Key Challenges in Team Care Late Stage PD · Lisa Mann, RN . Aimee Mooney, MSCCC-SLP-L . Jennifer...

OHSU Parkinson Center

April 30, 2017 Linda Bryans, MACCC SLP-L Allison Lindauer, NP, PhD Lisa Mann, RN

Aimee Mooney, MSCCC-SLP-L Jennifer Wilhelm, PT, DPT, NCS Rosanne Yee, OTR-L

Key Challenges in Team Care Late Stage PD

OHSU PARKINSON CENTER


Overview • Compare and contrast rehab needs for

Advanced PD

• Identify discipline specific treatments • Coordinate inter-disciplinary team care

• Swallowing /Nutrition • Falls/Vision • Incontinence • Orthostatic hypotension

• Cognition/Mood • Communication • Pain


Key Challenges in Advancing PD Nutrition, Feeding & Swallowing

Rosanne Yee, OTR Linda Bryans, MA, CCC-SLP


What? When? How? • What foods?

– Can be decided by ability to swallow, ability to manipulate food to mouth and foods that aid bowel movements (for constipation)

• When to eat? – Can be dependent on medications, energy level to maintain

proper posture during meal • How to make food?

– Can be decided on ability/endurance of balance and standing, energy and ability to use kitchen equipment, making the consistency allowed for swallow

• How much food? – Can be decided by caloric intake needed to maintain levels of

physical and cognitive activities, swallow abilities per bite

Interdisplinary Approach= Interplay with other team members


Nutrition • Important to understand the role nutrition

plays in both neuroprotection and neurodegeneration.

• Recent studies have revealed the promise of some nutrients in reducing the risk of PD and other nutrients may be involved with increasing the risk or quicken disease progression

• Important to understand effects of food on medications

(The emerging role of nutrition in Parkinson's disease Seidl. Et al. Front. Aging Neurosci., 07 March 2014)


Nutrients that may be Associated with an Increased Risk or Progression of PD • Dairy products

– the possible presence of neurotoxins, like pesticides in dairy products may increase the risk of PD

– mainly milk-strong positive association with the consumption of milk, but not cheese or yoghurt has been reported


Presenter

Presentation Notes

case of organic dairy products Milk May increase one's risk of PD


Nutrients that may be Associated with a Decreased Risk or Progression of PD

• Phytochemicals-Fruits and vegetables are rich sources of antioxidants

• Omega-3 polyunsaturated fatty acids-neuroprotective and has anti-inflammatory potential

• Soy-primary protein in soy appears to be neuroprotective • Caffeine- decrease triggers for neuroinflammation in

neuropathways may contribute to neuroprotection • Tea-Polyphenols in green and black tea provide potent

antioxidant-radicals • Alcohol-moderate consumption lowers the risk of PD. Red wine

especially neuroprotective (The emerging role of nutrition in Parkinson's disease Seidl. Et al. Front. Aging Neurosci., 07 March 2014)

Presenter

Presentation Notes

plant chemicals that have protective or disease preventive properties OM3-There have been no direct studies in PD patients that address whether omega-3s are neuroprotective, however, one study showed that supplementation with omega-3 reduced depression in PD patients Caffeine studies suggest that the beneficial effects of caffeine may be limited to men and post-menopausal women not receiving hormone-replacement therapy Tea-couple studies show 2-3 cups a day and decrease risk of PD and showed delay onset of motor symptoms Alcohol Great consumption raises the risk


Nutrients: Questionable Role in PD

• Fat-saturated may increase risk of PD vs. high fat diet (8% protein) provided symptomatic and beneficial disease modifying activity

• Meat- red meat heme iron content may act as a toxin when not digested properly vs higher intake of iron is associated with neuroprotection in PD

• Carbohydrates-high glycemic index decrease the risk of PD vs High carbohydrate diets are associated with an increased risk of type 2 diabetes, which numerous studies indicate type 2 diabetes is associated with an increased risk of PD


Presenter

Presentation Notes

Fat-link with protein may be reason for increase risk? Meat- iron derived from meat?


Nutrition and Medication Interactions

• All types of protein can interfere with Carbidopa-Levodopa absorption

• It is best to take the medication 30 to 60 minutes before eating protein and 1 to 2 hours after protein

• Take the medication along with foods that don’t contain proteins.

(National Parkinson Foundation (2017))

Presenter

Presentation Notes

Pt sometimes don't end up eating enough because they are scared that the meds will not work if they eat If taking long acting or taking meds every 2 hours pts to consult doctors Supplemental handout for Low protein foods


Meal Preparation

• Barriers to participation and completion: – Fatigue (PT and SLP) – Posture (PT) – Pain (PT) – Vision (Neuro-opt/neuro-ophth) – Tremor (PT) – Rigidity (PT) – Cognition (SLP)

Presenter

Presentation Notes

Fatigue-Physical how much chopping stirring moving around and cognitive fatigue keeping track next steps Posture- can decrease and limit reach causing increase risk of falls/burns Pain-in back from standing too long,in arms from repetitive actions Vision-poor lighting, decrease contrast sensitivity, reaching, cutting,mixing, stirring off,walking in kitchen off because depth perception is off or double vision Tremor-reaching, cutting,mixing, stirring effected, transporting/carrying items in kitchen tremor could be in trunk or neck Rigidity-reaching all ingredients and kitchen equipment for cooking Cognition-trouble with attention, memory, mulitasking, timing


Meal Preparation: OT Interventions • keep handles in and use the back burners if having balancing

problems • changing body positions: sit perching stool • good lighting • contrast colours: Equipment • gather ingredients all together before cooking • re-arrange kitchen for easier access to items used frequently • simple and less time depending recipes (limit multi task recipes) • use alarms/timers • use checklist to keep track of what has been done • Pacing: prep things throughout day, use crockpot

Presenter

Presentation Notes

Supplementary list of adaptive equipment


Eating and Drinking • Barriers to participation and completion: • Dexterity • Wrist rigidity • Bradykinesia • Tremor • Decreased appetite (meds and olfactory issues) • Rigidity (increase caloric expenditure) • Posture • Vision • Fatigue (hand to mouth and chewing)

Presenter

Presentation Notes

Dex-Trouble holding, gathering food and moving utensil with fingers Wrist-level off and adjust as food gets closer to mouth Brady-slowness getting food to mouth Tremor-gathering food on utensil, food may fall off if not gathered correctly, missing mouth App-most PD med may cause nausea and loss of smell can impact taste Rigidity-not having the ROM to get food to mouth Posture-can effect the reach,strength and endurance of U/E action hand to mouth Vision-unable to see food on plate, depth perception of aiming at food off, Repetitive motion of eating and chewing


Eating and Drinking: OT Interventions

• modify routines of meals: time of meals, texture, amount, environment

• only needed items on table • smaller portions • posture and proximity to table • Use of both hand • contrasting colours, proper lighting • adaptive equipment (plate guard, built up handles, off

set spoon and fork, liftware, Readi-steady glove, rocker knife, ergo knife, “nosey” cup, small opening bottles, non slip mats, box to raise eating surface)

Presenter

Presentation Notes

Straws are questionable. Helpful for tremor and neck pain and/or rigditity but not helpful for swallow


Feeding Habits that effect Swallowing

Observation during ADL’s: • Difficulty looking

down at the plate (make sure plate is in line of vision) • Mouth stuffing and rapid drinking • Tremor or stiffness interfere with self-feeding • Listening to patient/family about length of

mealtimes • Is my patient fatigued

from malnutrition or dehydration related to Dysphagia?

Presenter

Presentation Notes

what are things Im looking for to refer to other disciples like stop or avoid eating some foods, drooling,coughing,neck pain looking down at plate/bowl, forgetting to use the interventions


Dysphagia


Dysphagia in PD • Oral phase: PD can cause rigidity, tremor or dyskinesias in the muscles in the

tongue, jaw, lips and face which can impact the oral stage of the swallow. – Reduced or effortful chewing - Repetitive or excessive tongue movement (“tongue pumping") – Drooling - Reduced A-P transit – Decreased initiation - Oral residue

• Pharyngeal phase. PD can cause the swallow to be delayed, reduce pharyngeal contraction, reduced UES opening, reduce airway protection and reduce pharyngeal sensation.

