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A behavioural approach to the maintenance and rehabilitation of independent functioning with the institutionalized… Campbell, John Alexander 1978

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A BEHAVIOURAL APPROACH TO THE MAINTENANCE AND REHABILITATION OF INDEPENDENT FUNCTIONING WITH THE INSTITUTIONALIZED ELDERLY by JOHN ALEXANDER CAMPBELL B.A., York University, 1972 M.A., University of Guelph, 1974 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY i n THE FACULTY OF GRADUATE STUDIES (Department of Psychology) We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September, 1978 (c)John Alexander Campbell, 1978 In presenting th i s thes i s in pa r t i a l fu l f i lment of the requiremen an advanced degree at the Un ivers i ty of B r i t i s h Columbia, I agree the L ibrary sha l l make it f ree ly ava i lab le for reference and stud-I fur ther agree that permission for extensive copying of th i s the for scho lar ly purposes may be granted by the Head of my Departmen by his representat ives. It is understood that copying or pub l ica of th is thes is fo r f inanc ia l gain sha l l not be allowed without my writ ten permission. Department of The Univers i ty of B r i t i s h Columbia 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 i i ABSTRACT R e h a b i l i t a t i o n programs f o r the i n s t i t u t i o n a l i z e d e l d e r l y have o f t e n proved un s u c c e s s f u l . Recent behavioural research provides some t e n t a t i v e answers concerning the components needed f o r a s u c c e s s f u l program. A b a s i c problem, however, i s the g e n e r a l i z a t i o n of these b e h a v i o u r a l l y based programs to the n a t u r a l environment. This study focused on the development and e v a l u a t i o n of a program (CARE) which encouraged the maintenance and r e h a b i l i -t a t i o n of va r i o u s a c t i v i t i e s of d a i l y l i v i n g (ADL) w h i l e becoming a r e g u l a r and permanent p a r t of the i n s t i t u t i o n a l l i f e of the p a t i e n t . Two f a c i l i t i e s served as the s e t t i n g s f o r the study. These f a c i l i t i e s were a r c h i t e c t u r a l l y i d e n t i c a l as were the s t a f f i n g patterns and p a t i e n t c h a r a c t e r i s t i c s . F a c i l i t y A was randomly chosen as the experimental f a c i l i t y and contained 127 r e s i d e n t s 60 years of age and o l d e r (39 male, 88 female) w i t h a mean age of 82 years. F a c i l i t y B, the c o n t r o l f a c i l i t y , housed 130 re s i d e n t s 60 years of age and ol d e r (47 male, 83 female) w i t h a mean age of 79 years. No s i g n i f i c a n t d i f f e r e n c e s were found between the two f a c i l i t i e s on sex, primary d i a g n o s i s , length of stay or degree of confusion. However, F a c i l i t y A subjects were s i g n i f i c a n t l y o l d e r (p< .01) and more ambulatory (p_<.03) than those subjects i n F a c i l i t y B. A l l s u bjects were assessed on four measures e v a l u a t i n g various a c t i v i t i e s of d a i l y l i v i n g ( d r e s s i n g , grooming, e a t i n g and ambulation/transfer s k i l l s ) as w e l l as a: g l o b a l measure of these a c t i v i t i e s ( g l o b a l ADL). Assessments were conducted a t p a r a l l e l p o i n t s i n time, j u s t p r i o r to the beginning of treatment i n F a c i l i t y A and a f t e r 3 and 6 months. F a c i l i t y B re c e i v e d no i i i s p e c i a l treatment. F a c i l i t y A received a treatment program which consisted of: 1) s t a f f t r a i n i n g i n basic r e h a b i l i t a t i o n and behaviour change techniques; 2) a treatment manual o u t l i n i n g s p e c i f i c steps i n r e h a b i l i t a t i o n and behaviour change with various a c t i v i t i e s of d a i l y l i v i n g ; and 3) a v i s u a l chart used to communicate data as w e l l as treatment goals. ..Inter-rater r e l i a b i l i t y measures were obtained and were above .89 on a l l dependent measures over the three assessment periods. During the course of the study 15 subjects were l o s t from F a c i l i t y A and 22 subjects from F a c i l i t y B due to death or transfer to more intensive care. These subjects were not included i n the data analyses. No s i g n i f i c a n t pre-treatment d i f -ferences were found on any of the dependent measures other than ambulation/ transfer s k i l l s . Two subgroups were formed and analyzed separately for t h i s measure - ambulatory subjects ( F a c i l i t y A, n=100; F a c i l i t y B, n=78) and wheelchair subjects ( F a c i l i t y A, n=12; F a c i l i t y B, n=30). Repeated measures analyses of variance y i e l d e d s i g n i f i c a n t ' f a c i l i t y ' e f f e c t s f o r global ADL, dressing and grooming s k i l l s ( a l l p_<.04), as well as s i g n i f i c a n t ' f a c i l i t y by time' i n t e r a c t i o n e f f e c t s f o r global ADL, dressing and grooming s k i l l s (p<.001) and ambulation/transfer s k i l l s f o r wheelchair subjects Cp_<.04) . Tukey tests indicated that, although there were no s i g n i f i c a n t differences within e i t h e r f a c i l i t y over time, there were s i g n i f i c a n t differences i n favour of F a c i l i t y A f or global ADL. ,,and grooming s k i l l s at the 3 month assessment and i n global ADL, grooming and dressing s k i l l s at the 6:.month assessment ( a l l p<.05). The r e s u l t s demonstrated that t h i s program i s a f e a s i b l e and p o t e n t i a l l y e f f e c t i v e treatment approach and methodology. Increased maintenance and r e -h a b i l i t a t i o n was achieved under circumstances that l i m i t e d the p o t e n t i a l impact of the program. These r e s u l t s are discussed i n terms of the l i m i t a t i o n s of the study and future d i r e c t i o n s f or research. i v TABLE OF CONTENTS Page ABSTRACT .... i i TABLE OF CONTENTS .' iv LIST OF TABLES .... v i LIST OF FIGURES .... v i i ACKNOWLEDGEMENT .... v i i i CHAPTER 1 - Problems of the E l d e r l y in a Modern Society .... 1 - The I n s t i t u t i o n a l Solution .... 5 CHAPTER 2 - The Psychosocial Environment of G e r i a t r i c Care F a c i l i t i e s .... 13 CHAPTER 3 - Behavioural Approaches to Problems of the I n s t i t u t i o n a l i z e d E l d e r l y .... 20 CHAPTER 4 - Guidelines for Rehabilitation and Maintenance Programs i n G e r i a t r i c F a c i l i t i e s .... 34 CHAPTER 5 - CARE - A Program of Care and Rehabilitation for the E l d e r l y .... 44 Components of the Program .... 45 Assessment ..I. 45 Communication .... 48 Isolating target behaviours •••• 50 The r e h a b i l i t a t i o n program .... 52 Maintenance of change .... 53 Generalization of change .... 55 Training program .... 56 Organizational behaviour modification... 6 0 CHAPTER 6 - Procedure .... 62 Setting and Subjects .... 62 Confusion ..... 63 Dependent Measures .... ; 68 General Procedures . . . . . 69 V Table of Contents (con't) Page CHAPTER 7 - Results .... 7 4 R e l i a b i l i t y of ADL S k i l l Scores .... 74 Sample A t t r i t i o n . . .. 76 Generation and Standardization of Raw scores 7 6 Comparison of Pre-Treatment A s s e s s m e n t s * ^ Treatment E f f e c t s .... 77 Reduction and improvement i n Independent Functioning • * • « 86 CHAPTER 8 - Discussion • • • * 88 BIBLIOGRAPHY • • • • 1 03 APPENDIX A ADL v i s u a l explanation • « • • 113 APPENDIX B ADL treatment manual « • • * 119 APPENDIX C Floorplan for F a c i l i t y A and B • • • • 179 APPENDIX D Logbook • • « • 181 APPENDIX E Government long term care c r i t e r i a • » • • 184 APPENDIX F Primary diagnosis categories « • • « 189 APPENDIX G ADL assessment c r i t e r i a • * • • 1 92 APPENDIX H Raw data scores - F a c i l i t y A « * • * 1 95 APPENDIX I Raw data scores - F a c i l i t y B * • • * 200 APPENDIX J Demographic information - F a c i l i t y A • • • • -206 APPENDIX K Demographic information - F a c i l i t y B * * • « 209 APPENDIX L R e l i a b i l i t y data for confusion measure - F a c i l i t y A • • • * 21 2 APPENDIX M R e l i a b i l i t y data for confusion measure - F a c i l i t y B • « * • 214 APPENDIX N R e l i a b i l i t y data for ADL Assessments F a c i l i t y A » • • • 216 APPENDIX 0 Correlation data for mean rater score and v i s u a l chart assessments • * « • 222 APPENDIX P R e l i a b i l i t y Data for ADL Assessments F a c i l i t y B • • « • 228 v i LIST OF TABLES Page TABLE 1 Selected a c t i v i t i e s of d a i l y l i v i n g (ADL) used i n CARE program .... 46 TABLE 2 Demographic information .... 64 TABLE 3 Assessment of confusion .... 66 TABLE 4 Di s t r i b u t i o n of confusion scores .... 67 TABLE 5 Inter-rater r e l i a b i l i t y of ADL assessments... 75 TABLE 6 Comparisons of pre-treatment assessments (t-tests) .... 78 TABLE 7 Comparisons of ambulatory and wheelchair subjects (t-tests) on pre-treatment ambulation/transfer s k i l l scores .... 7 8 TABLE 8 Summary of mean scores for F a c i l i t y A and B.. 79 TABLE 9 Repeated measures analyses of variance comparing ADL s k i l l scores over three assessment periods i n F a c i l i t y A and B .... 80 TABLE 10 Number of subjects i n F a c i l i t y A and B showing improvement, maintenance and increased dependence i n global ADL over six month period .... 87 y i i LIST OF FIGURES FIGURE 1 Visual wall chart FIGURE 2 Group means (z-scores) for ratings on global ADL over the three time periods FIGURE 3 Group means (z-scores) for ratings on dressing s k i l l s over the three time periods FIGURE 4 Group means (z-scores) for ratings on grooming s k i l l s over the three time periods FIGURE 5 Group mean raw scores for ratings on eating s k i l l s FIGURE 6 Group mean raw scores for ambulatory . subjects on ambulation/transfer s k i l l s over the three time periods FIGURE 7 Group mean raw scores for wheelchair subjects on ambulation/transfer s k i l l s over the three time periods • • « « Page 49 83 83 84 84 85 85 v i i i ACKNOWLEDGEMENTS I wish to express my gratitude and appreciation to the many people who ass i s t e d me i n so many ways with t h i s project. To Dr. Jerry W i l l i s , my thesis supervisor, I wish to express sincere appreciation f o r his encouragement, guidance, patience and c r i t i c i s m throughout the duration of t h i s project. I want to thank Dr. G l o r i a Gutman, not only for her guidance and support, but for her:.responsibility i n .drawing my attention..to the problems faced by the e l d e r l y and thereby, i n s t i l l i n g i n me a deep concern for t h i s group of people. For t h i s I am deeply g r a t e f u l . My thanks go to Drs. Park Davidson and David Lawson for t h e i r assistance and advice i n the completion of t h i s project. I am also g r a t e f u l to ., Mr. R. Wand arid,the s t a f f of Dogwood Lodges for t h e i r co-operation throughout the project. Special thanks are due to Ms. Hazel Broadley for p a r t i c i p a t i n g i n the project and providing valuable suggestions and h e l p f u l advice i n implementing the program. I am also g r a t e f u l to Mr. Gordon Worsley who provided the i n i t i a l a r t i s t s designs used i n the project. To my wife, Annette, I want to express my gratitude and appreciation for her encouragement and help throughout the l a s t year. The t r i a l s of student l i f e were made much easier with her at my side. To my friends who provided support and understanding, I o f f e r my sincere appreciation. F i n a l l y , but most important, I wish to thank the residents of Dogwood Lodge for teaching me so much about so many things. Page 1 CHAPTER 1 PROBLEMS OF THE ELDERLY IN A MODERN SOCIETY Aging i s perhaps the most universal of a l l b i o l o g i c a l phenomena. Through time, the aging process leads to a gradual decline i n performance; i t a f f e c t s most of our organs, and i t leaves us vulnerable to a variety of physical and psychological d i s a b i l i t i e s . S u s c e p t i b i l i t y to disease, e s p e c i a l l y chronic disease, increases dramatically i n the l a t e r years of l i f e . A r t h r i t i s and rheumatism, heart conditions and high blood pressure are the most prevalent chronic diseases a f f e c t i n g the e l d e r l y (Kimmel, 1974). Levels of motor performance involving a g i l i t y and co-ordination decrease with old age, as do many of the sensory processes such as v i s i o n , reaction time and hearing (Birren, 1964). With increased age, there i s a reduction i n the amount of environmental information received. Each sensory element by i t s e l f appears to show an age related decrement: v i s u a l acuity, dark adaptation, auditory threshold and o l f a c t o r y s e n s i t i v i t y . Similar changes occur at higher l e v e l s of perceptual functioning such as f l i c k e r fusion threshold and perception of v e r t i c a l i t y (Lawton and Nehmahow, 1974). Environmental information i s processed at a slower rate as age progresses, although evidence now seems to indicate that, given time, the healthy older subject's performance qu a l i t y may be equal to the younger Page 2 p e r s o n ' s i n many t a s k s ( E i s d o r f e r , 1 9 6 9 ) . The e l d e r l y o f t e n e x p e r i e n c e m u l t i p l e d i s e a s e s w h i c h a r e b o t h b r o u g h t on and c o m p l i c a t e d b y t h e d e g e n e r a t i v e c h a n g e s t h e y e x p e r i e n c e . I n t h e 65 and o v e r segment o f t h e p o p u l a t i o n 8 3 p e r c e n t h a v e one o r more c h r o n i c d i s a b i l i t i e s . The e l d e r l y a r e a l s o more p r o n e t o t e m p o r a r y d i s a b i l i t i e s w h i c h accompany common i l l n e s s e s s u c h a s c o l d s a n d i n f l u e n z a ( B u s s e a n d P f e i f f e r , 1 9 6 9 ) . I n t h e e v e r y d a y l i v e s o f t h e e l d e r l y , d e c l i n i n g p h y s i c a l a b i l i t i e s make i t d i f f i c u l t t o c o p e w i t h a n d a d j u s t t o t h e demands o f d a i l y , r o u t i n e a c t i v i t i e s . C h o r e s t h a t t h e e l d e r l y p e r s o n o n c e p e r f o r m e d a s a m a t t e r o f c o u r s e o f t e n become d i f f i c u l t o r i m p o s s i b l e . I n a b i l i t y t o p e r f o r m t h e a c t i v i t i e s o f d a i l y l i v i n g o f t e n f o r c e s t h e e l d e r l y t o r e l u c t a n t l y r e l i n q u i s h an i n d e p e n d e n t l i f e s t y l e a n d t o a c c e p t a n i n s t i t u t i o n a l l i v i n g e n v i r o n m e n t w h e r e t h e i r i n a b i l i t y t o c a r e f o r t h e m s e l v e s i s a n t i c i p a t e d a n d e x p e c t e d . P h y s i c a l d e c l i n e , w h i l e more p r e v a l e n t and p e r v a s i v e i n t h e e l d e r l y i s n o t , h o w e v e r , t h e o n l y f a c t o r w h i c h makes f u n c t i o n i n g i n m odern s o c i e t y d i f f i c u l t . R e g a r d l e s s o f t h e p h y s i c a l h e a l t h o f an i n d i v i d u a l who h a s r e a c h e d 6 5 , he o r she m u s t d e a l w i t h l o n g s t a n d i n g c u l t u r a l s t e r e o t y p e s , a t t i t u d e s , s t i g m a a n d s o c i e t a l e x p e c t a n c i e s . T h e s e f a c t o r s t h e m s e l v e s h a v e a t r e m e n d o u s e f f e c t on t h e e l d e r l y and v e r y o f t e n p r o d u c e , r a t h e r t h a n f o l l o w p h y s i c a l d e c l i n e ( B i r r e n , 1 9 6 4 ) . I n o u r s o c i e t y , a g i n g i s Page 3 popularly viewed as a series of rather abrupt t r a n s i t i o n s between stages. E x i t from one stage and entry into the next i s generally a chronological pattern i n the minds of most. The l a t e r stages are defined i n terms of a progressive loss of roles and status, decreased physical and mental a b i l i t y and eventual termination of l i f e (Bruhn, 1971). That i s the popular view. The s i x t y - f i f t h year of l i f e has often been designated as the threshold of retirement and the beginning of "old age". Like other age based stages (e.g. adolesence at 13 and adulthood at 21), s i x t y - f i v e i s a c t u a l l y quite a r b i t r a r y . Some people are 'old' at age 55 while others are active and independent at age 80. While there i s no magic number that marks entry into "old age", the e l d e r l y as a group do frequently experience similar s o c i o c u l t u r a l problems, increasing l e v e l s of physical decline and are a l l subject to strong and widely held prejudices. Because of these factors, i t i s both convenient and reasonable to speak of the "problems of the e l d e r l y " . In recent years these problems have received increasing attention from researchers, a l l lev e l s of government and the general public. Part of the increase i n inte r e s t i s due to the fact that the e l d e r l y are a large and growing segment of our population. In 1971, for the f i r s t time, the number of people reaching the age of 65 in the United States was equal to the number of birt h s (Dancey, 1977). This proportion of the population continues to grow at a rate faster than that of any other segment of the population (Schreiber, 1972). In Canada Page 4 there were 1.7 m i l l i o n c i t i z e n s over the age of 65 i n 1971. This figure w i l l r i s e to 3.3 m i l l i o n by the year 2000 ( S t a t i s t i c s Canada, 19741. The changes i n population pattern noted above w i l l have a dramatic impact on North American society. Whereas the present l e v e l of population growth i s accounted for by the improvement in health measures a f f e c t i n g infancy and childhood, future growth may be accounted f o r , i n large part, by trends toward increased l i f e expectancy in older i n d i v i d u a l s . With major advances i n the treatment of cancer and cardiovascular disease, i t may be anticipated that the next set of medical advances w i l l influence the extension of l i f e of the older, rather than younger populations (Eisdorfer, 1973). Already, with current l e v e l s of medical technology and services, the average number of years of retirement of a person reaching 60 i n 1975 i s three times that of his or her counterpart i n 1900 (White House Conference on Aging, 1961). The changing proportions i n the population which favour the eld e r l y , instead of the young, have already begun to influence the supply and demand balance i n s o c i a l services for these groups. Many c i t i e s , for example, have empty elementary school classrooms and crowded, inadequately staffed hospitals and nursing home f a c i l i t i e s . In the United States, the 10 percent of the population that i s over the age of 6 5 require 2 0 percent of the acute hospital care provided and consume an even greater proportion of physicians' o f f i c e practice and outpatient care. In Page 5 addition, an estimated 5 percent of those over age 65 are so p h y s i c a l l y or psychologically disabled that they require long term care i n i n s t i t u t i o n s . A similar pattern i s evident in Canada with those over age 65 i n 1970 u t i l i z i n g over 33 percent of a l l government supported hospital beds (Weaver, McPhee and Lambert, 1 975).. While the e l d e r l y already consume a s i g n i f i c a n t proportion of the medical, psychological and s o c i a l services i n our society, the demand i s l i k e l y to grow dramatically. In the next 25 years the 55-64 age group w i l l increase by 10 percent, the 65-74 group by 23 percent, and the most vulnerable, the 7 5+ age group by 6 0 percent (-Brotman' 1 977) . A further complication to t h i s already complex picture i s the f a c t that, while the e l d e r l y tend to need more services, a substantial proportion are poor and have barely enough income to subsist (MacBonald , 1 973) . The I n s t i t u t i o n a l Solution Almost 100 years ago, Charcot (cited i n H a l l , 1975) outlined the need for a special study of the diseases of old age and claimed that "senile pathology too has i t s d i f f i c u l t i e s , which can only be surmounted by long experience and a profound knowledge of i t s peculiar characters". Progress has, unfortunately, not been rapid since Charcot c a l l e d f o r a greater understanding of the problems of the e l d e r l y . As Loether C1967) has noted, age i s a complicated concept with b i o l o g i c a l , Page 6 psychological and s o c i o l o g i c a l connotations. While Bromley (1972) and Lidz- (1968) both compare the adjustments an aged person must make to some of the c r i t i c a l developmental tasks experienced during adolescence, e f f o r t s to develop a t r u l y comprehensive model of the aging process have not been successful (Botwinick, 1 973). Much of the research on aging remains only d e s c r i p t i v e . In Canada, the si t u a t i o n was considered alarming by the Canada Council, a major funding agency for s o c i a l science research. In a review of support for research since the 1960's, i t concluded that there was an almost complete exclusion of any research related to aging (Report on Research i n Gerontology, 1976). I t was also noted that t h i s s i t u a t i o n has shown no sign of changing despite the fact that "Canada i s entering a stage where a considerable percentage of i t s population w i l l be aged". While we have no substantiated t h e o r e t i c a l base for looking at the o v e r a l l process of aging, we do have a considerable amount of s o c i o l o g i c a l and epidemiological data on the re s u l t s of aging and the ef f e c t s of current e f f o r t s to deal with the problems of the aged. When the d i s a b i l i t i e s of an el d e r l y person i n t e r f e r e with his or her competence i n the basic a c t i v i t i e s required for independent existence, the person's family are often confronted with a d i f f i c u l t decision. With the breakdown of t r a d i t i o n a l family patterns, the c e n t r a l i z a t i o n of people i n towns and c i t i e s , early retirement, and the movement of women into the job market, families are no longer i n a position to provide for th e i r Page 7 aging r e l a t i v e s i n the home. A common solution i s admission of the e l d e r l y disabled to a nursing home, chronic h o s p i t a l , or other long stay f a c i l i t y where patients are passive r e c i p i e n t s of 24 hour care. Society has, thus, taken over the r e s p o n s i b i l i t y to provide for many aged by establishing i n s t i t u t i o n s throughout the country to accomodate varying l e v e l s of aged patients with t h e i r problems of finances, health and reduced leve l s of a c t i v i t y . And, as pointed out by Burnside (1976), with the increase i n the proportion of the very old, the problem of i n s t i t u t i o n a l care and i t s f i n a n c i a l and s o c i a l costs may assume even greater importance. The e f f o r t to solve a growing s o c i a l problem with i n s t i t u t i o n s i s a f a m i l i a r pattern with f a m i l i a r r e s u l t s . The devastating and long term ef f e c t s of poor i n s t i t u t i o n a l care for children were documented years ago (Skeels and Dye, 1939). In that case the problem was one of understimulation and neglect. The less the children were talked to, played with and cuddled, the more detrimental was the i n s t i t u t i o n a l environment (Mussen, Conger and Kagen, 1963). I n s t i t u t i o n s for the el d e r l y are also frequent contributors to decline i n the el d e r l y who l i v e there, and for some of the same reasons. There i s an extremely low l e v e l of p a t i e n t - s t a f f in t e r a c t i o n i n many f a c i l i t i e s (MacDonald, 1973). I n s t i t u t i o n s for the el d e r l y also work against the health of t h e i r residents i n another way - a tendency to define the el d e r l y person as a service consumer and to provide an excessively high l e v e l of services to many e l d e r l y patients. Doing everything for the e l d e r l y patient r a p i d l y impairs the Page 8 individual's capacity for independent decision making, a s i g n i f i c a n t step towards becoming " i n s t i t u t i o n a l i z e d " (Bayne, 1971 ) . The i n s t i t u t i o n a l i z e d e l d e r l y are described as apathetic, withdrawn, unresponsive and uninterested i n a c t i v i t i e s (Charles, 1961; Lieberman, 1969). In many cases the i n s t i t u t i o n a l i z e d person, regardless of physical condition functions at a much lower l e v e l a f t e r entering an i n s t i t u t i o n than before. A number of researchers have, thus, become increasingly concerned about the damaging e f f e c t s of prolonged i n s t i t u t i o n a l i z a t i o n (MacDonald and Butler, 1974). Apathy, lack of motivation, p a s s i v i t y , dependent behaviour, hastened deterioration and induced s e n i l i t y are a l l byproducts of the " i n s t i t u t i o n a l i z e d " patient (Lowenthal and Z i l l i , 1969; Euster, 1971). As noted before, the qu a l i t y of l i f e i n many i n s t i t u t i o n s leaves much to be desired when compared to the q u a l i t y of l i f e available to non-in s t i t u t i o n a l i z e d people. Townsend (1971), a member of Ralph Nader's study group on nursing homes, suggested that i n s t i t u t i o n a l environments for the e l d e r l y are often d e f i c i e n t in meeting the human needs of the residents. Many behaviours thought to characterize the e l d e r l y , such as seclusiveness, dependence in self-care, incontinence, lack of personal communication, are very often environmentally determined (Labouvie-Vief, Hoyer, Baltes and Baltes, 1974; Lawton and Nahemow, 1973); they are learned behaviours and consequences of environmental deprivation including i n t e l l e c t u a l , s o c i a l and Page 9 emotional u n d e r s t i m u l a t i o n . I n s t i t u t i o n s , i n c l u d i n g nursing homes, o f t e n c o n t r i b u t e to the d e p r i v a t i o n status of the e l d e r l y (Euster, 1 9 7 1 ) . Why should expensive s o c i a l s e r v i c e s such as nursing homes produce such d e t r i m e n t a l e f f e c t s on t h e i r c l i e n t s ? One answer l i e s i n the model used i n o r g a n i z i n g and p r o v i d i n g s e r v i c e s . E f f o r t s to provide human s e r v i c e s to the e l d e r l y l i v i n g i n nursing homes have t r a d i t i o n a l l y used a medical or i l l n e s s model and have focused p r i m a r i l y on b i o l o g i c a l and medical treatment modes. Old age was, and s t i l l i s , perceived as a ' s i c k ' or 'abnormal' s t a t e i n l i f e which was l a r g e l y due to b i o l o g i c a l d e t e r i o r a t i o n ( E i s d o r f e r and Lawton 1 9 7 3 ; MacDonald and Butter;* .1 9 7 4 ) and (thus t r e a t e d a c c o r d i n g l y w i t h .chemical, and: " p h y s i c a l techniques. A person was, and i s perceived as 'o l d ' when he or she e x h i b i t s s i c k behaviour assumed to r e f l e c t aspects of b i o l o g i c a l d e t e r i o r a t i o n . In our s o c i e t y , o l d people are a c t u a l l y encouraged to f u l f i l l the ' s i c k ' r o l e as t h e i r l e g i t i m a t e s o c i a l r o l e (MacDonald and B u t l e r , 1 9 7 4 ) . This i s what we expect of them. E i s d o r f e r (1 969) . i s one researcher who has cogently made the poi n t t h a t , i n our s o c i e t y , the 'aged' stereotype i s synonymous wit h being s i c k . The contention t h a t i l l n e s s w i l l accompany and i n d i c a t e the onset of o l d age i s a powerful s e l f - f u l f i l l i n g prophesy (MacDonald, 1 9 7 3 ) . The person over 6 5 o f t e n expects sickness and p h y s i c a l discomfort to accompany aging n a t u r a l l y (Kastenbaum, 1 9 6 4 ) and, because i t i s s o c i a l l y appropriate and Page 10 consequently accepted by society, the older person i s l i k e l y to take on t h i s 'aged-sick' r o l e with l i t t l e resistance. C u l t u r a l l y , the 'sick' r o l e functions to protect and benefit persons in temporary states of decreased c a p a b i l i t y . Parsons (.cited i n Ullman and Krasner, 1 969) i d e n t i f i e d four c h a r a c t e r i s t i c s of the sick r o l e i n our society: 1. The person i s exempted from the performance of c e r t a i n of his or her normal s o c i a l functions. 2. The person i s not held responsible for his or her condition. 3. There i s a s o c i e t a l expectation for the person to return to a state of health as quickly as possible. 4. The person i s obligated to cooperate with persons who are s o c i a l l y sanctioned to 'help' the sick person. The c h a r a c t e r i s t i c s of t h i s r o l e provide reasonable benefits for persons i n a temporary state of decreased c a p a b i l i t y . However, prolonged f u l f i l l m e n t of t h i s r o l e r e s u l t s i n s o c i e t a l devaluation and r e j e c t i o n of the i n d i v i d u a l as a person who cannot overcome his or her d i s a b i l i t y , and Who, therefore, cannot a c t i v e l y p a r t i c i p a t e i n society. Once t h i s assumption has been made, e f f o r t s to improve the person's l e v e l of performance are defined not only as hopeless, but also as inappropriate. Research, t r a i n i n g and delivery i n health care intervention have been dominated u n t i l recently by conceptualizations derived from t r a d i t i o n a l medicine and from knowledge bases derived from the physical and b i o l o g i c a l sciences. Considering health Page 11 intervention for the e l d e r l y as primarily a medical process creates an orientation towards service that i s characterized by a focus on intervention to correct already e x i s t i n g problems rather than attempts to prevent deterioration i n the f i r s t place. I t also means that health care delivery personnel are trained i n the b i o l o g i c a l and physical services rather than the behavioural and s o c i a l sciences (Baltes, 1 976).. Recently, however, the concept of 'health' has evolved from a la r g e l y unidimensional b i o l o g i c a l concept into a multidimensional, m u l t i d i s c i p l i n a r y one. Terms l i k e environmental health, mental health, school health and community health are a l l examples of the expansion of the health concept into a multiprofessional construct. Medical health a c t i v i t i e s are being attacked because of t h e i r primary emphasis on remediation, correction and cure, rather than prevention and optimization. In f a c t , "the predominant focus of the medical profession on cure rather than optimization of health has often been seen as the key a t t r i b u t e of what has been c a l l e d the medical model" (Baltes, 1 974) . The medical model, as applied to the aged, i s p a r t i c u l a r l y detrimental since there i s a general tendency to expect the e l d e r l y to take the sick r o l e permanently. The r e s u l t i s often a program of services that minister to the health problems of the e l d e r l y with l i t t l e expectation or e f f o r t to help the e l d e r l y person improve or maintain t h e i r l e v e l s of functioning. While several studies have shown that the e l d e r l y can make major gains Page 12 in r e h a b i l i t a t i o n programs, in the t y p i c a l i n s t i t u t i o n "services are inadequate, are not reaching the appropriate people and are not making f u l l use of the available r e h a b i l i t a t i o n techniques. The need today i s for more research directed not only at programs and services but also toward the i d e n t i f i c a t i o n of factors which influence the existence of services and changes that occur i n them" (Gottesman, 1970). Page 13 CHAPTER 2 THE PSYCHOSOCIAL ENVIRONMENT OF GERIATRIC CARE FACILITIES In a comprehensive survey of nursing home residents, Kosberg and Gorman (.1 975) found that the residents had negative attitudes towards themselves as well as age peers. This tendency toward a low s e l f and peer esteem may be the r e s u l t of the constant reminder of i l l n e s s , d i s a b i l i t y , s e n i l i t y and death. A l t e r n a t i v e l y , these negative attitudes may be r e f l e c t i o n s of the attitudes of others such as s t a f f and r e l a t i v e s . Kahana and Coe (1969) concluded t h e i r study of s t a f f and resident attitudes by commenting that " s t a f f expectations and attitudes may contribute to the depersonalizing process of i n s t i t u t i o n a l i z a t i o n " . Factors that contribute to the low self-esteem of the el d e r l y are not found solely, however, i n the i n s t i t u t i o n a l environment. 