OCCTH 557 Finals Study Notes

• Anyone who has reason to believe, that a child has been, or there is substantial risk that he or she will be abused or neglected by a parent/guardian, has a legal duty under the Child, Youth and Family Enhancement Act to promptly report the matter to a caseworker.
• - at your Child and Family Services Authority office or First Nations Child and Family Services office

• Your report should include: ƒ
• - your name, telephone number and relationship to the child (all of this information remains confidential); ƒ
• - any immediate concerns about the child's safety; ƒ
• - the location of the child; ƒ
• - the child's name; ƒ
• - the child's age; ƒ
• - information on the situation; ƒ
• - any other relevant information concerning the child and/or family.

• 1. Neglect: a child is neglected if the guardian is unable or unwilling to: (a) provide the child with the necessities of life; (b) to obtain for the child, or to permit the child to receive, essential medical, surgical or other remedial treatment that is necessary for the health or well-being of the child, or; (c) to provide the child with adequate care or supervision.
• 2. Physical Abuse: Physical abuse is an intentional, substantial and observable injury to a child.
• 3. Sexual Abuse: Sexual abuse is inappropriate exposure or subjection to sexual contact, activity or behaviour, including prostitution-related activities. Exposing children to child pornography or luring children through the Internet are forms of sexual abuse. Sexual abuse might show itself in a broad range of indicators. Although these indicators might reveal sexual abuse, they might also reveal other psychological or physical trauma.
• 4. Emotional Abuse: Emotional abuse is the impairment of a child's mental or emotional functioning or development and there are reasonable and probable grounds to believe that the emotional injury is the result of: ƒ rejection; ƒ deprivation of affection and/or cognitive stimulation; ƒ exposure to domestic violence or severe domestic disharmony; ƒ inappropriate criticism, threats, humiliation, accusations or expectations; ƒ the mental or emotional condition of the guardian of the child or of anyone living in the same residence as the child; ƒ chronic alcohol or drug abuse by anyone living in the child's home

The World Health Organization defines abuse as a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust that causes harm or distress to an older person.

• 1. Respect personal values
• 2. Recognize the right to make decisions
• 3. Seek consent or permission
• 4. Avoid ageism 
• 5. Know that abuse and neglect can happen anywhere
• 6. Involve the older adult in problem solving and decision-making
• 7. Place high value on independence and autonomy
• 8. Respond appropriately

• (born before 1946)
• Grew up during the Great Depression and WWII

• (born 1946-1964)
• Born during a spike in child births after WWII

• (1965-1980) 
• Defined as “slackers”
• First generation to develop ease and comfort with technology
• “X” described the lack of identity that members of Generation X felt, not sure where they belonged

• (born 1981-1994)
• grew up with technology 
• entitlement generation

• (born after 1994)
• Grown up with world, wide, web.
• The children of Generation X

for every person at the age of leaving the labour force (55-64 years of age), there was just over one person at the age of labour force entry (15-24 year olds).

“Rough indicators of ability of a population to support itself”

• Elderly = 65 years and older
• Young = < 20 years
• Working = 20 to 64 years

• Gender
• Roles
• Cohort Effects
• Cultural Factors
• Place of Residence
• Social Attitudes
• Individ. char/exp
• Socio-economic Status 
• Public Policy

• Men: 77.8 years
• Women: 82.6
• Differences in life expectancy have begun to narrow
• The gender composition among seniors is expected to become more even in the coming years

• About 1 in 3 Canadians has developed a disability after age 65
• The likelihood continues to increase with age.

• About 70% of seniors live with family
• About 30% live alone

• Stochastic (insults): Genetic damage leads to functional failure & death 
• Developmental-genetic:  Neuroendocrine (decrease in neurons & associated hormones); Immunological (decrease in capacity of immune system); Free radicals; Caloric restriction 
• Cellular: “Hayflick Limit” (limit to number of times cells divide); Sets an upper limit on the number of years people can live.
• Evolutionary:  Genetic error/accidents over time lead to aging
• Neuropsychological: Cognitive change is an inevitable part of aging; Cognitive change is the result of damage and degeneration

• Focus largely on activities
• Life span development: universals with variability; interaction of biology & culture.
• Selective optimization with compensation: balance gains & losses; focus on fewer domains; optimize reserves; compensate for losses
• Socio-emotional selectivity: reduce some interactions; increase closeness in others
• Cognition & aging: factors that affect cognition reside outside the individual; fluid intelligence (genetic- biological, decline with age); crystallized abilities (socio-cultural influences on world knowledge- more stable)
• Personality & aging: traits are stable; goals/values/ coping styles/ beliefs can change.

