Clinical Rehabilitation

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1 Clinical Rehabilitation Short-term effectiveness of intensive multidisciplinary rehabilitation for people with Parkinson's disease and their carers Patrick Trend, Julie Kaye, Heather Gage, Charles Owen and Derick Wade Clin Rehabil : 717 DOI: / cr545oa The online version of this article can be found at: Published by: Additional services and information for Clinical Rehabilitation can be found at: Alerts: Subscriptions: Reprints: Permissions: Citations: >> Version of Record - Jul 1, 2002 What is This?

2 Clinical Rehabilitation 2002; 1 6: Short-term effectiveness of intensive multidisciplinary rehabilitation for people with Parkinson s disease and their carers Patrick Trend Royal Surrey County Hospital, Guildford, Julie Kaye Surrey Hampshire Borders NHS Trust, Heather Gage Department of Economics, University of Surrey, Guildford, Charles Owen Thomas Coram Research Centre, Institute of Education, University of London and Derick Wade Rivermead Rehabilitation Centre, Oxford Received 20th November 2001; returned for revisions 2nd January 2002; revised manuscript accepted 21st April Objective: To evaluate the short-term effectiveness of an intensive multidisciplinary rehabilitation programme for people with Parkinson s disease and their carers. Design: Observational, with assessments before and after intervention. Setting: An elderly care day unit in a district general hospital in south-east England. Subjects: One hundred and eighteen people with Parkinson s disease and no cognitive impairment, and their carers. Intervention: Participants attended the day hospital in groups of six patients with their carers for one day per week over six consecutive weeks. After assessment, they received individual treatment from a specialist team. Weekly group activities included relaxation and talks from experts. Outcome measures: Patients and carers were assessed for: health-related quality of life, psychological well-being, social services need, perceptions of the programme. Patients were additionally assessed for mobility, gait and speech. Carers were assessed for strain. Results: After treatment signi cant improvements were recorded in patients mobility and gait (p < 0.05), speech (p < 0.001), depression (p = 0.029), healthrelated quality of life (p = 0.001). People with more advanced disease at baseline gained signi cantly more from treatment (p 0.04). Carers were less depressed and had higher health-related quality of life than patients at baseline (p < 0.001) and no improvements in these indicators were recorded after treatment. A high unmet need for social services was identi ed in 31% of participants, and 10% of carers were found in danger of being unable to continue caring. Participants reported knowledge gains and high levels of satisfaction with both individual therapies and group activities. Conclusions: This intensive co-ordinated programme provided immediate bene ts to people with Parkinson s disease and their carers. Address for correspondence: Heather Gage, Department of Economics, University of Surrey, Guildford, Surrey GU2 7XH, UK. h.gage@surrey.ac.uk Arnold / cr545oa

3 718 P Trend et al. Introduction The importance of nonpharmacological approaches to the management of Parkinson s disease (PD) is well recognized, but a review of the literature revealed little robust researchbased evidence in support of this view. 1 Most existing studies are single discipline-based and evaluate the impact of occupational therapy or physiotherapy or speech therapy on a variety of outcome measures. Parkinson s disease in icts a range of distressing symptoms on sufferers, and imposes signi cant costs on carers, and a strong case has been made for integrated, team-based rehabilitative care An intensive multidisciplinary programme of rehabilitation was designed and introduced at the Royal Surrey County Hospital in Guildford in The setting up of this programme has been described elsewhere. 