MDS Alert

Utilize the MDS as a tool for navigating and documenting dementia.

Use the MDS assessment as an opportunity to paint a comprehensive picture of a resident’s condition. If you find signs of dementia from your MDS investigation, you’re better equipped to establish a comprehensive, holistic care plan. Watch for specific indicators lurking in various sections of the MDS.

Section B (Hearing, Speech, and Vision)
Evaluate Communication
How a resident communicates (or whether she even attempts to communicate) can provide you with helpful information for monitoring a resident’s progress and well-being. While deteriorating communication skills can be a red flag for dementia, you can also use your assessment in Section B as the basis for an interdisciplinary approach to making sure a resident has what he needs to communicate.

Check hearing ability, check glasses prescription, and perform an oral health assessment. If you identify a compromised capability, like a resident who suddenly seems to be in “her own world,” secure a hearing test to make sure she’s not just having a hard time hearing others who are trying to engage with her. If those “fixes” aren’t solutions, keep an eye out for other earlydementia signs, both in your assessment and coding of the MDS and in your everyday observations in your facility.

Section C (Cognitive Patterns)
Take Your time
Cognition is a major indicator of mental well-being, butbe careful to read and analyze the signs and symptoms before jumping to conclusions, especially with newly admitted residents. For example, if residents come directly from the hospital, they may appear confused from a medication adjustment or the change in environment.

Coding top tip: Complete a Brief Interview for Mental Status (BIMS) assessment on the day of admission to establish a baseline, but don’t code your findings from the initial assessment in the MDS. Instead, complete another assessment again in a few days.

A resident who just transferred to your facility from the hospital may fare poorly on a BIMS assessment due to delirium and the poor cognitive performance may be mistaken for dementia. Give yourself and your team enough time to help a resident resolve any acute medical conditions to get a better, more accurate picture of cognizance, says Sally Fecto, Senior Vice President of Field Operations at Harmony Healthcare International (HHI) in Topsfield, Massachusetts.

Section D (Mood)
Watch for Mood Changes
Section D is another place to watch for change over time; a noticeable shift in a resident’s PHQ-9© results could indicate underlying, undiagnosed depression or the beginning of dementia. Pay special attention to a resident’s self-reporting about concentration, Fecto says. Utilize the PHQ-9© as a tool: Conduct the interview more frequently than you need to code the MDS so you can more effectively monitor change over time.

Section E(Behavior)
Monitor Behavior
Keep tabs on a resident’s day-to-day state of being: Behavior changes can be a major indicator of evolving disease. “Personality changes are quite often an indicator of dementia that’s evolving,” Fecto says. Look out for visual hallucinations, delusions, changes in physical or verbal behaviors, or rejecting care as red flags to investigate further. A resident who’s suddenly avoiding or fighting bathing could be struggling with evolving dementia, Fecto adds.

Section F (Preferences for Customary Routine and Activities)
Maintaining Interests and Preferences
Look out for residents who no longer participate (or are not capable of participating) in activities they once markedly enjoyed. Keep an eye out for mood and behavior changes, which could be indicative of either depression or dementia.

Section G (Functional Status)
Beware of Changes in ADLs
Changes in ADL capabilities can be a major indicator that an underlying condition may be developing. Take a second look at residents who are no longer able to perform everyday tasks like getting dressed or need cues throughout most meals. Residents who can no longer perform activities they’ve managed their entire lives without assistance may present other signs of dementia, too. “Changes in ADL function clearly are or can be an indicator of different stages of dementia,” Fecto says.

Section H (Bladder and Bowel)
Incontinent or Forgetful?
Investigate various root causes for any change in continence. Incontinence could be caused by a change in medication or loss of muscle or bladder strength and function, but what appears to be incontinence could also be a sign of forgetfulness. A resident who appears to lose bladder or bowel control may be fighting forgetfulness. He may be voiding out of desperation and discomfort because he forgets how to get to the bathroom or what to do once he’s in there. This type of locational confusion is a red flag for dementia, but look to your team members for help.

Use environmental cues, interventions, and develop a care plan to help this resident remain in a higher continence level, Fecto suggests.

Coding top tip: Don’t forget to code any moisture associated skin damage in item M1040H (Other ulcers, wounds and skin problems … MASD).

Section I
(Active Diagnoses)Look through Web of active Diagnoses
Some diagnoses could be a cause for concern, but be careful to attribute signs and symptoms to the correct medical condition, whether underlying or diagnosed. For example, Mrs. Joseph’s aphasia could be the result of a recent stroke or it could be a sign of dementia. Here are some conditions to look for:

• Anemia,
• Thyroid disorders,
• Vascular disease,
• Diabetes,
• Parkinson’s disease that presents with Lewy Body type dementia, and
• Acute infections.

A good care plan goal is to resolve underlying issues with assessment monitoring and intervention, Fecto adds.

Section J (Health Conditions)
Watch for Falls
A resident’s ability to ambulate safely, as well as assess her own strength and mobility is a good measure of well-being; note and evaluate any loss of these functions. “Falls are a huge area that every facility is in tune with,” Fecto says. “Falls can indicate that other safety insight is diminished and that safety awareness is diminished. Looking at falls that recur could be an indicator to dig a bit deeper into root cause,” she adds.

Section K (Swallowing/Nutritional Status)
Self-Feeding is a Benchmark
As self-feeding is another activity that residents perform independently throughout their lives, a loss in eating ability is a red flag for dementia. Additionally, a swallowing disorder can be a sign of progressing dementia, Fecto says.

Section N(Medications)
Monitor Meds for Dementia Red Herrings
Some medication side effects or combinations of meds may provoke delirium, confusion, or other signs that you could mistake for dementia. Look through medication lists, see if there are bad combinations or unnecessary medications that you or a doctor could eliminate. Monitor residents to see if the delirium or confusion clears up; if not, discuss with physician to consider a dementia diagnsosis.

Section P (Restraints)
Last Line of Defense
Most facilities minimize their use of restraints and use them only as a last resort to keep a resident safe, so if you notice a resident is being restrained, find out why. If a resident no longer has much safety insight (and exhibits other signs of dementia), treating the underlying cause can make the resident safer and more comfortable, as well as reduce or eliminate the need for restraints. For example, Mr. Marshall becomes violent to staff each day as evening approaches, and team members restrain him, but you realize he may be “sundowning.” Adjust his routine so he’s safe in bed in late afternoon instead of trying to move him at the daily peak of his agitation or fear.