• Life course: focuses on expected & normal changes in life over its entire span
• Social exchange: individuals, including elders, make rational choices about interactions with others, based on their needs & norms of reciprocity
• Social constructionist: focusses on individual agency & social behavior within the larger structures of society, & on subjective meanings of age & the aging experience
• Feminist: give priority to gender as an organizing principle for social life across the life span
• Political economy of aging: focus on the interaction of economic & political forces in explaining how the treatment & status of older adults can be understood

The key feature is a state of vulnerability to adverse health outcomes. The balance between assets and deficits will determine the consequences for an individual. Adaptability, physical environment & social environment are important determinants of the impact of frailty.

• Overlapping of:
• AGING-Increased vulnerability to disease and accidents over time
• DISABILITY-Functional limitations resulting from impairments
• COMORBIDITY-Disease processes resulting from biologyand exposures

Frailty is most obvious under “stress” e.g. delirium, falls

• 1. Frailty Phenotype: If have 3/5 of - Weight loss; Slow walking speed; Low levels of physical activity; Subjective exhaustion; Weakness (Low grip strength) (1-2=intermediate)
• 2. Accumulation of Deficits: counting up the problems/deficits a person has 
• 3. Geriatric Syndromes
• 4. Life Course

• Clock Test or the Mini-Cog
• MMSE
• Montreal Cognitive Assessment

Frailty Phenotype: 3-5 is “frail” - Weight loss, Slow walking speed, Low levels of physical activity, Subjective exhaustion, Weakness (Low grip strength); 1-2 is “intermediate”; 0 is “not frail”

Clinical Frailty Scale:

Frailty Index-CGA:

Edmonton Frail Scale: Questions about - Cognition, Health Attitudes & Mood, Medication Use, Nutrition, Continence, Burden of Medical Illness, Social Support, Functional Independence & Performance (Not frail 1-4, Mild frailty 7-8, Mild frailty 7-8)

• Regularly scheduled discussion between a patient and a qualified health professional to:
• - Focus solely on medication
• - Assess appropriateness of medications
• - Educate/address patient’s concerns and medication management

Goals: reduce polypharmacy, ensure compliance and minimize adverse reactions

Do if: asks you for a review of meds; takes 5 or more meds; has 3 or more medical conditions; receives prescriptions from more than one doctor; has had a medication change in the past 12 months

• Criteria & Goals for SMR
• Calculate Creatinine Clearance - (140-age) x IBW / Creatinine 
• List all Medications & Indications
• Appropriateness of Dose & Frequency
• Administration Issues
• Identify Side Effects
• Action Plan

• Mood and anxiety disorders: depression of 80-90% in facilities; The most common mental health problem for older adults is depression; There is no difference in the frequency of depression between elderly men and women; Depression is common among older adults but is not a normal part of aging; lowest rates among elderly persons living independently in a community; anxiety disorders affects at least 5-10% of those over age 65
•  
• Cognitive and mental disorders due to a medical conditions: (including dementia and delirium) - risk of dementia 20% by age 80

Substance misuse: (including prescription drugs and alcohol) - 6-10% of older adults have problems with alcohol

Psychotic disorders: Overall prevalence of persistent psychotic disorders (schizophrenia and delusional disorders) is 1-2%; bipolar likely affects less than 1% of older adults

The patient with dementia is at high risk for DEPRESSION (and vice versa)

• The rate of suicide among older adults is higher than that for any other age group
• Suicide is 5x’s more likely in individuals over 60 yo
• Currently, men aged 80 + have the highest suicide rates in Canada
• The suicide rate for persons 85 yrs + is 2x’s the overall national rate.
• Suicide rates are under-estimated due to stigma

