2017Adi kumiko murashima

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The role and issues required for the Initial-phase Intensive Support Team of dementia (IPIST): From the viewpoint of the OccupationalTherapist

＊１：Sakura-shinmachi Urban Clinic＊２：Japanese Association of Occupation Therapists＊３：Preventive Long-term Care & Community Support

Division, Elderly Welfare Department City of Setagaya

Kumiko Murashima(OT)*1*2 Junichiro Toya(PHD,MD)*1

Chie Katayama(Ns.)*1 Hirotoshi Niikawa(PHD,MD)*1

Noriyuki Ogawa(OT)*2 Yuko Takahashi(PHN)*3

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ご紹介いただきました、桜新町アーバンクリニックの村島と申します。 Thank you for the introduction. I’m kumiko Murashima from Sakura-shinmachi Urban Clinic. 私たちは平成25年度から、認知症初期集中支援事業に携わってきました。 Our team has been part of the Initial Phase Intensive Support Team of dementia since 2013. その事業の役割と課題について考察したのでご報告します。 Please bear with me as I reflect on the role of the program and the challenges we have.


【Introduction】 Japan is one of the most super-aging societies in

the world. (26% > 65years old)→ One of the issues is related to dementia

5 million people have dementia

A national strategy for dementia“the Five-Year Plan for Promotion Dementia

Measures” (Orange Plan) since 2013→ Initial-phase Intensive Support Team of

dementia (IPIST)

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日本は世界が経験をしたことのない速さで「超高齢社会」に突入し、様々な問題を抱えています。 Japan is one of the most super-aging societies in the world, and this presents us with a range of issues to tackle. そのひとつに、「認知症」があります。現在、日本には認知症と診断された方が約500万人います。 One is dementia. There are currently about 5 million people who have dementia in Japan. そこで、認知症の人が住み慣れた地域で暮らし続けられるよう、政府は「オレンジプラン」を発表しました。 The situation was acted upon when the Japanese government announced the national Dementia Strategy called the Orange Plan. The plan is to ensure people with cognitive impairments are able to continue living in the community where they have lived and feel at home. その中には、今回報告する認知症初期集中支援事業・チームの設置も含まれています。 Featured in the plan is the establishment of dedicated teams under the Initial Phase Intensive Support Team for Dementia, on which I will explain to you in details in my presentation.


【IPIST】 IPIST objectives:・Continuation of living at home・Multi-disciplinary approach

Service Duration：about 6 months

Targeting populationPeople who- Live at home, and- Are aged 40 and over, and- have not received any healthcare or social care services, or- have difficulty in daily activities due to behavioural and phycological symptoms of dementia

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この初期集中支援チームは、認知症の方や家族に関わり、多職種で初動支援を集中的かつ包括的に行うことを目的としています。 Initial Phase Intensive Support Teams are designed to engage with people with dementia and their families. They provide early-stage support that is intensive and holistic, working across specialties. The team has objectives. One is continuation of living at home. The other is dealing with issues through multi-disciplinary approach. The team's targeting population is those who have not received any healthcare or social care services, or have difficulty in daily activities due to behavioral and phycological symptoms of dementia.


IPIST（team member）

More than 3 years experience in dementia care or in-home

care

NursePHN※

Occupational Therapist

CertifiedCare

Worker

CertifiedSocialWorker

Psychiatric Social Worker

Pharmacist

DentalHygienist

Medicaldoctor

Any two or more different disciplines+ medical doctors specialized in dementia care

※Public Health Nurse

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国家資格を有する者で、認知症ケア経験または在宅ケア経験が3年以上であることが求められています。 Team members must be state-licensed practitioners with more than 3 years experience in dementia care or in-home care.


【Typical users service of dementia】

Difficulty IADL:Cooking, Appointment, Financial management

Person with dementia:Loss of confidence

Family:Uncertainty

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Family and caregiver become over protective

Physical activities Feeling / Emotions

Person with dementia: Loss of capabilityLoss of independence

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このスライドは、認知症の初期段階の方に見られやすい傾向を示しています。 The slide shows changes commonly detected in the early stages of dementia. 今まで何の問題もなく行なっていた活動が脳の機能低下により難しくなってきます。 Some tasks that were previously easy become difficult as the disease progresses. 特に調理や金銭管理などIADLに関する活動から少しずつ難しくなります。 Instrumental activities of daily living known as IADLs, such as cooking, making an appointment and financial management, are the ones that people first find difficult to perform. この状況を本人は不安に感じ、家族はリスクを感じてその活動を回避しようとします。 Such changes make those affected and their families anxious. The families tend to limit what the person with dementia can do in order to protect them from the potential hazards. 結果として、本人にとっては意味のある活動の機会が減少してしまうのです。 This, however, has potentially negative impact on the person with dementia as it reduces the opportunity for them to engage in meaningful activities.


