This essay will include an introduction providing an overview of the placement undertaken and the relevant client group who access the service, a critical evaluation of three assessments that have been used within the service, one being Occupational Therapy specific, a discussion and examples given of how risk is assessed and managed within this practice setting, a discussion of the models of practice used, one intervention plan used with a particular client with an analysis of how the interventions were identified and prioritised, appraisal and justification of other potential intervention strategies, identification and evaluation of the impact of relevant legislation upon service provision within the practice setting, finally an evaluation of own performance as a student Occupational Therapist, and a conclusion.

The practice placement setting was a city-wide Memory Service situated in North Yorkshire. The Memory Service is made up of a multi-disciplinary team of mental health professionals, working alongside the Alzheimer’s Society. The service facilitates early detection, diagnosis, and assessment of needs for older people with a memory problem, as well as giving support to their carer’s. Group support is also provided.

Client’s who are referred to the Memory Service are generally older adults who are experiencing early-stages of dementia. This essay will focus on one service-user who has been referred to the service diagnosed with Alzheimer’s Dementia, we will call him Max. The NHS website defines Alzheimer’s as being ‘the most common form of dementia, which is a group of symptoms associated with a decline in mental abilities, such as memory and reasoning’ (NHS.uk, 2010) Max is in the early/forgetfulness stage of dementia (Schneck, Reisberg, & Ferris, 1982) This includes mild impairment in memory and language, personality alterations, increased depression and anxiety, although there is no significant deterioration in ADL and is still able to live independently, however, it is apparent that Max is in need of some support. Moniz-Cook & Wood (1997) suggest that psychosocial interventions are more effective in the early stages of dementia and memory services have great potential to provide early interventions for the service user.

Max is experiencing difficulties in certain areas of his occupational performance, such as cooking/social isolation

ASSESSMENT

Identify and critically evaluate 3 Ax’s that are/could be used with the client group.

The first step toward intervention is to assess the cognitive level of the client. An example of a standardised assessment is the Mini Mental State Examination 27/30 (MMSE) Folstein et al (1975) but in Memory Service the Addenbrooke’s cognitive examination (ACE-R) is used. The ACE-R is a brief cognitive test that assesses five cognitive areas: attention/orientation, memory, verbal fluency, language and visuo-spatial abilities. The total score is 100 of which Max scored 85/100. The ACE-R is easy to administer and only takes approximately 15 minutes to complete. The ACE-R results can vary depending on the intelligence of the client and their previous education, and also how literate they are.

The Hospital Anxiety and Depression Scale (HAD) was used to find out if Max was anxious or depressed. The results proved that Max was very anxious with him scoring 9/10 anxiety, however only 2/10 for depression which is not significant, therefore this score was discarded. it was highlighted that Max was anxious about beginning social contact again and integrating into the community

A kitchen assessment was undertaken with Max and the Occupational Therapist to assess and observe any risks to Max’s well-being. It was highlighted that Max often left pans on the gas cooker and ended up burning them, therefore setting off the smoke alarm, worrying the neighbours.

The unstructured observational assessment took place in Max’s kitchen at home which is a familiar environment and in keeping with his daily routine. Max decided to cook scrambled egg on toast as he felt comfortable making this. At the time the Occupational Therapist was also asking Max questions relevant to his daily routine and cooking, therefore also making it an informal interview. Although unstructured assessments cannot provide the reliability that structured assessments can, Kielhofner (2002) mentions several reasons that can justify the use of unstructured assessments, such as, to add to information previously gained through a structured assessment, lack of time, unacceptability of structured assessment by a client, lack of an appropriate structured assessment.

The negative points of carrying out a kitchen assessment are that quite often each client has a certain time of the day when they may function a lot better, Jack functions well around midday once he has taken his pain medication for arthritis and he is more able to focus on tasks. The client may also know that they are being assessed and may do things differently to how they would if they were alone.

The evidence gathered from these assessments showed the Occupational Therapist that Max is only slightly cognitively impaired and is still able to function relatively well and therefore it is important to support Max as much as we can in his own home.

