OT 827 - Enabling Occupation in Older Adults

Exam Prep

what is the definition of those with IDD?

people who experience significant limitation in cognitive functioning and/or adaptive functioning which originated before the age of 18, are likley to be life-long, and affect areas of makor life activity such as personal care, language skills or learning abilities and the capacity to live independently as an adult

what is the order and most common for of IDD? (percent)

85% mild, 10% moderate, 4% severe, 1% profound

what are the presentations of mild vs moderate IDD?

mild can be living on their own or with family with little to no support, many do not ever get identified, moderate need more support and their communication may be impacted

what is common in ontario regarding individuals with IDD? (4)

health disparities such as high prevelance of heart disease, hypertension, diabetes, mental health conditions; 40-50% will develop some form of condition or reaccurent condition, diagnostic overshadowing related to the progression of their symptoms, polypharmacy

what is the population of individuals with IDD in ontario?

1% or 67,000 people

please list the progression of deinstitutionalization in ontario?

1876 - first institution opened in ontario, 1970 - activisits call for commuity intergration, 1981 to 2009 - govenerment calls for deinstitutionalization and closes them, 2014 - moved to community integration model

what is the problem with the community integration model currently?

over 14,300 people with IDD are on residental waitlists in ontario, moving into group homes, supported living, however cannot keep up with the demand resulting in waitlists 20 years long.

what is ALC? what has occured with this?

alternative level of care, individuals with IDD are in hospital due to not having anywhere else to go

what is the chance of someone with IDD to go to LTC, impact?

17.5 times higher to go to LTC earlier in their life = dying earlier in their life

what is their a large need for with individuals with IDD? why?

neuropsychiatric services, twice as likely to have a mental disorder as the main diagnosis, with higher probabilties for suicide 1.6 x higher, neurologic disorder 5.6 x higher, and seizure diagnosis 8.1 x higher

why should individuals with IDD be screened earlier around 40 years of age for demetia?

they are twice as likley to have a dementia diagnosis and six times more likley if they have downs syndrome, more than 1 in 5 ED visits are for dementia and downs syndrome individuals younger than 70, 2.7 times higher than the general population

what are ways HCP can aid in transitioning from hospital to community for individuals with IDD? (10)

1. ongoing sharing of info between hospitals and IDD practioners

2. trauma-informed, developmentally appropriate assesments

3. include patients and families with accessible communication

4. train patients, families, and community staff for follow-up care

5. share a clear, flexible written transition plan

6. plan gradual, coordinated transitions with joint leadership

7. review and monitor medications pre and post discharge

8. confirm all community care providers before discharge

9. ensure safe, inclusive housing and community supports

10. provide flexible funding for housing, staffing, and services

why are service gaps more reactive than proactive in current service? (6)

1. stressed and fragmented residential system with long waitlists

2. inappropriate placements in hospitals and LTC

3. limtied options for families and professionals such as services from homecare, LTC and group home and case management which may need to overlap

4. barries to accessing health services and pallative care

5. low rate of predicatability for pallative care

6. delay moves or abrupt relocations

what are the 6 main challenges for aging and IDD?

1. fragmented health and developmental services

2. transitions between sectors

3. caregiver aging and succession planning

4. housing instability

5. inequities in access to primary care

6. challenges accessing dementia and palliative care supports

what is the life expectancy of people with IDD currently?

it has increased over the last decades, by 2040, 25% will be over the age of 65

what are the concerns with IDD clients living longer?

1. increased risk of older age-related conditions

2. begin screening earlier for age-related conditions

3. builing capacity within organizations, community, caregivers to support them as they age

what are the 6 areas of health promotion OT can develop to improve aging with IDD?

