Occupational_Therapy_&_Parkinson's_Disease

According to the Parkinson’s Disease Society (PDS) (2006), Parkinson’s Disease (PD) is a progressive neurological condition affecting the pathways in the brain concerned with the control of movement. PD occurs as a result of a loss of nerve cells in the part of the brain known as the Substantia Nigra. These cells are responsible for producing a chemical known as Dopamine, which enables messages to be sent to the parts of the brain that co-ordinate movement. With the reduction of dopamine-producing cells, these parts of the brain are unable to function normally. Beattie and Harrison state in Turner et al (2002) that PD is characterised by tremor, rigidity, bradykinesia/hypokinesia and postural instability. According to Jones and Playfer in Stokes (2004) the diagnosis of PD depends on the recognition of at least two of these clinical features. Beattie and Harrison in Turner et al (2002, pg.602) explain that progression is usually slow, enabling the person time to adjust to changes, however “the condition invariably leads to significant problems with functional mobility, occupational performance and social roles. According to Jones and Playfer in Stokes (2004), ‘tremor’ is defined as an alternating movement commonly seen in the upper limb as a reciprocal movement of thumb and forefinger (also known as a ‘pill-rolling’ tremor), with the frequency of 4-6Hz. According to Lindsay and Bone (2004) this tremor occurs at rest, improves with movement and disappears whilst sleeping. Beattie and Harrison in Turner et al (2002) add that anxiety and fatigue can aggravate these tremors. They explain that as the condition progresses, the tremor may affect other parts of the body. Beattie and Harrison in Turner et al (2002) state that ‘rigidity’ is the term used to describe an increase in muscle tone, leading to a resistance to passive movement throughout the range of motion. It can be described as ‘lead pipe rigidity’ when sustained resistance is felt (e.g. when passively moving a limb) or ‘cog-wheel rigidity’ when resistance is intermittent. Beattie in Turner et al (1996) states that rigidity increases with anxiety or concentration, and it becomes more pronounced as the condition progresses. Beattie in Turner et al (1996, pg.600) describes hypokinesia or bradykinesia as “…a slowness and poverty of voluntary movement”, resulting in the difficulty of initiating and carrying out coordinated movements. According to Clarke (2001) ‘hypokinesia’ describes the poverty of movement in PD (e.g. difficulty writing and fastening buttons, and displaying a mask-like facial expression), and ‘bradykinesia’ describes the slowness of movement, causing difficulties such as rising from a bed/chair, or getting in/out of the bath. Beattie in Turner et al (1996) explains that walking patterns can become severely impaired (e.g. short, shuffling steps with a flexed posture) and that small muscle groups are most affected causing activities such as cutting food or chewing difficult. Beattie in Turner et al (1996) states that the repeated effort used to carry out activities can lead to fatigue, aching muscles and muscular pain. According to Beattie in Turner et al (1996), PD can cause patients to frequently fall. Clarke (2002) explains that postural instability is a fundamental feature of PD that develops later on in the course of the condition, and is usually associated with a stooped posture (flexion of the cervical and thoracic spines). Beattie and Harrison in Turner et al (2002, pg.602) explain that depression is a common symptom experienced by many PD sufferers. They state that “…reduction in quality of life, concern over financial matters and a change of occupational role may be contributory factors”. Clarke (2002) mentions several other features of PD, such as: ‘freezing’ (inability to initiate movement or the sudden stopping of movement), speech disorders (dysphagia/dystonia) and oedema. According to CNN.com (2004) there is no diagnostic test that can confirm PD. Therefore, the physician must judge how closely the history of symptoms and the neurological findings match those typical of PD. The Parkinson’s Disease Society (2003) state that although currently there is no cure for PD, several drug treatments are available to help control the symptoms. The main aim of drug therapy is to restore dopaminergic function. This can be achieved by increasing the level of dopamine, or by using drugs that mimic the effects of dopamine. According to Beattie and Harrison in Turner et al (2002) drug therapy is the most important form of treatment for the condition and careful and regular monitoring is required. The PDS (2006) explain that currently there is no perfect drug for the treatment of PD, and medical management varies from one patient to the next. According to CNN.com (2006), ‘levodopa’ (L-dopa) has been considered the standard drug for PD. L-dopa has been found to be a precursor to dopamine. This is