– Choking or coughing while eating or drinking – Wet vocal quality after eating or drinking – Frequent throat clearing while eating or drinking – A sensation of food sticking in the throat

• Esophageal phase: PD can cause tightness in the cricopharyngeus muscle, reduced esophageal peristalsis and esophageal reflux.

– Heartburn – Food coming back up into the throat or mouth after swallowing – Coughing after eating – Frequent coughing or throat clearing

-Tjaden. Speech and Swallowing in Parkinson's Disease (2008)

Presenter

Presentation Notes

Oral phase deficits probably occur most frequently in PD and are usually first s/s of dysphagia- Yorkston et al (2004) Rosenbeck & Jones (2007) In red: Team members can be on the look out for these issue as PWP do not always appreciate s/s of dysphagia and will deny or simply not report. Reduced cough/airway protection Silent aspiration


PD Dysphagia Stats • 40-90% of persons with PD have dysphagia

– Rosenbeck & Jones (2007) – Leopold & Kagel (1997)

• Subjective dysphagia in 1/3 of community dwelling PD pts (higher numbers in advanced PD)

• Patients may remain clinically asymptomatic • Patients may have poor awareness of dysphagia • 15% of PD patients show silent aspiration • Dysphagia is more prevalent in advanced PD but often

does not correlate with disease severity • Moderate dysphagia: "The potential for aspiration that

is minimized by swallowing techniques and diet modifications"

– Yorkston, Miller, Strand (2004)


Cough • Airway protective mechanisms such as swallowing and

cough may play a role in aspiration pneumonia • Cough is an important defense mechanism

– Important to remove mucus, foreign bodies from airways by generating a high expiratory flow

• Impairment of cough – Motor dysfunction – Sensory dysfunction

• In early stages of PD, the motor component of cough was impaired

• In late advanced stages of PD, both the motor and the sensory component of cough were impaired -Ebihara et al (2003) Impaired efficacy of cough in pts with PD

Presenter

Presentation Notes

It's important to talk about cough and airway protection in PD as impairment of cough can play a role in aspiration pna We think about cough as having two areas of dysfunction including motor dysf (strength of cough) and sensory dysf. (laryngeal sensation that triggers cough)


Dysphagia Assessment • Clinical Assessment of Swallowing • Objective evaluation

– Modified Barium Swallow Study

(MBSS)

– Fiberoptic Endoscopic Evaluation of Swallowing (FEES)


MBSS

• Diagnostic • Determine safest texture • Determine effectiveness of compensatory

strategies • Determine ability to safely maintain

nutrition/hydration • Education


FEES

• Functional exam • Airway assessment • Vocal fold function • Secretion management • No exposure to radiation • Application of therapeutic techniques • Biofeedback

Presenter

Presentation Notes

Diagnostic and therapeutic


Complications of Dysphagia

• Aspiration pneumonia • Malnutrition • Dehydration

• Aspiration pneumonia is a leading cause of

death in PD

– Fernandez & Lapane. (2002) Predictors of mortality among nursing home residents with a diagnosis of Parkinson's disease.


Dysphagia Management

• Pt and caregiver education regarding s/s of dysphagia and aspiration

• Regular evaluations of pts with documented dysphagia • Compensatory Strategies

– Upright posture – Small bites/sips – Increase sensory input – Alternating liquids and solids – Chin tuck (maybe)

• Texture modification -Tjaden (2009)

Presenter

Presentation Notes

Sensory input:cold/hot, carbonated, highly seasoned foods,cold foods, sour foods.Luke warm and bland is worst Efficacy of these interventions can be established with MBS or FEES


Therapeutic Exercises • Active ROM exercises for tongue, lips, larynx • Sustaining high pitch which engages pharyngeal

wall contraction • Effortful swallow to improve BOT retraction,

clearance of residue • Mendelsohn Maneuver to increase laryngeal

elevation • Shaker exercises to improve hyolaryngeal

excursion

Presenter

Presentation Notes

Need for targeted exercises can be determined with MBSS or FEES


EMST and swallow safety • Promising treatment

– Expiratory Muscle Strength Training (EMST) – Randomized, blinded, sham-controlled study – EMST 5X/week for 4 weeks for 20 min per day – EMST group demonstrated improved swallow safety

as evidence by improved PA scores – EMST group demonstrated improvement of

hyolaryngeal function during swallow

– Troche et al (2010) Aspiration and swallowing in PD and rehabilitation with EMST


Improving Cough in PD • Promising treatment

– EMST to improve cough – 10 mid stage PD pts with penetration or

aspiration on MBS – 4 weeks of EMST – Significant decrease in duration

of the Compression Phase Duration and Expiratory Phase Rise Time; decrease in EPRT resulted in significant increase in cough Volume Acceleration

– Significant decreases in PA scores after treatment

Presenter

Presentation Notes

EMST-Aspire Products. PEMax-maximal exp pressure(start at 75% of this) Calibrated, one way, spring-loaded valve to overload the exp muscles mechanically The valve blocks the flow of air until sufficient exp pressure is produced The physiologic load on the targeted muscles can be increased or dec depending upon the device setting Result:HIGHER EXP FLOWS DURING COUGH


Contributing factors to dysphagia in mid-late stage • Cognitive impairment • Impulsivity when self feeding • UE Tremor • Dyskinesias • Poor awareness of dysphagia • Posture • Fatigue • Vision

Presenter

Presentation Notes

Can impact safe PO intake,weight maintenance, duration of meals PWP can benefit from CUES, CG training,adaptive equipment OT?=SLP


A word about drooling • Reported in >56% of pts • Secretion management vs sialorrhea

– 55% of PWP c/o xerostomia • Changes in sensation • Things that were once automatic are no longer automatic • Oropharyngeal dysphagia • Treatments:

– Botox injections – Meds: anticholinergics (can cause confusion, hallucinations, constipation,

urinary retention, drowsiness) or adrenergic receptor antagonists • Strategies:

– Think swallow – Before talking – Before bending – When concentrating – Intermittently

-Srivanitchapoom, Pandey & Hallett (2014)

Presenter

Presentation Notes

Poor secretion management: excessive pooling and poor control of saliva Sialorrhea: overflow or overproduction of saliva Many studies show that pts with pd produce less saliva than normal; can be related CL Dysphagia in PD: bradykinesia, reduced tongue fnction Increase awareness


When to talk about tube feeding…. • Important to understand pt's wishes • Usually in later stages of PD but some pts are more

proactive • s/s of dysphagia that are progressing • Conversation in conjunction with neurology/PCP • Offer support and understanding of implications of

TF • What does it mean to have TF?

– NPO? – Recreational PO? – Burden of PO – Extends life? – Prevents aspiration?


I takes a village..... • Keep an eye out • Weight Loss • Food/liquid avoidance • Taking longer to finish a meal • Coughing with water • Wet/gurgly vocal quality • Congestion • Fever


Key Challenges in Advancing PD Falls - Vision

Jennifer Wilhelm, PT, DPT, NCS Rosanne Yee, OTR-L


Falls

• Early PD: • 181 newly dx PWP vs 173 controls

– 64.1% of PWP fell over 7 years – 15% fell prior to dx; 13% within 1 year – Relative risk to controls: 3.1 – Higher rates of falls: higher age, UPDRS, PIGD

phenotype, dementia and lost to f/u

Hiorth Y et al; J Neurol 2017


Falls

• Hospital in Australia retrospectively looked at 342,265 fall-related hospital admissions ≥65 years

• 2.5% of falls were in PWP – Higher rate of admission – Longer hospitalization stay

Paul SS et al; Eur J Neurol 2017


Falls: where do they happen Fall location/circumstance PD admission

(n = 8628) Non PD

admission (n = 334,933)

Kitchen 2.2% 2.0% Bathroom 3.5% 4.1% Bedroom 3.2% 3.1% Elsewhere indoors at home 2.6% 2.6% Outdoors at home 3.6% 5.5% At home, unspecified 28.8% 29.0% Footpath 1.3% 2.7% Outdoors 1.5% 3.2% Residential living facility 28.6% 17.3% Healthcare facility 8.7% 7.0% Other buildings 1.7% 4.4% Unspecified/missing location 14.4% 19.3% Paul SS et al; Eur J Neurol 2017