1. physical activity

2. social connection

3. meaningful occupation

4. preventive health screening

5. management of chronic disease

6. dementia risk reduction

what are considerations of caregivers with IDD and aging?

due to death, poor health, and more complex needs of their aging child caregivers spend more time caring than any other informal caregivers in Canada over their lifetime

what is downs syndrome a predictor of with IDD? what is the likelyhood?

alzheimers disease, 50% more will develop dementia due to it making them 4 to 6 times more likley to get dementia compared to those without IDD

what are the 5 reasons a diagnosis of dementia/alzheimers more difficult with IDD?

1. few clincians familiar with adults with IDD

2. diagnositic overshadowing

3. lack a record of previous abilities

4. subtle changes

5. ability to report

why do doctors have diffculty using screening tools for IDD, dementia, alzheimers?

traditional screening tools for dementia are not standardized for those with IDD

what is an alternative early detection tool to screen for dementia with IDD?

Early Detection Screen for Dementia (NTG-EDSD)

what is Early Detection Screen for Dementia (NTG-EDSD)?

observing changes in sleep, appetitie, eating, mood, behaviour, and energy levels from their baseline in four domains often done by proxy to their HCP for longer than two weeks:

○ cognition (memory, attention, problem solving)

○ behavior (social and control of impulses)

○ emotion (mood, emotional regulation)

○ function (activities of daily living - ADLs)

what is the prevelance of falls in adults with IDD?

25-40% of adults with IDD living in community have atleast one fall a year, similar rate to older adults but at a younger age

what is the gap for falls prevention with IDD?

resources in practice are not accessible cognitively

fraw the cycle of falls

what are two tools HCP can use for IDD and screening for other conditions?

1. The nuts and bolts of healthcare provides information and resources on conditions that commonly affect people with IDD and what to expect

2. HELP chart which aids in explaining clinical steps

what are the 11 OT roles to support IDD?

1. Identify & implement aging in place supports

2. Functional assessments

3. Home safety

4. Mobility & falls risk

5. Engagement in meaningful activities and community participation

6. Community safety (both in-person and online)

7. Caregiver support and training

8. Sensory processing and self-regulation

9. Brain Health Promotion

10. Assistance with transition to residential care (if needed)

11. Transition planning x health and social care

what do you need to consider for assesment for IDD? (10)

1. limited available standardized measures for adults with IDD

2. Consent

3. Multiple assessments (consider both frequency and duration)

4. Occupation-based assessments

5. Ecologically relevant contexts

6. Involving caregivers (with consent)

7. Including client and caregivers in goal setting

8. Creating structure and reviewing plans

9. Offering choices

10. Communication approaches

what is communicate care?

1. communicating clearly (using accessible aids as needed)

2. attentively listening and observing with comprehension checks

3. responsively addressing concerns

4. engage the client and others as needed

what is the international consensus statement for IDD?

using a person-centered approach and aging in place as a priority

what are the considerations for interventions for IDD? (7)

1. Frailty must be considered earlier than in the general population

2. Improvement and maintenance are viable goals.

3. Intersectoral collaboration is needed to coordinate comprehensive,

multidisciplinary assessments and actions.

4. Safety is a priority

5. Planning for the future is important

6. Informal and formal caregivers also have needs

7. Evidence must be grown.

what are the common OT interventions with IDD?

1. Environmental adaptations

2. Adaptive equipment

3. Task analysis and modification

4. Skill-building

5. Client and caregiver education

6. Functional Mobility

what is aging into disabilty?

disability develops later in life

what is aging with a disability?

disability began earlier in their life

what is the difference in life expectancy for someone who accuqires a disability early in life vs aging with one

an individual who acquire a disability early in life have a near normal life expectancy vs someone aging with a disability later in life age faster than their non-disabled peers and have a more sevre onset of health conditions and seocndary conditions.

what does healthy aging include? (4)

1. preventing or managing secondary health conditions and comorbidies

2. supporting assisted autonomy, not just unaided independence

3. participation in meaningful activities with people of importance

4. maintaing a sense of purpose and quality of life

what does the ICF framework focus on?

body functions and structures, activity and activity limtitations, patricipation and partiicpation restrictions, personal and environmental factors that reduce functioning

