Dementia FAQs

Frequently Asked Questions

10 Signs of Alzheimers Disease +


Memory loss that disrupts daily life is not a typical part of aging. It may be a symptom of Alzheimer's, a fatal brain disease that causes a slow decline in memory, thinking and reasoning skills. Every individual may experience one or more of these signs in different degrees. If you notice any of them, please see a doctor.

 1. Memory loss that disrupts daily life

 2. Challenges in planning or solving problems

 3. Difficulty completing familiar tasks at home, at work or at leisure

 4. Confusion with time or place

 5. Trouble understanding visual images and spatial relationships

 6. New problems with words in speaking or writing

 7. Misplacing things and losing the ability to retrace steps

 8. Decreased or poor judgment

 9. Withdrawal from work or social activities

10. Changes in mood and personality

Source:  Alzheimers Association (

Alzheimer's To Cost $20 Trillion Over Next 40 Years +

The Alzheimer's Association ( has projected in it's 2010 Report that from 2010 to 2050, the costs will rise from $172 billion to $1.08 trillion!  These amounts represent direct costs of care including Medicare, Medicaid, insurance, and out-of-pocket costs of families.

The Alzheimer's Association reports that the chance of getting this disease for those over 65 is 1 in 8.

The chance of getting this disease if you are over 80 is 1 in 2.

Also noted in the report is the research showing African Americans and Hispanics are at high risk for developing Alzheimer's, about 1.5 times more likely than whites.

There are 11 million who take care of their family member with Alzheimer's at home.  Caregivers should watch their own health by looking for signs of 'Caregiver Burnout' such as depression, anger - especially inappropriate anger, sleeplessness, difficulty with concentration, and an increase in physical ailments

Alzheimers Facts +

                                         ALZHEIMERS FACTS

• As many as 5.3 million people in the United States are living with Alzheimer’s.

• Alzheimer's and dementia triple healthcare costs for Americans age 65 and older.

• Every 70 seconds, someone develops Alzheimer’s.

• Alzheimer's is the seventh-leading cause of death.

• The direct and indirect costs of Alzheimer's and other dementias to Medicare, Medicaid and businesses amount

   to more than $148 billion each year.

Source:  Alzheimers Association (

Avoiding Denials Due To Poor Documentation +


Skilled vs. unskilled intervention

-Clarify need for the expertise of a skilled therapist to treat the patient, vs. unskilled staff. Your evaluation and subsequent daily/weekly notes will determine whether you have been precise enough in your documentation for reimbursement.

Unreasonable amount of time for setting up the Functional Maintenance Plan

-It should not take more than 2 - 3 sessions to complete caregiver training of compensatory strategies, whether these are for mobility, communication, socialization, behavior or dysphagia (swallowing).          

Missing documentation

-Example: Therapist states on evaluation that the patient's gait has become unsteady, however, the nursing notes do not mention this.  Perhaps nursing meant to document, but forgot. It is the therapists duty to check and be sure nursing has documented on the patient's chart before proceeding.

Insufficient documentation

-'Patient receiving physical therapy 5 x's week, tolerating well'.  This is not enough anymore.  Medicare reviewers are wanting specifics relating to functional status.  Provide more information in your note.  Tolerating well relating to what functional improvement?  Provide details regarding standing balance, transfers, gait, or whatever your goals state that you are working on.

Conflicting documentation

-Nurses note: 'patient able to walk to bathroom unassisted daily'.

-Therapist's note: 'patient requires mod assist of 1 for toileting ADL's.

This is a problem for the Medicare surveyor and raises a red flag.  Do your best to make sure nurses notes are documented on the patient's chart that coincide with yours before proceeding with your evaluation and treatment.  If you check this before your evaluation, you can use the nurses documentation on your evaluation for prior level of function and reason for referral.

*Documentation is the key to opening up reimursement for our deserving patients with dementia. Medicare reviewers will deny reimbursement if your documentation is not properly written. Our book reviews appropriate documentation and, if you are unsure about this, may be useful by providing the protocols for placing a patient on therapy.

Patient is inappropriate for skilled intervention

-This happens when  documentation does not support expectation that the patient will achieve stated goals.  It is incumbent on the therapist to make sure the patient is a good candidate for therapy before ever starting therapy.  Understand the protocols for placing a dementia patient on your caseload. 

