let me ask you if i knew everything about your judgment over the past sixty days could i build a case that your judgment is impaired how many of you have signed up for nine hours today pink that's good judgment day here that's the case that families try to bill is that their judgment as bad a judgment as a cognitive area so now that the plane that they have memory problem and they got impaired judgment that's the diagnostic criteria for dementia the reason that this diagnosis is so prevalent is that physicians have the same problem that we have they like to get paid and for every treatment that they provide they have to have a diagnosis the coincides with that treatment what happens to be the case that what you guys know someone with senile dementia the alzheimer's type it opens the doors to a wide variety of treatments that need no additional diagnostic explanation so that diagnosis becomes a very efficient diagnosis for physicians to use and it's very unusual medicare despite the fact it feels to me that they try to find recent wire services were not medically necessary one of the diagnostic codes that they do allow psychotherapy to be provided for is senile dementia of the alzheimer skype now if it's true indicates that you are serving patients that really have senile dementia the alzheimer's tight and you're providing weekly psychotherapy this would be of the type that they get to meet you for the first time every single week what do you really think you're accomplishing here you know if i have a patient that truly has alzheimer's dementia i mainly with them a couple of times to make sure of the diagnosis and be supportive to the family but i'm going off the case because i don't think psychotherapy is applications for someone with moderate to severe dementia they've got to be another way to do this besides psychotherapy i just don't think it's a patient that medicare does pay fort generally start my progress notes by saying patient was alert naureen at times foreign demonstrated could carry over morning so that i'm documenting that even though the station as an alzheimer's diagnosis it's that special sub-type e_ c_ that they do have carryover working i do think there's some dementia out there it's not nearly as problem as you would think it is do not be swayed by the official diagnosis on the medical record because there will be a number of folks that have an outside worse diagnosis that when you do your revaluation you'll be under convinced that they truly have this so just because you're diagnosed as outside burst over a lot of psychotherapy candidates make your own evaluation diagnostic criteria for depression by the way i really don't need the glasses i'm just using them to sort of get myself into the mood of the topic so understand at least five of the following symptoms have been present during the same two week period and one of the symptoms as either depressed mood or loss of interest or pleasure the other symptoms significant weight loss or gain when not dieting significant defined as more than five percent of body weight now do be aware that sometimes in working with older adults you will be encouraging them to set goals and one of the first goals that they may set is to lose ten pounds and as you look at them it will occur to you that they have a to lose and you say well how do you plan on losing ten counts a one point ee plus an exercise more super so they set out on a goal to lose weight now once this nursing home residents has set out on a goal to lose weight and they've dropped five or six pounds you can expect the facility to step in and assist us by putting them on supplemental feedings appetite stimulants an extra portions now the reason for that is that when your client sets a goal to lose weight and does it they end up on a weight loss sheet and the statement comes in surveys the nursing home finds that there are no weight loss sheet and the state knows why people are losing weight it's because the food is called it's not palatable that's being served at the wrong times so the nursing home gets in trouble for it so anytime you have a client in a nursing facility that sets a weight loss cole make the director of nursing and the dietitian aware of what's going on and cover it heavily in your notes that way when the state comes in and says why is she on the weight loss chic the facility can say i'll because doctor tom helper set a goal to lose weight it's in his notes that that's what's going on and the state will say okay for you that otherwise you got to get your facilities cleared otherwise the facilities are going to fight against the school and then that becomes one more example to your older adult client that sure enough when i try to do something somewhat block slick and its frustrating unisa lichtman learned helplessness we do a wonderful job with older adults teaching them helplessness and then we treated for depression be much smarter to just give you some of their power back that would reverse the depression number four insomnia or hyper sonya nearly every day psychomotor agitation or retardation fatigue or loss of energy feelings of worthless nicer excessive or inappropriate guilt diminished ability to favor concentrate recurrent thoughts of death not just the fear of dying but thoughts of death maybe even suicidal ideation with a suicidal plant also keep in mind that with some older adults there does come a time that they realize this is pretty well over and that may not be depression one of the most rewarding cases i had over the last several years was a client who i had been working with for about six months good businessman had opened and closed a variety of businesses most known for a uh... locker business that he operated for years had a stroke came into rehab hospital ended up in a nursing facility where they continued to throw therapy adding he made some slow gains and then had another stroke cap stroke at some point after about six or seven months physical therapy discharge game it was very clear the odds of him going home we're very slim he called me in one day and he looked at me and he says i trust you doctor column and just want to say something i don't want you to go brandon with this and ended up with me on a bunch of medications for depression but if you think i'm depressed only sell that i don't think i a m doctor tom rhino will good business when i see one and i note that there's some businesses that you need apply all money into to make them work and there's other businesses that you're just wanna bet the good money after pat and you really ought to close them up as i look at myself as a business it's not going to make it and there's no reason for anyone to putting more money into it it needs to be close and you have closed businesses and don't exactly know how to close this that doctor tom harvesting can about the stop eating if i stop eating won't that result in my death fairly quickly and i said you know it seems like it should doesn't i've had patients that stopped eating it's absolutely amazing they will go five six months and it's an out a leader oddly oakland ca it's painful it's hard on families it's hard on staff it can't be a barrel of 