Falls and injuries Injury

PD admission (n =8487)

Non-PD admission

(n = 333,778) All fractures 34.9% 39.4% Hip fracture 17.0% 13.5% Other LE fracture 1.9% 5.1% UE fracture 6.3% 10.4% Other fracture 9.7% 10.5% TBI 3.1% 3.0% Other injury 29.4% 26.5% No injury 32.6% 31.0%

Paul SS et al; Eur J Neurol 2017


Falls • PSP:

– Early postural instability: key in diagnosis

– Posterior falls – Dystonic rigidity of neck and upper trunk – Gait: “drunken sailor” (clumsy, slow and unsteady) – Gaze palsy:

• Difficulty scanning environment: curbs, obstacles, judging distances and going up/down stairs

– Impulsivity and poor insight into deficits – Can identify fallers with dual task conditions


Falls

• PSP: Rapid progression of gait deficits – n = 50 pts with PSP followed

• To death (n = 21; mean duration 53.6 mo) • In ongoing fashion (n = 29; mean duration 46.2 mo)

– Loss of independent walking, inability to stand unassisted and requiring use of wheelchair

• Once you met 1 milestone: high probability of reaching others within 8 months

• All milestones occurred 59-62 mo from symptom onset; 36-39 mo from 1st visit

Goetz CG et al; Neurology. 2003


Falls: PT

• PSP – Heel wedge in shoe: shift COG anterior – U-step walker – Increase step height to improve clearance – Posterior stepping strategies – Increase base of support for ADLs: “Strong

stance” – Work with OT regarding visual scanning

and SLP regarding impulsivity


Falls

• MSA: – Can include cerebellar signs leading to ataxia – Often with bilateral involvement – Bradykinesia and rigidity – Initial symptoms in trunk and LEs – Can occur due to orthostatic hypotension – Often with urinary incontinence


Falls

MSA-C • Coordination

exercises • Narrow BOS • Unstable

surfaces • Strengthen

trunk and hip/shoulder girdle muscles

MSA-P • Similar

treatments as PD

MSA-A • Address

orthostatic hypotension

• 4WW with seat

• Transport wheelchair


Falls • Late Stage PD (study of n = 50; mean

duration of disease 17.94 yrs; H&Y 4/5) – Increased rate of falling with course of disease – Falls occurred in 50% of patients

• 28% had daily falls • 30% falls caused by freezing

– Caused an extreme impact on patients’ perceived health status

Coelho M et al; J Neurol. 2010 Sep;257(9):1524-32


Falls: PT • Late Stage PD (study of n = 24; mean duration of

disease 11 yrs; H&Y 4) – Impaired postural control in quiet stance: both static

and dynamic – Decreased ability to balance when vision or

proprioception is disturbed • Delay in adapting balance strategy with sensory changes

– High reliance on vision: even if it is conflicted – Postural strategies usually are ineffective to keep

balance and avoid falls: especially if dynamic conditions or if sensory info is conflicting

Colnat-Coulbois S et al; Neuroscience. 2011


Falls: PT

• Late Stage PD – Sensory integration training

• Try to decrease vision • Unstable surface: start with a towel

– Postural reactions: ankle, hip and stepping – Assistive equipment

• 4WW vs U-step walker: look at context • Wheelchair


Freezing

• Causes: step initiation, turning, walking through doorways, crowds, stress, distraction

• 3 subtypes – Shuffling with small steps – Trembling in place – Total akinesia

• May be L-dopa responsive: ON/OFF

Snijders AH et al; Ann Neurology 2016


Freezing • Correlated with

decline in miniBEST: – ↓ Anticipatory

reactions – ↓ Reactive postural

control – ↓ Dynamic postural

control

• Mechanisms: – Lack of APA: prevent

normal stepping pattern

• Treatment: weight shifting, lateral stepping

– Cognitive role: deficits in executive and visuospatial functions

• Treatment: external/sensory cues; SLP?

Vervoot G et al; Parkinsonism Relat Disord 2016 Jacobs JV et al; Exp Neurol. 2009 Kelly VE et al; Parkinsonism Relat Disord. 2015


Treatment: Assistive Devices

• Single point cane: with or without laser, inverted walking stick

• Bilateral trekking poles • Walker

– FWW: increases falls with PD – 4WW – U-step walker

• Transport wheelchair • Manual wheelchair • Power wheelchair


Falls/Vision: OT

Ocular and Visual disorders: • Impact on ADLs like walking, reading,

driving • typically have problems with internally

guided movements and postural control use vision to compensate

• (Ocular and Visual disorders in PD: Common but frequently overlooked. M.S. Ekker et al. Parkinsonism and Related Disorder (2017) 1-10)

Presenter

Presentation Notes

Visual cuing stationary stripes on floor and through doorways or laser beam can alleviate freezing


Falls/Vision: OT Ocular Disorders

• Dry eyes • Decrease blink rate • Blepharitis • Blepharospasm • Apraxia of eyelid opening

Presenter

Presentation Notes

Dry eyes and Decrease blink rate -Decrease tear production autonomic dysfunction solution use artificial tear, oral omega 3-6 and consciously increase blink freq Blepha means eye lid. Inflammed eye lid related to dry eyes. bacteria on the surface of the eye causing inflamation distortion of vision and pain Blepharospams abnormal, involuntary blinking or spasm of the eyelids. The reflex type occurs in response to certain stimuli, such as a sudden visual threat or auditory or tactile stimulus while Apraxia of eyelid opening is non-paralytic motor abnormality characterized by difficulty in opening the eyes at will in the absence of visible contraction �


Falls/Vision: OT Ocular Disorders Functional scan –Saccades tend to be slow and display delayed initiation –Pursuit movements become jerky and slow eye movements (cog-wheel) Depth Perception –Vergence becomes insufficient due to slowness of eye teaming and can result in eyestrain, headaches and double vision (diplopia) –Solution: eye exercises focused on concise movement and referral to neuro ophthalmology or neuro optometry

Presenter

Presentation Notes

Saccades-small rapid controlled movement of the eye that targets one point to another. Pursuits- tracking movements of the eyes designed to keep on a moving stimulus clearly. Vergence- both eyes together moving in different directions, (inward-convergence or apart divergence), while looking at an object in focus as it moves toward or away from our eyes.


Falls/Vision: OT Visual Disorders • Visual Processing

– Contrast sensitivity-problems seeing in low light during walking, ADLs and night driving. Solution: increase light. If too much glare yellow filtering glasses. Referral to Low vision optometry

– Colour discrimination-trouble with all colours except black and white. Solution: contrast colors

Presenter

Presentation Notes

Contrast sensitivity-the ability to differentiate the level of light emitted from a object or area. Colour discrimination-the ability to distinguish subtle differences in colour some studies say more trouble with red-green axis or blue-yellow axis


Falls/Vision: OT Visual Disorders

• Visual Processing – Visuoperceptual issues:

• Detection of motion • Human movement • Facial recognition

Presenter

Presentation Notes

Moving objects and people PD pt can bump into or be bumped


Falls/Vision: OT Visual Disorders • Visuospatial issues:

– Perception of space – Recognition of line orientation – Mental 3D rotation of object – ID figure embedded in complex figures – Visuospatial problem solving – Depth perception – Spatial working memory

Visuospatial dysfunction specifically associated to fatigue. (Is fatigue associated with cognitive dysfunction in early PD? B.M. Kluger at el. Parkinsonism and Related Disorders 37 (2017) 87-91)

Presenter

Presentation Notes

Visuospatial impairments related to freezing of gait Space perception awareness of the relative positions of their own bodies and objects around them. Line orientation in space Spatial Working Memory requires retention and manipulation of visuospatial information. Possible complaints of fatigue could be do to tasks that requires visuospatial attention or calculations Possible complaints of fatigue could be do to tasks that requires visuospatial attention or calculations


Falls/Vision: OT • PSP the predominant visual defects are:

– Vertical gaze palsy-vertical saccades slow and hypometric, both up and down direction

– impaired vergence – inability to modulate the linear vestibulo-

ocular reflex appropriately for viewing distance.

(The Disturbance of Gaze in Progressive Supranuclear Palsy: Implications for Pathogenesis A.L. Chen et al. Front Neurol. 2010; 1: 147.)