・loss of confidence in some activities・deterioration of procedural memory・increased care burden for family

【Positive changes through the IPIST】

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・family and care give… over-protection and understandingBefore

「IPIST」 Assessment and personalized interventions

・ Regaining confidence・ Enablement in some activities・ Access to social care

→ Reduced care burden for familyAs a result, the people with dementia can continue to live at home

After ・family and caregiver・・・ understanding and reassured

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家族や支援者はリスクを回避するために、様々な活動を制限してしまいます。 To protect people with dementia from potential hazards, family members and care givers feel necessary to keep a range of activities out of bounds. たとえ、工夫や調整、助言があれば本人の力で出来そうな活動であってもそうです。 There are, however, ways to keep people with dementia independent through creative adjustment, adaptation, and advice. そこで、認知症初期集中支援チームとして適切な評価を行い、本人の能力を活かす支援を考えていきます。 Our team emphasizes this perspective, sets out to evaluate each case in details and devises a support plan that makes the most of the person’s retained abilities. このように、本人の力で出来そうな活動を継続すると、次のような効果が期待できます。 We focuse on helping the person to carry on with activities they may be able to perform independently. This approach is helpful in the following three ways: １）本人の自信が回復し、自分の存在意義を認識する、 The person with dementia regains confidence and restores meaning in their life; ２）適切なサービスが導入され、家族の負担が軽減する、 2) The burden of family can be reduced as appropriate services are identified and introduced. ３）本人と家族の不安が減り、作業活動が再開・継続できる and 3) It helps to ease anxiety of the person with dementia and families. The family can support the person to continue or resume their usual activities


【Reasons for referral】2013~2017

23%

20%14%12%

10%

9%

6%6%

Lack of social care use

Lack of assessment/ diagnaose

Lake of awareness andunderstanding in familyNeeds for doctor appointment

Referral to social care

Increasen care burden

Lack of informaition on livingcondistionsothers

Lack of understanding in family

Lack of social care use

Lack of assessment

Reference: Sakura-shinmachi Urban Clinic database

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次に私たちのチームに依頼された内容を具体的に示したグラフです。ご参照ください。 his chart shows reasons for referral to our team. Top three reasons are: lack of social care use, lack of assessment and lack of awareness and understanding in family.


【Role of Occupational Therapist】

⇨ ・Confidence development・Supervised activities・Support for decision making

⇨ ・Education in dementia care・The residual abilities・Promotion of the person’s

independence⇨ ・Alteration of furniture

arrangement・Introduction of assistive technology

Assessment for dementia

⇨ ・To conduct assessment・To identify necessary interventions

Support for person with dementia

Support for family

Optimizationenvironment

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先ほどのグラフにあった依頼内容の中で、作業療法士として行っていることは主に次の４つです。 OT plays a key role in assessment and interventions in our team. 1つ目の「認知症評価」では、MMSEやHDS-Rなどの認知症評価の結果生活障害の原因を考えます。 We assess the person with dementia using dementia assessment tools, such as MMSE and Hasegawa’s dementia rating scale, as well as in-depth history taking. We, then, use the findings to determine what is at the root of the ADL dysfunction. Accurate assessment is essential in providing individualized support. We have three main pillars to work: support for the person with dementia, support for the family and environment optimization. ２つ目の「本人への支援」では、評価を踏まえて、生活上困っている活動が「なぜ」できないのか、「どうしたら」出来るようになるのか、ということを作業分析しながら解決策を考えます。 Our first pillar is to support the person with dementia. We support the person along their journey living with dementia. Based on the assessment, We focuse on why the person is not able to perform a specific activity that causes them trouble in daily life and how the person can manage the activity. We analyze the activity and find out solutions to their issues. いくら支援を考えたとしても、本人の気持ちと一致していないと無意味です。ですから、本人が何を望み、どんな将来を思い描いているのか知り、それに沿うような支援を考えていく必要があります。 Whatever support is drawn up, it is not meaningful to the person unless it fits with the person's wishes and aspirations. It is therefore essential for us to understand what support the person wants and what goals are in their mind for the future. We, then, can provide the support to accommodate them. ３つ目の「家族への支援」では、2つ目の解決策を踏まえて、本人が行いやすくなるような支援を家族と一緒に行います。 Our second pillar is to support the family. Based on what we do with the person with dementia, we encourage family members to join and to provide the support that promotes the person's independence. また、家族が本人の状況を理解できるよう、認知症に関する心理教育を実施します。 We also educate family members on dementia and its impact on the person, and aid them in understanding the person’s condition. ４つ目の「環境整備」では、自宅内外の住環境評価・調整や自助具・福祉用具の提案を行います。 Our last pillar is environmental assessment and optimization. We assess the person’s living environment, make necessary adaptations and advise on self-help devices.


【Case study: Initial information】

Person A)・Diagnosis: Alzheimer’s dementia・Referral: from family・Reason for referral : Difficulty in cooking for family

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Person with dementia

Family

・ Taking extra time for cooking・ Forgetting tasks asked for family・ Feeling frustrated for themselves

・Feeling irritated for person’s inability to do simple tasks

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ここで、例を通してOTの視点に基づいた支援をご紹介します。 Let me now share with you one of our case studies and explain how OT's views and approaches support the program. この方は、アルツハイマー型認知症の初期と診断されています。 This person was diagnosed with an early stage of Alzheimer’s disease. 本人も家族も、本人の役割として「調理」を続けることを望んでいました。 Both the person and family hoped that she would be able to continue to manage her role as cook for the family. しかし、以前より調理の完成までに時間がかかってしまっています。途中の工程も忘れてしまいます。 However, it became clear that it took more time to prepare the meals. She tended to forget the order of cooking during preparation. その結果、本人も家族も調理が思うように出来ないことに落胆してしまっていました。 Faced with this change, the person and family were despaired that she might no longer be able to cook for the family.


