How To Use The GDS As An Occupational Therapy Intervention

By Melissa Zahradka, MS, OTR/L

Occupational therapist

The Global Deterioration Scale can be the remedy to a common occurrence for an occupational therapist about to treat an older adult experiencing dementia. At some point in our careers, we have all been faced with the challenge of receiving a new patient that had only one diagnosis code provided: Unspecified Dementia.

This could not be vaguer, am I right?

Nothing is more intimidating than walking into a new patient’s home knowing only this small piece of information, especially for a new graduate.

So, now what?

Before entering the home, we already know there are clear deficits impacting the patient and their family, and it is our job to uncover what skills have been impacted as a result of this diagnosis.

Have no fear!

Let’s take a step back and do what occupational therapists do best: use a holistic approach to assess a patient’s needs starting with a standardized assessment. In this case, I’m referring to the Global Deterioration Scale.

The GDS is a standardized measure that provides an overview of cognitive function for persons diagnosed with dementia. Using this tool as the first step of the occupational therapy process is critical in identifying which stage of dementia your patient is in. Not only is it important to use during the evaluation, but the information you gather will assist in developing a clinically excellent plan of care, support your documentation, and be used to collaborate with your physical therapy or speech-language pathology counterpart.

STEP ONE: EVALUATE THE patient USING THE GLOBAL DETERIORATION SCALE

As we all know, dementia is progressive and presents differently in each person living with the disease. Within each stage of dementia, a person’s ability to process incoming information slowly deteriorates, resulting in visual deficits, challenges with auditory processing, and loss of fine motor skills.

The GDS organizes these changes into seven stages. Identifying the GDS stage will help you to better understand exactly what your patient sees, hears, and why they move the way they do. Having an understanding of these stages will assist in further evaluating your patient’s specific needs based on their challenges stemming from dementia and will help shape how you create your intervention plan.

A thorough interview with the patient, family, and/or caregivers, in addition to administering functional outcome measures, can support your staging and why the patient needs skilled intervention.

Measures such as the Barthel Index and the Bristol Activities of Daily Living Scale can be used in conjunction with the GDS to establish your patient’s baseline and paint a detailed picture of their performance within their daily routine. Both of these additional measures focus on participation in activities of daily living, an area that almost all of our patients with dementia have difficulties in. Establishing a baseline using these tools is vital in creating realistic goals for both the patient and their family.

So now you’ve assessed your patient using the GDS. How many times have you then heard the phrase, “But they can’t understand what you’re saying, so what’s the point of therapy?”

Using the GDS during the evaluation phase can assist in educating the family and/or caregiver on the disease progression, including what changes can be expected, the role they will play in the patient’s day-to-day routine, and why OTs are a key player in the patient’s care. Not only will this help you develop rapport, but it can assist in increasing the carryover of your recommendations as you begin the next step, intervention.

STEP TWO: OT INTERVENTION

Now it’s time to submit your goals and get to work. Yet where do you begin?

Because you gathered a plethora of information from the GDS and other functional outcome measures during the evaluation, you have a better understanding of what and how your patient is processing incoming information from others and their environment. Break down each task to identify the fundamental skills needed to complete the task. Once you have narrowed down these skills and difficulties, you can adapt, modify, and assist the patient in engaging in individualized therapeutic activities to improve their safety and participation during ADLs— classic OT!

Let’s go through an example:

You administered the GDS and Barthel Index during the evaluation and determined the patient is a stage 6: moderately severe dementia.

The patient’s caregiver is reporting that the patient does not follow instruction during toileting. The caregiver is very frustrated that the activity is taking too long and is worried the patient will have a fall. Knowing the patient is at stage 6, you understand the patient may only be processing about three to four words that are spoken and may have binocular vision, resulting in difficulties following multi-step directions and locating the button on her pants.

You can take this information to focus your session on caregiver education regarding communication strategies and safety techniques to implement in order to improve the patient’s understanding and engagement. Following this, you can take it a step further and perform blocked practice to access the patient’s procedural memory to address carryover of skills.