Presenter

Presentation Notes

Although some aspects of all forms of eye movements are affected in PSP these are the predominant � These vertical saccades and vergence eye movements habitually work in together to enable visuomotor skills that are important during locomotion (stairs curbs, uneven surfaces) hands free


Falls/Vision: OT • MSA Typical ocular features include:

– Blepharospasm-abnormal, involuntary blinking or spasm of the eyelids.

– excessive square-wave jerks-fixation instability – mild to mod saccade hypometria-undershooting

target – Impaired vestibular-ocular reflex (VOR)- eye

movement that is equal in magnitude but opposite in direction

– Nystagmus-involuntary movement of eye (Visual signs and symptoms of multiple system atrophy. Armstrong, Clin Exp Optom 2014 Nov;97(6):483-91.)

Presenter

Presentation Notes

Less typical features include slowing of saccadic eye movements, the presence of vertical gaze palsy, visual hallucinations Aspects of primary vision such as visual acuity, colour vision or visual fields are usually unaffected


Falls/Vision: OT OTs evaluate functional vision to understand how it hinders and facilitate occupational performance • Modify and adapt the environment • Increase contrast • Reduce patterns • Improve lighting • Magnification • Organization • Simplify tasks • Improve search of environment • Refer as needed to neuro-ophthalmologist/neuro-

optometrist

Presenter

Presentation Notes

no research yet supporting increased speed and ability of eye movements.


Falls: OT Examine home environment: • Rails for both sides stairs • Vertical grab bars when reaching overhead or opening doors • Remove clutter and throw rugs • Re-arrange environment to widen walking path and make

items more accessible • Good lighting and mark edges corners with contrasting colour

tape • Lower bars in clothes closet • Sit for shower, grooming and dressing • Education of family for future equipment needs for rapidly

progressing disease


Falls: OT Retropulsion triggers • carrying things in both hands in front • pulling or dragging anything ex. tools for house

and garden work Retropulsion compensation strategies • carry objects with handles at the side • use push rolling kitchen, laundry, garden cart to

transport items • sit to do self care


Key Challenges in Advancing PD Incontinence

Jennifer Wilhelm, PT, DPT, NCS Rosanne Yee, OTR-L


Incontinence • Seen primarily with MSA; can be early sign

due to autonomic dysfunction – 90.9% of MSA patients report symptoms

• PSP: 53.3% of patients report symptoms • Linked directly to quality of life


Incontinence

• MSA and end stage PD – Storage problems: frequency, urgency, urge

incontinence, noctureia

• MSA - can also have and may need to catherized


Toileting –behavioral modifications

Bladder • Record current habits/routine by using voiding diary • Monitor pm fluid intake

Bowel • Fiber and fluids • Height of toilet. • Exercise • Routine • Stress/rushing


Weekly voiding diary

Monday Tuesday Wednesday Thursday Friday Saturday Sunday Comments Waking Breakfast mid-morning Lunch Early afternoon

Late afternoon

Supper Evening Bedtime Night


Simple Voiding Diary

Document if you void or have an accident

Mon Tues Wed Thurs Fri Sat Sun

void

accident


Incontinence: OT

Prevention: • Timing fluid intake • Timing regular trips to bathroom


Incontinence: OT

Clothing Management: • Elastic waist pants • Velcro closure • Suspenders • Adult briefs/pads

Presenter

Presentation Notes

Pants that look like dress pants LL Bean


Incontinence OT • DME and adaptive equipment

– Elevated toilet seat • May need horseshoe/cutout for catherization • May need foot rests for bowel movements

– Condom catheter with Catheter clip – Incontinence pads/absorbent sheets. – Female/male urinal (non spill) – Catheter inserter – Bidet – Wet wipes – Commode

Presenter

Presentation Notes

All the above equipment you should consider using contrast colour and good lighting Like Tape on RTS arm rests


Incontinence: PT • Bed Mobility

– Improve speed in getting up from bed – No Tempur-Pedic! – Technique – Satin

• “Sheet” in middle 1/3 of bed • Boxers

– Assistive equipment • Handrails • Safe T pole


Incontinence: PT

• Mobility: able to get to bathroom on time? – Need for assistive equipment – Balance training

• Pelvic floor PT – Limited research in late stage PD or PD plus


Incontinence: PT • Exercise-based behavioral therapy and urinary

incontinence in PD – n = 20 (17 completed study; 90% male; mean

duration of PD 6.9 ± 5.4 yrs) – Intervention: every 2 wks for total of 5 visits over

8 wks • 1st visit: dual channel EMG to pelvic floor for contraction

and relaxation; education; exercises: 45 pelvic floor contractions daily: 3 sets of 15 (1 set in lying, sitting and standing)

• 2nd visit: Education of urge-suppression strategy • 3rd + visits: offered additional biofeedback to promote

exercise compliance and reinforce bladder control strategies


Incontinence: PT

• Outcomes: – 83.3% reduction in urinary incontinence – 94.4% reduction in urgency urinary

incontinence – 26.1% reduction in nocturia – Improvement in QOL scores from 71.1 ± 23.9

to 54.7 ± 15.4 (p = 0.002)

Vaughen CP et al; Neurology. 2011


Incontinence: PT • TTNS: Transcutaneous-tibial nerve

stimulation – Inhibit detrusor overactivity through

afferent fibers to sacral cord – Potential use for both bladder and bowel

issues – As effective as extended release oxybutynin

in overactive bladder

Manríquez VS et al; Eur J Obstet Gynecol Reprod Biol. 2016

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjGstKh8qfTAhVjImMKHaqYAQgQjRwIBw&url=http://html.rhhz.net/YZMNWKZZ/html/2015-2-91.shtml&psig=AFQjCNFauzwaztFXYz4cZJWS9XKuU-RH8Q&ust=1492394762270386


Incontinence: PT • TTNS and PD (n=8 TTNS; n=5 sham)

– 30 min, 2x/wk x 5 wks: 200 µs, 10 Hz – ↓ urgency and nocturia – Improved urodynamic testing with increased volumes

• PTNS and PD (n=47) – 30 min, 1x/wk x 12 wks: 200 µs, 20 Hz – Significant ↓ daytime frequency, nocturia, urge incontinence

episodes and urgency episodes – Improved urodynamic testing with increased volumes

Perissinotto MC et al; J Wound Ostomy Continence Nurs. 2015 Kabay S et al; Urology. 2016


Key Challenges in Advancing PD Orthostatic Hypotension

Jennifer Wilhelm, PT, DPT, NCS Lisa Mann, RN, BSN, MA


Orthostatic Hypotension in PD • Causes

– Autonomic system dysregulation – Medications

• Symptoms – Lightheadedness, dizziness – Vision disturbance or syncope – Impaired thinking – Lethargy / fatigue / weakness – Pain (neck, shoulder, chest)


Orthostatic Hypotension • Drop is SBP of at least 20 mm Hg or DBP of at least

10 mm Hg within 3 min of standing • Usually worse in the morning: nocturnal polyuria

results in reduced overall fluid volume • Other contributing factors

– Prolonged supine position – Quick position changes – Warm environment: lower BP in general – Ingestion of food

• Can lead to falls • Often multi-factorial for treatment


Orthostatic Hypotension

• MSA: commonly seen due to autonomic dysfunction – Occurs in 53-68% of patients – Causes falls in 54.6% of patients – Only 12% of patients were symptomatic with 24 hr

testing • PSP: less common

– Present in 8-13.3% of patients, usually with no symptoms

Colosimo C et al; J Neurol. 2010 Schmidt C et al; Mov Disord. 2009


Orthostatic Hypotension • Late stage PD (H&Y IV-5): often observed

– Present in 26% of patients; 8% of patients having syncope

– May not be as large of a problem: limited mobility prevents quick sit to stand

• 96% of patients had dysautonomic symptoms – Can occur due to medications (dopamine

agonists) – Incidence increases with higher age and longer

disease duration

Coelho M et al; J Neurol. 2010


Orthostatic hypotension: Diagnosis

• Change position and wait 1 minute


Orthostatic Hypotension

Complicating Factors • Medications

– PD meds – non-PD meds

• Environment • Activities

– Eating – Bathing – Exercise


Orthostatic Hypotension • Medication evaluation/change • Environmental cautions • Medications to compensate