Discuss relevance of risk AX and provide examples of how risk is assessed and managed

Risk assessment and management is an important part of professional processes in Occupational Therapy practice. Legislation and policies have been implemented to guide practice such as … Alzheimer’s Society

The risk profile section of the Functional Assessment of the Care Environment (FACE) assessment and outcomes system (Clifford, 1999) is used to allow the Occupational Therapist to assess and document any clinical risk that an individual may pose. FACE provides outcome data that enables a patient’s progress to be followed and also compared with other individuals. The FACE risk profile comprises of a ‘front sheet’ that summarises a patient’s contact details, and ratings of risk which are placed on a five-point scale ranging from 0=no apparent risk, through to 4=serious and apparent risk. The second sheet is a checklist of historical and current indicators of risk grouped into categories e.g. ‘clinical symptoms indicative of risk’ and treatment-related indicators of risk’. The third sheet comprises free text boxes where a description of the specific risk factors, both current warning signs and risk history, can be fully describes and individualised for the patient. The fourth sheet comprises relapse and risk management plan which can be specified and tailored for an individual.

Some specific events from Max’s past were documented:

Social isolation and exclusion. Max hardly ever left the house apart from to do a weekly shop on a Saturday morning; his wife died two years ago and has since been living alone. Max had very few leisure interests apart from painting, and there was no close family support. ‘As the course of Alzheimer’s progresses, the global function of individual’s with Alzheimer’s decline’. (Kuo, 2009) Max may therefore become increasingly unable to look after himself which could pose a risk in the future i.e. self-neglect?

Thom and Blair (1998) describe the role of Occupational Therapy in identifying actual risks to the individual through the use of functional assessment based on observation and interview. (MENTION ABOVE AX) It was observed that Max has limited mobility due to arthritis in his knees, this poses a physical risk of falls. Max is aware of his limited mobility, however does not walk with a stick unless outside as he feels a stick inside is a hindrance. All loose rugs have been removed and the access to Max’s house is flat. He is aware of falls prevention techniques but has requested a pendant alarm from Telecare, as he feels this is appropriate in case he has a fall at home. The furniture is placed so that Max can use this as an aid for walking from the lounge into the kitchen if he feels the need.

It was also highlighted that there was a risk operating household appliances safely after the Occupational Therapist carried out a kitchen assessment with Max. It was noted that once Max had started cooking he left the pans on the hob and went off to watch television because he got bored and then consequently forgot about the pan. From the kitchen assessment the Occupational Therapist was able to intervene and reduce the potential risk by suggesting Max engage himself in an activity in the kitchen whilst the food was cooking. Therefore Max could watch over the food but also read a newspaper, or do a jigsaw puzzle to keep himself entertained.

Explore application of a model of practice and a therapy approach that were/could be used

The Model of Human Occupation (Kielhofner, 1995) is founded on the belief that meaningful occupation is central to our well-being and that human occupation can best be understood as a dynamic system. (Duggan, 2004) This looks at physical and social environments, habituation, skills, and personal causation.

As dementia is a progressive disease, the physical environment may become less accessible. Dementia may also cause disorientation, making it harder for the individual to make their way around places they are not familiar with. Occupational Therapist’s focus on Occupational performance, therefore we are interested in how individual’s function on a day-to-day basis with their work, leisure, domestic life, and personal care. We follow a person-centred approach

A person-centred and holistic approach.; A holistic approach:leisure, personal care and occupation in relation to the physical, psychological, social, economic & spiritual aspects of life, (Reed & Sanderson, 1992) & Creek, 2002.

Kitwood describes: Personhood promotes older people as having the same basic rights to dignity, privacy, choice, independence & fulfilment as people of any other age group.

Social interaction will help maintain well-being (Kitwood & Bredin, 1992), preventing deterioration of mental function. People in a state of well-being are active & occupationally engaging by nature (Turner, 2001).

