Dementia

Management
EVALUATION AND STAGING
TONYA DEDERA

Objectives
Colleagues will be able to:

Locate Resources from Dementia Resource guide

Describe standardized assessments used to accurately

stage clients with dementia (how to calculate score)

Identify relationship of Global Deterioration Scale (GDS)

score to Allen Cognitive Levels (ACL) Table

Define ACL table, general grid, and specific level

Present 1 ACL example, example of intervention for

Feeding, walking, or dressing

Demonstrate how to document intervention to reflect GDS

score and ACL

What is Dementia?

Is not a disease, rather describes a group of

symptoms that are caused by various diseases or
conditions that leads to decline in daily functioning
(Mayo Clinic, 2015)

Progressive loss of cognitive, psychosocial and

physical skills and ability to adapt to everyday life.

General loss of cognitive abilities including

impairment in memory, and may include: aphasia,
apraxia, agnosia, disturbed planning, organizing
and abstract thinking abilities (Weissberg, 2013).

Irreversible causes include: Alzheimers disease,

Lewy Body, Multi-infarct or vascular dementia,
Huntingtons disease, Parkinsons disease, and
Creutzfeldt-Jakob disease
(Alzheimers Association, 2015)

Resource for Dementia

https://accessgenesishoc.com/site/rehabcentral/Cli
nical/ResourceGuides/Pages/.DanaInfo=central.ge
nesishoc.com+Dementia.aspx

Steps to retrieve the Dementia Resource Guide:

Rehab Central on Genesis website

Click on Clinical on selection bar

Clinical resource guide

Dementia Resource Guide

Evaluation: Brief Cognitive Rating

Scale (BCRS)

Developed by Dr. Barry Reisberg

Assesses magnitude of cognitive impairment on 5 areas

4 cognitive and 1 functional

Each area scored 1-7, where 7 is the worst

Total score divided by 5 producing a number

corresponding to a stage with the GDS

Accompanies the GDS and the Functional Assessment

Staging Test (FAST)

Utilization: Once at pretreatment, at least one posttreatment rating, and additional ratings at the discretion of
the investigator

(Graff et al., 2006)

Evaluation-Global Deterioration
Scale (GDS)

Developed by Dr. Reisberg

Overview of stages of cognitive function

7 stages

Stages 1-3= pre-dementia stages

Stages 4-7= dementia stages

Starting at stage 5, client can no longer survive without

assistance

(Einterz, Gilliam, Chang Lin, McBride, & Hanson, 2014)

GDS Score Correlation to ACLs

Higher the GDS number the more severe cognitive

decline

The ACLs evaluate global cognitive abilities and

functional cognition based on six hierarchical cognitive
levels

Higher the ACL number no signs of global cognitive

impairments (opposite to GDS)

Example: GDS 1=normal; ACL 6= No global cognitive

impairment
(Gitlin et al., 2009)

Defining ACL Table

Stage

Global
Deterioration
Scale

Allen Level

1-Normal
(No Cog. Deficits)

6-Planned Activities

30

2-Very Mild Cog.

Decline
(Forgetfulness)

5-Exploratory Actions

20

3-Mild Cog. Decline

Mini Mental

Developmental
Age
18 - 21
yrs.
(Allen
Level)
5.4-5.6

14 -17
yrs.

5-Exploratory Actions

(Allen
Level)
5.0-5.2

7-13
yrs.

4-Moderate Cog.
Decline
(Late Confusional)

4-Goal Directed
Activity

11-17

(Allen
Level)
4.0-4.4

4-6
yrs.

5- Moderately Severe
Cog. Decline

3-Manual Actions

(Allen
Level)
3.0-3.6

18 mos.3 years

MIDDLE STAGE
DEMENTIA

6-Severe Cog. Decline

2-Postural Actions

(Allen
Level)
2.0-2.6

9 23
mos.

LATE/END STAGE
DEMENTIA

7-Very Severe Cog.

Decline

(Allen
Level)
1.0-1.8

0 12
mos.