'Old age' i s perceived as beginning at age 65 and i s accompanied by rules such as mandatory retirement and c u l t u r a l expectations and models that e x p l i c i t l y define the e l d e r l y as d e b i l i t a t e d and in e f f e c t u a l . The entire culture sets the stage for d i f f i c u l t adjustment i n the l a t e r years of l i f e . The el d e r l y are often f o r c i b l y removed from a functional and independent role i n th e i r own l i f e and that of th e i r society without providing a s o c i a l l y valued a l t e r n a t i v e . The r e s u l t can be a negative self-image and s e l f - l a b e l (Kastenbaum, 1964). The older person i s required to stop working, because of a r b i t r a r y regulations and/or declining Rage 1.4 h e a l t h , i n a s o c i e t y whose v a l u e system degrades the non-worker. At the same time, f a c t o r s such as h e a l t h , the death of f r i e n d s and the i n c r e a s i n g geographic d i s p e r s a l of c h i l d r e n c o n t r i b u t e to a s o c i a l i s o l a t i o n of the e l d e r l y . Many r e s e a r c h e r s , such as Giordano and Giordano ( 1 9 6 9 ) b e l i e v e t h a t the withdrawal from work and s o c i a l c o n t a c t d i r e c t l y c o n t r i b u t e s to p s y c h o l o g i c a l d e t e r i o r a t i o n . Thus, when the e l d e r l y person reaches the n u r s i n g home or care f a c i l i t y he or she has a l r e a d y been prepared p s y c h o l o g i c a l l y to r e a c t n e g a t i v e l y to what f o l l o w s . Upon i n s t i t u t i o n a l i z a t i o n , there i s a morbid sense t h a t the r e s i d e n t i s ' c l o s e to the end'. Residents are v e r y o f t e n s o c i a l l y i s o l a t e d without o p p o r t u n i t i e s f o r community i n t e r a c t i o n s , c o n t a c t w i t h f a m i l y or younger persons and exposure to s t i m u l a t i n g a c t i v i t i e s (Turner, 1 9 6 7 ) . B e h a v i o u r a l a l t e r n a t i v e s to the aged and s i c k r o l e behaviours expected of the e l d e r l y are minimal (MacDonald, 1 9 7 3 ) . Emphasis i n i n s t i t u t i o n s f o r the e l d e r l y has t r a d i t i o n a l l y been p l a c e d on good m e d i c a l care w i t h l i t t l e o p p o r t u n i t y f o r engagement i n meaningful a c t i v i t i e s (Hoppa and Roberts, 1 9 7 4 ) . Many f a c i l i t i e s operate on an i m p l i c i t p h i l o s o p h y t h a t the e l d e r l y are 'too f a r gone' and s e n i l e to respond to any r e s t o r a t i v e a c t i v i t i e s , whether m e d i c a l , p s y c h o l o g i c a l or s o c i a l . Brody, Kleban, Lawton and Silverman ( 1 9 7 1 ) , Kleban and Brody (1 972)„, and Kleban, Brody and Lawton ( 1 9 7 1 ) observed i n t h e i r surveys of g e r i a t r i c c a r e , t h a t f u n c t i o n a l i n c a p a c i t y i s Page 15 frequently greater than that warranted by the actual impairment. Kahn (1965) found t h i s pattern to be widespread among aged persons l i v i n g i n i n s t i t u t i o n s . He used the term "excess d i s a b i l i t y " to i d e n t i f y the phenomenon. Lieberman (.1969) also found that i n s t i t u t i o n a l i z e d older people are less competent than those i n the community while Lieberman, Prock and Tobin (1968) reported that those i n i n s t i t u t i o n s were s i g n i f i c a n t l y poorer i n various cognitive, a f f e c t i v e and s o c i a l functions when compared with community residents of similar demographic and health status. I t would seem that factors other than actual physical d i s a b i l i t y must be considered to account for the low l e v e l of functioning that i s c h a r a c t e r i s t i c of t h i s group. Most r e s i d e n t i a l treatment programs, however, provide few opportunities for a c t i v i t i e s incompatible with s i c k - r o l e behaviours. As noted e a r l i e r , s t a f f members, e s p e c i a l l y nurses and nurses aides, are trained to treat residents as i f they were sick. Even the style and arrangement of the furniture suggests a h o s p i t a l - l i k e atmosphere (Kosberg and Gorman, 1975). Baltes and Lascomb (1 975). and Gottesman (1 973) have demonstrated that the nursing environment can be characterized as a s o c i a l l y and ph y s i c a l l y deprived environment. It has been demonstrated by several investigators (Harel, 1972) that nursing home s t a f f do a c t u a l l y adopt the s o c i e t a l conception of the e l d e r l y as 'sick*. In p a r t i c u l a r , i t appears that the occupational groups who have the highest l e v e l s of personal i n t e r a c t i o n with the i n s t i t u t i o n a l i z e d e l d e r l y have Page J 6 predominantly negative attitudes and expectancies. Handschu (1973) found non-professional s t a f f had the most negative attitudes while Kahana and Coe (1969) reported that the attitudes of the e l d e r l y residents about themselves were, unfortunately, very close to those of the non-professional s t a f f . F i n a l l y , Kosberg and Gorman (1975) found that 86 percent of the non-professional nursing s t a f f i n t h e i r study held negative attitudes toward the aged population's potential for improved functioning, as did 44 percent of the therapists and 100 percent of the housekeeping s t a f f . Perhaps the c o r r e l a t i o n a l studies c i t e d above are merely r e f l e c t i o n s of r e a l i t y . Perhaps the i n s t i t u t i o n a l i z e d e l d e r l y are a selected segment of the general aged population those who are most d e b i l i t a t e d and therefore u n l i k e l y to respond to attempts to provide therapy or r e h a b i l i t a t i o n . If such were the case, then, the negative attitudes of staff and the low self-esteem of residents would be a somewhat accurate r e f l e c t i o n of a bleak r e a l i t y . There are several strands of evidence which would argue against the hypothesis outlined above. Several investigators have concluded that many of the behaviours of the e l d e r l y i n i n s t i t u t i o n s are environmentally determined (Labouvie-Vief, Hoyer, Baltes and Baltes, 1974; Lawton and Nahemow, 1973). In theory, environmental conditions can either aggravate or compensate for aging losses (Chapanis, 1974; McClannahan, 1973). Environments can thus contribute to further deterioration or Page 17 f a c i l i t a t e maintenance of existing s k i l l s and r e h a b i l i t a t i o n of those s k i l l s which have already been l o s t . In actual f a c t , the deprived environmental conditions experienced by the i n s t i t u t i o n a l i z e d e l d e r l y are ra r e l y r e h a b i l i t a t i v e . These environments are the products of several factors including the dominance of the medical model, c u l t u r a l l y sanctioned prejudices on the part of s t a f f and resident a l i k e , and the loss of physical and cognitive a b i l i t i e s . The in d i v i d u a l i n a nursing home i s expected to be sick and to remain so. The care provided i s based on that expectancy and the limited s k i l l s of the el d e r l y resident prevent them from obtaining a normal l e v e l of stimulation through normal channels. Residents often experience a permanent change i n reinforcement patterns upon entrance into a nursing home. Losses to the resident are both extreme and permanent. These losses include the absence of s i g n i f i c a n t others who served as powerful re i n f o r c i n g agents, the loss of valued personal privacy, loss of the a b i l i t y to make decisions for oneself and loss of access to private possessions that are, themselves, strong re i n f o r c e r s . S i g n i f i c a n t others (e.g. s t a f f and family), i n the environment of the el d e r l y gradually withdraw t h e i r attention, support and encouragement. A r e s u l t of t h i s i s the extinction of many adaptive behaviours which were maintained by the rei n f o r c i n g attention and contact with s i g n i f i c a n t others. In addition, a detrimental reinforcement pattern i s a common component of i n s t i t u t i o n a l care. Many nursing homes and g e r i a t r i c care f a c i l i t i e s make attention and sympathy contingent upon 'negative 1 Page 18 behaviours such as discomfort, pain, complaint and increased dependence. In the context of a very low l e v e l of reinforcement, the primary way to obtain valued human attention from s t a f f i s to behave i n a dependent manner. In essence, taking on the "aged-sick" r o l e i s the primary means of obtaining reinforcement in the nursing home. Like the teacher who attends to a temper tantrum and thus, inadvertently rewards i t , the nursing s t a f f of many f a c i l i t i e s may a c t u a l l y " k i l l with kindness" or "help the resident to death". Several studies show that, i n many i n s t i t u t i o n s for the elde r l y , the s t a f f tend to treat the residents as i f they were sick and pay attention to them only i f medical attention i s required (Turner, 1967; MacDonald and Butler, 1973). In many cases, s t a f f a c t u a l l y encourage the resident to unnecessarily adopt the sick role through the pattern of care and reinforcement adopted i n the f a c i l i t y . Encouragement and reinforcement of obedient and thus, dependent behaviours, i s also common because i t allows the i n s t i t u t i o n to run more smoothly. Much of the reinforcement for dependent behaviour may occur without the s t a f f being aware of the e f f e c t since g e r i a t r i c i n s t i t u t i o n a l s t a f f report that dependency i s one of the most d i f f i c u l t management problems (Geiger and Johnson, 1974). The environmental c h a r a c t e r i s t i c s of nursing homes described thus f a r , however, are major factors i n determining the behaviour of the e l d e r l y resident. Their potency i s so strong, i n f a c t , that r e h a b i l i t a t i v e e f f o r t s in these settings have generally been Page 19 unsuccessful (Ochberg, Zarcone and Hamburg, 1972; Penchansky and Tauberhaus, 1965). CHAPTER 3 Page 20 BEHAVIOURAL APPROACHES TO PROBLEMS OF THE INSTITUTIONALIZED ELDERLY Some models of the aging process assume that behavioural d e f i c i t s of the e l d e r l y are the i r r e v e r s i b l e products of inevitable b i o l o g i c a l d eterioration. Prock (1 9 69), however, concluded that "a great deal of r e h a b i l i t a t i o n may be accomplished i f i t i s recognized that many, i f not most, components of the body have the capacity for normal function". X This author b e l i e v e s t h a t many older people are mistreated or inadequately treated because of the professional attitude that l i t t l e can a c t u a l l y be done to improve t h e i r condition. F i l e r and O'Connell (1 964). also remarked that "a greater percentage of aging, disabled, domiciliary residents would a t t a i n and maintain 'desirable' standards of behaviour i f they were subjected to a stimulating, demanding environment with d e f i n i t e expectancies translated into a system of consistent and discriminant rewards and r e s t r i c t i o n s " . A number of the t h e o r e t i c a l positions used as foundations for the development of therapeutic systems make assumptions that focus attention on the changeability rather than the permanency of the e l d e r l y person's d i s a b i l i t i e s . Proponents of the 's o c i a l learning' approach assume that behavioural d e f i c i t s may be Page 21 lessened or overcome through environmental modification (Hoyer, Mishara and Reidel, 1 975). Lindsley (.1 964) was one of the f i r s t to suggest the use of environmental manipulation to overcome behavioural d e f i c i t s among the e l d e r l y . He argued that operant techniques are useful i n determining the extent to which behavioural d e f i c i t s are either b i o l o g i c a l l y based and i r r e v e r s i b l e or environmentally based and due to inadequate reinforcement. An operant i s defined as any behaviour that i s strengthened, maintained or weakened by the events which contingently follow i t . An operant approach i s a set of techniques used to describe and modify behaviour. The management of contingencies i s the basic t o o l . Contingent environmental events are delivered or withheld i n order to strengthen, maintain or weaken behaviour. The use of behavioural technology to change behaviour assumes that the appropriate focus for intervention i s the indi v i d u a l ' s environment. This strategy i s geared towards three main problem areas:.1) the a c q u i s i t i o n of new behaviours; 2) maintenance of already existing behaviours but under new stimulus control; and 3) the extinction or r e s t r i c t i o n of unwanted behaviours. Well known intervention techniques such as token economies and contingency contracting have been successful i n a number of settings including p s y c h i a t r i c wards, classrooms and prisons. Although treatment programs based upon p r i n c i p l e s of Page 22 behaviour have been used by a wide v a r i e t y of c l i e n t populations :(Sherman and. Baer, V'969) \ there have a c t u a l l y been very few reports of th e i r use with e l d e r l y groups. And those that are reported i n the l i t e r a t u r e have dealt almost exclusively with the modification of simple operant behaviours of e l d e r l y c l i e n t s who are c l a s s i f i e d as psychogeriatric or reside i n mental hospitals. The fact that they were e l d e r l y was of l i t t l e importance. Treatment methods and target behaviours were similar to those reported i n the general psychiatric l i t e r a t u r e and i n work with the mentally retarded. Despite t h e i r l i m i t a t i o n s , however, the available studies report encouraging r e s u l t s . Mishara (.1 973) hypothesized that the occurrence of non-adaptive behaviour i n the e l d e r l y (seclusiveness, bizarre or unusual behaviour, dependence in self^-care, incontinence, lack of personal communication, lack of r e s p o n s i b i l i t y , and so on) may be a function of the q u a l i t y of the environment i n which the i n d i v i d u a l resides. Attention from s t a f f may be defined as rewarding and non-adaptive behaviour may bring about that attention. The unwanted behaviour, therefore, may be continually reinforced and thus increase i n frequency. In order to change t h i s pattern, i t would be necessary to be aware of the contingencies that are i n e f f e c t and change these, so that the behaviour i s no longer reinforced. Mishara and Kastenbaum (1 973). documented a case i n which a g e r i a t r i c mental hospital patient refused to wear clothing for Page 23 many years. This behaviour was changed by gradually requiring the patient to wear additional pieces of clothing for longer periods of time each day. The provision of beer contingent upon t h i s increase i n clothes wearing was used as reinforcement. Add i t i o n a l l y , the patient's verbalizations concerning "voices", which had been t e l l i n g him not to wear clothes, were extinguished. These researchers also attempted to apply behaviour modification strategies at a group l e v e l . Eighty subjects were selected from a medical unit i n a mental hospital and randomly assigned to two treatment wards. Each ward consisted of 20 males and 20 females and was environmentally enriched with "more a c t i v i t i e s , cheerier surroundings and opportunities for free choice". One treatment ward- also used a token economy. Tokens were used to reward indiv i d u a l s for engaging i n desirable behaviours. The r e s u l t s demonstrated that both treatment programs were successful i n increasing desirable behaviours when compared to matched subjects on a custodial care ward. There were no major differences between the two treatment wards. Baltes and Lascomb (1975) used an 'ABA' reversal design to demonstrate a change in the chronic 'screaming' behaviour of an 8 0 year old nursing home resident. Two contingencies were employed. Pos i t i v e reinforcement, using both tangible and token re i n f o r c e r s , was made contingent upon the occurrence of any desired 'normal' behaviours which were incompatible with Page 24 screaming. Also, when screaming did occur, the patient was ph y s i c a l l y withdrawn from the s i t u a t i o n so that no reinforcement could be applied to t h i s nonadaptive behaviour. These techniques resulted i n the elimination of screaming behaviour i n the patient. Disturbed s o c i a l i n t e r a c t i o n i s a common phenomenon among residents i n g e r i a t r i c care settings. The residents may be observed s i t t i n g or ly i n g i n bed, apathetic, l e t h a r g i c and withdrawn. Communication between residents i s minimal and very often avoided. Some contact occurs with s t a f f , but t h i s i s frequently i n i t i a t e d by s t a f f . Hoyer, Kafer, Simpson and Hoyer (19741 hypothesized that the absence of verbal communication among e l d e r l y residents represented operant behaviour maintained by existing reinforcement contingencies. Hospital environments do not support verbal communication but, instead, reinforce i t s absence. Hoyer et a l ( 1 9 7 4 1 reported on a study with four e l d e r l y male mental hospital residents drawn from an age integrated ward of a large mental h o s p i t a l . These patients displayed no verbal behaviour with either s t a f f o.r other patients. The subjects met with the experimenter for eleven bi-weekly sessions l a s t i n g from 45 to 55 minutes. The f i r s t f i v e sessions served as.a baseline assessment period. In the next six sessions there were two 10 minute reinforcement i n t e r v a l s alternating with three non-reinforcement or extinction i n t e r v a l s . During the Page 25 reinforcement i n t e r v a l s token reinfo r c e r s (pennies), were made contingent on the number of words emitted by two of the four subjects. These tokens were exchangeable for either candy or cigarettes at the end of the session. The investigators reported that during the reinforcement i n t e r v a l s , tokens were e f f e c t i v e in increasing verbal output. Verbal behaviour decreased during extinction, demonstrating the control of verbal responses by the immediate reinforcement contingencies. A second experiment conducted by Hoyer et a l 0 9.741 used a d i f f e r e n t experimental design. Four chronic schizophrenic patients served as subjects. These subjects, a l l male, met with the experimenter i n bi-weekly sessions l a s t i n g 45 to 55 minutes. The f i r s t f i v e sessions constituted 'baseline' i n which no re i n f o r c e r s were delivered. The next seven sessions were reinforcement sessions, using the same contingencies as i n the f i r s t experiment. Sessions thirteen through seventeen were extinction phases i n which no reinforcement was given. Reinforcment procedures were again implemented during sessions eighteen through twenty-four. Group f a c i l i t a t o r s used TAT cards as stimulus materials and presented the same selection of cards i n a d i f f e r e n t sequence to each of the participants i n each session. Although each subject was questioned i n d i v i d u a l l y , the experiment was conducted in a group session i n order to maximize any modeling e f f e c t s . Each verbal operant i n response to a question was followed d i r e c t l y by a reinforcer (candy or a c i g a r e t t e ) . The reinforcement conditions produced increases i n Page 26 verbal behaviour for a l l subjects while verbal behaviour declined when reinforcement procedures were not i n e f f e c t . Another behavioural approach to modifying s o c i a l behaviour was reported by Linsk, Howe and Pinkston (1975). They attempted to increase appropriate verbalizations by d i r e c t i n g task-related questions to i n d i v i d u a l patients i n a group context. The study was conducted on a ward of a home for the aged and included 31 female residents with a mean age of 85 years. A l l residents were invited to p a r t i c i p a t e in three group a c t i v i t i e s : a residents' meeting, a f o l k - t a l e a c t i v i t y and a newspaper reading a c t i v i t y . During a baseline period, the behaviours of residents i n these groups were c l a s s i f i e d as verbal or nonverbal and appropriate or inappropriate by means of a time sampling procedure. During the treatment phase, frequent questions about the material being discussed were directed to in d i v i d u a l members of the group. A reversal period was then implemented, i n which the number of questions was reduced considerably. After seven sessions the treatment program was begun again. The researchers found that the number of responses by residents doubled under treatment conditions. Other investigators have also reported improvement i n soc i a l behaviours when behavioural methods were used. Mueller and Atlas (1973) used food to reward the s o c i a l i n t e r a c t i o n s of f i v e regressed male subjects while Blackman, Howe and Pinkston (1976) increased resident interaction in small a c t i v i t y areas by Page 27 providing refreshments to those who attended. Attendance a t s o c i a l functions has also been increased by using prompts and cues (e.g. announcements and signs) and by making snacks and prizes contingent upon attendance (McClannahan, 1973). Researchers have, i n recent years, become concerned about the e f f e c t of the design of the l i v i n g environment on a c t i v i t y l e v e l s and p a r t i c i p a t i o n . McClannahan and Risley (1975) demonstrated that engagement with equipment, materials or other persons could be trebled by providing manipulative materials (e.g. games and c r a f t supplies) and prompting residents to use them. Merely making equipment available and waiting for residents to take the i n i t i a t i v e in requesting, selecting and using the materials resulted i n low l e v e l s of p a r t i c i p a t i o n . In a more ambitious project, Gottesman (1973) developed a milieu treatment program implemented i n a state mental hospital housing psychogeriatric patients. The researchers attempted to a l t e r the t o t a l environment i n ways that would change the behaviour of persons who were demonstrating inappropriate s o c i a l behaviour. Emphasis was placed on a c t i v i t y , money management and se l f - c a r e . A sheltered workshop, doing small parts jobs for l o c a l industry, was introduced. The physical environment was changed with the addition of mirrors, pictures, curtains, new furniture and bright colours. The money which patients were paid from the workshop resulted i n the opening of a ward store, a ward bank and shopping t r i p s to the community. While the program did create new Page 28 s o c i a l roles for the patients, observable symptoms did not decrease during the two year experimental period. A similar study was conducted by F i l e r and O'Connell (1964) on the effectiveness of a more stimulating environment. This project, however, combined general environmental changes with an operant behaviour modification program. T h i r t y - s i x male psychogeriatric patients formed Group A and were assigned to a ward which had a "better environment", monetary pay for work, club memberships, increased p r i v i l e g e s and feedback for t h e i r performance, i n the form of report cards. Another group of matched subjects, Group B, were assigned to a similar ward but in addition, received regular reinforcement contingent on t h e i r performance in eight target areas. These areas included: s e l f management of medications, dependability i n keeping appointments, p a r t i c i p a t i o n i n some productive work, housekeeping maintenance of t h e i r own l i v i n g area, personal appearance and hygiene, r e s p o n s i b i l i t y for maintenance of t h e i r clothing, management of personal finances, and not being a d i s c i p l i n a r y problem. At the end of the 16 week experimental period, both groups had improved compared to t h e i r pretreatment l e v e l s . Group B, however, attained s a t i s f a c t o r y l e v e l s of performance more often, more quickly, and maintained them for a longer period of time than Group A. Group B was s i g n i f i c a n t l y better than Group A i n three behaviour categories - constructive work, personal appearance, and dependability i n keeping appointments. Page 29 There have also been several other studies that used operant techniques i n combination with other approaches i n the treatment of the e l d e r l y . Salter and Salter (1975) used a r e a l i t y orientation program pTaulbee and Folsom, 1966) concurrent with structured a c t i v i t i e s , including the a c t i v i t i e s of d a i l y l i v i n g and recreational a c t i v i t i e s , to develop a stimulating environment. They attempted to determine i f t h i s kind of stimulating environment was e f f e c t i v e i n r e h a b i l i t a t i n g a psychogeriatric population. Re a l i t y orientation i s a program which attempts to bring confused patients back to r e a l i t y by reorienting them to basic information on a regular basis. Current and personal information i s presented over and over to the patient, beginning with his/her name, location and date. Each contact wih the patient i s u t i l i z e d to improve awareness of person, time and place. Twenty-one mentally d e f i c i e n t and/or mentally disturbed male patients, with a mean age of 68, served as subjects. Eighteen were disoriented, confused and unable to carry out basic a c t i v i t i e s of d a i l y l i v i n g , such as dressing, grooming, ambulation and eating. A treatment team developed an ind i v i d u a l i z e d a c t i v i t y schedule for each subject based upon an evaluation of his c a p a b i l i t i e s . The behaviour of the subjects had to be gradually shaped through reinforcement techniques. Subjects were given p o s i t i v e reinforcement, i n the form of approval, candy, or cigarettes, for even minimal attempts at p a r t i c i p a t i o n Page 3 0 in the r e a l i t y orientation, a c t i v i t i e s of d a i l y l i v i n g and recreation programs. Beyond that, patients were given large rewards for improved responses and consistently given small rewards for repeated responses at the same l e v e l . At the beginning of the treatment program only four subjects were p a r t i c i p a t i n g i n some of the educational and recreational a c t i v i t i e s a v a i l a b l e . Within four months, t h i s number gradually increased to sixteen. There i s , however, no in d i c a t i o n of the degree of r e h a b i l i t a t i o n or success obtained. Another major problem area for the i n s t i t u t i o n a l i z e d e l d e r l y i s self-maintenance s k i l l s . Operant techniques have also been used to increase behaviours in t h i s category. Libb\and Clements (1969) i n d i v i d u a l l y reinforced four g e r i a t r i c patients on a psy c h i a t r i c ward for exercising on a stationary b i c y c l e . Three subjects increased t h e i r rates of exercising. Geiger and Johnson (1974) used a p o s i t i v e reinforcement procedure with 6 g e r i a t r i c inpatients with very low rates of correct eating. The average number of meals eaten c o r r e c t l y increased from 12 percent to 84 percent over the duration of the study. Baltes and Zerbe (1976) were also concerned with the eating behaviour of 2 e l d e r l y patients. Using shaping, reinforcement and time-out procedures, they helped both patients reacquire and maintain self-feeding behaviours. In a frequently c i t e d study by MacDonald and Butler (1974), the authors used behavioural techniques to increase the walking Page 31 behaviour of nursing home residents. Walking i s an important target behaviour amongst the el d e r l y since at least 2 5 percent of the nursing home residents who can walk need help (Trends i n Long Term Care, 1970) and these persons are very often encouraged, by sta f f interactions, to be wheeled about i n wheelchairs'rather than to walk (Turner, 1967). In the MacDonald and Butler study, two nursing home residents who had been transported by wheelchair for several months, although f u n c t i o n a l l y unimpaired, served as subjects. With the use of praise and prompting to walk, they were e f f e c t i v e l y encouraged to walk. This review demonstrates the r e l a t i v e focus of a behavioural method as applied to health care intervention. Internal i n d i v i d u a l processes are secondary to external, environmental processes i n the attempt to prevent and correct i l l n e s s and enhance health status. This focus emphasizes that a more stable intervention may be found by attempting to modify the physical and s o c i a l environment and the s i g n i f i c a n t others i n that system, in order to achieve behavioural change i n a target person or group. An operant model does seem to be one of the more adequate approaches providing both a research and also an intervention model (Baltes, 1976; Labouvie-Vief, Hoyer, Baltes and Baltes, (1974). One factor which i s often overlooked or ignored in behavioural intervention studies i s the ef f e c t of the wider i n s t i t u t i o n a l environment on patients and s t a f f a l i k e . If there ?age 32 i s a weakness in the operant model as applied to i n s t i t u t i o n a l intervention, i t i s i n t h i s area. Lawton and Nahemow (1969) have defined 'ecology' as the study of natural systems, emphasizinq the interdependency of one element in a system upon every other element. An ecological perspective considers a multiple array of antecedents that are f u n c t i o n a l l y related to sick as well as healthy behaviour. Accordinq to Baltes (1974), there are four key aspects to the ecoloqical perspective: 1) the i n t e r a c t i o n and interdependence between behaviour and environment; 2) the environment as the area of change; 3) the immediate change i n behaviour by chancre i n the environment; and 4) the tr a i n i n g of care-qiving professionals to think i n terms of gains rather than cures. This approach produces intervention and research endeavours geared toward prevention of sickness as well as health promotion and maintenance. It i s compatible with an operant model and provides a needed extension of that model;"In combining a behavioural and an ecological approach, the focus should expand to examine sickness and health, not only as a function of the patient, but in r e l a t i o n s h i p to environmental determinants including the microecoloqy (human services personnel) as well as the macroecologv (conditions and persons i n the laraer l i f e environment of the person). The research reviewed i n previous chapters indicates that many el d e r l y people l i v e i n extremely deprived environments, both at the micro and macro l e v e l s (Baltes and Lascomb, 1971; Gottesman, 1973; Labouvie-Vief. Hover, Baltes Paqe 33 and Baltes, 1974; Lawton and Nahemow, 1973) and that . i n s t i t u t i o n a l i z a t i o n i n general hastens deterioration (Euster, 1971). A behavioural-ecoloqical framework provides a general set of guidelines for developing treatment programs to deal with the problems of the i n s t i t u t i o n a l i z e d e l d e r l y . Page 34 CHAPTER 4 GUIDELINES FOR REHABILITATION AND MAINTENANCE PROGRAMS IN GERIATRIC FACILITIES "The major r e h a b i l i t a t i o n goal in i n s t i t u t i o n s for the aged i s not vocational, rather i t i s of r e h a b i l i t a t i o n for independent l i v i n g , to help the patient help himself to his f u l l e s t p o t e n t i a l i t i e s for whatever s a t i s f a c t i o n s he wants i n l i f e and i s able to at t a i n " (Hefferin, 1968). Regardless of the goal, however, most attempts at r e h a b i l i t a t i o n with a g e r i a t r i c population have generally been unsuccessful (Kahn and Za r i t , 1974). Linsk, Howe and Pinkston (1975) support t h i s argument and pointed out that most of the available research supporting treatment e f f i c a c y has made use of c l i n i c a l t r i a l s and uncontrolled experiments. With those few studies that have demonstrated an e f f e c t in tangible terms, improvements in functioning have very often been tran s i t o r y , with the targeted behaviours declining following the cessation of the intensive therapy (Cosin, Mort ,Post, Westrupp and Williams, 1958; Brody, Kleban, Lawton and Moss, 1974). This has been the case even when the i n s t i t u t i o n ' s s t a f f have been esp e c i a l l y trained i n methods to counteract the harmful effects of custodial treatment (Penchansky and Tauberhaus, 1965). Page 3 5 I t seems c l e a r t h e n , t h a t m o s t o f t h e c o n c l u s i o n s d e r i v e d f r o m r e s e a r c h on r e h a b i l i t a t i o n m u s t be c a u t i o u s l y a c c e p t e d . F u t u r e r e s e a r c h s h o u l d p r o v i d e a f i r m e r f o o t i n g f o r c o n c l u s i o n s c o n c e r n i n g r e h a b i l i t a t i o n p r o g r a m s f o r t h e e l d e r l y . T h e r e i s , h o w e v e r , a n o t h e r i s s u e w h i c h m u s t be c o n s i d e r e d . The f a c t t h a t t h e more r i g o r o u s l y c o n d u c t e d s t u d i e s r e p o r t e d t e n d e d t o d e m o n s t r a t e t h e l e a s t s u c c e s s f u l r e s u l t s s u g g e s t s t h a t r e h a b i l i t a t i o n p r o g r a m s t o d a t e g e n e r a l l y l a c k one o r more c r u c i a l i n g r e d i e n t s w h i c h i s r e q u i r e d f o r s u c c e s s f u l i m p l e m e n t a t i o n . The b e h a v i o u r a l - e c o l o g i c a l a p p r o a c h o u t l i n e d i n t h e p r e v i o u s c h a p t e r and t h e r e s e a r c h c u r r e n t l y a v a i l a b l e p r o v i d e some t e n t a t i v e a n s w e r s c o n c e r n i n g t h e c o m p o n e n t s n e e d e d f o r a s u c c e s s f u l p r o g r a m . The r e s e a r c h c i t e d i n p r e v i o u s c h a p t e r s p r o v i d e s s u p p o r t f o r t h e c o n c l u s i o n t h a t i n c r e a s e d d e t e r i o r a t i o n i s a l i k e l y c o n s e q u e n c e o f i n s t i t u t i o n a l i z a t i o n . I n a d d i t i o n , r e h a b i l i t a t i v e p r o g r a m s w i l l f i n d s u c h s e t t i n g s h o s t i l e e n v i r o n m e n t s b e c a u s e o f t h e i r o p e r a t i n g p h i l o s o p h y and t h e a t t i t u d e s o f s t a f f a nd r e s i d e n t s . D e p e n d e n c y , p a r t i c u l a r l y f o r t h e p e r f o r m a n c e o f e v e r y d a y a c t i v i t i e s , i s a s e r i o u s p r o b l e m . D r e s s i n g , f o r e x a m p l e , may be a s l o w and p a i n f u l t a s k f o r many o l d e r p e r s o n s . W i t h s t a f f a s s i s t a n c e , d r e s s i n g i s made e a s i e r . B u t when t h e r e s i d e n t n e e d s a s s i s t a n c e , s t a f f g i v e s p e c i a l a t t e n t i o n a s w e l l . T h a t a t t e n t i o n o c c u r s i n an e n v i r o n m e n t w h i c h i s g e n e r a l l y b a r r e n w i t h r e s p e c t t o s o c i a l r e i n f o r c e m e n t , and i t i s b a s e d s p e c i f i c a l l y on t h e d e g r e e t o w h i c h t h e r e s i d e n t c a n n o t f u n c t i o n i n d e p e n d e n t l y . T h i s Page 3 6 attention may include warm physical gestures and/or sincere expressions of concern for the patient's well being (Mishara, 1 9 7 3 ; Hoyer and Mishara, 1 975).. In a world of custodial care, dependency may be one of the few e f f e c t i v e behaviours available to a patient i n order to obtain some form of personal attention and recognition from nursing s t a f f . To c i t e a concrete example, the dependency may st a r t with an occasional request for assistance. This occasional request soon becomes habit and follows a pattern of spreading from one a c t i v i t y to the next. It may star t with tying laces. But, as time passes the resident comes to ask for or demand complete assistance i n dressing. In addition, the lack of stimulation i n the i n s t i t u t i o n may encourage a sedentary pattern which does not provide the resident with an adequate l e v e l of exercise. As body processes slow down, the resident may experience problems with elimination, respiratory and c i r c u l a t o r y d i f f i c u l t i e s and muscular atrophy (Comstock, Mayers and Folsom, 1 9 6 9 ) . A vicious cycle i s thus established since further deterioration brings more attention, while attempts to regularly perform the simple process of dressing would involve muscles that otherwise would be i d l e i f someone else was dressing the resident. The nursing home environment i s c l e a r l y structured i n a way that works against the resident's independent functioning and for increased dependency. D i f f i c u l t y with self-care i s a common problem of the i n s t i t u t i o n a l i z e d e l d e r l y . Because t h i s problem i s so widespread, Page 37 i t i s often the case that a new patient w i l l imitate or model the behaviour of those patients i n his immediate environment. According to Giordano and Giordano (1969), many patients have adopted the sick role and suffered i r r e v e r s i b l e physical deterioration as a consequence. These patients, i n turn, serve as 'aged-sick' role models and provide the normative structure of the i n s t i t u t i o n (Nahemow and B.ejinett, 1 967). Since the dependent patient i s quickly reinforced for that behaviour, he or she i s a powerful model of i n s t i t u t i o n a l behaviour for the new patient. A further complication i s the fact that f a c i l i t i e s are frequently so understaffed that r e h a b i l i t a t i o n programs are non-existant or minimal (McKnight, 1971; Macdonald, 1973). The average unit has barely enough s t a f f to care for the patient's hygiene and feeding (Pollock and Lieberman, 1974). Understaffing makes i t extremely d i f f i c u l t for s t a f f members to know the individual c h a r a c t e r i s t i c s of a l l patients that come under the care of ind i v i d u a l s t a f f members. Residents vary considerably in the i r a b i l i t y to perform the a c t i v i t i e s of d a i l y l i v i n g (Hoyer, 1974) and provision of the proper l e v e l of nursing care requires accurate, s p e c i f i c and complete information on each resident. In many settings, however, the only r e l i a b l e information available to s t a f f i s the request for assistance or help from the patient. While r e l i a b l e , these requests for help may not be v a l i d indices of the actual l e v e l of physical a b i l i t i e s of the resident. Other and p o t e n t i a l l y more v a l i d means of obtaining i n d i v i d u a l patient information such as nursing assessments are often not carr i e d out Page 3 8 systematically (Hefferin and Hunter, 1975) and information obtained by one s t a f f member i s not regularly communicated to other s t a f f members. There i s often, i n f a c t , no vehicle for systematic communication of such data between s t a f f . Frequently, the r e s u l t i s almost t o t a l reliance on the only r e l i a b l e source of information, the patient himself. The unfortunate consequence i s increased dependency and further deterioration. The problem of communication i n g e r i a t r i c care f a c i l i t i e s goes well beyond the need to obtain accurate information on l e v e l of functioning of i n d i v i d u a l residents. Attempts at r e h a b i l i t a t i o n are also l i k e l y to f a i l without proper communication of information. A t y p i c a l pattern of r e h a b i l i t a t i o n begins with an i n d i v i d u a l s t a f f member who attempts r e h a b i l i t a t i o n with a p a r t i c u l a r goal in mind. Unfortunately, because of problems in communication of the treatment plan and goal, i t i s often u n l i k e l y that other s t a f f members are aware