FR3072277A1 - MODIFIED AMBULATORY REHABILITATION - Google Patents

Abstract

This patent aims to protect the model of "Ambulatory Ambulatory Modeled" RAM. It has been designed from the home care of the person with Alzheimer's disease or related diseases, but can be healed for other patients with chronic conditions leading to a loss of dependence or autonomy The RAM is built on a scientific basis and is aimed at the patient and his or her caregiver. It consists of a functional assessment tool for the sick person, a model of clinical reasoning that allows you to choose the most suitable activity for a patient and to design modalities support, a decision support tool for the most suitable activity that can shorten the evaluation time. This model is integrated into an Excel program.

Description

Context

Alzheimer's and related diseases are characterized by a progressive deterioration affecting memory and ideation, sufficiently marked to handicap the activities of daily life (ADL) and social. The impairment affects cognitive functions, emotional control, social behavior and motivation. This generates a loss of independence and autonomy.

Drug treatments are aimed at reducing the symptoms of the disease. Research into curative treatments shows efficacy and tolerance issues.

There is a growing interest in non-drug therapies. Among them, cognitive rehabilitation combines functional rehabilitation, provision of compensation strategies, adaptation of the environment and approaches aimed at regulating the emotional consequences of disabilities and other social difficulties (1).

A new care paradigm targets a quality of life based on the preservation of independence and autonomy for as long as possible. It concerns the dyad formed by the patient and his close caregiver (2).

On this model, a cognitive rehabilitation program has shown the improvement of the patient's skills in ADL and the reduction of the burden on caregivers (3). However, this study could not be reproduced (4). More recently, the ETNA3 study comparing three cognitive therapies with the intention of the dyad, showed the interest of an individualized management adapted to the profile of the patient. It shows a significant reduction in functional disability and a delay of 6 months in entering an institution (5). A meta-analysis had already shown the positive effect of non-drug interventions to delay institutionalization. These promising results, however, show the need to model the intervention and target the public.

We have designed a Modeled Ambulatory Rehabilitation (RAM) which concerns the dyad formed by the sick person and their close caregiver. The intervention is performed at home by a psychomotor therapist or an occupational therapist working in a Specialized Alzheimer Team. The intervention focuses on independence and autonomy.

1. Clare L. Cognitive réhabilitation and people with dementia. In: International Encyclopedia of Réhabilitation [Internet], 2010. p. 2-11. Available from: http://cirrie.buffalo.edu/encyclopedia/en/article/129/

2. Lavallart B AJ. Non-drug outpatient therapies in Alzheimer's disease: definition, interest and place in the therapeutic strategy. Alzheimer's strategies. current therapies in the disease Non-drug therapies: Rev Prat. 2011; 61 (7): 945-9.

3. Graff MJL, Vernooij-Dassen MJM, Thijssen M, Dekker J, Hoefnagels WHL, Rikkert MGMO. Community based occupational therapy for patients with dementia and their care givers: randomized controlled trial. BMJ [Internet], 2006; 333 (7580): 1196. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1693594&tool=pmcentrez&re ndertype = abstract

4. Voigt-Radloff S, Graff M, Leonhart R, Schornstein K, Vernooij-Dassen M, Olde-Rikkert M, et al. WHEDA study: effectiveness of occupational therapy athome for older people with dementia and their caregivers-the design of a pragmatic randomized controlled trial evaluating a Dutch program in seven German centers. BMC Geriatr [Internet], 2009; 9:44. Available from: http://www.ncbi.nlm.nih.gOv/pubmed/19799779%5Cnhttp://www.pubmedcentral.nih.go v / articlerender.fcgi? Artid = PMC2761388

5. Amieva H, Dartigues JF. ETNA3, a clinical randomized study assessing three cognitiveoriented therapies in dementia: Rationale and general design. Rev Neurol (Paris) [Internet], 2013; 169 (10): 752-6. Available from: http://dx.doi.Org/10.1016/j.neurol.2013.07.011

Bases of reasoning

The reasoning behind the RAM is based on several principles:

Principle 1: The human functions involved in the subject's psychomotricity and retained within the framework of AMR are:

Body image

Motor control: tone, dissociation coordination, postural control

Memory

Warning

praxis

gnosia

Language

Calculation

Reasoning

Mental flexibility

Inhibition

Space

Time

Emotional regulation

Self-representation

For each selected function, a specific evaluation tool is designed.

A specific order is defined for the sequence of functions during the evaluation.

Principle 2: Human functions are multi-modal: each function is involved, at various levels, in the structure and activity of the other functions. There are therefore synergies between the different functions.

A table of functional synergies describes the level of functional interactions between all the functions mentioned. The level of synergies is noted from 0 to 3, 0 corresponding to the absence of synergy, 1 to a weak synergy, 2 to a medium synergy, 3 to a strong synergy.

