Occupational therapy approaches for group work

in Aged Persons (65 years and over) Inpatient

Mental Health Unit

Georgia Berry

Alice McKinnon

Chloe Boughen

Georgia BerryAlice McKinnon Chloe Boughen

Project placement• Final year subject at La Trobe University. Aimed to

develop our skills in project management, working as contractors with health organisations.

• Ten week subject, part time at La Trobe University, part time at the Peter James Centre.

• Our project involved conducting a literature review of all relevant literature related to therapeutic group programs, and investigating other service provider’s group therapy programs within adult and older adult acute mental health units

• Recommendations for future research were also investigated

Content • Findings from the literature,

• Summary of Victorian inpatient mental health group programs,

• Recommendations for future practice,

• Future research opportunities.

Literature review • This literature review explored the effectiveness of four common

occupational therapy group work modalities available in Older Adult Acute Mental Health Settings which included

• Exercise,

• Relaxation,

• Skills training,

• Education.

• The findings from this review were used to provide evidence-based recommendations for therapeutic modalities that could be included within the current group program at Peter James Centre

Exercise • Regular participation in exercise can assist in preventing the

development of some mental health conditions. (Zschucke, Gaudlitz, & Strohle, 2013)

• Exercise interventions can also be a viable treatment option for people experiencing a mental illness. (Rosenbaum, Tiedmann, Sherrington, Curtis, & Ward, 2014; Schuch et al., 2015; Soundy et al., 2014; Stanton, Donohue, Garnon, & Happell, 2016; Stanton, Happell, Hayman, & Reaburn, 2014; Zchucke, Gaudlitz, & Strohle, 2013)

Exercise • Most of the evidence base for exercise interventions has been conducted with

community-dwelling and outpatient mental health populations

• There is a severe paucity of studies conducted within inpatient mental health settings (Stanton, & Happell, 2013)

• The validation for physical activity interventions for Australian adults with a mental illness is pertinent. This population has higher rates of CVD, diabetes and metabolic syndromes compared to those without a mental illness (Scott, & Happell, 2011)

ExerciseExercise intentions for depression

• Aerobic, and combined aerobic and anaerobic interventions may be a useful adjunctive

treatment for adults residing in inpatient settings, with improvements in general mood

and reduced symptoms of depression and anxiety recorded. Few adverse effects have also

been recorded (Knubben et al., 2007; Schuch et al., 2011; van de Vliet et al., 2003).

• For older adults residing in inpatient settings, the combination of walking and

validation psychotherapy may be beneficial, with reduced depression scores obtained

for those with moderate-severe depression (Nguyen et al., 2014).

ExerciseExercise intentions for anxiety

• In adult inpatient settings, the addition of moderate intensity aerobic exercises may assist

with decreasing state anxiety and improve wellbeing (Knapen et al., 2009).

Exercise intentions for schizophrenia

• For adults residing in inpatient settings there is weak support for exercise interventions.

High intensity aerobic training may be beneficial in improving peak oxygen consumption and

decrease energy intake required when walking (Heggelund et al., 2011).

• For older adults, brief wellness sessions may assist consumers to increase their motivation

levels to engage in healthier lifestyles (Wirshing et al., 2006).

ExerciseExercise intentions for bipolar disorder

• Walking interventions could be beneficial for adults and older adults in inpatient settings with decreases in depression, anxiety, and stress scores recorded (Ng et al., 2007).

• Two outpatient studies suggest that short term exercise interventions may be beneficial (Edenfield, 2004; Hays et al., 2008). More research is required (Wright, Evenson-Hock, and Taylor, 2009).

ExerciseExercise intentions for dementia

• Evidence suggests that for mild-moderate dementia, intensive progressive resistance and functional training may be beneficial (Schwenk et al., 2014).

• Specialised movement programmes may increase memory recall, and statistically decrease patients aphasia and/or agnosia for consumers with late-stage dementia (Dayanim, 2009).

• Low intensity group physical activity may assist in encouraging more positive behaviours for unspecified dementia diagnoses (Holliman, Orgassa, & Forney, 2001).

Relaxation• Therapeutic relaxation groups aim to create an environment which

reduces stress, anxiety, fatigue and insomnia while also improving concentration, energy levels and memory (O’Donovan & O’Mahony,

2009; York, 2007).

