Mental Health of the Older Adult November 12, 2008 Sandy Ceranski, MS, OTR [email_address]
Sandy’s Tips <ul><li>Compassion </li></ul><ul><li>Competence </li></ul><ul><li>Conscience </li></ul>
Depression <ul><li>Presentation generally different  </li></ul><ul><ul><li>Lack of energy </li></ul></ul><ul><ul><li>Lack ...
Dementia <ul><li>Diagnostic Criteria </li></ul><ul><ul><li>Memory impairment </li></ul></ul><ul><ul><li>At least ONE other...
Occupational Therapy  Purpose  <ul><li>Promote engagement in occupation to support participation </li></ul><ul><li>Restore...
Performance Based Assessment <ul><li>Identify  best ability to function and level of assistance in  B-ADLs and I-ADLs </li...
Quality of Life Assessment <ul><li>Mobility, social relations, affording and obtaining necessities, living independently, ...
Interventions <ul><li>Environmental Support and Adaptation </li></ul><ul><ul><li>Aging in Place </li></ul></ul><ul><ul><ul...
Interventions <ul><li>Occupational adaptation </li></ul><ul><li>Behavioral techniques </li></ul>
What do you … <ul><li>Want to know more about? </li></ul>
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Mental Health Of The Older Adult.Uwm.11.08

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  • Syndrome In medicine and psychology , the term syndrome refers to the association of several clinically recognizable features, signs (observed by a physician), symptoms (reported by the patient), phenomena or characteristics that often occur together, so that the presence of one feature alerts the physician to the presence of the others. In recent decades the term has been used outside of medicine to refer to a combination of phenomena seen in association. Aphasia (from Greek, aphatos  : &apos;speechless&apos;), also known as aphemia , is a loss of the ability to produce and/or comprehend language , due to injury to brain areas specialized for these functions, Broca&apos;s area , which governs language production, or Wernicke&apos;s area , which governs the interpretation of language. It is not a result of deficits in sensory, intellect, or psychiatric functioning, [1] nor due to muscle weakness or a cognitive disorder. Depending on the area and extent of the damage, someone suffering from aphasia may be able to speak but not write, or vice versa, or display any of a wide variety of other deficiencies in language comprehension and production, such as being able to sing but not speak. Aphasia may co-occur with speech disorders such as dysarthria or apraxia of speech, which also result from brain damage. Apraxia is a neurological disorder characterized by loss of the ability to execute or carry out learned purposeful movements, despite having the desire and the physical ability to perform the movements. It is a disorder of motor planning which may be acquired or developmental, but may not be caused by incoordination, sensory loss, or failure to comprehend simple commands (which can be tested by asking the person tested to recognize the correct movement from a series). Apraxia should not be confused with aphasia , an inability to produce and/or comprehend language, or abulia , the lack of desire to carry out an action. There are several types of apraxia including: ideomotor (inability to carry out a motor command, for example, &amp;quot;act as if you are brushing your teeth&amp;quot; or &amp;quot;salute&amp;quot;) - the form most frequently encountered by physicians , limb apraxia when movements of the arms and legs are involved, nonverbal-oral or buccofacial (inability to carry out facial movements on command, e.g., lick lips , whistle , cough , or wink ), ideational (inability to create a plan for or idea of a specific movement, for example, &amp;quot;pick up this pen and write down your name&amp;quot;), limb-kinetic (inability to make fine, precise movements with a limb), verbal (difficulty planning the movements necessary for speech ), also known as Apraxia of Speech (see below) constructional (inability to draw or construct simple configurations), oculomotor (difficulty moving the eye ) Agnosia ( a-gnosis , &amp;quot;non-knowledge&amp;quot;, or loss of knowledge) is a loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective nor is there any significant memory loss. [1] [2] It is usually associated with brain injury or neurological illness , particularly after damage to the occipitotemporal border , which is part of the ventral stream . [3] The executive system is a theorized cognitive system in psychology that controls and manages other cognitive processes. It is also referred to as the executive function , executive functions , or cognitive control . The concept is used by psychologists and other neuroscientists to describe a loosely defined collection of brain processes which are responsible for planning, cognitive flexibility, abstract thinking, rule acquisition, initiating appropriate actions and inhibiting inappropriate actions, and selecting relevant sensory information.[ citations needed ] The executive system is thought to be heavily involved in handling novel situations outside the domain of some of our &apos;automatic&apos; psychological processes that could be explained by the reproduction of learned schemas or set behaviors. Psychologists Don Norman and Tim Shallice have outlined five types of situation where routine activation of behavior would not be sufficient for optimal performance [1] : Those that involve planning or decision making. Those that involve error correction or troubleshooting. Situations where responses are not well-learned or contain novel sequences of actions. Dangerous or technically difficult situations. Situations which require the overcoming of a strong habitual response or resisting temptation