Body perception Body knowledge Structuring of the body diagram tonus Gait and balance Joint mobility Fine motor skills of the upper limbs Immediate memory Deferred memory Warning Ideative Praxies Ideomotor Praxia Constructive Praxies Graphic Praxies Visual gnosias Oral and / or written comprehension Body perception '2 ilBIIIll ieii® 1 miii 1 1 0 0 1 1 Body knowledge lllifl 0 1 0 111111 (1 0 1 2 0 Structuring of the body diagram iibiBs lllll iiiiiiiii 0 0 0 ? 0 1 1 0 tonus lllljll 0 0 1 1 1 0 0 0 Gait and balance ΙΙΙΐβ! 0 0 0 0 0 0 0 0 0 Joint mobility S1SB8®S 2 liBills ||||||| 2 0 0 0 0 0 0 1 0 0 Fine motor skills of the upper limbs z 0 lilji 0 0 0 1 1 1 Immediate memory 1 0 0 0 0 0 0 1 0 0 0 0 1 Deferred memory Ί 1 0 0 0 0 0 1 0 0 1 1 Warning 0 0 1 0 0 lilll 1 1 0 1 1 Ideative Praxies 1 2 1 0 0 SSSWSWHM® 0 0 1 1 1 1 ft. Ideomotor Praxia 1 Z. SlilllllO 1 0 0 0 2 1 1 0 0 0 1 Constructive Praxies 0 0 0 0 0 0 1 0 0 0 1 0 ii 1 1 Graphic Praxies 0 1 1 0 1 0 1 1 0 3 Visual gnosias 1 1 0 0 0 1 1 1 1 2. 0 1 0 Oral and / or written comprehension 1 0 0 0 0 0 1 Z 1 1 1 0 Oral and / or written expression 0 0 0 0 0 0 0 1 2 0 0 0 1 Calculation 0 1 0 0 0 0 0 1 0 0 0 0 0 0 Reasoning 0 0 0 0 0 0 0 bbbbQi 1 0 0 0 0 Inhibition 0 0 0 0 0 0 0 1 1 llliii 1 0 0 1 0 Mental flexibility 0 0 0 0 0 0 0 iiiil ijHilh 1 0 0 1 0 Space 0 0 0 1 0 1 1 1 2 3 IHlllÈ 1 2 Time 0 0 0 1 0 0 0 1 1 1 0 0 1 0 1 Emotional regulation 1 0 1 1 1110 lllfjl 1111 · 1 0 Affective representations of the body ! 1 I 1 Z 1 1 0 1 0 0

Table 1: Table, functional synergies

Principle 3: The functions are organized together into functional synergies. The solicitation of one of the functions makes it possible to bring into play the other functions in which it is involved.

Principle 4: Synergies can have structuring and regulatory effects.

Principle 5: Technical aids can be used to compensate for deficiencies (agenda, plan, etc.).

Principle 6: The intervention takes into account the dyad formed by the caregiver and the sick person. The caregiver’s participation in the activity is one of the criteria taken into account in the design of the intervention program.

Principle 7: a functional evaluation of the sick person is carried out to establish a functional profile.

Each function is scored from 0 to 3, 0 corresponding to very poor preservation, 1 to weak preservation, 2 to medium preservation, 3 to good preservation

Sufficiently preserved functions are those noted 2 and 3.

Principle 8: a database of activities of daily life or instrumental activities of daily life is established.

For each activity, the functions selected to perform the functional analysis of the sick person are analyzed to be able to note their level of involvement in this activity.

The level of involvement of each function is noted from 0 to 3.

corresponds to the absence of implication, 1 to a weak implication, 2 to an average implication, 3 to a strong implication.

The functions absolutely necessary for carrying out the activity are those noted 2 and 3.

Principle 9: the level of preservation of each function evaluated for the sick person is compared to their level of involvement in the activity chosen by the sick person from the activities in the activity database. The "functional delta" index is calculated:

Functional Delta = note of the preservation of the function in the sick person - note of the usefulness of the function in the activity

Principle 10: The functions absolutely necessary for carrying out the activity are noted 2 and 3:

functions with a functional delta = 0 or> 0 can be directly called upon.

functions with a negative functional delta must be directly requested and stimulated by bringing into play functional synergies.

Principle 11: for the functions necessary for activity and having a negative functional delta, the table of functional synergies makes it possible to identify the functions in synergy preserved.

Principle 12: Two strategies can be used to compensate for a functional deficit • Solicit functional synergies directly. Whenever possible, the synergistic functions of the motor field will be called upon.

• Design an activity to support this deficit function which will mainly mobilize preserved functions.

These strategies can be implemented simultaneously if necessary.