– fludrocortisone/Florinef ® – midodrine/Pro-Amatine®; – pyridostigmine/Mestinon® – droxidopa/Northera®

• Referral to Physical Therapy


Orthostatic hypotension: Patient Education • No quick postural changes, especially after

awakening • Scheduling activities for later in the day • Avoiding

– Motionless standing activities – Warm environments – Valsalva maneuver

• Postprandial


Orthostatic hypotension: Patient Education

• Non-pharmalogical interventions – ↑ use of caffeine, salt (8g/day), and fluids – ↓ alcohol intake – Eating smaller, more frequent meals (6/day) – Hydration: 1.5-2 L/day

• 2 8 oz glasses of water quickly: ↑ 20 mm Hg systolic BP in standing


Orthostatic hypotension: Patient Education • Mechanical interventions

– Elevating head of bed up to 8” – Use of compression stockings (>15-20 mm Hg) or

abdominal binder • Coordinate with OT for difficulty with donning

– Abdominal binder – Reverse Trendelenberg – Wheelchair recommendations

• Elevating leg rests • Tilt feature


Orthostatic hypotension: Patient Education • Exercise interventions:

– Maneuvers to increase BP: 20/10 mm Hg; 30 sec intervals • Squatting • Lower body muscle tensing • Crossing legs • Bending over

Krediet CT et al; Clin Auton Res. 2008 Krediet CT et al; Circulation. 2002


Orthostatic Hypotension • Home evaluation/DME evaluation

– Commode next to bed – Barrier free way of getting to the

bathroom – Using bedside equipment – Condom catheter or bedside urinal – Good lighting

• Caregiver training


Orthostatic Hypotension: PT • Monitor vitals during treatment • Exercise: swimming due to hydrostatic

pressure • LE exercises in bed or at EOB

– Hold knees to squeeze the legs before rising; do 10 times on each leg.

Fujimoto K; J Neurol. 2009


Orthostatic Hypotension: PT

• Implications for exercise – Study of MSA pts (n=15)

• Exercise: Supine position, pedaling cycle ergometer at workloads of 25, 50 and 75 W, each for 3 min

• BP ↓ and stayed low for 10 min post exercise

• Vasodilation of skeletal muscle without compensatory vasoconstriction in other large vascular beds

Smith GD et al; J Physiol 1995


Key Challenges in Advancing PD Cognition

Aimee Mooney, MS, CCC-SLP-L


Cognition in PD Incidence: >40% experience cognitive impairment after 10 years, 75% of people have Dementia Type: heterogenic; yet: Working Memory Processing Speed Executive Functioning Learning Efficiency (slower, more reps)

Impact: Independence (driving), Safety, Quality of Life, Carepartner Burnout, Emotional and Psychological Health


Continuum of Cognitive Changes in PD Mild cognitive impairment is common in nondemented Parkinson's disease (PD) patients and may be a harbinger of dementia. The Movement Disorder Society commissioned a task force to delineate diagnostic criteria for mild cognitive impairment in PD. The proposed diagnostic criteria are based on a literature review and expert consensus.

Presenter

Presentation Notes

Litvan, I., Goldman, J. G., Tröster, A. I., Schmand, B. A., Weintraub, D., Petersen, R. C., Mollenhauer, B., Adler, C. H., Marder, K., Williams-Gray, C. H., Aarsland, D., Kulisevsky, J., Rodriguez-Oroz, M. C., Burn, D. J., Barker, R. A. and Emre, M. (2012), Diagnostic criteria for mild cognitive impairment in Parkinson's disease: Movement Disorder Society Task Force guidelines. Mov. Disord., 27: 349–356. doi:10.1002/mds.24893


PD-MCI Criteria

I. Inclusion criteria • Diagnosis of Parkinson's disease as based on the UK PD Brain Bank Criteria20

• Gradual decline, in the context of established PD, in cognitive ability reported by either the patient or informant, or observed by the clinician • Cognitive deficits on either formal neuropsychological testing or a scale of global cognitive abilities (detailed in section III) • Cognitive deficits are not sufficient to interfere significantly with functional independence, although subtle difficulties on complex functional tasks may be present II. Exclusion criteria • Diagnosis of PD dementia 18

• Other primary explanations for cognitive impairment (e.g., delirium, stroke, major depression, metabolic abnormalities, adverse effects of medication, or head trauma) • Other PD-associated comorbid conditions (e.g., motor impairment or severe anxiety, depression, excessive daytime sleepiness, or psychosis) that, in the opinion of the clinician, significantly influence cognitive testing

http://onlinelibrary.wiley.com/doi/10.1002/mds.24893/full#bib20

http://onlinelibrary.wiley.com/doi/10.1002/mds.24893/full#bib18


Dementia 1. APHASIA: Difficulty with language 2. APRAXIA: Difficulty with performing tasks 3. AGNOSIA: Struggles with recognizing

known/familiar objects 4. EXECUTIVE FUNCTION: Creating difficulty

with planning, sequencing, organizing 5. Behaviorally/Personality Changes “ The loss of mental functions involving

thinking, memory, reasoning and language to such an extent that it interferes with a person’s daily living.”


“Must Knows” • See patients as EARLY in their Diagnosis as

possible • Education for patients and caregivers is KEY • Encourage patients to DO DO DO for

themselves! • Exercise (both physical and mental is

IMPERATIVE) • Give your patients Home Programs that are

specific & intense • Encourage check-ins every 6 months • ANTICIPATE needs as PD progresses


Questions SLP’s can answer: • Can they continue to live alone Independently?

• What level of residential care would be best?

• Are they safe while eating (i.e.: risk of aspiration?)

• Can they remember to take their medications on time?

• How can I get them to stop wandering?

• How can I reduce Care-giver Strain?

• Do they need Occupational Therapy? Do they need Physical Therapy?


ASHA: Roles of SLP’s Working with Individuals with Dementia-based Communication Disorders Identification: Screening (i.d. sensory

impairment, hearing, vision); consider mood, medications

Assessment: selecting and

administering clinically, culturally and linguistically appropriate approaches to diagnosis and assessment of cognitive-communication disorders of dementia across the course of the underlying disease complex

Intervention: identifying appropriate

evidence-based practice techniques for direct intervention with persons with dementia and indirect intervention through their caregivers and environmental modifications.

Counseling: to individuals with

Dementia and their significant others about nature of their dementia and its course

Collaboration: To develop intervention plans for maintaining cognitive-communication and functional abilities at highest level throughout the disease course

Case Management: serve as

coordinator or team leader to ensure appropriate and timely delivery of comprehensive management plan

Education

Advocacy

Research


Treatment Considerations • Direct: facilitate cognitive-communication

function • Indirect: environmental modifications,

development of therapeutic routines & activities and caregiver training.

Caregiver training is essential to optimal

outcomes for individuals with dementia.


(ASHA) Technical Report SLP Tx for deficits in Cognition

DIRECT: facilitate cognitive-communication function • Spaced Retrieval Training • Reminiscence • Montessori Based

activities • Graphic and written cues

in Memory Wallets and books

• Exploration of participation in cognitively stimulating activities; assistance in establishing community activities which enhance life

INDIRECT: environmental modifications; caregiver training

• Caregiver training in use of strategies and aides for successful cuing of patient in home and community environments

• Caregiver training in communication strategies

• Environmental modifications

• Development of therapeutic routines and activities

101


Factors which make cognitive function worse:

• Medication • Pain • Poor sleep • Fatigue • Low mood/depression • Stress • Over stimulation/distraction


Patient Education: Key for all SLP Interventions for deficits in Cognition

• Patient and Caregiver education about cognition strengths and weaknesses, their impact on ADL’s, and type of supervision required

• Patient and Caregiver education about factors which contribute to difficulties with cognition (fatigue, stress, pain, depression, anxiety, sleep, meds)


Area of Cognition Speech Therapy Speed of Information Processing

•Training in Speaker Control Strategies

Attention

•Guidance in energy conservation strategies/fatigue management (coord with OT) •Instruction in environmental modifications to maximize attention

Memory

•Development of external aides and environmental modifications in the home to support reduced skills (resources: epill.com) •Training in Internal Memory Strategies(repetition, visualization, association, location, attention) •Teaching of External Memory Compensations (daily journals, calendars, white boards, checklists, routines)

Executive Function •Education in Initiation Strategies (daily plan, scheduled routine activities, use of a timer to get started, dry erase board for caregivers)


SLP Treatment for Energy & Speed of Processing and Attention Training in energy conservation

strategies/fatigue management (coord with OT) Training in Speaker Control Strategies

Environmental Modification to

maximize attention (ie, reduce distractions, do one task at a time)


SLP Treatment for Memory Patient Education: Memory is an ACTIVE

process; you must consciously manipulate the information to get in into your brain.