Our book covers this and may be a good resource for you if you are unsure about whether a patient is a good candidate for therapy.

Goals are not functional

-Goals should be functional for the patient as it relates to their staging, spared capabilities and expectations related to their living environment. 

-Goals should be skilled, measurable, attainable, reasonable and necessary.

This is a huge area.  Medicare reviewers are looking for reasons to deny reimbursement.  Make sure your goals meet the above criteria and do not fall short.  After writing your goals, ask yourself , 'If I were a reviewer, would I deny or reimburse based on what I wrote?'.             

Our book spends a lot of time on appropriate goal writing and provides several pages of suggested goals relating to mobility, communication, socialization, behavior and dysphagia.  If you are needing information on goals, interventions, activities and strategies that are relevent to therapeutic intervention for patients with dementia, you might  find our book useful.  A broader description of topics covered within our book Dementia Therapy and Program Development, can be found in the 'Our Services' link.



Chronic Stress and Alzheimer's +

Monday, March 26, 2012

Chronic Stress, Phosphorylated Tau, Alzheimer's Disease

"Age is the primary, known risk factor for Alzheimer's disease. It may be that as we age, our neurons just aren't as plastic as they once were and some succumb."

Alzheimer's Reading Room

Does stress play a role in Alzheimer's disease?

Repeated stress triggers the production and accumulation of insoluble tau protein aggregates inside the brain cells of mice, say researchers at the University of California, San Diego School of Medicine in a new study published in the March 26 Online Early Edition of the Proceedings of the National Academy of Sciences.

Subscribe to the Alzheimer's Reading Room


Check out Scicurious's article in Scientific American for some additional "skinny" on this research.

Chronic stress spawns protein aggregates linked to Alzheimer's

The aggregates are similar to neurofibrillary tangles or NFTs, modified protein structures that are one of the physiological hallmarks of Alzheimer's disease. Lead author Robert A. Rissman, PhD, assistant professor of neurosciences, said the findings may at least partly explain why clinical studies have found a strong link between people prone to stress and development of sporadic Alzheimer's disease (AD), which accounts for up to 95 percent of all AD cases in humans.

"In the mouse models, we found that repeated episodes of emotional stress, which has been demonstrated to be comparable to what humans might experience in ordinary life, resulted in the phosphorylation and altered solubility of tau proteins in neurons," Rissman said. "These events are critical in the development of NFT pathology in Alzheimer's disease."

The effect was most notable in the hippocampus, said Rissman, a region of the brain linked to the formation, organization and storage of memories. In AD patients, the hippocampus is typically the first region of the brain affected by tau pathology and the hardest-hit, with substantial cell death and shrinkage.

Not all forms of stress are equally threatening. In earlier research, Rissman and colleagues reported that acute stress – a single, passing episode – does not result in lasting, debilitating long lasting changes in accumulation of phosphorylated tau. Acute stress-induced modifications in the cell are transient, he said, and on the whole, probably beneficial.

"Acute stress may be useful for brain plasticity and helping to facilitate learning. Chronic stress and continuous activation of stress pathways may lead to pathological changes in stress circuitry. It may be too much of a good thing." As people age, perhaps their neuronal circuits do too, he said, becoming less robust and perhaps less capable of completely rebounding from the effects of stress.

"Age is the primary, known risk factor for Alzheimer's disease. It may be that as we age, our neurons just aren't as plastic as they once were and some succumb."

The researchers observed that stress cues impacted two key corticotropin-releasing factor receptors, suggesting a target for potential therapies. Rissman noted drugs already exist and are in human trials (for other conditions) that modulate the activity of these receptors.

"You can't eliminate stress. We all need to be able to respond at some level to stressful stimuli. The idea is to use an antagonist molecule to reduce the effects of stress upon neurons. The stress system can still respond, but the response in the brain and hippocampus would be toned down so that it doesn't result in harmful, permanent damage."

Co-authors of the paper are Michael A. Staup and Allyson Roe Lee, UCSD Department of Neurosciences; Nicholas J. Justice, Baylor College of Medicine; and Kenner C. Rice NIDA/NIH, Wylie Vale and Paul E. Sawchenko, The Salk Institute for Biological Studies.

Falls May Indicate Earliest Stages of Alzheimer's & Need for Further Evaluation +

Falls May Indicate Earliest Stages of Alzheimer's and Need for Further Evaluation

Falls are more common among individuals with the earliest signs of Alzheimer's, according to a study presented at the Alzheimer's Association® International Conference 2011 (AAIC 2011).