Model of Healthcare Disparities and Disability

how personal and environemtnal factors interact to shape healthcare access and outcomes that are modifiable barriers within healthcare and community

Ecological model of Adaptation and Aging

considers the fit between individual cometence and enviornemntal demands, improper fit increases stress and limtis functioning, adaptations increase fit

assimilative mode - dominated

tenacious goal pursuit - direct action and probelm solving to solve the unfit between the person and enviornment

accommodative mode - when become uneffective

flexible goal adjustment - adjustment of goals, preferences, and expectations to situational constraints, unintentional process of restructing goal hierachies to achieve the best fit between what is expected and possible

what are the 5 OT practice principles to engage with a adult with disability

1. start with persons priorities - identify their meaningful occupations, roles, routines, and expectations

2. understand the life course - disability identity, previous experiences, adaptations, accumulated advantegours or disadvantages

3. assess person-enviornment fit - barriers and faciliattors in their home, healthcare, community, and transportation

4. support autonomy and participation - adaptations, social supports, transportation,

5. advocate beyond the individual- address inaccessible services, resources and exclusionary policies through collarboration and system advocacy

what are the physical symptoms you can see with decline in neurological/spinal conditions

progressive muscle weakness, fatgiue, pain, joint degeneration, declining mobiity, osteoporosis, contractures, greater dependence on caregivers and assitive deveice, increase risk of falls and fractures, respiratory complications, cogntive changes, mental health conditions, worsening balance, bladder and bowel dysfunction

what are the differences between older adults with serious mental illness such as schizophrenia and mental heath conditions and their experiences (4)

1. decreased access to social and economic resources

2. increased physical illness, functional impairements, cognitive deficits, and social disability

3. face barriers to services

4. caregiving issues

parapelgia

damage to thoracic, lumbar or sacral spine

tetrapelgia

damage to cervical spine

what factors influence the severity of Spinal Cord Injury?

level of severity and injury, age at injury, family health history, lifestayle behaviours, access to community services and social supports

canadian prevelance of SCI?

3 and 5 out of 100,000, peaks in 3rd and 8th decade

most common causes of SCI?

tramatic 60% - auto-collisions, falls, surgical, and 40% non-tramatic from tumors and neuroligcal conditions

common complications of SCI resulting in premature mortality?

respiratory and cardiovascular complications

why is their an increase of suicide in SCI?

pain, mental health, duration and severity of disability, financial, fracture, surgery, substance use

most common health concerns with SCI?

MSK and neurological pain, UTI, bowel problems, autonomic dysreflexia, pressure injuries, depression, sexual function

age related areas for consideration of SCI? (7)

what does the actionable nuggets resource provide?

resources for the different type of SCI, symptoms, comorbid conditions, and functioning

what is polypharmacy?

use of more medications than are needed or for which the harms outweight the benefits

when does polypharmacy increase?

1. 65 years and older

2. as frailty increases

3. frailty and physiologic age should be considered over chronological age when caring for older adults

what is the three problems with nonprescription, dietary supplements and natural health products

1. patients do not consider these medications so they do not inform HCP

2. they can have potential adverse drug reactions (ADR) with prescribed medications

3. in canada supplements and natural health products are not regulated the same as prescription drugs

what are the concerns for absorption of drugs as we age? (2)

1. reduced acid production in the stomach and gastric mobility leads to decreased absorption for some drugs

2. reduced first pass metabolism due to reduced liver mass and blood flow causing increased release of some drugs in the bloodstream

what are the age related concerns for distribution of drugs?

1. body composition changes as we age - more fat and less muscle and water

2. causing hydrophilic (water) drugs to be more concentrated because their is less body water and lipophilic drugs to take longer to reach steady state and take effect and accumulate in fat tissue causing prolonged effects

3. serum albumin (protien in blood) may decrease with age so drugs that are protien bound may be affected

what are the age related changes in metabolism of drugs?