11 The immediate effects of the treatment programme are reported in this paper. The cost-effectiveness and six-month effects will be reported separately. This evaluative study aimed to investigate the impact of intensive multidisciplinary rehabilitation and a supportive group programme of education on: Mobility and functional independence of people with Parkinson s disease. Awareness of speech problems by people with Parkinson s disease, and their ability to deal with them. Psychological well-being and health-related quality of life of patients and carers. It also sought to identify and refer people in need of further health and social services, and to explore participants perceptions of the programme. Methods Patients were recruited from outpatient clinics at the Royal Surrey County Hospital. Two inclusion criteria, designed to identify people with the potential to bene t from rehabilitative therapy, were applied. Patients had to have at least two signs or symptoms of Parkinson s disease, and a score of at least seven out of ten on Hodkinson s mini-mental test. 12 Informed consent was obtained at recruitment. All patients and carers were assessed using a variety of measures during the rst and last (sixth) week of the rehabilitation programme. Each person was assessed at the same time of day on both occasions to minimize the extent to which on off uctuations might affect patients responses. Baseline information was collected from medical records, and directly from participants during the rst treatment session. This covered gender, age, marital status, occupation, years since diagnosis, comorbidities, medications and services received. Hoehn and Yahr stage of disease 13 and Barthel ADL Index 14 were assessed by the PD nurse specialist. Two standardized self-report assessments were administered to participants in the rst and nal weeks of treatment by an independent research assistant. These took some 5 10 minutes to complete and comprised: Hospital Anxiety and Depression Scale (HAD) 15 ; Euroqol-5d (EQ-5d), which has two indicators of health-related quality of life a pro le measure covering ve domains (mobility, self-care, usual activity, pain / discomfort, anxiety / depression) converted to a utility index (1.00 for perfect health to 0.59 for worst health state), and a visual analogue scale ranging from 0 (worst imaginable) to 100 (best imaginable). 16 In addition, the speech therapist tested patients before and after treatment using abridged Emerson and Enderby measures of voice and articulation, 17 and a summary of respiration, laryngeal function, and intelligibility in words, sentences and conversation. 18 The physiotherapist assessed patients mobility using a timed walk over 10 metres, including a turn, at both normal speed and as fast as possible. Gait was measured by number of paces in the normal speed walk. Patients and carers were assessed at one point during the programme by a care manager (social worker) for unmet needs. They also completed programme evaluations at the last session. The latter was administered by an independent research assistant and took the form of a structured questionnaire covering all aspects of the intervention, three open questions, and enquiries about willingness-to-pay. Data were entered into SPSS version 10 and descriptive statistics were computed. Paired sam-

4 Short-term effect of multidisciplinary rehabilitation for PD 719 ple t-tests were used to statistically assess the extent of change in measures taken at the start and end of the treatment programme. Pearson correlation was used to explore whether age, years since diagnosis, Barthel score or Hoehn and Yahr staging affected bene t from the programme. The content of qualitative responses to open-ended items on the evaluation questionnaire was analysed and manually coded. Ethical approval for the study was obtained from South West Surrey Ethics Committee. The treatment programme The rehabilitation programme and the assessment instruments were piloted in the year before the evaluative study began, and some adjustments were made. A detailed description of the treatment protocol is available (from Julie Kaye, Parkinson s Disease Specialist Nurse, Royal Surrey County Hospital, Guildford, UK). Six pairs of participants (people with Parkinson s disease and their carers) attended a day care unit one day per week for six consecutive weeks. Each weekly session lasted from 10 am to 3:30 pm, during which time treatment was provided by a multidisciplinary team of therapists. The programme was co-ordinated by a PD nurse specialist under the direction of the consultant neurologist. At the rst of the six sessions, participants were individually assessed by a physiotherapist, an occupational therapist, a speech and language therapist, and a specialist PD nurse. In weeks 2 5 they received treatment according to individual needs. In the sixth week their condition was reassessed, and advice