• 1. Geriatric Depression Scale: Surveys subjective experiences of cognitive impairment; Uses simple yes/no items that decrease cognitive burden; 15 questions
• 2. Beck Depression Inventory (BDI-II): not developed specifically for older adults; useful because it surveys suicidal ideation; has item content consistent with DSM-IV diagnostic criteria for depression; score of 15 is the lower range of mild but clinically significant depression

• 1. Guy’s Hospital Age Concern (ADS): The generalized anxiety scales consist of 11 questions and the scale is constructed as a clinician-administered interview. The questions are rated on symptoms experienced by the subject one month prior to the interview.
• 2. FEAR - A shorter version of the Guys/Age Concern Generalized Anxiety Scale for use as a rapid screening instrument in primary care; F = frequency of anxiety (state anxiety) E = enduring nature of worry (trait anxiety) A = alcohol/drug use to self-treat R = restlessness (anxious behavior)

Modified Zarit Burden Interview - Screening tool used to determine the burden of caregiving

• To identify and rate the degree of accident risk for people with memory and cognitive deficits living at home.
• It has 19 questions contained within 7 sections of the scale. Questions on the scale relate either to the individuals health status and behaviours or to aspects of his/her living environment.

• - Anti-depressant medications
• - Psychotherapy
• - Cognitive-behavioural therapy
• - Electro convulsive therapy (ECT) - courses or tweek-up
• - Light therapy
• - Repetitive transcranial magnetic stimulation

• Alternative or complementary treatments include:
• • Exercise
• • Acupuncture
• • Relaxation techniques
• • Social recreation/diversion
• • Psychotherapeutic intervention
• • Grief therapy

• Enables a person living with a mental health problem to live a meaningful life in their community while striving to achieve his/her full potential.
• Reduction or elimination of symptoms & improved quality of life, even when dealing with progressive degenerative diseases

• The decline associated with aging which consists of mild changes in memory and the rate of information processing. It is not progressive and does not affect daily function
• Decision making decreased – possibly due to decreased episodic and working memories
• Crystalized intelligence remains relatively stable (socio-cultural influences on world knowledge- more stable)
• Fluid intelligence declines (genetic- biological, decline with age)

Impairment not within normal limits for a patient’s age and education but not severe enough to qualify as dementia.

• An organic mental disorder characterised by a general loss of intellectual abilities involving impairment of memory, judgement and abstract thinking, as well as changes in personality
• Memory impairment (impaired ability to learn new information or to recall previously learned information)
• Aphasia – language disturbance, changes in language used (word finding problems) (PHA-phrase=language)
• Apraxia – inability to carry out motor activities (previously learned activities) despite intact motor function (PRAX-practice=motor activity)
• Agnosia – inability to identify objects (people, places and things) despite intact sensory function (NO-know=don't know what that is)
• Consider Abstraction disturbance in ability to make decisions and proceed with tasks (executive functioning)
• Neurocognitive Level of Severity: MILD – decline in function but capable of independent living; MODERATE – decline in instrumental function, independent living hazardous,some supervision reqd; SEVERE – decline in basic function,continuous supervision reqd.

An acute fluctuating onset of confusion, disturbance in attention, disorganized thinking, and/ or a decline in level of consciousness

• RULE OUT DELIRIUM:
• – Acute onset
• – fluctuations in course
• – inattention
• – disorganized thinking
• – changes in level of consciousness

• Delirium
• Depression
• Dementia

• For mild impairments: Practice, repetition; Fitness (physical and mental); Simplify tasks; External memory aids; Maintain social and leisure connections
• For moderate-severe: Break tasks down to component parts; Minimize distractions; Simple instructions/guiding touch; Take advantage of episodic and procedural memory; Share strategies with the team

• The ability to understand the information that is relevant to making of a personal decision and the ability to appreciate the reasonable foreseeable consequences of the decision
• Capacity is not a medical diagnosis; Health care providers can provide a clinical opinion on capacity

• 1. Global Capacity: If a person lacks capacity to make one decision, they are considered to lack capacity for ALL decisions.
• 2. Domain-Specific Capacity: Decisions can be categorized into “Domains.” Capacity assessment focuses only on domain(s) in question.People can have capacity in some domains but not others
• 3. Decision-Specific Capacity: Each domain has a hierarchy of decisions ranging from simple to complex.Patients may have capacity for simple decisions within the domain, but lack capacity for more complex ones.Capacity assessment focuses on specific decisions.

