safety and health: the bottom line for persons with dementia

Safety and Health: The Bottom Line for Persons

with DementiaOctober 19, 2021

Mary Lou Donovan, PhD, OTR/L

Positive Dementia Paths

DISCLOSUREI have NO financial disclosures

or conflicts of interest with

the material in this presentation.

Mary Lou Donovan, PhD, OTR/L

Objective For This Presentation

•Summarize five key areas of safety concerns you can be aware of for a person with dementia

Mary Lou Donovan Positive Dementia Paths 218-391-0166 [email protected]

10/19/2021 3

Safety and Health - Why the Bottom Line?

•Safety and health not only for the person with dementia, but their caregivers, and the wider community

• Increased older adult numbers = Increased numbers of people with dementia diagnosis

•Staying at home vs going into an institution

•Caregiving is not intuitive for many

10/19/2021Mary Lou Donovan Positive Dementia Paths 218-391-0166

[email protected] 4

How will different stages of dementia affect a person’s safety and health inside and outside of the home, and when driving?

Type of support/interventions needed

10/19/2021 Mary Lou Donovan Positive Dementia Paths 218-391-0166 [email protected]

5

EarlyMiddle

Late

Things WILL change: YOU can look for these!!!

•Visual perceptual abilities

•Visuospatial abilities

• Field of vision and peripheral vision

•Depth perception

•What gets attention and for how long

•Ability to notice small changes in things - like water on the floor

• The way they interpret/or make sense of what they see/hear

•Physical limitations

•Hearing impairments10/19/2021

Mary Lou Donovan Positive Dementia Paths 218-391-0166 [email protected]

6

“I’m not losing my memory. I’m living in the now”

Higher Level

Thinking Skills

• Independent ADL’s

• Decrease in IADLs

• Independent learners…for a while

• Talks & works at same time… for a while

• Impulsive behavior/Poor judgement

• Blames others/directions for errors

• Misses social information

• Challenge areas: $$$ & Meds

• Accident waiting to happen

Early Stage… Mild Cognitive Impairment


[email protected] 8

Occupational Therapy (OT) Assessment of Person with Early Stage Dementia

Examples of assessments:

❑Allen Cognitive Leather Lacing Screen (ACLS) (Scores will be Level 5/6)

❑Cognitive Performance Test- medication management/

shopping subtests scores will be Level 5/6)

❑Montreal Cognitive Assessment (Score 19-25/30 for MCI)

❑Clinical observations/Information from family and person with MCI


[email protected] 9

Interventions for Early Stage• Have the person assessed earlier vs later

• Devise a PLAN B

• Talk about harmful devices and situations, i.e. Guns, ammo, other weapons, motors, power tools, machines

• Teach how to summon help

• Establish routines

• Begin simplifying responsibilities

• Use memory aids

• Tell friends and family about diagnosis - and need for them to continue being involved with the person with dementia

• Continue to enjoy life, laugh, be active, live one day at a time10/19/2021

Mary Lou Donovan Positive Dementia Paths 218-391-0166 [email protected] 10

Middle Stage Dementia – Safety Risks

• ADL’s - mostly OK, give help with details/supplies

• IADL’s - LOTs of problems

• Needs supervision

• Talks a good talk…Thinks nothing is wrong with them

• Sees striking visual cues but out of sight/out of mind

• May be functionally illiterate (Pretend to read..)

• Unable to understand precautions, hazards

• Still scans the environment - for a while

• Unreliable reporter 10/19/2021


OT Assessment of Person with Middle Stage Dementia

OT ASSESSMENT EXAMPLES

❑Allen Cognitive Leather Lacing Screen (Scores will be Level 3-4/6)

❑Cognitive Performance Test - medication management/

shopping (Scores will be Level 3-4/6)

❑Montreal Cognitive Assessment (Score < 19/30 for MCI)

❑Clinical observations/Information from family and person with Middle Stage Dementia


[email protected] 12

How To Identify Need For Assessment and Intervention – for Middle Stage Dementia

THINGS YOU CAN BE AWARE OF IN HOME

•Change in state of the apartment or house • Food management•Person’s clothing•Person’s makeup - or perfume•Person has an odor•Medications a mess•Paperwork piles up/Magazine numbers increase



THINGS YOU CAN BE AWARE OFIN A HOSPITAL OR CLINIC SETTING

•Remembers previous directions? •Uses the new walker/cane ?•Recalls recent events? •Needs lots of repetition•Puts both legs into one pant leg•Reassures you they don’t have troubles• Lots of refusals•Doesn’t remember their room number•Can’t learn how to use chair or TV controls



Middle Stage Interventions• OK for part of day alone? Need more supervision!