• Most of the evidence for therapeutic relaxation groups was conducted within the adult population excluding older adults (65 years or older) or in a community-dwelling or outpatient mental health populations

RelaxationMindfulness-based cognitive therapy (MBCT)

• Combines elements of cognitive behavioural therapy and mindfulness based stress reduction (Sipe & Eisendrath, 2012).

• Delivered over an 8 week period (Sipe & Eisendrath, 2012).

• Aims to;

• Increase intentional awareness of present moment through meditation exercises,

• Develop skills which enable reflection

• Increased insight into physical, emotional and cognitive processes and how these affect one’s experience of the world (Sipe, Eisendrath, 2012; York, 2007; Mason & Hargreaves, 2001)

RelaxationYoga

• Yoga has been found to be beneficial for individuals with a mental health diagnosis (Bayley-Veloso & Salmon, 2015; Visceglia & Lewis, 2011; Vancampfort, Vansteelandt, Scheewe, Probst, Knapen, De Herdt & De Hert, 2012)

• Yoga programs included breathing and relaxation exercises as well as yoga postures (Viscegila & Lewis, 2011).

Relaxation Depression & MBCT

• Reduces depressive symptoms and improves general well being (Soulsby & Williams, 2004; Mason & Hargreaves, 2001).

• Cost efficient intervention to reduce relapse of major depressive disorder (Smith, Graham & Senthinathan, 2007; Ma & Teasdale, 2004).

• Participants who have more flexible and open expectations of the program combined with a supportive group environment are more likely to acquire mindfulness skills and apply these to everyday life. Compared to participants with more rigid and optimistic expectations of MBCT (Mason & Hargreaves, 2001).

It was also concluded that MBCT sessions that contain participants who have more flexible and open expectations, and a supportive

group environment were more likely to acquire mindfulness skills and apply these skills to everyday life (Mason & Hargreaves, 2001).

In contrast participants who have more rigid or optimistic expectation of MBCT were less likely to acquire mindfulness skills and be

able to apply them to everyday life (Mason & Hargreaves, 2001).

Relaxation Depression & Yoga

• Yoga was found to have greater benefits than progressive muscle relaxation or no treatment (da Silva & Ravindran, 2009).

• Found to be a safe and tolerable short term treatment option (da Silva & Ravindran, 2009).

Relaxation Anxiety & MBCT

• MBCT was found to be an effective additional treatment option for individuals with anxiety disorder (Hofmann, Sawyer, Witt & Oh, 2010).

• No studies were located in an acute inpatient mental health setting therefore the transferability of these findings is unknown.

Anxiety & Yoga

• Yoga was found to be a more effective treatment option than no treatment and progressive muscle relaxation for individuals with an anxiety disorder diagnosis (da Silva & Ravindran, 2009).

Overall, it was found that MBCT is an effective additional treatment option for individual with anxiety disorders (Hofmann, Sawyer,

Witt & Oh, 2010). However no studies were able to be located in an acute inpatient mental health setting therefore the transferability of

these findings to this setting is questionable. Whereas yoga was found to be a more effective treatment option than no treatment and

progressive relaxation exercises for individuals with anxiety disorder diagnosis (da Silva & Ravindran, 2009).

Relaxation Schizophrenia & MBCT

• Assists individuals to relate differently to psychotic experiences, participants were able to accept and experience the psychotic experiences without reacting drawing on mindfulness techniques (Abba, Chadwick & stevenson, 2008).

Schizophrenia & Yoga

• Yoga was found to improve quality of life and reduces positive and negative symptoms (Viscegila & Lewis, 2011).

Relaxation Bipolar disorder

• Overall, there appears to be not enough research supporting the use of therapeutic relaxation groups for individuals with bipolar disorder in an older adult acute inpatient mental health setting

Bipolar disorder & MBCT

• MBCT was found to be effective in reducing suicidal ideation, manic, depressive and anxiety symptoms and may be a potential alternative treatment with more research (Miklowitz, Alatiq, Goodwin, Geddes, Fennell & Dimidjian. Et al., 2009).

Relaxation Dementia & Yoga

• Physical improvements included decreased blood pressure and respiration rate as well as increased;

• Strength,

• Endurance,

• Cardiopulmonary fitness,

• Flexibility,

• Balance and

• Joint motion (Fan & Chen, 2011).

