讲者 : 区启明 梁爱珠 香港作业治疗师协会 昆明医学院外聘教师 二００七年十二月 昆明 鸣谢：钟晶晶

1. 作业治疗评估 讲者:区启明 梁爱珠 香港作业治疗师协会 昆明医学院外聘教师 二００七年十二月 昆明 鸣谢：钟晶晶

2. General clinical measures in geriatric OT practice作业治疗常用的临床量度工具 Evaluation of functional performance 对功能表现的评估 Modified Barthel Index (MBI) Functional Independence Measure (FIM) Lawton’s Instrumental Activity of Daily Living (Lawton IADL) Evaluation of cognition 認知的评估 Mini-mental State Examination (MMSE) Evaluation of mood情绪的评估 Geriatric Depression Scale (GDS-15)

3. Modified Barthel Index改良的Barthel 指数 • developed by Mahoney and Barthel in 1965 • Modified by Shah et al in 1989 • to measure the ability of self-care independence of patients • administered by trained personnel • rate the performance of a patient in an institutionalized setting through direct observation • consist of 10 self-care items OT management in Geriatric Practice

4. Self-Care Activities Toileting Ambulation Dressing Feeding Bladder Control Bowel Control Transfer Bathing Grooming Stair climbing

5. Modified Barthel Index改良的Barthel 指数 • 5-point likert scale • Different weights to reflect the timeand amount of actual physical assistance required • The total sum of item scores yield 100 indicating complete independence in self-care performance • The most superior and widely used (Gresham, 1980; Dombory, 1987; Wade, 1988 & Shah, 1989) • BI is commonly used by local Occupational Therapists. Over 95% of OT settings use the instrument to measure self care independence of patients OT management in Geriatric Practice

6. Modified Barthel Index改良的Barthel 指数 • The modified BI (MBI) improved the sensitivity of the BI at both the item and scale levels • higher content reliability  = 0.87 of the MBI, than original BI • internal consistency was reported as 0.90 and 0.93 for admission and discharge stroke rehabilitation respectively (Keith, 1988; Shah et al., 1989) OT management in Geriatric Practice

7. OT management in Geriatric Practice (Shah et al., 1989)

8. Chinese Barthel Index – Introduction中文的Barthel 指数－介绍 Chinese Barthel Index是一个日常生活自我照顾能力的尺度。此尺度共有十项的活动，包括进食、个人卫生、穿衣、洗澡、如厕、大小便控制、床椅转移、步行和上落楼梯。每个活动的评级可分为五级，不同的级别代表了不同程度的独立能力。最低的是一级，而最高是五级。级数越高，代表独立能力越高。 (Leung, Chan & Shah 2007) OT management in Geriatric Practice

9. Chinese Barthel Index – Rating Criteria中文版的Barthel 指数－评分标准 基本的评级标准： • 完全依赖别人去完成整项活动。 • 某程度上能参与，但在整个活动的过程中都需要别人提供协助才能完成。 • 能参与大部份的活动，但在某些过程中仍需要别人提供协助才能完成整项活动。 • 除了在准备或收拾时需要协助，病人可以独立完成整项活动；或进行活动时需要别人从旁监督或提示，以策安全。 • 可以独立完成整项活动而毋需别人在旁监督、提示或协助。 注： 【整个活动的过程】可介定为有超过一半的活动过程 【准备或收拾】是指一些可在测试前后去处理的非紧急活动过程 OT management in Geriatric Practice

10. Chinese Barthel Index – Feeding中文版的Barthel 指数－进食 进食的定义是用合适的餐具将食物由容器送到口中。整个过程包括咀嚼及吞咽。 评级标准： • 完全依赖别人协助进食。 • 某程度上能运用餐具，通常是匙羹或筷子。但在进食的整个过程中都需要别人提供协助。 • 能运用餐具，通常用匙羹或筷子。但进食的某些过程仍需要别人提供协助。 • 除了在准备或收拾时需要协助，病人可以自行进食；或过程中需有人从旁监督或提示，以策安全。 • 可自行进食，而毋需别人在场监督、提示或协助。 OT management in Geriatric Practice

11. Chinese Barthel Index – Feeding 先决条件： • 病人有合适的座椅或靠背支撑 • 食物须放置于病人能伸手可及的盛盘或桌子上 进食方式： • 口部进食或使用喉管进食 准备或收拾活动： • 例子：戴上及除下进食辅助器具 考虑因素： • 哽咽并不视作进食的一部份，但如哽咽令安全受到影响，则表现应被降级 • 不需考虑病人在进食时身体是否能保持平衡，但如安全受到影响，则表现应被降级 • 喉管进食的过程并不需考虑插入及取出喉管 OT management in Geriatric Practice