• Capacity assessment is a process for determining whether there is sufficient evidence to declare a person incapable of managing their affairs
• The emphasis is on the quality of the decision-making process, not the actual course of action in which a person engages

• A capacity assessment may be necessary if there is:
• - An event or circumstance which potentially places a patient, or others, at risk
• - Apparently caused by impaired decision making
• - Necessitates investigation, problem-solving (and possibly action) by a health care professional

• ability to process, store, retrieve, and manipulate information
• Attention, orientation, memory, concentration are the basic processes upon which are built higher cognitive functions

• Higher level cognitive processes which mediate goal-directed activity and assist our ability to execute tasks.
• Reasoning; Selective attention; Response inhibition; Behavioral planning; Problem-solving skills; Ability to function effectively in the environment (task initiation/completion)

• A legal planning tool to help ensure personal wishes are followed when unable to make decisions because of illness or injury
• The Agent:the person(s) named to make personal decisions – legal representative

• The act recognizes a continuum of capacity and offers various options, including co-decision-making and temporary guardianship/trusteeship when appropriate
• decision making that focuses on the best interests of the adult and how the adult would have made the decision if capable
• 1. Supported Decision-making: An option for adults with capacity who would benefit from the assistance of a supporter.
• 2. Specific Decision-making: For adults who lack capacity a relative can be designated to make a time sensitive decision related to health care or temporary admission to or discharge from a residential facility (not court ordered)
• 3. Co-decision-making: Court ordered process. For adults whose decision-making capacity has been assessed as being significantly impaired BUT who could make personal decisions of a non-financial nature with guidance and support
• 4. Guardianship: Court ordered process. For adults who have been assessed as not having the capacity to make personal decisions
• 5. Temporary Guardianship: Adult must lack capacity and be in immediate danger of death or serious mental or physical harm unless someone appointed to make decisions to prevent this
• 6. Trusteeship: Court ordered process. For adults who do not have capacity to make decisions in financial matters.

• Best predictors of driving outcome appear to be vision, cognition, driving experience and functional ability… NOT AGE.
• Alberta is one of three provinces without mandatory reporting

• OT assessment of complex IADLs will identify potential issues with driving.
• Is knowledgeable regarding best practice as it pertains to screening tools for driving.
• Can inform Alberta Transportation if appropriate.
• Can discuss planning for or immediate driving cessation.
• Knows when to refer for more comprehensive driving assessment.
• Best practice is to collaborate with other members of the health care team.

• Other functional assessments
• Trails A and B
• MVPT-3
• UFOV
• MoCA
• Clock Draw

• Encourage client to self report
• Maintain transparency that you will report on their behalf
• Document the process clearly on the client’s health record
• Disclose only information pertinent to driving concerns to AB Transportation Driver Fitness and Monitoring who will follow-up with appropriate actions
• Use Form A – CAOT Driver Safety Concern Form adapted to fit the AB context

OT with expertise in assessing physical, cognitive, visual-perception, and behavioural aspects of safe driving using standardized pre-road and on-road assessments

• OT with highly specialized expertise in assessment, training/retraining of driving skills, vehicle modifications, use of assistive technology for driving etc.
• Includes on-road assessment with driving instructor