EARLY STAGE
DEMENTIA

1-Automatic Actions

(Dementia Resource Guide, 2004)

GDS Summary Grid

Stage 5 Moderately Severe Cognitive Decline

Memory
Unable to
recall major
relevant
aspects of
their lives
Frequent
disorientation
to time (date,
day of week,
season) or to
place

Behavior
Impatient
Paranoid
Unaware of
safety
hazards

ADL
Assistance
with higherlevel ADLs
Requires
moderate
cueing
Capable of
routine task
Unable to
problem
solve

Communicati
on

Motor/Mobilit
y

Repetitive
speech
Difficulty with
higher-level
executive
functioning

Fine-motor
and grossmotor intact
Control of
voluntary
movement

(Dementia Resource Guide, 2004)

Environmental Considerations

Setting up the environment for the evaluation and

intervention to help promote success and
participation for yourself and the patient.

Sample Intervention

Greet patient: Hello Mr./Mrs. _______

Next state to patient: I would like to ask you some

questions on concentration and memory would that be
okay?

Start with Axis I: Concentration and attentiveness

Start with serial subtraction (based on patients level of

education and how good they are at subtraction)

Subtract serial 7s from 100

Counting backwards from 40 by 4s

Stating 12 months of the year backwards or serial

subtracting 2s from 20

Count backwards from 10 by 1s

Difficulty counting forward to 10 by 1s

(Graff et al., 2006)

Occupational Therapy:
Routine Task Inventory

Task Analysis: Grooming

Cognitive Level

Observable
Behaviors

3.2

Spontaneously
initiates brushing
and combing
when objects
are in close
proximity
May attempt to
squeeze
toothpaste, turn
on water, pick
up bottles

Assistance
Needed
Caregiver places
objects in visible
close proximity
Cues patient to
start and stop
actions with verbal
commands
Does task requiring
sequencing of
actions for precise
results

Care Plan Goals

Patient will initiates
familiar actions of
brushing and
combing hair
Caregiver will
supervise and
provide assistance
to avoid harmful
effects and ensure
effective results

Special
Considerations
Restrict access to
harmful objects

(Dementia Resource Guide, 2004)

Occupational Therapy: considerations and

implications

Focus of
Performanc
e Skills

Priority
Assessment
Areas

Activities of Determine
Daily Living task abilities
for self care
and leisure
tasks and
how to
segment
tasks for
success

Treatment
Interventions
Adapt
activities for
poor
attention
span
Provide
cues to
initiate,
sustain, and
discontinue
task
Sit patient at
table with
stage 5 or 6

Sample
Documentation
/
Outcomes
Patient will
name comb
when
presented to
him and use
appropriately
100 % of the
time
Patient will
initiate use of
toothbrush
once placed in
hand and
complete task
with Min A and
50 % verbal
cues

Universal
Approaches
Limit
choices to 2
items
Allow
additional
time to
perform task
(2-3 times
longer)

(Dementia Resource Guide, 2004)

References

Alzheimers Association. (2015). What is dementia. Retrieved from http://www.alz.org/whatis-dementia.asp

Dementia Resource Guide. (2004). Retrieved from

https://accessgenesishoc.com/site/rehabcentral/Clinical/ResourceGuides/Pages/.DanaInfo=cent
ral.genesishoc.com+Dementia.aspx

Einterz, S. F., Gilliam, R., Chang Lin, F., McBride, J. M., & Hanson, L. C. (2014).
Development and Testing of a Decision Aid on Goals of Care for Advanced Dementia. Journal
of the American Medical Directors Association, 15 (4), 251-255. doi:
10.1016/j.jamda.2013.11.020

Gitlin, L. N., Winter, L., Vause Earland, T., Adel Herge, E., Chernett, N. L., Piersol, C. V., &
Burke, J. P. (2009). The tailored activity program to reduce behavioral symptoms in
individuals with dementia: Feasibility, acceptability, and replication potential. The
Gerontologist, 28 (3-4), 55-60. doi: 10.1093/geront/gnp087

Graff, M. J. L., Vernooij-Dassen, M. J. M., Zajec, J., Olde-Rikkert, M. G. M., Hoefnagels, W.

H. L., & Dekker, J. (2006). How can occupational therapy improve the daily performance and
communication of an older patient with dementia and his primary caregiver: A case study.
Dementia, 5 (4), 503-532. doi: 10.1177/1471301206069918..