  • Cognitive Performance Test Update Cognitive Performance Test Update By Theressa Burns, OTR The Cognitive Performance Test (CPT) was initially developed as a research instrument to provide a baseline measure of global function in individuals with Alzheimer’s disease (AD) and to track change over time. Currently, the test is used in clinics, long term care, and in the home; and with other dementia and geropsychiatric diagnoses, CVA, and TBI patients. Based on Allen’s ordinal scale of function, CPT total scores represent the cognitive levels delineated by the model. The original test uses six common daily living tasks, for which the information-processing requirements can be systematically varied. A gross level score is obtained for each task; these scores are then added and averaged to determine the cognitive level and mode. Recently, a new subtask titled “medbox” was added. Increasingly, the issue of patient capacity to safely manage medications is of concern, and is identified nationally as an area for quality improvement. Adverse drug events, medication underadherance and noncompliance are common problems, and in Geriatrics are associated with poor cognition, dementia, living alone, and having three or more medications. As with the other CPT subtasks, although the patient’s cognitive level is used to predict and explain actual performance, an objective measure of competency with a medication task offers face validity for the referring physician, family, and patient. The “medbox” task requires the patient to follow directions on four bottles of dummy medications (beads) and set-up two pillboxes accordingly, for one week. The bottle directions vary in complexity and two pillboxes are used to add complexity to the task. In addition to assessing the ability to follow medication directions, administration of the task involves giving cues to assess ability to identify inaccurate set-up and correct errors; and reducing the number of bottles and complexity of the task at lower cognitive levels. Studies of the medbox task show a significant difference in performance between normal control subjects and subjects with a dementia diagnosis, and correlation with the other subtasks and CPT total score. CPT total scores have been found through empirical study to be predictive of functional capacities and needs of patients. For example, with respect to managing medications, persons who function in level 5 can often manage their medications if a routine has been well established, or the management is simple, or there is room for error (can miss pills), or a compensatory strategy is in place. Caregivers may be needed to monitor compliance or to provide reminders. Persons who function in level 4 require close monitoring of medications, and depending on the complexity of the regime, usually require set-up or restriction or reminders to day-to-day supply. Compensatory strategies are often ineffective in mid to low level 4, as the capacity to learn and follow plans is significantly impaired. Persons who function in levels 3, 2, or 1 are not competent to manage any medications. Medications need to be given and access restricted. Studies of the CPT demonstrate that administering less than 4 subtasks skews the total score, as there are not enough performances to average. This author typically administers all 7 subtasks in about 45 minutes, since her population has very mild to moderate cognitive disability. Patients who live in restricted settings where safety is much less of a concern, may only need to perform portions of the test. Administration in the home does not allow for using the full test, since the DRESS and TRAVEL subtasks are not portable. However, it is feasible to use the remaining 5 tasks in the home, with standard props that the therapist brings in and sets-up according to the protocols. In response to the need for more portable props, an alternative to using belts in the SHOP subtask has been developed; the administration protocol is the same but gloves are used instead. The updated CPT manual includes these new revisions. Original studies of the CPT were initiated in 1991 at the Minneapolis Geriatric Research, Education, and Clinical Center (GRECC), as part of a National Institute of Aging longitudinal study of AD. The test was found to be valid and reliable and findings are reported in the Journals listed in the reference section of the manual. Recently, the CPT has been compared to Neuropsychological Assessment. Bares (1998) retrospective study of AD patients who were evaluated in the GRECC found significant relationships between performance on the CPT and on neuropsychological measures. The sample included 100 mostly male, Caucasian patients aged 59 or older with mild to moderate stage disease. The average age was 74.9 years. In a hierarchical regression analysis of neuropsychological variables predicting function as measured by the CPT, significant predictors were neuropsychological measures that involved psychomotor skill with a planning, sequencing, and attentional component, while measures of memory, language, background variables and comorbidity were not predictive of function. Neuropsychological predictors of performance on the CPT were characterized under the rubric of executive function. Other analyses showed the CPT subtasks were highly related to each other. The CPT was found to have high internal consistency reliability (a = .76), which