We learned so much in school about older people and dementia, but I have to say, it was quite the shock to go visit my grandmother and have her say to me, “you look so familiar, but I can’t place where I know you from.” I was just floored. I know she has Alzheimer’s, and I know it is progressive, but I was so shocked that she didn’t know who I was that I became dumbfounded and speechless. I stammered for what must have been 2 minutes and ended up abruptly changing the topic.
We all know that one of the purposes of splinting by occupational therapists is for joint protection and to preserve function and range of motion. I have blogged before about my experience with fabricating below knee amputation (BKA) splints, used to preserve knee extension for being able to fit orthoses at a later date.
Sometimes, however, I wonder if a patient really needs the splint. For example, I once had a 85 year old patient who had severe Alzheimer’s dementia, was completely bedbound at a nursing home at baseline and had a BKA due to gangrene. While normally I would make a splint, I wasn’t sure that it was indicated in this case.
First, the patient was bedbound at baseline, and therefore an unlikely canditate for a prosthetic. Second, a patient is very likely to develop skin breakdown and sores from a splint if the splint schedule isn’t adhered to, or frequently monitored. Third, splints aren’t generally the most comfortable things.
Providing a splint would not increase or improve quality of life, and so it would seem to me that a splint would not be indicated in this case for the reasons listed above. What are your thoughts?
Two sisters, ages 81 and 89, used a reacher to defend themselves from a burglary. Here’s the story:
While working with a patient who had cerebral palsy:
ME: “Can you try to relax your muscles?”
Patient: “You should know better than asking a spastic CP to relax! The only way to get me to relax is with alcohol!”
One thing I’ve learned in the last year as being a practitioner is to never make assumptions about anything. This lesson was really reinforced today.
I had a patient who had amputations below both of his knees, as well as on one of his hands, leaving only one finger on one of his hands. On top of this, he was blind.
Reading this information in the chart led me to automatically assume that this patient would be a cripple, dependent with all of his activities of daily living, unable to transfer, and unable to care for himself.
Was I ever wrong!
He lived in an assisted living facility, where he was extremely comfortable with his environment and he knew where everything was. In the room at the hospital, we only had to give him verbal cues as to where certain items were. Not only did he manage to don his prosthetic independently, he was also able to complete a wheelchair transfer completely by himself!
Once familiar with his surroundings, he was found to have no occupational therapy needs in the acute care setting.
In the past, I’ve made bad assumptions on lesser details. For example, if there is someone visiting in the room, I always ask, “how are you connected with the patient?” because I once made the mistake of assuming that a female friend of a female patient was a sibling instead ofa significant other. I’ve also mistaken visitors to be grandparents when they were really siblings (making them look older). But these are small assumptions that we make that don’t have an overall effect on patient care.
It is important to go into a patient’s room with an open mind and not assume that a patient performs at a low (or high) level just based on the chart review. The book often does not match the cover.
One thing that I have always observed while working in the hospital setting is that the patients who have family and friends that come to visit tend to fare better when it comes to physical rehabilitation and overall attitude towards the outcome. They are better able to laugh through their hospital stay and they have a strong support system. The patients who are alone during their entire hospital stay tend to be more depressed, less motivated to participate in therapy, and have a poorer affect.
As a result, I have always advocated that when possible, patients should encourage family and friends to visit. I recently had a situation where I questioned this for the first time. The patient was an older person who was completely independent with all her activities of daily living and participating in the community. She suffered a fall, fracturing some bones and having aches all over.
Once stable, therapy was called in to see the patient. On a typical patient, we would normally ask if the patient would be willing to get up, and work towards getting her out of bed and to a chair, at least for the first time in therapy. Patients usually complain of pain, but we try to coordinate with the nursing staff so that the patients can be fully medicated and ready to go. Usually, this is enough, and we can proceed with therapy.
However, with this patient, we saw that there would be problems from the start. Upon arrival, the patient’s son was in the room. Right away, he told us that she was sleeping and that he doesn’t think she should have therapy so that she could rest. If a patient is alert and oriented, I like to at least ask the patient their opinion on participating in therapy, which is what I did. The patient was quick to say that she would welcome sitting at the edge of the bed, so I’m happy I asked.
Then, when approaching the bed and reaching out to shake her hand and introduce myself, the son audibly gasped, worried that my touch would cause more pain. This went on throughout the entire 40-minute long evaluation. Any time I touched the patient in any way, the son could be seen and heard wincing and gasping, as if my touching the patient was actually hurting him!
Now as an aside, I completely empathize with the son, and I fully understand that his mom is in pain. I could not even begin to imagine what it would be like if that were my own mother. However, the son took this to an extreme that I had never seen before.
In moving the head of the bed upwards, the son demanded that we be “gentle” several times. Unfortunately, there is no gentle button, just an up and down button, but I managed to get the head of the bed situated in a way that was agreeable to everyone. Before removing the patients waffle boots (used to prevent heel sores), the son made us wait and ask the patient to make sure that it was ok to remove them, as her legs were very sore.
With literally every single movement, the son was involved, asking his mom to tell us to stop when it became too much. To get to the edge of the bed, we have to move one leg, then the other, adjust the shoulders and hips, move both legs again, adjust the shoulders and hips, sit her forward, etc. until she can sit at the edge of bed appropriately. Even then, we had to manage her sitting balance and control her dangling legs. Imagine for a moment getting stopped by the family member for each and every single one of those movements! I’m honestly quite surprised that we completed the evaluation in only 40 minutes. We had to reassure the son over and over again that we were being as gentle as possible, explaining exactly what we were doing, and why we were doing it.
Take note that I have spent most of this post discussing the son, and not the patient. When a family member gets so involved that we can barely pay attention to the patient, I think that there is something wrong. When the son asks the patient repeatedly to tell therapy to stop if it becomes too painful is absolutely detrimental to the patients ability to recuperate. Patients need to be encouraged to do more so that they can get stronger and healthier.
Once again, I empathize with the son and I think he is the greatest son a mother could have for his ability to be at her bedside throughout the day and worry about her. But there comes a time when it can be too much. I had actually heard rumors that when the patient was in the ICU (where they have very specific visiting hours), the patients heart rate and blood pressure was noted to be higher when family members were present! So, while I normally advoate for patients to welcome family members and friends to visit, I also think that there is a time when they need to step back and let the patient get therapy so that they can get well and go back to being independent.