• Primary Prevention:
• Screening: over 65 everyone; 50-64 use clinical judgment; Pediatrics - mental health, head injury, meds, behavioural; if fallen in last year, injured and have issues with gait proceed to assessment
• Assessment: Falls Risk Assessment;
• - Risk Factors - (BBSE) Biological– Age related changes, mobility, dementia, chronic illness; Behavioural– Fear of falling, risk taking, use of meds, lack of exercise, addictions; Social/Economic– Social isolation, low income, housing, literacy, access to transportation; Environmental– Home, community and institutional hazards
• - Interventions: BEEEACH Prevention Model (Behaviour change by motivation & risk taking - equipment, education, environment, activity, clothing & footwear, health management)
• - screening tools - Home Falls and Accidents Screening Tool (Home Fast), Westmead Home Safety Assessment (WeHSA), Safety Assessment of Function and Environment for Rehabilitation (SAFER)
• - Universal Falls Precautions - SAFE; Safe environment, Assist with mobility, Fall risk reduction, Engage patient and family
• Fall?:
• Post Fall Review: SPLATT -Symptoms, Previous Fall, Location, Activity, Trauma, Time of Day

• sound cannot efficiently get to inner ear
• blockage in ear canal, perforated ear drum, fluid in middle ear

damage to cochlea (inner ear), auditory nerve or both

• decrease in hearing associated with aging
• Difficulty with high frequency sounds
• Difficulty hearing speech in background noise

• when the speaker attempts to express every word and sentence in a precise, accurate, fully formed manner
• Naturally slower and louder
• Characterized by pauses between phrases and sentences
• Lively, with a full range of intonation and stress on key words

• Accommodation to communicating with older adults
• triggered by beliefs about older adults’ cognitive competence
• high pitch, exaggerated intonation, simplifiedgrammar, limited vocabulary, slow rate of speaking

• Speech disorder
• Impairment in motor control for speech
• Occurs when a stroke affects brain areas that control muscles involved in speech
• Can occur from damage to either hemisphere
• Dysarthria is a motor speech disorder, not a  disorder of language, cognition or intellect

• damage to right side of brain
• may present with subtle communication impairments
• Word retrieval problems
• May understand the content of conversation  but fail to get the gist
• Trouble with thought organization, staying on  topic in conversation
• Difficulty understanding and conveying  humour, sarcasm, irony

• An acquired impairment of language caused by  brain damage
• Typically on the left side of the brain in the “language  areas"
• Can affect speaking, listening/understanding, reading  & writing
• Two broad classifications: Nonfluent (Trouble speaking in sentences; Broca’s aphasia; Speech is slow & effortful); Fluent (Able to speak in sentences, but the words come out  wrong; Wernicke’s aphasia; lacks meaning)

• 1. Aggression
• 2. Agitation
• 3. Psychosis
• 4. Depression
• 5. Apathy

• The Person manifesting the behaviour
• The Environment
• The Disease Processes
• The Care Provider

• 1. Physiological Needs - food water shelter clothing
• 2. Security Need - social security in a family and a society that protects against hunger and violence
• 3. Love and Belonging Needs
• 4. Esteem Needs - unique individual with self respect 
• 5. Need for Self actualization - purpose and meaning

• P.I.E. an individual's Physical, Intellectual, and Emotional Health.
• C. centre-piece; maximizing Capabilities which promotes the attainment of the highest quality of life possible for an individual.
• E.S. represent the Environment that an individual interacts with (physical as well as emotional) and the person’s Social self (cultural, spiritual, “life story”).

• Antecedents (Causes) - PIECES
• Behaviour
• Consequences (Results)
• Care Strategies
• What has changed? What are the RISKS? What is the action?

• R – roaming
• I - imminent physical danger - delirium, fire, falls, fire arms, frailty
• S – suicidal ideation?
• K – kinship relationships family, staff, co-patients / residents
• S – self neglect, safe driving, substance use

• N – Know and use the name they prefer
• I – Identify yourself
• C – Contact
• E – Explain
• E – Enter their world
• A – Avoid Arguments
• S – Smile
• Y – You are the Key!