is comparable to although somewhat lower than the previous finding of .84. Factor analysis of the six CPT subtests supported the Burns et al. conclusion that the tasks are nonspecific, and reflect a single construct characterized as global functional status rather than discrete functional living skills. Findings support the conclusion that the CPT total score, not the individual tasks should be used. Jennings-Pikey (2001) conducted similar studies of the relationship between neuropsychometrics and the CPT. One hundred eleven inpatient records from an inpatient psychiatric hospital in the Upper Midwest were accessed for study through archival records. The sample was mostly female and Caucasian, average age was 79.6 years, and 61% of subjects received a primary diagnosis of dementia or memory loss. There was a significant difference on the CPT between the means of the group that was given a memory loss diagnosis and those who did not receive this diagnosis, demonstrating that people with a memory loss diagnosis functioned at a lower level on the CPT. The validity of the CPT was supported to the extent that the test showed significant correlations with measures known to be sensitive to cognitive functioning in older adults. Convergent validity was demonstrated with significant correlation to the Global Assessment of Functioning (GAF) and the internal structure of the CPT to measure competency to carry out independent living skills was upheld. Last Updated ( Friday, 09 May 2008 )   Routine Task Inventory-Expanded RTI-E Monday, 07 January 2008 02:06   The Routine Task Inventory was introduced in 1985 as an assessment of cognitive abilities in the context of routine daily activities. In 1989, Claudia Allen developed an expanded version of the original Routine Task Inventory (RTI-E). The RTI-E is widely used in clinical practice in Israel where it has also been used in several research studies. Noomi Katz PhD, OTR, (Professor of Occupational Therapy at Hebrew University, Jerusalem), has recently developed a manual for the RTI-E in order to encourage others to use this tool in clinical practice, and research. This manual includes the RTI-E as Allen presented in 1989 along with clarified instructions for administration, and a thorough summary of the research studies that have included the RTI. Dr. Katz has generously agreed to make this new manual available through the Allen Cognitive Network web site free of charge. If you would like to download a copy of this manual, click on the link below. RTI Manual  248.74 Kb   Last Updated ( Thursday, 19 June 2008 08:28 )   Brief History of the Allen Cognitive Battery Monday, 07 January 2008 01:51  The Allen Cognitive Battery consists of several tools for evaluating attention, problem solving, and learning in persons with brain conditions resulting in some cognitive restrictions. The idea of developing a scale to measure global functional abilities of persons with psychiatric disorders was originated over thirty years ago by Claudia Kay Allen, MA, OTR, FAOTA and her colleagues at Eastern Pennsylvania Psychiatric Institute in Philadelphia.  A leather-lacing test, now known as the Allen Cognitive Level Screen (ACLS) , was developed at this time to provide a quick measure of learning/cognitive abilities.The “Cognitive Levels”, as they were then called, consisted of six levels, measuring a continuum of clinically observable, qualitative differences in ability to perform functional activities. Work on the levels continued by Claudia and others at Johns Hopkins Hospital in Baltimore and subsequently at LAC+USC Medical Center in Los Angeles. A standardized procedure for administering the ACLS was developed in 1978 (D. Moore thesis). Several studies followed, establishing inter-rater reliability and correlations between the ACLS and other psychological tests including the Block Design of the WAIS, the Brief Psychiatric Rating Scale, Shipley Institute of Living Scales, and the Symbol Digit Modalities Test. Other studies examined the relationship of cognitive level, as measured by the ACLS, to different psychiatric disorders, and between normal and psychiatric populations. The standardized directions for the ACLS were first published in 1985 ( Occupational Therapy for Psychiatric Diseases: Measurement and Management of Cognitive Disabilities , Allen. Boston, Little Brown, out of print) and revisions in ratings were made in 1988, 1990, 1996, and in 2000. The ACLS kit has been available for purchase since 1990 from S&amp;S Worldwide, Colchester, CT. An enlarged version of the ACLS, the Large Allen Cognitive Level Screen (LACLS) , was developed to compensate for vision impairments commonly found in geriatric populations.The “Cognitive Levels” were expanded to 26 Modes of Performance to allow for more sensitive measurement of clinically significant functional improvements ( Occupational Therapy Treatment Goals for the Physically and Cognitively Disabled , Allen, Earhart, and Blue. 1992, Rockville, AOTA). In this text, a frame of reference for a clinical practice theory was first articulated. Included in this text was a second version of the Routine Task Inventory (RTI II) . The RTI II is an analysis of common activities of daily living by mode, intended to verify the initial ACLS score and set treatment goals. Within this text, Theressa Burns, OTR, introduced the Cognitive Performance Test (CPT) . First developed in 1985, the CPT used performance of six standardized tasks of daily living to identify global cognitive abilities in persons with dementia. Subsequent research studies have