Louise Briggs AHP Therapy Consultant November 2014
Provide an overview of the cognitive and motor problems commonly experienced in people with dementia Discuss the evidence on the relationship between cognition and outcomes in amputee rehabilitation Share some practical and evidence based strategies for delivering effective rehabilitation
4 2 2 2 10 Alzheimers disease Vascular dementia 17 Mixed dementia 62 Lewy body dementia Fronto-temporal dementia Parkinson's dementia Other Dementia UK 2007, AD UK.
Cognitive Reduced short term memory Reduced attention Reduced executive function Altered perception Lack of judgement Hallucinations Motor Balance and gait impairment Muscle weakness Freezing Difficulty dual tasking Dyspraxia Rigidity
More susceptible to cognitive impairment Significant increase in age at time of surgery Over 50% of all individuals referred to a prosthetic unit are over 65 years and ¼ are over 75 years National Amputee Statistical Database 2006-7 PVD and diabetes are linked with deterioration in cognitive function O Brien et al 2003, Strachan et al 1997, Gudula et al 2013
High cognitive capacity required! Memory Attention Concentration Visuo-spatial function Organisational skills O Neill et al 2008, 2009
Best available research Patient s characteristics, beliefs and preferences Clinical expertise
Early diagnostic assessment Identify cognitive strengths and weaknesses Type of dementia and stage? Post-operative delirium? Gather information about the person s life, background, family, family and social networks, past interests and hobbies This is me passport (Alzheimer s UK)
The person with dementia may not have the ability to verbally communicate what they are feeling The person with dementia may not be able to remember pain they experienced earlier The person with dementia may not be able to identify where their pain is located Mistaken assumptions get made: The erroneous belief that behaviours resulting from the pain are symptoms of the person s dementia The myth that People with dementia do not experience pain / their pain is less severe
Same principles apply Location Body chart Point to body part Intensity Verbal descriptor versus numerical Pictorial (pain thermometer) If unable to verbalise- Abbey pain scale or the Pain Assessment in Advanced Dementia Scale (PAINAD)
Footwear and clothing Glasses- clean and the correct ones in situ Hearing aids- in working order Is the person distracted by Pain Hunger/thirst Continence? Time therapy with familiar routines
Give the person plenty of time Use short sentences Experiment with familiar and local expressions Goal based to promote a specific action Use direct requests to avoid refusals Use positive phrasing
Limit requests to one at a time Use repetition and change wording if necessary Word requests for an automatic response Give step by step instructions if helpful Use tone of voice to suggest ease of task Listen to what you say and watch the person s reactions
Gesture: indicate direction of movement with hands Touch: give light hand pressure or taps to guide movement Auditory: make a chair/pillow noise to indicate here Visual: demonstrate the required movement
When there are two health care professionals, only one should speak Consider ward round structure, family meetings, goal setting meetings Decide who is going to lead the activity prior to meeting the patient Let the person who has the greater relationship with the patient lead
Demonstration and copy Be ready to cue each repetition or after 5 reps Pair patients together so that they can copy each other Be ready to give the person something new to do
The receiving chair should be positioned close to and at about 90 degrees to the chair the person is sitting on Use gap filling strategy Use auditory/visual/touch cue Reach across transfer The person may forget that the chair is behind them and not sit down- keep the chair in sight at all times!
Involves major changes of position Lie to sit Get up please Visual cue Gap filling strategy Moving along the bed Verbal cue Visual cue Invade personal space with care
Families and friends can contribute crucial information and understanding Do not assume that a carer can provide additional support and input Joint sessions with family and friends may be helpful Families and friends may require support and training Communication strategies Moving and handling techniques Consider their needs
Rehabilitation requires new learning / relearning Stages of learning Stage 1 Cognitive stage understanding task develop strategy cognitive hierarchy Stage 2 Associative refine skill reduced cognitive load Stage 3 Automatic low level of attention
Procedural memory underlies the performance of a motor or instrumental task and does not require effortful recall Thought that learning new motor tasks is relatively preserved in AD despite global cognitive decline Generalisability is difficult with dementia Need to be clear of steps required in task Stress level
Learn by repeated exposure to skill Frequent and consistent practice is essential Avoid practice under dual task conditions Train in an environment closely resembling where skill will be used Train with same equipment Amount of training will depend on the task Learning will not achieve the level that someone without dementia will be able to achieve Van Halteren-van Tilborg et al (2007) Motor-skill learning in Alzheimer's Disease: A review with an eye to the clinical practice. Neuropsychol Rev, 17 203-212.
A method of learning without errors or mistakes Provide enough support that the person is successful at the task Give positive feedback Gradually reduce the support given Learning environment Minimise internal and external distractions Context of learning must be structured but uncomplicated
Target the learning experience to specific functions Create plenty of opportunities for learning Tap into intact memory systems; encourage association between information that is new and what is familiar
Reduce information if required; less may be more! Verify the person s understanding Use prompts Ensure similarity between the environment where information is to be retrieved and where it is practiced
Any questions? Louise.briggs@stgeorges.nhs.uk