Early Indicators of Mild or Early Stage Dementia

Authored by: Kim Warchol, OTR/L

Research indicates that it is helpful to identify Alzheimer's and related dementias (ADRD) as early as possible. Early diagnosis can enable physicians to prescribe a cognitive enhancing medication such as Aricept. These medications may help to slow the progression, holding off the more severe symptoms that accompany the more advanced dementia stages as long as possible.

Early diagnosis has other benefits as well. A person who is functioning in the early stage or what is sometimes referred to as mild dementia (we would define this as a person in Allen level 4 or adapted FAST stage 4 or 5), is beginning to experience some functional and safety impairments due to the cognitive changes. These cognitive changes directly impact a person's IADL and ADL performance and safety.

Functional Performance Model
Remember, a person's highest level of function is comprised of several performance components including "cognitive level," "physical abilities," "sensory abilities," and "mood and behavior." We must evaluate each of these components when creating our goals and plans.

Claudia Allen describes function as being comprised of the "can do," "will do," and "may do" components.

• The "can do" is a person's actual Allen Cognitive Level and status in the other performance component named above.
• The "will do" relates to the person's interests, culture, and values.
• The "may do" relates to the person's external supports and resources.

Once again, using our clinical reasoning skills, we must consider and factor in all of these things before developing a plan.

According to the Allen theory, a person may be able to live at home alone if functioning at Allen level 4.6 or higher ("can do"). At 4.6 and 4.8 the person will require daily assistance to monitor safety, provide allowance, and check effectiveness of problem solving. At Allen Cognitive Level 4.6 or 4.8 we suggest that persons may have similar functional skills of a 6 to11-year-old and that their best ability to function would be at minimal cognitive assist.

However, despite the suggestion that a person at Allen level 4.6 or 4.8 might have the cognitive skills to live at home with daily checks/assist by a caregiver, this person is at a higher than average risk for an accident or injury to occur. Therefore, the professional must also put great emphasis on the "will do" and "may do" elements of the functional equation before making discharge or living environment recommendations. For example, is there a competent caregiver available to perform daily checks and to provide the assistance needed ("may do")? Is the patient a person who insists on driving based upon his or her interests, values and/or culture ("will do")? In the Allen theory, persons are not recommended to drive unless they have the cognitive skills present in Allen level 5 (5.6); therefore this desire might impact your recommendations.

Indicators of Early or Mild Dementia
As you can see, it is essential to identify indicators of early stage dementia. Identification of functional hallmarks associated with early dementia can be obtained via caregiver interview and/or observation of the patient. It is not recommended to rely on patient interview as this person lacks the insight and reasoning to accurately self-report.

The following are some questions that could be asked of the caregiver and/or obtained through patient observation:

IADL (Instrumental Activities of Daily Living) Performance—These changes are first seen in high Allen level 4 or adapted FAST stage 4

• Money management: Is the person paying the bills on time, writing the checks out correctly, are the calculations in the check book correct, is he/she balancing the check book? Also, look for indications of buying things the person can not afford or that they are not in need of (may be at risk for predatory crime).
• Medication Management: Is the person taking medications on time and following the prescribed dosages? Does he/she properly renew/fill medication prescriptions?
• Driving: Does the person get lost even to familiar places, leave the keys in the car, leave doors open, or make poor decisions when driving? Have you noticed any fender benders or scratches on the car?
• Housecleaning: Is there any difference in organization and cleanliness of the person's home/living environment? Are the proper cleaning materials in the house and used appropriately?
• Shopping: Does the person have any difficulty finding items in the store, making and using lists, managing the financial transaction? Does he/she keep the proper amounts and types of food in the home for adequate nutrition and according to any diet restrictions?
• Laundry: Is the person doing laundry routinely? Does he/she wash and dry the clothes correctly (i.e. whites and colors separated and correct detergents and amounts)? Does he/she put them away in the correct location?
• Meal Preparation/Cooking: How well does the person use the stove, oven, and microwave? Does he/she forget things on the stove, leave the stove on, or burn or undercook items? Does he/she leave food/drink open and/or out on a counter, or left until it spoils in the refrigerator?

ADLs (Activities of Daily Living) Performance—These changes are first seen in low Allen level 4 or Adapted FAST stage 5

• Dressing: Is the person changing clothes every day? Is the clothing clean and does the clothing match for color, season, event?
• Bathing: Is the person bathing/showering regularly? Do you notice any body odor, etc? Are the proper hygiene products in the home, being used, and being used correctly?
• Toileting: Is the person having any accidents (usually urinary incontinence happens before fecal)? Is he/she changing any incontinence pads regularly? Do you notice any odors or stains on furniture, bed lines, clothing?
• Eating: Is the person losing weight? Does he/she have the adequate food items in the refrigerator and cabinets?
• Grooming: Does the person keep well groomed or does he/she look disheveled? Is the person cleaning teeth properly, using make-up and deodorants as previously? Does his/her hair look as nice as always? Does the male shave with the same frequency and quality as previously?

In addition to inquiring about IADL and ADL performance, there are a few other general indicators of possible early cognitive decline.

They are:

• • Repeating questions
  • Word-finding problems
  • Difficulty learning something new, even if simple
  • Difficulty problem solving, even if simple
  • Forgetting or missing appointments
  • Disorganization

If the therapist identifies indicators of early stage dementia, validate these observations by administering one or more of the Allen Assessment Battery tools such as the RTI, Placemat Test, the LACLS (large leather lacing), or another one of the ADM projects, until you feel certain that you have found the pattern of behavior that is indicative of the person's Allen Cognitive Level.

Summary
There is a tremendous amount of value and practical application for a therapist who can identify possible early indicators of dementia. In fact, a doctor may not have made the ADRD diagnosis as the person may be able to hold a general conversation without flaw and therefore may fool the doctor during a routine visit.

The therapy team has the responsibility of evaluating cognition in order to identify best ability to function and to develop an accurate treatment plan, maintenance plan, and discharge plan. If we utilize a brief caregiver interview asking some of the questions suggested in this article, followed by administration of the Routine Task Inventory, Placemat Test, and/or LACLS, we will be able to clearly identify the person's cognitive status, which is a key element to the "can do" component of function.

Our cognitive evaluation and clinical reasoning skills set us apart from other health care professionals and are absolutely necessary to our patient's success and well-being.

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