Occupational Therapy Assessment In Long Term Care

Issues of Concern

Occupations are the set of activities significant for the patient's cultural context, age-appropriate, chosen, organized, and carried out by each individual to provide for himself, to feel joy in living, and to contribute to the economic and social life of the community (Canadian Association of Occupational Therapy, 1997). Occupation is the goal of occupational therapy but also the means by which we try to modify the body functions of the person (motor-sensory, perceptual-cognitive, emotional-relational abilities); generally, there are three areas within which we can find occupations: personal care, work (school) and free time. Occupational therapy is practiced in a wide range of settings, including hospitals, health centers, the home, workplaces, schools, and retirement homes (World Federation of Occupational Therapy). Occupational therapists have a person-centered approach and carry out their practice based on evidence (evidence-based health care).

Mobility: Walking and Moving Around

• Activities of Daily Living (ADL) Index: 
  • This is usually done through both interviews and observation. The observation aspect will include tasks such as going to the toilet, personal grooming, and hygiene, eating and drinking, dressing, and moving independently throughout the house. This is scored by whether the patient can perform these tasks independently or would be able to perform these tasks only with assistance from another person.
• AM-PAC: 
  • AM-PAC stands for "Activity Measure for Post-Acute Care." The AM-PAC is an outcomes instrument that measures three domains: applied cognitive, basic mobility, and daily activities. This is often used to monitor and research outpatient rehabilitation, nursing home, and long-term acute care settings (LTAC's). [2]
• Modified Berthel Index: 
  • MBI is used to assess the activities of daily living in 10 different domains. These include bathing, feeding, stair climbing, personal hygiene, dressing, bowel control, bladder control, chair transfer, and ambulation.[3]
• Stroke Impact Scale: 
  • This is a self-reported questionnaire that is able to evaluate the patient for disability and quality of life after a stroke. It takes about 15 to 20 minutes to administer and requires no training. It covers eight domains, including memory and cognition, emotion, strength, communication, ADL's, mobility, and hand function, and participation. Each item is given a score of 1 to 5. A lower score signifying more ease with completing the task.[4]

Self Care

• Cleveland Scale of Activities of Daily Living
  • This is a two-factor model that evaluates the basic activities of daily living in people with dementia.[5]
• Functional Assessment Scale 
  • This is a checklist-type of scale that is used for institutionalized patients.
• Klein-Bell Activities of Daily Living Scale
  • This is a scale that has been developed to assess independent functioning for research and clinical purposes. The interrater reliability of this test is 92% regardless of the level of training.[6]
• Melville-Nelson Self-Care Assessment
  • This is a scale used by occupational therapists in subacute rehabilitation or skilled nursing facilities (SNFs). The interrater reliability was 94%. The seven domains are bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. Each of these is divided into suboccupations. For instance, personal hygiene may be divided into hair brushing, handwashing, dental care, and even self-care. Those are then divided into sub-suboccupations. For dental hygiene may be subdivided into right, left, upper, and lower.[7]occupations (bed mobility, transfers, dressing, eating, toileting, personal hygiene, bathing) are rated in two ways: self-performance (how much the person did) and support (the degree of assistance needed from others) 
• Modified Barthel ADL Index
• AM-PAC

Swallowing

• The Mann Assessment of Swallowing Ability (MASA)
  • This was first introduced to identify dysphagia in acute-stage stroke patients. Now it can be used as a screening tool in any dependent older adult.[8] 
• Acute Stroke Dysphagia Screen
  • This is an easily administered and reliable tool that can be used to detect both dysphagia and aspiration risk in acute stroke patients. The interrater reliability is 93.6% and the test-retest reliability was 92.5%. It also has a sensitivity of > 90% and specificity of >68% for detecting dysphagia and aspiration.
• Victorian Dysphagia Screening Model ASSIST Tool
  • Completion of this is recommended by personnel that has completed approved training in dysphagia screening. This is recommended in the presence of persistent acute stroke symptoms. 
• Swallowing Ability and Function Evaluation
  • This is a test that evaluates swallowing. Before this test should be administered, a baseline evaluation of cognition and proper motor function should be assessed. 

