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STAGE-SPECIFIC NON-PHARMACOLOGICAL INTERVENTIONS FOR PERSONS WITH COGNITIVE IMPAIRMENT

STAGE-SPECIFIC NON-PHARMACOLOGICAL INTERVENTIONS FOR PERSONS WITH COGNITIVE IMPAIRMENT. DOLLY DASTOOR Ph.D Program in Dementia with Psychiatric Co-morbidity Douglas Mental Health University Institute, Alzheimer Disease International, Toronto , March 27, 2011.

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STAGE-SPECIFIC NON-PHARMACOLOGICAL INTERVENTIONS FOR PERSONS WITH COGNITIVE IMPAIRMENT

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  1. STAGE-SPECIFIC NON-PHARMACOLOGICAL INTERVENTIONS FOR PERSONS WITH COGNITIVE IMPAIRMENT DOLLY DASTOOR Ph.D Program in Dementia with Psychiatric Co-morbidity Douglas Mental Health University Institute, Alzheimer Disease International, Toronto , March 27, 2011

  2. Stage specific non-pharmacological interventions In collaboration with Hildegard Brack, PH.D Psychologist Celine Brunelle, B.Sc Nurse Clinician David Fontaine, PH.D Psychologist Nancy Grenier, B.Sc Occupational Therapist Lisa O’Reilly, B.A Recreational Therapist Katherine Thibodeau MSW. Social Worker ADI March 27, 2011

  3. Stage specific non-pharmacological interventions Conflict of Interest Disclosure Dolly Dastoor Ph.D Has no real or apparent Conflicts of interest to report ADI March 27, 2011

  4. Stage specific non-pharmacological interventions Globally the population is aging 2007 11% over 60 (700 million) 2050 22% over 60 (2 billion) Increased longevity comes with increased functional and cognitive impairment Incidence and prevalence of dementia is rising 2011, 500,000 Canadians with Dementia; 2031, 750,000 Canadians with Dementia, Dementia is the leading cause of disability, People can live up to 11.9 years with disability. ADI march 27, 2011

  5. Stage specific non-pharmacological interventions Models of best practices are needed to ensure the well- being of older people in the health system (World Health Organization 2001) A model of care refers to conceptual elements for delivery of health care considering patient, provider and system issues A model of care was developed for people with dementia based on the paradigm shift from custodial to individualized care

  6. Stage specific non-pharmacological interventions A MODEL BASED ON A CONTINUUM OF CARE WITH STAGE SPECIFIC INTERVENTINS HAS BEEN DEVELOPED AT MOE LEVIN CENTRE , PROGRAM IN DEMENTIA WITH PSYCHIATRIC CO-MORBIDITY ADI March 27, 2011

  7. Stage specific non-pharmacological interventions THE PROGRAM FOR DEMENTIA WITH PSYCHIATRIC CO-MORBIDITY (PDPC) PROVIDES: ► HIGHY-SPECIALIZED CLINICAL CARE ► TEACHING ► RESEARCH To a clientele with mild to severe cognitive loss, combined with psychiatric and behavioral problems. It offers a continuum of services – from a MEMORY CLINIC, TO A DAY CENTRE, TO AN INPATIENT UNIT ADI March 27, 2011

  8. Stage specific non-pharmacological interventions

  9. Stage specific non-pharmacological interventions Families McGill Centre for Aging Patient Research Treatment Management of behavioral problems Douglas Institute Research Centre Training CLSC Home care Other Organizations Community CHSLD Hospitals

  10. Stage specific non-pharmacological interventions In the absence of any cure for dementia at the present time , we provide interventions along a continuum which will: DELAY DISEASE PROGRESSION Memory Clinic (cognitive retraining, clinical drug trials, psycho education, pharmacotherapy ) DELAY FUNCTIONAL DECLINE, IMPROVE QUALITY OF LIFE Therapeutic Day Centre (symptomatic therapies, Nintendo Wii, computer assisted cognitive stimulation, relaxation, Coping Strategies) SUPPORT DIGNITY, CONTROL PSYCHIATRIC SYMPTOMS In-patient Unit (animal assisted therapy, music, reminiscence, social interactions, sensory stimulation, pharmacotherapy)

