Vol. 15 Issue 34
Goal-Setting in Dementia
Tap into remaining abilities
When nursing home residents are diagnosed with dementia, the diagnosis can have negative connotations if clinicians do not understand the condition. They can promote a positive perception by focusing on patients' functions to help them achieve their highest level of independence in such areas as swallowing, activities of daily living (ADLs), balance, mobility, strength and overall performance.
Setting goals for people with dementia is similar to setting goals for patients with stroke or Parkinson's disease. Although abilities may decline over time, patients continue to possess reservoirs of remaining function. Dementia is a chronic, progressive condition; but therapeutic strategies can help tap into a patient's abilities.
Fluctuations in behavior and functional abilities make it difficult to define dementia. Two scales can clear up the picture and promote better communication between therapy and nursing staffs: the Global Deterioration Scale (GDS) and the Allen Cognitive Level (ACL).1-2
The seven levels of GDS, which identifies stages of dementia and impairment levels over time, reflect the severity of the condition. The levels, ranging from no cognitive decline at level 1 to very severe cognitive decline at level 7, provide a snapshot of disease progression. While GDS works well in interdisciplinary settings because it doesn't require testing or lengthy observations, it only identifies levels of deterioration, not function. The ACL scale, which provides information about a patient's abilities, corresponds to GDS levels.
Once a cognitive level has been determined, the therapist can write a plan of care that will help patients succeed at functional tasks and reinforce repeat performance. It is important to look at swallowing and speech skills, ADLs, ability to follow commands, need for assistive devices, awareness of safety considerations, and ambulation.
If nurses in a facility are using the GDS to identify dementia, therapists can use the level to integrate information they've gathered from the ACL and an evaluation. The therapy and nursing staffs can collaborate in developing treatment interventions based on a resident's cognitive level.
There is little or no cognitive decline at GDS level 1/ACL level 5.8-6. Residents should be able to answer questions, read instructions, and report problems. They can learn to anticipate problems but may benefit from environmental modifications.
At GDS level 2/ACL level 5.4-5.6, residents may have trouble remembering. Self-cueing devices, such as notebooks and lists, can help facilitate memory. They also may benefit from written instructions to help complete tasks and comprehend verbal instructions.
Residents at GDS level 3/ACL level 5-5.2 can look at a clock and tell time, but they may need memory aids to keep appointments and synchronize activities. They may act impulsively, be argumentative, or say things without realizing the social consequences. Patients at this level should be able to compensate for mild to moderate physical limitations.
At GDS level 4/ACL level 4.4-4.8, residents obtain new information slowly. Memory tasks are effective to facilitate recollection. They benefit from word-finding techniques to maintain the expressive flow of communication and usually can learn a schedule because they are oriented to the day and date.
Reading skills are starting to decline at this level, but one- or two-word notes or reminders can be provided at eye level. Use bright colors and large print for visual cues to help patients stay on task. Patients can learn new functional tasks, but they require one-step directions and need to practice in situation-specific settings. They respond best to visual and tactile cueing. While patients may seem to be noncompliant and inflexible about the way they do things, it is merely a defense mechanism because of the difficulty they are experiencing in learning new material.
Residents at GDS level 5/ACL level 3.6-4.2 may be disoriented about the date and time of day, but they can still measure the passage of time by the activities they've completed, such as getting dressed and eating meals. A large calendar can serve as a reminder. They recognize the difference between friendly and unfriendly social greetings and can make choices if they are given an either/or option.
Patients at this level also can perform self-care if it's a habitual activity that doesn't require change, but they may need two to three times the normal amount of time to complete the task. Supplies for self-care routines should be within arm's reach, with objects organized from left to right. Patients can learn to use adaptive equipment successfully if the task is familiar and moderate verbal cues are provided.
Residents speak in short phrases at GDS level 6/ACL level 3-3.4 and may be able to follow commands to start and stop actions. They can be assisted to write and recognize objects by size, color and shape. Hand movements are only briefly sustained and usually are carried out in a back-and-forth motion.
Patients respond well to the calming effects of music at GDS level 7/ACL level 2-2.8. They can learn songs incorporated with actions, such as clapping, and enjoy activities, such as dancing, marching and rocking. Their vocabulary shrinks to only a few words, so they may communicate through gestures. They should be asked only yes-or-no questions. Patients demonstrate a heightened response to loved ones and favorite items at this level. They can use utensils for feeding, with appropriate cues; but caregivers should precut food and fill a cup halfway to decrease spills.
Evaluating and treating residents who are cognitively impaired can be demanding. Don't be reluctant to treat these patients out of concern that an intermediary may deny payment because of a diagnosis of Alzheimer's disease. Under Medicare, a dementia diagnosis doesn't restrict a beneficiary from receiving therapy.3
1. Reisberg, B., Ferris, S.H., deLeon, M.J., et al. (1982). The Global Deterioration Scale for assessment of primary dementia. American Journal of Psychiatry, 139: 1136-39.
2. Allen, C., Blue, T., Earhart, C. (1995). Understanding Cognitive Performance Modes. Ormand Beach, FL: C. Allen Conferences.
3. Centers for Medicare & Medicaid Services. (2001). Program transmittal AB-01-135. Sept. 25.
Ellen Strunk, and Sharon Host, are clinical consultants at Restore Therapy Services in Birmingham, AL.