The other day, I was part of a training group of nearly 15 occupational therapists (and one speech therapist) who are passionate about working with people with dementia.
We were being educated on an assessment tool that would help us evaluate specific cognitive functions and design appropriate treatment interventions for people with Alzheimer’s or other dementias. The tool is already being used worldwide with thousands of rehabilitation professionals.
This particular assessment targets folks with mild cognitive impairment and early stage dementia, and it has been proven to be a highly sensitive, reliable, and valid tool for evaluating the aspects of cognition that it claims to assess. We liked it very much.
But this test relies heavily on a verbal exchange between therapist and patient. So I asked about our folks with a bit more advanced dementia, the ones that are still in need of therapy services from time to time, but are unable to accurately answer a series of questions or consistently follow verbal commands.
So he offered another simple tool that targets lower level patients. It also requires a verbal exchange of information. I asked again about the verbal requirement, as many of our folks don’t have good language skills but can still benefit from therapeutic interventions.
The other therapists chimed in too, as they had been wondering the same thing.
The PhD developer of the tool laughed. He was surprised by our enthusiasm, that we wanted more information and a better tool for assessing middle to late stage Alzheimer’s patients. He said, “Most of the therapy groups I work with use this tool as a way to justify NOT working with a patient.”
First, a collective gasp. Then silence. Then outrage.
This belief is so old school- the mindset of therapists and other healthcare providers from a decade ago.
I thought we (the rehab community) were doing a better job in addressing the needs of the patient with dementia at all stages of the disease. I never thought that any of “us” would be excluding patients from therapy based on a verbal assessment that isn’t even appropriate for someone with more advanced dementia.
There are two issues we need to work on: assessment and intervention.
Evaluation tools should indicate whether treatment approaches should be rehabilitative or habilitative in nature. Can we actually improve cognitive function at a certain stage? Or do we need to compensate for it.
And for motor and ADL function: if we tap into non-traditional learning methods, using procedural/motor learning instead of declarative memory, can we still improve function? If we employ neuromuscular facilitation techniques and plain old strengthening and balance activities, can we improve motor skills?
Are successful outcomes dependent on executive reasoning and language skills? I think not.
Assessment tools and treatment interventions for Alzheimer’s disease should work around language deficits. Function and disease severity should not be measured in terms of language, and treatment interventions should not be dependent on language-based approaches.
And while we’re at it, we might as well define successful outcomes differently. Success can be so subjective, and can relate to a target that is not even the patient with the disease. Success can be how the patient navigates the environment or a particular task that becomes easier for the caregiver to manage. Success is hard to measure by traditional standards.
Until we’ve muscled the rest of the world over to this newer paradigm, please don’t ever let it be said that a person with a progressive, neurodegenerative disease could not benefit from therapy services.
In the words of one of my favorite patients, “That’s a load of codswallop!”
We’ve got a lot a long way to go.