The study measured the rate of falls among cognitively healthy older adults with and without preclinical Alzheimer's – as measured by amyloid imaging using positron emission tomography (PET) with Pittsburgh compound B (PiB) – and found twice the risk of falls for people with higher levels of PiB on their scan.

In older adults, falls contribute to increased disability, premature nursing home placement and injury-related mortality. There are also higher health care costs associated with falls – more than $19 billion could be attributed to the direct medical costs of falls in 2000.

Older adults with Alzheimer's may be at higher risk for falls because of balance and gait disorders and problems with visual and spatial perception that are caused by the disease.

"Understanding the traditional hallmarks of Alzheimer's, including cognitive impairment and memory loss, are important; however, these study results also illustrate the significance of understanding that, in some people, changes in gait and balance may appear before cognitive impairment," said Maria Carrillo, PhD, Alzheimer's Association Senior Director of Medical and Scientific Relations.

"Growing scientific evidence suggests that 'silent' biological changes may be occurring in the brain a decade or more before we can see the outward symptoms of Alzheimer's. According to this study, a fall by an older adult who otherwise has a low risk of falling may signal a need for diagnostic evaluation for Alzheimer's," continued Carrillo.

Led by Susan Stark, PhD, Assistant Professor of Occupational Therapy and Neurology at Washington University in St. Louis, the 8-month study followed 125 older adults currently enrolled in longitudinal studies of memory and aging at Washington University's federally funded Knight Alzheimer's Disease Research Center (ADRC). All participants had PiB PET imaging and contributed samples of cerebrospinal fluid (CSF). Each participant was asked to record in a journal how many times they experienced a fall, which was defined as unintentional movement to the floor, ground or an object below knee level. Some of participants had preclinical Alzheimer's and some did not. With an average of 191 days of data collected for participants, the study found that 48 people experienced at least one fall. A positive PiB PET image resulted in a 2.7 times greater risk of a fall for each unit of increase on their PiB PET scan.

"To our knowledge, this is the first study to identify a risk of increased falls related to a diagnosis of preclinical Alzheimer's disease," said Stark. "This finding is consistent with previous studies of mobility problems among persons with very early symptomatic Alzheimer's or mild cognitive impairment. It suggests that higher rates of falls can occur very early in the disease process."

"In the near future, with continued research, we will improve our ability to detect and intervene early in Alzheimer's disease. With earlier detection, perhaps we can also lower the risk of falls, which can be disabling, expensive and even deadly in older adults," said Carrillo. "Additional research is urgently needed, for example to further explore the connection between motor deficits and falls as possible early signals of Alzheimer's.

Susan Stark, PhD, et al. Risk of falls among older adults with Preclinical Alzheimer's Disease. (Funders: U.S. National Institute on Aging, the Knight Alzheimer's Disease Research Center at Washington University).

Grace Kearney Writes an Award Winning Essay About Alzheimer's +

Grace Kearney Writes an Award Winning Essay About Alzheimer's

Through the Looking Glass: Understanding the World of the Alzheimer’s Patient

Each year the Alzheimer’s Foundation of America offers several scholarships for graduating high school seniors. Scholarships are offered for both essay and video entries.

This year's winning entry was written by Grace Kearney from Baltimore, Maryland.

Please take the time to read this remarkable essay.

Congratulations Grace!

Through the Looking Glass: Understanding the World of the Alzheimer’s Patient

By Grace Kearney

The waiting room could belong to a dentist’s office. There are bright lights and comfortable chairs and plenty of People magazines. But the vacant expressions of those waiting makes it clear that they are not about to have their teeth checked. Standing inside the geriatric psychiatry clinic, I feel as if I have already entered something more personal than an internship. Before I can fully absorb the scene, a nurse calls me into her office. She is administering a diagnostic test to a new patient.

“Where are we today, Mr. Perkins?*”

“Appling, Georgia. I wouldn’t dream of leaving.”

“What day of the week is it?”


“What day of the week was it yesterday?”


The Red Queen’s words spring into my head. “Now here, we mostly have days and nights two or three at a time, and sometimes in the winter we take as many as five nights together - for warmth, you know.”** As an eight year old reading this passage from “Through the Looking Glass and What Alice Found There” for the thousandth time, I found myself laughing long before the punchline. Residing permanently on this side of the mirror, I failed to grasp the absurd logic of the Red Queen’s statement, and could only laugh at the suggestion of stacking days for warmth.