of these e f f o r t s . Rehabilitation may be i n i t i a l l y successful, but i t i s l i k e l y to be quickly undone by s t a f f who have no knowledge of what i s being attempted or what has been achieved. This i s e s p e c i a l l y true of r e h a b i l i t a t i o n e f f o r t s that provide a concentrated period of t r a i n i n g each day (e.g. sessions with occupational therapists or physiotherapists) without d i r e c t l y involving s t a f f who work with the resident during the remainder of the day. There may be l i t t l e generalization from such programs, and the generalization that does occur may be short l i v e d (Kahn and Z a r i t , 1974). Without accurate information about Page 39 l e v e l of functioning, program goals and methods of maintaining gains, the u n i t s t a f f are often e f f e c t i v e agents f o r anti-therapeutic change. It would thus be c l e a r l y desirable to have regular s t a f f involved i n any therapeutic e f f o r t . But f r o n t - l i n e s t a f f often do not have the s k i l l s and techniques needed by e f f e c t i v e change agents. Setting unobtainable goals, attempts to bring about improvement too rapidly, f a i l u r e to use e f f e c t i v e p r i n c i p l e s of behaviour change, and lack of coordination between s t a f f are a l l factors that may actually contribute to the confusion, anxiety, f r u s t r a t i o n and depression that i s often displayed by the i n s t i t u t i o n a l i z e d e l d e r l y (Laurence, 1976). Failures are l i k e l y to reinforce stereotypes and make future attempts at r e h a b i l i t a t i o n more d i f f i c u l t . Even when r e h a b i l i t a t i o n i s successful, the patient may find that these newly acquired s k i l l s are a c t u a l l y punished by the withdrawal of valued attention and care on the part of nursing s t a f f . Pollock and Lieberman (1974) have shown that the patient with the l e a s t problems gets the l e a s t attention from s t a f f . F a i l u r e to provide an a l t e r n a t i v e means of obtaining the reinf o r c e r s that were acquired by adopting the aged-sick r o l e can c r i p p l e an otherwise e f f e c t i v e program. While i t i s clear from the l i t e r a t u r e that i n s t i t u t i o n s produce deleterious e f f e c t s , i t must be emphasized that Page 4 0 i n s t i t u t i o n s are merely settings i n which events either happen or do not happen. The d e f i c i e n t behaviour of the e l d e r l y patient can be modified (Baltes and Zerbe, 1976; Rebok and Hoyer, 1977). An appropriate focus for the treatment of the e l d e r l y i n d i v i d u a l involves a systematic program of r e h a b i l i t a t i o n and maintenance that focuses on reprogramming the behaviour-environment relationships so as to consistently strengthen and maintain optimal functioning. Such a program should be grounded i n the general data base of psychology and sociology and make use of the treatment technology which has strong empirical support. It should also have an empirical evaluation component i t s e l f . U n t i l 1971, very few applied research studies on aging had been reported (Tobin, 1971). Although many innovative programs have been introduced since then, few have been evaluated experimentally i n rigorous research (Carsyn, Fergus and York, 1977). Bennett, Wilder, Blumner and Furman (1977), i n a review of the published studies on innovative i n s t i t u t i o n a l programs, found that few, i f any, reported any long-term follow-up data. Most of the reports did not indicate whether they were incorporated into the routine services or programs of the i n s t i t u t i o n s i n which they were introduced or whether they were disseminated to any other i n s t i t u t i o n s . Without t h i s information, Bennett and his colleagues believe that i t i s d i f f i c u l t to assess whether these programs are i n t r i n s i c a l l y useful or whether they were successful for other reasons. A sim i l a r point was made by Hoyer (1973), who Page 41 stated that "much time i s spent on expensive, short-term demonstration projects that are e f f e c t i v e under t i g h t l y controlled laboratory conditions and that have a limited g e n e r a l i z a b i l i t y to n a t u r a l i s t i c contexts". Behavioural psychologists (Baer, Wolf and Risley, 1968; Risley, 1970) have also been concerned about the need for building generalization into r e h a b i l i t a t i o n projects. One method of accomplishing t h i s goal i s to make r e h a b i l i t a t i o n a regular part of the day-to-day p r a c t i c a l care of the e l d e r l y . The program described i n the next chapter used just that approach. The behaviours targeted for r e h a b i l i t a t i o n are generally referred to as the a c t i v i t i e s of d a i l y l i v i n g (ADL) and w i l l be designated as such for the purposes of t h i s program. I n a b i l i t y to perform these tasks i s a central problem in health care for the e l d e r l y ( S i l b e r s t e i n , Kossowsky and L i l u s , 1977). It i s also the decisive factor i n determining the need for long term care. With an aged population, the highest r i s k of becoming fu n c t i o n a l l y dependent i s in the area of sel f - c a r e . Self-care i s represented i n the A c t i v i t i e s of Daily Living (ADL) and includes dressing, grooming, eating and ambulation/transfer s k i l l s . These behaviours demand a high degree of coordination and are generally the f i r s t to suffer with time. The i n s t i t u t i o n a l i z e d elderly, as a group, have an "excess d i s a b i l i t y " i n the areas of ADL (Brody, Kleban, Lawton and Silverman, 1971) and thus, have considerable pot e n t i a l for r e h a b i l i t a t i o n . Pa,ge 4 2 ADL i s not only a p o t e n t i a l target for r e h a b i l i t a t i o n , i t i s an important one. It i s an objective measure of health (Rosow and Breslau, 1966; Shanas, 1968) and i s an accurate predictor of mortality ( S i l b e r s t e i n , Kossowsky and L i l u s , 1977). I t has also been accepted as the best way to assess physical and mental functioning i n the e l d e r l y (Grauer and Birnbom, 1975). ADL i s a measure of the "quality of l i f e " since i t r e f l e c t s one of the most important aspects of an individual's s e l f - s u f f i c i e n c y and self-worth (.Yates, 1 976). It i s highly correlated with self-reports of extreme loneliness and a l i e n a t i o n (Shanas, 1968) and provides an i n d i c a t i o n of most of the mental health problems seen i n the e l d e r l y (Weissman, Prusoff and Pincus, 1975; Burnside, 1976). Independence i n ADL, then, i s a r e a l i s t i c and worthwhile goal i n the treatment of the i n s t i t u t i o n a l i z e d e l d e r l y . To summarize, a successful program of r e h a b i l i t a t i o n i n a g e r i a t r i c f a c i l i t y should s p e c i f i c a l l y deal with six major problems that have had a deleterious e f f e c t on much of the work to t h i s point: 1). There are often no consistent, clear and rapid channels of communication between s t a f f (Comstock, Mayers and Folsom, 1969; Schwartz, 1974; Hefferin and Hunter, 1975). 2) Lack of consensus between st a f f on present l e v e l of patient functioning produces c o n f l i c t i n g patterns of custodial care and r e h a b i l i t a t i o n (Comstock, Mayers and Folsom, 1969; Hefferin and Page 43 Hunter, 1975). 3) Front-line s t a f f must carry the load of any major, ongoing r e h a b i l i t a t i v e and maintenance e f f o r t but often lack the t r a i n i n g and supervision to choose appropriate goals for r e h a b i l i t a t i o n (Laurence, 1976; Gottesman, 1970). 4) The i n s t i t u t i o n a l environment often provides both r o l e models and contingencies that work against the development and maintenance of an e f f e c t i v e program of r e h a b i l i t a t i o n by s t a f f (Repucci and Saunders, 1969; Nahemow and Bennett, 1967; Giordano and Giordano, 1967). 5) . Chronic understaffing of f a c i l i t i e s creates a work pattern that emphasizes accomplishment of d a i l y routines (e.g. feeding, transporting patients) i n the fastest rather than the most therapeutic manner (Pollock and Lieberman, 1969). 6) Most f r o n t - l i n e s t a f f lack the knowledge needed to incorporate a treatment program into t h e i r d a i l y routines while well trained s t a f f , such as occupational therapists, generally have such high patient loads that they cannot provide an ongoing, continuous program themselves (Gottesman, 1970). The program described in the next chapter attempted to deal with these problems. Page 44 CHAPTER 5 CARE - A PROGRAM OF CARE AND REHABILITATION FOR THE ELDERLY Since the i n s t i t u t i o n a l i z e d e l d e r l y are characterized by "excess d i s a b i l i t i e s " , the goal of t h i s study was to develop and evaluate a program which encouraqed the maintenance and r e h a b i l i t a t i o n of the A c t i v i t i e s of Daily Living (ADL) i n a group of i n s t i t u t i o n a l i z e d e l d e r l y . Accomplishing t h i s goal involves at least two major aspects at the resident l e v e l . Many el d e r l y , because of d i s a b i l i t i e s or disuse, lack independence in various ADL 1s in t h e i r current behavioural repetoire. Retraining in order that the resident i s capable of performing the ADL's that are important i n his/her d a i l y l i v i n g pattern i s one major focus. Another, equally important aspect of the program, i s the creation of a l i v i n g environment where the contingencies of d a i l y l i f e encourage rather than discourage performance of the ADL's which are within the resident's behavioural repetoire. "Elderly patients must be r e h a b i l i t a t e d to do for themselves these d a i l y necessities of self-care that are learned as a c h i l d , done automatically by the adult, but sometimes neglected by the e l d e r l y " (Comstock, Mayers and Folsom, 1969). The program described here attempted to r e d i r e c t and Page 45 r e p r o g r a m t h e i n s t i t u t i o n f r o m a c u s t o d i a l t o a t h e r a p e u t i c m o d e l o f c a r e w i t h a minimum o f i n t e r f e r e n c e w i t h t h e r e g u l a r i n s t i t u t i o n a l r o u t i n e and w i t h o u t c r e a t i n a c o s t s t o e x i s t i n q p r o g r a m s . Components o f The P r o g r a m A s s e s s m e n t The f i r s t s t e p i n a n y p r o g r a m o f r e h a b i l i t a t i o n i s t o e v a l u a t e e a c h r e s i d e n t ' s c u r r e n t p a t t e r n and l e v e l o f f u n c t i o n i n g . A c c o r d i n g t o H e f f e r i n and H u n t e r ( 1 9 7 5 ) , t h e u s e o f a n a p p r o p r i a t e and s y s t e m a t i c t o o l m i g h t w e l l p r o m o t e g r e a t e r o b j e c t i v i t y i n n u r s i n g j u d g m e n t and h e l p t o a s s e m b l e u s e f u l i n f o r m a t i o n f o r m e a s u r i n g p a t i e n t o r o g r e s s . To be u s e f u l t h e i n f o r m a t i o n s h o u l d be e a s i l y o b t a i n a b l e , r e l i a b l e , s p e c i f i c and c a p a b l e o f r e f l e c t i n g b o t h s h o r t t e r m v a r i a t i o n s i n p e r f o r m a n c e and l o n g t e r m p a t t e r n s o f c h a n g e . I t s h o u l d a l s o be e a s i l v communicated to a l l s t a f f i n v o l v e d i n t h e Droaram. The assessment comDonent o f t h i s D r o a r a m i n v o l v e s an e v a l u a t i o n o f t h e r e s i d e n t ' s a b i l i t i e s and d e f i c i t s , w h a t t h e r e s i d e n t can do f o r h i m s e l f , what s u p e r v i s i o n i s n e c e s s a r y and what h e l p i s a c t u a l l y g i v e n . I n t h i s s t u d y 3 5 d i f f e r e n t a c t i v i t i e s w e r e s e l e c t e d f o r i n c l u s i o n i n t h e p r o g r a m . T h e s e a r e l i s t e d i n T a b l e 1. I n g e n e r a l , t h e y a r e ADL's r e q u i r e d f o r n o r m a l i n d e p e n d e n t f u n c t i o n i n g ( e . g . a b i l i t y t o wash h a n d s , u s e a s p o o n , w a l k , p u t Page 46 T A B L E 1 S e l e c t e d A c t i v i t i e s o f D a i l y L i v i n g ( A D L ) U s e d i n C A R E P r o g r a m D r e s s i n g S k i l l s ' O n ' A c t i v i t i e s ' O f f A c t i v i t i e s a b i l i t y t o p u t o n p a n t s / d r e s s a b i l i t y t o p u t o n u n d e r p a n t s a b i l i t y t o p u t o n a n o p e n - f a c e d g a r m e n t ( b u t t o n - t h r u d r e s s , s h i r t , c a r d i g a n , e t c . ) a b i l i t y t o p u t o n s h o e s a b i l i t y t o p u t o n s o c k s / s t o c k i n g s a b i l i t y t o d o u p l a c e s a b i l i t y t o d o u p b u t t o n s a b i l i t y t o p u t o n b r a s s i e r e ( f o r f a m i e s o n l y ) a b i l i t y t o t a k e o f f p a n t s / d r e s s a b i l i t y t o t a k e o f f u n d e r p a n t s a b i l i t y t o t a k e o f f o p e n - f a c e d g a r m e n t a b i l i t y t o t a k e o f f s h o e s a b i l i t y t o t a k e o f f s o c k s / s t o c k i n g s a b i l i t y t o u n d o l a c e s a b i l i t y t o u n d o b u t t o n s a b i l i t y t o t a k e o f f b r a s s i e r e ( f a n a l e s o n l y ) E a t i n g S k i l l s a b i l i t y t o u s e a s p o o n a b i l i t y t o u s e a f o r k a b i l i t y t o u s e a k n i f e a b i l i t y t o u s e a c u p o r g l a s s a b i l i t y t o s e l e c t a n d a s s s r i b l e c l o t h i n g G r o a n i n g S k i l l s a b i l i t y t o w a s h h a n d s a b i l i t y t o w a s h f a c e a b i l i t y t o c c m b a n d d o u p h a i r a b i l i t y t o s h a v e ( e l e c t r i c o r m a n u a l -m a l e s o n l y ) a b i l i t y t o t a k e s e l f t o t o i l e t w h e n n e c e s s a r y a n d c l e a n l i n e s s ( n o t p h y s i c a l t r a n s f e r ) a b i l i t y t o b r u s h t e e t h o r c l e a n d e n t u r e s A i r i b u l a t i g n / T r a n s f e r S k i l l s a b i l i t y t o w a l k w i t h o r w i t h o u t a i d s a b i l i t y t o u s e a w h e e l c h a i r i f a p p r o p r i a t e a b i l i t y t o t r a n s f e r i n t o a c h a i r a b i l i t y t o t r a n s f e r o u t o f a c h a i r a b i l i t y t o t r a n s f e r i n t o b e d a b i l i t y t o t r a n s f e r o u t o f b e d a b i l i t y t o t r a n s f e r o n t o t o i l e t a b i l i t y t o t r a n s f e r o f f o f t o i l e t Page 47 on pants). These s p e c i f i c a c t i v i t i e s were chosen because they are most subject to deterioration, d i r e c t l y influenced by attendant contact, e a s i l y observable and measurable and are appropriate targets for r e h a b i l i t a t i o n and intervention. Each of these 3 5 behaviours was assessed using a three l e v e l code developed bv Benjamin (1 976). and similar to that of Katz (1 963): Level 1 ^ Total Independence - ' _The patient' has'\ the a b i l i t y to perform an a c t i v i t y without supervision, d i r e c t i o n or active personal assistance. A patient who refuses to perform a function i s defined as t o t a l l y dependent, even though he or she i s deemed able. The patient mav choose anv method or aid to perform the a c t i v i t y . Level 2 - P a r t i a l Dependence - The patient can perform the greater part of the a c t i v i t y himself or herself, but needs assistance (verbal or physical) or supervision to complete the a c t i v i t y . Level 3 - Total Dependence - The a c t i v i t y i s carried out for the patient. The assessment t o o l developed thus covers 3 5 d i f f e r e n t behaviours with three l e v e l s of functioning - a possible 105 units of Page 48 . information. Communication Once an i n d i v i d u a l resident's a b i l i t i e s and d i s a b i l i t i e s have been c a r e f u l l y assessed, the information must be communicated to everyone who comes in contact with him or her. The importance of t h i s aspect of communication between s t a f f has been noted by several writers (Comstock, Mayers and Folsom, 1969; Schwartz, 1974) . Techniques t y p i c a l l y employed to communicate information r e l a t i n g to ADL most often use a written form, place a major emphasis on d e f i c i t s rather than a b i l i t i e s , lack s p e c i f i c i t y and provide only a minimum of information (Hefferin and Hunter, 1975) . A c c e s s i b i l i t v to such information systems i s qenerally limited and time consuming, whether i t i s kept at the bedside i n a chart or at the nursinq station. For t h i s study, a v i s u a l wall chart (see Figure 1) was desiqned to communicate the necessary information. This chart displays t h i r t v - f i v e a c t i v i t i e s of d a i l y l i v i n g p i c t o r i a l l v , usinq e a s i l v recognizable symbols. It shows detailed dressing, qrooming, eating and ambulat'ip.h/transfer a c t i v i t i e s (see Appendix A). Colour coding, i n the form of s t i c k on dots, i s used to indicate the degree of independence and the amount of assistance needed i n each of these a c t i v i t i e s . A 'green' dot i s placed beside the a c t i v i t y depicted on the chart when the resident i s t o t a l l y independent with regard to that ADL. 'Yellow' dots represent p a r t i a l dependence and 'red' refers to t o t a l F i g u r e 1 VISUAL WALL CHART Page ,49 ( a c t u a l s i z e - 9 3/4" by 14") Page 50 dependence, The v i s u a l chart i s an economical and e f f i c i e n t means of communicating information. It i s also e a s i l y updated as the resident's l e v e l of performance changes. The most common methods of changing charts seem to be crossina through, rubbina out, or writing over existing information. The r e s u l t i s often a rather messy and i n e f f e c t i v e communication device. An alte r n a t i v e i s to develop a new l i s t of information, but acrain, there i s a problem with continuitv and with the time required to do the task. With the v i s u a l chart, changes are e a s i l y indicated by simply placing a new colour dot, representing the new l e v e l of performance, over the already existing colour. By placing the new dot over most, but not a l l . of the old dot i t i s possible to r e t a i n e a r l i e r information as well as to make a judgment as to the pattern of improvement or deterioration i n the resident. The v i s u a l chart i s placed by the resident's bed and i s a r e a d i l y available, continuously accessible method of communication. Isol a t i n g Target Behaviours Behavioural strategies must necessarily start with a precise d e f i n i t i o n of target or goal behaviour. The wall chart attempts to meet t h i s requirement bv reducing the A c t i v i t i e s of Daily Living to kev behavioural events. Complex chains of behaviour (i . e . dressing) must be reduced to behavioural events that can be Page. 51 e f f e c t i v e l v modeled, shaped and reinforced. Each behavioural event i s c r i t i c a l to successful independence and t h i s breakdown crives the therapists a base for desicming an e f f e c t i v e intervention strategy. In t h i s program the goals for r e h a b i l i t a t i o n are chosen by f r o n t - l i n e s t a f f (nurses, aides and attendants) i n consultation with the occupational therapist. These goals are determined on the basis of "pr o b a b i l i t y of success" and resident p r i o r i t y -that i s , the needs and wishes of the residents themselves. A resident, for example, may wish to be able to transfer out of bed rather than be able to nut his/her shoes on. A l l ADL which are 'yellow' or 'red' are poten t i a l goals. Front-line s t a f f decide which of these a c t i v i t i e s has the highest p r o b a b i l i t y of beinq successfully r e h a b i l i t a t e d . This decision i s based on both the complexity of the a c t i v i t y and the resident's d i s a b i l i t y . For many, eating s k i l l s are less complex than transferinq s k i l l s , which are less complex than dressing s k i l l s (Katz and Akpom, 1975). The resident's d i s a b i l i t y i s an important factor i n determining the complexity of the a c t i v i t y . Whether residents are hemiplegics. paraplegics, amputees or bli n d has a bearing on the complexity of the a c t i v i t y . Goals for r e h a b i l i t a t i o n are designated on the chart bv a 'blue' dot placed adjacent to the symbol of the a c t i v i t y . No more than one blue dot i s placed on the chart at any one time. The r e s t r i c t i o n of one r e h a b i l i t a t i o n goal at a time was based on the Page 52 work of Comstock, Mayers and Folsom (1 969) who concluded that many e l d e r l y people need more than average time to complete one simple task before being assigned another. Too many demands or too many goals mav only lead to f r u s t r a t i o n and f a i l u r e . Thus, i f a resident i s comnletelv dependent upon s t a f f for dressing, a s p e c i f i c component of dressing i s chosen as the f i r s t r e h a b i l i t a t i o n target. For example, the procedure may begin with •putting on shoes'. When the goal i s achieved a green dot i s placed over the blue dot and a second blue dot i s placed beside the next goal, perhaps 'putting on stockings'. Thus, bv moving from one small r e h a b i l i t a t i v e goal to the next, the end r e s u l t i s independent dressing. The Rehabilitation Program Once a target behaviour has been selected by s t a f f , each person who comes i n contact with the resident i s a member of the treatment team. The treatment program i t s e l f i s described i n d e t a i l i n Appendix B. which contains a copv of the treatment manual available to a l l s t a f f , and i n a section of t h i s chapter which describes the st a f f t r a i n i n q component. Stated b r i e f l y , th r e h a b i l i t a t i o n program has two maior components. The f i r s t involves the use of r e h a b i l i t a t i v e procedures taken from r e h a b i l i t a t i o n medicine and occupational as well as physical therapy. S p e c i f i c suggestions for r e h a b i l i t a t i o n of each of the pote n t i a l ADL targets are available i n the treatment manual. The second component i s a behavioural one which involves the use of standard behavioural procedures such as reinforcement, shaping, chaining and modeling i n the r e h a b i l i t a t i o n e f f o r t . Through a tra i n i n a program and by reading tne manual, st a f f learn to incorporate behavioural p r i n c i p l e s into t h e i r everyday interaction patterns with the resident. Thus, each s t a f f member has access to information about the ADL behaviour of the resident,, the current r e h a b i l i t a t i o n goal and the methods that can be used to reach that goal. Maintenance of Change As previously mentionedyafter the targeted behaviour has become a part of the resident's repetoire and he or she i s independent in that a c t i v i t y , a green dot i s placed on the chart so that i t covers most, but not a l l . of the blue dot. (A new target mav also be selected i f the available treatment methods do not prove e f f e c t i v e on the selected ADL.) The purpose of overlapping the green and blue dots on the v i s u a l chart i s to sensi t i z e s t a f f to the newly r e h a b i l i t a t e d a c t i v i t y and provide a cue for s t a f f behaviours that w i l l maintain t h i s change. Maintenance i s established i n two ways. Staff are directed, bv the colour cue, to attend to and acknowledge newly acquired behaviour through praise and encouragement. Second, when any a c t i v i t y i s designated by a green dot, no assistance i s given. A green dot defines that a c t i v i t y as being t o t a l l y independent. Not Page 54 only does t h i s rule help to maintain newly r e h a b i l i t a t e d behaviours but i t serves to maintain already existing independent behaviours. The chart i s a means of a s s i s t i n g the s t a f f i n developing a uniform and consistent set of expectations i n r e l a t i o n to the resident's ADL s k i l l s . Reinforcement, which might be given for inappropriate behaviour, i s given for resident e f f o r t s toward independence. As an a c t i v i t v becomes r e h a b i l i t a t e d , that a c t i v i t v comes under environmental control while s o c i a l reinforcement from s t a f f i s directed towards the next targeted a c t i v i t y . Newly re h a b i l i t a t e d behaviours are at f i r s t attended to and praised frequently as they are performed independently. This attention i s graduallv reduced over time as work on other behaviours becomes the focus. By s h i f t i n g the emphasis of s t a f f attention from negative attention getting dependent behaviours to more desirable a c t i v i t i e s , n o s i t i v e behaviours increase (Hoyer, Mishara and Riedel, 19751. It should be noted, however, that s t a f f t r a i n i n g emphasizes using d i s c r e t i o n i n following the rules described above. While there i s a standard method of dealing with resident behaviour, the increased knowledge base provided by the v i s u a l chart enables st a f f to use t h e i r own i n i t i a t i v e i n o f f e r i n g encouragement, empathy and/or understanding to residents on some occasions when a resident asks for unnecessary assistance. The emphasis i s on making an informed choice rather than simply 'doing for' the Page 55 r e s i d e n t a t e v e r y r e q u e s t o r r o u t i n e l y r e q u i r i n g t h e r e s i d e n t t o p e r f o r m e v e r y b e h a v i o u r t h e c h a r t i n d i c a t e s . h e o r she i s c a p a b l e o f p e r f o r m i n g . S i c k n e s s , g r i e f and t r a n s i t o r y e m o t i o n a l u p s e t s a r e a l l e x a m p l e s o f s i t u a t i o n s w h i c h demand f l e x i b i l i t y a n d u n d e r s t a n d i n g . I n a d d i t i o n , i f d e t e r i o r a t i o n o c c u r s so t h a t t h e r e s i d e n t i s u n a b l e t o p e r f o r m b e h a v i o u r s t h a t w e r e o n c e i n d e p e n d e n t o r p a r t i a l l y i n d e p e n d e n t , t h e v i s u a l c h a r t i s r e p l a c e d w i t h a new one t h a t a c c u r a t e l y r e f l e c t s c u r r e n t f u n c t i o n i n g . G e n e r a l i z a t i o n o f Change T h i s i s s u e i s o f c e n t r a l i m p o r t a n c e i n t h e p r o g r a m . Many r e h a b i l i t a t i o n p r o g r a m s a r e c o n d u c t e d b y s p e c i a l i s t s i n a p a r t i c u l a r s i t u a t i o n and w i t h i n a s p e c i f i c t i m e f r a m e . O f t e n , t h e e f f e c t s o f t h e s e p r o g r a m s do n o t g e n e r a l i z e t o t h e i n s t i t u t i o n a l e n v i r o n m e n t . D e v e l o p i n g a means o f b r i d g i n g t h e g a p b e t w e e n s u c h p r o g r a m s and t h e d a i l y l i v i n g e n v i r o n m e n t o f t h e p a t i e n t h a s a l w a y s b e e n a p r o b l e m . I n t h i s s t u d y t h e p r o b l e m was a v o i d e d by m a k i n g t h e r e h a b i l i t a t i o n p r o g r a m a p a r t o f t h e d a i l y r o u t i n e o f . a l l s t a f f c o m i n g i n c o n t a c t w i t h t h e r e s i d e n t . T a r g e t s f o r r e h a b i l i t a t i o n a r e s u c h t h a t t h e y c a n be e a s i l y a c c o m o d a t e d i n t o e a c h s t a f f member's w o r k r o u t i n e . The p r o g r a m t h u s becomes a r e g u l a r and p e r m a n e n t p a r t o f t h e i n s t i t u t i o n a l l i f e o f t h e r e s i d e n t . Page 56 Training Program A l l f r o n t - l i n e s t a f f were involved i n a systematic t r a i n i n g program. The components of the t r a i n i n g program included: the process of aging and i n s t i t u t i o n a l i z a t i o n , r e h a b i l i t a t i o n t r a i n i n g , behaviour modification and program rationale. Training involved 5 lectures of 45 minutes duration as well as weekly small group meetings held i n each of the four sections of the experimental f a c i l i t y (see Appendix C for f l o o r p l a n ) . 1. The Process of Aging and I n s t i t u t i o n a l i z a t i o n . Information was given on the process of aging ( b i o l o g i c a l , s o c i a l and psychological changes that occur with age) and the r e l a t i o n s h i p of these changes and the environment. The r o l e of the i n s t i t u t i o n i n fostering the sick role and dependence was also discussed. The information presented i n the f i r s t three chapters of t h i s thesis formed the basis for the i n s t r u c t i o n . 2. Rehabilitation Training. Staff were given basic t r a i n i n g i n strategies of r e h a b i l i t a t i o n . Information included d e t a i l s of basic aids and devices used to promote independence i n various a c t i v i t i e s (velcro fasteners, dressing s t i c k s , zipper p u l l s , s p e c i a l l y designed clothing) and techniques for performing ADL for those with s p e c i f i c d i s a b i l i t i e s (e.g. hemiplegia, amputations, balance problems). This information was provided by the i n s t i t u t i o n ' s occupational therapist. In addition to the Page -57-t r a i n i n g , each s t a f f member had access to a treatment manual that included detailed 'how to' guides for each of the target ADL (see Appendix B for d e t a i l s ) . Most of the ADL's were broken down into a series of smaller steps which could be trained i n d i v i d u a l l y . Staff were taught to determine the f i r s t step in a p a r t i c u l a r series a resident could not complete independently and to begin working at that point. 3. Behaviour Modification. Training was also given i n the basic techniques of behaviour modification (see Appendix B). Modeling, shaping, behavioural rehearsal and reinforcement were emphasized. A. Modeling. It has been established that one can. learn new behaviours or responses by imitation of others (Bandura, 1969). This process i s c a l l e d modeling and occurs when an i n d i v i d u a l learns a new response by i d e n t i c a l l y reproducing a response observed i n another i n d i v i d u a l . Also, responses already i n the individual's repetoire may be cued by a model's behaviour. Modeling has been shown to be e f f e c t i v e i n many v a r i e t i e s of response a c q u i s i t i o n and has d i r e c t application to the learning and relearning of the ADL v /.] B. Shaping. Where immediate imitation of a complex behaviour i s impossible, successful performance of successive approximations may be i n i t i a t e d . Shaping by successive approximations i s often useful i n teaching a new response. In t h i s procedure, the desired t o t a l response i s broken down into a series of smaller steps Page 58 which are necessary for mastery of the f i n a l response. Each step i s completed progressively, u n t i l the f i n a l or complete response i s obtained. In shaping, the therapist at f i r s t reinforces responses which may have l i t t l e s i m i l a r i t y to the desired behaviour, but which are c l e a r l y within the subject's current behavioural repertoire' The therapist then reinforces successively only behaviours which are increasingly similar to the desired behaviour. F i n a l l y , only the desired behaviour i s reinforced, u n t i l i t attains suitable strength. Modeling and shaping may also be used i n combination by breaking the desired behaviour into steps and modeling each of these steps u n t i l the f i n a l response i s obtained. C. Behavioural Rehearsal. Behavioural rehearsal i s a tool that has been employed i n a v a r i e t y of therapeutic contexts with useful r e s u l t s . This technique involves allowing the subject to practice or rehearse the behaviour being modeled or shaped. Repetition and practice has been demonstrated to be e f f e c t i v e in the learning and relearning of behaviours. Rehearsal also provides the opportunity for s e l f - c o r r e c t i o n and feedback from others. The i n d i v i d u a l can 'try out' new responses i n simulated situations without r i s k i n g f a i l u r e . Rehearsal also permits the a n t i c i p a t i o n of d i f f i c u l t problems and ways of handling them. D. Reinforcement. The most commonly used technique of operant behaviour modification has been posit i v e reinforcement. Millenson (1 967). claims that reinforcement i s "a fundamental p r i n c i p l e i n the analysis and control of adaptive behaviour". Vroom (1964) also states that "the p r i n c i p l e of reinforcement must be included among the most substantiated findings of experimental psychology and i s , at the same time, among the most useful findings for an applied psychology concerned with the control of human behaviour", Praise i s a useful aspect of reinforcement. Individuals enjoy being praised and i t has been found to increase the occurrence of those behaviours that i t i s directed towards. 'These techniques have been applied to the problems of increasing behaviours currently occurring at low rates, r e i n s t a t i n g behaviours once present but no longer exhibited and building completely new behavioural repetoires (Sherman and Baer, 1 969).. Using these s k i l l s , the new behaviour to be taught to the resident i s broken down into various steps (shaping); he or she i s provided with s p e c i f i c and v i v i d displays of the s k i l l or step the therapist i s seeking to teach (modeling); he or she i s given considerable opportunity, tr a i n i n g and encouragement to behaviourally rehearse or practice the modeled behaviour (behaviour rehearsal); and he or she i s provided with p o s i t i v e feedback, approval and praise as the enactments increasingly approximate those of the therapist (social reinforcement). 4. Program Rationale. Staff were given a detailed explanation of the CARE program, including i n s t r u c t i o n i n the use of the v i s u a l charts, colour coding, ADL manual and th e i r use. Organizational Behaviour Modification I t has been demonstrated that i n s t r u c t i o n i n p r i n c i p l e s of behaviour modification can e f f e c t i v e l y change non-professionals' behaviour (McKeown, Adams and Forehand, 1 975).. There i s some question, however, about the permanence of t h i s change (Andrasik and McNamara, 3 977). According to Rappaport (.1 977)., i n s t i t u t i o n a l change must include personal s a t i s f a c t i o n of the members of the i n s t i t u t i o n . Feedback i s an important form of reinforcement i n maintaining s t a f f behaviour (Panyan, Boozer and Morris, 1 970)... Training programs for s t a f f and s p e c i f i c procedures that assign increased r e s p o n s i b i l i t y for patient care also help to increase morale and s a t i s f a c t i o n (Schwartz, 1974), Staff p a r t i c i p a t i o n i n goal setting f a c i l i t a t e s commitment to those goals; goals give the s t a f f something for which to s t r i v e . The program that has been described places much emphasis on these factors. Front-line s t a f f are exposed to a t r a i n i n g program that provides them with s p e c i f i c s k i l l s that have d i r e c t implications for resident care and treatment. The procedures are available to these s t a f f and provide f o r increased r e s p o n s i b i l i t y and decision making power r e l a t i n g to resident care. In defining s p e c i f i c and iso l a t e d ADL as target goals, successful change i s more l i k e l y . This success i s , i n i t s e l f , rewarding to s t a f f . Recognition for staff performance i s also provided i n the weekly meetings through feedback on success i n meeting targeted goals. These group meetings involve a l l s t a f f members who provide care Page 61 for the resident. A log book (see Appendix D) , which contains a r e p l i c a of the i n f o r -mation on every resident's wall chart, s erves as. the focus of the group meetings. The log book provides a s i x month record of ADL functioning for a resident on one page. The resident's l e v e l of functioning i s assessed each week at the meetings and any changes from the previous week are re-corded on the dated page by means of the appropriate coloured dot. Wall charts are then updated as w e l l . Each resident's progress i s reviewed at the weekly meeting .and s t a f f have an opportunity to modify programs or i n i t i a t e new ones. The group meeting i s one means of dealing with the problem noted by Brody (1976) i n discussing the use of data i n health care delivery systems; "the u t i l i t y of data can be n i l unless i t i s injec t e d into an organization prepared to adjust i t s performance to a problem-defining and problem-solving approach". Page 62 CHAPTER 6 PROCEDURE Setting and Subjects Two facilities served as the setting for the study. They were architecturally identical 152 bed, single story buildings in Metropolitan Vancouver. Each facility consisted of 4 living units of 38 residents. The residents share a common dining room, a communal lounge and a hobby room. A recreational program at each facility includes such activities as bowling, newspaper readings, outings, films and visiting groups of entertainers. Arts and craft activities are also available. The institutions are publicly supported and had been in operation for approximately two and a half years prior to the beginning of the study. Both facilities are under the management of the same administrator. The nursing director, dietician and social worker are shared equally between the two buildings and each facility has its own occupational therapist. Staffing patterns are identical and include four full-time registered nurses, forty attendants and six activity aides at each facility. Budgets are also identical as is the purpose of each facility - provision of intermediate long term care (see Appendix E for explanation and criteria). One facility (A) was randomly chosen to serve as the setting for the experimental treatment program while the other (B) served as the control. Within each facility a l l persons 60 years of age or over were included in the study. As shown in Table 2, 127 (83.5%) at facility A and 130 (85.5%) at Facility B were aged 60 or more. Among those residents 60 and over, Page the mean age at Facility A was 82.1 years (s.d.