作业治疗评估课件

1、作业治疗评估讲者: 区启明梁爱珠香港作业治疗师协会昆明医学院外聘教师二七年十二月昆明 鸣谢：钟晶晶1OT management in Geriatric PracticeGeneral clinical measures in geriatric OT practice作业治疗常用的临床量度工具Evaluation of functional performance 对功能表现的评估Modified Barthel Index (MBI)Functional Independence Measure (FIM)Lawtons Instrumental Activity of Daily Liv

2、ing (Lawton IADL)Evaluation of cognition 認知的评估Mini-mental State Examination (MMSE)Evaluation of mood 情绪的评估Geriatric Depression Scale (GDS-15)2OT management in Geriatric PracticeModified Barthel Index 改良的Barthel 指数developed by Mahoney and Barthel in 1965Modified by Shah et al in 1989to measure the ab

3、ility of self-care independence of patientsadministered by trained personnel rate the performance of a patient in an institutionalized setting through direct observationconsist of 10 self-care items3OT management in Geriatric PracticeSelf-Care Activities Feeding Bowel ControlBladder ControlToileting

4、Stair climbing Grooming Bathing Transfer Dressing Ambulation 4Modified Barthel Index改良的Barthel 指数5-point likert scale Different weights to reflect the time and amount of actual physical assistance required The total sum of item scores yield 100 indicating complete independence in self-care performan

5、ceThe most superior and widely used (Gresham, 1980; Dombory, 1987; Wade, 1988 & Shah, 1989)BI is commonly used by local Occupational Therapists. Over 95% of OT settings use the instrument to measure self care independence of patients5OT management in Geriatric PracticeModified Barthel Index改良的Barthe

6、l 指数The modified BI (MBI) improved the sensitivity of the BI at both the item and scale levelshigher content reliability = 0.87 of the MBI, than original BIinternal consistency was reported as 0.90 and 0.93 for admission and discharge stroke rehabilitation respectively (Keith, 1988; Shah et al., 198

7、9)6OT management in Geriatric Practice(Shah et al., 1989)7OT management in Geriatric PracticeChinese Barthel Index Introduction中文的Barthel 指数介绍Chinese Barthel Index是一个日常生活自我照顾能力的尺度。此尺度共有十项的活动，包括进食、个人卫生、穿衣、洗澡、如厕、大小便控制、床椅转移、步行和上落楼梯。每个活动的评级可分为五级，不同的级别代表了不同程度的独立能力。最低的是一级，而最高是五级。级数越高，代表独立能力越高。 (Leung, Cha

8、n & Shah 2007)8OT management in Geriatric PracticeChinese Barthel Index Rating Criteria中文版的Barthel 指数评分标准基本的评级标准： 完全依赖别人去完成整项活动。某程度上能参与，但在整个活动的过程中都需要别人提供协助才能完成。 能参与大部份的活动，但在某些过程中仍需要别人提供协助才能完成整项活动。除了在准备或收拾时需要协助，病人可以独立完成整项活动；或进行活动时需要别人从旁监督或提示，以策安全。可以独立完成整项活动而毋需别人在旁监督、提示或协助。注：【整个活动的过程】可介定为有超过一半的活动过程【准备

9、或收拾】是指一些可在测试前后去处理的非紧急活动过程 9OT management in Geriatric PracticeChinese Barthel Index Feeding中文版的Barthel 指数进食进食的定义是用合适的餐具将食物由容器送到口中。整个过程包括咀嚼及吞咽。评级标准：完全依赖别人协助进食。某程度上能运用餐具，通常是匙羹或筷子。但在进食的整个过程中都需要别人提供协助。能运用餐具，通常用匙羹或筷子。但进食的某些过程仍需要别人提供协助。除了在准备或收拾时需要协助，病人可以自行进食；或过程中需有人从旁监督或提示，以策安全。可自行进食，而毋需别人在场监督、提示或协助。10OT

