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Assessment & outcome measures
Elderly Rehabilitation
Rotational B5 PT Core IST
Why is good assessment important?
• Specific treatment planning
• Decision making – rehab goals
• MDT contribution – eg M&H, medical management
• Discharge planning
• Delegation
• Patient confidence
• Person centred
Subjective assessment
• HPC• PMH• DH• Social history• Falls history• Symptoms – pain, dizziness• Cognition – AMT4, AWI, or delirium? 4AT?• Consent• Patient’s perceptions and expectations
Objective Assessment (1)
• Observation• ROM• Strength• Quality of movement• Co-ordination – tremor, dysmetria,
bradykinesia• Tone – resistance, rigidity, cogwheeling• Proprioception• Sensation
Objective Assessment (2) - Function
• Bed TF’s and mobility
• Sitting balance
• STS
• Standing balance
• Gait
• Risk Assess for moving and handling
• I Can board
Problem lists
Don’t forget impairments as well as function – eg:• Low back pain • Reduced swallow• Kyphosis & decreased ROM neck & T/sp• Tight hams, adductors and gastroc/soleus• Weak quads and gluts• Reduced bed mobility – Ao2• Reduced STS – Ao1• Reduced standing balance – decreased fwd wt TF• Altered gait pattern – Ao1 with WWF
Making decisions(1) Does the patient have rehab goals?
Things to consider:• Cognitive function• Previous ability and input• Family/carer support• Degree of physiological changes• Medical causes of deterioration• Motivation• Underlying problem – can it be changed? eg
strength, length, or can it be compensated for eg with equip.
Goals
• Person centred
• SMART
• Short term and long term
• Discharge orientated
• Involvement of family / carers
• In agreement with MDT
Making decisions (2) How do we assess risk?
• What do we put on their I Can board?
• Move Goals
• Will they make it the distance to the toilet with the nurses?
• Could they walk with family members?
• Is the person safe to walk by themselves?
How do we assess risk?
• Risk vs consequences
• But what about real patients/people in real life situations?
• Do we weigh up with positives as well as the negatives?
• And do we consider their choice? (?capacity)
Consider:
Degree of risk of falls
• Insight/safety awareness
• Mobility
• Tinetti < 18?
• Vision
• Age
• Medical condition
Consequences of fall
• High fracture risk eg osteoporosis
• Potential for injury related to IV lines, catheter, O2 therapy etc
• Increased length of stay
• previous falls
Benefits of walking
• Maintain /improve strength and balance therefore may reduce falls risk
• Maintain / improve cardiovascular fitness
• Emotional wellbeing
• Improve quality of life
• Mental stimulation
What does the patient/person want?
Practicalities – how do we decide degree of risk?
• Tinetti balance – use it and prove it
• Functional reach – literally functional – can they open the toilet door? Can they reach their trousers? Can the let go to wash their hands
• Walk through their ADLs
• Is the WWF going to be left beside them or will others keep moving it out of the way?
Jimmy
• TL = WWF and AO1 on ward
• Tinetti 16 – poor gait but can stand narrow BOS and reach unaided
• NS think he’s taking risks ‘wandering’
• Jimmy’s desperate to get going!
• What do you do?
• What else do you want to know to help your decision?
Jimmy
• Is Jimmy distressed by not being allowed to walk independently?
• Does he have capacity?
• What do the family think?
• What do the MDT think?
• Do the benefits of walking (physical and emotional) outweigh the risk?
• I think Jimmy should go for it! ??
• But address risks…
• Footwear
• Ensure walking aid nearby
• Chair and bed at appropriate height
• Glasses / hearing aids in use
• Strength and balance programme
• I Can board
• Educate staff on benefits of walking and quality of life *active wards*
• Involve family /carers
• Check signage
• Monitor /treat pain
What about Jean?
• Persistently trying to get up indep
• Tinetti 10
• Can’t stand without support of WWF
• Delirium
• Poor vision despite glasses on
• Several falls on ward already
• Family putting in a complaint
Not safe to mobilise
independently
Assist Jean to walk on all occasions
she wishes (where possible)
Strategies to help:
•Address need (eg toilet, hunger, pain…)
•Involve family/carers to assist where
appropriate
• Consider falls alarm if not distressed by
it??
•Encourage MDT to walk with Jean
regularly especially if showing signs of
trying to get up
•Consider stimulation / Activity
Coordinators / Volunteers
•Encourage appropriate seating to
promote safety and independence
Take home message re risky decisions:
• People (with dementia) have the right… – “to maintain their best level of physical, mental, social and
emotional wellbeing”– “to be as independent as possible”
• Start with what the patient/person wants to do• Choose the least restrictive option• Balance the risk with the reward – think quality of
life (but be sensible and use your PT toolkit)
Outcome Measures
• Not only help our decision making…
• What else? • Evidence value of input
• Validated tools
• Reference point for problems
• Part could be used as an objective marker eg TUSS/6MTW –or even a treatment
• Marker of progression/regression
• Relevant across admissions
• Reference point of function – admission/discharge
Which outcome measure to choose?
• Appropriateness - is the content of the measure appropriate to the context of the intervention?
• Reliability - does the measure produce results that are reproducible and internally consistent?
• Validity - does the measure record what it claims to record?• Responsiveness - does the measure detect changes over
time that matter to the patient / team?• Interpretability - how interpretable are the scores – will it
pick up a clinically significant difference?• Acceptability - is the measure acceptable to the patient?• Feasibility - how easy is the measure to administer and
process?
Common Outcome Measures
• Elderly Mobility Score• Tinetti gait and balance score• Berg balance scale• ‘Get-up and go’ timed (not TUAG)
• Other potential OMs Elderly Rehab: 30s chair stand, FES-I (falls efficacy scale), Lindop, UPDRS, 6min walk, 2min walk
• Can’t use 4 test balance scale – but could use part as an objective marker? Eg TUSS, timed tandem stand, SLS
• www.quest.scot.nhs.uk (GG&C library network)
Group work…
• Look at each outcome measure
• Consider positives and negatives of each
• When would you use it?
• Have a go at carrying it out on each other
• How would you measure 6mTW, FR etc?
• Talk about common uncertainties – are we all doing the same thing?
EMS
Positives
• Validated
• Reliable
• Easy to use
• Useful for frail elderly
Note functional reach test:
Unwilling to reach – 28x more likely to fall
Reach less than 15cm - 4x more likely to fall
Negatives
• Lacks specificity
• Plateaus quickly
• Cannot measure change in people who are independent
SCORES:<10 = dependent
>14 = independent
Tinetti
Positives
• More comprehensive measure of balance and gait
• Reliable
• Valid
• Responsive to change
• Easy to use, no equip
• Predicts falls risk:– <18 high
– 19-23 moderate
– >24 low
Negatives
• Predicts falls risk but doesn’t take into account other factors such as cognition, vision etc
• Doesn’t measure reach
• Some lack of clarity between staff on 360 turn and other parts?
• Not as good for frailer pts
Berg
Positives
• Comprehensive measure of balance
• Good selection of functional real life activities
• Good for assessment and finding an objective marker
• Best for higher level patients such as day hospital, community
Negatives
• Doesn’t look at gait
• Most of our inpatients don’t get far through test – really need to be able to stand unsupported for 1 min
• Need some equipment
• Takes longer
• Scores: <23 high falls risk, >45 safe to be indep unaided