neurogenic disorders: assessing/managing patient motivation 30 biel.pdf · mscc - biel 3/30/13 1...

MSCC - Biel 3/30/13

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Neurogenic Disorders:

Assessing/Managing Patient

Motivation Michael Biel, CScD, CCC-SLP

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Motivation and Rehabilitation

Assessment

Management

Disorders of diminished motivation 2

Motivation 1

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4

5

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Most of us rely on an intuitive

sense of what motivation is

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Why study motivation?

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‣ Because we believe it’s important to outcomes

(Kaufman & Becker, 1986; Maclean et al., 2002)

‣ Because we make treatment decisions based

on it (Enderby & Petheram, 1992; Mackenzie et

al., 1993)

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Not a new concern

‣ Darley (1972), Eisenson,

(1949) and Wepman (1953)

made understanding

motivation a prominent

part of aphasia treatment

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What do we believe?

‣ Age, stroke severity,

cognition, personality and

depression influence

motivation

‣ Cultural factors, including

religious beliefs influence

motivation

Kaufman & Becker, 1986; Maclean et al., 2002

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Maclean et al. (2002) More beliefs...

Motivated Unmotivated

‣ Asks questions about therapy

‣ Asks for more therapy

‣ Demonstrates understanding of the

purpose of therapy

‣ Initiates therapy

‣ Does exercises alone

‣ Passive

‣ Pessimistic

‣ Lack of interaction with staff

‣ Little overt interest in rehab

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Viewing motivation as a

personality trait can lead

to moralizing

Maclean et al. (2002)

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Two basic aspects

There is an urge/desire

to act Which is goal directed

WHO (2001) ICF definition...”Mental

functions that produce the incentive to

act; the conscious or unconscious

driving force for action”

Goals can be external (e.g. food) or

internal (e.g. self-esteem, autonomy,

competence, and relatedness)

(Lequerica & Kortte, 2010; Marin &

Wilkosz, 2005)

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“Motivation” does not imply action or participation in therapy

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Motivation and Rehabilitation

Assessment

Management

Motivation 1


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4

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Disorders of diminished

motivation (DDM)

‣ Diminished overt

behavior

‣ Diminished goal-related

thought content

‣ Diminished emotional

response to goal related

events

Marin & Wilkosz (2005)

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Apathy Abulia

Akineti

c

mutism

Diminished

motivation

Poverty of

behavior, lack

of initiative,

loss of

emotional

responses

Total absence

of

spontaneous

behavior and

speech


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16 Marin & Wilkosz (2005)

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Robert et al. (2009) Dx criteria for Apathy in AD

‣ Diminished overt behavior, diminished goal-

related thought content, and diminished

emotional responses to goal-related events

‣ Symptoms of apathy should cause significant

impairment in personal, social, occupational or

other areas of functioning

‣ Should not be attributable to physical or motor

disabilities, depressed consciousness, or due

to the effects of substances such as drug

abuse or medications

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Clark et al. (2011) Apathy Assessment

‣ Reviewed 15 apathy scales and subscales

‣ Apathy Evaluation Scale (AES) and the apathy

subscale of the Neuropsychiatric Inventory

(NPI) were psychometrically the strongest and

covered a broad range of disease processes

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Marin (1996) Apathy Evaluation Scale (AES-C)

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van Reekum et al. (2005) Apathy Prevalence

‣ Alzheimer’s disease - 60%

‣ TBI - 61%

‣ Basal Ganglia (focal lesions, PD, HD, and PSP) -

41%

‣ Vascular dementia - 34%

‣ Cortical stroke - 35%

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van Reekum et al. (2005) Apathy - Associated Outcomes

‣ Decreased functional level (ADLs)

‣ Caregiver (but possibly not patient) distress

‣ Poorer outcome of illness

‣ Poorer treatment response

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Assessment

Management

Motivation 1

Motivation and Rehabilitation 3


4

5

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Lequerica & Kortte (2010)

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Bandura’s Self-efficacy Theory