10、management in Geriatric PracticeChinese Barthel Index Feeding先决条件：病人有合适的座椅或靠背支撑食物须放置于病人能伸手可及的盛盘或桌子上进食方式：口部进食或使用喉管进食准备或收拾活动：例子：戴上及除下进食辅助器具 考虑因素：哽咽并不视作进食的一部份，但如哽咽令安全受到影响，则表现应被降级不需考虑病人在进食时身体是否能保持平衡，但如安全受到影响，则表现应被降级喉管进食的过程并不需考虑插入及取出喉管11OT management in Geriatric PracticeFunctional Independence Measure 功

11、能独立性的评价Developed by Granger, Hamilton, & Sherwin in 1986 Measure severity of disability in terms of burden of careReflect both the impact of impairment and ability to compensate for lossesFocus on actual task accomplishmentType and amount of assistance required for effective performance of basic dai

12、ly living12OT management in Geriatric PracticeFunctional Independence MeasureStructureTwo domains: motor and cognitive 18 functional items6 self-care activities 自我照顾活动2 sphincter control 大小便控制3 mobility tasks 转移2 locomotion tasks 运动2 communication tasks 交流3 social cognition社会认知13OT management in Ger

13、iatric Practice6 Function Categories & 18 Items6个功能范畴及18个条目Self-careEating Dressing UBGrooming Dressing LBBathing ToiletingSphincter ControlBladder ManagementBowel ManagementTransfersBed, Chair, WheelchairToiletTub or ShowerLocomotionWalk / WheelchairStairsCommunicationComprehensionExpressionSocial

14、CognitionSocial InteractionProblem SolvingMemory14OT management in Geriatric PracticeFIM Scoring: Level of AssistanceFIM 评分：辅助分级The NO-HELPER Scores7 = Complete Independence6 = Modified IndependenceThe HELPER ScoresModified Dependence5 = Supervision, Setup or Standby Prompting4 = Minimal / Contact A

15、ssistance or Prompting3 = Moderate Assistance or PromptingComplete Dependence2 = Maximal Assistance or Prompting1 = Total AssistanceTotal Score Range: 18-126Moderately dependent: 10015OT management in Geriatric PracticeGeneral Description of FIM Levels of Function and Their ScoresStartDoes Subject n

16、eed help?NoDoes Subject need more than reasonable time or a device or is there a concern for safety?NoSCORE 7COMPLETE INDEPENDENCESCORE 6MODIFIED INDEPENDENCEYesNo helperYesHelperDoes Subject do half or more of the effort?YesNoDoes Subject need total assistance?YesNoSCORE 1SCORE 2TOTAL ASSISTANCEMAX

17、IMUM ASSISTANCEDoes subject need setup or supervision, cueing or coaxing only?YesSCORE 5SUPERVISION OR SETUPNoDoes Subject need only incidental assistance?YesSCORE 4MINIMUM ASSISTANCENoSCORE 3MODERATE ASSISTANCE16OT management in Geriatric PracticeLawton Instrumental ADL Scale 工具性的ADL量表Developed by

18、Lawton & Brody in 1969Chinese version validated by Tong & Man in 2002 To measure the ability of instrumental activities of daily living independence of patients that are essential for community livingConsisted of 9 itemsAdministered by trained personnel Rate the performance of a patient in home and

19、community settingsFormat of administration: self report, proxy, observation, performance-based17OT management in Geriatric PracticeLawton Instrumental ADL Scale工具性的ADL量表Distinct characteristics of IADLMulti-step & more complex, require high level of social, physical and mental skillsIncreased intera

20、ction with environment Failure of performance affects community participation and/or reintegrationPoor IADL predicts poor future health and functional status (Kovar & Lawton 1994)Target populationPre-discharge, out-patient, community-dwelling older people 18OT management in Geriatric PracticeLawton

21、Instrumental ADL ScaleEqual weights are assigned to each item to reflect the amount of actual assistance or supervision required Performance is rated against a four-point scale ranging from score 0 for inability to perform the task to score maximum i.e. 3 for total independenceThe total sum of item

22、scores yield 27 indicating complete independence in instrumental ADLAn average score is usually obtained for interpretation19OT management in Geriatric Practice日常家居及社区活动能力评估“你能唔能够自己用电话呢?” 包括找电话号码, 打及接听电话“你能唔能够自己搭车呢?” 包括自己上到正确的车, 俾车钱/买车票, 上/落车(假设你必须要搭交通工具去一个 远的地方例如探朋友 / 睇医生) 20OT management in Geriat