for the future was provided. At each visit, participants received 2 hours of individual attention. The objectives and treatment offered by each professional are summarized in the Appendix. Group activities including relaxation were arranged for each afternoon. Talks from experts were designed to broaden participants knowledge about Parkinson s disease and its treatment, and included presentations by a bene ts agent, chiropodist, continence advisor, dietician, pharmacist, Parkinson s Disease Society welfare visitor, PD specialist nurse, and consultant neurologist. The care manager ran a carers group on two occasions. Lunch was provided for patients while carers were encouraged to take lunch together in the hospital cafeteria. Transportation was provided to and from the day hospital for participants, as indicated. Results A total of 137 patients were recruited over three years. Of these 118 (86%) proceeded to treatment in 24 groups of six with their carers. The drop-out occurred entirely amongst patients allocated for treatment after a six-month delay. During the wait patients became ill, died, lost interest, or moved away. Where possible patients personal circumstances, such as holidays, were accommodated in the scheduling. Most patients (n = 101, 86%) were recruited from the local neurology outpatients clinic. The rest were self-referred because they had seen publicity about the programme (n = 12, 10%), or were referred by local geriatricians (n = 5, 4%). The programme was planned to treat a maximum of six patients and carers at each session. Five groups (24%) ran at capacity and a further 12 groups (50%) had one vacancy. Only two groups involved fewer than four couples. Most participants (n = 97, 81%) completed the sixweek programme, and a further 16 people (13%) attended ve of the meetings. Ninety-two patients (79%) had live-in carers, of whom 81 (88%) were spouses. Seventy-eight carers (85%) attended at least ve of the six treatment sessions. Background information about patients and their self-reported service utilization are shown in Tables 1 and 2 respectively. The pre- and post-treatment means and standard deviations of outcome measures are shown in Table 3. Signi cant improvements after treatment were recorded in patients health-related quality of life, depression, mobility and gait, voice, articulation and speech. The results of the correlation analysis showed that greater improvements in normal walking speed and gait were associated with a longer diagnosis of Parkinson s disease (p = 0.04, p = 0.003), lower baseline Barthel scores (p = 0.001, p = 0.012), and higher baseline Hoehn and Yahr stages (p = 0.003, p = 0.02). Larger improvements in health-related quality of life (Euroqol score:

5 720 P Trend et al. p = 0.04) were associated with higher baseline Hoehn and Yahr stages. A variety of aids to assist independence in daily activities were introduced to patients, as appropriate. At the end of the treatment programme 63% of patients reported purchasing an average of 1.8 items of assistive technology. Most popular were simple and affordable items such as dycem (non-slip matting for use in kitchens), button hooks, sock helpers and kitchen aids. A few purchased more substantial items such as walkers, swivel car seats and bathing aids. As a group, carers were signi cantly less anxious (p = 0.019) and depressed (p < 0.001) on HAD instrument than patients, and had higher health-related quality of life (p < 0.001) on the Euroqol score and thermometer. Carers registered no signi cant improvements in any of these measures over the period of the treatment programme. A danger that the carer would be unable to continue his/her role, was found in seven (9.9%) Table 1 Pro le of 118 patients who received treatment Characteristic n (%) Male 73 (61.9) Age <60 years 12 (10.2) years 35 (29.6) years 49 (41.6) 80 years and over 22 (18.6) Mean years, SD 8.27 Occupations Managerial, professional 40 (36.7) Technical 31 (28.4) Clerical, service 22 (20.2) Skilled manual 12 (11.0) Unskilled manual 4 (3.7) (n = 109) Years since diagnosis <6 years 59 (50.0) 6 10 years 33 (28.0) years 19 (16.1) years 4 (3.4) over 20 years 3 (2.5) Hoehn and Yahr stage 1.0 Unilateral disease 2 (1.9) 1.5 Unilateral, with axial involvement 2 (1.9) 2.0 Bilateral, no impaired balance 13 (12.0) 2.5 Mild bilateral with recovery on pull test 24 (22.1) 3.0 Moderate bilateral, some postural instability, physically independent 56 (51.9) 4.0 Severe disability, still able to walk or stand unassisted 11 (10.5) Rank correlation; Hoehn and Yahr and years since diagnosis: 0.26 (p < 0.01) (n = 108) Barthel: activities of daily living index 0 4 Heavily dependent 0 (0) (3.6) (9.8) (49.1) 20 Completely independent 42 (37.5) Mean 17.58, SD 3.02 (n = 112)