1. hepatic blood flow reduces with age to the liver causing reduced rates of drug metabolisms due to less enzymes and higher steady-state concentrations of some drugs

what are the age related changes with excretion of drugs?

our kidney function decreases with age causing some drugs to accumulate in the body rather than being excreted causing an increased time of drug action

what are the age related changes which occur → pharmacodynamics?

1. increased receptor sensitivity causing increased sedative effects for opiods, antidepressents, benzos

2. decreased receptor sensitivity to beta blockers for heart rate

3. decreased baroreceptor function causing increased orthostatic hypotension with blood pressure medications

4. increased response to medications

what is the rate of polypharmacy in canada?

1 in 4 canadians take 10 or more medications

what is the prescribing casscade?

the prescribing of a new medication to treat a symptom that has arisen from an unrecognized adverse drug reaction related to existing therapy or medications

how to minimize polypharmacy?

1. comprehensive medication review using an interdisciplinary approach

2. simplify to reduce number of dosing times per day and overall pill burden

3. deprescribe and medication tappering

4. make one chnage at a time, starting with lower or easier medications

5. clear communication with community pharmacy

what is involved in a comprehensive medication review?

1. best possible medication history

2. medication adherence

3. identify drug therapy problems

4. identify high risk medications

5. identify age related changes in pharmacokinetics and pharmacodynamics

6. comunicate any changes with patients care team

what are drug therapy problems?

an event or circumstance involving drug therapy that actually or potentially interferes with an outcome of therapy

what makes a drug high risk?

1. bleeding risk

2. risk of hypoglycemia

3. falls risk

4. risk of memory loss

5. Anticholinergic activity - reduction in nerve communication

what are types of medication adherance aides which OT can use as intervention?

• Daily routine
• Calendars
• Medication charts
• Pill organizers
• Blister packages
• Medication dispenser
• Scheduled alarms
• Reminder calls
• Nursing or family administration

what are types of medication adaptive devices?

• Large print labels
• Non-child proof tops
• Pill splitter
• Pill crusher
• Eye drop squeezers
• Spacers for inhalers

what are the 5 M’s?

mind, mobility, medications, multicomplexity, matters most

what falls within the 5M’s mind?

impaired cognition such as delirium, dementia, depression, and MCI

what is latrogenesis

adverse patient outcome due to health care intervention not part of the natural cause of the illness, most commonly from polypharmacy and adverse effects

what falls within the 5M’s mobility?

mobility impairements or immobility is often multifactorial; musculoskeletal, cardiorespiratory, neuro, sensory, falls

what percentage of older adults fall every year?

20-30%

what are the impacts and risks of immobility? (7)

1. deconditioning

2. incontience

3. decreased skin integrity

4. osteoporosis

5. other medical conditions

6. increased informal and formal care needs

7. decreased occupational engagement

what does multicomplexity mean in the 5M’s?

multimorbidity and comorbidities and complex biopsychosocial situations

what are the red flags of multicomplexity?

UTI’s, Respiratory infections, frailty, major life events such as moving, loss of loved one, and change in supports

what does the 5Ms matters most - incontience mean? risk factors?

involuntary loss of urine

1. social stigma/burden

2. limited occupational performance

3. limits mobility

4. finacial burden for supplies

what are the physical changes which can increase incontience symptoms in older age?

smaller bladder capacity and weaking muscles of pelvic floor, obstructed prostrate gland in males, changes in pelvic floor due to pregnancy in females, kidneys become less able to concentrate urine, increasing output

what are OT interventions for incontience?

 Address occupational engagement and social participation
 Knowledge and understanding, collaboration with others (e.g.
physician, physio, etc.)
 Environmental modification
 Adaptive approaches (routines, incontinence products)
 Referral

what is in the 5Ms medications?

implications of polypharmacy and physiological changes as we age that affect drug tolerance and adherance

what is in the 5M’s matters most section?

gathering social history, context and preferences, individual beliefs, concerns, expectations, caregiver burden, resources, saftey

what is a mild cognitive impairement?

a cognitive impairement greater than expected for their age, but can be fucntioning imdependently and do not meet criteria for dementia

what is the MoCA score considered to be for MCI

23/30

what is the prevelance of MCI?

