My hope is to shed some light and insight on assessment for patients with low-level cognitive function based on my clinical experience and what is allowed per regulations. This is Part 1 of a two-part series which will primarily focus on assessments, from screening to baseline data collection to how we assess these patients. The series will provide guidance on the assessment and treatment of individuals who present with low-level cognitive functioning. This course will examine methods for speech-language pathologists on the evaluation of patients, including methods for collecting baseline data and creating of functional, measurable, timely goal targets based on analysis of our clinical findings.
Regulatory Background - Medicare
Before addressing assessment, it is best to start with understanding what is allowable per regulation. The primary populations that I will be discussing in this course include stroke and dementia. The majority of those individuals fall into a Medicare benefit and oftentimes when looking for guidance in regulation we look to Medicare as the gold standard. If you treat for Medicare replacement or an HMO, most often other payers look to Medicare for guidance and language from Medicare regulation is used by other payers.
Many SLPs ask if they can provide services to individuals who “present with low-level cognitive functioning”. I often get this question when it is a patient who presents with a chronic, progressive or neurological condition and the therapist is trying to determine if there is a benefit to assessing and/or treating the patient. It is important to remember that when treating individuals with low-level functioning that are from a cognitive, progressive, or neurological condition, the services will most likely be rehabilitative or maintenance-based in nature.
Medicare regulations that are currently in place were set forth in 1987 as part of OBRA87 (the Omnibus Budget Reconciliation Act of 1987). This Act dramatically changed the approach to resident care for individuals in skilled nursing facilities. It required the federal government to establish a comprehensive assessment as the foundation for planning and delivering care to nursing home residents. This is one of the first regulations where a full interdisciplinary approach is required and a full comprehensive measurable assessment is required at various intervals. So, if you currently practice in long-term care or a skilled nursing facility this was the basis for the Minimal Data Set (MDS) that is used today.
This regulation also mandated that care providers and facilities "provide the necessary care and services to help each individual attain or maintain their highest practicable physical, mental, and psychosocial well-being” and “to ensure that the resident obtains optimal improvement or does not deteriorate within the limits of the residents right to refuse treatment and within the recognized pathology of the normal aging process." (Code of Federal Regulations [CFR] Title 42, Part 483.25).
Why is this important? As practicing clinicians, it is important to not only understand regulation but to know where to find it and know how to communicate regulatory information to other members of the interdisciplinary team. We need to be able to advocate to treat patients and to have that assessment opportunity. Unfortunately, in my clinical experience I have been given feedback such as, "Well, it's a chronic condition" or "It was such a severe stroke, do we really need to treat right now?" Therefore, it is important understand what is allowable within the regulation and provide care in order to help individuals attain and maintain. We aren't always looking for improvement. We can provide services to individuals with very low-level functioning in order to attain and maintain their highest practicable levels. This is also applicable to the PTs and OTs you may be working with in a team environment. Speech-language pathology services alone, when treating a low-level functioning patient, is not going to yield the best outcomes. Whereas, if all disciplines are intervening, there will be greater success for those individuals.
Anyone who is treating geriatric Medicare beneficiaries needs to be familiar with Chapter 15 of the Medicare Benefit Policy Manual. In particularly, Sections 220 and 230 are key reference areas. (As an aside, when we get into the clinical categories of stroke and dementia, there are new regulations in the Journal of Stroke from the American Heart Association and the American Stroke Association that tasks caregivers with seeing stroke as a chronic condition as well. So, not simply looking at stroke as a new onset, neurological condition but recognizing that for the majority of stroke patients the condition will be chronic in nature and there will be residual impairments for a significant period of time. Be aware of that as we discuss these regulations).