• Take over their meds and $$

• REALLY simplify routines, closets, drawers

• Provide needed supplies

• Label contents of cupboards/drawers

• Avoid light/dark floors- but DO have a dark toilet seat on a white floor and toilet

• Avoid tripping - keep furniture in the same place

• Of course - remove throw rugs!

• Update PLAN B with caregiver and family members10/19/2021


Late Stage Dementia Safety/Health

• 24 hour supervision

• Worried about falling down! Can still stand/walk/sit, pull/push…not always safely because not looking at the ground

• Can do gross motor movements - take advantage of that. Use grab bars to pull up, have them move body parts for care

• More assaultive or resistive behavior, slow or agitated

• May refuse to do actions they perceive as dangerous

• No awareness of having a physical disability, i.e., one side affected by CVA or amputation

10/19/2021 May Lou Donovan Positive Dementia Paths 218-391-0166 [email protected]

16

Very Late Stage Dementia Safety and Health

•VERY vulnerable for abuse and neglect - no language skills to report their issues

•Needs 24 hour total care/ ROM and position changes

•Nutrition and skin care are key

•Attends best to stimulation from nipple line up = sense of taste, smell, hearing, vision, and touch

•Person still has needs and desires -may show preferences



OT Assessment of Person with Late Stage Dementia

•Assessment of person’s abilities done with input from staff and family for specific purpose, i.e., decrease inappropriate behaviors

•Use “ABC” method to analyze behaviors… Antecedent/behavior/consequence

• Find what calms them and what perks them up

•Assess Caregiver’s ability to transfer, feed, bathe, clothe the person using good body mechanics and equipment.

•Assess Caregiver’s support system10/19/2021


Late Stage Interventions

• Instruct caregiver on proper feeding, bathing, clothing, and transferring

• Instruct on proper use of equipment

• Instruct on ways to soothe and increase alertness for the person

•Educate caregivers on available support systems



Areas for Safety Considerations Inside the Home

• Footwear

•Clutter

•Communication systems

•Ability to handle Emergencies

• Flooring

• Lighting

•Appliances

• Locks

• Stairs

• Surface Heights


[email protected]

BathroomKitchenLiving room

Helpful equipment tips to follow!

Burner and Oven locks


[email protected]

Bathroom Safety

• Install grab bars, add non-skid tape in the tub or shower

• Replace glass shower doors with curtain

• Shower chair/tub bench

• Hand-held shower spray

• Pump dispensers for liquid soap

• Non-skid bathmat

• Raised toilet seat/grab bars



Hot beverages

Sources for Burns/Scalds


Stoves and ovens



Check Home For Potentially Dangerous Objects/Situations

Prevention of Wandering- Simple Approaches


[email protected]

Door Top LockWander Alert Door-or Motion Alarm Kits

Vinyl Door Murals-Peel and Stick

Prevention of Wandering- More Technology

10/19/2021

Mary Lou Donovan Positive Dementia Paths 218-391-0166

[email protected]

Safety Considerations Outside the Home

• Exterior of home-• Think: Fall prevention - especially with winter/snow/ice• Accessibility - stairs/railings/ lighting• Mailbox location• Distance to street/road

• Tools-• Think: lawnmowers, tractors, chainsaws, 4-wheelers• Operation AND maintenance? Use of protective

devices?

• Flammables/Toxic chemicals10/19/2021


For a person left alone at home, ask yourselves these questions: Can They…

• Safely get themselves to the bathroom/get food and water throughout the day?

• Clean themselves up if they have an accident?

• Recognize spoiled food?

• Burn themselves because water temp is set too hot?

• Operate a key or lock system?

• Know who to let in/not let in to the house?

• Operate a communication system?

??? Is anyone checking their mail for scams/fraud?10/19/2021


Skills Needed for Safe Driving - PhysicalRed Highlights = Skills Affected By Dementia

Specific To Driving

•ROM and strength upper/lower body

•Neck ROM

•Coordination

•Proprioception/Reaction time

•Balance

•Mobility

•Transfers10/19/2021


Skills Needed for Safe Driving - Vision90% of information in driving

comes through our vision

•Distance acuity •Visual field •Depth perception •Shift of attention •Dynamic acuity/ Visual pursuits•Perceptual rxn time

•Sign recognition•Contrast sensitivity •Eye movement control •Scanning speed/ processing •Glare recovery



Skills Needed for Safe Driving - Cognition

•Processing speed• Executive function (high level thinking)• Shift of attention

For people with Dementia:

•Known changes with vision•Add other health conditions to that--- decreased

mobility, strength/ROM = SCARY!