Attention 

• Test of Everyday Attention (TEA)
  • The TEA is a test of attention that gives an overview by breaking attention down into very distinct factors. This is done by dividing and including sub-tests that such as searching a telephone directory or listening to lottery results, that mimic everyday tasks. This is a useful assessment tool to help in work rehabilitation programs, especially in those jobs that rely heavily on focused attention, such as an air traffic controller.[9]
• Neurobehavioral Cognitive Status Screening Examination (COGNISTAT)
  • This assessment provides a brief screening of cognitive dysfunction. It provides profile scores for language constructions, memory, calculations, reasoning. It also separately and independently assesses orientation, level of consciousness, and attention.
• D2 Test of Attention 
  • This assessment is a cancellation test that can measure attention, visual scanning, and processing speed. It is a paper and pencil test that assessed if the patient is able to focus their attention on specific numbers and letters and combinations of the two over a specific period of time. cancellation test to measure attention, visual scanning, and processing speed.[10]

Memory

• Contextual Memory Test 
  • This is an assessment tool that can measure both the memory and metamemory of people with cognitive disabilities. The domains assessed include memory capacity, strategy of use, and recall. 
• Rivermead Behavioral Memory Test
  • This assessment identifies everyday problems and is good at tracking change over time. The RBMT can help distinguish between MCI and mild dementia.[11]
• AM-PAC

Carrying Objects

• Functional Reach Test
  • A valuable tool for those who are at risk of falls. It can test AP (anteroposterior) stability.
• Action Research Arm Test 
  • This test can assess and measure the limitations a person has with upper limb mobility after an insult to the brain. It should be used in people with a TBI (traumatic brain injury).[12] The scores of 19 specific tests are added together. These 19 specifics are spread along 4 specific subsets (grasp, grip, pincer, and gross movement). The 19 tests are given a number 0-3.  0 = no movement, 1 = the movement is partially performed, 2 = the movement is completed but takes a long time, and 3 = the movement is performed normally. 
• The Arm Motor Ability Test (AMAT) 
  • This is also a test to identify and assess upper extremity limitations quantitatively in patients who have had a stroke or any other insult to their brain. One study showed that a change of 0.44 or greater in the AMAT shows clinically meaningful and statistically significant change. AMAT assesses functional ability, quality of movement, and time of performance. [13]

Changing and Maintaining Body Position

• Assessment of Motor and Process Skills (AMPS)
  • This assessment takes time to administer. Those that are evaluated with AMPS are rated on 15 motor skills and 20 process skill items after they have been observed doing two or three IADLs. This will provide an objective assessment of both motor and process skills.[14]
• Berg Balance Scale
  • This was an assessment developed in 1989 to help identify and measure balance in the elderly population. It measures both static and dynamic abilities using functional tasks that are commonly performed in everyday life. The scale has 14 items and each is scored on a scale of 0 to 4 with a total of 52 points. The higher the score, the better the balance. The interrater reliability is 97%.[15]
• Timed Get Up and Go Test
  • The patient is observed and assessed as they get up from a chair, walk 3 meters, turn around, walk back, and sit back down. The patient is timed during this test and it has good interrater reliability. This corresponds well with the previous Berg Balance Scale and is able to predict if it would be safe for the patient to go outside.[16]

Clinical Significance

The goal of rehabilitation, especially occupational therapy, is to help those return to their activities that they need and want to do. To achieve this, it is important to apply the current research, evidence, and critical reasoning to better achieve certain outcomes. Formalized assessments are important because they reduce biases, which is very important to classify specific categories being assessed. These specific assessments listed above are important because they serve as a way to identify any deviations from 'normal.' These deviations can then be analyzed, and there can be specific therapies that can be used to help address the needs of the patient/client. Finally, the assessments also provide a way to measure the change over time and are a way to track the progress the patient/client has made. 

Occupational therapists work with many people, from children to the elderly. The first appointment with an occupational therapist typically involves an assessment of the situation. This includes the history of any condition that the patient had and, in particular, the evaluation of the difference between what could be done in the past and what can be done now. Goal setting is an important part of occupational therapy. The occupational therapist will work with the patient to determine which activities are most important to him and establish clear goals that will improve his ability to perform them. What often distinguishes occupational therapy from physiotherapy is that while a physical therapist focuses on improving physical function and movement, an occupational therapist tries to figure out if there is an alternative way to perform a certain activity. Occupational therapy is, therefore, much more oriented towards adaptation.

Another important distinction with the physiotherapist is that the latter works with patients in acute and chronic phases, while the occupational therapist works with chronic or resolving diseases.

Nursing, Allied Health, and Interprofessional Team Interventions

The occupational therapist works in a multidisciplinary team, which is the best strategy for the patient's well-being.[17][18][19]

Nursing, Allied Health, and Interprofessional Team Monitoring

In multidisciplinary treatment, each figure who follows the patient's care and well-being must monitor the results with specific and possibly validated scales; this serves to obtain a more scientific measurement of the results obtainable and obtained in the patient's recovery path.[20][21]