because, when it is given to people with PD, the L-dopa is converted into dopamine by nerve cells in the brain. It is this increase in dopamine that may reverse many of the disabling symptoms of the disease. The PDS (2006) state that the majority of people using L-dopa experience considerable long-term improvement, especially in stiffness and slowness of movement. However, some patients have experienced a less reliable response to these drugs when used longer-term; often experiencing periods when the effect of the most recent dose wears off before the next one is due (end-of-dose-deterioration). According to the PDS (2003), ‘dopamine antagonists’ work by stimulating the parts of the brain where dopamine works; and unlike levadopa, do not require conversion by the brain cells first; it is also longer lasting. Clarke (2002) explains that ‘apomorphine’ is often used when other drugs are not tolerated/ineffective. According to the PDS (2003) apomorphine is a dopamine agonist given by injection which is usually prescribed to provide additional/alternative benefit to patients who have PD for some time. Clarke (2002) states that the drug acts quickly and reliably so that patients needing to be active at specific times can continue with their normal activities. The PDS (2006) explain that apomorphine can cause nausea/sickness, and soreness can develop at the injection sites. Symonds (1999) explains that improved techniques and the limitations of drug treatment have prompted the return of surgery. ‘Thalamotomy’ and ‘pallidotomy’ are surgical treatments used to destruct certain brain cells that interfere with normal movement. Symonds (1999) continues to explain that surgery is only offered to patients suffering from the specific symptoms for which a procedure was developed; and when medication produces intolerable side effects or can no longer provide adequate control of symptoms. Fawcett in Turner et al (2002) states that the purpose of assessment is to gain a clear picture of the patient, to enable the therapist to develop an effective intervention plan that will improve and enhance the patients quality of life. According to Beattie in Caird (1991), occupational therapy assessment should cover activities of daily living such as mobility, personal care, domestic care, leisure pursuit and general information about how the patient and carer are coping with the difficulties imposed by PD. Sam is currently experiencing difficulties with transfers and personal care tasks. Therefore, it is important that these areas are assessed. According to Foster in Turner et al (2002), personal care is comprised of activities such as washing, grooming and dental hygiene. Foster continues to explain that assessment of this area is important because these activities are essential in the maintenance of good hygiene and the prevention of infection, and will also contribute to Sam’s self-esteem and confidence. Foster in Turner et al (2002) states the ability to transfer is crucial in enabling Sam to move from place to place (e.g. from chair to toilet). Assessment will highlight the exact difficulties Sam is experiencing, enabling the therapist to plan intervention that will enable Sam to maintain a satisfactory level of independence in this area. One method for assessing Sam’s difficulties concerning transfers and personal care; is ‘observation’. Law (1993) in Turner et al (2002) believes that observing Sam’s performance in these areas acts as the most reliable form of functional assessment. Laver Fawcett in Turner et al (2002) states that this method should not be used alone to assess Sam’s needs; she explains that studies have highlighted discrepancies between reported and observed function, and therefore suggests the most reliable method of assessment is to use a standardised method; and from the results, select a few key activities for observation. According to the CAOT (1991), the Canadian Occupational Performance Measure (COPM) is an individualised, client-centred measure designed to detect changes in Sam’s self-perception of occupational performance over a period of time. The COPM is a standardised measurement involving a semi-structured interview format and structured scoring method. According to Sumsion and Blank in Duncan (2006), this measure is suitable to use with Sam because it is simple to follow and requires him to identify the daily activities he wants, needs or is expected to perform. The PDS (1996) recommends using COPM to assess activity and plan the most appropriate intervention programme for Sam. Another assessment that is suitable to use with Sam is the Assessment of Motor and Process Skills (AMPS). In contrast with the COPM which requires a subjective response (e.g. Sam’s point of view); the AMPS requires the objective views of the therapist. Forsyth and Kielhofner in Duncan (2006) state that AMPS is a structured, observational evaluation that aims to measure the quality of Sam’s activities of daily living. AMPS