23、ric Practice日常家居及社區活動能力評估“你能唔能夠自己買野呢?”包括自己揀貨品俾錢及攞番屋企(假設你必須要到附近商店買食物或日用品)“你能唔能夠自己煮食呢?” 包括自己諗食乜準備材料煮熟食物及放入碗碟裡(假設你必須要自己準備兩餐)21OT management in Geriatric Practice 日常家居及社區活動能力評估“你能唔能夠自己做家務呢?” 包括簡單家務(如抹檯執床洗碗)及較重的家務(如抹地/窗)(假設你必須要自己做家務)“你能唔能夠應付簡單的家居維修呢?” 例如換燈泡維修檯及上緊螺絲等(假設你必須要自己做)22OT management in Geriatric

24、 Practice日常家居及社區活動能力評估“你能唔能夠自己洗衫呢?” 包括清洗及曬自己的衫被床單等(假設你必須要洗自己的衫,被,床單等)“你能唔能夠自己服用藥物呢?” 包括能依照指示在正確的時間內服用正確的份量(假設你必須要自己查藥油或食藥等) 23OT management in Geriatric Practice日常家居及社區活動能力評估“你能唔能夠處理自己的財務呢?” 包括日常錢銀的找續交租/水電費及到銀行提款(假設你必須要買自己交租/水電費及有將錢放在銀行) 24OT management in Geriatric PracticeLawton Instrumental ADL S

25、cale Rating CriteriaScore 3 : independent to do 独立完成Score 2 : 独立完成但是存在困难independent to do but with difficulty (i.e. poor safety; special arrangement needed; verbal prompt needed; slow in speed; seldom to do due to with difficulty but able to do if required)Score 1 : 需要帮助need some help Score 0 :unabl

26、e to do 不能完成25OT management in Geriatric Practice Use of Functional Assessments 功能评价的使用Set up a baseline on functional levelProgress monitoringQuantify the changes after interventionDischarge planningPart of decision making of placement recommendations A communication tool among settings and discipl

27、ines26OT management in Geriatric PracticeFunctional Assessment 功能评估Functional performance of older adults in self care and/or instrumental ADL can be restricted due to injury/illness.Supporting clients to attain optimal functional independence is one of the goals for OT geriatric practice.27OT manag

28、ement in Geriatric PracticeWhat are the common criteria used in functional evaluation? 在功能评估中的共通标准是什么？28OT management in Geriatric PracticeCommon criteria used in functional evaluationIndependence / level of assistance独立/需要协助的分级Frequency/Amount of physical or verbal assistance that a client asks for

29、 during task performance患者在完成指定任务中所需要体力上的帮助/口头的提示程度/数量29OT management in Geriatric PracticeHow about these criteria? 这些标准怎么样？Effort 成果 Amount of physical difficulty or fatigue that clients demonstrates during task performanceEfficiency 效率Degree of disorganization, inappropriate use of time and space

30、 that clients demonstrates during task performanceSafety 安全性Clients potential of injuring himself or causing damage to environments during task performance30OT management in Geriatric PracticeAssessment for Cognitive ImpairmentIn Hong Kong, prevalence of moderate to severe dementia is 6.1% in people

31、 who aged 70 or above (Chiu et al., 1998)24.6% in high risk elders who are living in institution or home (SSP Survey 2005)31OT management in Geriatric PracticeMini-Mental State ExaminationDeveloped by Folstein & Folstein in 1975Bedside screening instrument for detection of cognitive impairmentAdmini

32、stration time: about 10 minutesReliably tested across different culturesSensitive to changes32OT management in Geriatric PracticeMini-Mental State ExaminationComposed of 6 domainsOrientation (time & place)RegistrationAttention & calculationMemory (short term)Language & ComprehensionVisual spatial or

33、ientation33OT management in Geriatric PracticeMMSE - InterpretationGeneralAn aid to document the presence of cognitive impairment or monitor progress of disease Serial MMSE scores is sensitive for progressive mild cognitive problemEducation level, sensory impairments, language and communication prob