12. Functional Independence Measure功能独立性的评价 • Developed by Granger, Hamilton, & Sherwin in 1986 • Measure severity of disability in terms of burden of care • Reflect both the impact of impairment and ability to compensate for losses • Focus on actual task accomplishment • Type and amount of assistance required for effective performance of basic daily living OT management in Geriatric Practice

13. Functional Independence Measure…Structure • Two domains: motor and cognitive • 18 functional items • 6 self-care activities自我照顾活动 • 2 sphincter control大小便控制 • 3 mobility tasks转移 • 2 locomotion tasks运动 • 2 communication tasks交流 • 3 social cognition社会认知 OT management in Geriatric Practice

14. Self-care Eating Dressing UB Grooming Dressing LB Bathing Toileting Sphincter Control Bladder Management Bowel Management Transfers Bed, Chair, Wheelchair Toilet Tub or Shower Locomotion Walk / Wheelchair Stairs Communication Comprehension Expression Social Cognition Social Interaction Problem Solving Memory 6 Function Categories & 18 Items6个功能范畴及18个条目 OT management in Geriatric Practice

15. FIM Scoring: Level of AssistanceFIM 评分：辅助分级 Total Score Range: 18-126 Moderately dependent: <75 Independent: >100 The NO-HELPER Scores 7 = Complete Independence 6 = Modified Independence The HELPER Scores Modified Dependence 5 = Supervision, Setup or Standby Prompting 4 = Minimal / Contact Assistance or Prompting 3 = Moderate Assistance or Prompting Complete Dependence 2 = Maximal Assistance or Prompting 1 = Total Assistance OT management in Geriatric Practice

16. Does Subject need more than reasonable time or a device or is there a concern for safety? SCORE 7 Does Subject need help? No Start No COMPLETE INDEPENDENCE Yes SCORE 6 MODIFIED INDEPENDENCE Yes No helper Helper Does subject need setup or supervision, cueing or coaxing only? Does Subject do half or more of the effort? Yes Yes SCORE 5 SUPERVISION OR SETUP Does Subject need only incidental assistance? No No Does Subject need total assistance? General Description of FIM Levels of Function and Their Scores Yes No Yes No SCORE 2 SCORE 1 SCORE 3 SCORE 4 TOTAL ASSISTANCE MAXIMUM ASSISTANCE OT management in Geriatric Practice MODERATE ASSISTANCE MINIMUM ASSISTANCE

17. Lawton Instrumental ADL Scale工具性的ADL量表 • Developed by Lawton & Brody in 1969 • Chinese version validated by Tong & Man in 2002 • To measure the ability of instrumental activities of daily living independence of patients that are essential for community living • Consisted of 9 items • Administered by trained personnel • Rate the performance of a patient in home and community settings • Format of administration: self report, proxy, observation, performance-based OT management in Geriatric Practice

18. Lawton Instrumental ADL Scale工具性的ADL量表 • Distinct characteristics of IADL • Multi-step & more complex, require high level of social, physical and mental skills • Increased interaction with environment • Failure of performance affects community participation and/or reintegration • Poor IADL predicts poor future health and functional status (Kovar & Lawton 1994) • Target population • Pre-discharge, out-patient, community-dwelling older people OT management in Geriatric Practice

19. Lawton Instrumental ADL Scale • Equal weights are assigned to each item to reflect the amount of actual assistance or supervision required • Performance is rated against a four-point scale ranging from score ‘0’ for inability to perform the task to score maximum i.e. ‘3’ for total independence • The total sum of item scores yield 27 indicating complete independence in instrumental ADL • An average score is usually obtained for interpretation OT management in Geriatric Practice

20. 日常家居及社区活动能力评估 • “你能唔能够自己用电话呢?” 包括找电话号码, 打及接听电话 • “你能唔能够自己搭车呢?” 包括自己上到正确的车, 俾车钱/买车票, 上/落车(假设你必须要搭交通工具去一个 远的地方例如探朋友 / 睇医生) OT management in Geriatric Practice

21. 日常家居及社區活動能力評估 • “你能唔能夠自己買野呢?” 包括自己揀貨品﹑俾錢及攞番屋企 (假設你必須要到附近商店買食物或 日用品) • “你能唔能夠自己煮食呢?” 包括自己諗食乜﹑準備材料﹑煮熟食物及 放入碗碟裡(假設你必須要自己準備兩餐) OT management in Geriatric Practice

22. 日常家居及社區活動能力評估 • “你能唔能夠自己做家務呢?” 包括簡單家務(如抹檯﹑執床﹑洗碗)及 較重的家務(如抹地/窗)(假設你必須要 自己做家務) • “你能唔能夠應付簡單的家居維修呢?” 例如換燈泡﹑維修檯及上緊螺絲等(假設 你必須要自己做) OT management in Geriatric Practice

23. 日常家居及社區活動能力評估 • “你能唔能夠自己洗衫呢?” 包括清洗及曬自己的衫﹑被﹑床單等 (假設你必須要洗自己的衫,被,床單等) • “你能唔能夠自己服用藥物呢?” 包括能依照指示在正確的時間內服用正確的 份量(假設你必須要自己查藥油或食藥等) OT management in Geriatric Practice

24. 日常家居及社區活動能力評估 • “你能唔能夠處理自己的財務呢?” 包括日常錢銀的找續﹑交租/水電費及到銀行 提款(假設你必須要買﹑自己交租/水電費及 有將錢放在銀行) OT management in Geriatric Practice

25. Lawton Instrumental ADL Scale – Rating Criteria Score 3 : independent to do独立完成 Score 2 :独立完成但是存在困难 independent to do but with difficulty (i.e. poor safety; special arrangement needed; verbal prompt needed; slow in speed; seldom to do due to with difficulty but able to do if required) Score 1 :需要帮助 need some help Score 0 : unable to do不能完成 OT management in Geriatric Practice

26. Use of Functional Assessments功能评价的使用 • Set up a baseline on functional level • Progress monitoring • Quantify the changes after intervention • Discharge planning • Part of decision making of placement recommendations • A communication tool among settings and disciplines OT management in Geriatric Practice

27. Functional Assessment功能评估 Functional performance of older adults in self care and/or instrumental ADL can be restricted due to injury/illness. Supporting clients to attain optimal functional independence is one of the goals for OT geriatric practice. OT management in Geriatric Practice

28. What are the common criteria used in functional evaluation?在功能评估中的共通标准是什么？

29. Common criteria used in functional evaluation Independence / level of assistance 独立/需要协助的分级 • Frequency/Amount of physical or verbal assistancethat a client asks for during task performance • 患者在完成指定任务中所需要体力上的帮助/口头的提示程度/数量 OT management in Geriatric Practice

30. How about these criteria?这些标准怎么样？ Effort成果 Amount of physical difficulty or fatiguethat clients demonstrates during task performance Efficiency效率 • Degree of disorganization, inappropriate use of time and space that clients demonstrates during task performance Safety安全性 • Client’s potential of injuring himself or causing damage to environments during task performance OT management in Geriatric Practice

31. Assessment for Cognitive Impairment • In Hong Kong, prevalence of moderate to severe dementia is 6.1% in people who aged 70 or above (Chiu et al., 1998) • 24.6% in high risk elders who are living in institution or home (SSP Survey 2005) OT management in Geriatric Practice

32. Mini-Mental State Examination • Developed by Folstein & Folstein in 1975 • Bedside screening instrument for detection of cognitive impairment • Administration time: about 10 minutes • Reliably tested across different cultures • Sensitive to changes OT management in Geriatric Practice

33. Mini-Mental State Examination Composed of 6 domains • Orientation (time & place) • Registration • Attention & calculation • Memory (short term) • Language & Comprehension • Visual spatial orientation OT management in Geriatric Practice

34. MMSE - Interpretation General • An aid to document the presence of cognitive impairment or monitor progress of disease • Serial MMSE scores is sensitive for progressive mild cognitive problem • Education level, sensory impairments, language and communication problems may affect the reliability of the test OT management in Geriatric Practice

35. MMSE - Interpretation Score • 30 : no impairment •  or = 24 :“normal” in general population • 20-23 : cognitive impaired but still live independently •  20 : usually cannot live independently : problems in instrumental ADL : still manage basic ADL OT management in Geriatric Practice

36. Cantonese MMSE • Cantonese version of MMSE was developed by Chiu et al in 1994 • Some items revised according to the Chinese culture in Hong Kong • Validation studies conducted for elderly population • Cut-off scores developed according todifferent education level of subjects OT management in Geriatric Practice

37. Cantonese MMSE OT management in Geriatric Practice

38. Cantonese MMSE 現在是什麼時候? • 年份 • 季節 • 月 • 號數 • 星期 這裡是什麼地方? • 香港/九龍/新界 • 地區 (深水步 / 長沙灣) • 醫院名字 • 部門 • 層數 OT management in Geriatric Practice

39. Cantonese MMSE • 我會講三種東西的名字給你聽，講完之後請你重覆一次並緊記，因為幾分鐘後我會問你。　 • 蘋果、火車、報紙 • 你用一百減七，然後再減七，一直減落去直至我叫停。 • 現在我會講幾個數字請你倒轉讀出： • ４２７３１ • 我較早前請你記住的三種東西是什麼？ OT management in Geriatric Practice

40. Cantonese MMSE • 這樣是什麼東西？（手錶 / 鉛筆） • 請你跟我講句說話，姨丈買魚腸。 • 現在檯上有一張紙，請你用左(右)手拿起張紙，用雙手對摺一次，然後放回檯上/交給我。 • 請讀出紙上的字，然後照住去做。 （拍手） • 請你講/寫出一句完整句子。 • 這裡有一幅圖形，請你照住畫。 OT management in Geriatric Practice

41. CMMSE - Interpretation Cut-off Score • 22 or below : for elder with more than 2 years of education • 20 or below : for elder with less than 2 years but more than 6 months education • 18 or below : for elder with less than 6 months of or no education (Chiu et al., 2000) OT management in Geriatric Practice

42. Characteristics in different diagnostic groups Alzheimer’s Disease • Usually the first deficits is the short term memory • Disorientation to time and is followed by disorientation to place • Language deficits start to appear late • Usually continue to try to get the right answer OT management in Geriatric Practice

43. Characteristics in different diagnostic groups Stroke • Deficits are more patchy • No specific profile • May have aphasia / dysphasia (expressive, receptive or global ) • May have speech / language problems earlier than Alzheimer’s disease OT management in Geriatric Practice

44. Characteristics in different diagnostic groups - Depression • Seem less distressed than Alzheimer’s patients about their problems • More likely to answer “ I don’t know” or “it doesn’t matter” • When pressed they often know the answer • Presented with “disability gap” • No obvious STM loss • Other symptoms: appetite change, energy loss, weight loss, sleep disturbance, mention about suicide, etc. OT management in Geriatric Practice

45. Developing the Care Plan Problem with judgment: • Get a power of attorney, advance directive and start building a support network STM loss: • Use reminders, lists, cues, calendars or diaries Language difficulties: • Avoid open ended questions • Avoid idiomatic expression OT management in Geriatric Practice

46. Developing the Care Plan Word finding difficulties: • Keep language simple • Give adequate time to respond • Communicate one idea at a time • Avoid words with more than one meaning 3-step command deficit: • Give one instruction / idea at one time OT management in Geriatric Practice

47. Why the evaluation of mood is important in geriatric practice?情绪的评估为什么重要？ • 11 – 15% of local elderly people showed depressive symptoms (Chi, Yip, Chiu et al., 2005) • Poor self-rated health, chronic pain, vision problems, ADL impairment, financial strain, few social support are associated with an increased likelihood of geriatric depression (Chi, Yip, Chiu et al., 2005) • Aversive consequences of depressive mood include increased disability, treatment refusal, suicidal attempts or acts, and a decreased quality of life. OT management in Geriatric Practice

48. Geriatric Depression Scale (Short-form) 老人抑郁短量表 • Developed by Sheikh & Yesavage in1986 • Screening tool for geriatric depression • Assess affective and behavioural symptoms of depression • Mainly focus on psychological aspects of depression rather than somatic items OT management in Geriatric Practice

49. Geriatric Depression Scale (Short-form) …structure and format • 15 items • Self-report using a dichotomous format (yes/no) • Time reference: past week • Score interpretation: • A cut-off score ≥ 8 was established for elderly HK Chinese people (Boey & Chiu, 1998; Chiu, Lee, Wing, et al., 1994) OT management in Geriatric Practice

50. 老人抑鬱短量表-測驗形式 - 測驗時間約五至十分鐘 - 共十五條題目, 全以是非題作答 - 每條是非題之分數分佈不同, 最 高得一分, 最低零分. 評估員應因 應每條題目的評分方法, 給予該 題目分數. - 總分最高為十五分