How allied health can help – part 2

This is the second in a two-part series highlighting the vital contribution that allied health professionals make to the support of people living with dementia and carers. On the following pages, geriatrician Dr Clair Langford (below), clinical nurse specialist Alexia Bradley and three allied health professionals (dementia advisor Robert Pinchin, physiotherapist Melissa Roach and speech pathologist Katie Tsacounis) explain what this support looks like in practice. Part one*, in the previous issue of AJDC, looked at the role of dieticians and occupational therapists, along with neuropsychologists and geriatricians

Allied health is a term used to describe a range of health professionals who are not doctors, dentists or regular nurses. Allied health professionals aim to prevent, diagnose and treat a range of conditions and illnesses and work with doctors and nurses to optimise patient outcomes.

They include: physiotherapists and exercise physiologists, occupational therapists, social workers, neuropsychologists and clinical psychologists, dieticians, speech pathologists, Aboriginal and cultural and linguistically diverse health workers, counsellors, podiatrists, dental hygienists, dementia advisors, diversional therapists, music therapists, pharmacists, optometrists and audiologists.

The different types of dementia and different stages of dementia may require the input of different allied health professionals at different times.

It is not uncommon for dementia to be first flagged by an allied health professional while seeing a person for a routine issue. For example:

• A pharmacist may notice the person is missing tablets in a blister pack or that scripts are being renewed too often or not enough.
• A physiotherapist might notice the person is not remembering an exercise from one visit to the next or not remembering to use their walking aid.
• An optometrist or audiologist may not be able to fix a sight or hearing problem because the brain is not understanding what the person sees and hears – it is not processing the information correctly.
• The person may be losing weight and a dietitian realises that they are forgetting to eat.

These allied health professionals will then contact the person’s GP and recommend further assessment.

Dr Clair Langford

Geriatrician, based at Bulli Hospital and Aged Care Centre, Illawarra Shoalhaven Local Health District, NSW

*Part one in this series is available to read in full on the AJDC website at https://journalofdementiacare.com/articles/how-allied-health-can-help-part-1/

THE PHYSIOTHERAPIST

Melissa Roach

Outpatient Physiotherapy Clinical Lead Bulli Hospital and Aged Care Centre Illawarra Shoalhaven Local Health District

As a physiotherapist, my main role is in falls prevention, mobility retraining, strength and conditioning and improving activity levels in the elderly. The following story illustrates how physiotherapy helped Jim* and his wife, and main carer, Carol*.

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Jim was referred to me in the early stages of Alzheimer’s disease, with worsening mobility and recent falls – two in the last 12 months from tripping and losing balance on turning. He was having to hold onto furniture to keep his balance, had lost his confidence and was no longer going for his daily walk around the block. Jim’s activity levels were decreasing and, as a result, his mood was low. He was starting to watch more TV and sleep through the day.

My assessment found that Jim’s balance needed improving. He was slow and shuffling when walking and was struggling to get out of a chair without using his hands. Jim wanted to be able to walk around the neighbourhood on his own and visit local friends, go to the local café or club with his wife, catch up with family, and to overcome his fear of falling.

To achieve this, his physiotherapy goals were to improve his leg strength and ability to get out of a chair, along with his walking ability and balance. This would lower his risk of falls and improve function.

Jim’s treatment sessions involved his wife Carol and included:

• Walking practice where Jim was taught to take ‘big steps’ and put his heel first. Carol was able to prompt and remind him with the same instructions at home.
• Jim purchased a four-wheeled walking frame to increase his confidence. We practised walking outdoors on slopes, ramps and grass. If Jim got tired, he was able to sit and rest.
• Jim practised how to get out of a chair easily and transfer safely from a car. Carol was given clear, simple instructions that she could use with Jim at home.
• A home exercise program was provided to improve Jim’s leg strength and balance.