‣ Different experiences

shape our beliefs in our

abilities to do different

behaviors

• Past performance

• Vicarious experience

• Verbal persuasion

• Physiological states

Bandura (1986;2000)

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Types of self-efficacy

‣ Task self-efficacy

• Belief in ability to complete

a specific task

‣ Self-regulatory efficacy

• Belief in ability to complete

a task in the face of some

barrier

Bandura (1986;2000)

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Self-efficacy and outcomes

‣ Self-efficacy post-stroke is an important

variable in outcomes, such as quality of life,

depression, ADLs, and, to a lesser degree,

physical functioning (Jones & Riazi, 2010)

‣ Elderly adults with high memory self-efficacy

maintained a more consistent level of practice

on inductive reasoning tasks (w/ greater

improvement) than low memory self-efficacy

adults (Payne et al.,2012)

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Outcome expectancies

‣ Judgement that a certain

outcome will result from a

certain behavior

• Self-efficacy is our belief in

our ability to do the

behavior, outcome

expectancies are our beliefs

about the results

Bandura (1986;2000)

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Subjects may have high

self-efficacy but if they do

not believe in the

outcomes associated with

a therapy then it is unlikely

that they will persist, this is

particularly true for the

elderly

Resnick (1996); Resnick et al. (2005); Shaugnessy et al.(2006)

30 Lequerica & Kortte (2010)

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Engagement is "a

deliberate effort and

commitment to working

toward the goals of

rehabilitation

interventions, typically

demonstrated through

active, effortful

participation in therapies

and cooperation with

treatment providers"


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Throughout the

engagement phase,

patients are assessing the

costs and benefits of

treatment and deciding

whether to continue to

engage or not.


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Management

Motivation 1

Assessment 4



5

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Assessing Awareness

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Background

‣ ↓ awareness can be domain specific or global

‣ Individuals post-CVA and TBI appear to

acknowledge motor/sensory impairments more

often than cognitive, social, and emotional

changes (Fleming & Strong, 1999; Toglia & Kirk,

2000; Trahan, Pepin, & Hopps, 2006)

‣ Higher levels of awareness on the Self-

Awareness of Deficits Interview (SADI) were

associated with higher levels of motivation in

TBI (Fleming et al., 1998)

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Direct Assessment

‣ Self-family/friend discrepancy

‣ Performance-based discrepancy

‣ Structured interviews

‣ Clinician ratings

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Indirect Assessment

‣ Verbal reports from staff/family

‣ Ability to set realistic goals

‣ Presence or absence of use of compensatory

strategies

‣ Compliance with therapy (both medical and

rehab)

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Measurement instruments

‣ Awareness Questionnaire-AQ (Sherer et al.,

1998)

‣ Patient Competency Rating Scale-PCRS

(Prigatano et al., 1990)

‣ Self-Awareness of Deficit Interview-SADI

(Fleming et al., 1996)

‣ Visual-Analogue Test Assessing Anosognosia

for Language Impairment-VATA-L (Cocchini et

al., 2010)

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For persons with aphasia VATA-L

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Assessing Self-Efficacy

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Background

‣ Self-awareness and self-efficacy are

interrelated → when deficit awareness is poor,

beliefs and judgements about what one is

capable of may become distorted (Toglia &

Kirk, 2000)

‣ Overestimation of abilities can lead to

unexpected difficulties performing a task and

erode self-efficacy

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Assessment process

‣ Self-efficacy scales are typically done via

confidence ratings on a 0-10 or 0-100 scale

(Jones et al., 2008)

‣ Should be task specific, contain different levels

of challenge, and contain contextual conditions

(Bandura, 1997)

‣ Contextual conditions that impose some

challenge or barrier to doing a behavior can be

added to improve the predictive ability, e.g.

"How confident are you that you can do your

practice when you are home alone?"

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Van Leer & Connor (2012)

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Assessment process cont

‣ Wording: "can do" asks for a judgement of

capabilities (i.e. self-efficacy), "will do" asks for

a judgement of intention

‣ Make sure clients are judging their capabilities

now, not in the future or in the past

‣ May need to use a very concrete example of

self-efficacy before asking about speech,

language or cognitive abilities/tasks, e.g. "How

confident are you that you can lift a 10 lb

weight? A 50 lb weight? etc.

