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..