In a nurse’s office far from that childhood bedroom, I hear echoes of the Red Queen in Mr. Perkins’ words, but they are no longer humorous. For it is not a fictional character speaking; it is a person, one for whom multiple Tuesdays is reality. Like the guests at the
Mad Hatter’s tea party, Mr. Perkins is trapped in time, trapped in an inner world that clashes with his surroundings, yet he is not aware of the dissonance.

Months of observing the same sad scene reveal the futility of trying to convince Alzheimer’s patients that they are wrong.

These patients are not waiting to be brought back to the real world; they are seeking someone who will validate their version of reality.

Gradually, I come to understand that the world inside each patient’s mind is as legitimate as the world inside mine—that our interior reality is the only one that matters. Perhaps there is an objective reality to which most of us subscribe, but the smaller details, the intricacies of the world around us, are to each person unique. My perception of reality, though unaffected by brain disease, is not universal. Acknowledging this, I am better able to accept and welcome the range of perspectives I will encounter in this clinic and beyond.

When Mr. Perkins returns to the clinic six months later, I do not attempt to bring him to Baltimore, but instead travel with him to Georgia. When he asks me to close the windows because “the flies are ruthless this time of year,” I comply, knowing that the flies are as real to him as the Baltimore heat is to me. In doing so, I accomplish what my eight-year-old self could not have imagined. I manage to join his tea party.

For the past three years, I have worked as a research assistant at
Johns Hopkins Hospital in the Department of Geriatric Psychiatry. As part of the research practicum course at my high school, each student has the opportunity to find a mentor at a nearby research institute and complete an independent research project throughout their junior and senior years of high school. Though my research primarily concerns autism in older adults, I have had the chance to meet geriatric patients of all kinds.

Every Wednesday afternoon, I leave the hospital and go across the street to the outpatient clinic, where dementia patients are brought in by their caregivers to meet with a doctor and receive treatment. I have met with them, spoken with them, learned their stories, and told them mine, only to be unfamiliar to them the next week. Still, their presence in the clinic has made an impact on my understanding of Alzheimer’s disease, my attitude toward these patients and their families, and my plans for the future.

My interest in the aging mind springs from a childhood spent listening to stories of my father’s patients, who always seemed too old to cure but too alive to ignore. Though the majority of his patients were inflicted with Alzheimer’s or similar degenerative diseases, I would not realize this until the end of the story. The description of a particular patient’s personality and background always came first; their medical issues later, almost as a side note. I learned to consider patients as more than the sum of their parts, as people first and foremost.

My father is an end-of-life care physician, and unlike cancer specialists or brain surgeons, he treats problems that everyone will face someday, if we are lucky. No one can avoid growing older or watching as loved ones grow older, and seeing firsthand how painful the transition to old age can be, particularly for those inflicted with Alzheimer’s disease, has instilled in me a desire to help geriatric patients of my own one day.

Spending time in the geriatric psychiatry clinic has taught me lessons in life as well as medicine. The day I recognized an Alzheimer’s patient’s wife as the receptionist who had snapped at me earlier, I learned compassion. You never know what sort of pain a person is concealing behind their plastered smile. When I had a conversation with a man who needed several reminders to keep his shoes on and his shirt buttoned, I learned patience. Alzheimer’s patients may often seem as stubborn and confused as young children, but they prove invaluable sources of wisdom if you only pause to listen. But perhaps most importantly to a medical career, I learned that caring for those with Alzheimer’s is not about ridding them of their disease (such a thing is currently impossible) but helping them live in a way that is dignified and graceful until the very end.

Ask any child what a doctor does, and he or she will tell you that a doctor saves lives. To me, saving a life does not always mean finding a cure or even making a person live longer. It means allowing patients to live according to their own desires. It means placing yourself in the shoes of patients, and taking the time to learn about their family, their relationships and their past in order to figure out what those desires might be. It means opening your mind to the possibility that there are some things you will never understand, and accepting the fact that others do not see the world the way you do.