• Statistically significant decrease in depressive state and problem behaviour after 12 weeks (Fan & Chen, 2011)

Relaxation Dementia & Yoga

• Yoga was found to significantly improve visual, attention, working, immediate and delayed recall of verbal memory (Sivakumar et al., 2013).

• Yoga was also found to improve verbal fluency, progressing speed and executive functioning (Sivakumar et al., 2013).

Skills training• Multi-functional

• Different purposes

• Different aims and objectives

• Tailored to different conditions

Skills training• Socialisation

• Supportive team environment

• Use of an activity in therapy = An increase of involvement in therapy

(Cowls and Hale, 2005)

Skills training• Psychopharmacology as most important treatment refuted

(Wiscocki, 1991)

• Social skills training for depression

• Coping, adjusting, living a functional life, building positive relationships

(University of Adelaide, 2016)

Skills trainingMedication adherence training

• Medication adherence declines as the number of medical prescriptions and frequency of medication administration increases

• Medication non compliance can be intentional or unintentional

• Older adults tends to be unintentional

• Medication non compliance can be:

• Patient-related,

• Provider located or

• Medication related

(Depp, Lebowitz, Patterson, Lacro, and Jeste, 2007)

Skills trainingMedication Adherence Skills Training for Bipolar Disorder (MAST-BD)

• Incorporates;

• Education,

• Motivational Training,

• Medication Management,

• Symptom Management(Depp, Lebowitz, Patterson, Lacro, and Jeste, 2007)

Skills trainingCooking/baking groups

• Immediate therapeutic benefits

• Shift of focus from condition and symptom management to participation in an activity

• Easily graded to suit consumers needs

(Haley and McKay, 2004)

Skills trainingDifferent types of skills training groups

• Non activity based

• Symptom management

• Medication management

• Incorporation of activity

• Cooking or baking

• Use of activity in therapy increases participation and involvement in therapy

• Activity groups can be both a catalyst for therapeutic change and result in practical skill development (Haley and McKay, 2004)

EducationTypes of educational sessions for consumers;

• Psychoeducation

• Pharmaceutical counselling;

- MIDS (Medication and Information Discharge Summaries)

- Reminder Cards

• Patient friendly question and answer sessions

• Education is a fluid process and can also occur within other group programs.

(Al-Rashed, Wright, Roebuck, Sunter, and Chrystyn 2002)

Recommendations from the literatureExercise

• Overall, research indicates that all individuals with a mental health condition should

be able to engage in and benefit from exercise, provided no substantial risk of

engaging in exercise exist (Meyer, & Broocks, 2000).

• However at this current time there is a scarcity of studies and methodological

limitations exist within, which present significant challenges in applying clinical

exercise intervention findings to Aged Person Inpatient Mental Health populations. The

high degree of diagnostic and individual variabilities that can exist between mental

health populations further confound this task

Recommendations from the literature

• Currently exercise guidelines for mental health populations do not exist, and exercise

programs vary in their implementation. Thus the findings presented for exercise

interventions should be approached with caution (Rosenbaum et al., 2014; Stanton, &

Happell, 2014) and graded and client-centered exercise interventions should be

prioritised (Marcus et al., 1998; Meyer & Broocks, 2000).

Recommendations from the literatureRelaxation

• Tailor yoga to individuals ability (Cramer, Lauche, Langhorst and Dobos, 2016).

• Keep patients expectations open and flexible (Mason & Hargreaves, 2001).

• Have a consistent facilitator (Mason & Hargreaves, 2001).

• Allow all consumers with an anxiety diagnosis the opportunity to participate in at least one MBCT session (Hofmann, Sawyer, Witt & Oh, 2010).

• Include Yoga exercises in the routine of older adults with a diagnosis of dementia as it has

been found to improve both the physical and mental health of participants (Fan & Chen, 2011).

Recommendations from the literatureRelaxation

• Add MBCT to the treatment plan for individuals with a depression diagnosis as it has

been found to be a cost efficient and safe intervention to use with adults over the

age of 65 (Smith, Graham, & Senthinathan, 2007).

• Offer consumers with a schizophrenia diagnosis the opportunity to participate in a yoga

program which incorporates breathing and relaxation exercises as well as yoga postures

as it improved quality of life and symptoms for individuals (Visceglia & Lewis,

2011;Vancampfort, Vansteelandt, Scheewe, Probst, Knapen, De Herdt & De Hert , 2012).