6 Short-term effect of multidisciplinary rehabilitation for PD 721 Table 2 Service utilization of 118 patients who received treatment Patients using service: In the past Ongoing n (%) n (%) Hospital admissions in the last 12 months 29 (16) GP visits in the last 12 months 0 32 (28) (23) (21) (25) >10 4 (3) missing 2 (2) Other health and social service professionals PD nurse 21 (19) 12 (11) Occupational therapist 28 (25) 0 (0) Physiotherapist 78 (70) 7 (6) Speech therapist 33 (3) 2 (2) Chiropodist 11 (10) 52 (46) Dietician 17 (15) 1 (1) Continence advisor 7 (6) 1 (1) Psychologist/counsellor 9 (8) 1 (1) Social worker 5 (5) 6 (5) Home care 1 (1) 13 (12) Sitting/respite care 2 (2) 4 (4) Day centre/day hospital 12 (11) 5 (5) Parkinson s Disease Society 88 (79) cases. Using the locally agreed norms, 29 (31.4%) of participants were identi ed as having high need for social services, and 35 (37.6%) as having medium need. The names of people whose needs were not being met within the family were forwarded to local Social Service departments Participants feedback was strongly positive and indicated high satisfaction with all aspects of the programme. Some patients (n = 30, 27.7%) reported that they found the schedule too tiring. Most patients (n = 103, 95.4%) and carers (n = 67, 93%) reported that their knowledge and understanding of Parkinson s disease had been extended. Over 90% of participants said that they would like the programme to be repeated within 12 months. The analysis of three open-ended questions found eight positive comments for each negative remark. The most frequently cited successful aspect of the programme was the therapies, but participants also appreciated the opportunity to meet others affected by Parkinson s disease, the educational components and the friendly, supportive atmosphere. No improvements were suggested by 150 (82%) of participants. There were ve (4.6%) patients who felt the lunches could be improved, and three (2.7%) who found parking problematic. Suggestions for rescheduling the day by seven (6.5%) participants were evenly divided between requests for more activities and requests for a less intensive timetable. Helpful suggestions from participants included that psychological counselling might be added to the programme, and that liaison with their GPs might be formalized for follow-up care. Discussion This study is unusual because of the integrated nature of the multidisciplinary treatment programme. With more than 100 patients and carers participating, it is larger than other nonpharmacological trials of Parkinson s disease. 1 Although cognitively impaired people with Parkinson s disease were not recruited, the sample of patients and carers was similar to other recent UK studies with respect to age, gender, years since diagnosis and Barthel scores. 20,21 The proportion of participants that had previously

7 722 P Trend et al. Table 3 Pre- and post-treatment outcomes Outcome Measure n Week 1: Week 6: Signi cant Mean (SD) Mean (SD) difference Range Range Patient: Timed walk As fast as possible (6.58) (4.85) p = (secs) Normal speed (7.19) (5.67) p = Patient: Gait Number of paces (8.70) (7.50) p = Patient: Voice 7 point scale: 0 (no impairment), 3 (severe (0.725) 0.83 (0.60) p < impairment) Articulation As Voice (0.72) 0.35 (0.52) p = Patient: Frenchay 9 items (respiration, laryngeal function, (4.85) 4.57 (4.29) p < summary intelligibility) scored on 5 point scale: 0 (no impairment), 5 (severe impairment) max 45 Patient: Anxiety 7 indicators, 4-point scale: range 0 (no problem) (3.31) 5.19 (3.43) n.s. to 21 (max) Patient: Depression As Anxiety (2.88) 5.57 (2.80) p = Patient: Health-related Euroqol utility index: 0.59 (worst) to 1.00 (best) (0.24) 0.63 (0.22) p = quality of life Euroqol thermometer: 0 (worst) to 100 (best) (17.77) (15.77) p = Carer: Anxiety 7 indicators, 4-point scale: range 0 (no problem) (3.30) 4.90 (3.51) n.s. to 21 (max) Carer: Depression As Anxiety (2.55) 2.96 (2.48) n.s Carer: Health-related Euroqol utility index: 0.59 (worst) to 1.00 (best) (0.23) 0.82 (0.23) n.s. quality of life Euroqol thermometer: 0 (worst) to 100 (best) (17.68) (18.91) n.s n.s., not signi cant.

