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Contribution of a functional cognitive assessment in evaluating power mobility

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Contribution of a functional cognitive assessment in evaluating power mobility

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    1. Contribution of a functional cognitive assessment in evaluating power mobility Sheryl Tenenbaum Jacqueline Partnoy Lynda Dunal Health Care Innovations Nov 18, 2008

    3. Outline Background Approaches to assessing power driving Approaches to assessing cognition Our approach and experiences Next Steps Questions

    4. Background and Our issue increase in use of power mobility by elderly increase in users with cognitive changes increase in risk ? accidents Issue – our need to better assess cognition in addition to driving skills in order to provide best recommendations “Rehabilitation providers can be held liable when clients they document to be safe drivers are involved in an accident resulting in harm to the client or a third party (Dawson et al., 1994).” The prevalence of use – expected to increase - One facility in western Canada has a fact sheet that presents some of the cognitive and perceptual basic requirements for using a power wheelchair § § The driver must be able to show § Understanding of cause and effect § Motivation to move and explore his/her environment § The ability to focus, or be refocused, on one activity for 15 minutes § The ability to follow directions and indicate correct answers § Adequate vision skills to be a safe and functional driver. The prevalence of use – expected to increase - One facility in western Canada has a fact sheet that presents some of the cognitive and perceptual basic requirements for using a power wheelchair § § The driver must be able to show § Understanding of cause and effect § Motivation to move and explore his/her environment § The ability to focus, or be refocused, on one activity for 15 minutes § The ability to follow directions and indicate correct answers § Adequate vision skills to be a safe and functional driver.

    5. Past approach to assessing power mobility Components Baycrest mobility and seating assessment – to identify wheelchair needs Power Indoor Driving Assessment (PIDA) – to identify driving skills Driving practice – and lots of it sometimes Repeat of Power Indoor Driving Assessment (PIDA) GAP – “grey zone” feedback from unit staff about everyday driving were not exhibited on the PIDA (one shot assessment only focusing on discrete driving skills doesn’t capture the “grey” cognitive stuff) Need to identify our populations we serve – institutional and communityNeed to identify our populations we serve – institutional and community

    6. Literature few objective, comprehensive assessment tool kits to assess driving skills Power Indoor Driving Assessment – PIDA (Dawson, Chan, Kaiserman, 1994) a standardized assessment that helps to identify where driver training, adaptation, and environmental modifications might be needed, but not the underlying factors influencing poor or good driving performance Power Mobility Assessment (PMAX) (Brighton, 2003) a non standardized assessment screening tool - includes vision, perception, cognition and behaviour Power Mobility Road Test (Massengale et al, 2005) Their study provide preliminary data on factors affecting powered mobility driving performance in adults. Identified important factors to consider when evaluating and training clients for power wheelchair use Factors included cognition, visual perception, and areas of visual function. PIDA – can be 30 minutes to more than 1 hour based on tolerance and cognitionPIDA – can be 30 minutes to more than 1 hour based on tolerance and cognition

    7. Current cognitive assessments OT’s tend to use top-down non-standardized cognitive assessments to predict safety - Top-down assessments are more clinically useful than bottom-up assessments of cognition in older adults and fit with the therapists' theoretical approach Barriers to use these assessments include availability and training required. Douglas, Liu, Warren, and Hopper (2007) Douglas and others send out a questionnaire to a random sample of Canadian OT’s to see what cognitive assessments they used and for what purpose. Some examples of Standardized Assessments included in top-down group (FIM) SMAF (Functional Autonomy Measurement System Barthell ADL Assessment (modified) Canadian Occupational Performance Measure (COPM AMPS (Assessment of Motor and Process Skills) Cognitive Performance Test (CPT) The authors support the development and promotion of standardized top down assessments Douglas and others send out a questionnaire to a random sample of Canadian OT’s to see what cognitive assessments they used and for what purpose. Some examples of Standardized Assessments included in top-down group (FIM) SMAF (Functional Autonomy Measurement System Barthell ADL Assessment (modified) Canadian Occupational Performance Measure (COPM AMPS (Assessment of Motor and Process Skills) Cognitive Performance Test (CPT) The authors support the development and promotion of standardized top down assessments

    8. The Assessment of Motor and Process Skills (AMPS) Developed from the human occupation model An observation assessment that measures a person’s quality of performance of ADL, in addition to motor and process skills Enables us to identify problematic areas for treatment. A test of skill in occupational performance Both motor and process scales may reflect safety and/or independence The Assessment of Motor and Process Skills (AMPS)requires training time and cost that make this much less accessible to therapists and, therefore, limits use – however we do have 6 AMPs trained therapists at Baycrest. Many of our clients are already in LTC The Assessment of Motor and Process Skills (AMPS)requires training time and cost that make this much less accessible to therapists and, therefore, limits use – however we do have 6 AMPs trained therapists at Baycrest. Many of our clients are already in LTC

    9. Issues Challenging to use with our older adult population – limits the choices of available tasks Although the ADL motor and ADL process ability measures can indicate how much ADL ability this person has – it is still difficult to relate that to the level of task challenge that power mobility driving may pose Requires training time and cost

    10. The Cognitive Performance Test (CPT) A cognitive-functional measure that identifies patterns of occupational performance. Guides intervention plans Measures working memory/executive function processing capacities that underlie functional performance deficits Based on Allen’s Cognitive Disability Theory and Cognitive Disabilities Model Provides a functional profile to design intervention approaches that match clients abilities with desired occupations and roles.

