes the
same place over and over.
 Can assist caregiver by
holding onto grab bar.
Copyright © 2002
I can turn my head to
track a moving object
even at the last stages
of my disease.
Give me moving stuff
to look at!
Functional Mobility:
 Higher level “hearts”
walk aimlessly, pace,
rock, and march.
 Lower level “hearts”
can only respond with a
grimace or glance.
 Seek stability and
comfort
 Enjoy gross motor
activities- without a
sense of purpose.
Copyright © 2002
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Lift someone under the
arms, legs will flex
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Have person pull up at
bar, legs will extend to
bear weight.
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Sucking reflex
Rooting reflex
Palmar grasp reflex
Babinski reflex
*The areas of the brain that are last
to be myelinated during development
are the most vulnerable to death*
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Seating and Positioning
Functional use of hands
Interaction with environment
Caregiver training for quality of life issues
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Aspiration
Skin breakdown
Comfort/pain
Contractures
Touching
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ADLs for object recognition
 How do they hold it in their hand?
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Pull to stand
Self feeding
Visual tracking, turning head, reaching for
items
Use reflexes to elicit movement- rooting,
protective extension, hand-to-mouth
movement patterns.
Activity #3
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Nonverbal
Bilateral UE/LE
contractures
Rigidity
Death grip
Falls forward out of chair
Inconsistently uses fork
appropriately, puts
everything in mouth
Does not consistently
bear weight for transfers
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Find the exit signs
Count the pictures on the wall
Pull off the post its
Balloon batting
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Completed by OT online near end of episode
Copy is sent to physician and family
Copy placed in ALF chart if applicable
Used as a tool to educate caregivers and give
objective recommendations based on
dementia findings
Make it smart!
 What is the purpose of your intervention?
▪ To improve..
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Trunk and pelvic stability?
Functional reach on a stable base?
Sequencing and task organization?
Postural deformities?
Risk of falls?
Risk of contractures?
Risk of skin breakdown?
Socialization and interaction with environment?
Who cares how you get there!
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“Upright and midline posture necessary for:”
 Improved air exchange
 Improved socialization
 Preventing abnormal postures
 Promoting functional use of upper extremities
 Improved communication
 Decreased caregiver burden
 Preventing falls and decreased skin integrity
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Balloon
Pen, screwdriver, paintbrush, toothbrush,
flashlight
Lipstick, mascara, nail file, nail polish, brush
Post-it Notes
Painter’s tape
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Start with what you know
 Don’t listen, watch.
 What does this disease looks like at the end?
 What are the associated complications of
Alzheimer’s?
 What can you do to put off the inevitable?
 What works? What doesn’t work?
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Determine the level of dementia
 Visualize one level down the road
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Use the backdoor to the brain
 Implicit/motor memory
 Demonstration
 Repetition and consistency
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Alzheimer’s research- prevention
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Estrogen
Insulin
Antioxidants
Anti-inflammatory
Genetics
Alzheimer’s research- therapies
 Aricept stops breakdown of acetylcholine
 Namenda works by binding to the NMDA receptor
and preventing excessive excitation by glutamate.
http://www.wiredtowinthemovie.com/mindtrip
_xml.html
 http://www.bakerrehabgroup.com/assets/cms/f
iles/Articles/Retrogenisis%20Theory.PDF
 http://www.bakerrehabgroup.com/assets/cms/f
iles/Articles/Alz%20Disease%20and%20Implici
t%20Memory.PDF
 http://www.bakerrehabgroup.com/assets/cms/f
iles/Articles/Routine%20Task%20Inventory%20
Expanded0023.PDF
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http://www.bakerrehabgroup.com/assets/c
ms/files/Articles/Assess%20Approach%20of
%20Pt%20w%20dementia.PDF
http://www.bakerrehabgroup.com/assets/c
ms/files/Articles/Primitive%20Reflexes%20i
n%20AD%20.PDF

http://thedementiaqueen.com/about/
Sue M. Paul OTR/L
Chief Operating Officer
Baker Rehab Group
http://www.bakerrehabgroup.com
Download

The Head, Hands, Heart Dementia Assessment