8 Short-term effect of multidisciplinary rehabilitation for PD 723 Clinical messages Intensive multidisciplinary rehabilitation for people with Parkinson s disease and their carers results in immediate improvements in patients mobility, speech, depression and health-related quality of life, but no change in carer well-being. Assessments reveal some unmet need for social services, and carer strain. Participants report knowledge gains and high satisfaction. received occupational and speech therapy, or had seen a specialist PD nurse, was broadly in line with other research ndings, but a substantially greater proportion of programme participants had already received physiotherapy. This is possibly because recruitment occurred mainly through a specialist Parkinson s disease clinic that routinely makes such referrals. This multidisciplinary rehabilitation programme was client-centred. By focusing on the practical problems experienced by people with Parkinson s disease in their everyday lives, it broke down discipline-based demarcations. 26 It recognized the importance of multiple professions for addressing the variety of problems experienced by people with Parkinson s disease. 5 By providing a blend of tailored individual therapy and group social and educational activities, it offered practical help, information and support to patients and carers, and motivated self-care. It addressed two important needs identi ed by the 1998 Parkinson s Disease Society Member s Survey 25 because it explicitly included carers, and provided a structured programme of education about Parkinson s disease. At the end of the treatment programme signi cant improvements were recorded for patients on a range of outcome measures: mobility, gait, speech, health-related quality of life and psychological well-being. Most improvement was recorded for patients with more advanced disease. Many unmet needs were identi ed and participants were introduced to appropriate assistive technology and services to improve their independence and quality of life. No signi cant changes were recorded in the health-related quality of life or psychological well-being of carers, possibly because their mean baseline scores were signi cantly higher than those of the people with Parkinson s disease. Carers subjective evaluations of the programme were, however, very positive. Overall the results suggest that an intensive, co-ordinated intervention that incorporates targeted advice from a range of professionals can provide immediate bene ts for people with Parkinson s disease and their carers. The ndings reinforce the importance of multidisciplinary clinical teams. 27 There are limitations associated with an uncontrolled, pre-post study as used here. Some of the assessments were of a self-report nature, and some were conducted by the therapists themselves. Others, however, were administered by an independent research assistant. To guard against potential bias, participants and therapists did not have access to baseline scores when completing nal week assessments. All data was independently entered and processed. Most measures used are validated. In the absence of a control group, there is no way of telling to what extent the favourable outcomes arise from the speci c rehabilitative therapy, or are the result of placebo effects. The main drawback of this particular intervention was its one-off nature. Patients and therapists alike recognized a need for follow-up care at some point in the future, in order to capitalize on immediate bene ts generated by this intensive intervention, and to address new issues as they arise. Further research is needed into what form of follow-up care would be most effective for maintaining the health-related quality of life of people with Parkinson s disease and for providing continuing support for their carers. Acknowledgements Funds for this project were provided by the Parkinson s Disease Society of the UK, Royal Surrey County Hospital NHS Trust, Surrey Hampshire Borders NHS Trust, Guildford Rotary, Guildford Inner Wheel, and many individual donors. This paper was drafted whilst HG was on sabbatical leave at the Center for Health Quality, Outcomes and Economic Research, Bedford, MA, USA.

9 724 P Trend et al. The authors would like to thank Jane Allen (physiotherapist), Jane Farquharson (occupational therapist), Sarah Morrison and colleagues (speech and language therapists) and guest speakers, for their professionalism and loyalty to the project; Chris Marney, for secretarial assistance; the Steering Group, for giving time and providing support and guidance; Emma Farnsworth, Jo Hart, Leigh Johnson and Anne Bird, for data collection and entry, and the programme participants, for their trust and appreciation. Thanks also go to anonymous referees for helpful comments. The usual disclaimer applies. Contributions The treatment programme was devised by PT and JK and co-ordinated by JK. Recruitment was undertaken by PT and JK. Data collection and entry was organized by HG and JK. Data analysis was conducted by CO and HG. This paper was drafted by HG, with assistance from DW, who supervised the project. References 1 Gage H. The effectiveness of rehabilitation in Parkinson s disease: A review of available evidence. Mimeo, available from the authors. 