What is rehabilitation?

Transcription

1 Maximising rehabilitation potential in people living with dementia Aims for today What the current research evidence tell us about rehabilitation approaches for people with dementia Approaches to maximise abilities and potential Approaches that might create excess disability How to engage people in setting goals Implications for practice Varied definitions What is rehabilitation? At your tables come up with a definition. From the latin, habilitate. to make able Restoring to previous levels? Independence? Quality of life? WHO ICF framework Rehabilitation of people with disabilities is a process aimed at enabling them to reach and maintain their optimal physical, sensory, intellectual, psychological and social functional levels. Rehabilitation provides disabled people with the tools they need to attain independence and selfdetermination. Emphasises interplay of person and environmental factors in physical and psychosocial functioning and participation. 1

2 Defining rehab and dementia Worthy goal is stabilisation Preserving existing skills Compensating for existing deficits Rehab outcomes could include: Slowing deterioration Living at home for longer Improved well being (physical & psychological) Decreased stress & burden for carers Buchan et al 2011 Defining rehabilitation and dementia 3 primary goals: Maintain/improve function /engage in ADL to extent possible Restore/compensate for functional decline associated with other events/illness Carer education Reifler & Larson 1990 Defining rehabilitation & dementia The rumour is. 4 approaches Post acute illness (physical) Post acute dementia related episode Cognitive rehabilitation As a general approach to working with people living with dementia Mary Marshall (2004?) People with dementia don t have rehab potential.or do they? Rehabilitation potential What is rehabilitation potential? No accepted standard definition Predicted by observations of carryover & functional gain (Burton et al 2014) At your tables come up with a definition. & how does it get assessed in practice? Estimate of capacity of cooperating & making functional gains (New 2009) 2

3 How do we assess rehab potential? Service criteria Assumptions Timing Expectations patients should have the opportunity to demonstrate rehab potential by participation in therapy Burton et al (2014) Assessment static or dynamic? Static assessment identify & quantify degree of impairment compared with normative sample/external criteria Objective What does this tell us about the approach we should take or an intervention we should us? Assessment static or dynamic? Dynamic interactive procedure measuring response to cues, strategies, feedback, task conditions introduced during testing Intervention/approach embedded within assessment Focus on individual variations rather than typical performance zone of proximal development Toglia (2009) Dynamic assessment & dementia? hypotheses generated by standardised instruments should also be tested in more ecologically valid contexts Bourgeois & Hickey (????) Helps us set the just right challenge level Non-threatening opportunity to show best ability despite limited awareness, anxiety etc The historical perspective Downward spiral View of dementia as an inevitable decline Low expectations of others Denial of opportunity to participate Preconceptions of futility of interventions to restore/maintain function Further deskilling deskilling Very little research carried out More denial to participate Further lowering Of expectations Inability to participate 3

4 Glass is half empty Dialectical model of dementia Deteriorating condition No cure Few available drug treatments which have been shown to have only a modest effect size?hope D = P + B + H + NI + SP Clearly, people with dementia are rarely going to return to their level of functioning before they had dementia, but many can function a great deal better than they do at present Mary Marshall (2004) It is a paradox that dementia patients are sometimes regarded as having no rehabilitation potential when they have the most to gain from a problem solving multidisciplinary approach George J, Long S & Vincent C (2013) How can we keep patients with dementia safe in our acute hospitals? A review of challenges and solutions. Journal of the Royal Society of Medicine 106(9) Evidence of rehab potential. Range of therapeutic interventions showing positive impact Cognitive Rehabilitation COTiD TAP CST Activity Glass is half full? The right support + Supportive environment + Recognition of skills and abilities as well as disabilities = Living well with dementia 4

5 Rehab potential? Yes. But maybe we need a different emphasis. And different approaches So it is possible but do we know how, and is it happening routinely in practice? Some of the challenges. Can people with dementia learn? Stressed & distressed behaviours might disrupt therapeutic processes How best to support and encourage carer involvement to maximise benefit? What can we learn from the evidence base? We don t have all the answers.. Traditionally people with dementia excluded from rehab research Starting to change but often Small sample sizes Small effect sizes Lack of methodological rigor Focus on NH residents what does this mean for people living at home? Hallmark characteristics (Gitlin & Earhart 2010) But there are some emerging themes Tailored to individual capabilities & environmental context Involvement of family (education & support) Simplification strategies (communication, environment & task) Habilitative rather than a restorative framework 5

6 Best practice principles (Ciro 2013) Role-based & task-specific training Client & family driven goals Motor learning Errorless learning External memory strategies Ciro C (2013) Improving occupational performance in people with dementia through role-based, task specific training. OT Practice 18(3) 9-12 Key concepts (Marshall 2004) Teamwork Working with families/support networks Prostheses Removing excess disability Learning and motivation Provides a focus Therapeutic relationships What do these suggested approaches look like in practice? Essential Getting to know the person Establishing rapport - therapeutic visiting Taking our time Understanding individual capabilities Do our assessments talk about strengths and remaining abilities as well as challenges and impairments? Does our approach to risk allow abilities to be seen and supported in action? Do we create opportunities to understand what cues, strategies, feedback, task conditions, environmental conditions etc help? Context environ, task, roles Physical environment Social environment Role-based Task-specific 6

7 Involvement of family Widely recognised as important How do you involve family in your practice settings? What does this look like when it works really well? What are some of the challenges? Are people with dementia able to learn new skills and are we as professionals able to train them? Van Halteren et al (2007) All memory is not equal. Episodic memory & working memory more likely to be impaired earlier Semantic memory & non declarative memory may be relatively intact until later Implicit memory less affected than explicit memory Need to distinguish between explicit & implicit learning and exploit in interventions Motor learning Possible under the right conditions Constant practice conditions Visual feedback Verbal praise Errorless learning Errorless learning Implicit learning might be impacted by presence of errors e.g. more difficult to learn from mistakes Errorless learning = elimination or prevention of errors during encoding (Laffan et al 2010) Maximises exposure to correct material Not one particular protocol External vs internal strategies Suggested that external strategies may be more effective Particularly if embedded in relevant tasks Individualised approaches Internal strategies don t consistently improve performance 7

8 Simplification Just right fit Too easy undermines confidence, boring, reduced opportunities Too hard undermines confidence, stressful, opt out of opportunties Rehabilitation can be effective if therapists bring to the treatment context an understanding of the person and their environment, use effective communication strategies, providing a supportive and simplified environment in which new learning and tasks occur, and offering caregiver education, support and training What does this mean in practice and for your own practice? Take a few moments to jot down the best of now and anything you think could add to your current good practice. 8