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Lauren O’Neill and Louise McCombe Occupational Therapists at Graham Anderson House, Glasgow,

Brain Injury Rehabilitation Trust

Sequencing difficulties post brain injury

Scaffolding

What is GUIDE?

Single n study as part of a wider randomised control

Activities of daily living are complex sequences

A set of actions that must be performed in a certain order to achieve a goal state

Inability to carry out a complex sequence

safely is widespread and disabling for many: ◦ Learning disability ◦ Mental health problems ◦ Degenerative neurological conditions ◦ Stroke ◦ Acquired brain injury

Four categories of behaviour control impairments

◦ Energization (motivation / sustaining activity) localized to SMPFC

◦ Emotional regulation (prioritisation / inhibition) VMPFC

◦ Task setting (verbal self regulation) LPFC

◦ Meta cognition (monitoring) Area 10

Within rehab units the use of scaffolding techniques to prompt self-care task are common

It facilitates ability to build on skills and knowledge

Instructions given are just beyond the level of what the service user could do without prompts

The staff member provides the service user with the scaffolding to achieve an end goal (Olsen and Pratt, 2000)

Support staff use a wide range of subtle strategies

Service users are not passive

Service users often request help

But, service users often also resist help

Maybe service users are less likely to resist scaffolding from a technology?

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Assistive Technology for cognition is the use of technology to extend or augment the mental functions, with particular application meeting the needs of people with cognitive impairment

Research includes use of paging system to provide reminders of everyday tasks (Wilson et al 2001).

Other media have also used text or auditory prompts to overcome prospective memory difficulties;

• Voice recorders with a timer function (eg. van den Broek, Downes, Johnson, Dayus, & Hilton, 2000);

• text messaging to mobile phones (Pijnenborg, Withaar, Evans, van den Bosch, & Brouwer, 2007)

• smartphone reminders (Svoboda & Richards, 2009)

Care-givers provide cognitive support ◦ Talking service users through tasks ◦ Providing prompts and checks

GUIDE models care giver cognitive support ◦ Prompts user through tasks ◦ Receives verbal input ◦ Simulates naturalistic conversation ◦ Automated, non-judgemental and

emotionally neutral prompter (preferred by some individuals)

Rehabilitation relevant behaviour in persons with early stage vascular dementia

O'Neill, B. Moran, K. & Gillespie, A. (2010). Scaffolding rehabilitation behaviour using a voice-mediated assistive technology for cognition. Neuropsychological Rehabilitation, 18, 1-19.

User

Computer

GUIDE software

User

Computer

GUIDE software

Prompt or

Question

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User

Computer

GUIDE software

Prompt or

Question

Speech

Recognition

The only prompting system that uses speech recognition ◦ It simulates natural conversation

No difficult technology interface ◦ It is as easy to use as having a conversation

Builds upon users abilities o Rather than by-passing their abilities

Technology may aid the transition from rehabilitation unit to home

Randomised control trial

To develop and test laundry and morning routine GUIDE protocols for use by people with acquired brain injury.

Three year research project 2010-2013

◦ at Brain Injury Rehabilitation Trust’s Graham Anderson

House in Glasgow

◦ funded by Chief Scientist Office of the Scottish Government

Single n experimental design – as part of the larger randomised control trial

62 year old man

Twelve month history after intracerebral haemorrhage

Severe cognitive impairment - memory

n=1, Inpatient A-B-A-B; At home A-B

Morning Checklist a. sequence performance score and b. carer prompts

Inpatient = six weeks baseline then three weeks intervention

Home = one week baseline then two week intervention (trial)

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During the first intervention phase the Morning Checklist score was significantly increased in comparison with baseline

This indicates that the number of prompts given by support staff significantly decreased in the first intervention phase, where the participant approached perfect performance (4.94/5.00).

The use of guide was withdrawn due to subject error (being turned off ) for 4 days

Within this period the results demonstrate a greater number of prompts required

When the GUIDE was re-introduced the results indicate an increase in function

Similar pattern of improvement at home

Significant improvement in morning checklist ratings from baseline and intervention conditions

Guide error rates at home were slightly higher

This may have been an artefact of difference in observers or due to the change of environment

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Inpatient errors: getting up and going straight back to bed, hesitating during sequence, not being able to find clothes that are in the room, and not getting all the clothes ready to be fully dressed

Home errors: not getting all clothes to be fully dressed, wearing dirty or mismatched clothes, forgetting to pick up phone/GPS and inappropriate clothes for the weather

Guide reduced participant errors to near zero in the intervention phase

Led to ratings of ‘independent’ on half of intervention trials

Guide can emulate the supportive action of carers in the performance of a complex ADL sequence

Augmentation of rehabilitation, facilitating discharge and home support

Increased prompting without increasing staff costs

Many service users object to being observed and prompted. The use of an automated, non-judgemental and emotionally neutral prompter may be preferable (O’Neill & Gillespie, 2008; Lo Presti et al., 2004)

The technology may aid in the transition from rehabilitation centre to home

This could have huge financial implications

If the person can carry out the sequence with prompting support, then Guide or a context aware prompter may allow that person to be independent

This could have functional implications in terms of discharge planning and could perhaps reduce the need for long term carer support

Single n experimental design Participant had interested in technologies

Highly motivated by hope of discharge home Increases in error rates and decreases in

prompt score ratings of independence occurred on return home and baseline

Feedback on appearance and performance Perhaps once more settled within his home

environment and into an established routine with support the long term use of GUIDE could have maximised his function

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From a functional perspective the use of the GUIDE system alongside a rehabilitation program could maintain sequencing abilities with complex ADL tasks

It could be implemented as a less intrusive

way of supporting an individual with personal care routines

This could in turn perhaps have longer term implications for reducing carer costs