  11. Stage specific non-pharmacological interventions- MEMORY CLINIC The Memory Clinic is a non-sectorized service which offers external evaluation to adults of all ages with different degrees of memory loss which may be accompanied by dementia-related psychiatric symptoms. The primary symptom must be cognitive impairment The specialized interdisciplinary clinic team can: Identify cognitive losses and evaluate the stages in memory impairment, clarify diagnosis, Inform clients and their families of the changes related to the illness, Propose treatment plans for management of disturbing behaviors Provide the appropriate follow-up ,Enrollment in non-pharmacological and pharmacological research protocols

  12. Stage specific non-pharmacological interventions INTERVENTION AND FOLLOW-UP Pycho education for the patient and their family (including how to access services) Pharmacotherapy SPECIALIZED INTERVENTIONS Therapeutic Day Centre Cognitive Retraining program Participation in Clinical Drug Trials Links with the CLSC, Alzheimer Society, etc. Patients referred back to the community after 6 months FOLLOW-UP Generally 6 months with the exception of patients with Mild Cognitive impairment (MCI) patients waiting for MRI and PET appointments and analysis

  13. Stage specific non-pharmacological interventions INTEGRATION OF RESEARCH AND CLINICAL WORK The Memory Clinic is now integrated in research protocols and in the development of Cognitive Retraining Programs Establishing a clinical data base for the Memory Clinic to track executive function and drug efficacy in patients ADI March 27, 2011

  14. Stage specific non-pharmacological interventions COGNITIVE RETRAINING Intervention Technic for early stage cognitive loss Alternative treatment ADI March 27, 2011

  15. Stage specific non-pharmacological interventions COGNITIVE RETRAINING PROGRAM 20 week program divided into 3 sections: Two groups of 8 patients (morning and afternoon) Relaxation and Tai Chi 4 weeks MEMO : memorization strategies 8 weeks Computer assisted stimulation 8 weeks LAB funded by the Foundation ADI March 27, 2011

  16. Stage specific non-pharmacological interventions STIMULATION COGNITIVE-Individual Stimulation of cognitive functions viz memory and concentration/attention Different soft ware used and different exercises (ex. visual memory, verbal memory, attention, language, calculation, …) according to the needs of the participants ADI March 27, 2011

  17. Stage specific non-pharmacological interventions RESULTS Experimental Group 17 MCI vs 9 control Groupe témoin 8 TCL et 8 contrôles, N=42 Pre et post test measures : 3 principal criteria related with episodic memory 1. Delayed Recall : name –face association (N+V) 2. Immediate Recall with delay of 12 words (M des lieux) 3. Delayed Recall with written material (PRST) Results: Significant improvement in the 3 measures for the expérimental group compared to the control group ADI March 27, 2011 Belleville,S., et al.Cognitive training for persons with mild cognitive impairment. Int Psychogeriatris 2008. 20(1): p 57-66

  18. Stage specific non-pharmacological interventions THERAPEUTIC DAY CENTRE

  19. Stage specific non-pharmacological interventions The Therapeutic Day Centre specializes for people suffering fromMild to Moderate Dementia (MMSE 12 to 26) Maximum per day 10 Most live in the community, either alone or with a family member. Some live in a private residence. Transportation is provided for patients living in the territory of the Institute (Verdun, LaSalle and Lachine areas) If outside these areas, the family has to provide transportation ADI March 27, 2011

  20. Stage specific non-pharmacological interventions EVALUATION 100 % of the patients are referred from the Memory Clinic with a complete evaluation OT evaluation completed if needed Groups are organized based on level of cognitive functioning and the language spoken. The patient is assigned to an appropriate group. Length of stay 3-6 months ADI March 27, 2011