34、lems may affect the reliability of the test34OT management in Geriatric PracticeMMSE - Interpretation Score30 : no impairment or = 24 : “normal” in general population20-23 : cognitive impaired but still live independently 20 : usually cannot live independently : problems in instrumental ADL : still

35、manage basic ADL35OT management in Geriatric PracticeCantonese MMSE Cantonese version of MMSE was developed by Chiu et al in 1994Some items revised according to the Chinese culture in Hong KongValidation studies conducted for elderly populationCut-off scores developed according to different educatio

36、n level of subjects36OT management in Geriatric PracticeCantonese MMSE37OT management in Geriatric PracticeCantonese MMSE現在是什麼時候?年份季節月號數星期這裡是什麼地方?香港/九龍/新界地區 (深水步 / 長沙灣)醫院名字部門 層數38OT management in Geriatric PracticeCantonese MMSE我會講三種東西的名字給你聽，講完之後請你重覆一次並緊記，因為幾分鐘後我會問你。蘋果、火車、報紙你用一百減七，然後再減七，一直減落去直至我叫停。現

37、在我會講幾個數字請你倒轉讀出：我較早前請你記住的三種東西是什麼？39OT management in Geriatric PracticeCantonese MMSE這樣是什麼東西？（手錶 / 鉛筆）請你跟我講句說話，姨丈買魚腸。現在檯上有一張紙，請你用左(右)手拿起張紙，用雙手對摺一次，然後放回檯上/交給我。請讀出紙上的字，然後照住去做。（拍手）請你講/寫出一句完整句子。這裡有一幅圖形，請你照住畫。40OT management in Geriatric PracticeCMMSE - Interpretation Cut-off Score22 or below : for elder w

38、ith more than 2 years of education20 or below : for elder with less than 2 years but more than 6 months education18 or below : for elder with less than 6 months of or no education (Chiu et al., 2000) 41OT management in Geriatric PracticeCharacteristics in different diagnostic groupsAlzheimers Diseas

39、eUsually the first deficits is the short term memoryDisorientation to time and is followed by disorientation to placeLanguage deficits start to appear lateUsually continue to try to get the right answer42OT management in Geriatric PracticeCharacteristics in different diagnostic groupsStrokeDeficits

40、are more patchyNo specific profile May have aphasia / dysphasia (expressive, receptive or global )May have speech / language problems earlier than Alzheimers disease43OT management in Geriatric PracticeCharacteristics in different diagnostic groups - DepressionSeem less distressed than Alzheimers pa

41、tients about their problemsMore likely to answer “ I dont know” or “it doesnt matter”When pressed they often know the answer Presented with “disability gap”No obvious STM lossOther symptoms: appetite change, energy loss, weight loss, sleep disturbance, mention about suicide, etc.44OT management in G

42、eriatric PracticeDeveloping the Care PlanProblem with judgment:Get a power of attorney, advance directive and start building a support networkSTM loss:Use reminders, lists, cues, calendars or diariesLanguage difficulties:Avoid open ended questionsAvoid idiomatic expression45OT management in Geriatri

43、c PracticeDeveloping the Care PlanWord finding difficulties:Keep language simpleGive adequate time to respondCommunicate one idea at a timeAvoid words with more than one meaning3-step command deficit:Give one instruction / idea at one time46OT management in Geriatric PracticeWhy the evaluation of mo

44、od is important in geriatric practice? 情绪的评估为什么重要？11 15% of local elderly people showed depressive symptoms (Chi, Yip, Chiu et al., 2005)Poor self-rated health, chronic pain, vision problems, ADL impairment, financial strain, few social support are associated with an increased likelihood of geriatri

45、c depression (Chi, Yip, Chiu et al., 2005) Aversive consequences of depressive mood include increased disability, treatment refusal, suicidal attempts or acts, and a decreased quality of life. 47OT management in Geriatric Practice Geriatric Depression Scale (Short-form) 老人抑郁短量表Developed by Sheikh & Yesavage in1986 Screening tool for geriat