safety and health: the bottom line for persons with dementia
TRANSCRIPT
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
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
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
10/19/2021Mary Lou Donovan Positive Dementia Paths 218-391-0166
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
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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
Mary Lou Donovan Positive Dementia Paths 218-391-0166 [email protected] 11
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
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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
10/19/2021Mary Lou Donovan Positive Dementia Paths 218-391-0166
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
10/19/2021Mary Lou Donovan Positive Dementia Paths 218-391-0166
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
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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
10/19/2021Mary Lou Donovan Positive Dementia Paths 218-391-0166
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
Mary Lou Donovan Positive Dementia Paths 218-391-0166 [email protected] 18
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
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Areas for Safety Considerations Inside the Home
• Footwear
•Clutter
•Communication systems
•Ability to handle Emergencies
• Flooring
• Lighting
•Appliances
• Locks
• Stairs
• Surface Heights
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BathroomKitchenLiving room
Helpful equipment tips to follow!
Burner and Oven locks
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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
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Hot beverages
Sources for Burns/Scalds
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Stoves and ovens
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Check Home For Potentially Dangerous Objects/Situations
Prevention of Wandering- Simple Approaches
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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
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
Mary Lou Donovan Positive Dementia Paths 218-391-0166 [email protected] 27
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
Mary Lou Donovan Positive Dementia Paths 218-391-0166 [email protected] 28
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
Mary Lou Donovan Positive Dementia Paths 218-391-0166 [email protected] 29
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
10/19/2021Mary Lou Donovan Positive Dementia Paths 218-391-0166
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!
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Drivers With Dementia and Outcomes Of Becoming Lost While Driving
Journal of Occupational Therapy, 64, 225-232 (2010)
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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
10/19/2021Mary Lou Donovan Positive Dementia Paths 218-391-0166
(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
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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.
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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
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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?
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Older Adults and NEW CARS!!!
Fit the car to the person -Check out CarFit Programshttps://www.car-fit.org/
Simplify technology use if needed
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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..”
10/19/2021Mary Lou Donovan Positive Dementia Paths 218-391-0166
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
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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!
10/19/2021Mary Lou Donovan Positive Dementia Paths 218-391-0166
Questions???
Thanks for your attention!
Mary Lou Donovan, PhD, OTR/LPositive Dementia Paths218-391-0166mldonovan@positivedementiapathswww.positivedementiapaths.com
10/19/2021Mary Lou Donovan Positive Dementia Paths 218-391-0166
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
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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
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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
10/19/2021Mary Lou Donovan Positive Dementia Paths 218-391-0166
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
10/19/2021Mary Lou Donovan Positive Dementia Paths 218-391-0166
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.
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/
10/19/2021Mary Lou Donovan Positive Dementia Paths 218-391-0166
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
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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
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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/
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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
10/19/2021Mary Lou Donovan Positive Dementia Paths 218-391-0166
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
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