Rehabilitation of patients with cognitive deficits

1
Rehabilitation of patients with cognitive deficits

• Dr Derick T Wade
• Professor in Community Rehabilitation
• Faculteit der Geneeskunde, Universiteit
  Maastricht
• Research Advisor, iRv, Hoensbroek
• Professor in Neurological Disability
• Oxford Centre for Enablement
• Windmill Road, Oxford OX3 7LD
• Email derick.wade_at_dial.pipex.com

2
Constraints in rehabilitation

• Action taken is constrained by model (paradigm)
  used
• Only act on those items considered to be
  relevant.
• If consider rehabilitation therapy as consider
  other health interventions, then
• Natural to target faulty part.

3
The conference title

• Rehabilitation of patients with cognitive
  deficits
• NOT
• Cognitive rehabilitation or
• Rehabilitation of cognitive deficits
• To widen discussion

4
Subject of talk

• Consider
• What are cognitive deficits?
• How do they cause the patient problems?
• What factors may influence causation?
• What can be done to ameliorate problems?
• Messages
• Cognitive deficits are in our (therapists)
  minds!
• Treat the person in their environment, not the
  deficits

5
Models

• All analysis and decisions take place within a
  conceptual framework
• Framework
• A way of describing the situation
• Model
• A way of understanding inter-relationships
  between items

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What is a model of illness?

• Illness refers to all aspects of ill health
• personal, family, Society etc
• Need a framework to analyse illness
• To describe it
• Need a model
• To plan rational interventions

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WHO ICIDHInternational Classification
ofImpairments, Disabilities, andHandicaps

• Developed in 1970s
• Published first in 1980
• revised 1995-99 now ICF

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WHO ICFInternational Classification of
Functioning

• Revised ICIDH framework -gt ICF
• adds contextual factors
• physical (buildings, carers, clothes etc)
• personal (experiences, strengths, attitudes etc)
• social (family/friends, culture etc)
• changes words (not concepts)
• disability -gt activity
• handicap -gt participation
• Global concept of functioning

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ICIDH ICF

• Put forward as a classification system
• like ICD a descriptive framework of illness
• for all consequences of illness
• But could be developed into a model

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WHO ICF model of illness

• The framework
• can be seen as a systems analytic approach,
• considering illness as a hierarchy of systems
• A MODEL
• In this model, illness comprises
• interacting systems
• which may have emergent properties

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WHO ICF Model of illness
Four Levels
Three Contexts
Organ (pathology)
Personal
Person (impairment)
Physical
Person in environment Behaviour (activities)
Social
Person in society Social position (Participation)
Well-being
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Cognitive deficits

• Are abnormalities/phenomena at the level of
  impairment
• Are abstract constructs used
• To summarise a wealth of observed behaviour
• To predict other observations
• Are not real
• they do not have an independent existence

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Cognitive disability

• Does not exist
• Disability refers to
• Activities that are limited
• Behaviours that are changed or restricted
• Cognitive impairments may limit behaviour
• Certain behaviours may be more affected by
  certain cognitive impairments

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Rehabilitation aims (outcome)

• To maximise patient participation in society
• maximise role function in community
• maximise status in community
• To maximise patient well-being
• somatic and emotional
• achieving satisfaction (adaptation)
• To minimise stress on distress of relatives
• somatic and emotional

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Rehabilitation objectives

• To maximise patients behavioural repertoire
• Optimising contexts
• Personal, physical, social
• Minimising impairments
• All, but especially key impairments impacting on
  activities
• Minimising pathology
• Optimising opportunities for social interaction

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Rehabilitation interventions

• Multi-focal (i.e. affecting several factors)
• Any level
• pathology, impairment, disability, handicap
• Any context personal, physical, social
• All contexts are based where the patient is, in
  the community

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WHO ICF Model of illness
Four Levels
Three Contexts
Organ (pathology)
Personal
Person (impairment)
Physical
Person in environment Behaviour (activities)
Social
Person in society Social position (Participation)
Well-being
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Intervention - pathology