What does Medicare say about chronic conditions? Can an SLP assess and treat patients with chronic conditions? Yes, we can treat them for maintenance therapy. Medicare also says that if someone has a chronic, neurological condition we can treat them for rehabilitative therapy. Using direct language from the benefit policy manual, Medicare states that “rehabilitative therapy may be needed and improvement in a patient's condition may occur even when a chronic, progressive, degenerative or terminal condition exists.” Understand that this is general regulation for all therapy disciplines but we also know for speech language pathology, in addition to PT and OT, we have to treat within our scope and within our evidence base. This regulation does not supersede our evidence base. We must have an evidence-based approach to go to. The deciding factor for determining if a service is considered reasonable and effective for the patient's condition and requires the skill of a therapist is based on whether or not the service is skilled in nature. If there is something that you can do for the patient that no one else can do and your unique skill set yields a greater functional outcome for them, then we can and should be providing that level of care regardless of the fact that they are low functioning and may have a chronic, progressive neurological condition.
Clinical Categories: Stroke and Dementia
The two clinical categories that are the focus for this course are stroke and dementia because these are the two primary areas where we see low-level cognitive patients. I want to start by reviewing the guidelines. The American Heart Association and the American Stoke Association announced new guidelines based on literature in the medical journal, Stroke, about a year ago. These guidelines have been endorsed by ASHA, APTA, and AOTA and they give guidelines on what evidence base is present for the assessment, treatment, and prevention for stoke patients. The guidelines show that a treatment plan should include the following five elements:
(1) The Rehabilitation Program, which includes system-level sections (e.g., organization, levels of care)
(2) Prevention and Medical Management of Comorbidities, in which reference is made to other published guidelines (e.g., hypertension)
(3) Assessment, focused on the body function/structure level of the International Classification of Functioning, Disability, and Health (ICF)
(4) Sensorimotor Impairments and Activities (treatment/interventions), focused on the activity level of the ICF; and
(5) Transitions in Care and Community Rehabilitation, focused primarily on the participation level of the ICF.
Looking at the third element, the assessment should be focused on the body function/structure level within the ICF. There are more patient-centered payment models moving towards ICF language. Now is the time, if you are not familiar with ICF, to have an understanding of what that structure looks like. It's something that is currently utilized more often in other countries compared to its use in the states.
Stroke as a Chronic Condition
The AHA and ASA want providers to take a different look at the way we treat stroke patients. Stroke, fundamentally, is a chronic condition so we are not just treating that new onset for a short period of time. Formal rehabilitation, in general, ends about three to four months after the stroke. Of course, timing depends on type, severity and location of the stroke.
Prior treatment approaches have managed stroke medically as a temporary or transient condition, looking more at the acute event. But currently we know that there are unmet needs that persist in many areas. When looking at these chronic outcomes and what they are impacted by, there is a huge link to communication and cognition.
Oftentimes, care providers want to get someone to the point where they are physically able to return home or to their environment. However, we can’t forget about the communication and cognitive piece that is so important. The research shows that those unmet needs are related to social reintegration, health-related quality of life, the ability to maintain an activity and self-efficacy (i.e., the belief that someone has the ability to carry out a behavior). There is a high incidence of depression, reduced drive and reduced belief that they can still do things the way they did before. Apathy is manifested in greater than 50% of stroke survivors at one year after stroke. Fatigue is a common condition. Daily physical activity is low and depression is high.
By four years after the stroke, greater than 30% of stroke survivors report persistent participation restrictions (e.g., difficulty with autonomy, engagement, or fulfilling societal roles). Oftentimes that ties back into communication and cognition.
Stroke: Cognition and Communication
The AHA and ASA clinical findings recommend SLPs assess certain areas for cognition and communication abilities. (The actual article has tables with all of the areas broken down with the level of efficacy listed for each area.) The focus areas that should be assessed for cognition and communication include:
- Simple attention and complex attention
- Receptive, expressive, and repetition language abilities
- Perceptual and constructional visual-spatial abilities
- Memory, including language-based memory and visual-spatial memory - When thinking about language and cognition across a continuum in relation to memory, it is important to remember the language-based aspects that are tied to memory. This is not just short-term, long-term memory and immediate recall. It also includes sematic memory and word finding. Memory is multifactorial in nature. Therefore, if there is a lower-level language impairment, then there is also an impact on higher-level memory abilities.