= 8.8 years) and the average length of stay was 11.7 months. At Facility B the mean age was 79.2 years (s.d.= 9.9 years) and the average length of stay was 12.7 months. The experimental group consisted of 39 males and 88 females while the control group comprised 47 males and 83 females. Demographic information is shown in Table 2 (age, sex, primary diagnosis, length of stay and ambulation status). This information was obtained from the medical charts. Chi-square or t-tests were used to test the equivalence of the two groups at the beginning of the study. The two groups differed on 2 of the 5 demographic variables - age and ambulation status. The residents of A were significantly older and more ambulatory than those in B. Since age is correlated negatively with a l l variables used as dependent measures in the study, the difference in age probably biased the results against the treatment group and in favour of the control group. Ambulation status was considered in some of the analyses of the dependent measures. Confusion A l l subjects were rated as to degree of confusion..Assessing confusion among the elderly is problematic (Slater and Lipman, 1977) . Formal des-/^ criptions of the condition differ markedly and, in some instances, include factors specifically excluded from other definitions of the same phenomena (Meacher, 1972). In addition, measures of confusion vary in the method of administration and content. Many geriatric patients cannot undergo the Page 64 T a b l e 2 Demographic I n f o r m a t i o n F a c i l i t y . A n=127 F a c i l i t y B S i g n i f i c a n c e n=13 0 T e s t Age ( i n y e a r s ) X=82.1 ,s.d.=8.8 X=79 . 2 , s ,d . = 9 , 9 t_=2.5 r a n g e 60-102 y r s , ra n g e 60-101 y r s , p_<.01 L e n g t h of s t a y : ( i n months) X = l l • . 7 , s . d . = 9.2 r a n g e 1-24 mon, X=12 . 7 , s .d ..= 7 . 0 t=-0.9 r a n g e 1-26 mon. n . s . Sex: Male Female 39 88 47 83 X* =4 . 6 n . s Ambulat i o n : A m b u l a t o r y W h e e l c h a i r 110 17 98 32 X 2=4 . 6 P < .03 P r i m a r y D i a g n o s i s * : P s y c h i a t r i c H e a r t D i s e a s e C i r c u l a t o r y P r o b l e m s C e r e b r a l I n s u l t M u s c u l o / S k e l e t a l M e t a b o l i c D i s o r d e r M i s c e l l a n e o u s 32 37 8 22 9 11 26 26 6 27 1 6 15 14 X2 = 9 . 4 n.s. * See A p p e n d i x F f o r d e t a i l s Page 65 standard techniques of psychological testing. Usually mental, perceptual, or physical impairment is present to some degree and the elderly often find the testing^ situation stressful. Lack of cooperation, hostility and difficulty in understanding the requirements of the task are common (Goya, 1977). One common factor in a l l tests of confusion, however, is a disturbance in orientation to time, place and person (Lawton, 1973). Of these, orientation to place is the most readily observable by front line staff. Slater and Lipman (1977) found spatial disorientation to have the highest correlation with subjective assessments of confusion by nurses. In this study subjects were classified into three categories of confusion, based upon the criteria outlined in Table 3. An advantage of this measure is that the subject's cooperation is not needed. Staff are able to evaluate subjects on the basis of their observation and experience alone. A l l subjects were rated on the basis of this criteria, prior to the initiation of the study. Two staff: members, primary care-givers for the subject being rated, independently assessed the subject. Reliability of the confusion scores was computed using the following equation: agreements X 10° agreements + disagreements Overall rater agreement, using this equation, was 94 percent. Non-occurrence reliability, that is, agreement that no confusion was present (Score 1) was 96.6 percent. Occurrence reliability, or agreement that confusion was present (Score 2 or 3) was 88.8 percent. However, agreement on the level of confusion (Score 2 versus Score 3) was only 75 percent and, therefore, no differentiation was made between these two levels. The distribution of Page 66 Table 3 Assessment o f Confusion Items Score 1 ) i s a b l e t o f i n d way around without g e t t i n g l o s t . Knows where he/she i s a t a l l times 2 ) can f i n d way t o d i n i n g room, bathroom and h i s / h e r bedroom Score as unimpaired i f item 1 a p p l i e s . Score as m i l d l y impaired i f o n l y item 2 a p p l i e s . 3 ) n e i t h e r item 1 or 2 apply score as dLmpaired Page 67 Table 4 Distribution of Confusion Scores no confusion (score 1) confusion (score 2 or 3) Facility A 95 32 Facility B 103 27 Page the . confusion scores between the two f a c i l i t i e s appears i n Table 4. A Chi-square analysis showed no significant difference between groups (X2 = 0.71, n.s.). Dependent Measures Subjects from A and B were also evaluated on the level at which they carried out specific a c t i v i t i e s of daily l i v i n g . This group of behaviours constituted a l l dependent measures in this study. The World Health Organization (cited i n Schwab, 1976) has stated that "health i n the elderly i s best measured i n terms of function". In this study, resident functioning was evaluated by means of staff ratings of a b i l i t y to complete the specific a c t i v i t i e s of daily l i v i n g outlined i n the previous chapter. A score of 1 was given for t o t a l independence while par t i a l dependence and total dependence were given scores .of 2 and 3, respectively (see Appendix G for further details). These assessments were made i n each f a c i l i t y at parallel points i n time, just prior to the beginning of treatment i n A and after 6 months. B subjects were also evaluated after three months. Three month data for subjects i n F a c i l i t y A were taken from their wall charts. Thirty-five different a c t i v i t i e s or items have been identified for evaluation. With the scoring system outlined above, the minimum and maximum scores for the four components of ADL are : dressing (17 to 51 for females, 15 to 45 for males); grccming (5 to 15 for females, 6 to 18 for males); eating s k i l l s (4 to 12 for a l l subjects); and ambulation/transfer (7 to 24 for a l l subjects) . A f i f t h measure, Global ADL, was calculated by sumrning the scores of the four ADL measures. The itdnimum scores possible for males i s 32, while the maximum i s 103 on this measure. For females, the irdnimum i s 33 and the maximum i s 106. Higher values refl e c t more negative ratings. Page General Procedures Assessment Only Control - Subjects in Facility B received only the pre-treatment, 3 month and 6 month assessments. Treatment Group - After the pre-treatment assessment of a l l subjects was completed, the wall charts were implemented and placed in each subject's bedroom at their bedside. The training program was then begun. Instruction and training of staff was conducted by the experimenter and consisted of 5 lectures of 45 minutes duration in addition to weekly small group meetings The formal lectures took place each week for the f i r s t month. In order to accommodate the two time shifts, these lectures occurred at 2:00 p.m. and 7:30 p.m. each week. A l l front-line staff (nurses, attendants and activity aides ) and the cleaning staff were requested to attend. The purpose of the small group meetings was to informally discuss the content of the lectures and to provide a means of teaching the skills to be used in implementing the program. These small group meetings were 45 minutes in duration and occurred weekly in each of the four units of the facility. Thirty-eight residents are accommodated in each unit and staffing patterns included 2 attendants, one activity aide and a licenced practical nurse (LPN) shared between each unit. Only those staff responsible for the residents on that unit attended. The experimenter used a modeling and verbal instruction format for staff training in the small groups. The particular skills the staff members were to acquire - modeling, shaping, behavioural rehearsal and social Page 7 reinforcement - were demonstrated by the experimenter. Hypothetical problems in the performance of the activities of daily living were used to discuss and demonstrate these skills. The staff then practiced these behaviours under the supervision of the experimenter before actually applying the skills with the subjects. Positive reinforcement, in the form of praise and feedback, was given to staff as they developed these skills. The schedule of special activities which occurred during the 24 weeks of the study are summarized below: Week 0. The f i r s t lecture provided an introduction to the program and an explanation of the wall charts: each activity and its pictorial representa- . tion, the colour coded criteria and the use of the blue dot to designate targets for rehabilitation. A group meeting was also conducted on each unit to informally discuss the content of the lecture and deal with any misconceptions or ambiguities that arose. During this week the experimenter was available to individual staff members to informally discuss the program and explain the use of the wall chart. The wall charts were completed and placed in each subject's bedroom at their bedside. In addition, a recording sheet was placed beside each wall chart. A l l staff providing primary care to each subject were required to i n i t i a l the recording sheet to indicate agreement with the assessment. If disagreement did occur, the activity/ activities in question was recorded and discussed with the staff at the group meeting the following week. P a g e Week 1. The second l e c t u r e covered aging and i n s t i t u t i o n a l i z a t i o n . A major focus o f t h i s l e c t u r e was the way i n which u n d e s i r a b l e behaviour and i n c r e a s e d dependence i s produced and maintained i n an i n s t i t u t i o n . The s m a l l groups met t o d i s c u s s the content o f the l e c t u r e and t o review any s t a f f disagreements on ADL assessments r e f l e c t e d on the w a l l c h a r t s . Any disagreements between s t a f f t h a t were unresolved r e q u i r e d t h a t the subj e c t ' s w a l l c h a r t be changed t o r e f l e c t the lowest l e v e l o f agreement i n the a c t i v i t y i n qu e s t i o n . T h i s procedure was i n s t i t u t e d i n order t h a t s t a f f agreement be maintained and an accurate b a s e l i n e developed. S t a f f were a l s o encouraged t o cooperate i n determining r e h a b i l i t a t i o n g o als f o r each s u b j e c t . T h e i r choices were t o be based on a c t i v i t i e s t h a t had the h i g h e s t p r o b a b i l i t y o f being s u c c e s s f u l l y changed. S t a f f were d i r e c t e d t o e x p l a i n the program t o those s u b j e c t s who were capable o f understanding and t o consider the su b j e c t ' s cwn choic e i n determining g o a l s . A l l p o s s i b l e goals were d i s c u s s e d w i t h the o c c u p a t i o n a l t h e r a p i s t and r e p o r t e d a t the f o l l o w i n g meeting. Week 2. The f a c i l i t y o c c u p a t i o n a l t h e r a p i s t conducted a l e c t u r e on b a s i c r e h a b i l i t a t i o n s k i l l s and a i d s t h a t were a v a i l a b l e t o he l p i n d i v i d u a l ' s w i t h s p e c i f i c problems. S t a f f were a l s o introduced t o the ADL Treatment Manual and i t s purpose was ex p l a i n e d . These manuals were f r e e l y a c c e s s i b l e t o s t a f f ; a number o f copies were p l a c e d i n each u n i t o f the f a c i l i t y . The s m a l l groups met t o d i s c u s s the content o f the l e c t u r e and were again made f a m i l i a r w i t h the manuals. Subject assessments were reviewed and app r o p r i a t e goals were designated. Page 72 Week 3. Basic 'social learning1 theory was discussed in the fourth lecture. Specific emphasis was placed on the role of shaping and modeling in behaviour change procedures. Instruction and practice were conducted in the group meetings. Subjects' assessments continued to be reviewed and appropriate goals were designated. Week 4. Basic operant theory was discussed in the final lecture. Behavioural rehearsal and social reinforcement were emphasized. The group meeting was used to discuss the content of the lecture as well as to practice the techniques under the direction of the experimenter. Assessment reviews were completed and a l l subject wall charts contained one blue dot. Week 5 to 12. Small group meetings in each unit continued under the direction of the experimenter. Subjects' assessments were reviewed, progress was discussed and new goals established. A l l changes were recorded in the log book during the meeting and after review, the experimenter updated the wall charts with the appropriate changes in colour coding. A 'changes l i s t ' was then forwarded to the occupational therapist for verification. Any problems in program implementation were also discussed at the meeting. Weeks 13 to 24. Small group meetings continued but were no longer under the direction of the experimenter. Instead, one staff member in each unit served as the leader, while another acted as secretary. The leaders were responsible for making sure that a l l subjects were properly reviewed. The secretary completed the 'changes l i s t ' while the leader recorded these changes on the appropriate log book page. Progress in goal achievement was discussed and new goals were established as appropriate. The leader was Page 7 3 chosen from the front line staff of the unit on the basis of their interest in taking on the role and also their ability to work cooperatively with others. These leaders reported to the experimenter each week on any problems and a l l progress that occurred. Post-Treatment Assessment. At the end of the six month period a l l subjects in Facility A and B were reassessed as to their level of functioning in the designated activities of daily living. Two staff members, primary care givers for the subject being rated, independently assessed the subject. Inter-rater reliability measures were computed using Pearson product-moment correlations. Page 74 CHAPTER 7 RESULTS Reliability of ADL Skill Scores Reliability was computed on the staff assessments of the dependent measures (dressing, eating, grooming, ambulation/transfer and' global ADL skills). Assessment occurred in each facility at parallel points in time, just prior to the beginning of treatment in Facility A and after 6 months. Facility B subjects were also assessed after three months. Reliability was, therefore computed at the pre and post-assessments in each facility and at the three month assessment in Facility B. Two staff members, the primary care-givers for the subject being assessed, independently rated the subject using the ADL criteria outlined in Appendix G. The raters met with the experimenter prior to the assessment, were given instruction in the scoring criteria and content, and practiced in a simulated situation in which they rated a resident not included in the study. The two staff members then independently rated a l l subjects for which they were primary care-givers. In the experimental facility these assessments were conducted prior to the installation of the wall charts and provided the basis for the wall chart assessment. These wall chart assess-ments were not available to the raters at the six month assessment. In no case did staff members rate subjects more than once during the course of the study. Pearson product-moment correlations were used to compute inter-rater reliability and appear in Table 5. These correlations indicated substantial agreement between raters. Reliability was also computed between the mean rater score and the scores derived from the wall chart in Facility A at the six month assessment. Pearson correlations were above .97 on a l l measures and indicated considerable agree-ment between raters and wall chart assessments. Page 75 Table 5 Inter-Rater Reliability of ADL Assessments Facility A Facility B Dependent Measure Baseline 6 mon. Baseline 3 mon. 6 mon, Global ADL Skills .95 .97 .94 .95 .95 Dressing Skills .95 .96 .93 .94 .94 Eating Skills .95 .96 .97 .92 .98 Grooming Skills .89 .91 .89 .90 .90 Ambulation/transfer .95 .94 .90 .93 .92 Skills Page 76 Sample Attrition During the course of the study attrition occurred in both Facility A and B. This attrition was primarily due to the deterioration in functioning of a number of the subjects and necessitated transfer to more intensive care (extended care - see Appendix E). In a small number of cases death occurred while the subject was residing in the facility. In Facility A, seven subjects were transferred before the three month assessment while an additional eight subjects (6 transfers, 2 deaths) were lost between the three and six month assessment. Ten subjects (8 transfers, 2 deaths) were lost before the . three month assessment in Facility B as well as twelve subjects (11 transfers, 1 death) between the three and six month assessments. These subjects were not included in the data analyses. Generation and Standardization of Raw Scores The mean score of the two raters' assessments was used as the raw score for the purposes of the study. For the three month assessment in Facility A, raw scores were derived from the visual wall chart assessments. Since males and females were rated in a slightly different way in the areas of dressing, grooming and global ADL, scores on these measures were converted into standard scores with a mean of 0 and a standard deviation of 1. Data from the pre-treatment assessment was used as a basis for the conversion with male and female data conversion based only on pre-treatment scores of subjects of the same sex. Data analyses for grooming, dressing and global ADL used standard scores. Comparison of Pre-Treatment Assessments There were no significant pre-treatment differences between Facility A Page 77 and B on global ADL, dressing, groaning or eating raw score measures (see Table 6 ) . The medical charts had indicated that a significantly greater proportion of subjects were ambulatory i n F a c i l i t y A. This i s reflected i n a difference approaching s t a t i s t i c a l significance (t = -1.92, p<.06) between ambulation/transfer s k i l l scores computed for the two f a c i l i t i e s . A subject who i s independent and ambulatory receives a ndnimum score of 7 whereas one who i s independent i n transfers and mobility but confined to a wheelchair receives a ndnimum score of 10. Therefore, these two subgroups were analyzed separately. No significant pre-treatment differences were found on ambulation/ transfer s k i l l s i n these two subgroups between F a c i l i t y A and B (see Table 7 ) . Treatment Effects Treatment effects were analyzed with repeated measures analyses of variance for pre-treatment, 3 month and 6 month scores. Subsequent comparisons were performed using the Tukey Test. Mean scores on a l l measures over the three time period are presented in Table 8. The results of a series of repeated measures ANOVA appear in Table 9. These results demonstrated a significant main effect due to f a c i l i t y for global ADL (F = 7.17, p<.008), dressing (F = 4.19, p<.04) and groaning s k i l l scores (F = 9.23, p<.003). There was no difference between the two f a c i l i t i e s i n eating s k i l l scores (F = 1.43, p<.23). In the area of ambulation/transfer s k i l l s , no significant between group differences were found for subjects who were confined to wheelchairs (F <= 0.05, p<-:.82) or those who were ambulatory (F = 2.80, p<.10) . There P a g e 7 8 T a b l e 6 C o m p a r i s o n s o f p r e - t r e a t m e n t a s s e s s m e n t s ( " t r t e s t s l F a c i l i t y A F a c i l i t y B Mean S.D, Mean S,D, t r ^ a l u e G l o b a l ADL D r e s s i n g S k i l l s E a t i n g S k i l l s G r o o m i n g S k i l l s A m b u l . / t r a n s f e r 3 8.15 10,62 r a n g e 32-85 2 0,20 08,40 r a n g e 15-51 04.27 00.74 r a n g e 4-8 06,01 01,83 r a n g e 5-18 07.66 01,99 r a n g e 7-20 3 8 ,35 10,61, ^0.41 r a n g e 3 2-90.5 19.35 07 ,10 + 0 U 0 r a n g e 15r-51 04,27 00,97 +0,04 r a n g e 4-12 0 6 t 5 0 02^76 ^1^.54 r a n g e 5<rl8 08^12 0 l!96 ^ l ; 9 2 r a n g e 7-24 df 218 218 2. 0.8 9 218 0.42 218 0, 97 0 A,17 218 0;06 T a b l e 7 C o m p a r i s o n s o f A m b u l a t o r y and W h e e l c h a i r S u b j e c t s ( t r t e s t ) on E r e - T r e a t m e n t A m b u l a t i o n / T r a n s f e r S k i l l S c o r e s F a c i l i t y A F a c i l i t y B n Mean S.D. n Mean S.D. _ t - V a l u e d f p_ A m b u l a t o r y S u b j e c t s 100 07,13 0,43 78 7,20 0,54 -0,98 176 0.33 W h e e l c h a i r S u b j e c t s 12 12 , 60 3 . 81 30 i 0,70 2,05 +1 }43 4 0 0,16 Page 79 T a b l e 93 Summary of Mean S c o r e s F o r F a c i l i t y A and B* F a c i l i t y A F a c i l i t y B T l T2 T3 T l T2 T3 G l o b a l ADL** -0 , 08 -o . 25 -0 ,25 -0 :, 04 0 : i s 0 .32 Dres s i n g * * -0 . 03 -0 . 23 -0 .22 -0 .10 0 . i i 0 .26 Grooming** -0 ,14 -0 .23 -0 .21 0 . 08 0 . 26 0 ,25 E a t i n g 4 . 27 4 .20 4 .20 4 . 27 4 .68 4 .34 A m b u l a t i o n / t r a n s f e r A m b u l a t o r y S u b j e c t s 7 ,13 7 .20 7 , 24 7 .20 7 .36 7 ,67 A m b u l a t i o n / t r a n s f e r W h e e l c h a i r S u b j e c t s 12 . 00 10 .75 10 .42 10 . 70 11 ,52 11 .58 * H i g h e r v a l u e s r e f l e c t * * S t a n d a r d s c o r e s more n e g a t i v e r a t i n g s Page 80 Table 9 Repeated measures analyses of variance comparing ADL s k i l l scores over three assessment periods in Facility A and B Source MS df F E Global ADL Facility 19.53 1 7.17 .008 Assessment Time .54 2 2.24 .108 Facility Assessment Time 4.28 2 17.74 .001 Dressing Facility 10.25 1 4.19 .040 Assessment Time . .51 2 1.99 .140 Facility Assessment Time 4.55 2 17.65 .001 Grooming , Facility 25.34 1 9.23 .003 Assessment Time .15 2 .86 .424 Facility Assessment Time 1.28 2 7.29 .001 Eating .231 Facility 6.65 1 1.43 Assessment Time 1.92 2 .59 .560 Facility Assessment Time 3.16 2 .98 .383 Ambulation/transfer (Ambulatory Subjects) 1 2.80 .102 Facility 6.30 Assessment Time 3.79 2 3.43 .034 Facility Assessment Time 1.56 2 1.41 .251 Artibulation/transfer (Wheelchair Subjects) Facility 1.15 1 .05 .823 Assessment Time 1.07 2 .29 .754 Facility Assessment Time 15.02 2 4.01 .024 Page 81 was a significant main effect due to time of assessment for the ambulatory subject group in ambulation/transfer skills (F = 3.43, p<.03). Significant facility by time interaction effects also occurred for global ADL (F = 17.74, p<.001), dressing (F = 17.65, p<.001), grooming (F = 7.29, p<.001) and ambulation/transfer (wheelchair subjects) (F = 4.01, p<.02). The nature of the main effects and interactions are apparent from Figures 2 - 7 and from the Tukey tests performed on the data. Figure 2 shows the mean z-scores of the two groups on global ADL scores across the three assessment periods. Comparisons using the Tukey test indicated that there were no significant within group differences between pre-treatment, 3 month and 6 month assessments. The experimental group, however, was significantly better than the control group on the 3 and 6 month assessments (all p<.05). Mean z-scores for the two groups on dressing skills across the three assessment periods are shown in Figure 3. Again, witliin group comparisons failed to demonstrate any significant differences between assessment periods in either facility. There were no significant differences between the two groups before treatment or at the 3 month assessment. The experimental group, however, was significantly better than the control group at the 6 month assessment (p<-05). In the case of groaning skills (Figure 4 ) , significant differences in favour of the experimental group occurred between facilities at the 3 and 6 month assessments (all g<.05). No significant differences were found on any of the comparisons involving eating (Figure 5) or ambulation/transfer scores (Figure 6 and 7 ) . Page 82 Global ADL, dressing and grccming scores showed a similar pattern. Although, in each case, there were no significant within group differences, there was a trend towards improvement in the experimental group and increased dependence in the control group. Significant between group differences, in favour of the experimental group, were found on global ADL and grconing scores at the 3 month assessment and on global ADL, grooming and dressing scores at the 6 month assessment. Most professionals expect residents in geriatric facilities to show a steady decline in ADL across time. It appears from the trends shown in Figures 2 - 4, that the program's effectiveness was due to its ability to improve scores from the pre-treatment level while patients who did not receive the program became gradually more dependent and their scores increased. Page 83 F i g u r e 2 Group means ( z - s c o r e s ) f o r r a t i n g s on G l o b a l ADL o v e r t h e t h r e e t i m e p e r i o d s ( h i g h e r v a l u e s r e f l e c t more n e g a t i v e r a t i n g s ) + 0.44 + 0.3 + + 0.2-+ 0.1-0.0--0.1-T -0.2--0.3--0.4 + _^ — — F a c i l i t y B ' F a c i l i t y A 4 - 4_ 4_ b a s e l i n e 3 month 6 month Fig-uxe 3 Group means ( z - s c o r e s ) f o r r a t i n g s on D r e s s i n g S k i l l s o v e r t h e t h r e e t i m e p e r i o d s ("higher v a l u e s r e f l e c t more n e g a t i v e r a t i n g s ) + 0,3 +0.2 --+0.1 --0. 0 - --0.1 ---0.2 ---0.3 --—- — T a c i l i t y B 4- 4_ ba s e l i n e 3 month F a c i l i t y A 4-6 month F i g u r e 4 Group means ( z - s c o r e s ) f o r r a t i n g s on G r o o m i n g S k i l l s o v e r t h e t h r e e t i m e p e r i o d s ( h i g h e r v a l u e s r e f l e c t more n e g a t i v e r a t i n g s ) P a g e 84 + 0.3 — + 0.2 — + 0.1 — 0.0 — -0.1 — -0.2 — -0,3 — F a c i l i t y B F a c i l i t y A _1_ _1_ b a s e l i n e 3 -month 6 month F i g u r e 5 Group mean raw s c o r e s f o r r a t i n g s on E a t i n g S k i l l s ( h i g h e r v a l u e s r e f l e c t more n e g a t i v e r a t i n g s ) +4.7--+4 . 5 — +4.3--+4,1--. +3 . 9-T + 3 . 7--+ 3 . 5--F a c i l i t y B F a c i l i t y A b a s e l i n e 3 month 6 month Page 85 F i g u r e 6 Group mean raw s c o r e s f o r a m b u l a t o r y s u b j e c t s on A m b u l a t o r y / T r a n s f e r S k i l l s o v e r t h e t h r e e t i m e p e r i o d s ( h i g h e r v a l u e s r e f l e c t more n e g a t i v e r a t i n g s ) +7.70--+ 7 . 60- -+7.50--+7.40--+7.30--+ 7 .20--+7.10--Facility B Facility A i : 1 • * — b a s e l i n e 3 month 6 month F i g u r e 7 Group mean raw s c o r e s f o r W h e e l c h a i r s u b j e c t s on A m b u l a t i o n / T r a n s f e r S k i l l s o v e r t h e t h r e e t i m e p e r i o d s ( h i g h e r v a l u e s r e f l e c t more n e g a t i v e r a t i n g s ) + 12.5-+ 12. 0-1-+ 11.5-+11.0--+10.5--+ 10.0-*-Facility B 'acility A J b a s e l i n e 1 3 month I . . • 6 month Page Reduction and Improvement In Independent Fxinctioning Although the Tukey Test indicated that scores i n F a c i l i t y A were not significantly different across the three assessment periods, the pattern of individual scores indicated that a large number of subjects who received the program had gradually increasing scores. Table 1 0 indicates the number of subjects i n each f a c i l i t y whose global ADL increased or decreased by at least two points (the score needed to refle c t a change from red (total dependence) to green (total independence) on at least one activity, or vice-versa) over the course of the study. A Chi-square analysis indicated a significant difference i n the d i s t -2 ribution of scores between the two f a c i l i t i e s (X = 36.87, p<.001). The table shows that, for the experimental group, five times as many subjects improved instead of becoming more dependent while, i n F a c i l i t y B, three times as many subjects became more dependent than independent. The failure of the Tukey Test to show significant changes toward greater independence i s probably due to the fact that, while many subjects had small to moderate variations i n their scores, a few had huge differences from one test to another (e.g. because of a stroke or rapid recovery from a stroke). Page 87 T a b l e 10 Number of s u b j e c t s i n F a c i l i t i e s A and B showing improvement, m a i n t e n a n c e and i n c r e a s e d dependence i n G l o b a l ADL o v e r s i x months Improvement M a i n t e n a n c e I n c r e a s e d (< 2) Dependence (> 2) F a c i l i t y A 30 76 6 F a c i l i t y B 9 65 34 CHAPTER 8 DISCUSSION Despite the general acceptance of the e f f i c a c y of behaviour modification techniques, l i t t l e mention has been made of these procedures i n recent reviews of the c l i n i c a l psychology of aging (Busse and P f e i f f e r , 1973; Butler and Lewis, 1972) or i n the general textbooks on aging (Botwinick, 1973; Burnside, 1 976; Kimmel, 1973). Apart from those few studies referred to i n Chapter 3, there remains in gerontological theory and practice, a tendency to de-emphasize the ro l e of environmental contexts i n understanding e l d e r l y behaviour (Rebok and Hoyer, 1977). According to Hoyer (1973), behavioural d e f i c i t s in the el d e r l y are not immutable, but are p a r t i a l l y a function of environmental or expe r i e n t i a l d e f i c i e n c i e s which can be modified. Unfortunately, with the i n s t i t u t i o n a l i z e d e l d e r l y , r e i n f o r c i n g events are often non-existent or are contingent upon the exhibition of dependent behaviours. In a world of custodial care, dependency may be one of the few e f f e c t i v e behaviours available to a patient i n order to obtain some form of personal attention and recognition from the s t a f f . The CARE program attempted to influence and modify the environmental determinants of behaviour found with the i n s t i t u t i o n a l i z e d e l d e r l y . The re s u l t s demonstrated that t h i s program i s a fea s i b l e and p o t e n t i a l l y e f f e c t i v e treatment Page .8 9 approach and methodology. There was a s i g n i f i c a n t difference i n favour of the experimental group for the global ADL score, for dressing scores and for grooming scores. Although no s i g n i f i c a n t between group differences occurred before treatment, the experimental group was s i g n i f i c a n t l y more independent than the control group on each of these measures at the six month assessment. Content v a l i d i t y and treatment e f f i c a c y are inseparable concerns i n therapy research. According to Goldsmith and McFall (1975), "the ultimate measure of a program's content v a l i d i t y i s i t s therapeutic u t i l i t y ; conversely, therapy out-come inev i t a b l y depends on the v a l i d i t y of the program's content". The combined components of assessment, wall chart, r e h a b i l i t a t i o n and behaviour modification t r a i n i n g , taken together, demonstrated s i g n i f i c a n t therapeutic u t i l i t y . When the treatment group was compared to the control group i t was demonstrated that the CARE program was e f f e c t i v e i n preventing dependence and a c t u a l l y improved the l e v e l of independence of a number of residents. The CARE program exerted i t s influence on the environmental determinants of behaviour and i s consistent with those c h a r a c t e r i s t i c s i d e n t i f i e d by Baltes (1976) as necessary i n health care research with the e l d e r l y . This author states that Page 90 the type of research needed " i s one that demands clear i d e n t i f i c a t i o n of the target behaviours for intervention, that re d i r e c t s the intervention emphasis from b i o l o g i c a l to environmental behaviour va r i a b l e s , that tests the v a l i d i t y of behavioural interventions promptly i n i t s immediate and n a t u r a l i s t i c context, and that makes the patients or c l i e n t s active participants i n the process of health promotion and maintenance". Hoyer (1973) and others have recommended that researchers concern themselves not only with the immediate a l l e v i a t i o n of d e f i c i e n t behaviours but also with the prevention of future and further losses. This program, as a whole, demonstrated that increased maintenance can be achieved. The purpose of the program was to develop a l i v i n g environment where the contingencies of d a i l y l i f e encourage, rather than discourage, the performance of the a c t i v i t i e s of d a i l y l i v i n g which are within the residents' behavioural repertoire.