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Introduction to psychosocial OT practice in dementia

Tuesday 18th January 2011

John Stone Teresa Bartram Yvonne Thompson Nicola Gibbs Jo Gambrill


Introduction to psychosocial OT practice in relation to persons with dementia (PWD). Personhood; new ways of working NICE guidelines Pool Activity Level


Dementia and loss

Brain Pathology in Dementia

Neuropsychology of Dementia
(Wisconsin DOH, 2003)

Thinking processes: Judgement* Attention* Perceptions* Reasoning* Organisation* Memory recall* Communication* Abstract thinking* Disorientation Disrupted social functioning
* >2 Occupational & Social functioning.

Perceptual disturbance Stimulation level Cliffs Heightened intuition Tunnel vision Depth perception Reading Out of sight .... / cues Fluffy Sundowner syndrome

Neuropsychological Factors
(Finkel, et al, 1998)

Perceptual Affective

Delusions Misinterpretations Hallucinations Depression Mania Anxiety Apathy

20 - 73 32 - 50 15 - 49 up to 81 3 - 15 ? ? up to 90 up to 50 up to 20


Personality change Agitation Behavioral


Why is the degree of expressed Dementia and performance in tasks not linked to extent of brain pathology we see in scans and autopsies (Kitwood, 1993) & (Snowdon, 1996)? Do psychometric assessments offer the best prediction of real world functional performance (Lowenstein & Acevedo , 2010)?
Is Dementia a process of degeneration with little hope of improvement in functional performance (Gail Mountain, unpublished)?


D dementia P personality B biography H physical health NI neuropathology SP social psychology

Dementia: a psychological response as a means of coping with brain damage Tom Kitwood (2003)

Attachment LOVE

ICT Mental Health Assessment

Physical health/medication

Social/family history

Mental Health ax
Occupational performance Psychiatric inventory

Past psychiatric history

PAL AMPS Interest checklist

Model of creative ability

Sleep, cognition (ACE-R), psychosis, appetite Mood/affect Interaction/communication risk assessment

NICE (2006) Diagnosis and assessment

Basic dementia screen, usually in primary care: - routine haematology (nurses) - Biochemistry tests - thyroid function tests - Serum vitamin B12 and folate levels Perform midstream urine test if delerium is a possibility. Conduct investigations such as chest X ray or ECG by clinical presentation. Factors that may affect performance, including educational level, skills, prior level of functioning and attainment, language, sensory impairment, psychiatric illness and physical or neurological problems.

NICE Guidelines Dementia (2006) Promoting Independence and Maintaining Function

ADL advice and skill training from an OT Advise re independent toileting skills Environmental modifications to aid independence Physical exercise Support for people to go at their own pace and take part in activities they enjoy

Pool Activity Level (PAL) Instrument for Occupational Profiling

Profiles what level of ability the person has. Designed to enable carers to use the PAL instrument to engage clients in meaningful occupation.

The Pool Activity Level (PAL) Instrument for Occupational Profiling (Pool, 2008)

PAL Personal History Profile PAL Checklist Individual Action Plans for personal care activities PAL Activity Level Profile Outcome Sheet for recording results

Life History Work

As we go through life we build up a personal history with its unique mix of joys and pleasures, sorrows and pains. Our sense of who we are is linked to that history and if we lose that we lose something of ourselves (Kitwood)

PAL checklist
1 2 3 4 Bathing / washing Getting dressed Eating Contact with others 5 Groupwork skills 6 Communication skills 7 Practical activities (craft, domestic chores, gardening) 8 Use of objects 9 Looking at a newspaper / magazine

PAL Levels

Planned; Can work towards goal directed activities with a tangible outcome, but may not be able to solve problems that arise Exploratory; Can carry out familiar activities in familiar surroundings, but more concerned with the effect of doing the activity than the final outcome. Sensory; Primarily concerned with experiencing the sensation of the activity and moving their body in response Reflex; Often unaware of surrounding environment, moves as a sub conscious, reflex response to direct sensory stimulation.


In groups complete the PAL checklist based on your observations of the video OBJECTIVE: Decide on the overall level the client is functioning at.

Going Home


Final Statement
As we become more emotional and less cognitive, its the way you talk to us, not what you say, that we will remember. We know the feeling, but dont know the plot. Your smile, your laugh and your touch are what we will connect with. Empathy heals. Just love us as we are. Were still here, in emotion and spirit, if only you could find us.
Christine Bryden, Dancing with Dementia, 2005 p138)

References and Bibliography

Chester, R and Bender, M (1999) Understanding Dementia: The Man with the Worried eyes. Jessica Kingsley, London. Finkel SI, Costa e Silva J, and Cohen G (1996) Behavioural and psychological signs and symptoms of dementia: a consensus statement on current knowledge and implications for research and treatment. International Psychogeriatrics; 8 (Supplement 3): 497500. Kitwood, T (1993) Person and Process in Dementia. International Journal of Psychiatry 8 (7): 541-545.

Lawlor, B (2002) Managing behavioural and psychological symptoms in dementia The British Journal of Psychiatry 181: 463-465.
Lowenstein, D and Acevedo, A The relationship between Instrumental Activities of Daily Living and Neuropsychological Performance. In Thomas, D and Grant, I (eds) (2010) Neuropsychology of Everyday Functioning Guildford Press. London. U.K. Snowdon, D, A., Kemper, S, J., Mortimor, J, A., Greiner, L, H., Wekestein, D, R., and Markesbery, W, R. (1996) Linguistic ability in early life and cognitive function, and Alzheimers disease in later life: Findings from the Nun study. Journal of the American Medical Association 275, 7, 528-532. Wisconsin DOH (2003) Progressive Declines of Alzheimers Disease & Related Dementia: Physical Changes That Effect Perception of the Environment. Bureau of Aging & Long Term Care Resources, Wisconsin. USA.

Wenborn et al (2008) Assessing the validity and reliability of the PAL Checklist. Aging & Mental Health, in press. Stoddart (1998) Dementia Care: Supporting a plea for personhood. Scottish Journal of Healthcare Chaplaincy 1: 9-11. Everybodys business: integrated mental health service for older adults: a service development guide. Department of Health (2005) The National Institute for Clinical Excellence (2006): dementia. Pool (2007) The Pool Activity Level (PAL) Instrument for Occupational Profiling: A Practical Resource for Carers of People with Cognitive Impairment. Bradford Dementia Group Good Practice Guides. Jessica Kingsley Publishers; 3Rev Ed edition.