Recommendations from the literatureSkills training

• Considerations for conducting skills training groups should include;

• Repeating instructions and checking consumer’s understanding

• Conduct skills sessions that focus on the interests of the population

• It is suggested that skills training be specifically tailored to the gender, age, and diagnosis of the consumers

• Tailor written instructions to suit the visual capacities of consumers

• Consider duration of sessions and incorporate breaks to assist with sustaining consumers concentration levels

(Depp, Lebowitz, Patterson, Lacro, Jeste, 2007)

Recommendations from the literatureSuggestions from skills training studies

• Therapists should;

• Create positive therapeutic relationships by developing trust and creating supportive environments

• Deliver content in a confident and clear manner

• Demonstrate understanding and empathy

• Tailor groups to different functioning levels(Cowls, & Hale, 2005; Depp et al., 2007; Haley, & McKay, 2004; Wiscocki, 1991)

Recommendations from the literatureEducation

• Strategies to deliver effective educational sessions to consumers could include;

• Professional development sessions with specialists to gain awareness and understanding of mental health diagnosis

• Tailor education to suit the individual, their diagnosis and symptoms

• Consider the optimal learning style for the individual (ie. visual, auditory, experiential)

(Chater, 2012)

Service providers• Purpose was to scope the types of group programs

available within adult and older adult acute mental health units

• The information obtained was used to compare and contrast similarities and/or differences between group programs

Service providersOlder Adult Acute Mental Health Units/Extended Care Centres• Contacted = 12• Questionnaires returned = 4• No group program currently in operation = 2

Adult Acute Mental Health Units

• Contacted = 16• Questionnaires returned = 6• No group programs currently in operation = 1

Service providersQuestionnaire responses returned

• Broadmeadows Aged Persons Mental Health Unit• Normanby House• IPU2 Maroondah Hospital• Older Adult Acute Mental Health Unit, The Peter James Centre • Upton House• Acute Inpatient Mental Health Service, St Vincent's Hospital • Acute Psychiatric Unit, Austin Hospital• Broadmeadows Adult Inpatient Mental Health Unit• Aged Mental Health Inpatient Unit, Frankston Hospital • The Northern Psychiatric Unit, North West Mental Health

Service providersThe 4 main themes derived from questionnaire responses included;

1. The purpose of group program

2. Clinical reasoning

3. Program logistics

4. Consumer evaluation

Service providers - purpose of the group programAims and objectives

9 out of 10 group programs stated that an aim and/or objective of the group program was to provide consumers with opportunities to engage in meaningful and stimulating occupations during their admission

“The overall aim of the OT group program is to provide meaningful activity and participation while consumers are in the inpatient unit to ensure that their admission is more than just providing medication or containment. OT group program is aimed at adding value and therapeutic benefit to the consumer’s admission”

“The primary aim of the group program is to support our consumers to engage in meaningful and purposeful activity during their stay”

“[Promotes] an opportunity to engage in activities that are meaningful / promote normalisation”

“The aim of the program is to engage consumers in meaningful activity during their time on the unit”

“To engage patients in activities that is meaningful & provides a sense of purpose.”

Service providers - purpose of the group programAims and objectives

6 out of 10 group programs stated that an aim and/or objective of the group program was to assist consumers to develop life skills to manage emotion and increase overall well-being

“To provide strategies for symptom reduction, increase use of adaptive behaviors and decrease subjective distress”

“Maintain or develop life skills, learn new ways to manage emotion and to provide psychoeducation”

“Promote opportunities to relieve and manage stress” [and] “[consumers have] an ability to increase self-esteem, self-confidence and improve mood”

Service providers - purpose of the group programAims and objectives

6 out of 10 group programs stated that an aim and/or objective of the group program was to provide environments that fostered social connections and support

“To promote hope and support consumers in using their strengths”

“Promotes social interaction, encouragement of others, group cohesiveness, altruism (supporting others), sense of fun” [and] “Provides a chance for discussion; fostering of friendships; development of social skills” [and] “An opportunity to build connections with those who share similarities with them” [and] “Promote a sense of belonging via being a valuable member within a group.”