demonstrated this instrument&apos;s efficacy in measuring change and predicting long-term risk of institutionalization in populations with progressive dementia (Burns, Mortimer, and Warmbler, 1991.)The Allen Diagnostic Module (ADM) by Earhart, Allen, and Blue, (1993, Colchester, S &amp; S), a collection of 26 standardized craft tasks, was developed to verify the initial ACLS scores of persons with moderate to mild global impairments (modes 3.0 - 5.8.) Expanded to include 35 tasks in 2004, the ADM has the distinct advantage of using working memory in new learning, thus avoiding procedural memory tasks that may inflate performance scores.The Sensory Motor Stimulation Kits I and II by Blue (1995, Colchester, S &amp; S) were designed to assess and treat the most severely impaired persons (modes 1.0 - 3.2) often encountered in geriatric and rehabilitation medicine practice areas.The Allen Scale is currently used by therapists across a broad range of practice areas, including mental health, forensic psychiatry, rehabilitation medicine, and geriatric care. Specific application varies by setting and the clinical problem to be solved. In acute care settings, changing functional capacities are assessed and monitored for anticipated improvements. In post-acute or stable conditions, the Allen Scale provides an activity analysis to identify the cognitive and motor requirements of meaningful activities that the person wants to do, leading to treatment goals that match current abilities. Methods of teaching or training compensatory or new skills are inherent in the mode of performance. In deteriorating conditions, therapists may recommend meaningful activities that help maintain capacities, protect the person’s safety, and reduce the burden of care. Understanding remaining abilities fosters a realistic optimism for success in community life.The Allen Cognitive Network encourages collaboration and exchange between clinicians, educators, students, and clients in the continuing quest to understand the nature of functional abilities and disabilities. Welcome to the journey!Cathy Earhart, OTR/L Last Updated ( Monday, 30 June 2008 04:21 )
  • The Short Form (36) Health Survey is a survey of patient health. The SF-36 is commonly used in health economics as a variable in the QALY unit to determine the cost-effectiveness of a health treatment. Contents [hide] Scoring Uses Limitations Notes Further reading [ edit ] Scoring [1] The SF-36® consists of eight scaled scores, which are the sums of the questions in their section. Each scale is directly transformed into a 0-100 scale on the assumption that each question carries equal weight. The eight sections are: vitality physical functioning bodily pain general health perceptions physical role functioning emotional role functioning social role functioning mental health [ edit ] Uses [2] Evaluating individual patients Researching the cost-effectiveness of a treatment Monitoring and comparing disease burden The Canadian Occupational Performance Measure (COPM) is an individualized, client-centred measure designed for use by occupational therapists to detect change in a client&apos;s self-perception of occupational performance over time. It is designed to be used as an outcome measure. The COPM is designed for use with clients with a variety of disabilities and across all developmental stages.  The COPM is a standardized instrument, in that there are specific instructions and methods for administering and scoring the test. It is designed as an outcome measure, with a semi-structured interview format and structured scoring method. Change scores between assessment and reassessment using the COPM are the most meaningful scores derived from this assessment. Originally published in 1991, with the latest fourth edition released in May 2005, the COPM has been used in more than 35 countries and has been translated into over 20 languages. For information about obtaining translated versions, contact Mary Law . The COPM has undergone extensive research in many different occupational therapy practice situations. The majority of clients and therapists indicate that the measure is easy to administer, taking 20-40 minutes. A recent review of the published literature found 98 papers that focused on the COPM. Psychometric properties including clinical utility, validity and responsiveness were studied in many of the papers. The results were very positive, demonstrating support for the reliability and validity of the COPM. Clinical utility, examined through a number of different studies supports the use of the COPM with a wide variety of clients in many different settings. The COPM is also responsive to change and is widely used as an outcome measure for individuals and programs. For details on the development of the COPM and ongoing research, please refer to the references cited below. Technology for application The Canadian Occupational Performance Measure (COPM) [1] is a semi structured interview developed to apply the model [16] [17] and is the only prescribed assessment. This allows freedom to choose other supporting assessments but also restrict the methods of application for the model [18] . Therapists have praised its client centred approach, relatively quick administration, role in promoting occupational therapy in multidisciplinary teams and compatibility with other assessment tools [4] [19] [20] [21] [22] [23] [24] . However these properties are compromised by most therapists using COPM without training or knowledge of the model, particularly when the tool is used without implementing the model [21] .