In the conversations that took place in that geriatric clinic each Wednesday, there was one phrase I heard more often than any other. When patients were asked for their most fervent desire, I heard again and again “I just want to go home.” This sentence contains what I think should be a doctor's main objective—to find that place where a patient can feel at home and do everything possible to help them get there. As I pursue a career in medicine, this is how I want to save lives.

*Name changed to protect privacy of individual.
** Carroll, Lewis. "Queen Alice." Through the looking-glass and what Alice found
Long Term Memory +

                                                                       LONG TERM MEMORY (LTM)

          LTM’s are those that last for years or even decades.  LTM differs structurally and

          functionally from STM and working memory. STM’s move into LTM via the process of

          potentiation, the process of strengthening the connections between existing neurons to

          improve the effectiveness of their communication.

          LTM’s fade as part of the natural forgetting process, which increases with age,

          stress and illness.  Serious loss of LTM, however, is the result of either TBI, or

          neurodegenerative disease – the most prevalent is alz., dementia, huntingtons

          disease, multiple sclerosis and parkinsons.


Managing Difficult Behaviors +



Many of the dementia patient's problem behaviors such as wandering, repetitive questioning, hitting or yelling outbursts can be diminished or eliminated by providing stimulating, meaningful activities. Use of external cues and procedural memory are central to the Montessori technique.  Ideas include placement of signage in the room, either written or pictures, denoting location of their room, bathroom, call light, water, dining room and whatever else in important to their ADL's.  Engage the patient in activities that match their skill level and interests, break activities down into increments that they are able to comprehend.  All interventions that work should be taught to caregivers after individuals with dementia are discharged from skilled therapeutic intervention.

The most important thing is to identify the trigger for the agression.  Include the following in your search for the trigger:

Has the patient:

- changed roommates or tablemates

- increased in staging level

- demonstrated increased confusion related to the environment (even though you think it should be familiar because the patient has lived in the same environment a long time) 

- demonstrated decreased ability to verbally communicate basic and medical needs causing frustration  

- is the patient's vision changing causing anxiety and frustration

- is the patient's hearing changing causing difficulty in the ability to auditorily access the environment

- did someone startle the patient by walking up from behind

- is the patient becoming frustrated by increasing mobility issues

- is the patient hungry

- is the patient feeling pain

- does the patient need briefs changed

- is there discomfort for some other reason

- is the patient in distress

If you or the caregivers can identify the trigger(s) for the agression, remove the trigger from the patient's environment.

Agressive behavior is a serious problem for caregivers, families and patients themselves. 

- always approach from the front, smile and talk in a calm tone of voice  

- validate their feelings and then try to redirect 

Agressive behavior may well be an adaptive form of communication. Undesirable, yes, but may be their means of communicating distress or discomfort for one of the reasons listed above. Don't give up!  Keep searching and ask the staff to keep searching for consistencies in agressive behavior to find the cause. 

Medicare and Documentation of Therapy Progress +

CMS states that therapy services shall be payable when the medical record and information on claim form consistently and accurately report covered therapy services. Documentation should also include objective measures of the patient's improvement as a means to justify therapy services. Documentation should justify the necessity of the services provided during the reporting period, and include objective evidence, or, clinically supportable statement of expectation that the patient's condition has the potential to improve, or is improving, in response to therapy, with maximum progress yet to be attained, and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.

Objective evidence consists of standardized patient assessent instruments, outcome measurement tools or measurable assessments of functional outcomes. Use of objective measures at the beginning, during and after treatment is recommended to quantify progress and support justifications for continued treatment. Such tools are not required, but their use will enhance the justification for needed therapy and repeat evaluations, including the MBSS.

Diagnostex, August 2012 Newsletter, Ronda Polansky MS, CCC-SLP

Medicare Audits for Anti-Fraud Efforts +

Medicare Audits for Anti-Fraud Efforts

New fraud-fighting efforts have been initiated by the US Department of Justice (DOJ) and Department of Health and Human Services (HHS) through the Health Care Fraud Prevention and Enforcement Action Team (HEAT). The Affordable Care Act has provided HEAT with an additional $350 million for the next 10 years. In partnership with HEAT, Medicare has expanded the Fraud Strike Force Operation to include nine fraud hot spots: Baton Rouge, Brooklyn,Dallas,Detroit,Houston,Los Angeles,Miami, andTampa. HEAT claims data is available simultaneously to all investigators and allows for real-time analysis of claims. In 2011, $735 million was recovered as a result of whistleblower complaints, which is a 50% increase under the new Senior Medicare Patrol.

