Certified Recreational Therapist, Allison Menard and I have been using the Mini Mental State Exam (Folstein) and the Montreal Cognitive Assessment along with a variety of other standard assessments to get a baseline for new residents. Allison then develops a recreational therapy program for each person. She does some individual and group work while the activities and nursing departments integrate her recommendations in their treatment plans.

We’ve been comparing scores between the Mini Mental and the Montreal, re-testing a few months after admission and identifying domains within the assessments that are sensitive to the changes in cognition attributable to Alzheimer’s and subtypes like Lewy Body, Frontotemporal, vascular dementia and others.

Generally, we’re finding the Montreal to be “harder” in that it places higher value on executive functioning skills than the Mini Mental. When we compare the two scores from the same people, the Montreal produces lower scores with the same 30 point scale.

Over time, as expected, people lose points from the initial baseline and this correlates with families’ descriptions of declines in social and behavioral skills when the residents are out with families.

The sample size isn’t big enough for statistical significance analysis and that’s not our intent, especially in a real-life practice setting.

The breakdowns for both instruments into thirds (0-10, 11-20, 21-30) correlates highly with the amount of ADL care needed by the residents, as in lower scores=higher care needs.

When Alzheimer’s dementia transitions from a cognitive disease to a neurological one, the 0-10 score group develops gait, balance and small motor deterioration, so there are other behavioral/observational assessments to rate the nature, extent and frequency of staff interventions for hygiene, groom, safety etc. around the communities.

Residents with Lewy Body dementia and some vascular/multi-infarct syndromes have earlier and more debilitating central nervous system challenges.

Looking at a sample of 25 new residents, there are factors other than cognitive decline (on either assessment) that account for placement. With the disclaimer about small samples and statistical significance, we can report an informal analysis of variance (ANOVA) as follows:

Features reported by families, significant others, clinical providers and geriatric case managers contributing to placement are psychiatric and behavioral disturbances, increase in medical co-morbidities, wandering away from the primary residence, duration of dementia syndrome/s and decrease in available family and professional resources.

More than one feature is often cited, as a second or third challenge coming a few years into the course of the illnesses has an additive effect.

DISCUSSION

None of the placement variables is surprising, nor is any one new. There is a tolerance/intolerance variable in the family analyses which has both direct and inverse correlations. Family values like “the promise” (promise me you’ll never put me away), also known as “the pledge” apply in both directions, e.g. honoring the promise leads to longer tolerance of deterioration, which, in turn, leads to more negative features when placement is finally necessary to avert a crisis and/or manage a dangerous situation.

At this stage of our assessment and analyses, the scores on the Mini Mental and the Montreal are, in themselves, not seemingly predictive of placement. In a larger sample, for statistical significance, we project that scores in the lower two thirds are associated with psychiatric and behavioral challenges. We know that the lowest third has much higher needs for ADL support, when we compare repeated scores that decline and staff reports about increasing care needs.

RECOMMENDATIONS

More than 1/3 of Fields admissions come from other facilities. Dementia syndromes are “degenerative” by definition, so having a continuum of increasing care and counseling families at the time of admission about what’s inevitably coming are required from licensed facilities. Medical ethics demands reasonably good diagnoses and transparent prognoses across all medical disciplines and dementia practitioners have to meet a higher standard akin to oncology, cardiology, etc.

While nothing is certain or guaranteed, the past decade of dementia care and the absence of effective treatments point to a “typical” course of 8-12 years of illness, after diagnoses, ending with palliative and hospice interventions.

Our current guests maintain community living after diagnoses for up to five years before placement, if medical co-morbidities and the other risk variables don’t shorten the duration of community life.

While there are fast and slow progressions and early onset/late onset cases, as there are in all medical conditions, the placement “profile” is becoming quite clear.

Probably before Allison was born, I was attending lectures by Dr. Folstein, who, along with his wife, developed the Mini Mental State Exam. The Montreal and many similar assessment tools in the public domain place different emphasis on screening elements that go into a cognitive assessment (Montreal wants to charge you to become “certified” to administer and score the test. We don’t think that’s necessary).

By themselves, none can stand alone. A package that identifies several cognitive, emotional, medical, psychological and social variables is a reliable and valid approach to planning good dementia care. Then by tracking those variables over time and adjusting treatment plans to reflect changes, dementia-specialized communities can keep pace with the greatest challenges in aging.

Allison Menard, C-R.T.
John Hopkins Dr. P.H.

Happiness & Cognition at Bellamy & Watson Fields

What this graph shows

• These scores show no correlation between cognition & happiness
• A person w/ severe dementia can be just as happy as someone w/ mild, moderate, or no dementia
• All 5 residents retested 6 months later either had the same or an increased happiness score despite cognitive decline
  • You’ll notice. . .
    • No one’s cognition improved
    • No one’s happiness decreased

What We Do at the Fields

• Improve happiness & quality of life
• Maintain cognition & slow the progression of the disease
• The recreational therapist & other staff at the Fields work to improve or maintain happiness as they inevitably experience a cognitive decline
• We work to maintain cognition level as long as possible & to slow cognitive decline

Notable Info About Data

• Data cannot & is not intended to be considered statistically significant due to a small sample size
• There are many residents with severe-profound dementia that are not represented as they were unable to complete either assessment instruments used in this graph & were each assessed using simpler instruments and/or with observation.

Assessments Used

• MoCA (Montreal Cognitive Assessment)
  • Access test at https://www.parkinsons.va.gov/resources/MOCA-Test-English.pdf
  • More info about test at https://www.mocatest.org/
• SHS (Subjective Happiness Scale)
  • Access test at SUBJECTIVE HAPPINESS SCALE.pdf

More info at http://sonjalyubomirsky.com/subjective-happiness-scale-shs/