“Groups are aimed more at encouraging engagement and socialisation with others”

“To provide a climate of acceptance, warmth & optimism [and] To allow patients opportunity to impart knowledge & hope to each other”

“Provide opportunities for participation and interaction in a supportive environment”

Service providers - purpose of the group programAims and objectives

3 out of 10 group programs stated that an aim and/or objective of the group program was to assist consumers to continue their recovery journey

“Each group has different aims and goals but are ultimately all aimed at supporting and promoting recovery”

“To equip consumers with skills and supports that they are able to utilize during hospitalization and into the community with their continuing recovery journey”

“To assist patients with their journey of recovery”

Service providers - purpose of the group program

Therapeutic modalities

Service providers - clinical reasoning

Occupational therapy models

• 8 out of 10 services use Model of Human Occupation (MOHO) as there underpinning framework for the development and implementation of their group programs

• 2 services used Person, Environment, Occupation (PEO) as there underpinning framework for the development and implementation of their group programs

Service providers - clinical reasoningOccupational therapy models and frameworks

• Narrative theory

• Trauma & crisis theory

• Cognitive behavioural therapy

• Peer support

• Group theory

• Occupational science

• Sensory modulation

• Recovery model

• Strengths based model

• Person centred approach

Service providers - clinical reasoningOccupational therapy models and frameworks

• Biopsychosocial model

• Canadian model of occupational performance and engagement(CMOP-E)

• Social model of health

• Attachment model

• Humanistic model

• Needs driven behaviour model

• Psychodynamic/psychoanalytical model

• Progressively lowered stress threshold model

• Sensory modulation approach

Service providers - clinical reasoning

Clinical reasoning behind the group program structure

• 8 group programs cited elements of MOHO as a reason for the group program structure - focus on consistency/routines, interests, strengths, occupational balance and engagement

• 5 group programs stated that an underpinning philosophy is to assist consumers to build on skills that are necessary for recovery and community reintegration

• 2 group program stated that being client-centered and flexible were important due to changing demographics of the group, and challenges conducting group programs with diverse consumer needs

Service providers - clinical reasoning

Clinical reasoning behind the group program structure

• 1 group program cited that activities were structured around providing sensory input to arouse or calm consumers for different activities on the ward, for example exercise groups in the morning and relaxation groups in the afternoon

• 1 group program stated that group work has an evidence-base for supporting recovery from mental illness

• 1 group program expressed that different multiplinary staff bring their own ethos to the group program structure

service providers - program logistics

Staffing

• 9 out of 10 respondents reported that occupational therapists were responsible for coordinating the group therapy program and also assisting in facilitation. While the other service employes an activity nurse to run groups and activities. Another program is looking into the inclusion of allied health assistants and volunteers to assist with facilitation when staff shortages are apparent

• Other services contacted whose data was not included in the summary;• Did not have a current occupational therapist and therefore there group

program were not currently operating.• Had recreational therapists and lifestyle officers responsible for

developing and facilitating activities and outings

Service providers - program logistics

Staffing • All 10 respondents acknowledges the contribution of other staff

members and external support in the facilitation of groups, these included;

• Nurses,• Art therapists • Music therapists• Reflexologists• Social workers• Psychologists• Occupational therapy students • Activities nurse

Service providers - program logistics

Consumer workers

• 5 out of 10 services have consumer workers actively facilitating groups these include;

• Aromatherapy groups

• Gardening groups

• Exercise groups

• Music groups

• While 2 services have previously employed consumers the positions are currently vacant one stating that it has been vacant for “some time”.

Service providers - program logistics

Volunteers

• 6 service providers have volunteers who assist with running some group therapy sessions.

• 4 service providers do not have any volunteers assisting with the operation of the group program.

• Although 1 service is in the process of adding a pet therapy group which would involve the inclusion of volunteers.

• Another service is considering including volunteers to assist with group facilitation.

• While another service provider stated that they currently do not have any volunteers but have previously had volunteers working within the group setting and found it to be effective.

Service providers - program logistics

People who volunteer include;

• Retired nurses,

• OT students,

• Artists,

• Musicians,

• Church representatives.

Groups which volunteers assist include;

• Art therapy groups,

• Church services,

• Pet therapy,

• Music therapy groups.

Service providers - program logistics

Targets

• No group program have targets to meet as directed by management

• 7 occupational therapists from different services collect data related to;

• Number of attendees,

• Number of groups ran,

• Type of groups ran.