    11. Advantages training more accessible Able to use most CPT tasks with our population Intervention guidelines that address consequences of functional performance limitations Issues training more accessible but less standardized

    12. Cognitive Levels (Allen, Earhart & blue, 1995) Level 6. Normal functioning (absence of cognitive disability). Level 5. Mild functional decline, beginning deficits in abstract thought processes. Level 4.5. Mild to moderate functional decline; significant deficits in abstract thinking abilities; increased difficulty with solving problems or considering consequences. Level 4. Moderate functional decline, from abstract to concrete thought processes. Level 3.5. Moderate functional decline; increased cues needed for task completion. Level 3. Moderate to severe functional decline; increased cues needed during tasks. Level 2. Severe functional decline, poor use of familiar objects. Level 1. Late stage dementia. Consider a handout? Consider a handout?

    13. CPT Video

    14. PIDA Video

    15. Preliminary data – CPT scores >4.7

    16. Preliminary data – CPT scores <4.7

    17. Feedback to date Clients / Families / SDM Clinical teams Occupational Therapists

    18. Impressions so far Additional evidence of client’s cognitive performance related to driving skills Helps OT better describe and analyse our observations Particularly helpful for those clients in the “grey zone” If client already has a chair… If someone is starting fresh…

    19. Lessons learned up to now Cognition is a critical piece of the PM assessment Improved ability to inform about the level of risk Using the CPT and Allen’s model provides therapists with a numerical score that is predictive of a client’s best ability to function, and their optimal learning conditions that includes level of risk The CPT might be able to provide a cutoff score

    20. Next steps To test these findings through research – looking for possible partners To examine other factors that impact a person’s safe driving such as Visual function behaviour diagnoses health issues and stability medications Under other factors What is the most effective way to evaluate that will inform our recommendation. What contribution do these have. Under other factors What is the most effective way to evaluate that will inform our recommendation. What contribution do these have.

    21. Questions

    22. References Brighton, C. (2003) Rules of the Road. Rehab Management. The Interdisciplinary Journal of Rehabilitation. Burns, T., Mortimer, J. A, & Merchek, P. (1994). Cognitive performance test: A new approach to functional assessment in Alzheimer’s disease. Journal of Geriatric Psychiatry and Neurology, 7, 46–54. Dawson, D., Chan, R., & Kaiserman, E. (1994). Development of the power-mobility indoor driving assessment for residents of long-term care facilities: A preliminary report. Canadian Journal of Occupational Therapy, 61(5), 269-276. (available from http://www.fhs.mcmaster.ca/powermobility/index.htm) Douglas, A., Liu, L., Warren, S., & Hopper, T. (2007) Cognitive assessments for older adults: Which ones are used by Canadian therapists and why. Canadian Journal of Occupational Therapy, 74 (5), 370-381. doi:10.2182/cjot.07.010 This paper was published in the CJOT Early Electronic Edition, Fall 2007. Hall K. Partnoy J. Tenenbaum S. Dawson D. (2005) Power mobility driving training for seniors: a pilot study. Assistive Technology. 17(1):47-56.

    23. Katz, N (ed) (2005) Cognition and occupation across the life span: Models of Intervention in occupational therapy. 2nd ed. AOTA press chapter V pp 347-385. Letts, Lori & Dawson, Deirdre. Power-Mobility Community Driving Assessment (PCDA) http://www.fhs.mcmaster.ca/powermobility/pcda.htm Marom, B., Jarus, T., & Josman, N. (2006). The Relationship Between the Assessment of Motor and Process Skills (AMPS) and the Large Allen Cognitive Level (LACL)Test in Clients with Stroke, Physical & Occupational Therapy in Geriatrics, Vol. 24(4) Mendoza RJ. Pittenger DJ. Saftler Savage F. Weinstein CS. (2003) A protocol for assessment of risk in wheelchair driving within a healthcare facility. Disability & Rehabilitation. 25(10):520-6. Mortenson, W.B., Miller, W.C., Boily, J., Elgood, B., Desharnais, & G., Crawford, E., & Odell, L. Power Mobility Assessment and Safety Guidelines. Available at http://www.rehab.ubc.ca/miller/ Mortenson WB. Miller WC. Boily J. Steele B. Crawford EM. Desharnais G. (2006) Overarching principles and salient findings for inclusion in guidelines for power mobility use within residential care facilities. Journal of Rehabilitation Research & Development. 43(2):199-208,

    24. CPT References Allen Cognitive Level websites http://www.allen-cognitive-network.org/history.htm - Brief History of the Allen Battery http://www.allen-cognitive-network.org/routine_task_inventory.htm - Routine Task Inventory PDF 2006 manual http://www.ot-innovations.com/content/view/22/28/ - The Cognitive Performance Test (CPT) http://www.ot-innovations.com/content/view/21/28/ - The Allen Cognitive Level Battery and caregiver guides Where to buy the CPT - http://service.maddak.com/catalog/718370000.html

    25. Contact Us Jacqueline Partnoy jpartnoy@baycrest.org Sheryl Tenenbaum stenenbaum@baycrest.org Lynda Dunal ldunal@baycrest.org

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