Diagnostex LLC, June 2012 Clinical Cafe

Normal Aging vs. Dementia +

Normal Aging vs. Dementia


“Normal aging” describes natural changes that occur in the absence of any organic brain disease. People can grow old and continue to be independent. However, there are developments that generally occur in the brain in even healthy individuals who are 60 years old and up. Common age related changes include decreased hippocampal, frontal and temporal lobe volumes. These changes result in decreases in immediate memory, sustained attention, and the ability to generate words.


Before a diagnosis of dementia is made, general guidelines emphasize the need to see a pattern of development over six months, and a diagnosis is not made unless there is impairment in memory, social functioning and independent living. This is due to the fact that aging varies from person to person.


Typical Aging: 
- Independence in daily activities preserved - Dependent on others for ADL’s
- Complains of memory loss but able to provide detail regarding incidents of forgetfulness
- Unable to recall instances where memory loss was noticed by others
- Recent memory for important events intact

- Decline in memory for recent events
- Occasional word-finding problems - Frequent word-finding problems
- Will not get lost in familiar area
- Gets lost in familiar area
- Able to manage common appliances - Unable to operate common appliances and unable to learn to operate them

- Maintains social skills and enjoys socialization
- Noted loss of interest in social activities and may be showing signs of inappropriate behaviors


- Normal performance on mental status exams
- Abnormal performance on mental status exams




The family plays a key role in determining the presence of dementia. The caregiver is generally

given questions to complete regarding historical events, mental status changes, behavioral

changes, recent falls or loss of balance, medication history and supplements. Based on multiple criteria, the interviewer will be able to determine the presence of dementia vs. normal aging.




Overview of Dysphagia, Dining and Dementia +


As with cognition, the swallowing mechanism deteriorates over time. With a decline resulting from dementia, the SLP and OT are typically called upon many times to assess those who lose their swallowing capabilities and become aspiration risks, lose weight, become dehydrated, are positioned improperly, display behaviors or simply lose the ability to feed themselves.  PT’s are called upon to address deconditioning that may be affecting sitting tolerance, wheelchair mobility and/or balance.

General Dysphagia Behaviors Common in Dementia:

-  Oral sensory changes/poor sensory awareness

-  Difficulty with utensils 

-  Eating with fingers

-  Changes in mastication/munching pattern or suck/swallow pattern

-  Holding bolus 

-  Weight loss/dehydration

 - Oral care

-  Loss of interest in eating

-  Playing with food

-  Taking food from neighbor’s plate/behavioral issues

-  Anxiety at mealtime

-  Leaves the table

-  Positioning (tilting, leaning)

-  Coughing/choking

-  Wet, gurgly voice


PET May Help Identify Alzheimer's Lesions in Brain +

Monday, July 11, 2011

Positron Emission Tomography May Help Identify the Presence of Alzheimer’s Disease Lesions in the Brain

Positron Emission Tomography May Help Identify the Presence of Alzheimer’s Disease Lesions in the Brain

The differences may be large enough to help distinguish between the conditions, and between impaired versus unimpaired brains.

Alzheimer's Reading Room

“With the potential emergence of disease-specific interventions for AD,” state Wolk et al, “biomarkers that provide molecular specificity will likely become of greater importance in the differential diagnosis of cognitive impairment in older adults.”

Positron Emission Tomography May Help Identify the Presence of Alzheimer’s Disease Lesions in the Brain

The use of positron emission tomography (PET) imaging may help identify findings in brain tissue associated with Alzheimer’s disease (AD), according to two articles published Online First today by
Archives of Neurology.

As scientists seek to understand more about AD and other forms of dementia, they are exploring the use of PET, according to background information in the article.

This imaging technique involves the use of radioactive tracers to highlight areas of the brain affected by these conditions. Various teams of researchers are studying the effectiveness of different types of tracers for identifying brain findings associated with these conditions.

David A. Wolk

In one study, David A. Wolk, M.D., from the Penn Memory Center in Philadelphia, and colleagues, evaluated use of a tracer called fluorine 18-labeled flutemetamol for imaging the brain.

The study involved conducting PET scans on seven patients who were given a dose of this substance.

