Verbal Overload

Allen Level 4 patients become anxious/angry when someone talks too much around them... gives them too many directions all at once... too much noise around them.... information is too complicated..... or when more than one person is trying to talk at the same time. Patients at this level become easily overwhelmed with auditory "clutter" and will refuse to participate... go back to his/her room... or lash out in anger.

Don't Let a Level 4 Fool You!!

I can't tell you how many therapists have told me that an Allen Level 4 patient was safe to go home by his/herself because the patient has answered every question correctly. As a therapist in a sub-acute rehab facility or as a caregiver/family member assisting someone with early dementia; it is vital that you understand the difference between cognition and executive functions. WATCH what the patient does; don't test by asking questions. They will pass the Mini-Mental and every other test you throw at them. Neurologists and physicians will say that these patients are fine because they test using questions. Watch for impulsiveness, hallucinations, excessive blaming, paranoia, unusual anxiety, persistent loss of items, getting lost when driving in familiar areas, asking "What do I do now?" after every step of a task, visual changes coupled with body awareness decrease which results in him/her bumping into doorways/edges of furniture/people frequently, personality changes, unusual actions to fix problems (not something they would normally do to correct a problem - very unusual fixes that don't make sense), have difficulty talking and working on a task at the same time, dangerous reaching and bending without regard for safety, look at family members to answer questions requiring complex memory, and unable to solve complex problems. Although this level of mental ability appears normal when answering your test questions; this is the same person that will go home and burn to death in his/her kitchen because they can't react fast enough to an emergency situation.... this is the same person who will bleed to death in their home because they don't recognize an emergency.... and the same person that although he/she will tell you how they should take their medicine - frequently this level takes their medications wrong even when they are set up for them in advance... it is this level more than any other that falls due to poor safety judgements/impulsive movements.

Allen Level 4

I have therapists ask me all the time why so many of their SNF patients have dementia. That's easy. Dementia is the number one reason people are admitted to sub-acute rehab units so it stands to reason that a majority of people will have some form of dementia. The Allen Cognitive Levels go from 1 (end stage before death) to 6 (Normal). Levels 5 and 6 are fairly normal and can live alone without difficulty. But when the cognitive ability dips down to a Level 4, then major problems begin to interfere with a person's ability to be safe without help. You'll recognize someone in this early stage of dementia because they begin to talk A LOT. In fact, it's difficult to get a word in edgewise. Patients at this level blame everyone else for their difficulties or failures. Often he/she have personality changes and have a very difficult time understanding reason/ logic especially when it applies to his/her health/safety. This level often will answer all questions correctly, yet they do things impulsively/unsafely. This is the type of patient that will tell you he/she has to use their walker or they will fall down and break their hip...... yet when you leave the room he/she gets up and goes to the bathroom without the walker. It's because their cognition is fine (WHAT they know), but his/her executive functions (WHAT THEY DO with what they know) is impaired. Often these patients carry their walker down the hall and lift it up and over obstacles instead of navigating safely around them. To keep walkers on the floor put weights on the walker and then gradually take the heavy weight away until the patient is using the walker appropriately without the help of weights. These patients require 4x as much color contrast as the normal person and they use what they see. Often the front of his/her hair will be fixed nicely, but the back will be unkept/stick up. So since this patient uses what they see... to get a patient like this to use his/her walker... color it up!! Tape it up with colorful tape...spray paint it a fluorescent color etc. Want this patient to use the brakes on the wheelchair? Color them up. Always look at things from the patient's perspective.... color helps him/her pay attention to the borders of furniture like sofas or chairs or beds. I recommend to families to throw a colorful bedspread on the bed... a colorful throw on the sofa or chair so the patient doesn't miss the furniture when they try to sit down and fall. Color can be used all over their house to help this patient be more independent and keep him/her off the floor.

