of 24
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Introduction to psychosocial OT
practice in dementia
Tuesday 18th January 2011
John Stone
Teresa Bartram
Yvonne ThompsonNicola Gibbs
Jo Gambrill
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Exercise
Dementia and loss
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Brain Pathology in Dementia
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Neuropsychology of Dementia(Wisconsin DOH, 2003)
Thinking processes: Perceptual disturbance
Judgement* Stimulation level
Attention* Cliffs
Perceptions* Heightened intuitionReasoning* Tunnel vision
Organisation* Depth perception
Memory recall* Reading
Communication* Out of sight .... / cuesAbstract thinking* Fluffy
Disorientation Sundowner syndrome
Disrupted social functioning
* >2 Occupational & Social functioning.
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NeuropsychologicalFactors(Finkel, et al, 1998)
%
Perceptual Delusions 20 - 73Misinterpretations 32 - 50
Hallucinations 15 - 49
Affective Depression up to 81Mania 3 - 15
Anxiety ?
Apathy ?
Personality Personalitychange up to 90Agitation up to 50
Behavioral up to 20
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Questions
Why is the degree of expressed Dementia and performance in
tasks not linked to extent of brain pathology we see in scans
and autopsies (Kitwood, 1993) & (Snowdon, 1996)?
Do psychometric assessments offer the best prediction of real
world functional performance (Lowenstein & Acevedo ,
2010)?
Is Dementia a process of degeneration with little hope of
improvement in functional performance (Gail Mountain,
unpublished)?
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POEM
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D=P+B+H+NI+SP
Ddementia
Ppersonality
BbiographyHphysical health
NIneuropathology
SPsocial psychology
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Dementia: a psychological response as a means of
coping with brain damage
Tom Kitwood
(2003)
LOVEAttachment
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Mental
Health ax
Physicalhealth/medication
Social/family history
Past
psychiatrichistory
Psychiatricinventory
Sleep, cognition (ACE-R),psychosis, appetite
Mood/affect
Interaction/communication
risk assessment
Occupationalperformance
COTES
AMPS
Interestchecklist
PAL
Model ofcreativeability
COPM
ICT Mental Health Assessment
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NICE (2006)
Diagnosis and assessment Basic dementia screen, usually in primary care:
- routine haematology (nurses)
- Biochemistry tests
- thyroid function tests
- Serum vitamin B12 and folate levels Perform midstream urine test if delerium is a possibility.
Conduct investigations such as chest X ray or ECG by clinicalpresentation.
Factors that may affect performance, including educationallevel, skills, prior level of functioning and attainment,language, sensory impairment, psychiatric illness and physicalor neurological problems.
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NICE Guidelines Dementia (2006)
Promoting Independence and
Maintaining Function
ADL advice and skill training from an OT
Advise re independent toileting skillsEnvironmental modifications to aid
independence
Physical exerciseSupport for people to go at their own pace and
take part in activities they enjoy
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Pool Activity Level (PAL)
Instrument for Occupational
Profiling
Profiles what level of
ability the person has.
Designed to enable carers
to use the PAL instrument
to engage clients in
meaningful occupation.
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The Pool Activity Level (PAL)
Instrument for Occupational Profiling
(Pool, 2008) PAL Personal History Profile
PAL Checklist Individual Action Plans for personal care
activities
PAL Activity Level Profile
Outcome Sheet for recording results
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Life History Work
As we go through life we build up a personal historywith its unique mix of joys and pleasures, sorrows andpains. Our sense of who we are is linked to that historyand if we lose that we lose something of ourselves
(Kitwood)
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PAL checklist
1 Bathing / washing
2 Getting dressed
3 Eating4 Contact with
others
5 Groupwork skills6 Communication
skills
7 Practical activities
(craft, domestic
chores, gardening)
8 Use of objects
9 Looking at a
newspaper /magazine
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PAL Levels
Planned; Can work towards goal directed activities with atangible outcome, but may not be able to solve problems thatarise
Exploratory; Can carry out familiar activities in familiar
surroundings, but more concerned with the effect of doing theactivity than the final outcome.
Sensory; Primarily concerned with experiencing the sensationof the activity and moving their body in response
Reflex; Often unaware of surrounding environment, moves asa sub conscious, reflex response to direct sensory stimulation.
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Exercise
In groups complete the PAL checklist based on
your observations of the video
OBJECTIVE:
Decide on the overall level the client isfunctioning at.
.
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Going Home
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Discussion
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Final Statement
As we become more emotional and less cognitive, its the way
you talk to us, not what you say, that we will remember. We
know the feeling, but dont know the plot. Your smile, your
laugh and your touch are what we will connect with. Empathy
heals. Just love us as we are. Were still here, in emotion and
spirit, if only you could find us.
Christine Bryden, Dancing with Dementia, 2005 p138)
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References and Bibliography
Chester, R and Bender, M (1999) Understanding Dementia: The Man with the Worried eyes. Jessica Kingsley, London.
Finkel SI, Costa e Silva J, and Cohen G (1996) Behavioural and psychological signs and symptoms of dementia: a consensus
statement on current knowledge and implications for research and treatment. International Psychogeriatrics; 8 (Supplement
3): 497500.
Kitwood, T (1993) Person and Process in Dementia.International Journal of Psychiatry8 (7): 541-545.
Lawlor, B (2002) Managing behavioural and psychological symptoms in dementia The British Journal of Psychiatry 181: 463-465.
Lowenstein, D and Acevedo, A The relationship between Instrumental Activities of Daily Living and Neuropsychological
Performance. In Thomas, D and Grant, I (eds) (2010) Neuropsychology of Everyday Functioning Guildford Press. London.
U.K.
Snowdon, D, A., Kemper, S, J., Mortimor, J, A., Greiner, L, H., Wekestein, D, R., and Markesbery, W, R. (1996) Linguistic abilityin early life and cognitive function, and Alzheimers disease in later life: Findings from the Nun study. Journal of the
American Medical Association275, 7, 528-532.
Wisconsin DOH (2003) Progressive Declines of Alzheimers Disease & Related Dementia: Physical Changes That Effect
Perception of the Environment. Bureau of Aging & Long Term Care Resources, Wisconsin. USA.
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References/resources
Wenborn et al (2008) Assessing the validity and reliability of the PAL Checklist. Aging & Mental Health, in press.
Stoddart (1998) Dementia Care: Supporting a plea for personhood. Scottish Journal of Healthcare Chaplaincy 1: 9-11.
Everybodys business: integrated mental health service for older adults: a service development guide. Department of Health (2005)
www.dh.gov.uk
The National Institute for Clinical Excellence (2006): dementia. www.nice.org.uk
Pool (2007) The Pool Activity Level (PAL) Instrument for Occupational Profiling: A Practical Resource for Carers of
People with Cognitive Impairment. Bradford Dementia Group Good Practice Guides. Jessica Kingsley Publishers; 3Rev Ed
edition.
http://www.dh.gov.uk/http://www.nice.org.uk/http://www.nice.org.uk/http://www.dh.gov.uk/