The exercise routine was incorporated into Jim’s daily activities – for example doing standing-up practice and leg extensions whilst watching TV or doing balance exercises while at the kitchen bench. At a later time, Jim’s Home Care Support person would also prompt and perform exercises with him after his shower or accompany him on a walk.

Physiotherapy helped improve Jim’s strength, balance and walking after eight to 10 weeks. He was able to achieve his goal of walking around the neighbourhood using his four-wheel frame, and then later with his carer when he required more support. He could visit the local café or club safely and maintain social contacts with friends and family. His activity levels and his mood improved and he was able to stay connected with people – all things we know are important in slowing the progression of dementia.

*The information presented here is de-identified

The Speech Pathologist

Katie Tsaccounis

Speech Pathologist Aged Care, Rehabilitation and Palliative Care Speech Pathology Clinical Leader Illawarra Shoalhaven Local Health District

People with dementia may develop problems with both communication and swallowing.

For some people with dementia, difficulty talking is the first symptom they experience. Problems with communication can involve difficulty finding the right words to use when talking, making errors when talking, difficulty reading or writing, talking but not making sense, or difficulty understanding instructions.

Signs of problems with swallowing may include coughing when eating or drinking, needing to use extra swallows, eating and drinking less or taking longer to finish a meal.

Communication and swallowing problems can be distressing for both the person with dementia and the people around them. Education and support from a speech pathologist can help the person with dementia to live well despite these challenges.

We aim to promote independence, participation and maximise quality of life. For example:

• If a person with dementia has difficulty calling their family members by the right names, we might work with them to make some photo cards to use to remind them who is who.
• If a person gets stuck when talking because the word they want is ‘on the tip of their tongue’, we might work with them to find a strategy that is helpful, such as describing the word instead.
• If a person is coughing when drinking, we may be able to stop that by using a special cup or making the drink slightly thicker.
• If a person has a soft voice, we can try therapy to make it louder.
• If a person is unable to have a conversation but still enjoys interacting with others, we might work with their loved ones to make a life story book to help make those interactions meaningful and relevant.
• If a person has difficulty communicating, we might teach their loved ones how best to communicate with them using Communication Partner Training.

Speech pathologists often work together with dietitians and occupational therapists to help a person with dementia achieve their goals.

The following stories involve people with dementia who have recently seen a speech pathologist at my workplace.

The first story is about a 75-year-old man with a type of dementia called Lewy body disease. People with Lewy body disease can develop problems with communication and swallowing. This man was slowly talking less and less because of changes to his speech and voice. His voice was getting softer and his speech less clear, making it difficult for people to hear and understand him. This man saw a speech pathologist who did Lee Silverman Voice Treatment (LVST) with him – an intensive treatment program that has made his voice louder, his speech clearer and made it easier for him to have a conversation with his family and friends.

The second example is an 82-year-old woman with Alzheimer’s disease. She had always been a quiet person but was getting quieter with time. She was able to say hello, ask simple questions and follow simple instructions but was unable to have a conversation. The speech pathologist worked with her husband to create a life story book.

A life story book is a book about someone, with words and pictures or photos. It can include information about where the person was born, their life, family members, interests, previous hobbies, likes/dislikes etc. Having this book meant that when carers came to the house they could look through this book and have a meaningful interaction. “Oh I didn’t know you were born in Canberra, I was born there too!” “Is that your daughter, doesn’t she look lovely on her wedding day” or “Do you like roses? I’ll bring some from my garden next time”.

*The information presented here is de-identified

The Clinical Nurse Specialist

Alexia Bradley

Clinical Nurse Specialist Geriatric Outpatients Therapy Unit Bulli Hospital Aged Care Centre Illawarra Shoalhaven Local Health District

People referred to the Bulli Health Aged Care Centre’s Geriatric Outpatients Therapy Unit (GOTU) undergo a comprehensive geriatric nursing assessment by a clinical nurse specialist before seeing a geriatrician. The areas assessed include: eyesight and hearing, falls history, exercise, continence, nutrition, medication use and management, pain, functional ability and independence, home environment, cognitive ability, mood and social activity.

