SEATING FOR CLIENTS WITH DEMENTIA AND CHALLENGING BEHAVIOURS CARMEN MURRAY AND KATHERINE MOROS Hamilton Health Sciences-St. Peter s Hospital Introduction The Behavioural Health Program is a 63 bed, specialized, inpatient service for adults with a diagnosis of dementia and who exhibit challenging behaviours. The overall goal of the program is to maximize clients abilities and help achieve a successful transition back to a community setting. Clients typically present in the moderate to severe stage of the illness with falls and mobility issues being significant concerns. The provision of seating and mobility devices is one treatment intervention that is part of the occupational therapist s (OT) role in this program. Although provision of seating and mobility devices is common practice, it is the integration of the behavioural component that presents a challenge to the OT so that the client can receive a mobility device that maintains safety, enhances mobility and meets the client s functional needs over the course of the progressive illness. This presentation will provide the clinician with a structured method, guided by the Canadian Practice Process Framework, to identify and address the challenging seating issues with this client population. Canadian Practice Process Framework (CPPF) The CPPF is a framework designed to enable occupational therapists to facilitate client-centred, evidence-based practice, as well as participate in reflective practice (Craik, Davis & Polatajko, 2007). The CPPF highlights eight key action points that guide the therapeutic process in occupational therapy practice (Davis, Craik, & Polatajko, 2007). The CPPF consists of 3 contextual elements and the practice process element. Each of the contextual elements permeates the 8 practice process action points. 1) Societal context this refers to the broad societal context that includes cultural, institutional, physical and social environmental elements (Craik, Davis & Polatajko, 2007). Applicable elements for seating this population include: relevant legislation (i.e. Long-Term Care Homes Act, 2007; Health Care Consent Act, 1996); policies related to funding of equipment (i.e. Assistive Devices Program (ADP), Department of Veterans Affairs, private extended health care benefits, charitable foundations); the Regulated Health Professions Act, 1991 and associated professional regulations (i.e. College of Occupational Therapists of Ontario). 2) Practice context This refers to the personal and environmental factors that influence the OT/client relationship, which is initiated at the time that the referral is received. It is important to reflect on the views, values, beliefs and experiences that the OT, client and families bring to the therapeutic relationship. Elements that fit within the practice context of the Behavioural Health Program include: a. The philosophy of the Behavioural Health Program which supports the concepts of personhood and enablement whereby the client and family are partners with the interdisciplinary (ID) team in planning care. The client has the opportunity to engage in meaningful and purposeful activities that build on their strengths and abilities. b. Relevant policies pertaining to use of devices for positioning or restraining within the practice environment. c. OT s bring to the relationship the ideas, values, beliefs and theories of the profession. Relevant professional resources include professional ethics and code of conduct, competency requirements, the occupational therapy scope of practice, and practice frame(s) of reference. (Craik, Davis & Polatajko, 2007). 3) Frames of Reference Context This refers to the models of practice, theories and methods of service delivery that guide the OT s decision making through the practice process. On the Behavioural Health Program, Person-Environment-Occupation Model (Law et al., 1996) and the Canadian Model of Occupational Performance and Engagement (CAOT 2002) are used to guide the OT's practice.
4) Occupational Therapy Process Element This is composed of 8 action points, which can be used in linear fashion, or in selected pathways, through the process. Action Point 1: Enter/Initiate This is the first contact between the OT and the client. The goal of this action point is to obtain informed consent for the seating and mobility assessment. Key information to be conveyed by the OT includes: (Advocacy Centre for the Elderly 2003): o The nature or purpose of the treatment provide clinical rationale regarding the need for a wheelchair. o Benefits provide information regarding the benefits of wheelchair use for the client. o Risks provide information regarding the safety risks that may result from wheelchair use. o Side effects of seating provide information regarding the impact on the client s functional abilities, finances, and discharge location. o Alternative courses of action provide information regarding viable alternatives. o Possible consequences of not receiving treatment/seating provide information regarding impact to the client. Once consent is obtained for the assessment, provide the client or substitute decision maker (SDM) regarding the seating and mobility process as per provincial funding body policies (i.e. ADP provide information sheet and approved vendor list). Action Point 2: Set the stage At this stage in the process, the OT meets with the client/ SDM to clarify values, beliefs, expectations and desires. It may be necessary to negotiate common ground and identify priorities for seating and occupational issues related to mobility. Action Point 3: Assess-evaluate A comprehensive review of the