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The role of a cognitive function assessment in informing level of

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					Contribution of a functional
  cognitive assessment in
 evaluating power mobility

        Sheryl Tenenbaum
        Jacqueline Partnoy
           Lynda Dunal

        Health Care Innovations
             Nov 18, 2008
                  Outline
•   Background
•   Approaches to assessing power driving
•   Approaches to assessing cognition
•   Our approach and experiences
•   Next Steps
•   Questions
      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).”
 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)
                          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.
 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)
  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
                     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
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.
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
       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.
CPT Video
PIDA Video
 Preliminary data                                     – CPT scores >4.7
Client               PIDA                      CPT    Client Outcome          Analysis
                     recommendations

New admission with   Restricted                4.75   Indoor driving          CPT supports
PM
                                                                              that training
New admission with   training                  4.75   Indoor driving          or driving with
PM                                                                            restrictions is
New Admission with   Supervision outdoors      4.9    Indep. Indoors,         indicated
PM                                                    supervision outdoors
New driver           training                  5.4    Driving on unit

New driver           Training                  5.1    Indep. on unit, still
                                                      in training

New driver           training                  5.0    Indoor driving

New driver           Drive with restrictions   4.75   Indoor driving, very
                                                      slow speed
New driver           Restricted to indoor      4.7    Indoor driving
                     driving
 Preliminary data
Client          PIDA                    CPT
                                               – CPT scores <4.7
                                               Client Outcome     Analysis
                recommendations
New admission   Driving with            4.0    Driving with       OUTLIER
with power      restrictions                   restrictions and
mobility                                       distant
experience                                     supervision.
New driver      Very poor driver on     4.7    Power not          OUTLIER
                orientation/unsafe to          recommended
                drive
                 PIDA not done
New driver      training                4.3    Did not learn
                                               Power not
                                               recommended
New Driver      Driving with            3.92   Not                CPT supports
                restrictions                   recommended        that Driving is
Re-evaluation   Shouldn’t drive                Remove chair       not indicated
                                        4.1
requested
Re-evaluation   Should not drive        3.75   Remove chair
requested

Re-evaluation   Should not drive        3.6    Remove chair
requested
          Feedback to date
• Clients / Families / SDM
• Clinical teams
• Occupational Therapists
         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…
    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
                  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
Questions
                       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.
• 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,
              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
             Contact Us
• Jacqueline Partnoy jpartnoy@baycrest.org
• Sheryl Tenenbaum stenenbaum@baycrest.org
• Lynda Dunal ldunal@baycrest.org

				
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