-. To t h i s end, the program became a regular and permanent part of the i n s t i t u t i o n a l l i f e of the resident and r e f l e c t s Lindsley's (1 964). b e l i e f that operant techniques should be applied on a large scale i n the design of prosthetic environments which maintain competent performance i n the aged. Although operant techniques are generally applied singularly, t h i s study has demonstrated that they may be p a r t i c u l a r l y valuable as part of a 'package' treatment plan when attempting to modify and maintain ADL behaviours. A l l components may be Page 91 conceptualized as methods of conveying a behavioural expectation - an expectation which i s counter to both the s o c i e t a l 'sick-aged' role and the more immediate normative structure of the f a c i l i t y . Assessment The goals of long term health care, for the e l d e r l y are to improve and maintain the a b i l i t y of i n d i v i d u a l s to function independently and to cope with impairments and d i s a b i l i t i e s (Brody, 19761. This author believes that information on functional status, the degree to which a patient can carry out a c t i v i t i e s of d a i l y l i v i n g and other aspects of independent l i v i n g , i s necessary as a basis f o r assigning appropriate services to that i n d i v i d u a l - either to restore functioning, to improve functioning or at least to maintain functioning. Brody further believes that, since t h i s i s an objective of long term health care, i t must be evaluated. Chronic conditions are common among the i n s t i t u t i o n a l i z e d e l d e r l y and may be experienced as symptoms, i l l n e s s e s , handicaps, d i s a b i l i t i e s or impairments. Information about the patient's functional l e v e l s describes t h e i r health or i l l n e s s status and thus r e f l e c t s both their needs and outcomes (Katz and Akpom, 1 9 7 6 ) . The a c t i v i t i e s of d a i l y l i v i n g are well suited to t h i s kind of evaluation. The s p e c i f i c a c t i v i t i e s chosen for assessment i n this, study were behaviours that are most subject to deterioration, are d i r e c t l y influenced by attendant contact, are Page 92• ea s i l y observable and measurable and are appropriate targets f o r r e h a b i l i t a t i o n and maintenance. Regardless of whether reinforcement p r i n c i p l e s are employed, the emphasis placed on the measurement of observable behaviour and on the i n d i v i d u a l i z a t i o n of treatment has implications for most, i f not a l l therapeutic attempts. The assessment and scoring system used i n t h i s study was found to be a highly r e l i a b l e instrument. The use of t h i s kind of empirical data as a tool for planning and evaluating treatment has several advantages: i t provides needed information for patient care, i t increases accountability, i t measures behavioural changes and i t provides a means of comparing ind i v i d u a l behaviour at d i f f e r e n t stages of treatment and evaluating the effectiveness of treatment. The Wall Chart Current i n s t i t u t i o n a l structures such as nursing homes, f o r reasons both f i n a n c i a l and p r a c t i c a l , are not geared to deal with the i n d i v i d u a l , but rather with the average i n d i v i d u a l (Rebok and Hoyer, 1977). Understaffing, a common c h a r a c t e r i s t i c of most f a c i l i t i e s , makes i t d i f f i c u l t for st a f f members to know the .individual c h a r a c t e r i s t i c s of a l l patients that come under t h e i r care. Residents vary considerably in the i r a b i l i t y to perform the ADL's (Hoyer, 1974) and provision of the proper l e v e l of nursing care requires accurate, s p e c i f i c and complete information on each patient. There i s often, however, no e a s i l y accessible vehicle for systematic communication of assessment data between s t a f f . In many settings, the only r e l i a b l e information available i s the Page 93 request for assistance or help from the patient. While r e l i a b l e , these requests for help may not be v a l i d indices of the. ..actual performance capacity of the patient. The v i s u a l chart used i n t h i s study was designed to communicate the assessment information and treatment goals. I t shows detailed dressing, grooming, eating and ambulation/transfer s k i l l s . Colour coding was used to indicate the degree of independence and the amount of assistance needed i n each of the a c t i v i t i e s , as well as treatment goals. The wall chart, however, is,.'not considered an end i n i t s e l f . I t i s a beginning for f r o n t - l i n e s t a f f . I t i s a means of i n d i v i d u a l i z i n g the delivery of health care; i t helps i n communicating information i n a systematic way; i t creates an expectation of health promotion and maintenance. With these charts, s t a f f members are able to make use of behavioural data i n formulating and implementing treatment intervention. By s h i f t i n g the focus of s t a f f attention from negative attention-getting behaviours to more desirable a c t i v i t i e s , p o s i t i v e behaviours are more l i k e l y to increase. Behavioural and Rehabilitation Training It i s c l e a r l y desirable to have f r o n t - l i n e s t a f f involved in any therapeutic e f f o r t . Without knowledge of basic r e h a b i l i t a -t i o n and behaviour change techniques directed towards increasing and maintaining independence, f r o n t - l i n e s t a f f are often e f f e c t i v e i n promoting dependence rather than preventing i t s occurrence. According to Baltes and Zerbe (1976), "permanent changes from Page 94.. dependence to independence i n nursing home residents can be produced i f administrative and caring s t a f f change t h e i r 'attitude' toward nursing home residents, or, i n other words, are taught behavioural s k i l l s and management with the acceptance of the basic p r i n c i p l e that most behaviours, including undesired dependent behaviours i n the e l d e r l y are learned". One advantage of the operant approach i s that treatment i s ind i v i d u a l i z e d . Hoyer et a l (1974) have reported that, by trai n i n g s t a f f members to give contingent reinforcement and feedback, behavioural functioning i n the e l d e r l y can be restored. With the CARE program i t i s important to note that the reinforcement used was s o c i a l praise delivered by f r o n t - l i n e s t a f f who were part of the resident's everyday natural environment. The t r a i n i n g program and ADL treatment manual provided a means for s t a f f to incorporate behavioural p r i n c i p l e s and r e h a b i l i t a t i o n techniques into t h e i r everyday i n t e r a c t i o n with the residents. The effectiveness of i n s t i t u t i o n a l programs which employ behaviour modification strategies have recently come under increased scrutiny (Andrasik and McNamara, 1 977).. According to these authors, a common element underlying many of the problems with these programs i s the inadequate p a r t i c i p a t i o n of the s t a f f i n performing program related duties. The CARE program, however, i s the r e s p o n s i b i l i t y of the f r o n t - l i n e s t a f f and the interventions are carr i e d out so l e l y by these s t a f f . Recognition for t h e i r performance i s provided i n the weekly meetings through feedback on success in meeting targeted goals. P a g e 95 The e x p e r i m e n t a l / f a c i l i t y , a l t h o u g h d e m o n s t r a t i n g p o s i t i v e c h a n g e , d i d n o t show s i g n i f i c a n t i m p r o v e m e n t i n a n y o f t h e d e p e n d e n t m e a s u r e s u n d e r s t u d y . T h i s may n o t be a r e f l e c t i o n o f p r o g r a m e f f i c a c y , b u t r a t h e r , a c o n s e q u e n c e o f t h e l i m i t e d r e s o u r c e s a v a i l a b l e . No new s t a f f w e r e a d d e d , no r o u t i n e s w e r e c h a n g e d and no r e i n f o r c e m e n t c o n t i n g e n c i e s , o t h e r t h a n t h o s e a l r e a d y a v a i l a b l e i n t h e n a t u r a l e n v i r o n m e n t , w e r e i n t r o d u c e d . T h e s e f a c t o r s h a v e r e d u c e d t h e p o t e n t i a l s t r e n g t h o f t h e b e h a v i o u r a l i n t e r v e n t i o n . However, m o s t i n s t i t u t i o n s do n o t h a v e t h e s e k i n d s o f r e s o u r c e s a v a i l a b l e on a p e r m a n e n t b a s i s a n d t h i s s i t u a t i o n i s l i k e l y t o c o n t i n u e . The CARE p r o g r a m was d e s i g n e d t o be c o m p a t i b l e w i t h t h e l i m i t a t i o n s f o u n d i n m o s t i n s t i t u t i o n s f o r t h e e l d e r l y . I m p l i c i t i n p r o g r a m e v a l u a t i o n i s t h e n e e d t o d e v e l o p a more r e a l i s t i c a p p r e c i a t i o n o f t h e c o s t o f a p a r t i c u l a r p r o g r a m . Many i n n o v a t i v e d e m o n s t r a t i o n p r o j e c t s a r e e x p e n s i v e i n t e r m s o f n e c e s s a r y r e s o u r c e s a n d , t h u s , h a v e l i m i t e d g e n e r a l i z a b i l i t y t o m o s t l o n g t e r m c a r e f a c i l i t i e s f o r t h e e l d e r l y . O f t e n t h e human and non-human r e s o u r c e s a r e l a c k i n g and i t i s n e c e s s a r y t o o p t i m i z e e x i s t i n g r e s o u r c e s . M o s t f a c i l i t i e s a r e f r e q u e n t l y s o u n d e r s t a f f e d t h a t t h e p a t i e n t ' s h y g i e n e a n d f e e d i n g a r e o f c e n t r a l i m p o r t a n c e w h i l e r e h a b i l i t a t i o n p r o g r a m s a r e n o n - e x i s t a n t o r m i n i m a l . The CARE p r o g r a m s u c c e e d e d i n r e d i r e c t i n g a n d r e p r o g r a m m i n g t h e i n s t i t u t i o n f r o m a c u s t o d i a l t o a t h e r a p e u t i c Page 96 model of care. The program was implemented using already ex i s t i n g resources and created l i t t l e interference with the regular i n s t i t u t i o n a l routine or existing programs. The only additions to the i n s t i t u t i o n were the v i s u a l charts (approximately $0,03 each), ADL -manuals (approximately $2.50 each), as well as s t a f f t r a i n i n g i n r e h a b i l i t a t i o n and behaviour change. \ Bennett, Wilder, Blumner and Furman (1977)., remarked that few innovative treatment programs provided any indicat i o n whether they were incorporated into the routine services or programs of the i n s t i t u t i o n s i n which they were introduced. Without t h i s information, Bennett and his colleagues believe that i t i s d i f f i c u l t to assess whether these programs are i n t r i n s i c a l l y useful or whether they are successful for other reasons. The CARE program has become a regular and permanent part of the i n s t i t u t i o n a l l i f e of the residents at the experimental f a c i l i t y since the completion of the study. According to Brody et a l (1974), maintenance of gains can only be achieved by sustained treatment input. The CARE program was designed to provide a continuous and on-going treatment strategy. The f a c i l i t y has demonstrated a committment to the program. An orientation program has been developed for new st a f f and consists of a slide-tape presentation of the CARE program as well as various information o u t l i n i n g i t s procedures and use. The v i s u a l charts and an explanation of the program accompany the Rage 97 r e s i d e n t u p o n d i s c h a r g e t o a n o t h e r i n s t i t u t i o n . The c o n t r o l f a c i l i t y i s p r e s e n t l y i m p l e m e n t i n g t h e p r o g r a m and i t h a s b e e n i n s t i t u t e d i n a number o f d i f f e r e n t i n s t i t u t i o n s p r o v i d i n g v a r i o u s l e v e l s o f c a r e , i n c l u d i n g a c u t e and e x t e n d e d c a r e . A l s o , many r e q u e s t s h a v e b e e n r e c e i v e d f r o m v a r i o u s p a r t s o f t h e c o u n t r y f o r i n f o r m a t i o n on t h e p r o g r a m and t h e e x p e r i m e n t a l f a c i l i t y h a s b e e n v i s i t e d b y many i n t e r e s t e d g r o u p s w a n t i n g f i r s t h a n d k n o w l e d g e o f t h e p r o g r a m . The s u c c e s s o f t h e p r o g r a m i n c h a n g i n g t h e i n s t i t u t i o n t o a t h e r a p e u t i c m o d e l o f c a r e i s b a s e d on a number o f p r i n c i p l e s o u t l i n e d by R e p p u c c i (19731: 1. "A g u i d i n g i d e a o r p h i l o s o p h y , w h i c h i s u n d e r s t a n d a b l e t o , a n d p r o v i d e s hope f o r , a l l members o f t h e i n s t i t u t i o n , m u s t be d e v e l o p e d i n c o n j u n c t i o n w i t h t h o s e members", 2. "An o r g a n i z a t i o n a l s t r u c t u r e t h a t w i l l e n c o u r a g e c o n s i s t e n c y , c o m m u n i c a t i o n and c o o p e r a t i o n b e t w e e n v a r i o u s s t a f f members and b e t w e e n s t a f f a n d r e s i d e n t s i s a n e c e s s i t y " . 3. " D e c i s i o n m a k i n g m u s t i n v o l v e a l l l e v e l s o f s t a f f i n a m e a n i n g f u l f a s h i o n " . 4. " E m p l o y e e s m u s t be u t i l i z e d i n w h a t e v e r m a n n e r p l a y s t o t h e i r s t r e n g t h s and f i l l s p r o g r a m n e e d s , r e g a r d l e s s o f p a p e r q u a l i f i c a t i o n s o r j o b s p e c i f i c a t i o n s " . Page 98 The CARE program has implemented these p r i n c i p l e s e f f e c t i v e l y . The guiding idea of the program i s that the a c t i v i t i e s of d a i l y l i v i n g are appropriate targets for r e h a b i l i t a t i o n and, since they are d i r e c t l y influenced'by s t a f f contact, i t i s c l e a r l y desirable to have regular s t a f f involved in any treatment e f f o r t . The v i s u a l chart was designed to encourage consistency, communication and cooperation between various s t a f f members and between the st a f f and residents. Front-line s t a f f are exposed to a tr a i n i n g program that provides them with s p e c i f i c s k i l l s that have d i r e c t implications for resident care and treatment. They are also given the r e s p o n s i b i l i t y f o r choosing the goals for r e h a b i l i t a t i o n . Regardless of job s p e c i f i c a t i o n , a l l s t a f f can play a ro l e i n the program. Targets for r e h a b i l i t a t i o n are such that they can be e a s i l y accomodated into each s t a f f member's work routine. The major d i f f i c u l t y i n the early stages of the project was an i n i t i a l resistance on the part of some s t a f f members to the program's goals. These s t a f f , who were i n the minority, held the be l i e f that l i t t l e could be done for the aged residents and any e f f o r t s to do so were f u t i l e . These attitudes changed, however, as these s t a f f soon began to see that some residents were improving and that co-operation \ among. s t a f f had increased. The peer pressure to function as part of the 'team' and to maintain consistency created an informal contingency for behaviours compatible with the CARE program. An example of t h i s was one sta f f member who i n i t i a l l y c r i t i c i z e d the procedures but, i n the Page- 9 9.-l a t e r s t a g e s o f t h e s t u d y , became a g r o u p l e a d e r . Some u n e x p e c t e d b e n e f i t s a l s o became e v i d e n t a s t h e s t u d y p r o g r e s s e d . A number o f t h e s u b j e c t s i n t h e e x p e r i m e n t a l g r o u p c o m p e t e d w i t h e a c h o t h e r i n g a i n i n g g r e e n d o t s on t h e i r w a l l c h a r t s . W i t h many o f t h e s u b j e c t s , t h e i m p r o v e m e n t e x p r e s s e d o n t h e i r w a l l c h a r t s became a t o p i c o f c o n v e r s a t i o n . Many o f t h e f a m i l i e s became i n t e r e s t e d i n t h e p r o g r a m and some became a c t i v e t r e a t m e n t a g e n t s i n p r o m o t i n g m a i n t e n a n c e and r e h a b i l i t a t i o n . ; . P h y -" s i c i a h s - . .valso f o u n d t h e v i s u a l c h a r t s u s e f u l i n m o n i t o r i n g a n d c o m m u n i c a t i n g h e a l t h s t a t u s . The s p e c i f i c c o n t r i b u t i o n s o f t h e i n d i v i d u a l p r o g r a m c o m p o n e n t s w e r e n o t a s s e s s e d . F u t u r e r e s e a r c h m u s t make t h i s a s s e s s m e n t a n d t h e n r e f i n e a n d e x t e n d t h e p r o g r a m t o i n c r e a s e i t s e f f e c t i v e n e s s . L o g i c a l d i r e c t i o n s f o r e x p a n d i n g t h e p r o c e d u r e s w o u l d be t o : 1. P r o v i d e s t a f f w i t h more t r a i n i n g and i n s t r u c t i o n , m a k i n g u s e o f ' b o o s t e r ' s e s s i o n s . The t r a i n i n g p r o g r a m was n e c e s s a r i l y l i m i t e d i n t h i s s t u d y and f u r t h e r r e s e a r c h s h o u l d make u s e o f f i l m s , v i d e o t a p e a n d more e x t e n d e d t r a i n i n g and p r a c t i c e s e s s i o n s . 2. P r o v i d e a d d i t i o n a l s t a f f whose s o l e r e s p o n s i b i l i t y i s t o t h e p r o g r a m . The CARE p r o g r a m was l i m i t e d b y t h e u s e o f e x i s t i n g r e s o u r c e s a nd e f f e c t i v e n e s s may be i n c r e a s e d b y a d d i t i o n a l r e s o u r c e s s u c h a s a d d i t i o n a l s t a f f s p e c i f i c a l l y t r a i n e d i n t h e CARE p r o g r a m a s w e l l Page .1 00 as r e h a b i l i t a t i o n and behaviour modification procedures. 3, Use other, more powerful forms of reinforcement. Social praise was used as reinforcement i n the present study. Future research might attempt to better equate reinforcement with in d i v i d u a l factors and therefore, i n d i v i d u a l i z e treatment plans to a greater extent. 4. Test the effectiveness of the program with newly admitted residents, residents at d i f f e r e n t l e v e l s of care, and i n conjunction with d i f f e r e n t treatment programs, A research l i m i t a t i o n of t h i s study i s that treatment s t a f f were also the primary raters for a l l ADL measures. One must, therefore, question the extent of observer bias i n reporting ADL assessments. There are, however, several factors that lend support to the argument that observer bias was minimal. Inter-rater r e l i a b i l i t y of assessments was quite high i n the experimental f a c i l i t y , both at pre-assessment (.89 - .95) and post-assessment (.91 -.97) and corresponded to the i n t e r - r a t e r r e l i a b i l i t y scores obtained from the control f a c i l i t y . Observer bias would most l i k e l y have led to a reduction i n r e l i a b i l i t y since each rater would have based the assessment on t h e i r own i n d i v i d u a l biases rather than on a common factor such as actual functioning status. Secondly, the mean rater scores correlated very highly with Page 1 0 1 w a l l c h a r t a s s e s s m e n t s (,97 t o . 9 9 ) , A v i t a l c omponent o f t h e CARE p r o g r a m was t h e v a l i d i t y o f t h e s e w a l l c h a r t a s s e s s m e n t s . • The c h a r t r e f l e c t e d t h e a g r e e m e n t o f a l l s t a f f o n t h e f u n c t i o n i n g s t a t u s o f e a c h s u b j e c t a n d t h e c h a n g e s t h a t o c c u r r e d o v e r t i m e . I t w o u l d c e r t a i n l y h a v e b e e n e x p e r i m e n t a l l y a p p r o p r i a t e t o h a v e u s e d i n d e p e n d e n t o b s e r v e r s , o t h e r t h a n t h e t r e a t m e n t s t a f f , i n r a t i n g t h e s u b j e c t s i n F a c i l i t y A. However, t h e r e w e r e c e r t a i n l i m i t a t i o n s i n t h e f e a s i b i l i t y o f t h i s a p p r o a c h . P r i m a r i l y , t h e r e s o u r c e s n e c e s s a r y w e r e n o t a v a i l a b l e t o t h e i n v e s t i g a t o r . Had t h e y b e e n , i n d e p e n d e n t r a t e r s o b s e r v a t i o n s may n o t be a c c u r a t e r e f l e c t i o n s o f d a y t o d a y f u n c t i o n i n g b u t , r a t h e r , i s o l a t e d i n s t a n c e s o f p o t e n t i a l f u n c t i o n i n g . Many r e s i d e n t s h a v e t h e c a p a b i l i t i e s t o be more i n d e p e n d e n t t h a n i s u s u a l l y d i s p l a y e d . S t a f f , t o o , may c h a n g e t h e i r p a t t e r n o f ' d o i n g f o r ' a n d a t t e n d i n g t o t h e r e s i d e n t . N o v e l s i t u a t i o n s w i t h u n f a m i l i a r i n d i v i d u a l s i n a t t e n d a n c e a r e l i k e l y t o p r o d u c e n o v e l e f f e c t s , b o t h o n t h e p a r t o f r e s i d e n t s and a t t e n d a n t s a l i k e . A l s o , t h e n e c e s s a r y i n v a s i o n s o f p r i v a c y w o u l d h a v e p o s e d e t h i c a l a n d p r o c e d u r a l p r o b l e m s i n many c a s e s . A l t h o u g h t h e p r e s e n t s t u d y f o c u s e d on t h e r e h a b i l i t a t i o n a n d m a i n t e n a n c e o f s p e c i f i c ADL, i t d e m o n s t r a t e d a u s e f u l m e t h o d o l o g y t h a t c o u l d be u s e d f o r t h e a s s e s s m e n t a nd c o m m u n i c a t i o n o f b e h a v i o u r a l c o m p e t e n c e i n o t h e r p r o b l e m b e h a v i o u r s o f t h e e l d e r l y ( i n t e r p e r s o n a l s k i l l s , s o c i a l i n t e r a c t i o n , c o n f u s i o n , e t c . ) . Page. ,1.0.2 Future r e h a b i l i t a t i o n e f f o r t s could use t h i s methodology to develop programs to deal with many of the prevalent behaviour problems i n the i n s t i t u t i o n a l i z e d e l d e r l y . Page 103 BIBLIOGRAPHY Andrasak, F. arid McNamara; J.R. 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Psychological functioning of older people i n i n s t i t u t i o n s and i n the community. New York: National Council on Aging, 1967. Ullman, L.P. and Krasner, L. A psychological approach to abnormal behavior. Englewood C l i f f s , N.J.: P r e n t i c e - H a l l , 1969. Vroom, J.H. Work and motivation. Chicago: Wiley, 1964. WEaver, H., McPhee, M. and Lambert, P. G e r i a t r i c s Report. Vancouver Regional Hospital D i s t r i c t , 1975. Weissman, M.M., Prusoff, B. and Pincus, C. Symptom patterns i n depressed patients and depressed normals. Journal of Nervous and Mental Disease, 1975, 160, 1, 15-23. Yates, J.E. Measuring the q u a l i t y of l i f e . B r i t i s h Journal of Occupational Therapy. 1976, 34, 12, 18-19. A P P E N D I X A A D L V I S U A L E X P L A N A T I O N Page .11 4 DRESSING SKILLS LOCATION - UPPER LEFT SECTION OF CHART ABILITY TO PUT ON ' DOT PANTS ABILITY TO PUT ON DOT DRESS . ABILITY TO PUT ON 1 DOT BRASSIERE j (FEMALES ONLY) ' ABILITY TO PUT ON DOT UNDERPA17JB ' ABILITY TO PUT ON"^  DOT OPEN-FACED GARMENT ABILITY TO PUT ON DOT SHOES DOT - ABILITY TO TAKE OFF PANTS DOT - ABILITY" TO TAKE OFF DRESS DOT , -DOT ABILITY TO TAKE OFF BRASSIERE (FEMALES ONLY) DOT - ABILITY TO TAKE OFF UNDERPANTS ABILITY TO TAKE OFF OPEN-FACED GARMENT DOT - ABILITY TO TAKE OFF SHOES Page 115 DRESSING SKILLS (CONT'D) ABILITY TO PUT ON 'SCCKS/STOCKINGS ABILITY TO DO UP LACES ABILITY TO DO UP BUTTONS DOT CATEGORY SYMBOL - DRESSING DOT REPRESENTS THE ABILITY TO SELECT AND ASSEMBLE CLOTHING AMBULATORY/TPANSFER SKILLS LOCATION - LOWER LEFT SECTION OF CHART Page 6 ABILITY TO USE A DOT DPRIATE) WHEELCHAI &^ ABILITY TO TRANSFER INTO BED ABILITY TO TRANSFER INTO CHAIR ABILITY TO TRANSFER ONTO TOILET ABILITY TO TRANSFER OUT OF BED • ABILITY TO TRANSFER OUT OF CHAIR DOT . - ABILITY TO TRANSFER OFF OF TOILET DOT CATEGORY SYMBOL - AMBULATICN/TRANSFERS DOT REPRESENTS ABILITY TO WALK WITH OR WITHOUT AIDS GROOMING SKILLS TDCATION - UPPER RIGHT SECTION OF CHART Page _1J DOT : - ABILITY TO WASH HANDS DOT : - ABILITY TO WASH FACE DOT : - ABILITY TO COMB AND DO UP HAIR DOT i - ABILITY TO SHAVE (ELECTRIC OR MANUAL - MALES.ONLY) DOT ; - ABILITY TO BRUSH TEETH OR CLEAN DENTURES DOT ABILITY TO TAKE SELF TO TOILET WHEN NECESSARY AND CLEANLINESS (NOT PHYSICAL TRANSFER) CATEGORY SYMBOL - GROOMING DOT REPRESENTS ABILITY TO FIND WAY TO WASHING AREA (NOT USED AS PART OF RESEARCH CRITERIA) DOT EATING SKILLS Page 118 LOCATION - LOWER RIGHT SECTION OF CHART DOT - ABILITY TO USE A SPOON DOT ; - ABILITY TO USE A FORK DOT - ABILITY TO USE A KNIFE DOT - ABILITY TO USE A CUP OR GLASS CATEGORY SYMBOL - EATING DOT REPRESENTS ABILITY TO FIND WAY TO DINING AREA (NOT USED AS PART OF RESEARCH CRITERIA) DOT INDEPENDENT T i m m LEGEND NEEDS SUPERVISION LOCATION - UPPER RIGHT CORNER - ALSO INCLUDES PATIENT'S NAME AND NEEDS TOTAL HELP PROSTHETIC AIDS USED TARGET FOR REHABILITATION APPENDIX B ADL TREATMENT MANUAL Page J20 PUTTING ON DRESS (FRONT BUTTONING) Pg.13 PUTTING OH DRESS (PULLOVER) Pg. 16-17 PUTTING ON TROUSERS Pg. 8-10 £AXING OFF TROUSERS Pg. 10 BACK-FASTENING BRA Pg. 11-12 UNDERPANTS Pg. 8-10 PUTTING ON SHIRT Pg. 13-14 TAKING OFF SHIRT Pg. 15 PUTTING ON SHOES Pg. 18 PUTTING ON SOCKS (STOCKINGS) Pg. 19-20 LACES Pg. 21 BUTTONS Pg. 22 Page 121 MOVING FROM WHEELCHAIR TO TOILET Pg.23-24 MOVING FROM TOILET TO WHEELCHAIR Pg.25-2b MOVING FROM WHEELCHAIR TO BED Pg.27-2t; MOVING FROM BED TO WHEELCHAIR Pg.29-30 MOVING FROM WHEELCHAIR TO CHAIR Pg. 31 MOVING FROM CHAIR TD WHEELCHAIR Pg. 32 TRANSFERING FROM WHEELCHAIR TO STANDING TRANSFERING FROM STANDING TO WHEELCHAIR Pg. 33-3 PR. 35 0 f ° ° \ ( A ) J^!iiitiii.ii[iiiiiiiifii;iiiS.iuj1 m *L 1 Bid Page 1 2 2 H A N D W A S H I N G P g . 4 3 - 4 4 F A C E U J A 5 H I N G P g .. 45t*49 H A I R C O M B I N G P g . 5 0 - 5 1 S H A V I N G T O O T H B R U S H I N G P g . 5 2 - 5 6 T O I L E T I N G U S E OF S P O O N P g . 3 6 - 4 0 U S E OF F O R K P g . 41 Page 123 1 A Guide to the A c t i v i t i e s of Daily L i v i n g (ADL). Methods as described i n t h i s booklet are generally applicable to the r e s i -dents of and always are only intended as a guide. A l l persons should be i n d i v i d u a l l y assessed and appropriate methods used for them. Poor muscle strength, l i m i t e d j o i n t mobility, confusion or, perhaps, a combin-ation of these factors w i l l :causei.lack of achievement of independence i n a c t i v i t i e s of d a i l y l i v i n g . A c t i v i t i e s of Daily L i v i n g , where indicated, should be started and encouraged as soon as possible a f t e r assessment. The green area of the v i s u a l schematic designates independence i n that a c t i v i t y and should be treated by the s t a f f as such. The blue area of the v i s u a l display i s the target for r e h a b i l i t a t i o n by a l l the s t a f f coming into contact with the resident. Most people w i l l regain some strength and mobility with any a c t i v i t y . Most important of a l l , a f t e r achievement of an a c t i v i t y to be r e h a b i l i t a t e d , they w i l l regain or maintain t h e i r s e l f - r e s p e c t . With any such program, a c t i v i t -i e s should be simple enough and j u s t enough help should-:be given to ensure that the person w i l l succeed. Once the person has succeeded, congratulate him on t h i s and encourage him to continue. Never chastize or c r i t i c i z e someone who i s progressing, or i s i n fact regressing i n the a c t i v i t i e s of d a i l y l i v i n g . Page 124 2 Things to Remember 1. Spoken i n s t r u c t i o n s must be clear and simple. Staff should demonstrate while speaking. I t may be necessary to repeat over and over again, always allowing time f o r the resident to respond. Make sure you have the r e s i d e n t v s attention and that they understand you. 2. Work slowly. Try and try again. Accomplishment of each part of the a c t i v i t y i s an achievement. 3. Work with the person at the appropriate time and i n the appropriate place, i . e . , dressing i n person's bedroom. 4. Devices and aids should be used only when necessary. 5. When standing and/or s i t t i n g balance i s poor some a c t i v i t i e s can be performed when l y i n g . Page 125 Techniques f o r R e h a b i l i t a t i o n  Shaping Shaping by successive approximations i s o f t e n u s e f u l i n teaching a complex behaviour or a c t i v i t y . I n the procedure the d e s i r e d a c t i v i t y i s broken down i n t o a s e r i e s of smaller steps which are necessary f o r mastery of the f i n a l response or a c t i v i t y . Each smaller response i s p r a i s e d by s t a f f u n t i l i t i s under the c l i e n t ' s c o n t r o l . G r a d u a l l y , more and more accurate approx-imations of the f i n a l response are required before p r a i s e i s d e l i v e r e d , u n t i l g r a d u a l l y , the e n t i r e response i s learned. Thus, the r e s i d e n t should be taught a complex a c t i v i t y i n successive steps — w i t h each step g r a d u a l l y l e a d i n g to an approximation of the d e s i r e d t a r g e t behaviour. For example, i n teaching a r e s i d e n t to use a f o r k p r o p e r l y , p r a i s e may i n i t i a l l y be given f o r simply h o l d i n g the f o r k i n the r i g h t hand. L a t e r , p r a i s e i s given only when the r e s i d e n t b r i n g s the f o r k to h i s mouth, then i n s e r t i n g the f o r k i n t o h i s mouth, then using the f o r k to p i c k up food and put i t i n h i s mouth, and so on. The idea i s : Don't wait f o r a p e r f e c t execution before dispensing p r a i s e . During t r a i n i n g , p r a i s e each s m a l l successive approximation of the d e s i r e d behaviour — that behaviour marked i n blue. As you can see the steps are l i s t e d i n order from the l a s t step i n the procedure, which the r e s i d e n t performs f i r s t , to the f i r s t step, which the re s i d e n t performs l a s t . The reason f o r t h i s i s that i n developing most new behaviours we s t a r t w i t h teaching the l a s t step and then work backward Page 126 4 through the step-wise progression. We do t h i s because we sant the r e s i -dent to have maximum opportunity to pr a c t i c e those steps which always lead to completion of the a c t i v i t y . There are f i v e very important points to remember i n developing a new behaviour. 1. Reward the resident with your praise each time he su c c e s s f u l l y completes a step. We want to maximize the resident's opportunity for success and the receiving of praise and minimize h i s f a i l u r e s . We want the resident to learn i n a.;positive way and, thereby, help him him b u i l d up h i s self-confidence. Be c a r e f u l , however, not to praise the resident for f i n i s h i n g the same step over and over. The resident must also learn that he has to continue to make progress even i f i t i s slow — i f he i s to receive praise. 2. The most basic aspect of the r e h a b i l i t a t i o n a c t i v i t y should be taught f i r s t . Refinements i n the a c t i v i t y should be taught only a f t e r the basic behaviour i s learned. 3. I f the resident has d i f f i c u l t y mastering a p a r t i c u l a r step, break up the step into smaller components so that the resident can s t i l l experience suc-ess. Let us suppose that a resident i s to be r e h a b i l i t a t e d f o r 'putting on pants' and that he cannot p u l l up h i s pants from j u s t below h i s waist. What could we do to make the learning experience a p o s i t i v e one for him? We could break up the step into smaller components. For example, we could place our hands over the resident's hands and help him p u l l up his pants. In t h i s way, he p a r t i c i p a t e s i n the learning process and his behaviour also Page 127 5 leads to success and praise. We could then repeat t h i s step u n t i l the r e s i -dent learns what to do, and then gradually withdraw our assistance — making sure the resident s t i l l experiences success. T e l l the resident what you want him to do before he a c t u a l l y performs the behaviour. You eventually want the resident to learn to perform the complete a c t i v i t y without always having to praise him for doing i t . To accomplish t h i s , i t i s necessary for the resident to learn to respond to your i n s t r u c -tions. The easiest way for him to learn t h i s i s to pa i r your i n s t r u c t i o n s with h i s performance of the various steps. The performance of steps by the resident should always be followed with praise. The number of steps i n an a c t i v i t y i s l a r g e l y determined by the resident's own c a p a b i l i t i e s and the s t a f f ' s subjective evaluation of how many steps there should be i n the program. The general r u l e i s to l e t the resident's behaviour guide you i n determining how many steps there should be and when add i t i o n a l steps should be added. In t h i s manual you w i l l n o tice that most of the a c t i v i t i e s of d a i l y l i v i n g are broken down into a serie s of smaller steps which are necessary components of the t o t a l a c t i v i t y . Staff should determine at which step the resident i s at i n the series (which steps they are able to complete independently) and then continue to work on the remaining steps, one at a time, u n t i l the f i n a l response i s achieved. These steps may be broken down further i n order for the resident to achieve some success at every stage along the way to independence. Page 128 6 Modeling One of the most e f f e c t i v e procedures for teaching a new behaviour to a resident involves f i r s t demonstrating the behaviour yourself and then p r a i s i n g the resident for s u c c e s s f u l l y t r y i n g to imitate what you did. Modeling often reduces the amount of time a resident needs to learn a p a r t i c u l a r behaviour. Modeling may be employed to teach new behaviours by providing the opportunity for the resident to observe the behaviour without taking an immediate r i s k himself. Therefore, at each step i n the s e r i e s leading to the f i n a l behaviour show them how you would do i t . Demonstrate each step i n the behaviour or a c t i v i t y slowly and p r e c i s e l y and make sure they are paying attention. Explain to them as you demonstrate. Make sure the resident i s watching and can see what you are doing. Rehearsal Rehearsal allows the resident to 'try out' new responses i n simulated s i t u -ations without r i s k i n g f a i l u r e ; i t provides the opportunity f o r s e l f - c o r r e c t i o n and feedback from others; i t permits the a n t i c i p a t i o n of d i f f i c u l t problems and the rehearsal of ways of handling them. Rehearse the step of behaviour you are concentrating on with the resident. Have him repeat the behaviour (with assistance .if required) u n t i l he learns to do i t . P r a c t i c e makes perfect! Praise Praise i s what may be c a l l e d s o c i a l reinforcement. People enjoy being praised or reinforced and i t has been found to increase the occurrence of those Page 129 7 responses i t i s directed towards. Thus, when one praises a person for doing 'a good job', a c h i l d for f i n i s h i n g h i s dinner, or a resident showing inde-pendent behaviour, i t has been found that a person does 'a good job', a c h i l d does f i n i s h h i s dinner, and a resident does show independent behaviour on future occasions. Praise can be a powerful t o o l i n increasing the occurrance of a behaviour, e s p e c i a l l y one that i s being taught or relearned. Therefore, as the resident approximates the desired behaviour that you are teaching, he should be praised for doing so. I f he does not progress, say nothing. Do not c r i t i c i z e as t h i s w i l l have a detrimental e f f e c t . Examples of praise are the following: "Good"; "Very Good"; "I Like that"; "That's good"; "You did a good job"; "You did i t . Very good"; "Thank you", "Thank you very much". "I'm glad you did that"; "I appreciate what you have done"; "That's r i g h t " ; "Fine" "I'm so pleased with you", "I'm proud of you" Page 130 8 Dressing Trousers/Underpants (when s i t t i n g ) PUTTING ON TROUSERS Silting on side of bed, with strong hand cross weak leg, pull right pants leg over weak loot. If sLimliii" balance against bed with-out Mipporl of strong hand is possible, Maud leaning against bed for support anil pull up p:i"<s w i U l s l r o n S h a n J ' Place strong foot in left pants leg and pull pants up as far as possible. • J[ patient cannot stand without sup-port, lie down and proceed as illus-trated in steps 3 and 4. • If patient can stand without support, proceed to step 2a. • 3. L ie down; bend strong knee and hip pushing strong foot against bed to raise hips. Pul l pants up over hips. - - f l 4. Fasten front of pants. Note: If patient cannot cross legs, he car. rest his weak fool on a small stool to assist in this activity. 1 . Place one l e g over the knee of the other l e g . (If t h i s i s d i f f i c u l t -with the 'strong hand grasp the ankle or j u s t behind the knee .-ind l i f t the weaker l e g over the knee of the strong leg.) .2. S l i p the trouser l e g (underpants) over the foot that i s elevated. 3 . Insert the other foot Into the trouser/underwuar (Use Step 1 i f necessary). Page 131 9 4. Work the trousers/underwear up to the knees. 5. Work the trousers/underwear up to the hips. 6. Stand i f possible. 7. P u l l up trousers to waist. 8. Tuck i n s h i r t . 9. Close the zipper and waist button. I f balance does not permit standing, s i t and place one hand at the lower end of the f l y to sta b a l i z e the zipper before c l o s i n g . Techniques 1. Shaping - Remember to s t a r t with step 9 and work backwards, making sure that the resident achieves success at each step. I f success cannot be achieved at a p a r t i c u l a r step, break that step down into smaller steps thus increasing the chances for success. 2. Ins t r u c t i o n s . - Remember to i n s t r u c t the resident at every step. This i s accomplished with verbal i n s t r u c t i o n s . 3. Modeling - Demonstrate to the resident the step you want him to accomplish. 4. Rehearsal - Allow the resident to p r a c t i c e the step over and over without Page 132 10 c r i t i c i s m u n t i l in- ;;ut.s i t r i g h t . 