  21. Stage specific non-pharmacological interventions INTERVENTIONS Therapeutic groups (reminiscence, relaxation) Cognitive Stimulation (group discussions) Individual cognitive stimulation with the computer (every Thursday and Friday) Animal Assisted Therapy Theme related activities for special occasions Nintendo Wii (bowling & Wii Fit) ADI March 27, 2011

  22. Stage specific non-pharmacological interventions Nintendo Wii GENERAL USE: Adaptation of the technical aids technique (remote) Adaptation of different needs of each group (ex. level of help offered rappel de la consigne, give step by step instructions, physical help) Presents an environnement stimulating and pleasant for physical exercises ADI March 27, 2011

  23. Stage specific non-pharmacological interventions SPECIFIC USE Wii Fit « Step » Aerobic Improvement of equilibrium dynamic, of coordination and laterality Help social abilities Help with concentration *Can be used according to the level of functioning of the client **Adequat space is important – space large enough to accomodate the group ADI March 27 2011

  24. Stage specific non-pharmacological interventions Wii BOWLING SPECIFIC USE OF REMOTE CONTROL Improvement of mobility and static equilibrium Improvement of social habits Improvement in concentration Easily adaptable for clients with more severe cognitives ADI March 27, 2011

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  26. Nintendo Wii (Bowling et « Step » en action)

  27. Therapeutic Garden SENSORY GARDEN (fines herbes, flowers, etc.) Appreciation of nature and outdoors Inviting space (members participated in the design of the therapeutic garden) Memories of their past ADI March 27 2011

  28. Stage specific non-pharmacological interventions The perceived success of the DAY CENTRE program lies in the collaborative partnership with the families, the small group setting to develop individualized intervention programs and close work with the Memory Clinic to review patient needs, identify gaps and area for enhancement The specialized team of Occupational Therapist, Recreational Therapist, and Rehab Assistant are developing innovative therapeutic programs which can be exported to the community Day Centres *The Therapeutic Day Centre has been transformed from a respite care model to an active therapeutic setting *

  29. Stage specific non-pharmacological interventions MOE LEVIN UNIT IS A MEDIUM TERM TREATMENT SETTING WITH 18 BEDS (moderate to severe cognitive loss with behavioural and psychiatric problems) Non-sectorized Treats people, aged 65 and over, (and people under 65 with a dementia profile). The average age : 73 years (range 50 to 93 years)

  30. Stage specific non-pharmacological interventions Agression Physical and verbal Agitation Wandering Resistance to personal care (e.g. hygiene) Refusal to take medications Disorganized for ADL Hallucinations, delusions, paranoid behaviour SYMPTOMS SUPERIMPOSED ON SEVERE COGNITIVE DEFICITS

  31. Stage specific non-pharmacological interventions Cohen-Mansfield Agitation Inventory Neuropsychiatric Inventory (NPI) 32 32

  32. Stage specific non-pharmacological interventions AT THE 18 BED UNIT FOCUSED PERSON-CENTERED CARE-GIVING The physical, psychological, social, spiritual needs are evaluated with the view of maintaining quality of life , preserving dignity and personhood SUPPORTIVE ENVIRONMENTS The environment is specially designed on environment- behavior principles to minimize the effect of loss of function PHARMACOLOGY The use of appropriate medication by specially trained psychiatrist to reduce psychiatric symptoms associated with dementia

  33. Stage specific non-pharmacological interventions IDENTIFICATION OF THE PATIENT: NOT BEING A FILE NUMBER Assessing the person as a whole: who was the person, who is the person and who will be the person Preserving personhood Assessing and meeting needs ADI March 27, 2011 PDPC, CML

  34. Stage specific non-pharmacological interventions INTERVENTION Snoezelen Therapy (a multisensory stimulation approach) Music Therapy decreases aggressive behaviors, relieves anxiety and agitation) Walking Program (to maintain mobility and balance) Animal Assisted Therapy (stroking animals has a soothing effect) Pastoral Services (maintains earlier life connections) Dietary Program Constant social interaction with the PABs ( provides stimulation at the emotional , and cognitive , and helps maintain social graces) Family support provided by psycho-education Team meeting with families where treatment options and long term plans are discussed, any questions which the family may have are answered Regular formal meetings either in person or on phone with family members Psychotherapeutic support if and when needed *FAMILY IS CONSIDERED AN INTEGRAL PARTNER IN THE TREATMENT OF THE PATIENT*

