Cognitive Impairment

ISO/IEC Guide 71 & CEN/CENELEC Guide 6 – Flawed ?

International Guidance Document … ISO/IEC Guide 71 : Guidelines for Standards Developers to Address the Needs of Older Persons and Persons with Disabilities was issued in November 2001.

European Guidance Document … CEN/CENELEC Guide 6 : Guidelines for Standards Developers to Address the Needs of Older Persons and Persons with Disabilities … a similar document … was issued a little later, in January 2002.

These Guides provide basic guidance to people drafting International & European Standards on how to take into account the needs of people with activity limitations, particularly older persons and people with disabilities.  While recognizing that some people with very extensive and complex impairments may have requirements beyond the level addressed in these documents, a very large number of people have minor impairments which can easily be addressed with a very small change of approach by people writing the Standards.  Typically, the problem is solely a lack of awareness.

Unfortunately, few Standards Developers … in either organization … are paying the slightest bit of attention to these Guides.

People with Activity Limitations:  Those people, of all ages, who are unable to perform, independently and without aid, basic human activities or tasks – because of a health condition or physical/mental/cognitive/psychological impairment of a permanent or temporary nature.

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1.  A full six months before the appearance of ISO/IEC Guide 71 … all of the 191 Member States of the World Health Organization endorsed, and officially adopted, the International Classification of Functioning, Disability & Health (ICF) on 22nd May 2001 … which replaced the earlier International Classification of Impairment, Disability & Handicap (ICIDH), dating from 1980.

While the previous health indicators had been based on the mortality (i.e. death) rates of populations … the new 2001 WHO ICF dramatically shifted the focus to ‘life’ and ‘living’ … in other words, how everyone is living with his/her health condition(s) and how improvements can be made to ensure a productive, fulfilling life in society.

This had important implications for medical practice; for legal, social, economic, institutional, design and spatial planning policies to improve accessibility, equal opportunity for all and inclusion; and for the protection of the rights of all individuals and groups.

Of special interest for people involved in any of the technical fields mentioned above … the 2001 WHO ICF also introduced a new disability-related language and terminology.

BUT … But … but … ISO/IEC Guide 71 and CEN/CENELEC Guide 6 do not use the 2001 WHO ICF’s innovative language and terminology.  Consequently, these International & European Guides are flawed.

For a very good example of WHAT MUST BE AVOIDED (!) in the drafting of International & European Standards … please examine the following text …

ISO DIS (Draft International Standard) 21542 : Building Construction – Accessibility and Usability of the Built Environment … dated November 2009 …

Section 3   Terms & Definitions

‘ #3.36  Impairment

Limitation in body function or structure such as a significant deviation or loss which can be temporary due, for example, to injury, or permanent, slight or severe and can fluctuate over time, in particular, deterioration due to ageing.

[ISO/TR 22411:2008]

NOTE 1   Body function can be a physiological or psychological function of a body system; body structure refers to an anatomic part of the body such as organs, limbs and their components (as defined in ICIDH-2 of July 1999).

NOTE 2   This definition differs from that in ISO 9999:2002 and, slightly, from ICIDH-2/ICF: May 2001, WHO: ‘any loss or abnormality of a body function, or body structure’.

NOTE 3   The word ‘abnormality’ is strictly used here to refer to a significant deviation from an established population mean, within measured statistical norms. Impairments can be physical, mental, cognitive or psychological.’

As clear as mud … what a mess !   This does nothing only sow needless confusion in the mind of a reader.

Unless and Until … we properly harmonize, at a technical level, disability-related language and terminology … in order to improve communication … we will all continue to run around in circles and make little forward progress !!!

[ At the level of the individual, people should always be free to use whatever language they wish. ]

Our Guidance to All Standards Developers is … whether working within the International Standards Organizations (ISO & IEC) or the European Standards Organizations (CEN & CENELEC) … or both …

People with Activity Limitations must be properly considered at all stages in the development of a Standard … and any disability-related terminology used … should be fully consistent with the World Health Organization’s 2001 International Classification of Functioning, Disability & Health (ICF).  Confusing and contradictory texts should be avoided.’