medical record and consultation with the ID team is used to gather information regarding the client s medical status, functional abilities, behavioural profile and general overview of the client's occupational performance issues. The SDM is invited to attend the mobility assessment to ensure that they are involved in all aspects of the process as well as to provide support to the client. The client s vendor of choice is invited to observe the assessment in order to understand the client s issues and work in partnership with the OT to select appropriate equipment. A thorough physical mat assessment is completed to ensure success of the final seating prescription. To maintain client and therapist safety, a minimum of 2 people (minimum 1 OT) are present. The OT analyzes the information gathered from chart review and physical mat assessment to generate a comprehensive list of problems and issues. Due to the complicated safety issues, it is recommended that another OT is consulted to provide an alternate perspective to ensure the best possible outcome for the client, mitigate safety risks and prevent critical incidences. Action Point 4: Agree on objectives and plan Based on the comprehensive list of problems/issues that were identified during Action Point 3, goals are established and then equipment recommendations are made to specifically address each problem and goal. The OT s equipment recommendations are then compared to the client/sdm goals. If the OT's equipment recommendations do not align with the client/sdm goals, then the OT meets with the client/sdm to negotiate and make decisions that are agreeable to all parties. If agreement between the parties cannot be achieved then it may be necessary to go to Action Point #8 and conclude/exit the relationship. Complete seating and mobility report. Place in client s medical record. Action Point 5: Implement the plan
Trial seating and mobility equipment is provided by the vendor based on the equipment recommendations from action point 4. Due to the behavioural profiles and associated risks with this population, it is imperative that the vendor and OT work collaboratively to dispense trial equipment (i.e. adjust all components of the wheelchair, especially mounting and adjustment of positioning devices to reduce risk of injury due to falls and strangulation). Notify SDM of provision of trial equipment so that they are able to provide the OT with feedback. Notify ID team of provision of trial equipment for transfer of accountability regarding any potential safety issues and to obtain feedback from others. Document the provision of trial equipment in the medical record. Action Point 6: Monitor and Modify Assess the client when they are seated in the trial equipment. Determine whether the trial equipment achieves the goals that were identified during the seating and mobility assessment. This is also the opportunity to determine whether any unexpected issues arise from the recommended equipment. Obtain feedback from SDM and ID team. Modify equipment recommendations based on clinical evaluation of the equipment trial and feedback. Contact vendor to provide alternate equipment and/or make modifications to existing equipment. Document results of the evaluation. **At this point in the CPPF process, the OT may go back to Action Points #3, 4, or 5 to make and evaluate equipment modifications. Once all parties are satisfied that the seating equipment addresses the issues/goals, the process may move to Action Point #7. Action Point 7: Evaluate outcome Finalize prescription and complete appropriate funding and medical record documentation. Together with the vendor, dispense the final prescribed equipment. Adjust and modify equipment. In the Behavioural Health Program, the OT continues to evaluate the client on an ongoing basis due to the progressive nature of the disease and behavioural changes over time. New problems and goals may be identified that result in re-engagement in the CPPF process to guide changes in equipment prescription. **If it is noted at a much later date, that the prescribed seating or components do not meet the client s needs, then it is necessary to go back to Action Point # 3, 4, 5. Action Point 8: Conclude/exit Provide education for families (i.e. role of vendor, role of OT, equipment warranty and maintenance, when to request a referral to review seating, ADP eligibility for funding due to changes in functional status and equipment breakdown) Prior to discharge, the OT educates the SDM regarding the goals of seating and use of positioning or restraining devices to assist the SDM with selecting a discharge location that ensures a good person-environment-occupation fit. Upon discharge the OT supports the SDM to advocate on behalf of the client for continued use of mobility equipment as it was prescribed by the OT. Communicate with the receiving facility and SDM regarding the therapist s seating recommendations as well as any risk issues and clinical rationale for positioning devices and restraint use. Forward relevant documentation pertaining to seating to the receiving facility and/or OT. Educate SDM and facility that due the nature of the disease, it is expected that the client will continue to change over time. If significant changes to functional or behavioural status occur, the client should be referred to an OT to review seating needs. Risk Issues/Considerations