The built environment is everything humanly made, arranged or maintained to fulfill human purposes (needs, wants and values)

• 1. Hearing: Difficulty hearing higher frequencies, Reduced speech discrimination
• 2. Tactile: Decreased response tactile stimuli, Adversely affected by thermal extremes
• 3. Smell/Taste: Decline sensitivity to odors, Require higher thresholds
• 4. Vision: Not uncommon 80% loss of acuity by 85 years, pupils smaller – less light reach retina, decrease vision in dim light, reduced colour discrimination, Lens thickens, yellow – affects colour vision
• 5. Cognition: Decline in fluid intelligence, Memory, Attention, Language, Reasoning and Problem Solving, Speed of processing and many clinical conditions

Behaviour is a function of the competence of individual and the demand made by environment (environmental press)

“a lifelong process of optimizing opportunities for improving and preserving health and physical, social and mental wellness, independence, quality of life and enhancing successful life-course transitions”

• Home in community
• Seniors apartment
• Lodge
• SL1 & 2 (Lodges (SL1/2) are not care facilities (nursing care and OT services provided through home care; there may be HCAs and recreation therapists on site), Meals and housekeeping provided)
• SL3
• SL4 &4D
• LTC - LTC facilities provide 24hr nursing care (nursing care and OT services provided by ID team on site), Provincial transition services determines placement, Specialized dementia care environments (locked units)
• Acute Care

• Under normal lighting conditions, twice as much light is required at age 40 as at 20, three times at age 60
• Need colour contrast
• Difficult to discern colours especially blue, green, violet
• Difficulty between 2 shades of same

The ability to think, feel and act in ways that acknowledge, respect, and build upon ethic, (socio) cultural, and linguistic diversity

• Beliefs: A point of view that the individual deems to be true or false.
• Values: An individual’s sense of right and wrong concerning an appropriate course of action or outcome.
• Norms: What an individual does in every day contexts. Social norms are how a group expects an individual to behave in any given context.

• B eliefs, Values, Norms
• R oles and relationships with family/relatives
• I dentify language, literacy, communication
• D ecision-making methods/practices
• G roup, community, organizations
• E xtraordinary issues in health
• S hare, understanding of cultures, reach common ground & compromise

• tool for cultural awareness and cross-cultural understanding
• L = Listen
• E = Explain
• A = Acknowledge
• R = Recommend
• N = Negotiate

• 1. Meaning, purpose and hope
• 2. To transcend circumstances
• 3. For support in dealing with loss
• 4. For continuity
• 5. For validation and support of religious behaviours
• 6. To engage in religious behaviours
• 7. For personal dignity and sense of worthiness
• 8. For unconditional love and acceptance
• 9. To express anger and doubt
• 10. To feel that God/ a Higher Power is on their side
• 11. To love and serve others
• 12. To be thankful
• 13. To forgive and be forgiven
• 14. To prepare for death and dying

• F: Faith or Beliefs
• I: Importance and Influence
• C: Community
• A: Address -How would you like me, your healthcare provider to address these issues in your healthcare? NOTE the A can also Assessment--- spiritual diagnosis, issue or resource of strength and then plan in a treatment/care plan.

• Level 1: very poor skills, trouble with nearly all text.
• Level 2: can deal with only simple, clearly laid out material.
• Level 3: minimum skills level suitable for coping with demand of everyday life.
• Level 4/5: demonstrates a command of higher order information processing skills.

the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions

Literacy - ability to read and write

• A shift of approach from:
• The curative – restoration
• The rehabilitative – remediation
• The adaptive – compensation

To:The supportive – acceptance, adjustment, comfort, prevention, quality of life

• Simplification of transfers, mobility, ADLs, IADLs
• Maintenance of skin integrity
• Feeding and Swallowing
• Pain management
• relief of emotional and spiritual suffering
• Family support and education

• MORALITY - refers to what we would call moral conduct or standards (historically, culturally, socially situated); may be seen as “ethics in action”
• ETHICS - refers to the formal study of and reflection on those standards or conduct (clarifies, organizes and critiques morality); sometimes viewed as broader “umbrella” term

• 1. Quest to Understand the “Good”
• 2.  Consequences or Duties
• 3.  A Process of Deliberation

• Ethical Uncertainty: Being unsure about which moral principles apply or if a problem is indeed a moral problem
• Ethical Distress: Knowing the “right” course of action but feeling constrained to act by institutional rules
• Ethical Dilemma: Facing two or more equally unpleasant alternatives that are mutually exclusive