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2.  In relation to ISO/IEC Guide 71 & CEN/CENELEC Guide 6 – Table 7 (Page 13 in both Guides) … #8.23 Fire Resistance requires a complete re-assessment.  On Page 21 of ISO/IEC Guide 71 and Page 22 of CEN/CENELEC Guide 6 … the supporting text for #8.23 has the different heading of ‘Fire Safety of Materials’ ?!?   Confusing, isn’t it ?

The Revised Title in Table 7 and the supporting text should read … Fire Safety.  ‘Fire Resistance’ is but one of many passive fire protection concepts … a very small sub-set in the wide technical field of ‘fire safety’ in buildings.  ‘Fire Resistance’ is not used in connection with the ignition and fire development behaviour of materials or fabrics.

Relevant Factors for #8.23 are not properly indicated, in Table 7, under Columns #9.2, #9.3, #9.4 (a glaring omission !) & #9.5.

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3.  Pertinent to ‘fire safety’ in buildings … this text was removed from ISO CD (Committee Draft) 21542 … the previous version of the ISO Standard, dating from December 2008 …

ISO CD 21542 – Annex A.1.2 – 2nd Paragraph

‘ Building users should be skilled for evacuation to a place, or places, of safety remote from the building.  In the case of people with a mental or cognitive impairment, there is a particular need to encourage, foster and regularly practice the adaptive thinking which will be necessary during a ‘real’ fire evacuation.’

The Definition for the Term Skill (#3.60) is still retained in the later ISO DIS 21542 version of the Standard …

‘ The ability of a person – resulting from training and regular practice – to carry out complex, well-organized patterns of behaviour efficiently and adaptively, in order to achieve some end or goal.’

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4.  While there are eight references to ‘Cognitive Impairment’ in both Guides … nowhere is this term defined … or distinguished from ‘Mental Impairment’ …

Cognitive Impairment:  A deficiency of neuropsychological function which can be related to injury or degeneration in specific area(s) of the brain.

Mental Impairment:  A general term describing a slower than normal rate in a person’s cognitive developmental maturation, or where the cognitive processes themselves appear to be slower than normal – with an associated implication of reduced, overall mental potential. 

A deeper understanding, at a technical level, of the many different types of health conditions and impairments (physical/mental/cognitive/psychological) … can only result in a better designed, more facilitating Human Environment.

One final important term … when considering Fire Safety in Buildings

Panic Attack:  A momentary period of intense fear or discomfort, accompanied by various symptoms which may include shortness of breath, dizziness, palpitations, trembling, sweating, nausea, and often a fear by a person that he/she is going mad.

I have long held the view that, in Fire Engineering, dramatic breakthroughs will result from a closer study of Cognitive Psychology.

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Older People in Emergencies – Urgent Action Required !! (I)

2009-11-25:  In the midst of an economic, financial and fiscal crisis in Ireland … the country has recently been hit by a Major Flood Emergency in the West and South … extending inland almost to the centre.  The emergency will continue over the next few days.

There appears to be no central co-ordination of the response to this National Emergency.  No public guidance or other announcements have been published in the national media.

Further to the full page advertisement promoting the National Older & Bolder Campaign, which was printed on Page 7 of The Irish Times (2009-11-19) … the contents of World Health Organization (WHO) Fact Sheet: ‘Older Persons in Emergencies’, drafted following the 2006 Lebanon Humanitarian Crisis, are both appropriate and particularly relevant for Ireland now …

When dealing with older people in emergencies, a number of issues which might affect them will require special consideration.  Apart from specific chronic disease and disability related issues, two major factors contribute to increased vulnerability of older people in emergencies: the ‘normal’ challenges of physical ageing and social loss, and the ‘environmental’ challenges.  In a crisis, minor impairments which do not interfere with daily functioning in the normal environment can quickly become major handicaps that overwhelm an individual’s capacity to cope.  For instance, an older person with arthritic knees and diminished vision, living alone in a high-rise apartment with no family members or friends nearby, can become incapable of getting food or water or of fleeing danger, and may be overlooked by neighbours.