Memory has 3 Stages: Input: when information is coming into

your brain; effected by: Storage: maintaining information;

consolidation with info you already know Retrieval: ability to access information

when it is needed.


Memory Strategies: the “why” • Remember to take medications as prescribed • Remember to use good posture strategies • Remember and keep medical appointments • Remember how to use adaptive equipment

and assistive devices • Remember to use safety swallow precautions • Remember golf score or bridge score • Remember stories that your granddaughter

tells you


Internal Strategies Repetition Association Visualization Location Mnemonics First Letter

External Strategies Write it down!!! Calendar/dry erase board Diary/memory book Paper & Pencil by each

telephone Timers (epill.com) Memory Shrine Established routines Checklists Signs & Labels

Training Memory Strategies


SLP Treatment for Executive Function: Training Initiation Strategies Consistent & predictable routines Checklists for tasks: “Things to do before

leaving the house”: 1. Turn off the lights, TV and Stove 2. Check to make sure I have my meds 3. Lock the Doors 4. Set the Alarm

Make a daily plan and schedule activities Use timer to help get started Dry erase board: Caregiver writes down the

plan for TODAY


Effective Instructional Strategies

• Encourage appropriate independence • Simplify complex tasks • Avoid multiple sensory cues • Avoid over stimulation


Academy of Neurologic Communication Disorders and Sciences

Evidence Based Practice Guidelines for the Management of Communication Disorders in

Neurologically Impaired Individuals : DEMENTIA

• Spaced Retrieval Training • Montessori-Based Interventions • Validation Therapy • Graphic and Written Cues • FOCUSED Caregiver Training Program


Montessori-based interventions

• Based on work done with children by Maria Montessori in the early 1900s and continuing today.

• Basic technique is to create structured,

stimulating activities that are appropriate to an individual's cognitive abilities, allowing engagement in tasks and the opportunity for social interaction.

• Activities can be conducted individually with clients or in groups.


Validation therapy

• A method of communication initially described by Naomi Feil, a gerontological social worker

• Basic technique is to validate (through

words, gestures) what the person with dementia says, regardless of accuracy or basis in fact, rather than correcting or re-orienting the person


Graphic and written cues • Basic technique involves providing written

factual information and/or familiar photos to facilitate communication

• Capitalizes on recognition memory and the

ability to read aloud, both of which may be relatively preserved in many individuals with Alzheimer's dementia

• Photographs and words can be incorporated

into memory books/wallets, memo boards, and activity calendars


FOCUSED caregiver training program FOCUSED is an acronym for the key features of the communication enhancement program: F = functional and face-to-face; O = orient to topic; C = continuity of topic-concrete topics; U = unstick any communication blocks; S = structure with yes/no and choice questions; E = exchange conversation--encourage interaction; D = direct, short, simple sentences Designed to be used with both family and professional caregivers


Cognitive Intervention: 5 evidence-based principles for enhancing learning in Dementia

1. Strengthen memory traces with repetition 2. Engage the non-declarative memory system:

active involvement promotes better learning 3. Reduce errors during learning. Minimizing

errors during learning is essential b/c every time an error is repeated, this erroneous response is strengthened. (Spaced Retrieval)

4. Structure intervention so clients focus attention on a single task

5. Use salient cues to aid successful retrieval (free recall harder than cued recall or forced choice)


Other considerations re: Cognition

• Cognitive Stimulation • Maintain participation in as many activities

as possible- and train caregivers about this!!


Utilizing the knowledge and power of Neuroplasticity

• Neuroplasticity: The ability of the brain to change and adapt to circumstances of injuries by forming new pathways, making new cells and getting bigger.

• Patient Message: “You can make a difference in the course of your disease by what you choose to do.” – Exercise – Cognitive Fitness – Emotional Resilience


Recommendation • Exercise in Stimulating environment

with a range of cognitive and sensory stimulating activates

• Exercise with others • Cognitive Stimulating activities • Creativity • Connectedness • Cognitive Behavioral Therapy


Updated Evidence for Cog Rehab in PD

• Watermeyer, T. J., Hindle, J. V., Roberts, J., Lawrence, C. L., Martyr, A., Lloyd-Williams, H., ... & Clare, L. (2016). Goal Setting for Cognitive Rehabilitation in Mild to Moderate Parkinson’s Disease Dementia and Dementia with Lewy Bodies. Parkinson’s Disease, 2016.

• Vlagsma, T. T., Koerts, J., Fasotti, L., Tucha, O., Van

Laar, T., Dijkstra, H., & Spikman, J. M. (2016). Parkinson's patients’ executive profile and goals they set for improvement: Why is cognitive rehabilitation not common practice?. Neuropsychological rehabilitation, 26(2), 216-235.


Key Challenges to Late Stage PD

Communication Linda Bryans, MA, CCC-SLP-L

Aimee Mooney, MS, CCC-SLP-L


Patient’s Communication

Care Path

Stage 1 Normal Speech

Processes

Stage 2 Detectable Speech

Disturbance

Stage 3 Reduction in speech

intelligibility

Stage 4 Natural speech

supplemented by Augmentative and

Alternative Communication

Stage 5 No Functional

Speech

What’s going on with your speech and writing?

Is your voice soft? Are you or others noticing changes in your voice?

Do others ask you to repeat? Is your voice soft? Are you noticing stuttering or mumbling?

Is your voice soft? Are you mumbling? Are you talking less or avoiding some communication situations?

Are you giving up on conversations? Is your voice inaudible? Are you communicating less, to a smaller group of people? Have you limited your topics and messages?

Do you rely on nonverbal ways of communicating with your carepartner, family and friends? Have you stopped or limited your participation in conversations?

Assessment

Your PCO health care provider or Speech-Language Pathologist (SLP) will listen for any changes in your voice, loudness or speech.

Your SLP will listen to your speech and voice and evaluate for changes in loudness, voice quality, articulation and overall speech intelligibility. An ENT or SLP may look at your voice box.

Your SLP will listen to your speech and voice and evaluate for changes in loudness, voice quality, articulation and overall speech intelligibility . Your SLP will help you identify best strategies for your needs.

Your SLP will: -Listen to your speech and voice and evaluate for changes in overall speech intelligibility. -Evaluate of your communication needs. -Conduct a formal augmentative and alternative communication (AAC) assessment.

Your SLP will help you identify the best speech generating device and low technology options to meet your communication needs.

Intervention

If your voice is noticeably soft or hoarse, you may benefit from Lee Silverman Voice Treatment (LSVT) to improve loudness and quality of your voice.

If your voice is noticeably soft or hoarse and speech slurred, you may benefit from Lee Silverman Voice Treatment (LSVT) to improve loudness and quality of your voice.

-You may benefit from LSVT to improve loudness and speech. -Have an attention getting strategy -Consider voice amplification as needed -Suggest changes in your environment for more effective communication

No matter how difficult it is to “talk”, you CAN still communicate. Consider a speech generating device to use when oral speech is inadequate. Consider voice amplification if voice is weak and volume is low.

Consider a speech generating device for functional communication and daily needs. You will learn how to use the speech device for conversation and telephone.

Patient Education Your SLP will give you information about possible changes in your speech and communication due to PD. Other services are available through the PCO.

Your SLP will provide you with information about: -LSVT -Ways to make your speech more understandable -Ways to enhance your written and verbal communication -Planning and preparation for further changes in communication.

Your SLP will discuss enhancement techniques: -LSVT -Loudness and rate exercises if needed -Learning to use low technology strategies -Preparing for other “tools” for speech and written communication.

