The Mental Health Foundation (2006) defines dementia as “a decline in mental ability which affects memory, thinking, problem-solving, concentration, and perception. Dementia is almost invariably a disease of aging.”

Building upon the ten warning signs (see Part I Dementia), the following dementia best practices from the Alzheimer’s Association and other valued sources, focus on early recognition of symptoms with suggested best practice interventions.

Assess the person to determine level of difficulty with activities listed below. A positive finding may be considered an indication for further screening and history identified. A Home Health Agency protocol will no doubt include a directive to report results to the physician.

The Assessment should include:

Learning of new information

• Does the person exhibit repetitive stating?
• Does the person have difficulty remembering recent conversations, events, or
• placement of personal objects?
• Does the person utilize memory aids?

Reasoning ability

• Is the individual able to respond with a reasonable plan for problems at home,
• such as knowing what to do if there were a kitchen fire?
• Do they know how to handle telephone calls from family, from telemarketers?

Language recall

• Does the individual have increasing difficulty finding the correct words to express what he or she wants to say?
• Do they struggle finding the right work for a sentence or call something by the incorrect name and not correct it?

Handling complex tasks

• Does the individual have difficulty following a complex train of thought or
• performing tasks  that require many steps such as following a recipe?
• When out walking with a family member, can the patient retrace their path home?

Spatial ability and orientation

• Does the individual have trouble driving, organizing objects around the house, and finding his or her way around familiar places?

Behaviors

• Does the individual appear silent more frequently?
• Does the individual appear more passive and less responsive?
• Is the individual more irritable than usual; is suspicious of others, or misinterprets visual or auditory stimuli?
• Do certain events trigger behavioral responses?
• Is there difficulty discussing current event in an area of interest?

The Home Health clinician understands that a thorough assessment of the patient, support services, and environment is necessary so that an appropriate plan of home health care can be implemented. The National Care Forum (2007) supports the need for an overall assessment. They identify that this is crucial to the development of a useful care plan.  The Forum states additional indicators of best practice include:

• Evaluation and re-evaluation (Specific services are provided based on the patient’s health care, physiotherapy, and nutritional needs)
• Involve the patient and family with the careplan. Life stories are used to ensure understanding of the individual.
• Consider cultural needs and their implementation into the plan of care.
• Promote the well being for the individual. (Develop measurements of well being and satisfaction for the individual)
• Care Plans will be used as communication tools, so they must be clear and concise but house depth so the team can individualize care.
• Match personnel with patients. (Suggest to the family that caregivers must match the well being needs of the individual).
• Actively involve family and friends, not only for the patient’s needs, but also for the respite of primary family caregivers
• Technology and telecare telemonitoring may be used to complement care to promote safety and maximize independence (Monitoring bracelets may be needed for individuals who attempt to leave the home).

The Alzheimer’s Association of Australia(2007) state that patterns, convenient schedules and consistent personnel are essential for care. Consistency aids to promote calm. A schedule is necessary.  Focus on retained abilities. What are and have been interests of the individual? Incorporate these interests into the careplan and plan of care. Use the familiar environment as a therapeutic psychosocial tool; i.e. continue favorite activities such as have tea in the afternoon using their familiar china so a sense of comfort is encouraged. Have behavioral management guidelines for the patient and family in place and understood.

The Alzheimer’s Association Campaign for Quality Care (2007) states that a developed checklist can assist to identify certain behavioral symptoms. The list includes observing for:

• Changes in ability to focus
• Changes in emotional and physical agitation
• Changes in mood, suspicion of others
• Hallucinations, illusions, withdrawal from others
• Wandering, pacing, rocking

Any symptoms from the above list should not routinely be attributed to Alzheimer’s Disease. A health care professional needs to rule out other causes such as environment, medication, or another health condition (infection, pain, depression, or boredom).

Families can provide information regarding the individual’s prior and present life, customary routines, preferences, behavior triggers, and results of attempted interventions. They can help interpret language, nonverbal interactions and the meaning behind the behaviors affected by major life events and traditions. Include caregivers in the assessment process, as they are an integral part as they notice subtle, individual cues they’ve come to understand.