Principle 13: An activity is possible if:

• No essential function has a functional delta = -3;

• There is no more than one essential function with functional delta = -2.

• When a function has a negative functional delta, at least two synergistic and preserved functions in the patient can be mobilized, • To choose an activity to support a deficit function, the essential functions must be identified to carry out this support activity, and verify that at least 75% of essential functions are preserved in the patient.

Principle 14: the solicitation of functions in synergies during activities is done by targeted inductions on these preserved functions.

Principle 15: Identify the functional impairment of the sick person, the consequences of which could be increased by the spatial configuration or the physical properties of the objects or the layout.

Principle 16: Identify impairments of the motor or cognitive functions of the sick person which could be the subject of replacement tools, or prostheses, including mental ¹ .

Principle 17: Identify the necessary adaptations in terms of the material environment for achieving the objective.

Principle 18: Observe the natural interactions between the caregiver and the sick person in carrying out the activity in general and the chosen objective in particular.

Identify the relational skills ² to reinforce in the caregiver in connection with achieving the objective

Principle 19: Identify the skills ³ to reinforce in the caregiver so that he can ask the sick person for the skills necessary to achieve the objective.

Principle 20: Identify the complementary knowledge to bring to the caregiver (on the disease, on the helping relationship, on the condition of the caregiver ...) so that he can seek in the sick person the skills necessary to achieving the goal.

Principle 21: Design intervention times for the caregiver focused on knowledge, skills and / or know-how in the presence of the sick person and face to face if necessary.

Tools available to rehabilitators

Rehabilitators have a computer tool that analyzes data in real time and offers decision support.

It is an Excel program with the following tabs and functions

Inclusion tabs:

o First telephone interview o Patient identity and ESA 'Example of mental prostheses: diary, notebook, written procedure, plan, routine ...

² Examples of relational skills: thinking of the other, listening, taking into account a different point of view, appeasing, encouraging, influencing, regulating one's emotions, adapting to rhythm, verbalizing from non-verbal communications ...

³ Examples of know-how: soliciting a motor function, memory, attention, location in time, location in space, organization of tasks ...

o Inclusion criteria

Functional assessment tabs o MMSE o Cross-sectional observations o color palette (not rated) o ADL SI o I-ADL SI o Body perception o Ideational praxis o Knowledge of the body o Idomotor praxis o Structuring of the body diagram o Proprioceptive and kinesthetic immediate memory o Constructive praxies o Attention (part 2) o Proprioceptive and kinesthetic deferred memory o Tonus o Gait and balance o Gnosia o Immediate visual memory) o Graphic praxies o Calculation (MMSE report) o Delayed visual memory o Joint mobility o Fine motor skills of the upper limbs o Language (understanding and expression) o Reasoning o Inhibition o Mental flexibility o Space o Time o Summary table of the patient's functional evaluation

Tabs for analysis of standard activities o List of 17 standard activities o Correspond in writing with someone (letter) o Host family, friends o Call family or friends by phone o Use a computer to correspond with someone a o Leisure activities (hiking, sport, choir, lotto, senior citizens) o Take a walk outside o Take public transport o Fine manual activities o Take your treatment o Administrative management (and budget management) o Shopping o To wash, to look good, to look good (hygiene, make-up, clothes ...) o To cook, to eat o To garden o DIY, To paint, to draw, To sew, to knit o To do housework, to do laundry o To do storage o Make board games (cards, scrabble, failure, etc.) o Table of functional synergies

General Protocol

The purpose of the initial assessment is to define targeted objectives for a given activity and to define an intervention project to achieve them.

4.1 Design of the RAM intervention towards the patient

Design of the RAM intervention towards the patient

Reasoning steps Operational steps

1) Carry out the preliminary operational steps. Initial telephone interview with the caregiver. Collect information from the initial telephone interview. Know if the diagnosis was made and announced before the sick person.

Carry out targeted interviews with the sick person and the caregiver.

Perform the assessment of autonomy, the functional assessment of the sick person using the computer application (computerized data entry).

Consult the summary grid for the assessment of the sick person.

Identify the preserved functions and the deficit functions in the sick person. The preserved functions are noted 3 or 2 in the "Summary of the functional evaluation of the sick person".

The altered functions are noted 1 or 0.

) Identify one or more activities potentially interesting for the sick person from interviews with the sick person and the caregiver.

4) Offer these potentially interesting activities to the sick person and the caregiver.

5) Discuss with the sick person and the caregiver to determine the objective (s) for each activity chosen.

·. ·: Analyze the functions necessary for the achievement of each objective: Consult the tab of the typical activity.

The patient's profile is reported there

For each function, a delta is calculated between the patient's score and the level deemed necessary for carrying out the activity.

