Rehabilitation for Community Living

Transcription

1 Rehabilitation for Community Living Its not just the maid! Dr Roy Lee FRACGP, FAFRM(RACP) Rehabilitation Medicine Changi General Hospital 71 year old Lives with wife, son and DIL, 8th floor non lift landing Left CVA in July, recovered Fall: # left NOF in Sept 2010 Why the difference in function? Integrated care plans : stroke Integrated care plan *evidence is equivocal *Dowsey etal (1999),hip/ knee replacement (decr. LOS, time to ambulatn., complications) *Panella etal. (2005), CCF ( lower mortality) * little advantage over conventional rehab. care in LOS, mortality or institutionalisation.. poorer QOL, slower functional improvement but better documentation (Sulch) * No difference except less UTI. (Kwan) * difficult to apply where clinical practice is variable or patients..with multiple and different pathologies.. (Campbell) Allen et al: The effectiveness of integrated care pathways for adults and children in health care settings: a systemic review ; JBI Library of Syst. Rev.;2009;7 (3): Sulch D et al: Randomized controlled trial of integrated care pathway for stroke rehabilitation, 2000;31; Sulch D et al: Integrated pathways and quality of life on a stroke rehabilitation unit, 2002;33; Taylor WJ et al: Effectiveness of a clinical pathway for acute stroke care in a district general hospital, 2006 BMC Health Serv.Res.6(1):16 Campbell H et al: Integrated care pathways, 1998, Brit. Med. J. 316(7125): Kwan J, Sandercock P, In-hospital care pathway for stroke: an updated systemic review, 2005;36;

2 Rehabilitation Medicine Acute stroke: Organisation of care a.f.r.m. All people admitted to hospital should be treated in a comprehensive or rehabilitation stroke unit Level 1 evidence Science of Medicine in the prevention and reduction of disability and handicap arising from impairment. Management is from a physical, psychosocial and vocational viewpoint. Aust. Faculty of Rehabilitation Medicine. Rehabilitation Principles and Methodology Multimodal approach Reduce impairments Patient/ client (eg. family) focused Goal directed- functional Multidisciplinary & multi modal Assessment by all disciplines: FIM Discharge planning: Length of stay determined Weekly case conference- FIM achieved-new goals: flexibility pharmacological surgical modalities Reduce disabilities retrain function substitute function provide aids Reduce handicaps change environment family & carer support community support community access psychological adjustments Rehab environment: Disabled not sick Spasticity multi-modal approach Oral Baclofen, Gabapentin, Diazepam Management of pain, anxiety Botulinum toxin (1) Motor point injections: alcohol, Phenol Intrathecal baclofen (1) Vibration (2) Stretching (2) FES (1) Serial casting Dynamic splinting (3) EMG biofeedback (3) Orthotics 2

3 Brain plasticity Active not passive convalescence & engrams Treadmill walking +Partial weight support + other gait activities Lokomat robotic gait orthosis Upper limb activity Upper limb function Constraint Induced Movement therapy Strong evidence in chronic stroke & moderate evidence in acute stroke for patients with some active arm movement. Aphasia Task specific training (2) ADL Joint position biofeedback (3) Robot assisted reaching (2) Visuo-spatial/ perceptual Prism glasses for homonymous hemianapia (2) Computer based visual training (2) Cognitive rehab eg scanning for neglect (1) Strategy training for planning and task execution in apraxia (2) 3

4 6th World Congress for NeuroRehabilitation, 2010 FAMILY CONFERENCE education psycho-social support level 1 *Music as language of the human brain: implications for Neuro-rehabilitation *From singing to speaking: Observations in healthy singers and patients recovering from non-fluent aphasia *Learning to play piano supports fine motor rehabilitation after stroke Carer Training before discharge Personal care Physical handling Communications Swallowing Diet Home visit Community Rehabilitation Hospital based OP Day hospitals Community Early supported discharge Home based rehab. Level 2 Summary of findings of RCTs on client outcomes Dow B etal, Valuation of home-based rehabilitation in Victoria, Literature Review. National Aging Research Institute 2003 Client Outcomes Study No difference betw. Groups Anderson etal 2002; Anderson et al 2000; Gladman et al, 1995; Rudd etal, 1997; von Koch et al, 2000 Improved outcomes for home based rehab. Better outcomes for hosp/ outpatient group Indredavik etal, 2000; Mayo etal 2000; Rodgers etal 1997; Shepperd etal 1998 Ronning etal 1998 Level 1 evidence Home based rehabilitation Studies of cost effectiveness Dow B etal, Valuation of home-based rehabilitation in Victoria, Literature Review. National Aging Research Institute 2003 Anderson etal 2000 stroke Decr. LOS, Home no less costly.. Some cost shifting Beech etal, 1999 Decr. Inpt, higher non inpt. costs Farnworth etal 1994 # hip Reduced LOS Gladman J etal 1994 Day hosp care 2.5X>Dom care 2.5X>OP Indreavik etal 2000 Decr. LOS Mayo etal 2000 Decr. LOS Rodgers etal 1997 Decr. LOS Ronning 1998 Decr. LOS Shepperd etal 1998 Hip/knee No difference COAD Home based more expensive Cost shifting to GPs 4

5 TQEH Adelaide Argyle Diamond Mine Kimberleys WA CGH Singapore Snowy Mountains NSW Cultural difference?: independence & dependency Country Vs City Eastern Vs Western Comparison between Adelaide and Singapore factors affecting rehabilitation outcomes for community living: personal observations Dependence of the elderly and the disabled: Singapore Financial dependency from family 75% depend on allowance from children 74% >65years live with their children Medisave 51% of elderly paid from family member s medisave Educational level 70% no qualif.; 13% primary school in 2000 census lications/documents/how%20he%20elderlley.pdf tate%20of%20the%20elderly_release%203.pdf All Australians covered for free basic hospital and medical care under medicare Aged and disabled eligible for government pension ($1316/month) + other benefits if meet asset/income test. REHAB. GOALS MAY DIFFER 5

6 Accommodation and accessibility 23% Australian 50+ females live alone Less than 12% 65+ Singaporeans do not live with family member. TRADITIONAL SUPPORT SERVICES Domicillary care service Home nursing Local Council Options coordination Meals on wheels Independent Living centres Church and charity groups Access: public transport (subsidised for people with disabilities) The Singapore family 6

7 Family support and stress Review 2003: most studies no difference in carer stress betw. Hosp vs home based carers Crotty 2002 carers in home rehab. Greater improvement in SF36 mental health scores than carers of pts in hospital Singapore carers? Singapore: carer stress? Many families have no-one at home to care for elderly: all adults working Over 30,000 sandwich families- middle aged couples with young children and elderly parents. State of Families in Singapore from he%20elderly_release%203.pdf Crotty M etal: Early discharge and home rehabilitation after hip fracture achieves functional improvements: a randomised controlled trial. Clin Rehab. 2002; 16(4) Residential Care Lee R. etal Slow stream rehabilitation- a partnership between nursing homes, general practitioners and hospital based rehabilitation services 1998 Support in community, professional and voluntary Counselling service (1) support groups (2) Aphasia groups (2) SA Services Review, Phillipa Milne & Assoc

8 Volunteers? Strong evidence for using volunteers in aphasia training Level 2 evidence in group training State Bank of South Australia Mareeba social club association Amputee association Aphasia group Rehabilitation for community living impairment disability handicap WHO ICIDH 1980 body functions & structures activities and participation environmental factors personal factors WHO ICF

9 Johannes Vermeer The kitchen maid, c 1658 Thank You 9