All had previously undergone a biopsy for normal pressure hydrocephalus, a progressive condition that includes dementia and can be difficult to distinguish from AD. Researchers found correspondence between readings of the PET scans and evidence of amyloid lesions—the plaque associated with AD—provided by microscopic evaluation of the biopsied tissue.

In another study, Adam S. Fleisher, M.D., from
Banner Alzheimer’s Institute in Phoenix, and colleagues, evaluated PET imaging using the tracer florbetapir F 18.

The study population included 68 individuals with probable AD, 60 individuals with mild cognitive impairment, and 82 healthy individuals who served as controls.

PET scanning was used to monitor activity of the agent being studied.

These researchers found differences in the brain uptake of florbetapir F 18, between the three groups, and in the detection of amyloid plaque; the differences may be large enough to help distinguish between the conditions, and between impaired versus unimpaired brains.

The authors of both articles suggest that their results may demonstrate ways in which PET imaging can be used with selected tracers to help identify findings associated with AD.

“With the potential emergence of disease-specific interventions for AD,” state Wolk et al, “biomarkers that provide molecular specificity will likely become of greater importance in the differential diagnosis of cognitive impairment in older adults.”

Staging Information +

Staging Information

Effective management of each dementia patient requires an in-depth look at spared (preserved) versus impaired capabilities. Staging the patient is how you determine what the main elements of your intervention will be. The following stages are comprehensive and go far beyond the original ‘mild-moderate-severe’ or ‘early-middle-late’ ratings.

There are seven distinct stages. However, therapists in the SNF setting will be primarily responsible for administering intervention programs for stages 4, 5, 6 and 7.

By the time patients reach stages 4 to 5, they become a safety risk and generally cannot be responsible for themselves. As a result, stage 5 is when we see the most admits to an SNF.

The patient’s family has likely been seeing ‘out of the ordinary’ behaviors for some time. Perhaps a family member has been caring for their loved one at home, but due to progressing dementia is no longer able to provide for them. At this point the family makes the difficult decision to place their relative in assisted living or a nursing home in an effort to keep their loved one safe.

The seven stages of dementia are outlined in the Global Deterioration Scale (GDS).

Stages 1 – 3 are pre-dementia, stages 4 – 7 are considered involved dementia stages when safety becomes a concern.


What are F-tags and why SNF's don't want them +

F-Tags and Why Skilled Nursing Facilities Don’t Want Them                                            

Long-Term Care Facility Regulations and Guidance to Surveyors

A facility that a Medicare surveyor determines is not in compliance with certain regulations will get an F-Tag corresponding to that regulations number. It is in this manner that the nursing home’s quality of services is monitored.

Below are several Medicare surveyor guidelines for the long-term facility regarding speech therapy, occupational therapy and physical therapy.

CDT members will find the link to the complete long term care Medicare regulations and surveyor guidelines under support websites. We cannot stress enough that you should be familiar with these regulations and follow them closely. Medicare investigators look for fraudulent therapeutic intervention. Stay within the boundaries and you will be able to provide your facility with therapy for an often overlooked and difficult population.


The following is an excerpt from the Medicare long term facility regulations that pertain to therapeutic intervention for SLP, OT, and PT.

Regulation 483.25: Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Use F-Tag 309 for quality of care deficiencies.

Guidance to Surveyors: 483.25: Use F-Tag 309 when the survey team determines there are quality of care deficiencies not covered by 483.25 (a)-(m). ‘Highest practicable’ is defined as the highest level of functioning and well-being possible, limited only by the individual’s presenting functional status and potential for improvement or reduced rate of functional decline. Highest practicable is determined through the comprehensive resident assessment by competently and thoroughly addressing the physical, mental or psychosocial needs of the individual.

The facility must ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident’s right to refuse treatment, and within the limits of recognized pathology and the normal aging process.

In any instance in which there has been a lack of improvement or a decline, the survey team must determine if the occurrence was unavoidable or avoidable. A determination of unavoidable decline or failure to reach highest practical well-being may be made only if all of the following are present:

- An accurate and complete assessment

- A care plan which is implemented consistently and based on information from the assessment

- Evaluation of the results of the interventions and revising the interventions as necessary.

Determine if the facility is providing the necessary care and services based on the findings of the RAI (resident assessment instrument). If the services and care are being provided, determine if the facility is evaluating the outcome to the resident and changing the interventions if needed. This should be done in accordance with the resident’s customary daily routine. Use F-Tag 309 to cite quality of care deficiencies that are not explicit in the quality of care regulations.

