1 DOLLY DASTOOR Ph.D Program in Dementia with Psychiatric Co-morbidity Douglas Mental Health University Institute, Douglas Mental Health University Institute,

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DOLLY DASTOOR Ph.D DOLLY DASTOOR Ph.D

Program in Dementia with Psychiatric Co-Program in Dementia with Psychiatric Co-morbidity morbidity

Douglas Mental Health University Institute, Douglas Mental Health University Institute,

Alzheimer Disease International, Alzheimer Disease International,

Toronto , March 27, 2011Toronto , March 27, 2011

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

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Stage specific non-pharmacological Stage specific non-pharmacological interventionsinterventions

In collaboration with In collaboration with Hildegard Brack, PH.D PsychologistHildegard Brack, PH.D PsychologistCeline Brunelle, B.Sc Nurse ClinicianCeline Brunelle, B.Sc Nurse ClinicianDavid Fontaine, PH.D Psychologist David Fontaine, PH.D Psychologist Nancy Grenier, B.Sc Occupational Nancy Grenier, B.Sc Occupational

TherapistTherapistLisa O’Reilly, B.A Recreational Therapist Lisa O’Reilly, B.A Recreational Therapist Katherine Thibodeau MSW. Social WorkerKatherine Thibodeau MSW. Social Worker ADI March 27, 2011ADI March 27, 2011

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Conflict of Interest Disclosure

Dolly Dastoor Ph.D

Has no real or apparent Conflicts of interest to report

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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.

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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

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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

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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

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Program in Dementia with Psychiatric Co-morbidity

Moe Levin Centre

Memory ClinicMild To Moderate Cognitive Loss

Day CentreMild to Moderate Cognitive Loss

Inpatient UnitSevere Cognitive Loss

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ResearchResearch

Families

Management of behavioral problems

TreatmentTreatment

TrainingTraining

PatientPatient

CLSC

Home care

Community HospitalsCHSLD

Other Organizations

McGill Centre McGill Centre for Agingfor Aging

Douglas Institute Research Centre

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Stage specific non-pharmacological interventionsStage 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)

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Stage specific non-pharmacological Stage specific non-pharmacological interventions- MEMORY CLINIC 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

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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

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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

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COGNITIVE COGNITIVE RETRAINING RETRAINING

Intervention Technic for early stage Intervention Technic for early stage cognitive losscognitive loss

Alternative treatment Alternative treatment

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Stage specific non-pharmacological Stage specific non-pharmacological interventionsinterventionsCOGNITIVE RETRAINING PROGRAM

20 week program divided into 3 sections: Two groups of 8 patients (morning and afternoon)

1. Relaxation and Tai Chi 4 weeks2. MEMO : memorization strategies 8 weeks3. Computer assisted stimulation 8 weeks

LAB funded by the Foundation

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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

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RESULTSExperimental Group 17 MCI vs 9 control Groupe témoin 8 TCL et 8 contrôles,N=42Pre 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

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Belleville,S., et al.Cognitive training for persons with mild cognitive impairment. Int Psychogeriatris 2008. 20(1): p 57-66

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Stage specific non-pharmacological Stage specific non-pharmacological interventionsinterventionsTHERAPEUTIC DAY CENTRE

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Stage specific non-pharmacological Stage specific non-pharmacological interventionsinterventionsThe Therapeutic Day Centre specializes for people suffering from Mild 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

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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

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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)

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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

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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

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Stage specific non-pharmacological Stage specific non-pharmacological interventionsinterventionsWii 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

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Nintendo Wii (Bowling et « Step » en action)

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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

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Stage specific non-pharmacological Stage specific non-pharmacological interventionsinterventionsThe 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 *

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MOE LEVIN UNIT IS A MEDIUM TERM TREATMENT SETTING

WITH 18 BEDS

(moderate to severe cognitive loss with behavioural and psychiatric problems)

Non-sectorizedTreats people, aged 65 and over, (and people under 65 with a dementia profile).The average age : 73 years (range 50 to 93 years)

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Stage specific non-pharmacological Stage specific non-pharmacological interventionsinterventions Agression Physical and verbal

AgitationWandering Resistance to personal care (e.g. hygiene)Refusal to take medications Disorganized for ADL Hallucinations, delusions, paranoid

behaviour

SYMPTOMS SUPERIMPOSED ON SEVERE COGNITIVE DEFICITS

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Cohen-Mansfield Agitation Inventory Cohen-Mansfield Agitation Inventory Neuropsychiatric Inventory (NPI) Neuropsychiatric Inventory (NPI)

NPI

Cohen-Mansfield Agitation InventoryNON-AGGRESSIVE AGGRESSIVE TOTAL

PHYSICAL VERBAL PHYSICAL VERBAL

2008-09 32.48 22 6.95 22.7 7.17 45.00

2009-10 40.75 28.61 9.79 30.41 8.24 62.63

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Stage specific non-pharmacological Stage specific non-pharmacological interventions 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

PHARMACOLOGYThe use of appropriate medication by specially trained psychiatrist to reduce psychiatric symptoms associated with dementia

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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 personhoodAssessing and meeting needs

ADI March 27, 2011 PDPC, CML

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Stage specific non-pharmacological Stage specific non-pharmacological interventionsinterventionsINTERVENTION 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*

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SNOEZELEN ROOMSNOEZELEN ROOM

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Stage specific non-pharmacological Stage specific non-pharmacological interventionsinterventionsINTERVENTION 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

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Stage specific non-pharmacological Stage specific non-pharmacological interventionsinterventionsE-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

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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

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Camouflage alarm and exit door


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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)

Stage specific non-pharmacological Stage specific non-pharmacological interventions interventions

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Stage specific Stage specific non-non-

pharmacologicapharmacological interventionsl interventions

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pharmacological pharmacological interventionsinterventions

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pharmacological pharmacological interventionsinterventions

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TEACHING CLINICAL RESEARCH

Graduate Undergraduate PharmacologicalNon-Pharmacological

PsychiatricFellowship

Diploma inPsychiatry

Nursing

Social Work

Psychology

Medical

TherapeuticRecreation

Therapeutic Relations

InternshipsInternantExternant

Bapinenzemab

Y-Secretase inhibitor

Nicotinic L7agonist

Insulin Resistance

As preclinical marker

Snoezelan

CognitiveRetraining

Meditation

Caregiver Workshops

Patients of the PDPC Program(Centre Moe Levin)

Community PartnersTransfer of Knowledge

Visiting Fellows

MScPsychiatryStudents

Psycholinguistics

IM ResidentMUHC

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Stage specific non-pharmacological Stage specific non-pharmacological interventionsinterventions1 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

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Stage specific non-Stage specific non-pharmacological interventionspharmacological interventions

MODEL THAT HAS WORKED GEOGRAPHICALLY LOCATED IN ONE BUILDING facilitates

communication of information between staff of the three arms ACCESSIBILITY OF DIFFERENT ARMS OF THE SERVICE according

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)

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Stage specific non-Stage specific non-pharmacological interventionspharmacological 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 GROUPS which permits individualized attention (Day

Centre)ACTIVITIES SUITED FOR THE LEVEL OF FUNCTIONINGCOGNITVIE STIMULATION offered to individuals with dementia (Best practices Scottish Guidelines 2006)STAFF WHO CAN PROVIDE EMPATHY, respect, compassion to both the

patient and the familyHOLISTIC APPROACH to patient care

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Documents

1 DOLLY DASTOOR Ph.D Program in Dementia with Psychiatric Co-morbidity Douglas Mental Health University Institute, Douglas Mental Health University Institute,