【Case study: OT assessment】

Cognitive function：memory disorder

Environment：inefficient arrangement of furniture in kitchen 【see next slide】

Meaningful activity：Cooking dinner for family everyday

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そこで、作業療法士として評価を実施したところ、次のような問題が見られました。短期記憶障害が調理に大きく影響を与えていました。 When our team got involved in this case, we undertook a series of assessments and identified a key problem, that is, short-term memory loss. 具体的には、キッチン内の食器棚や電子レンジを使うために体の向きを何度も変える必要がありました。 On assessment, we found out that the activities in the kitchen were involved with repeated turns as she needed to reach for the cupboard and the microwave within the kitchen. その体の向きを変えたときに、何をしていたのか忘れてしまい、思い出すのに時間がかかってしまうということがしばしばありました。 She frequently forgot what she was doing when she turned and took time to remember. ですが、それでも家族のために夕食を作りたいという気持ちは持ち続けていました。 Even in this situation, she strongly wished to cook the meals for the family. そこで、まずは調理の妨げとなっていた「短期記憶障害」が影響しないようにキッチン内の動線を工夫しました。 We first analyzed the area where she moved around while cooking, We, then, devised modifications in the kitchen, according to the flow of the movement. This makes her movement in the kitchen more simple and clear so that she can perform the activities despite of her short term memory loss.


【Case study: Support for person with dementia】 Analysis of movements in the kitchen:

The person had to make a number of turns in the kitchen. Environment modification:

All cooking equipment was moved from cupboard to undersink and hung cupboards.→ Reduction in the number of directional changes

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fridgekitchen sink

・microwave・cupboard

fridgekitchen sink

・microwave・cupboard

A) Before B) After

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左の図は環境調整前の図です。 Please have a look at the diagrams. The diagram at the left hand side shows the way she cooked before we recommended environmental optimization. シンクを中心として、横の動き・90度180度の方向転換など、複雑な動きをしていました。 It revealed how complex her movements were, including sideways steps and 90 to 180 degree turns, centered around the sink. それを右の図のように変更しました。 The alteration we recommended is on the right-hand side of the slide. 左側にあった食器棚は使用せず、シンクの足元と頭の上にある棚を使用することで方向転換する回数を減らしました。 One cupboard was taken out. Instead, the shelves were installed at the base and overhead. This reduced the frequency of turns she had to make.


【 Case study: outcome】

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Reduction in the number of directional changes

Personwith dementia

・ Simpler movements for cooking in kitchen

・ Less confusion during cooking

Family ・ Regaining confidence in person with dementia for cooking

The person with dementia continues to live at home.

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このようにキッチン内の動線をシンプルにしたことにより、体の向きを変えることなく横と上下の動線だけで調理を行うことが出来るようになりました。 As I just described, making the movements more simple and clear within the kitchen allowed her to prepare the meals without a lot of turns. It now requires just simple movements. また、家族に対して認知症の基礎的情報を説明し、本人の状況や活かせる能力も伝えました。 At the same time, we provided her family with the basic knowledge of dementia and clarified her conditions and retained abilities. 結果、本人がスムーズに調理できるようになり、家族も安心して夕食の準備を任せられるようになり、在宅生活が継続できています。 Eventually, our interventions have restored her ability to cook without difficulty. In addition, the family feels safe for her to prepare the meals. She currently still continues to live at home.


【Issues of IPIST】

It is important to get all stakeholdersinvolved in dementia care

Current situation >3500 new IPIST nationwide

Issues Quality

Solution Quality improvement

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今後、認知症初期集中支援チームは全国に設置数が増えていく予定であり、より多くの認知症の人およびその顔族への支援ができます。 With success of local trials, Dementia Initial Phase Intensive Support Teams have been rolled out nationwide. This makes their support available to greater numbers of people with dementia and their families. しかし、その一方でチームが急速に増えていくため、それぞれのチームの成熟が求められます。 In order to allow the program's rapid expansion, we, as qualified professionals, need to grow as an individual as well as a team. 単に支援プランを立てるだけではなく、先ほどの事例のようになぜ生活障害が生じているのか、どうしたら本人の能力を活かせる支援が行えるかということを考えることが期待されます。 We are not merely required to draw up support plans. We are expected, as illustrated in the case study, to consider why ADL dysfunctions develop and what support can be provided to make the most of the person's retained abilities. つまり、認知症支援に関わる全ての人の意識改革が必要です。 This means that all people involved in supporting people with dementia need to raise their awareness to new heights.

2017Adi kumiko murashima

Healthcare

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