OT, Dementia and Palliative Care
Recognising the skills you have,
developing the skills you need
Living and Dying Well . HOPC National Conference.
Liz Copley Consultant OT
Overview
• Drivers
• OT roles, priorities, interventions and approaches
• Future direction: our shared worlds – collaboration
• Principles of supportive design
Living and Dying Well . HOPC National Conference.
Liz Copley Consultant OT
Key Drivers
• NICE Dementia Guidelines (2006); National Dementia Strategy (2009) Living
Well with Dementia; NICE Quality Standards
– Prime Minister’s Dementia Challenge (2012)
http://dementiachallenge.dh.gov.uk/about-the-challenge/
• My Life Until The End: Dying Well with Dementia (2012)
http://www.alzheimers.org.uk/site/scripts/download_info.php?downloadID=945
– Highlights: public awareness, care planning and proxy decision making, dignity at
end of life, pain, withholding and withdrawing treatment, emotional and spiritual
concerns, place of care and death
– Includes recommendations related to all of these areas
Commissioning
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Dementia (including end of life care) is within a range of NHS/ CCG work-streams;
Palliative care priorities incentivised as part of QIPP spending review
http://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions-and-integratedcare/end-of-life-care.aspx
Living and Dying Well . HOPC National Conference.
Liz Copley Consultant OT
• NCPC publications/ work-streams
– ‘Priorities for dementia within end of life care strategy’
– The Power of Partnership; Palliative care in dementia; Out of the Shadows
– ‘Pain and distress in advanced dementia’
– http://www.ncpc.org.uk/news/how-would-i-know-what-can-i-do
• ‘One chance to get it right’
– Review of LCP; 5 new priorities of care http://www.england.nhs.uk/ourwork/qual-clinlead/lac/
Living and Dying Well . HOPC National Conference.
Liz Copley Consultant OT
We have so much in common!
Cross-cutting Themes
Clinically
Services and systems
• Earlier interventions/ advanced
planning
• Person centred care
• Well-being: emotional and
psychological needs, prevention
of isolation, maintenance of
relationships
• Pain assessment/management**
• Prevention of hospital admissions
• Non-pharmacological/ holistic
approaches
• Increased public awareness and
information
• Community engagement and
choice – support to stay at home
• In-reach and liaison with care
homes and acute hospitals
• Collaborative working across
services and specialisms
• Streamlining processes and
simplifying or removing interfaces
• Training/ education
• Team working
Living and Dying Well . HOPC National Conference.
Liz Copley Consultant OT
OT in Dementia Care
Roles and priorities - across the pathway
OT aims: to help person stay engaged and involved in their
routines, occupations and relationships, to stay safe, to stay
physically and mentally well.
Living and Dying Well . HOPC National Conference.
Liz Copley Consultant OT
• Contribute to baseline assessments, team formulations, signposting
• Occupational and functional assessment of person’s abilities and needs
• Educative and leadership role - assist person with dementia, their families
and any carers/ colleagues:
• To understand about the brain, the impact of their illness, their needs,
and ways of maintaining skills, roles and activities - may be simple
advice, may be specific interventions, may be a detailed plan for
others to follow.
• To recognise the significance of the undamaged sub-cortex and
importance of occupation and activities to support person-hood and
well-being. In people with severe dementia this may be on a sensory
or reflex level
• To use a ‘Cognitive support/ scaffolding approach’ in line with the
person’s needs– see illustration
Living and Dying Well . HOPC National Conference.
Liz Copley Consultant OT
Supporting Cognitive Function
a guide for carers
Supporting Parietal Lobe Function
Touch and name body parts when
assisting
Gently pat small of back before and during
physical assistance
Help to direct gaze in the right place
Help to sequence tasks and to complete
dressing, washing
Help to maintain comfortable and safe body
posture
Slow down when assisting
Remove clutter
Parietal Lobe
body management
and integration of
physical experiences
Occipital Lobe
visual processing
Supporting Frontal Lobe Function
Talk about what needs to be done
today/tomorrow (planning)
Talk about anticipated problems
Talk about the likely consequences for chosen actions
(judging)
Give clear verbal and non-verbal signals, messages and
responses (controlling)
Frontal Lobe
planning, judging,
controlling
Temporal Lobe
auditory processing of
language and words,
memory and ‘save button’
for information,
knowledge, memories
Supporting Occipital Lobe Function
Use colours to help to distinguish object; dark on
light background or light on dark background
Name objects when presenting them
Presents object at eye level – within 15-20 cm
Avoid shiny flooring
Avoid heavily patterned flooring
Use classic shaped objects and furniture
Use uplift lighting to avoid shadows
Make objects needed visible
Be aware of areas of visual inattention or blind spots
Remove objects not needed from eyeshot
Pay extra attention to lighting
Remove clutter
Supporting Temporal Lobe Function
Repeat information as often as needed in a positive
relaxed manner
Adopt a running commentary when assisting
Use simple concrete language
Know as much as possible about the person’ and their memories
Give ‘safe’ verbal and non-verbal signals
Provide environmental cues telling of the place, time of day, time
of year
Always introduce yourself by name and remind person who you
are regularly
Initiate conversation about person’s family, likes and dislikes
‘Fill in the gaps’ with the required word or name if struggling
• Risk assessor/ advisor; – ‘Assistive Technology expert role’ (prompting
devices, alert and safety systems, clocks and orientation equipment)
• ‘Environmental expert role’, support for orientation, independence, safety
and well-being.