Your SLP will provide you and your communication partners will information about resources for a communication system. The system will most likely include: -Your natural speech, gestures, and facial expressions; -Low and/or high tech

i t

Your SLP can help provide information and ways to change your communication system as needed. The ways you use your communication system are based on the time of day, medication regimen, your communication partners, and the disease progression.

Presenter

Presentation Notes

These are pts in stages 4 and 5. they may be struggling more to communicate, withdrawing from communication situations, not participating as they once did. This is where is gets more difficult to optimize communication. This is where the real work begins. Most SLPs are aware of the need to approach these pts from a multimodality perspective. OT/PTs need to be aware that these pts can benefit from intervention…..maximizing commmc by supporting commc with nonverbal or combines methods.


Late Stage PD • Stages 4 and 5 • Most patients have had LSVT….maybe • More barriers to successful LSVT outcomes • Complexity of communication disorder in context

of progression of disease and other health issues • May need to used combined interventions • Care Partner support and education

Presenter

Presentation Notes

These pts may be hard to capture. Usually have had DBS, physicians may not see benefit of referring back to SLP As a team, we need to be aware of these pt’s specific needs and their potential to communicate, even at end stage.


How can I help my pt with advanced PD? • Prioritizing needs and interventions

– What is important to my pt? • Refresher LSVT with multimodality communication support as

needed….and if pt is able/interested • Team approach to managing complex problems in PD

– SLP spear heads communication – OT can facilitate access of supports – PT can support with positioning – All disciplines can support communication

• Refer to SLP if pt is struggling with cognition or communication • Encourage use of loud voice, communication supports, communication

strategies

• Care Partner support and education

Presenter

Presentation Notes

TEAM: Neuro (fellow, PA, NP), SLP, PT, SW, RN What is most important to patient and CG? Identifying more pts at end stage


Treatment considerations

Four purposes of communication

(Light, 1988) – Express wants and needs

– Information exchange

– Social closeness

– Social etiquette

“Communication is not only the essence of being human, but

also a vital property of life.” John Piece

Presenter

Presentation Notes

Pts need to be able to do more than just communicate basic needs. When we review Light’s 4 purposes of communication, we see that commc serves to exchange information, provide social closeness and social etiquette. Impt to remember that communication is not only the essence of being human, the also a vital property of life. Recent research by Holt-Lundstad and collegues has demonstrated that social connectedness or lack there of is a risk factor for mortality – on the same par as obesity, smoking, etc***



Communication Disorders in Older Adults -Palmer et al (2016)

Predictor of: Smaller social networks

Fewer positive social

exchanges

Less frequent participation in social

activities

Higher levels of loneliness

Potentially leading to:

Social isolation

Reduced social

participation

Increased loneliness

Placing older adults at risk for:

Increased risk for mental and physical

health problems

Holt-Lunstad, J., Smith, T. B., & Layton, J. B. (2010). Social relationships and mortality risk: a meta-analytic review. Kawachi,I.,&Berkman,L.F.(2001).Social ties and mental health.

Presenter

Presentation Notes

We know that pts with PD do demonstrate decreased participation (Werthhiemer et al ***; Miller et al ***


PD are at risk for decreased participation and social isolation

• PD patients socialize less • PD patients avoid participation in

communication

• Wertheimer, Gottuso, Nuno, Walton, Duboille, Tuchman, & Ramig (2014) • Miller, et al (2006)

Presenter

Presentation Notes

We know from the work of C Baylor and N Miller that PD pts change patterns depending upon a variety of variables that contribute to interfere with communication. Interference can be functional or emotional. Pts make decisions based on symptoms, environment and personal priorities.


Keeping pts engaged and staying socially connected…including 4 purposes of communication

• Modified goals ? cued LOUD • Tailoring therapy to pts needs, motivation, abilities,

endurance • Social participation • Consider complexity of communication challenges

– Hypokinetic dysarthria – Cognitive communication challenges – Apathy?

• Amplification – Personal amplifier – Amplified telephone

• Augmentative Alternative Communication – Supported communication

• Care partner education

Presenter

Presentation Notes

So, what we all want to do is Keep pts engaged and socially connected. What commc situations or environments is the pt w/d from or avoiding. Not playing bridge, not answering or talking on the phone. Looking at what your pt needs and wants. OT/PT be on the look out for withdraw from participation…refer


Communication Supports

Presenter

Presentation Notes

Identify current strategies and what is working We all use all these things; when we work with families, we’re not introducing a brand new system; just shifting the balance = better buy-in


A shift toward aided approaches Fried-Oken, Beukelman & Hux, (2012)

• Expressive language less efficient

• Verbal participation decreases • Telephone use declines or is

avoided • Conversations become

imbalanced


Communication demands Settings

• Employment • Home • Groups • Community events

Partners

• Familiar/Unfamiliar Topics

• Familiar vs. unfamiliar

Modes of communication • Telephone • Face to face, spontaneous • Written • Electronic (email, text)


Partners and Modes:

Partners • Primary partner? • Most skilled? • Spends most time with ? • Willing to learn new

communication skills? • Willing to teach others

how to communicate with individual?

Modes • Influence by the situation,

intent, content and individuals involved

• Performance is multi-modal

• Modes uniquely constrain types of information conveyed


Communication Supports

UNAIDED: Natural • Speech • Vocalization • Gestures • Eye gaze • Body language • Sign language • Partner co-

construction

AIDED: Low & High tech • Paper and pencil • Communication

books boards and cards

• Speech generating devices

• Mobile technologies and apps

flex

ible

mu l t i -modal

Presenter

Presentation Notes

Aided- low tech to high tech (starting with speaking computers); on a natural continuum We talk about each person as having a full communication system with many modes to comm. Left = unaided (just using body) or another person (person who can’t think of the word and their wife knows it)- things that don’t require any THING; on right are aided approaches (aids or tools) tools range from low-tech all the way to high tech tools; We all use all these things; when we work with families, we’re not introducing brand new things; just shifting the balance = better buy-in


Low tech options – Paper/pencil

– Communication books

– Photo albums

– Pictures

– Newspapers

– Communication boards

– White board


Low tech options – Cards – Remnants – Written choice and

continuum lines – Paper and pencil – Lanyards


Low tech options: pre-planned scripts

• Can be prepared with conversation partner

• Used over telephone • Order food, set up

appt, ask directions • Explain PD, ask for

support • Personal information • MUST be practiced

Presenter

Presentation Notes

Using Dysarthria mgmt. techniques for ppa-G


Anne: an arsenal of options


AAC tools people report using: • Address

book/Resident/staff directory

• Calendar • Comm. Board • Comm. photo booklet • Church bulletin • Computer • Cookbook • Electronic photo frame • E-mail • Gestures/ sign

language/ pantomime • Letters/Mail

• Magazine/Ads/Newspaper • Maps • Museum brochures • Newsletters (school,

neighborhood) • Numbers • Paper & pen/writing • Photos & photo albums • Post it notes • Scrap book • Show Me • Skype

Presenter

Presentation Notes

What do we notice?? We ALL Do these things!


High tech options

• Dedicated speech generating devices

• Mobile technology devices


Mobile Technology • Social acceptance • Consumer empowerment in accessing assist • Connections to social network • Native applications • Multiple Communication applications: ProLoquo2Go Lingraphica SmallTalk Pictello Scene and Heard Verbally Sounding Board Doceri White Board

Presenter

Presentation Notes

“I bought this for my Mom”… But she gets so confused going from page to page… Still need to do PERSON to TECHNOLOGY matching!!


Shift to environmental modifications “Engineering the environment” means ... • Using ALL previous compensations and

determining what CURRENTLY fits.

• training use of natural supports • training partners


Natural environmental supports • Pointing to weather pictures in newspaper to

indicate time of day • Using mail received from the bank to indicate

questions about finances • Flipping through pictures in photo book during

family visit • Remnant boxes • Sharing news about religious services by looking at

bulletin together • Native apps on mobile devices (weather, photos,

calendar, maps, etc)


As person with PD loses speech/voice/language, partner assumes more responsibility for interaction and message co-construction.

Evidence shows training is effective in improving communication activities and participation.