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INTERVENTION PLANNING

Provide 1 intervention plan which you have implemented and justify this with evidence and clinical reasoning

Following Max’s assessment, an occupational strengths and needs list was drawn up for Max and from this an intervention plan was made based on Max’s desired aims, including long-term goals. ‘Goals are targets that the client hopes to reach through involvement in occupational therapy’ (Creek, 2002, p.129)

STRENGTHS

NEEDS

Insight into condition

Socially isolated although Max is very easy to get on with

Enjoys drawing/painting-expresses interest in joining a local group

Lost wife 2 years ago-feels as though he has lost his role in life

Physically functions quite well apart from arthritic knees

Burnt Pans

Identifies positive qualities: kind, talkative, sense of humour

Appears anxious about social involvement

Prioritising the plan involved negotiating with Max and other members of the mental health team e.g. community support team, and making sure that Max’s goals were realistic in terms of being achieved within the 6 weeks. Cox (2007) states that ‘symptoms of dementia can significantly disrupt a person’s ability to set or meet realistic goals’, therefore it is important to make sure each goal is achievable within the six weeks.

By prioritising which goals Max wishes to achieve first this highlights the use of a person-centred approach, although risk factors must be taken into consideration e.g. Max’s top priority is to be able to make an evening meal safely and independently without burning pans, this is obviously a potential risk to Max and should be carried out with a member of the mental health team first.

To meet the following goals, SMART (specific, manageable, achievable, realistic and time specific) objectives were also established.

Long-term goal 1

Max to make some of his historically favourite meals safely and independently.

Week 1: Max and the Occupational Therapist will meet on Monday morning at Max’s house, to discuss the risks of cooking with a gas cooker and write these down.

Week 2: Max and Occupational Therapist to discuss whether Max would like some reading material in the kitchen to engage Max whilst his meal is cooking, therefore allowing Max to be occupied but also to check his food regularly to prevent burning pans and potential fire hazards.

Week 3: Max and Occupational Therapist to walk to the local shop on Monday morning, to gather ingredients for the meal Max has chosen and Occupational Therapist to write down basic instruction for making of the meal.

Week 4: Max and Occupational Therapist to make the meal together at 5.30 pm on Tuesday, using the gas cooker and ingredients that were previously bought

Due to the nature of dementia, cognitive abilities decrease over time, the environment must be adapted accordingly. People with dementia may be unable to learn new skills; however old skills and habits remain deeply ingrained, and these can be used long into the disease

Basic Living skills can be of more purposeful and value to the older person than leisure, PADL skills have been found to be important in the goals of treatment with early onset dementia as they value their independence, dignity & privacy (Willard & Spackman, 2001)

It is important to facilitate plenty of praise and encouragement, through positive reinforcement. It is easier for Max to complete a cooking task when it is broken down into sections, so putting out the ingredients on the worktop in the order they need to go in the pan. Achieving only one or two steps of a task may help to give Max a sense of achievement.

Max has a short attention span and finds it hard to remember instructions, so writing down a list of short instructions on how to make his favourite meal will facilitate him in the cooking process. When making the meal for the first time the Occupational Therapist gave tactful verbal reminders and simple instructions to encourage Max.

Long-term goal 2

Max will attend creative community based activities and social groups every week for 10 weeks.

Max is a friendly and sociable person once he is around people, and he shows a strong interest in art and has many paintings around the house. Aims of the art group: to meet new people and develop social interaction through art work.

Week 1: Provide Max with information about his local neighbourhood network, available Memory Service groups, and provide transport information so that Max can attend.

Week 2: Accompany Max to attend a local art gallery, and establish a therapeutic relationship with him. Allow Max to socialise with other people at the Art Gallery and start to build up his confidence whilst getting him to talk about his favourite interest.

Week 3: Support Max to access the service for the first time; attend a Memory Service lunch club on a Wednesday morning for two hours accompanied by the Occupational Therapist.

Week 4: Max to attend a local Memory Service Open Art group for service-users once a week on Monday morning for two hours for 10 weeks.

Week 5: Max to continue attending the open art group and aim to achieve a higher level of occupational performance, by grading activities.