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Can be used to assess generalization of self-efficacy beliefs

Communication Confidence

Rating Scale for Aphasia-CCRSA

Babbitt & Cherney (2010)

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Assessing Participation

and Engagement

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Rehabilitation Therapy

Engagement Scale-RTES ‣ Designed to help rehabilitation therapists...

• Quantify the level of observed engagement during

rehab

• Identify factors contributing to reduced

engagement

• Serve as a basis for thinking about interventions to

improve engagement

‣ High correlation between higher engagement

scores and better motor and cognition FIM

scores in a group of 75 acute rehab patients

with ABI Lequerica et al. (2006)

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Pittsburgh Rehabilitation

Participation Scale-PRPS

‣ Measures observed patient participation in a

therapy session

‣ Doesn’t measure different aspects of

participation/engagement

• Once those areas are identified by other means,

the scale may be useful in tracking change over

time to evaluate the effectiveness of interventions

designed to improve participation in therapy.

Lenze et al. (2004)

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Motivation for Traumatic Brain

Injury Rehabilitation

Questionnaire (MOT-Q)

‣ Likert scale questionnaire developed to assess

motivation to participate in post-acute

rehabilitation

‣ 31 items in 4 subscales: (lack of denial, interest

in rehabilitation, lack of anger, reliance on

professional help)

Chervinsky et al. (1998)

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Motivation 1

Management 5



Assessment 4

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Bandura & Locke (2003); Shaughnessy & Resnick (2009)

Bandura's 4 determiners of self-

efficacy

Mastery experience Vicarious experience

Verbal persuasion Physiologic feedback

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Mastery experiences

‣ Client-centered goal-setting

• Success on meaningful goals can promote setting

more challenging goals in order to experience

greater reward (Bandura, 1986), while failure to

achieve goals can erode self-efficacy (Bandura &

Jourden, 1991)

• Individuals tend to discount the intensity of the

value of goals the further out in the future they are

(Green & Myerson, 2004)

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Mastery experiences cont.

‣ Rosewilliam et al. (2011) systematic review -

patient-centered goal setting has the following

positive psychological outcomes, leading to

greater participation in rehab

• Self-efficacy and confidence

• Sense of autonomy

• Motivation

• Reduction of anxiety

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Mastery experiences cont.

‣ Rosewilliam et al. (2011) systematic review

cont.

• Need to educate patients about the concept and

the process of patient-centered goal setting,

provide clear information regarding the condition,

its prognosis and time course in order to avoid

unrealistic expectations

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Vicarious experience

‣ Self-efficacy increases when watching others

successfully complete a similar task (Bandura,

1986)

• Peer mentorship, one-on-one (Coles & Snow, 2011)

or via group therapy

• Video self-modeling (Cream et al., 2010)

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Verbal persuasion

‣ Appropriate persuasion builds task self-efficacy

(Bandura, 1986)

• Closely aligned with goal-setting...need to make

sure that clients are placed in a context in which

they will succeed

• Can include a review of past successes

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Physiologic feedback

‣ Physical and emotional (e.g. anxiety)

experiences associated with task self-efficacy

or regulatory self-efficacy (Bandura, 1986)

• Help clients understand common experiences,

such as anxiety, stress, or fatigue associated with

therapy and provide strategies to counteract them.

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59 Lane-Brown & Tate (2010)

Apathy

treatment

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Motivational interviewing

‣ “a client-centered, directive method for

enhancing intrinsic motivation to change by

exploring and resolving ambivalence” (Miller &

Rollnick, 2002)

‣ Four guiding principles to create the conditions

for change: express empathy, develop

discrepancy, roll with resistance, and support

self-efficacy (Miller & Rollnick, 2002)

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61 Medley & Powell (2010)

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Thank you!

neurogenic disorders: assessing/managing patient motivation 30 biel.pdf · mscc - biel 3/30/13 1...

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