I’m sure you’re thinking this is much easier said than done. You’re right. But that doesn’t mean it’s impossible. Of course, your patient will have cognitive challenges, and maybe even negative behaviors when you’re addressing these challenges, but this is where your craft and expertise comes into play.

If the GDS was not used in this example, you may experience challenges identifying why the patient is unable to understand the caregiver’s instruction or you may find that it takes you a few sessions to uncover it. Using the GDS to your advantage during step one sets you up for success during the intervention planning and implementation phases of the OT process.

STEP 3: DOCUMENTATION

Documenting a patient’s progress can get tricky when there is a dementia diagnosis.

In many cases, our goals are focused on caregiver carryover and understanding of strategies provided, with no change in the level of assistance the patient physically needs. Unfortunately, insurance sometimes does not understand this, which is why using the GDS starting at the initial evaluation and throughout the plan of care is crucial in supporting the need for skilled care now.

Even without a dementia diagnosis, insurance wants to know, “why therapy now?” or “why is it medically necessary to have an assistive device?”

You and I both know why it’s necessary, but referring to the GDS during your assessment takes your evaluation to the next level. The GDS clearly communicates that the patient has cognitive deficits that prohibit independence and run the risk of further functional decline. A simple statement with this information exemplifies that your skills are needed to improve the patient’s and family’s quality of life, no matter what stage.

However, this doesn’t mean it can only be mentioned once. Referring to the GDS in a daily or progress note shows insurance that you are continuously assessing your patient’s and family’s needs as a result of the diagnosis and further justifies the need to continue therapy.

We’ve all been in those situations where it’s late at night and you have a durable medical equipment request to submit on behalf of your patient, who is a stage 7. Don’t overthink it; remember the handy GDS!

Here’s a short example:

The patient has mobility limitations due to a diagnosis of dementia, with a score of 7 on the GDS, in addition to decreased strength and chronic pain. The patient is unable to perform functional weight shifting due to her cognitive status, leaving her at risk for the development of pressure ulcers or choking during meals.

If the GDS was not previously mentioned in your plan of care, justifying the medical necessity of equipment described in the above example would pose a challenge or the delivery of that equipment may be delayed until you do so. Our time is valuable. So set yourself and your patient for success by using the GDS early and often.

STEP 4: COLLABORATION BETWEEN REHABILITATIVE CLINICIANS

Now that you’ve obtained all of this useful information using the GDS, it’s time to spread the wealth! Your therapy counterpart(s) may be facing some challenges when trying to communicate with or engage your shared patient in activities. Providing them with the information you found using the GDS can prove helpful in their arena, just as it did for you.

As an OT, we are well-versed in how to adapt and modify a task or the environment to better suit a patient’s needs, in addition to how to communicate with the patient. If you found a successful way to achieve either of these goals, sharing that information with your interdisciplinary team can further help your patient and their family succeed.

On the flip side, maybe the patient has not been evaluated by an SLP or PT. If so, open the line of communication with your counterparts before an evaluation is completed. This will help everyone get on the same page and communicate the need for completing the GDS if a diagnosis is present. This is also a good time to plan a follow-up call regarding your assessment and plan of care to ensure the patient is receiving well-rounded care.

READY TO DIVE IN?

As a new FOX clinician, I will never forget my first patient with dementia.

I felt overwhelmed.

I felt intimidated.

I feared that I would not be able to give this patient and their family the help they needed.

In learning more about the GDS, my perspective changed and I realized I had all of the tools I needed from the start. Using the GDS can help to focus on what the patient and family need to improve their quality of life. It can assist in looking at the bigger picture and go back to the basics of what skills the patient needs to purposefully engage no matter what stage they are in.

“I long to accomplish a great and noble task; but it is my chief duty to accomplish small tasks as if they were great and noble,” Helen Keller said.

Occupational therapists know all too well that accomplishing or engaging in even the smallest of tasks can make an immense difference in a patient’s life, especially those diagnosed with dementia. Have confidence that, as an OT, you are the best for the job with a little help from the tools created for us.