For an occupation to have any therapeutic benefit it must have purpose, value and meaning to the individual (McLaughlin-Gray, 1998). For Max, this is taking part in Art based activities, in his past he was a strong artist and spent most of his free time outside painting, therefore attending a local art group with similar people with memory loss this is an ideal chance for Max to express his creativity and becoming more socially integrated into the community. It is important that we find out what Max wants to do and what he would enjoy, otherwise there will be little therapeutic benefit. This is an example of ‘Person-centred care: we look for the client to lead us into an understanding of what is good and right for them’. Perrin & May (2000, p.77)

Research is beginning to indicate the value of providing educational and supportive memory groups for people in the early stages of dementia. This can be seen as a cost effective, successful intervention that provides an alternative treatment for people in the early stages of dementia (Knapp, 2006) When looking at the College of Occupational Therapist’s online dementia clinical forum, there was evidence by Graff et al, 2006, for community based occupational therapy for people with dementia and their caregivers. It found that ten sessions of community occupational therapy over five weeks improved the daily functioning of patients with dementia.

Creative activity in groups has also been shown to reduce depression and isolation, offering the power of choice and decisions. Non-verbal therapy methods, such as painting, are able to influence the well-being of the patients positively. (Hannemann,2006)

The role of the OT with general goals is in promoting occupation, health & well-being taking into consideration that dementia is progressive when making intervention plans (Pedretti, 2001).

Analyse how the interventions implemented were identified and prioritised

Appraise and justify other potential intervention strategies

Another potential intervention strategy was to install ‘Just Checking’, a web-based activity monitoring system that provides a chart of daily living activity via the web, allowing the Occupational Therapist to track (via sensors in each room) where the individual has been, for how long, and at what time. A Just Checking system could be used for Max to establish his daily routine and activity levels during the day/night. Max states that he is anxious and sits on the sofa most of the day, Just Checking can monitor what he gets up to on a daily basis for 2-3 weeks and then the Occupational Therapist can be sure that the care plans and interventions that they put into place are based on objective information, rather than on supposition. They can be confident that the plan more closely meets Max’s needs. It may highlight that Max needs extra support which can be provided by the Community Support Team.

It was suggested to Max that he try a dosset box for his daily medication, as it was noted that Max was not always compliant with his medication. However, Max refused this idea as he was happy taking his medication from the packet, and he felt that a dosset box would upset his daily routine. Another suggestion for Max could be for him to keep a diary so he can note down everything that is important like taking medication at a certain time, and attending any necessary appointments.

The Occupational Therapist also gave Max some information about a Reminiscence group that is starting in the New Year. On nearly every visit Max would get round to talking about his past or photographs that he had on the wall, so it seemed like a good suggestion for Max to attend this group. When searching the Cochrane Library database, Woods et al (2005) looked at the effects of reminiscence therapy for older people with dementia and their care-givers. The results were statistically significant for cognition (at follow-up), mood (at follow-up) and on a measure of general behavioural function (at the end of the intervention period).

The use of reminiscence therapy with people with dementia has been linked with improvements in behaviour, well-being, social interaction, self-care and motivation (Gibson 1994) Although there is little specific evidence for the effectiveness of reminiscence in dementia care (Carr, Jarvis and Moniz-Cook 2009) Max has expressed an interest in joining because he feels as though he would gain some therapeutic benefit being able to talk about past events with people of a similar age and with memory problems.

The Cochrane review concluded that there was inconclusive evidence of the efficacy of reminiscence therapy for dementia. However, taking studies together, some significant results were identified, including improvements in mood and cognition, lessening of care giver strain and improved functional ability. No harmful effects were identified.

Identify and evaluate the impact of relevant legislation, health and social policy and clinical guidelines upon service provision overall

It is important that Occupational Therapists have a clear set of principles to work alongside when working with a person with Dementia. Also it is important to follow the Codes of Ethics and Professional Conduct (COT, 2010)

The Mental Capacity Act 2005 (MCA) is underpinned by 5 guiding principles which all staff must follow

These are

an assumption of capacity

supporting people to make their own decisions

people have the right to make eccentric or unwise decisions

where someone lacks capacity staff must act in the person’s best interests

where someone lacks capacity any action we take on their behalf must generally be the least restrictive option

The National Dementia Strategy for England (DoH, 2009a) is a five-year plan which has three main aims: to ensure better knowledge, to ensure early diagnosis and to develop services. The strategy has put a focus on improving support for this large and growing group of people. It sets out a vision to raise the standards of care for people with dementia and is of great significance to Occupational Therapists working in the Memory Service.