Ask questions in a systematic way, write down the answers, incorporate these interests into the careplan, observe and intervene.

Include in the Plan:

• Many home health assessments for Dementia include the CLOCK Drawing Test (CDT).

This exam includes the patient being asked to:

1. Draw a clock
2. Draw in all of the numbers
3. Set the hands at ten minutes past eleven

The Alzheimer’s Disease cooperative scoring system for the Clock Drawing Test is based on a score of five points.

1 point for the clock circle

1 point for all the numbers being in the correct order

1 point for the numbers being in the proper special order

1 point for the two hands of the clock

1 point for the correct time

A normal score is four of five points

The test assists in identifying general cognitive and adaptive functioning such as memory, information processing, and vision issues. Research supports a normal drawing of a clock almost always predicts cognitive abilities within normal limits. Remember, the Clock Drawing Test does not aid in differentiating between vascular dementia and Alzheimer’s Disease and is not sensitive for mild cognitive impairments.

Best Practices from Alzheimer’s Association (2006) Alzheimer’s Association Australia (2007):

• Have a well established philosophy of care that is shared with all of the team
• Establish timelines for ongoing formal assessments
• Identify the care will be person-centered with flexible scheduling of care
• Identify there will be interdisciplinary care supported with a consistent approach to care
• Consistency with personnel and other caregivers.
• Medication optimization
• All personnel need to be well trained in dementia care
• Acknowledgement of previous skills
• Work closely with the family and caregivers
• Use the environment as a psychosocial tool
• Have behavioral management guidelines taught to entire team

Implementing the Practices:

• Have the baseline Clock Drawing Test available
• Communication should be open and supportive to patients, family, and caregivers
• Provide Person-Centered Care Philosophy which honors an individual’s personhood (Kirkwood, 1997)
• Medication Optimization teaching
• Optimize functioning to include walks and exercise movement as tolerated
• Institute a Falls Risk Program with special equipment recommendations
• Assess environment and institute safety and care suggestions
• Have extended meal times to allow for conversation and a calming environment
• Assess and institute a Pain Management Program

Coding Tip: If the physician diagnosis for the patient is dementia, expect the Select Data coding team to code 294.8 (other persistent mental disorders due to conditions classified elsewhere, or dementia). If the physician lists or confirms the clinician’s assessed symptoms, the Select Data team will code them separately such as paranoid state would be coded 297.9 (Unspecified paranoid state) for delusions. Should the physician identify a specific diagnosis, then codes such as 290.3 (Senile dementia with delirium) will be listed. If the dementia is from an underlying condition, the physical condition, such as 331.0 (Alzheimer’s Disease) is listed first then a code from subcategory 294.1 (Dementia in conditions classified elsewhere) will be chosen to capture the related dementia.

Instituting a best practice dementia care practice can be challenging but fulfilling. Momentum can be maintained by frequent case conferences and seeking ongoing feedback from family and caregivers. Ongoing personnel education is needed so competency skill levels remain high.

ADDITIONAL SOURCES:

Alzheimer’s Association Campaign for Quality Care: Dementia Care Practice Recommendations for Professionals Working in a Home Setting, Phase 4, 2009

2010 Alzheimers Facts and Figures
http://www.alz.org/documents_custom/report_alzfactsfigures2010.pdf

Hudson, R. (Ed), (2003). Dementia nursing: a guide to practice. Ausmed Publications, Melbourne Australia

Kirkwood, J. (1997). Dementia reconsidered: The person comes first. Open University Press. Berkshire, UK.

McCann-Beranger, J., (2002). A caregiver’s guide for Alzheimer and related disorders. The Acorn Press, Chalottetown, PEI.

National Care Forum Older People and Dementia Care Committee (2007) Statement of best practice: Key principles of person-centred dementia care. Coventry CV1 2DY www.nationalcareforum.org.uk

Robinson, J. (March/April, 2007). Utilizing best practice in dementia care. In Canadian Nursing Home Journal.