Specific Issues

There are several specific issues that affect older people, separately or in combination, and which can impact on their ability to respond or react in an emergency.  Awareness of these specific issues by all those giving aid, or surrounding them, will improve interactions.  Knowledge of the age profile in an affected community, as an emergency response is prepared, will help to ensure that older people at risk are identified and that appropriate supplies and services are provided on-site.

The specific issues affecting older people are:

1.   Sensory Deficits (especially vision and hearing)

  • reduced awareness ;
  • difficulty accessing and comprehending visual and auditory information, and responding appropriately ;
  • reduced mobility and risk of disorientation.

2.   Slower Comprehension and Retention of Information (especially new, complex or rapidly delivered information)

  • difficulty accessing information ;
  • difficulties in understanding and acting on risks, warnings, directions ;
  • reduced capacity for self-protection and avoidance of harm ;
  • disorientation in unfamiliar environments ;
  • greater risk for abuse and exploitation ;
  • provision of information in more accessible and structured formats.

3.   Less Efficient Thermoregulation

  • greater susceptibility to hypothermia, hyperthermia and dehydration ;
  • appropriate shelter, clothing and food, as well as adequate fluid intake.

4.   Reduced Functional Ability (poorer balance and reduced speed, psycho-motor co-ordination, strength and resistance)

  • reduced mobility and risk of being housebound ;
  • increased risk of falling ;
  • decreased capacity for self-protection and harm-avoidance ;
  • difficulty getting basic necessities and accessing health facilities, e.g. local clinics ;
  • increased vulnerability to abuse and exploitation.

5.   Difficulties in Urinary Continence

  • need for adequate toilet facilities and continence supplies.

6.   Oral Health & Dental Problems

  • easy-to-eat soft food and fluids may be necessary.

7.   Changes to Patterns of Digestion 

  • need for smaller, more frequent portions of easily-digestible, nutrient-dense food and adequate fluids.

8.   Increased Body Fat Composition, with Decreased Muscle Mass and Metabolic Rates

  • greater sensitivity to certain medications with potential adverse effects on functional ability and cognition.

9.   Greater Prevalence, and Co-Morbidity of Ageing-Related Chronic Disease and Disability (e.g. coronary heart disease, hypertension, stroke, cancers, diabetes, chronic obstructive pulmonary disease, osteoarthritis, osteoporosis, cognitive impairment)

  • need for condition-specific medications, treatments, medical device and assistance aids (oxygen, crutches, walkers, wheelchairs, glasses) ;
  • higher risk for adverse drug reactions.

10.  Weaker and Smaller Social Networks (e.g. widowed, living alone, minimal contact with neighbours, dispersion of family)

  • reduced awareness and comprehension of the situation ;
  • greater risk of social isolation, neglect, abandonment, abuse and exploitation.

11.  Heavy Reliance on Care and Support by Very Few Family Members

  • when essential family support is disrupted, physical and psychological functioning can deteriorate rapidly ;
  • reunification with family is particularly important.

12.  Psycho-Social Issues

  • reactions to loss of home, family and possessions can be more acute for older people who cannot rebuild their lives ;
  • resistance to leaving, and grieving, may be strong.

13.  Reliance of Other Family Members on Older People

  • older people often care for other dependent adults and children and may require resources for others as well as themselves.

Last but not least: Older People should not be considered solely as a Special Needs Group.  From numerous accounts of natural disaster and armed conflict situations, it is known that their knowledge of the community, previous experiences with such events, and position of respect and influence within their families and communities are critical resources in dealing effectively with emergencies.

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