The Memory Unit OT

I think it’s safe to say that many of us are confident in thinking through a more “typical progression” of therapeutic improvement. Patient requires max assist at evaluation, we use therapeutic training, to improve to moderate, then minimal, then standby/setup, then independent – at which point the patient is ready for discharge home.

But what about when we’re dealing with a long-term care Resident who is living with chronic cognitive impairment?

For some of us, this might feel “atypical” and therefore harder to understand or determine. The individual is living in a long-term care setting. Is the goal ever to get to an independent level?

I’m not saying that we should never strive for independence in a long-term care setting. But there are qualifiers that insurance companies use when determining a need for long-term care residency. And if those insurance companies are paying for a long-term care level of stay, the chances of achieving full independence 100% of the time (in an instance of a progressive, degenerative disease like dementia) are likely not as high when compared to individuals living in an assisted living or better level of care.

So how does this relate to establishing a current ADL status?

Well it means that you as the therapist are likely going to have to educate and advocate to maximize continuity of whatever level of independence your Resident does have.

There are 4 main points to remember when determining ADL status.

First, the assist level you recommend should be the level that the Resident has required the most consistently. Make you determination based on the most recent overall performance. Within the last 10 days, what has been the most consistent performance level?

Second, we have to factor in all aspects of the task when determining the level of assistance required. Strength (of the entire body), balance (in both sitting and standing), standing tolerance (measured in time), transfer status, assistive devices (the most likely in this case being walkers and wheelchairs), cardiopulmonary function (based on objective data), memory, attention, sequencing, the use of cues (visual, verbal, and tactile), emotional regulation, and overall understanding of the task. All body systems are integrated into the ADL routine, make sure you account for all of them.

Third, and especially when working on The Memory Unit, the less complicated you make things, the better. Don’t worry about adding in a bunch of fancy techniques or adaptive equipment. The most familiar parts of the task will be the easiest for your Residents to recall with increased repetition AND the easiest for the staff to carryover after therapy discharge.

Lastly, try to keep things as objective as possible. Remember the basic breakdown of assist levels.

• Max Assist means the Resident performs 25% or less of the task
• Mod Assist means the Resident performs 50% of the task
• Min Assist means the Resident performs 75% or greater of the task

The same is true of cognitive assistance or cues.

And remember that performance levels are always changing on The Memory Unit.

Sometimes therapeutic intervention promotes a greater level of independence and participation for just a short while, sometimes only a few months, before the disease progresses. It is the unfortunate reality of dementia. But this does not mean that you’re a bad therapist or you haven’t done your job.

Bottom line is, we work with individuals living with dementia to promote their comfort and quality of life as much as possible. It doesn’t have to be perfect, it just has to be meaningful.