Drivers With Dementia and Outcomes Of Becoming Lost While Driving

Journal of Occupational Therapy, 64, 225-232 (2010)



207 drivers with dementia lost over 10 year time 70 drivers not found32 drivers found dead116 drivers found alive (35 injured)10 people killed by actions of the lost driver

Clinical Driving Assessment Areas:

1. Medical And Driving History2. Physical Skills3. Vision Skills4. Cognitive Skills

• Information from Ann Forrest Clark, OTR/L Certified Driving Rehab Specialist, and MN Licensed Driving Instructor



(Certified) Driving Rehab Specialists in Montana:

• Missoula Community HealthMichelle Moser - Dreher OTR/L and Julie Craft OTR/L406-327-4050

• St. Vincent Healthcare Rehabilitation Center - BillingsKaitlyn Radi OTR 406-238-6400 (how much???)

• St. John’s United Occupational Therapy Dept - BillingsNicole Gross OTR/L 406-655-5759

NO longer available in Bozeman-Closed in June10/19/2021


Montana Driving Laws• License renewal: Every 12 years for regular, 8 years for Real ID

• At 74 y.o. renew in office every 4 years, vision and “cognitive” tested• If failed - referred to MD/ completes medical form. If MD says OK

have to retake rewritten and Behind the Wheel (BTW) every 1-2 years.

• People with Chronic Diseases screened through “Affirmation” process - have MD sign medical form. New quads or paras/amputees have to take a BTW with their equipment.

• Law enforcement can also request person go to MD for eval. If license revoked people can protest outcome at a hearing.

• Private citizens can report unsafe drivers anonymously.



Forms from Montana Motor Vehicle Division

• Recommendation for Re-Examination https://media.dojmt.gov/wp-content/uploads/Recommendation-for-Re-examiniation.pdf

• Eye Evaluationhttps://media.dojmt.gov/wp-content/uploads/Eye-Evaluation.pdf

• Driver Medical Evaluationhttps://media.dojmt.gov/wp-content/uploads/Driver-Medical-Evaluation.pdf



Family Questionnaire1. Number of times stopped or ticketed in the last 3 years?2. Number of accidents including fender benders had in the

last 3 years?3. Does family member get lost while driving in familiar

locations?4. What is their response to honking or person following too

close?5. Does your family member repeat things often?6. Do they have problems remembering appointments? 7. Would you allow your family member to drive alone with

your five year old grandchild in the vehicle?



Older Adults and NEW CARS!!!

Fit the car to the person -Check out CarFit Programshttps://www.car-fit.org/

Simplify technology use if needed



Have a Plan For Reduction of Driving… Some Options

• Person has clinical and behind the wheel assessments to determine continuation of driving status.

• Driving Restrictions - Driving during daytime, drive only on roads with speed limit ≤ 50 mph, drive within X miles from home.

• Driving Retirement • Use of family and friends for transportation• Public transportation - Examples in Montana; Rural

coverage: “Very little or no public transportation… some options available..”



Driving Resources for Professionals and for the PATIENT AND CAREGIVERS

• Driving and Dementia Tool Kit For Health Professionals: https://www.rgpeo.com/wp-content/uploads/2020/04/Driving-and-Dementia-Toolkit-3rd-Ed-pdf-July-2009.pdf

• Driving and Dementia Tool Kit For Patients and Caregivers: https://www.rgpeo.com/wp-content/uploads/2020/04/Driving-and-Dementia-Toolkit-3rd-Ed-pdf-July-2009.pdf



Take Away Points:

• Safety and Health have to be considered for ALL people- not just person with dementia

• People with dementia need different levels of support as their disease progresses

• Family members can be educated about concerning signs/changes

• Family members can be taught how to modify their homes for increased safety and accessibility

• IT IS UP TO ALL OF US TO KEEP THE ROADS SAFE!



Questions???

Thanks for your attention!

