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 • • • • • • • • 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 • • • • • • • • 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: – – – – – 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: – – – – 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: – – – – – 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: – – – – – – 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 – – – – 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 • • • • 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+) – – – – – – – – – – – – – – 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) – – – – – – – – – 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) – – – – – – – – – 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) – – – – – – – – – – 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) – – – – – – – – – – – 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. – – – – – – – – 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 • • • • 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 • • • • 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 • • • 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 • • • 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.