Medicare gives SLP’s, OT’s, and PT’s guidelines for approved intervention throughout their regulatory document, but none more specific than:

Regulation 483.45 (a) (1) (2) and F-Tag 406 (a):

Provision of Services – If specialized rehabilitative services such as, but not limited to, physical therapy, speech-language pathology, occupational therapy and mental health rehabilitative services for mental illness and mental retardation, are required in the resident’s comprehensive plan of care, the facility must (1) provide the required services; or (2) obtain the required services from an outside resource (in accordance with Reg. 483.75 (h) of this part) from a provider of specialized rehabilitative services.

Reg. 483.45 Guidance to Surveyors Probe for Speech-Language Pathology:

(a) What did the facility do to improve auditory comprehension such as understanding

common, functional words, concepts of time and place and conversation?

(b) What did the facility do to improve speech production?

(c) What did the facility do to improve the expressive behavior such as the ability to name

common, functional items?

(d) What did the facility do to improve the functional abilities of residents with moderate to

severe hearing loss who have received an audiologic evaluation? For example, did the

facility instruct the resident how to effectively and independently use environmental

controls to compensate for hearing loss such as eye contact, preferential seating, use of

the better ear?

(e) For the resident who cannot speak, did the facility assess for a communication board or

an alternate means of communication?

Reg. 486.45 Guidance to Surveyors Probe for Occupational Therapy

(a) What did the facility do to decrease the amount of assistance needed to perform a task?

(b) What did the facility do to decrease behavioral symptoms?

(c) What did the facility do to improve gross and fine motor coordination?

(d) What did the facility do to improve sensory awareness, visual-spatial awareness, and

body integration?

(e) What did the facility do to improve memory, problem solving, attention span and the

ability to recognize safety hazards?

Medicare Surveyor Guideline: F-Tag 310:

Were individual objectives of the plan of care periodically evaluated, and if objectives were not met, were alternative approaches developed to encourage maintaining toilet use abilities (e.g., if resident has not increased sitting stability, seek occupational therapy consult to determine the need for therapy to increase sitting balance, ability to transfer safely and manipulate clothing during the toileting process. For residents with dementia, remind periodically to use the toilet)?

Reg. 483.45 Guidance to Surveyors for Physical Therapy:

(a) What did the facility do to improve the resident’s muscle strength? The resident’s balance?

(b) What did the facility do to determine if an assistive device would enable the resident to

reach or maintain his/her highest practicable level of physical function?

(c If the resident has an assistive device, is he/she encouraged to use it on a regular basis?

(d) What did the facility do to increase the amount of physical activity the resident could do

(for example, the number of repetitions of an exercise, the distance walked?)

(e) What did the facility do to prevent or minimize contractures, which could lead to

decreased mobility and increased risk of pressure ulcer occurrence?

It is the rules and regulations of CMS that gives the SLP, PT and OT the approval to proceed, given the proper protocols, with skilled dementia intervention.

We are charged with achieving or maintaining the highest level of functioning of the dementia patient, which is in a constant flux. A stage four will become a stage five; a stage five will become a stage six; and a stage six will become a stage seven.

Working Memory +


The term working memory is used to describe the process where one “holds on” to small bits of recently learned information. An example of working memory would be the ability to hold on to the digits of a phone number in the short time between hearing them and dialing the number. Another example would be the base runner in a baseball game that must keep track of the number of outs and runners on base. The capacity of our working memory is limited, allowing us to remember only a few bits of information at one time.

Working memory is thought to involve the frontal cortex and parietal lobe.

Source: UCSF Memory and Aging Center

Writing Appropriate Goals +

Writing Appropriate Goals

Your goals will reflect spared capabilities identified by the presenting stage determined by the evaluation. For example, it would not be appropriate to write goals suited to a stage 4 for a patient who has advanced to a stage 5, because a stage 5 cannot function as a stage 4 anymore.

Always relate goals to functional outcomes for the patient within the SNF environment.

Long-Term Goals describe the desired end result over the expected duration of therapy.

Short-Term Goals describe expected progress for the specified billing period.

All goals should be: a) functional for the patient’s capabilities according to staging

b) skilled, measurable, attainable, reasonable and necessary (SMARN)

Manifestations of mental and psychosocial adjustment in each of the stages can be broken down into these five major areas: