Establishing the role of GNC CAPAC TACP OTs in Assessment, monitoring and reporting of cognitive deficits

A quality improvement project.

Prepared by Tim Wroot (Occupational Therapist).July 2014

Purpose of todays presentation

• Sharing good news• Demonstrate CAPAC TACP OT role• Provide assurance of quality

Back to basics: What is Cognition?

• BRIEFLY:– Mental abilities and functions– neurological synapses, current experience and

past memories– a complex, invisible, multifactorial, cerebral

process.

Cognitive assessments undertaken by CAPAC OTs

• Standardised screening tools• Non standardised screening tools• Functional assessments• Reporting and recommendations.

Rationale for Quality improvement.

• Prevalence and timely access to help• O.T. role poorly understood.• Multidisciplinary implications• Varied clinical experience and treatment.• No standardised approach• Differences in service provision

Project Aims

• Evaluate / validate cognitive screens• Clinical competence in cognitive

screening.• Informing the multidisciplinary team• Equitable service provision• Documentation to support other clinical

roles

Achieving the aims

Aim 1: Evaluate and standardise cognitive screens

• Team effort • Common screening tools examined• Version control applied• Evaluated against criteria• Fit for purpose assessments chosen

The reliability of screening tools

• Is reliability the best description?• One client…..3 screens undertaken MMSE 27/30 (90%) cut off 24 (80%)

ACE-111 85/100 (85%) cut off 89 (89%)

MOCA 21/30 (70%). Cut off point 26 (86%)• screens are indicators, not definers.

The OT cognitive screening tool kit

• Standard toolkit MMSE, Clock Drawing Test, ACE 111, Australian format)

• Standard toolkit to fit MDT pathways• Other assessments might be included• Traditional functional assessments

Why use the ACE 111?

• Ongoing development.• Neuropsychology input.• Recommended by leading organisations.• Well validated.• Time efficient• Clear instructions• Free validated training.• More sensitive than MMSE

Aim 2: Clinical competence in assessments

• Professional duty and ethics• Universal competency training • Training recognised as correct standard

Aim 3: Informing the multidisciplinary team

• Multidisciplinary approach• Reporting templates suit end user• Positive initial results.

OT cognitive screening report• Standardised “WORD” template• Valid information for GP or Geriatricians • Performance against expected norms • Strengths and weaknesses• Functional abilities in ADLs• Carer/relatives and clients perspective• Recommendations• Ongoing development• Copies available tim.wroot@hnehealth.nsw.gov.au

Aim 4: Equality of service provision in cognitive work

• Agreed screening tools• Agreed competency levels• Equal access for all clients• Equal access to further support

Aim 5: To lead to in-service training

• Validated competency for OTs• Informing for the MDT

Process map for O.T. cognitive screening.

CAPAC O.T. Cognitive screening process pathway for ACE-111

O.T. aware that client has a potential cognitive deficit.

MMSE undertaken by CAPAC Nursing staff?

Yes No

O.T. to undertake MMSE and record results.

O.T. reviews evidence of cognitive issues, including progression from client, medical notes and family/carers and determines the need for screening.

Is client being treated or monitored by Geriatrician or specialist for cognition?

Yes

No No cognitive screening assessment required from O.T. Consider providing information from intervention to specialist on discharge from CAPAC.

Discuss cognitive history, explain potential causes. Discuss benefits of ACE 111 screening with client and carers. If consent gained proceed with ACE 111 screen.

ACE 111 Screen completed.

ACE 111 results below cut off score of normal functioning or below 98% for previously high functioning individuals.

ACE 111 results above cut off score of normal functioning or above 98% for previously high functioning individuals.

Cognitive impairment not indicated.

Cognitive impairment detected and an 80% chance of dementia.

Complete O.T. cognitive report template, using CHIME appointment for G.P. letter. Send to CAPAC Medic and G.P for HAH clients or send to G.P. for HITH and TACP clients for access to specialist. E-mail copies to program leads. Post letter to G.P. If client has a geriatrician, send copy to them.

Applications to TACP

• Clients with cognitive issues• Accurate, age appropriate assessments• Access to timely psychiatric review• A multidisciplinary team approach• Retaining clients in their own homes

Case Study

• Illustrative case study• Gentleman of 84• Vascular risks, diabetes• Cerebral tumour, VP shunt.• Poor memory, variable confusion• ACE-111 score 69/100• Verbal fluency significant.

Case Study

• Initial improvements.• Sudden decline• Mini craniotomies• Re screened• Memory strategies applied.• Rescreened at end of cognitive

intervention.• ACE-111 advantages.

Where are we now?

• Agreed the role of CAPAC OTs• Agreed screening toolkit• Quality assured training• Cognitive pathway and reporting• Reduced inequality• Approvals received• Compliments multidisciplinary team

Acknowledgements

• Tim Wroot Project Lead• The entire Occupational Therapy team• The CAPAC Aged Care Education Group• Nicole Murdoch (IT saviour)• NHS Scotland and University of Glasgow• Our clients and their carers

References

• Alzheimers Society, College of Psychiatrists and U.K. Dept of Health (2012). Helping you to assess cognition. A practical toolkit for clinicians.

• Dubois, B., Slachevsky, A., Litvan, I., & Pillon, B. (2000). The FAB: a Frontal Assessment Battery at bedside. Neurology, 57(3), 1621-1626. AAN Enterprises. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11113214

• Dubois B, Slachevsky A, Litvan I, Pillon B. The FAB: a Frontal Assessment Battery at bedside. Neurology. 2000 Dec 12;55(11):1621-6.

• Grieve, J. Gnanasekaren, L (2008) Neuropsychology for Occupational Therapists 3rd edition, Oxford: Blackwell Publishing.

• National Ageing Research Institute. (2011) The assessment of older people with dementia and depression from culturally and linguistically diverse background. A review of current practices and development of guidelines for Victorian Aged Care Assessment Services. Sourced via internet on 25/02/13.

• NeuraAustralia Frequently asked questions about the ACE-111 http://www.neura.edu.au/sites/neura.edu.au/files/page-downloads/ACE-III%20FAQ%20July%202013.pdf Accessed January 2014

• KICA Instruction Booklet (2006) • Kimberley Indigenous Cognitive Assessment (2004)• Nasreddine, Z. (MOCA Test Author and copyright owner). Various articles related to the MOCA and alternative

versions, published at www.mocatest.org/moca-news.asp on 13/02/2013.• Vertesi et al (2001) Canadian Family Physician. Standardised Mini-Mental State Examination, use and

interpretation.• Zoltan, B. (2007) Vision, Perception and Cognition: A Manual for the evaluation and treatment of the adult with

acquired brain injury.

Any questions?