• identify vocabulary for external lexicon • support use of tools in different settings • initiate conversation during late stages of PD • train other partners

Communication Partner training (see updated Systematic review by Simmons-Mackie et al, 2016)

Presenter

Presentation Notes

Turner & Whitworth (2006) 9 studies of communication partner training in aphasia reported favorable outcomes Type or severity of aphasia did not matter Bradley & Douglas (2008) 19 studies of communication partner training in aphasia reported favorable outcomes Wilkinson, R. & Wieleart, S. (2012) 6 studies of ‘conversation analytic’ approaches reported positive outcomes of dyad training Simmons-Mackie 2014 IARC Update since the Simmons-Mackie et al. 2010 systematic review 14 additional published research articles All 14 reported positive outcomes from partner training


Communication Partner training:

Communication ramp!

Communication access

Minimizes communication disability


Train partners to facilitate Comprehension

• Face to Face; get attention 1st

• Manage the environment • Speak slowly, allow to

respond • Augmented inpwith pictures

• One direction at a time • Written choice • Yes/no choice

Expression • “Should I finish his

sentences? • Support all forms of

communication • Count to 10 before

expecting a response • Set up a way to “come

back to that later.”


Training Communication Partners 1. ID partner behaviors that elicit desired client

outcomes 2. Start small and expand after mastery 3. Use Systematic Instruction CHOOSE to take strategic approach: imPAACT Program (Kent-Walsh &

McNaughton, 2005) Communication Partner Instruction Model

(CPI) (Kent-Walsh & McNaughton, 2005 ). Self anchored Rating Scale (SARS) (Fox,

2012)

Presenter

Presentation Notes

5 Instructional Components: Video Review, Modeling, Role Play, Verbal Rehearsal, Coached practice The ImPAACT (Improving Partner Applications of Augmentative Communication Techniques) CPI designed to assist stakeholders with learning, generalizing, and applying strategies supporting individuals with CCN


Amplification

• Crutch or support • When amplification should be considered • Amplified telephone application

– Public Utility Commission (PUC) – http://www.puc.state.or.us/rspf/tdapapp.pdf

Presenter

Presentation Notes

When pts are withdrawing from communication Case: Steve, gradual intro to amp. Started with public speaking, gradually with wife and friends. Became more accepted by him and his friends/family


PUC Speech-to-Speech

• http://www.oregonrelay.com/ • 711 or 877-735-7525 • Speech-to-Speech (STS) allows a

speech-disabled person to voice his/her conversation.

• A specially trained STS operator repeats the words of the person with a speech disability or synthesizer output to the other person.

• No special equipment is needed to use this service


Team supported communication How can we work together as a team to support communication?

– Can they provide input regarding their care/goals/needs? (express needs)

– Can they tell you about their weekend? (exchange

info) – Can you get to know them? (social closeness)

– Can your pt greet you? (social etiquette)


Supporting participation For example…. • Intervention several years ago with group tx,

LSVT, medialization thyroplasty • Withdrawing from conversations • “It’s not just being heard” • Fast moving conversations • Initiation

– He just doesn’t talk at home • Refresher LSVT in context of conversational

strategies • Involving wife, family and friends • Invite PWP to participate • Practice strategies to stay in conversation

Presenter

Presentation Notes

Seen in NSC with his wife. Beginning to w/d from conversations. NEEDS FOR SUPPORT SHIFTING FROM LOUD TO COGNITION AND SPEAKER CONTROL Speaker control strategies (Aimee): ask to slow down, one thing at a time, ask to repeat or clarify, take notes, etc


Key Challenges in Late Stage PD

Pain

Jennifer Wilhelm, PT, DPT, NCS


Pain

• Pain and PD: Recent cross-sectional survey (n =181; Germany; H&Y 1-5) – 95% of PWP reported pain

• 91% > 6 months • 79% > 1 yr • 40% > 5 yrs

– Type: back, nerve, joint, head, abdomen, traumatic, after surgery, infection

Buhmann C et al; J Neurol 2017


Pain

% of patients given a certain therapy

% of patients reporting at least some efficacy

% of patients reporting at only temporary effect

Buhmann C et al; J Neurol 2017


Pain

• PD and Pain Study – n = 450 with PD; n = 98 without PD – PD patients: average duration: ~6 yrs

• 61.8% had chronic pain; 5.6% had non-chronic pain (control: 58.2% had chronic pain)

• Chronic pain: 60.1% “PD pain” – Direct pain: 61.7%

» “off” dystonia, “neuropathic” pain, akathisia, deep aching, myalgia, cramps, stiffness, articular or abdominal discomfort

– Indirect pain: 38.3%

Nègre-Pagès L et al; Mov Disord. 2008


Pain

• PD and Pain study con’t – Pain topography

Non PD pain

(n=111)

PD pain indirect (n = 64)

PD pain direct

(n = 103) Head 12.6% 10.9% 8.7%

Back 44.1% 60.9% 12.6%

UE 23.4% 14.1% 21.4%

LE 31.5% 29.7% 67%

Nègre-Pagès L et al; Mov Disord. 2008


Kings Parkinson’s Pain Scale

• 7 domains: – Musculoskeletal pain – Chronic pain – Fluctuation-related

pain – Nocturnal pain

(includes RLS) – Orofacial pain – Discoloration:

Swelling/edema – Radicular pain

• Each item is scored by severity (0-3)

• Multiplied by frequency (0-4)

• Results in a subscore of 0 to12

• Sum gives the total score (0 to 168)

Chaudhuri KR Mov Disorders 2015

Presenter

Presentation Notes

Addresses localization, intensity, and frequency of pain as well as its relationship with motor fluctuations or musculoskeletal pain.



Pain

• Late stage PD – Varies greatly between studies

• 24% of patients reported severe, disabling pain • 67.3% of PD patients (avg 6 yr duration) with pain

(Negre-Pages (2008): see next slide) – Paresthesias: 20% – Dystonia: 48%

Coelho M et al; J Neurol. 2010


Pain

• MSA: – 70.6% of pts had complaints of pain

associated with disease progression – Often affect extremities > neck/spine – Most common: sensory symptoms

• Cold or burning sensations • Paresthesia • Numbness

– Dystonia: can be related to levodopa


Pain

• MSA/(PSP): Antecollis (head drop) – Stretching – Positioning (work with OT) – Tilt-in-space wheelchair – *Botox NOT used due to concerns with

swallowing


Pain • PSP:

– 40%-56% of patients reported symptoms – Often non-specific – Dystonia: axial (antecollis or extension of neck)

or flexion of hands – Case study for chronic neck pain

• IV administration of lidocaine x 30 min every 2 wks: dramatic improvement in pain for 10 days and improvement in QOL

Colosimo et al; J Neurol. 2010 Shrag A et al; Mov Disord. 2010 Schlesinger I et al; Clin Neuropharmacol. 2009


Pain

• Musculoskeletal – Related to rigidity, postural changes and co-

morbidities • Dystonia

– Occurs during “off” or peak dose • Neuropathic

– Radicular pain from compressive root lesions, focal or peripheral neuropathy

• Central – Unusual burning, unrelated to motor phenomena – Neurontin

• Akathisia: inner restlessness – Restless leg syndrome


Pain • Musculoskeletal

– Most common type of pain – Found in #1 low back, knee, shoulder – Re-balance muscles: stretch the flexors – Education: joint protection – Rotational exercises to decrease rigidity – Bracing – Consider ortho or pain consult: injections or

other intervention


Pain • Stretching: passive and caregiver

training • Kinesiotape • Palm shields • Splinting • Paraffin bath • Collar (headmaster collar) • TENS • Manua therapy


Pain

• Dystonia – Common in foot, neck or trunk

(Camptocormia/Pisa syndrome) – Relationship to medication timing? – Botox – Bracing for neutral joint position


Pain • Dystonia

– Stretching to maintain ROM – Non-weight bearing treatment:

• Yoga toes or foam (pedicure) when sleeping – Weight-bearing treatment:

• Taping 2 pennies to head of 2nd MTP: tone inhibition orthotic

• Taping to ankle for subtalar neutral: Supramalleolar Orthosis (SMO) + tone inhibition plate

– Rigid taping for Upper Trap – Botox: coordinate for home program


Pain

• Neuropathy – Mineral ice – Compression stockings – ROM exercises – TENS/IFC/micro-current

Thank You

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