Project International (2005) continues to explain that this assessment uses goal-directed actions, and is aimed at testing the skills Sam has in relation to occupational performance. However, Murphy and Tickle-Degen (2000) explain that the AMPS cannot be administered to clients when they are ‘off’ (in a state of immobility and dependency). Sam is showing signs of memory loss; according to Wheatley in Pedretti and Early (2001, pg. 462) “memory is the process by which all information is stored and retrieved in the cognitive system”. Wheatley explains that without sufficient ‘implicit’ memory, Sam may lose his ability to perform ADL tasks independently, and an inability to maintain ‘explicit’ memory may mean new techniques the therapist has taught Sam cannot be recalled. Therefore, it is important for the therapist to identify what type of memory loss Sam is suffering from, to determine what intervention can be used to overcome Sam’s difficulties. One measure that could be used to assess Sam’s capacity for memory is the Riverside Behavioural Memory Test (RBMT). According to Duchek and Abreu in Christiansen and Baum (1997), this test was developed to assess visual/verbal memory impairment in everyday functioning. According to Wheatley in Pedretti and Early (2001), the RBMT is useful for immediately providing relevant information concerning Sam’s capacity to function safely. Green in Goodwill et al (1997, pg.411) states the test is short, undemanding and easy to administer which is “…particularly effective with patients whose comprehension is poor or whose level of attention and concentration is circumscribed”. Another assessment that could be used to confirm Sam has a memory deficit is the Mini Mental State Examination (MMSE). According to TUFTS (no date) the exam consists of questions split between five areas of cognition (orientation, registration, attention and calculation, recall, and language). The maximum score is thirty, and a score lower than twenty-three is indicative of cognitive impairment. Wallace (1999) explains that the MMSE relies heavily on verbal response, reading and writing. Therefore, this tool would not be appropriate to use with Sam if he is severely suffering from tremors or dysphagia/dysarthia. Sam’s family are concerned by his low mood, it is therefore important his psychological state is assessed. Bonder (1993) is discussed in Christiansen and Baum (1997) for stating that psychological factors are basic to ‘doing’, and therefore influence occupational performance. The therapist needs to assess Sam’s psychological state to enable her to find an appropriate fit between how Sam feels and the tasks she sets for him. An ideal measure for monitoring Sam is to use the Hospital Anxiety and Depression Scale (HADS). Tattersall in McIntyre and Atwal (2005) states that this scale is an easy-to-use self-report questionnaire for measuring anxiety and depression. According to Priest (no date), HADS comprises statements which Sam can rate based on his experience over the past week. These ratings are scored, with scores of 11/21 indicating the probable presence of a mood disorder. If the HAD scale indicates Sam is likely to be depresses, the Beck Depression Inventory (BDI) could be used to measure the intensity, severity and depth of his depression. It is a form consisting of twenty-one questions, each designed to assess a specific symptom. The purpose of the BDI is to detect, assess, and monitor changes in depressive symptoms. It is also important that Ellie’s needs are assessed as Sam’s carer. According to Bakheit and McLellan in Goodwill et al (1997) caring for Sam can be a heavy burden. To prevent Ellie from suffering from stress and depression herself, it is important that she is offered relief from her caring role. Carers UK (2007), explains that Ellie has the right to a Carers’ Assessment which can be completed by the OT or social worker. The purpose of this assessment is to identify the help Ellie requires caring for Sam, and help with maintaining her own health and occupational balance. Beattie in Turner et al (1996) state that dues to the progressive nature of PD Sam will need to compensate for reduced function and adapt to each stage of the condition. Therefore, his intervention programme will consist of using compensatory techniques and the use of adaptive/assistive equipment to enable Sam to achieve a satisfactory level of independence by the time of discharge. According to Foster in Turner et al (2002, pg.77), one of the basic assumptions of the Compensatory Frame of Reference is: “people suffer short-and-long term dysfunction that cannot immediately or significantly improved by other therapeutic methods, so there is a need for compensation for lost of limited abilities”. Foster in Turner et al (2002) states one of the benefits of using this frame of reference is that it has no rigidly structured sequence, therefore creating a flexible approach to meeting the individual’s