Allen Cognitive Levels

Why do I like to use Allen Cognitive Levels (ACL) to track the abilities of dementia patients? Because other scales such as the Global Deterioration Scale only list skills that the patient has already lost. As a therapist, I can't do anything about the abilities that have been lost. I want to know what abilities are left and which skills are most at risk of being lost in the near future. My role as a therapist is identifying these "at risk" abilities and designing a program that will reinforce these skills to delay the progression of the disease. In later posts we will be exploring in detail this process.

Dementia vs Depression

These two diagnoses can occur together. They can also be misdiagnosed for each other. Depression presents as low energy, poor appetite, generalized pain, may have accompanying anxiety, and are aware of memory difficulties. Dementia patients have a lot of energy, but they say one thing and do another. They may describe to you what they are supp0sed to do regarding safety, but then do the complete opposite. There's a huge difference between their cognition (WHAT they know) and executive functions (What they do with what they know). I'll be describing executive functions in future blog posts.

Dementia vs Normal Aging

Ever been asked what the difference is between normal aging and dementia? Mental changes that occur with normal aging involve the forgetting of details. One might forget someone's name or something that was served at a birthday party etc. Mental changes that occur with dementia involve forgetting entire events. One might forget that he/she went to the birthday party completely. Personality changes occur with early dementia and navigational skills become impaired (finding his/her way to and from the store etc).

Understanding Levels of Dementia

The progression of dementia can be explained when visualized like a flight of steps leading to the basement. Our duty as dementia rehab specialists or even more importantly a close family member is to keep the patient on their current step as long as possible by stimulating abilities he/ she still uses. Is this possible? Yes it is. It is not possible to cure the disease, but it is possible to dramatically slow it down. Step #6: Normal Abilities (you or I on a good day :) Step #5: Mild Impairments - can be due to illness/normal aging. This level forgets details; forgets where they parked their car frequently; forgets names of acquaintances; house isn't as neat as it used to be; forget ingredients in familiar recipes. Step #4: The Talkers - The longer a person is on this step... the more they talk! Talk and talk and talk and talk - you can barely get a word in the conversation. When he/she is on this step for awhile, they start using primarily those things that catch his/her attention (bright colors or things they see in a mirror). Often fix the front of his/her hair, but not the back...often will tell you they must use their walker, but then they don't. A big difference between what he/she tells you they need to do and what they actually do. Step #3: The Walkers - Although he/she begins talking significantly less, unfortunately all kinds of behaviors begin. Things like yelling, pinching, spitting, hitting, aimless walking, and the worst behavior of all (at least the most dangerous for the patient) is withdrawal (often he/she sit with his/her eyes closed, but he/she isn't sleeping). Eating often declines in this stage. Step #2: The Feelers - He/she speaks in 1-2 word phrases and usually only when spoken to first. In this stage the patient does whatever "feels good"...they seek circumstances that make them feel comfy. Step #1: The Sleeper - He/she interacts very little with their environment. He/she gives eye contact when spoken to and may reach for shiny/bright objects.

The important thing to remember with all of these steps is the behaviors, appetite decline, etc are treatable. I can help you figure out things to do with him/her to help them feel safe, be healthy, and most importantly delay the progression of the disease. Ask me questions on this blog and let's share our stories.

Introduction

I am a Speech-Language Pathologist with 20 years of experience and currently work for an amazing company: Transitions Rehab out of Tampa, FL. I’ve been a National Director (Garden Terrace Centers of Excellence for Dementia Research/Rehab), Regional Director, Facility Rehab Director, Program Development Consultant and Continuing Education Provider. I’ve written numerous continuing education courses for all disciplines in sub-acute rehab. Have specialized in Sensory Disorders/Fall Prevention (adults), Dementia Rehab, Behavioral Modification, Montessori Techniques (adults), Oral Motor Therapy, and Soft Tissue Mobilization. I’m certified in Vital Stim Dysphagia Treatment and the Allen Cognitive Levels. Not only do I have experience rendering and teaching therapy techniques for Patients suffering with Dementia, but also took care of my Mother (suffering with Binswanger's Dementia) for many years in our home so I understand the challenges of caring for a loved one with Dementia.