  35. SNOEZELEN ROOM

  36. Stage specific non-pharmacological interventions INTERVENTION SUPPORTIVE ENVIRONMENT The most important and effective intervention is to provide the best fit between the environment and the behavior, with the environment compensating for the sensory and functional losses of the person with dementia

  37. Stage specific non-pharmacological interventions E-B Principles –Walking Path Straight connection between common space Day light at the end of the corridor, helps in way finding Destination or event at the end of the corridor, no dead end Photographs with a theme as wall hangings for orientation Floor materials different for different areas of the building non-glare floor

  38. Stage specific non-pharmacological interventions • E-B Principles Environment as a Behavior Regulator • Each common space is clear in its meaning, dining area, living area, bedroom • There is no mistaking the identity

  39. Stage specific non-pharmacological interventions Camouflage alarm and exit door

  40. Stage specific non-pharmacological interventions E-B Principles Garden access and security - Garden adjacent - Lock on ramp entrance - Lock on gate - Garden can be surveyed - Planters, activity areas - Walking path (figure of 8)

  41. Stage specific non-pharmacological interventions

  42. Stage specific non-pharmacological interventions

  43. Stage specific non-pharmacological interventions

  44. TEACHING CLINICAL RESEARCH Graduate Undergraduate Pharmacological Non- Pharmacological Nursing Bapinenzemab Snoezelan Psychiatric Fellowship Patients of the PDPC Program (Centre Moe Levin) Social Work Y-Secretase inhibitor Cognitive Retraining Psychology Diploma in Psychiatry Nicotinic L7 agonist Medical Therapeutic Recreation Insulin Resistance As preclinical marker Meditation Visiting Fellows Therapeutic Relations Caregiver Workshops Internships Internant Externant Psycholinguistics MSc Psychiatry Students Community Partners Transfer of Knowledge IM Resident MUHC

  45. Stage specific non-pharmacological interventions 1 Teaching to families: 5 week training twice a year (English and French ) 2 Professionals: students of all disciplines, workshops for CHSLD staff (in person centered approach, specialized activities for people with dementia, for behavioral management issues) to CLSC professionals, video conferences, seminars, TV , radio, newspaper articles, conferences. 3 Community at large: Public lectures in Libraries, CHSLD, special interest groups

  46. Stage specific non-pharmacological interventions MODEL THAT HAS WORKED GEOGRAPHICALLY LOCATED IN ONE BUILDINGfacilitates communication of information between staff of the three arms ACCESSIBILITY OF DIFFERENT ARMS OF THE SERVICEaccording to the needs of the patients (continuum of care model) SPECIALLY ADAPTED ENVIRONMENT(Scottish National Guidelines 2006 Best Practices:  interventions delivered by clinicians with expertise in dementia and in dedicated settings, improves outcomes) HOMOGENOUS PATIENT POPULATION(experience based: patients discharged improved in their functionality and behaviors, regress in non-homogenous settings of the CHSLD) (Best Practices Scottish National Guidelines 2006)

  47. Stage specific non-pharmacological interventions PSYCHO-EDUCATION FOR FAMILIES (Recommendation 17: Best Practices in the Treatment of Alzheimer’s Disease in managed care. American Journal of Geriatric Pharmacotherapy, June 06) CAREGIVERS SHOULD RECEIVE COMPREHENSIVE TRAINING on interventions that are effective for people with dementia (Scottish Guidelines 2006) SMALL GROUPSwhich permits individualized attention (Day Centre) ACTIVITIES SUITED FOR THE LEVEL OF FUNCTIONING COGNITVIE STIMULATIONoffered to individuals with dementia (Best practices Scottish Guidelines 2006) STAFF WHO CAN PROVIDE EMPATHY, respect, compassion to both the patient and the family HOLISTIC APPROACHto patient care

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