3. l ' r a i s c - Kcincinbcr to pr a i s e the resident eacli time he s u c c e s s f u l l y completes a step and to say to him, "(Name), p u l l up your pants". Right before he begins to p u l l his pants up. You may have to prompt the resident a few times at various points to help him completely learn a p a r t i c u l a r step. NOTIi: To undress, reverse the procedure. TAKING OFF TROUSERS If standing balance is good enough, stand leaning against Ix-d with strong leg and pull trousers down. 2. Sit on side of bed. Push left • pants leg olf strong leg. 3. Cross weak leg and pull pants off weak leg. la. If standing balance.is poor, lie down in bed. Unfasten trousers. Bend strong knee and hip pushing strong fool against bed to raise hips. Tush panis down below hips.. Note: Foot stool may be useful in this activity. Page 133 11 9 Hl'.'lHSlUL'U PUTTING OH A BACK-FASTENING BRA 2. Turn bra around into proper position. Willi strong hand place weak hand in-side right strap and pull strap up weak arm. cc bra around waist with k in from. Fasten hooks. 3. Insert strong hand in left strap; pull strap up strong arm lo shoulder. 4. Tush right strap up arm to shoulder. Adjust bra. Tighten, straps if neces-sary. 1. Pick up brassier and bring one end behind bnck (upright). 2. Hook the brassier i n front a t waist. 3. Slide i t around to the back. C 4. Put one a n (weaker one) through the shoulder strap. Page 134 12 5. Put the other arm (stronger one) through the strap. 6. Place both straps i n proper p o s i t i o n . Techniques 1. Shaping - s t a r t with step 6 and work backwards. 2. Instructions 3. Rehearsal 4. ! Praise NOTE: To undress, reverse the procedure. Page 135 13 Front F u l l y Opening S h i r t s , S W C J . I , Dresses , and Jackets PUTTING ON A SHIRT (OR DRESS) I. Spread shirt on lap inside up and collar away from body. 6, ^.•le: Piessing while silting cm kiilc (if bed is easier than in whcckliair if balance is good. IF HAI .ANO- IS POOR. IIAVF. PATIP.NT SIT IN \Vlli:i I.CIIAIK OK H H A V Y A R M C H A I R TOI>KI:SS. A n •ipcn-down-ihc-front dress, sweater or coal is put nn live same way as a shirt hut it is necessary lo slam! tip and straighten the skirt before it can he fastened. l_argc buttons arc easier lo fasten than snaps. V.\ 2. Using strong hand place weak hand in rigln e \ armhole and pull sleeve up weak arm. 3.. Throw; the rest of the garment behind body and pull right sleeve all Ihc way up 4. Rciich behind with strong hand, and place it in left armhole. Work sleeve into position. I. Hold collar on neck where label i s located. .*. Allow li> straighten by shaking. 3. Tlacc t h e ».tncnt on the lap with the collar towards the waist and trout down. A. f u t ane fcand inside aleove and work i t over the oibow. Page 136 14 5. Work the garment over the shoulder. 6. Leaning forward, grasp the edge of the neckline and bring the rest of the garment behind the body. 7. Put the other arm into i t s arm hole and work the sleeve on. 8. Button s t a r t i n g with bottom button. Techniques 1. Shaping - begin with step 7 and work backwards. 2. Instructions 3. Modeling 4. Rehearsal 5. Praise 0 Page 137 1 5 l i u T u undress, reverse Llie procedure. TAKING OFF A SHIRT (OR DRESS) Using strong hand push shirt oil weak shoulder. • A. Using strong hand grasp right cud and pull right sleeve off weak arm. 2. Grasp middle or left front edge of shirt and pull it out to the side pulling slii: I o!F strong shoulder. 3. Work strong arm out of left sleeve. (It may be helpful lo tuck tail of shirt under hip when removing strong arm from sleeve.) -Techniques 1. Shaping 2. Inst r u c t i o n s 3. Modeling 4. Rehearsal 5. Praise Page 138 16 P u l l - Over Garment (Dress, Sweaters, etc.) 1. Place garment on the lap with the f roht ;'f acing downcand the .bottom' towards, you waist. 2. Gather the garment up the back. 3. Place one arm i n the sleeve and push the sleeve up past the esbow. 4. Put remaining arm into i t ' s sleeve 5. Gather the garment up the back — lean forward and p u l l garment over head. 6. P u l l garment down the body with hands. Techniques 1. Shaping - Remember to s t a r t with Step 6 and work backwards, making sure that the resident achieves success at each step. I f success cannot be achieved at any of the 6 steps, break down the step i n question into smaller steps so that success may then be achieved. 2. Instructions - Remember to i n s t r u c t the resident at each step. This i s accomplished with verbal i n s t r u c t i o n s . 3. Modeling - Demonstrate to the resident the step you want him to accomplish. Page 139 17 Rehearsal - Allow the resident to pr a c t i c e the step over and over without c r i t i c i s m u n t i l he gets i t r i g h t . Encourage him to p r a c t i c e . Praise - Remember to praise the resident each time he suc c e s s f u l l y completes a step. NOTE: To undress reverse the procedure. Page 140 1 8 I'M l l i nn nn Shoes I'liniNG Oil SHOES • le: Sew tongue to lop s ' , 1 , c •'' 0 1 1 0 s ' ' ' c picecnl it from doubling under. When ice is aliachcd to shoe, he sure that leg is front of hraec when placing fool in shoe. i f fV i ron i : hniul. cross the weak leg so ijWeak loo! is within easy reach. Slip uic on the foul as far as possible. 2. If shoe cannot he completely slipped on foot, place ii shoe horn al the heel and push up on the heel of the shoe lo lit the fool into the shoe. I*lace the other shoe on the floor. Slip the strong foot into the shoe. Use a shoe • horn lo prevent rolling in of the leather. 3. If the foot does not go into the shoe easily, place the foot on the floor and push down on the knee being careful lo keep the shoe horn in place. Note: Footstool may be useful in this ac-tivity. Techniques I. Shaping, .'. Ins t ruc t ions t. fkidi.-i in,; t>. Jtohcarsal . . l'rnise. . KUTK; To undress reverse the procedure. Page 141 19 S l o c k in ; ;s ( s o c k s ) PUTTING ON SOCKS 1-2. Using the strong liaml, cross weak leg so that foot is free anil in easy ic.acli of strong hand. Using strong hand hold sock at front or the opening and pull over weak foot. Place weak foot on lloor. I 1 \ K I S O C K S or i ; . W i l l i •.hour hand, i IOSS weak leg as shown in 2 and i c n i i n c sock. Tiovs s.i• • •• i;; leg. as shown in 3 and re-move other siick. 3. Cross strong leg so that fool is free and in ease reach of strong hai"l. Using sluing hand pull oliier sock ovei sluing foot in same manner. Note: II" P A T H - N T ' S U A I . A N C I l IS N O T C.OOI). I I A V I ; IIIM S i r IN Will-1.11.-C I I A I I i O K A R M C H A I R . I'ootslool may be useful. 1. C r o s s o n e l e g , o v e r t h e o t h e r ( I f p r o b l e m , p l a c e w e a k e r l e g o v e r t h e s t r o n g o n e ) . 2 . Open t h e t o p o f t h e s t o c k i n g by i n s e r t i n g a hand ( s t r o n g hand) i n t o t he c u f f . 3 . U i t l i e r i n s t o c k i n g s up Co t h e h e e l . 4 . Work t h e s t o c k i n g o n t o t h e f o o t e n s u r i n g t h a t t h e r e a r c no w r i n k l e s l e f t . Page 142 20 5. Place the foot on the f l o o r . 6. P u l l the stockings up. 7. Fasten the garter. NOTE: Round garters should never be used as they may Impair c i r c u l a t i o n . Techniques 1. Shaping - s t a r t with Step 7 and work backwards. 2. Instructions - show them the manual i f necessary. 3. Modeling 4. Rehearsal 5. Praise I ' u L L i i i j ; <>n l a c e s TYING A SHOE ONE-HANDED Free end ying a shoe one-handed: a. Knot one e«wl of (lie shoe- string and lace the shoe leaving the knotted end at the Inwvsl eyelet. Iv In the lop eyelet feed the end of the shoe sii ing from outside lo inside and throw the end over the top of the laces. c. Make a loop in the free end of the shoe lace and pull i i loop within a loop as shown in-2. d. Pull the laec light (King careful not to pull the free end all the way through. e. To untie, pull the free end. Note: lilaslic shoelaces arc available but arc not preferred if patient can lie laces. The above type of shoes arc preferable to loafers. Technic, ucs 1 . Shaping, 2. i n s t r u c t i o n s 3. Modeling, ti. Rehearsal 5. 1 'raise Buttons Bring fingers of dominant hand to bottom button. Manipulate button back and f o r t h . Place other hand at appropriate button hole. Bring button hole close to button. S l i p button i n s i d e button hole. Repeat procedure with next button proceeding upwards Techniques Shaping - begin with Step 5 Instructions Modeling Rehearsal Praise Page 145 23 llovjn;; from Wlieclcliiii' Lo T o i l e t MOVING FROM WHEELCHAIR TO TOILET 'osition wheelchair facing the loilct. Irakcs on. font rests up. c: Wall liar can he used for support, pali inl can he taught lo unfasten his • ^ j k ' v f o i c getting out of I lie whccl-ihev fall when he si.mils, cinalc palienl can si a ml in front of miotic instead of silting down im-lialelv aiul either lean against the wall nisii her strong leg against (lie com-ic for suppoii lo free her strong hand allelic her clothing. Nnic. If a liar is needed on the other side of I he commode and there is no wall lo attach il to. consider usin^ a i ighl angle bar as illustrated on the next page. 3. Place, strong hand on wall liar (or on far side of toilet seal if no wall bar is present). 4. Lean forward, turn on strong fool and slowly sit down on toilet seal. 1 . P o s i t i o n whee lchair f a c i n g the t o i l e t . 2. P lace brakes o n , foot r e s t s up. 3. Stand up. rj.-tct!'»trong hand on w a l l bar (or on f a r s ide o f t o i l e t s ca t i f no w a l l bar i s p r e s e n t ) . 5. Lean . forward, turn on s t r o n g foot . Page 146 24 6. Slowly s i t down on t o i l e t seat. Techniques 1. Shaping - Remember to s t a r t with Step 6 and work backwards, making sure that the resident achieves success at each step. 2. Instructions - Remember to i n s t r u c t the resident at every step. This i s accomplished with verbal i n s t r u c t i o n s . 3. Modeling - Demonstrate to the resident the step you want him to accomplish. 4. Rehearsal - Allow the resident to p r a c t i c e the step over and over without c r i t i c i s m u n t i l he gets i t r i g h t . 5. Praise - Remember to praise the resident each time he su c c e s s f u l l y completes a step. Movini; Croin Toilet to Wheelchair Page 147 7 5 25 MOVING PROM TOILET TO WHEELCHAIR 1. Position wheelchair facing toilet. Brakes locked, footicsts up. r : While the patient is sitting on the toilet ran pull his tiousers up above his knees. As T^K he can spread his knees so that the wi!' ••"! fall. Then l e can lean against wall or push the strong leg back against the it for support and use the strong hand lo pull trouseis up ihe rest of the way. Also the its can be buttoned to the shirt and they will ie up when he stands. Suspenders if used u 111 be placed over the shoulders before iding. Place strong hand on wall bar (or or right armrest of wheelchair if no wall bai is present). Stand up as in Number (•. Place strong hand on left armrest of whcelch.iii turn on strong fool ami slowly sit down in wheelchair. 1. P o s i t i o n wheelchair f a c i n g t o i l e t . Brakes locked, foot r e s t s up. 2. Place strong hand on w a l l bar (or on armrest of wheelchair i f no w a l l bar i s present).. 3 . Stand. Page 148 26 4. P l a c e strong hand on l e f t armrest of wheelchair, t u r n on r i g h t f o o t . 5. Slowly s i t sown i n wheelchair. Techniques 1. Shaping - s t a r t w i t h Step 6 and work backwards. 2. /I n s t r u c t i o n s 3. Modeling 4. Rehearsal 5. P r a i s e Page 149 27 a Moving [ r u i n W h e e l c h a i r to ttod MOVING FROM WHEELCHAIR TO BED I. l-'ace wheelchair toward head of bed. Keep fionl corner of chair (on palienl 'rslrong side) as close lo bed as possible as wheelchair is shown in No. 2. I'osilion Hie wheelchair so ! ihe patient sils near the center of the bed, ^/s closer to the fool for a tall person. Lock V \ brakes, lift foot rests. H i c • l . I l o i w a r d . l i n n on strong foot and slowly l . 'i' .rl l o Mtl i l lg position. 2. Assume standing position from wheelchair (as in Number d ) . 3. Move strong hand 10 edge of bed for support. J . P o s i t i o n c h a i r f r o m m i d d l e t o f o o t o f bed w i t h s t r o n g s i d e n e a r e s t t o t he b o d . Move t o w a r d s t h e f r o n t o f t h e c h a i r . I P e d a l s up 11 leaks on DI. tt 2 . S i t w i t h f e e t w e l l u n d e r n e a t h a n d s t r o n g hand on the a rm o f t h e c h a i r . Page 150 28 3. Stand up by leaning forward and pushing with the strong hand and l e g . Balance. 4. Put the strong hand on the bed. Turn so that backs of legs are against the bed. 5. S i t . 6. Put the strong leg under weaker leg. In one motion swing legs on to bed and l i e back on the pi l l o w . 7. Grasp the top of the bed with the strong hand and bend the knee. P o s i t i o n yourself i n bed. Techniques 1. Shaping-- Remember to s t a r t with Step 7 and work backwards. 2. "Ihstfuctlohs 3. Modeling 4. .Rehearsal 5. TPraise 0 Page 15J halving from Bed l o Wheelchair • 2 9 MOVING INTO A WHEELCHAIR FROM THE BED lace whcclchaiV al slight angle In bed. on patient's !rong side, facing fool of bed. Keep the right front ninor of the chair as close lo the hcil as possible s shown below.* Ilrakcs locked. I voolrcsls up. In vjrn.il i . 1 ' V - d t - ' t ir V/HfcElCHAIR Note-. A n armchair can he used by the bed instead of a wheelchair, A chair that is heavy enough not lo slide and with a linn scat thai is not too soft or too low will IK suitable. Keep feel beneath body. Iran forward placing strong hand near edge of bed and push lo standing position keeping weight well over strong fool. When standing position is steady enough for mo-mentary release of support by strong hand, move strong hand lo farther arm rest of wheelchair. Keeping body weight well forward, l inn <*n slo-iig foot and lower to silting position. 1. Chair i s po s i t i o n e d from Middle to head of bed at a s l i g h t angle. Brakes oil. 2. Res ident puts s t r o n g foot under weaker ank le and aoves towards the edge o f Che bed. 3 . Res iden t grasps edge o f Mattress, s l i d e s l e g s over s i d e o f bed a t the Page 152 30 _•. .same time r o l l i n g on to the strong side and s i t t i n g up. 4. Push to an upright p o s i t i o n . Balance on side of bed with feet f i r m l y on the f l o o r and apart. P o s i t i o n feet so that t i p s of toes are i n l i n e with front of knees. 5. Put hand on edge of bed and stand up. 6. Place strong hand on the nearest arm of the chair, balance, change strong hand to other arm of chair. 7. Turn so that back of legs are against the chair. 8. S i t . Techniques 1. Shaping - Remember to s t a r t with Step 8 and work backwards. 2. Instructions / 3. Modeling 4. Rehearsal 5. ' Praise Page 153 31 Mn vj HI; I! rum Winn Lcliair Lo Armchuji MOVING FROM WHEELCHAIR TO 1. Place llie front corner of the wheelchair (on the patient's strong side) as close lo the arm-chair as possible, shown in illustrations 1 and 2 above. Brakes on, foolrcsts up. ARMCHAIR 3. Place strong hand on farther arm of armchair. Page 154 32 Moving I row Armchair Lo Wheclcha: i o MOVING FROM ARMCHAIR TO WHEELCHAIR 0 Page 155 33 Transferring from Wheelchair to Standing 1. Apply both brakes, "securely. 2. L i f t the pedal on the strong side with the strong foot. 3. S l i d e the weaker foot on to the f l o o r using strong foot or hand and l i f t the pedal. 4. Move towards the front of the chair. Bring the feet under the knees u n t i l the t i p s of the toes are i n l i n e with the knees. Ensure that both feet are f l a t on the f l o o r and s l i g h t l y apart. 5. Place both hands on chair arms and lean forward. 6. Stand by pushing with strong leg and arms simultaneously and using other arm and leg when possible. 7. Balance. Grasp salking a i d . Balance. Walk. Techniques 1. Shaping 2. Instructions 3. Modeling 4. Rehearsal 5. Praise Page J 5 6 34 FROM WHEELCHAIR TO STANDING . 0*. brakes ami lift footrcsls. Place (eel inW^ oi l ' l i t Unor close to chair, with liecl of ihe strong loot slightly back and directly be-neath the edge of scat. e: If patient is tall, be probably cannot stand t while holding armrest, l i e will have belter, nice leaning lo the strong side and slightly vard. 2. Move forward in the wheelchair. Place Strong hand on front part of armrest. Lean forward over strong leg and push to standing position with stroiie arm and leg. Stand as straight as possible; hold left arm rest for balance and support. Keep feel slightly separated for belter balance. Page 157 35 Transferring from Standing to Wheelchair 1. Approach facing the wheelchair. 2. Ensure that brakes are secure and pedals are up. 3. P o s i t i o n walking a i d . 4. Place the strong hand diagonally across on the arm of the chair. 5. Turn u n t i l the backs of the knees touch the chair. 6. S i t down slowly. 7. Push with strong arm and leg u n t i l comfortable p o s i t i o n i n chair. Techniques 1. Shaping 2. Instructions 3. Modeling 4. Rehearsal 5. Praise Page 158 36 Program for Independent Eating. Use of Spoon. Try to use only foods that the resident l i k e s . Throughout the program, praise the resident for h i s progress. 1. Put the resident's hand around the handle portion of the spoon and gently wrap you hand over h i s . 2. A s s i s t the resident i n scooping the food and bringing the food to h i s mouth. Scoop food i n a motion toward the resident. 3. A f t e r the resident receives the food, continue to hold h i s hand gently i. and d i r e c t h i s hand (and the spoon) back to the food. 4. Repeat Steps 2 and'3. 5. While repeating Steps 2 and 3, gradually begin to loosen your grip on the resident's hand j u s t before he puts the food i n h i s mouth. Maintain t h i s loose grip u n t i l a f t e r the resident has received the food, then return h i s hand (spoon) to the food with the o r i g i n a l amount of guidance. 6. Repeating .Steps\2 and' 3, graduallyMoosen/you grip on the resident's hand j u s t a f t e r he puts the food on h i s spoon. Don't l e t go of h i s  hand, j u s t loosen you g r i p . Maintain the loose grip u n t i l a f t e r the resident has received the food, then r e d i r e c t h i s hand and the spoon to the food with the o r i g i n a l amount of guidance. Page 159 37 7. Repeat Step '.6, except loosen your grip even more when you return h i s hand to the plate. Don't l e t go of his hand. 8. Repeat Step 7 except also loosen your grip even more j u s t before he places the spoon i n his mouth. 9. Repeat Step 8. except t h i s time l e t go of h i s hand completely j u s t ; c ': as the spoon enters h i s mouth. Retake h i s hand witfr.yburvloose grip immediately a f t e r he receives the food i n h i s mouth. 10. Repeat Step 9, except now place you hand j u s t under h i s wrist immediately before he places the spoon i n h i s mouth. Retake h i s I..-:., hand with the loose grip and bring i t back to the pla t e . 11. Repeat Step 10, except move your hand under the resident's wrist about halfway between the 'scoop' and h i s mouth. 12. Repeat Step 11, except move your hand under h i s forearm about one quarter of the way. 13. Repeat Step 12-with your hand under h i s forearm about one quarter of the way. 14. Repeat Step 13, except move your hand under the resident's wrist a f t e r the food enters h i s mouth and then guide h i s hand back to the pla t e . Page 160 38 15. Repeat Step 14 except place your hand under h i s forearm a f t e r the food enters the mouth. At t h i s point, there should be firm pressure on the resident's hand only when scooping the food. There should only be gentle forearm pressure for a l l other movements. 16. Repeat Step 15 except move your hand to the resident's wrist while he i s scooping food. ( You may have to gently guide him at f i r s t by grasping h i s hand. ) 17. Repeat Step 16 except move your hand to j u s t under the resident's elbow immediately a f t e r he scoops the food. A f t e r he receives the food, keep your hand under h i s elbow, guiding the spoon back to the pl a t e . 18. Repeat Step 17 except l e t go of the resident's hand and arm completely about three-quarters of the way up from the scoop to h i s mouth. Continue guiding the return of the spoon to the food by placing your hand under h i s elbow. 19. Repeat Step 18 except l e t go of the resident's hand and arm ha l f way between the scoop and h i s mouth. 20. Repeat Step 19 except l e t go of the resident's hand and arm one-quarter of the way between the scoop and h i s mouth. 21. Repeat Step 20 b u t - l e t go completely j u s t a f t e r he makes the scoop. You may have to touch h i s hand gently to s i g n a l him to move the spoon. Page 161 39 to h i s mouth. His return to the plate should s t i l l be elbow guided. 22. Repeat Step 21 except place your hand on the resident's elbow while he's scooping. 23. Repeat Step 22 except l e t go of the residents elbow on the return t r i p to the p l a t e . (You may have to touch h i s hand gently to s i g n a l him to return spoon to food) 24. Repeat Step 23 except l e t go of the resident's elbow completely. (You may have to guide the resident's hand at various points at f i r s t ) As the resident continues to p r a c t i c e t h i s step, gradually remove any prompting. I f the resident drops the spoon at any point a f t e r he has held the spoon without assistance (Step 10), the food and then the resident should be immediately removed from the table. One hour l a t e r , the resident should be given another opportunity to feed himself using t h i s program. Ad d i t i o n a l Comments: 1". „ While using t h i s program i t i s a good idea to use a bib which has a pouchlike l i p at the bottom. This type of bib usually catches most of the food which s p i l l s out of the spoon. 2. I f the resident has repeated d i f f i c u l t y holding the spoon over a num-ber of sessions, you may want to consider modifying the spoon's shape Page 162 40 to further help him. For example, you can enlarge the handle of the spoon by wrapping adhesive tape around i t . Then, as the resident develops s k i l l i n holding the spoon, you can gradually remove some of the tape u n t i l he i s again using a spoon with a 'normal' handle. See Hazel Broadley about other modified spoons. I f at a l l possible, you  should only use a modified spoon on a temporary basis. As the resident develops expertise i n using the modified spoon, you should gradually begin introducing him to the use of a normal spoon.. Techniques 1. Shaping - Start with Step 1 and proceed slowly to step 24 ensuring that resident succeeds at each and every step along the way. 2. Instructions - Remember to i n s t r u c t the resident at every step. 3. Praise - Remember to praise the resident each time he suc c e s s f u l l y completes a step. Page 41 Program f o r Independent Eating — Use of Fork This program w i l l follow the same format as that of the "Use of Spoon". Replace "spoon" with "fork" when following program. Try to use only foos that the resident l i k e s . Throughout the .program praise the resident for h i s progress. Page 164 42 Program for Independent Eating — Use of Knife Since most residents who are dependent, i n the use of a k n i f e are hemiplegic due to a stroke — see the Occupational Therapist about modified knives used f or cutting and spreading. Page 165 43 Program for Independent Handwashing. Throughout the program, praise the resident f o r any progress. Also, reward him at the end of each session with an appropriate amount of h i s favourite food or drink i f possible. 1. Bring the resident to the bathroom and stand him i n front of the sink. Say to him, "(NAME), wash your hands". 2. Guide him i n turning on the appropriate amount of hot and cold water to achieve a warm water temperature. 3. A s s i s t him i n picking up the soap and gripping i t i n one hand. 4. Bring h i s hands under the water. 5. Move his hands back and f o r t h over the soap, thus creating a lath e r . 6. Place soap back i n soap dish and move hands to d i s t r i b u t e the lath e r to a l l parts of the hands. 7. Rinse lat h e r o f f with water. 8. Turn o f f water. 9. Use towel to dry hands and face. Page 166 44 Techniques Shaping - Remember to s t a r t with Step 9 and work backwards, making sure that the resident achieves success at each step. Instructions - Remember to i n s t r u c t the resident at every step. This i s /^accomplished -with '.verbal i n s t r u c t i o n . Modeling - Demonstrate to the resident the step you want him to accomplish. Rehearsal - Allow the resident to p r a c t i c e the step over and over without c r i t i c i s m u n t i l he gets i t r i g h t . Praise - Remember to praise the resident each time he suc c e s s f u l l y completes a step and say to him, "(NAME), wash your hands" j u s t before he begins to wash his hands. You may have to prompt the resident a few times at various points to help him completely learn a p a r t i c u l a r step. As the resident progresses, gradually withdraw your guidance i n these a c t i v i t i e s — u n t i l he can perform them by himself. Page 167 45 Program for Independent Face Washing. Throughout;; the program, praise the resident f o r any progress. Also, reward him at the end of each session with an appropriate amount of h i s favourite food or drink i f possible. 1. Bring the resident to the bathroom and stand him i n front of the sink. Say to him, "(NAME)", Wash your face." Then turn on the water. 2. Bring the resident to the bathroom and have him stand i n front of the sink. Say to him,"(NAME), Wash your face." Then guide him i n turning on the appropriate amount of hot and cold water to achieve a warm water tempera-ture. A s s i s t him i n cupping h i s hands, i n bringing h i s cupped hands under the water, and then i n patting h i s face with the warm water (t h i s process should be performed i n one continuous motion). 3. Repeat Step 2. A f t e r the resident pats hi s face with the water, continue to hold h i s cupped hands and gently d i r e c t them back to the water. 4. Repeat Step 3. 5. While repeating Step 3, gradually begin to loosen your grip oh the resident's cupped hands j u s t before he places the water on his face. Maintain the loose grip u n t i l a f t e r he has placed the water on his face; then return his hands to the water with the o r i g i n a l amount of guidance. Page 168 46 6. Repeat Step 3, but t h i s time gradually loosen your grip on the resident's hand j u s t a f t e r he gets water i n h i s hands. Don't l e t go of his hands, merely loosen you gr i p . Maintain t h i s loose grip u n t i l a f t e r he has patted his face with the water, then r e d i r e c t his hands to the water with the o r i g i n a l amount of guidance. 7. Repeat Step 6, except also loosen you grip on his hands as you return h i s hands to the water. 8. Repeat Step 7, except t h i s time loosen you grip on h i s hands even more, without l e t t i n g go of h i s hands e n t i r e l y . 9. Repeat Step 8, except l e t go of his hands j u s t as he splashes the water on h i s face, retaking h i s hands with you loose grip immediately a f t e r he f i n i s h e s splashing h i s face. 10. Repeat Step 9, except place your hand j u s t under h i s wrist immediately before he pats water on his face. There should be no support of his hands while he i s splashing h i s face but you should retake h i s hands with the loose grip and bring them back to the water. 11. Repeat Step 10, except move your hand under the resident's wrist about three-quarters of the way between the water and h i s face. 12. Repeat Step 10, except move you hand under the resident's wrist about h a l f way between the water and his face. Page 169 47 13. Repeat Step 10, except move your hand under the resident's wrist about one-quarter of the way between the water and h i s face. 14. A s s i s t the resident i n cupping h i s hands and bringing h i s cupped hands under the water; Then as you guide the resident's hands (at the wrist) to his face, move your hand to h i s forearm about three-quarters of the way between the water and h i s face. 15. Repeat Step 14,^except move your hand under the resident's forearm about h a l f way between the water and h i s face. 16. Repeat Step 14, except move you hand under the resident's forearm about one-quarter of the way between the water and hi s face. 17. Repeat Step 14, except t h i s time move you hand to the resident's wrist r i g h t a f t e r he splashes h i s face. 18. Repeat Step 14, except place your hand under the resident's forearm r i g h t a f t e r he splashes h i s face. (At t h i s point there should be firm pressure on the resident's hands only as he begins to cup the water. Gentle fore-arm pressure should be present for a l l other movements.) 19. Repeat Step 14,~.except move your hands to the resident's wrist j u s t as he i s cupping h i s hands. (You may have to guide him gently f i r s t by gripping h i s hands.) Page 170 48 20. Repeat Step 14, except move your hand to j u s t under the resident's elbow ju s t as he cups h i s hands. Af t e r t h i s , continue to have your hand under his forearm and gently guide him through the other motions. 21. Repeat Step 20, except l e t go of the resident's forearm completely about three-quarters of the way from placing water i n his hands. Continue guiding the return of his hands to the water by placing your hands under his elbow. 22. Repeat Step 20, except l e t go of the resident's hand and arm halfway between the water and h i s face. 23. Repeat Step 20, but l e t go of the resident's hand and arm one-quarter of the way between the water and h i s face. 24. Repeat Step 20, but l e t go completely j u s t a f t e r the resident places water i n his hands. You may have to touch h i s hand gently to si g n a l him to move his hands to h i s face. His retutn to the water should s t i l l be elbow guided. 25. Repeat Step 20, except do not guide the resident's arm back to the water.' (You may have to prompt the resident occasionally.) Remember to say, "(NAME), wash your face", and to praise the resident f o r the successful completion of each step. Page 171 49 I f you wish to teach the r e s i d e n t to wash h i s face w i t h soap and/or a washcloth, you can extend t h i s program using the same graduated format. You can a l s o apply t h i s program ( a f t e r minor m o d i f i c a t i o n ) to teaching the r e s i d e n t to wash other parts of the body, e.g., neck, underarms. At the end of each s e s s i o n a s s i s t the r e s i d e n t i n t u r n i n g o f f the water and i n using a towel to dry h i s face and hands. As the r e s i d e n t progresses, g r a d u a l l y withdraw your guidance i n these a c t i v i t i e s — u n t i l he can perform them by h i m s e l f . Page 172 50 Program f o r Independent Hair Combing Make sure that you use a comb which can be e a s i l y handled by the resident. Throughout the program praise the resident for any progress. Also reward the resident at each step with small amounts of h i s favourite food or drink i f p ossible. Pick up the comb and place i t i n the resident's hand, cuping you hand over h i s . Say to the resident, "(NAME), .comb.:ybur h a i r . " 4 Repeat Step 1 and guide the resident's hand and comb to the resident's h a i r . Repeat Step 2 (again saying, "(NAME), comb your h a i r . " ) ; then, while holding h i s hand over the comb, comb the resident's h a i r i n accordance with your preference. Repeat Step 3 except s l i g h t l y loosen your grip on the resident's hand. Repeat Step 3 except loosen your grip even more. Repeat Step 3 except gradually move you hand to the resident's wrist and continue guiding h i s h a i r conbing. Repeat Step 6 except move your hand to the resident's w r i s t . Loosen your grip s l i g h t l y so that he can have the opportunity to move the comb. Page 173 51 Repeat Step 6 except move your hand j u s t under the r e s i d e n t ' s elbow. Continue guiding him whenever i t seems necessary. Repeat Step 8 except remove your guidance completely. (You may have to guide the r e s i d e n t o c c a s i o n a l l y . ) Remember to say, "(NAME), comb your h a i r . " , and to p r a i s e the r e s i d e n t each time he s u c c e s s f u l l y completes a step. You may have to prompt the r e s i d e n t a few times at va r i o u s p o i n t s to help him reach complete mastery. Page 174 52 Program f o r Independent Toothbrushing Throughout t h i s program praise the resident f o r any progress. Also reward the resident at the end of the session with an appropriate amount of h i s favourite food or drink. 1. Bring the resident to the washroom and place h i s toothbrush and a tube of open toothpaste d i r e c t l y i n front of him. T e l l the resident, "Pick up the tube of toothpaste and place some toothpaste on the toothbrush." I f the resident follows t h i s i n s t r u c t i o n , go to Step 10. I f he does not follow t h i s i n s t r u c t i o n , gently cover h i s hands with yours and guide him i n spreading the toothpaste on the toothbrush and then place the toothpaste down (the toothbrush should be placed i n h i s preferred hand)i 2. Repeat Step 1, except loosen your grip on the resident's hand. 3. Repeat Step 1,' except loosen your grip even more, but do not l e t go of v h i s hand. 4. Repeat Step 1, except place your hand j u s t under the resident's wrist immediately before he places the toothpaste on the toothbrush. Continue guiding him from t h i s p o s i t i o n and p r a i s i n g him (you may have to grasp one of h i s hands i n i t i a l l y to help him spread the toothpaste). 5. Repeat Step 1, except move your hand down toward the middle of the resident's arm. Continue guiding him and p r a i s i n g him for making progress. Page 175 53 6. Repeat Step 5, except remove your hands from h i s arms immediately before he places the toothpaste down (you may have to guide him occasionally on thi s and l a t e r steps.) 7. Repeat Step 5, except remove your hand from h i s arms immediately before he f i n i s h e s putting the toothpaste on the toothbrush. 8. Repeat Step 5, except remove your hands j u s t as he begins placing the tooth-paste on the toothbrush. 9. Repeat Step 1. (You may have to guide him gently at times u n t i l he develops mastery of the s k i l l . ) 10. A f t e r the resident s u c c e s s f u l l y completes Step 1 or Step 9, he should be to l d , "Now I want you to brush your:.teeth." I f the resident does not follow t h i s i n s t r u c t i o n , then you should gently cover h i s hands with yours and guide his hand through the following sequence: a. Turn the water on i n the wash basin to a moderate degree and then bring h i s hand slowly toward h i s mouth. b. Touch the toothbrush b r i s t l e s to his teeth and move the toothbrush up and down on the outer surface of h i s front teeth f o r 5 to 10 seconds. (Avoid placing undue pressure on the resident's gums.) c. Then gently move the toothbrush to one side of the resident's mouth (the resident's preferred side) and brush t h i s side for 5 to 10 seconds i n an up-and-down motion. d. iThen gently move the toothbrush to the other side of his mouth and brush Page 176 54 th i s side f or 5 to 10 seconds i n an up-and-down motion. e. Then gently move the toothbrush to the bottom surfaces of h i s top teeth on h i s preferred side and brush them for 5 to 10 seconds. f. Then gently move the toothbrush to the bottom surfaces of h i s top teeth on the other side and brush them for 5 to 10 seconds. g. Then guide h i s hand and toothbrush to the upper surfaces of h i s bottom teeth on h i s preferred side and brush them for 5 to 10 seconds. h. Then guide h i s hand and toothbrush to the upper surfaces of h i s bottom teeth on the other side and brush them for 5 to 10 seconds. i . Then guide the resident i n brushing the i n s i d e surfaces of h i s bottom .teeth. j . Then guide him i n brushing the i n s i d e surfaces of h i s top teeth, k. Then guide the toothbrush out of h i s mouth and back toward the wash basin. 1. Place the toothbrush under the water, r i n s e i t o f f , and put i t down, m. Then encourage the resident to s p i t out the toothpaste which has remained i n h i s mouth, n. Then guide him i n picking up a cup, f i l l i n g i t with water, r i n s i n g out h i s mouth, and placing the cup back down, o. And, f i n a l l y , guide him i n turning o f f the water and wiping h i s face and hands with a towel. 