Issue: Injury to self Strangulation due to use of positioning devices Considerations - Ensure stable pelvic position this can be achieved through use of a pelvic positioning device mounted and adjusted appropriately; or support feet on stable surface. - Use positioning devices according to manufacturer s guidelines. - Be aware of the strangulation risks associated with use of seatbelts, headrests, harnesses and full lap trays (note: lap trays are not designed to stabilize the pelvis). - Obtain informed consent by explicitly stating risk/benefits of the device including risk of client mortality. - Implement close monitoring and document specifically to the identified risk issues and develop a plan of action if safety issues arise. Tipping wheelchair - Use wheelchair frames which increase stability (i.e. tilt frames with low centre of gravity, long frames, frames with wide base of support, position of rear wheels) - Modify wheelchair frames (i.e. addition of weights, rear floor jacks) - Apply wheel locks strategically (i.e. one on/one off) - Achieve an appropriate seat to floor height to reduce the risk of the client tipping the wheelchair. Skin Breakdown - Use tilt (attendant or self tilt) to offload pressure, reduce friction or shear forces. - Evaluate use of cushions which have unstable properties in relation to strangulation risk and consider whether these should be used in conjunction with other positioning devices to increase pelvic stability and enhance lower extremity positioning. Unsafe self transfer - Provide client with a monitoring device (i.e. wheelchair alarm) - Use automatic wheel lock engagement (limited application with client population due to frame style and method of transfer). - Adapt wheel locks to increase access and visibility. - Modify environment to decrease risk of injury (i.e. room setup) Issue: Injury to others Indiscriminate wheelchair mobilization Physically responsive behaviours Considerations - Modify environment to decrease risk of injury to others (i.e. room setup and monitoring devices) - Facilitate interdisciplinary team discussion to problem solve alternative strategies prior to use of wheel locks, tilt or immobilizing client to mitigate risk. Issue: Damage to property Considerations Premature breakage - Select a wheelchair frame and custom modifications that are durable (i.e. double struts; heavy duty frame; shock absorbers; style of armrest posts and footrests/hangers; headrest mount location; mounting hardware of seating components). - Select seating equipment that will withstand client behaviour (i.e. construction material of backrest shell and hardware, durability of cushion material and incontinence cover, mounting mechanism and durability of positioning devices such as laterals, adductor
pads) - Select equipment that can be easily and inexpensively replaced (ie. style of armrest pads) - Educate SDM on the ramifications of providing devices with adjustable features vs. client behaviours when establishing priorities with client/sdm. - Educate SDM on selecting a vendor that will commit to responding promptly and effectively when an urgent safety issue arises. Dismantling of equipment - Modify the wheelchair to reduce risk of adjustable parts being removed by the client (i.e. seatbelt mounting mechanism, secure removeable parts such as armrests) - Consider safety issues for client and others if equipment dismantled (ie. parts used as weapon, exposed metal, ingestion of dismantled material) For clients who present with significant risk issues, the OT should collaborate with the vendor and manufacturer to customize seating solutions to mitigate these risks. This may ultimately result in equipment redesign by the manufacturer. References: Polatajko, H.J., Craik, J., Davis, J., & Townsend, E.A. (2007). Canadian Process Practice Framework. In E.A. Townsend & H.J. Polatajko, Enabling occupation II: Advancing an occupational therapy vision for health, well-being, & justice through occupation (pp.233). Ottawa, ON: CAOT Publications ACE. Craik, J., Davis, J., & Polatajko, H.J. (2007). Introducing the Canadian Process Practice Framework: Amplifying the contexts of practice. In E.A. Townsend & H.J. Polatajko, Enabling occupation II: Advancing an occupational therapy vision for health, well-being & justice through occupation (pp.229-246). Ottawa, ON: CAOT Publications ACE. Long-Term Care Homes Act (2007). S.O. 2007, c.15. Retrieved from http://www.elaws.gov.on.ca/html/statutes/english/elaws_statutes_07l08_e.htm Health Care Consent Act (1996), S.O. 1996, c.2. Retrieved from http://www.elaws.gov.on.ca/html/statutes/english/elaws_statutes_96h02_e.htm Regulated Health Professions Act (1991). S.O. 1991, c. 18. Retrieved from http://www.elaws.gov.on.ca/html/statutes/english/elaws_statutes_91r18_e.htm Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The Person-Environment- Occupation Model: A transactive approach to occupational therapy. Canadian Journal of Occupational Therapy, 63, 9-23. Canadian Association of Occupational Therapists. (2002). In Enabling Occupation: An occupational therapy perspective (Rev. ed.) Ottawa, ON: CAOT Publications ACE. Davis, J., Craik, J., & Polatajko, H.J. (2007). Using the Canadian Process Practice Framework: Amplifying the process. In E.A. Townsend & H.J. Polatajko, Enabling occupation II: Advancing an occupational therapy vision for health, well-being & justice through occupation (pp 247-272). Ottawa, ON: CAOT Publications ACE.
Advocacy Centre for the Elderly (2003). Tool on Capacity & Consent: Ontario Edition. Government of Canada: Networks of Centres of Excellence. Speaker Bio Carmen Murray and Katherine Moros are occupational therapists on the Behavioural Health Program at Hamilton Health Sciences, St. Peter s Hospital. Combined, they have over 35 years of clinical experience with the inpatient population.