2 McCall B. Coping with Parkinson s disease: the patients and carers experience. Br J Ther Rehabil 1995; 2: MacMahon D. Parkinson s disease. Geriatr Med 1996; 26: 35 36, 59 62, Carlson-Davis J. Team management of Parkinson s disease. Am J Occup Ther 1977; 31: Cutson T, Cotter Laub K, Schenkman M. Pharmacological and nonpharmacological interventions in the treatment of Parkinson s disease. Phys Ther 1995; 75: Feldman R. Parkinson disease. Individualising therapy. Hosp Pract 1985; 80A 80FF: 7 Lannon M, Thomas C-A, Bratton M, Jost M, Lockhart-Pretti P. Comprehensive care of the patient with Parkinson s disease. J Neurosc Nurs 1986; 18: Lieberman A. An integrated approach to patient management in Parkinson s disease. Neurol Clin 1992; 10: Risdale L. Community care for patients with idiopathic Parkinson s disease. Br J Gen Pract 1995; Schankman M, Butler R. A model for multisystem evaluation treatment of individuals with Parkinson s disease. Phys Ther 1989; 69: Kaye J. A rehabilitation programme for people with Parkinson s Disease. Elderly Care 1999; 11: Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972; Hoehn MM, Yahr MD. Parkinsonism: onset, progression and mortality. Neurology 1967; 17: Wade DT, Collin C. The Barthel ADL index: a standard measure of physical disability? Int Disabil Stud 1988; 10: Zigmond AS, Snouth RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983; 67: Kind P. The EuroQol instrument: an index of health-related quality of life. In: Spiker B ed. Quality of life and pharmacoeconomics in clinical trials, second edition. Philidelphia: Lippincott-Raven, 1996: Emerson J, Enderby P. Prevalence of speech and language disorders in a mental illness unit. Eur J Disord Commun 1996; 31: Enderby PM. Frenchay dysarthria assessment. Texas: Pro-ed, Inc, Schulz G, Grant M. Effects of speech therapy and pharmacologic and surgical treatments on voice and speech in Parkinson s disease: a review of the literature. J Commun Disord 2000; 33: Lloyd M. The new community care for people with Parkinson s disease and their carers. In: Percival R, Hobson P eds. Parkinson s disease: studies in psychological and social care. The British Psychological Society and The Parkinson s Disease Society, 1999: chapter Jones R, D eath C, Harnsford J, Hutchinson H, Hyde L, Thurlow L, Spanton L. The needs of people with Parkinson s disease and their families: The Parkinson s disease study, Devon and Cornwall In: Percival R, Hobson P eds. Parkinson s disease: studies in psychological and social care. The British Psychological Society and The Parkinson s Disease Society, 1999: chapter Clarke CE, Zobkiw RM, Gullaksen E. Quality of life and care in Parkinson s disease. Br J Clin Pract 1995; 49: Mutch W, Strudwick A, Roy S, Downie A. Parkinson s disease: disability, review and management. BMJ 1986; 293: Peto V, Fitzpatrick R, Jenkinson C. Self-reported health status and access to health services in a community sample with Parkinson s disease. Disabil Rehabil 1997; 19:

10 Short-term effect of multidisciplinary rehabilitation for PD Yarrow S. Members 1998 survey of the Parkinson s Disease Society in the UK. In: Percival R, Hobson P eds. Parkinson s disease: studies in psychological and social care. The British Psychological Society and The Parkinson s Disease Society, 1999: chapter Ward C. Rehabilitation in Parkinson s disease. Rev Clin Gerontol 1992; 2: Greenwood R. The future of rehabilitation. BMJ 2001; 323: Appendix Summary of objectives and treatment provided by therapists Profession PD specialist nurse Physiotherapist Occupational therapist Speech and language therapist Care manager Objectives and treatment provided Aimed to provide information, advice, support and counselling on issues related to Parkinson s disease. Focused on: optimizing medication; recognizing problems associated with side-effects of medication, e.g. dykinesia and hallucinations, and initiation of appropriate action; maintenance of bladder and bowel function; monitoring blood pressure; pain control; sexual dysfunction; anxiety and depression. Aimed to assist people with Parkinson s disease in the performance of daily functional activities. According to individual need, focused on: mobility, to ameliorate problems of initiating gait and freezing ; the regulation of stride length, to increase overall control of Parkinsonian gait; postural awareness, because improvements can contribute to greater mobility; balance, to avoid falls; upper limb problems, where relevant; relaxation. Written materials were used to reinforce verbal advice, and exercises were prescribed for practise at home. Aimed to address daily living problems in the order of their importance to clients. Concentrated on exploring alternative ways of undertaking daily activities, and on making participants aware of aids and adaptations that could improve their independence. Assistance with handwriting, a common problem in Parkinson s disease, was offered. Aimed to raise participants awareness of how Parkinson s disease affects communication and to enable patients to recognize their own communication patterns. Demonstrated ways to address the typically quiet, hoarse, monotonous voices of people with Parkinson s disease, and the reduced intelligibility of their speech. 19 Participants were encouraged to practise daily a variety of speech exercises designed to help respiration, tone, pitch, volume and intelligibility. As a result it was hoped that people with PD would reduce the extent to which they sought to avoid potentially dif cult social situations, and tendencies for social isolation could be avoided. Aimed to identify people in need of assistance from social services through an assessment of the capabilities of the patient with respect to personal care, mobility, domestic tasks and mental health status. The care manager held group discussions with carers aimed at facilitating their expression of any dif culty they were experiencing in that role.