11. Repeat the sequence presented i n Step 10, except loosen your grip on the res ident '• s. hands 12. Repeat the sequence i n Step 10, except loosen your grip even more. DO NOT LET GO OF HIS HAND. Page 177 55 13. Repeat the sequence i n Step 10, except place your hand j u s t under the r e s i d e n t ' s w r i s t immediately before he places the toothbrush i n h i s mouth. Continue guiding him from t h i s p o s i t i o n and p r a i s i n g him f o r doing w e l l . Retake h i s hand a f t e r he i s f i n i s h e d using the toothbrush i n h i s mouth. 14. Repeat the sequence i n Step 10, except move your hand j u s t under h i s w r i s t about three-quarters of the way up between the wash b a s i n and h i s mouth. Retake h i s hand a f t e r he i s f i n i s h e d using the toothbrush i n h i s mouth. 15. Repeat the sequence i n Step 10, except move your hand j u s t under h i s w r i s t about h a l f way up between the wash b a s i n and h i s mouth.. Retake h i s hand a f t e r he i s f i n i s h e d using the toothbrush i n h i s mouth. 16. Repeat the sequence i n Step 10, except move your hand under h i s w r i s t about one-quarter of the way up between the wash b a s i n and h i s mouth. "Leave your hand i n t h i s p o s i t i o n a f t e r he i s f i n i s h e d w i t h the toothbrush i n h i s mouth. (You may have to regrasp h i s hand o c c a s i o n a l l y to a i d him i n :: r i n s i n g the toothbrush.) 17. Repeat the sequence i n Step 10, except move your hand under the r e s i d e n t ' s forearm about three-quarters of the way up between the wash b a s i n and h i s mouth. Leave your hand i n t h i s p o s i t i o n a f t e r he i s f i n i s h e d w i t h the toothbrush i n h i s mouth (again, you may have to guide him ge n t l y through the remainder of the sequence). 18. Repeat the sequence i n Step 10, except move your hand under the r e s i d e n t ' s Page 178 56 forearm about h a l f way up between the wash basin and h i s mouth. (Again, leave your hand i n t h i s p o s i t i o n throughout the remainder of the sequence, although you may have to retake h i s hand at c e r t a i n times to further guide him.). 19. Repeat the sequence i n Step 10, except move your hand under the resident's forearm about one-quarter of the way between the wash basin and h i s mouth. Leave your hand i n t h i s p o s i t i o n throughout the remainder of the program. 20. Repeat step 10 (you may have to gently guide the resident throughout various v. :parts:of the sequence u n t i l he develops expertise i n brushing h i s teeth). 21. Repeat steps 1 and 10 (again, you may have to guide the resident occasionally u n t i l he develops complete mastery of these s k i l l s ) . Remember to praise the resident each time he completes a step and su c c e s s f u l l y brushes h i s teeth. excerpts of t h i s manual are taken from: Up and Around: A Booklet to Aid the Stroke Patient i n A c t i v i t i e s of Daily L i v i n g . U.S. Government P r i n t i n g O f f i c e , Washington, 1972. Morris, R.J. Behavior Mod i f i c a t i o n with Children. Cambridge; Winthrop, 1976. APPENDIX C FLOORPLAN FOR FACILITY A AND B A s-ec-Uon 6 scciiorr From this point to lounge is G5 feet £RONT ENTRANCE J S F R V I C F 7 7 7 7 7 7 /APPENDIX LOGBOOK APPENDIX E GOVERNMENT LONG-TERM CARE CRITERIA Page 185 Intermediate Care The B.C. Department of Health (1972) defines intermediate care as "the type of care required by persons of any age whose physical d i s a b i l i t i e s are such that t h e i r primary need i s for room and board, d a i l y p r o f e s s i o n a l nursing supervision, assistance with some of the a c t i v i t i e s of d a i l y l i v i n g and a planned programme of s o c i a l and r e c r e a t i o n a l a c t i v i t i e s " . Also included i n t h i s type of care are those persons with mental disorders who p r i m a r i l y require room and board as well as " d a i l y p r o f e s s i o n a l super-v i s i o n by a person with appropriate p s y c h i a t r i c t r a i n i n g and a programme designed to a s s i s t them to reach t h e i r maximum p o t e n t i a l i n the a c t i v i t i e s of d a i l y l i v i n g " . Excluded from t h i s type of care are those persons who have behavioural or p s y c h i a t r i c problems which unduly disturb other residents or who require treatment of a s p e c i a l i z e d nature not needed by other residents. Those persons requiring intermediate care have the following c h a r a c t e r i s t i c s : 1) P hysical Status Residents are independently mobile, with or without the use of mechanical aids (handrails, grab bars, ramps, canes, crutches, walkers or wheelchairs). They are able to eat t h e i r meals i n a dining room, although some assistance with eating may be provided. Room tray service i s required only occasionally, during b r i e f periods of i l l n e s s . These residents may be at l e a s t p a r t i a l l y and even f u l l y dependent on others for many aspects of s e l f care (ex., dres-sing, grooming,, bathing: and t o i l e t i n g ) . Incontinence of both bladder and bowel may be handled with an indwelling catheter. V i s i o n and hearing i s ofen diminished or absent. Page 186 2) Mental Status "Forgetfulness, periods of confusion, m i l d l y disturbing behaviour and a tendency to wander away may be expected, as may varying degrees of mental defect or d e t e r i o r a t i o n r e s u l t i n g from disease, s e n i l i t y , r e s i d u a l p s y c h i a t r i c disorder or mental retardation" (B.C. Department of Health, 1972). 3) Services The services of a consultant d i e t i c i a n may be needed on a part-time basis to supervise the preparation of s p e c i a l d i e t s . Supervision i s also needed to assure that prescribed medication i s taken as directed and that required medical, dental and other health care appointments are made and kept. Special procedures (ex., postural drainage, oxygen therapy, intermittent p o s i t i v e pressure breathing, peritoneal d i a l y s i s or ad-justment of a colostomy) may be required. Services of paramedical s p e c i a l i s t s (physiotherapist, occupational t herapist, p r o s t h e t i s t , or hearing a id s p e c i a l i s t ) may also be required,in order to a t t a i n and maintain maximum function. The services offered i n a f a c i l i t y providing intermediate care are " b a s i c a l l y those which w i l l maintain and, i f poss i b l e , improve the health status and func t i o n a l a b i l i t y of the residents. A planned programe of s o c i a l , r e c r e a t i o n a l and occupational a c t i v i t i e s i n d i v i d u a l l y adapted to the age of the person, h i s needs, c a p a b i l i t i e s and desires, i s an e s s e n t i a l component of these services" (B.C. Department of Health, 1972). Page 187 Extended Care The B.C. Department of Health (1972) defines extended care as "the type of care required by persons of any age with a severe chronic d i s a b i l i t y , which has usually produced a f u n c t i o n a l d e f i c i t , who require 24 hour a day nursing services and continuing medical supervision but who do not require a l l the resources of an acute care h o s p i t a l . Most people who need t h i s type of care have a l i m i t e d p o t e n t i a l for r e h a b i l i t a t i o n and often require i n s t i t u t i o n a l care on a permanent basis?. Those persons re q u i r i n g extended care have the following c h a r a c t e r i s t i c s : 1) P h y s i c a l Status Residents are unable to get i n or out of bed (or wheelchair or to walk or wheel t h e i r own wheelchair).without the a i d of an a s s i s t a n t . They usually require considerable assistance i n the a c t i v i t i e s of d a i l y l i v i n g (dressing, washing, feeding and using t o i l e t ) and require tray service (at bedside or i n dining room). Assistance i s also required i n adjusting prosthetic appliances or a colostomy apparatus, and with s p e c i a l medical treatments (ex., postural drainage, oxygen therapy or intermittent p o s i t i v e pressure breathing). "Some persons w i l l require extended care even though t h e i r f u n c t i o n a l a b i l i t y i s not s e r i o u s l y impaired because of the need for regular and continuing medical supervision and professional nursing careV(B.C. Depart-ment of Health, 1972). 2) Mental Status "There may be periods of forgetfulness, confusion and restlessness. Varying degrees of mental d e t e r i o r a t i o n r e s u l t i n g from s e n i l i t y or r e s i d u a l psychiat-r i c disorders may also be present. Persons with serious mental problems Page 188 which are d e s t r u c t i v e or threate n i n g to others can hotebe:cared f o r i n a f a c i l i t y p r o v i d i n g t h i s type of care" (B.C. Department of He a l t h , 1972). 3) S e r v i c e s . The s e r v i c e s of a d i e t i c i a n on a f u l l - t i m e or consultant b a s i s i s needed to supervise the pr e p a r a t i o n of s p e c i a l d i e t s . S u p ervision i s a l s o needed to assure that p r e s c r i b e d medication i s taken as d i r e c t e d and that r e q u i r e d medical, d e n t a l and other h e a l t h care appointments are made and kept. The p a t i e n t r e q u i r e s 24 hour a day s k i l l e d maintenance nursing s e r v i c e s as w e l l as the s e r v i c e s of a p h y s i o t h e r a p i s t and occupational t h e r a p i s t on a r e g u l a r b a s i s . The s e r v i c e s o f f e r e d i n a f a c i l i t y p r o v i d i n g extended care are "those which w i l l help to ma i n t a i n , and where p o s s i b l e improve, the h e a l t h s t a t u s and f u n c t i o n a l a b i l i t y of the p a t i e n t s . Programmes must be s p e c i f i c a l l y d i r e c t e d toward maintaining maximum independence i n the a c t i v i t i e s of d a i l y l i v i n g . A planned programme of s o c i a l , r e c r e a t i o n a l and occupational a c t i v i t i e s i s an e s s e n t i a l component of these s e r v i c e s " (B.C. Department of Health , 1972). APPENDIX F PRIMARY DIAGNOSIS CATEGORIES Page 190 PRIMARY DIAGNOSIS CATEGORIES CATEGORY 1 PSYCHIATRIC CLASSIFICATION SENILITY SENILE DEMENTIA CHRONIC/ACUTE BRAIN SYNDROME ORGANIC BRAIN DISORDER CEREBRAL ARTERIOSCLEROSIS SCHIZOPHRENIA DEPRESSION PARANOIA CATEGORY 2 HEART DISEASE ARTERIOSCLEROTIC HEART DISEASE ANGINA/ISCHEMIA BLOCK/OTHER CONDUCTIVE PROBLEM (PACEMAKER) ARRHYTHMIA (TACHYCARDIA, BRADYCARDIA, FIBRILLATION EPISODES) CONGESTIVE HEART FAILURE COR PULMONALE VALVE INSUFFICIENCY INFARCT CATEGORY 3 CIRCULATORY PROBLEMS GENERALIZED ARTERIO/ ATHEROSCLEROSIS INTERMITTENT CLAUDICATION ,& OTHER FORMS OF PERIPHERAL ARTERIOSCLEROSIS HYPER/HYPOTENSION EMBOLUS, THROMBUS, OR OTHER ARTERY/VEIN OCCLUSION RAYNAUD'S DISEASE THROMBOPHLEBITIS CATEGORY 4 CEREBRAL INSULT CEREBROVASCULAR ACCIDENT ~ HEMORRHAGE/ANEURISM INJURY/HEMATOMA/CONCUSS ION SMALL STROKES/TRANSIENT ISCHEMIC ATTACKS TUMOUR PARKINSON'S DISEASE EPILEPSY TARDIVE DYSKINESIA CATEGORY 5 MUSCULO/SKELETAL PROBLEMS AMPUTATIONS (LIMB PART) CATEGORY 6 METABOLIC DISORDERS FRAC URES (UNRESOLVED) JOINT REPLACEMENTS ARTHRITIS - OSTEO, RHEUMATOID OSTEOPOROSIS CONTRACTURE OR OTHER STRUCTURAL DEFORMITY (MAJOR) SPINAL PROBLEMS (DEGENERATIVE ; DISC, TABES DORSALIS, PAGET '"s"' DISEASE, COMPRESSED VERTEBRAE MYASTHENIA GRAVIS MUSCULAR DYSTROPHY DIABETES - MELLITUS, INSIPIDUS ADRENAL INSUFFICIENCY HYPO/HYPERTHYROIDISM PITUITARY PROBLEMS RENAL FAILURE CATEGORY .7 MISCELLANEOUS / DIVERTICULITIS ULCERATIVE COLITIS ULCER (DUODENAL, PEPTIC) BOWEL FISTULA BOWEL OBSTRUCTION IMPACTION GASTROENTERITIS TUBERCULOSIS ORGAN FAILURE (KIDNEY, LIVER) STASIS ULCERS OPEN WOUND (SURGICAL OR DECUBITI) ANEMIA ALCOHOLISM SENSORY IMPAIRMENTS (HEARING OR VISION LOSS) CANCER EMPHYSEMA CHRONIC OBSTRUCTIVE LUNG DISEASE APPENDIX G ADL ASSESSMENT CRITERIA ASSESSMENT CRITERIA (ADL) Page J93 Total Independence - Green - Score 1 Total Independence means the ability to perform an activity without supervision, direction or active personal assistance. A patient who refuses to perform a function i s defined as totally dependent, even though he or she i s deemed able. The patient may choose any method or aid to perform the activity. This criteria directly applies to a l l designated ADL's with the exception of walking. In this case, green designates the ability to walk independently, such that no restriction i s placed on the individual i n carrying out daily routines within the institution or on excursions outside. Partial Dependence - Yellovj - Score 2 The patient can perform the greater part of the activity himself or herself, but needs assistance (verbal or physical) or supervision to complete the activity. This criteria refers to the degree of dependence i n the designated ADL's. Verbal assistance refers to instruction and direction in conducting an activity. This may include direction in what garment to put on next, to pick up the soap to wash hands, to put paralyzed arm into sleeve of shirt before other arm, to put toothpaste on toothbrush, to put brakes on wheel chair when sitting at a table. Physical assistance refers to minor active personal assistance. This may include handing a towel or soap to the resident while washing, handing toilet paper to the resident when toileting, doing up the pants fastener when putting on pants, steadying a wheelchair during a transfer. Basically Partial Dependence i s designated when one step in a series of behaviours involved in the completion Page J of an activity requires physical assistance from a staff mariner. Supervision occurs when there i s the possibility that the activity may not be completed adequately and, therefore the activity must be supervised. This occurs even though the resident i s able to conduct the activity independent at times. This supervision may occur when a resident i s transfering into bed, when the resident i s dressing or grooming or when he or she i s eating. In the case of walking, yellow refers to the ability to walk short dis-tances without assistance or supervision. This may include mobility in one's room, or within a circumscribed area where miiumum mobility i s necessary. Otherwise, the resident must be assisted in walking, such as the use of a staff's arm for stability or the use of a walker. Total Dependence - Red - Score 3 The activity i s carried out for the patient. This criteria directly applies to a l l designated activities. With walking, the resident i s unable and thus, is required to use a wheelchair for mobility. For those using wheelchairs, the resident must be pushed rather than propelling himself or herself.. APPENDIX H PAW DATA SCORES - FACILITY A Page 1 Dressing Eating Groaning 7Ar±»./Trans. Global ADL T1 T2 T3 T1 T2 T3 T1 T2 T3 T1 T2 T3 T1 T2 T3 001 22.0 17.0 17. 0 04.0 04.0 04. 0 07.0 07.0 05. 0 07.0 07.0 07. 0 40.0 35.0 33. 0 002 18.0 18.0 04.0 04.0 07.0 05.0 07.0 07.0 34.0 34.0 003 49.0 30.0 29. 0 06.0 04.0 06. 0 14.0 05.0 10. 0 09.0 07.0 07. 0 78.0 55.0 52. 0 004 51.0 39.0 39. 5 06.0 06.0 06. 0 13.0 13.0 13. 0 09.0 08.0 08. 0 79.0 66.0 66. 5 005 17.0 17.0 17. 0 04.0 04.0 04. 0 05.0 05.0 05. 0 07.0 07.0 07. 0 33.0 33.0 33. 0 006 17.0 17.0 17. 0 04.0 04.0 04. 0 05.0 05.0 05. 0 07.0 07.0 07. 0 33.0 33.0 33. 0 007 17.0 17.0 17. 0 04.0 04.0 04. 0 05.0 05.0 05. 0 07.0 07.0 07. 0 33.0 33.0 33. 0 008 25.0 31.0 04.0 04.0 07.0 05.0 07.0 07.0 i' 43.0 47.0 009 17.0 04.0 05.0 07.0 33.0 010 17.0 17.0 17.0 04.0 04.0 04.0 05.0 05.0 05.0 07.0 07.0 07.0 33.0 33.0 33.0 011 17.5 04.0 05.0 07.0 33.5 012 17. 0 17.0 17.0 04. 0 04. 0 04. 0 05.0 05.0 05.0 07. 0 07. 0 07. 0 33.0 33.0 33.0 013 17. 0 17.0 17.0 04. 0 04. 0 04. 0 05.0 05.0 05.0 07. 0 07. j 0 07. 0 33.0 33.0 33.0 014 17. 0 17.0 17.0 04. 0 04. 0 04. 0 05.0 05.0 05.0 07. 0 07. 0 07. 0 33.0 33.0 33.0 015 17. 0 17.0 17.0 04. 0 04. 0 04. 0 05.0 05.0 05.0 07. 0 07. 0 07. 0 33.0 33.0 33.0 016 17. 0 17.0 17.0 04. 0 04. 0 04. 0 05.0 05.0 05.0 07. 0 07. 0 07. 0 33.0 33.0 33.0 017 17. 0 17.0 17.0 04. 0 04. 0 04. 0 05.0 07.0 05.0 07. 0 07. 0 07. 0 33.0 35.0 33.0 018 17. 0 17.0 17.0 04. 0 04. 0 04. 0 05.0 05.0 05.0 07. 0 07. 0 07. 0 33.0 33.0 33.0 019 17. 0 17.0 17.0 04. 0 04. 0 04. 0 05.0 05.0 05.0 07. 0 07. 0 07. 0 33.0 33.0 33.0 020 17. 0 17.0 17.0 04. 0 04. 0 04. 0 05.0 05.0 05.0 07. 0 07. 0 07. 0 33.0 33.0 33.0 021 17. 0 17.0 17.0 04. 0 04. 0 04. 0 05.0 05.0 05.0 07. 0 07. 0 07. 0 33.0 33.0 33.0 022 34. 0 28.0 24.0 06. 0 04. 0 04. 0 05.0 05.0 05.0 07. 0 07. 0 07. 0 52.0 44.0 40.0 023 17. 0 17.0 17.0 04. 0 04. 0 04. 0 05.0 05.0 05.0 07. 0 07. 0 07. 0 33.0 33.0 33.0 024 51. 0 43.0 43.0 04. 0 04. 0 04. 0 05.0 05.0 05.0 07. 0 07. 0 07. 0 67.0 59.0 59.0 025 17. ,0 17.0 17.0 04. 0 04. 0 04. 0 05.0 05.0 05.0 07. 0 07. 0 07. 0 33.0 33.0 33.0 026 37. ,0 25.0 04. 0 04. 0 06.0 07.0 12. 0 12. 0 ",- v 59.0 47.0 027 15. .0 04. ,0 06.0 07. ,0 32.0 028 31. .0 08. .0 13.0 10. ,0 62.0 029 15. ,0 15.0 15.0 04. ,0 04. ,0 04. ,0 06.0 06.0 06.0 07. ,0 07. ,0 07. ,0 32.0 32.0 32.0 030 17. ,0 17.0 17.0 04. ,0 04. ,0 04. .0 05.0 05.0 05.0 07. .0 07. .0 07. ,0 33.0 33.0 33.0 031 17. ,0 17.0 17.0 04. ,0 04. .0 04. ,0 05.0 05.0 05.0 07. ,0 07. ,0 07. .0 33.0 33.0 33.0 032 16. ,0 15.0 15.0 04. .0 04. ,0 04. .0 06.0 06.0 06.0 07. .0 07. .0 07. ,0 33.0 32.0 32.0 033 23. .0 21.0 20.5 04. .0 04. .0 04. .0 08.0 05.0 05.0 07. .0 07. .0 07. .0 42.0 37.0 36.0 034 27. .0 19.0 17.0 04. .0 04. ,0 04. .0 07.0 07.0 07.0 08. .0 07. .0 07. .0 46.0 38.0 36.0 035 43. .0 35.0 51.0 04. .0 04. .0 04. .0 13.0 15.0 15.0 12. .0 12. .0 12. .0 72.0 66.0 80.0 P a g e 197 036 35.0 35.0 19.0 04.0 04.0 04.0 09.0 07.0 07.0 07. 0 07. 0 07, .0 55. 0 53. 0 37. 0 037 30.0 23.0 18.0 06.0 06.0 06.0 05.0 05.0 05.0 07. 0 07. 0 07 .0 48. 0 41. 0 36 ? 0 038 17.0 17.0 17.0 04.0 04.0 04.0 05.0 05.0 05.0 07. 0 07. 0 07 .0 33. 0 33. 0 33. 0 039 23.0 17.0 17.0 04.0 04.0 04.0 05.0 05.0 05.0 07. 0 07. 0 07 .0 39. 5 33. 0 33. 0 040 35.0 04.0 09.0 07. 0 55. 0 041 24.0 23.0 17.0 06.0 06.0 06.0 06.0 06.0 06.0 07. 0 07. 0 07 .0 43. 0 42. 0 36. 0 042 17.0 17.0 17.0 04.0 04.0 04.0 05.0 05.0 05.0 07. 0 07. 0 07 .0 33. 0 33. 0 33. 0 043 17.0 17.0 17.0 04.0 04.0 04.0 05.0 05.0 05.0 07. 0 07. 0 07 .0 33. 0 33. 0 33. 0 044 18.0 18.0 17.0 04.0 04.0 04.0 05.0 05.0 05.0 07. 0 07. 0 07 .0 34. 0 34. 0 33. 0 045 18.0 17.0 17.0 04.0 04.0 04.0 05.0 05.0 05.0 07. 0 07. 0 07 .0 35. 0 33. 0 33. 0 046 19.0 19.0 19.0 04.0 04.0 04.0 05.0 05.0 05.0 07. 0 07. 0 07 .0 35. 0 35. 0 34. 0 047 17.0 17.0 17.0 04.0 04.0 04.0 05.0 05.0 05.0 07. ,0 07. 0 07 .0 33. 0 33. 0 33. 0 048 50.0 35.0 28.0 04.0 04.0 04.0 09.0 09.0 07.0 09. ,0 09. 0 07 .5 71. 0 57. 0 46. 0 049 17.0 17.0 17.0 04.0 04.0 04.0 05.0 05.0 05.0 TO. ,0 10. 0 10 .0 36. ,0 36. ,0 36. 0 050 17.0 17.0 17.0 06.0 06.0 06.0 05.0 05.0 05.0 07. .0 07. 0 07 .0 35. ,0 35. ,0 35. 0 051 35.0 04.0 05.0 07.0 51.0 052 35. 0 18. 0 25.0 08.0 04.0 04. 0 07.5 06.0 06.0 07.0 07. 0 07. 0 57. 5 35.0 42. 0 053 17. 0 17. 0 17.0 04.0 04.0 04. 0 05.0 05.0 05.0 07.0 07. 0 07. 0 33. 0 33.0 33. 0 054 23. 0 21. 0 04.0 04.0 05.0 05.0 07.0 07. C 39. 0 37.0 055 41. 0 23. 0 23.0 04.0 04.0 04. 0 09.0 07.0 07.0 20.0 18. 0 20. 0 74. 0 52.0 54. 0 056 23. 0 17. 0 17.0 04.0 04.0 04. 0 05.0 05.0 05.0 08.0 08. 0 08. 0 40. 0 34.0 34. 0 057 51. 0 51. 0 04.0 04.0 13.0 13.0 07.0 07. 0 75. 0 75.0 058 19. 0 17. 0 17.0 04.0 04.0 04. 0 05.0 05.0 05.0 07.0 07. 0 07. 0 35. 0 33.0 33. 0 059 21. 0 19. 0 17.0 04.0 04.0 04. 0 05.0 05.0 05.0 07.0 07. 0 07. 0 37. 0 35.0 33. 0 060 17. 0 17. 0 17.0 04.0 04.0 04. 0 05.0 05.0 05.0 08.0 08. 0 08. 0 34. 0 34.0 34. 0 061 35. 0 18. 0 18.5 04.0 04.0 04. 0 05.0 05.0 05.0 07.0 07. 0 07. 0 51. 0 35.0 35. 0 062 35. 0 19. 0 19.0 04.0 04.0 04. 0 05.0 05.0 05.0 07.0 07. 0 07. 0 51. 0 35.0 35.0 063 40. 0 51. 0 06.0 06.0 08.0 08.0 07.0 07. ,0 61. 0 72.0 064 18. 0 17. 0 17.0 04.0 04.0 04. 0 05.0 05.0 05.0 07.0 07. ,0 07. 0 34. 0 33.0 33. 0 065 17. 0 17. ,0 17.0 04.0 04.0 04. 0 05.0 05.0 05.0 07.0 07. ,0 07. ,0 33. ,0 33.0 33. 0 066 17. ,0 17. ,0 17.0 06.0 06.0 06. 0 05.0 05.0 05.0 07.0 07. ,0 07. ,0 35. 0 35.0 35. 0 067 39. ,0 33. ,0 49.0 04.0 04.0 04. ,0 10.0 10.0 10.0 08.5 08. ,0 08. .0 61. 5 55.0 71. 0 068 32. ,0 19. ,0 17.0 04.0 04.0 04. ,0 09.0 06.0 06.0 08.0 08. ,0 08. ,0 53. .0 37.0 35. ,0 1/069 15. ,0 15. .0 15.0 04.0 04.0 04. ,0 08.0 08.0 06.5 07.0 07. .0 07. ,0 34. ,0 34.0 32. ,5 070 17. .0 17. .0 17.0 04.0 04.0 04. ,0 05.0 05.0 05.0 07.0 07. ,0 07. ,0 33. ,0 33.0 33. .0 Page 1 071 17.0 17.0 17. 0 04. 0 04. 0 04. 0 05.0 05. 0 05. 0 07.0 07.0 07.0 33. 0 33. 0 33.0 072 17.0 17.0 17. 0 04. 0 04. 0 04. 0 05.0 05. 0 05. 0 07.0 07.0 07.0 33. 0 33. 0 33.0 073 17.0 17.0 17. 0 04. 0 04. 0 04. 0 05.0 05. 0 05. 0 07.0 07.0 07.0 33. 0 33. 0 33.0 074 21.0 19.0 18. 0 04. 0 04. 0 04. 0 05.0 07. 0 07. 0 07.0 07.0 07.0 37. 0 37. 0 36.0 075 17.0 17.0 17. 0 04. 0 04. 0 04. 0 05.0 05. 0 05. 0 07.0 07.0 07.0 33. 0 33. 0 33.0 076 17.0 17.0 17. 0 04. 0 04. 0 04. 0 05.0 05. 0 05. 0 07.0 07.0 07.0 33. 0 33. 0 33.0 077 15.0 15.0 15. 0 04. 0 04. 0 04. 0 06.0 06. 0 06. 0 07.0 07.0 07.0 32. 0 32. 0 32.0 078 15.0 15.0 15. 0 04. 0 04. 0 04. 0 07.0 07. 0 06. 0 10.0 10.0 10.0 36. 0 36. 0 35.0 079 15.0 15.0 15. 0 06. 0 06. 0 06. 0 06.0 06. 0 06. 0 07.0 07.0 07.0 34. 0 34. 0 34.0 080 15.0 15.0 15. 0 04. 0 04. 0 04. 0 06.0 06. 0 06. 0 07.0 07.0 07.0 32. 0 32. 0 32.0 081 15.0 15.0 15. 0 04. 0 04. 0 04. 0 07.0 07. 0 06. 0 07.0 07.0 07.0 33. 0 33. 0 32.0 082 17.0 17.0 16. 0 04. 0 04. 0 04. 0 12.0 09. 0 08.0 07.0 07.0 07.0 40. 0 37. 0 35.0 083 17.0 17.0 17-.0 04. 0 04. 0 04. 0 05.0 05. 0 05. 0 07.0 07.0 07.0 33. 0 33. 0 33.0 084 17.0 17.0 17. 0 04. 0 04. 0 04. 0 05.0 05. 0 05. 0 07.0 07.0 07.0 33. 0 33. 0 33.0 085 17.0 17.0 17. 0 04. 0 04. 0 04.0 05.0 05. 0 05. 0 07.0 07.0 07.0 33. 0 33. 0 33.0 086 31.0 25.0 21. 0 04. 0 04. 0 04. 0 05.0 05. 0 05. 0 12.0 12.0 08.0 52. 0 46. 0 38.0 087 17.0 17.0 17. .0 04. 0 04.0 04. 0 05.0 05. .0 05. 0 07.0 07.0 07.0 33. 0 33. 0 33.0 088 23.0 19.0 19. 0 04. 0 04. 0 04. 0 06.0 05. 0 06. .0 10.0 10.0 10.0 43. 0 38. 0 39.0 089 15.0 15.0 15. 0 04. 0 04. 0 04. 0 06.0 06. 0 06. 0 07.0 07.0 07.0 32. 0 32. 0 32.0 090 15.0 15.0 15. 0 04. 0 04. 0 04. 0 06.0 06. 0 06. 0 10.0 10.0 10.0 35. .0 35. 0 35.0 091 45.0 45.0 07. 0 07. .0 18.0 18. 0 07.0 07.0 77. 0 77. 0 092 15.0 1 5-0 45. 0 04. 0 04. 0 04. 0 08.0 08. .0 .18. 0 07.0- 18.0 .18.0 34. 0 45. .0 85.0 093 15.0 15.0 15. ,0 04. 0 04. 0 04. 0 06.0 06. 0 06. ,0 07.0 07.0 07.0 32. .0 32. 0 32.0 094 15.0 15.0 15. .0 04. .0 04. ,0 04. .0 06.0 06. .0 06. ,0 10.0 10.0 10.0 35. ,0 35. .0 35.0 095 17.0 17.0 17. ,0 04. .0 04. .0 04. 0 06.0 06. .0 06. ,0 07.0 08.0 10.0 34. .0 35. .0 37.0 096 19.5 15.0 15. ,0 04. 0 04. ,0 04. ,0 11.0 08. .0 08. .0 07.0 07.0 07.0 41. .5 34. ,0 34.0 097 21.0 04.0 06.0 10.0 41.0 098 20.5 19. 0 15.0 06. 0 06.0 06. 0 06. 0 06. 0 06. 0 20. 0 07. 0 07.0 52. 5 38.0 34. 0 099 15.0 15. 0 15.0 04. 0 04.0 04. 0 06. 0 06. 0 06. 0 07. 0. 07. 0 07.0 32. 0 32.0 32. 0 100 15.0 17. 0 15.0 04. 0 04.0 04. 0 06. 0 06. 0 06. 0 07. 0 07. 0 07.0 32. 0 34.0 32. 0 101 15.0 15. 0 15.0 04. 0 04.0 04. 0 06. 0 06. 0 06. 0 08. 0 08. 0 08.0 33. 0 33.0 33. 0 102 15.0 .15. 0 15.0 04. 0 04.0 04. 0 06. 0 06. 0 06. 0 07. 0 07. 0 07.0 32. 0 32.0 32. 0 103 15.0 27. 0 27.0 04. 0 04.0 04. 0 06. 0 06. 0 06. 0 07. 0 07. 0 10.0 32. 0 44.0 47. 0 104 15.0 15. 0 15.0 04. 0 04.0 04. 0 08. 0 08. 0 08. 0 07. 0 07. 0 07.0 34. 0 34.0 34. 0 105 15.0 15. .0 15.0 04. 0 04.0 04. 0 06. .0 06. .0 06. .0 10. .0 10. .0 10.0 35. 0 35.0 35. 0 Page 106 15. 0 15.0 15.0 06. 0 06. 0 06. 0 06.0 06. 0 06. 0 10.0 10. 0 08. 0 37.0 37. 0 35.0 107 15. 0 15. 0 15.0 06. 0 06. 0 06. 0 06.0 06. 0 06. 0 07.0 07. 0 07. 0 34.0 34. 0 34. 0 108 17. 0 17. 0 17.0 04. 0 04. 0 04. 0 08.0 06. 0 06. 0 07.0 07. 0 07. 0 36.0 34. 0 34. 0 109 15. 0 15. 0 15.0 04. 0 04. 0 04. 0 06.0 06. 0 06. 0 10.0 10. 0 10. 0 35.0 35. 0 35. 0 110 15. 0 15. 0 15.0 04. 0 04. 0 04. 0 06.0 06. 0 06. 0 07.0 07. 0 07. 0 32.0 32. 0 32. 0 111 17. 0 17. 0 17.0 04. 0 04. 0 04. 0 05.0 05. 0 05. 0 07.0 07. 0 07. 0 33.0 33. 0 33. 0 112 17. 0 17. 0 17.0 04. 0 04. 0 04. 0 05.0 05. 0 05. 0 07.0 07. 0 07. 0 33.0 33. 0 33. 0 113 17. 0 17. 0 17.0 04. 0 04. 0 04. 0 05.0 05. 0 05. 0 07.0 07. 0 07. 0 33.0 33. 0 33. 0 114 17. 0 17. 0 17.0 04. 0 04. 0 04. 0 05.0 05. 0. 05. 0 07.0 07. 0 07. 0 33.0 33. 0 33. 0 115 17. 0 17. 0 17.0 04. 0 04. 0 04. 0 05.0 05. 0 05. 0 07.0 07. 0 07. 0 33.0 33. 0 33. 0 116 15. 0 15. 0 15.0 06. 0 06. 0 04. 0 06.0 06. 0 06. 0 07.0 07. 0 07. 0 34.0 34. 0 32. 0 117 15. 0 15. 0 04. 0 04. 0 06.0 06. 0 .10.0 10. 0 35.0 35. 0 118 15. 0 15. 0 15.0 04. 0 04. 0 04. •0 06.0 06. 0 06. 0 07.0 07. 0 07. 0 32.0 32. 0 32. 0 119 17. 0 17. 0 17.0 04. 0 04. 0 04. 0 05.0 05. 0 05. 0 07.0 07. 0 07. .0 33.0 33. 0 33. 0 120 17. 0 17. 0 17.0 04. 0 04. 0 04. 0 05.0 05. .0 05. 0 07.0 07. 0 07. 0 33.0 33. 0 33. .0 121 17. ,0 17. 0 17.0 04. .0 04. 0 04. 0 05.0 05. 0 05. .0 07.0 07. .0 07. ,0 33.0 33. .0 33. .0 122 17. .0 17. 0 17.0 04. .0 04. 0 04. 0 05.0 05. .0 05. .0 07.0 07. .0 07. ,0 33.0 33. 0 33. .0 123 17. 0 17. ,0 17.0 04. 0 04. 0 04. 0 05.0 05. .0 05. .0 07.0 07. 0 07. ,0 33.0 33. .0 33. ,0 124 17. .0 17. ,0 17.0 04. .0 04. 0 04. .0 05.0 05. ,0 05. .0 07.0 07. ,0 07. ,0 33.0 33. .0 33. .0 125 17. ,0 17. ,0 17.0 04. .0 04. .0 04. .0 05.0 05. ,0 05. .0 07.0 07. .0 07. .0 33.0 33. ,0 33. .0 126 17. ,0 17. ,0 17.0 04. ,0 04. ,0 04. .0 05.0 05. ,0 05. ,0 07.0 07. .0 07. .0 33.0 33. ,0 33. .0 127 35. .0 21. .0 19.0 06. ,0 06. .0 06. .0 07.0 07. .0 07. ,0 07.0 07. .0 07. .0 55.0 41. .0 39. .0 APPENDIX I RAW DATA SCORES - FACILITY B P a g e 2.0.1 Pft4£ "Does MoT D r e s s i n g E a t i n g G r o a m i n g 7Arrib. /Trans. G l o b a l 7ADL T1 T2 T3 T1 T2 T3 T1 T2 T3 T1 T2 T3 T1 T2 T3 001 17.0 17 . 0 17.0 04 . 0 04. 0 0 4 . 0 0 7 . 0 07.0 07.0 1 0 . 0 10 . 0 10.0 3 8 . 0 38.0 3 8 . 0 002 5 1 . 0 5 1 . 0 5 1 . 0 1 2 . 0 0 8 . 0 0 8 . 0 1 5 . 0 1 5 . 0 1 5 . 0 1 2 . 0 16 . 5 1 6 . 5 9 0 . 0 9 0 . 5 9 0 . 5 003 3 4 . 0 5 1 . 0 5-1.0 0 6 . 0 0 6 . 0 06-.0 0 9 . 0 1 3 . 0 13 . 0 1 4 . 0 14 . 0 1 4 . 0 . 6 3 . 0 8 4 . 0 8 4 . 0 004 1 7 . 0 1 7 . 0 1 7 . 0 0 4 . 0 0 4 . 0 04.0 0 5 . 0 0 5 . 0 0 5 . 0 1 0 . 0 10 . 0 1 0 . 0 3 6 . 0 3 6 . 0 3 6 . 0 005 17.0 1 7 . 0 17.0 0 4 . 0 0 4 . 0 04 . 0 0 5 . 0 0 5 . 0 0 5 . 0 0 7 . 0 0 7 . 0 0 7 . 0 33. 0 3 3 . 0 3 3 . 0 006 1 7 . 0 1 7 . 0 17.0 0 4 . 0 04. 0 04 . 0 0 5 . 0 05 . 0 05.0 07.0 0 7 . 0 0 7 - 0 33. 0 3 3 . 0 3 3 . 0 007 1 7 . 0 1 7 . 0 1 7 . 0 0 4 . 0 0 4 . 0 04.0 0 5 . 0 0 5 . 0 0 5 . 0 0 7 . 0 0 7 . 0 0 7 . 0 33. 0 3 3 . 0 3 3 . 0 008 17 . 0 1 7 . 0 17.0 04 . 0 04. 0 04 . 0 0 5 . 0 0 5 . 0 05.0 09 . 0 0 8 . 0 09.0 3 5 . 0 34.0 3 5 . 0 009 26.0 3 5 . 0 5 1 . 0 04. 0 0 4 . 0 0 4 . 0 0 5 . 0 07.0 09.0 09.0 0 9 . 0 10.0 44. 0 55.0 7 4 . 0 010 1 7 . 0 19 . 0 1 9 . 0 04 . 0 0 4 . 0 0 4 . 0 0 5 . 0 0 8 . 0 0 8 . 0 0 7 . 0 0 7 . 0 0 7 . 0 3 3 . 0 3 8 . 0 3 8 . 0 011 51 . 0 0 4 . 0 1 5 . 0 0 9 . 0 7 9 . 0 012 39.0 2 3 . 0 2 9 . 0 0 4 . 0 0 4 . 0 0 4 . 0 14 . 0 13.5 13.5 0 7 . 0 0 7 . 0 0 8 . 0 64 . 0 47.5 54.5 013 2 9 . 0 3 3 . 0 3 7 . 0 0 6 . 0 0 6 . 0 0 6 . 0 0 6 . 0 0 5 . 0 0 5 . 0 0 8 . 0 0 8 . 0 0 8 . 0 4 9 . 0 5 2 . 0 56.0 014 19.0 19. 0 17.0 0 4 . 0 0 4 . 0 04.0 05. 0 05.0 05.0 10.0 10 . 0 10.0 38. 0 38 . 0 36.0 015 1 7 . 0 17 . 0 1 8 . 0 0 4 . 0 0 4 . 0 0 4 . 0 0 5 . 0 0 5 . 0 0 5 . 0 0 7 . 0 0 7 . 0 0 7 . 0 3 3 . 0 3 3 . 0 3 4 . 0 016 51.0 04.0 ' 15.0 13.0 83.0 017 17.0 04.0 05.0 07.0 33.0 018 24.0 19.0 19. 0 04. 0 04. 0 04. 0 14.5 11.0 09. 0 07.0 07.0 09.0 49.5 41. 0 41.0 019 17.0 17.0 17. 0 04. 0 04. 0 04. 0 05.0 05.0 05. 0 08.0 08.0 08.0 34.0 34. 0 3.4.0 020 23.5 25.0 25. 0 06. 0 06. 0 06. 0 05.0 07.0 07. 0 07.0 08.0 08.0 41.5 46. 0 46.0 021 17.0 17.0 17. 0 04. 0 04. 0 04. 0 07.0 06.0 05. 0 07.0 07.0 07.0 35.0 34. 0 33.0 022 17.0 19.0 19. 0 04. 0 04. 0 04. 0 05.0 06.0 06. 0 10.0 10.0 10.0 36.0 39. 0 39.0 023 17.0 17.0 17. 0 04. 0 04. 0 04. 0 05.0 05.0 05. 0 10.0: 10.0 10.0 36.0 36. 0 36.0 024 21.5 51.0 04. 0 04. 0 05.0 14.0 10.0 21.0 40.5 90. 0 025 19.0 31.0 27. 0 06. 0 06. 0 06. 0 05.0 05.0 10. 0 10.0 10.0 10.0 40.0 52.0 53.0 026 17.0 18.0 19. 5 04. 0 04. 0 04. 0 05.0 05.0 05. 0 07.0 07.0 07.0 33.0 34. 0 35.5 027 19.0 41.0 49. 5 04. 0 04. 0 04. 0 09.0 12.0 10. 5 07.0 07.0 07.0 39.0 64. 0 71.0 028 17.0 17.0 17. 0 04. 0 04. 0 04. 0 05.0 05.0 05. 0 07.0 07.0 07.0 33.0 33. 0 33.0 029 22.0 50.0 50. 0 04. 0 04. 0 04. 0 09.0 14.5 14.5' 08.0 08.0 08r.O 43.0 76. 5 76.5 030 17.0 19.0 1.9. 0 04. 0 04. 0 04. 0 05.0 07.5 10. 0 07.0 07.0 07.0 33.0 37. 5 40.0 031 35.0 51.0 - 06. 0 06. 0 07.0 15.0 07.0 07.0 55.0 79. 0 032 33.0 38.0 38.0 06. 0 06. 0 06. 0 12.0 15.0 15. 0 07.0 07.0 07.0 58.0 66. 0 66.0 033 17.0 17.0 17. ,0 04. 0 04. 0 04. 0 05.0 05.0 05. 0 07.0 07.0 07.0 33.0 33. 0 33.0 034 17.0 17.0 17. 0 04. 0 04. 0 04. 0 05.0 05.0 05. 0 10.0 10.0 10.0 36.0 36. 0 36.0 LEAF 202 OMITTED IN PAGE NUMBERING. P a g e 2 03 035 26.0 30.0 08. 0 08. 0 11. 0 11.0 07.0 07. 0 52.0 56.0 036 17.0 17.0 17. 0 06. 0 06. 0 06. 0 05. 0 05.0 05. 0 10.0 10. 0 10. 0 38.0 38.0 38.0 037 17.0 17.0 17. 0 04. 0 04. 0 04. 0 10. 0 07.5 05. 0 07.0 09. 0 08. 0 38.0 37.5 34.0 038 17.0 17.0 17. 0 04. 0 04. 0 04. 0 05. 0 05.0 05. 0 07.0 07. 0 07. 0 33.0 33.0 33.0 039 33.0 33.0 35. 0 04. 0 04. 0 04. 0 05. 0 05.0 05. 0 10.0 11. 0 12. 0 52.0 53.0 56.0 040 17.0 17.0 17. 0 04. 0 04. 0 04. 0 05. 0 05.0 05. 0 10.0 10. 0 10. 0 36.0 36.0 36.0 041 17.0 17.0 17. 0 04. 0 04. 0 04. 0 05. 0 05.0 05. 0 10.0 10. 0 10. 0 36.0 36.0 36.0 042 17.0 17.0 19. 0 04. 0 04. 0 04. 0 05. 0 07.0 05. 0 07.0 07. 0 07. 0 33.0 35.0 35.0 043 17.0 17.0 19. 0 04. 0 04. 0 04. 0 05. 0 05.0 05. 0 08.0 08. 0 08. 0 34.0 34.0 36.0 044 17.0 17.0 17.0 04. 0 04. 0 04. 0 06. 0 06.0 06. 0 07.0 07. 0 07. 0 33.0 33.0 33.0 045 17.0 17.0 19. 0 04. 0 04. 0 04. 0 09. 0 10.0 05. 0 07.0 07. 0 07. .0 37.0 38.0 35.0 046 19.0 21.0 20. 0 04. 0 04. 0 04. 0 05. 0 05.0 05. 0 10.0 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07.0 69.5 096 17.0 17. 0 17.0 04. 0 04. 0 04. 0 05.0 05.0 05. 0 07. 0 07. 0 07. 0 33.0 33.0 33. 0 097 15.0 15. 0 15.0 04. 0 04. 0 04. 0 06.0 06.0 06. 0 07. 0 07. 0 07. 0 32.0 32.0 32. 0 098 15.0 15. 0 15.0 04. 0 04. 0 04. 0 06.0 06.0 06. 0 08. 0 08. 0 08. 0 33.0 33.0 33. 0 099 15.0 28. 0 40.0 04. 0 06. 0 06. 0 06.0 09.0 10. 0 10. 0 18. 0 24. 0 35.0 61.0 80. 0 100 40.0 46. 0 46.0 04. 0 04. 0 04. 0 15.0 18.0 18. 0 07. 0 07. 0 07. 0 66.0 75.0 75. 0 101 15.0 15. 0 15.0 04. 0 04. 0 04. 0 06.0 06.0 06. 0 07. 0 07. 0 07. 0 32.0 32.0 32. 0 102 17.0 17. 0 17.0 04. 0 04. 0 04. 0 05.0 05.0 05. 0 08. 0 08. 0 08. 0 34.0 34.0 34. 0 103 17.0 17. 0 17.0 04. 0 04. 0 04. 0 05.0 05.0 05. 0 08. 0 08. 0 08. 0 34.0 34.0 34. 0 Page. 205 104 15.0 45.0 04.0 06.0 06.0 14. 0 07.0 08. 0 32.0 73.0 105 17.0 17.,0 17. P 04.0 04.0 04. 0 06.0 06. 0 06. 0 07.0 07. 0 07. 0 34.0 34.0 34. ,0 106 15.0 15.0 15. 0 04.0 04.0 04. 0 06.0 06. 0 06. 0 10.0 10. 0 07. 0 35.0 35.0 34. ,0 107 17.0 17.0 17. 0 04.0 04.0 04. 0 06.0 06. 0 06. 0 07.0 07. 0 07. 0 34.0 3S.0 34. .0 108 39.5 45.0 04.0 04.0 06.0 '13. 0 11.5 11. 0 61.0 73.0 109 17.0 04.0 06.0 08.0 35.0 110 17.0 15.0 17. 0 04.0 04.0 04. 0 06.0 06. 0 06. 0 10.0 10. 0 10.0 37.0 35.0 37, .0 111 17.0 17.0. 17. 0 04.0 04.0 04. 0 05.0 05. 0 05. 0 07.0 07. 0 07. 0 33.0 33.0 33, .0 112 17.0 17.0 17. 0 04.0 04.0 04. 0 05.0 05. 0 05. 0 07.0 07. 0 07. 0 33.0 33.0 33, .0 113 38.0 37.5 38. 0 04.0 04.0 04. 0 06.0 06. 0 06. 0 20.0 20. 0 20. 0 68.0 67.5 68, .0 114 15.0 15.0 15. 0 04.0 04.0 04. 0 06.0 06. 0 06. 0 07.0 07. .0 07. 0 32.0 32.0 32.0 115 15.0 16.0 31. 0 04.0 04.0 04. 0 08.0 08. 0 10. 0 10.0 10. ,0 10. .0 37.0 38.0 55, .0 116 15.0 04.0 06.0 10.0 35.0 117 17.0 17.0 20. 5 04.0 04.0 04. .0 06.0 06. ,0 06. ,0 08.0 08. .0 08. 0 35.0 35.0 38, .5 118 17.0 17.0 19. 0 04.0 04.0 04. .0 05.0 05. ,0 05. 0 07.0 07. ,0 07. ,0 33.0 33.0 35 .0 119 45.0 45.0 45. 0 06.0 06.0 12. ,0 18.0 18. ,0 18. ,0 07.0 07. ,0 08. ,5 76.0 76.0 83 .5 120 15.0 15.0 04.0 04.0 06.0 06. ,0 07.0 07. ,0 32.0 32.0 121 17.0 17.0 17. ,0 04.0 04.0 04. ,0 05.0 05. ,0 05. .0 07.0 07. ,0 07. ,0 33.0 33.0 33 .0 122 17.0 5.1.0 04.0 04.0 05.0 15. ,0 10.0 22. ,0 36.0 92.0 123 15.0 15.0 15. ,0 04.0 04.0 04. ,0 07.0 07. .0 08. .0 10.0 10. .0 10. ,0 36.0 36.0 37 .0 124 31.0 04.0 07.0 10.0 52.0 125 17.0 17.0 24. ,0 04.0 04.0 04. ,0 10.0 12. .0 10. .0 10.0 10. ,0 10, .0 41.0 43.0 48 .0 126 38.0 45.0 45. .0 07.0 07.0 08. .0 12.0 14, .0 16. .0 14.0 11, .0 10, .0 71.0 77.0 79 .0 127 29.0 29.0 29. .0 06.0 04.0 06. .0 10.0 10, .0 16, .0 10.0 10. .0 10. .0 55.0 53.0 61 .0 128 20.0 45.0 04.0 04.0 09.0 12, .0 07.0 07. .0 40.0 68.0 129 15.0 15.0 21. .0 04.0 04.0 04. .0 06.0 06, .0 06, .0 10.0 10, .0 10, .0 35.0 35.0 41 .0 130 23.0 45.0 45. .0 04.0 05.0 05, .0 06.0 14, .0 14, .0 11.0 22, .0 19, .0 44.0 86.0 83 .0 APPENDIX J DEMOGRAPHIC INFORMATION - FACILITY A Page. 207 Demographic Information (Facility A) Primary Length Primary Length Subj.# Sex Age Diagnosis of Stay Subj.# Sex Age Diagnosis of Stay 001 F 90 1 19 mon. 046 F 99 6 22 mon. 002 F 96 2 02 047 F 77 2 01 003 F 85 4 22 048 F 99 2 23 004 F 94 1 25 049 F 73 5 21 005 F 89 7 " 20 050 F 85 4 09 006 F 88 1 01 051 F 71; 4 15' 007 F 82 1 20 052 F 83 1 01 008 F 83 1 01 053 F 79 2 06. 009 F 83 2 12 054 F 84 5 22 010 F 65 1 01 055 F 90 1 17 011 F 87 2 05 056 F 83 2 01 012 F 91 1 22 057 F. 83 2. 03 013 F 66 1 06 058 F 79 6 21 014 F 91 1 01 059 F. 77/ 4 14 015 F 63 2 10 060 F 88 5 01 016 F 80 3 02 061 F 85 3 02 017 F 78 4 23 062 F. 85 2 01 018 F 84 1 25 063 F. 95 5 10 019 F 82 2 04 064 F: 94 2 25 020 F 89 2 04 065 F 92 3 23 021 F 86 3 24 . 066 F 71: 7 24 022 F 60 4 05 067 F 84 5 25 023 F 87 2 11 068 F 85 1 04 024 F 89 1 06 069 M 66 7 25 025 F 90 2 02 070 F 88 i 05 026 M 66 4 24 071 F. 88 1 06 027 M 89 6 25 072 F 79 7 07 028 M 69 4 02 073 F 95 7 05 029 M 71 4 15 074 F 95 1 03 030 F 76 2 01 075 F 85 4 20 031 F 90 2 24 076 F 86 2 12 032 M 77 5 17 077 M 84 3 25 033 F 77 6 01 078 M 62 1 12 034 F 86 1 05 079 M 81 4 09 035 F 84 3 10 080 M 76 2 01 036 F 83 1 11 081 M 69 1 24 037 F 75 4 01 082 M 92 2 10 038 F 76 6 01 083 F 81 6 21 039 F 91 1 21 084 F 78 2 25 040 F 83 6 01 • 085 F 86 2 25 041 M 68 4 18 086 F 83 4 06 042 F 90 2 08 087 F 90 4 02 043 F 90 2 22 088 M 79 4 01 044 F 89 4 11 089 M 89 2 01 045 F 80 1 06 090 M 82 2 08 Page 208 Primary Length Subj.# Sex Age Diagnosis of Stay 091 M 66 1 12 mon. 092 M 73 4 18 093 M 82 2 01 094 M 68 6 25 095 M 87 1 24 096 M 75 1 01 097 M 87 6 03 098 M 77 4 02 099 M 93 2 13 100 M 90 7 06 101 M 66 2 01 102 M 89 2 24 103 M 84 2 20 104 M 94 2 23 105 M 79 4 24 106 M 78 2 01 107 M 74 4 25 108 M 70 2 05 109 M 72 3 19 110 M 91 5 20 Primary Length Subj.# Sex Age Diagnosis of Stay 111 F 86 2 06 mon. 112 F 82 1 25 113 F 91 3 01 114 F 92 1 21 115 F 78 5 20 116 M 85 6 01 117 M 77 5 13 118 M 83 6 25 119 F 85 2 01 120 F 74 4 10 .121 F 85 1 24 122 F 61 1 • 13 123 F 95 1 01 124 F 75 7 02 125 F 62 7' 02 126 F 79 2 05 127 F 82 1 06 /APPENDIX K DEMOGRAPHIC INFORMATION - FACILITY B Page 2.1 0 Demographic Information (Facility B) Primary Length Primary ./. Length Subj.# Sex Age Diagnosis of Stay Subj.# Sex Age Diagnosis of Stay 001 F 79 1 06 mon. 046 F 60 9 7 16 mon. 002 F 71 1 15 047 F 87 1 15 003 F 71 6 19 048 F 86 2 17 004 F 68 1 19 049 F 80 5 15 005 F 80 2 10 050 F 86 5 15 006 F 76 5 05 051 F 94 2 22 007 F 88 6 19 052 F 85 1 16 008 F 92 2 19 053 F 93 1 16 009 F 80 5 22 054 F 93 2 07 010 F 87 2 25 055 F 83 6 16 011 F 82 1 22 056 F 85 4 07 012 F 85 3 21 057 F 95 5 19 013 F 81 4 05 058 F 90 5 23 014 F 85 5 18 059 F 96 3 06 015 F 68 4 02 060 F 96 2 06 016 F 92 4 20 061 F 78 2 16 017 F 61 4 15 062 F 85 6 12 018 F 78 3 11 063 F 64 4 15 019 F 86 2 09 064 F 66 1 20 020 F 85 2 05 065 F 82 7 ' 14 021 F 74 6 05 066 F 80 7 01 022 F 75 6 10 067 M 60 4 04 023 F 90 2 13 068 M 65 7 04 024 F 70 4 10 069 M 79 7 04 025 F 60 1 06 070 F 92 2 20 026 F 75 5 21 071 F 83 4 19 027 F 83 1 14 072 M 62 4 01 028 F 85 7 02 073 M 74 5 02 029 F 77 2 16 074 M 71 6 01 030 F 79 2 25 075 F 92 2 06 031 F 86 1 15 076 F 74 6 12 032 F 82 1 16 077 F 79 2 20 033 F 85 1 18 078 M 83 7 03 034 F 86 4 21 079 M 70 3 13 035 F 90 2 15 080 M 65 4 17 036 F 62 4 04 081 M 75 7 15 037 F 82 3 18 082 F 88 4 10 038 F 95 6 18 083 F 79 4 14 039 F 82 7 15 084 M 68 1 19 040 F 63 6 15 085 M 75 2 26 041 F 61 5 17 086 M 72 1 01 042 F 72 1 07 087 M 65 6 19 043 F 85 1 15 088 M 71 6 11 044 F 76 6 04 089 M 63 6 17 045 F 91 1 04 090 M 88 6 11 Page 211 3ubj.# Sex Age Primary Diagnosis Length of Stay Subj.