needs. This is particularly useful in Sam’s situation because the disease is consistently changing Sam’s abilities. Foster in Turner et al (2002) explains that the recognition of permanent loss of function is the basis for using this frame of reference, and therefore could create negative connotations. According to the Department of Health (DOH) (2007), the National Service Framework for Long-Term Conditions states that PD sufferers who can benefit from rehabilitation should receive timely, ongoing, high quality rehabilitation services. Over the weeks, goals will be set for Sam gradually enabling him to do more for himself, with the therapist continually adopting a facilitative role rather than assisting. Sharp in Caird (1991) explains that it is important for Sam to progress in these tasks at a pace appropriate to him, and that adequate time is allocated for all treatment sessions. Turner in Turner et al (1996) explains that because Sam may be suffering from memory loss and poor retention of new knowledge, once a suitable method has been found, it should be used consistently and taught using simple commands given one at a time. Sharp in Caird (1991) explains that it is important to know the timings of Sam’s medication in planning these sessions because it is likely to affect his ability to cope with these activities. For the purpose of safety and energy conservation Sam has been advised to remain sitting during personal care activities with all items close at hand. Foster in Turner et al (2002) suggests provision of equipment (e.g. rails, boards, seat and non-slip mats) and appropriate techniques can make these activities easier/safer for Sam. After washing, Sam will participate in dressing practice. This may need careful consideration because Sam’s activity tolerance is likely to be lowered by this time. Beattie and Harrison in Turner et al (2002) state that Sam should be advised to wear loose, stretchy and easy-to-manage clothes, for reducing the amount of energy required for carry out dressing. As a way of involving Ellie, it may be suggested that she takes responsibility for adapting Sam’s clothes, such as: wider openings, use of elastic/velcro larger buttons. According to Imke et al (2003), helping Sam to get dressed can be simplified by establishing routine. For example, prior to dressing; Ellie could lay out Sam’s clothes in the order to be put on, also assembling any adaptive equipment (e.g. buttonhook or shoehorn). Imke et al (2003) suggest dressing should be done sitting, and advise that clothes are put of Sam’s most affected side first as a compensatory method. Sam has set a joint goal with the OT and physiotherapist to improve his ability to transfer. The therapists aim to find simpler and less effortful ways for Sam to transfer to/from bed, chair and toilet. Depending on Sam’s energy levels, Sam will be expected to practice transfers with the OT and physiotherapist during most sessions. During the first weeks, Sam will be set the goal of transferring in a low-pivot using the therapist for guidance and assistance. Once Sam feels confident with transferring in this way, the goal will move up to a stand and step transfer. Creel et al in Pedretti and Early (2001) explain that a standing/stepping transfer is generally used when patients can take small steps towards the surface goal and not just a pivot. It is hoped by the end of the six weeks; Sam will have the confidence to transfer independently or with minimal facilitation. Beattie in Turner et al (1996) states that Ellie will need to be taught manual/therapeutic handling techniques to safely facilitate Sam with his transfers, and that she only offers minimal assistance to Sam. The PDS (1996) explain that a very common problem in PD is the inability to turn in bed and get in/out of bed, and that there are no straight forward solutions to these problems. To ease turning in bed, Sam should be advised to purchase a firm mattress with the advantage of a silky sheet placed under his hips to aid sliding, and/or wear bed-socks for grip. According to Beattie in Turner et al (1996) if Sam opposes using silk sheets, another suggestion could be the use of non-slip sheets for providing more “grip” to resist against. According to the PDS (1996), Sam should be given the opportunity to use grab rails attached to the side of the bed to aid him in turning. The PDS (1996) also suggest Sam may find it useful to have a focal point on each side of the bed (e.g. a luminous clock-face or bedside lamp) that can aid concentration whilst he is turning/getting out of bed. Grieve (2000) states that the outcome of the memory assessments carried out with Sam will determine what compensation strategies can aid Sam with functioning in his own environment (e.g. diaries/ wall planners). Currently, Sam is experiencing difficulty in his abilities to learn new skills and recall previously learnt skills. Beattie in Turner et al (1996) states that these compensatory strategies