By Robert Clark, PT, DPT, GCS, PSM, PSPO
Product Manager, Net Health
Dementia is an umbrella term used to describe the loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with a person’s activities of daily living (ADL).
And, it can worsen over time.
Alzheimer’s is the most common cause of dementia, accounting for 60% to 80% of cases. An estimated 6.5 million Americans age 65 and older (almost 11%) are living with Alzheimer’s in 2022, a number that is expected to nearly double by 2050 … unless a cure is found.
Today, however, Alzheimer’s has no known cure. As such, Alzheimer’s and other dementias will cost the nation about $321 billion this year, including $206 billion in Medicare and Medicaid payments combined.1
In this article, I will highlight the critical role rehab therapists play to treat and care for those with dementia, how dementia capable care (DCC) is emerging as an effective way to support patients and educate caregivers, and how rehab therapists can effectively document such treatments in a reimbursable way.
The Role of Rehab Therapy in Dementia Care
Increased help from family members, friends, and caregivers is often needed to help dementia patients carry out ADLs, such as dressing, bathing, grooming, swallowing, and to keep the individual safe from injury, especially falls.
Due to these ADLs impairments, referrals are made to physical and occupational therapists and speech-language pathologists are common.
Persons with dementia may be receiving short-term rehab after a fall or other medical condition, may be in long-term care in a skilled nursing facility, may be in a senior living community that has access to therapy services, or may be seen in an outpatient clinic.
Therapists in all of these practice settings are faced with creating plans of care and documenting in a way that not only addresses the patient’s functional deficits but also incorporates a strategy that supports the person’s cognitive ability.
This can best be done through a dementia capable care (DCC) approach.
What is Dementia Capable Care?
Dementia capable care involves gathering a person’s life history (interests, habits, preferences, routines, work history, family history, etc.) in order to approach a person in a way that gains trust. This has been described as “reaching the person behind the dementia” through creating a relationship with the person.2
In essence, DCC is about “finding a hook” for each person through the establishment of topics to discuss through meaningful events and memories that create confidence and a safe space during the treatment interaction.3
Once trust is gained, a therapist can then complete his or her assessment using both skilled observation and objective testing (i.e., ACLS) to determine a person’s cognitive function level.
Determining this level of function guides a therapist in his or her approach to make changes to the activity, care approach, and/or environment in order for the person with dementia to achieve his or her best ability to function (BATF).
Maintaining a best ability to function may slow the deterioration process. It may lessen unwanted behaviors through the understanding that many of these are a result of the therapist or healthcare provider not understanding the person’s wants, desires or needs.
And, it may help family members and friends regain a meaningful role in the life of their loved one.
From Treating the Patient to Teaching the Caregiver
Therapists are in a unique position to assist families and other caregivers manage behavioral symptoms. Understanding and properly responding to behavioral symptoms can help to maintain the patient’s physical, mental and medical health.
Therapists play a significant role in providing a DCC approach as behavioral symptoms may impact a patient’s mobility and safety, as well as the patient’s communication and performance of basic care tasks. Reducing behavioral symptoms may be the key to improvement in these areas.
Besides focusing on functional deficits and underlying impairments, the majority of treatment may be focused on caregiver training. And, the goals will often be met when the caregiver has demonstrated competence in the teaching techniques.
In doing so, treatment should shift from just teaching the patient to more of an emphasis on teaching the caregiver – from a pure impairment-based approach to a BATF approach, using “just-right” cognitive challenges.
What Are “Just-Right” Cognitive Challenges?
We as rehab therapists can help promote independence by teaching caregivers to properly cue the patient through “just right” challenges.
As therapists, we often focus on deficits and impairments. There needs to be a paradigm shift when treating persons with dementia. The focus needs to be less on what the patient can’t do and more on what he can do.
It’s not as complicated as it may seem. And, when possible, treatment should include family and caregiver training that includes task analysis and simplification.
For example, what if a person with dementia loves to cook and always cooked for the family? Due to cognitive deficits, not being able to plan the meal, shop and prepare the meal independently may cause stress, anxiety and unwanted behaviors.
Perhaps it has been determined that the person can follow one-step instructions. And, when all of the ingredients are made available, pre-measured, and the order of the recipe is verbally provided, he or she can create their favorite family meal and feel proud of their efforts.
Document this caregiver training, as well as the competency of the caregiver through return demonstration.
Plans of Care & Documentation for Dementia Patients
When creating a plan of care for a person with dementia, establish goals that meet the following criteria:
Goals should be functional. Strength goals should indicate the need for strengthening. For example, when the activity has been simplified through task analysis and simplification, the patient will have the strength (I.e., 4/5) to complete lower-body dressing.
Given the level of cognitive impairment, goals need to be realistic. Progress can be demonstrated by the patient requiring less cognitive assistance – from moderate to minimal cognitive assistance.
Goals need to be measurable. “The patient will complete sink side ADLs with minimal cognitive assistance,” not “The patient will reach maximum rehab potential.” Goals should also identify the caregiver and include all aspects of modifying the approach, the activity, and/or the environment for the patient to function at their highest level of function.
Treatment documentation should describe expected outcomes and include any suggested environmental adaptations to improve patient success in their “home” environment (i.e., SNF, senior living community, private home).
Include an assessment of progress in each note with an objective description of the patient’s status (i.e., the patient demonstrated an improved ability to ambulate 125’ with his walker with appropriate verbal cueing from his spouse.)
If progress slows, or there is a decline, document it and describe potential causes, such as pain, fatigue, stress, anxiety, depression, etc. These are known limiters of progress for those with dementia and can justify the duration of treatment.
When goals are met, document it contemporaneously, not at the end of the overall episode of care. If goals are no longer reasonable, modify them accordingly with a change in the approach, activity, or environment.
If the goal is no longer reasonable but partially met, document that and discharge it for a more reasonable goal.
Dementia Patients Have the Right to Reimbursable Care
Therapists sometimes believe that Medicare and other payors won’t reimburse treatment when a patient is diagnosed with dementia. It’s also sometimes misunderstood that a person with dementia can’t benefit from therapy as he or she can’t learn a new skill or participate.
Flipping the paradigm from a “can’t do” to a “can do” approach, using a person-centered care approach and gaining trust, using both skilled observation and cognitive functional testing to determine the patient’s BATF, and artfully documenting all the skills involved with doing this demonstrates the need for the skills of a therapist.
As a colleague of mine once taught me many years ago, Joe at the deli can make the best chicken salad sandwich as he’s been doing it for years, but he doesn’t have the skills, knowledge or ability to document a plan of care for a person with dementia.
Therein lies the difference in what a rehab therapist can do.
Our patients with dementia have the right to reimbursable care and, as therapists, we deliver those services and avoid denials through a skilled approach and documentation that support it.
How-To Guide for Part B in the ALF/Home
Advice for rehab consultants seeking to expand their service options.
1 Alzheimer’s Association, “What Is Dementia?” Oct. 2, 2022
2 3 National Library of Medicine, “Reach the Person Behind the Dementia – Physical Therapists’ Reflections and Strategies When Composing Physical Training,” Dec. 1, 2016