The scores of the functions for carrying out the activity highlight the functions absolutely necessary for the carrying out of this activity.

| 7) A first automatic sorting (Tl) allows to retain only the functions deemed essential for carrying out the activity.

8) For these essential functions:

- functions with a delta = 0 or> 0 can be directly called upon.

- functions with a negative delta must be directly solicited and stimulated by the use of synergies.

I 9) A second automatic sorting (T2) relates to the delta between the skills of the patient and the skills expected to perform the activity. Only negative deltas are retained, that is to say those for which it will be necessary to find a way to compensate for the functional deficit.

10) On each line:

- The functions in green are available for synergies.

- Functions in gray are not.

11) Two strategies to compensate for a functional deficit (they can be combined):

• apply for functional synergies directly. Whenever possible, the synergistic functions of the motor field will be called upon.

• design an activity to support this deficit function which will mainly mobilize preserved functions.

12) Rules of feasibility of an activity: this activity is possible if:

• for all of the essential functions for this o no essential function with a delta o no more than one essential function with Δ • To directly request synergies to compensate for a functional deficit: At least two functions in synergies and preserved in the patient can be mobilized, • for a support activity for a deficient function: identify the essential functions to perform this support activity, check that at least 75% of the essential functions are preserved in the patient.

13) Conclude on the feasibility of each activity.

14) Propose these activities to the sick person and the caregiver and determine with them the most

115) Confirm the objective with the sick person and the caregiver and obtain their support for the program.

16) Design the progression of the intervention and the.

targeted inductions, adapt them according to their

17) Implement the intervention sessions.

4.2 Design of the RAM intervention on the material environment

Design of the RAM intervention on the hardware environment

I stages of reasoning I operational stages

8) During the first session following the evaluation, implement the chosen activity with the help of the caregiver.

I ¹ )) identify the functional impairments (cf. <· Patient summary table ») whose consequences may be increased by the spatial configuration or the physical properties of the objects or the layout.

20) Identify the impairments (motor or cognitive functions (cf. “Table on patient's nerve”) which could be the subject of replacement tools, or prostheses, including nienlales-1.

21) Identify the adaptations necessary at the level of the material environment for the realization of liiiiiiilliiiiiiiiiiiijiiiï ·

Evenluellemenl design substitute tools or 22) Possibly make substitute tools or prostheses to compensate for damaged Innclinns. prostheses to compensate for damaged Innclinns.

2.1) train and support the assistant and the assistant in the use of these substitute tools or prostheses.

4.3 Design of the RAM intervention towards the caregiver (conception of the RAM intervention towards the caregiver

Reasoning steps Operational steps

24) During the first session following the evaluation, implement the chosen activity with the help of the caregiver.

2.1) Observe the natural interactions between the caregiver and the sick person in carrying out the activity in general and the chosen objective in particular.

⁴ Example of mental prostheses: diary, notebook, written procedure, plan, routine ...

2 (>) Identify relational skills '' to reinforce in the caregiver in connection with the realization of · ί1 ^^ · Ι1β ······ ΙΙ ··· Ι · ^ ········· ······················ Ι Ι · · · · · · Ι Ι Ι · · · · · · Ι Ι Ι ····· ··

2 ~) klenlilïer the know-how '· to reinforce in the caregiver so that he can request from the sick person the skills necessary for the achievement of the objective ·

2i!) Identify additional knowledge to bring to the caregiver (on the disease, on the helping relationship, on the condition of the caregiver ...).

29) Design intervention times for the general practitioner focusing on knowledge, skills and 'or know-how in the presence of the sick person and face to face if necessary.

0] Implement these targeted intervention times with the caregiver.

⁵ Examples of relational skills: thinking of others, listening, taking into account a different point of view, appeasing, encouraging, influencing, regulating emotions, adapting to rhythm, verbalizing from non-verbal communications ...

⁶ Examples of know-how: soliciting a motor function, memory, attention, location in time, location in space, organization of tasks ...

Claims (1)

6 Claim This patent filing claims intellectual property on the following elements: • The name "Modeled Ambulatory Rehabilitation - AMR" • Clinical evaluation tools designed for AMR • The reasoning model used for AMR and described in 21 principles, in particular: o The principle of the table of functional synergies and a rating of the levels of synergies between the functions. o The principle of an activity database and a functional profile defined for each activity. This profile is made up of the ratings of the importance levels of the functions for each activity. • Any updating of the ratings in the synergies table or in the functional profiles of the activities based on scientific data. • The description of the protocol for designing the RAM intervention. • The Excel file which groups together all of the model and tools. • All adaptations of the AMR for other pathologies than Alzheimer's disease or related diseases, or for other places of use than the home. • All computer applications, in all known or future forms (for example: websites, mobile applications) which would use the RAM model or its derivatives.