Mary Lou Donovan, PhD, OTR/LPositive Dementia Paths218-391-0166mldonovan@positivedementiapathswww.positivedementiapaths.com



References- Sectioned by topicStages of Dementia

Donovan, ML. (2017) May 23. Maximizing a Person’s Ability to Function in Daily Life. University of Wisconsin-Superior Dignity and Purpose Workshop series, Superior, WI. Personal communication

Donovan, ML. (2017) June 15 & September 19. Cognitive Disability Theory; The Allen Cognitive Levels (ACL) and Allen Cognitive Level Screening (ACLS) Tools. Cranbrook, British Columbia Occupational Therapists. Personal Communication

Caregiver Education and Training

Alzheimer’s Association. Caregiving Safety (n.d.) https://www.alz.org/help-support/caregiving/safety



https://www.alz.org/help-support/caregiving/safety

Donovan, ML & Forrest Clark, A. (2017) April 24. Triggers, Tips and Tactics for Caregivers. Alzheimer’s Association Twin Ports Conference. Essentia Health, Duluth, MN. Personal communication

Donovan, ML. (2018) August 17. Dementia, Caregiving and the DSM-5. Doctor of Nurse Practitioner students at College of St. Scholastica. Personal communication

Donovan, ML. (2020) July 6. Education on Dementia Caregiving. Arizona University OT Geriatric Class. Personal communication

Montana Department of Health and Human Services. Caregiver Corner

https://dphhs.mt.gov/respite/caregivercorner



https://dphhs.mt.gov/respite/caregivercorner

Safety and Accessibility in the Home

10 Useful Aids to Help You Live With Memory Loss. (2015, August). Lifted Team.https://www.liftedcare.com/10-useful-aids-to-help-you-live-with-memory-loss/

Cooking Safety Prevent Kitchen Burns. CDC. (2020). October 14. Center for Preparedness and Response. https://www.cdc.gov/cpr/socialmedia/cooking_safety_3.htm

Home Fire Safety for Older Adults Safety Awareness Program Toolkit, (2015). February 12 in Home Safety by Electrical Safety Foundation International. https://www.esfi.org/resource/home-fire-safety-for-older-adults-safety-awareness-program-toolkit-248#CookingAndKitchenSafety



https://www.liftedcare.com/10-useful-aids-to-help-you-live-with-memory-loss/

https://www.esfi.org/resource/home-fire-safety-for-older-adults-safety-awareness-program-toolkit-248#CookingAndKitchenSafety

Johnson, C. Common Home Accidents for the Elderly and How to Prevent Them. n.d. Caring Village https://www.caringvillage.com/2018/09/29/common-home-accidents-for-the-elderly-and-how-to-prevent-them/

Pet lovers beware: Cats, dogs are tripping hazards. (2009) March, 26.

https://www.reuters.com/article/us-injuries-pets/pet-lovers-beware-cats-dogs-are-tripping-hazards-idUSTRE52P79H20090326

STEADI: Stopping Elderly Accidents, Deaths & Injuries- Older adult Fall Prevention. n.d. https://www.cdc.gov/steadi/

Take a Stand on Falls (2017) September 22. National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention https://www.cdc.gov/features/older-adult-falls/index.html



https://www.caringvillage.com/2018/09/29/common-home-accidents-for-the-elderly-and-how-to-prevent-them/

https://www.reuters.com/article/us-injuries-pets/pet-lovers-beware-cats-dogs-are-tripping-hazards-idUSTRE52P79H20090326

https://www.cdc.gov/steadi/

https://www.cdc.gov/injury

https://www.cdc.gov/features/older-adult-falls/index.html

Driving and Dementia

Clark, Ann F. (Personal Communication, November 6, 2015). Driving and Dementia: Independence & Public Safety.

Driving and Dementia Tool Kit For Health Professionals: https://www.rgpeo.com/wp-content/uploads/2020/04/Driving-and-Dementia-Toolkit-3rd-Ed-pdf-July-2009.pdf

Driving and Dementia Tool Kit For Patients and Caregivers: https://www.rgpeo.com/wp-content/uploads/2020/04/Driving-and-Dementia-Toolkit-3rd-Ed-pdf-July-2009.pdf

Hunt, L. A., Brown, A. E., & Gilman, I. P. (2010). Drivers with dementia and outcomes of becoming lost while driving. American Journal of Occupational Therapy, 64, 225–232.

https://www.rgpeo.com/wp-content/uploads/2020/04/Driving-and-Dementia-Toolkit-3rd-Ed-pdf-July-2009.pdf

https://www.rgpeo.com/wp-content/uploads/2020/04/Driving-and-Dementia-Toolkit-3rd-Ed-pdf-July-2009.pdf

Driving Assessment

Ashley K Smith Watts, David C Ahern, Jacob D Jones, Thomas J Farrer, Stephen Correia, Trail-Making Test Part B: Evaluation of the Efficiency Score for Assessing Floor-Level Change in Veterans, Archives of Clinical Neuropsychology, Volume 34, Issue 2, March 2019, Pages 243–253, https://doi.org/10.1093/arclin/acy025