  • Mental Health Of The Older Adult.Uwm.11.08

    1. 1. Mental Health of the Older Adult November 12, 2008 Sandy Ceranski, MS, OTR [email_address]
    2. 2. Sandy’s Tips <ul><li>Compassion </li></ul><ul><li>Competence </li></ul><ul><li>Conscience </li></ul>
    3. 3. Depression <ul><li>Presentation generally different </li></ul><ul><ul><li>Lack of energy </li></ul></ul><ul><ul><li>Lack of pleasure in activities </li></ul></ul><ul><ul><li>Poor concentration </li></ul></ul><ul><ul><li>Psychomotor disturbance </li></ul></ul><ul><li>Screening </li></ul><ul><ul><li>Geriatric Depression Scale (GDS) </li></ul></ul><ul><ul><ul><li>http://www.stanford.edu/~yesavage/GDS.html (on-line) </li></ul></ul></ul><ul><ul><ul><li>http://en.wikipedia.org/wiki/Geriatric_Depression_Scale </li></ul></ul></ul>
    4. 4. Dementia <ul><li>Diagnostic Criteria </li></ul><ul><ul><li>Memory impairment </li></ul></ul><ul><ul><li>At least ONE other cognitive impairment: </li></ul></ul><ul><ul><ul><li>aphasia, </li></ul></ul></ul><ul><ul><ul><li>apraxia, </li></ul></ul></ul><ul><ul><ul><li>agnosia </li></ul></ul></ul><ul><ul><ul><li>disturbance in executive functioning </li></ul></ul></ul><ul><ul><li>Significant impairment in social or occupational function and a significant decline from previous level of functioning </li></ul></ul>
    5. 5. Occupational Therapy Purpose <ul><li>Promote engagement in occupation to support participation </li></ul><ul><li>Restore, maintain and/or prevent premature decline in level of function, safety and quality of life in the least restrictive alternative </li></ul>
    6. 6. Performance Based Assessment <ul><li>Identify best ability to function and level of assistance in B-ADLs and I-ADLs </li></ul><ul><ul><li>Cognitive Performance Test </li></ul></ul><ul><ul><li>Routine Task Inventory </li></ul></ul>
    7. 7. Quality of Life Assessment <ul><li>Mobility, social relations, affording and obtaining necessities, living independently, occupations, comfort, self esteem, satisfaction with daily activities, sources of pleasure </li></ul><ul><li>Assessment </li></ul><ul><ul><li>SF 36 </li></ul></ul><ul><ul><li>COPM </li></ul></ul>
    8. 8. Interventions <ul><li>Environmental Support and Adaptation </li></ul><ul><ul><li>Aging in Place </li></ul></ul><ul><ul><ul><li>New Certification (AOTA & NAHB) </li></ul></ul></ul><ul><ul><ul><ul><li>http://www.nahb.org/generic.aspx?genericContentID=9334 </li></ul></ul></ul></ul>
    9. 9. Interventions <ul><li>Occupational adaptation </li></ul><ul><li>Behavioral techniques </li></ul>
    10. 10. What do you … <ul><li>Want to know more about? </li></ul>

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