– In person’s home -hazards, lights, clear clutter/simplify, visual/ in line of sight prompts
– Leadership on upgrades and re-designs of hospital and care environments. A MASSIVE
area of need/ work
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Valuing Active Life in Dementia Programme- ‘VALID’
Cognitive Stimulation (CST groups; 1:1; supervisory/ support role)
Falls risk assessment and programmes- OTAGO
Sensory Work –OT Winnie Dunn’s profiling tool; measures sensory processing
and promotes theory based decision making and intervention planning.
http://www.pearsonclinical.com/therapy/products/100000434/adolescentadult-sensoryprofile.html?Pid=076-1649-700#tab-details
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In later stages- specialist seating, postural care
Living and Dying Well . HOPC National Conference.
Liz Copley Consultant OT
Person Centred Practice
Meeting the person’s psychological needs
‘Personhood’
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Comfort
Identity
Occupation
Inclusion
Attachment
• OTs have a clear leadership role in
‘operationalising’ person centred care ..
what is it? what does it look and feel like?
how person centred are you, your
colleagues and team? - take the test!
Enriched Care Planning for People with Dementia - A Good Practice Guide to Delivering PersonCentred Care
• Hazel May, Paul Edwards and Dawn Brooker builds on Tom Kitwood’s work
Practical framework for whole person assessment, care planning and review of persons with
dementia (including those with learning disabilities). provides photocopiable assessment forms,
guidelines for carrying out the assessment, and suggestions for tailored interventions
assessment process. http://www.jkp.com/catalogue/book/9781843104056
• Dementia Care Mapping, Bradford well-being tools, ‘Cornerstones training
Living and Dying Well . HOPC National Conference.
Liz Copley Consultant OT
Therapies and Interventions
Do they meet Person centred care needs?
• Reminiscence & Life story work identity – inclusion – comfort - attachment
• Creative and Sensory approaches occupation- inclusion – attachment
(music, arts, exercise, dance, aromatherapy, cooking/ food etc)
• Cognitive Support: occupation- inclusion, adapt the world to the person,
match ability with opportunity, support brain lobe functions, add
appropriate-remove inappropriate stimulation, support underlying needs
• Cognitive Stimulation Therapy occupation- inclusion- rehab-identity
• Doll Therapy, Pets & Robotic animals comfort- attachment- occupationinclusion
• Reality Orientation (running commentary techniques) comfort- identity attachment
• Validation Therapy comfort- identity- attachment- inclusion
Not always about what you do- more about how you do it
THERAPEUTIC USE OF SELF!!
Living and Dying Well . HOPC National Conference.
Liz Copley Consultant OT
OT Models and Approaches in Dementia
What helps us get it right?
Utilise a mixture of structured and unstructured approaches
Living and Dying Well . HOPC National Conference.
Liz Copley Consultant OT
OT Models and approaches
what helps us get it right?
Allen’s Cognitive Disability Model – based on a developmental approach to
cognitive disability (Piaget).
• Emphasis is on discovering what the person needs and wants to do,
observing how they do things and their abilities and performance.
Activities themselves are analysed in terms of the cognitive requirements
• Once a person’s level of cognitive ability is established the OT is able to
adapt activities and occupations to suit.
– LACL (Large Allen Cognitive Level Screen) – visuomotor lacing task
– RTI (Routine Task Inventory) – completed by carer
– CPT (Cognitive Performance Tests) – 6 standardised tasks assessed by observation
• The model helps carers understand what the person with dementia can
and cannot do and to support/engage the person at the appropriate level.
• Caregiver support and guidance is an important element of the approach
Living and Dying Well . HOPC National Conference.
Liz Copley Consultant OT
Model of Occupation MOHO
a framework to help understand how occupation and activity is motivated,
patterned, and performed; recognises the importance of physical and social environments to
participation in activities and occupations.
Domains:
• The physical and social environment place where you live, places you go to, who you spend your
time with and the resources you have to support you.
• Motivation to do things most important to you, confidence in your own abilities, hope for the future.
• Roles day-to-day duties and responsibilities and your relationships with others
• Routine on a daily or weekly basis. How your time is organised and balance between self-care, work
and leisure.
• Performance capacity abilities and skills needed to concentrate on your tasks, physically manage
what you need to do and get along with others
Application in terms of dementia? - gather info and assess in line with domains, particularly consider use
of occupational performance history interview (OPH-II), Volitional Questionnaire (VQ) and Assessment of
Communication and Interaction Skills (ACIS).
