Occupational Therapy
screening for cognitive and
perceptual deficits for mild
stroke patients
Presented By:
Lise Zakutney, BSc. OT, OT Reg. (Ont.)
Best Practices Team, Occupational Therapist
Champlain Regional Stroke Program, Ontario
The Ottawa Hospital
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
2
Context of the OT CQI Project
“Is there a need to screen mild stroke
patients for cognitive or perceptual
deficits?”
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
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How do we determine mild stroke
patients?
• AlphaFIM® Instrument abbreviated version of the FIM®
• Assists in triaging stroke patients
The AlphaFIM® and FIM® instruments are the property of Uniform Data System
for Medical Rehabilitation, a division of UB Foundation Activities, Inc.
All marks associated with AlphaFIM®, FIM® and UDSMR are owned by UBFA.
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
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What is the AlphaFIM®
• Consistent method of assessing disability and functional
status
• 6 items of the FIM®
• Completed on or before day 3
• No doctor’s referral needed
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
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6 items AlphaFIM®
Patient walking < 45 metres
Patient walking > 45 metres
without a rest period
•
•
•
•
•
•
•
•
•
•
•
•
May 28, 2015
Eating
Grooming
Bowel management
Toilet transfers
Expression
Memory
Transfers: Bed, Chair
Walking
Bowel management
Toilet transfers
Expression
Memory
CAOT Conference • 2015 • Congrès de l’ACE
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AlphaFIM®
May 28, 2015
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Triage guidelines using the AlphaFIM®
Stroke severity
Mild
AlphaFIM® Score
> 80
Moderate
Severe
40 to 80
< 40
Recommended Referral
Community-based rehabilitation
Inpatient stroke rehabilitation
Restorative care with regular assessments for
rehab potential
*The AlphaFIM® score is only one component for consideration in discharge planning
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
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AlphaFIM® score provides information
about the burden of care
AlphaFIM®
scores
80 to 90
100 to 116
Daily care requirements
(hours in assistance,
Burden of Care)
Level of deficits
Approximately 1 to 2 hours Mild stroke
Minimal or no assistance
Mild non disabling stroke
Lowest AlphaFIM® score is 20
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
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Problems Identified
• AlphaFIM® alone may not have properly identified rehab
needs
• Cognitive scores on AlphaFIM® do not always agree with
findings on cognitive and perceptual screening tests.
• Not all mild stroke patients are being referred to
Occupational Therapy prior D/C.
• Staffing FTE requirement on acute care stroke units for OT
have not been determined by the Canadian Stroke Best
Practices
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
10
Response
Planned to See and Do
Did See and Do
• Mild stroke patients in ER and
Neurosciences unit:
• TIA or mild stroke:
• Mild stroke patients only
admitted to Neurosciences
• Chosen Indicator: AlphaFIM®
score of ≥79 completed on or
before day 3
• OT ax, cognitive screens and
some perceptual screens
• Project done: 2 months
– ≥1 on visual and /or extinction
and inattention items on
NIHSS
– Planned d/c within 72 hours of
admission
– ≥80 on AlphaFIM®
– OT ax, cognitive and perceptual
screens on all of these patients
– CQI Project: 3 months
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
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How I identified mild stroke patients
•
•
•
•
May 28, 2015
Reviewed daily list of patients admitted under Neurology
Attended rounds 1 to 2 times a week
Maintained a daily tracking sheet
OT referral AlphaFIM® score of ≥79
CAOT Conference • 2015 • Congrès de l’ACE
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Process changes
Planned
Final process
• OT neuro initial assessment
and online OT report
completed
• Cognitive screen on all
patients (MoCA)
• Perceptual screen on all
patients (Balloon Test or
Star cancellation test )
• Trails A and B for executive
function
• OT neuro initial assessment
completed with online OT
report
• Cognitive screen on all
patients (MOCA)
• If OT initial ax or MoCA
indicated rehab needs, no
other perceptual screening
tests were done.