• Diagnose and treat disease
• Beta-interferon for cognitive losses in MS
• Diagnose and treat complication
• Hydrocephalus after head injury/SAH
• Diagnose and treat incidental other disease
• Brain tumour, when had a stroke

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WHO ICF Model of illness
Four Levels
Three Contexts
Organ (pathology)
Personal
Person (impairment)
Physical
Person in environment Behaviour (activities)
Social
Person in society Social position (Participation)
Well-being
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Intervention - impairment

• The cognitive impairment
• Training to reduce neglect
• Training word finding
• Another impairment
• To enable an adaptive behaviour
• E.g. motor control to allow writing
• Avoid worsening impairment
• Reduce/stop drugs!

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WHO ICF Model of illness
Four Levels
Three Contexts
Organ (pathology)
Personal
Person (impairment)
Physical
Person in environment Behaviour (activities)
Social
Person in society Social position (Participation)
Well-being
22
Intervention - activities

• Practice the affected activity
• Led by patients goals
• In expected environment
• May lead to reduction in impairment

23
WHO ICF Model of illness
Four Levels
Three Contexts
Organ (pathology)
Personal
Person (impairment)
Physical
Person in environment Behaviour (activities)
Social
Person in society Social position (Participation)
Well-being
24
Intervention - participation

• Set up opportunities for participation
• Enable transport etc
• May lead to increase in practice of activities
  using impaired function
• May lead to reduction in impairment

25
WHO ICF Model of illness
Four Levels
Three Contexts
Organ (pathology)
Personal
Person (impairment)
Physical
Person in environment Behaviour (activities)
Social
Person in society Social position (Participation)
Well-being
26
Intervention personal context

• Increase self-confidence
• Reduce expectations of failure
• Increase activities
• Reduction in impairment

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WHO ICF Model of illness
Four Levels
Three Contexts
Organ (pathology)
Personal
Person (impairment)
Physical
Person in environment Behaviour (activities)
Social
Person in society Social position (Participation)
Well-being
28
Intervention physical context

• Cognitive prostheses
• Diaries, alarm reminder system (NeuroPage)
• NeuroPage leads to sustained change
• Post-its
• Person to remind patient
• Increase activities
• Reduce impairments

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WHO ICF Model of illness
Four Levels
Three Contexts
Organ (pathology)
Personal
Person (impairment)
Physical
Person in environment Behaviour (activities)
Social
Person in society Social position (Participation)
Well-being
30
Intervention social context

• Structure daily/social routines
• Work, stable social context
• Part of a routine community
• Increase activities
• Reduce impairment

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WHO ICF Model of illness
Four Levels
Three Contexts
Organ (pathology)
Personal
Person (impairment)
Physical
Person in environment Behaviour (activities)
Social
Person in society Social position (Participation)
Well-being
32
Interventions well-being

• Money?
• Car parking?
• Respect?
• Probably have no affect on anything else!

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Interventions and WHO ICF Model of illness
Organ (pathology)
Personal
Person (impairment)
Physical
Person in environment Behaviour (activities)
Social
Person in society Social position (Participation)
Well-being
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Rehabilitation - summary

• Cognitive impairment is only one factor
• Reduce cause(s)
• Drugs, disease
• Reduce effects
• Beliefs, expectations and self confidence
• Support alternative routes to activity
• Provide support
• Internal teach to use diaries etc
• External provide routines

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Rehabilitation - summary

• Minimise other impairments
• To allow an alternative strategy
• To reduce synergetic effects
• Increase level of practice of activity
• Directly, or
• Thorough social participation

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Rehabilitation of patients with cognitive deficits

• Dr Derick T Wade
• Professor in Community Rehabilitation
• Faculteit der Geneeskunde, Universiteit
  Maastricht
• Research Advisor, iRv, Hoensbroek
• Professor in Neurological Disability
• Oxford Centre for Enablement
• Windmill Road, Oxford OX3 7LD
• Email derick.wade_at_dial.pipex.com