• If time, discussion of case to illustrate how the framework can support effective intervention
Living and Dying Well . HOPC National Conference.
Liz Copley Consultant OT
Not forgetting…
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Jackie Pools work – Pools Activity level Instrument for Occupational Profiling (PAL)
now on-line, NICE recommends. PAL is also based on developmental approach to
cognitive disability, great resources
C.OT Living well in care homes toolkit – fantastic resource
Traditional OT observational/ functional approaches, plus other OT models
Range of neuropsych and cog assessments – use depends on role and objectives.
– MocA (Montreal Cognitive Assessment) – screening tool, takes about 10 minutes
– Addenbrookes Cognitive Assessments (ACE R; ACE III) – often in memory services
– Abbreviated Mental Test (AMT) – used in Fallsafe approach for cog screening, often
used in general hospital screening
– BADLs (Bristol Activities of Daily living) –memory services at baseline, sometimes in
primary care; Geriatric Depression Scale (GDS); MEAMS
– tests of executive function
– 6 CIT – often used in primary care screening
– CAM – confusion assessment method – for Delirium
Many others
Living and Dying Well . HOPC National Conference.
Liz Copley Consultant OT
Discussion Points
Key tasks/ challenges?
• Broadening out palliative care services and models to support people with
dementia
• Improving end of life care in other settings e.g. care homes, where most
people with dementia end their lives (Namaste project is an example of
good practice ?other examples)
• Do OTs in Dementia and OTs in Palliative Care recognise their shared
worlds and shared skills?
• As OTs how can we lead and capitalise on opportunities there are for
improving patient care, for collaborative working and for developing new
models of care and practice?
Consider your own role?
Consider how will you influence and shape future direction
Living and Dying Well . HOPC National Conference.
Liz Copley Consultant OT
Useful resources
• C.OT
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– Occupational Therapy Assessments for Older People with Dementia
http://www.cot.co.uk/sites/default/files/ss-older-people/public/OT-Assessments-forOlder-People-with-Dementia.pdf
– Various C.OT briefings, including ‘Dementia, Delirium and Depression’; Meaningful
Activity and Dementia’; ‘Cognitive Stimulation Therapy’’ ‘Dementia: adapting the
hospital environment’; ‘Dementia: adapting the care home environment’
http://www.cot.co.uk/docs/briefings/all
http://www.kingsfund.org.uk/projects/enhancing-healing-environment
http://dementia.stir.ac.uk/design
http://www.cot.co.uk/living-well-care-homes
Robotic animals – Paro seal-more info
http://journalofdementiacare.com/robots-in-dementia-care/
Living and Dying Well . HOPC National Conference.
Liz Copley Consultant OT
A few slides about the principles of supportive
design and environments for dementia…
Living and Dying Well . HOPC National Conference.
Liz Copley Consultant OT
Principles of Supportive Design
• The environment supports
meaningful interaction between
staff
• The environment supports
wellbeing
• The environment supports
eating and drinking
• The environment supports
mobility
• The environment supports
continence and independence
• The environment
supports orientation
• The environment
supports calm and
security
Kitwood’s needs- ask are
these supported by the
environment?
 Comfort , Identity,
Occupation, Inclusion,
Attachment
Dementia Friendly Environments and principles of
supportive design: King’s Fund EHE
LEGIBILITY - aided by
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Clear sight lines
Discrete security measures (‘hide’ doors by painting same colour as walls)
Even lighting, avoid shadows
Matt, even coloured flooring
Noise reduction, Uncluttered spaces
COLOUR CONTRAST very important
WAYFINDING - helped by
• Accent colours
• Artworks
• Identification of bays, bed and social spaces using appropriate reference
objects
• Signage – pictures and text. Keep it simple AT CORRECT HEIGHT – EYE LEVEL
Dementia Friendly Environments and principles of
supportive design: King’s Fund EHE
FAMILIARITY enabled by
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Domestic scale seating and dining areas
Personal items, photographs, memory boxes
Recognisable ‘traditional’ sinks, taps, handles
Traditional crockery and cutlery
MEANINGFUL ACTIVITY encouraged by
• Opportunities for carrying out everyday tasks
• Drinks and snacks – in easy reach or in labelled cupboards
• Gardens and a range of social spaces (books, games and other activities to
hand). A ‘discovery’ or ‘Seize the moment’ approach
• Handrails which guide to destinations
• Interactive artworks and memorabilia – conversation points
• Places to walk - resting points – chairs on corridors at ‘stop off ‘s’
Dementia Friendly Environments and principles of
supportive design: King’s Fund EHE
ORIENTATION supported by
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Artworks that reflect the seasons
Calendars
Large face clocks in every bedroom
Natural light
Outside spaces
Photographs of local scenes
Signs denoting location / ward and name
• Views of nature !!!!!!!!!!!
• Visible and interactive staff, wearing first name
badges that are easily readable
Dementia Friendly Environments and principles of
supportive design: King’s Fund EHE