Montreal Cognitive Assessment Website: https://www.mocatest.org/

Staplin, L., Gish, K.W. Gish, Lococo, K. H. et al. (2013). The Maze Test: A significant predictor of older driver crash risk, Accident Analysis & Prevention, (50) 483-489, ISSN 0001-4575,https://doi.org/10.1016/j.aap.2012.05.025 https://pubmed.ncbi.nlm.nih.gov/22683280/



https://doi.org/10.1093/arclin/acy025

https://www.mocatest.org/

https://pubmed.ncbi.nlm.nih.gov/22683280/

Trailmaking Test Parts A & B http://apps.usd.edu/coglab/schieber/psyc423/pdf/IowaTrailMaking.pdf

Driving and older adults

Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years — United States, 2014. Morb Mortal Wkly Rep 2016;65:993–998. DOI: http://dx.doi.org/10.15585/mmwr.mm6537a2external icon

Older Drivers (2021) April. Insurance Institute for Highway Safety (IIHS) https://www.iihs.org/topics/older-drivers



http://apps.usd.edu/coglab/schieber/psyc423/pdf/IowaTrailMaking.pdf

https://www.cdc.gov/mmwr/volumes/65/wr/mm6537a2.htm?s_cid=mm6537a2_w

http://dx.doi.org/10.15585/mmwr.mm6537a2

https://www.iihs.org/topics/older-drivers

Vision / Vision in People with Dementia

Heerema, E., (2020) February 7. How Dementia Affects Visuospatial Abilities and Skills. verywellHealth https://www.verywellhealth.com/how-does-dementia-affect-visual-spatial-abilities-98586

Pal, A., Viswas, A., Pandit, A., et al. (2016) February 2. Study of visuospatial skill in patients with dementia. Annals of Indian Academy of Neurology (19)1 83-88. https://www.annalsofian.org/article.asp?issn=0972-2327;year=2016;volume=19;issue=1;spage=83;epage=88;aulast=Pal



https://www.verywellhealth.com/how-does-dementia-affect-visual-spatial-abilities-98586

https://www.annalsofian.org/article.asp?issn=0972-2327;year=2016;volume=19;issue=1;spage=83;epage=88;aulast=Pal

Fall prevention

Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years — United States, 2014. MMWR Morb Mortal Wkly Rep 2016;65:993–998. https://www.cdc.gov/mmwr/volumes/65/wr/mm6537a2.htm

Take a Stand on Falls. n.d. https://www.cdc.gov/features/older-adult-falls/index.html

Quain, John, R., (2021) February 11. AARP Older Drivers are Now Safer Drivers Better Healthhttps://www.aarp.org/auto/driver-safety/info-2021/older-drivers-are-now-safer-drivers/



https://www.cdc.gov/mmwr/volumes/65/wr/mm6537a2.htm

https://www.cdc.gov/features/older-adult-falls/index.html

https://www.aarp.org/auto/driver-safety/info-2021/older-drivers-are-now-safer-drivers/

Montana Driving Forms

Driver Medical Evaluation

https://media.dojmt.gov/wp-content/uploads/Driver-Medical-Evaluation.pdf

Montana Driver Licensing Forms

https://dojmt.gov/driving/driver-licensing-forms/ From Rebecca Connors rebeccaconnors @mt.gov Personal communication 9/16/2021

Eye Evaluation

https://media.dojmt.gov/wp-content/uploads/Eye-Evaluation.pdf

Recommendation for Re-Examination

https://media.dojmt.gov/wp-content/uploads/Recommendation-for-Re-examiniation.pdf



https://media.dojmt.gov/wp-content/uploads/Driver-Medical-Evaluation.pdf

https://dojmt.gov/driving/driver-licensing-forms/

https://media.dojmt.gov/wp-content/uploads/Eye-Evaluation.pdf

https://media.dojmt.gov/wp-content/uploads/Recommendation-for-Re-examiniation.pdf

Montana Public Transportation Information (some of state)

MET Transit https://ci.billings.mt.us/335/MET-

Missoula Aging Services- Transportation https://missoulaagingservices.org/get-help/daily-living/transportation.html

Montana Department of Health and Human Services Transportation information

https://dphhs.mt.gov/detd/transportation/publictransit



https://ci.billings.mt.us/335/MET-

https://missoulaagingservices.org/get-help/daily-living/transportation.html

https://dphhs.mt.gov/detd/transportation/publictransit

safety and health: the bottom line for persons with dementia

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