10% of canadians over the age of 65 years more common in men

what are the four types of MCI?

1. Amnestic sing domain, memory type

2. Amnestic multiple domain, memory type

3. Non-Amnestic single domain, no memory

4. Non-Amnestic multiple domain, without memory involvement

what are potentially modefiable risk factors for dementia? (8)

diabetes, obesity, stroke, western diet, hypertension, mood/anxiety disorders, hearing loss, physical inactivity

MCI is sometimes caused by what treatable health conditions?

1. sleep disorders

2. medications

3. low blood pressure

4. mental health disorders

5. sight or hearing loss

6. infections

7. sevre constipation

8. alcohol consumption

9. hgih or low levels of vitamins, minerals, hormones, or sugars

what types of assesments can you use for MCI?

self report, standardized impairement based like MoCA, MMSE, trails, performance based like AMPS, EFPT, and observation

what are the 5 interventions used with MCI to decrease risk of dementia and cognitive decline?

1. neuroplasticity - preserved ability to learn new information and adapt behaviours

2. cognitive reserve - ability to cope with cerberal damage by using pre-existing or compensatory cogntive processes

3. physical exercise - aerobic resistance traning frequently at high intensity, resistance exercises and min-body exercises

4. cognitive interventions - cognitive stimulation, cognitive training, computerized cognitive training

5. music therapy

what is the best proven goals and strategies for MCI?

1. individual and goal-oriented rehabilitation

2. use of internal and external strategies which are individualized

what is the prevelance of only dementia in older adults in canada?

477,000 people aged 65 plus are living with dementia, 86,000 are newley diagnosed, every 5 years it doubles amoung older adults less than 1% in 65-69 to 25% in 85 years and older

what are the four types of dementia? what are the rates of each type?

1. Alzheimers (50-80% of all cases)

2. Vascular dementia (20-30% of all cases)

3. Lewy body dementia (10-25% of all cases)

4. Frontotemporal dementia (10-15% of all cases)

what is the pathology and signs and symptoms of alzheimers disease?

gradual, progressive onset

1. memory loss - names and recent events

2. rapid forgetting

3. language deficits

4. impaired visuospatial skills

5. normal gait and neuro exam in early stages

6. affective disturbances and behavioural symptoms in later stages

pathology: generalized atrophy in the medial temporal lobe

what is the pathology and signs and symptoms of Vascular dementia?

abrupt or gradual onset

1. focal neurological signs

2. signs of vascualar disease

pathology: stroke, TIA, white matter stroke

what is the pathology and signs and symptoms of Lewy Body Dementia?

insidious onset, progressive with fluctuations

1. fluctuating cognition

2. visual hallucinations

3. sensitivity to antipsychotic medications

4. shuffling gait

5. increased tone

6. tremors

7. falls

pathology; generalized atrophy as a result of lewy bodies in the cortex and midbrain

what is the pathology and signs and symptoms of frontotemporal dementia?

insidious onset usually in the 50-60s; rapid progression

1. disinhibition - impulsivity

2. socially inappropriate behaviour

3. poor judgement

4. apathy - decreased motivation

5. poor executive function

pathology; frontal and temporal atrophy, pick cells and pick bodies in cortex (swollen, balloon like shape in cortex)

what is delirium? what are the 3 types? defintions?

delirium - acute onset of altered level of consciousness, inattention, disorganized thinking, memory impairment, disorientation, and perceptual disturbances, often with fluctuations in symptoms

1. hyperactive form - agitation, irritability, combative outbursts, hallucinations that are disturbing to patients family

2. hypoactive form - somnolence, decreased vocalizations and motor activity and cognitive detachment

3. Mixed - a combination of hyperactive and hypoactive