- Executive functioning abilities, including awareness of strength and weaknesses, organization and prioritization of tasks, task maintenance and switching, reasoning and problem solving.
For lower-level individuals, treatment usually starts with simple attention tasks. We are not discussing treatment in this course, but for treatment planning, attention is very difficult to manage aside from managing external distractions. Oftentimes, we start treatment with attention to tasks, complex attention, and then move to those lower-level cognitive-language abilities for stroke.
Dementia: Medical History Work-Up
When looking at low-level cognitive function individuals who have a chronic, progressive, neurological condition, we likely see our highest incidents of patients in the dementia category. The remainder of this course will address considerations in the medical history work up for patients with dementia, what the assessment should include, what the benefits are as well as the pros and cons of dementia staging. Then, how the plan of care should be written, goal writing and case studies will be addressed.
With dementia, some background work should be done to ensure there is not another root cause tied to the low-level of cognitive function. First, a thorough medical and family history should be conducted. I recognize that could be challenging to do since the patient has dementia but there are some tips for creating a baseline that will be outlined later.
It is important to document any recent cognitive or behavioral changes reported by the family or caregivers. Before creating a comprehensive plan of care, it is also important to makes sure that the root cause of the low-level cognitive functioning is not due to a recent change in medication or addition of certain medications. Psychotropics, any sedative medications and hypnotics will impact cognitive function.
Depression also needs to be ruled out. The Geriatric Depression Scale – Short Form is used by many nurses and can be beneficial for differentially diagnosing between cognitive impairment and depression. It is very easy for someone with low-level cognitive functioning to have the root cause be a new onset of depression or worsening depression.
The final area to consider is delirium which is an acute disturbance in brain function. For example, a person with a moderate cognitive impairment who lives in an assisted living facility goes in for a surgical intervention because they fell and broke a hip. They go into surgery for a resection, are under anesthesia and when they come out of the anesthesia for a period of time they move from a moderate cognitive impairment to a low-level cognitive impairment.
We can't say that the root cause isn't just that anesthesia fog. So, that is a delirium. Any infection, surgical intervention or polypharmacy that would cause that course of delirium must be ruled out. Often, the difference is that the delirium has more of a sudden onset than a progression that is characteristic of low-level cognitive function. Delirium is usually more insidious in nature.
How is Dementia Diagnosed?
Why is cognition even a part of dementia? Cognition is part of dementia because it impacts one of the four core cognitive domains for actually receiving the diagnosis. Even though we, as SLPs, do not diagnose dementia it's important as a member of the interdisciplinary team that we are able to guide the other caregivers.
Dementia is not a specific disease but a series of symptoms that present for six months or longer, must occur from a higher level of function, is severe enough to interfere with the usual activities of daily life, and affects more than one of the four core cognitive domains:
- Recent memory
- Language - either comprehension or expression
- Visuospatial ability
- Executive function - abstract reasoning, problem solving and focus despite distractions
To Stage or Not to Stage?
Assessment for an individual with dementia often includes staging with the interdisciplinary team. Staging can be beneficial when it is done properly.
Pros. It can be beneficial in order to identify functional declines in the early stages. This course is focused on assessment of individuals with low-level cognitive functioning but what about chronic, progressive, neurological conditions where an individual was at a higher level and they have progressed to a lower level? If you have the opportunity to provide care in a certain setting like a SNF or a community outpatient center where you are able to follow individuals across the course of their disease process, staging in the early stages helps to identify functional changes as the person declines. Staging can help the entire team make the appropriate referrals and it helps us to individualize a plan of care based not simply on impairments but also based on residual abilities. As SLPs, we have a unique eye and a unique skill set to pick up on what individuals can do. Therefore, our assessment is not just about impairment but it is about tapping into residual abilities and developing our treatment plan around that to determine the appropriate level of care. Staging can also increase the awareness for family and caregivers of the natural progression of a disease process.