Service providers - program logistics

Funding• 8 out of 10 group programs received funding for the group program

• 6 group programs received funds from petty cash on the ward ranging from $50-$210 per week for resources and community outing expenses

• 1 group program received time and products from Bunnings volunteers to assist in the development of planting and creating garden beds in two separate courtyards which is linked to the gardening group

• 1 group program has funding for Tai Chi and activity resources through a hospital account

• 1 group program received one off funding for sensory items through a hospital account

• 1 group program received funding for music therapy through grants and fundraising activities

• 2 group programs did not receive funding for the group program

Service providers - program logisticsProgram operations

• All group run Monday-Friday. However the group programs are conducted at different frequencies

• 3 of the centres aim for 2 groups per day

• Another centre aims for 1 group per day. Within the low dependency unit there is are a higher frequency of activities offered (5 on Monday, 3 on Tuesday, 3 on Wednesday, 5 on Thursday, 4 on Friday)

• On the weekends;

• 7 service provider offer groups programs on the weekend, these sessions are usually facilitated by nurses or other staff members

• 2 service providers reported that consumers have access to the group program room on the weekends

• 2 service providers did not report offering any groups programs on weekends

Service providers - consumer evaluationConsumer evaluation

• 1 service has previously used a consumer evaluation tool, however is currently not

• 9 services collect consumer evaluation data

• The data is collected infrequently by 1 service and weekly or monthly by other services through;

• Confidential drop boxes

• Verbal feedback

• Consumer evaluation forms

• Community meetings

• Consumer surveys

Recommendations for future researchSome limitations of current research;

• Heterogeneous study designs and often had small sample sizes

• Difficult to replicate studies as the methodologies are not clearly outlined;

• Many studies are individualised to consumers needs, and thus details of exercise and relaxation programs often lack detail

• Lack of clear inclusion and exclusion criteria, studies often excluded consumers who were deemed to be difficult or disruptive in a group setting

• Studies often lacked clarity regarding program implementation

• Cause-effect relationship difficult to ascertain

• Poor blinding of assessments

• Optimal dose and frequency of exercise interventions are highly debatable and difficult to generalise

• Adverse effects of exercise interventions are often not reported

• Long term follow up is scarcely reportedStanton, & Happell, 2014

Recommendations for future researchStudies which could be replicated within the Peter James Centre

• Considerations for recruiting mental health consumers for a study;

• Falls risk assessment

• Mini-Mental Status Examination

• Informed consent or nominated person

• Health conditions that may impact exercise engagement, such as physical, metabolic and neurological conditions

• Potential side effects of medication

• Risk of harm to self or others within a group setting

Stanton, & Happell, 2014; Stanton, Reaburn, & Happell, 2016

Recommendations for future researchConsiderations for designing an exercise-based study;

• Resource allocation

“Aerobic exercise program appear to be popular and beneficial, partly because they can be implemented with little or no cost, and with minimal training of supervisory staff. [In contrast, resistance-based exercises] typically require expensive equipment, qualified instructors, and significant physical space commitments” (Stanton, Happell, 2014, p. 241)

• Self-selected and/or prescribed exercise regimes (moderate or high intensity) appear to be beneficial across a variety of mental health diagnoses

• The practicalities of conducting exercise studies around routine procedures of inpatient mental health settings should be considered, for example, time conflicts

Stanton, & Happell, 2014; Schwenk et al., 2014

Recommendations for future researchSome common outcome measures used within exercise and relaxation studies

Depression

• Quality of life scales

• Self-reported feelings of depression, anxiety, tension and physical well-being

• Rating scales for depression

• Symptom and behavioural checklists

• Melancholia scales

• Self-esteem scales

• Cathexis scales

• Incidence of depressive episodes

Anxiety

• Anxiety scales

• Global impression scale

• Phobic avoidance scale

• Agoraphobia scale

• Symptom checklists

Bipolar disorder

• Depression scales

• Anxiety scales

• Global impression scales

Recommendations for future researchSchizophrenia

• Symptom scale

• Self reported reduction in stress

• Interference rating

• Depression scale

• Quality of life

Dementia

• Activities of daily living scale• Improvements in visual, attention, working,

immediate and recall of verbal memory• Verbal fluency, progressing speed and

executive functioning• Reported improvements in physical and mental

health • Blood pressure and respiratory rates• Flexibility, balance, cardiopulmonary fitness,

endurance and strength• Quality of life scales• Fear of falling scales• Observation• Behaviour scales• Dependency scales

Questions?

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