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
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Stroke patients admitted to our stroke
unit
January 2015
February 2015
35
35
30
30
25
28
25
20
25
20
15
17
15
10
10
5
5
0
0
Mod-severe Stroke
(AlphaFIM® 20-78)
May 28, 2015
30
Mild Stroke
(AlphaFIM® 79-116)
Mod-severe Stroke
(AlphaFIM® 20-78)
CAOT Conference • 2015 • Congrès de l’ACE
Mild Stroke
(AlphaFIM® 79-116)
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Number of mild stroke patients assessed
by OTs in 2 months
33 out of 42 mild stroke patients
assessed by OT
21%
79%
Patients Seen
Patients No Assessed
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
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Data comparison
AlphaFIM® Range 79-99
AlphaFIM® Range 100-116
N = 23
Range
Median
N = 19
Range
Median
Age
34-92
68
Age
40-85
65
LOS
2-19
8
LOS
2-12
5
MoCA (18/23)
15-29
23
MoCA (8/19)
23-29
27
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
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Data on MoCA and AlphaFIM®
completion
• 29 out of 42 mild level stroke patients had a MoCA (69%)
• 42 out of 42 patients had an AlphaFIM® score (100%)
• Reasons 13 MoCA were not completed:
– 1 patient had a cerebellar stroke with no cognitive
deficits
– 8 out of 42 patients were not referred or discharged
before seen in OT
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
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Some perceptual tests were completed
• Balloon tests: 8 patients, all were normal
• 4 Trails tests were completed on patients
(AlphaFIM®:100-116)
• 2 of these patients had normal MoCA scores (28 and 27)
however the Trails tests showed higher level
cognitive/perceptual deficits. (18 percentile and 0.1
percentile)
• 2 other patients had normal Trails and did not require
outpatient stroke rehab.
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
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Discrepancies between the AlphaFIM®
and MoCA
Patients
MoCA
Score
Memory
AFIM
Expression
AFIM
AlphaFIM®
Score
1
22
7
6
92
2
17
7
7
92
3
16
7
6
91
4
18
7
7
95
5
18
7
7
91
6
18/29
Not in chart
Not in chart
111
(N:6/29)
May 28, 2015
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AlphaFIM® 79-99
Outcomes
N=23
%
Outpt stroke rehab: (Ottawa or rehab in home city)
10
43%
Outpt stroke rehab recommended → pt refused
1
4%
Private PT services
3
13%
Home with community rehab services (University of Ottawa
Inter-professional clinic)
1
4%
Community services with Homecare OT
3
13%
No outpatient therapy indicated
3
13%
Inpatient rehabilitation or readmitted to await for inpt
3
13%
Discharged before seen in OT
1
4%
87% discharged to the community, 97% were assessed in OT
(N:23)
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
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AlphaFIM® 100-116
Outcomes
N=19
%
Outpt stroke rehab in Ottawa or rehab
home city
6
32%
Transferred to home acute care hospital
1
5%
No outpatient therapy indicated
4
21%
Not seen in OT
8
42%
Pts requiring inpatient stroke rehab
0
11 stroke patients assessed by OT (58%)
(N:19)
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
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Case study
• Female in her early 50s admitted with right hemisphere stroke,
she had left sided weakness and dysarthria on admission. Pt
had mechanical thrombectomy with significant improvements.
Pt had a physically demanding work
• AlphaFIM® 116, expression: 7 Memory: 7
• MoCA 26/30, slower performance on word fluency, patient also
noticed she was slower at texting and spelling.
• Trails B, had 1 error: 8th percentile, performance described as
poor, slower mental processing
Was indep with ADLS, indep with mobility
• Plan: OT recommended referral to outpatient stroke rehab. Pt
was seen by physiatry and was accepted to the program
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
22
Context of the OT CQI Project
“Is there a need to screen mild stroke
patients for cognitive or perceptual
deficits?”
Answer: YES
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
23
Discussion / Recommendations
• OT assessment, the MoCA and additional perceptual
screening tests are helping to identify mild stroke patients
who require stroke rehab services
• Need more than an AlphaFIM® score to help triage
patients
• Mild stroke patients would benefit to be screened by OT
prior to their discharge.
• Need for evidences for staffing ratio for OT FTE on acute
stroke units.
May 28, 2015
CAOT Conference • 2015 • Congrès de l’ACE
24
References
1.
2.
3.
May 28, 2015
The AlphaFIM® and FIM® instruments are the property of Uniform Data System
for Medical Rehabilitation, a division of UB Foundation Activities, Inc. All marks
associated with AlphaFIM®, FIM® and UDSMR are owned by UBFA.
Canadian Stroke Best Practice Recommendations:
http://www.strokebestpractices.ca
1. Canadian Best Practice Recommendations for Stroke Care (Update 2013),
Taking Action Towards Optimal Stroke Care, May 23, 2013
2. Vascular cognitive impairment and dementia, 4th Edition 2012-2013
UPDATE March 19, 2013
Stroke Rehab Screening & Assessment Tools Evidence Based Review of Stroke
Rehab:
http://www.ebrsr.com/clinician-handbook Teasell R, Hussein N, Viana, R,
Madady M, Donaldson S, McClure A, Richardson M, Stroke Rehabilitation
Clinician Handbook, Canadian Stroke Network
Ontario Stroke Network: The Ontario Stroke System
CAOT Conference • 2015 • Congrès de l’ACE
25
Questions?
Occupational Therapy
screening for cognitive and
perceptual deficits for mild
stroke patients
Presented By:
Lise Zakutney, BSc. OT, OT Reg. (Ont.)
Best Practices Team, Occupational Therapist
Champlain Regional Stroke Program, Ontario