should enhance Sam’s ability in these areas. Grieve (2000) explains that the success of implementing strategies devised to improve memory function will depend on Sam’s awareness and his cognitive ability to use memory aids. One of the leisure activities Sam enjoys is gardening. It is therefore important that gardening is incorporated in to his intervention programme. Turner and MacCaul in Turner et al (1996) state that gardening is an extremely versatile activity because it involves a variety of tasks which require a range of physical movements and cognitive skills. Turner and MacCaul in Turner et al (1996) continue to explain that gardening is an activity that can be graded/adapted to meet successfully with Sam’s needs. During Sam’s stay in intermediate care, he will be set the remedial task of preparing a window box. After, highlighting the difficulties Sam is currently experiencing in this area, he will be given the opportunity to practice using compensatory techniques and adaptive equipment (e.g. lighter or long-handled tools) during these sessions. This task aims to improve Sam’s activity tolerance, and will be graded so that Sam spends increasingly more time on this activity. Beattie in Caird (1991) suggests during sessions, Sam should be given advice about making gardening more manageable at home (e.g. raising flower beds to a suitable height to prevent bending down). A joint goal has been set with Sam between the OT and physiotherapist, to learn and develop some strategies to enable him to improve/overcome his difficulties with walking/freezing. The PDS (1996) state that safety in walking is extremely important and the OT and physiotherapist should work together with Sam and his family to maintain the required degree of walking, standing and balance needed for transfers in particular. It is hoped that if Sam’s capabilities improve in this area, he will regain confidence giving him the strength and motivation to continue the social activities he has currently withdrawn from. It is also hoped that gaining confidence back in this area will contribute to lifting Sam’s low mood. Beattie in Caird (1991) states that treatment for mobility problems such as walking and turning should be provided by the physiotherapist and reinforced by the OT. It has been agreed with Sam that he should attend exercise classes during his stay in intermediate care. This in turn will improve Sam’s fitness and provide him with much needed social contact. Gauthier (1987) in Turner et al (1996) reinforces this point by explaining that people with PD often enjoy learning in groups and can benefit from the social contact provided. Strategies for overcoming walking difficulties and freezing will be incorporated into all occupational therapy sessions (e.g. when Sam is walking to the bathroom to practice toilet transfers). According to Beattie and Harrison in Turner et al (2002), initiation strategies Sam may choose to use are: counting, singing, focusing on points across the room, visualising lines on the floor or placing specific cues in places. Beattie and Harrison in Turner et al (2002) continue to explain that in consideration of ‘risk’, the therapist should be aware that although some obstacles, such a rugs and furniture are a hindrance, other can be a positive help because they act as cues. Beattie and Harrison in Turner et al (2002) state that is important that the occupational therapist/social worker ensure that Sam and Ellie are aware of mobility allowances and local mobility schemes that can be of assistance (e.g. enabling Sam to attend his gardening club and fellowship group). Beattie and Harrison in Turner et al (2002) state that a wheelchair should not be seen as the automatic solution to mobility problems because the emphasis should be on maintaining walking. However, the therapist can provide Sam with a wheelchair if it will benefit Sam in mobilising outside the home, thus improving his independence and sociability. It is hoped that at the end of his stay in intermediate care, Sam has regained some motivation and satisfaction within his life, which will in-turn lift his current low mood. REFERENCES Amps Project International. (2005) AMPS. Available at: http://www.ampsintl.com (Accessed: 4 February 2007). Bakheit, A.M.O. & McLellan, D.L.L. (1997) ‘Parkinson’s Disease and Other Forms of Parkisonism’, in Goodwill, C.J. Chamberlaine, M.A. & Evans, C. (ed.) Rehabilitation of the Physically Disabled Adult. 2nd edn. Cheltenham: Stanley Thornes. Beattie, A. & Harrison, J. (2002) ‘Parkinson’s Disease’, in Turner, A. Foster, M. & Johnson, S.E. (ed.) Occupational Therapy and Physical Dysfunction: Principles, Skills and Practice. 5th edn. London: Churchill Livingstone. Beattie, A. (1991) ‘Occupational Therapy’, in Caird, F.I. (ed.) Rehabilitation in Parkinson’s Disease. London: Chapman & Hall. Beattie, A. (1996) ‘Parkinson’s Disease’, in Turner, A. Foster, M. & Johnson, S.E. 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