# Sex Age Primary Diagnosis Length of Stay 091 M 65 1 20 mon. 111 F 87 5 10 mon. 092 M 65 4 21 112 F 77 5 04 093 M 68 4 18 113 M 85 3 05 094 M 61 1 21 114 M 72 7 06 095 M 88 2 19 115 M 85 4 18 096 F 79 2 02 116 M 88 4 01 097 M 73 7 01 117 M 75 4 18 098 M 65 5 03 118 F 87 1 15 099 M 66 4 04 119 M 72 1 07 100 M 93 1 17 120 M 87 2 19 101 M 77 2 18 121 F 87 1 19 102 F 89 2 18 122 F 99 4 21 103 F 92 5 19 123 M 77 1 22 104 M 86 4 03 124 M 90 1 02 105 F 89 2 01 125 M 74 7 02 106 M 91 2 16 126 M 78 4 22 107 F 84 2 17 127 M 66 4 05 108 M 85 5 18 128 M 80 7 06 109 M 79 4 04 129 M 62 4 17 110 M 84 5 15 130. M 65 1 02 APPENDIX L RELIABILITY DATA FOR CONFUSION MEASURE FACILITY A Page 213 Re l i a b i l i t y Data For Confusion Measure (Facility A) Subj.# Rater 1 Rater 2 5ubj.# Rater 1 Rater 2 Subj.# Rater 1 Rater 2  001 3 3 046 1 1 091 002 3 3 047 1 1 092 003 3 3 048 3 2 093 004 3 3 049 1 1 094 005 1 1 050 1 1 095 006 1 051 1 1 096 007 1 1 052 3 3 097 008 053 1 1 098 009 1 1 054 1 1 099 010 1 1 055 3 3 100 011 1 056 1 1 101 012 1 1 057 3 2 102 013 1 1 058 1 1 103 014 1 1 059 1 1 104 015 1 1 060 1 1 105 016 1 1 061 1 1 106 017 1 1 062 2 1 107 018 063 3 3 108 019 1 1 064 1 1 109 020 1 1 065 1 1 110 021 1 1 066 1 1 111 022 1 1 067 2 1 112 023 1 1 068 2 2 113 024 069 1 1 114 025 070 1 1 115 026 1 1 071 1 1 116 027 1 1 072 1 1 117 028 1 1 073 1 1 118 029 1 1 074 3 3 119 030 1 1 075 1 1 120 031 1 1 076 1 1 121 032 2 1 077 1 1 122 033 3 3 078 1 1 123 034 3 2 079 1 1 124 035 3 3 080 1 1 125 036 2 2 081 2 1 126 037 1 1 082 3 3 127 038 1 1 083 1 1 039 1 1 084 1 1 040 085 1 1 041 1 1 086 1 1 042 1 1 087 1 1 043 1 1 088 1 1 044 1 1 089 1 1 045 2 3 090 1 1 APPENDIX M RELIABILITY DATA FOR CONFUSION MEASURE FACILITY B Page 2J 5 Rel i a b i l i t y Data For Confusion Measure (Facility B) Subj.# Rater 1 Rater 2 Subj.# Rater 1 Rater 2 Subj.# Rater 1 Rater 2 001 1 1 046 1 1 091 002 3 3 047 3 3 092 003 3 3 048 3 3 093 004 1 1 049 1 1 094 005 1 1 050 1 1 095 006 1 1 051 1 1 096 007 1 1 052 1 1 097 008 1 1 053 1 098 009 3 2 054 1 1 099 010 1 1 055 1 1 100 011 3 3 056 101 012 3 3 057 1 1 102 013 1 1 058 1 1 103 014 1 1 059 1 1 104 015 2 2 060 1 1 105 016 3 3 061 1 1 106 017 1 1 062 1 1 107 018 3 3 063 108 019 1 1 064 1 1 109 020 2 2 065 1 1 110 021 1 1 066 1 1 111 022 1 1 067 1 1 112 023 1 1 068 1 1 113 024 1 1 069 1 1 114 025 1 1 070 1 1 115 026 1 1 071 1 1 116 027 3 3 072 1 1 117 028 1 1 073 1 1 118 029 1 1 074 1 ,1 119 030 1 1 075 1 1 120 031 3 2 076 1 1 121 032 3 3 077 1 1 122 033 1 1 078 1 1 123 034 1 1 079 1 1 124 035 3 3 080 1 1 125 036 1 1 081 1 1 126 037 1 1 082 1 1 127 038 1 1 083 1 1 128 039 1 1 084 1 1 129 040 1 1 085 1 1 130 041 1 1 086 042 1 1 087 1 1 043 1 1 088 1 1 044 1 1 089 1 1 045 3 2 090 1 1 APPENDIX N RELIABILITY DATA FOR ADL ASSESSMENTS FACILITY A Page 217 Dr e s s i n g E a t i n g Grooming Amb./Trans. G l o b a l ADL Tl T2 T1 v \T2 T1 T2 T l T2 T1 T2 R1 R2 R3 R4 R1 R2 R3 R4 R1 R2 R3 R4 R1 R2 R3 R4 R1 R2 R3 R4 001 17 27 17 17 OA 04 04 04 07 07 05 05 07 07 07 07 35 45 33 33 002 18 18 04 04 07 07 07 07 34 34 003 51 47 31 27 06 06 06 06 15 13 12 08 10 08 07 07 82 74 56 48 004 51 51 41 38' 06 06 06 06 15 11 13 13 09 09 07 09 81 77 67 66 005 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 006 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 007 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 008 22 28 04 04 05 09 . 07 07 - 38 48 009 17 17 04 04 05 05 07 07 33 33 010 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 011 18 17 04 04 05 05 07 07 34 33 012 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 013 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 014 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 015 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33. 016 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 017 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 018 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 019 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 020 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 021 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 022 41 27 19 29 06 06 04 04 05 05 05 05 07 07 07 07 59 45 35 45 023 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 024 49 53 41 45 04 04 04 04 05 05 05 05 07 07 07 07 65 69 59 59 025 17 17 17 17 04. 04 04 04 05.05 0.5.05 07 07 07 07 33 33 33 33 Page 218 026 29 45 V . .  04 04 : 06 027 15 15 04 04 06 028 29 33 08 08 11 029 15 15 15 15 04 04 04 04 06 030 17 17 17 17 04 04 04 04 05 031 17 17 17 17 04 04 04 04 05 032 15 17 15 15 04 04 04 04 06 033 24 22 20 21 04 04 04 04 10 034 25 29 16 18 04 04 04 04 06 035 40 46 51 51 04 04 04 04 12 036 31 39 21 17 04 04 04 04 10 037 29 31 17 19 06 06 06 06 05 038 17 17 17 17 04 04 04 04 05 039 21 25 17 17 04 04 04 04 05 040 35 35 04 04 10 041 23 25 17 17 06 06 06 06 06 042 17 17 17 17 04 04 04 04 05 043 17 17 17.17 04 04 04 04 05 044 1 8 18 17 17 04 04 04 04 05 045 17 19 17 17 04 04 04 04 05 046 17 21 18 20 04 04 04 04 05 047 17 17 17 17 04 04 04 04 05 048 46 51 21 35 04 04 04 04 08 049 17 17 17 17 04 04 04 04 05 050 17 17 17 17 06 06 06 06 05 06 / 12 i 2 ^ ; V £ ^ 51 67 -: = 06 07 07 32 32 15 10 10 5 8 6 6 06 06 06 07 07 07 07 32 32 32 32 05 05 05 07 07 07 07 33 33 33 33 05 05 05 07 07 07 07 33 33 33 33 06 06 06 07 07 07 07 32 34 32 32 06 05 05 07 07 07 07 45 39 35 37 08 07 07 07 09 07 07 42 50 34 38 14 15 15 12 12 14 10 68 76 84 76 08 08 06 07 07 07 07 52 58 40 34 05 05 05 07 07 07 07 47 49 35 37 05 05 05 07 07 07 07 33 33 33 33 06 05 05 07 07 07 07 37 42 33 33 08 07 07 56 54 06 06 06 07 07 07 07 42 44 36 36 05 05 05 07 07 07 07 33 33 33 33 05 05 05 07 07 07 07 33 33 33 33 05 05 05 07 07 07 07 34 34 33 33 05 05 05 07 07 07 07 33 37 33 33 05 05 05 07 07 07 07 33 37 34 34 05 05 05 07 07 07 07 33 33 33 33 10 06 08 08 10 07 08 64 78 38 54 05 05 05 10 10 10 10 36 36 36 36 05 05 05 07 07 07 07 35 35 35-35 Page 219 051 32 38 04 04 05 052 41 29 29 21 08 08 04 04 08 053 17 17 17 17 04 04 04 04 05 054 2 1 2 5 . 04 04 05 055 43 39 24 22 04 04 04 04 10 056 22 24 17 17 04 04 04 04 05 057 51 51 04 04 15 058 20 18 17 17 04 04 04 04 05 059 23 19 17 17 04 04 04 04 05 060 17 17 17 17 04 04 04 04 05 061 31 39 17 20 04 04 04 04 05 062 32 38 18 20 04 04 04 04 05 063 42 38 06 06 07 064 17 19 17 17 04 04 04 04 05 065 17 17 17 17 04 04 04 04 05 066 17 17 17 17 06 06 06 06 05 067 37 41 51 47 04 04 04 04 12 068 30 34 17 17 04 04 04 04 11 069 15 15 15 15 04 04 04 04 10 07 0 17 17 17 17 04 04 04 04 05 071 17 17 17 17 04 04 04 04 05 072 17 17 17 17 04 04 04 04 05 073 17 17 17 17 04 04 04 04 05 074 19 23 17 19 04 04 04 04 05 075 17 17 17 17 04 04 04 04 05 05 07 07 48 54 07 06 06 07 07 07 07 64 51 46 38 05 05 05 07 07 07 07 33 33 33 33 05 07 07 • .. • 41 37 ' . 08 08 06 22 18 21 19 79 69 53 55 05 05 05 09 07 08 08 39 41 34 34 11 07 07 .77 7 3 05 05 05 07 07 07 07 36 34 33 33 05 05 05 07 07 07 07 39 35 33 33 05 05 05 08 08 08 08 34 34 34 34 05 05 05 07 07 07 07 47 55 34 36 05 05 05 07 07 07 07 49 53 34 36 09 07 07 62 60 05 05 05 07 07 07 07 33 35 33 33 05 05 05 07 07 07 07 33 33 33 33 05 05 05 07 07 07 07 35 35 35 35 08 08 12 10 07 09 07 63 60 72 70 07 07 05 09 07 07 09 54 52 35 35 06 07 06 07 07 07 07 36 32 3"3 32 05 05 05 07 07 07 07 33 33 33 33 05 05 05 07 07 07 07 33 33 33 33 05 05 05 07 07 07 07 33 33 33 33 05 05 05 07 07 07 07 33 33 33 33 05 06 08 07 07 07 07 35 39 34 38 05 05 05 07 07 07 07 33 33 33 33 Page 22 0 076 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 077 15 15 15 15 04 04 04 04 06 06 06 06 07 07 07 07 32 32 32 32 07 8 15 15 15 15 04 04 04 04 06 08 06 06 10 10 10 10 34 38 35 35 079 15 15 15 15 06 06 06 06 06 06 06 06 07 07 07 07 34 34 34 34 080 15 15 15 15 04 04 04 04 06 06 06 06 07 07 07 07 32 32 32 32 081 15 15 15 15 04 04 04 04 08 06 06 06 07 07 07 07 34 3 2^ 32 32 082 17 17 17 15 04 04 04 04 12 12 10 06 07 07 07 07 40 40 38 32 083 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 084 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 085 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 33 33 33 33 086 30 32 20 22 04 04 04 04 05 05 05 05 11 13 08 08 50 54 37 39 087 17 17 17 17 04 04 04 04 05 05 05 05 07 07 07 07 3 3 33 33 33 088 26 20 : 17 21 04 04 04 04 0 6 0 6 0| 06 10 10 10 10 46 40 37 41 089 15 15 15 15 04 04 04 04 06 06 06 06 07 07 07 07 32 32 32 32 090 15 15 15 15 04 04 04 04 06 06 06 06 10 10 10 10 35 35 35 35 091 45 45 08 06 „ 18 18 • •.• i 07 07 78 76 092 15 15 45 45 04 04 04 04 08 08 18 18 07 07 18 18 34 34 85 85 093 15 15 15 15 04 04 04 04 0 6 06 06 0 6 07 07 07 07 32 32 32 32 094 15 15 15 15 04 04 04 04 06 06 06 06 10 10 10 10 35 35 35 35 095 17 17 17 17 04 04 04 04 06 06 0 6 06 07 07 12 08 34 34 39 35 096 22 17 15 15 04 04 04 04 12 10 10 06 07 07 07 07 45 38 3 6 32 097 21 21 04 04 06 0 6 10 10 41 41 098 24 17 15 15 06 06 06 06 06 06 0 6 06 22 18 07 07 58 4 7 34 34 099 15 15 15 15 04 04 04 04 06 06 06 06 07 07 07 07 32 32 32 32 100 15 15 15 15 04 04 04 04 06 06 06 06 07 07 07 07 32 32 32 32 101 15 15 15 15 04 04 04 04 06 06 06 06 07 09 07 09 34 32 34 32 Page 2 2 1 102 15 15 15 15 04 04 04 04 06 103 15 15 25 29 04 04 04 04 06 104 15 15 15 15 04 04 04 04 10 105 15 15 15 15 04 04 04 04 06 106 15 15 15 15 05 07 05 07 06 107 15 15 15 15 06 06 06 06 06 108 17 17 17 17 04 04 04 04 08 109. 15 15 15 15 04 04 04 04 06 110 15 15 15 15 04 04 04 04 06 111 17 17 17 17 04 04 04 04 05 112 17 17 17 17 04 04 04 04 05 - 113 17 17 17 17 04 04 04 04 05 114 17 17 17 17 04 04 04 04 05 115 17 17 17 17 04 04 04 04 05 116 15 15 15 15 06 06 04 04 06 117 15 15 04 04 06 118 15 15 15 15 04 04 04 04 06 119 17 17 17 17 04 04 04 04 05 120 17 17 17 17 04 04 04 04 05 121" 17 17 17 17 04 04 04 04 05 122 17 17 17 17 04 04 04 04 05 123 17 17 17 17 04 04 04 04 05 124 17 17 17 17 04 04 04 04 05 125 17 17 17 17 04 04 04 04 05 126 17 17 17 17 04 04 04 04 05 127 32 38 17 21 06 06 06 06 08 06 06 06 07 07 07 07 32 32 32 32 06 06 06 07 07 10 10 32 32 45 49 06 06 10 07 07 07 07 36 32 36 32 06 06 06 10 10 10 10 35 35 35 35 06 06 06 10 10 08 08 36 38 37 33 06 06 06 07 07 07 07 34 34 34 34 08 06 06 07 07 07 07 36 36 34 34 06 06 06 10 10 10 10 35 35 35 35 06 06 06 07 07 07 07 32 32 32 32 05 05 05 07 07 07 07 33 33 33 33 05 05 05 07 07 07 07 33 33 33 33 05 05 05 07 07 07 07 33-33 33 33 05 05 05 07 07 07 07 33 33 33 33 05 05 05 07 07 07 07 33 33 33 33 0g 06 0 6 07 07 07 07 34 3'i 3 2 32 06 10 10 35 35 06 06 06 07 07 07 07 32 32 32 32 05 05 05 07 07 07 07 33 33 33 33 05 05 05 07 07 07 07 33 33 33 33 05 05 05 07 07 07 07 33 33 33 33 05 05 05 07 07 07 07 33 33 33 33 05 05 05 07 07 07 07 33 33 33 33 05 05 05 07 07 07 07 33 33 33 33 05 05 05 07 07 07 07 33 33 33 33 05 05 05 07 07 07 07 33 33 33 33 06 08 06 07 07 07 07 53 57 42 36 APPENDIX O CORRELATION DATA FOR MEAN RATER SCORE AND VISUAL CHART ASSESSMENT X - mean raters' score Y - visual chart assessment Dressing Eating Goroaming Amb./Trans. Global ADL Tl T2 Tl T2 Tl T2 T1 T2 T1 T2 X Y X Y X Y X Y X Y X Y X Y X Y X Y X Y 001 22.0 19.0 17.0 17.0 04.0 04.0 04.0 04.0 07.0 07.0 05.0 05.0 07.0 07.0 07.0 07.0 40.0 37.0 33.0 33.0 002 18,0 17.0 04.0 04.0 07.0 07.0 07.0 07.0 34.0 33.0 003 49.0 51.0 29.0 31.0 06.0 06.0 06.0 06.0 14.0 15.0 10.0 12.0 09.0 10.0 07.0 07.0 78.0 82.0 52.0 56.0 004 51.0 51.0 39.5 38.0 06.0 06.0 06.0 06.0 13.0 15.0 13.0 13.0 09.0 09.0 08.0 09.0 79.0 78.0 66.5 66.0 005 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 006 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 007 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 008 25.0 30.0 04.0 04.0 07.0 07.0 07.0 07.0 43.0 48.0 009 17.0 17.0 04.0 04.0 05.0 05.0 07.0 07.0 33.0 33.0 010 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 011 17.5 17.0 04.0 04.0 05.0 05.0 07.0 07.0 33.5 33.0 012 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 013 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 014 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 015 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 016 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 017 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 018 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 019 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 020 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 021 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 022 34.0 38.0 24.0 22.0 06.0 06.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 52.0 56.0 40.0 38.0 023 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 'hi ro co 024 51.0 51.0 43.0 41.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 025 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 026 37.0 45.0 04.0 04.0 06.0 06.0 027 15.0 15.0 , 04.0 04.0 06.0 06.0 028 31.0 34.0 08.0 08.0 13.0 15.0 029 15.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 030 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 06.0 ^ 06.0 06.0 031 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 032 16.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 033 23.0 24.0 20.5 20.0 04.0 04.0 04.0 04.0 08.0 10.0 05.0 034 27.0 29.0 17.0 15.0 04.0 04.0 04.0 04.0 07.0 08.0 07.0 035 43.0 48.0 51.0 51.0 04.0 04.0 04.0 04.0 13.0 15.0 15.0 036 35.0 40.0 19.0 21.0 04.0 04.0 04.0 04.0 09.0 11.0 07.0 037 30.0 33.0 18.0 17.0 06.0 06.0 06.0 06.0 05.0 05.0 05.0 038 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 039 23.0 27.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 040 35.0 35.0 04.0 04.0 09.0 10.0 041 24.0 26.0 17.0 17.0 06.0 06.0 06.0 06.0 06.0 06.0 06.0 042 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 043 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 044 18.0 18.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 045 18.0 19.0 17.0 17.0*04.0 04.0 04.0 04.0 50.0 05.0 05.0 046 19.0 21.0 19.0 20.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 047 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 048 50.0 51.0 28.0 32.0 04.0 04.0 04.0 04.0 09.0 11.0 07.0 049 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05. ,0 07.0 07.0 07. ,0 07, .0 67.0 67.0 59. 0 57.0 05. ,0 07.0 07.0 07, .0 07, .0 33.0 33.0 33. 0 33.0 12.0 12.0 59.0 67.0 07.0 07.0 32.0 32.0 10.0 10.0 62.0 67.0 06, .0 07.0 07.0 07 .0 07, .0 32.0 32.0 32. 0 32.0 06, .0 07.0 07.0 07 .0 07 .0 33.0 33.0 33. 0 33.0 06, .0 07.0 07.0 07 .0 07 .0 33.0 33.0 33. 0 33.0 06, .0 07.0 07.0 07 .0 07 .0 33.0 32.0 32. 0 32.0 05, .0 07.0 07.0 07 .0 07 .0 42.0 45.0 36.0 36.0 07 .0 08.0 09.0 07 .0 07 .0 46.0 50.0 36. 0 34.0 15 .0 12.0 12.0 12 .0 12 .0 72.0 79.0 80. 0 80.0 06 .0 07.0 07.0 ft 07 .0 07 .0 55.0 62.0 37. 0 38.0 05 .0 07.0 07.0 07 .0 07 .0 48.0 51.0 36. 0 35.0 05 .0 07.0 07.0 07 .0 07 .0 33.0 33.0 33. 0 33.0 05.0 07.0 07.0 07 .0 07 .0 39.5 43.0 33. 0 33.0 07.0 07.0 55.0 56.0 06 .0 07.0. .07.0 07 .0 07 .0 43.0 45.0 36. 0 36.0 05 .0 07.0 07.0 07 .0 07 .0 33.0 33.0 33. 0 33.0 05 .0 07.0 07.0 07 .0 07 .0 33.0 33.0 33. ,0 33.0 05 .0 07.0 07.0 07 .0 07 .0 34.0 34.0 33. ,0 33.0 05 .0 07.0 07.0 07 .0 07 .0 35.0 36.0 33. ,0 33.0 05 .0 07.0 07.0 07 .0 07 .0 35.0 37.0 34. ,0 35.0 05 .0 07.0 07.0 07 .0 07 .0 33.0 33.0 33. ,0 33.0 08 .0 09.0 10.0 07 .5 07 .0 71.0 75.0 46. ,0 41.0 05 .0 10.0 10.0 10 .0 10.0 36.0 36.0 36. ,0 36.0 +0 pj 050 17.0 17.0 17.0 17.0 06.0 06.0 06.0 06.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 35.0 35.0 35.0 35.0 051 35.0 40.0 04.0 04.0 05.0 05.0 07.0 07.0 51.0.56.0 052 35.0 39.0 25.0 27.0 08.0 08.0 04.0 04.0 07.5 08.0 06.0 06.0 07.0 07.0 07.0 07.0 57.5 62.0 42.0 44.0 053 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 054 23.0 27.0 , . 04.0 04.0 05.0 05.0 07.0 07.0 39.0 43.0 055 41.0 43.0 23.0 18.0 04.0 04.0 04.0 04.0 09.0 10.0 07.0 08.0 20.0 20.0 20.0 21.0' 74.0 77.0 54.0 51.0 056 23.0 25.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 08.0 09.0 08.0 08.0 40.0 43.0 34.0 34.0 057 51.0 51.0 04.0 04.0 13.0 15.0 07.0 07.0 75.0 77.0 058 19.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 35.0 33.0 33.0 33.0 059 21.0 24.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 37.0 40.0'33.0 33.0 060 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 08.0 09.0 08.0 08.0 34.0 35.0 34.0 34.0 061 35.0 37.0 18.0 20.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 51.0 53.0 35.0 37.0 062 35.0 37.0 19.0 20.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 51.0 53.0 35.0 36.0 063 40.0 44.0 06.0 06.0 08.0 09.0 07.0 07.0 61.0 66.0 064 18.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 34.0 33.0 33.0 33.0 065 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 066 17.0 17.0 17.0 17.0 06.0 06.0 06.0 06.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 35.0 35.0 35.0 35.0 067 39.0 41.0 49.0 51.0 04.0 04.0 04.0 04.0 10.0 12.0 10.0 12.0 08.5 10.0 08.0 09.0 61.5 67.0 71.0 76.0 068 32.0 32.0 17.0 17.0 04.0 04.0 04.0 04.0 09.0 12.0 06.0 07.0 08.0.09.0 08.0 09.0 53.0 57.0 35.0 37.0 069 15.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 08.0 08.0 06.5 07.0 07.0 07.0 07.0 07.0 34.0 34.0 32.5 33.0 070 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 071 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 072 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 073 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 074 21.0 22.0 19.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 07.0 08.0 07.0 07.0 07.0 07.0 37.0 39.0 36.0 34.0 075 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 70.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 076 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 077 15.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 06.0 07.0 07.0 07.0 07.0 32.0 32.0 32.0 32.0 078 15.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 07.0 08.0 06.0 06.0 10.0 10.0 10.0 10.0 36.0 37.0 35.0 35.0 079 15.0 15.0 15.0 15.0 06.0 06.0 06.0 06.0 06.0 06.0 06.0 06.0 07.0 07.0 07.0 07.0 34.0 34.0 34.0 34.0 080 15.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 06.0 07.0 07.0 07.0 07.0 32.0 32.0 32.0 32.0 081 15.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 07.0 08.0 06.0 06.0 07.0 07.0 07.0 07.0 33.0 34.0 32.0 32.0 082 17,0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 12.0 12.0 08.0 10.0 07.0 07.0 07.0 07.0 40.0 40.0 35.0 37.0 083 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 084 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 085 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 086 31.0 32.0 21.0 22.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 12.0 14.0 08.0 08.0 52.0 55.0 38.0 39.0 087 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 05.0 07.0 07.0 07.0 07.0 33.0 33.0 33.0 33.0 088 23.0 24.0 19.0 21.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 06.0 10.0 10.0 10.0 10.0 43.'0 44.0 39.0 41.0 089 15.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 06.0 07.0 07.0 07.0 07.0 32.0 32.0 32.0 32.0 090 15.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 06.0 10.0 10.0 10.0 10.0 35.0 35.0 35.0 35.0 091 45.0 45.0 07.0 08.0 18.0 18.0 07.0 07.0 77.0 78.0 092 15.0 15.0 45.0 45.0 04.0 04.0 04.0 04.0 08.0 08.0 18.0 18.0 07.0 07.0 18.0 18.0 34.0 34.0 85.0 85.0 093 15.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 06.0 07.0 07.0 07.0 07.0 32.0 32.0 32.0 32.0 094 15.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 06.0 10.0 10.0 10.0 10.0 35.0 35.0 35.0 35.0 095 17.0 17.0 17.0 17/0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 06.0 07.0 07.0 10.0 10.0 34.0 34.0 37.0 37.0 096 19.5 23.0 15.0 15.0 04.0 04.0 04.0 04.0 11.0 12.0 08.0 10.0 07.0 07.0 07.0 07.0 41.5 47.0 34.0 36.0 097 21.0 21.0 04.0 04.0 06.0 06.0 10.0 10.0 41.0 41.0 098 20.5 25.0 15.0 15.0 06.0 06.0 06.0 06.0 06.0 06.0 06.0 06.0 20.0 24.0 07.0 07.0 52.5 61.0 34.0 34.0 099 15.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 06.0 07.0 07.0 07.0 07.0 32.0 32.0 32.0 32.0 100 15.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 06.0 07.0 07.0 07.0 07.0 32.0 32.0 32.0 32.0 101 15.0-15.0 15.0 15.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 06.0 08.0 09.0 08.0 09.0 33.0 34.0 33.0 34.0 102 15.0 15.0 15.0 15.0 04.0 04^ 0 04.0 04.0 06.0 06.0 06.0 103 15.0 15.0 27.0 30.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 104 15.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 08.0 10.0 08.0 105 15.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 106 15.0 15.0 15.0 15.0 06.0 06.0 06.0 06.0 06.0 06.0 06.0 107 15.0 15.0 15.0 15.0 06.0 06.0 06.0 06.0 06.0 06.0 06.0 108 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 08.0 08.0 06.0 109 15.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 110 15.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 111 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 112 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 113 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 114 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 115 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 116 15.0 15.0 15.0 15.0 06.0 06.0 04.0 04.0 06.0 06.0 06.0 117 15.0 15.0 04.0 04.0 06.0 06.0 118 15.0 15.0 15.0 15.0 04.0 04.0 04.0 04.0 06.0 06.0 06.0 119 17.0 17.0 17.0 71.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 120 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 121 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 122 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 123 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 124 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 125 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 126 17.0 17.0 17.0 17.0 04.0 04.0 04.0 04.0 05.0 05.0 05.0 127 35.0 40.0 19.0 21.0 06.0 06.0 06.0 06.0 07.0 08.0 07.0 06 .0 07.0 07 .0 07.0 07 .0 32 .0 32 .0 32.0 32.0 06 .0 07.0 07 .0 10.0 10 .0 32 .0 32, .0 47.0 50.0 08 .0 07.0 07 .0 07.0 07 .0 34 .0 36 .0 34.0 34.0 06 .0 10.0 10 .0 io.o: 10 .0 35 .0 35 .0 35.0 35.0 06 .0 10.0 10 .0 08.0 08 .0 37 .0 37 .0 35.0 35.0 06 .0 07.0 07 .0 07.0 07 .0 34 .0 34 .0 34.0 34.0 06 .0 07.0 07 .0 07.0 07 .0 36 .0 36 .0 34.0 34.0 06 .0 10.0 10 .0 10.0 10 .0 35 .0 35 .0 35.0 35.0 06 .0 07.0 07 .0 07.0 07 .0 32 .0 32 .0 32.0 32.0 05 .0 07.0 07 .0 07.0 07 .0 33 .0 33 .0 33.0 33.0 05 .0 07.0 07 .0 07.0 07 .0 33 .0 33 .0 33.0 33.0 05 .0 07.0 07 .0 07.0 07 .0 33 .0 33 .0 33.0 33.0 05 .0 07.0 07 .0 07.0 07 .0 33 .0 33 .0 33.0 33.0 05 .0 07.0 07 .0 07.0 07 .0 33 .0 33 .0 33.0 33.0 06 .0 07.0 07 .0 07.0 07 .0 34 .0 34 .0 32.0 32.0 10.0 10 .0 35 .0 35 .0 06 .0 07.0 07 .0 07.0 07 .0 32 .0 32 .0 32.0 32.0 05 .0 07.0 07 .0 07.0 07 .0 33 .0 33 .0 33.0 33.0 05 .0 07.0 07 .0 07.0 07 .0 33 .0 33 .0 33.0 33.0 05 .0 07.0 07 .0 07.0 07 .0 33 .0 33 .0 33.0 33.0 05 .0 07.0 07 .0 07.0 07 .0 33 .0 33 .0 33.0 33.0 05 .0 07.0 07 .0 07.0 07 .0 33 .0 33 .0 33.0 33.0 05 .0 07.0 07 .0 07.0 07.0 33 .0 33 .0 33.0 33.0 05 .0 07.0 07 .0 07.0 07 .0 33 .0 33 .0 33.0 33.0 05 .0 07.0 07 .0 07.0 07 .0 33 .0 33 .0 33.0 33.0 08 .0 07.0 07 .0 07.0 07 .0 55 .0 61 .0 39.0 42.0 ro N J N J APPENDIX P RELIABILITY DATA FOR ADL ASSESSMENTS FACILITY B P a g e 2 2 9 VO CO "OO- so co ro ro m os 00 CM sO OS <r 00 co Pi cn as oc. ro ro ro CO ro sO CO *sO. m CO CO CO CO EH LD 00 . o so ro CO ro m Cf\ 00 00 SO CO <r '<r rt cn 00 CO, CO CO ro CO CO ro ,• • * • in CO ro <f CO • <r oo <r o so ro CO ro <r r H 00 CO, CM ,o CO i—1 o- so CM co Os co CO CO CO ro ro <f ro m <f CO co <f EH ro co r-~ CO SO ro CO ro <r OS 00 Jpsj CM so CO i - H SO rt co 00 CO ro ro ro ro ro SO ro m m CO co CO <f CM 00 o o sO CO CO CO m m ro Os sO m 00 CO CO CO C3 <r CM I - Pi CO OS CO ro ro ro CO CO ro r-» SO - CO ro 00 CO m CO <f EH r - CO o sO SO ro CO CO m CO ro OS ' CMv co 00 CO CO ro OS <r r H PH CO os in CO ro CO ro CO m CO so .. in CO ro 00 ro <f CO <r vo o o •vO/ o r-~ os co P~ Os : 00 o 00 00 ' Os'' cn CH r H CM . i—l' . r-H O O O o o O o o r H o O o o EH LD O CO CM O r-- r-- OS CM r-~ r-~' 00 o O CO CM r H r H r-H r-H o o O o r H O O .  o r H O o O rf o o CM O r- r-- r-. 00 r~- 00 o r-- 00 00 CN P£| r H CM r H i—1 o O O o o o ;o o i - H O O o O EH- CO O CO SO o r-- r-- CO r H r-~ 00 o r- r- 00 00 •Pi ' ' * i—l r-H 1—1 O O O o r H O . 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OS o r-H CM CO <r in so 00 OS O o o o O o O O o O 1—1 t -H i - H i - H i - H i - H I - r H r H r H r-H CM o o o O o O O o o o O o o o o ,.o O O o o Page 23 o o o o o o O o o o O o o o O o O O o o -P- OJ OJ OJ OJ OJ OJ OJ OJ OJ 0J NJ NJ Ni NJ NJ NJ NJ NJ NJ O VO 00 OS Ul 4> OJ NJ i — * o VD 00 -~J OS Ul 4^ OJ NJ i—' h-' OJ h-' h-' rO 1—1 h-' -P- OJ h-• NJ 1—• • I—1 h-' M NJ h-1 I-~J h-' ^1 ~J h-' 0J 4> VO VD 00 ~J 1—* OJ h-' !—• 1—» tsj I—* I— 1 NJ OJ }—• NJ h-' 1—' h-• h-' NJ I— 1 ~J Ul Ul ~J Ul ^4 -J O ~J VO ~J SO O •^J <J 1—' OJ I—1 1—' h - ' 0J l — 1 I— 1 Ul Ul I— 1 On 1—' 00 H-» NJ On h - ' N I---J •P- ~J NJ <J t—" 1—' VO t—' '•"'Sj. I— 1 00 -J i — 1 1—• Sj h-» OJ I—" I— 1 h-' NJ H-» h-' NJ Ul 4> I— 1 Ul I— 1 00 on lr-> i - ' NJ ~-J ~J 00 Ul h-* VD vO 1—' 00 Ul I—1 OJ H-» h-» h-» 1—1 1—1 Ui Ul H-* •P>- i — 1 4> NJ NJ t—' -J Ul -J -J I— 1 H VD SD 00 O Ul ~~J <j t—' OJ h-* )—1 h-' NJ Ul On i—• Ul \—1 NJ (-> NJ. 1—1 Ul —J —J --J Ul ' H VD t—' • -~J VD SO <4 o o o o o O o o O o O O O o O o O o o o 4> 4> OS VO 4^ •P- OS OS 4> 4> 4> 4^ -P- OS 4^ 4;- 4S -p-O o O o O o O o O o O O O o o o O o O o 4>- -p- 4> 4> OS 4>- 4> OS Os 4^ 4i~ -P- -P~ -p- OS 4>- 4> 4> 4> O o O O o o O o O o O o' O o o o O O O O 4> 4> -P- -F> as VO -P- 4> OS OS 4^ 4>- 4^ 4> 4> OS 4^> 4> 4> O o o O o o O o O O O O O O O o O O O O -P- -P- -P- 4> OS -P- 4> OS Os -P- 4> 4^ 4> -P~ OS 4^~ -P- -P- 4^ O o O O o O o O to. 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Ul h-* Ul ' oo : Ul Ul Ul O o o o o o o I—* 1—* M' - o h-' o ' • 't' o o o On Ul Ul Ul Ul Ul Ul Ul ,Ul o 4> Ul o Ul NJ Ul Ul t—' o o o o o o o O o o o i— • I— 1 o o o - j o o — i -J vO ~-J : O ' o o o o o I—* o I—* o o o o O o o o l—* •, I— 1 o o o '—I o -~J o --J --4 ~ j •^4 •-J ° o o o <J 1—' I— 1 o o h-* o I—1 o o o o o o o o ': 1—• , NJ l-< 1—' o o NJ VO o -J o 00 ~J ~J : o •' ' 1 NJ o o -^4 1—» o o o o o o o o o o o NJ 1—" o o o -J VO o -J o ~J ~-J --J 00 --J ~J --4 o : O o o I— 1 1—* o o 1—1 1—1 o o o' o '"<:£>" o o o I—* I— 1 o o -p~ -J 00 o o ~J <1 ~-J 's-Oi^. >-J o o 1—' I— 1 o o 1—" o o to o Q o o o ' 1 — 1 'f M M o o o -J 00 o o <4 ' ~J •—1 .to \ o o ~J u> Ul OJ OJ OJ On OJ OJ OS Ul OJ 4> OJ 00 OJ -P- OJ OJ OJ OS o OJ 00 00 On Os 0J VD . 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SD o OS OJ • Ul as 00 OJ Page 231 o O o o O O o o o o O o o o O o o o o o Os On On On On On On On On On On 4> •P- 4> 4> 4> -P- -p> 4> 4> o vO 0 0 -J On 4>- OJ NJ 1—* O SO 0 0 Os On 4> 0 0 NJ I—1 i — • t—' NJ NJ I—> NJ 1 — ' i — • h-* I—" ys- h-' I—1 1—' t—' (—* ' 0 J 0 J OJ 0 0 ~J ~J 0 0 OJ VO ~J -~4 NJ *»' 1—' h-' I — 1 1—• (-» f—' VO ~-J -~4 SO_ -J 0 0 ~~4 ~J o NJ VO -J - J ^ 4 -~4 h-» h-1 h-' NJ On On NJ On NJ I—" h-' NJ On NJ 1—' 1—' >—• I—1 0 0 I—1 i — " t—' o t—* O •~J ~-J o I—- (—» ^ 4 <1 •^ J ~-J ~~J h - ' 1—1 NJ On on I—1 On NJ h-" 1—1 >—• On NJ h-' h - ' h - ' P—' I—1 ^ 4 ^ 1 H- ' i — 1 h-' oo h-' 0 J CD h-* 1—' OJ ^ 1 4^ h - 1 On NJ (—' h - ' 1—' On t—» I—1 i—» 1—' I—1 ~J (—* 1—' oo ^ 4 i—- VO S i VO ~J ^J 1—• I—" On NJ H- ' h-1 t—' w "Cn NJ NJ h-> t—• NJ I-" h-' i—1 VO VO h-' h-« 0 J VO I—1 o o o o O O o o o o o o o o o o o o o o 4>- -p- 4> -P- -P- 4> -p- 4>- -p- 4 S 4 > 4> 4> 4>- 4> 4>- 4^  4^  4^  4>-O o O O o O o o o O O O o o O O O o O O •E- -P- •P- -P- -P- 4> 4>- -p- -p- -P- 4> 4^  4^  4^  4> 4^  4> 4^  4> 4> O O O O o O o o O O O O O O O O o O O -P- •P- •P- 4>- •P- -P- 4> 4> •P- 4> 4^- 4^  4> -P- •P- 4^  4> 4> -P-O O O O O O o O O O O O O o o O o O O 4> •P- •P- 4> -P- -p- 4> 4>- 4> 4> -P- 4> 4> 4> 4> 4^  4> 4> o o O O O o O O O O O O O o O O 4> 4^  •P- 4>- 4>- 4> 4> -P- 4> 4> 4> 4> 4^  4^  4> 4>-O O O O O O O O O O O O O O O O -P- 4^  4^  4> 4> 4 N -P- 4 S 4^  4^  4> -P- 4> 4S 4^  -P-O o O O o O O O O O O O O O h-' O O O O On On On on On On 0 0 On On On Os OJ On I—» UV On On On o O O O O O O O o O O O O h-' O o O O O O ~~J On On On On On On OS On On On 0 0 NJ On ~-4 On On On o O O O O O o I—1 O O O o t— 1 O h - 1 o O O O -J On On On On VO On On On On CO OJ On I—1 orn On ~J On o O O O O O o O O O o h-• O O o O O O On On On On VO on On On On OS OJ On VO on On -~J On o O h-' O O o O O o H-» O o o O O O On On h-» On On 0 0 On On On On On . 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Os OS Ul Ul Ul Ul Ul O O O O o O o O O O O o o O O o O o 1—I o Os OS OS Ln OS Ln OS Os OS Ln Ln OS « OS Os Ul Ul Ul Ul Ln Ul o O O O . o O O O o O O O O O o O o t—• o OS Os Os Ln OS • Ln OS Os OS Ln Ln Os Os Ul Ul Ul Ul un Ul o O O O o O O o o O O o o O o o o r—' o OS OS OS Ln OS > Ln Os OS OS Ln Ln OS OS Ul Ul Ul Ul U T Ul o o o O o O O o o O O o o o o o o r - i o OS OS OS Ln OS ' Ln OS OS OS Ln Ln OS OS Ul Ul Ul Ul (jn> v ^ o O O O o O o o o O O o o o o o o r - ' o OS Os Os Ln OS Ln OS OS OS Ln Ln OS OS Ln Ul Ul Ul ~» Ul 1—' o o O o O o o o O O o r- ' o O o o o r—1 o o - J ~ J ~ J ^ t '•~J '• o 00 ~~J -~J o o o O o O o o o O O O : r—1 o O o o o o o ~ J ~~J ~ J ~ J - J . o 00 ~ J - J o ,_, o o o o O o o o O O o o o o o r—1 o o -~J CO -~J ~ J o 00 " J ~-J - J ~-J o <J r—' o o o o o o o o O o t—» o o o o o t—' o o ~ J -~J 00 ~~J --J ~ J -~J o CO - J - J o <J t—' o o o o o o o o o o H- 4 o o o o o t—' M o >-J ~~J 00 -~J - J - J o CO - J -~J 4^- <J o o o o o o o o o o r-* o o o o o r—• t o o ~ J CO - J ~ J ~ J •^J o CO - J ~ J o 4> LO LO LO LO LO LO Lo LO LO Lo LO LO Lo LO L0 LO L0 LO Ul L0 Ln NJ t o LO 1 LO NJ t o t o Ln LO t o Ln LO LO LO L0 LO CTl LO LO LO LO LO Lo LO LO LO LO LO LO LO LO LO LO LO LO LO •P- L0 Ln t o NJ LO i ts LO r o t o t o Ln LO t o Ln LO L0 LO LO LO 00 L0 LO LO LO LO LO LO LO LO LO LO LO LO LO LO L0 LO LO Ul L0 Ln ho NJ - J t n LO N3 t o LO 4> LO Ln LO LO LO L0 LO UT • LO LO LO LO LO LO LO LO LO LO LO LO LO LO L0 LO LO Lo -p- LO Ln NJ NJ LO On LO t o t o LO Ln LO Ln LO LO LO LO LO vo- L0 Lo LO OS LO LO LO LO LO LO LO LO LO L0 LO L0 LO LO 4^ Ln NJ NJ -P- LO K> LO t o Ln LO Ln LO L0 LO LO LO CTl L0 LO LO OS LO LO LO LO LO LO LO LO LO LO LO L0 LO L0 Ul Ul Ln NJ NJ LO v LO t o r o t o Ln LO Ln LO L0 LO LO LO 0M 4^ Page 233 I—' o o o o o O o o O O o O O o O o O o o o so VD VD VD VO VO VO VO SO VO 00 00 00 00 00 00 , 00 00 00 o VO 00 •-4 OS On -P- OJ NJ 1—" O SD 00 -~1 Ps On -P- 0 0 NJ h-• oo I—1 00 Ul Ul Ul - - 4 VO On On On On On On On On Ul Ul ~~4 ~-4 On •P- I—1 (— 1—' 1—' -P~ i — 1 1—' 1—• 1—1 i—» I—1 I—' h-1 1—1 1—' I—1 I—1 Ul Ul Ul ^ 4 l—1 On On On On On On On On On Ul Ul ~-4 -~4 On 4^  NJ I—1 1—' 1—» i — • i—* • i — 1 H- ' i — * 1—» 0 0 H-* I—1 I—1 00 VD Ul Ul VO On On PS ~d On On o Ul Ul ~-4 00 On 4> NO 1-4 I—1 h-» I—• h-» i—1 I—• 0 0 1—' 1—• h-' I—1 h-' -P- ~J Ul Ul ~J ^ 4 On On ps VO On On o Ul Ul -^4 VO On •P- -P- M I-" I—1 1—» I—1 1—' I—1 i — * i — * i — • I—1 I—1 h-' i— " •P- h-> Ul Ul 1^ -~J On On On On On on Ul ~J vO On •P- CO 1—» I—1 I—1 h-1 I—• i — • t-> I—1 I—1 I—1 NJ i — ' 00 VO Ui Ul -•J On On On ~- l VO On On Ul ^ 4 O On O O o o o O O O O O O o O O o o o o O O -P- 4>- •P- 4> -P- Os 4> •P- -P- 4> 4 > -p- 4> 4> 4^  •p- 4> 4> -P- -P-O O O o O O O O O O O o O O O o O O o O 4> -P- -P- 4>- •P- ps -P- 4> 4> -P- P- 4> -P- 4> -P- 4>- 4> -P- 4> 4> O O o O, O O O O O O o O o O O O O O 4> ps •P- 4> 4>- 4>- •P- 4> •P- 4> •p- 4> -p- 4>- 4> 4> PS 4> O o O O O O O O O O o O o O O O O O •P- os -P- -P- 4> -P- •P~ -P~ 4> 4> 4> -P~ 4> 4> -P- •P- On 4> O p O o O O O O O O O o O O o O O 4>- OS -P- 4> 4^- 4> 4> 4>- 4> 4^  -P- 4> 4^  4> 4^  ps 4> O o O O O O O O O O o O O O O O O 4 > OS 4> 4> 4> 4^  4^  4> 4> 4> -P- 4^  4> 4^  4^  Ps 4> l-i o O O O I—1 l—* O O O o • O o O o O O O O O 0 0 OS 0> OS On On h-' Os ps PS 00 PS ps ps PS Ps 00 On On PS h-i o p p O i—4 o o O O O O O O O O O O O O Si OS Os On 00 VD Os PS Ps Ps PS Ps Ps Ps ps 00 On On Ps 1—1 o P O 1—1 O O O O O O O O O O O O 00 p OS OS On I—1 00 PS VO Ps ps Ps Os Ps 00 On On PS M o o o O O O O h-' O O O O O o O O O 00 00 OS Os On VO Ps OS I—1 Ps ps Os PS ps 00 On On PS 1—1 l-> p O O H-» O O o . O O O O o O O O 00 oS P> On o PS Ps OS ps ps ps Ps ps On On Ps 1-1 p o o O O O O o O O O O O O O O 00 bo ps °) On OS PS PS vO PS PS PS Os ps On On PS o M o o O o O o O O O O O O O O O O O O S j p 00 kl ^J ~-4 —J -^1 -J ~J -~4 - - 4 -~4 ~-4 -J -J -~J p o p O o O o O o o O O O o O o O O O ~-4 p bo S] -~J - - 4 -~4 -~4 ^ 4 •^4 •~J -~4 ~J -J -J O NJ p o o o o o o o O o o o o o o O ki p. 00 Sj -J ~~4 -~4 -J -J -J -J -~4 o o p o o o o o o o o o o o o o o oj OS 00 kl ~-J —1 ~~J ~-4 —J -^1 -~J - - 4 -~4 -~J ~~4 ^ 4 p S 3 p p o o o o o o o o o o o o o s i il> 00 >4 ~J ~-4 --J ~-J -~4 •~J -~J -J ^ 4 -^ J 00 -~4 NJ o o o o o o o o o o o o o o S P- oo Si ~J ~J ~-J ~J ^ 4 ~J ~^1 ~J -J 00 ~-4 PS CO CO 0 0 Os 0O 0 0 0 0 0 0 oo 0 0 0 0 0O 0 0 OJ oo . 0 0 0 0 OO NJ Ul lo So; 0O '-~J -^1 NJ NJ NJ PS NJ NJ NJ NJ NJ -p- 0 0 oo NJ S] CO CO 0 0 0 0 ~J OJ OJ oo 0 0 0O OJ oo 0 0 0 0 0 0 OJ OJ 0 0 0 0 ci to M 0 0 NJ On NJ NJ NJ NJ NJ NJ NJ NJ NJ . 4>- 0 0 0 0 NJ S i ON Co 0 0 0 0 4> OO 0O 0 0 OO OO OJ -P- OO 0O 0 0 0O 0O Si Ui Lo i NJ oo I—1 4> NJ PS 4> NJ NJ SJ NJ 4> 0 0 PS NJ <I Ul 0 0 0 0 0 0 0 0 0 0 0 0 0O 0O 0 0 4> OJ OJ 0 0 0 0 OO Co SI Co NJ 0 0 -~J NJ NJ 00 PS NJ NJ Sl NJ 4S. 0 0 PS NJ S I 00 CO CO, 0 0 OO 0 0 0 0 0 0 0 0 OO 0 0 0 0 0 0 0O 0 0 0 0 L3 CO Lo NJ, : oo 00 NJ NJ NJ NJ NJ NJ NJ -P~ OJ 00 NJ Sj Si 0 0 ^ 0 0 S] Si OO NJ 0O 0 0 NJ 0 0 0 0 0 0 0 0 0 0 0 0 NJ NJ —^1 PS NJ NJ 0 J 0 0 OJ OJ 0 0 NJ 4^  0 J SO NJ 101 15 15 15 15 15 15 04 04 04 04 04 04 06 06 102 17 17 17 17 17 17 04 04 04 04 04 04 05 05 103 17 17 17 17 17 17 04 04 04 04 04 04 05 05 104 15 15 45 45 04 04 06 06 06 06 105 17 17 17 17 17 17 04 04 04 04 04 04 06 06 106 15 15 15 15 15 15 04 04 04 04 04 04 06 06 107 17 17 17 17 17 17 04 04 04 04 04 04 06 06 108 37 42 45 45 04 04 04 04 06 06 109 17 17 04 04 06 06 110 17 17 15 15 17 17 04 04 04 04 04 04 06 06 111 17 17 17 17 17 17 04 04 04 04 04 04 05 05 112 17 17 17 17 17 17 04 04 04 04 04 04 05 05 113 31 45 32 43 31 45 04 04 04 04 04 04 06 06 114 15 15 15 15 15 15 04 04 04 04 04 04 06 06 1 1 5 1 5 15 17 15 33 29 04 04 04 04 04 04 10 06 116 15 15 04 04 06 06 117 17 17 17 17 21 20 04 04 04 04 04 04 06 06 118 17 17 17 17 17 21 04 04 04 04 04 04 05 05 119 45 45 45 45 45 45 06 06 06 06 12 12 18 18 120 15 15 15 15 04 04 04 04 06 06 06 06 06 06 07 07 07 07 07 07 32 32 32 32 32 32 05 05 05 0 5 0 8 08 08 08 08 08 34 34 34 34 34 34 05 05 05 05 08 08 08 08 08 08 34 34 34 34 34 34 12 16 07 07 09 07 32 32 72 74 06 06 06 06 07 07 07 07 07 07 34 34 34 34 34 34 06 06 06 06 10 10 10 10 07 07 35 35 35 35 35 35 06 06 06 06.07 07 07 07 07 07 34 34 34 34 34 34 10 16 11 12 10 12 58 64 69 77 08 08 35 35 06 06 06 06-10 10 10 10 10 10 37 37 35 35 37 37 05 05 05 05 07 07 07 07 07 07 33 33 33 33 33 33 05 05 05 05 07 07 07 07 07 07 33 33 33 33 33 33 06 06 06 06-18 22 18 22 19 21 59 77 60 75 60 76 06 06 06 06 .07 07 07 07 07 07 32 32 32 32 32 32 09 07 12 08-10 10 10 10 10 10 39 35 40 36 59 51 10 10 35 35 06 06 06 06 08 08 08 08 08 08 35 35 35 35 39 38 05 05 05 05' 07 07 07 07 07 07 33 33 33 33 33 37 18 18 18 18-07 07 07 07 09 08 76 76 76 76 84 83 06 06 07 07 07 07 32 32 32 32 M CO Pag e r—' I—" t—• r—• 1—1 1—1 h-' r-» r-* p-• co NJ NJ NJ NJ NJ NJ NJ NJ NJ o SO CO - J OS Ln J N Lo NJ h—» NJ r-* NJ NJ LO r—' NJ h—• r— 1 r—' Ln Ln r-* U) ~J 00 Ln <J ~J NJ r-» t—' LO L0 h-1 L0 r—1 r-» r- 1 r- 1 Ln SO Ln SO J N Ln ~ J J N r-' J N NJ J N P—• t—* Ln r- 1 Ln Ln Ln Ln Ln Ln J N r—» J N LO J N h—• r—' Cn r—' Ln Ln Ln Lo Ln Ln 1 4^  NJ NJ J N NJ h-' 1—' Ln LO LO Ln Os Ln ~J J N r-' LO J N NJ r— 1 t—' Ln SO Ln Ln NJ Ln O O O O O O O O o o J N J N J N OS OS J N J N J N J N J N O O O O O o o O o O J N J N J N Os CO J N J N J N J N J N O o O O O o o O o J N J N J N J N 00 J N J N J N J N O o O O O O o o O 0> J N J N J N Os J N J N J N J N O o O O O o O J N J N Os CO J N J N J N O O O O O O o Os J N OS 00 J N J N J N O O O r-' I—* o o o O OS OS o ~-J o o -~J cn. Ln O o o r-' r-' r—* o o O O Os OS 00 LO J N o cr> Ln r-' o r-' O t—' o h-1 . O NJ OS NJ OS J N N4 (j* i Ln r—' o r- 1 r-' r- 1 o r-' O OS OS NJ LO NJ O Cn "Ln h-' o r- 1 t—' r-' o O NJ OS J N CO o 00 Ln h-' o r—» r- 1 o O OS OS 00 J N o CO Ln r—1 O t—1 h-1 r—' 1—' t—' h-' O NJ o O J N O o o O t—1 o r—' r—' t—' r—• O o o O J N o o o o NJ p—1 o h-' O I—" r-* NJ o NJ o - ~ J o CO o o NJ N J NJ o t—' 1—' r-» NJ o NJ o o J N o o NJ r-' r—• O r—» o OS o o SO o O ~J NJ t—' r—* r-• o NJ o o I—' o O ^1 J N LO J N J N OS J N J N LO CO Lo ~ - J Ln NJ OS H—1 SO Os OV Co J N LO LO OS J N Ln LO Lo LO r—' Ln CO J N Ln h-> Ln Os cr\ CO 00 LO Os J N - J J N LO sO CO LO) Ln 00 OS ~J Ln OS ISO Co 00 LO OS OS ~ J JN< LO SO CO SO Ln CO o Os NJ Co J N Ln CO J N LO CO LO L0 o 00 ~J U) CO LO OS J N L0 CO SO SO SO CO CO 

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