Occupational therapists can ensure that both the clients and their carers have a better understanding about the impact of dementia. Occupational Therapists working in the Memory Service get to see clients performing various activities that are directly or indirectly affected by memory and other cognitive functions through observation and assessment and are, therefore, able to identify early signs of cognitive impairments and raise awareness about the functional implications of memory and other cognitive impairments.

In the UK, the National Service Framework for Mental Health (DoH, 1999) has been the main guide for how services should be run. It is now being replaced by the ‘New Horizons’ strategy (DoH, 2009b), which aims to promote good mental health and well-being whilst improving services for people who have mental health problems. Occupational Therapist’s need Includes early intervention: to improve long-term outcomes, personalised care: ensuring that care is based on individuals’ needs and wishes, leading to recovery

New Horizons sets out an intention across a wide range of agencies to move towards a society where people understand that their mental well-being is as important as their physical health if they are to live their lives to the full. It describes some of the factors that affect well-being and some everyday strategies for preserving and boosting it.

It is important that Occupational Therapist’s specialising in the field of dementia ensure that they have a copy of the National Service Framework for Older People and use it a guide for the minimum level of service provided.

EVALUATION

Analyse how evaluation of interventions was completed

Analyse your own performance as a student OT

Having completed this 7 week placement I feel as though I have grown in confidence and learned so around the field of Dementia. I have had the chance to observe and assess many people with different diagnosis of dementia and every single person has been different and unique, with different goals they want to achieve and what they wish to receive out of the service. I have learned that communicating with a person with dementia can be a slow process, it is important to be able to actively listen not only to the service-user but to the carer as well as they provide so much valuable information and they are usually so much involved in the care of the service-user.

Reflective practice has been identified as one of the key ways in which we can learn from our experiences. It helps to develop knowledge and skills towards becoming professional practitioners. (Jasper, 2003)   It is important that as a student Occupational Therapist I learn from my experiences on placement in order to understand and develop my practice, this involves consciously thinking about things I am doing, actively listening and making decisions. From what I have observed I can then start the reflective process and describe the experience and analyse it. I used Gibbs’s reflective cycle (Gibbs, 1988) that consists of six stages of the reflective process and asks cue questions to prompt the memory.

CONCLUSION

Provide summary of key points

Every individual has certain strengths and weaknesses, likes and dislikes, emotions and habits, needs and preferences, and this makes them unique. People with dementia are often denied these things as their disease progresses, therefore it is important to try and maintain as best as possible the individual characteristics that makes up that person. As Occupational Therapist’s we need to acknowledge the uniqueness of the person and realise that even if they have dementia they are still living their life.

Structure and predictability are important aspects of the environment in which people with dementia live.

Summarise how the interventions improved or maintained health and well being for the individual

Brooker p.44 (2007) states that ‘It is important to and appreciate that all people have a unique history and personality, physical and mental health, and social and economic resources, and that these will affect their response to dementia’.

There is good evidence that people with dementia can learn, and respond to their environment, and through groups they can experience an improvement in the quality of life. It may not be possible to reverse the effects of dementia, but some of the major difficulties for Dementia sufferers are caused by under-stimulation, withdrawal, depression, and anxiety, and these can be reduced. This can make a real difference to the person. Max has lost his motivation and he was anxious about leaving the house and becoming socially involved again because of his memory deficits and it took some gentle persuasion to get him involved again. However, the Occupational Therapist described to Max what was going to happen, and what he would be doing, and reminded him when to attend the group sessions so he did not need to worry. The Art Group is a closed group, and the same people meet for a number of sessions and they get to know each other and become familiar with the routine of the group. This is good for Max as he is able to make some new friends, return to a familiar environment each week, and start to establish a routine. The leaders of the group get to know the members and are able to plan activities according to each member. Max expressed a strong interest in watercolour painting, and the art group leader was able to accommodate this. The achievement of leisure goals helped Max to sustain his self-esteem and morale.