I’ll use the example of John* to illustrate what this involves. John, 83, lives with his wife Jan. His GP has referred him to the clinic due to a history of memory impairment over the past several years.

First, I check if John has any eye or hearing impairments and a history of falls. If he hasn’t had any falls I will discuss if he exercises daily, or has a home exercise program, and will refer him to the clinic’s physiotherapist or provide him with a falls prevention booklet, Staying Active On Your Feet. If John has had falls in the past year, I will refer him to the occupational therapist and the physiotherapist.

I will then discuss with John if he is incontinent and whether this bothers him. If so, I can refer him to the clinical nurse specialist in the community.

A nutrition assessment determines if John has lost weight or has any difficulty with eating, including coughing. I will refer John to the dietician if he’s lost weight, and to the speech therapist if he coughs when eating. People with dementia may experience difficulties chewing and swallowing, and repeated coughing or throat clearing after swallowing food or drinks can be one of the signs.

I check if John is managing his own medications, does he forget, or take too many, and how many is he taking? We are concerned if he is on more than five medications.

How is John functioning at home? Can he go to the toilet by himself, does he need help to get in and out of bed, can he shower and dress himself? John does need a little help with showering and sometimes forgets, so I ask if Jan is happy to help, or could John access a community carer though his Home Care Package to help with this activity?

Next, I check if John and Jan need an occupational therapist to assess their home for safety (does the house have stairs, is the bathroom suitable?)

Each client has a cognitive assessment. John scored 25/30 on the Mini-Mental State Examination (MMSE), showing difficulties with remembering three items.

We then talk about John’s mood – is he generally happy or sad, is he sleeping well? Because John is experiencing some agitation in the evening, I refer him to our dementia advisor Robert Pinchin, from the Dementia Advisory Service, who can help John and Jan with some strategies to manage this.

Because John is not able to manage at home alone, I will ensure that he has approval for respite care, in case Jan has to be away from home for any reason.

Each client and carer also receives advice on making an Advance Care Directive, which lets family and health care staff know your wishes about treatment and care should you become seriously ill or injured and not be able to make decisions.

Based on my assessment, I have referred John to the occupational therapist, physiotherapist, speech therapist, dietitian and dementia advisor. Jan has received a booklet for carers and the couple has received an Advance Care Directive booklet and the exercise guide, Staying Active On Your Feet to help with John’s exercise program.

After completing my assessment, I then hand over to one of the unit’s geriatricians who will see John (along with Jan) for further assessment and treatment.

*The information presented here is de-identified

The Dementia Advisor

Robert Pinchin

Dementia Advisor Dementia Advisory Service Illawarra Shoalhaven Local Health District

As a dementia advisor with the Dementia Advisory Service, I work with the Bulli Hospital and Aged Care Centre’s team to provide counselling and support for our clients and their carers. My role is to explain what dementia is, what is happening to the person who has been diagnosed, what is happening inside their brain, and how that will affect their overall life experience and that of the carer who is living with them.

I also work with the team to provide clients with a range of therapeutic approaches to help them achieve specific goals and improve their confidence to continue with activities they enjoy or skills they want to retain, such as singing, for example.

An example of the work I do with carers is the cooking group we established, at the Carunya Dementia Day Therapy Centre in Warilla, for the male partners of some of our female clients. After telling us they needed help with learning to cook, we set up the group so the men could join a cooking class while their partner was attending respite at the centre.

The male carers learnt how to prepare and cook a meal, their partners then joined them in the dining room and everyone had a lovely meal while sharing their stories. You don’t need a good memory to enjoy beautiful meals, a beautiful cup of coffee or a beautiful walk along the beach.

People with dementia live in the moment and it is up to us as clinicians and carers and families to make that a good moment.